Chronic Pain Management Case Studies
Secondary diagnosis: Chronic pain. Code 2480- but that code is “Diagnosis established – no predetermined list code of medical nature applicable. Did not find code for pain or chronic pain.
The claimant was a 59-year-old woman.
Alleged disability: She could not sit for more than 20-35 minutes at a time, had muscle and bone aches, lack of energy, no sexual activity, and depression.
Her physical discomfort did not allow her to “stand or sit for very long.” She had chronic pain, problems sleeping, cooking, and doing house chores. She reported mobility difficulties, as well as problems with concentration and memory. She felt overwhelmed and needed encouragement …show more content…
She had difficulty handling stress, became disoriented very quickly, and her depression worsened. She was “like night and day in regards of what she used to be able to do and what she is able to do now.” She received treatment for fatigue, lack of strength and energy, pain management, and depression. She took a psychotropic medication for depression and anxiety.
Education: 8th grade in a foreign country.
Work experience: Per “Request for Reinstatement – Title II” (06/23/2015), the claimant reported that she had multiple jobs in the past; some of them lasted a short period. Her jobs included working in a kitchen and home care. Two days a week, she cared for an elderly woman; the rest of the week, she did some house chores and tried to cook.
It seemed that the Comparison Point Decision (CPD) date was 05/26/2015, cessation of benefits related to substantial gainful activity (SGA). The diagnoses listed were “Other disorders of the urinary tract,” and “Affective/mood disorders.” The previous CPD date was 03/11/2002; the diagnoses were chronic pain and …show more content…
The claimant indicated that she used to work as a sewing factory worker. She reported body aches, bilateral knee and hip pain, loss of energy, muscle pain, depression, and “four surgeries for female issues.” She indicated that she was able to stand for five minutes and walk for five minutes. She took over the counter medication for pain control. She received mental health treatment some years before this examination and took a psychotropic medication for a short period, but stopped it because it worsened her depression. The physical examination was grossly normal, except for some limitation in the hips range of motion and back pain with a couple of the maneuvers performed during the examination. Her mental status was difficult to assess because she answered through an