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Cannady v. Berryhill

United States District Court, D. South Carolina

April 13, 2019

Clara Cannady, 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 that the Commissioner's decision be reversed and remanded for further proceedings as set forth herein.

         I. Relevant Background

         A. Procedural History

         On or about March 25, 2014, [1] Plaintiff filed applications for DIB and SSI in which she alleged her disability began on August 9, 2013. Tr. at 300- 10. Her applications were denied initially and upon reconsideration. Tr. at 199-200, 234-41, 245-49. On December 8, 2016, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Thaddeus J. Hess. Tr. at 140-73. (Hr'g Tr.). The ALJ issued an unfavorable decision on February 23, 2017, finding Plaintiff was not disabled within the meaning of the Act. Tr. at 36-56. 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 April 2, 2018. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 40 years old at the time of the hearing. Tr. at 146. She completed high school. Tr. at 161. Her past relevant work (“PRW”) was as a hair stylist and cashier. Tr. at 143, 169. She alleges she has been unable to work since August 9, 2013. Tr. At 145.

         2. Medical History

         On August 8, 2013, Plaintiff was transported by ambulance to the emergency room for chest pain. Tr. at 445, 418-29, 441-507, 883-89. Plaintiff reported having had an argument earlier in the night, but the argument was over and she was sitting on the couch when she started having chest pain in her substernal area radiating down both arms with sweating and nausea. Tr. at 445. She reported shortness of breath, chest discomfort, and arm tightness, with a strong family history of heart disease and cigarette use, but no previous history of hypertension or diabetes. Tr. at 418, 425-26. An electrocardiogram (“EKG”) showed sinus rhythm with right bundle-branch block, evidence of anterior infarction, and some ST-segment changes anterolaterally. Id. She had a consultation with Francis Michael Eickman, M.D. (“Dr. Eickman”), was admitted to the hospital, and underwent an emergent catheterization. Tr. at 418-19, 425-26. A transthoracic echocardiography report (“TTE”) showed mild, concentric, left ventricular hypertrophy and an ejection fraction (“EF”) of 40 to 45% and moderate-to-severe apical septal or inferior and anteroseptal wall hypokinesis. Tr. at 422. Her A1c was found to be 11.4% and consistent with long-term hyperglycemia. Tr. at 425. Longinus Agors, M.D. (“Dr. Agors”), assessed diabetes mellitus type two, ST elevation myocardial infarction (“STEMI”) status post-left anterior descending artery (“LAD”) stenting, dyslipidemia, tobacco dependence, gastroesophageal reflux disease (“GERD”), obesity, and aspirin allergy, with a plan to adjust Plaintiffs diet and possibly initiate insulin with counseling. Tr. at 427. She was discharged on August 12, 2013, with the following diagnoses: coronary atherosclerotic heart disease; acute anterior myocardial infarction; stent; left anterior descending acutely; newly-diagnosed diabetes mellitus; hypertension; and dyslipidemia. Tr. at 441. Plaintiff was advised she could return to full employment after several weeks. Tr. at 443.

         On August 19, 2013, Kimberly L. Bridges, M.D. (“Dr. Bridges”), evaluated Plaintiff to establish primary care. Tr. at 559-63. Plaintiff complained of fatigue, insomnia, anxiety, and blurred vision. Id. Dr. Bridges elicited a detailed history, including Plaintiff had quit smoking, and noted Plaintiff suffered from diabetes, hypertension, and coronary artery disease. Id. Dr. Bridges also noted Plaintiff was supposed to start cardiac rehabilitation. Id. Dr. Bridges found no edema in Plaintiffs extremities and normal mood, affect, attention span, and concentration. Id. Dr. Bridges assessed diabetes and hypertension. Id. Dr. Bridges indicated Plaintiff seemed motivated and would do well with rehabilitation. Id.

         On August 22, 2013, Plaintiff received an assessment and exercise prescription for cardiac rehabilitation from the Heart Center for Cardiac and Pulmonary Rehab (“Heart Wellness Center”). Tr. at 1049-53. Plaintiff reported her symptoms included fatigue, trouble concentrating, and depression, and they made it “somewhat difficult” to do her work, take care of things at home, or get along with others. Tr. at 1050. The attending physician noted Plaintiff tolerated exercise well, as she had been walking at home, but stopped early due to heartburn. Tr. at 1053, 1057. An additional visit was reflected on August 29, 2013, but Plaintiff missed her September 16, 2013 appointment due to transportation issues. Tr. at 1058.

         On September 10, 2013, Erin Nash, M.D. (“Dr. Nash”), at Dr. Bridges' office evaluated Plaintiff for complaints of swelling. Tr. at 568-71. Plaintiff reported having had shortness of breath three days prior and indicated she was propping herself up to sleep. Id. Plaintiff also reported going to cardiac rehabilitation three times per week. Id. Dr. Nash diagnosed peripheral edema likely related to increased sodium intake. Id. Dr. Nash prescribed furosemide and ordered chest x-rays that showed possible bronchitis. Id.; Tr. at 507, 607-08.

         On September 19, 2013, Dr. Bridges evaluated Plaintiff for follow up of peripheral edema. Tr. at 526-30. Plaintiff reported improved shortness of breath and eagerness to return to work. Id. Plaintiff admitted to having some problems with depression and crying, but indicated her sugars had been good. Id. Plaintiff had a depressed affect, but no edema in her extremities. Tr. at 528. Dr. Bridges assessed improved hypertension and depression, prescribed Celexa, and continued other medications. Id.

         On October 4, 2013, the Heart Wellness Center dismissed Plaintiff for noncompliance with the program, as she had been absent due to transportation issues and had not returned their calls. Tr. at 1054-56.

         On October 21, 2013, Dr. Bridges evaluated Plaintiff for depression. Tr. at 522-25. Plaintiff reported Celexa kept her awake at night and caused abdominal bloating. Id. Dr. Bridges noted Plaintiff was working two days a week at Burger King, but she could not breathe well in the kitchen and did better at the counter. Id. Dr. Bridges indicated Plaintiffs blood sugars had been up and she started using Glipizide. Id. Plaintiffs affect was depressed, but she had no edema in her extremities. Tr. at 524. Dr. Bridges assessed improved hypertension, coronary artery disease, deteriorated diabetes, and depression, and modified Plaintiffs medications accordingly. Tr. at 524-25.

         On November 6, 2013, Louis L. Martin, M.D. (“Dr. Martin”), performed an eye examination. Tr. at 414-16. Plaintiff complained of blurred vision at a distance, especially at night. Id. Dr. Martin noted Plaintiff had type two diabetes and suffered a major heart attack in August. Id. Plaintiffs visual acuity was 20/20 for oculus dextrus (“OD”) and oculus sinister (“OS”). Id. The dilated fundus exam found mild non-proliferative diabetic retinopathy in OD and OS. Tr. at 416. She had mild myopia. Id.

         Also on November 6, 2013, Dr. Eickman evaluated Plaintiff and performed an EKG that showed sinus rhythm with old anteroseptal infarction and a nonspecific T-abnormality. Tr. at 420, 430-32. Plaintiff reported she had done well overall and worked two days per week, but wanted to work fulltime. Id. Plaintiff complained of intermittent bloating treated with Lasix. Id. Dr. Eickman encouraged weight loss, indicated Plaintiff could return to work, and continued her treatment regimen. Id.

         On November 21, 2013, Dr. Bridges evaluated Plaintiff for follow up. Tr. at 572-76. Plaintiff reported swelling in her hands or feet, muscle aches, and poor sleep due to anxiety that caused her heart to race. Id. Plaintiff also reported she had stopped taking Celexa and took Lasix once a week due to increased swelling and shortness of breath when lying down at night. Id. Plaintiff stated she checked her blood sugar three times per day, ate healthy, exercised three times per week, such as walking half a mile, and worked four days a week. Id. Dr. Bridges found no edema in her extremities, no focal deficits, and normal heart sounds, mood, affect, attention span, and concentration. Id. Dr. Bridges assessed hypertension, diabetes, and depression and switched Plaintiff from Celexa to Buspirone. Id. Dr. Bridges ordered blood work and adjusted Plaintiff's medications for anxiety and heartburn. Id.; Tr. at 508-09, 581-82, 594 (providing laboratory results), 759-66.

         On December 5, 2013, Dr. Bridges evaluated Plaintiff's right arm pain that had lasted one week. Tr. at 540-42. Plaintiff reported the pain was cramp-like and had been so intense she considered taking Nitroglycerin. Id. Plaintiff indicated her symptoms had been in both arms, but moved to the right arm. Id. Plaintiff reported insomnia and muscle aches. Id. Dr. Bridges noted Plaintiff was tender in her upper extremities, but had normal mood, affect, attention span, and concentration. Id. Dr. Bridges assessed myalgia, improved hypertension, and unchanged coronary artery disease. Id. Dr. Bridges ordered blood work, advised Plaintiff to hold her Pravastatin for a week, and continued her other medications. Id.; Tr. at 510-11, 595-96, 754- 58.

         On January 23, 2014, Dr. Bridges evaluated Plaintiff for increased pain in her arms and legs for one month and tingling and numbness sensations. Tr. at 548-51, 751-53. Plaintiff reported she stopped Pravastatin because it had not made a difference, but Tylenol helped. Id. Dr. Bridges noted Plaintiff had returned to work part-time, but could not increase her hours due to fatigue. Id. Dr. Bridges diagnosed diabetic peripheral neuropathy. Id. Dr. Bridges added Neurontin to Plaintiff's medications, discussed the need for good diabetic control, and advised her to stay off the statin at that time. Id.

         On February 10, 2014, Dr. Bridges evaluated Plaintiff for neuropathy. Tr. at 564-67, 747-50. Plaintiff had not taken a statin in two months, but took Neurontin at night, which she did not feel helped much. Id. Plaintiff reported continued problems with numbness and tingling, but that her pain and sugars had improved. Id. Dr. Bridges assessed fatigue, diabetic peripheral neuropathy, and coronary heart disease. Id. She referred Plaintiff for a cardiology evaluation, and increased her dose of Gabapentin. Id.; 577-80 (providing laboratory results), 742-45.

         On March 10, 2014, Plaintiff presented to Dr. Bridges and complained of blurred vision and dizziness for two days. Tr. at 543-47. Plaintiff also reported episodes of blurred vision, a glucose level of 300, headaches, and weakness that lasted for several days and worsened when changing from sitting to standing. Id. Plaintiffs dizziness was associated with visual changes and headache. Id. Plaintiff admitted her glucose had been running higher and her diet had not been good. Id. Dr. Bridges indicated Plaintiff had decreased sensation to light touch in both feet nearly to her knees, but no edema in her extremities and normal concentration. Id. Dr. Bridges assessed blurred vision, transient ischemic attack (“TIA”), hypertension, and diabetes. Id. Dr. Bridges continued Plaintiffs medications, ordered magnetic resonance images (“MRIs”), and scheduled an appointment for the following week. Id.; Tr. at 512-15 (providing blood work), 583-84 (same), 551, 733-41.

         On March 20, 2014, Dr. Bridges evaluated Plaintiff and reviewed MRIs that showed areas consistent with multiple sclerosis (“MS”). Tr. at 552-53, 516-17, 599-600, 728-32, 746, 1253-54. Dr. Bridges indicated Plaintiff needed a neurological evaluation and added Trazodone for sleep. Id.

         On March 27, 2014, Plaintiff presented to Dr. Eickman and reported she tried to work for an hour at Burger King, but became so fatigued she had to quit. Tr. at 433-34, 890-96. Dr. Eickman noted Plaintiff completed cardiac rehabilitation without much complaint, but had not attended vocational rehabilitation. Tr. at 433. Plaintiff complained of visual disturbances and indicated she had an MRI and was told over the phone there may be some concern about MS that was being investigated. Id. Dr. Eickman's overall impression was Plaintiff was overweight, with no significant murmurs or edema. Id. Dr. Eickman noted Plaintiff seemed stable and should be able to maintain an active lifestyle. Id. He instructed her to check with vocational rehabilitation, continued her medications, and indicated she should consider long-term Plavix as she was aspirin-intolerant. Id. Dr. Eickman performed an EKG that showed sinus rhythm with poor R-wave progression, old anterior infarct, and a non-specific T-abnormality. Tr. at 435-39. A TTE report showed Plaintiffs left ventricle chamber was mildly dilated and an EF of 35 to 40% with septal mid-hypokinesis and severe apical hypokinesis. Tr. at 438-39.

         On April 14, 2014, Plaintiff presented to C. Todd Walter, Jr., M.D. (“Dr. Walter”), for an evaluation of possible MS. Tr. at 531-36. Dr. Walter noted Plaintiffs memory was intact, and she had normal attention, concentration, fund of knowledge, gait, and coordination. Id. Dr. Walter also noted Plaintiff complained of muscle fatigue, and he scheduled various screenings and additional MRIs. Id.; Tr. at 585-93 (providing laboratory results), 718-27.

         On April 21, 2014, Plaintiffs cervical spine MRI showed central disc protrusions at several levels and mild central canal stenosis at the C3-4, C4-5, and C5-6 levels, but no evidence of a demyelinating disease. Tr. at 518-19, 597-98, 1255-56. Plaintiff also had an unremarkable thoracic spine MRI and a lumbar spine MRI that showed mild degenerative disc disease (“DDD”) at ¶ 3-4 and L4-5. Tr. at 519-20, 601-06, 1256-58.

         On April 29, 2014, Dr. Bridges evaluated Plaintiff and reviewed her updated MRIs. Tr. at 555-58, 714-17. Plaintiff reported continued left visual field deficit and an ophthalmologist visit was scheduled. Id. Plaintiff also reported she was no longer working and had applied for disability. Id. Dr. Bridges noted Plaintiff had gained ten pounds and had decreased sensation to light touch in both feet to nearly her knees, but no edema in her extremities and a normal mood and concentration. Id. Dr. Bridges gave Plaintiff a trial voucher of Belviq for weight loss. Id.

         On May 13, 2014, Plaintiff was airlifted to the hospital and admitted for chest pain. Tr. at 628, 610-700, 855-60, 864-65, 867-70. Plaintiff reported her chest pain began when she awoke that morning and was relieved by Nitroglycerin, but the pressure continued and worsened throughout the day. Tr. at 628. Plaintiffs husband reported she complained of chest pressure, vomited, passed out, and fell to the floor. Id., Tr. at 636. Plaintiffs EKG did not show any clear evidence of acute ischemia. Tr. at 630. Plaintiff continued to have chest pain at the hospital, and the doctor obtained a troponin ultra that was elevated. Id. Another EKG was performed that showed some vague inferior ST-elevation and anterior ST-depression. Id. However, this was not significant enough to meet the criteria for a STEMI. Id. Plaintiff was diagnosed with acute myocardial infarction or inferolateral STEMI and underwent catheterization that showed severe circumflex lesion. Tr. at 626. On May 18, 2014, Plaintiff was discharged with medication adjustments. Id.; Tr. at 867.

         On May 21, 2014, Dr. Bridges evaluated Plaintiff for follow up. Tr. at 706-13. Dr. Bridges noted Plaintiffs EF was 25% when she left the hospital and she was on Aldactone, Coreg, and an angiotensin-converting enzyme (“ACE”). Id. Plaintiff reported pain in her left arm and neck and shortness of breath upon exertion and fatigue. Id. Dr. Bridges found Plaintiff had a few crackles in both lung bases, trace ankle edema, and decreased sensation to light touch in both feet to nearly her knees. Id. Dr. Bridges prescribed Crestor. Id.

         On June 6, 2014, Larry Clanton, Ph.D. (“Dr. Clanton”), a state agency psychologist completed a psychiatric review technique (“PRT”) questionnaire that indicated Plaintiffs mental impairments were non-severe and imposed minimal limitations on her ability to perform basic work-related tasks or functions. Tr. at 179-80, 191-92. Dr. Clanton opined Plaintiff only had mild difficulties in maintaining concentration, persistence, or pace. Tr. at 180.

         On June 9, 2014, Dr. Bridges evaluated Plaintiff for a long-lasting cough and fatigue and noted she had lost significant weight. Tr. at 702-05. Dr. Bridges found Plaintiff had trace ankle edema and a few crackles in her lungs, diagnosed congestive heart failure, and switched her Lisinopril to Cozaar. Id.

         On June 10, 2014, Plaintiff presented to the Heart Failure Center for management. Tr. at 898-904.

         On June 20, 2014, Kimberly S. Wilson, N.P. (“Nurse Wilson”), at the Heart Failure Center evaluated Plaintiff. Tr. at 906-19. Plaintiff reported retaining fluid and leg pain. Id. Her lab results showed increased brain natriuretic peptide (“BNP”) with a six-pound weight gain. Id. Nurse Wilson advised Plaintiff on fluid restriction and sodium intake and assessed deteriorated chronic systolic heart failure, improved hypertension and diabetes, and unchanged dyspnea, anemia, hyperlipidemia. Id. She also ordered bloodwork. Id.

         On July 23, 2014, Plaintiff presented to the Heart Failure Center and reported she felt better overall, was walking and swimming, and had lost three pounds, but had not attended cardiac rehabilitation and complained of fatigue and dyspnea with exertion. Tr. at 920-26. Plaintiff also reported she stopped Losartan because it dropped her blood pressure and made her feel “bad.” Id. Nurse Wilson noted Plaintiffs heart rate was elevated and she was not taking medications as prescribed. Id. Plaintiff had a steady gait and normal mood and concentration, with no edema in her extremities. Id. Nurse Wilson assessed improved chronic systolic heart failure, hypertension, and hyperlipidemia, and unchanged dyspnea, anemia, and diabetes. Id. She prescribed Cozaar and continued Plaintiffs other medications. Id. However, Plaintiffs bloodwork revealed her hemoglobin level had increased, and she was referred to hematology. Tr. at 927-32.

         On July 28, 2014, Plaintiff called the Heart Failure Center to report a cough, weight gain of two pounds in twenty-four hours, edema in her legs, and chest pain. Tr. at 933. Bobbie Little, R.N. (“Nurse Little”), noted it was asymptomatic to congestive heart failure symptoms and instructed her to take an additional Lasix. Id.

         On July 30, 2014, Plaintiff was admitted to the hospital after being transported by ambulance to the emergency room due to shortness of breath, heart failure, and shock. Tr. at 768-850. Plaintiff reported sitting up straight in her bed to breathe for the prior five nights and having shortness of breath for two days that worsened over three hours. Tr. at 772, 811. Plaintiff's family reported noticing she had gained ten pounds in two days. Id. Plaintiff reported having had more swelling than normal in her lower extremities and a cough that produced lightly blood-tinged sputum. Id. While in the ambulance, Plaintiff was able to shake or nod her head, but not speak. Id. She was tachypneic with a respiratory rate of 32 and tachycardic with a heart rate of 140. Tr. at 776. She exhibited expiatory rhonchi bilaterally and 1 pitting edema of her lower extremities. Id. Her symptoms were consistent with acute pulmonary edema and acute respiratory distress. Id. Plaintiff's chest x-ray showed bilateral increased hazy lung opacities centered at the perihilar region with probable cardiomegaly. Tr. at 810, 838. The attending physician's impression was cardiomegaly probably with vascular congestion compatible with congestive heart failure. Id.

         Plaintiff's lab results showed an elevated BNP of 543 and A1c of 7.7%. Tr. at 769, 796. Plaintiff was also mildly anemic, nauseas, and vomiting. Tr. at 815. The attending physician noted advising Plaintiff was having heart failure. Tr. at 816. She was diagnosed with acute systolic congestive heart failure, severe ischemic cardiomyopathy with left ventricular EF measuring 30 to 35% that was decreased compared to the prior year when it was 40 to 45%, iron deficiency anemia thought to be secondary to menorrhagia, diabetes, coronary artery disease with stent placement, chronic obstructive pulmonary disease, dyslipidemia, obesity, diabetes, stable angina, and hypertension. Tr. at 769, 841-42. Her discharge medications included Coreg, Plavix, Crestor, Lasix, Glipizide, Levemir insulin, Losartan, Metformin, Nitroglycerin, Ranitidine, and Spironolactone. Tr. at 770. Plaintiff was discharged with a LifeVest for her severe EF. Tr. at 769-70.

         On August 18, 2014, Plaintiff presented to Dr. Eickman, reported her better breathing and no edema, admitted she had not taken her insulin because it was too expensive, and inquired about exercise. Tr. at 861-63, 866. Dr. Eickman noted Plaintiff was unhappy with the Life Vest, but would have to wait for an echocardiogram (“echo”) in one month to determine if it could be discontinued. Id. Plaintiff was also unhappy with her morning fatigue after taking her medications, and Dr. Eickman indicated it was likely from Coreg and continued her treatment regimen. Id.

         On August 19, 2014, Plaintiff presented to Dr. Bridges and reported being prescribed Levemir, but could not afford it and took Metformin and Glipizide. Tr. at 871-77. Dr. Bridges noted Plaintiff had been wearing a LifeVest, she realized how serious things were, and she wanted to take better care of herself. Id. Dr. Bridges indicated Plaintiffs biggest complaint was fatigue. Id. Dr. Bridges found Plaintiff had an A1c of 6.5%, trace ankle edema, and decreased sensation to light touch in both feet to nearly her knees, but she had normal mood, affect, attention span, and concentration. Id. Dr. Bridges assessed chronic systolic heart failure, cardiomyopathy, hypertension, and diabetes. Id. Dr. Bridges adjusted Plaintiffs medications and provided samples of Levemir. Id.

         On August 26, 2014, Plaintiff presented to Nurse Wilson at the Heart Failure Center and reported fatigue, low blood pressure, and dizziness when changing positions from standing or sitting. Tr. at 935-37. Nurse Wilson noted Plaintiff was supposed to be wearing a LifeVest, but had stopped because the “alarms kept acting up.” Id. Nurse Wilson encouraged Plaintiff to wear the LifeVest, noted she was not exercising, and adjusted her medications. Id.

         On September 22, 2014, Plaintiff had an echo that showed global left ventricle (“LV”) systolic dysfunction and an EF of 35 to 40%. Tr. at 939-40, 1120. It also showed mild LV dilation, grade 3 diastolic dysfunction, and suggested moderate pulmonary hypertension, but no significant valvular pathology. Id.

         On September 24, 2014, Plaintiff presented to the Heart Failure Center. Tr. at 879-82. Her weight was reduced, her gait was steady, and she had normal attention span and concentration, but trace ankle edema. Id. The attending physician assessed unchanged chronic systolic heart failure, hypertension, anemia, tachycardia, improved diabetes and dyspnea, and unchanged hyperlipidemia. Id. However, the attending physician noted Plaintiffs blood pressure was too low and she must continue to wear her Life Vest as directed. Id.

         On October 27, 2014, Judy Thomas, N.P. (“Nurse Thomas”), at the Heart Failure Center evaluated Plaintiff. Tr. at 1142-1147. Plaintiff reported feeling “pretty good overall” and medication compliance. Id. She also reported fatigue, abdominal fullness, the need to sleep on two pillows, weight gain, and dyspnea with exertion and climbing stairs, but no dyspnea with walking. Id. Plaintiff stated Dr. Eickman removed the LifeVest in August due to an improved echo. Tr. at 1142. Nurse Thomas noted Plaintiff had lost weight, a steady gait, and no edema. Tr. at 1145. Nurse Thomas increased Plaintiffs Carvedilol dose to address her blood pressure and scheduled an appointment in two months. Tr. at 1145-46.

         On December 3, 2014, Dale Van Slooten, M.D. (“Dr. Van Slooten”), a state agency physician, completed a physical residual functional capacity (“RFC”) assessment and concluded Plaintiff was capable of performing light work with postural and visual limitations. Tr. at 181-84, 193-96. Dr. Van Slooten opined Plaintiff could lift, carry, push, or pull twenty pounds occasionally and ten pounds frequently; walk, stand, or sit for about six hours in an eight-hour workday; stoop, kneel, crouch, or crawl frequently; climb stairs and balance occasionally; never climb ladders, ropes, or scaffolds; avoid jobs that required a full visual field for job performance or worker safety; and avoid concentrated exposure to heat, cold, humidity, and all hazards. Id.

         On January 6, 2015, Dr. Bridges ordered bloodwork that found Plaintiffs hemoglobin was 10.7%. Tr. at 942, 947-49, 953, 1038-39.

         On February 11, 2015, Dr. Bridges evaluated Plaintiff for fatigue and increased shortness of breath that began one week prior. Tr. at 954-59, 1036-37. Dr. Bridges noted Plaintiff gained nine pounds, had abdominal bloating, and paroxysmal nocturnal dyspnea (“PND”), and that her A1c increased from 6.5 to 6.7%. Id. Dr. Bridges evaluated Plaintiffs diabetes, noting Plaintiff reported her dietary and medication compliance, but was not exercising. Id. Dr. Bridges found Plaintiff had trace edema and decreased sensation to light touch in her feet nearly up to her knees, but had normal mood and concentration. Id. Dr. Bridges ordered updated blood work and continued Plaintiffs medications. Id.

         On February 24, 2015, Susan Elliott, N.P. (“Nurse Elliott”), at the Heart Failure Center evaluated Plaintiff. Tr. at 1148-54. Plaintiff reported she had not slept well, had cramps in her legs, and required three to four pillows to breathe while sleeping. Id. Nurse Elliott indicated Plaintiff had fluid present despite her increased Lasix dosage. Id. Nurse Elliott assessed deteriorated chronic systolic heart failure, insomnia, and obstructive sleep apnea, but unchanged hypertension and coronary artery disease. Id. Nurse Elliott increased Plaintiffs Lasix dosage, added potassium, magnesium, and furosemide, ordered a sleep study, advised her on diet and weight control, and continued her other medications. Id.

         On March 10, 2015, Plaintiff presented to Dr. Bridges and reported inability to sleep, shortness of breath with exertion, and increased fluid retention, but denied anxiety and depression. Tr. at 960-65. Plaintiff continued to have trace edema bilaterally and decreased sensation to light touch, but normal mood and concentration. Id. Dr. Bridges advised Plaintiff to take an extra Lasix and continued her medications. Id.

         On March 27, 2015, Ruth Ann Lyman, Ph.D. (“Dr. Lyman”), a state agency psychologist, completed a PRT assessment upon reconsideration and affirmed Dr. Clanton's findings that Plaintiffs mental impairments were non-severe. Tr. at 210-12, 226-28.

         On April 1, 2015, Dr. Bridges evaluated Plaintiff for increased shortness of breath the prior week and noted she slept propped up and had gained twenty pounds. Tr. at 966-69. Dr. Bridges noted Plaintiff was seen at the clinic earlier that day. Id. Plaintiff reported she “just didn't feel good” and complained of swelling and abdominal bloating, but denied chest pain and reported medication compliance. Id. Dr. Bridges found Plaintiff's abdomen was distended, she had 2 left and 1 right pedal edema, and decreased sensation to light touch in both feet to knees, but normal mood, affect, attention span, and concentration. Id. Dr. Bridges diagnosed chronic systolic heart failure, anemia, diabetes, and hypertension and adjusted Plaintiff's medications. Id.

         On April 8, 2015, Dr. Bridges evaluated Plaintiff's congestive heart failure. Tr. at 970-73. Plaintiff reported her symptoms were improving, she had been walking, she lost twenty pounds, and Metolazone had helped. Id. Dr. Bridges noted no edema, assessed improved chronic ...


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