United States District Court, D. South Carolina
REPORT AND RECOMMENDATION
V. HODGES, UNITED STATES MAGISTRATE JUDGE.
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.
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].
Plaintiff's Background and Medical History
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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
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”).
April 29, 2013, pulmonary function testing showed Plaintiff
to have a moderately-severe restrictive abnormality. Tr. at
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.
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
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.
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.
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.
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.
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.
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.
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
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
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.
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.
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.
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
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.
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.
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 ...