Apa Case Study

DDS determined the claimant is disabled at step 5 of sequential evaluation; however, a denial is warranted.
CASE DISCUSSION & POLICY ANALYSIS (INCLUDING SPECIFIC REFERENCES)
This 57-year-old claimant is filing a DIB claim alleging disability since 07/15/2016 due to multiple medical conditions including anxiety and depression.
The evidence in file shows the claimant has a history of anxiety and depression. She is prescribed mild psychotropic medication from her primary care manger. At the mental status exam, she indicated she has been in and out of treatment since the death of her mother in in 1986. At the exam, she denied homicidal and suicidal ideals. Her thoughts were linear and memory was unimpaired. The examiner indicated she was functioning with average intelligence and her judgment and insight were fair. The examiner opined the claimant would have mild difficulty with complex tasks, and no difficulty with simple tasks.
The functional report shows the claimant spends time with friends and family attend church and is able to go out alone. She has some issues with memory and concentration, but she is able to concentrate up to 45 minutes.
The DDS also prepared a MRFC, which indicated that the claimant should be generally able to sustain concentration and persist at range of occupational tasks within physical tolerances and skill levels. The evidence in file reasonably supports the DDS’ physical RFC. Based on the psychiatric evidence in file, the claimant retains the ability to understand, remember and follow simple, detailed, and complex instructions with adequate concentration, persistence and