United States District Court, D. South Carolina
REPORT AND RECOMMENDATION
V. Hodges Columbia, South Carolina United States Magistrate
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 his claim for Disability Insurance Benefits
(“DIB”) and 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.
April 19, 2013, Plaintiff protectively filed applications for
DIB and SSI in which he alleged his disability began on March
30, 2013. Tr. at 339-47 and 348-53. His applications were
denied initially and upon reconsideration. Tr. at 277-81,
285-86, and 287-88. On May 20, 2015, Plaintiff had a hearing
before Administrative Law Judge (“ALJ”) Thomas G.
Henderson. Tr. at 175-98 (Hr'g Tr.). The ALJ issued an
unfavorable decision on June 15, 2015, finding that Plaintiff
was not disabled within the meaning of the Act. Tr. at
149-74. 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 6, 2017. [ECF No.
Plaintiff's Background and Medical History
was 36 years old at the time of the hearing. Tr. at 178. He
completed high school. Id. His past relevant work
(“PRW”) was as a bookkeeper and an assistant
director of pharmacy services. Tr. at 195. He alleges he has
been unable to work since March 30, 2013. Tr. at 339.
Evidence Presented to ALJ
developed necrotizing pancreatitis in April 2010, secondary
to gallstones. Tr. at 661. He was subsequently diagnosed with
a pseudocyst as a complication of necrotizing pancreatitis
and underwent open cystogastrostomy in June 2010.
Id. He required a secondary suture in September 2011
because of delayed wound healing. Id.
presented to the emergency room (“ER”) at
Carolinas Hospital System (“CHS”) on February 9,
2012, with moderately-severe left upper quadrant pain,
nausea, and vomiting. Tr. at 665. John Wolford, M.D.
(“Dr. Wolford”), observed Plaintiff's abdomen
to be soft and slightly protuberant and noted mild left upper
quadrant tenderness. Tr. at 666. He stated Plaintiff's
pain likely resulted from a new pseudocyst. Tr. at 667. He
did not suspect Plaintiff had “pancreatitis per se,
” but indicated “the redevelopment of the
pseudocyst suggests there may be a ductular abnormality that
may need to be corrected.” Id. He stated
Plaintiff would need drainage of the duct if his symptoms
continued and surgical resection if he had a stricture.
was admitted to CHS for abdominal pain, nausea, and vomiting
on February 24, 2012. Tr. at 661. Badri Giri, M.D.
(“Dr. Giri”), indicated Plaintiff had a history
of hypertension, hyperlipidemia, anxiety, and polycystic
kidney disease. Id. He stated Plaintiff had
presented to his clinic earlier in the day with vomiting and
increased abdominal pain that failed to respond to Dilaudid.
Id. He observed Plaintiff to be tender at the upper
epigastric region. Tr. at 662. An abdominal computed
tomography (“CT”) scan revealed a residual tiny
fluid collection, calcification of an area of speculated scar
tissue; splenomegaly; a four-millimeter cyst in the liver;
numerous renal cystic lesions; and two small ventral
abdominal wall hernias. Tr. at 681-82. Robert Garris, M.D.
(“Dr. Garris”), examined Plaintiff and determined
that the pseudocyst was too immature to drain. Tr. at 664.
Dr. Giri indicated Plaintiff's pain did not seem
proportionate to the size of the pseudocyst, but might be
exacerbated by its position. Id. He discharged
Plaintiff on February 29, 2012, with a prescription for two
milligrams of Dilaudid, every four hours, as needed, and
instructed him to follow up with a gastroenterologist and a
March 6, 2012, Plaintiff complained of abdominal pain and
nausea that had rendered him unable to work. Tr. at 588. John
Bennett Martinie, M.D. (“Dr. Martinie”), assessed
a persistent pseudocyst and possibly disconnected pancreatic
stump in the splenic hilum. Tr. at 590. He discussed the
risks of completion distal pancreatectomy and splenectomy,
and Plaintiff elected to proceed with the surgery.
Id. Dr. Martinie noted that the fact that Plaintiff
had not requested narcotic pain medications had
“reinforce[d] my belief that he truly is
symptomatic.” Id. He believed that Plaintiff
would benefit from surgery. Id.
March 28, 2012, Plaintiff underwent an open pancreatic
cystogastrostomy. Tr. at 587. He had no surgical
complications and was discharged home on April 4, 2012.
presented to Alan Barrett, PA-C (“Mr. Barrett”),
for anxiety on June 25, 2012. Tr. at 550. He complained of
depressed mood, difficulty falling asleep, diminished
interest and pleasure, being easily startled, worrying
excessively, decreased appetite, racing thoughts,
restlessness, headache, and irritability. Id. Mr.
Barrett noted no abnormalities on physical examination. Tr.
at 552-53. He authorized a refill of Klonopin and referred
Plaintiff for lab work. Tr. at 553.
16, 2012, David Culpepper, M.D. (“Dr.
Culpepper”), indicated Plaintiff's impairments
included stable hypertension, mild gastroesophageal reflux
disease (“GERD”), stable hyperlipidemia, mild
chronic pancreatitis, and anxiety with good response to
medication. Tr. at 545. He administered a B12 injection and
prescribed Cozaar and Toprol XL for hypertension; Klonopin
and Lexapro for anxiety; Prilosec for GERD; Zocor for
hyperlipidemia; and Nicotrol and nicotine patches for smoking
cessation. Tr. at 546.
December 28, 2012, Plaintiff reported that Dilaudid was too
strong. Tr. at 544. Dr. Culpepper prescribed Tramadol to be
used as needed. Id.
January 4, 2013, Plaintiff reported that Tramadol was not
helping to control his pain. Tr. at 536. Dr. Culpepper
observed Plaintiff to have a protuberant abdomen and central
abdominal tenderness. Tr. at 539. He prescribed pancreatic
enzymes and referred Plaintiff for pain management and
evaluation of sleep disturbance. Tr. at 540.
presented to Patrick Honaker, M.D. (“Dr.
Honaker”), for a pain management consultation on
January 24, 2013. Tr. at 577. He reported a history of
chronic pancreatitis that caused him to experience aching,
constricting, knifelike, sharp, and throbbing abdominal pain.
Id. He indicated he was taking two milligrams of
Dilaudid twice a week, but did not take the medication more
often because he could not take it while he was working. Tr.
at 579. Dr. Honaker observed that Plaintiff's abdomen was
mildly tender to palpation and had multiple surgical scars.
Tr. at 578. He refilled Plaintiff's prescription for
Dilaudid. Tr. at 579. He explained a controlled substances
agreement, and Plaintiff agreed to the terms. Id.
Dr. Honaker authorized Plaintiff to receive 60 pills and
instructed him to follow up in six months. Id.
letter dated February 11, 2013, R. Joseph Healy, M.D.
(“Dr. Healy”), informed Dr. Culpepper that
Plaintiff's sleep was non-productive and that he suffered
from excessive daytime sleepiness. Tr. at 560. He noted that
Plaintiff had lost a good bit of weight and that his snoring
had improved with the weight loss. Id. He explained
that polysomnography showed Plaintiff to have some early
rapid eye movement (“REM”)-related obstructive
sleep apnea (“OSA”); to sleep predominantly in
superficial sleep stages; and to have periodic limb movements
of sleep (“PLMS”). Id. He prescribed two
milligrams of Requip XL and recommended that Plaintiff
continue to lose weight. Tr. at 560.
presented to the ER at McLeod Regional Medical Center
(“MRMC”) on March 12, 2013, for left lower
quadrant abdominal pain, nausea, and vomiting. Tr. at 508.
Lab tests were negative. Tr. at 509. The attending providers
administered medication for pain and nausea and discharged
Plaintiff with instructions to follow up with his physicians
and to return if he continued to experience pain, vomiting,
or other concerns. Tr. at 509 and 512.
returned to the ER the next day. Tr. at 489. He stated he had
been unable to control his pain with prescribed medications.
Id. The attending physician observed Plaintiff to
have epigastric tenderness, guarding, and hyperactive bowel
sounds. Tr. at 493. A CT scan was consistent with
postoperative partial pancreatectomy with mild inflammation
stranding near the splenic hilum; unremarkable small bowel
anastomosis; and multiple bilateral renal cysts that were
consistent with polycystic kidney disease. Tr. at 496-97. The
attending physician diagnosed chronic pancreatitis and
abdominal pain and prescribed Dilaudid and Zofran. Tr. at
followed up with Dr. Culpepper on March 20, 2013. Tr. at 533.
He complained that he was experiencing constant left quadrant
pain that was exacerbated by work-related stressors.
Id. He reported decreased appetite and nausea. Tr.
at 534. Dr. Culpepper observed Plaintiff to appear ill and
anxious and to have a protuberant abdomen, hypoactive bowel
sounds, and left upper abdominal tenderness. Id.
followed up with Dr. Martinie on March 26, 2013. Tr. at 585.
He reported intermittent abdominal pain and chronic nausea.
Id. Dr. Martinie indicated Plaintiff's most
recent CT scan showed no new fluid collection or other
abnormality that would necessitate further surgery.
Id. He observed Plaintiff to be “somewhat pale
looking.” Id. He had “a long frank
discussion” with Plaintiff “about the lifelong
debilitating pain that often accompanies these types of
pancreatitis.” Id. He expected that Plaintiff
might be applying for disability and indicated he would
“enthusiastically support” that decision.
Id. He recognized a need to balance Plaintiff's
“need for adequate pain control” and “the
potential for addiction” to narcotic pain medications.
Tr. at 586.
followed up with Dr. Honaker on April 1, 2013. Tr. at 574. He
reported severe and worsening abdominal pain. Id. He
indicated he was taking Dilaudid more often than he had
anticipated and had only 15 pills remaining. Tr. at 576. Dr.
Honaker observed Plaintiff's abdomen to be soft and
mildly tender to palpation. Tr. at 575. He authorized
Plaintiff to receive 45 additional Dilaudid tablets.
presented to gastroenterologist Palmer M. Kirkpatrick, Jr.,
M.D. (“Dr. Kirkpatrick”), for recurrent
pancreatitis on April 9, 2013. Tr. at 521. Dr. Kirkpatrick
noted that Plaintiff had been hospitalized repeatedly for
biliary tract disease and was continuing to experience
abdominal pain. Id. He observed generalized
abdominal tenderness and multiple scars and noted that
Plaintiff weighed 244 pounds. Tr. at 522-23.
diagnosed chronic pancreatitis and suspected chronic pain
syndrome and prescribed Bentyl 20 mg. Tr. at 523. He stated
“[t]his unfortunate man has recurrent severe
pancreatitis with sever[e] pseudocyst formation most likely
due to biliary tract disease (no ETOH) history. My concern at
present is that he may be developing, or already has chronic
pain syndrome. He mentioned he is trying to get on
disability.” Tr. at 523-24.
complained of fatigue, abdominal pain, decreased appetite,
and nausea on April 15, 2013. Tr. at 530-31. Dr. Culpepper
observed surgical scars and central abdominal tenderness. Tr.
at 531. He prescribed Requip XL for restless leg syndrome and
refilled Plaintiff's other medications. Tr. at 531-32.
presented to the ER at CHS on May 4, 2013, with generalized
abdominal pain. Tr. at 606. The attending physician observed
moderate tenderness to palpation in the periumbilical region
of Plaintiff's abdomen. Tr. at 607. He diagnosed a
urinary tract infection and acute abdominal pain. Tr. at 608.
14, 2013, Plaintiff indicated he was tolerating Requip XL and
that his sleep had greatly improved. Tr. at 558. He indicated
he was feeling refreshed when he woke. Id. Dr. Healy
authorized a 90-day refill. Tr. at 559.
followed up with Dr. Honaker for a recheck of abdominal pain
on May 31, 2013. Tr. at 571. Dr. Honaker observed
Plaintiff's abdomen to be mildly tender to palpation, but
noted no other abnormalities on physical examination. Tr. at
572. He refilled Dilaudid. Id.
presented to Peter O'Kelly (“Dr.
O'Kelly”), for enlarged prostate, chronic
pancreatitis, and polycystic kidney disease on June 12, 2013.
Tr. at 728. Dr. O'Kelly noted no abnormalities on
genitourinary examination, but a urinalysis showed trace
blood and a glucose reading of 100 mg/dL. Tr. at 730. He
diagnosed a urinary tract infection and prostatitis and
prescribed Flomax. Tr. at 731.
presented to the ER at CHS on July 5, 2013, with pain in his
lower back and pancreas. Tr. at 634. An abdominal CT scan
showed no significant change. Tr. at 677-78. The attending
physician observed Plaintiff to be in mild distress and to be
mildly tender to palpation in the epigastrum and bilateral
upper abdominal quadrants. Tr. at 635. He diagnosed acute
pancreatitis and prescribed medication for nausea.
was hospitalized at CHS on July 7, 2013, for persistent
abdominal pain, nausea, and vomiting. Tr. at 689. His blood
sugar was 430. Id. He was treated for volume
depletion, persistent hyperglycemia, and pancreatitis. Tr. at
691. The attending physician prescribed Metformin.
Id. He discharged Plaintiff on July 9, 2013, with
instructions to test his blood sugar daily and to share his
readings with Dr. Culpepper during his next visit.
followed up with Dr. Culpepper on July 17, 2013, for
hypertension, hyperlipidemia, diabetes, and enlarged
prostate. Tr. at 704. He endorsed nausea, change in appetite,
and markedly diminished interest or pleasure. Tr. at 706. Dr.
Culpepper observed Plaintiff to be “chronically
ill-appearing” and to have a compensated gait,
hypoactive bowel sounds, and a protuberant abdomen. Tr. at
presented to Krista Kozacki, M.D. (“Dr.
Kozacki”), on July 26, 2013, for urinary tract
infection, chronic pancreatitis, and diabetes mellitus. Tr.
at 700. Dr. Kozacki observed Plaintiff to have slight
abdominal tenderness in his left upper abdominal quadrant and
mid-pelvis. Tr. at 702. She assessed acute prostatitis,
dysuria, and constipation; prescribed an antibiotic; and
instructed Plaintiff to hydrate and to use Metamucil or fiber
powder. Tr. at 700.
complained of constant, sharp, and aching abdominal pain on
July 30, 2013. Tr. at 863. Dr. Honaker observed
Plaintiff's abdomen to be mildly tender to palpation. Tr.
at 864. He acknowledged that Plaintiff had developed
diabetes, secondary to pancreatitis. Tr. at 865. He stated
Plaintiff's pain was stable and refilled his prescription
for Dilaudid. Id.
August 7, 2013, Dr. O'Kelly noted no abnormalities on
genitourinary examination. Tr. at 725. He prescribed Cipro
for prostatitis. Tr. at 726.
August 12, 2013, state agency consultant Olin Hamrick, Ph.D.
(“Dr. Hamrick”), reviewed the evidence and
completed a psychiatric review technique form
(“PRTF”). Tr. at 204-05. He considered Listings
12.04 for affective disorders and 12.06 for anxiety-related
disorders and found that Plaintiff's mental impairments
were non-severe because he had only mild restriction
activities of daily living (“ADLs”), mild
difficulties in maintaining social functioning, and mild
difficulties in maintaining concentration, persistence, or
pace. Id. A second state agency psychological
consultant, Kathleen Broughan, Ph.D. (“Dr.
Broughan”), reviewed the records and indicated similar
findings on the PRTF. Tr. at 236-37.
August 19, 2013, Plaintiff indicated acute prostatitis and
constipation were improved. Tr. at 768. Dr. Culpepper noted
diabetes was uncontrolled, but stated Plaintiff's insulin
resistance should respond to nutritionist-supervised weight
loss. Id. He noted Plaintiff's umbilical hernia
had been asymptomatic since his hospital stay, but indicated
he would refer Plaintiff to a surgeon, as needed.
Id. He stated Plaintiff continued to be disabled as
a result of pain secondary to chronic pancreatitis, but
indicated his office was not equipped to perform a true
functional capacity assessment. Id.
September 17, 2013, Plaintiff complained of new-onset nausea
since starting Metformin. Tr. at 773. He reported severe,
constant, and poorly-controlled symptoms of chronic
pancreatitis. Id. Dr. Culpepper observed Plaintiff
to be chronically ill-appearing. Tr. at 775. He instructed
Plaintiff to take 500 mg of Metformin with dinner and to
start Actos for diabetes. Tr. at 773. He changed
Plaintiff's dosage of Ropinirole from extended-release to
followed up with Dr. Honaker the same day and reported
constant, sharp, and aching abdominal pain. Tr. at 860. Dr.
Honaker indicated Plaintiff's abdomen was mildly tender
to palpation. Tr. at 861. He declined to increase
Plaintiff's medication dosage and recommended that he try
interventional procedures to address his pain. Id.
Tr. at 862.
presented to Harriet Steinert, M.D. (“Dr.
Steinert”), on September 20, 2013, for a consultative
examination. Tr. at 710. Dr. Steinert noted Plaintiff was
5'9” tall and weighed 269 pounds. Tr. at 711. She
observed Plaintiff to walk into the room without an assistive
device and to climb on to the examination table without
assistance. Id. She indicated Plaintiff was neatly
groomed, had a normal affect, and was able to provide a good
medical history. Id. She noted Plaintiff's
abdomen was “soft, obese and tender to palpation over
the area of the tail of the pancreas.” Tr. at 712. She
indicated no impairments to Plaintiff's vision, hearing,
neck, cardiovascular system, respiratory system, extremities,
orthopedic system, or neurological system. Tr. at 711-13. She
diagnosed morbid obesity, hypertension, dyslipidemia,
diabetes, polycystic kidney disease, and chronic pancreatitis
with pancreatic pseudocyst formation and stated Plaintiff was
limited by recurrent bouts of pancreatitis. Tr. at 713.
agency medical consultant Jean Smolka, M.D. (“Dr.
Smolka”), reviewed the evidence and completed a
physical residual functional capacity (“RFC”)
assessment on October 1, 2013. Tr. at 206-09. She found that
Plaintiff could occasionally lift and/or carry 20 pounds;
frequently lift and/or carry 10 pounds; stand and/or walk for
about six hours in an eight-hour workday; sit for a total of
about six hours in an eight-hour workday; never climb
ladders, ropes, or scaffolds; occasionally crawl, crouch,
kneel, stoop, and climb ramps and stairs; frequently balance;
and should avoid concentrated exposure to extreme heat and
hazards. Id. A second state agency medical
consultant, Tom Brown, M.D. (“Dr. Brown”),
reviewed the evidence and indicated the same restrictions in
a physical RFC assessment on December 30, 2013. Tr. at 240.
followed up with Dr. O'Kelly on October 9, 2013. Tr. at
718. His glucose was 500 mg/dL. Tr. at 721. Dr. O'Kelly
prescribed Cipro for prostatitis. Id.
presented to the ER at MRMC on October 13, 2013, with
abdominal pain, nausea, and elevated blood glucose. Tr. at
833. He received intravenous insulin. Tr. at 835.
denied symptoms from chronic pancreatitis on October 15,
2013, but indicated his symptoms flared when he experienced
hyperglycemia in preceding days. Tr. at 778. He stated his
blood sugar continued to be over 300 mg/dL, despite his use
of medication. Id. Dr. Culpepper ordered lab work
and instructed Plaintiff on use of long-acting insulin.
October 15, 2013, Plaintiff complained of constant, sharp,
and aching abdominal pain that was exacerbated by movement.
Tr. at 857. Dr. Honaker observed Plaintiff's abdomen to
be soft and mildly tender to palpation. Tr. at 858. He noted
that Plaintiff was having increased symptoms and added a
prescription for 300 milligrams of Neurontin, twice daily.
Tr. at 859.
presented to the ER at MRMC on October 17, 2013, for
abdominal pain and nausea. Tr. at 809. He was admitted and
started on a low dose of Lantus. Tr. at 810. He was
discharged with instructions to follow up with Dr. Culpepper
in two weeks and to follow a low fat diet with no
concentrated sweets. Tr. at 820.
presented to Dr. Culpepper with hyperglycemia on October 31,
2013. Tr. at 898. Dr. Culpepper noted that Plaintiff was
taking 12 units of insulin from a Novolog Flexpen at each
meal and was no longer taking Actos and Metformin.
Id. Plaintiff reported that he was checking his
blood sugar four to six times a day. Id. He stated
his blood glucose level had ranged from 76 to 246 mg/dL, but
had averaged 140 mg/dL or below over the prior week.
Id. Dr. Culpepper referred Plaintiff for lab work
and for assessment for an insulin pump. Id.
complained of constant, sharp, and aching abdominal pain on
November 15, 2013. Tr. at 855. He denied side effects and
indicated his pain medications were improving his ADLs and
allowing him to do more. Id. Dr. Honaker observed
Plaintiff's abdomen to be mildly tender to palpation. Tr.
at 856. He refilled Dilaudid and Neurontin and recommended
that Plaintiff be evaluated for an insulin pump. Id.
December 5, 2013, Plaintiff reported his home glucose
readings ranged from 75 to 179 mg/dL and averaged 120 mg/dL.
Tr. at 904. He complained of a headache and sinus pressure,
and Dr. Culpepper prescribed an antibiotic. Id.
Culpepper completed a mental status form on January 3, 2014.
Tr. at 880. He indicated he had prescribed Lexapro to treat
Plaintiff's symptoms of depression. Id. He noted
that medication had helped Plaintiff's condition and that
he had previously participated in psychiatric treatment.
Id. He described Plaintiff as being oriented to
time, person, place, and situation; having an intact thought
process; demonstrating appropriate thought content; and
having adequate attention, concentration, and memory.
Id. He stated Plaintiff exhibited obvious
work-related limitation in function. Tr. at 880. He indicated
Plaintiff experienced stress secondary to pain and multiple
disease processes. Id.
presented to endocrinologist Meenakshi Pande, M.D.
(“Dr. Pande”), on February 3, 2014. Tr. at 1091.
Dr. Pande noted that Plaintiff had been diagnosed with type I
diabetes four months prior. Id. However, he
indicated there was “also an element of Type 2 DM given
[Plaintiff's] obesity, h/o of hypoglycemia prior to the
pancreatitis episodes and his stron[g] f/h/o DM2.” Tr.
at 1093. He noted that Plaintiff frequently skipped a mid-day
meal because of chronic abdominal pain. Id. He added
Metformin to help with insulin sensitization and increased
Levemir to 20 units. Tr. at 1093-94.
March 3, 2014, Plaintiff reported his blood glucose readings
ranged from 66 to 177 mg/dL. Tr. at 909. He had gained 13
pounds. Id. Dr. Culpepper counseled Plaintiff on
smoking cessation and refilled his medications. Id.
complained of abdominal pain on March 3, 2014. Tr. at 887. He
rated his pain as a one to two on a 10-point scale with
medication and a 10 without medication. Tr. at 889. He stated
his pain interfered with his abilities to work and to engage
in ADLs and was so severe that he could not eat or otherwise
function without opiates. Id. Scott Mayhew, M.D.
(“Dr. Mayhew”), stated Plaintiff “certainly
has a legitimate medical need for his pain medications, based
on records review.” Id. However, he did not
believe Methadone was the appropriate medication for
Plaintiff. Id. He stated he would consider
prescribing Exalgo 16 mg, after a urine drug screen and more
thorough review of Plaintiff's records. Id. He
subsequently noted that Plaintiff's records showed
“no aberrant behaviors or signs of abuse or
diversion.” Id. He stated he would prefer that
Plaintiff discontinue Benzodiazepines for anxiety and
recommended that Plaintiff consult a psychiatrist to discuss
alternative treatments for anxiety. Tr. at 890.
presented to Dr. Culpepper on March 11, 2014, with fever,
body aches, joint pain, chills, shivering, and sweating. Tr.
at 915. He feared he was having a reaction to Methadone.
Id. Dr. Culpepper assessed gastroenteritis and
referred Plaintiff for lab work. Id.
followed up with Dr. Culpepper on March 24, 2014. Tr. at 920.
He indicated that his blood cultures had revealed Escherichia
coli (“E. coli”) during a recent hospitalization
for sepsis. Id. Dr. Culpepper indicated
Plaintiff had received intravenous antibiotics through a
peripherally inserted central catheter (“PICC”)
line in his right upper arm. Id. He noted that
Plaintiff had lost 18 pounds. Id. Plaintiff
indicated he had not used insulin in over two weeks because
his blood sugar had been low or within normal limits.
Id. He requested that Lexapro be refilled for
anxiety, and Dr. Culpepper authorized the refill.
March 24, 2014, Plaintiff described his pain as a two on a
10-point scale with medication and a seven without
medication. Tr. at 885. He stated his pain interfered with
his ADLs and ability to work. Id. Dr. Mayhew noted
that Plaintiff had recently been hospitalized for sepsis and
was continuing to receive intravenous antibiotic medications.
Id. He indicated Plaintiff had been weaned off
Methadone and switched back to Dilaudid during his
hospitalization. Id. He observed Plaintiff to have
minimal abdominal tenderness. Id. Dr. Mayhew
indicated he agreed with the discontinuation of Methadone
because Dilaudid would allow Plaintiff “better quality
of life and better function in that it reduces pain after
eating allowing him to eat.” Tr. at 886. He prescribed
four milligrams of Dilaudid and instructed Plaintiff to take
one to two tablets daily, as needed for pain. Id.
April 7, 2014, Plaintiff informed Lindsay Powell, PA
(“Ms. Powell”) that he had lost 14 pounds and had
been able to control his blood glucose with diet since his
hospitalization. Tr. at 1084. He weighed 272 pounds. Tr. at
1086. Ms. Powell instructed Plaintiff to remain off insulin,
but to monitor and record his blood glucose levels twice a
day and to bring the log to his next visit. Id.
April 23, 2014, Plaintiff reported that he had been
exercising, walking, and doing yard work in an attempt to
lose weight and had lost 14 pounds. Tr. at 958. He stated he
felt as if he had pulled a muscle in his back. Id.
Dr. Mayhew indicated Plaintiff's pancreas was producing
some insulin, but his pain was unchanged. Id. He
observed Plaintiff to have left paravertebral tenderness on
musculoskeletal examination. Tr. at 959. He indicated
Plaintiff's urine drug screen was consistent with the
prescribed medications and refilled Dilaudid. Id.
23, 2014, Plaintiff complained of more frequent flare ups of
abdominal pain. Tr. at 955. Dr. Mayhew noted tenderness in
Plaintiff's left upper abdominal quadrant. Id.
Plaintiff indicated he would follow up with his
endocrinologist for the increased flare ups. Id. Dr.
Mayhew stated there had been no aberrant behaviors or signs
of abuse or diversion. Id. He refilled
Plaintiff's prescription for Dilaudid. Id.
9, 2014, Plaintiff reported that his post-prandial glucose
readings were typically around 200 if he was inactive, but
would drop to the 60s if he engaged in any activity. Tr. at
1080. He indicated his typical fasting glucose was around
115. Id. He stated his blood glucose level would
rise above 200 if he took Dilaudid and slept for a
significant period. Tr. at 1082. Ms. Powell instructed
Plaintiff to maintain a blood sugar log for 10 days and
indicated Dr. Pande would adjust his medication based on the
readings in the log. Tr. at 1083.
1, 2014, Plaintiff reported two severe pain attacks during
the prior week that had necessitated ER visits. Tr. at 951. He
indicated testing had shown elevated enzymes. Id.
Dr. Mayhew observed Plaintiff to have mild tenderness in his
left upper abdominal quadrant. Id. He refilled
Plaintiff's prescription for Dilaudid and indicated he
would review the ER records. Tr. at 951-52. He stated
Plaintiff's last urine drug screen was consistent with
his prescribed medications. Tr. at 952.
was treated for acute pancreatitis in the ER at MRMC on July
27, 2014. Tr. at 1048. He reported a one-week history of
abdominal pain, nausea, and vomiting. Tr. at 1054. The
attending physician indicated Plaintiff had normal lipase and
no acute changes on CT scan. Tr. at 1067. Plaintiff reported
feeling better after having received two doses of Dilaudid.
29, 2014, magnetic resonance imaging (“MRI”) of
Plaintiff's abdomen showed no acute pancreatic
inflammation; atrophy of the pancreatic tail portions of the
body from prior necrotizing pancreatitis; pancreatic stump
tethered to the wall of the stomach by scar tissue; and
polycystic kidney disease with some hemorrhagic or
proteinaceous cysts. Tr. at 1045.
presented to the ER at MRMC on July 29, 2014, for abdominal
pain and acute pancreatitis. Tr. at 1022. He reported that he
had developed left upper quadrant pain while undergoing the
MRI. Tr. at 1035. The attending physician noted moderate
epigastric and left upper quadrant abdominal tenderness. Tr.
August 1, 2014, Plaintiff reported to Dr. Mayhew that he had
recently visited the ER on two occasions. Tr. at 947. He
indicated an imaging report had shown “lots of scar
tissue.” Id. He rated his pain as a two to
three with medication and a nine without medication.
Id. Dr. Mayhew noted mild left upper quadrant
tenderness with no guarding or rebound. Id. He