Medical Vocational Allowance Determination Case Study

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Group I, Category 19 Incorrect RFC Decision
ISSUE
The DDS proposed a medical vocational allowance determination. The evidence in file does not support the severity as assessed by the DDS.
CASE DISCUSSION & POLICY ANALYSIS (INCLUDING SPECIFIC REFERENCES)
This 52-year-old claimant is filing a DIB Claim alleging disability due to stage 4-breast cancer, problems in the lower back, and muscle spasms as of 07/20/2015.
The evidence in file shows the claimant has a history of moderate obesity and invasive ductal adenocarcinoma of the right breast, stage IIIA. A bone scan done on 07/24/15 showed no evidence of bony metastatic disease. By 9/22/15, she was tolerating chemotherapy quite well. On 11/18/15, she underwent a right modified radical mastectomy. The surgery was incomplete as the surgeon was unable to remove all the tissue. A complete physical exam including muscular skeletal findings was within normal limits, except for the surgical changes. There was no specific MDI to support the complaint of muscle spasms and LBP.
ADLs show the claimant does not do chores or cook. She shops in stores riding in a cart when feeling up to it. She is able to walk 3 feet and pay attention for 15 minutes. The claimant has a history of …show more content…
The evidence in file supports a projected RFC of 20/10/6/6 with right overhead reaching limited to occasionally. Forward and lateral reaching is limited to frequently on the right. DI 24510.020 indicates a RFC must be projected 12 months from the date of onset when the case is adjudicated within 12 months of onset. DI 25505.030B indicates when projecting the RFC we must consider the symptoms, signs and laboratory findings, and treatment and response to treatment. In this case, the claimant appears to be responding to the chemotherapy and there is no evidence in file to suggest she will be unable to sustain a “light” RFC as of
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