United States District Court, S.D. West Virginia, Bluefield Division
PROPOSED FINDINGS AND RECOMMENDATIONS
A. Eifert, United States Magistrate Judge.
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).
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
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).
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.
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.
Summary of ALJ's Decision
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).
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.
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).
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).
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
(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
Claimant's Challenge to the Commissioner's
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).
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).
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.
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.).
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).
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
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.).
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).
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.
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.).
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. (Id.). She was prescribed a
steroid treatment. (Id.).
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.
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.).
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.).
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).
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.).
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.).
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).
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).
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).
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).
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).
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