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Tint v. Saul

United States District Court, D. South Carolina

July 19, 2019

Paul Tint, Plaintiff,
v.
Andrew M. Saul,[1] 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 his claim for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the undersigned recommends the Commissioner's decision be affirmed.

         I. Relevant Background

         A. Procedural History

         On October 20, 2011, Plaintiff filed applications for DIB and SSI in which he alleged his disability began on June 9, 2011. Tr. at 89, 97, 159-65, 166-76. His applications were denied initially and upon reconsideration. Tr. at 133-37, 143-44, 145-46. On October 9, 2013, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) John S. Lamb (“Lamb”). Tr. at 24-55, 604-35. ALJ Lamb issued an unfavorable decision on January 10, 2014, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 7-23, 541-57. Subsequently, the Appeals Council denied Plaintiff's request for review, making ALJ Lamb's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 1-4, 558-61. Thereafter, Plaintiff brought an action seeking judicial review of the Commissioner's decision, which was reversed and remanded by the United States District Court on March 23, 2016, with instructions for the ALJ to evaluate the treating physician's opinion under the standards of the Treating Physician Rule. Tr. at 562-603.

         On April 29, 2016, the Appeals Council remanded the case for further evaluation by an ALJ. Tr. at 599-603. On August 3, 2016, Plaintiff had a hearing before ALJ Ann G. Paschall (“Paschall”). Tr. at 508-540. ALJ Paschall issued an unfavorable decision on October 13, 2016, finding Plaintiff was not disabled within the meaning of the Act. Tr. at 485-507. Subsequently, the Appeals Council denied Plaintiff's request for review, making ALJ Paschall's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 464-69. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on April 3, 2018. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 32 years old at the time of the 2013 hearing and 35 years old at the time of the 2016 hearing. Tr. at 29. He completed the eleventh grade and obtained a general equivalency diploma (“GED”). Id. His past relevant work (“PRW”) was as a cook's helper. Id. He alleges he has been unable to work since June 9, 2011. Id.

         2. Medical History

         On October 6, 2008, Plaintiff presented to Charles V. Mullen, M.D. (“Dr. Mullen”), at Palmetto Pulmonary & Critical Care Associates. Tr. 302- 05. He complained of anterior chest pain that Dr. Mullen indicated was likely related to costochondritis. Tr. at 302. Dr. Mullen noted that a computerized tomography (“CT”) scan showed bullous changes that were consistent with emphysema. Id. He observed no abnormalities on examination. Tr. at 303-04.

         On March 12, 2009, Plaintiff complained to Dr. Mullen of chest pain that was exacerbated by a recent chest infection. Tr. at 298. He reported a daily cough and some dyspnea on exertion. Id. He indicated he had tried to stop smoking with Chantix, but discontinued the medication because of nausea. Id. Dr. Mullen noted no abnormalities on examination. Tr. at 299- 300. Plaintiff underwent a complete pulmonary function study, which showed normal spirometry and lung volumes, but decreased diffusion capacity consistent with emphysema. Tr. at 296, 300. Dr. Mullen referred Plaintiff to a rheumatologist, recommended a nicotine patch for smoking cessation, and prescribed Spiriva. Tr. at 300-01.

         On May 4, 2009, Plaintiff presented to Scott Weikle, M.D. (“Dr. Weikle”), with a complaint of anxiety. Tr. at 362. He stated his anxiety had been occurring for months, but was exacerbated by the recent death of a baby cousin. Id. He indicated his mind was racing and that he was experiencing chest pain and shortness of breath. Id. He endorsed symptoms that included anxiety, depression, fearfulness, inability to concentrate, changes in mood, and panic attacks. Id. Dr. Weikle observed Plaintiff to be anxious and alert, but well-groomed. Id. He noted Plaintiff could articulate well and demonstrated normal speech and language. Tr. at 363. He indicated Plaintiff had normal thought content and could perform basic computations and apply abstract reasoning. Id. He saw no evidence of hallucinations, delusions, obsessions, or homicidal or suicidal ideation. Id. He indicated Plaintiff showed appropriate judgment and insight; was able to recall recent and remote events; and had a normal attention span and ability to concentrate. Id. Dr. Weikle diagnosed adjustment disorder with anxiety and prescribed Trazodone and Ativan. Id.

         On July 20, 2009, Plaintiff followed up with Dr. Weikle and reported a recent episode of numbness in his arms, legs, and lips. Tr. at 364. He indicated the numbness resolved after he fell asleep, but that he continued to experience some dizziness. Id. Plaintiff reported anxiety, depression, and panic attacks. Id. Dr. Weikle described Plaintiff's mood and affect as anxious, but noted that his mental status was otherwise normal. Tr. at 365. He noted that Plaintiff's adjustment disorder with anxiety was “SOMEWHAT BETTER” and diagnosed depressive disorder. Id.

         On August 24, 2009, Plaintiff presented to Greenville Memorial Medical Center with chest pain. Tr. at 309. An x-ray showed no acute abnormalities. Tr. at 313. Plaintiff was diagnosed with anterior chest wall pain. Tr. at 311.

         On August 31, 2009, he followed up with Dr. Weikle. Tr. at 366. He indicated he had moderate-to-severe sharp and stabbing pain on his sternum that was precipitated by shoulder movement, local pressure, and deep breathing. Tr. at 366. Dr. Weikle indicated Plaintiff was tender to palpation in his bilateral anterior chest walls and had decreased breath sounds in both lung fields. Tr. at 366. He indicated Plaintiff's mood and affect were anxious, but that his mental status was otherwise normal. Tr. at 367. He diagnosed a rib strain or sprain and noted that it was “probably costochondritis.” Id. He stated he would not treat a 27-year-old with chronic narcotics, and indicated he would try Relafen and steroid and Toradol shots. Id. He encouraged Plaintiff to stop smoking and stated “THIS IS VERY KEY FOR ANY LUNG DISORDER PREVENTION.” Id.

         On September 21, 2009, Plaintiff again complained of chest pain. Tr. at 368. He indicated that he had experienced numbness in his hands that caused him to miss several days of work. Id. Dr. Weikle observed tenderness to palpation (“TTP”) in Plaintiff's bilateral anterior chest walls and decreased breath sounds in both lung fields. Id. He indicated Plaintiff had an anxious mood and affect, but his neuropsychiatric examination was otherwise normal. Id. Dr. Weikle noted Plaintiff's adjustment disorder had improved with Trazodone. Tr. at 369. He administered injections for emphysema and prescribed a nicotine patch. Id.

         On September 25, 2009, a computed tomography (“CT”) scan showed a large bullous lesion at Plaintiff's right lung apex. Tr. at 343.

         On October 27, 2009, Plaintiff presented to Dr. Weikle with neck pain and stiffness after falling down a couple of steps. Tr. at 370. Dr. Weikle observed tenderness in Plaintiff's paracervical area, around C5-6, and in his right upper trapezius area. Id. He diagnosed a muscle spasm, referred Plaintiff for an x-ray of his cervical spine, and prescribed Darvocet and Flexeril. Tr. at 371.

         On December 17, 2009, state agency consultant Robbie Ronin, Ph. D. (“Dr. Ronin”), reviewed the record and completed a psychiatric review technique (“PRT”) assessment. Tr. at 374-87. He found Plaintiff's mental impairments were not severe. Tr. at 374.

         Also on December 17, 2009, state agency medical consultant Seham El-Ibiary, M.D. (“Dr. El-Ibiary”), reviewed the record and completed a physical residual functional capacity (“RFC”) assessment. Tr. at 388-95. He found Plaintiff could perform work that required he occasionally lift and/or carry 50 pounds, frequently lift and/or carry 25 pounds, stand and/or walk for about six hours in an eight-hour workday, and sit for about six hours in an eight-hour workday, but must avoid even moderate exposure to fumes, odors, dusts, gases, poor ventilation, etc. Id.

         On June 13, 2011, Plaintiff presented to North Greenville Hospital with pleuritic chest pain and a cough. Tr. at 415. He indicated the right upper quadrant of his chest was painful with movement, palpation, and breathing. Tr. at 415. A nurse's note indicated Plaintiff rested quietly in the room until she entered and then began to hold his chest, groan, and request pain medication. Tr. at 419. The nurse indicated she informed Plaintiff that no pain medication could be dispensed without a diagnosis and that Plaintiff became emotional and indicated he was going to leave. Id. Jeffrey Leshman, M.D. (“Dr. Leshman”), entered the room shortly thereafter and observed moderate tenderness in Plaintiff's posterior right chest. Tr. at 416. He diagnosed chest wall pain, prescribed Lortab, and discharged Plaintiff. Tr. at 423.

         On July 28, 2011, Plaintiff presented to B. Rhett Myers, M.D. (“Dr. Myers”), for a psychiatric evaluation. Tr. at 451. Dr. Myers indicated Plaintiff was dressed casually and had a fairly normal affect and a positive mood. Id. He described Plaintiff as oriented to time, place, person, and situation. Id. He noted Plaintiff's thoughts were goal-directed and that he had no hallucinations, delusions, or suicidal or homicidal thoughts. Id. He described Plaintiff as having fair memory and concentration, average intelligence, and adequate insight. Id. He diagnosed major depressive disorder; anxiety disorder, not otherwise specified (“NOS”); and attention deficit disorder with hyperactivity (“ADHD” or “ADD”). Id. He assessed a global assessment of functioning (“GAF”)[2] score of 65[3]; prescribed Prozac, Xanax, Restoril, Risperidone, and Adderall; and instructed Plaintiff to follow up in two months. Tr. at 451-52.

         On August 12, 2011, Plaintiff followed up with Dr. Myers and generally reported doing well. Tr. at 450. Dr. Myers refilled Adderall. Id.

         On November 7, 2011, Plaintiff presented to North Greenville Hospital with a complaint of rib pain. Tr. at 398. He indicated he was injured when a freezer fell onto his left side. Id. Nadim Salman, M.D. (“Dr. Salman”), observed Plaintiff to have anterior tenderness in his left chest. Tr. at 399. A chest x-ray showed no fracture or other abnormality. Tr. at 400. Plaintiff complained of shortness of breath, but his oxygen saturation was 100 percent on room air and he had clear breath sounds. Id. Dr. Salman diagnosed a rib contusion and directed the nurse to administer 400 milligrams of Ibuprofen. Tr. at 399-400. Plaintiff refused to take the Ibuprofen and “was seen storming out of ER” before receiving discharge instructions. Tr. at 400-01.

         On November 30, 2011, state agency consultant Craig Horn, Ph. D. (“Dr. Horn”), reviewed the record and determined Plaintiff had no medically-determinable mental impairment. Tr. at 93.

         On December 6, 2011, Plaintiff indicated to Dr. Myers that he stopped taking Prozac because of sexual side effects. Tr. at 449. Dr. Myers prescribed Celexa. Id.

         On December 13, 2011, state agency medical consultant Matthew Fox, M.D. (“Dr. Fox”), assessed Plaintiff's physical impairments as non-severe. Tr. at 94.

         On February 14, 2012, Plaintiff presented to New Horizon Family Health Services with a complaint of congestion. Tr. at 436. Plaintiff indicated he continued to smoke one pack of cigarettes per day. Id. The provider noted that Plaintiff had 100 percent oxygen saturation on room air. Id. She prescribed Azithromycin, Symbicort, and Albuterol and referred Plaintiff to a pulmonary clinic. Id. Plaintiff called the office later to indicate he was allergic to Azithromycin and to request another medication. Id. The provider indicated Plaintiff should discontinue the Azithromycin and start Doxycycline. Id. Lab work showed Plaintiff's cholesterol to be elevated. Tr. at 437. The provider sent a letter to Plaintiff that indicated he should increase his exercise and avoid fatty foods. Id.

         On May 10, 2012, Plaintiff underwent pulmonary function testing. Tr. at 443-46. His forced expiratory volume after one second (“FEV1”) was over 100 percent without administration of bronchodilators, and the testing was considered normal. Tr. at 443. Mike Magee, CPFT (“Mr. Magee”), indicated Plaintiff experienced coughing and dyspnea and required several minutes rest between trials. Id.

         On June 13, 2012, state agency consultant Anna P. Williams, Ph.D. (“Dr. Williams”), reviewed the record and determined that Plaintiff's diagnoses of affective disorders and anxiety-related disorders imposed no limitations on his activities of daily living (“ADLs”), social functioning, or concentration, persistence, and pace. Tr. at 112-13.

         Also on June 13, 2012, state agency medical consultant Dale Van Slooten, M.D. (“Dr. Van Slooten”), reviewed the record and determined Plaintiff's physical impairments to be non-severe. Tr. at 111-12.

         On August 24, 2012, Plaintiff followed up with Dr. Myers and reported that his medications were helpful. Tr. at 448.

         On October 18, 2012, Plaintiff reported to Dr. Myers that his wife was in the hospital because of a pregnancy-related complication. Tr. at 453. He indicated he was “more edgy.” Id. He denied suicidal or homicidal ideations. Id. Dr. Myers noted Plaintiff was stable. Id.

         On February 5, 2013, Dr. Myers noted that Plaintiff's behavior was hyperactive and that his mood was anxious and irritable. Tr. at 454. He described Plaintiff's affect as labile and his judgment/insight as limited. Id. He noted Plaintiff's thought content was normal. Id. Plaintiff indicated he was agitated by some records he reviewed from the Veterans' Administration Clinic. Id.

         On May 16, 2013, Plaintiff reported no side effects from his medications. Tr. at 456. Dr. Myers indicated Plaintiff was cooperative and had a euthymic mood, congruent affect, normal thought content, fair judgment and insight, intact orientation, and normal concentration/memory. Id.

         On September 11, 2013, Plaintiff reported no side effects to Dr. Myers. Tr. at 458. Dr. Myers indicated the following findings on mental status examination: cooperative behavior, anxious and upset mood, affect congruent with mood, normal thought content, fair judgment/insight, intact orientation, and normal concentration/memory. Id. Dr. Myers completed a mental evaluation form on September 26, 2013. Tr. at 459-63.

         On January 8, 2014, Plaintiff presented to Dr. Myers and reported no side effects. Tr. at 819. Dr. Myers indicated the following findings on mental status examination: cooperative behavior, euthymic mood, affect congruent with mood, normal thought content, fair judgment/insight, intact orientation, and normal concentration/memory. Id.

         On April 21, 2014, Plaintiff presented to S. John Milton, M.D. (“Dr. Milton”), at the Hand Center, with complaints of pain in his right hand. Tr. at 708. Plaintiff reported he fell down and caught his hand a week prior. Id. Dr. Milton found the “slightest swelling” over the dorsal ulnar with tenderness and swelling in the small carpometacarpal (“CMC”), but “excellent extension and flexion of his small finger without any malrotation.” Id. An x-ray reflected a right, small CMC fracture dislocation, with just slight dorsal subluxation of his metacarpal base, and some intraarticular displacement, but no major malalignment or apparent fractures in the carpus itself. Id. Dr. Milton assessed right, small carpometacarpal fracture dislocation, provided a splint, prescribed Norco, scheduled a visit in two weeks, and restricted Plaintiff to not lift, push, or pull more than two pounds. Id.

         On May 1, 2014, Plaintiff contacted Dr. Milton and reported “a lot of pain.” Tr. at 709-10. Dr. Milton recommended two Aleve in addition to his medication. Id.

         On May 5, 2014, Plaintiff presented to Dr. Milton with “intermittent ulnar sided hand pain with a little bit of drama.” Tr. at 711. Dr. Milton noted Plaintiff thought it was “terrible, ” but “[o]bjectively, on exam he ha[d] just the slightest swelling over the dorsal ulnar hand” that was “quite subtle, ” but he had good extension and flexion with “some tenderness over [the] dorsal ulnar hand over his small metacarpal base.” Id. An x-ray reflected a small metacarpal fracture that appeared to be healing in a reasonable position with slight shortening. Id. Dr. Milton opined the fracture was healing and Plaintiff's discomfort was consistent with a fracture that would likely improve with time. Id. Dr. Milton recommended a splint and “gentle, active, light activities, nothing heavy.” Tr. at 711.

         Also on May 5, 2014, Plaintiff presented to Dr. Myers and reported no side effects. Tr. at 818. Dr. Myers indicated the following findings on mental status examination: cooperative behavior, euthymic mood, affect congruent with mood, normal thought content, fair judgment/insight, intact orientation, and normal concentration/memory. Id.

         On October 7, 2014, Plaintiff presented to Dr. Myers and reported no side effects. Tr. at 817. Dr. Myers indicated the following findings on mental status examination: cooperative behavior, depressed and irritable mood, flat affect, normal thought content, fair judgment/insight, intact orientation, and normal concentration/memory. Id.

         On January 2, 2015, a chest CT scan reflected paraseptal and center lobar emphysema, with a huge right-upper lobe bulla compromising the adjacent lung. Tr. at 720.

         On January 15, 2015, Plaintiff presented to Douglas P. McCormick, A.P.R.N. (“Nurse McCormick”), at Greenville Health System Cancer Institute, for a smoking cessation session upon referral by William Bolton, M.D. (“Dr. Bolton”). Tr. at 725-26. Plaintiff reported he had smoked since he was 7 years old, “developed some chest wall pain” in 2009, recently developed worsening pain, and a chest x-ray revealed a large, right-upper lobe bulla. Tr. at 725. Plaintiff also reported he smoked thirty cigarettes a day, his fatigue was 9/10, and he had severe pain in both hands and chest, anxiety, and depression. Id. Nurse McCormick developed a plan with Plaintiff to quit smoking by February 5, 2015. Tr. at 726.

         On February 5, 2015, Plaintiff presented to Nurse McCormick for a second session. Tr. at 723-24. Plaintiff reported he had quit smoking the prior evening and his fatigue was 6/10 and his pain was 5/10, with chest and right-sided thoracic pain. Tr. at 723. Nurse McCormick noted Plaintiff could not afford gum or lozenges and utilized a nicotine replacement patch. Id. Nurse McCormick provided counseling and recommended certain techniques and coping mechanisms. Tr. at 723-724.

         On February 19, 2015, Plaintiff presented to Dr. Myers and reported no side effects. Tr. at 816. Dr. Myers indicated the following findings on mental status examination: cooperative behavior, euthymic mood, affect congruent with mood, normal thought content, fair judgment/insight, intact orientation, and normal concentration/memory. Id.

         On April 3, 2015, Plaintiff underwent a right-upper lobe bullectomy or lobectomy. Tr. at 712.[4]

         On June 4, 2015, Plaintiff presented to Dr. Myers and reported no side effects. Tr. at 815. Dr. Myers indicated the following findings on mental status examination: cooperative behavior, irritable mood, flat affect, normal thought content, fair judgment/insight, intact orientation, and normal concentration/memory. Id.

         On August 10, 2015, Plaintiff reported to the Phoenix Center for addiction counseling. Tr. at 792-808. Stephanie Hoover, a counselor, noted Plaintiff presented as a referral from Pre-Trial Intervention for charges regarding manufacturing, possessing, and selling synthetic marijuana in 2014. Tr. at 804. Plaintiff was visibly frustrated and felt he was being mistreated by being required to attend classes for “taking [his] prescription med[ications].” Id. Plaintiff admitted selling and using synthetic marijuana in 2014, but not manufacturing and reported he did not realize it became illegal in 2011. Tr. at 797, 804. Ms. Hoover assessed substance abuse and nicotine dependence, noted Plaintiff reported anxiety, depression, and ADD, and assigned a GAF score of 55.[5] Tr. at 805-06.

         On August 26, 2015, a chest CT scan was normal. Tr. at 720.

         On September 2, 2015, Plaintiff presented to Dr. Bolton, with complaints of chest pain after surgery in April. Tr. at 714-22. Dr. Bolton found Plaintiff was in no acute distress. Tr. at 720. Dr. Bolton also found Plaintiff was “doing okay” and his chest CT scan “look[ed] good” and referred him to pain management. Tr. at 721.

         Also on September 2, 2015, Plaintiff presented to Dr. Myers and reported no side effects. Tr. at 813. Dr. Myers indicated the following findings on mental status examination: cooperative behavior, depressed mood, flat affect, normal thought content, fair judgment/insight, intact orientation, and normal concentration/memory. Id.

         On September 10, 2015, Plaintiff presented to Nurse McCormick for a “repeat attempt at smoking cessation.” Tr. at 712-13. Nurse McCormick noted he previously treated Plaintiff prior to his lobectomy. Id. Plaintiff reported he began smoking again due to chronic anxiety, pain, and multiple psychosocial stressors and smoked forty cigarettes a day. Id. Plaintiff also reported he was unsatisfied with Dr. Bolton's referral to pain management, his fatigue was 7/10 and pain was 10/10 in his hands and back, his quality of life was “mixed good and bad, ” and he had chronic anxiety and depression. Id. Nurse McCormick noted he had a “blunt discussion” with Plaintiff and believed he would be unsuccessful in his attempt to quit smoking if his anxiety and pain were not controlled. Id. Nurse McCormick scheduled a follow-up visit after Plaintiff expected to modify his pain management and recommended therapy exercises, psychosocial counseling, decreasing to thirty cigarettes a day, and switching to cigarettes with less nicotine. Id. Nurse McCormick noted Plaintiff reported he did not have the necessary finances to purchase nicotine and lozenges. Id.

         On September 28, 2015, Plaintiff presented to David Rogers, M.D. (“Dr. Rogers”), at Oaktree Medical Centre[6] for pain management. Tr. at 756-57, 783-86. Plaintiff reported he had a lung lobectomy in April 2015 that removed a large portion of his lung and resulted in persistent thoracic pain that was aggravated by most activity with only minimal analgesic benefit from Oxycodone 30 mg a day. Tr. at 756. Plaintiff also reported bilateral upper extremity pain from a right wrist fracture and left boxer's fracture due to a fall one year prior and chronic low back pain “as far back as [he] could remember.” Id. Dr. Rogers noted Plaintiff had been evaluated at his office three years prior, but, “due to an inconsistent urine drug screen, no medications [would be] issued until [he] completed substance abuse counseling” and Plaintiff had presented a statement from the Phoenix Center that confirmed he was receiving care. Id. Plaintiff smoked 1 ½ packs of cigarettes a day and slept four hours a night, with difficulty falling and staying asleep. Tr. at 757. Plaintiff scored 13 on Beck's Depression Inventory and his Mood Disorder Questionnaire was negative. Id. Dr. Rogers found Plaintiff had TTP of the bilateral sacroiliac joints, his mood appeared depressed with flat affect, his gait was slow and deliberate, and he exhibited no overt pain behavior. Id. Dr. Rogers assessed thoracic spine and low back pain and arthritis and ordered a drug screen as a precaution prior to prescribing opioids. Id.

         On October 2, 2015, Plaintiff reported to Greenville Health System with complaints of a left-sided neck mass. Tr. at 727-36. Plaintiff reported he smoked a pack of cigarettes a day. Tr. at 733. Nicole Amber Henderson, P.A. (“P.A. Henderson”), found fullness on the left side of Plaintiff's neck, with a soft-domed mass just below the left jaw about half the size of a tennis ball and scheduled a neck CT scan. Tr. at 735.

         On November 9, 2015, Plaintiff presented to Dr. Rogers with complaints of bilateral hand pain of 7 to 10/10. Tr. at 780-83. Dr. Rogers found Plaintiff was in no acute distress, oriented, alert, and active and had a normal gait and stance with pleasant mood and congruent affect. Tr. at 782. Dr. Rogers assessed thoracic spine pain and prescribed Morphine. Tr. at 782- 83.

         On November 11, 2015, Plaintiff presented to Greenville Health System with complaints of recent dramatic left neck swelling. Tr. at 737-47. A neck CT scan reflected a large cystic level II mass with a well-defined margin lying essentially between the submandibular gland and the sternocleidomastoid. Tr. at 743. Paul L. Davis, III, M.D. (“Dr. Davis”), found Plaintiff was oriented and had a normal mood and affect, with normal cognition and memory, but a “[b]ulky but mobile level II neck mass.” Tr. at 746. Dr. Davis assessed left-sided neck mass and chronic pain syndrome and scheduled a panendoscopy and biopsy. Id.

         On November 20, 2015, Dr. Davis performed an excision of the left neck ...


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