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Disabilities: DM (diabetes mellitus) with neuropathy, history of stroke (CVA) with resultant ataxic gait, anemia with severe fatigue, recent diagnosis of prostate cancer, and kidney disease
Notice of Decision: Fully Favorable
Administrative Law Judge: D. Kevin Dugan
Office of Disability Adjudication & Review (ODAR): Fort Lauderdale, Broward County, Florida & Palm Beach County, Florida
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The claimant has a long history of diabetes and hypertension (HTN) and has been receiving treatment from Dr. Wayne Fraser, MD, since 2002 (Exhibits 2F, 10F, & 12F). Dr. Fraser's notes are very difficult to read, but relate that he was taking multiple medications (around 10) for his numerous medical problems.
The medical evidence in the claimant's record relates that he was in his normal state of health until September 2006 when he suddenly developed left sided weakness. The claimant went to the emergency room at Florida Medical Center on September 5, 2006, and reported that his symptoms started the previous Sunday. The claimant was having problems moving his left leg and he called his doctor who told him to go to the emergency room. Dr. Julian Abich, MD, noted that the claimant had suffered a previous TIA in the past. The claimant also had a history of chronic anemia and was receiving treatment. The claimant was admitted at that time with assessment including left sided weakness, rule out vertebrobasilar ischemia; rule out cerebrovascular accident; anemia of chronic disease; diabetes; and hypertension. The claimant was admitted at that time and discharged on September 7, 2006. The claimant's discharge diagnoses included left sided weakness; chronic anemia; hematuria; diabetes; and hypertension.
The claimant was discharged home with instructions to follow-up with his doctor in 1 week and he was to undergo home physical therapy with the help of his wife (Exhibit 1F).
Later in 2006, at the South Florida Health System, it was found that testing done on the claimant showed subacute and chronic ischemic changes in the cerebellar area. The claimant underwent rehabilitation, but did not improve very much. The claimant's record indicates that he continues to have problems with walking and standing (Exhibits 2F, 4F, & 12F). The claimant had an abnormal prostate exam on June 13, 2007, and was diagnosed with prostate cancer in July 2007 (Exhibit 7F). The claimant has also been undergoing treatment for kidney disease since at least 2005 (Exhibits 3F & 5F).
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