Allegations: Post traumatic stress disorder, depression, bladder problem, female

problems.
History of Chief Allegation:
1.) Post traumatic stress disorder: Claimant says, she was raped on September 1,
!"1! by the assailant in her house. Claimant and the assailant went to dinner on
the night of the rape and when they got bac# to her home the Claimant was
physically attac#ed, and body slammed to the floor, as a result claimant went in
and out of consciousness. $he assailant then continued with the assault and raped
the claimant which included penetration in the %aginal canal only. After rape the
assailant left the premises& claimant got herself together too# a shower and went
to bed. 'n September !(, !"1! the claimant reported the rape to her Principal)s,
office of special in%estigation and na%y *ag officer. $he same day claimant was
ordered to go to woman)s clinic at the military base where claimant was gi%en a
complete medical e+am. ,o se+ually transmitted diseases were found but the
assailant was diagnosed with pel%ic inflammatory disease. $he claimant was
ordered to see the psychologist at the military base where she was diagnosed with
Post traumatic stress disorder in 'ctober !"1!. Claimant has been ha%ing
following symptoms of P$S-& night mare about the rape, flashbac#s, .ittery, and
had a hard time sleeping.
!.) -epression: $he claimant went into depression after the rape happened and was
diagnosed with depression the same time as post/traumatic stress disorder in
'ctober !"1!. Claimant has difficulty sleeping, loss of interest in life)s daily
acti%ities, unable to concentrate, and low on energy.
0.) 1ladder problem: After the claimant was raped, the claimant started ha%ing
difficulty urinating, no pain or burning was felt during urination but urine would
only tric#le. $he claimant pursued medical attention and was told the urethra was
not fully patent. $o help claimant with urination the claimant was gi%en self/
catheteri2ation #it and 3elo+icam to control inflammation.
Past 3edical History:
4nflammatory bowel syndrome in early 155". Claimant does not remember what
treatment was prescribed other than reducing gluten and wheat products in the diet.
6ndometriosis in early 155", claimant does not remember the treatment and e%entually
the claimant had hysterectomy. H$,, fibromyalgia, chronic lower bac# pain, carpel
tunnel syndrome, and urinary obstruction.
7amily History: 3other had hypertension, diabetes, Schi2ophrenia with multiple
hospitali2ation and suicide attempt %ia '- on pills. 3other died from a stro#e. 7ather
had hypertension, was in%ol%ed in an accident was paraly2ed nec# down, died from
un#nown health complication. ,o #nown diseases in the siblings. Some female cousins
ha%e died from colorectal cancer
Surgical History: Hysterectomy in late 155")s
Social History: Claimant wor#ed as a teacher with department of defense and taught
elementary and middle school students. Currently li%es alone in an apartment and co%ers
the window to the rooms with cardboard. Claimant is on an unpaid lea%e until .anuary
!"1(. Claimant does not smo#e, drin#, or use any illicit drug. Claimant is not se+ually
acti%e.
3edication: $ra2adone 8"mg, 1aclofen !"mg, Hydrochlorothia2ide !8mg, Pra2osin,
3elo+icam,
Allergies: ,9-A
Records Reviewed:
-isability :eport SSA/00;
Atlanta <A3C/ Chronic lower bac# pain and carpal tunnel syndrome
Impact on Activities of Daily Living:
Claimant is able to urinate with difficulty =urine only tric#les), defecate, brush teeth,
comb hair, dress self, eat, stand, sit, recline, wal# greater than 1"" feet, able to climb
stairs, able to taste, smell, and feel. Claimant is able to tra%el without difficulty. Claimant
is able to handle own money. Claimant does shop for own groceries, clean home, does
laundry and is able to ma#e bed. Claimant is able to prepare his own food. Claimant is
able to lift 0" lbs from the floor. Claimant is able to sort and handle papers and files and
is able to place files in a cabinet at or abo%e waist le%el.
Review of Systems:
>eneral: no fe%er no chills or night sweats.
H66,$: ,o eye pain, no ear pain, no sore throat, no rhinorrhea, no nasal congestion, no
%ision complaints.
Cardio respiratory: no cough, S'1?-'6, no whee2e, denies CP
>astrointestinal: no nausea, no %omiting, no diarrhea, no constipation
>enitourinary: ,o hematuria, urgency, dysuria, polyuria, no flan# pain, @decreased urine
output.
6+tremities: no arthralgia, chronic lower bac# pain
S#in: ,o rashes or sores.
,eurologic: no current numbness?tingling, headache, no focal wea#ness, no present
confusion.
6ndocrine: no weight change, polyuria?polydipsia
Physical Exam:
<itals =without shoes and using medium 1P cuff)
Height: 8 !A 1?P: 10"?5! $emp:5B.(
Ceight lbs. 10!.! :espiration: 1 Pulse:B!
Snelling 6ye 6+am: Cithout Correction Cith Correction
:ight ='.-.) !"?!8 !"?
Deft ='.S.) !"?!" !"?
1oth ='.E.) !"?!" !"?
>eneral: 6motionally distressed, well/nourished appearing AA7, no dyspnea during
e+amination, gets up from chair easily. Claimant occasionally cried during e+amination
and showed some signs of an+iety.
H66,$: normal cephalic, atraumatic, 6'34, P6::D, no papilledema, $3)s pearly
white, no nasal discharge, no oropharyn+ lesions?erythema
,ec#: no carotid bruit, no .<-.
C<: ,ormal Dimit S1 and S!, no systolic e*ection murmur, no S0 or S(, no clic#s or rubs.
Dungs: Clear to auscultation bilaterally. ,o whee2es, no rales, no rhonci
Abdomen: 7lat, Soft, tender in :EF and DEF, and bowel sounds positi%e. ,o
hepatosplenomegaly. ,o rebound, non/distended, no shifting dullness or fluid wa%e.
6+tremities: ,o edema. ,o cyanosis, no clubbing, non/tender. ,egati%e anterior drawer
sign, and no *oint la+ity, no crepitus with fle+ion or e+tension, pulses are @! throughout,
no e%idence of claudication.
S#in: ,o rashes or sores, or %aricosities
,eurological: >CS of 18, no focal deficit. ,o ata+ia, normal gait, C, !/1! intact, upon
Guestioning with short and long recall and ob*ect recognition the patient was accurate
consistently throughout the e+am. Sensation is intact to pin pric# and light touch
throughout
:efle+es are !@ in both upper and lower e+tremities babins#i shows down going toes. ,o
tremor at rest or with e+ertion
7ine and gross manipulations are normal with the right and left hand able to pic# up small
ob*ects and manipulate ob*ects without difficulty.
H>eneral 7indings: ,o cer%ical para%ertebral muscle spasm, no tenderness, nor effusion,
no ob%ious deformities. ,o Dumbar para%ertebral muscle spasm without tenderness,
without e%idence of scoliosis.
Coordination, Station and >ait: Claimant is able to demonstrate, finger to nose, able to
perform heel to toe wal#ing, able to sGuat and rise, able to stoop, able to pic# up ob*ects
from floor with both hands, able to perform :homberg.
:ange of 3otion:
,ec#: ,ormal Actual Actual
7le+ion "/8" 8"
6+tension "/" "
:t. Dateral 1ending "/(8 (8
Dt Dateral 1ending "/(8 (8
:t. :otation "/;" ;"
Dt. :otation "/;" ;"
Shoulder: :ight Deft
Abduction "/18" 18" 18"
7orward 6le%ation "/18" 18" 18"
4nternal :otation "/;" ;" ;"
6+ternal :otation "/5" 5" 5"
6lbow and 7orearm:
7le+ion "/18" 18" 18"
6+tension " " "
Supination "/;" ;" ;"
Pronation "/;" ;" ;"
Hip:
Abduction "/(" (" ("
Adduction "/!" !" !"
7le+ion "/1"" 1"" 1""
6+tension "/0" 0" 0"
4nternal :otation "/(" (" ("
6+ternal :otation "/8" 8" 8"
Deg :aise:
Supine "/5" 5" 5"
Sitting "/5" 5" 5"
1ac#: ,ormal Actual Actual
7le+ion "/5" 5"
6+tension "/!8 !8
:t. Dateral 1ending "/!8 !8
Dt. Dateral 1ending "/!8 !8
:ight :otation "/0" 0"
Deft :otation "/0" 0"
9nee: :ight Deft
7le+ion "/18" 10" 10"
6+tension " " "
An#le and 7eet:
-orsifle+ion "/!" !" !"
Plantar 7le+ion "/(" (" ("
4n%ersion "/0" 0" 0"
6%ersion "/!" !" !"
Crist:
-orsifle+ion "/" " "
Palmer 7le+ion "/B" B" B"
:adial -e%iation "/!" !" !"
Elnar -e%iation "/0" 0" 0"
Hands and 7ingers:
3CP 7le+ion "/5" 5" 5"
3CP 6+tension " " "
P4P 7le+ion "/1"" 1"" 1""
P4P 6+tension " " "
-4P 7le+ion "/B" B" B"
-4P 6+tension " " "
Grip and Pinch: ,ormal in both hands
Assistant Device: ,one
Impairments: 1.) P$S-
!.) Chronic lumbar strain
0.) Erethral stricture reGuiring catheteri2ation

!nctional Assessment: Claimant may sit up to ; hours& stand wal# up to ; hours.
Claimant should be able to bend, #neel, crawl, stoop, and crouch. $here are no limitations
to reaching, handling, feeling or grasp. Claimant should be able to push and pull without
limitations. 4 would e+pect Claimant to ha%e no limitations in lifting with both hands.
$hey claimant may feel unsafe in a room with closets and where she has to wor# alone in
a room. $here is no need for any assisti%e de%ices. Claimant does not ha%e any ob%ious
learning disabilities that could be limiting. Claimant would benefit from a complete
psychological e%aluation.