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Reed v. Berryhill

United States District Court, S.D. West Virginia, Bluefield Division

March 22, 2018

TAMMY LAVONNE REED, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.

          PROPOSED FINDINGS AND RECOMMENDATIONS

          Cheryl A. Eifert, United States Magistrate Judge.

         This action seeks a review of the decision of the Commissioner of the Social Security Administration (hereinafter “Commissioner”) denying Plaintiff's applications for a period of disability and disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-433, 1381-1383f. The matter is assigned to the Honorable David A. Faber, United States District Judge, and was referred to the undersigned United States Magistrate Judge by standing order for submission of proposed findings of fact and recommendations for disposition pursuant to 28 U.S.C. § 636(b)(1)(B). Presently pending before the Court are Plaintiff's Brief in Support of Judgment on the Pleadings and the Commissioner's Brief in Support of Defendant's Decision, requesting judgment in her favor. (ECF Nos. 13, 17).

         Having fully considered the record and the arguments of the parties, the undersigned United States Magistrate Judge respectfully RECOMMENDS that Plaintiff's request for judgment on the pleadings be DENIED, the Commissioner's request for judgment on the pleadings be GRANTED, the Commissioner's decision be AFFIRMED, and that this case be DISMISSED and removed from the docket of the Court.

         I. Procedural History

         On January 14, 2013, Plaintiff Tammy Lavonne Reed (“Claimant”), completed applications for DIB and SSI, alleging a disability onset date of March 15, 2012 due to “coronary heart disease, diabetes, hypertension, depression, anxiety, arthritis, high cholesterol, and degenerative disc disease.” (Tr. at 356-66, 390). The Social Security Administration (“SSA”) denied Claimant's applications initially and upon reconsideration. (Tr. at 202-11, 214-19). Claimant filed a request for an administrative hearing, which was held on November 17, 2015 before the Honorable Steven A. DeMonbreum, Administrative Law Judge (“ALJ”). (Tr. at 56-124). By written decision dated December 28, 2015, the ALJ found that Claimant was not disabled as defined in the Social Security Act. (Tr. at 19-55). The ALJ's decision became the final decision of the Commissioner on February 10, 2017, when the Appeals Council denied Claimant's request for review. (Tr. at 1-7).

         Claimant timely filed the present civil action seeking judicial review pursuant to 42 U.S.C. § 405(g). (ECF No. 2). The Commissioner subsequently filed an Answer opposing Claimant's complaint and a Transcript of Proceedings. (ECF Nos. 7, 8). Claimant then filed a Brief in Support of Judgment on the Pleadings. (ECF No. 12, 13). In response, the Commissioner filed a Brief in Support of Defendant's Decision. (ECF No. 17). Consequently, the matter is fully briefed and ready for resolution.

         II. Claimant's Background

         Claimant was 46 years old at the time of her alleged onset of disability and 50 years old at the time of the ALJ's decision. She has a college undergraduate degree in psychology and she communicates in English. (Tr. at 61, 389). Claimant previously worked as bookkeeper, telephone customer service representative, Headstart teacher's aide, social services aide, and skill program training coordinator. (Tr. at 114-15).

         III. Summary of ALJ's Decision

         Under 42 U.S.C. § 423(d)(5), a claimant seeking disability benefits has the burden of proving a disability. See Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972). A disability is defined as the “inability to engage in any substantial gainful activity by reason of any medically determinable impairment which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A).

         The Social Security regulations establish a five-step sequential evaluation process for the adjudication of disability claims. If an individual is found “not disabled” at any step of the process, further inquiry is unnecessary and benefits are denied. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The first step in the sequence is determining whether a claimant is currently engaged in substantial gainful employment. Id. §§ 404.1520(b), 416.920(b). If the claimant is not, then the second step requires a determination of whether the claimant suffers from a severe impairment. Id. §§ 404.1520(c), 416.920(c). A severe impairment is one that “significantly limits [a claimant's] physical or mental ability to do basic work activities.” Id. If severe impairment is present, the third inquiry is whether this impairment meets or equals any of the impairments listed in Appendix 1 to Subpart P of the Administrative Regulations No. 4 (the “Listing”). Id. §§ 404.1520(d), 416.920(d). If so, then the claimant is found disabled and awarded benefits.

         However, if the impairment does not meet or equal a listed impairment, the adjudicator must assess the claimant's residual functional capacity (“RFC”), which is the measure of the claimant's ability to engage in substantial gainful activity despite the limitations of his or her impairments. Id. §§ 404.1520(e), 416.920(e). After making this determination, the fourth step is to ascertain whether the claimant's impairments prevent the performance of past relevant work. Id. §§ 404.1520(f), 416.920(f). If the impairments do prevent the performance of past relevant work, then the claimant has established a prima facie case of disability, and the burden shifts to the Commissioner to demonstrate, in the fifth and final step of the process, that the claimant is able to perform other forms of substantial gainful activity, given the claimant's remaining physical and mental capacities, age, education, and prior work experiences. 20 C.F.R. §§ 404.1520(g), 416.920(g); see also McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir. 1983). The Commissioner must establish two things: (1) that the claimant, considering his or her age, education, skills, work experience, and physical shortcomings has the capacity to perform an alternative job, and (2) that this specific job exists in significant numbers in the national economy. McLamore v. Weinberger, 538 F.2d 572, 574 (4th Cir. 1976).

         When a claimant alleges a mental impairment, the SSA “must follow a special technique at each level in the administrative review process, ” including the review performed by the ALJ. 20 C.F.R. §§ 404.1520a(a), 416.920a(a). Under this technique, the ALJ first evaluates the claimant's pertinent signs, symptoms, and laboratory results to determine whether the claimant has a medically determinable mental impairment. Id. §§ 404.1520a(b), 416.920a(b). If an impairment exists, the ALJ documents his findings. Second, the ALJ rates and documents the degree of functional limitation resulting from the impairment according to criteria specified in Id. §§ 404.1520a(c), 416.920a(c). Third, after rating the degree of functional limitation from the claimant's impairment(s), the ALJ determines the severity of the limitation. Id. §§ 404.1520a(d), 416.920a(d). A rating of “none” or “mild” in the first three functional areas (activities of daily living, social functioning, and concentration, persistence or pace) and “none” in the fourth (episodes of decompensation of extended duration) will result in a finding that the impairment is not severe unless the evidence indicates that there is more than minimal limitation in the claimant's ability to do basic work activities. Id. §§ 404.1520a(d)(1), 416.920a(d)(1). Fourth, if the claimant's impairment is deemed severe, the ALJ compares the medical findings about the severe impairment and the rating and degree and functional limitation to the criteria of the appropriate listed mental disorder to determine if the severe impairment meets or is equal to a listed mental disorder. Id. §§ 404.1520a(d)(2), 416.920a(d)(2). Finally, if the ALJ finds that the claimant has a severe mental impairment, which neither meets nor equals a listed mental disorder, the ALJ assesses the claimant's residual mental functional capacity. Id. §§ 404.1520a(d)(3), 416.920a(d)(3). The regulations further specify how the findings and conclusion reached in applying the technique must be documented by the ALJ, stating:

The decision must show the significant history, including examination and laboratory findings, the functional limitations that were considered in reaching a conclusion about the severity of the mental impairment(s). The decision must include a specific finding as to the degree of limitation in each functional areas described in paragraph (c) of this section.

20 C.F.R. §§ 404.1520a(e)(4), 416.920a(e)(4).

         Here, the ALJ determined as a preliminary matter that Claimant met the insured status for disability insurance benefits through December 31, 2015. (Tr. at 24, Finding No. 1). At the first step of the sequential evaluation, the ALJ found that Claimant had not engaged in substantial gainful activity since her alleged onset date, March 15, 2012. (Tr. at 25, Finding No. 2). At the second step of the evaluation, the ALJ found that Claimant had the following severe impairments: “coronary artery disease (CAD) status post- stenting, chronic obstructive pulmonary disease (COPD), stage 3 chronic kidney disease (CKD), diabetes mellitus, bilateral carpal tunnel syndrome (CTS) status-post surgery, Hebron's nodes in the hands, osteoarthritis, degenerative disc disease with chronic cervical and lumbar strains, and obesity.” (Tr. at 25, Finding No. 3). Under the third inquiry, the ALJ found that Claimant did not have an impairment or combination of impairments that met or medically equaled any of the impairments contained in the Listing. (Tr. at 27, Finding No. 4). Accordingly, the ALJ determined that Claimant possessed:

[T]he residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except the claimant can lift or carry, including upward pulling, 20 pounds occasionally and 10 pounds frequently; stand or walk, with normal breaks, for a total of about six hours in an eight-hour workday. The claimant can continuously operate foot controls; occasionally reach overhead bilaterally; frequently reach in other directions, handle, finger, feel, push, or pull with the bilateral upper extremities; occasionally climb ramps or stairs; never crawl or climb ladders, ropes, or scaffolds; and occasionally balance, stoop, kneel, or crouch. The claimant can have no more than occasional exposure to temperature extremes, dust, odors, fumes, gases, or vibrations. She can have no exposure whatsoever to hazards like dangerous moving machinery and unprotected heights.

(Tr. at 29, Finding No. 5). At the fourth step, with the assistance of a vocational expert (“VE”), the ALJ determined that Claimant was able to perform past relevant work as a bookkeeper, telephone representative, and skill training program coordinator. (Tr. at 46, Finding No. 6). In addition, considering Claimant's age, education, work experience, and RFC, the ALJ determined with the VE's assistance that Claimant was capable of making a successful adjustment to other work that existed in significant numbers in the national economy such as a cashier, gate guard, or rental clerk. (Tr. at 48). Therefore, the ALJ found that Claimant was not disabled as defined in the Social Security Act, and was not entitled to benefits. (Tr. at 48, Finding No. 7).

         IV. Claimant's Challenge to the Commissioner's Decision

         Claimant raises four challenges to the Commissioner's decision. First, Claimant argues that the ALJ erred in not recognizing her depression and anxiety as severe impairments. (ECF No. 13 at 23-26). In her second challenge, Claimant contends that the ALJ's decision does not properly consider her obesity. (Id. at 27). Third, Claimant argues that the ALJ's credibility determination was deficient because the ALJ analyzed her RFC before evaluating her credibility and provided improper bases to discount her allegations. (Id. at 27-29). Finally, Claimant asserts that the ALJ erred in assigning only “some weight” to the opinion of a consultative examiner. (Id. at 30-32).

         In response to Claimant's challenges, the Commissioner argues that substantial evidence supported the ALJ's finding that Claimant's mental impairments were non-severe and the ALJ properly considered Claimant's obesity, evaluated her credibility, and explained why the consultative opinion was entitled to only some weight. (ECF No. 17 at 7-20).

         V. Relevant Evidence

         The undersigned has considered all of the evidence of record, including documentation of medical examinations, treatment, evaluations, and statements. The information most relevant to Claimant's challenges is summarized as follows.

         A. Treatment Records

         On October 17, 2011, Claimant presented to Florencio Neri, M.D., at Prime Care 12, Inc. (Tr. at 718). Claimant reported having severe depression over the past two months after she ran out of Cymbalta. (Id.). She was stressed by her brother's recent death. (Id.). Claimant reported fatigue, dizziness, and headaches; she believed the depression was causing her headaches. (Id.). She was noted to be 5 feet 9 inches tall and weighed 219 pounds. (Tr. at 720). Her body mass index was 32.3, her blood pressure ranged between 175/94 and 185/102 when measured at that visit, and her resting heart rate was within the normal range at 81 beats per minute. (Id.). Claimant smoked one pack of tobacco products per day. (Tr. at 719). Her current medications included Benadryl; Toprol, a beta-blocker used to treat cardiac issues; the antidepressant Cymbalta; Metformin, a medication used to treat type 2 diabetes; and the blood pressure medication Benicar. (Tr. at 720). Claimant stated that she had been tracking her blood pressure and it had “been okay” and she was tolerating her medications well without side effects. (Tr. at 718). Her respiratory and cardiovascular examinations were normal; she had normal range of motion, strength, and tone on her musculoskeletal examination; she had no neurological issues, including intact motor and sensory function, reflexes, gait, and coordination; and she was in no apparent distress with appropriate affect and demeanor, normal speech pattern, and grossly normal memory. (Tr. at 720). Claimant's Cymbalta was refilled and she was advised to avoid caffeine, reduce stress, and follow up in three months. (Tr. at 721). For hypertension, Claimant was to continue monitoring her blood pressure at home, exercise, reduce her salt intake, and lose weight. (Id.). For hyperlipidemia, Claimant was likewise advised to exercise and lose weight, as well as follow a low cholesterol/low fat diet. (Id.).

         On December 4, 2011, Claimant was admitted to the Intensive Care Unit at Princeton Community Hospital due to a “hypertensive crisis” in which her blood pressure was 243/169 and she was in acute respiratory failure. (Tr. at 641). Her symptoms were initially believed to be caused by flash pulmonary edema, but testing showed that she was negative for the condition and it was determined that she was likely suffering from a cardiac issue. (Id.). Claimant was transferred to Roanoke Memorial Hospital on December 6, 2011 and underwent a heart catheterization the following day. (Tr. at 468). Claimant had high grade stenosis in the first diagonal branch of her heart in which a cardiac surgeon performed percutaneous coronary intervention to place a drug eluting stent. (Id.). Claimant also had some moderate stenosis in her left anterior descending (“LAD”) artery, but there was a low likelihood of physiological significance and medical intervention was deferred. (Tr. at 561-62). Claimant tolerated the heart catheterization well and had “no complaints” at the time of discharge on December 8, 2011. (Tr. at 468).

         On January 9, 2012, Claimant followed up with Dr. Neri. She reported fatigue and seasonal allergies, but denied chest pain or palpitations; edema; shortness of breath; back, muscle, or joint pain; dizziness; headaches; weakness; endocrine issues; depression; anxiety; or sleep disturbances. (Tr. at 722). It was noted that Claimant was divorced with two children, she enjoyed reading, and her primary form of exercise was walking. (Tr. at 723). Claimant continued to smoke one pack of cigarettes per day. (Id.). Her weight was 220 pounds with a body mass index of 32.5, her heart rate was 91, and her blood pressure was 146/89 when measured in her left arm and 152/90 as measured in her right arm. (Tr. at 724). Claimant's physical examination was again normal, corresponding with the same results of her October 2011 visit. (Id.); see (Tr. at 720). No. changes were made to Claimant's medication regimen. (Tr. at 724). Regarding Claimant's type 2 diabetes, Claimant was advised to lower her blood pressure, monitor her glucose levels, adhere to a 1, 200 calories diabetic diet, lose weight, and exercise 30 minutes daily. (Tr. at 725). For hypertension, Claimant was to reduce her dietary salt intake, monitor her blood pressure, and exercise and lose weight. (Id.). For hyperlipidemia, Claimant was advised to quit smoking, follow a low cholesterol/low fat diet, and lose weight. (Id.). For her coronary artery disease, in addition to the prior recommendations, Claimant was to continue her medications and take a daily aspirin. (Id.).

         On January 19, 2012, Claimant followed up with cardiologist, Shahid R. Rana, M.D., following her heart catheterization and stenting procedure. Claimant stated that her breathing was “ok” and she had occasional “twinge like” chest pains, but she denied shortness of breath, chest palpitations, dizziness, weakness, numbness, fever, or chills. (Tr. at 714). She was currently taking high blood pressure medications, insulin, Lipitor to treat high cholesterol, a diuretic, Cymbalta, aspirin, Effient, and nitroglycerin. (Id.). Claimant's blood pressure was 130/68, and her heart rate was 68. (Id.). Her physical examination was normal, including her cardiac and pulmonary systems, and she had no edema in her extremities. (Id.). The assessment was coronary artery disease status post stent of her diagonal branch of the LAD artery, hyperlipidemia, hypertension, and Type 2 diabetes mellitus. (Id.). The plan was for Claimant to continue her current medications, quit smoking, and return for follow up in one month. (Id.).

         On January 24, 2012, Claimant reported to Dr. Neri that she had fatigue, dizziness, back and joint pain, headaches, easy bruising, anxiety, and depression, but she denied shortness of breath. (Tr. at 726). Claimant's weight was 225 pounds and her blood pressure was 151/75 in her left arm and 134/58 in her right arm. (Tr. at 728). Her dosage of insulin was increased to treat her Type 2 diabetes, she was to continue taking Novolog before each meal and Metformin HCI twice daily, continue her hyperlipidemia regimen, and take vitamin D capsules. (Tr. at 729).

         On February 7, 2012, Claimant presented to endocrinologist James R. Mulinda, M.D., for follow up after her hospitalization for acute coronary syndrome. (Tr. at 699). Dr. Mulinda noted that Claimant was diagnosed with Type 2 diabetes two years earlier and it was managed with medication until she began taking insulin in late 2011. (Id.). Her glucose levels remained elevated in the upper 100-200 range. (Id.). On her review of systems, Claimant complained of joint pains, especially in her hips and shoulders; fatigue; weight gain; depressive anxiety; dizziness; and headaches. (Id.). However, Claimant denied chest pain or shortness of breath. (Id.). Claimant's blood pressure was 132/68, her lungs were clear, and she had normal cardiac rhythm. (Id.). For her diabetes, Claimant was encouraged to be more diligent with her glucose monitoring and take her medications appropriately; also, Claimant was advised regarding proper diet and exercise and Tradjenta was added to her medication regimen. (Tr. at 700). Her hypertension was controlled and she was to continue taking statins for her hyperlipidemia. (Id.). Claimant was noted to weigh 224 pounds and measured 5 feet 8 inches tall; she was advised to lose weight due to her obesity and Type 2 diabetes. (Tr. at 699-70).

         On March 14, 2012, Claimant followed up with her cardiologist Dr. Rana. (Tr. at 717). Claimant stated that she had chest pain for an hour the previous day, but she took nitroglycerin and the pain resolved. (Id.). Claimant also had mild shortness of breath on exertion, continued to smoke, and had not taken medications for several days. (Id.). Dr. Rana strongly advised compliance with medications. (Id.). Claimant was prescribed Zocor in place of Lipitor and Plavix in place of Effient, but her medication regimen was otherwise unchanged. (Id.). She was advised to follow a heart healthy and low lipid diet and return for follow up in two months. (Id.).

         On June 26, 2012, Claimant was transferred to Charleston Area Medical Center after presenting to Princeton Community Hospital with left facial numbness, blurred vision, and left shoulder and neck discomfort. (Tr. at 743). Claimant's stress test was normal and it was determined that Claimant had not suffered a transient ischemic attack or cerebrovascular accident (“stroke”), but her symptoms were instead caused by a Bell's Palsy.[1] (Id.). She was prescribed a steroid treatment. (Id.).

         On July 20, 2012, Claimant followed up with physician's assistant, Amy Goode, at the office of Jana Peter, D.O. (Tr. at 840). In addition to Bell's palsy, Claimant reported constant low back pain that radiated into her hips and lower extremities, as well as headaches. (Id.). Claimant's height was noted as 5 feet 8 inches; her weight was 246 pounds, her body mass index was 37.4; her blood pressure was 137/86; her pulse was 73 beats per minute; and the oxygen saturation in her blood was 95 percent. (Tr. at 841). Claimant's respiratory and cardiovascular examinations were normal. She had an asymmetrical smile with left facial drooping, but was neurovascularly intact in all extremities. (Id.). Claimant's Cymbalta was refilled and x-rays of her spine and hips were ordered. (Tr. at 841-42).

         On August 6, 2012, Claimant followed up with Dr. Peters's physician's assistant, Matthew Dincher. (Tr. at 843). Claimant reported that her back pain was unchanged, noting that it first began in 2000 when she had her son. (Id.). The back pain continued to radiate into her hips and legs and she also experienced leg numbness, headaches, and burning and numbness in her left arm. (Id.). Claimant's weight was 247 pounds; her blood pressure was 160/84; her pulse was 101 beats per minutes; and her oxygen saturation was 97 percent. (Tr. at 844). Claimant denied chest pain, shortness of breath, dizziness, or weakness. (Tr. at 843). On examination, Claimant was in no apparent distress and was ambulating normally. (Tr. at 844). Her respiratory, cardiovascular, neurologic, and psychiatric examinations were normal. However, Claimant showed tenderness in her left arm and her straight leg raising test was positive. (Id.). Claimant was referred to a neurologist. (Id.).

         On September 19, 2012, Claimant saw Dr. Peters's physician's assistant, Melissa Hurst. (Tr. at 846). Claimant denied fatigue, chest pain, dizziness, shortness of breath, anxiety, depression, or sleep disturbances. (Id.). Claimant stated that her low back pain was unchanged and caused associated stiffness, numbness, and weakness in her legs. (Id.). Claimant's weight was still 247 pounds; her blood pressure was 135/83; her pulse was 74; and her oxygen saturation was 96 percent. (Tr. at 847). She was still in no apparent distress, ambulating normally, and had normal respiratory, cardiovascular, and psychiatric examinations. (Id.).

         On October 3, 2012, Claimant saw Ms. Goode for a flu shot. (Tr. at 849). Claimant reported that she had a nerve conduction study on her left side and it was negative. (Id.). Claimant asked if she could have further evaluation of the issues in her left extremity, stating that her symptoms worsened after a car accident in December, which also precipitated left hip pain radiating into her left leg. (Id.). Claimant's weight was 249 pounds; her blood pressure was 148/93; her pulse was 84; and her oxygen saturation was 97 percent. (Tr. at 850). She was in no apparent distress, ambulating normally, and had normal respiratory, cardiovascular, neurologic, and psychiatric examinations, although Claimant complained of tenderness in her left hip and shoulder. (Id.). A MRI was ordered of Claimant's lumbar spine. Her Neurontin was refilled, and she was prescribed Trilipix. (Tr. at 850-51).

         On November 7, 2012, Claimant followed up with Ms. Goode. (Tr. at 852). She reported that Neurontin helped her hip pain, but she still had significant pain during the day. (Id.). The pain was aggravated by weight-bearing, standing, and sitting. (Id.). Claimant's MRI showed a possible left anterolateral annular disc tear at ¶ 2-L3. (Id.). Claimant's weight was 252 pounds; her blood pressure was 143/75; her pulse was 81 beats per minute; and her oxygen saturation was 96 percent. (Tr. at 853). Like her prior visit, Claimant was in no apparent distress, ambulating normally, and had normal respiratory, cardiovascular, neurologic, and psychiatric examinations, although Claimant complained of tenderness in her left hip and shoulder. (Id.). Claimant was referred to a neurosurgeon and her Neurontin was refilled. (Id.).

         On December 7, 2012, Claimant again saw Ms. Goode. Claimant complained of pain all over, not just in her back, and stated that the pain was getting worse. (Tr. at 854). She indicated that Neurontin helped, but she still had significant pain. (Id.). Claimant's physical examination was the same as her prior visits in October and November. (Tr. at 855). She was referred to a rheumatologist and x-rays of her hips were ordered. (Id.).

         On January 11, 2013, Claimant returned to Ms. Goode. (Tr. at 857). She reported a moderate degree of depression, stated that she was compliant with her Type 2 diabetes treatment, and was diagnosed with carpal tunnel syndrome in August 2012, although she had never seen an orthopedist. (Id.). Claimant weighed 256 pounds; her blood pressure was 148/92; her pulse was 83 beats per minute; and her oxygen saturation was 95 percent. (Tr. at 858). Like her prior visit, Claimant was in no apparent distress, ambulating normally, and had normal respiratory, cardiovascular, neurologic, and psychiatric examinations, although Claimant complained of tenderness in her left hip and shoulder. (Id.). Laboratory tests were ordered, Claimant was given a prescription for writs splints, and was referred to an orthopedist. (Tr. at 859).

         On February 27, 2013, Claimant saw nurse practitioner, Robyn Adkins, at Dr. Peters's office. She reported a fall one week earlier and complained of joint pain in her left knee. She denied chest pain, shortness of breath, dizziness, headaches, or weakness. (Tr. at 871). Her weight was 259 pounds; her blood pressure was 149/92; her pulse was 85 beats per minute; and her oxygen saturation was 96 percent. (Tr. at 872). Claimant did not appear to be in distress, was ambulating normally, and had normal respiratory and cardiovascular, examinations. (Id.). Claimant had pain in her left knee with flexion and extension and tenderness, but no laxity or subluxation of any joints, crepitus, or effusion. (Id.). The assessment was a sprain/strain of her left knee and leg. She was ordered to use a knee brace and an x-ray would be considered in one week if the pain did not resolve. (Tr. at 873).

         On March 12, 2013, Claimant saw Ms. Goode to review laboratory results. Regarding her Type 2 diabetes, Claimant's compliance with treatment was poor. (Tr. at 874). She did not follow the proscribed diet and exercise regimen. (Id.). She did not have any complaints other than joint pain and denied fatigue, chest pain, edema, shortness of breath, or any other constitutional, cardiac, or respiratory issues. (Id.). Claimant's weight was 259 pounds; her blood pressure was 154/85; her pulse was 89 beats per minute; and her oxygen saturation was 95 percent. (Tr. at 875). Claimant was in no apparent distress, ambulating normally, and had normal respiratory, cardiovascular, neurologic, and psychiatric examinations. (Id.). Claimant complained of tenderness in her left hip and shoulder, chest, and upper arms, but she had no crepitus or effusion. (Id.). For her Type 2 diabetes, Claimant was advised to follow a strict diabetic diet and to bring in her glucose and food diaries for review. (Id.). A referral to an endocrinologist was considered. (Id.). Fish oil capsules were added to her treatment regimen for hypertriglyceridemia. Claimant was also referred to a rheumatologist regarding her diffuse arthralgia. (Tr. at 875-76).

         On April 9, 2013, Claimant followed up with Ms. Goode. Claimant's compliance with her Type 2 diabetes treatment was better since her last visit. (Tr. at 877). She continued to have knee pain that began two months prior when she was walking up steps and her left knee gave out; since then, she could not put weight on it and had difficulty bending to dress herself. (Id.). She reported non-exertional chest pain, shortness of breath with mild exertion, and arthralgia. (Id.). Claimant's weight was 260 pounds; her blood pressure was 142/83; her pulse was 84 beats per minute; her oxygen saturation was 97 percent; and her glucose level was 146 mg/dl. (Tr. at 878). Like her prior visit, Claimant was in no apparent distress, ambulating normally, and had normal respiratory, cardiovascular, neurologic, and psychiatric examinations, although Claimant complained of tenderness in her left hip and shoulder, chest, and upper arms. (Id.). Claimant was referred to a cardiologist for her chest pain and x-rays were ordered of her left knee, which showed new joint effusion, but were otherwise normal. (Tr. at 879, 885). There was also no evidence of significant peripheral artery disease in Claimant's legs. (Tr. at 885). Claimant had not yet received an appointment with a rheumatologist pursuant to her previous referral. (Tr. at 879).

         On April 17, 2013, Claimant followed up with Ms. Hurst at Dr. Peters's office. (Tr. at 880). Claimant stated that her blood glucose levels had been a “bit high” at home with average fasting readings in the 150-180 mg/dL range. (Id.). She denied having any chest pain or palpitations, edema, shortness of breath, anxiety, depression, sleep disturbances, or other issues in her review of systems. (Id.). Claimant's weight was 261 pounds. (Tr. at 881).

         The following month, on May 6, 2013, Claimant saw cardiologist, Mohammad Javed Rana, M.D., at the referral of Dr. Peters for evaluation of chest pain. (Tr. At 897). Claimant reported fatigue, headache, insomnia, dizziness, shortness of breath on exertion, pitting edema in her left leg, and nausea. (Tr. at 898). Claimant's respiratory and cardiovascular examinations were normal, but Claimant had left and right trace edema. (Id.). Dr. Rana ordered an EKG and pulmonary function testing. (Id.). Her HCTZ was ...


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