United States District Court, D. South Carolina
Melissa J. Sanders-Hall, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant.
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 Disability Insurance Benefits
(“DIB”). 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.
August 14, 2012, Plaintiff protectively filed an application
for DIB in which she alleged her disability began on March
22, 2012. Tr. at 87 and 174-81. Her application was denied
initially and upon reconsideration. Tr. at 105-09, 111-16. On
June 14, 2016, Plaintiff had a hearing before Administrative
Law Judge (“ALJ”) Paul Elkin. Tr. at 31-74
(Hr'g Tr.). The ALJ issued an unfavorable decision on
July 14, 2016, finding that Plaintiff was not disabled within
the meaning of the Act. Tr. at 8-30. 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 1-5.
Thereafter, Plaintiff brought this action seeking judicial
review of the Commissioner's decision in a complaint
filed on August 7, 2017. [ECF No. 1].
Plaintiff's Background and Medical History
was 48 years old on her date last insured. Tr. at 23. She
completed the ninth grade. Tr. at 42. Her past relevant work
(“PRW”) was as a cashier and a fiber machine
operator. Tr. at 66. She alleges she has been unable to work
since March 22, 2012. Tr. at 174.
underwent anterior cervical fusion at the C4-5 level in April
2002. Tr. at 337 and 358.
October 11, 2012, neurosurgeon J. Marc Guitton, M.D.
(“Dr. Guitton”), informed Plaintiff that magnetic
resonance imaging (“MRI”) of her lumbar spine
showed degenerative changes with mild-to-moderate stenosis at
¶ 4-5. Tr. at 300. He assessed lumbar spondylosis,
lumbar disc disease, lumbar radiculopathy, and lumbar
stenosis. Id. He advised Plaintiff that treatment
options included medications, injections, therapy, and
December 12, 2011, Plaintiff presented to pain management
specialist Allen L. Sloan, M.D. (“Dr. Sloan”).
Tr. at 328. She reported sharp, aching pain across her lower
back that was exacerbated by maintaining positions, standing,
walking, sitting, and climbing stairs. Id. Dr. Sloan
observed Plaintiff to have difficulty rising from a seated to
a standing position; a stiff and slightly forward-flexed
gait; decreased range of motion (“ROM”) to
extension; tenderness to palpation in the midline and
paraspinal facets at ¶ 3-4, L4-5, and L5-S1 and over the
bilateral sacroiliac joints; positive Patrick's sign; and
pain on straight-leg raise (“SLR”) testing.
Id. He administered bilateral L3-4, L4-5, and L5-S1
lumbar facet and sacroiliac joint injections. Tr. at 328-29.
February 20, 2012, Plaintiff reported that her pain had
worsened. Tr. at 303. Dr. Guitton observed Plaintiff to have
limited motion in her back; lumbar stiffness; positive
bilateral SLR testing; and intact strength and sensation.
Id. Plaintiff indicated she would consider surgery.
March 13, 2012, an MRI of Plaintiff's lumbar spine showed
moderate central canal stenosis at ¶ 4-5. Tr. at 314-15.
March 23, 2012, Dr. Guitton performed decompressive lumbar
laminectomy at Plaintiff's L4-5 level. Tr. at 291.
Plaintiff reported she was doing well during a postoperative
visit on April 23, 2012. Tr. at 305. Dr. Guitton advised
Plaintiff to gradually increase her activity and to be
careful with bending and lifting. Id.
presented to Kraig Wangsnes, M.D. (“Dr.
Wangsnes”), for sleep apnea follow up on May 1, 2012.
Tr. at 395. She complained of an irregular heartbeat and pain
in her back and leg. Tr. at 396. Her blood pressure was
elevated at 160/90 mm/Hg. Tr. at 397. Dr. Wangsnes encouraged
Plaintiff to use her continuous positive airway pressure
(“CPAP”) machine, to increase her dose of
Micardis/Hydrochlorothiazide, and to maintain a log of her
blood pressure and pulse readings. Tr. at 396 and 398.
12, 2012, Plaintiff presented to Julie Sears, P.A.
(“Ms. Sears”), to follow up on sleep apnea and
hypertension. Tr. at 398. She reported she was tolerating her
blood pressure medications. Tr. at 399. Ms. Sears reviewed
Plaintiff's log and noted that her blood pressure
readings were controlled. Id. Her diagnostic
impressions were dizziness, controlled hypertension,
migraine, palpitations, and degenerative disc disease. Tr. at
16, 2012, Plaintiff complained to Dr. Guitton's nurse of
pain in her right knee, left foot, and lower back and
swelling in her bilateral ankles and feet. Tr. at 306.
17, 2012, Plaintiff complained of pain in her lower back and
left foot. Tr. at 337. Podiatrist Mackie J. Walker, D.P.M.
(“Dr. Walker”), observed Plaintiff's left
heel temperature to be increased with significant effusion
and swelling. Id. He stated he was unable to palpate
Plaintiff's pulse on the left side of her foot because of
2 bilateral pitting edema. Id. He observed
decreased sensorium bilaterally on monofilament testing and
abnormal sharp/dull and light touch sensation. Id.
He noted 4/5 muscle strength, limited dorsiflexion, and
exquisite pain on the left Achilles tendon. Id. He
described a palpable washboard-type feel to Plaintiff's
bilateral plantar fascia that he considered to be consistent
with plantar fibromatosis. Id. Dr. Walker indicated
ultrasound images showed multiple interligamentous legions.
Id. He stated examination of Plaintiff's
Achilles tendon revealed a very hypoechoic signal and
apparent disruption and tear on the medial aspect.
Id. He placed Plaintiff in a controlled ankle
movement (“CAM”) walker and referred her for an
MRI of her left ankle and midfoot. Tr. at 338.
19, 2012, an MRI of Plaintiff's left ankle showed severe
distal Achilles tendinopathy, tendinitis, and interstitial
partial tearing, as well as mild thickening of the proximal
plantar fascia. Tr. at 339. There was no evidence of plantar
fibromatosis. Id. An MRI of Plaintiff's right
ankle indicated an unremarkable Achilles tendon; very minimal
signal abnormality at the plantar fascial insertion; mild
hyperintensity surrounding the lateral fascicle; soft tissue
edema over the anterolateral ankle and foot; unremarkable
medial and lateral flexor and extensor tendons; fluid within
the sinus tarsi projecting from the posterior subtalar joint;
and intact talofibular, calcaneofibular, and deltoid
ligaments. Tr. at 340. It showed no clear evidence of plantar
31, 2012, Plaintiff complained of pain in her back, foot,
left suprascapular area, and bilateral knees. Tr. at 326. Dr.
Sloan observed Plaintiff to have positive patellar grinding
of the bilateral knees and to be tender in her left
suprascapular area, the left paraspinous muscles of her
cervical spine, and the medial joint lines of her bilateral
knees. Tr. at 327. He assessed “lumbar spondylosis,
facet arthropathy, and sacroiliac/hip pain improved with
recent lumbar laminectomy, ” cervical spondylosis and
suprascapular neuropathy, and bilateral knee patellofemoral
arthritis. Id. He refilled Plaintiff's
prescriptions for Flexeril and Lortab and indicated she
should follow up in three months for injections. Id.
August 28, 2012, Dr. Walker informed Plaintiff that the MRI
demonstrated interstitial tearing of the left side of the
Achilles tendon, tendinitis on the right, and arthritis at
the ankle. Tr. at 341. He noted that Plaintiff had
significant peripheral neuropathy. Id. He instructed
Plaintiff to continue to take Theramine and Naproxen.
October 9, 2012, Plaintiff reported pain and swelling in her
left Achilles area and pain in her knee. Tr. at 371. X-rays
of Plaintiff's heel showed modest posterior heel spur
formation. Id. Dr. Walker indicated Plaintiff
appeared to “have a little periostitis posteriorly and
inferiorly, ” but intact osteology. Id. He
stated Plaintiff had “a mild Haglund's deformity,
but nothing severe.” Id. He prescribed an
anti-inflammatory compound of nonsteroidal anti-inflammatory
drugs (“NSAIDs”), Ketamine, Tramadol,
Bupivacaine, and Clonidine. Id.
October 30, 2012, Plaintiff complained of left foot pain at
the contralateral side, plantar fascia, and Achilles tendon.
Tr. at 372. Dr. Walker observed that Plaintiff remained
“quite effused at the Achilles tendon with
Haglund's deformity and significant periostitis.”
Id. He placed Plaintiff in a Velocity-type brace to
immobilize the back of her left foot. Id.
November 13, 2012, Plaintiff complained that the topical
medication had provided little relief and that the brace had
irritated her leg and tendon. Tr. at 373. Dr. Walker observed
that Plaintiff continued to have significant Haglund's
deformity and bursitis at the medial insertion. Id.
He prescribed a steroid, but indicated he would consider
November 26, 2012, Dr. Walker described surgery that would
include removal of a portion of Plaintiff's left heel
bone, repair of the left Achilles tendon, and permanent
removal of the third, fourth, and fifth toenails on the right
foot. Tr. at 374. Plaintiff communicated her understanding
and desire to proceed with surgery, and Dr. Walker performed
it on December 28, 2012. Tr. at 374 and 376.
January 7, 2013, Plaintiff's surgical wounds showed no
signs of infection and x-rays of her left heel showed
“excellent reduction of deformity.” Tr. at
January 14, 2013, Plaintiff reported constant chest heaviness
and dyspnea on exertion. Tr. at 401. She complained that she
felt claustrophobic and was unable to continue to use her
CPAP machine. Id. Ms. Sears indicated
Plaintiff's pressure readings had been controlled.
Id. A physical examination was normal. Tr. at 403.
January 7, 2013, Dr. Walker noted that Plaintiff's wounds
were healing well, but that she had slight dehiscence
proximally. Tr. at 379. He instructed Plaintiff to wean off
the walker and to continue to use the ankle-foot orthosis
(“AFO”) with limited ambulation. Id.
January 29, 2013, Plaintiff reported minimal discomfort in
her feet. Tr. at 380. Dr. Walker observed Plaintiff to have
slight central dehiscence, but to be healing. Id. He
prescribed a topical wound medication and instructed
Plaintiff to begin ROM exercises and increase partial weight
bearing as tolerated. Id.
February 14, 2013, Dr. Walker stated Plaintiff's heel was
“remodeling very nicely, ” but he noted Plaintiff
had some wound complications and pain. Tr. at 381. He stated
Plaintiff had recently been diagnosed with diabetes.
Id. He prescribed another topical wound medication
and instructed Plaintiff to monitor her wounds for signs of
March 11, 2013, Dr. Walker indicated Plaintiff's wound
had finally healed and that she was doing “reasonably
well.” Tr. at 382. He instructed Plaintiff to follow up
in three weeks and indicated he would refer her to physical
therapy at that time. Id.
presented to Susan J. Tankersley, M.D. (“Dr.
Tankersley”), for a consultative examination on March
27, 2013. Tr. at 358-62. She complained of joint pain in her
neck, lower back, knee, leg, and left foot. Tr. at 358. She
described her lower back pain as frequently radiating to her
thoracic spine and rarely radiating to her lower extremities.
Tr. at 359. She stated her bilateral anteromedial thighs felt
numb all the time. Id. She reported persistent
muscle spasms and indicated her pain was exacerbated by
prolonged sitting, standing, lifting, and bending.
Id. She complained of swelling in her bilateral feet
that was worse on the left than the right. Id. She
indicated she had experienced prolonged healing following
Achilles tendon repair surgery. Id.
Tankersley observed Plaintiff to be ambulating with a CAM
walker and an antalgic and uneven gait. Tr. at 360.
Plaintiff's blood pressure was elevated at 150/90 mm/Hg.
Id. She was obese at 5' 2” tall and 225
pounds. Id. Dr. Tankersley observed no edema, muscle
wasting, or significant degenerative joint changes and intact
sensorium, strength, and ROM in Plaintiff's bilateral
upper extremities. Tr. at 361. She noted 2 bimalleolar edema
in Plaintiff's left lower extremity and 1 pretibial
edema in her right lower extremity. Id. She
indicated Plaintiff had trace effusion in her bilateral knees
that was more pronounced on the right. Id. She
observed no muscle wasting. Id. She noted that
Plaintiff had “fairly scattered paresthesias to touch
throughout both legs.” Id. She indicated
Plaintiff had intact strength on the right and 4 to 4-/5
proximal and distal strength on the left. Id. She
stated Plaintiff had intact ROM in her hips. Id. She
noted crepitus on ROM of Plaintiff's bilateral knees and
decreased ROM to flexion and extension of the right knee.
Id. She indicated Plaintiff had positive
Lachman's and McMurray's tests at the right knee.
Id. She observed reduced ROM of Plaintiff's
right ankle. Id. She noted that Plaintiff had
“essentially no range of motion at all” at the
left ankle, but indicated that she did not “push
it” as she had not yet been cleared for physical
Tankersley observed Plaintiff to have intact cranial nerves,
normal tone, and no rest or indention tremors or
bradykinesis. Id. She indicated Plaintiff was unable
to toe or heel stand. Id. She was unable to elicit
any reflexes. Id. She noted paraspinous muscle
spasms in Plaintiff's lumbar and cervical spine and
muscle spasms in her trapezius and strap muscles.
Id. She indicated Plaintiff's cervical spine was
tender in all planes, but that her ROM was normal, aside from
right rotation that was reduced to 60 degrees. Id.
She stated Plaintiff's lumbar ROM was reduced to 65
degrees on forward flexion, but was otherwise intact. Tr. at
362. The SLR test was negative in the sitting and supine
positions. Id. An x-ray of Plaintiff's left knee
showed minimal degenerative changes and no acute osseous
abnormality. Tr. at 357.
Tankersley's impressions were chronic neck pain with
history of degenerative joint and disc disease of the
cervical spine, status post anterior cervical fusion at
¶ 4-5; chronic lower back pain with history of
degenerative joint disease, degenerative disc disease of the
lumbar spine, status post discectomy and laminectomy in July
2012; left foot and ankle pain with history of left Achilles
tendinopathy and tear, status post repair in December 2012;
right knee pain with probable osteoarthritis and possible
internal derangement; new-onset diabetes mellitus; history of
sleep apnea; history of hypertension; history of
migraine-type headaches; new-onset dysphagia with history of
gastroesophageal reflux disease (“GERD”); history
of depression and anxiety; and obesity. Tr. at 362.
13, 2013, a colonoscopy showed diverticulitis and multiple
colon polyps. Tr. at 713. On August 13, 2013, upper
gastrointestinal endoscopy indicated a normal esophagus,
stomach, and duodenum. Tr. at 716.
complained of increased pain in her feet and bilateral legs
on September 20, 2013. Tr. at 424. She indicated she was
hardly able to wear a shoe or ambulate. Id. Dr.
Walker observed that Plaintiff's gait was antalgic.
Id. X-rays of Plaintiff's bilateral ankles
showed recurring bilateral heel spurs with decreased
calcaneal inclination angle. Id. Dr. Walker
indicated Plaintiff was experiencing pain related to diabetic
neuropathy and had significant scarring and thickening of the
tendon. Id. He prescribed Metanx. Id.
September 27, 2013, an MRI of Plaintiff's left ankle
showed a greater degree of thickening and signal abnormality
within the distal Achilles tendon. Tr. at 426.
Walker fitted Plaintiff for an orthotic device on October 30,
2013. Tr. at 427. On November 13, 2013, Plaintiff complained
of heavy and painful scarring on her anterior ankle and left
foot that was irritated by wearing shoes. Tr. at 428. She
indicated the orthotic provided relief from plantar
fasciitis. Id. Dr. Walker prescribed a scar cream
and refilled Metanx. Id.
November 27, 2013, x-rays of Plaintiff's bilateral knees
showed advanced degenerative joint disease that primarily
involved the medial tibial femoral compartments and was worse
on the right than the left. Tr. at 458.
complained of pain on December 11, 2013. Tr. at 429. Dr.
Walker described Plaintiff's Achilles tendon as
“quite puffy” and indicated she had either
developed a cyst at the Achilles insertion or sustained
another tear. Id. An MRI of the left ankle did not
suggest a new Achilles tendon tear. Tr. at 431.
January 16, 2014, Dr. Walker observed Plaintiff to
demonstrate an antalgic gait and pain on palpation. Tr. at
432. He instructed Plaintiff to continue home physical
therapy and to use the topical compound. Id.
February 18, 2014, Plaintiff reported that her Achilles
tendon was improving and responding well to the topical
compound and that her scar was remodeling well. Tr. at 433.
She indicated orthotics were providing some relief and
March 11, 2014, Dr. Walker noted that Plaintiff's plantar
fasciitis continued to improve, but still persisted. Tr. at
434. He indicated the edema had decreased. Id. He
instructed Plaintiff to continue to use the topical compound.
April 4, 2014, Plaintiff complained of heel and ankle pain
with cramping and burning, as well as a fractured right fifth
toe. Tr. at 435. Dr. Walker administered an injection of
Depo-Medrol and Carbocaine and instructed Plaintiff to
continue to take Vimovo. Id.
complained of left ankle and foot pain on May 16, 2014. Tr.
at 436. She reported some relief from the injection, but
continued to endorse some pain and burning. Id. Dr.
Walker observed Plaintiff to have 1 pedal edema on the right
and 2 pedal edema on the left. Tr. at 438. He noted
swelling, deformity, and hindfoot varus on the right and
swelling and hindfoot varus on the left. Id. He
observed tenderness of the calcaneal tuberosity, the Achilles
tendon insertion, and the bilateral plantar fascia and
Achilles tendons. Id. Plaintiff demonstrated 4/5
strength in the bilateral peroneus longus, brevis, and
gastrocnemius. Tr. at 439. She had no plantar or Babinski
reflex on the left or right. Id. She had
hypersensitivities at the lateral plantar nerve, the medial
plantar nerve, and the deep peroneal nerve and tactile
dysesthesia/hyperesthesia in her bilateral distal
extremities. Id. Dr. Walker assessed Achilles
bursitis, calcaneal spur, tenosynovitis of the foot, plantar
fascial fibromatosis, neurological disorder associated with
type II diabetes mellitus, thoracic neuritis, obesity, and
cellulitis and abscess of the upper arm. Id.
December 4, 2014, Dr. Walker examined Plaintiff's left
heel with ultrasound. Tr. at 443. He noted a thickened and
hypoechoic ligament and the plantar facia's insertion
into the inferior tuberosity of the left calcaneus.
Id. The left plantar fascia was approximately twice
its normal thickness. Id. Dr. Walker stated the
findings were consistent with acute plantar fasciitis and
tarsal tunnel syndrome of the left foot. Id. He
administered an injection at the left peroneal area.
December 30, 2014, Plaintiff rated her pain as a seven. Tr.
at 474. She described sharp, aching pain across her back,
both hips, and her right knee that was aggravated by
activities of daily living (“ADLs”), walking
distances, and maintaining positions for any length of time.
Id. Dr. Sloan administered bilateral facet joint
injections at ¶ 3-4, L4-5, and L5-S1. Id.
January 8, 2015, Dr. Walker observed 1 pedal edema to
Plaintiff's bilateral feet. Tr. at 447. He described
Plaintiff as having an antalgic gait on the right and
ambulating with a cane. Id. He noted Haglund's
deformity, hindfoot varus, and midfoot cavus in the bilateral
feet. Id. Plaintiff demonstrated tenderness at the
Achilles tendon insertion, sinus tarsi, peroneal retinaculum,
and deltoid ligament. Id. She reported painful ROM
and decreased subtalar ROM bilaterally. Id. She had
4/5 strength at the bilateral gastrocnemius. Tr. at 448. Her
reflexes were diminished in her bilateral ankles.
Id. She was hypersensitive at her bilateral medial
and lateral plantar nerves. Id. She had tactile
dysesthesia/hyperesthesia in her bilateral distal
extremities. Id. Tinel's test was positive
presented to Leopoldo Muniz, M.D. (“Dr. Muniz”),
for a primary care new patient visit on January 13, 2015. Tr.
at 570. Dr. Muniz noted tenderness to Plaintiff's lumbar
spine, negative SLR test, and good ROM, sensation, pulses,
and strength. Tr. at 571. He instructed Plaintiff to stop
smoking and referred her for blood work and urinalysis. Tr.
January 22, 2015, Plaintiff rated her pain as an eight and
complained of spasms in her lower back and legs. Tr. at 471.
Dr. Sloan observed Plaintiff to have an abnormal gait;
bilateral shoulder tenderness to palpation; limited ROM and
4/5 muscle strength of the upper extremities; bilateral knee
joint crepitus; bilateral hip tenderness radiating to the
buttocks; decreased ROM and 4/5 strength of the bilateral
lower extremities; middle and lower back tenderness to
palpation; 4/5 strength and decreased ROM of the spine;
cervical tenderness with palpation; and decreased reflexes.
Tr. at 472.
January 28, 2015, Plaintiff reported doing well in general,
but complained of tenderness over her left elbow. Tr. at 568.
Dr. Muniz indicated Plaintiff's blood sugar had
decreased. Id. He noted a small nodule over
Plaintiff's left elbow, but indicated she demonstrated
good ROM, sensation, pulses, and strength. Tr. at 569. He
referred Plaintiff for an ultrasound of her left elbow and
recommended that the frequency of her steroid injections be
decreased because of adrenal insufficiency. Id.
February 12, 2015, Dr. Walker fitted an ankle stabilizer to
Plaintiff's right foot. Tr. at 453.
February 18, 2015, Dr. Muniz indicated the ultrasound showed
a cystic mass that was likely a synovial cyst, but possibly a
ganglion cyst or schwannoma. Tr. at 581. He recommended an
MRI of the left elbow. Id.
February 19, 2015, Plaintiff rated her pain as a ten. Tr. at
467. Dr. Sloan noted abnormal gait; bilateral shoulder
tenderness to palpation; 4/5 muscle strength in the bilateral
upper extremities; limited upper extremity ROM; bilateral
knee joint crepitus; bilateral hip tenderness radiating into
the buttocks; decreased ROM in the bilateral lower
extremities; 4/5 muscle strength in the bilateral lower
extremities; and decreased reflexes. Tr. at 468. He observed
no edema and indicated Plaintiff had intact sensation to
light touch. Id. He instructed Plaintiff to quit
smoking and to continue to take the same medications. Tr. at
February 26, 2015, Plaintiff reported some improvement in her
right ankle. Tr. at 658. Dr. Walker instructed her to
continue the same treatment regimen. Id.
March 9, 2015, Plaintiff presented to orthopedist Andrew W.
Torrance, M.D. (“Dr. Torrance”), for painful
swelling of her left elbow. Tr. at 476. Dr. Torrance assessed
a complex, multi-lobulated cystic structure at the anterior
lateral aspect of Plaintiff's left elbow that was likely
a ganglion cyst. Id. He performed ultrasound-guided
aspiration on March 11, 2015. Tr. at 477.
March 12, 2015, Dr. Walker observed Plaintiff to be obese and
in distress. Tr. at 492. He indicated Plaintiff was
ambulating with crutches and an antalgic gait. Id.
He noted 1 bilateral pretibial edema. Id. He
observed deformities in Plaintiff's bilateral feet,
tenderness to palpation, decreased ROM and strength, medial
column collapse, hammertoe deformities, neurological
dysesthesias and hypersensitivities, and positive Tinel's
March 19, 2015, Plaintiff complained of pain in her right
knee and lower back. Tr. at 462. She rated her back pain as a
seven and her knee pain as a ten. Id. Dr. Sloan
observed Plaintiff to ambulate with an antalgic, waddling
gait with boots on her bilateral feet; to have bilateral knee
joint crepitus; to have bilateral hip tenderness radiating
into her buttocks; to demonstrate decreased ROM and 4/5
muscle strength in her bilateral lower extremities; to have
minimal bilateral ankle swelling; to demonstrate tenderness
to palpation in her lower back; and to demonstrate decreased
reflexes. Id. He made no adjustments to
Plaintiff's medication regimen. Id.
reported feeling better on March 24, 2015. Tr. at 584. Dr.
Muniz continued her on the same medications and instructed
her to follow a low-salt diet, avoid ...