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Moore v. Berryhill

United States District Court, D. South Carolina

October 18, 2018

Stacy Renarda Moore, [1] Plaintiff,
v.
Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant.

          REPORT AND RECOMMENDATION

          Shiva V. Hodges, United States Magistrate Judge.

         This appeal from a denial of social security benefits is before the court for a Report and Recommendation (“Report”) pursuant to Local Civ. Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying her claim for 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 the Commissioner's decision be reversed and remanded for further proceedings as set forth herein.

         I. Relevant Background

         A. Procedural History

         On March 18, 2014, Plaintiff filed applications for DIB and SSI in which she alleged her disability began on August 1, 2007. Tr. at 176-79 and 180-89. Her applications were denied initially and upon reconsideration. Tr. at 54-73 and 76-99. On December 10, 2015, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Edward T. Morriss. Tr. at 36-49 (Hr'g Tr.). The ALJ issued an unfavorable decision on February 3, 2016, finding Plaintiff was not disabled within the meaning of the Act. Tr. at 18-35. 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 1-7. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on August 24, 2017. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 45 years old at the time of the hearing. Tr. at 39. She completed the twelfth grade. Id. Her past relevant work (“PRW”) was as a cook, cashier, housekeeper or childcare giver, bus driver, and patient transporter. Tr. at 97-98, 678. She alleges she has been unable to work since February 10, 2014.[2] Tr. at 678.

         2. Medical History

         a. Evidence Submitted to the ALJ

         On March 29, 2013, [3] Plaintiff presented to University Hospital, part of the Medical University of South Carolina (“MUSC”), with complaints of abdominal pain, nausea, vomiting, and diarrhea. Tr. at 695-701. Plaintiff reported nausea and vomiting every morning for the prior month, as well as increased epigastric pain and unintended weight loss over the prior few months. Tr. at 695-96, 699. Plaintiff also reported fevers and chills in the forty-eight hours prior to her hospital visit. Id. Plaintiff's blood sugar was 550 with a minimal gap of 13, her last hemoglobin A1C was 16.6, and her urine tested positive for ketones. Tr. at 699-700. Plaintiff was given two liters of fluid, and the gap closed. Id. Plaintiff was diagnosed with starvation ketosis, uncontrolled diabetes, dehydration, and hypertension. Tr. at 700-01. She responded to medication and was placed back on her home dose of Levemir. Tr. at 700. The treatment notes indicated that the rapid normalization of her sugars suggested she may not have been compliant with her home regimen of insulin. Id. Plaintiff was instructed to follow up with the Franklin C. Fetter Clinic (“F.C. Fetter”). Tr. at 701.[4]

         On May 26, 2013, Plaintiff presented to University Hospital with abdominal pain, nausea, vomiting, diarrhea, and a syncopal episode, reporting pain intensity of 7/10. Tr. at 691-93. Plaintiff's children witnessed her lose consciousness for a few seconds and fall to the floor. Tr. at 692. Plaintiff was 5'1” and 270 pounds with a body mass index (“BMI”) of 51.02. Id. The notes from Plaintiff's visit indicated her syncopal event and abdominal pain were likely secondary to her vomiting and dehydration. Tr. at 694. Plaintiff's lab results were within normal limits. Id. Plaintiff was given fluids and nausea medication intravenously and was discharged with instructions to follow up with her primary care provider. Id.

         On May 29, 2013, Plaintiff visited F.C. Fetter. Tr. at 801-04. The notes stated Plaintiff was a “43 year-old with [diabetes mellitus] for several years, but poorly compliant who comes for follow up after months of not being seen.” Tr. at 801. Plaintiff reported her recent syncopal episodes. Id. The notes from the visit indicated she had symptoms of gastroparesis. Id. Plaintiff was assessed for diabetes, diabetic gastroparesis, obesity, and abdominal pain. Tr. at 803. Plaintiff's A1C was 14.3. Tr. at 787.

         On July 3, 2013, Plaintiff presented to F.C. Fetter, complaining of dizziness when her glucose was closer to normal values. Tr. at 797-800. Charles Effiong, M.D. (“Dr. Effiong”), explained to Plaintiff that her dizziness was likely autonomic neuropathy. Tr. at 797. Plaintiff weighed 265 pounds and “was applauded for weight loss.” Tr. at 797-98. Plaintiff was assessed for diabetic gastroparesis, diabetes, and autonomic neuropathy. Tr. at 799. Dr. Effiong noted Plaintiff's diabetes mellitus was not adequately controlled and increased Novolog. Tr. at 799-800.

         On August 26, 2013, Plaintiff presented to F.C. Fetter for hypertension and complained of dizziness and feeling lightheaded for one week. Tr. at 794- 96. Dr. Effiong ordered lab tests and the results revealed Plaintiff's A1C was 14.3. Tr. at 787.

         On November 6, 2013, Plaintiff presented to University Hospital after a syncopal episode. Tr. at 688. Plaintiff reported she had episodes of lightheadedness at work in prior months, but had never passed out. Id. During the episode, Plaintiff had a heavy feeling in her chest, took a few steps, and lost consciousness, but was unsure how long she was unconscious. Id. When she awoke, she had right hip pain. Tr. at 691. Her electrocardiogram (“EKG”) showed no ischemic changes and no ectopy. Id. Plaintiff's blood sugar was in the high 200s, and it was unclear whether she was dehydrated. Id. Plaintiff was given intravenous fluids and felt better. Plaintiff was advised to keep track of her blood sugar and drink plenty of fluids. Id.

         On February 16, 2014, Plaintiff presented to University Hospital with complaints of losing consciousness. Tr. at 684. Plaintiff reported she had been passing out for over a month, but was unsure how long she had been unconscious during those episodes. Id. Plaintiff indicated she was “under a lot of stress at work[.]” Id. She had hyperglycemia with a glucose level of 487. Id. The physical exam notes indicated Plaintiff could walk without difficulty, but she had bilateral paresthesia in her feet. Tr. at 685. The clinical impression was syncope. Tr. at 687. Plaintiff was given intravenous fluids, and her blood glucose level improved. Id. She reported improvement and was discharged. Id.

         On February 17, 2014, Plaintiff presented to F.C. Fetter to follow up on her fall. Tr. at 790-93. Plaintiff reported numbness in both feet, an unsteady gait, and frequent falls. Tr. at 790. Plaintiff also reported her symptoms were aggravated by movement, resting, standing, and walking, with no relieving factors. Id. Dr. Effiong stressed the importance of controlling Plaintiff's diabetes mellitus. Id. Dr. Effiong assessed diabetes mellitus, obesity, diabetic neuropathy, and polyneuropathy in diabetes. Tr. at 793.

         On March 13, 2014, Plaintiff presented to F.C. Fetter. Tr. at 788-89. Dr. Effiong noted Plaintiff was a “44-year-old with poorly controlled [diabetes mellitus] with complications including severe neuropathy. Comes in following a recent fall at her home in the hallway.” Tr. at 788. Dr. Effiong reviewed Plaintiff's lab results and scheduled a follow-up appointment. Tr. at 789.

         On March 25, 2014, Plaintiff presented to F.C. Fetter Family Health Center for a gynecologist visit. Tr. at 783-85. Sharon Bullard, a family nurse practitioner, noted Plaintiff had insomnia and instructed her to schedule a follow-up visit with Dr. Effiong for diabetes mellitus in June 2014. Tr. at 784-85.

         On April 5, 2014, Plaintiff presented to MUSC complaining of right leg pain, which she described as sharp and constant in the posterior aspect of her calf and up the back of her leg. Tr. at 805-10. Plaintiff reported swelling of her leg with numbness and tingling. Id. Plaintiff's blood pressure was 164/104. Tr. at 806. The physical exam showed minimal appreciable swelling of Plaintiff's right leg, joint swelling, and a gait problem. Id. Plaintiff's pain was exacerbated by a straight leg raise (“SLR”) test. Id. Plaintiff's strength was four out of five on the right. Id. Dr. Brett W. McGary, M.D. (“Dr. McGary”), noted the most likely cause of Plaintiff's pain was an exacerbation of her peripheral neuropathy, as it appeared her glucose levels were not adequately controlled due to the increased insulin. Tr. at 807. He also noted she would likely benefit from neuropathic modulating or receptor medications. Id.

         On May 2, 2014, Bernard Arnold, O.D. (“Dr. Arnold”), completed a vision exam of Plaintiff for a “South Carolina Vocational Rehabilitation Department Disability Determination Services Medical Summary.” Tr. at 815-18. Plaintiff reported blurred vision and inability to drive. Tr. at 816. In the diagnosis and prognosis section, Dr. Arnold noted Plaintiff needed a prescription for reading glasses and her vision was stable. Tr. at 818. Dr. Arnold opined Plaintiff's mobility, visual activities, and fundus photography were normal. Id. Dr. Arnold also opined Plaintiff's work-related activities were “normal (somewhat), ” and he recommended a “GDx or equivalent due to CUD/DISC Rati.” Id.

         On May 5, 2014, Hugh Wilson, M.D. (“Dr. Wilson”), a state agency consultant completed a physical residual functional capacity (“RFC”) assessment. Tr. at 57-73. He indicated Plaintiff had the following limitations: occasionally lift, carry, push or pull twenty pounds; frequently lift, carry, push, or pull ten pounds; stand, walk, or sit with normal breaks for about six hours; frequently stoop, kneel, crouch, and crawl; and never climb ladders, ropes, or scaffolds. Tr. at 59-60. In addition, he opined Plaintiff should avoid concentrated exposure to hazards, such as machinery or heights, because she “[m]ay have dizziness from uncontrolled [blood sugar].” Tr. at 60-61.[5]

         On May 19, 2014, Plaintiff returned to F.C. Fetter for a follow-up appointment with Dr. Effiong. Tr. at 824. Plaintiff reported she quit her job because of neuropathic pain and had difficulty standing due to pain and weakness in her leg. Id. Plaintiff reported she had fallen twice in the prior few weeks. Id. Plaintiff also reported having nausea and vomiting daily, being stressed due to lack of work and her medical conditions, and not sleeping. Id. Dr. Effiong noted Plaintiff would need magnetic resonance imaging (“MRI”) of her lower back, as she had a positive SLR test, which potentially indicated ongoing disc disease. Tr. at 827. Plaintiff was instructed to check her blood sugar once a day, check her feet daily, and follow a prescribed diet. Id. Dr. Effiong assessed diabetes mellitus, gastroparesis, obesity, autonomic neuropathy, and insomnia. Id. Dr. Effiong increased Novolog and Reglan and started Gabapentin. Id.

         On June 18, 2014, Plaintiff presented to MUSC with complaints of constant fatigue, abdominal pain, non-bloody vomiting, and non-bloody diarrhea for five to six days. Tr. at 861. Plaintiff reported she had been off her diabetic medication since losing her job. Id. Plaintiff also indicated she had not taken her Novolog because she had not felt like eating. Tr. at 869. During the physical exam, Plaintiff was tender in the epigastric area. Tr. at 863. Plaintiff's glucose was 558, which decreased to 226 with the medications given in the emergency room. Tr. at 863-64, 869. An x-ray of Plaintiff's abdomen showed no acute intrathoracic or abdominal process. Tr. at 923. The clinical impression recorded during Plaintiff's visit was hyperglycemia, nausea and vomiting, and diarrhea. Tr. at 869. It was noted the primary care provider at F.C. Fetter “had utilized social work to help [Plaintiff] pay for [L]evemir and [N]ovolog” and she would have them “filled by Friday.” Id.

         On July 10, 2014, Angela Saito, M.D. (“Dr. Saito”), a state agency consultant completed a physical RFC assessment upon Plaintiff's request for reconsideration. Tr. at 82-97. She adopted the same exertional limitations as Dr. Wilson, but opined Plaintiff had the following additional postural and environmental limitations: occasionally climb ramps or stairs; occasionally balance, stoop, kneel, crouch, or crawl; and avoid all exposure to hazards, such as “[u]nprotected hts for Endocrine imp.” Tr. at 83-84.[6] Dr. Saito limited the RFC assessment to the period of February 10, 2014, to February 10, 2015. Tr. at 82, 94. Moreover, Dr. Saito provided the following additional explanation within her report:

Endo - Severe. Poorly controlled DM with evid of EOD disease. see neuro and GI below.
Neuro - Severe. Autonomic neuropathy or other cause for Syncope/Falling. Curious that clmt is not seen day of the falls or syncope but a few days later. Has not had complete evaluation or been referred to specialists yet. Neuropathic pain in leg is a new symptom. MRI of Lumbar spine ordered 5/19/14 for positive SLT. MSK was o/w nl.
GI - Mention of Gastroparesis on 5/14. Admitted 3/13 for “starvation ketosis”. Clmt's regular 5/13 wt 273 with BMI 40.31. Not severe.
Vision - n/s 5/2/14 Vision CE - c/o blurred vision. w/o correction 20/30 bilat near 20/25. Mobility normal. work related activities normal. visit normal.
Pain and limitations of leg pain are partially credible. Atypical of diabetic neuropathy. W/u for lumbar radiculopathy has been initiated with 5/14 order of MRI. Has not had trials of medications for neuropathic pain as of yet.
Clmts sxs of blurred vision is credible but not to the degree she has stated. Has 20/30 VA bilat. Could be result of high BS.
MSS from Bernard Arnold that work related activities based on patient's mobility and visual activities are normal (somewhat). Great wt is given to this provider as it is not inconsistent with the majority of objective evidence in the file. It is unclear why Mr Arnold wrote “somewhat”. This may be due to clmt's level III obesity or possible blurred vision due to poorly controlled DM.
Clmt has a severe endocrine imp with some possible end organ disease. She is undergoing a work up for peripheral neuropathy v. lumbar radiculopathy. Her evaluation has been incomplete. With further investigation and compliance with appropriate treatment, clmt should be capable of the RFC as outlined within one year.

Tr. at 84, 96 (emphasis added).

         On September 14, 2014, Plaintiff presented to Walter E. Limehouse, M.D. (“Dr. Limehouse”), at MUSC with complaints of blurred vision, fatigue, polydipsia, and polyphagia for the prior week, noting she had been compliant with treatment most of the time. Tr. at 870-80. Although Plaintiff was taking insulin as prescribed, her blood glucose level had been 400 or higher. Tr. at 870. The recorded clinical impression was hyperglycemia and dehydration. Tr. at 880. Plaintiff was given fluids and medication. Id.

         On September 24, 2014, Plaintiff presented to MUSC with complaints of high glucose, abdominal pain, nausea, and vomiting. Tr. at 881-90. Plaintiff reported her gastroparesis symptoms had been bad and she had not been eating much, so she had not taken her Novolog in two weeks. Id. The recorded clinical impression was hyperglycemia without ketosis. Tr. at 889. Plaintiff's blood glucose improved from over 500 to 282 with fluids and insulin, noting the hyperglycemia was likely from not taking Novolog for two weeks. Id.

         On November 21, 2014, Plaintiff presented to MUSC after experiencing two syncopal events in two days. Tr. at 890-96. Plaintiff reported her blood glucose had been in the 400s, but as low as 60 to 80 at night. Id. Plaintiff admitted she had stopped taking Novolog, as she had not been eating, but she continued to take Levemir. Id. Plaintiff's blood pressure was 160/92, and her glucose was greater than 500. Tr. at 891-93. Plaintiff's syncope presentation was consistent with orthostasis. Tr. at 895. She was given fluids and insulin, and her blood glucose level lowered to 280. Id. The recorded clinical impressions were hyperglycemia, vasovagal syncope, type two diabetes mellitus, nausea and vomiting, and leg pain. Id. Results of an EKG reflected: sinus tachycardia, possible left atrial enlargement, left ventricular hypertrophy, nonspecific T wave abnormality, abnormal ECG, and, “when compare[d] with ECG taken on June 18, 2014, nonspecific T wave abnormality [was] now evident in lateral leads.” Tr. at 926.

         On December 9, 2014, Plaintiff began treatment with Don A. Schweiger, M.D. (“Dr. Schweiger”), for uncontrolled diabetes. Tr. at 834. Plaintiff reported she had lost over 100 pounds in the prior eight months, and Dr. Schweiger noted she weighed 230 pounds, which was still significantly overweight. Id. Plaintiff also reported she had no appetite, vomited everything, had weakness, and experienced stomach pain. Id. Dr. Schweiger suspected diabetic gastroparesis. Id. Dr. Schweiger's exam showed significant diabetic retinopathic changes. Id. Dr. Schweiger's assessment was diabetes mellitus, abdominal pain, hypertension, and diabetic gastroparesis. Tr. at 834-35. He adjusted Plaintiff's medications by stopping Norco; continuing Phenergan, Levemir Flexpen, and Novolog; and starting Tramadol, Lisinopril, and Metoclopramide. Tr. at 835. Dr. Schweiger scheduled a follow-up appointment for Plaintiff because he needed medical records from MUSC and F.C. Fetter. Id.

         At the follow-up appointment with Dr. Schweiger on December 16, 2014, Plaintiff reported her nausea after meals persisted, although she had seen some improvement after starting Reglan. Tr. at 836-38. Plaintiff continued to report abdominal pain after eating. Id. Her glucose was 545. Id. Dr. Schweiger continued Lisinopril, NovoLog, Phenergan, Metoclopramide, Tramadol; started Lisinopril-Hydrochlorothiazide; increased Plaintiff's Levemir; and referred her to Theodore Gourdin, M.D. (“Dr. Gourdin”), a gastroenterologist, due to “weight loss and poorly controlled diabetes with gastroparesis.” Tr. at 836-37. Dr. Schweiger noted Plaintiff was to follow up in one week because there was “no charge until approved for Roper charity.” Tr. at 837.

         On December 18, 2014, Plaintiff had a computed tomography (“CT”) scan of her abdomen and pelvis, which showed the following: (1) small periumbilical hernia with omentum extending into it, no associated dilatation of bowel; (2) multiple small groundglass nodules within the right lower lobe, which were presumed inflammatory; and (3) a small appendicolith within a normal appearing appendix. Tr. at 856-57; 929-30.

         On December 23, 2014, Plaintiff saw Dr. Schweiger for a follow-up appointment. Tr. at 839-40. Dr. Schweiger noted,

[H]ere for follow up patient problems or obesity hypertension poorly controlled diabetes diabetic gastroparesis as well as a newly identified pulmonary nodules and right lower lobe she also has hyperlipidemia she is on a host of new medicines and I will adjust some of her medicines as her A1c is 17-1/2. She cannot be seen by endocrine until March. I also referred her to surgery because of a[n] umbilical hernia noted and abdominal pain I [am] not sure that her pain is from . . . hernia [, ] other issues are weight loss which I believe is related to poorly controlled diabetes.

Tr. at 839. Dr. Schweiger adjusted Plaintiff's medications; assessed hypertension, diabetes mellitus, diabetic gastroparesis, leg pain, hyperlipemia, and pulmonary nodule; and ordered a CT chest imaging, without contrast, for March 23, 2015. Tr. at 839-40; 856-57.

         Plaintiff had two biopsies done on January 23, 2015. Tr. at 931-33. One biopsy was of a small bowel mucosa designated duodenum, which showed no diagnostic histologic abnormalities. Tr. at 932. The other biopsy was of a gastric mucosa consistent with antrum and showed inactive chronic gastritis and histologic features consistent with reactive or chemical gastropathy. Id. The biopsy was negative for helicobacter organisms. Id. In addition, Plaintiff had a normal upper endoscopy. Tr. at 931.

         On January 28, 2015, Plaintiff presented to Dr. Schweiger for a follow-up appointment. Tr. at 841-44. Plaintiff reported having headaches for three weeks, which she indicated could be caused by her insulin. Tr. at 841. Dr. Schweiger assessed hypertension, diabetes mellitus, diabetic gastroparesis, pulmonary module, and hyperlipemia. Tr. at 842. Dr. Schweiger adjusted medications and ordered several labs, including a basic metabolic panel, hemoglobin A1C lab report, hepatic function panel (liver), and lipid panel. Id.

         On February 17, 2015, Plaintiff presented to Simon Watson, M.D. (“Dr. Watson”) at MUSC, with complaints of facial pain on the left side of her face and full body aches. Tr. at 896-99. As to her facial pain, Plaintiff reported a sharp pain in the upper aspect of her jaw when she opened and closed her mouth. Id. As to her leg pain, Plaintiff indicated her neuropathy was not well controlled, but she was taking Tramadol for pain. Id. On exam, Plaintiff was tender over the left temporomandibular joint, and the pain was exacerbated by opening and closing her mouth. Tr. at 898. Plaintiff had a normal motor exam in her bilateral lower extremities, but reported subjective decreased sensation to light touch. Id. Plaintiff's gait and stance were normal. Id. The clinical impression was peripheral neuropathy and facial pain. Tr. at 899.

         On February 23, 2015, Dr. Gourdin noted Plaintiff had a normal upper endoscopy. Tr. at 931. Dr. Gourdin also noted Plaintiff “overall states that she is doing much better lately” and he “continue[d] her Nexium therapy.” Id.

         On February 26, 2015, Plaintiff saw Dr. Schweiger for a follow-up appointment. Tr. at 845-48. Plaintiff reported pain on the left side of her face and leg pain, which Dr. Schweiger noted could be diabetic neuropathy. Id. Dr. Schweiger noted his treatment options for Plaintiff had been limited for insurance reasons, as she received Medicaid. Id. He started Gabapentin, Amlodipine Besylate, Crestor and Nexium. Tr. at 846.

         On March 5, 2015, Plaintiff became a patient of Sweetgrass Endocrinology and saw Temple W. Simpson, P.A. (“Simpson”) upon referral by Dr. Schweiger. Tr. at 957-59. Plaintiff reported she had been diagnosed with diabetes in 2007 or 2008 and felt her diabetes had never been well controlled. Id. Plaintiff reported she started with Metformin, which gave her gastrointestinal issues, then placed on several insulins, and she expressed frustration with her lack of control. Id. Simpson noted Plaintiff had neuropathy, but her kidney function remained intact and her diet consisted of whatever she could tolerate, as she had abdominal pain and vomiting at times. Id. During her examination, Simpson noted the diabetic nephropathy screening was met by Plaintiff “currently on ACE-I or ARE.” Id. Simpson assessed Plaintiff for diabetes, hypertension, and hypercholesteremia. Tr. at 958. Simpson continued Plaintiff on Levemir, Novolog, Tradjenta, Lisinopril-Hydrochlorothiazide, Amlodipine Besylate, and Atorvastatin Calcium. Id.

         On March 20, 2015, Plaintiff saw Simpson at Sweetgrass Endocrinology for a follow-up appointment. Tr. at 960-61. Simpson noted samples of Janumet and Invokana were given to Plaintiff at the previous visit, but she developed candidiasis. Tr. at 960. Simpson also noted she was not recommending glucagon-like peptide 1 drugs due to Plaintiff's ongoing gastrointestinal issues. Id. Plaintiff's A1C was 10.3, down from 17. Tr. at 961. Simpson continued Plaintiff on Levemir, Novolog, and Janumet. Id.

         On March 25, 2015, Plaintiff presented to Dr. Schweiger, complaining of pain in her feet, face, and right leg and rating the pain intensity 10/10. Tr. at 849. Dr. Schweiger attributed Plaintiff's facial pain to neuropathy. Id. Plaintiff took Gabapentin and Tramadol for neuropathic pain. Id. Dr. Schweiger noted he believed Plaintiff's abdominal pain was “mostly diabetic gastroparesis [as] she's had a thorough GI workup.” Id.[7]

         On April 3, 2015, Plaintiff presented to Dr. David Manning French, M.D. (“Dr. French”) at MUSC, with complaints of tightness in her chest, pain in her right arm and flank, and vomiting. Tr. at 899. Plaintiff indicated the pain had been going on for a week and continued to worsen, despite taking Neurontin and Tramadol. Id. Plaintiff reported her blood sugar ranged from 70 to 300 daily. Tr. at 899. Her blood pressure was 172/118 and her glucose was 308. Tr. at 899-901. A chest x-ray showed no evidence of acute or chronic cardiopulmonary disease. Tr. at 903, 924. Plaintiff was given fluids, pain medication, and nausea medication. Tr. at 904. The recorded clinical impressions were chest pain and myalgia. Tr. at 901, 904.

         On April 14, 2015, Plaintiff presented to Jeffrey Paul Caporossi, M.D. (“Dr. Caporossi”) at MUSC, with complaints of yellow and green emesis and diarrhea. Tr. at 905-09. Plaintiff indicated a blood glucose level in the 200s was “good for her.” Id. Plaintiff's blood pressure was 220/137. Tr. at 906. On exam, Plaintiff had mild ...


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