The claimant has a past medical history significant for a fibromyalgia, cardiomyopathy, migraines, osteoarthritis, endometriosis, recurrent MRSA, and severe exhaustion.
A progress note from Henry Echiverri, MD, dated 06/07/2017, indicated that the claimant presented with a possible diagnosis of multiple sclerosis. She stated that bumping into walls had been on for years, but had worsened the past few months. She felt that her vision was off and the pupils just dilate without a cause. She reported frequent headaches and was diagnosed with migraines in 2010. She also had neck pains and recurrent swelling lymph nodes for few days. Objective findings showed exotropia on the right eye. It was noted that her findings are consistent with diffused fibromyalgia syndrome. MRI of the brain was recommended.
A progress note from Dr. John Gleason (Family Medicine), dated 06/11/2017, indicated that the claimant had been unable to work as she had been very fatigued and had a lot of pain and issues. She reported having a weakness, a burning sensation in at her back, and a poor balance with dilated eyes all the time. She also had a burning sensation in her legs and stated that she was unable to achieve orgasm for many years. Her BMI …show more content…
She had not repeated the 2D echocardiogram as recommended previously. She reported getting fatigued easily and feel dyspneic with low amounts of exertional efforts. The physical examination was unremarkable. It was noted that the claimant had no signs of heart failure at this time of visit. She has had palpitations in the past and event monitors had shown sinus tachycardia which was likely related to her anxiety, chronic pain syndrome, and fibromyalgia. She was diagnosed with systolic heart failure, dilated cardiomyopathy, and fatigue/malaise. A series of laboratory tests and a 2D echocardiogram were
A progress note from Henry Echiverri, MD, dated 06/07/2017, indicated that the claimant presented with a possible diagnosis of multiple sclerosis. She stated that bumping into walls had been on for years, but had worsened the past few months. She felt that her vision was off and the pupils just dilate without a cause. She reported frequent headaches and was diagnosed with migraines in 2010. She also had neck pains and recurrent swelling lymph nodes for few days. Objective findings showed exotropia on the right eye. It was noted that her findings are consistent with diffused fibromyalgia syndrome. MRI of the brain was recommended.
A progress note from Dr. John Gleason (Family Medicine), dated 06/11/2017, indicated that the claimant had been unable to work as she had been very fatigued and had a lot of pain and issues. She reported having a weakness, a burning sensation in at her back, and a poor balance with dilated eyes all the time. She also had a burning sensation in her legs and stated that she was unable to achieve orgasm for many years. Her BMI …show more content…
She had not repeated the 2D echocardiogram as recommended previously. She reported getting fatigued easily and feel dyspneic with low amounts of exertional efforts. The physical examination was unremarkable. It was noted that the claimant had no signs of heart failure at this time of visit. She has had palpitations in the past and event monitors had shown sinus tachycardia which was likely related to her anxiety, chronic pain syndrome, and fibromyalgia. She was diagnosed with systolic heart failure, dilated cardiomyopathy, and fatigue/malaise. A series of laboratory tests and a 2D echocardiogram were