Eating Disorders Case Study

The claimant testified that he can mow the yard but his neighbor has to do any weed eating. He can drive but only short distances. Walking is also difficult and he can only do it for short distances. He uses a cane. He can sit in a soft chair for a little bit. He can lift/carry 20-30 pounds. He gets mental health treatment through the VA every six months. His current VA rating is 90%. At this point in the hearing, the claimant handed to the ALJ a copy of the VA rating who requested it be uploaded after the hearing. The claimant continued to testify that he last worked as a waiter but when a bunch of glasses and pans fell down; he had a flashback and told the customers to get down. One customer was injured. After the incident, it was a “mutual understanding it was best not to work there any longer”. He also has headaches that started after he was in Iraq. Bright sun brings them on and he will need to lay down in total darkness for an hour or two. He has them at least two times a week. He has seen a neurologist for his migraines. He has had multiple knee surgeries. His knee is not stable and gives out when he walks. He has trouble sleeping. On a good night if he has slept well, he wakes up around five a.m., takes a shower and has a cup of coffee. He takes the kids to school and may watch a little news. If

it is a good day, he will mow the yard and do what he can inside the house. The Gabapentin makes him sleepy. He takes one nap around 12:30 and if it is short he will take another one around 4:30 or 5 p.m. He further stated that because of his PTSD he does not like to be around many people. On the July 4th holiday, he stays in his room. He has difficulty remembering things. His wife posts on a board what needs to be done.
The claimant completed an Adult Function Report and Pain Questionnaire on October 18, 2016 that was consistent with his testimony (Ex. 5E and 7E).
The claimant underwent two consultative examinations in 2006 performed by Michael W. Parker, Ph.D. and Dr. Jeff Carfagno. Dr. Carfagno opined that the claimant was severely limited in his ability to stand, walk, or carry heavy objects. In addition, he stated the claimant’s anger and agoraphobia might moderately limit his work place options. Dr. Parker opined the claimant would have some limitations relating to his knee injury such as lifting, bending, etc. Dr. Parker diagnosed the claimant with PTSD and knee problems. He also opined that the claimant’s limited social interactions might limit his employment options (Ex. 1F, 2F).
The claimant was evaluated by the Veterans Administration and was awarded 90% disability. He was diagnosed with Post Traumatic Stress Disorder (PTSD), Knee Prosthesis, and Traumatic Brain Disease.
The claimant had a MRI of the left knee performed on April 25, 2013 that indicated moderate cartilage degeneration in the patellofemoral compartment with focal grade four cartilage degeneration along the inferior most aspect of median patellar eminence suggested.

There was also grade two to three cartilage degeneration in the upper one third of the patella more marked along the lateral patellar facet and mid aspect of the trochlea seen. The MRI also showed degenerative signal in the anterior root of the lateral meniscus and minimal grade 2 cartilage changes along the posterior non-weight bearing surface of the medial femoral condyle. (Ex.

4F).
On May 21, 2014, the claimant reported to Dr. James Ralph McCoy that he did not want any more knee steroid injections because they did not help. He stated that when sitting the pain is a four on a pain scale of 0 to 10. When he is moving around the pain increases to the point he wants the leg cut off. He cannot play with his child or do any of the activities he likes to do. He was taking Methadone for pain but it does not alleviate it entirely. (Ex. 4F).
The claimant was treated at the VA Medical Center on October 22, 2014 for disorder of patella femoral joint. The claimant was injured in the military and had three knee surgeries including a distal patellar realignment in 2005. A Maquet type procedure in 2007 and a third patellar decompression in 2009 (Ex. 3F).
Due to cognitive issues, on November 7, 2014 the claimant was provided services of a caregiver when traveling to Houston, Texas for knee surgery. He had a left patellofemoral joint (PFJ) arthroplasty on February 6, 2015 (Ex. 3F).
An x-ray of the left knee was performed on February 18, 2015 and indicated a small amount of joint fluid in the supra patellar and infra patellar region. There was also moderate subcutaneous edematous changes in the anterior soft tissues of the knee (Ex. 4F).
The claimant underwent a Mental Health Diagnostic Assessment on March 11, 2015. The claimant reported that he has problems sleeping and is depressed. He has bad dreams and then wakes up and attacks his wife. He was deployed to combat zones in Falujah and Ramadi and was in seven IED attacks. When discharged due to medical reasons he was jumpy and did not like loud noises. At his welcome home party, a neighbor shot off a bottle rock and he attempted to kill him. His wife has to help him with his medications, shopping, and household chores. He has problems with memory and concentration. He had a traumatic brain injury (TBI) evaluation was was diagnosed with minimal TBI. The claimant was diagnosed with chronic pain, patella damage, depression, anxiety, degenerative joint disorder, degenerative disc disorder, and PSD. The claimant was prescribed Cyclobenzaprine HCL, Metoprolol Tartrate, Oxycodone, and Paroxetine. He was also referred for group therapy (Ex. 4F).
On March 9, 2016 the claimant reported to Dr. Richard McKelvey that his left knee “gave out” the previous week. When he fell, he suffered low back sprain. He has to be helped getting out of bed. He was observed ambulating with a cane and moving slowly (Ex. 4F).
On May 12, 2016, the claimant was diagnosed with depression and prescribed Paroxetine HCL (Ex. 4F).
On May 24, 2016, the claimant underwent a lumbar spine x-ray, which indicated slight anterior spurring (Ex. 3F).
On June 3, 2016, Dr. Robert E. Harrell, Jr. diagnosed the claimant with degernative joint disorder due to injury to his lower back during military service (Ex. 4F).
The claimant began physical therapy for pain in the left knee on May 11, 2016 and continued for eight weeks (Ex. 4F).
On July 5, 2016, the claimant reported to Dr. Kurt M. Johnson that after the PFJ arthroplasty he was pain free for months. Then three months ago, he had anteromedial knee pain with popping and swelling with movement. He stated he had been participating in physical therapy regularly, but it was discontinued a few months before the pain began. The claimant was advised to restart physical therapy (Ex. 3F).
On August 1, 2016 the claimant was prescribed and instructed in the use to a TENS unit to assist for pain control (Ex. 4F).
An x-ray of the left knee was conducted on October 4, 2016 and indicated an interval patellofemoral arthroplasty with soft tissue swelling and effusion in the anterior knee (Ex. 4F).

The claimant underwent a MRI on January 24, 2017 that indicated mild degernative changes at L3-L4 (Ex. 7F).
The claimant had a left knee diagnostic arthroscopy on February 24, 2017 that indicated patellar tracking symmetric but at about 100 degrees the patellar component started to contact an area inferior to the trochlear implant. There was also a cyclops lesion involving the lateral femoral condyle and trochlear groove and significant scar tissue in the subrapatellar pouch. He was also given a brace to wear at night for knee extension (Ex. 5F, 6F).
On March 15, 2017, Dr. Richard Erin McKelvey saw the claimant for medication management. The claimant continued to be prescribed Atorvastatin Calcium, Diphenydramine, Hydrocodone, Metformin, Methocarbamol, and Paroxetine (Ex. 6F).
On May 26, 2017, the claimant applied for temporary 100% disability for recovery of his service connected injury. He previously had several surgeries of the left knee and recent debridement synovectomy on February 24, 2017. He has saphenous neuropathic pain and loss of motion. He also had lower left extremity muscle atrophy and mild weakness. He was granted 100% VA disability on October 7, 2017 (Ex. 9F).
The claimant had physical therapy for his left knee pain and group therapy for PTSD from June 29, 2017 through July 27, 2017 (Ex. 8F).
On October 12, 2017, Dr. Richard McKelvey saw the claimant. He reported to Dr. McKelvey that he was still having pain from his left knee and had peripheral neuropathy. He was prescribed Gabapentin (Ex. 10F).