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Disabilities: Chronic low back pain status post traumatic herniated disc and discectomy, peripheral vascular disease, and depressive syndrome
Notice of Decision: Fully Favorable
Administrative Law Judge: Carol J. Pennock
Office of Disability Adjudication & Review (ODAR): Fort Lauderdale, Broward County, Florida & Palm Beach County, Florida
FINDINGS OF FACT AND CONCLUSIONS OF LAW
After careful consideration of the entire record, I make the following findings:
1. The claimant has not engaged in substantial gainful activity since August 1, 2003, the alleged onset date (20 CFR 416.920(b) and 416.971 et seq.).
2. The claimant has the following severe impairments: chronic low back pain status post traumatic herniated disc and discectomy, peripheral vascular disease, and depressive syndrome (20 CFR 416.920(c)).
On the alleged onset date, the claimant was assaulted and her back was injured. She was treated for back pain, and in November 2003, a CT scan documented a large L5-S1 disc herniation with compression of the S1 nerve root. The claimant continued to complain of pain after conservative treatment including epidural nerve blocks. In January 2004, she underwent surgical treatment, a right L5-S1 micro discectomy. The claimant continued after surgery to complain of intractable back pain. (Exhibits 1F, 4F, SF, 6F, 11F, 12F, 13F, and 14F)
A consultative psychological evaluation was performed on December 15, 2004, at the request of the State agency. The claimant reported a history of depression, with suicide attempts and age 10 and 32. The claimant acknowledged a history of polysubstance abuse. The claimant initially stopped working as a bar tender due to a high risk pregnancy. She miscarried, and then returned to work as a private duty nursing assistant. Her employer's son attacked her and sexually assaulted her, and in the course of the attack, injured her back. The claimant reported that at the time of the evaluation, she was drinking a 6-pack of beer a day. Dr. Gonzalez-Diaz, PhD, opined that the claimant suffered from bipolar II disorder, depressed type, and alcohol abuse, with a history of post traumatic stress disorder, cocaine abuse, and specific phobia. She assessed her global assessment of function (GAF) as 64.
In March of 2005, a CT scan documented post surgical scarring at the L5-S1 level compressing the right L5 nerve root and touching the S1 nerve root. The CT scan also revealed severe calcific atherosclerotic disease of the abdominal aorta with 60 to 70% occlusion. (Exhibit 23F/6-9.) The claimant continued to complain of severe back pain and buttock pain, and was diagnosed with severe bilateral buttock claudication due to aortoiliac stenosis. The claimant was hospitalized February 28-March 1, 2006 and underwent a balloon angioplasty of the distal aorta and proximal common iliac arteries. (Exhibit 30F)
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