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Update On Ce Exam

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ltate90

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this was written by a orthopedic ssa dr requested by an alj : he is able to get off the exam table with difficulty by himself. there is decreased range of motion of the cervical spine. he can fully flex his cervical spine to 50 degrees, 0 degrees of extension, 30 degrees of lateral flexion and 50 degrees of rotation, more to the left than the right. there is moderate tenderness to palpation of the cervical spine and the trapezius muscles bilaterally. there is full range of motion of all joints in all four extremities except for his shoulders that he can only raise to 90 degrees due to the pain from his neck. grip strength is decreased and equal bilaterally (3/5) due to pain in his hands from his neck. there are decreased fine motor and gross motor skills in both hands, again due to pain from his neck. he has a tremor in both hands, worse on the right than the left. the patient can flex at the waist to 20 degrees, extend 3 degrees and laterally flex 5 degrees. there is moderate tenderness to palpation of the lumbar spine. straight leg raises are positive bilaterally, at 5 degrees on the right and 10 degrees on the left. the patient is able to walk across the room with a rolling walker with a very antalgic gait. the patient cannot walk on his toes and heels. he cannot do tandem walking. he cannot squat down.

limitations of adl's and work activities: he has severe pain in his neck and lumbar spine with radiation into his extremities. he walks with a rolling walker.

diagnosis: herniated lumbar disc, probable herniated cervical disc, morbid obesity, ptsd, hypertension, gerd

can anyone give me there input on this report written by the ssa dr that was given to the alj.

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i called social security today and they told me a decision was made on my case but the judge hasn't signed off on it yet. she said it will be a week or so before a get something in the mail about a decision. has anyone been through this before after going through a hearing before a alj.
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