United States District Court, D. South Carolina
REPORT AND RECOMMENDATION
V. HODGES UNITED STATES MAGISTRATE JUDGE.
appeal from a denial of social security benefits is before
the court for a Report and Recommendation
(“Report”) pursuant to Local Civ. Rule
73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action
pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to
obtain judicial review of the final decision of the
Commissioner of Social Security (“Commissioner”)
denying her claim for Disability Insurance Benefits
(“DIB”) 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.
about March 25, 2014,  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].
Plaintiff's Background and Medical History
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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,
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.
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.
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.
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.
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.
10, 2014, Plaintiff presented to the Heart Failure Center for
management. Tr. at 898-904.
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.
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.
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.
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.
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.
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.
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.
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.
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
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
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.
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
January 6, 2015, Dr. Bridges ordered bloodwork that found
Plaintiffs hemoglobin was 10.7%. Tr. at 942, 947-49, 953,
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.
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.
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.
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.
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.
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 ...