8th Circuit Social Security Disability

Sensory Impairments, Including Hearing, Meniere’s Disease and Speech Disorders

8:00 a.m.-9:00 a.m. Presented By Ethel Schaen St. Paul, Minnesota [email protected] 651-642-9520

Thursday, August 20, 2015

Ethel Schaen, Attorney at Law St. Paul, Minnesota [email protected] 651 -642-9520

THE SPECIAL SENSES LISTINGS AT 2.07 AND 2.09 TOPICS

I. Listing at 2.07, Disturbance of labyrinthine-vestibular function including Meniere ' s Disease, vertigo, balance disturbance, tinnitus, and hearing loss A. Anatomy of the Head, Ear, and Brain and definitions B. Review of the Listing and how to establish the MDI and prove disability l. Evaluation and Management of Meniere ' s Disease from American Speech-Language and Hearing Association

2. Medical examinations, tests, and treatment (caloric and audiograms) and use ofthe National Dizzy and Balance Center 3. Meniere ' s Disease 2.07 Listings Residual Functional Capacity Questionnaire C. Tinnitus D. Hyperacusis II. Listing at 2.09, Loss of Speech and SSR 82-57 A. Stuttering, articulation issues, vocal cord dysfunction, and speech tics B. Is "stage whispering" a disability? Beau voir v. Chater, 104 F .3d 1432 (2d Cir. 1997) C. Consideration of psychiatric or psychological factors and need for evaluation

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Definitions: anvil- (also called the incus) a tiny bone that passes vibrations from the hammer to the stirrup. cochlea- a spiral-shaped, fluid-filled inner ear structure; it is lined with cilia (tiny hairs) that move when vibrated and cause a nerve impulse to fonn. eard rum - (also called the -tympanic membrane) a thin membrane that vibrates when sound waves reach it Eustachian tube- a tube that connects the middle ear to the back of the nose; it equalizes the pressure between the 111 idd le ear and the air outside. When you "pop" your ears as you change altitude _(going up a mountain or in an airplane), you are equalizing the air pressure in your middle ear. hammer- (al so called the malleus) a tiny bone that passes vibrations from the eardrum to the anvil.

nerves- these carry electro-chemical signals from the inner ear (the cochlea) to the brain. outer ear canal- the tube through which sound travels to the eardrum. pinna- (also called the auricle) the visible part of the outer ear. It collects sound and directs it into the outer ear canal semicircular canals - three loops of fluidfilled tubes that are attached to the cochlea in the inner ear. They help us maintain our sense of balance. stirrup- (also called the stapes) a tiny, Ushaped bone that passes vibrations from the stirrup to the cochlea. This is the smallest bone in the human body (it is 0.25 to 0.33 em long).

2.00-Special Senses and

Spee~:h-Adult

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4.How do we evaluate your word recognition ability if you are not fluent in English? If you are not fluent in English, you should have word recognition testing using an appropriate word list for the language in which you are most fluent. The person conducting the test should be fluent in the language used for the test. If there is no appropriate word list or no person who is fluent in the language and qualified to perform the test, it may not be possible to measure your word recognition ability. If your word recognition ability cannot be measured, your hearing loss cannot meet 2.108 or 2.118. Instead, we will consider the facts of your case to determine whether you have difficulty understanding words in the language in which you are most fluent, and if so, whether that degree of difficulty medically equals 2.108 or 2.11 8. For example, we will consider how you interact with family members, interpreters, and other persons who speak the language in which you are most fluent. C. How de we evaluate vertigo associated with disturbances of labyrinthine-vestibular function, including Meniere's disease?

1. Vertigo associated with disturbances of labyrinthine-vestibular function, including Meniere's disease. These disturbances of balance are characterized by a hallucination of motion or a loss of position sense and a sensation of dizziness which may be constant or may occur in paroxysmal attacks. Nausea, vomiting, ataxia, and incapacitation are frequently observed, particularly during the acute attack. It is important to differentiate the report of rotary vertigo from that of "dizziness" which is described as light-headedness, unsteadiness, confusion, or syncope.

2. Meniere's disease is characterized by paroxysmal attacks of vertigo, tinnitus, and fluctuating hearing loss. Remissions are unpredictable and irregular, but may be long-lasting; hence, the severity of impairment is best determined after prolonged observation and serial reexaminations.

3. The diagnosis of a vestib ular disorder requires a comprehensive neuro-otolaryngologic examination with a detailed description of the

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vertiginous episodes, including notation of frequency, severity, and duration of the attacks. Pure tone and speech audiometry with the appropriate special examinations, such as Bekesy audiometry, are necessary. Vestibular function is accessed by positional and caloric testing, preferably by electronystagmography. When polytomograms, contrast radiography, or other special tests have been performed, copies of the reports of these tests should be obtained in addition to appropriate medically acceptable imaging reports of the skull and temporal bone. Medically acceptable imaging includes, but is not limited to, x-ray imaging, computerized axial tomography (CAT scan) or magnetic resonance imaging (MRI), with or without contrast material, myelography, and radiocnuclear bone scans. "Appropriate" means that the technique used is the proper one to support the evaluation and diagnosis of the impairment. . D. Loss of speech.

In evaluating the loss of speech, the ability to produce speech by any means includes the use of mechanical or electronic devices that improve voice or articulation. Impairments of speech may also be evaluated under the body system for the underlying disorder, such as neurological disorders, ll.OOff. E. How Do We Evaluate Impairments That Do Not Meet One Of The Special Senses And Speech Listings?

1. These listings are only examples of common special senses and speech disorders that we consider severe enough to prevent an individual from doing any gainful activity. If your impairment(s) does not meet the criteria of any of these listings, we must also consider whether you have an impairment(s) that satisfies the criteria of a listing in another body system . 2. If you have a medically determinable impairment(s) that does not meet a listing, we will determine whether the impairment(s) medically equals a listing. (See §§404.1526 and 416.926.) If you have an impairment(s) that does not meet or medically equal a listing, you may or may not have the residual functional capacity to engage in

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subst antial gainful activity. Therefore, we proceed to t he fourth, and if necessary, the fifth steps of the sequential eval uation process in §§404.1520 and 416.920. When we decide whether you continue to be di sab led, we use the rules in §§404.1594, 416.994, or 416.994a, as appropriate.

2.01

Category of Impairments, Special Senses and Speech

2.02

Loss of Central Visual Acuity. Remaining vision in the

better eye after best correction is 20/200 or less.

2.03

Contraction o f the visual field in the better eye, w ith:

A. The widest diameter subtending an angle around the point of fixation no greater than 20 degrees; OR

B. An M D of 22 decibels or greater, determined by automated static threshold perimetry that measures the central 30 degrees of the visual field (see 2.00A6d). OR

C. A visual fi eld efficiency of 20 percent or less, determined by kinetic perimetry (see 2.00A7c).

2.04 Loss o f visual efficiency, or visual impairment, in the better

eye: A. A visual efficiency percentage of 20 or less after best correction

(see 2.00A7d). OR

B. A visual impairment value of 1.00 or greater after best correction (see 2.00A8d).

2.07

Disturbance of labyrinthine-vestibular function (Including

Meniere's disease), characte rized by a history of frequent attacks of

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balance disturbance, t innitus, and progressive loss of hearing. With both A and B: A. Disturbed function of vestibular labyrinth demonstrated by caloric

or other vestibular tests; and

B. Hearing loss established by audiometry.

2.09

Loss of speech due to any cause, with inability to produ ce by

any means speech that can be heard, understood, or sustained.

2.10

Hearing loss not treated with cochlear implantation.

A. An average air conduction hearing threshold of 90 decibels or

greater in the bette r ea r and an average bone conduction hearing threshold of 60 decibels or greater in the better ear (see 2.00B2c). OR

B. A word recognition score of 40 percent or less in the bette r ea r determined using a standard ized list of phonetically balanced monosyllabic words (see 2.00B2e).

2.11

Hearing loss treated with cochlear implantation.

A. Consider under a disability for 1 year after initial implantatio n. OR

B. If more than 1 year after in it ial implantation, a word recognition score of 60 percent or less determined using the HINT (see 2.00B3b). Back to Top

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!:;valuation and Management of Meniere' s Di sease

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American Speech-Language-Hearing Association

Evaluation and Management of Meniere's Disease Meniere's di sease is a chronic illness that is characterized by sy mptom s of episodic verti go. aural fullness. tinnitus, and nuctuating sensorineural hearing loss. There are approxima tely 615,000 cases of Meniere's di sease in the United States (Nat ional Institute on Deafness and Other Commun ication Disorders, 2008). The diagnosis is most common in adults durin g their 4th or 5th decade of life and has a sli ght female preponderance. There also appears to be a strong ge netic compo nent (Sajjadi & Paparella. 2008). Meni ere' s has been studied since 1861. when Prosper Meniere first described a condition with the symptoms as li sted. Although there is still much to be understood about the underl ying phy siological mechani sms that cause Meniere's di sease, resea rch has shown that a majority of patient receive benefit either from a change in lifestyle or from medical or surgical intervention.

Pathophysiology The pathophysiology of Meni ere's di sease is not clearly understood . lt was previously tho ught that Meniere's was closely correlated with endolymphatic hydrops. a condition in which endolymph builds up due to an obstruction in the endolymphatic sac. Horm ones such as sacci n and glycoproteins are produced in excess. which may relieve the blockage and cause vertigo due to the sudden relea se of endolymph across the sac (Sajjadi & Paparella, 2008). However. histological studies of temporal bones have shown the presence of endolymphatic hydrops in patients without sy mptom s associated with Meniere's di sease (McCa ll et al., 2009). raising the question of why some people with hydrops arc sy mptomatic while others arc not. Other possible origins of the di sease are perisacc ular tibrosis, atrophy of the endolymphatic sac and loss of epithelial integrity, hypoplas ia of the vestibular aqueduct. and narrowin g of the lumen ol'the endolymphatic duct (Sajjadi & Paparella, 2008). McCall and cc,lleagues (2009) examined the vestibular end organs of patients with intractable Meniere's that were obtained during labyrinthectomy. They noted that the specimens showed "variable degrees of neuroepitheli al degeneration including conversion of the senso ry epithelium to a monolayer. rbase mentmembranelthickening, cellular vacuoli zation , absence of hair cell stereocilia. and increased intercellular stromal spaces" (McCall et al.. 2009, p. 10). Further resea rch is needed to replicate this study and obtain more information regarding the pathophysio logical processes underlying Meniere's di sease.

Symptoms Meniere's di sease is characterized primarily by its accompanying sy mptom s. wh ich include tinnitus. hearing loss, aural fullness, and vertigo. The tinnitus is typic al! _ desc ribed as a "roaring" so und that becom es louder

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prior to the onset of vertigo. Hearing loss typically follows the configuration of low-frequenc" sensorineural hearing loss and commonly fluctuates. Many patients describe a sensation of aura l fullness or press ure prior to the onset of vertigo, which may be accompanied by tinnitus. F:.pisodes of vertigo typica ll y last at least 20 minutes and may persist for up to several hours. In 1995. the American Academy of Otolaryngology-Head and Neck Surgery established the following criteria for diagnosis of Meniere's disease (p. 182): Certain Meniere's disease

• Definite Meniere's disease, plus histopathological confirmation Defin ite Me ni ere's disease

• Two or more definitive spontaneous episodes of vertigo 20 minutes or longer • Audiometrically documented hearing loss on at least one occasion • Tinnitus or au ral fullness in the treated ear • Other causes exc luded Probable Me ni ere's disease

• One definitive episode of vertigo • Audiometrically documented hearing !oss on at least one occasion • Tinnitus or aural fullness in the treated ear • Other causes excluded Possible Meniere's disease

• Episodic vertigo of the Meniere's type without documented hearing loss. or • Sensorineural hearing loss. fluc tuating or fixed. with dysequ ilibrium but without definitive episodes • Other causes excluded (Reprinted from Otolaryngology-Head and Neck Surge1y. 113, American Academy of Otolaryngology-! lead and

eck Surgery Committee on Hearing and Equilibrium. "Commit1ee on hearing and equilibrium

guidelines for the diagnosis and evaluation of therapy in Meniere's disease," 181-185. Copyright 1995. with permission from Elsevier.) These criteria ill ustrate the importance of integrating case history and the patient's report of symptoms with objective test measures to reach a diagnosis of Meniere's disease.

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Evaluation and Management of Meniere' s Di sease

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Evaluation Evaluation of patients with Meniere's sy mptom s is very impo rtant in determ ining a diagnosi s. 13efore the patient is seen by an oto laryngologist. the phys ician may req uest a variety of c linica l tests . The case hi story is crit ical. It is especia lly important to determine the onset of sy mptom s and to describe the freq uency and durat ion of vert ig inou s episodes as well as identify any accompanying ear complaints . A comprehen s ive audio logic evaluation should be completed. including pure-tone air and bone conduction thres ho lds at standard audiometric frequencies. word recognition sco res. and immittance testing. Audiometri c threshold s shou ld be close ly monitored to document any fluctuations in hearing sens itivity . Forma l vestibular testing should be done to assess the integ rity of the vestibular system a nd may include dy namic posturog raphy. rotary cha ir. and videony stagmography evaluations. Electrophysiological evaluations such as electrococh leography and vestibular evoked myogenic potenti als may be co mpleted as we ll. Finally. the patient w ill be seen by an o tolaryngologist to determine a diagnosis and di sc u s treatment options.

Treatment Options Muc h re earch has bee n done to determine the efficacy of treatment op tion s for patients with Meni e re's di sease. These treatment options range from changes in lifesty le to ab lati ve s urge ry. A fairly high correlation of seasona l a ll e rg ies exi sts in patient s diagnosed with Meniere' s disease. and studies have shown a s ignilicant decrease in vertigo sy mptom s for these patients afte r implementing allergy-avoidance behaviors and /or sta rting immunothera py fo r allergies. Other lifesty le changes. such as limiting caffeine. chocolate. alcohol. and sa lt, have been effective in reducing vertigo attacks. Patients di agnosed w ith Me niere's di sease arc typically counseled to adopt a low-sa lt diet ( I ,500-2.000 mg per day). and some arc a lso sta rted on a diuretic. If changes in li resty le are not sufficient for the suppression of vertigo attacks, o ther treatments are considered. The Meniette dev ice is a m inimally invasive form of therapy in which pressure pul ses are de live red to the car th rough a small device followi ng placement of a tympanostomy tube in the tympanic membrane . These press ure changes are thoug ht to he lp stimul ate the flow of e ndo lym ph. which ca n result in a reduction of vertigo sy mptom s. Studies have shown thst up to 67% of pati ents report an improvement in sy mptom s at 2 years, while longer term studies have shown a success rate of up to 58% ( DornholTcr & King. 2008). T he primary draw back to use of the Meniette device from the patient s' perspective is the cost: third-pa1ty payers do not cover the device at thi s time . Steroid the rapy has also been utili zed for treatment of sy mptom s associated with Meniere's di sease. espec ia ll y in patients with a sudden decrease in hearing . It is a nonablativc form of treatment th at docs no t require s urge ry. S tero ids ca n be g iven orally or via intratympanic (IT) injec tion. A review of the literature in 2004 concluded th at the strongest evidence of improvement was seen in patients with s udde n. id iopathic hear ing loss, while evidence of improvement in patients with Meniere's disease is weak ly correlated ( Doyle et al. .

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Evaluation and Management ofMeniere' s Disease

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2004). A study completed by Boleas-J\ g uin·e. Li n. Della Santina. Minor, and Carey (2008) reported a 91% s uccess rate in Meniere's patients Gfter 2 years fo llowing IT dexamethasone. Of the patients followed fo r longer than 2 years. 70% did not require any further treatment. It is important to consider other autoimmune inner car di sorders if a patient respond s favorably to the ste ro id treatm ent. Some patients elect to undergo endolymphatic sac decompress ion surgery, whic h has a high preservation rate for hearing and balance function. In thi s procedure, a Silastic sheet is inserted into the lumen o f the endolymphatic sac. Efficacy of thi s s urgery is fairly controversial. Some studies report improvement in verti go sy mptom s, while others note no difference between the su rgica l and placebo g roups (Sajjadi & Paparella, 2008). If treatments aimed at restoring normal functi o n of the inner ear a re not s uccessful , ablative form s of treatm ent are considered. One of th ese forms is IT gentamicin injection. in which ge nt am icin is inj ected directl y into the middle ear space. Thi s fo rm of treatment has been found to successfully treat ve rti go attacks in many patients, but potential seconda ry effects inc lude disequilibrium and se nso rineural hearing loss. and these must be explained to the patient. Surgical options for patients with intracmble Meniere's are vestibular nerve sect ion or laby rinthect omy . Vestibular nerve section has been performed in cases where hea ring preservation is des ired . Howeve r, thi s form of surgery has become less popular since the widespread introduction of IT ge ntamicin . Labyrinthectomy is more desirable in patients who already have a substa ntial deg ree of hearing loss (Gacek & Gacek, 1996). Ablative procedures are generall y effective in alleviating the disabling attack of vertigo, and patients typically recover quite well due to the principles of ce ntral compensation following a stable unilateral vestibular syste m weakness. Althoug h Meniere' s di sease affects a s ubstanti al number of people in the United States, control of vertigo attacks can often be achieved through a variety of lifesty le c ha nges co upled with other medical or s urg ica l interventions. T he proper diagnosis of Meniere' s depends on an accu rate case hi story, com pletion of a uditory and vestibul a r testing measures. and a thorough medical evaluatio n. A majority of patients benefit from dietary changes o r minimally invasive medical treatment s and procedures. wh il e those who do not may explore options such as IT ge ntamicin. vestibular nerve section .. a nd labyri nthectomy. Vestibu lar reh abilitati on can be useful in patients who are no lo nger experiencing acute attacks of spontaneous vertigo but who may be left with sy mptom s of disequilibrium or unstead iness. While much is known about the sy mptom s and treatments assoc iated with Me ni e re's disease. the underlying pathophysio logy of the di so rd er is poorly understood. Further research is necessary to obta in a better understan ding of the disease process. which will likely increase treatment efficacy.

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\:'_valuation and Management of Meniere's Disease

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Crystal YanDerlleyden. AuD. CCC-A Univers ity of Michigan Health System n anderhu med.umich.c'du Jaynee A. llandel sman, PhD, CCC-A University of Michigan I Icalth System

References American Academy of Otolaryngology-! lead and

eck Surgery Committee on Hearing and Equilibrium.

( 1995). Committee on hearing and equilibrium guidelines for the diagnosis and evaluat ion of therapy in

Meniere's disease. Otolary ngology- Head and Neck Surgery, 1 I 3. 181 -185. Boleas-Aguirre, M.S., Lin. F. R., Della Santina, C. C. , Minor. L. B., & Carey, J.P. (1008). Longit udinal results with intratympanic dexamethasone in the treatment of Meniere's disease. Otology & Neuroto /ogy. 29. 33-38.

Dornhoffer, J. L.. & King. D. (2008). The effect of the Meniette device in patients with Meniere's disease: Long-term results. Otology & New·otology, 29. 868-874 . Doyle, K. J., Bauch, C., Battista, R .. Beatty, C.. Hughes. G. B.. Mason. J.. .. . & Musick. F. L. (2004). Intratympanic steroid treatment: A review . Otology & Neurotology. 2 5. I 034-1039. Gacek, R. R. , & Gacek, M. R. ( 1996). Comparison of labyrinthectomy and vestibular neurectomy in the control of vertigo. Lmyngoscope, I 06, 225-230. McCall, A. A., lshiyama, G. P., Lopez, I. A., Bhuta. S .. Vetter, S., & lshiyama, A. (2009). llistopathological and ultrastructural analysis of vestibular endorgans in Meniere's disease reveals basement membrane pathology. BMC Ear, Nose and Throat Disorders, 9(4). Retrieved from \\\"-\\ .biom.cdcentralcom 1 l ,.p:.

ati ona l Institute on Deafness and Oth er Communication Disorders. (1008). Quick statistics. Retrieved from \\ '' w .mdcd. ni h.go'

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-.tati~tics

qu ick.h till .

Sajjadi, H., & Papare lla. M. M. (2008). Meniere's disease. Lancet. 3 72, 406-414.

About the Authors Crystal VanDerHeyden is an audiologist at the University of Michigan llealth System in Ann Arbor.

Michigan. Her clinical interests focus on the area of diagnostic testing. including vestibular asses ·ments.

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1:-, valuatlOn and Management of Meniere's

Di~case

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auditory evoked potentials. and comprehensive pediatric and adult audiologic evaluations. She is actively involved with the training and mentorship of audiology graduate students and is a member ofthe 2010 Michigan Audiology Coalition conference planning committee.

Ja ynee A. Hande ls ma n is Assistant Director of the Ve stibular Testing Center in the Department of Otolaryngology I lead and Neck Surgery in the University of Michigan Health System . I fer clinical. teaching. and research areas of focus include the assessment and management of patients with dizziness and balance disorders, as well as the impact of potentially ototoxic medications on auditory and vestibular system function. Dr. Handelsman is ASHA Vice President for Audiology Practice (20 I 0-20 12) and an ASIIA Fellow.

Coding and Reimbursement Resources on the ASHA Web site !( D-'>-C\l

Di~gJHhh t.."nd~'

related to Meniere's Disease:

386 .0 Meniere's disease Endolymphatic hydrops Lcrmoycz's syndrome Meniere's syndrome or vertigo 386.00 Meniere's disease. un pccified Meniere's disease (active) 386.0 I Active Meniere's disease. cochleovestibular 386.02 Active Meniere's disease, cochlear 386.03 Active Meniere's disease. vestibular 386.04 Inactive Meniere's disease. Meniere's disease in remi ss ion

© 1997-2014 American Speech-Language-:-learing Association

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National Dizzy & Balance Center - Medical Department INITIAL PATIENT EVALUATION

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DATE: 08/03/2010 DEMOGRAPHIC INFO~MATION:

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AGE: 35

GENDER: Male PROVIDER: . . . . . . . . . . .. -

REFERRAL:

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CHIEF COMPLAINT I PURPOSE OF VISIT: ?Ps presents today with a chief cornplainl of:

Jill _I

• Dizzfness • Imbalance

• Lightheadedness • Unsteadiness • Vertigo (spinning)

• Falling • Blacking out or fainting • Nausea/vomiting HISTORY OF PRESENT ILLNESS: Nature of the Problem · • • • • • -reca lls his problem started July 11, 2010 following no related event, with the onset of symptoms occurring gradually_The condition is currently variable with the severity of symptoms ranging from 2 at the best times to 10 at the worst times on a scale of 0 to 10 (with 10 being the worst) .. .... ••••~a rates the average severity of his symptoms a 10 on a scale of 1 to 10 (with 10 being the worst) . reports that his diZZiness/imbalance comes and goes in spells and attacks. He reports his dizziness/imbalance is affected by different body positions including: rolting his body to the left or right, going from lying to sitting positions, looking up or h~ad back positions. turning head left or right and bending over or head down positions. He reported that limited head movement, rest, and meclizine makes the dizziness!lmbalance better, and moving his head, riding or driving in a car, large crowds or busy environments and quick movements makes the problem woi'Se_ Walking in the dark is not difficult for him, and walking on uneven surfaces, such as lawn, is not difficult. When the dizziness/imbalance occurs, he needs support to prevent falling. said he has fallen 3 times due to his dizzinessiimbalance problem , and has had 10 or more near falls, and he tends to tall in all directions. He reports no history of migraines_

Ear ..

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Symptoms a reports having hearing problems that started over the past two years in both ears, and

currently does not wear any hearing aides. He reported having noise ln both ears, describes the noise as a nngtng, it's variable in volume/ intensity He reported having pain, fullness , or pressure in both ears. Asscxiatef;l Symptoms While Dizzy/Imbalanced

When · dizzy/imbalanced, he experiences lightheadedness or floating sensations. Experiences objects or surroundings spinning and tuming around him . Experiences a sensation that he is turni ng or spinning while objects remain statio~ary around him . Does experience some nausea or vomiting . No tingling of the hands, feet or lips.

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National Dizzy & Balance Center ~ Medica! Department INITIAL PATIENT EVALUATION Patient: I ·I )' 57 7 DATE: OS g_TR

Page:2

Prior Relevant Medical Evaluations and Treatment

41•1111illl••lh:as seen his primary care physician and an ENT regarding his condition prior to coming to NDSC. Prior Diagnostic Testing • • • • • - has undergone the foHowing studies relevant to this condition : MRI of the Brain performed at Hospital in July 2010. Hearing test performed at t il' ia in July 2010.

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PAST MI::DICAL HISTORY: Serious Injuries/ illnesses: enies history any serious injury/iHness relevant to his condition. Surgeries: History is positive for the the following procedures: Neck fusion CS-C6 in 2000, Neck fusion C6-C7 in 2008 . Serious hospitalizations; See above.

CURRENT MEDICATIONS:

=-:oA~c~o~m~p)ille~t~ellli~st~o~f~t·P~~~~,ifial.••tt medications is fried in his medical record. ALLERGIES; Medications: !Iii I I Non-medications: ••?II '

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& REPORTED NO MEDICATION ALLERGIES repo rted a h'tsto ry of seasona I aII ergtes. ·

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SELF AND FAMILY MEDICAL HISTORY: He reports a personal medical history of arthritis. He reports a family medical history of arthritis, cataracts. Type II diabetes, fibromyalg fa, high blood pressure, high cholesterol, osteoporosis and thyroid disease. SOCIAL HISTORY:

Marital/Children Status: reports being married. Curl'ent living Situation: He currently lives in a house with his spouse and children. Exercise/Activity/Hobbies: He has decreased activity, due to: Dizziness. imbalance, fear of failing, neck pain and headaches, and vomiting. Smoking: .He \s an ex-smoker. Alcohol use: He does no: consume alcohol. Caffeine use: He consumes 1 caffeinated beverages per day, Recreational drug use: reported no use of recreational drugs, no history of chemical dependence or addiction.

REV\EW OF SYSTEMS Of the systems reviewed, these systems were positive: Excess thirst or hunger. Fatigue, F"evers/chills/sweats, Fluid retention, General weakness, Allergies/hay fever, Blurred vision , Ear pain, Headilches, Hearing problems, Nasal congestion, Ringing in ears, Sinus infections (chronic) ,

Ughtheaded on arising quickly, Poor circulation , Confusion, Coordination problems, Insomnia, Memory loss, Stress , Tremoi , Walking difficulty or disorder, Heartburn/reflux/ulcers, Nausea/vomiting and Aching

muscles, Back pain/disc disease, Foot pain/problems , Joint pain/stiffness, Leg cramps/spasms, Neck pain/stiffness . PHYSICAL EXAM Constitutional: Vital si gns~ Blood pressure-134/94. Pulse 90.

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