A Long-Term Disability Claimant's Case

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The main medical issues, in this case, are right arm and leg weakness along with speech and word-finding difficulties. The submitted documentation revealed that the claimant underwent a tomography scan on 03/15/2015 which revealed a basal ganglia bleed and a severe accelerated hypertension. She was admitted under Neurocritical Care Service. She was extubated on 03/24/2015 and was discharged on 03/27/2015. During a chart review, the claimant had difficulty expressing herself due to severe receptive and expressive aphasia. However, it was noted that all oral motor structures and functions appeared to be within normal limits. Other conservative measures such as medications, neurology consultation, Botox injections, cane utilization, and laboratory testing were provided. A Long-Term Disability Claim dated 07/25/2017, stated that the claimant was unable to work at a compensable employment for a minimum of 25 hours per week.…show more content…
The claimant met 6/6 expressive language goals and 7/7 motor speech goals. However, the residual deficits were noted as the claimant still had some palpitations, a slightly slurred speech, a shuffling gait, right-sided weakness (leg > arm), a flexion contracture in the right upper extremity, muscle spasms, and an elevated cholesterol level. A recent diagnostic study with an official result that would further show improvement in her cardiac condition was not submitted for review. Although EKG revealed no acute changes, the actual report was not delineated. Also, the claimant only met 3/8 cognitive and communication
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