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DDS Case Study Sample

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The DDS proposes a fully favorable allowance for this claimant with an EOD 04/01/2016. The evidence in file supports a later onset date.
CASE DISCUSSION & POLICY ANALYSIS (INCLUDING SPECIFIC REFERENCES)
This 58-year-old claimant is filing a concurrent claim alleging disability due to chronic obstructive pulmonary disease, high blood pressure, and an enlarged heart as of 04/01/2016.
The evidence in file shows the claimant was seen 8/1/2016. He reported feeling fine and his lungs were clear. He was seen again on 1/24/17 complaining of congestion. On exam, he was positive for wheezing. He was seen in the emergency room 2/7/18 due to chest pain and shortness of breath. On 3/1/17 He complained again of shortness of breath. The physical exam showed bilateral edema in the lower extremities. The chest CT taken on 4/3/17 showed a stable compression deformity on T6 with a lytic lesion at T5, which was similar to prior exam. Hazy infiltrates in the right lung and minimally mid and upper lung was noted. On 4/4/17, he had shortness of breath walking from the waiting room to the exam room and the bilateral pitting edema in the lower extremities. …show more content…
Additionally, he should avoid crawling and climbing ladders, ropes and scaffolds as the increased weight on the upper extremities will increase the work of breathing. The earliest possible medical onset date is 1/1/2017. This date is inferred in accordance with DI 25501.450.A.1. This policy states we may infer the onset date of a disabling impairment to a date before the first recorded medical examination or the earliest available medical records. In this case, the claimant presented to his physician on 1/24/17 and complained of breathing problems for the past three

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