Zinnia’s Super Great Chronic Fatigue Syndrome Disability Letter

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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.


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


 

6 thoughts on “Zinnia’s Super Great Chronic Fatigue Syndrome Disability Letter”

  1. Read through some, definitely a save for me. Extremely helpful.

    Thank you so much for making this!!! also I haven’t applied for disability yet, but want to.

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  2. After reading their doc for 20 pages, so far….it seems there is a way to spin things and I had awful outcome because ALJ notes a comment from an ER dr. that wasn’t even true and merely opinion…then another Dr that stated normal gait (yet no mention of the reason I was there but those drs were first drs. So ALJ found “inconsistencies” about bus riding however between the form and an RFC I had been robbed and witnessed a bloody assault so I was just being honest with my dr. cuz taking into account walking, waiting etc. and I have ptsd but the bus issue was something I didn’t consider as I had wrecked car so I had to use bus and casually said so without saying I got ride to bus stop and after walking 10 mins I was in misery and I took a nasty fall on platform cuz my slow pace… Then I used the word “ok” to describe the stupid question asked by my PC “how’s your bi Polar?” I have psych dr n being asked that question to me is literally the stupidest question but it made it in my denial. I really don’t see how ALJ could pick n choose. Inconsistencies is part of being ill and unreliable to work but it won’t work for ssdi. I should have read records!!!!!

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  3. After reading the blue books opinion on how they consider these medical statements and their opinion that they meet “impairment” as per ssdi, do realize that ssdi still holds the ultimate say on whether their impairment is met. Under the section of Revisions, https://www.ssa.gov/disability/professionals/bluebook/documents/Medical%20Evidence%20NPRM%20published.9.9.16.pdf
    Somewhere it states a medical opinion must be persuasive etc., but a Dr. cannot determine if ssdi listings are “met” or call someone disabled. Just a heads up so check out section about Rulings under the Revision section. It’s 40 pgs.

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    1. Thank you this is an excellent point. Yes only a Social Security administration adjudicator can make this decision.

      If a doctor has clearly and specifically documented the way a person’s condition matches a listing or ruling this can be a great help to the adjudicator and may have a big impact, but it is not guaranteed.

      Like

  4. Thanks for great posts. This one very helpful. I have symptoms exactly like this and found out through labs I had fifteen toxic metals at red zone levels which fortunately I’ve found a dr that’s working to resolve.
    Just wanted to share as I’m finding a cure for myself for these symptoms. Yeay!

    Like

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