Zinnia’s Super Great Chronic Fatigue Syndrome Disability Letter

Robin Mead

Here’s the amazingly great letter Zinnia used to get approved for Social Security Disability for Chronic Fatigue Syndrome.

This letter did not just happen by magic, she took some extra special steps to make it happen. Here’s how Zinnia got this super great letter.

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12/10/16

I am writing in support of the Social Security Disability application for Zinnia M. Ms. M has been my patient under my medical care for the past four years. Ms. M has been diagnosed with Fibromyalgia, Chronic Fatigue Syndrome and Depression.

Her clinical findings and symptoms include: Persistent Fatigue and Weakness, Muscular pain and Joint pain, Memory and concentration problems, Headaches, Tender Points, Positive test for Epstein-Barr virus, Fibromyalgia Symptoms, and Chronic widespread pain. Ms. M’s symptoms impair her ability to perform daily tasks. Her impairments affect her mobility and dexterity, persistence and pace, and memory and concentration.

Ms. M’s conditions meets the criteria listed in the Social Security Ruling: SSR 14-1p: Evaluating Cases Involving Chronic Fatigue Syndrome

Evaluation of Chronic Fatigue Syndrome

Ms. M’s medical records document that her medical condition meets the case definition listed in SSR 14-1p.  Her condition includes the presence of clinically evaluated, persistent or relapsing chronic fatigue that: Is of new or definite onset; Cannot be explained by another physical or mental disorder; Is not the result of ongoing exertion; Is not substantially alleviated by rest; and Results in substantial reduction in previous levels of occupational, educational, social, or personal activities.

In February 2013, Ms. M experienced a sudden severe illness, including affected sight and balance, high fever, shaking, chills, sore throat, and fatigue. She was treated at the Somewhereville emergency room After this episode, she began experiencing persistent symptoms of severe cognitive dysfunction, unrelenting fatigue, and full body pain. She could no longer perform many daily activities and she was unable to maintain her previous employment.

Ms. M’s was diagnosed with Chronic Fatigue Syndrome. Her medical records show that other diseases that could cause the same symptoms were ruled out. (Laboratory tests for Lupus, Hypothyroidism, and Rheumatoid Arthritis 06/2015)

Diagnostic Symptoms from SSR 14-1p

Diagnostic Symptoms that have persisted or recurred during 6 or more consecutive months present include:

• Memory and concentration problems – Memory and concentration problems that cause a serious reduction activities are documented repeatedly throughout Ms. M’s medical records from 2013-2016. Her medical records from Dr. L and Dr. J include findings of “memory problems” “difficulty with comprehension” and “Slow reaction time” As well as clinical observations of difficulty with attention span, comprehension and calculation.
• Tender cervical or auxillary lymph nodes – Swollen glands are documented in Ms. M’s medical records and health status report from Dr. J.
• Muscle pain and Multi-joint pain without joint swelling or redness – Muscular pain and Joint pain– Pain in multiple joints and ongoing muscular pain was exhibited during repeated examinations is documented repeatedly in medical records from Dr. J, including “overwhelming continuous pain” and back pain, muscle pain, spasms, jaw pain, and neck pain.
• Headaches – Headaches of a different quality than before the onset of the fatigue are documented repeatedly in the past 3 years of medical records from Dr. J.

Co-Occuring Conditions from SSR 14-1p

Ms. M has been diagnosed with the co-occuring condition of Fibromyalgia.

Medical Signs from SSR 14-1p

The following medical signs were clinically documented over a period of more than 6 consecutive months:

• Palpably swollen or tender lymph nodes on physical examination; Medical records and health status report from Dr. J include clinical observations of “swollen glands”
• Persistent, reproducible muscle tenderness on repeated examinations, including the presence of positive tender points – The presence of positive tender points are documented in Dr. R’s treatment records “14/18 trigger points ” Ongoing muscular pain and tenderness was exhibited during repeated examinations.

Laboratory Findings from SSR 14-1p

Laboratory findings for Ms. M’s condition include:

• Elevated Antibody to Epstein Barr virus (Such and Such labs, 1/1/2015)
• Abnormal MRI – Emergency Room Report from Somewhereville Hospital shows MRI “hypertensive T2 the T3” (3/1/2015)

Mental Limitations from SSR 14-1p

• Memory and concentration problems that cause a serious reduction activities are documented repeatedly throughout Ms. M’s medical records. Her medical records from Dr. L and Dr. J in 2013-2016 include clinical observations of: cognitive dysfunction, trouble with word retrieval, short-term memory problems, confusion, and difficulty with focus and concentration.

Functional Impairments

Ms. M’s symptoms impair her ability to perform daily tasks and make her unable to maintain gainful activity.

Persistence and Pace – Ms. M’s symptoms of persistent fatigue and weakness limit her ability to perform daily tasks. Her medical records document fatigue and limited endurance and unrelenting fatigue. Her medical condition requires her to lie down throughout the day.

Mobility and Dexterity – Fibromyalgia, pain and chronic inflammation impair her ability to perform tasks. Her pain is aggravated by any physical activity. She experiences neurological dysfunction. Her medical records include clinical observations of trouble balancing, unsteady walk, and poor coordination.

Unpredictability – Ms. M’s symptoms of fatigue, pain, weakness and cognitive dysfunction are variable and unpredictable, making her unable to meet deadlines or consistently participate in activities. She can sit for about 30 minutes, recline about one hour at a time. She can only stand comfortably for 5-15 minutes, and if she walks leisurely up to 15 minutes, then she must retire to the bed afterward.

Memory and Concentration – Ms. M experiences significant cognitive dysfunction. Her ability to process and retain information has been severely affected. In addition, chronic pain and fibromyalgia cause her problems with focus and attention. Clinical observations of concentration and memory problems are reported on multiple occasions throughout her medical records.

In summary, Ms. M continues to experience a severe medical condition that affects her activities of daily living. In my medical opinion, she is unable to perform work-related activities on a sustained basis.

Sincerely,

Dr. J, MD

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