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Crohn Case Summary

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Primary diagnosis: Other disorders of gastrointestinal system.

Secondary diagnosis: Disorders of back (discogenic and degenerative).
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The claimant was a 40-years and 11 months old woman.
Alleged disability: Crohn’s disease, torn cartilage in a knee, severe anxiety, and severe abdominal pain.
The claimant indicated that she experienced abdominal cramping and numerous bowel movements (more than 10) every day; she did not eat the day before she had an appointment to avoid going to the bathroom. She was tired, needed naps, and stayed in the house most of the time because of having to use the bathroom so frequently.
She reported difficulty caring for her hair because had trouble holding her hands over the head. …show more content…
Because of Crohn’s, she had numerous bowel movements every day that also affected her skin. The claimant also had a history of lower back pain and headaches that required injections in the lumbar spine and narcotics for pain control. Additionally, the claimant was obese (242 pounds and 66 inches tall) and had mobility difficulties. She had a history of mental issues including depression and panic attacks, received outpatient psychotherapy and took psychotropic medications, “which have apparently proven to be of minimal avail in the long-term.” The claimant was compliant with her medical and mental health treatment; unfortunately, she experienced side effects from the medications that interfered with her ability to …show more content…
She also had moderate to marked impairment in her ability to relate socially and marked impairment in her ability to adapt to change; she appeared able to follow instructions as well as able to manage her finances. The diagnoses listed included unspecified anxiety disorder.

This writer did not agree with the SSA determination to cease benefits; it did not seem that there was improvement in the claimant’s condition. She had lost 90 pounds, complained of abdominal pain, had numerous bowel movements per day, and was evaluated in the ER multiple times for problems related to Crohn’s disease.
It seemed that there was no improvement in her mental issues either. She still complained of depression and anxiety, isolated herself from others, and took psychotropic medications. The observations and statements from the psychologist who performed the 06/01/2017 CE also indicated that the claimant’s mental issues had not improved or resolved. At that CE, she presented with an exaggerated sense of self-importance, was highly attention seeking; she had rapidly shifting emotions, and appeared excessively impressionistic and theatrical. Her responses were overly detailed and difficult to follow and her thought process included a flight of

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