On December 11, 2014, the claimant was counseled by Dr. Lester Alexander about the health risks associated with an increased BMI. The claimant was evaluated and had a BMI of 34.8 kg. The claimant was referred for a dietary consult (Ex. 22F).
On February 5, 2015, the claimant underwent a stress myocardial perfusion imaging that indicated the left ventricular function was normal. The recommendation was to treat the chest palpitation, …show more content…
Ghulam M. Khaleel examined the claimant on April 24, 2015 for left shoulder and forearm pain and lower back pain and had a nerve conduction study performed. The study was normal and there was no evidence of peripheral neuropathy or cervical or lumbosacral radiculopathy. A MRI of the lumbar spine indicated mild degenerative disc changes with predominantly anterolateral disc bulging. Also indicated was left mild foraminal narrowing due to disc bulging and facet arthropathy at L4-L5. A MRI of the cervical spine indicated degenerative disc changes at C5-C6 with chronic anterior disc osteophyte complex (Ex. …show more content…
Ghulam M. Khaleel continued treatment of the claimant on January 8, 2016. She reported to Dr. Khaleel that she was found to have obstructive sleep apnea on October 23, 2015. In addition, even though she had surgery to repair a rotator cuff tear in her left shoulder joint she had not regained the full use of her left hand and continued to drop things. She was also not able to climb stairs due to uncertainty of her balance, as her left leg would give in without warning. She was referred for evaluation by a rheumatologist and given a prescription of Oxycodone. On February 25, 2016, she was diagnosed with spondylosis of the cervical region without myelopathy or radiculopathy, primary osteoarthritis of both hips, and inflammatory neuropathy. She was prescribed Percocet and Soma and a MRI of the cervical spine was ordered (Ex.