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Jackson v. Berryhill

United States District Court, D. South Carolina

January 4, 2019

Juanita Jackson, Plaintiff,
v.
Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant.

          ORDER

          Shiva V. Hodges United States Magistrate Judge

         This appeal from a denial of social security benefits is before the court for a final order pursuant to 28 U.S.C. § 636(c), Local Civ. Rule 73.01(B) (D.S.C.), and the order of Honorable Timothy M. Cain, United States District Judge, dated October 10, 2017, referring this matter for disposition. [ECF No. 8]. The parties consented to the undersigned United States Magistrate Judge's disposition of this case, with any appeal directly to the Fourth Circuit Court of Appeals. [ECF No. 4].

         Plaintiff files this appeal pursuant to 42 U.S.C. § 405(g) of the Social Security Act (“the Act”) to obtain judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying the 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 court affirms.

         I. Relevant Background

         A. Procedural History

         On December 13, 2013, Plaintiff filed an application for DIB in which she alleged her disability began on March 1, 2013. Tr. at 168-69. Her application was denied initially and upon reconsideration. Tr. at 62-70 and 74-85. On October 11, 2016, Plaintiff had a video hearing before Administrative Law Judge (“ALJ”) Carl B. Watson. Tr. at 35-61 (Hr'g Tr.). The ALJ issued an unfavorable decision on March 2, 2017, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 8-34. 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 October 9, 2017. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 64 years old at the time of the hearing. Tr. at 38. She completed high school and obtained a licensed practical nursing (“LPN”) degree. Id. at 42. Her past relevant work (“PRW”) was as an insurance clerk and a LPN. Tr. at 40. She alleges she has been unable to work since June 2013. Tr. at 39.

         2. Medical History

         On March 1, 2013, Emergency Medical Services (“EMS”) took Plaintiff to the emergency department at Carolinas Hospital System for treatment of a scalp laceration. Tr. at 303-11. Plaintiff reported she was injured at work when an angry patient pushed her into a door frame. Tr. at 303. The treating physician, Dr. Scott Burns (“Dr. Burns”), noted the laceration was two centimeters long, linear, extended through the dermis into the subcutaneous tissue, and had sharp, clean margins and minimal bleeding. Id. He noted there was no tendon or vascular involvement. Id. Dr. Burns closed the wound with three staples and sutures. Id. He prescribed Vicodin and ibuprofen for pain. Tr. at 304.

         On March 1, 2013, Plaintiff also saw Dr. Maria Perez-Garcia (“Dr. Perez-Garcia”) at Carolinas Urgent Care and Occupational Health Center. Tr. at 334-36. Dr. Perez-Garcia noted a head contusion with laceration on the left parietal area. Tr. at 334. Plaintiff reported losing consciousness for a few seconds after the injury and complained of neck pain and headache. Id. Plaintiff stated the pain from her headache was a 6 out of 10 and did not radiate to her upper extremity. Id. She denied tingling, numbness, or weakness in her upper and lower extremities. Id. On examination, Dr. Perez-Garcia noted Plaintiff had tenderness to palpation (“TTP”) on the left side of her neck and pain with range of motion (“ROM”) on the left side and posterior neck. Id. Dr. Perez-Garcia indicated Plaintiff's upper extremity, pupils, nose, ears, throat, lungs, heart, abdomen, and neurologic exam were all normal. Id.

         Plaintiff received a plain x-ray of her cervical spine. Tr. at 335. The reviewing radiologist, Dr. Steven Creedman (“Dr. Creedman”), noted moderate C5-6 interspace narrowing with small dorsal and bilateral uncovertebral spurs and assessed C5-6 degenerative disc disease (“DDD”). Id. Dr. Perez-Garcia stated Plaintiff's x-ray was normal. Tr. at 334. She assessed status post-fall with head contusion and laceration on the scalp (that was repaired with three staples and neck pain). Id. She also noted loss of consciousness was questionable. Id. Dr. Perez-Garcia opined Plaintiff could return to work the following day, but should be restricted to desk work and should not handle patients without assistance. Id. She referred her for a brain computerized tomography (“CT”) scan. Id.

         On March 6, 2013, Plaintiff received a head CT. Tr. at 396. Dr. Charles Parke found mild frontal periventricular white matter low attenuation and a small area of low attenuation in the right anterior limb internal capsule. Id. He noted these findings were most suspicious for mild small vessel ischemic disease and that demyelination seemed less likely. Id. He did not find evidence of posttraumatic contusion, mass, or hemorrhage intracranially. Id. He noted the left parietal scalp laceration with small staples were in place and indicated he did not see any underlying hematoma or calvarial fracture. Id.

         On March 8, 2013, Plaintiff had a follow-up appointment with Dr. Perez-Garcia. Tr. at 332-33. Plaintiff complained of headache in the area of the laceration and pain in her right shoulder, posterior neck, and lumbar area. Tr. at 332. She denied tingling, numbness, or weakness in her extremities and denied vision problems. Id. Dr. Perez-Garcia indicated Plaintiff's head CT scan was normal. Id. On examination, Dr. Perez-Garcia noted Plaintiff had mild TTP of the posterior neck and TTP on the top of the shoulder and the trapezial muscle, but full ROM and very minimal pain with ROM. Id. She assessed status post-fall, head contusion, laceration of the scalp, neck pain, lumbar pain, and local reaction to a tetanus shot. Id. She continued to restrict Plaintiff to desk work and no patient handling without assistance. Id.

         On March 11, 2013, Dr. Perez-Garcia continued Plaintiff's work restrictions and prescribed prednisone. Tr. at 331. She noted Plaintiff's diagnoses included status post-fall, head contusion and laceration, neck pain, lumbar sprain, headache, and local reaction to tetanus shot. Id.

         On March 18, 2013, Plaintiff returned to Dr. Perez-Garcia. Tr. at 329- 30. Plaintiff reported worsening lumbar pain radiating to the posterior right leg with tingling sensation. Tr. at 329. She denied weakness. Id. She said the prednisone helped, but the pain returned. Id. She also continued to complain of neck pain rated 4 out of 10. Id. On examination, Dr. Perez-Garcia noted Plaintiff had no TTP or pressure to her neck and she had full ROM and no pain with ROM. Id. Plaintiff had no TTP to her lumbar area, but did have pain with ROM. Id. Her reflexes, sensitivity, and muscle strength were normal. Id. Dr. Perez-Garcia referred Plaintiff for an MRI of her lumbar spine and continued to restrict her to desk work only. Id. She assessed status post-fall with head contusion, neck sprain, lumbar sprain, and paresthesias of the right leg. Id. She prescribed Motrin and Flexeril. Id.

         On March 21, 2013, Plaintiff began seeing Dr. Jimena C. Burnett (“Dr. Burnett”) at McLeod Physician Associates. See Tr. at 416-18. Plaintiff reported her history of hypertension and low back pain. Tr. at 416. She indicated she had been taking her hypertension medication as directed and had been responding to them well. Id. She complained of pain in her lower back on the right side and numbness in her right leg. Id. Plaintiff's medications included Synthroid, Aspir-81, Enalapril Maleate, and Ibuprofen. Id. Plaintiff's blood pressure was 164/84. Tr. at 417. Dr. Burnett assessed essential hypertension, colon cancer screening, hypothyroid, annual physical exam, lipid screening, neck pain, and back pain. Tr. at 418. She increased Plaintiff's Enalapril Maleate Tablet dosage and ordered a comprehensive metabolic panel. Id.

         On March 25, 2013, in another follow-up appointment with Dr. Perez-Garcia, Plaintiff reported her headache had improved and was intermittent, but she continued to experience tinnitus in both ears. Tr. at 327. Plaintiff also reported continued posterior non-radiating neck pain rated 4 out of 10. Id. She rated her lumbar pain 3 out of 10 and indicated it continued to radiate to the lateral right thigh. Id. Dr. Perez-Garcia noted having ordered an MRI, but it was still pending. Id. She noted Plaintiff appeared uncomfortable, but not in acute distress. Id. On examination of Plaintiff's neck, Plaintiff experienced TTP posteriorly and at the base of her neck, but only on the soft tissue. Id. Plaintiff had full ROM and no pain with ROM. Id. Plaintiff had no TTP on her lumbar spine, but had pain with flexion, extension, and lateral movement radiating to her right leg. Id. Dr. Perez-Garcia's assessment did not change. Id. She continued to restrict Plaintiff to desk work and prescribed diclofenac. Id.

         On March 27, 2013, Plaintiff received an MRI of her lumbar spine. Tr. at 397. Dr. Charles Parke (“Dr. Parke”) noted very mild convex curvature in the upper lumbar spine apex at the L1 level; moderate marked disc degeneration and moderate disc narrowing at ¶ 11-12 with circumferential disc bulging, greatest anteriorly; posterior disc bulging causing mild thecal sac effacement and mild right foraminal stenosis, but no focal cord compression; minor left sided annular bulging extending to the foramen and mild facet arthrosis at ¶ 4-5; mild disc degeneration peripherally, left anterior and left lateral annular bulging with mild left foraminal narrowing due to disc bulge at ¶ 2-3 and L3-4; and a small annular fissure on the left side at ¶ 2-3. Id. His impression included no evident fractures or lumbar compressive discopathy; moderate to advanced T11-12 disc degeneration with chronic circumferential annular bulging, but no defined cord compression and mild right foraminal narrowing due to asymmetric disc bulging and spondylosis; and left-sided mild disc degeneration and annular bulging at ¶ 2-3 and L3-4. Id.

         On April 1, 2013, Plaintiff returned to Dr. Perez-Garcia. Tr. at 324. Plaintiff rated her neck pain 4 out of 10, but only to touch, and Dr. Perez-Garcia noted Plaintiff had full ROM in her neck and no pain with ROM. Id. Plaintiff continued to report a posttraumatic headache. Id. She indicated her lumbar pain as 4 out of 10 and radiating to the right leg with numbness. Id. Dr. Perez-Garcia stated a lumbar spine MRI revealed DDD, but no herniated disc or other acute injury. Id. She noted Plaintiff had lumbar pain with ROM on flexion, extension, and lateral movement. Id. Her assessment did not change. Id. She continued to restrict Plaintiff to desk work and referred her to four weeks of physical therapy. Id.

         On April 8, 2013, Dr. Perez-Garcia noted Plaintiff was improving. Tr. at 321. Plaintiff reported her neck pain had improved with Flexeril and Voltaren. Id. She described her head pain as a frontal headache that started on the right side and went to the left side and denied neurological symptoms. Id. Dr. Perez-Garcia noted Plaintiff's uncontrolled blood pressure may be contributing to her headaches. Id. Plaintiff indicated her right leg pain was worse when sitting and reported stiffness after long periods of immobility. Id. She also complained of constant numbness in her first two toes and low back pain that worsened with movement. Id. An examination of Plaintiff's neck showed point tenderness over C7 and no ROM restrictions. Id. A lumbar examination revealed pain with movement around L1-L2. Id. Dr. Perez-Garcia continued to restrict Plaintiff to desk work, recommended she not take Voltaren on a daily basis, and recommended she follow up with her primary care physician about her blood pressure, as it may be contributing to her headache. Id.

         On April 9, 2013, Plaintiff attended her first physical therapy session at Progressive Physical Therapy. Tr. at 339. On her medical history form, Plaintiff indicated her pain was aching and constant. Tr. at 353. She stated leaning, sitting, and laying down made her pain feel worse. Id. She rated her pain as 8 out of 10, noted her worst pain over the past 30 days had been 10 out of 10, and indicated the least pain she had experienced over the prior 30 days was 4 out of 10. Id. The therapist noted Plaintiff had symptoms consistent with a differential diagnosis of low back strain and cervicogenic headaches and recommended she continue physical therapy two to three times a week for four weeks. Tr. at 339.

         On April 11, 2013, Plaintiff returned to physical therapy. Tr. at 340. Plaintiff reported a little extended relief after her last session. Id.

         On April 15, 2013, Plaintiff followed up with Dr. Perez-Garcia. Tr. at 319. She reported continued sharp, intermittent headache pain in the left temporal area and shooting to the right frontal area. Id. She rated her headache pain 4 out of 10. Id. Plaintiff continued to complain of pain across her lumbar area, with numbness and pain in her right leg and right toe. Id. She rated this pain 4 out of 10. Id. She reported continued neck pain with flexion and rated that pain 3 out of 10. Id. She complained that flexing her neck caused headaches. Id. Dr. Perez-Garcia noted Plaintiff's blood pressure was still elevated, but her family doctor was working on changing her medication. Id. Plaintiff reported her two physical therapy sessions had helped a little, especially with her right leg pain. Id. On examination, Dr. Perez-Garcia found Plaintiff had mild tenderness on the posterior right side of her neck, full ROM, and some pain with flexion. Id. Plaintiff had mild tenderness on the mid and upper lumbar area and across the lumbar spine; normal muscle sprain, reflexes, and sensitivity; and pain with ROM. Id. Dr. Perez-Garcia continued to restrict Plaintiff to desk work only. Tr. at 320. She assessed status post-fall with head and brain contusion, neck sprain, lumbar sprain, and posttraumatic headache. Tr. at 319.

         On April 16, 2013, Plaintiff told her physical therapist she had done her exercises at home, but not every day, and indicated the Voltaren seemed to numb the pain. Tr. at 341.

         On April 18, 2013, Plaintiff returned to physical therapy and reported experiencing a lot of pressure in her neck. Tr. at 342. She indicated a decrease in her headache pain at the end of her session. Id.

         On April 22, 2013, Plaintiff told Dr. Perez-Garcia she was feeling about the same. Tr. at 316. She stated physical therapy had been helping. Id. She reported intermittent pain behind her eyes, alternating from the left to the right eye. Id. Plaintiff's current medications included Enalapril, which Dr. Perez-Garcia noted was not effectively controlling Plaintiff's blood pressure, Synthroid, aspirin, Motrin, and Flexeril. Id. On examination, Dr. Perez-Garcia indicated Plaintiff seemed pleasant and comfortable; had TTP on the left and posterior neck; had full ROM in her neck, but complained of pain with ROM; and complained of severe pain to palpation of her lumbar area and numbness of the right leg. Id. Plaintiff had normal ambulation and normal reflexes and sensitivity of the lower extremity. Id. Dr. Perez-Garcia continued to restrict Plaintiff to desk work only. Id. She assessed posttraumatic headache, neck sprain, and lumbar sprain. Id. She recommended discontinuing non-steroid anti-inflammatory drugs due to Plaintiff's hypertension. She prescribed Lortab and instructed Plaintiff to continue taking Tylenol and Flexeril and referred her to a neurologist for her headaches. Id.

         On April 23, 2013, Plaintiff reported her pain returned about two hours after her last physical therapy session. Tr. at 343.

         On April 26, 2013, in physical therapy, Plaintiff stated she experienced increased pain with increased pressure on her right lower extremity. Tr. at 344. She again reported decreased headache pain after therapy. Id.

         On April 29, 2013, Plaintiff returned to Dr. Perez-Garcia. Tr. at 314. Plaintiff continued to report head pain, describing it as piercing and intermittent and rating it a 6 out of 10. Id. She also reported a headache across the left side of her head, rated 4 out of 10. Id. She denied vision and hearing problems. Id. Dr. Perez-Garcia noted having referred Plaintiff to a neurologist for her posttraumatic headache. Id. Plaintiff complained of severe posterior pain in her neck, not radiating to her upper extremities. Id. She reported improved pain in her lumbar area and indicated the pain was intermittent with movement and rated 4 out of 10. Id. She continued to complain of pressure and numbness in her right leg that had not improved. Id. Dr. Perez-Garcia noted Plaintiff had limited ROM in her lumbar spine. Id. She assessed posttraumatic headache and neck and lumbar sprain and noted Plaintiff's high blood pressure remained uncontrolled. Id. She continued to restrict Plaintiff to desk work only. Id.

         On April 30, 2013, Plaintiff told the physical therapist she had been really sore. Tr. at 345. She reported her headache decreased initially after her last session, but then returned about one hour later and lasted longer. Id.

         On May 3, 2013, Plaintiff's physical therapist noted she experienced increased headache pain throughout all of her cervical spine activities, especially stretches. Tr. at 346.

         On May 5, 2013, Plaintiff told her physical therapist she was not doing well and felt like she had been hit. Tr. at 347. She reported decreased pain following her session. Id.

         On May 9, 2013, Plaintiff reported her back was feeling better, but her neck had been really bothering her, and her leg still felt heavy. Tr. at 348. She reported decreased headache and neck pain following her physical therapy session. Id.

         On May 13, 2013, Dr. Perez-Garcia continued Plaintiff's work restriction. Tr. at 313. She noted Plaintiff's diagnoses included neck and lumbar sprain and posttraumatic headache and indicated Plaintiff was to see the neurologist that day. Id.

         On May 14, 2013, a physical therapy assistant indicated Plaintiff's compliance with her home exercise plan was fair; her pain was aggravated when she turned her head or walked more than ten feet; and Plaintiff could complete 20 squats and could push and pull a sled with 45 pounds for three minutes with some increased discomfort and headache pain. Tr. at 379. Her report included an Oswestry low back pain questionnaire that Plaintiff apparently completed. Tr. at 380. On the questionnaire, Plaintiff indicated pain medication provided her with little relief from pain; she could take care of herself normally without causing increased pain; she could lift only very light weights; pain prevented her from walking more than a quarter mile, sitting for more than 10 minutes, and standing for more than 30 minutes; she could sleep well only by using pain medication; pain prevented her from going out very often, restricted her travel to short, necessary journeys under 30 minutes, and prevented her from doing anything but light duties. Id.

         The records from Progressive Physical Therapy also include an undated Oswestry neck questionnaire, on which Plaintiff indicated her pain was mild at the moment; she could look after herself normally without causing extra pain; she could lift only very light weights; she could not read as much as she wanted because of moderate pain in her neck; she had headaches almost all the time; she had a lot of difficulty concentrating when she wanted to; she could not do her usual work; she could not drive her car as long as she wanted because of moderate pain in her neck; her sleep was moderately disturbed; and she could hardly do any recreational activities because of pain in her neck. Tr. at 377.

         On May 17, 2013, Plaintiff returned to physical therapy. Tr. at 350. She reported neck pain following her last session and expressed concern there might be a more serious problem. Id. She complained of increased pulling and tenderness in her cervical spine. Id.

         On May 20, 2013, Dr. Perez-Garcia indicated Plaintiff's work restriction would continue until her neurologist indicated otherwise. Tr. at 312. She discharged Plaintiff with diagnoses of neck sprain, lumbar sprain, right leg numbness, and posttraumatic headache. Id.

         On June 3, 2013, Dr. George Sandoz (“Dr. Sandoz”) of Grand Strand Spine and Neuro examined Plaintiff for complaints of headache, neck pain, back pain, and loss of consciousness. Tr. at 558-60. Plaintiff indicated her headaches were moderate to severe; had been occurring daily for three months; we located in the frontal left, frontal right, and occipital, with radiation to posterior. Tr. at 558. She reported debilitating pressure, mostly during the daytime, aggravated by head position, noise, and stress. Id. She reported associated blurred vision, memory loss, neurological symptoms, performance changes, stiff neck, and visual aura, but denied dizziness. Id. Plaintiff described her neck pain as daily moderate aching and burning and located in the bilateral posterior neck with radiation to the bilateral head and upper arm. Id. She indicated the pain was aggravated by flexion, hyperextension, kneeling, walking, and working, and that she experienced relief from massage. Id. She noted associated symptoms of trouble sleeping, muscle spasm, and tenderness, and denied bladder retention. Id. Plaintiff described her back pain as moderate to severe, persistent, worsening, located in the lower back, and radiating to the dermatome anteriorly. Id. She noted her symptoms were aggravated by daily activities and denied any relieving factors. Id. Plaintiff reporting losing consciousness when she fell in March and indicated associated symptoms of headache, memory loss, and neurological symptoms and denied bladder incontinence. Id.

         On examination, Dr. Sandoz noted Plaintiff experienced muscle spasms in both her cervical and lumbar spine. Tr. at 559. He assessed headache, neck pain, back pain, and syncope. Id. He ordered a brain MRI to evaluate the possibility of a stroke and recommended Plaintiff continue with light duty work and tramadol for her pain. Tr. at 559-60.

         On June 4, 2013, Plaintiff canceled her physical therapy appointment, stating she wanted to have additional tests done by a doctor before continuing physical therapy. Tr. at 351.

         On June 19, 2013, Plaintiff's physical therapist discharged her from physical therapy because she had been referred to a specialist and was undergoing testing. Tr. at 369.

         On July 1, 2013, Dr. Stephen Gordin (“Dr. Gordin”) administered an MRI of Plaintiff's cervical spine. Tr. at 398. Dr. Gordin noted some degenerative spurring off the anterior aspect of the C4 vertebral body; a small central disc protrusion mildly attenuating the ventral subarachnoid space, but not touching the spinal cord, and bilateral facet joint arthropathic changes at ¶ 4-5; bilateral facet joint arthropathy, small disc bulge, and bilateral arthropathic facet changes at ¶ 5-6; and small disc bulge and bilateral facet joint arthropathy at ¶ 6-7. Id. His impression included multilevel spondylitic changes, but no focal disc herniation or severe central canal stenosis; only fat noted beneath Plaintiff's marker, but a well-defined lipoma not identified; and some heterogeneity to the left thyroid lobe. Id.

         On July 9, 2013, Dr. Gordin administered an MRI of Plaintiff's brain. Tr. at 399. Dr. Gordin noted an area of low signal in the periventricular white matter on the right adjacent to the anterior angle of the right lateral ventricle that was of low signal on T1 sequence and bright on T2. Id. He stated this suggested a small area of prior ischemia and noted this seemed to correspond with Plaintiff's March 6, 2013 CT scan. Id. Dr. Gordin noted some foci on T2 hyperintensity in the left corona radiate and in the right centrum semiovale that suggested gliosis from small vessel ischemia. Id. The scan was otherwise unremarkable. Id. His impression included evidence of chronic ischemic changes affecting the brain. Id. He did not find evidence of pathologic enhancement. Id. He indicated white matter disease, which he opined was most likely reflective of small vessel ischemia and was unlikely to reflect demyelination because there were no associated pathologic enhancements or mass effect to suggest any were acute. Id.

         On July 22, 2013, Plaintiff had a follow-up appointment with Dr. Sandoz. Tr. at 555-57. Plaintiff indicated her neck pain had worsened and was aggravated by driving, straining, Valsalva, and working. Tr. at 555. She reported relief from narcotic analgesics. Id. She reported the pain in her lower back had radiated to the right foot and indicated pain medications relieved her symptoms. Id. Plaintiff reported associated symptoms of clumsiness, confusion, memory difficulty, vomiting, and syncope. Id. On examination, Dr. Sandoz indicated Plaintiff had muscle spasms in her cervical and lumbar spine, mildly reduced ROM in her cervical spine, and moderate pain with motion in her lumbar spine. Tr. at 556. He noted Plaintiff had been compliant with her medication and was responding to current treatment. Id. Dr. Sandoz assessed post-trauma headache, late effect of intracranial injury without mention, cervical spondylosis without myelopathy, and lower back pain. Id. He noted changes on her brain and neck MRI; recommended neuropsychological testing, an EEG, a nerve conduction study, and a lumbar spine MRI; and limited Plaintiff to light duty with a 10 pound weight restriction. Id.

         On August 15, 2013, Plaintiff returned to Dr. Sandoz. Tr. at 552-54. Dr. Sandoz continued to rate Plaintiff's headache and back pain as moderate to severe. Tr. at 552. Plaintiff reported experiencing headaches daily upon awakening. Id. Dr. Sandoz noted muscle spasm in Plaintiff's cervical and lumbar spine. Tr. at 553. He assessed posttrauma headache, cervical disc displacement without myelopathy, late effect of intracranial injury without mention, and back pain. Id. He recommended Plaintiff continue taking Ultram and noted results of an epidural steroid injection. Id. He continued to limit Plaintiff to light duty. Id.

         On September 26, 2013, Dr. David Scott (“Dr. Scott”) at Moore Orthopedics began treating Plaintiff. Tr. at 540-41. Plaintiff reported back, neck, and leg pain since her March 2013 injury. Tr. at 540. She also complained of constant tinnitus and headaches. Id. Dr. Scott did not note any abnormalities on physical examination. Id. He reviewed Plaintiff's cervical spine MRI and noted some areas of modest neuroforaminal stenosis, but nothing that approached a severe level or that he would expect to manifest in substantial symptoms. Tr. at 541. He took plain films of the cervical and lumbar spine during the visit. Id. The cervical spine films showed some DDD and anterior spurring with relative reversal of the normal cervical lordosis. Id. The lumbar spine films showed some modest DDD and a little facet arthrosis, but no impressive listhesis, fracture, DDD, or other impressive pathology. Id. Dr. Scott recommended Plaintiff see an ENT for her headaches and tinnitus. Id. He indicated he did not see anything overwhelming in her cervical spine, but noted epidural injections may be indicated if her symptoms did not resolve. Id.

         On October 3, 2013, Plaintiff returned to Dr. Scott with her lumbar spine MRI. Tr. at 539. Dr. Scott examined Plaintiff and noted good cervical ROM and a little bit of pain in the soft tissues around the neck in the paraspinal muscles. Id. Dr. Scott reviewed the cervical and lumbar MRIs and did not see anything overly impressive concerning central canal or neural foraminal stenosis. Id. He stated he did not see any reason why Plaintiff could not return to work, but noted Plaintiff was adamant that she could not work. Id. Plaintiff's insistence that she could not work made Dr. Scott uncomfortable returning her to a place where she was charged with caring for people, so he indicated he would keep her out of work or at least impose lifting, pulling, and pushing restrictions to keep her from having responsibility for lifting or pushing patients. Id.

         From October 11, 2013, to November 22, 2013, Plaintiff was treated by Dr. Leah Hamoy (“Dr. Hamoy”) at Dynamic Physical Therapy of Florence. Tr. at 338, 446, 451-54, 457, 459, 464, 466, 468, 470, 472, 477, 479, 480, 482, 483-85, 486-88. Dr. Hamoy noted Plaintiff had made progress and reported decreased pain following treatments, but her subjective complaints continued to fluctuate, even without strenuous activities. Id.

         On October 24, 2013, Plaintiff returned to Dr. Scott for an evaluation of her right hip. Tr. at 537-38. Plaintiff noted her back still hurt and her neck was causing her some discomfort, but she wanted Dr. Scott to pay closer attention to her hip. Tr. at 537. Dr. Scott's physical examination was unremarkable. Id. He obtained plain films of the right hip and found no signs of fracture, dislocation, or other bony abnormality; no evidence of femoral head, neck, or shaft fracture; and no impressive overwhelming signs of arthritis. Id. Dr. Scott noted Plaintiff seemed generally dissatisfied with her progress and said he would seek another opinion regarding possible interventional procedures. Tr. at 537-38.

         On October 29, 2013, Plaintiff returned to Dr. Sandoz. Tr. at 549-51. She rated her headaches as moderate to severe and her neck pain as moderate and indicated that both problems had worsened. Tr. at 549. Plaintiff continued to complain of back pain and memory loss and reported moderate, persistent dizziness. Id. Plaintiff described the dizziness as an unstable horizon, occurring spontaneously, aggravated by turning, and relieved by changing position. Id. She reported experiencing associated symptoms of headache and paresthesias, but denied diplopia. Id. On examination, Dr. Sandoz indicated muscle spasm in Plaintiff's cervical spine, but found no lumbar spine tenderness and normal mobility and curvature. Tr. at 550. He assessed posttrauma headache, dizziness, lumbar disc displacement, cervical disc displacement without myelopathy, and late effect of intracranial injury without mention. Id. He noted Plaintiff's headache was not responding to medication and prescribed Elavil and Imitrex. Id. He indicated Plaintiff had seen an ENT, but they were awaiting a neuropsychological evaluation to determine if further treatment was warranted for memory loss. Id.

         On November 25, 2013, Dr. Amit Sanghi (“Dr. Sanghi”) at South Carolina Diagnostic Imaging administered a brain MRI. Tr. at 435-36. He noted Plaintiff continued to experience headaches on the right side of her head, hearing loss in her right ear, blurred vision, and changes in her speech. Tr. at 435. The MRI showed mild diffuse cerebral atrophy, which Dr. Sanghi noted may be age-related, and multiple punctate FLAIR[1] signal abnormalities within the deep white matter of the brain in the basal ganglia and distribution on T2 FLAIR sequences. Id. He found no evidence of mass at the costophrenic (“CP”) angle, specifically the seventh and eighth cranial nerves. Id.

         On November 27, 2013, Plaintiff saw Dr. John Clavet (“Dr. Clavet”) at Moore Orthopedics for a second opinion regarding her neck and lower back pain. Tr. at 533-36. Plaintiff described her neck pain as located on the left side of the neck at the base of the neck, left upper trap area, 5/10 in severity, aching and throbbing in characteristic. Tr. at 533. She indicated she did not have pain radiating down the arms and the pain was aggravated with flexion, particularly with looking down to read. Id. She reported topical heat, massage, and a TENS unit provided relief and that physical therapy had been helpful. Id. Plaintiff described her lower back pain as right-sided lumbosacral back pain with a radiating component down the back of the leg to the foot, sharp pain, 4/10 in severity, aggravated with lying in bed, and alleviated with massage and a TENS unit. Id. She reported she returned to work on light duty from April 1st through June 8th, but was subsequently told no further light duties were available. Id.

         Dr. Clavet reviewed Plaintiff's radiographs. Tr. at 533-34. He noted Plaintiff's October 21, 2013 hip films showed enthesopathic changes at bilateral ASIS; minimal inferior changes with preservation of joint spaces at the SI joints; unremarkable bilateral hips with intact femoral acetabular joint spacing; and unremarkable frog-leg view of the right hip. Id. Her lumbar spine films from September 2013 did not show any traumatic changes or evidence of spondylolisthesis or spondylolysis, and intervertebral disc heights were well maintained. Tr. at 534. Her lumbar spine MRI from March 2013 showed intact intervertebral disc heights and minimal degenerative disc changes; patent canal at all levels; mild to moderate left neuroforaminal narrowing; and no indication of any high-grade stenosis at any level. Id. Plaintiff's September 2013 plain films of the cervical spine showed straightening of the cervical spine with loss of normal cervical lordosis, mild to moderate spondylitic changes centered at ¶ 5-6, and narrowing at the right C5-6 foramen due to bony osteophytic changes. Id. Her July 2013 cervical MRI showed mild to moderate degenerative changes centered at ¶ 5-6 and mild to moderate right neuroforaminal narrowing. Id.

         On physical examination of Plaintiff's cervical spine, Dr. Clavet indicated Plaintiff experienced moderate tenderness at the base of the neck extending to the left upper trapezius and achieved chin-to-chest with good extension and full lateral rotation without significant discomfort. Tr. at 534. Regarding Plaintiff's lumbar spine, Dr. Clavet noted palpation of the thoracolumbar and lumbosacral spine was unremarkable; Plaintiff experienced a little bit of discomfort with flexion and extension; flexion to 60 degrees and extension to 10 degrees beyond neutral. Id. In addition, Dr. Clavet noted Plaintiff's right hip ranged well without pain and FABER (flexion, abduction, and external rotation) testing was negative on the right. Id.

         Dr. Clavet assessed cervical sprain/strain and lumbar sprain/strain. Tr. at 535. He reported no acute traumatic changes he would attribute to her March 2013 injury. Id. Dr. Clavet agreed with Dr. Scott's treatment plan and did not recommend any more aggressive neuraxial procedures. Id.

         On December 17, 2013, Plaintiff was seen by Dr. Hopla. Tr. at 492. Dr. Hopla noted Plaintiff's head MRI was normal and Plaintiff should probably see a neurologist about her headaches. Id.

         On January 21, 2014, Plaintiff followed up with Dr. Scott. Tr. at 531- 32. Plaintiff reported her neck and back were feeling a little bit better, but had persistent radiating pain in her right leg and hip. Tr. at 531. Dr. Scott performed a physical examination and found negative straight leg raise bilaterally, good functional knee flexion-extension and hip flexion bilaterally, mild to modest discomfort with internal and external rotation of the right hip, and intact sensation to light touch and pressure in her upper and lower extremities. Id. After examining Plaintiff on multiple occasions, Dr. Scott could not identify any impressive substantial pathology and said he did not have anything else to offer her for her neck and back. Id. Dr. Scott noted he offered Plaintiff a therapeutic intra-articular hip injection, which she declined, and offered a referral to a surgical hip specialist for another opinion. Id. Dr. Scott stated he felt Plaintiff's neck and back should not keep her from working and that she could work without restrictions. Tr. at 531-32.

         On January 24, 2014, Plaintiff followed up with Dr. Sandoz about her head injury. Tr. at 546-48. Plaintiff described her symptoms as incapacitating. Tr. at 546. She indicated the pain was aggravated by sitting up and sound and associated symptoms included clumsiness, gait disturbance, headache, irritability, and visual disturbance. Id. Dr. Sandoz also noted her associated tinnitus and back pain and that she was taking medication on a daily basis to control her headache and pain. Id. Dr. Sandoz indicated Plaintiff had muscle spasm in her cervical and lumbar spine, experienced mild pain with motion in her cervical spine, and experienced moderate pain with motion in her lumbar spine. Tr. at 547. He assessed posttrauma headache, lumbar disc displacement, other and unspecified disc disorder of cervical radiculopathy, and dizziness. Id. He prescribed Imitrex, Tramadol, and Elavil for her pain and noted she needed to take the Tramadol on a daily. Id. Dr. Sandoz stated Plaintiff had achieved maximum medical improvement for her headache and lumbar and cervical disc disease. Id. He said one other option for her headache might be Botox and indicated she needed a functional capacity evaluation (“FCE”). He noted awaiting a neuropsychological exam. Id.

         On February 17, 2014, Tracy Hill (“Ms. Hill”), a physical therapist at Columbia Rehabilitation Clinic, performed an FCE. Tr. at 573-594. Plaintiff reported an initial pain level of 5/10. Tr. at 573. Her highest pain level during the exam was an 8/10 with lifting. Id. Ms. Hill found Plaintiff could meet the demands of limited sedentary to limited light work. Id. Plaintiff tolerated occasional walking, stairclimbing, kneeling, bending, and reaching. Id. She did not tolerate occasional squatting or twisting. Id. Plaintiff could lift 9 to 14 pounds at various heights on an occasional basis, carry 13 pounds with two hands; carry 9 pounds in each hand, and push and pull 10 pounds loaded in a sled. Id. Plaintiff reported a sitting tolerance of 45 minutes, a standing tolerance of at least 15 minutes, and a standing/walking tolerance of at least 30 minutes. Id. Ms. Hill observed Plaintiff to sit for a maximal time of 15 minutes, stand for a maximal time of 13 minutes, and stand/walk for a maximal time of 17 minutes. Id. Plaintiff's cervical and lumbar ROM were limited. Id. The results of Plaintiff's treadmill test placed her in the fair classification of aerobic capacity and her functional aerobic capacity qualified her for light work. Id. Ms. Hill noted Plaintiff put forth a consistent effort during the evaluation and she had taken one Ultram two hours prior to testing and took an Ultram one hour and 40 minutes into testing. Id.

         On May 9, 2014, Plaintiff underwent a neuropsychological evaluation, performed by Dr. Nicholas Lind (“Dr. Lind”). Tr. at 596-615. Plaintiff reported experiencing headaches since her March 2013 injury with an intensity of 8/10 without medication and 3/10 with medication. Tr. at 608. She also reported decreased sleep, ability to engage in previously enjoyed activities, energy, and concentration, but denied feelings of guilt or changes in appetite, irritability, or sex drive. Tr. at 609. Plaintiff acknowledged apprehension about returning to work, but denied any PTSD symptoms. Id. She noted a change in her speech pattern after her injury and reported forgetfulness and eye fatigue when reading. Id. Plaintiff reported injuring her neck and lower back in an automobile accident approximately 30 years prior to the evaluation, but denied any dizziness, headaches, or difficulty thinking associated with it or any other accident. Id. She stated she was diagnosed with high blood pressure three or four ...


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