Primary diagnosis: Other and unspecified arthropathies.

Secondary diagnosis: Fractures of upper limb.
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The claimant was a 57-years and 10 months old man.
Alleged disability: “Left foot, left hand, right bicep and shoulder, back pain, stomach.”
The claimant reported falling from a roof some years ago; he complained of pain and mobility difficulty because of issues with his left foot, in addition to problems gripping and handling objects with his left hand. He needed to rest 15-20 minutes after ambulating approximately 100 yards. He stated that he had issues with concentration when he was in pain; he also had trouble completing tasks and handling stress. He drove a car and was able to do some light chores; …show more content…
The primary diagnosis was other and unspecified arthropathies. The secondary diagnosis was fractures of upper limb.

Per medical records (2013, 2016-2017) and a consultative examination (CE on 06/28/2017), the claimant reported a history of left foot and ankle injury in 2004 that required surgery, as well as injury to his left hand in 2013 with a high-powered saw that required immediate surgery with hardware placement. He also had a history of traumatic amputation of the tip of the left fourth finger and right biceps injury.

The claimant had limited range of motion of the back, right shoulder, and right foot and ankle, as well as deformities in both hands. X-rays (2016) showed severe degenerative joint disease (DJD) in both hands. He had post-traumatic arthritis in his left hand and ankle; he ambulated with a mild limp. He complained of pain because of his musculoskeletal issues. The documentation also included documentation of uncontrolled high blood pressure.

The SSA determined that the claimant had a residual functional capacity (RFC) to perform work that required light exertion with some mobility limitations. The medical vocational rule 202.06 was used as a framework to make the disability