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Disabilities: Uncontrollable muscle tremors
Notice of Decision: Fully Favorable
Administrative Law Judge: Dean W. Determan
Office of Disability Adjudication & Review (ODAR): Fort Lauderdale, Broward County, Florida & Palm Beach County, Florida
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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.
Claimant has continued to experience this generalized "shaking all over" since his 18th birthday. He sought treatment at Martin Memorial Health Systems emergency room on September 7, 2007 after having multiple seizures the day before and continuing that day. These seizures were leaving him with numbness and he was unable to walk. (Martin Memorial treatment record 09/07/2007.)
A magnetic resonance image (MRI) of claimant's brain taken in May of 2007 did not show any significant brain abnormalities. He did have a small mucosal cyst in his sphenoid sinus, otherwise it was an unremarkable study. (Dr. William Merrell, M.D., report of brain MRI 05/30/2007.)
Claimant began treatment through Neurodiagnostics of Stuart, P.A. following those seizures. Dr. Henry Calas, M.D., performed a thorough physical examination of claimant in September of 2007. He was unable to find any significant abnormalities in any neurological area. His therapeutic plan for claimant was to give claimant a prescription for a small amount of Clonazepam during the evening hours. Claimant was told to keep a daily diary of his symptoms because they did not appear to be genuine. Consequently, if the symptoms continued to recur, the claimant would be referred to a psychologist. (Dr. Henry Calas' treatment note 09/2612007.)
An MRI of claimant's lumbosacral spine taken in September of 2007 showed that claimant had very mild lumbar scoliosis convex to the left. His vertebral bodies were normally aligned and he had very mild disc protrusion at the Ll-2, L2-3, L3-4, and U-5 levels possibly representing physiologic disc bulge. He had no focal disc herniation. The central canal was well maintained and the conus medullaris was in normal position and signal. (Helen Sax, M.D., reading of claimant's MRI 09/26/2007.)
A Physical Residual Functional Assessment (PRFC) of claimant was done in October of 2007. The medical consultant, Jennifer Cuyler, determined that claimant was capable of medium work. She did not note any change in claimant's physical condition since the examination by Dr. Calas in September of 2007 (Jennifer Cuyler, PRFC 10/04/2007.)
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