Therapeutic Summary

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This writer understands that if there is no CPD documentation it is not possible to determine if there was medical improvement and the SSA disability benefits must continue. However, there was no documentation related to SSA attempts to reconstruct the CPD folder. “When the DDS determines not to reconstruct a prior lost or destroyed paper CDP folder, the DDS must document the reason for the determination …” (DI 28035.025). It seemed that a consultative examination (CE) was not ordered.

Blood glucose and hemoglobin A1C laboratory reports were not submitted in order to determine if in fact the claimant’s diabetes was uncontrolled. The claimant’s home records of blood glucose control were not provided.

The physical examination in the medical records did not contain a single foot exam, which would give an idea of the extent of the claimant’s peripheral neuropathy. The “neurological” section indicated normal findings. Neurological studies related to the alleged numbness in upper and lower extremities were not submitted. …show more content…
The physical examination in the medical records provided (2015) indicated that her respiratory system was normal.

The claimant’s mother stated that the claimant’s “sugar is low she goes in and out of a diabetic coma if sugar is high she can’t concentrate.” Hospital records related to the evaluation and treatment of diabetic coma were not found in the electronic records.

On 07/02/2015, the claimant complained of vertigo and doctor AH evaluated her. The claimant reported the following associated

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