Age: 50.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19
Symptoms: Abdominal pain lower, Affect lability, Anal fistula repair, Anovulvar fistula, Anxiety
Clinical narrative: Laboratories: CT ABDOMEN PELVIS W IV CONTRAST This document is currently in Final Status     CT ABDOMEN PELVIS W IV CONTRAST   INDICATION: RLQ pain evaluation;     COMPARISON: Ultrasound 4/2/2025, CT chest 1/6/2025 and MRI pelvis 6/30/2020   FINDINGS: Similar mild nodularity in the right middle lobe. Cholecystectomy. Tiny renal hypodensities, likely benign cysts. Liver, adrenal glands and pancreas are negative.   Normal caliber small bowel. No free fluid.   IMPRESSION: 1. No acute findings in the abdomen or pelvis. 2. Similar mild nodularity in the right middle lobe, presumably treatment related.   Electronically Signed: physician 5/8/2025 10:46 AM I am in month 50.  MY VACCINE ADVERSE REACTION HORROR STORY:  as a healthcare worker I was in the first group of vaccinations January 2021.  My last vaccination was May 2022. I had 4 Moderna shots total.  Shortly after being vaccinated I developed an anal fissure that spread to my vulva, and I suffered vaginal lesions until a biopsy was performed and determined that I have an autoimmune disease with no cure, called Vulvar Lichen Sclerosis.  I have over 440 photographs of my vulva since 2021 and all the medical records including testing positive for Epstein Barr virus when my clitoris hood swelled up and split open oozing for 5 weeks until that one healed.  I have been documenting it all and have high resolution horrifying images of other oozing ulcers on my clitoris, vaginal lesions and atrophy of my vagina and labia that has completely decimated and severely disfigured me.  The pain is unbearable, then in 2022 I developed a painful anal fistula.  One doctor cut it out right there in the office but that procedure failed and on February 17, 2023 I went under full anesthesia for an Anal Fistulatomy.  It would take more than 8 weeks of suffering for me to heal from that HORRIFIC procedure.  Then in April, 2023 my annual mammogram came back abnormal, a biopsy was performed on my right breast and right axillary lymph node and determined I have invasive Ductal Carcinoma Cancer in my right breast and Metastatic Cancer to 3 of 9 (all removed) lymph nodes. I am devastated and can?t stop crying.  Surgery for a double lumpectomy and complete lymph node removal was May 17, 2023 ? followed by 12 weeks of chemo (final chemo 8/22/23) and mapping for radiation starting the first week of September and I just finished 33 rounds of radiation.  Next up is a treatment of gene therapy pills for 10 years to remove any remaining estrogen.  Two spots in the breast were biopsied and about 20 days later in surgery there were four spots removed, making it a very aggressive ?Turbo Cancer?.  I also experienced ?died suddenly clots?  in my surgery drain lines - look for those photos on my social media account too.  All nine lymph nodes were removed from my right armpit and three nodes had metastatic cancer.  I have filed adverse reactions with V-SAFE, agency, and health department (Health Department where I received my first 2 doses of Moderna).  They tricked me. It wasn?t a vaccine, it was an experimental gene therapy and now my immune system is scrambled - and there is nothing anyone can do.  MY ILLNESSES: CANCER:  Breast Cancer (Invasive Ductal Carcinoma + Metastatic Carcinoma to Lymph Nodes).  VULVAR: Vulvar Lichen Sclerosus, Vulvar Aphthous Ulcers, Vaginal Lipschütz Ulcers,  Anal Fissures + Fistulas, Right Arm Lymphedema, Two Lung granulomas (recently biopsied no carcinogens detected).  A couple of months ago my claim required me to get an attorney to represent me and I am near maxed out on credit cards. Minimal balances are giving me anxiety and I?m terrified I won?t make it to disability approval. Please, God help me.  I am praying for us all.  My vaccines and vaccination dates are as follows, January 7, 2021 ? Moderna lot 032H20A, February 3, 2021 Moderna lot 010M20A, November 11, 2021 Moderna lot 091D21A,  May 19, 2022 Moderna lot 056A22A.  I?m now permanently disabled and these injuries have no doubt taken years off my lifespan.  It?s never to late to file a VAERS report so here is mine.  You better Welcome and stop the shots!  God Bless  Assessment: 54-year-old female with:   1.  Right breast invasive ductal carcinoma, T1 (m) N1 M0, stage II.  Grade 1.  ER/PR 99% positive, HER2 negative.  Ki-67 2%. Multifocal tumor with 4 lesions measuring less than 1 cm.  Right axillary lymph node biopsy showed metastatic carcinoma suspicious for focal extracapsular extension. Reviewed MRI breast results and images from 4/20/2023 which showed abnormal masslike and non-mass-like enhancement in the right breast with a 1 cm mass in the anterior right breast and a cluster of small masses in the right breast at the middle approximately 8 to 9 cm from the nipple.  Mildly prominent lymph nodes noted in the right axilla.   Discussed diagnosis of stage II ER positive HER2 negative breast cancer and management with surgery followed by possible adjuvant chemotherapy, adjuvant radiation therapy and endocrine therapy. Her case was discussed with the tumor conference earlier today.  Lumpectomy of both breast lesions is feasible.  Given focal extracapsular extension noted in the axillary biopsy, she would be a candidate for axillary lymph node dissection. Discussed this with patient.  She currently has other issues going on such as her lichen sclerosus and worsening of chronic pain issues.  She has an appointment with Dermatology at Clinic in the works. She prefers to have surgery first which is reasonable.  We will make referral.   Underwent right lumpectomy and right axillary node dissection on 5/17/2023.  Reviewed surgical pathology results which showed multifocal tumor with 4 separate masses measuring 14 mm, 10 mm, 4 mm and 2.5 mm, all grade 1 with accompanying DCIS and foci of ALH.  Margins clear.  3 of 9 sentinel lymph nodes were involved with metastatic adenocarcinoma, the largest focus measuring 8 mm with extranodal extension. Recovering well from her surgery.   Discussed adjuvant treatment with radiation therapy and endocrine therapy for 10 years.  Given her node positive disease, I am leaning towards systemic chemotherapy.  Discussed utilization of Oncotype DX test to define benefit from systemic chemotherapy.  Patient is willing to proceed with the above tests. Discussed obtaining a PET CT scan to complete staging work-up.   Reviewed PET CT scan images and results from 6/2/2023 which showed posttreatment changes in the right breast and no evidence of metastatic malignancy in the neck chest abdomen or pelvis. Oncotype DX test returned with recurrence score of 14. However given her node positive disease with extracapsular extension, I recommend 4 cycles of adjuvant Taxotere Cytoxan chemotherapy with Neulasta support.  Reviewed schedule potential side effects.  She is agreeable. Cycle 1 TC chemotherapy administered on 6/20/2023 with Neulasta support. Had bone pains with Neulasta.  Also developed a groin rash which improved with creams.  Currently on antibiotics for bacterial infection of skin. Completed 4 cycles of TC chemotherapy with fairly good tolerance. Completed adjuvant radiation treatments on 10/23/2023.   Patient recently had COVID infection, recovering from it.  She has intermittent flareups of her autoimmune conditions causing significant discomfort.  Recovering from skin toxicity from radiation. Reviewed CT scan images and results from 12/8/2023 which showed decrease in the nodule of the right lower lobe consistent with granulomatous change.  Lung findings noted consistent with recent inflammation/infection. Discussed adjuvant endocrine therapy for breast cancer with aromatase inhibitors.  Reviewed schedule.  The side effects including joint aches and pains, hot flashes, decrease in bone density etc. Started letrozole in December 2023. Follow-up CT scan in April 2024 showed minimal change in the postoperative seroma in the right breast and right axilla and stable lung findings.  No evidence of recurrent disease.  Seroma in the right breast appears larger than the right axilla. CT chest in January 2025 showed no etiology for the right axillary pain.   Reviewed CT scan images and results from earlier today which showed no evidence of malignancy or any acute findings. Patient is doing fairly well clinically.  Tolerating letrozole well. 2.  Lichen sclerosis- improved. 3.  Hypothyroidism-on Synthroid.  TSH normal. 4.  Labs in epic reviewed.  CBC CMP normal. 5.  Right upper extremity and breast lymphedema-seeing occupational therapy.  Using sleeve.  Using compression pump intermittently. 6.  Groin rash-improved. Follows with Dermatology. Improved. 7.  Right upper lobe lung nodule-measuring 1.9 cm.  Reviewed CT images from outside facility.  PET CT scan shows uptake with right hilar uptake as well.  Recent scan shows improvement in lung nodule. 8.  Tobacco abuse. 9.  Bone health-reviewed bone density scan results from November 2024 which showed osteopenia.   10.  COVID-vaccine injury-recent spike protein antibody test returned positive. 11.  Complaints of frequent palpitations.  No abnormalities on labs or EKG. 12.  Left heel pain-ongoing for several months.  X-ray did not show any acute issues.   Plan:  1.  Continue letrozole. 2.  Return to office with me in 3 months with labs for follow-up. 3.  Ortho referral for heel pain evaluation.   Patient understands and agrees with the plan.  Her questions were answered satisfactorily.  She knows to call with any issues in the interim.   Cancer Center, Hematology/Oncology  Site:  Cancer Center      Reason for Visit: Right breast cancer Referred by: Physician (redacted)   History of Present Illness:  Patient is a 54 year old pleasant female with a diagnosis of thyroid disease, eczema etc. who underwent screening mammogram in March 2023 and was found to have a 6 mm lateral right breast abnormality.  Further evaluation with ultrasound showed 2 suspicious masses in the right breast and associated abnormal axillary lymph node.  Ultrasound biopsy of the 2 breast lesions and the lymph node were performed on 4/12/2023 and returned positive for invasive ductal carcinoma ER/PR strongly positive and HER2 negative, Ki-67 2%. Referred here for further evaluation and management.   Patient also gives a history of significant side effects after receiving a COVID 19 vaccination.  She was diagnosed with vaginal lichen sclerosis for which she has been referred to Dermatology at Clinic. Developed a perianal fistula for which she had examination under anesthesia with fistulotomy by Doc in February 2023.   4/19/2023-MRI breast showed abnormal mass like and non mass enhancement in the right breast with a 1 cm mass in the anterior right breast at 3 o'clock position and a cluster of small masses in the right breast at middle depth approximately 8 to 9 cm from the nipple.  Right axillary biopsy clip noted, no suspicious lymph nodes noted.  Left breast examination showed a few small sub-5 mm foci of enhancement.   5/17/2023-underwent right lumpectomy and right axillary lymph node dissection by Dr.  Specimen sent for Oncotype DX testing.   6/2/2023-PET CT scan showed posttreatment changes in the right breast with fluid collection and no evidence of distant metastatic disease or other malignancy.   6/20/2023-started Taxotere Cytoxan chemotherapy with Neulasta support.   9/20/2023-low-dose lung cancer screening performed at facility showed a new spiculated lung nodule in the right upper lobe medially measuring 1.9 cm in maximum dimension, concerning for lung primary.   8/22/2023-completed cycle 4 chemotherapy. 10/19/2023-PET CT scan showed prior granulomatous disease process. 10/31/2023-right lung lesion biopsy was negative for malignancy, showed granulomatous inflammation. Completed adjuvant radiation treatments on 10/23/2023. Started letrozole.   Patient presents today for their follow-up visit.  She had a follow-up CT scan of the abdomen pelvis earlier today for evaluation of lower abdominal pain.  Disability DETERMINATION  This case is before the undersigned on a request for hearing dated January 3, 2024. On October 22, 2024, the undersigned held a telephone hearing. All participants attended the hearing by telephone. The claimant agreed to appear by telephone before the hearing and confirmed such agreement at the start of the hearing. The claimant is represented by, an attorney. an impartial vocational expert, also appeared at the healing. The claimant is alleging disability since September 18, 2021.   FINDINGS OF FACT AND CONCLUSIONS OF LAW After careful consideration of the entire record, the undersigned makes the following findings: 1. The claimant's date last insured is December 31, 2028. 2. The claimant has not engaged in substantial gainful activity since September 18, 2021, the alleged onset date.   The claimant has worked after the alleged onset date; however, the amounts earned fall below the requisite threshold for classification as substantial gainful activity. 3. The claimant has the following severe impairments: degenerative disc disease of the cervical lumbar and thoracic spine; lymphedema status-post breast carcinoma; anal fissures / fistula; Lichen Sclerosis; genital ulcers; and herpes simplex virus (HSV). The claimant has the following degree of limitation in the four broad areas of mental functioning set out in the disability regulations tor evaluating mental disorders and the mental disorder. Next Page     remembering, or applying information; no limitation in interacting with others; no limitation in concentrating, persisting, or maintaining pace; and no limitation in adapting or managing oneself.   4. The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments.   5. The claimant has the residual functional capacity to perform sedentary work as defined in article with the following additional limitations: occasional climbing ramps and stairs; never climbing ladders, ropes, or scaffolds; occasional stooping, kneeling, and crouching; no crawling; the avoidance of unprotected heights and workplace hazards; occasional oreaching to shoulder height with the right upper extremities and never reaching above shoulder height ,with the right upper extremity; frequent handling and fingering with the right hand; occasional pushing and pulling with the upper and longer extremities; the avoidance of beat and humidity; and the claimant must alternate between sitting and standing every 30 minutes while claimant on task.   In making this finding, the undersigned has considered all symptoms and the extent to which these symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence, based on the requirements. The undersigned also considered the medical opinion(s) and prior administrative medical] finding(s) in accordance with the requirements.   After careful consideration of the evidence, the undersigned finds that the claimant's medically determinable impairments could reasonably be expected to cause the alleged symptoms. The claimants statements concerning the intensity, persistence and limiting effects of these symptoms are generally consistent with the objective medical evidence and other evidence in the record. The description of the symptoms and limitations that the claimant has provided throughout the record generally has been consistent and persuasive. The claimant persuasively testified that her limitations hinder her ability to maintain functionality for extended periods of time. Her allegations are supported by doctor staten1ents, and the record contains no inconsistencies that bring her allegations into serious question.   Examination of the record reveals ample evidence of the claimant severe impairments to merit the restrictions adopted above. J'he medical evidence of record shows that the claimant has a history of degenerative disc disease of the cervical, lumbar, and thoracic spine; lymphedema status-pos~ breast carcinoma; anal fissures/fistula; Lichen Sclerosis; genital ulcers; and herpes simplex virus (I-ISV). She has complained of physical symptoms including painful vaginal and anal lesions/growths, swelling/pain in the upper extremities, back pain, neck pain, and fatigue. (See generally treatment records)  The extent of the claimant's physical allegations is supported by  the findings on physical examination, imaging/testing, and the nature of the claimant's treatment. See Next Page  :he_ claimant's allegations are supported by physical examination. Physical examination reveals a mildly antalgic gait, decreased range of motion in the lumbar and cervical spine:, straight leg raising, and positive facet compression maneuvers.  The claimants?s allegations are supported by radiographic and other objective evidence. In 2021 imaging of the cervical spine revealed degenerative change most mar e a k d t C4 is where there is moderate spinal canal narrowing with cord contact and mild to moderate neural foraminal narrowing. In 2023, a thoracic MRI showed mild scattered degenerative changes, and a lumbar MRI showed multilevel degenerative disc disease and disc protrusion.   The claimant's treatment for her physical conditions has been extensive and exhaustive in nature. The claimant was diagnosed with right breast invasive ductal carcinoma in April 2023. On May 17, 2023, the claimant underwent right lumpectomy and right axillary lymph node dissection with pathology showing a multifocal tumor with 4 separate masses. 3 out of 9 sentinel axillary lymph nodes were involved with metastatic adenocarcinoma. On June 2, 2023, a PET CT scan showed post treatment changes in the right breast and no evidence of metastatic malignancy in the neck chest abdomen or pelvis. On June 20, 2023, the claimant started Taxotere Cytoxan chemotherapy with Neulasta support. In August 2023, the claimant completed chemotherapy, and in November 2023, the claimant completed radiation. While malignancy has not recurred, the claimant is in occupational therapy for resultant lymphedema affecting the upper extremities.   The claimant has a history of genital HSV infection, lichen sclerosis on the anus and vulva, and anal fissures. She has been treated with antiviral medication and high potency topical steroids and calcineurin inhibitors.  She required anal fistula surgery in February 2023.   Concerning the claimant' s musculoskeletal impairments, treatment has included opioid pain medication,. chiropractic, physical therapy, activity modifications, NSAID p medications, epidural steroid injections, and radio-frequency neurotonty.  As for medical opinion(s) and prior administrative medical finding(s) we will not defer or give any specific evidentiary weight, including controlling weight, t any prior administrative medical finding(s) or medical opinion(s), including those from your, medical sources. We fully considered the medical opinions and prior administrative medical findings in your case as follows:   Specifically, the undersigned considered the prior administration consultants. These doctors found to have findings of the state agency work with postural and environmental limitations. These doctors have a high level evidence in the record when generating their findings. However, the undersigned does not find  the conclusions persuasive. The conclusions are partially supported by the examiners' detailed summary and analysis of records reviewed citing intact strength and range of motion in spite of multi-level degenerative disc disease throughout the spine. However, they are not consistent with records submitted after they reviewed the file.  Later submitted records are consistent with greater exertion limitation. While malignancy has not reoccurred, the claimant is in occupational therapy for resultant lymphedema affecting the upper extremities. This in combination with her severe spinal impairments is consistent with sedentary work.   The undersigned considered the opinion of M.D.  The undersigned finds the opinion persuasive. Dr. supports his opinion citing aggressive non-surgical treatment in the form of physical therapy, medications, activity modification, epidural steroid injections, and radiofrequency neurotomy. Likewise, the opinion is consistent with the claimant's aggressive treatment for breast cancer resulting in upper extremity lymphedema.   The undersigned considered the opinion of PT, DPT. The undersigned finds the opinion persuasive. Mr. supports his opinion citing ongoing chronic pain despite aggressive intervention. Likewise, the opinion is consistent with physical examination findings. Physical examination reveals a mildly antalgic gait, decreased range of ,notion in the lumbar and cervical spine, positive straight leg raising, and positive facet compression maneuvers. The undersigned considered the opinion of M.D. The undersigned finds the opinion persuasive. Dr. suppose her opinion citing painful lichen sclerosus and complex anal fissure impacting the claimant's ability to sit. Likewise, the opinion is consistent with physical examination findings. Physical examination reveals a mildly antalgic gait, decreased range of motion in the lumbar and cervical spine, positive straight leg raising, and positive facet compression maneuvers.   Additionally, the undersigned considered the prior administrative findings of the state agency psychological consultants. These consultants found that the claimant?s mental impairments were non-severe. As with the medical consultants, the psychological consultants' findings deserve consideration as these doctors have a high level of understanding of the disability program and enjoy a review of all the available evidence in the record when finding their conclusions.   The undersigned finds the conclusions persuasive. The conclusions are supported by the examiner' summary and analysis of records reviewed citing the claimant's conservative mental health treatment. Likewise, the conclusions are consistent with the largely intact mental status examination findings provided by the claimant's therapist. The undersigned considered the opinion of the psychological consultative examiner. The undersigned does not find the opinion persuasive. The opinion is partially supported by the claimant's performance at the psychological consultative explanation. At this exam, mental status examination revealed distractibility, tearfulness, labile affect, and depressed mood. However, the degree of limitation opined is not consistent with the claimant's Sec Nexl Page       conservative mental health treatment. The claimant did not begin psychotherapy until 1 March 2024 ,. and mental status examination from these notes reveals largely intact mental status. examination findings. The claimant has not required psychiatric inpatient admission.   In view of all the factors discussed above, the evidence supports the limitations on the claimant's capacities described earlier in this decision.   6. The claimant has no past relevant work.   7. The claimant was an individual closely approaching advanced age on the established disability onset date.   8. The claimant has at least a high school education.   9. Transferability of job skills is not an issue in this case because the claimant does not have past relevant work.   10. Considering the claimant's age, education, work experience, and residual functional capacity, there are no jobs that exist in significant numbers in the national economy that the claimant can perform. Even if the claimant had the residual functional capacity for the full range of sedentary work, a finding of '"disabled .. ' would be directed. by Rule.   11. The claimant has been under a disability as defined in the Act since September 18, 2021, the alleged onset date of disability.   12. The claimant's substance use disorder(s) is not a contributing factor material to the determination of disability.   Applying the sequential evaluation process a second time, the claimant's other impairments would not improve to the point of non disability in the absence of the substance use disorder(s). In making this determination, the Administrative Law Judge noted that the claimant's records contained references to a history of stimulant use disorder. However, pursuant, the undersigned determined that this was not material to the outcome of this decision as the impact of her prior stimulant use was fully considered in developing the residual functional capacity statement. In particular, records revealed that the claimant's impairments exist independently of: her prior use, and there was no evidence that her impairments would improve in the absence of stimulant abuse. Furthermore, records indicate that the claimant's stimulant use disorder has been in sustained remission. According)y, the claimant would still be disabled in the absence of the substance use disorder(s). See Next Page     Based on the application for disability and disability insurance benefits protectively filed on October 24 2024 the claimant has been disabled under sections of the Act since September 18, 2021   DECISION . . Page