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Poston v. Berryhill

United States District Court, D. South Carolina

November 13, 2017

Joseph Edward Poston, Plaintiff,
v.
Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant.

          REPORT AND RECOMMENDATION

          Shiva V. Hodges Columbia, South Carolina 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 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.

         I. Relevant Background

         A. Procedural History

         On 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. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff 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.

         2. Medical History

         a. Evidence Presented to ALJ

         Plaintiff 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.

         Plaintiff 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. Id.

         Plaintiff 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 surgeon. Id.

         On 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.

         On 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. Id.

         Plaintiff 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.

         On July 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.

         On December 28, 2012, Plaintiff reported that Dilaudid was too strong. Tr. at 544. Dr. Culpepper prescribed Tramadol to be used as needed. Id.

         On 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.

         Plaintiff 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.

         In a 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.

         Plaintiff 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.

         Plaintiff 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 497-98.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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. Id.

         Plaintiff 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.

         He 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.

         Plaintiff 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.

         Plaintiff 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.

         On May 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.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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. Id.

         Plaintiff 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. Id.

         Plaintiff 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 706-07.

         Plaintiff 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.

         Plaintiff 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.

         On August 7, 2013, Dr. O'Kelly noted no abnormalities on genitourinary examination. Tr. at 725. He prescribed Cipro for prostatitis. Tr. at 726.

         On 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.

         On 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.

         On 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 fast-acting. Id.

         Plaintiff 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.

         Plaintiff 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.

         State 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.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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. Id.

         On 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.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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.

         On 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.

         Dr. 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.

         Plaintiff 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.

         On 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.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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.[1] 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. Id.

         On 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.

         On 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.

         On 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.

         On May 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.

         On June 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.

         On July 1, 2014, Plaintiff reported two severe pain attacks during the prior week that had necessitated ER visits.[2] 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.

         Plaintiff 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. Id.

         On July 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.

         Plaintiff 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. at 1037.

         On 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 ...


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