Group I, Category 41 Insufficient Medical Documentation to Determine Impairment Severity ISSUE Additional evidence is needed to determine the degree of the severity imposed by the claimant’s physical condition. CASE DISCUSSION & POLICY ANALYSIS (INCLUDING SPECIFIC REFERENCES) This 56- year old claimant is filing a concurrent claim alleging disability due to cysts on the fallopian tubes, back pain, stomach pain, ulcers, arthritis and asthma as of 05/09/2016. The evidence in file shows the claimant has a history of asthma, lumbago, and abdominal pain. An office visit on 12/4/15 shows the claimants had a BMI of 30.5, she complained of shortness of breath, (SOB) and she walked with a cane. On exam, her lungs were clear and x-rays were …show more content…
Review of the file shows here is insufficient evidence to assess her condition. The claimant’s only treatment was provided by a nurse practitioner who is a non acceptable medical source (AMS). DI 22505.003.3.a indicates non-AMS medical sources include medical personnel who are not AMSs but, are legally permitted to provide health care, such as nurse practitioners. DI 22505.003.3.B.2 indicates we require evidence from an AMS to establish that an individual has an MDI at step 2 of sequential evaluation. In this case, there is no MDI from an AMS. In addition, there is no detailed physical examination in the file and no explanation of the claimant’s rapid decline in ambulation, from cane usage to walker usage four months later. There is no indication that either device was medically prescribed or required for ambulation. On the SSA 3368, the claimant does not list any additional medical sources; therefore, it is unclear who prescribed the medical devices. Evidence in file references spine and knee x-rays. These reports are not in file. There is no evidence to suggest the DDS attempted to obtain these reports. DI 22505.001.B.4 states the DE should make every reasonable effort to help claimants obtain evidence. This includes re-contacting the source to obtain records, which were not originally
Anne is a seventy-four year old female with multiple comorbidities. The patient I interviewed is a sixty five year old male with a past medical history of hypothyroidism and no other reported medical conditions. Additionally, Anne requires assistance with completing her activities of daily living such as shopping, transportation and managing her finances. Also she rarely leaves her home, and is inactive due to chronic pain. The patient I interviewed is able to care for himself independently and is rather active. The patient I interviewed continues to work outside his home and routinely
This data is not from the defendant in question, but rather from other parties who will help give the court an insight into him or her. They include reports from psychiatrists and other doctors, and the defending attorney.... ... middle of paper ... ...
Also, nurses and single parents with a life changing medical condition need to read this memo because it shows how various stressors impact health outcome and leads to poor health. According to Denollet, J., et al. (2010), suggest stress leads to high blood pressure, high cholesterol, obesity, cancer and heart diseases. The stress of not being able to get child care services for her two children has significant contributed to her illness. Many parents are faced with this issue across the United States, but in Katy’s case, she has inflicted with a life changing event a terminal illness that prevents her from working and paying for child care services. Katy received a letter from her employer stating that they will no longer reimburse for child care services because of her not working. Denial of child care has contributed to the exacerbation of Katy’s symptoms and poor health outcome. Therefore, I am requesting a meeting held during this week with Katy and the Department of Social Services (DSS). The discussion will be focused on denial of child care payments and agreement for a Fair Hearing to discuss Katy’s inability to work and her limitations. According to the Legal Aid Society (2016), a fair hearing
“Ask the client to list the changes, losses, or limitations that have resulted from the medical condition” (Jongsma, A. E., Jr., Peterson, L. M., & Bruce, T. J., 2014, p. 260). For instance, I will identify the limitations that Mary has because of her ovarian cancer.
Our system isn’t require to provided five star services to its incarcerated members of society, our justice system is only require to provide enough care to not inflict any addition harm. The Plaintiff may or may not have been aware of his medical condition prior to entering pretrial confinement, therefore, it was not noted on the intake
216/2016, CM met with the client and completed Bi-Weekly ILP Review. Client was dressed appropriately for the weather. She was welled groomed. She continues to walk with a cane stating that her foot is broken and her back hurt. In the meeting client affect was flat. She appears confused and space out.
When she was admitted into our insured’s home on January 20, 2015, she was four feet nine inches tall and weighed 137 pounds, and had a prior diagnosis of Alzheimer’s related dementia. Prior to moving into the insured’s CILA at 3 Lynnwood AVENUE, Fairview Heights, Illinois, she lived with the plaintiff, who is her sister and guardian. Her father, formerly a minister, took care of her previously until he needed to move into assisted living
I am writing to inform you I intend to pursue legal action in the form of a medical malpractice/elder abuse lawsuit. The filing will be on behalf of my 73-year old wife and myself. The facts will clearly demonstrate you were guilty of gross medical negligence and elder abuse in your management of my wife’s health care. I have been advised to afford you the opportunity to settle this claim without protracted litigation.
Rehabilitation has been described as a secondary goal of incarceration. The concept of rehabilitation was not adapted until the 1870s as delegates in Cincinnati encouraged the reformation of prisoners. Rehabilitation remained a primary goal of incarceration for nearly one hundred years, until the 1970s. It was then that Americans began to reject the notion of rehabilitation. With a shift away from rehabilitation, Americans adopted punishment, deterrence, and incapacitation as the primary goals of imprisonment. It can be argued that there was a shift away from rehabilitation due to high recidivism rates; however, it becomes questionable whether or not offenders were continuing to commit crime because they were not given adequate support and
At admission, Mollie’s main complaint was right hip pain. She was not oriented to person, place or time, responding with “I don’t know” to questions asked. While the emergency department nurse completed a physical assessment, Molly’s hospital record was retrieved. Molly was discharged from the hospital two weeks ago, having been admitted for dehydration. Her health history was significant for hypertension and diabetes. Her primary care provider and home health care information were included in Mollie’s hospital record, as was her daughter’s contact information. The emergency department performed an x ray to evaluate Mollie’s right hip pain and there was no evidence of a fracture. Per MD order, labs and samples were collected and processed: CBC-diff, CRP, hyperal, blood culture, prealbumin level and urinalysis. Molly was evaluated for sexual assault and the appropriate samples were gathered. The forensic nurse gently scraped material from underneath Mollie’s fingernails. Bruises were measured and age of each bruise was estimated by
“The earth is the mother of all people, and all people should have equal rights upon it” -Chris Joseph
First explain the differences between low incidence disabilities (LID) and High Incidence Disabilities (HID). Then discuss three specific transition services for either LID or HID in 2015 and why they are viable for this population. Then, explain 2 specific local/state and/or federal regulations that are in place to support this population of students with disabilities? Be Specific!
In countries with life expectancies over 70 years of age, people spend on average about eight years, or 11.5 percent of their life span, living with disabilities. The passage "A Giant Step” by Henry Louis Gates Jr is a memoir about how he came to injure his foot, and all the complications that went along with the permanent injury. Similarly “The Absolutely True Diary of a Part-Time Indian” is a story about a teen named Junior who has hydrocephalic, we learn the many complications that come along with this disability. There are similarities and differences in how both people live their lives. Both people with their disabilities find it within themselves not to give up and still overcome challenges. On the other hand both mothers aren't the same, their motives for their children are completely different. Junior was also able to live a little more normal life, have freedom meanwhile Gates was held back a little more from
Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 6/18/96. for " atypical chest pain and hemoptysis". V/S BP 114/51, P 84, R 24, T 97.4. He seems alert and oriented x 3 and cheerful. Bowel sounds present x 4. Pt. has a red area on his coccyx. Silvadene treatments have been started. Pt. Has a fungal lung infection with a pleural suction drainage tube inserted in his chest . Pt is extremely thin with poor skin turgor with a diagnosis of cachexia ( wasting) secondary to malnutrition and infection. Patient is no known allergies to drugs but is allergic to aerosol sprays disinfectants and dust.. Advanced directives on chart. Code status DNR. Primary physician Dr. R, Thoracic surgeon Dr. L. Psychology Dr.W. There is PT, OT Dietary and Infectious Disease consults when necessary. He lives with his wife who he has been married to for 56 years. His son and his daughter come to visit him. He does not smoke. He wears dentures but did not bring them. He dose not use a hearing aid but he does have a hearing deficit.
High Incidence disabilities are mild disabilities that affect most of the special education students in schools today. “Approximately 36 percent of all students with disabilities served under IDEA have specific learning disabilities.” (Turnbull, Turnbull, Wehmeyer & Shogren, 2016 p. 104)The three areas that fall under the title of a high incidence disabilities are learning disabilities, mild intellectual disabilities, and emotional/ behavioral disorders. Students with high incidence disabilities are taught and spend most of their time in the general education classroom. They are supported in the classroom with accommodations, modifications, paraprofessionals and related services to help them succeed. They may spend a portion of their day receiving support from a special education teacher, or another related service providers such as a speech pathologist, physical therapist, occupational therapist, or social worker outside of the classroom. It becomes apparent when students start school which ones have a high incidence disability. This is because when they start school educators begin to notice they are different from their peers sometimes socially, behaviorally, or they begin to struggle academically. They all share some similar traits such as a short attention span and lower academic skills in certain areas or subjects. They may also have difficulties with their behavior or social development. At that point they may be referred to for testing or an evaluation to see what might be going on with the student.