Opinion ID: 1379917
Heading Depth: 4
Heading Rank: 1

Heading: Medical RecordsPhysical

Text: In January 2006, Ealy claimed disability for the period beginning December 2, 2005, based on seizures, heart trouble, sleep apnea, restless leg syndrome, trouble with memory, high blood pressure, and gout. Ealy had worked as a spray line operator and coiler when he had a stroke in October 2002. A.R. at 176, 184. He returned to work with restrictions that he not climb, operate equipment, or be around heavy equipment. Also, before December 2005, Ealy was diagnosed with obstructive sleep apnea and restless leg syndrome and was prescribed medication for swelling in his right ankle. On December 2, 2005, Ealy went to the hospital complaining of loss of consciousness. While in the hospital, he had episodes of slurred speech and spells during which he stared blankly and was unable to speak. A.R. at 270. He was transferred to a different hospital to receive a higher level of care, eventually diagnosed with new-onset seizure and focal motor seizure, and given antiepileptic medication. A.R. at 271, 279. The discharge notes on the doctor's report stated that Ealy was not to work or drive for a month, at which point he could be reevaluated. A.R. at 280. Ealy sought treatment from Dr. Gregory Wheatley, a neurologist, from January through August of 2006. Ealy was instructed in January 2006 not to drive for six months, not to swim or climb ladders, and to remain off work because of the type of work that he has described and [the need] to investigate other options. A.R. at 357. By February 2006, Dr. Wheatley noted that Ealy relates no definite episodes of any alterations in awareness A.R. at 355. Dr. Wheatley also noted that Ealy will need to remain on anticonvulsants for the indefinite future. The main concern presently is the choice of anticonvulsants. Id. Dr. Wheatley saw Ealy again in March 2006 and noted that Ealy had not had recurrent seizures. About Ealy's job, Dr. Wheatley wrote, [h]e has not been able to return to work as he does do a heavy, potentially hazardous job. He will be under restriction from this for six months from his last seizure. A.R. at 354. When Ealy saw Dr. Wheatley in May 2006, the doctor noted that Ealy relates no convulsive events since I last saw him but he has had some brief episodes in which he believes he may have some brief alteration in his awareness, or some symptoms suggestive of partial seizure. Dr. Wheatley increased Ealy's dosage of Trileptal and noted, I am not sure if these lesser symptoms are related to any brief partial seizure activity or not. He seems to have done fairly well otherwise. He does have the residual deficits from his remote left hemorrhage. He remains off work and I think that he is going to likely be chronically disabled from employment. A.R. at 353. Ealy followed up with Dr. Wheatley in August 2006. Ealy reported and his wife confirmed that he had not had any seizures. A.R. at 545. Dr. Wheatley wrote that Ealy has remained stable from a neurologic standpoint. He is tolerating the Trileptal and his seizure control is good. A.R. at 545. Dr. Wheatley concluded that he did not need any other studies, that Ealy would follow up with another doctor locally, and that he would be happy to see Ealy if any future seizure problems arose. Meanwhile, in February and May of 2006, Ealy had visited his treating physician, Dr. Rhonda Sivley, complaining of (among other things) shortness of breath. Dr. Sivley suspected deconditioning and noted in February that the plan was for Ealy to increase his exercise and lose weight. A.R. at 371. In May, Sivley noted the need for Ealy to exercise and lose weight, and also noted that he might benefit from a pulmonary function test. A.R. at 376. In May, Ealy underwent a cardiolite stress test that yielded borderline results with a very minimally reversible apical defect which may have represented a very small region of ischemia but the myocardium at risk would be felt to be quite small. A.R. at 393. Ealy exhibited normal ventricular function and showed a [m]ild exercise intolerance for the patient's age, sex, and physical condition. A.R. at 392-93. Dr. Sivley referred Ealy to Dr. Barry Michelson for evaluation of Ealy's chest pain and shortness of breath. A.R. at 474. In May 2006, Dr. Michelson recommended that Ealy undergo a cardiac catheterization in order to obtain a definitive diagnosis. A.R. at 475. In June 2006, Ealy underwent a heart catheterization and stent placement. A.R. at 441-42. Dr. Michelson noted single-vessel coronary disease and successful deployment of ... stent. A.R. at 442. Upon Ealy's June 10th discharge, Dr. Michelson indicated that he could return to work on June 12th, but that he should not lift greater than ten pounds for a one-week period. A.R. at 444. In July 2006, Ealy followed up with Dr. Michelson for his coronary artery disease. According to Dr. Michelson's notes, Ealy did not have chest pain, but he did have breathing problems with activity. A.R. at 472. Dr. Michelson also noted that Ealy does complain of smothering, but is morbidly obese. Id. Dr. Michelson reviewed with Ealy the importance of regular exercise and weight reduction and planned a follow-up visit in six months. During his February 2007 visit to Dr. Michelson, Ealy reported increasing shortness of breath with activity and a hot sensation in his upper chest and face. A.R. at 527. Ealy again underwent a stress test, and in March 2007, Dr. Michelson conducted a left heart catheterization. A.R. 512. Dr. Michelson noted small vessel disease distal posterior descending artery (left dominant system), but normal left ventricular function, and concluded [b]ecause of the small vessel size, medical management has been recommended. We will add a beta blocker to his therapeutic regimen. A.R. at 513. Ealy was again instructed to avoid lifting more than ten pounds for a one-week period. Ealy followed up with Dr. Michelson in April 2007. Although Ealy did not have chest pain, he did complain of smothering. A.R. at 525. Dr. Michelson noted that Ealy's left ventricular function is normal by catheterization. I do not feel that this is the etiology of his shortness of breath. I have therefore recommended, given his smoking history, that [pulmonary function tests] be performed. A.R. at 525. In the recommendations portion of his report, Dr. Michelson wrote that he did discuss with [Ealy] the importance of weight reduction. I believe that this and regular exercise may help his dyspnea [(shortness of breath)] as well. A.R. at 526. In a May 2007 pulmonary function study, Ealy showed a moderate lung restriction. A.R. at 544. In his May 2007 medical appointment, Ealy complained of shortness of breath. The advanced registered nurse practitioner who treated Ealy assessed hypertension, sleep apnea, and seizure disorder, and recommended additional labs, including bloodwork, but did not indicate that Ealy had any physical or work-related restrictions. A.R. at 534.