The Dazzling Disability Doctor Letter of Miss Ruby Fierce

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Writing by Miss Ruby Fierce AF

Art by Robin Mead

At the beginning of my hearing, the Judge said that he does not make a decision during the hearing. He told me that I could expect a decision in writing in several weeks.

At the end of the hearing, he said he’d never before made a decision during a hearing, but today he was making a bench decision that I am fully disabled.

Below is a copy of the letter from my doctor. My doctor is a general practitioner / primary care. Both my attorney and the judge commented that this letter was very helpful for my case. My lawyer also drew heavily on this letter when writing his pre-hearing brief.

Before my doctor completed this letter, I wrote down my medical background to give to him. It took me more than two months to put together, because I have so much complexity in my medical history, and I was so sick then. When I gave it to my doctor, he thanked me and acknowledged that he would not have had time and would not have written a letter for me if I had not done this first. If it had not been for the examples shared by other readers here, I could not have done it.

My disability case focused on Peripheral Neuropathy, Autonomic Dysfunction, and POTS, as well as mental health symptoms. Some of the other diagnosis listed in the letter below are not that significant or disabling (For example: Kidney disease sounds like a big deal, but it’s not. It’s been stable for almost 20 years and requires no treatment.)

My hearing went well. The judge was kind. The vocational expert said that his opinion was: There is not a job I can do. I would get fired.

It was hard to hear. I miss my job very much.

Thank you to everyone on this site, which helped me so much. I wanted to share my doctor’s letter with all of you.  ❤️🌷


Ruby’s Doctor’s Letter

August  24, 2018

RE: Ruby Fierce AF

SSN: 000-00-0000

DOB: 0/00/1972

To Whom It May Concern:

I am writing in support of the application for disability benefits submitted by my patient, Ruby Fierce AF. Ms Fierce AF has been a patient of North Carolina State University Health Group since September, 2006, and has been seen regularly by me, as her family medical physician, since October, 2016. I have met with the patient in clinic approximately once per month since that time, and most recently on August 23, 2018.

Ms. Fierce AF has been diagnosed with the following pertinent medical conditions:

  • Postural Orthostatic Tachycardia Syndrome (POTS) and Autonomic Dysfunction
  • Autonomic Neuropathy (a type of Peripheral Neuropathy)
  • ADHD– Combined Type
  • Anxiety
  • Asthma
  • Circadian Rhythm Sleep Disorder– Delayed Sleep Phase Type
  • Psychophysiological Insomnia
  • Mild Sleep Apnea
  • Fibromyalgia
  • Cervical Spine Arthritis
  • Degenerative Arthritis of the Thoracic Spine
  • Chronic Kidney Disease (CKD)– Stage 3
  • Allergic Rhinitis
  • Acquired Hypothyroidism
  • Migraine
  • Endometriosis
  • Pure Hypercholesterolemia

Ms. Fierce AF is currently prescribed the following medications:

  • Gabapentin
  • Duloxetine
  • Escitalopram
  • Singulair
  • Clonazepam
  • Clonidine
  • Synthroid
  • Nortriptyline
  • Symbicort
  • Beclomethasone
  • Microgestin
  • Albuterol inhaler & nebulizer
  • Ambien
  • Trazodone
  • Chlorexidine oral solution
  • Ondansetron

Ms. Fierce AF has been unable to work in any capacity since July, 2015 and only able to work part time in 2013 and 2014 secondary to severe and relentless fatigue, muscle pain and weakness, unmanaged rapid heart rate and tachycardia with and without exertion, shortness of breath, nausea, night sweats and daytime hyperhidrosis, thermoregulatory dysfunction and heat intolerance, anxiety-like symptoms, dizziness and lightheadedness, poor tolerance to stress, blurry vision and sometimes double vision, headaches including migraines, tremulousness in hands and arms, palpitations, daytime sleepiness, inability to concentrate and focus, non-refreshing/restorative sleep, post-exertional fatigue, and medication side-effects.

Full autonomic testing, including tilt table testing (TTT) through North Carolina State University Hospital’s Neurophysiology Lab on November 19, 2016 (Gina Carson, MD) showed abnormal laboratory findings which clearly indicate autonomic dysfunction. Thermoregulatory Sweat Testing (TST) and Sudomotor Axon Reflex Testing (Q-SART) provided evidence of autonomic neuropathy (small fiber) explaining many of the symptoms Ms. Fierce AF exhibits. Many of the symptoms persist chronically, as routine with such disorders, but some may improve when Ms. Fierce AF assumes a reclined or supine position.

On January 31, 2017,  Ms. Fierce AF began treatment with Juan Anderson, MD at NCSU Hospital for Autonomic neuropathy, and Postural Orthostatic Tachycardia Syndrome (POTS). Standard treatment for POTS was initiated at that time, which included sodium loading (3-5 mg per day), increased water intake (minimum of 64 oz per day), knee-high compression stockings (when up and about), a conscientious effort with water exercise and recumbent bike riding for over 5 months, warm water therapy, and medication trials with both midodrine and fludrocortisone. All standard treatments failed to relieve the patient’s symptoms despite Ms. Fierce AF’s strict adherence to the prescribed treatment, and were consequently discontinued.

Prior to the formal diagnoses of autonomic neuropathy and POTS, gabapentin, various benzodiazepines, and diltiazam were initiated by previous clinicians in an effort to lower heart rate and initiate sleep. While gabapentin and clonazepam have provided a small benefit, these medications result in noteworthy sedating side effects. Unsuccessful trials were conducted with four different beta blockers in an effort to treat tachycardia. All were discontinued due to severe side effects. These medications made asthma unmanageable, caused rapid and severe clinical depression, and dramatically increased fatigue.

A trial of Mestinon, a muscle strengthener sometimes used to treat the type of fatigue Ms. Fierce AF endures, was given a fair trial, and discontinued with no improvement noted. Multiple stimulant medications used to treat ADHD in the past were shown only to exacerbate symptoms, and have been discontinued. Additionally, Flexeril was prescribed by a past provider for several months, with no marked improvement in muscle pain.

Ms. Fierce AF also participated in lengthy physical therapy at St. Mary’s Medical Center at the Raleigh location, referred by her former family practice physician, Derek Caldwell, MD of NCSU Health Group- Raleigh’s downtown clinic. Physical therapy was discontinued due to a lack of remarkable improvement.

Ms. Fierce AF’s symptoms have challenged her for many years prior to being under my care, with symptoms increasing dramatically in 2007 when unexplained night sweats began. During that time she was under the care of my colleague, Derek Caldwell, MD. I encourage you to explore records during that time for further evidence of ongoing disability.

Ms. Fierce AF has numerous symptoms that result in her inability to work (provided in table form below) as well as further objective evidence for disability.

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Screen Shot 2020-04-14 at 11.35.39 AM

In summary, Ms. Fierce AF has severe symptomatology with resultant inability to be gainfully employed. She is unable to perform the material and substantial duties of any reasonable occupation, including that which she was formerly engaged. Typical prognosis with this level of autonomic nervous system dysfunction is at best slightly improved with symptom management, but most symptoms continue to return to baseline.

It is my professional opinion that Ms. Fierce AF is disabled and unable to perform any meaningful employment, including sedentary work. Ms. Fierce AF’s medical conditions have kept her unable to work for more than the past twelve months, and conditions are expected to last well beyond the twelve month mark in the future, likely lifelong.

Please do not hesitate to contact me for any additional information.

Sincerely,

Ruby’s Doctor, MD, Clinic Director


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