Moses v. Berryhill, No. 3:2016cv06581 - Document 13 (S.D.W. Va. 2017)

Court Description: MEMORANDUM OPINION denying Plaintiff's 11 Brief in Support of Judgment on the Pleadings, granting Defendant's 12 Brief in Support of Judgment on the Pleadings/Defendant's Decision; and dismissing this action from the docket of the Court. Signed by Magistrate Judge Cheryl A. Eifert on 5/22/2017. (cc: counsel of record) (jsa)

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Moses v. Berryhill Doc. 13 IN TH E U N ITED STATES D ISTRICT COU RT FOR TH E SOU TH ERN D ISTRICT OF W EST VIRGIN IA H U N TIN GTON D IVISION AN GELA D AW N MOSES, Plain tiff, v. Cas e N o .: 3 :16 -cv-0 6 58 1 N AN CY A. BERRYH ILL, 1 Actin g Co m m is s io n e r o f th e So cial Se cu rity Ad m in is tratio n , D e fe n d an t. MEMORAN D U M OPIN ION This is an action seeking review of the decision of the Com m issioner of the Social Security Adm inistration (hereinafter the “Com m issioner”) denying plaintiff’s application for supplem ental security incom e (“SSI”) under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1383f. This case is presently before the Court on the parties’ m otions for judgm ent on the pleadings as articulated in their briefs. (ECF Nos. 11, 12). Both parties have consented in writing to a decision by the United States Magistrate J udge. (ECF Nos. 7, 8). The Court has fully considered the evidence and the argum ents of counsel. For the reasons that follow, the Court finds that the decision of the Com m issioner is supported by substantial evidence and should be affirm ed. 1 Pursuant to 42 U.S.C. § 40 5(g) and Rule 25(d) of the Federal Rules of Civil Procedure, the current Acting Com missioner of the Social Security Adm inistration, Nancy A. Berryhill, is substituted for form er Acting Com missioner Carolyn W. Colvin as Defendant in this action. 1 Dockets.Justia.com I. Pro ce d u ral H is to ry Plaintiff, Angela Dawn Moses (hereinafter referred to as “Claim ant”), com pleted an application for SSI benefits on August 7, 20 12, alleging a disability onset of Decem ber 12, 20 0 4 2 due to “Psychological problem s, back lum bar problem s, ibs [IBSIrritable Bowel Syndrom e], vision, back injury, depression, anxiety, m igraines, knee problem s, shoulder problem s, hands, [and] allergies.” (Tr. at 216). The Social Security Adm inistration (“SSA”) denied the application initially and upon reconsideration. (Tr. at 11). On May 23, 20 13, Claim ant filed a written request for an adm inistrative hearing, which was held on Novem ber 10 , 20 14 before the Honorable Maria Hodges, Adm inistrative Law J udge (“ALJ ”). (Tr. at 31-64). By decision dated Novem ber 20 , 20 14, the ALJ determined that Claim ant was not entitled to benefits.3 (Tr. at 11-25). The ALJ ’s decision becam e the final decision of the Com m issioner on May 20 , 20 16, when the Appeals Council denied Claim ant’s request for review. (Tr. at 1– 3). On J uly 21, 20 16, Claim ant brought the present civil action seeking judicial review of the adm inistrative decision pursuant to 42 U.S.C. § 40 5(g). (ECF No. 2). The Com m issioner filed an Answer and a Transcript of the Proceedings. (ECF Nos. 9, 10 ). Thereafter, the parties filed their briefs in support of judgm ent on the pleadings, each requesting relief on her behalf. Consequently, this m atter is fully briefed and ready for resolution. 2 At the adm inistrative hearing held on November 10 , 20 14, Claim ant am ended her onset date of disability to August 7, 20 12, the date of her application. (Tr. at 37). 3 Claim ant previously filed for DIB and SSI benefits on December 7, 20 0 6, which were denied initially and upon reconsideration on April 5, 20 0 7 and Septem ber 26, 20 0 7, respectively. Claim ant received an unfavorable decision from ALJ Rosanne Dum mer (“ALJ Dum m er”) on August 6, 20 0 9, which was subsequently affirm ed by the Appeals council on August 26, 20 10 , and by U.S. District Court on J anuary 5, 20 11. (Tr. at 11). 2 II. Claim an t’s Backgro u n d Claim ant was 35 years old at the tim e of the adm inistrative hearing and the ALJ ’s decision. (Tr. at 36). She has at least high school education and is able to com m unicate in English. (Tr. at 36, 215, 217). Claim ant previously worked as a hom e health caregiver, cleaner, restaurant worker, and cashier. (Tr. at 38-42, 218). III. Su m m ary o f ALJ’s Fin d in gs Under 42 U.S.C. § 423(d)(5), a claim ant seeking disability benefits has the burden of proving disability, defined as the “inability to engage in any substantial gainful activity by reason of any m edically determ inable im pairm ent which can be expected to last for a continuous period of not less than 12 m onths.” 42 U.S.C. 423(d)(1)(A). The Social Security Regulations establish a five-step sequential evaluation process for the adjudication of disability claim s. If an individual is found “not disabled” at any step of the process, further inquiry is unnecessary and benefits are denied. 20 C.F.R. § 416.920 . The first step in the sequence is determ ining whether a claim ant is currently engaged in substantial gainful em ploym ent. Id. § 416.920 (b). If the claim ant is not, then the second step requires a determ ination of whether the claim ant suffers from a severe im pairm ent. Id. § 416.920 (c). If severe im pairm ent is present, the third inquiry is whether this im pairm ent m eets or equals any of the im pairm ents listed in Appendix 1 to Subpart P of the Adm inistrative Regulations No. 4. Id. § 416.920 (d). If the im pairm ent does, then the claim ant is found disabled and awarded benefits. However, if the im pairm ent does not, the adjudicator m ust determ ine the claim ant’s residual functional capacity (“RFC”), which is the m easure of the claim ant’s ability to engage in substantial gainful activity despite the lim itations of his or her 3 im pairm ents. Id. § 416.920 (e). After m aking this determ ination, the next step is to ascertain whether the claim ant’s im pairm ents prevent the perform ance of past relevant work. Id. § 416.920 (f). If the im pairm ents do prevent the perform ance of past relevant work, then the claim ant has established a prim a facie case of disability, and the burden shifts to the Com m issioner to establish, as the final step in the process, that the claim ant is able to perform other form s of substantial gainful activity, when considering the claim ant’s rem aining physical and m ental capacities, age, education, and prior work experiences. Id. § 416.920 (g); see also McLain v. Schw eiker, 715 F.2d 866, 868-69 (4th Cir. 1983). The Com m issioner m ust establish two things: (1) that the claim ant, considering his or her age, education, skills, work experience, and physical shortcom ings has the capacity to perform an alternative job, and (2) that this specific job exists in significant num bers in the national econom y. McLam ore v. W einberger, 538 F.2d. 572, 574 (4th Cir. 1976). When a claim ant alleges a m ental im pairm ent, the Social Security Adm inistration (“SSA”) “m ust follow a special technique at every level in the adm inistrative review.” 20 C.F.R. § 416.920 a. First, the SSA evaluates the claim ant’s pertinent signs, sym ptom s, and laboratory results to determ ine whether the claim ant has a m edically determ inable m ental im pairm ent. If such im pairm ent exists, the SSA docum ents its findings. Second, the SSA rates and docum ents the degree of functional lim itation resulting from the im pairm ent according to criteria specified in 20 C.F.R. § 416.920 a(c). Third, after rating the degree of functional lim itation from the claim ant’s im pairm ent(s), the SSA determ ines the severity of the lim itation. A rating of “none” or “m ild” in the first three functional areas (activities of daily living, social functioning, and concentration, persistence or pace) and “none” in the fourth (episodes of 4 decom pensation) will result in a finding that the im pairm ent is not severe unless the evidence indicates that there is m ore than m inim al lim itation in the claim ant’s ability to do basic work activities. 20 C.F.R. § 416.920 a(d)(1). Fourth, if the claim ant’s im pairm ent is deem ed severe, the SSA com pares the m edical findings about the severe im pairm ent and the rating and degree and functional lim itation to the criteria of the appropriate listed m ental disorder to determ ine if the severe im pairm ent m eets or is equal to a listed m ental disorder. 20 C.F.R. § 416.920 a(d)(2). Finally, if the SSA finds that the claim ant has a severe m ental im pairm ent, which neither m eets nor equals a listed m ental disorder, the SSA assesses the claim ant’s residual function. 20 C.F.R. § 416.920 a(d)(3). The Regulation further specifies how the findings and conclusion reached in applying the technique m ust be docum ented at the ALJ and Appeals Council levels as follows: The decision m ust show the significant history, including exam ination and laboratory findings, the functional lim itations that were considered in reaching a conclusion about the severity of the m ental im pairm ent(s). The decision m ust include a specific finding as to the degree of lim itation in each functional areas described in paragraph (c) of this section. 20 C.F.R. § 416.920 a(e)(4). In this case, the ALJ determ ined that Claim ant satisfied the first inquiry because she had not engaged in substantial gainful activity since August 7, 20 12. (Tr. at 13-14, Finding No. 1). Under the second inquiry, the ALJ found that Claim ant suffered from the severe im pairm ents of obesity, degenerative disc disease, Irritable Bowel Syndrom e (IBS), Bipolar Disorder, Anxiety-related Disorder, and Alcohol Abuse in remission.” (Tr. at 14-15, Finding No. 2). However, the ALJ found that Claim ant’s im pairm ents of endom etriosis, polycystic ovarian syndrom e, diabetes m ellitus, hypertension, headaches, and vision issues were non-severe. (Tr. at 14-16). 5 At the third inquiry, the ALJ concluded that Claim ant’s im pairm ents did not m eet or equal the level of severity of any im pairm ent contained in the Listing. (Tr. at 16-19, Finding No. 3). Consequently, the ALJ determ ined that Claim ant had the RFC to: [P]erform m edium work as defined in 20 CFR 416.967(c) except should never clim b ladders, ropes, or scaffolds; can frequently clim b ram ps/ stairs, balance, stoop, kneel or crouch; occasionally crawl; should avoid concentrated exposure to tem perature extrem es, hazards, and vibration; is lim ited to understanding, rem em bering and carrying out sim ple instructions in a work setting involving occasional interaction with others; and low-stress work, defined as no fast-paced production rate or strict tim e lim its. (Tr. at 19-23, Finding No. 4). Based upon the RFC assessm ent, the ALJ determ ined at the fourth step that Claim ant was unable to perform her past relevant work. (Tr. at 23, Finding No. 5). Under the fifth and final inquiry, the ALJ reviewed Claim ant’s prior work experience, age, and education in com bination with her RFC to determine if she would be able to engage in substantial gainful activity. (Tr. at 24, Finding Nos. 6-8). The ALJ considered that (1) Claim ant was born in 1979 and was defined as a younger individual; (2) she had at least a high school education and could com m unicate in English; and (3) transferability of job skills was not m aterial to the disability determ ination because using the Medical-Vocational Rules supported a finding that the Claim ant is “not disabled,” whether or not the Claim ant had transferable job skills. (Id.). Given these factors, Claim ant’s RFC, and the testim ony of a vocational expert, the ALJ determ ined that Claim ant could perform jobs that existed in significant num bers in the national econom y. (Tr. at 24-25, Finding No. 9). At the light level, Claim ant could work as a garm ent bagger or hotel m aid; and at the m edium level, Claim ant could work as a laundry worker or night cleaner and at the sedentary level, Claim ant could work 6 as an inspector or assem bler. (Id.). Therefore, the ALJ concluded that Claim ant was not disabled as defined in the Social Security Act. (Tr. at 25 Finding No. 10 ). IV. Claim an t’s Ch alle n ge s to th e Co m m is s io n e r’s D e cis io n Claim ant asserts two challenges to the Com m issioner’s decision. First, she claim s that the ALJ failed to consider the com bined effect of Claim ant’s im pairm ents when determ ining her RFC. (ECF No. 11 at 4-6). As part of this challenge, Claim ant argues that the ALJ erred by finding that Claim ant’s statem ents regarding the severity and persistence of her pain, fatigue, and other sym ptom s were not fully credible. (Id. at 6). According to Claim ant, her statem ents and the objective evidence are m utually supportive of a finding of disability under the Social Security Act; therefore, the statem ents are entitled to full credibility. Second, Claim ant contends that the ALJ ’s RFC finding is not supported by substantial evidence, because the ALJ ’s discussion is internally inconsistent. Specifically, Claim ant points to the sum m ary RFC finding set forth on page 19 of the transcript, which indicates that Claim ant is capable of less than a full range of m edium level work, and com pares it to a statem ent in the associated discussion at page 21, which states that Claim ant is restricted “to a reduced range of light work.” (Tr. at 21) (em phasis added). Claim ant argues that both statem ents cannot be correct and questions which RFC finding was intended by the ALJ . In response to Claim ant’s criticism s, the Com m issioner asserts that the ALJ clearly considered all of Claim ant’s im pairm ents when analyzing her RFC. (ECF No. 12 at 9-12). The Com m issioner argues that the ALJ ’s com prehensive RFC discussion included an analysis of all of Claim ant’s functional lim itations that were established by the record, and also accounted for all of those lim itations in the RFC finding. The Com m issioner rejects Claim ant’s credibility argum ent, em phasizing that the ALJ 7 provided m ultiple reasons for discounting the severity of sym ptom s described by Claim ant. (Id. at 10 ). With respect to Claim ant’s argum ent regarding the internal inconsistency of the RFC discussion, the Com m issioner apparently m isunderstood the argum ent, because she failed to directly address the discrepancy between the two exertional findings in the RFC section of the written decision. Instead, the Com m issioner discusses all of the evidence that supports the ALJ ’s determ ination that Claim ant could perform a reduced range of m edium level work. (Id. at 11-13). V. Sco p e o f Re vie w The issue before this Court is whether the final decision of the Com m issioner denying Claim ant’s application for benefits is supported by substantial evidence. In Blalock v. Richardson, the Fourth Circuit Court of Appeals defined substantial evidence as: Evidence which a reasoning m ind would accept as sufficient to support a particular conclusion. It consists of m ore than a m ere scintilla of evidence but m ay be som ewhat less than a preponderance. If there is evidence to justify a refusal to direct a verdict were the case before a jury, then there is “substantial evidence.” 483 F.2d 773, 776 (4th Cir. 1972) (quoting Law s v. Celebrezze, 368 F.2d 640 , 642 (4th Cir. 1966)). Additionally, the Com m issioner, not the court, is charged with resolving conflicts in the evidence. Hay s v. Sullivan, 90 7 F.2d 1453, 1456 (4th Cir. 1990 ). The Court will not re-weigh conflicting evidence, m ake credibility determ inations, or substitute its judgm ent for that of the Com m issioner. Id. Instead, the Court’s duty is lim ited in scope; it m ust adhere to its “traditional function” and “scrutinize the record as a whole to determ ine whether the conclusions reached are rational.” Oppenheim v. Finch, 495 F.2d 396, 397 (4th Cir. 1974). Thus, the ultim ate question for the Court is not whether the Claim ant is disabled, but whether the decision of the Com m issioner 8 that the Claim ant is not disabled is well-grounded in the evidence, bearing in mind that “[w]here conflicting evidence allows reasonable m inds to differ as to whether a claim ant is disabled, the responsibility for that decision falls on the [Com m issioner].” W alker v. Bow en, 834 F.2d 635, 640 (7th Cir. 1987). VI. Re le van t Me d ical Re co rd s The Court has reviewed the Transcript of Proceedings in its entirety, including the m edical records in evidence, and sum m arizes below Claim ant’s m edical treatm ent and evaluations to the extent that they are relevant to the issues in dispute. A. Tr e a t m e n t R e co r d s On April 28, 20 11, Claim ant was exam ined by Ricardo Roa, M.D., in preparation for nasal septoplasty, endoscopy, tonsillectom y, and adenoidectom y. (Tr. at 30 2-0 4). Claim ant’s current m edical issues included adenoid hypertrophy, benign neoplasm of the soft palate, deviated nasal septum , hypertrophied nasal turbinate, sinusitis, and tonsillar hypertrophy. Her past m edical history included arthritis, depression with anxiety, otitis m edia, and sinusitis. Claim ant presented with norm al m ood and affect. A CT scan of the sinuses taken on March 21 revealed m inim al m ucosal thickening of the right m axillary and left sphenoid air cells with m inim al leftward deviation of the nasal septum . A CT scan of the neck showed a subtle polypoid nodule projecting from the soft palate just to the right of the m idline that m ight represent a superficial m ucosal inclusion cyst. There appeared a possible cem entom a near the first m axillary m olar. The surgery was perform ed on May 4, 20 11. (Tr. at 298-30 0 ). The post-operative diagnosis included lesion of the palate, chronic tonsillitis, adenotonsillar hypertrophy, chronic sinusitis, nasal obstruction, nasal septal deviation, bilateral inferior turbinate hypertrophy, and failure of m edical m anagem ent. 9 On August 25, 20 11, Claim ant presented to her prim ary care physician, Daniel Whitm ore, D.O., with com plaints of fatigue and persistent low back pain for the past two to three years. (Tr. at 410 ). Claim ant reported that she took Tylenol and Motrin for pain, and they provided som e relief. On exam ination, Claim ant weighed two hundred twenty-nine pounds with a blood pressure of 127/ 84. Claim ant was alert and had an appropriate m ood. Her physical exam ination was otherwise unrem arkable, except for som e pain elicited on palpation of her dorsolum bar spine and paraspinal m uscles. She did not have evidence of scoliosis, and her straight leg raise was negative. Claim ant was assessed with lum bago and was told to lose weight. She was also assessed with fatigue due to weight gain and depression, although Dr. Whitm ore felt Claim ant’s depression was under control with Celexa and hydroxyzine. Dr. Whitm ore ordered x-rays of Claim ant’s thoracic and lum bar spine that were perform ed on August 29, 20 11. (Tr. at 421). The thoracic spine x-ray dem onstrated norm al spinal alignm ent with no evidence of acute fracture and well-preserved vertebral body heights and disc spaces. The lum bar spine x-ray showed Grade I anterolisthesis of the L5-S1, secondary to bilateral pars defects; however, no acute fracture was seen. Claim ant returned to Dr. Whitm ore on Septem ber 22, 20 11 inform ing him that she had undergone physical therapy and chiropractic care for back pain that gave her very little relief. Nonetheless, Claim ant advised Dr. Whitm ore that she was no longer having back pain. (Tr. at 40 9). Claim ant was assessed with resolved back pain and encouraged to lose weight and go for daily walks. The following m onth, on October 27, 20 11, Claim ant presented to Robert Lowe, M.D., with com plaints of pain from her “neck to her tail,” causing her legs to give out and go num b.(Tr. at 369-71). Claim ant described the back pain as radiating into the 10 neck area, bilateral hips and legs along with num bness and tingling in the arm s, legs, and feet. She also com plained of bowel and bladder issues, as well as urinary tract infections. Claim ant reported having ongoing back pain for several years that began when she injured her back lifting a 15-pound bucket at work. Claim ant denied dizziness, abdom inal pain, blurred vision, or bleeding. A review of system s was determ ined to be within norm al lim its. On exam ination, Claim ant m easured five feet, seven inches in height and weighed two hundred twenty-eight pounds. She was pale and walked with a lim p, but could bear weight equally. Claim ant flexed forward eighty degrees and could lateral bend twenty-five degrees; however, her extension was stiff. Her reflexes appeared intact at the knees and ankles, and her toe extensors were strong. Straight leg raise while seated m easured ninety degrees bilaterally, and while supine, m easured eighty degrees bilaterally. Sensation appeared less in the right leg; however, there was no derm atom e pattern. Dr. Lowe thought he would find a stocking pattern, which he did, but to a lesser degree. There were no real trigger points located in Claim ant’s back. Her thigh and calve circumferences were sym m etrical. Dr. Lowe opined that Claim ant had L5-S1 25% spondylolisthesis. Although Dr. Lowe could not visualize this on plain xrays, he observed that Claim ant m oved at L5-S1 and the disc heights were subtly increased in height, which was com patible with a potential m al-absorption syndrom e that could explain her head to toe pain. Claim ant was diagnosed with spondylolisthesis and low back pain. For treatm ent, Dr. Lowe prescribed a lum bosacral support brace, as he did not elicit any physical findings that warranted surgical intervention. Dr. Lowe felt a positive Knudsen sign at L5-S1 with disc degeneration and narrowing of the disc m ight also be a source of the back pain. Dr. Lowe did not believe Claim ant’s back pain 11 would be altered by m ore conditioning; however, he would consider physical therapy for Claim ant in the future. Claim ant returned to Dr. Lowe on Novem ber 17, 20 11. (Tr. at 367-68). Laboratory reports revealed that Claim ant had a low level of Vitam in D. Claim ant continued to com plain of constant neck and back pain causing her legs to give out and go num b. Claim ant also reported bowel issues; however, she had never received m edical treatm ent for this, and a review of system s was negative for abdom inal pain, nausea, or vom iting. Claim ant’s gastrointestinal system was noted to be within norm al lim its. Her physical exam ination was also norm al. Claim ant was prescribed Vitam in D and instructed to return in six m onths. Claim ant presented to Sanjay Masilam ani, M.D., on Decem ber 5, 20 11 with com plaints of anxiety and depression. (Tr. at 391-96). Claim ant reported that her psychological sym ptom s began in her twenties and were related to fam ily issues. She had never seen a psychiatrist, but she had previously received counseling. Claim ant began drinking alcohol in her teens, causing her to build up a tolerance; however, Claim ant reported that she no longer drank alcohol and had not done so for over three years. Claim ant described her sym ptom s as m ania, not being able to sleep, elevated energy, racing thoughts, irritability, fatigue, m uscle aches, and agoraphobia. Claim ant was being prescribed Celexa and hydroxyzine, noting these m edications were helpful, but her insurance no longer covered them . On exam ination, Claim ant was cooperative with good eye contact, norm al speech, and no evidence of psychom otor agitation. She showed logical and coherent thought processes. Her affect appeared restricted; her m ood was irritable and depressed; and her judgm ent and insight were lim ited. Claim ant was assessed with bipolar disorder, type 1; generalized anxiety disorder; full, 12 sustained rem ission of alcohol abuse; and agoraphobia without history of panic disorder. Dr. Masilam ani felt that borderline intellectual functioning versus m ental retardation should also be ruled out. He gave Claim ant a Global Assessm ent of Functioning (“GAF”) score of 65-70 .4 He docum ented that Claim ant was having a difficult tim e dealing with the loss of fam ily m em bers, but she was not suicidal at the tim e. Dr. Masilam ani talked to Claim ant about following up with a therapist in addition to providing her with a prescription for Lam ictal. Claim ant was advised to return in one m onth. Claim ant presented to Dr. Masilam ani on J anuary 16, 20 12 reporting no side effects from her m edication. Since increasing her dosage of Lamictal, her irritability had slightly im proved. (Tr. at 389-90 ). Dr. Masilam ani recorded that Claim ant was wearing a back brace, was cooperative, and showed no sign of psychom otor agitation. However, her m ood was “jum py” and her affect was slightly restricted. Claim ant did say she had m et with a therapist, J essica William s, and felt it was very helpful. Claim ant dem onstrated norm al speech, logical thought processes, and fair insight and judgm ent. Dr. Masilam ani increased the dosage of Lam ictal in addition to scheduling Claim ant for m ore therapy with Ms. William s. As Claim ant com plained of sleep issues, her hydroxyzine dosage was increased. 4 The Global Assessm ent of Functioning (“GAF”) Scale is a 10 0 -point scale that rates “psychological, social, and occupational functioning on a hypothetical continuum of m ental health-illness,” but “do[es] not include im pairm ent in functioning due to physical (or environm ental) lim itations.” Diagnostic Statistical Manual of Mental Disorders, Am . Psych. Assoc., 34 (4th ed. text rev. 20 0 0 ) (“DSM– IV”). On the GAF scale, a higher score correlates with a less severe im pairm ent. The GAF scale was abandoned as a m easurem ent tool in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed. 20 13) (“DSM– 5”), in part due to its “conceptual lack of clarity” and its “questionable psychom etrics in routine practice.” DSM– 5 at 16. A GAF score between 61 and 70 indicates “[s]om e m ild sym ptom s (e.g., depressed m ood and m ild insomnia) OR som e difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has som e m eaningful interpersonal relationships.” DSM– IV at 34. 13 Claim ant was exam ined by Ben Edwards, M.D., on February 1, 20 12, for com plaints of pelvic discom fort. (Tr. at 320 -24). On a review of sym ptom s, Claim ant denied having fatigue, m alaise, headache, gastrointestinal issues, genitourinary com plaints, endocrine abnorm alities, or psychological distress. (Tr. at 322). Her physical exam ination was entirely norm al. Claim ant weighed two hundred forty-seven pounds, and her blood pressure was 122/ 80 . Claim ant displayed a euthym ic m ood, appearing alert and in no distress. Upon exam ination, Claim ant had no abdom inal tenderness; her bladder, urethra and uterus were norm al. Claim ant was assessed with candida albecans vaginitis, vaginal candidiasis, and contraceptive m anagem ent. Claim ant was provided prescriptions for Enpresse and Fluconazole. On February 16, 20 12, Claim ant returned to Dr. Masilam ani reporting that the increase in Lam ictal helped stabilize her m ood. (Tr. at 386-88). Overall Claim ant believed she was “functioning better.” Her issues with sleep were im proved with hydroxyzine. Claim ant described a slightly depressed m ood, which she attributed to a recent loss of fam ily m em bers, although she reported she was coping well. Claim ant had m et with Ms. William s and used som e of the therapist’s ideas of how to change things at Claim ant’s hom e, such as re-arranging the furniture in her and her daughter’s room s. Claim ant’s assessm ent was unchanged, and her m edication regim en rem ained the sam e, as it appeared to be controlling her sym ptom s. On March 14, 20 12, Claim ant presented to St. Mary’s Medical Center after having been assaulted by a fam ily m em ber. (Tr. at 338-47). Claim ant com plained of m oderate pain caused by blows to her head. Although she did not lose consciousness, Claim ant felt “dazed.” In addition, Claim ant com plained of a headache and nausea, but no num bness, loss of vision, dizziness, hearing loss, chest pain, difficulty breathing, 14 weakness, abdom inal pain or vom iting. On exam ination, her right tem ple was m oderately tender and m ildly swollen; however, there was no Battle’s sign and no “raccoon” eyes. Claim ant’s neck was supple, non-tender, and displayed norm al range of m otion. Claim ant had m ild, soft tissue tenderness in the right and left lower lum bar area. The rem ainder of her exam ination was unrem arkable. A CT scan of Claim ant’s head revealed a nearly total opacified left m axillary sinus, but no traum atic findings were seen. (Tr. at 344). An x-ray of the lum bar spine revealed an L5 spondylolysis with grade 1 spondylolistheses at L5-S1. This finding had not changed since Septem ber 20 0 9 when a prior film was perform ed. The rem ainder of the findings were unrem arkable. (Tr. at 343). Claim ant was assessed with m inor closed head injury resulting from a physical assault and sinusitis. Claim ant was provided ibuprofen, Augm entin, and Ultram , advised to apply ice to the head injury, and told to drink fluids. Claim ant was discharged in good condition. Claim ant returned to Holzer Clinic on March 29, 20 12 for evaluation of her sinuses. (Tr. at 358-61). She com plained of nasal congestion, postnasal drainage, frontal headache, and pain in both ears. Claim ant also reported decreased bilateral hearing as well as yellow drainage noting the pain was constant and dull both inside and behind her ears. On exam ination, Claim ant presented with norm al m ood and affect. There was sinus tenderness upon palpation in the bilateral m axillary regions. Otoscopy of the ears showed norm al auditory canals and tym panic m em branes with ETD bilaterally. Claim ant was assessed with postnasal drip, Eustachian tube dysfunction, allergic rhinitis, laryngitis, and pharyngitis. Claim ant was provided prescriptions for Zithrom ax, Astepro, and a Medrol Pak, in addition to a recom m endation of daily use of nasal wash and Alkalol. 15 On April 9, 20 12, Claim ant returned to Dr. Masilam ani. (Tr. at 384-85). Claim ant told Dr. Masilam ani that she felt depressed, rating her depression as four out of ten but overall, she continued to “function fair.” Claim ant expressed having difficulties with her sister and com plained that she could not visit her m other’s house as often because of her sister’s presence there. She com plained of headaches and reported to Dr. Masilam ani that she had been involved in a physical altercation with her sister. Claim ant was sleeping m ore, but her appetite was decreased. On exam ination, Claim ant m ade good eye contact, was cooperative, and had no psychom otor agitation. Her m ood was som ewhat depressed, and her affect was restricted. Claim ant had lim ited judgm ent and insight; however, her thought processes were logical, linear, and coherent. Claim ant was assessed with bipolar disorder, type 1; generalized anxiety disorder; alcohol abuse in full, sustained rem ission; agoraphobia without a history of panic disorder; and rule out borderline intellectual functioning. Claim ant’s m edication regim en of Lam ictal and Celexa rem ained unchanged. On April 17, 20 12, Claim ant presented to Dr. Whitm ore for follow-up of injuries received in the physical altercation with her sister. (Tr. at 40 8). Claim ant described pain that appeared to be post-concussive headaches, located in the right tem ple and top of her head. A physical exam ination was unrem arkable. Dr. Whitm ore assessed Claim ant with post-concussion headaches, allergic rhinitis, and elevated blood pressure. Claim ant was provided a prescription for Naproxen. Claim ant returned to Dr. Masilam ani on May 9 with com plaints of stress, low m ood (three out of ten on a ten-point scale), frustration, and irritability. (Tr. at 38283). On the plus side, Claim ant was tolerating her m edications well and sleeping well m ost of the tim e. She appeared fairly well groom ed and was cooperative, although she 16 m ade poor eye contact. Claim ant was alert and oriented with norm al speech and thought process; however, her judgm ent and insight were lim ited. Claim ant’s m ood was “som ewhat down,” and her affect slightly restricted. Claim ant’s diagnoses did not change. Her prescription for Lam ictal was increased to help ease her frustration and irritability. On May 17, 20 12, Claim ant presented to Dr. Lowe com plaining of back pain. (Tr. at 365-66). Although she wore a lum bar support brace that did offer som e relief, Claim ant continued to com plain of constant back pain that stem m ed from her “neck to her tail,” causing her legs to get num b and “give out.” (Tr. at 365). She reported that her back hurt when she did housework, such as laundry and cleaning floors. Claim ant told Dr. Lowe she had a lot of bowel problem s and been going to the bathroom quite a bit for several m onths; however, a review of system s was negative for abdom inal pain, nausea or vom iting, and her gastrointestinal system was within norm al lim its. On exam ination, Claim ant weighed two hundred forty-three pounds. Her blood pressure m easured 122/ 72. Claim ant walked without a lim p, flexed forward eighty degrees, extended twenty to twenty-five degrees, and could laterally bend twenty-five degrees. While seated and while supine, straight leg raising m easured ninety degrees bilaterally; however, there were obvious trigger points in the low back. While lying recum bent, Claim ant had som e pain across the back and had to roll to the side. Her diagnosis rem ained spondylolisthesis and low back pain. Dr. Lowe rem arked that the Claim ant was “doing rather well.” Claim ant was interested in physical therapy, which considering her status, Dr. Lowe felt was worth a try. He also felt however, that wearing her back brace when perform ing household tasks or prolonged activities would be beneficial. On the other hand, Dr. Lowe concluded that, ultim ately, as Claim ant was a 17 young wom an, she needed to work on building her m uscles as opposed to wearing the back brace. Claim ant was provided an order for physical therapy. Claim ant reported to Huntington Physical Therapy for an initial evaluation on May 21, 20 12. (Tr. at 372-74, 796-98). Claim ant told Kelly Akers, DPT, that in 20 0 3, while lifting buckets of ice at work, she hurt her low back and, since then, had bilateral leg to ankle sym ptom s. Claim ant stated that the pain m ade it difficult to walk. Her neurological status exam ination showed norm al sensation. However, m anual m uscle testing m easured 2+/ 5 strength in all m uscle groups. The m otion lim itation at the m ost sym ptom atic area of Claim ant’s low back segm ent was due to excessive stiffness and tissue resistance. Claim ant was scheduled for physical therapy, two tim es a week for a total of six weeks. Beginning on May 25, 20 12, Claim ant participated in nine physical therapy sessions: May 25, May 30 , J une 1, J une 5, J une 7, J une 12, J une 18, J une 22 and J une 26. (Tr. at 778-95). At the May sessions, Claim ant was not able to appreciate any change in her pain. The therapist felt Claim ant could benefit from increased strength to her transverse abdom inis m uscle to help stabilize the lum bar spine. At her J une 1 session, Claim ant reported increased pain in the groin after her last treatm ent. Claim ant had no complaints of num bness with bridges but continued to rely on her back brace to “stand up straight and bend over.” Claim ant did report she was com pliant with her hom e exercise program . On J une 5, Claim ant reported soreness from her low back to the bilateral glutes, rating the discom fort at eight on the ten-point pain scale. When asked about com pliance with hom e exercises, Claim ant responded “som e.” Claim ant presented to Dr. Masilam ani on J une 6, 20 12. (Tr. at 380 -81). Claim ant continued to tolerate her m edications with no side effects. She com plained of 18 decreased sleep due to pain, decreased appetite, and her m ood had been “up and down.” Claim ant attributed her increased pain to physical therapy. She reported trying to walk for exercise. Upon exam ination, Claim ant’s affect was restricted, her judgm ent and insight lim ited, and her m ood fluctuated. Claim ant’s assessm ent rem ained the sam e. Dr. Masilam ani increased Claim ant’s dosage of Lam ictal and encouraged her to try to go for daily walks. Continuing with physical therapy, on J une 7, Claim ant told the physical therapist she was able to finish one load of laundry before having to stop and rest. (Tr. at 786-87). On J une 12 Claim ant reported pain that radiated down the right leg which began the day before. During therapy, Claim ant com plained of pain in the left leg radiating to the knee. The left leg pain was centralized to the low back. (Tr. at 784-85). On J une 18, Claim ant reported she was feeling better rating her pain at rest as five out of ten. She experienced slight pain in the left leg the day before but it resolved that evening and she did not have any at this session. Upon finishing her session, Claim ant reported she was able to com plete all the exercises easier than last visit and her pain was reduced to four out of ten. The therapist recorded Claim ant did not com plain of radicular pain at rest or during therapy. (Tr. at 782-83). Claim ant returned to Dr. Lowe on J une 21, 20 12. (Tr. at 363-64). Claim ant had been receiving physical therapy for one m onth and was no worse, but according to Dr. Lowe, Claim ant had “a hard tim e saying she is better.” (Tr. at 363). Claim ant was not wearing her back brace at this appointm ent; however, she indicated that she norm ally wore it quite a bit. Claim ant com plained of pain that radiated from the neck to the bilateral hips and legs with num bness and tingling in her bilateral arm s, legs, and feet. Claim ant said she had not been wearing her brace as m uch as she should, noting that 19 she continued to have constant, low back pain m aking her legs weak and causing her legs to give out. She also reported bowel and bladder issues; however, a review of system s was negative for abdom inal pain, nausea or vom iting, and her gastrointestinal system was within norm al lim its. On exam ination, Claim ant could lie recum bent and prone with no com plaints. Her sitting straight leg raise was negative, but her supine straight leg raise was slightly reduced. When palpating her back over the L5-S1 area, and in the area where a free fragm ent should be found, there was no jum ping or reaction by Claim ant, nor was there any swelling or trigger points. Dr. Lowe discussed with Claim ant that, generally, non-operative care was preferred over surgery for treatm ent of spondylolisthesis. She was instructed to continue with her m edication and return in four m onths. At her J une 22 physical therapy session, Claim ant noted she was confused about continuing with physical therapy as her doctor had discussed surgery but also talked about continuing physical therapy, so she elected to keep this appointm ent. (Tr. at 780 81). Claim ant had increased pain, rated six out of ten, which had been constant for the past several days. She also reported radicular knee pain as well as occasional increase in pain after physical therapy that m ade her very uncom fortable and “puts [her] to bed.” At this visit, Claim ant wore her back brace, although she had not worn it at the prior visit. Claim ant dem onstrated som e increased radicular pain was not exacerbated by exercise. Finally, on J une 26, Claim ant reported no change in her pain level from her last visit. (Tr. at 778-79). She described the pain as radiating from her m id back to bilateral knees. She stated that hom e exercises did not alleviate her pain. During the session, Claim ant had worsening leg pain in som e positions, which radiated from her legs to her feet. Claim ant was placed on her back and after a short while, she 20 com plained of dizziness, ended the physical therapy session, and called her fam ily to com e get her. Claim ant followed up with Daniel Whitm ore, D.O., on J uly 17, 20 12, for her post- concussion headaches sustained after the altercation with her sister. (Tr. at 40 7). As the headaches were im proving, Dr. Whitm ore elected to avoid m aintenance therapy, instead, advising Claim ant to take Motrin as needed. Claim ant was also assessed with lum bago, knee pain, and GERD for which Claim ant was prescribed Dexilant. Claim ant returned to Dr. Masilam ani on J uly 26, 20 12. (Tr. at 378-79). On a scale of one to ten, Claim ant reported her m ood at a one. She was only getting three to four hours of sleep at night, causing her to nap throughout the day. Claim ant attributed this to her back pain, noting that participating in physical therapy only m ade it worse. Claim ant’s assessm ent rem ained the sam e. Dr. Masilam ani added Celexa to Claim ant’s m edication regim en. Claim ant saw Dr. Whitm ore on August 15, 20 12 with com plaints of exhaustion and lack of energy. (Tr. at 40 6). Claim ant’s physical exam ination was unrem arkable; however, Dr. Whitm ore noted that Claim ant wore a back brace. Dr. Whitm ore indicated Claim ant m ight require a psychiatric referral as depression could be a cause of her fatigue. The following week, on August 27, Claim ant presented to Dr. Masilam ani com plaining of lack of sleep and energy for the past two m onths. (Tr. at 375-77). At this visit, Claim ant weighed two hundred forty pounds with a blood pressure of 135/ 89. Claim ant advised that she had starting seeing a m ental health therapist again and was tolerating her m edications well. She described her m ood as antisocial and indicated that her m ost stressful issue was “fighting disability and getting her disability.” Dr. 21 Masilam ani diagnosed Claim ant with bipolar disorder, type 1; generalized anxiety disorder; alcohol abuse in full sustained rem ission; agoraphobia without panic disorder; and rule out borderline intellectual functioning. Claim ant was advised to continue therapy to im prove her coping skills, and Trazodone was added to her m edication regim en to treat insom nia. Claim ant returned to Dr. Masilam ani on Septem ber 27, reporting that the Trazodone helped som e with her sleeping issues. (Tr. at 50 3-0 4). She rated her m ood as four out of ten and com m ented that if she could sleep through the night, her m ood would m ost likely im prove. Consequently, Dr. Masilam ani increased the Trazodone dosage to alleviate Claim ant’s sleep and m ood issues. On October 18, 20 12, Claim ant was seen by Larry Hagan, M.D., for treatm ent of chronic, recurrent sinus issues. (Tr. at 456-58). Claim ant reported she had suffered chronic sinus infections since the age of 12. She also coughed at night and wheezed with exercise or respiratory infections; however, she had never been diagnosed with asthm a. Claim ant had an eight year history of chronic urticarial (skin rash causing itch and som etim es swelling) and recurrent angioedem a (rash sim ilar to hives) that were recurrent, m igratory, pruritic and resolved without sequellae. Claim ant also reported a history of recurrent ear and urinary tract infections. A review of system s was positive for GERD; however, Claim ant denied nausea, vom iting, diarrhea or any sym ptom s of IBS. Claim ant reported a history of joint pain and m yalgia. Claim ant was assessed with non-allergic rhinitis, chronic sinusitis, chronic urticarial/ angioedem a, recurrent sinus, otitis m edia and urinary tract infections, and possible asthm a. Claim ant was scheduled for allergy tests and a chest x-ray, as well as provided a prescription for Allegra, Plaquenil, and Vistaril. 22 Claim ant reported to Matthew C. Wilson, M.D., on October 18, 20 12, for allergy and pulm onary function tests. (Tr. at 459-62). The spirom etry test revealed no significant sign of obstructive pulm onary im pairm ent or restrictive ventilator defect. Claim ant did not test positive for any inhalant allergies. On October 23, 20 12, Claim ant returned to Dr. Lowe, com plaining of back pain and left leg pain. (Tr. at 431-32). The pain was located in the neck and radiated to the bilateral hips and legs. It was worse on the left side and was associated with bilateral num bness and tingling in the arm s, legs, and feet. Claim ant reported bowel and bladder problem s that had been ongoing for years; however, she did not receive treatm ent for those issues. A review of system s was negative for abdom inal pain, vom iting, or nausea, and Claim ant’s gastrointestinal system was found to be within norm al lim its. She reported that the pain in her low back was increasing and that participating in physical therapy only m ade it worse. Claim ant also com plained of weakness in her legs that caused them to go num b and “give out.” Her m edications included Em presse, Celexa, Vitam in D, hydroxyzine, Nasonex, cetirizine, Lam ictal, Astelin, Dexilant, Calcium , m ultivitam in, and naproxen. On exam ination, Claim ant walked with an erect posture and could bear weight equally. Straight leg raising while seated m easured ninety degrees bilaterally and eighty degrees bilaterally while supine. Her toe extensors were strong, and pedal pulses were intact. Her knee and ankle reflexes were found intact. Claim ant described having “no feeling” in her feet, legs, and at her waist. She did have sensation in a circle around her body at the bottom of her chest between the chest and um bilicus. Dr. Lowe described this as “alm ost a hysterical type pattern.” An x-ray of the thoracic spine did not reveal widening of the pedicles or any unusual findings. An x-ray of the lum bar 23 spine showed L5-S1 spondylolisthesis as well as a loss of height of the L5-S1 disc space with a positive Knudsen sign. The slippage was nearly twenty percent. The rem aining discs were m aintained. Claim ant was assessed with spondylolisthesis, low back pain, thoracic back pain (non-injury), and osteopenia. She was advised to continue with the current treatm ent plan, including taking Vitam in D. Dr. Lowe felt surgical intervention was not indicated at this tim e, as surgical intervention on spondylolisthesis with a patient experiencing a hysterical sensory pattern would provide unpredictable results. Claim ant was given an exercise program to help with core strength and was told to continue wearing her back brace. On October 29, 20 12, Claim ant reported to Dr. Masilam ani that she was still having sleep issues, stating that she was not getting as m uch sleep as she used to get. Although her m ood was slightly agitated (rating it five out of ten), she was “overall okay.” (Tr. at 50 5-0 6). Claim ant rated her m ultiple doctor visits, m edical tests, and increased pain as the m ost stressful events in her life. On exam ination, Claim ant’s m ood was “in the m iddle” and her affect slightly restricted. Claim ant dem onstrated thought processes that were logical, linear, and coherent, but her judgm ent and insight were lim ited. Dr. Masilam ani increased the Trazodone dosage to help with sleep issues and advised Claim ant to go outside m ore—at least one to two tim es per day. Claim ant returned to Dr. Wilson on Novem ber 8, 20 12 with com plaints of congestion. (Tr. at 440 -43). Claim ant reported after her last visit with him , her toe, then chest and arm started to swell. She was seen in the em ergency room and told she had allergies, was placed on prednisone that resolved the issue eventually. Claim ant had negative results on all allergy skin tests. With the exception of history of joint pain and/ or m yalgia and “urinary problem s noted,” a review of system s was negative, 24 including no sym ptom s of IBS, no dysuria, hem aturia, polyuria, urinary urgency or hesitancy. A spirom etry test was adm inistered with negative results. Claim ant was assessed with non-allergic rhinitis, history of nasal polyps, chronic sinusitis, history of angioedem a/ urticarial and bipolar disorder. Dr. Lowe saw Claim ant on Novem ber 20 , 2o12. (Tr. at 429-30 ). He noted Claim ant wore her back brace and had been doing her hom e exercises, but according to Claim ant, there was no im provem ent. She com plained of constant back pain, weakness, and num bness in her legs that caused them to “give out,” and she had bowel problem s, ongoing for several m onths. A review of system s was negative for abdom inal pain, vom iting, nausea, and Claim ant’s gastrointestinal system was within norm al lim its. On exam ination, Dr. Lowe recorded Claim ant was “doing better.” Claim ant dem onstrated norm al m ovem ent with extension, as well as lateral bending m easuring twenty to twenty-five degrees. While seated, bilateral straight leg raise was negative. While supine, straight leg raise was tolerated to eighty degrees bilaterally. Sensation was intact in her feet, though “less than perfect,” and sensation in her abdom en between the pelvic and um bilicus, as well as in the back, was norm al. Claim ant was assessed with spondylolisthesis, low back pain, non-injury thoracic pain, and osteopenia. Dr. Lowe rem arked that the findings were as expected in a patient who had spondylolisthesis with superim posed hysterical, unexplained sensory pattern. Claim ant was advised to continue taking Naproxen and wear her back brace interm ittently. Dr. Lowe opined there was no special m edical treatm ent needed at this tim e. Claim ant continued m ental health treatm ent with Dr. Masilam ani on December 10 , 20 12. (Tr. at 50 7-0 8). Claim ant reported she was not feeling well and her m ood was 25 down due to back pain and fam ily issues; however, she reported her overall functioning was “ok.” Claim ant appeared depressed, with a broad, reactive affect. She was alert, m ade good eye contact, dem onstrated norm al speech and thought process, but her judgm ent and insight rem ained lim ited. Claim ant was diagnosed with alcohol abuse, in rem ission; bipolar disorder, type 1, m ost recent episode depressed; and generalized anxiety disorder. Claim ant was advised to continue taking her m edications and work with her therapist, and she was encouraged to exercise. Claim ant returned to Dr. Wilson on Decem ber 28, 20 12, with excessive nasal congestion and drainage. (Tr. at 433-34). A review of system s was unrem arkable other than history of joint pain or m yalgia and GERD. The review was negative for nausea, vom iting and diarrhea. There were no IBS sym ptom s, such as abdom inal cram ping, bloating, hem atochezia, m elena, or m ucoid bowel m ovem ent. Dr. Wilson noted Claim ant had negative results to all tests for inhalant and food allergies and a negative urticarial profile. Claim ant was assessed with probable acute sinusitis, chronic urticarial, and GERD. Claim ant was provided with a Medrol Dose Pak and Augm entin. Claim ant presented to Dr. Whitm ore on J anuary 17, 20 13. (Tr. at 467-68). She told him that, overall, she was “doing well.” Claim ant had lost nine pounds since her last visit. They discussed m eeting with the nutritionist to work-up a diet and exercise plan with a goal of exercise for forty-five m inutes a day. Claim ant was assessed with depression, (“doing very well on Celexa and hydroxyzine), GERD, (“doing well on Dexilant”), hyperglycem ia and hyperlipidemia, (to be treated with diet and exercise). On J anuary 23, 20 13, Claim ant was seen by Dr. Masilam ani. (Tr. at 50 9-10 ). She reported im proved sleep, even without taking trazodone, and a stable m ood, m ade better since she began to lose weight. Upon exam ination, Claim ant’s m ood was good 26 and her affect euthym ic. Claim ant was encouraged to start walking twenty m inutes a day for exercise, see the nutritionist, and m eet with her therapist. Claim ant was advised to continue her m edication regimen. Claim ant returned to Dr. Lowe on February 13, 20 13, reporting that her back sym ptom s rem ained the sam e. (Tr. at 472-73). A review of system s was within norm al lim its. On exam ination, Claim ant walked without a lim p, and had relatively good m obility of her back, intact reflexes at the ankles and knees, strong toe extensors, negative straight leg raise both supine and sitting, and no trigger points in the low back. Claim ant was advised to continue to work on strengthening her core and to return in two to three m onths. Claim ant saw Dr. Masilam ani on February 25, 20 13. (Tr. at 511-12). Claim ant reported her m ood was stable, rating it five to six out of ten. Also, she was not having any trouble sleeping, describing her sleep as “good.” At this visit, Claim ant weighed two hundred twenty-three pounds, and her blood pressure was 132/ 86. On exam ination, her m ood was fair, affect euthym ic, speech and thought process norm al, although her judgm ent and insight rem ained lim ited. Claim ant was encouraged to continue to walk for exercise, rem ain on her m edication, and take som e tim e for herself. On February 27, 20 13, Claim ant presented to Ben Edwards, M.D., for an annual gynecologic exam ination. (Tr. at 556-61). Claim ant com plained of pelvic pain. A review of system s was positive for abdom inal pain, pelvic pain, and painful periods with excessive bleeding, but was negative for abdom inal bloating, diarrhea, constipation, urinary urgency, anxiety, depression, or prem enstrual syndrom e. On exam ination, the abdom en was non-tender with no m asses found. The uterus was norm al in size with 27 no tenderness or m asses. Claim ant’s m ood and affect were norm al. Claim ant was assessed with dysm enorrhea, endom etriosis, and fem ale pelvic pain. Dr. Edwards prescribed Naproxen and Em presse and ordered an ultrasound to investigate her com plaints of pelvic pain. One m onth later, on March 27, Claim ant underwent a transvaginal ultrasound perform ed by William Burns, M.D. (Tr. at 554-55). The ultrasound revealed that Claim ant’s uterus was norm al in size with no evidence of m yom etrial lesion. The endom etrial stripe was well defined, following a norm al anatom ic course m easuring 4.9 m m in thickness. A tiny hyperechoic focus was found in the anterior endom etrium that was possibly a m iniscule polyp. Claim ant’s ovaries were norm al in size with no evidence of intra-ovarian or extra-ovarian adnexal lesion seen. The findings, other than the endom etrial finding, were found to be norm al. Claim ant returned to Dr. Edwards on April 17, 20 13 with com plaints of pelvic pain and m enoetrrhagia. (Tr. at 547-51). She described the onset of m oderate deep pelvic pain that was gradual over a period of m onths. A review of system s was positive for painful and irregular periods, and excessive bleeding during periods; however, it was negative for abdom inal pain, bloating, diarrhea, constipation or bright red blood from the rectum , anxiety, depression or prem enstrual syndrom e. Claim ant’s physical exam ination was unrem arkable, except for tenderness of the uterus. At this visit, Claim ant’s listed active problem s included arthritis, backache, bladder disorders, candida albicans vaginitis, change in stool, chest tightness, cholelithiasis, cholelithiasis with chronic cholecystitis, dysm enorrhea, endom etriosis, GERD, fem ale pelvic pain, polyuria, hay fever, headache, heart rate and rhythm , hem orrhoids, IBS, recent change in weight, vaginal candidiasis, and vision im pairm ent. Claim ant was scheduled for a 28 laparoscopy, D & C, and hysteroscopy that occurred on April 25. (Tr. at 530 -32).The post-operative diagnosis was m enom etrorrhagia and chronic pelvic pain, polycystic ovarian syndrom e, and endom etriosis. On April 23, 20 13, Claim ant was exam ined by Dr. Lowe with com plaints of back pain after doing housework. (Tr. at 678-79). She described the pain as radiating from her neck to her hips and legs, worse on the left. She had num bness and tingling in her arm s, legs, and feet. On exam ination, Claim ant walked without a lim p and had strong toe flexors and intact reflexes. Claim ant had no specific trigger points in the low back. While seated, her straight leg raise was negative, but while supine, it was lim ited to sixty-five degrees. Dr. Lowe rem arked that after her last visit, he was concerned about trunk conditioning; however, at this visit, Claim ant was able to get on and off the exam ining table with ease. Claim ant was able to sit with legs extended, the only problem being the positive supine straight leg raising in the form of tight ham string m uscles. Claim ant was advised to exercise and continue her m edications. Claim ant saw Dr. Masilam ani on April 29, 20 13 reporting that her m ood was stable, and she had no sleep issues; however, she was having pelvic pain due to endom etriosis and described the pain as ten out of ten. (Tr. at 744-46). On exam ination, Claim ant presented with a down m ood and euthym ic affect. Her weight at this visit was two hundred twenty-two pounds. Claim ant was encouraged to exercise and see her therapist, as well as continue with her m edication regim en. Claim ant returned to Dr. Edwards on May 15, 20 13 for post-surgical exam ination. (Tr. at 525-29). An exam ination of Claim ant’s abdom en was unrem arkable. Claim ant was assessed with endom etriosis and polycystic ovarian syndrom e. She was given a prescription for J olessa. 29 Claim ant saw Dr. Masilam ani on J uly 1, 20 13. (Tr. at 740 -43). Claim ant rated her sleep as “fair,” and her m ood stable, but with periods of irritability that she attributed to her physical health. On exam ination, Claim ant’s m ood was fair and her affect euthym ic. Claim ant was cooperative with norm al speech and thought process, and her judgm ent and insight were deem ed fair. Claim ant was advised to exercise, go out as m uch as possible, and continue her m edication regim en. On J uly 18, 20 13, Claim ant saw Dr. Whitm ore, rem arking to him that, overall, she was “doing well,” and had no specific com plaints. (Tr. at 771-72). Claim ant took Naproxen for back pain as needed. Her physical exam ination was unrem arkable other than som e acanthus nigricans of the skin. Claim ant was assessed with a history of L5S1 anterolisthesis and L5 spondylosis; however, at this tim e, Claim ant was stable with no “out of the ordinary” back pain. Claim ant was assessed with back pain; depression for which she received treatm ent from Dr. Masilam ani; allergic rhinitis; GERD that was controlled well with Dexilant; hyperglycem ia; and hyperlipidem ia. Claim ant returned to Dr. Lowe on J uly 23, 20 13, with com plaints of pain throughout her entire back, as well as occasional neck pain. (Tr. at 680 -81). She described the pain as radiating from her neck bilaterally to her hips and legs, worse on the right side. She had num bness and tingling in her feet, again worse on the right. Claim ant rated the pain as seven on a ten-point pain scale. She also com plained of bowel and bladder problem s; however, a review of system s was negative for abdom inal pain, nausea or vom iting, and her gastrointestinal system was within norm al lim its. On exam ination, Dr. Lowe noted that he was seeing Claim ant on a “good day.” She walked without a lim p, flexed forward to eighty degrees, extended twenty-five degrees, and could laterally bend twenty-five degrees. While seated, straight leg raise m easured 30 ninety degrees bilaterally and, while supine, eighty degrees bilaterally. The bowstring sign was negative. Range of m otion of the hips was norm al, and Claim ant’s sensation was intact. Dr. Lowe did not find any trigger points. Dr. Lowe felt that Claim ant could lim it wearing her back brace, using it if the pain were to flare up, or if she was going to walk for an extended tim e, such as when shopping at stores. Dr. Lowe opined that Claim ant was doing well and did not need to alter her m edication regim en. He urged her to continue being active. Claim ant returned to Dr. Masilam ani on August 5, 20 13, reporting that, overall, her m ood was stable despite having som e pain issues. (Tr. at 737-39). She reported that she was able to get adequate sleep and had no problem with appetite; in fact, she was trying to “eat better.” Claim ant’s exam ination rem ained unchanged from her last visit. She reported the m ost stress related to getting her child ready for school. Claim ant was advised to exercise, try to walk, m ake healthy dietary choices, and continue her current m edication regim en. On Novem ber 4, 20 13, Claim ant saw Dr. Masilam ani and told him her depression had increased due to the loss of a pet and the recent loss of loved ones. (Tr. at 733-36). She had not been sleeping well, and although Claim ant said her m ood was stable, she had a lot of stress due to fam ily issues. On exam ination, Claim ant’s m ood was down and her affect euthym ic. Claim ant was encouraged to exercise, walk daily, and return in one m onth. Dr. Masilam ani increased Trazodone and noted that they m ight discuss a referral to a psychologist at her next visit. On December 4, 20 13, Claim ant reported to Dr. Masilam ani that she was getting enough sleep, she had no problem with her appetite, and her m ood was stable, describing m ost days as “decent.” (Tr. at 729-32). However, she did report continued 31 back problem s. On exam ination, Claim ant’s m ood was fair and her affect euthym ic. Claim ant was encouraged to exercise and continue her m edication. Claim ant advised Dr. Masilam ani she would like to schedule m onthly appointm ents. On Decem ber 10 , 20 13, Claim ant presented to Med Express with com plaints of abdom inal pain and left upper quadrant pain, as well as diarrhea, constipation, nausea and vom iting that began three days prior. (Tr. at 637-41). At this visit, Claim ant weighed two hundred thirty-eight pounds and her blood pressure m easured 124/ 78. On exam ination, both the right and left upper quadrants were tender to palpation. There were no m asses or m egly noted and there was negative CVA tenderness. An xray of the abdom en was found unrem arkable. Claim ant was assessed with constipation and advised to drink fluids. She was given a prescription for Senokot. Claim ant returned to Dr. Masilam ani on J anuary 8, 20 14 reporting she was not having sleep or appetite issues and her m ood was stable. (Tr. at 725-28). On exam ination, Claim ant was cooperative, dem onstrated norm al speech and thought process, and showed fair insight and judgm ent. Claim ant’s m ood was down and her affect euthym ic. She was advised to exercise and begin walking twenty m inutes per day, as well as m aintain her current m edication regim en. Dr. Masilam ani listed Claim ant’s active problem s as allergic rhinitis (unspecified); bipolar, affective, depression (m oderate); coronary atherosel, unspecified vessel; GERD; generalized anxiety disorder; m anic depressive, unspecified; other and unspecified hyperlipidem ia; other disorders thyroid; and other m alaise and fatigue. On February 5, 20 14, Claim ant returned to Dr. Masilam ani reporting she had no sleep or appetite issues and her m ood was stable; however, she was feeling increasingly tired and did not feel like being active. (Tr. at 721-24). At this visit, 32 Claim ant weighed two hundred forty-three pounds. Upon exam ination, Claim ant m ade good eye contact, showed norm al speech, coherent thought process, dem onstrated a fair m ood and euthym ic affect, and her judgm ent and insight were fair. Claim ant was once again encouraged to exercise and start walking outside once the weather im proved. Claim ant reported her biggest stressor to be her sister-in-law. Claim ant was scheduled to follow up with her therapist. Claim ant returned to Dr. Whitm ore on February 12, 20 14, stating that other than a recent diagnosis of sinusitis, she was “doing well” with “no com plaints or concerns.” (Tr. at 766-67). On exam ination, Claim ant’s heart and lungs were norm al with no wheezes, rhonchi, or rales noted. Her abdom en was soft, obese, and nontender. There was no edem a or rash on the extrem ities and no neuropathy with filam ent testing. Claim ant was assessed with m axillary sinusitis, (treated with Augm entin); depression (treated by Dr. Masilam ani and doing well with Celexa and hydroxyzine); chronic, annual allergic rhinitis (treated with Astelin, Nasonex and Zyrtec); GERD (treated with Om eprazole); hyperglycem ia; obesity (Claim ant had gained sixteen pounds since her last visit and did not appear to be m otivated to lose weight); and chronic lum bar back pain from L5-S1 anterolisthesis and spondylolysis (treated with naproxen on per need basis as well as encouraged to exercise and lose weight). On March 5, 20 14, Claim ant told Dr. Masilam ani that her sleep was variable, her appetite norm al, and her m ood stable; however, she continued to have severe back pain. (Tr. at 717-20 ). Upon exam ination, Claim ant’s m ood was fair and her affect euthym ic. Claim ant was diagnosed with alcohol abuse in rem ission; bipolar disorder, type 1, m ost recent episode depression; and generalized anxiety disorder. Dr. 33 Masilam ani referred Claim ant to Dr. J im m y Adam s at active physical m edicine to help with Claim ant’s pain issues. For generalized anxiety disorder, Claim ant was provided prescriptions for Celexa, Hydroxyzine, Lam ictal and Trazodone. Claim ant was again encouraged to exercise and follow-up with her therapist. Dr. Whitm ore exam ined Claim ant on March 25, 20 14 to follow up her hypertension, noting Claim ant had started taking Lisinopril the week before and her blood pressure had im proved. (Tr. at 763). Claim ant reported that she continued to have low back pain. At this visit, Claim ant weighed two hundred forty-four pounds and had a blood pressure of 127/ 73. Her physical exam ination was unrem arkable other than it was noted Claim ant wore a back brace. Claim ant was advised to continue taking Lisinopril and follow-up with Dr. Lowe for back pain. On April 1, 20 14, Claim ant returned to Dr. Lowe, reporting that she was “getting along pretty good.” (Tr. at 682-83). Nevertheless, Claim ant com plained of pain in the entire back, along with occasional neck pain that radiated into her hips and legs, worse on the right side. Claim ant rated the pain as seven out of ten. In addition, she reported num bness and tingling in both feet, worse on the right, and bowel and bladder problem s that had been ongoing for years. A review of system s was within norm al lim its. On exam ination, without wearing her back brace, Claim ant had a norm al gait with no lim p. While seated, her straight leg raise m easured ninety degrees and was seventy degrees in the supine position. There were no radicular issues, although Claim ant exhibited som e low back pain. When bending the knees, Claim ant could do abdom inal isom etrics. Claim ant m entioned that she lost weight after having sinus surgery and wanted to continue losing weight, but had been gaining weight back instead. Dr. Lowe noted that Claim ant was wearing her back brace outside her clothes 34 so he talked with her about wearing it between a t-shirt and her outer shirt. He advised that although surgery could be helpful for spondylolisthesis in som e instances, when considering Claim ant’s com bined issues of nerve problem s and anxiety, and the fact that she was “getting along rather well,” he was not inclined to change her current course of treatm ent. She was told to return in three weeks to review her laboratory results. Claim ant presented to Dr. Edwards on April 9, 20 14, with breast-related com plaints. (Tr. at 515-20 ). A review of system s was negative for m alaise, fatigue, abdom inal pain, abdom inal bloating, diarrhea, constipation, urinary incontinence or frequency, depression or prem enstrual syndrom e. Claim ant’s m ood and affect were norm al, as was her physical exam ination. Claim ant was assessed with endom etriosis, polycystic ovarian syndrom e, nipple discharge, and non-puerperal galactorrhea. That sam e day, Claim ant was seen by Dr. Masilam ani, reporting that she was having a flare up of back pain; however, she had no sleep or appetite issues, and her m ood was stable. (Tr. at 713-16). Claim ant’s physical exam ination was unrem arkable; her m ood was fair and her affect was euthym ic. Claim ant received refills of Celexa, hydroxyzine, and Trazodone. She was advised to exercise and continue her current m edication regim en. Later that m onth, on April 22, Claim ant returned to Dr. Lowe. On exam ination, Claim ant weighed two hundred forty pounds. (Tr. at 684-85). Claim ant presented in “good spirits,” and according to Dr. Lowe wore her back brace and seem ed “to be doing well with it.” Claim ant walked without a lim p. Straight leg raise while seated m easured ninety degrees. Claim ant’s lab reports indicated that her vitam in D level had risen to norm al range; however, the platelet volum e had increased from 20 11. Claim ant was 35 assessed with low back pain, spondylolisthesis, non-injury thoracic back pain, and osteopenia. Dr. Lowe opined that Claim ant’s “total picture is favorable at this point.” She was advised to return in three to four m onths and in the m eantim e, her platelet volum e would be re-exam ined. On May 6, 20 14, Claim ant presented to J essica L. William s at Midland Behavioral Health for counseling. (Tr. at 80 0 -0 2). With respect to her history, Claim ant reported having som e problem s with reading. She had worked off and on over the years, and was applying for disability due to a back injury. Claim ant attended church interm ittently and lived with her child. Claim ant currently com plained of depression and insom nia, describing her depression as m oderate and her insom nia as frequent. Claim ant had problem s dealing with stress, but her strengths included fam ily support, ability to learn and im plem ent new coping skills, and access to transportation and com m unity resources. Claim ant presented with a depressed m ood and affect; however, she was oriented to tim e, place, and people. Her thought process, m em ory, cognitive function, judgm ent, and insight were intact. Claim ant was encouraged to use im proved coping skills. Ms. William s noted that Claim ant was capable of recognizing her em otions and regulating them m ost of the tim e. Claim ant was diagnosed with bipolar II disorder, which was stable and controlled. The following week on May 14, Claim ant returned to Dr. Masilam ani, stating that while her m ood was stable, she felt increased irritability and had not been sleeping well. (Tr. at 710 -12). At this visit, Claim ant weighed two hundred forty-one pounds and her blood pressure was 138/ 81. Claim ant dem onstrated norm al speech and thought process; her eye contract was good; there was no psychom otor agitation noted; her m ood was irritable; and her affect was euthym ic. Dr. Masilam ani increased Claim ant’s 36 dosage of Trazodone and advised her to follow up with her other physicians for sinus issues and fatigue. She returned to Dr. Masilam ani one m onth later on J une 18 advising him that she now slept fairly well m ost nights, and although she was upset about a recent fam ily issue, her m ood had been stable. (Tr. at 70 7-0 9). Claim ant presented with an upset m ood and euthym ic affect. Claim ant was encouraged to exercise, rem ain on her m edication regim en, and participate in outside activities. Dr. Masilam ani advised Claim ant he would schedule her to see a psychologist. On J une 23, 20 14, Claim ant returned to counseling with J essica William s. (Tr. at 80 3-0 4). Claim ant presented with an anxious m ood and affect. She was upset with fam ily m em bers over their criticism s about the way she cared for her child. Claim ant reported she was trying to organize her child’s things, but it was very difficult due to her depression. Ms. William s encouraged Claim ant to continue with the project and by the end of the counseling session, Claim ant was “laughing and appeared to feel a little better.” Claim ant was advised to continue doing things, both inside and outside her hom e, to help im prove her m ood. Claim ant returned to Ms. William s one m onth later on J uly 21 reporting she was doing “pretty well” but had low energy. (Tr. at 80 5-0 6). Her m ood and affect were depressed at this visit. Claim ant was diagnosed with bipolar II disorder, which was stable and controlled. The following day, on J uly 22, Claim ant presented to Dr. Lowe with com plaints of continued low back and bilateral leg pain, left side greater than right. (Tr. at 68687). Claim ant rated her back pain as averaging seven to eight out of ten. Claim ant also continued to wear her back brace. On exam ination, Claim ant walked without a lim p and did not have any trigger points in her back. Straight leg raise while seated m easured ninety degrees. Straight leg raise while supine m easured seventy degrees; 37 however, this caused knee pain as opposed to back pain. As Claim ant’s back brace appeared worn out, Dr. Lowe provided Claim ant with a prescription for a new back brace and ordered lab work. Claim ant returned to Dr. Whitm ore on August 12, reporting no specific com plaints or concerns. (Tr. at 761-62). Claim ant’s current m edication regim en included Naproxen (pain relief), Celexa (depression), hydroxyzine (anxiety), Astelin (rhinitis), Zyrtec (antihistam ine), Enpresse (birth control), om eprazole (GERD), Lisinopril (hypertension), Lam ictal (m ood), and trazodone (depression and anxiety). A review of system s was negative for any gastrointestinal issues such as constipation, diarrhea, m elan, or hem atochezia and was otherwise unrem arkable with the exception of chronic back pain. Nevertheless, Claim ant’s past m edical history included, in part, irritable bowel syndrom e. At this visit, Claim ant weighed two hundred fifty-five pounds and had a blood pressure of 123/ 79. Claim ant’s physical exam ination was unrem arkable. Claim ant was assessed with hypertension that was well-controlled, allergic rhinitis well controlled; depression; GERD, well controlled; and history of hyperglycem ia. Claim ant’s weight had increased by eleven pounds since her last visit; attributed, in part, to her inability to be active due to back pain. On August 19, 20 14, Claim ant presented to Dr. Lowe with com plaints of back pain and occasional neck pain that radiated into her hips and legs. She continued to rate her pain as seven to eight out of ten. (Tr. at 688-89). On exam ination, her sitting straight leg raise m easured ninety degrees. Claim ant’s toe extensors were strong, and the reflexes in her knees and ankles were intact. Dr. Lowe discussed whether Claim ant’s condition warranted fusion surgery; however, he believed there was not enough evidence to change Claim ant’s current treatm ent plan. Claim ant was advised 38 to wear her back brace and return in six weeks. Claim ant m et with J essica William s for therapy on August 21, 20 14. (Tr. at 80 70 8). Ms. William s found Claim ant to have a depressed m ood and affect; however, she was alert, dem onstrating intact thought process, m em ory, judgm ent, insight and cognitive function. Claim ant rem ained able to learn and im plem ent new coping skills. Claim ant reported fatigue due to getting her child back in the routine of going to school. She reported avoiding certain family m em bers who were causing her stress, telling Ms. William s “things have been okay.” On Septem ber 10 , 20 14, Claim ant returned to Dr. Masilam ani, reporting she had no sleep or appetite issues, nor did she have any recent stressful events. (Tr. at 70 4-0 5). Claim ant reported her m ood had been stable (five to six on a scale of ten). On exam ination, Claim ant m ade good eye contact, showed no psychom otor agitation, and dem onstrated norm al speech and thought processes. Her m ood was good, and her affect was broad and reactive. Claim ant was advised to continue her m edication regim en and avoid fam ily m em bers who caused her stress. Claim ant returned to Med Express on Septem ber 22, 20 14 with com plaints of painful, swollen left knee not attributed to an injury. (Tr. at 647-49). Claim ant said the pain began the day before and was located in the anterior left knee with worsening pain upon weight bearing and with m ovem ent. Upon exam ination, there appeared full strength against resistance in the left knee; however, there was lim ited flexion and extension due to pain. There appeared norm al laxity of the left knee but swelling was noted and there was tenderness to the left patella on palpation. An x-ray of the left knee revealed well-m aintained joint spaces with no abnorm al calcification, fracture or periosteal reaction. There was no evidence of focal lytic or sclerotic lesion. Trace 39 suprapatellar effusion was noted. The overall im pression was no acute bone abnorm ality. (Tr. at 659). Claim ant was assessed with left knee effusion and advised to apply ice to the knee, get adequate rest, wrap the knee with ace bandage, and take prednisone for five days. One day later, Claim ant presented to Dr. Whitm ore for follow up of diabetes m ellitus. (Tr. at 753-57). Claim ant had no com plaints of worsening vision, chest pain, dyspnea, num bness, or tingling in her lim bs. A review of system s was negative. Past m edical history included recent non-com pliance with diet and exercise. Claim ant’s active m edical problem s included allergic rhinitis, unspecified; benign neoplasm lesion of the m outh; bipolar affective disorder, depression, m oderate; cholelithiasis; diabetes m ellitus, type 2; endom etriosis; GERD; generalized anxiety disorder; m anic depressive, unspecified; hyperlipidem ia; m alaise and fatigue; and spondylolisthesis at L5-S1. At this visit, Claim ant weighed two hundred fifty-three pounds with a m easured blood pressure of 131/ 88. Her physical exam ination was norm al. Claim ant had norm al deep tendon reflexes, and no peripheral neuropathy was noted during filam entis testing. She was assessed with Type 2 diabetes m ellitus, well controlled with Metform in. Claim ant returned to Dr. Lowe on Septem ber 30 , 20 14 reporting she was having a bad day due to pain located in her entire back and occasionally in her neck. (Tr. at 690 -91). The pain radiated into both hips and legs, worse on the right side, with num bness and tingling of the feet. Claim ant rated her pain as averaging eight out of ten. Claim ant reported bowel and bladder problem s and urinary tract infections. Claim ant also reported left knee pain and swelling. On exam ination, Claim ant walked without a lim p. Dr. Lowe noted that Claim ant wore her back brace. Her toe extensors 40 were strong, and straight leg raise while seated was ninety degrees. The reflexes in her knees and ankles were intact, and she did not appear to have any significant sensory change. Dr. Lowe advised Claim ant that, frequently at her age, patients with spondylolisthesis required surgical intervention; however, considering that he was seeing her on a “bad day,” he did not feel surgery was an appropriate course of action in her case. Instead, Claim ant was prescribed Neurontin for pain relief and Vitam in D. Claim ant was advised to continue her m edication regimen. Claim ant returned to Dr. Lowe the following m onth on October 21, reporting continued back pain that rated seven out of ten. (Tr. at 692-93). Dr. Lowe noted that an x-ray of the lum ber spine showed osteopenia. Claim ant was counseled on exercise, abdom inal isom etrics, and press-up exercises. Dr. Lowe advised Claim ant to work on strengthening and stretching at hom e. The following day, on October 22, Claim ant presented to Dr. Masilam ani com plaining of back pain and anticipating back surgery. (Tr. at 70 0 -0 3). Claim ant told Dr. Masilam ani that her m ood was helped by taking Celexa and, overall, trazodone had helped with her sleep issues. Claim ant described her m ood as stable, but she had been irritable at tim es due to illness and back pain. On exam ination, Claim ant’s m ood was fair, and her affect was euthym ic. She was encouraged to exercise, return to Ms. William s for therapy, continue her m edications, and follow up with Drs. Lowe and Whitm ore for her m edical issues. On October 28, 20 14, Claim ant was seen by Ms. William s reporting ongoing issues with som e fam ily m em bers. (Tr. at 80 9-10 ). Ms. William s noted that Claim ant was continuing to clear out her house, a project she had been talking about since starting therapy with Ms. William s. Claim ant presented with a depressed m ood and 41 affect. However, her thought process, m em ory, cognitive function, judgm ent, and insight were intact. Claim ant was assessed with controlled bipolar II disorder. B. Co n s u lt a t iv e As s e s s m e n t s a n d Ot h e r Op in io n s On December 21, 20 12, G. David Allen, Ph.D., com pleted a Psychiatric Review Technique. (Tr. at 89-91). He found that Claim ant had m edically determ inable im pairm ents under Listing 12.0 4 (affective disorders) and Listing 12.0 6 (anxiety related disorders), which did not precisely satisfy the diagnostic criteria. Dr. Allen determ ined that Claim ant had m ild restrictions of activities of daily living and in m aintaining social function, concentration, persistence, and pace. Claim ant had no episodes of decom pensation, and there was no evidence to satisfy the paragraph “C” criteria. Dr. Allen opined that Claim ant’s m ental functional lim itations did not exceed m ild severity. On April 3, 20 13, Philip E. Com er, Ph.D., com pleted a Psychiatric Review Technique, concurring with the findings of Dr. Allen. (Tr. at 10 4-0 6). Dr. Com er agreed that the severity of m ental functional lim itation did not exceed m ild, adding that the new m edical evidence in the file did not show any additional significant m ental and/ or em otional lim itations. Therefore, Dr. Com er affirm ed Dr. Allen’s findings as written. On Decem ber 26, 20 12, Rabah Boukhem is, M.D., com pleted a Physical Residual Functional Capacity Assessm ent. (Tr. at 91-93). Dr. Boukhem is determ ined that Claim ant could occasionally lift and/ or carry fifty pounds; frequently lift and/ or carry twenty-five pounds; stand, walk and/ or sit about six hours in an eight hour workday; and had unlim ited ability to push and/ or pull with the listed weight restrictions. Claim ant could frequently clim b ram ps or stairs, balance, stoop, kneel, or crouch and could occasionally crawl and clim b ladders, ropes, or scaffolds. Claim ant had no m anipulative, visual, or com m unicative lim itations. As for environm ental lim itations, 42 Claim ant was unlim ited in her exposure to wetness, hum idity, and noise; however, she needed to avoid concentrated exposure to extrem e cold or heat, vibration, fum es, odors, dusts, gases, poor ventilation and hazards, such as m achinery or heights. On April 3, 20 13, Pedro F. Lo, M.D., com pleted a Physical Residual Functional Capacity Assessm ent, drawing identical conclusions to those of Dr. Boukhem is. (Tr. at 10 6-0 8). Under the additional explanation section of the form , Dr. Lo comm ented that Claim ant was previously denied disability at m edium residual functional capacity. He listed Claim ant’s allegations as lum bar back problem s, IBS, vision problem s, m igraines, knee problem s, problem s with shoulders and hands, and allergies. Dr. Lo opined that Claim ant had spondylolisthesis 20 % grade and pars defect; however, there was no neurological loss. Claim ant had fair range of m otion; her straight leg raise was negative; and she was obese with a body m ass index of 36. Dr. Lo affirm ed the Physical Residual Functional Capacity Assessm ent prepared by Dr. Boukhem is as written. VII. D is cu s s io n Having thoroughly considered the record, the Court concludes that neither of Claim ant’s challenges to the Com m issioner’s decision has m erit. Each challenge is considered below. A. R FC Fin d in g Claim ant is critical of the ALJ ’s RFC finding, arguing that it failed to account for the com bined effect of all of her im pairm ents and was based on an im proper assessm ent of her credibility. Between the third and fourth steps of the sequential disability determ ination process, the ALJ m ust ascertain a claim ant’s RFC, which is the claim ant’s “ability to do sustained work-related physical and m ental activities in a work setting on a regular and continuing basis.” See Social Security Ruling (“SSR”) 96-8p, 43 1996 WL 374184, at *1 (S.S.A. 1996). RFC is a m easurem ent of the m o s t that a claim ant can do despite his or her lim itations, and the finding is used at steps four and five of the sequential evaluation to determ ine whether a claim ant can still do past relevant work and, if not, whether there is other work that the claim ant is capable of perform ing. Id. According to SSR 96-8p, the ALJ ’s RFC determ ination requires “a function-by-function assessm ent based upon all of the relevant evidence of an individual’s ability to do work-related activities.” Id. at *3. The functions that the ALJ m ust assess include the claim ant’s physical abilities, “such as sitting, standing, walking, lifting, carrying, pushing, pulling, or other physical functions (including m anipulative or postural functions, such as reaching, handling, stooping or crouching);” m ental abilities; and other abilities, “such as skin im pairm ent(s), epilepsy, im pairm ent(s) of vision, hearing or other senses, and im pairm ent(s) which im pose environm ental restrictions.” 20 CFR 416.945(b-d). Only by exam ining specific functional abilities can the ALJ determ ine (1) whether a claim ant can perform past relevant work as it was actually, or is generally, perform ed; (2) what exertional level is appropriate for the claim ant; and (3) whether the claim ant “is capable of doing the full range of work contem plated by the exertional level.” SSR 96-8p, 1996 WL 374184, at *3. Indeed, “[w]ithout a careful consideration of an individual’s functional capacities to support an RFC assessm ent based on an exertional category, the adjudicator m ay either overlook lim itations or restrictions that would narrow the ranges and types of work an individual m ay be able to do, or find that the individual has lim itations or restrictions that he or she does not actually have.” Id. at *4. In determ ining a claim ant’s RFC, the ALJ “m ust include a narrative discussion describing how the evidence supports each conclusion, citing specific m edical facts 44 (e.g. laboratory findings) and nonm edical evidence (e.g., daily activities, observations).” Id. at *7. Further, the ALJ m ust “explain how any m aterial inconsistencies or am biguities in the evidence in the case record were considered and resolved.” Id. at *7. “Rem and m ay be appropriate where an ALJ fails to assess a claim ant's capacity to perform relevant functions, despite contradictory evidence in the record, or where other inadequacies in the ALJ ’s analysis frustrate m eaningful review.” Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 20 15) (quoting Cichocki v. Astrue, 729 F.3d 172, 177 (2d Cir. 20 13)) (m arkings om itted). Here, the ALJ provided a thorough discussion of Claim ant’s im pairm ents and her RFC, addressing the objective m edical evidence, Claim ant’s statem ents regarding the severity and persistence of her sym ptom s, Claim ant’s reported activities, and the function-by-function assessm ents provided by agency consultants. Contrary to Claim ant’s assertion, the ALJ did consider the functional lim itations associated with all of Claim ant’s m edically determ inable im pairm ents, including her non-severe conditions. For example, at step two of the process, the ALJ addressed Claim ant’s functional lim itations, acknowledging that she had som e m otion loss, loss of sensation, and stiffness in her back. (Tr. at 14). The ALJ also accepted that Claim ant had som e incontinence related to her IBS, and experienced m ood swings and related sym ptom s. (Tr. at 14-15). The ALJ reviewed the evidence regarding Claim ant’s gynecological and pelvic issues, concluding that these im pairm ents were entirely asym ptom atic after treatm ent in April 20 13. (Tr. at 15). Sim ilarly, while Claim ant had hypertension and diabetes, her sym ptom s were well controlled on m edication and, with diet and exercise, Claim ant would likely have no abnorm al findings at all. As far as Claim ant’s headaches and vision problem s, the ALJ indicated that these conditions should not interfere with 45 Claim ant’s ability to work, because they could be corrected with an updated prescription for eyeglasses. Consequently, the ALJ clearly considered the functional effect of each of Claim ant’s im pairm ents. In analyzing Claim ant’s RFC, the ALJ also reviewed and considered the reliability of Claim ant’s statem ents regarding the disabling effects of her im pairm ents. Pursuant to 20 C.F.R. § 416.929, when evaluating a claim ant’s report of sym ptom severity and persistence, the ALJ is required to use a two-step process. First, the ALJ m ust determ ine whether the claim ant’s m edically determ inable m edical and psychological conditions could reasonably be expected to produce the sym ptom s alleged by the Claim ant. 20 C.F.R. § 416.929(a). “[A]n individual's statem ents of sym ptom s alone are not enough to establish the existence of a physical or m ental im pairm ent or disability.” SSR 16-3p, 20 16 WL 11190 29, at *2 (effective March 16, 20 16).5 Instead, there m ust exist som e objective “[m ]edical signs and laboratory findings, established by m edically acceptable clinical or laboratory diagnostic techniques” which dem onstrate “the existence of a m edical im pairm ent(s) which results from anatom ical, physiological, or psychological abnorm alities and which could reasonably be expected to produce the pain or other sym ptom s alleged.” 20 C.F.R. § 416.929(b). Second, after establishing that the claim ant’s conditions could be expected to produce the alleged sym ptom s, the ALJ m ust evaluate the intensity, persistence, and 5 The SSA recently provided guidance for evaluating a claim ant’s report of sym ptom s in the form of SSR 16-3p. In doing so, the SSA rescinded SSR 96-7p, 1996 WL 374186, which Claim ant relied on in her m em orandum . The undersigned finds it appropriate to consider Claim ant’s second challenge under the m ore recent Ruling as it “is a clarification of, rather than a change to, existing law.” Matula v. Colvin, No. 14 C 7679, 20 16 WL 2899267, at *7 n.2 (N.D. Ill. May 17, 20 16); see also Morris v. Colvin , No. 14CV-689, 20 16 WL 30 85427, at *8 n.7 (W.D.N.Y. J une 2, 20 16). 46 severity of the sym ptom s to determ ine the extent to which they prevent the claim ant from perform ing basic work activities. Id. § 416.929(a). If the intensity, persistence, or severity of the sym ptom s cannot be established by objective m edical evidence, the ALJ m ust consider “other evidence in the record in reaching a conclusion about the intensity, persistence, and lim iting effects of an individual's sym ptom s,” including a claim ant’s own statem ents. SSR 16-3p, 20 16 WL 11190 29, at *5-*6. In evaluating a claim ant’s statem ents regarding his or her sym ptom s, the ALJ will consider “all of the relevant evidence,” including (1) the claim ant’s m edical history, signs and laboratory findings, and statem ents from the claim ant, treating sources, and non-treating sources, 20 C.F.R. § 416.929(c)(1); (2) objective m edical evidence, which is obtained from the application of m edically acceptable clinical and laboratory diagnostic techniques, id. § 416.929(c)(2); and (3) any other evidence relevant to the claim ant’s sym ptom s, such as evidence of the claim ant's daily activities, specific descriptions of sym ptom s (location, duration, frequency and intensity), precipitating and aggravating factors, m edication or m edical treatm ent and resulting side effects received to alleviate sym ptom s, and any other factors relating to functional lim itations and restrictions due to the claim ant’s sym ptom s. Id. § 416.929(c)(3); see also Craig, 76 F.3d at 595; SSR 16-3p, 20 16 WL 11190 29, at *4-*7. In Hines v. Barnhart, the Fourth Circuit stated that: Although a claim ant’s allegations about her pain m ay not be discredited solely because they are not substantiated by objective evidence of the pain itself or its severity, they need not be accepted to the extent they are inconsistent with the available evidence, including objective evidence of the underlying im pairm ent, and the extent to which that im pairm ent can reasonably be expected to cause the pain the claim ant alleges he suffers. 453 F.3d at 565 n.3 (citing Craig, 76 F.3d at 595). The ALJ m ay not reject a claim ant’s allegations of intensity and persistence solely because the available objective m edical 47 evidence does not substantiate the allegations; however, the lack of objective m edical evidence may be one factor considered by the ALJ . SSR 16-3p, 20 16 WL 11190 29, at *5. SSR 16-3p provides further guidance on how to evaluate a claim ant’s statem ents regarding the intensity, persistence, and limiting effects of his or her sym ptom s. For exam ple, the Ruling stresses that the consistency of a claim ant’s own statem ents should be considered in determ ining whether a claim ant’s reported sym ptom s affect his or her ability to perform work-related activities. Id. at *8. Likewise, the longitudinal m edical record is a valuable indicator of the extent to which a claim ant’s reported sym ptom s will reduce his or her capacity to perform work-related activities. Id. A longitudinal m edical record demonstrating the claim ant’s attem pts to seek and follow treatm ent for sym ptom s m ay support a claim ant’s report of sym ptom s. Id. On the other hand, an ALJ “m ay find the alleged intensity and persistence of an individual's sym ptom s are inconsistent with the overall evidence of record,” where “the frequency or extent of the treatm ent sought by an individual is not com parable with the degree of the individual's subjective com plaints,” or “the individual fails to follow prescribed treatm ent that m ight im prove sym ptom s.” Id. Ultim ately, “it is not sufficient for [an ALJ ] to m ake a single, conclusory statem ent that ‘the individual's statem ents about his or her sym ptom s have been considered’ or that ‘the statem ents about the individual's sym ptom s are (or are not) supported or consistent.’ It is also not enough for [an ALJ ] sim ply to recite the factors described in the regulations for evaluating sym ptom s. The determ ination or decision m ust contain specific reasons for the weight given to the individual's sym ptom s, be consistent with and supported by the evidence, and be clearly articulated so the individual and any subsequent reviewer can assess how the [ALJ ] evaluated the 48 individual's sym ptom s.” Id. at *9. SSR 16-3p instructs that “[t]he focus of the evaluation of an individual's sym ptom s should not be to determ ine whether he or she is a truthful person”; rather, the core of an ALJ ’s inquiry is “whether the evidence establishes a m edically determ inable im pairm ent that could reasonably be expected to produce the individual's sym ptom s and given the adjudicator's evaluation of the individual's sym ptom s, whether the intensity and persistence of the sym ptom s lim it the individual's ability to perform work-related activities.” Id. at *10 . When considering whether an ALJ ’s evaluation of a claim ant’s reported sym ptom s is supported by substantial evidence, the Court does not replace its own assessm ent for those of the ALJ ; rather, the Court scrutinizes the evidence to determ ine if it is sufficient to support the ALJ ’s conclusions. In reviewing the record for substantial evidence, the Court does not re-weigh conflicting evidence, reach independent determ inations as to the weight to be afforded to a claim ant’s report of sym ptom s, or substitute its own judgm ent for that of the Com m issioner. Hay s, 90 7 F.2d at 1456. Moreover, because the ALJ had the “opportunity to observe the dem eanor and to determ ine the credibility of the claim ant, the ALJ ’s observations concerning these questions are to be given great weight.” Shively v . Heckler, 739 F.2d 987, 989 (4th Cir. 1984). Claim ant’s contention that the ALJ erred in discounting Claim ant’s credibility, because Claim ant’s statem ents and the objective evidence were m utually supportive of a disability finding does not actually address the propriety of the ALJ ’s credibility assessm ent. Instead, Claim ant is m erely reweighing the evidence, choosing to place m ore evidentiary em phasis on her own statem ents than did the ALJ . Such an exercise is not one in which this Court will engage. Rather, the Court will only review the 49 decision to ascertain whether the proper process was followed and the resulting finding is supported by substantial evidence. Here, as m ore fully discussed below, the written decision clearly reflects that the ALJ perform ed the proper two-step credibility analysis and supported her finding with detailed pieces of evidence. Claim ant’s related criticism , that the ALJ sim ply regurgitated credibility “boilerplate,” is not a fair representation of the ALJ ’s discussion. Indeed, the ALJ provided num erous case-specific reasons for her decision to discount the reliability of Claim ant’s statem ents. For exam ple, the ALJ felt that Claim ant’s “subjective descriptions of sym ptom s severity and functional lim itation seem [ed] rather excessive and exaggerated” in light of Claim ant’s noncom pliance with treatm ent recom m endations. (Tr. at 21). In addition, the ALJ pointed out that Claim ant had not required surgical intervention or aggressive m edical managem ent, and her diagnostic studies and clinical findings did not reflect any significant progression of her im pairm ents. The ALJ also noted that Claim ant had no physician support for a finding of disability; to the contrary, Dr. Lowe seemed to feel that conservative treatm ent had been successful. (Id.). The ALJ further considered the record regarding Claim ant’s IBS, indicating that although Claim ant com plained of incontinence, there were few reported incidents in the record. Claim ant was not required to wear protective undergarm ents, and she reported a healthy appetite, denying significant weight loss attributable to her disease. (Tr. at 22). In fact, the record shows that Claim ant had a tendency to gain weight. Despite repeated advice from her treating providers to lose weight, Claim ant did not dem onstrate any effort to pursue a weight loss regim en. In addition, Claim ant’s m ental health treatm ent was ongoing, and her psychological conditions were deem ed stable on m edication. (Id.). As part of the credibility analysis, the ALJ com m ented on 50 the m edical evidence from a longitudinal perspective and referenced particular clinical notes and diagnostic findings corroborating her conclusion that Claim ant exaggerated the disabling effects of her sym ptom s. Consequently, the ALJ ’s credibility analysis and discussion com plied with the applicable rules and regulations. Finally, the ALJ also considered the findings m ade by ALJ Dum m er in Claim ant’s prior Social Security disability proceeding, as well as the RFC assessm ents of the consulting experts. The ALJ placed significant weight on the opinions of the agency consultants, who provided function-by-function assessm ents based upon the evidence as a whole. The ALJ concluded that the evidence collected since the last proceeding, com bined with the opinions of the m edical sources supported a reduction in ALJ Dum m er’s RFC finding. After having thoroughly reviewed and analyzed the relevant evidence, the ALJ m ade an RFC finding and fully explained the basis of the finding in a detailed discussion of the record. Therefore, the undersigned finds no error in the ALJ ’s RFC finding. B. In co n s is t e n cy in t h e R FC D is cu s s io n For her second challenge, Claim ant highlights an “internal inconsistency” between the RFC finding and the RFC discussion. In particular, the ALJ m ade a determ ination that Claim ant could perform a reduced range of m edium exertional work. (Tr. at 19). However, at the sam e tim e, the ALJ stated in the discussion that she had reviewed ALJ ’s Dum m er’s RFC finding and felt “that additional evidence subm itted since the last decision provides a basis to warrant further reduction and accordingly; has not fully adopted the prior findings.” (Tr. at 21). The ALJ added that “[s]ignificant weight has been afforded the prior assessm ents and opinions of the nonexam ining State agency physicians, Dr. Rabah Boukehem is and Pedro Lo. Restriction 51 to a reduced range of light w ork as set forth appears reasonable and well supported.” (Id.). Claim ant stresses the confusion created by the two apparently inconsistent findings and asks: “At any rate, did the Adm inistrative Law J udge lim it Plaintiff to m edium or light work?” Obviously, the ALJ did m isspeak at one point in the decision, or at the other. However, a review of the decision and related evidence strongly suggests that the ALJ intended to find Claim ant capable of a reduced range of m edium work, and the reference to “light” work was a clerical error. Not only did the ALJ write the RFC finding for m edium work, but she asked the vocational expert to assum e a reduced range of m edium level work in the controlling hypothetical question. Furtherm ore, although ALJ Dum m er’s prior decision likewise found Claim ant capable of a reduced range of m edium level exertional work, their RFC findings are not the sam e. As the ALJ indicates, her RFC finding does constitute a “further reduction” of the occupational base when com pared with ALJ Dum m er’s RFC finding. In this case, the ALJ concluded that Claim ant should n e ve r clim b ladders, ropes, or scaffolds; could only o ccas io n ally crawl, and had additional lim itations associated with her m ental im pairm ents. In contrast, ALJ Dum m er found that Claim ant was lim ited to o ccas io n al clim bing of ladders, ropes, and scaffolds; fre qu e n t crawling; and she had n o lim itations related to her m ental im pairm ents. (Tr. at 19, 73). As such, although both ALJ s found Claim ant’s m axim um exertional level to be m edium , ALJ Dum m er’s finding included less lim itation than the current RFC finding. Lastly, the ALJ explicitly gave significant weight to the physical RFC findings of Dr. Boukhem is and Dr. Lo, who both expressly concluded that Claim ant was capable of m edium level exertional work with additional nonexertional lim itations. (Tr. at 21, 52 91, 10 6). Had the ALJ intended to find Claim ant capable of only light level exertional work, she would not have afforded significant weight to those opinions. Accordingly, the record, the written decision, and the transcript of the adm inistrative hearing all indicate that the ALJ intended the RFC finding to include an exertional level of m edium , and the reference to light level work was a typographical error. Nonetheless, any error in the RFC discussion is harm less, because the vocational expert found work that Claim ant was capable of doing work at the m edium , light, and sedentary exertional levels, even when assum ing the additional nonexertional lim itations set forth in the RFC finding. Courts have applied a harm less error analysis to adm inistrative decisions that do not fully com port with the procedural requirem ents of the agency’s regulations, but for which rem and “would be m erely a waste of tim e and m oney.” Jenkins v. Astrue, 20 0 9 WL 10 10 870 at *4 (D. Kan. Apr. 14, 20 0 9) (citing Kerner v. Celebrezze, 340 F.2d 736, 740 (2nd Cir. 1965)). In general, rem and of a procedurally deficient decision is not necessary “absent a showing that the [com plainant] has been prejudiced on the m erits or deprived of substantial rights because of the agency’s procedural lapses.” Connor v. United States Civil Service Com m ission, 721 F.2d 10 54, 10 56 (6th Cir. 1983). “[P]rocedural im proprieties alleged by [a claim ant] will therefore constitute a basis for rem and only if such im proprieties would cast into doubt the existence of substantial evidence to support the ALJ 's decision.” Morris v. Bow en, 864 F.2d 333, 335 (5th Cir. 1988). The Fourth Circuit has sim ilarly applied the harm less error analysis in the context of Social Security disability determ inations. See Morgan v. Barnhart, 142 Fed. Appx. 716, 722– 23 (4th Cir. 20 0 5) (unpublished); Bishop v. Barnhart, 78 Fed. Appx. 265, 268 (4th Cir. 20 0 3) (unpublished). In this case, the testim ony of the vocational expert, coupled with the 53 written decision, provide substantial support for the conclusion that Claim ant is not disabled regardless of whether she is lim ited to a reduced range of m edium work or a reduced range of light work. Therefore, the Com m issioner’s disability determ ination should be affirm ed. VIII. Co n clu s io n After a careful consideration of the evidence of record, the Court finds that the Com m issioner’s decision is supported by substantial evidence. Therefore, the Court D EN IES Plaintiff’s m otion for judgm ent on the pleadings, GRAN TS Defendant’s request that the Com m issioner’s decision be affirm ed, and D ISMISSES this action from the docket of the Court. A J udgm ent Order shall be entered accordingly. The Clerk of this Court is directed to transm it copies of this Mem orandum Opinion to counsel of record. EN TERED : May 22, 20 17 54

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