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Sams v. Saul

United States District Court, D. South Carolina

August 14, 2019

Arlene F. Sams, 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 her 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 he 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 September 4, 2012, Plaintiff protectively filed an application for DIB in which she alleged her disability began on June 7, 2011. Tr. at 64, 134- 37. Her application was denied initially and upon reconsideration. Tr. at 85- 88, 92-93. On August 14, 2014, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Edward T. Morriss. Tr. at 25-49 (Hr'g Tr.). The ALJ issued an unfavorable decision on October 30, 2014, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 10-24. Subsequently, the Appeals Council denied Plaintiff's request for review. Tr. at 1-4. Thereafter, Plaintiff brought an action seeking judicial review of the Commissioner's decision in a complaint filed on March 30, 2016. Sams v. Colvin, No. 1:16-999-PMD-SVH, ECF No. 1. Following the parties' motion, the court entered a January 5, 2017 order remanding the case to the Commissioner for further administrative proceedings. Id. at ECF No. 16.

         On May 25, 2017, the Appeals Council issued an order remanding the case to the ALJ. Tr. at 898-902. Plaintiff had a second hearing on February 1, 2018. Tr. at 877-97. The ALJ issued an unfavorable decision on May 16, 2018, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 859-76. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on July 17, 2018. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 48 years old at the time of the second hearing. Tr. at 880. She completed three years of college. Id. Her past relevant work (“PRW”) was as an inventory management specialist in the military, but the ALJ concluded there would be no civilian equivalent to the position. Tr. at 894. She alleges she has been unable to work since June 7, 2011. Tr. at 134.

         2. Medical History

         On October 21, 2009, Joanne Dorn, ARNP (“N.P. Dorn”), provided restrictions for no prolonged or repetitive bending and a 25-pound lifting restriction. Tr. at 270. She stated Plaintiff had chronic low back pain. Id.

         On December 10, 2009, N.P. Dorn provided the following functional limitations based on a functional assessment: occasionally lifting 35 pounds floor to waist and 25 pounds waist to shoulder. Tr. at 266, 267. She indicated Plaintiff had disqualified herself from the assessment because of pain and had failed to meet walking, lifting, bending, stooping, and crouching elements for the proposed job of laundry worker. Id.

         On July 1, 2010, the Veterans Administration (“VA”) issued a decision granting Plaintiff a 30% impairment rating for major depressive disorder (“MDD”), continuing a 20% impairment rating for chronic lumbar strain and urticaria, and denying entitlement to individual unemployability. Tr. at 219- 25.

         Plaintiff presented to Alberto Luis Torres, M.D. (“Dr. Torres”), for primary care on December 28, 2010. Tr. at 467. She complained of constant, throbbing low back pain that was exacerbated by activity and alleviated by heat, medication, and transcutaneous epidural nerve stimulation (“TENS”) unit. Tr. at 468. She requested a psychiatric consultation. Id. Dr. Torres noted no abnormalities on physical exam. Tr. at 469. He instructed Plaintiff to continue analgesic medication and use of heating pad and TENS unit for back pain. Id. He declined to refer Plaintiff to a psychiatrist and indicated he could manage her depression by changing her medication as needed. Id.

         Plaintiff reported severe low back pain and depression and requested a psychiatric consultation on June 24, 2011. Tr. at 450. She complained of depressed mood, lack of energy, tiredness, lack of interest in activities of daily living (“ADLs”), and wanting to sleep all the time. Id. She endorsed shooting back pain that she rated as a nine on a 10-point scale. Tr. at 451. Dr. Torres observed pain to palpation in the paravertebral muscles of Plaintiff's lumbar spine with limited flexion and extension. Id. He noted constricted affect, depressed mood, poor insight, and fair judgment, but good hygiene, cooperative behavior, normal speech, steady motor function, linear thought process, and no suicidal or homicidal ideation. Id. He ordered Triamcinolone and Ketorolac injections, prescribed a Medrol Dosepak for inflammation, requested a psychiatric consult, and recommended Plaintiff engage in exercise for 40 minutes, four-to-five times per week. Tr. at 451-52.

         Plaintiff presented to David Walter Hiott, M.D. (“Dr. Hiott”), for a mental health diagnostic assessment on June 27, 2011. Tr. at 334-38. She reported a history of depression with anhedonia, lack of energy, tiredness, and lack of interest in ADLs. Tr. at 334. She indicated she was taking Citalopram occasionally, as opposed to daily, because it caused her to feel like she was in a daze. Id. She reported a history of suicidal thoughts, but denied having a suicide plan. Id. Dr. Hiott observed Plaintiff to appear somewhat unkempt, to demonstrate slight psychomotor retardation, to have a depressed mood and blunted affect, to show problems with long-term memory, and to have fair judgment and insight. Tr. at 337. He diagnosed MDD, unspecified anxiety disorder, and post-traumatic stress disorder (“PTSD”) and assessed a global assessment of functioning (“GAF”)[2] score of 45-50.[3] Tr. at 338. He discontinued Citalopram and prescribed Sertraline and Seroquel. Id.

         On July 12, 2011, Plaintiff complained of depressed mood, inability to experience pleasure, low energy, low motivation, low self-esteem, feelings of hopelessness and helplessness, reduced activity level, and isolating behavior. Tr. at 439. She reported she woke between 8:30 and 9:00 a.m., engaged in minimal activity, and went to bed around 6:30 p.m. Id. She endorsed passive suicidal ideation, but denied specific intent or plan. Id. She reported stressors that included lack of steady employment, finances, chronic pain, unreliable transportation, and her mother's declining health because of cancer. Tr. at 440. She indicated her mood and energy level had improved slightly in response to Sertraline. Id. Erin M. Jones, LMSW, observed the following on mental status exam: appropriate appearance, grooming, and hygiene; limited engagement; normal psychomotor activity; normal speech; depressed mood; flat affect; linear, logical thought process; difficulty maintaining train of thought during discussion; and impaired insight and judgment. Tr. at 441. She assessed MDD and PTSD and a GAF score of 45-50. Id. She noted Plaintiff did not typically watch television or movies, but encouraged her to watch a movie with her son and to sit outside to watch him ride his bike. Tr. at 442.

         On August 19, 2011, Plaintiff presented to James A. Hutchingson, M.D. (“Dr. Hutchingson”), for a mental disorders compensation and pension (“C&P”) examination related to her request for an increased VA disability impairment rating. Tr. at 229-36. Dr. Hutchingson observed Plaintiff to “appear[] very depressed, ” demonstrate flat affect, be “slow to answer questions, ” be hypokinetic and anhedonic, “ha[ve] difficulty concentrating, ” and “feel[] great guilt.” Tr. at 236. He stated Plaintiff was “isolative and clearly not functioning well.” Id. He identified Plaintiff's symptoms as including depressed mood; anxiety; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; flattened affect; disturbance of motivation and mood; and inability to establish and maintain effective relationships. Tr. at 234-35. He confirmed Plaintiff's diagnosis of MDD. Tr. at 230. He assessed a GAF score of 50. Tr. at 231.

         On August 19, 2011, Plaintiff also presented to Jason K. Trigiani, M.D. (“Dr. Trigiani”), for a thoracolumbar spine C&P exam. Tr. at 236-47. She described burning, pulsating, twitching pain in her lower back that radiated to her left calf. Tr. at 237. She stated her pain was exacerbated by activity and decreased by medication. Id. She indicated her back pain flared up three to four times per week. Id. Dr. Trigiani noted the following range of motion (“ROM”) in Plaintiff's lumbar spine: forward flexion to 20/90 degrees; extension to 10/30 degrees; right lateral flexion to 30/30 degrees; left lateral flexion to 25/30 degrees; right lateral rotation to 30/30 degrees; and left lateral rotation to 30/30 degrees. Tr. at 238-39. Plaintiff was able to engage in repetitive use testing without additional limitation in ROM. Tr. at 239-40. Dr. Trigiani noted Plaintiff had functional loss in the thoracolumbar spine that included less movement than normal and pain on movement. Tr. at 240. He stated Plaintiff had pain to palpation of the entire lumbar spine, but no paraspinal tenderness. Id. He observed no guarding or muscle spasm. Id. He noted normal 5/5 strength in bilateral hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension. Tr. at 241. He indicated Plaintiff did not have muscle atrophy. Id. He noted normal bilateral knee and ankle deep tendon reflexes. Tr. at 242. A sensory examination was normal in all dermatomes. Tr. at 242. A straight leg raising (“SLR”) test was negative bilaterally. Id. Dr. Trigiani indicated Plaintiff had mild radicular pain in her left lower extremity. Tr. at 243. He stated Plaintiff's left L4/L5/S1/S2/S3 nerve roots were involved. Id. He assessed mild left-sided radiculopathy. Id. He indicated Plaintiff constantly used a lumbar corset brace as a normal mode of locomotion. Tr. at 244-45. He indicated imaging studies had confirmed arthritis in Plaintiff's thoracolumbar spine. Tr. at 246.

         Plaintiff participated in a mental health telemedicine appointment with Dr. Hiott on August 22, 2011. Tr. at 226-29. She reported improved symptoms, but indicated she continued to wake and be unable to return to sleep on some nights. Tr. at 227. She indicated she was “not doing very much each day” and felt “overwhelmed frequently.” Id. Dr. Hiott observed Plaintiff to appear “somewhat unkempt, ” to demonstrate psychomotor retardation, to have a depressed and anxious mood and blunted affect, and to have fair judgment and insight. Tr. at 228. Plaintiff denied recent suicidal thoughts and showed no overt evidence of psychosis. Id. She was fully oriented and her memory was intact. Id. Dr. Hiott diagnosed MDD, dysthymia, and unspecified anxiety disorder and assessed a GAF score of 45. Id. He increased Plaintiff's Zoloft to 100 mg daily, continued Seroquel, and instructed Plaintiff to continue regular individual therapy. Tr. at 229.

         On October 4, 2011, Plaintiff initiated mental health treatment with Angela M. Court, M.D. (“Dr. Court”). Tr. at 409-10. She endorsed depressed mood, feelings of hopelessness and worthlessness, passive suicidal ideation without plan or intent, poor concentration, no interest in activities, low self-worth, increased sleep, and constant fatigue. Tr. at 410. She reported dizziness and lightheadedness following an increase in her Sertraline dose. Id. Dr. Court noted the following observations on mental status exam: somnolent; fair hygiene; poor eye contact; normal rate and volume, but monotone speech; depressed mood; blunted-to-flat affect; linear thought process; intact recall of information; and impaired judgment and insight. Tr. at 411. She assessed recurrent, moderate-to-severe MDD and a GAF score of 55.[4] Tr. at 411, 412. She discontinued Quetiapine secondary to excessive sedation and indicated she would continued to monitor Plaintiff's somnolence because several of her medications could be contributing to the problem. Tr. at 411.

         Plaintiff complained of excessive fatigue, low energy, and no interest or desire for activity on November 7, 2011. Tr. at 407. She reported that she had recently attended a festival with her sister, but had argued with several attendees. Tr. at 408. She indicated she typically sat at home all day in isolation and with her curtains drawn. Id. She endorsed poor concentration. Id. She stated she was unable to sleep for more than two hours at a time. Id. She denied hopelessness and suicidal thoughts, plan, or intent. Id. Dr. Court observed the following on mental status exam: somnolent; fair hygiene; poor eye contact; normal rate and volume, but monotone speech; tired mood; blunted-to-flat affect; linear thought process; intact recall of information; and impaired judgment and insight. Tr. at 409. She assessed recurrent, moderate- to-severe MDD with continued excessive fatigue and isolation. Id. She increased Plaintiff's Sertraline dose and encouraged her to continue activities as able. Id.

         On December 29, 2011, Robert W. Rectenwald, M.D. (“Dr. Rectenwald”), reviewed Plaintiff's VA records as a follow up to the C&P exams and to provide an opinion as to whether Plaintiff met the requirements for a finding of individual unemployability. Tr. at 397. He specified he was not commenting on Plaintiff's mental health issues. Tr. at 398. He opined that Plaintiff “should be able to perform sedentary to mildly physical labor without stooping/squatting or lifting carrying more than twenty pounds.” Id. He further stated Plaintiff “should be able to perform work from the waist up.” Id.

         On February 3, 2012, Plaintiff reported depression, low energy, poor sleep, fatigue, little interest, and isolation. Tr. at 385. She complained that the increased dose of Sertraline had caused shaking, yawning, and teeth chattering. Id. She denied suicidal and homicidal thoughts. Id. She endorsed conflict with her brother. Id. Dr. Court observed the following on mental status exam: somnolent; fair hygiene; okay eye contact; normal rate and volume, but monotone speech; tired mood; blunted-to-flat affect; linear thought process; intact recall of information; and impaired judgment and insight. Tr. at 386. She assessed recurrent, moderate-to-severe MDD with continued excessive fatigue and isolation. Id. She reduced Plaintiff's Sertraline dose to 100 mg daily, added Ritalin, and encouraged Plaintiff to engage in activities as able. Id. She assessed a GAF score of 55. Tr. at 387.

         On March 20, 2012, Plaintiff reported increased energy since starting Ritalin. Tr. at 379. She continued to endorse anger and irritability, but indicated it had been better controlled. Id. She denied hopeless, suicidal, and homicidal thoughts. Id. Dr. Court observed the following on mental status exam: fair hygiene, but wearing a ball cap because of self-consciousness related to hair loss; good eye contact; normal rate and volume, but monotone speech; constricted affect; linear thought process; intact recall of information; and improved judgment and insight. Tr. at 380. She increased Plaintiff's Ritalin dose. Tr. at 381.

         On May 1, 2012, Plaintiff reported improved sleep, increased energy, and feeling better. Tr. at 376. She denied hopeless, suicidal, and homicidal thoughts and plan. Id. Dr. Court noted the following findings on mental status exam: alert; fair hygiene; good eye contact; normal rate and volume, but monotone speech; constricted affect; linear thought process; intact recall of information; and improved judgment and insight. Tr. at 377. She assessed mild, recurrent MDD and continued Plaintiff's medications. Tr. at 377-78.

         On June 14, 2012, Plaintiff reported intermittent low back pain and rated it as a six on a 10-point scale. Tr. at 368. Dr. Torres observed no spinal tenderness or cyanosis, edema, or clubbing in Plaintiff's extremities and no gross neurological deficit. Tr. at 369-70.

         On July 10, 2012, Plaintiff reported feeling “down” as a result of grieving her mother, who had recently passed away. Tr. at 364. She indicated she had been isolating in her room and sleeping all day. Id. She reported having decreased energy, no interest, and hopeless thoughts. Id. She denied suicidal and homicidal ideation and plan. Id. Dr. Court observed the following on mental status exam: alert; fair hygiene; good eye contact; normal rate and volume of speech, but monotone; constricted affect; linear thought process; intact recall of information; fair judgment; and fair insight. Tr. at 365. She assessed recurrent, moderate MDD with increased depression following mother's recent passing. Id. She increased Plaintiff's Ritalin dose and encouraged her to continue her other medications as prescribed and activities as able. Id.

         Plaintiff presented to Dr. Court for mental health follow up on August 28, 2012. Tr. at 354-56. She reported pain, but indicated her mood had improved. Tr. at 354-55. She stated she had been more energized and had engaged in some cleaning, but indicated she was “still not getting out much” and was “not identifying anything she want[ed] to be doing.” Tr. at 355. Plaintiff denied arguments, confrontations, hopeless thoughts, and suicidal or homicidal ideation or intent. Id. Dr. Court observed the following on mental status examination: alert with fair hygiene; good eye contact; normal rate and volume of speech, but monotone; constricted affect; linear thought process; instant recall of information; fair judgment; and fair insight. Tr. at 355-56. She assessed recurrent, mild MDD and a GAF score of 55. Tr. at 356. She increased Plaintiff's Ritalin and continued her other medications. Id.

         Plaintiff followed up with Dr. Torres on August 30, 2012. Tr. at 349. She reported chronic low back pain that she rated as a five-to-six on a 10-point scale. Id. She indicated her pain increased with exercise and decreased with rest and lying down. Id. Dr. Torres noted pain at palpation in the paravertebral muscles of Plaintiff's thoracolumbar spine, limited flexion and extension, pain at palpation in the left sacroiliac (“SI”) joint, no muscle wasting, good ROM in the joints, and normal curvature in the spine. Tr. at 351. He observed Plaintiff to demonstrate normal gait and balance. Id. He assessed acute-on-chronic low back pain and prescribed Ibuprofen 800 mg, Ketoroloac and Solu-Cortef injections, and a TENS unit. Id. He recommended Plaintiff continue to use her back brace, use a heating pad, engage in 40 minutes of exercise four to five times weekly, and follow an 1800-calorie diet. Id.

         State agency psychological consultant Camilla Tezza, Ph.D. (“Dr. Tezza”), reviewed the evidence and completed a psychiatric review technique (“PRT”) on October 22, 2012. Tr. at 54-55. She considered listings 12.04 for affective disorders and 12.07 for somatoform disorders. Id. She assessed mild restriction of ADLs, moderate difficulties in maintaining social functioning, and moderate difficulties in maintaining concentration, persistence, or pace. Tr. at 55. She provided the following explanation:

Longitudinal review indicates moderate impairment in social and mild-to-moderate impairment in CPP. Although it is felt that the clmt could perform tasks of at least moderate complexity, her vulnerability to depressive episodes and to associated neurovegetative sxs suggests that simple routine tasks might be a better recommendation. The clmt does appear to be capable of more than simple routine work in future should her depressive sxs remain in remission.

Id. Dr. Tezza also completed a mental residual functional capacity (“RFC”) assessment and indicated Plaintiff was moderately limited in the following abilities: to carry out detailed instructions, to maintain attention and concentration for extended periods; to work in coordination with or in proximity to others without being distracted by them; to complete a normal workday and workweek without interruptions from psychologically-based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods; to interact appropriately with the general public; and to get along with coworkers or peers without distracting them or exhibiting behavioral extremes. Tr. at 59-61. She provided the following additional explanation:

Based on the evidence cited on the PRT, it is expected that the clmt-
1) is able to understand, remember and carry out simple instructions
2) is able to understand and remember detailed instructions but may have difficulty carrying out detailed instructions
3) can maintain attention and concentration for at least two hour blocks of time throughout a regular work day
4) can tolerate and work cooperatively with coworkers, but may perform better if substantial interaction with coworkers is not required
5) can accept feedback from supervisors
6) may perform better if substantial interaction with the public is not required
7) can sustain an ordinary routine without special supervision
8) may perform better if tasks are routine or are already familiar to her
9) may miss an occasional day or half-day of work due to psych sx or need to attend a MH appt.
10) can attend work regularly and avoid workplace hazards.

Tr. at 60. A second state agency psychological consultant, Olin Hamrick, Jr., Ph.D. (“Dr. Hamrick”), indicated similar findings on a PRT and mental RFC assessment on April 8, 2013. Compare Tr. at 54-55 and 59-61, with Tr. at 73-74 and 78-80.

         On November 8, 2012, Plaintiff reported recent chest pain she believed to be stress-induced. Tr. at 548. She complained of significant stress related to her living situation. Id. She stated she was no longer using Doxepin on school nights because she had been too tired to wake and get her son ready, resulting in him being late for school on 16 occasions. Id. She endorsed down mood and hopeless thoughts, but denied suicidal ideation, plan, or intent. Id. She reported attending church for support. Id. Dr. Court observed the following on mental status examination: fair hygiene, good eye contact, normal psychomotor activity; normal rate and volume, but monotone speech; linear thought processes; intact recall of information; and fair judgment and insight. Tr. at 550. She discontinued Ritalin based on Plaintiff's complaints of chest pain and added Bupropion. Id.

         On November 26, 2012, x-rays of Plaintiff's lumbar spine were unremarkable. Tr. at 838.

         On December 21, 2012, state agency medical consultant Katrina B. Doig, M.D. (“Dr. Doig”), reviewed the evidence and assessed the following physical RFC: occasionally lift and/or carry 20 pounds; frequently lift and/or carry 10 pounds; stand and/or walk for a total of about six hours in an eight-hour workday; sit for a total of about six hours in an eight-hour workday; never climb ladders, ropes or scaffolds; occasionally climb ramps or stairs, stoop, kneel, crouch, and crawl; and avoid even moderate exposure to hazards. Tr. at 56-59. A second state agency medical consultant, Stephen Wissman, M.D. (“Dr. Wissman”), assessed the same physical RFC on April 8, 2013. Compare Tr. at 56-59, with Tr. at 75-78.

         On January 3, 2013, Plaintiff reported doing poorly with continued depressed mood, anhedonia, tiredness, and poor concentration. Tr. at 544. She denied suicidal ideation and plan. Id. She indicated she was taking her medication as prescribed, but Dr. Court noted the refill history did not support Plaintiff's report. Id. Dr. Court observed the following on mental status exam: fair hygiene; good eye contact; normal psychomotor activity; normal rate and tone, but monotone speech; down mood; constricted affect; occasional hopeless thoughts; linear thought process; intact information recall; and fair insight and judgment. Tr. at 545-46. She assessed recurrent, moderate MDD with continued depressed mood and financial and living situation stressors and provided a GAF score of 55. Tr. at 546. She increased Bupropion SA to 200 mg daily and encouraged Plaintiff to use her medications more consistently. Id.

         On February 28, 2013, Plaintiff reported depressed mood, anhedonia, lack of motivation, increased distractibility, poor concentration, impaired memory, fatigue, hopeless thoughts, and fleeting suicidal ideation. Tr. at 537. Dr. Court observed the following on mental status exam: slight odor and disheveled appearance; intermittent eye contact; normal rate and volume, but monotone speech; down mood; constricted affect; linear thought process; intact recall of information; and fair judgment and insight. Tr. at 538. She assessed moderate, recurrent MDD with continued depressed mood and financial and living stressors. Tr. at 539. She added a prescription for Lamotrigine 25 mg for depression and encouraged Plaintiff use her medications consistently and to continue activities as able. Id.

         On April 8, 2013, Plaintiff reported no change in her mental status. Tr. at 825. She endorsed feelings of hopelessness, anxiety, restlessness, depression, variable energy, and impaired concentration. Id. She denied side effects from the increased dose of Lamotrigine. Id. Dr. Court noted fair hygiene and grooming, down mood, constricted affect, monotone speech, intermittent eye contact, and fair insight and judgment, but the remainder of the mental status exam was normal. Tr. at 826. She increased Plaintiff's Lamotrigine dose to 50 mg twice daily and continued Sertraline and Bupropion. Tr. at 826-27. She assessed a GAF score of 55. Tr. at 827.

         On April 9, 2013, Plaintiff presented to General Theophilus Little, M.D. (“Dr. Little”), for severe posterior cervical pain extending into her shoulders and causing numbness in her hands. Tr. at 820. She denied upper extremity weakness. Id. Dr. Little observed tenderness and muscle spasm in Plaintiff's posterior cervical muscles and trapezius. Tr. at 822. Plaintiff reported pain on rotation of her head to the right. Id. Dr. Little noted normal flexion and extension of Plaintiff's neck, normal upper extremity motor function, negative Tinel's test, mild swelling of the fingers and tenderness of the proximal interphalangeal (“PIP”) joints of both hands, no tenderness of the metacarpophalangeal (“MCP”) joints in either hand, and normal wrist exam. Tr. at 823. He continued Plaintiff on 800 mg of ibuprofen three times daily and ordered magnetic resonance imaging (“MRI”) of her cervical spine. Id.

         On May 1, 2013, the MRI showed mild discogenic-type degenerative changes at ¶ 2-3, C4-5, and C5-6 with no significant central canal or neural foraminal stenosis. Tr. at 703.

         On May 16, 2013, the VA notified Plaintiff that she was entitled to a higher level of disability due to being unemployable. Tr. at 828. It found Plaintiff to be totally and permanently disabled due to her service-connected disabilities effective June 23, 2011. Id. It assigned an impairment rating of 70% for MDD, 40% for chronic lumbar strain, 10% for urticaria, and 10% for radiculopathy of the left lower extremity associated with chronic lumbar strain. Tr. at 832.

         On May 23, 2013, Plaintiff reported a slight improvement in mood, some improvement in energy, leaving her home more often, and taking short walks. Tr. at 815. She endorsed periods of hopeless thoughts and overall depressed mood, but denied suicidal thoughts, plan, or intent. Id. Dr. Court's observations on mental status exam were consistent with prior findings. Tr. at 816. She increased Plaintiff's Lamotrigine prescription to 50 mg in the morning and 100 mg at bedtime. Id.

         On June 7, 2013, Plaintiff complained of unrefreshing sleep and indicated she desired to sleep all the time. Tr. at 809. She also reported depressed mood, occasional palpitations, and a rash. Id. Dr. Boyle noted a patch of erythema in Plaintiff's right inguinal area and indicated she was depressed. Tr. at 810. She prescribed an antifungal cream and continued Plaintiff's other medications. Id.

         On July 9, 2013, Plaintiff complained of increased family stressors following her uncle's death. Tr. at 800. She reported hopeless thoughts and restless sleep, but denied suicidal thoughts, plan, or intent. Id. Dr. Court's observations on mental status exam were consistent with prior exams. Tr. at 801. She continued Plaintiff's medications and assessed a GAF score of 55. Tr. at 802.

         On August 20, 2013, Plaintiff participated in a mental telehealth visit with Floyd Sallee, M.D. (“Dr. Sallee”). Tr. at 792. She reported feeling more tired over the prior weeks. Id. She stated she had felt increased grief over her mother's death following her uncle's passing in July. Id. Plaintiff complained of depressed mood, restless sleep, reduced appetite, anhedonia, no energy, and poor concentration. Id. Dr. Sallee observed the following on mental status exam: fair hygiene and grooming; intermittent eye contact; slow moving with psychomotor retardation; slow rate and volume with monotone speech; depressed mood; sad and constricted affect; linear and logical thoughts process; intact recall; and fair judgment and insight. Tr. at 794. Plaintiff denied suicidal and homicidal ideations and auditory and visual hallucinations. Id. Dr. Sallee increased Lamotrigine to 200 mg per day. Tr. at 795.

         On August 20, 2013, Plaintiff complained of a frontal headache and blurred vision. Tr. at 787. She indicated she woke during the night with left arm and hand pain, noticed recent left arm weakness, and felt as if she were dragging her left foot. Tr. at 789. Dr. Boyle noted positive Phalen's sign in Plaintiff's left upper extremity, microvesicles and scaling on her feet, and depressed affect. Tr. at 790. She assessed headache secondary to hypertension and left arm and hand pain possibly related to carpal tunnel syndrome. Id. She ordered a left wrist splint, referred Plaintiff for an eye exam, and instructed her to take Amlodipine at bedtime and Hydrochlorothiazide in the morning for hypertension, Motrin for headaches, and to engage in a regular walking routine. Id.

         On October 16, 2013, Plaintiff complained of feeling tired and not sleeping well. Tr. at 764. She reported decreased energy, “okay” concentration, and increased appetite and denied hopeless or suicidal thoughts and side effects from medication. Id. Dr. Court noted the following findings on mental status exam: fair hygiene and grooming; intermittent eye contact; normal psychomotor activity; normal rate and volume, but monotone speech; linear thought process; intact recall; and fair insight and judgment. Tr. at 765. She increased Plaintiff's Doxepin prescription to 20 mg and instructed her to take it one hour prior to bedtime. Tr. at 766. She assessed a GAF score of 55. Id.

         Plaintiff presented to Deena J. Flessas, M.D. (“Dr. Flessas”), at the Goose Creek VA Clinic for an initial psychiatric visit on January 15, 2014. Tr. at 759. She indicated her medication was working and her energy level had improved. Tr. at 760. She reported being more social and attending church with a friend, as well as spending time and talking with her son more often. Id. Dr. Flessas observed Plaintiff to have “ok” mood and reserved affect, but noted no other abnormalities on mental status exam. Tr. at 761. She continued Plaintiff's medications and encouraged her to attend group therapy at the clinic. Id.

         On April 22, 2014, Plaintiff reported she enjoyed attending a women's support group at her church. Tr. at 755. She indicated she had no friends and felt like should could not trust people. Id. She endorsed early waking at 4 a.m. on three days per week. Id. She reported suicidal ideation two weeks prior. Id. She denied problems with medications. Id. Dr. Flessas observed 6/10 mood and constricted affect, but noted no other abnormalities on mental status exam. Tr. at 757. She continued Plaintiff's medications and encouraged her to attend a group therapy session at the clinic. Id.

         Plaintiff attended a group therapy session on April 22, 2014. Tr. at 754. Ashley Tate Hatton, Psy. D. (“Dr. Hatton”) and Sarah B. Stevens, Ph.D. (“Dr. Stevens”), noted no abnormalities on mental status exam. Id. They indicated Plaintiff participated, sharing ideas and engaging in activities. Tr. at 754-55.

         On May 12, 2014, Plaintiff complained of “feel[ing] tired all the time.” Tr. at 751. She reported isolation, limited social interaction, limited engagement in activities, anxiety, road rage, feeling depressed most of the time, and preferring to remain at home. Id. Sondra R. Bryant, LMSW (“S.W. Bryant”), indicated Plaintiff's medications were somewhat helpful. Id. Plaintiff agreed to participate in monthly therapy sessions. Id. S.W. Bryant observed Plaintiff to have a tired mood and constricted affected, but noted no other abnormalities on mental status exam. Tr. at 752.

         On May 28, 2014, Plaintiff presented to the emergency room (“ER”) at the Charleston VA Medical Center with complaints of numbness and tingling in her right middle three fingers, as well as a tender lump on her posterior spine. Tr. at 740. X-rays of Plaintiff's cervical spine showed straightening of the cervical spine; moderate C2-3, C4-5, and C5-6 disc space narrowing with mild adjacent endplate spurring; no vertebral height loss; normal Atlantodental inverval; no prevertebral soft tissue swelling; moderate right-sided osseous neural foraminal narrowing at ¶ 6-7; and moderate-to-severe left-sided osseous neural foraminal narrowing at ¶ 6-7. Tr. at 743-44. Plaintiff reported improved symptoms following Toradol injection. Tr. at 743. The attending physician discharged Plaintiff with prescriptions for a nonsteroidal anti-inflammatory drug (“NSAID”) and low-dose Elavil. Id.

         Plaintiff followed up with S.W. Bryant on June 9, 2014. Tr. at 730. She reported feeling “extremely tired” and sleeping the entire prior day and all morning prior to the 1:20 p.m. visit. Id. She felt her medication was causing extreme drowsiness. Id. She reported isolation, limited social interaction, limited engagement in activities, anxiety, and road rage. Id. She stated she felt depressed most of the time and preferred to remain in her home. Id. S.W. Bryant observed Plaintiff to demonstrate a tired mood and constricted affect, but to have no other abnormalities on mental status exam. Tr. at 731.

         On July 9, 2014, Plaintiff complained of right arm pain and numbness, decreased right hand grip, and right shoulder pain radiating to her fingers. Tr. at 1686. Candace C. Chidester, M.D. (“Dr. Chidester”), observed tenderness to the back of Plaintiff's neck, painful cervical abduction, tenderness to palpation in her right shoulder, decreased right hand grip, and increased pain upon turning her neck. Tr. at 1688. She prescribed Vicodin and Flexeril and referred Plaintiff for an x-ray of her right shoulder and an MRI of her cervical spine. Tr. at 1689.

         On July 10, 2014, an MRI of Plaintiff's cervical spine showed mild S-shaped cervicothoracic scoliosis; mild congenital narrowing of the cervical spinal canal; mild-to-moderate spondylosis at ¶ 2-3, C4-5, and C5-6; and degenerative disc disease, mild-to-moderate broad-based disc/osteophyte complex, moderate right and mild left foraminal narrowing, and slight broad cord flattening at ¶ 4-5. Tr. at 835.

         Plaintiff complained of pain on July 29, 2014. Tr. at 1679. She indicated her pain affected her mood and sleep. Id. She stated she avoided socializing because she did not trust most people, including her family members. Id. Rukhsana W. Mirza, M.D. (“Dr. Mirza”), observed Plaintiff to have low and sad mood and constricted affect, but no other abnormalities on mental status exam. Tr. at 1680. He diagnosed MDD and borderline personality traits with a need to rule out borderline personality disorder. Tr. at 1680-81. He continued Plaintiff's medications and instructed her to follow up with Dr. Flessas in four weeks. Tr. at 1681.

         Plaintiff followed up with S.W. Bryant the same day. Tr. at 1681. S.W. Bryant helped Plaintiff to process her feelings related to pain issues. Tr. at 1682. She assessed a GAF score of 55 and recommended Plaintiff attend group therapy. Tr. at 1683, 1684.

         Plaintiff presented to orthopedic surgeon Michael S. Wildstein, M.D. (“Dr. Wildstein”), for consultation regarding neck and arm pain on August 14, 2014. Tr. at 1203. She described sharp pain that radiated from her neck through her right shoulder and arm. Id. She stated her pain was exacerbated by right arm movement. Id. She rated the pain as a constant 10 on a 10-point scale. Id. Dr. Wildstein observed Plaintiff to be in moderate distress; decreased and painful ROM of the right shoulder; 4/5 strength of the right upper extremity; and negative Hoffman's, L'Hermite's, and Spurling's maneuvers. Tr. at 1203-04. He assessed cervical spondylosis with radiculopathy. Tr. at 1204. He recommended conservative options, including physical therapy and injections and prescribed a Medrol Dosepak. Tr. at 1205.

         On August 20, 2014, Plaintiff reported improved sleep, but declined mood. Tr. at 1673. She complained of “a lot of pain issues” and continued to isolate at home and spend most of her time “resting” in bed. Id. Dr. Flessas encouraged Plaintiff to avoid staying in bed all day, to engage in activities, to socialize with others, and to attend a support group. Id. She observed decreased mood and mildly constricted affect, but noted no other abnormalities on mental status exam. Tr. at ...


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