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Broadwater v. Berryhill

United States District Court, D. South Carolina

November 1, 2017

Millileen Broadwater, Plaintiff,
v.
Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant.

          REPORT AND RECOMMENDATION

          SHIVA V. HODGES, UNITED STATES MAGISTRATE JUDGE.

         This appeal from a denial of social security benefits is before the court for a Report and Recommendation (“Report”) pursuant to Local Civ. Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying her claim for Supplemental Security Income (“SSI”). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the undersigned recommends that the Commissioner's decision be reversed and remanded for further proceedings as set forth herein.

         I. Relevant Background

         A. Procedural History

         On December 17, 2012, Plaintiff filed an application for SSI in which she alleged her disability began on December 1, 2012. Tr. at 145-54. Her application was denied initially and upon reconsideration. Tr. at 89-92 and 101-06. On September 3, 2015, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Colin Fritz. Tr. at 29- 59 (Hr'g Tr.). The ALJ issued an unfavorable decision on September 23, 2015, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 11-28. Subsequently, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 1-6. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on February 23, 2017. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 53 years old at the time of the hearing. Tr. at 22. She completed the eighth grade. Tr. at 35. She has no past relevant work (“PRW”). Tr. at 37. She alleges she has been unable to work since December 1, 2012. Tr. at 145.

         2. Medical History

         Plaintiff presented to Marguerite Vardman, ANP-C (“Ms. Vardman”), for routine follow up regarding hypertension and diabetes mellitus on February 9, 2012. Tr. at 357. She indicated she had experienced heart palpitations for a brief period during the prior week. Id. She reported she was doing well, despite the fact that she was no longer taking Valium. Id. Ms. Vardman observed that Plaintiff appeared older than her stated age. Tr. at 358. She stated Plaintiff was morbidly obese at 288 pounds, but indicated she had lost 12 pounds during the prior three-month period. Id.

         Plaintiff presented to Frank Kitchens PA-C (“Mr. Kitchens”), for treatment of diabetes mellitus on June 27, 2012. Tr. at 361. Mr. Kitchens noted Plaintiff was 5'3” tall, weighed 230 pounds, and had a body mass index (“BMI”) of 40.75. Tr. at 363. He observed pitting edema to the ankles. Id. He assessed stage III chronic kidney disease, chronic obstructive pulmonary disease (“COPD”), malignant essential hypertension, and proteinuria. Tr. at 364.

         On September 5, 2012, Plaintiff informed Mr. Kitchens that she had been unable to afford to keep scheduled appointments with the podiatrist and eye clinic. Tr. at 366. Mr. Kitchens observed Plaintiff to have trace pitting edema to the ankles and onychomycosis to the first and fourth toes. Tr. at 368.

         On October 17, 2012, Plaintiff reported feeling down following the death of her sister-in-law. Tr. at 372. She stated she had been taking more Clonidine than usual. Id. Mr. Kitchens observed Plaintiff to have trace pitting edema to her ankles. Tr. at 374.

         On November 14, 2012, Plaintiff reported Sertraline had made her feel less stressed and depressed. Tr. at 377. Her blood pressure was elevated at 171/106 mm/Hg. Tr. at 379. Mr. Kitchens observed Plaintiff to have diminished breath sounds over the right mid-lung field and trace pitting edema to the ankles. Tr. at 380. He increased Plaintiff's dosage of Norvasc to 10 mg and indicated he would consider a renal ultrasound. Id. He recommended that Plaintiff undergo overnight oximetry and start Flonase. Id.

         On December 12, 2012, Plaintiff reported occasional feelings of nervousness that were accompanied by sweat and tightness or fullness in her chest. Tr. at 381. Mr. Kitchens noted that Plaintiff had reduced her salt intake and was doing better on the increased dose of Norvasc. Id. He observed diminished breath sounds over the bases of both lungs and trace pitting edema to the bilateral ankles. Tr. at 383. Because Plaintiff's blood pressure readings from her home log were within normal limits, Mr. Kitchens suspected that Plaintiff had “WHITECOAT HTN.” Tr. at 384. He arranged for Plaintiff to receive nocturnal oxygen through a patient assistance plan and indicated he would schedule a follow up overnight oximetry test to assess whether the oxygen was beneficial. Id.

         On January 30, 2013, Plaintiff reported that use of overnight oxygen had improved her sleep and made her feel better-rested and less winded. Tr. at 385. She indicated she had observed that her blood pressure increased when she was upset. Id. She reported nasal congestion, lightheadedness, lower extremity edema, shortness of breath, headache, hot flashes, and night sweats. Id. Mr. Kitchens observed frontal sinus pressure, diminished breath sounds over the bases of both lungs, and trace pitting edema to the ankles. Tr. at 387-88. He added Hydrochlorothiazide for hypertension and indicated he would consider a renal ultrasound if Plaintiff's blood pressure continued to be elevated. Tr. at 388.

         Mr. Kitchens completed a mental status form on February 20, 2013. Tr. at 290. He noted Plaintiff's mental diagnosis was grief reaction. Id. He indicated Sertraline had helped Plaintiff's condition. Id. He noted that he had recommended psychiatric care, but that Plaintiff had deferred treatment. Id. He stated plaintiff was receiving support from family and friends and denied suicidal and homicidal ideation. Id. He described Plaintiff as being oriented to time, person, place, and situation; having an intact thought process; demonstrating appropriate thought content; having a normal mood/affect; showing good attention/concentration; and demonstrating good memory. Id. He stated Plaintiff exhibited no work-related limitation in function due to a mental condition and indicated she was capable of managing her own funds. Id.

         On March 15, 2013, Mr. Kitchens noted that Plaintiff had initially reported lightheadedness and a racing heart with use of Hydrochlorothiazide, but the side effects had decreased after she increased her water intake. Tr. at 389. He indicated Plaintiff's blood pressure readings had improved. Id. Plaintiff reported knee pain and lower extremity edema, but indicated the edema had improved with the addition of Hydrochlorothiazide. Id. Mr. Kitchens observed Plaintiff to be obese; to have diminished breath sounds over the bases of both lungs; to have grade II diastolic heart murmur; and to have trace pitting edema to her ankles. Tr. at 392. He prescribed Hydrocodone-Acetaminophen and Tramadol. Id. He indicated he would check Plaintiff's uric acid level because her pain seemed to have worsened after she started taking a diuretic. Tr. at 393.

         On March 21, 2013, an x-ray of Plaintiff's right knee showed mild degeneration, joint space narrowing, and small osteophytes in the medial compartment of the knee joint. Tr. at 273. An x-ray of her lumbar spine showed facet degeneration that resulted in grade I spondylolisthesis of L5 on S1. Tr. at 274.

         Plaintiff presented to David N. Holt, M.D. (“Dr. Holt”), for a consultative examination on March 21, 2013. Tr. at 247. She complained of depression, anxiety, hypertension, COPD, lower leg pain and edema, and sleep apnea. Tr. at 247-48. She reported hypertension-related headaches that lasted for two hours at a time and occurred approximately three times per week. Tr. at 248. Dr. Holt noted that Plaintiff was using nasal oxygen at night. Id. He indicated Plaintiff had been diagnosed with diabetes mellitus ten years prior, but had experienced good control with use of Glyburide. Id. Plaintiff reported that she could “read and write a little.” Tr. at 249. Dr. Holt observed Plaintiff to have a subtle antalgic gait and normal station. Tr. at 250. He indicated Plaintiff rose slowly from a seated position, but was able to dress, undress, and get on and off the examination table. Id. He observed a muscle spasm in Plaintiff's trapezius muscle; 4 lateral, medial, and posterior tenderness in her right knee; and 4 lateral and posterior tenderness in her left knee. Tr. at 251. Plaintiff demonstrated normal pulses and deep tendon reflexes. Id. A straight-leg raising (“SLR”) test was negative at 85 degrees in each leg. Id. Plaintiff demonstrated no clubbing, cyanosis, or edema in her extremities. Id. Motor and sensory examinations were normal. Tr. at 252. Plaintiff's cervical flexion and extension and lumbar extension and bilateral lateral flexion were each reduced by five degrees. Tr. at 255. Her bilateral cervical lateral flexion was reduced by 15 degrees, and her lumbar flexion was reduced by 30 degrees. Id. Her bilateral wrist dorsiflexion and palmar flexion were reduced by 10 degrees, and her right knee flexion was reduced by 20 degrees. Id. Plaintiff's left hip flexion was reduced by 10 degrees, and her right hip flexion was reduced by 20 degrees. Id. Dr. Holt noted that Plaintiff had a “somewhat flattened affect, ” but smiled after she became more comfortable with him. Tr. at 251. Plaintiff demonstrated normal hygiene; followed directions; counted backward from 20; performed serial sevens from 100; and spelled “world” backward. Id. She named the current and prior president, but was unable to recall the name of the vice president. Id. Dr. Holt noted that Plaintiff had 5/5 grip strength in both hands, but that her gross manipulation was interrupted by left shoulder pain. Tr. at 252. He indicated Plaintiff had mild loss of ROM at the cervical and lumbar spines and right knee. Id. He observed that Plaintiff was cooperative and put forth her best effort. Id. He diagnosed “[a]nxiety and depression, mild to possibly moderate”; hypertension; “COPD, by history”; “[b]ilateral knee pain/tenderness, probably osteoarthritis”; “[l]ower leg and ankle pain, without demonstrated or known pathology”; sleep apnea; and type II diabetes mellitus. Id.

         Plaintiff presented to Kyle R. Cieply, Ph.D. (“Dr. Cieply”), for a psychological evaluation on April 9, 2013. Tr. at 258. Dr. Cieply noted Plaintiff was cooperative and attempted to respond adequately to all questions during the interview. Tr. at 259. He stated Plaintiff was able to follow simple instructions and was a normal historian. Id. However, he indicated Plaintiff's affect appeared to be diminished. Id. Plaintiff reported problems with bereavement following the deaths of her brother-in-law, father-in-law, mother-in-law, and brother. Id. She indicated she had repeated both the sixth and ninth grades, but had not been diagnosed with a learning disability or developmental delay. Id. She complained of sadness, sleep disturbance, fatigue, psychomotor retardation, feelings of worthlessness, poor concentration, thoughts of death, nervousness, restlessness, irritability, muscle tension, and panic attacks. Tr. at 259-60. She denied hallucinations, delusions, paranoia, and suicidal ideation. Id. She indicated she sometimes did not desire to complete basic activities of daily living (“ADLs”) and household chores. Tr. at 260. She endorsed some social isolation and indicated she had a limited social network. Id. Dr. Cieply found it difficult to relate to Plaintiff during the interview. Id. He observed Plaintiff to demonstrate a flat affect and diminished demeanor. Id. He indicated she had “poor initiation with difficulty starting tasks”; “issues with poor attention and concentration”; and appeared “to move and think at a somewhat slower pace.” Id. However, he stated Plaintiff had adequate reasoning and judgment. Id. Dr. Cieply administered the fourth edition of Wechsler's Adult Intelligence Scale (“WAIS-IV”). Tr. at 260-61. Plaintiff's intelligence quotient (“IQ”) scores were 58 for verbal comprehension, 67 for perceptual reasoning, 77 for working memory, 68 for processing speed, and 61 for full scale. Tr. at 261. Dr. Cieply explained the scores as follows:

Ms. Broadwater has an Extremely Low IQ based on standardized testing. Although there is a significant difference between her very poor verbal and non-verbal skills, both areas of functioning fall in the Extremely Low range of functioning. There is a significant weakness in relation to her verbal comprehension, processing, and concept formation. Her abstract and local thinking and verbal concept formation is particularly poor. Ultimately, her verbal skills have the most negative impact on her overall IQ. Her nonverbal and fluid reasoning are also extremely low, indicating difficulty working with visual information or novel and unexpected situations. Tasks associated with Processing Speed and Working Memory range from borderline to extremely low respectively. Borderline working memory indicates issues with concentration, ability to sustain attention, planning ability, cognitive flexibility, and sequencing skills. The extremely low processing speed skills and speed of mental operation indicates problems focusing her attention, while quickly scanning, discriminating between, and sequentially ordering visual information.

Id. Dr. Cieply also administered the fourth edition of the Wide Range Achievement Test (“WRAT-4”). Id. Plaintiff's scores were consistent with the following grade equivalents: 6.5 for reading, 4.7 for sentence comprehension, 6.8 for spelling, and 4.3 for arithmetic. Id. Dr. Cieply determined Plaintiff's scores were consistent with her reported academic difficulties and grade retentions. Tr. at 262. He stated Plaintiff's IQ scores fell in the range for mild mental retardation. Id. He noted that there was no history of the disorder, but “at the very least, ” Plaintiff met the criteria for borderline intellectual functioning (“BIF”). Id. He diagnosed a history of major depressive disorder (“MDD”), recurrent; a history of generalized anxiety disorder (“GAD”); panic disorder; adjustment disorder related to bereavement; BIF; and learning disorder, not otherwise specified (“NOS”). Id.

         On April 29, 2013, pulmonary function testing showed Plaintiff to have a moderately-severe restrictive abnormality. Tr. at 265.

         Plaintiff presented to Locke Simons, M.D. (“Dr. Simons”), on May 2, 2013. Tr. at 394. She complained of bilateral ankle edema and indicated Hydrochlorothiazide had caused weakness and fatigue. Id. Dr. Simons indicated Plaintiff had “[n]o real ankle pain, just the discomfort from the swelling in her ankles.” Id. Plaintiff indicated the swelling would increase throughout the day. Id. She reported pain in her left shoulder and numbness in her bilateral upper extremities. Id. Dr. Simons observed 2 pitting edema in Plaintiff's ankles and 2 pretibial pitting edema. Id. He prescribed Lasix to reduce Plaintiff's fluid retention. Tr. at 397.

         State agency medical consultant Adrian Corlette, M.D. (“Dr. Corlette”), reviewed the evidence and completed a physical residual functional capacity (“RFC”) assessment on May 3, 2013. Tr. at 66-68. He determined Plaintiff had the following RFC: occasionally lifting and/or carrying 20 pounds; frequently lifting and/or carrying 10 pounds; standing and/or walking for about six hours in an eight-hour workday; sitting for about six hours in an eight-hour workday; occasionally climbing ramps and stairs, kneeling, crouching, and crawling; frequently balancing; never climbing ladders, ropes, or scaffolds; avoiding concentrated exposure to extreme cold, extreme heat, humidity, fumes, odors, dusts, gases, poor ventilation, and hazards. Id.

         On May 29, 2013, state agency psychological consultant Anna P. Williams, Ph.D. (“Dr. Williams”), reviewed the record and completed a psychiatric review technique form (“PRTF”). She considered Listings 12.02 for organic mental disorders, 12.04 for affective disorders, and 12.09 for substance addiction disorders. Tr. at 64-65. She found that Plaintiff had mild restriction of ADLs, mild difficulties in maintaining social functioning, and mild difficulties in maintaining concentration, persistence, or pace. Tr. at 65. She provided the following explanation:

MS BROADWATER HAS A SEVERE MENTAL IMPAIRMENT W/ POSSIBLE BIF. THE TESTING DONE BY DR CIEPLY AT A RECENT PSYCH EVAL HAS DISCREPANCIES THAT ARE NOT EXPLAINED AND ARE AT ODDS W/ HER PRESENTATION AT HER CME A MONTH EARLIER, SO THE BIF IS NOT SEEN [AS] A FIRM DX. WHILE DR CIEPLY DX'D PANIC D/O, HX OF MDD RECURRENT AND HX OF GAD, THESE DXS ARE NOT GIVEN GREAT WEIGHT, AS MS BROADWATER HAS A LONG AND FREQUENT RELATIONSHIP W/ HER PCP WHO HAS DX'D ONLY A HX OF ADJUSTMENT D/O W/ DEPRESSSION AND IS TREATING HER ONLY FOR BEREAVEMENT WHICH DR CIEPLY HAS ALSO DX'D. HER PCP ALSO GIVES A HX OF ALCOHOLISM. FINALLY, THE LIMS FROM HER PCP'S OFFICE INDICATES NO LIKELY WORK-RELATED LIMITATIONS AND NOTES HER MEMORY AND ATTN/CONC AS GOOD AND HER MOOD/AFFECT AS NORMAL. HER STATEMENTS ARE SEEN AS NOT FULLY CREDIBLE GIVEN THE TESTING DISCREPANCIES. MOST WEIGHT IS GIVEN TO THE PCP'S OPINION. SHE WOULD BE CAPABLE OF ROUTINE WORK ACTIVITIES.

Tr. at 65.

         Plaintiff reported some improvement in her ankle and leg swelling on July 8, 2013. Tr. at 398. Lisa Jennings, M.D. (“Dr. Jennings”), observed Plaintiff to have 1 edema in her bilateral ankles. Tr. at 400. Plaintiff's glucose and creatinine were slightly elevated. Tr. at 401. Dr. Jennings indicated Plaintiff's edema had improved with use of Lasix. Tr. at 402.

         On September 3, 2013, Plaintiff complained of increased swelling and pain in her legs during the prior week, but indicated the problems appeared to be improving. Tr. at 403. Casie Anderson, APN (“Ms. Anderson”), noted an abnormal peripheral vascular examination, delayed capillary refill of the toes, bilateral 1 pitting edema to the ankles, and bilateral 1 pretibial pitting edema. Tr. at 405. She instructed Plaintiff to keep her legs elevated above her heart level while resting and to wear compression stockings each day. Id.

         On September 6, 2013, a second state agency psychologist, Cal Vanderplate, Ph.D, ABPP (“Dr. Vanderplate”), reviewed the evidence and completed a PRTF. Tr. at 78-80. He considered Listing 12.06 for anxiety-related disorders, in addition to Listings 12.02, 12.04, and 12.09. Tr. at 78-79. He determined Plaintiff had mild restriction of ADLs, moderate difficulties in maintaining social functioning, and moderate difficulties in maintaining concentration, persistence, or pace. Tr. at 79. He noted that Plaintiff had a history of MDD, GAD, panic disorder, adjustment disorder related to bereavement, BIF, and learning disability. Id. He stated Plaintiff's IQ scores were a “low estimate” and that a diagnosis of BIF was more consistent with her adaptive functioning and work history. Id. Dr. Vanderplate also completed a mental RFC assessment. Tr. at 82-85. He determined Plaintiff was moderately limited with respect to the following abilities: to understand and remember detailed instructions; to carry out detailed instructions; to maintain attention and concentration for extended periods; to complete a normal workday and workweek without interruptions from psychologically-based symptoms; to perform at a consistent pace without an unreasonable number and length of rest periods; to interact appropriately with the general public; and to accept instructions and respond appropriately to criticism from supervisors. Tr. at 83-84. He stated Plaintiff maintained abilities “to understand, remember, and carry out simple one and two step instructions”; “to maintain concentration, persistence and pace for periods of two hours, perform activities within a schedule, maintain regular attendance, be punctual, and complete a normal workday and workweek”; “to make simple work-related decisions”; to “work in coordination with others without being distracted by them”; “to relate adequately to the public, coworkers, and supervisors”; “to respond appropriately to criticism from supervisors”; “to respond appropriately to changes in the work setting”; and to “be aware of normal hazards.” Tr. at 84-85.

         State agency medical consultant Stephen Burge, M.D. (“Dr. Burge”), completed a physical RFC assessment on September 11, 2013. Tr. at 80-82. He indicated Plaintiff could perform work with the following restrictions: occasionally lifting and/or carrying 20 pounds; frequently lifting and/or carrying 10 pounds; standing and/or walking for about six hours in an eight-hour workday; sitting for a total of about six hours in an eight-hour workday; frequently stooping and balancing; occasionally crawling, crouching, kneeling, and climbing ramps and stairs; never climbing ladders, ropes, or scaffolds; and avoiding concentrated exposure to extreme cold, extreme heat, humidity, fumes, odors, dusts, gases, poor ventilation, and hazards. Id.

         On September 30, 2013, Plaintiff reported a two-year history of swelling in her bilateral legs. Tr. at 345. She complained of leg and ankle pain. Id. Ms. Anderson observed Plaintiff to have 1 edema to the posterior tibialis and dorsalis pedis, 1 pitting edema to the bilateral ankles, 1 pretibial pitting edema. Tr. at 347. She assessed ankle joint pain and advised Plaintiff to wear compression stockings and to exercise her legs. Id.

         Plaintiff reported bilateral leg pain, aching, and cramping that radiated from her knee to her hip on October 28, 2013. Tr. at 348. She indicated her pain was worsened by standing and walking for seven hours while working. Id. Plaintiff had 1 edema to the posterior tibialis and right ankle. Tr. at 350. Ms. Anderson authorized Plaintiff to return to work the following day, but indicated she should wear compression stockings and keep her legs elevated while resting. Tr. at 351.

         Plaintiff complained of right knee pain and more frequent anxiety attacks on December 13, 2013. Tr. at 314. She felt that Zoloft was providing no relief. Id. She indicated she was enrolled in a vocational rehabilitation program, but was having difficulty working because of shortness of breath, cramping and numbness in her hands, right knee pain, and swelling in her legs. Id. Plaintiff's blood pressure was elevated at 152/76. Tr. at 316. Ms. Anderson noted the presence of a grade II systolic heart murmur. Tr. at 317. She observed Plaintiff to have a grade I effusion; diffuse tenderness to palpation; crepitus; and painful restricted active and passive ROM of her right knee. Id. She assessed ankle joint pain, knee joint pain, and anxiety. Id. She prescribed Hydrocodone-Acetaminophen for knee joint pain and replaced Zoloft with Wellbutrin XL 150 mg for anxiety. Id. Ms. Anderson noted that Plaintiff had undergone multiple heart tests that had revealed nothing more significant than tachycardia. Id.

         On December 13, 2013, an x-ray of Plaintiff's right knee showed moderate medial compartment knee joint degeneration. Tr. at 275. Dr. Jennings stated Plaintiff needed to see an orthopedist, but had no insurance. Id.

         On January 8, 2014, Ms. Anderson noted that Plaintiff's creatinine had been elevated during her last visit. Tr. at 331. Plaintiff indicated Wellbutrin had helped her anxiety and using oxygen during the night had caused her to feel less tired during the day. Id. She endorsed pain in her right knee and bilateral wrists and numbness in her fingers. Id. Ms. Anderson recorded Plaintiff's height as 5'3, ” her weight as 241.5 pounds, and her body mass index (“BMI”) as 42.78. Tr. at 333. She noted Plaintiff had positive Phalen's tests bilaterally, but negative Tinel's sign over the carpal tunnel. Tr. at 334. She assessed degenerative joint disease (“DJD”) of the knee and carpal tunnel syndrome (“CTS”). Id. She stated Plaintiff would need a referral to an orthopedist and, possibly, to a nephrologist. Tr. at 335. She applied a knee brace to Plaintiff's right knee and prescribed Meloxicam. Id.

         Plaintiff complained of pain in her left thigh on February 20, 2014. Tr. at 337. She demonstrated painful flexion, extension, internal and external rotation, abduction, and adduction of her left hip. Tr. at 339. Ms. Anderson assessed left thigh pain, administered an injection, and prescribed Cyclobenzaprine. Tr. at 340.

         On April 29, 2014, Plaintiff requested that her pain medication be prescribed more frequently. Tr. at 292. She indicated the medication was wearing off after four hours and stated she had stopped participating in vocational rehabilitation because of her pain. Id. Ms. Anderson noted no abnormalities on physical examination. Tr. at 294-95. She assessed type II diabetes mellitus and DJD of the knee. Tr. at 295. She discontinued Meloxicam and prescribed 800 mg of ibuprofen. Id. She declined to increase Plaintiff's dosage of Hydrocodone-Acetaminophen, but indicated she could alternate it with ibuprofen. Tr. at 295-96.

         On August 4, 2014, Plaintiff complained of a two-week history of left leg pain. Tr. at 299. She described the pain as starting in her foot and traveling to her hip. Id. She also reported a burning sensation in her left foot. Id. She stated she had been unable to attend her last appointment because she could not afford it. Id. Ms. Anderson noted no abnormalities on physical examination. Tr. at 301-02. She administered injections for left leg pain and renewed Plaintiff's prescriptions. Tr. at 302.

         Plaintiff followed up on August 18, 2014, and reported that the injection had failed to relieve her left leg pain. Tr. at 306. She requested that her Hydrocodone-Acetaminophen dosage be increased. Id. Ms. Anderson prescribed Gabapentin and declined to increase Plaintiff's dosage of Hydrocodone-Acetaminophen. Tr. at 308.

         On September 30, 2014, Plaintiff complained of pain from her hips through her feet. Tr. at 310. She stated Gabapentin had provided no relief. Id. She indicated her pain was more severe “at night after she has been on her feet all day.” Id. Ms. Anderson noted no abnormalities on examination. Tr. at 312. She assessed bilateral leg pain. Id. She prescribed Amitriptyline and Tramadol and ...


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