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Status/Post CVA | Residual Left Hemiparesthesis Upper Lower Extremities | Limited Use of Left Arm | No use of Left Hand | Weakness in Left Leg | Bipolar Disorder | Claudication Lower Extremities| Status/Post DVT Right Upper Extremity (Case 61, p.2)

Disabilities: Status/post CVA 1999 with residual left hemiparesthesis upper and lower extremities with limited use of left arm and no use of left hand and weakness in left leg, residual cognitive impairments, bipolar disorder, claudication lower extremities, status/post DVT right upper extremity

Notice of Decision: Fully Favorable
Administrative Law Judge: Irwin Bernstein
Office of Disability Adjudication & Review (ODAR): Fort Lauderdale, Broward County, Florida & Palm Beach County, Florida

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In making this finding, the undersigned considered all symptoms and the extent to which these symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence, based on the requirements of 20 CFR 404.1529 and 416.929 and SSRs 96-4p and 96-7p. The undersigned has also considered opinion evidence in accordance with the requirements of 20 CFR 404.1527 and 416.927 and SSRs 96-2p, 96-5p, 96-6p and 06-3p.

The claimant has been treated at the VA medical centers since at least 2003. At that time the claimant was status/post CVA 1999 which left him with inability to use the left hand, limited use of left arm and weakness in left leg. He was treated for septic arthritis of the left shoulder with abscess and MRSA infection in May 2006. In May 2006 he was also diagnosed with deep vein thrombosis in the right upper extremity. In August 2006 he was diagnosed with severe advanced iliac disease in left lower extremity. The claimant's record reflects that he also suffered with problems with his comprehension skills as a result of his stroke.

The claimant has also been diagnosed with bipolar mood disorder and has past suicide ideation with visual and auditory hallucinations. That disorder has worsened since his 1999 CVA. There is past alcohol use but the claimant has abstained from use of alcohol or drugs since he entered treatment at Oakwood Center April 2008, attends AA meetings and has a sponsor. The claimant also receives treatment for his mental problems from the VA and medical notes report that his medications included quetiapine fumarate (for mood), citalopram hydrobromide (for depression), and bupropion.

As stated by his treating physician at WPB VA medical center, he can sit for less than 2 hours, stand for less than 2 hours, walk for less than 2 hours. He has no use of the left hand, arm, or fingers. He cannot stoop, crouch, kneel, or climb stairs. He can occasionally lift less than 10 pounds. He must take unscheduled breaks every 20-30 minutes in an 8-hour workday, of 20 minutes each. The undersigned gives controlling weight to this opinion because it is consistent with the record as a whole, and is well documented and supported by clinical notes and medical testing (MRI, EMG/EEG, CT scan, etc.). If a treating physician's medical opinion is well-supported and not inconsistent with the other substantial evidence in the case record, it must be given controlling weight; i.e., it must be adopted (Social Security Ruling: 96-2p).

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