United States District Court, W.D. Missouri, Western Division
ROSEMARIE A. WILLIAMS, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
ORDER DENYING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT
ROBERT E. LARSEN, Magistrate Judge.
Plaintiff Rosemarie Williams seeks review of the final decision of the Commissioner of Social Security denying plaintiff's application for disability benefits under Titles II and XVI of the Social Security Act ("the Act"). Plaintiff argues that the ALJ erred in (1) finding that plaintiff's depression and anxiety are not severe impairments, (2) failing to provide a narrative bridge linking the medical evidence with the limitations found in the residual functional capacity, and (3) failing to properly analyze plaintiff's credibility. I find that the substantial evidence in the record as a whole supports the ALJ's finding that plaintiff is not disabled. Therefore, plaintiff's motion for summary judgment will be denied and the decision of the Commissioner will be affirmed.
On September 23, 2011, plaintiff applied for disability benefits alleging that she had been disabled since September 10, 2011. Plaintiff's application was denied initially. On April 2, 2013, a hearing was held before Administrative Law Judge Raul Pardo. On April 25, 2013, the ALJ found that plaintiff was not under a "disability" as defined in the Act. On July 17, 2013, the Appeals Council denied plaintiff's request for review. Therefore, the decision of the ALJ stands as the final decision of the Commissioner.
II. STANDARD FOR JUDICIAL REVIEW
Section 205(g) of the Act, 42 U.S.C. § 405(g), provides for judicial review of a "final decision" of the Commissioner. The standard for judicial review by the federal district court is whether the decision of the Commissioner was supported by substantial evidence. 42 U.S.C. § 405(g); Richardson v. Perales , 402 U.S. 389, 401 (1971); Mittlestedt v. Apfel , 204 F.3d 847, 850-51 (8th Cir. 2000); Johnson v. Chater , 108 F.3d 178, 179 (8th Cir. 1997); Andler v. Chater , 100 F.3d 1389, 1392 (8th Cir. 1996). The determination of whether the Commissioner's decision is supported by substantial evidence requires review of the entire record, considering the evidence in support of and in opposition to the Commissioner's decision. Universal Camera Corp. v. NLRB , 340 U.S. 474, 488 (1951); Thomas v. Sullivan , 876 F.2d 666, 669 (8th Cir. 1989). "The Court must also take into consideration the weight of the evidence in the record and apply a balancing test to evidence which is contradictory." Wilcutts v. Apfel , 143 F.3d 1134, 1136 (8th Cir. 1998) (citing Steadman v. Securities & Exchange Commission , 450 U.S. 91, 99 (1981)).
Substantial evidence means "more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales , 402 U.S. at 401; Jernigan v. Sullivan , 948 F.2d 1070, 1073 n. 5 (8th Cir. 1991). However, the substantial evidence standard presupposes a zone of choice within which the decision makers can go either way, without interference by the courts. "[A]n administrative decision is not subject to reversal merely because substantial evidence would have supported an opposite decision." Id .; Clarke v. Bowen , 843 F.2d 271, 272-73 (8th Cir. 1988).
III. BURDEN OF PROOF AND SEQUENTIAL EVALUATION PROCESS
An individual claiming disability benefits has the burden of proving he is unable to return to past relevant work by reason of a medically-determinable physical or mental impairment which has lasted or can be expected to last for a continuous period of not less than twelve months. 42 U.S.C. § 423(d)(1)(A). If the plaintiff establishes that he is unable to return to past relevant work because of the disability, the burden of persuasion shifts to the Commissioner to establish that there is some other type of substantial gainful activity in the national economy that the plaintiff can perform. Nevland v. Apfel , 204 F.3d 853, 857 (8th Cir. 2000); Brock v. Apfel , 118 F.Supp.2d 974 (W.D. Mo. 2000).
The Social Security Administration has promulgated detailed regulations setting out a sequential evaluation process to determine whether a claimant is disabled. These regulations are codified at 20 C.F.R. §§ 404.1501, et seq. The five-step sequential evaluation process used by the Commissioner is outlined in 20 C.F.R. § 404.1520 and is summarized as follows:
1. Is the claimant performing substantial gainful activity?
2. Does the claimant have a severe impairment or a combination of impairments which significantly limits his ability to do basic work activities?
3. Does the impairment meet or equal a listed impairment in Appendix 1?
4. Does the impairment prevent the claimant from doing past relevant work?
5. Does the impairment prevent the claimant from doing any other work?
IV. THE RECORD
The record consists of the testimony of plaintiff and vocational expert Jennifer Teixeira, in addition to documentary evidence admitted at the hearing.
A. ADMINISTRATIVE REPORTS
The record contains the following administrative reports: Earnings Record
The record shows that plaintiff earned the following income from 1974 through 2010:
Year Earnings Year Earnings 1982 $ 2, 843.17 1998 $ 0.00 1983 4, 862.611999 4, 419.82 1984 2, 672.46 2000 5, 843.95 1985 6, 105.30 200110, 909.28 1986 4, 724.08 2002 7, 950.57 1987 4, 457.36 2003 438.55 1988 5, 813.78 2004 5, 458.12 1989 1, 520.77 2005 0.00 1990 0.00 2006 4, 037.35 1991 5, 954.46 2007 4, 625.06 1992 1, 842.20 2008 6, 612.00 1993 0.00 2009 0.00 1994 5, 335.74 2010 1, 478.88 1995 1, 265.25 201112, 359.44 1996 1, 120.95 2012 0.00 1997 76.32
(Tr. at 177-178, 180).
In a Function Report dated November 20, 2011, plaintiff reported that she tries to take care of her daughter, she takes care of a pet, she needs help getting dressed because she cannot fasten buttons or clips, she needs someone to help her cut up her food, she needs help washing herself. It takes plaintiff 45 minutes to an hour to prepare a microwaveable meal. She folds laundry for an hour at a time. Plaintiff goes out of her home once a week on average; and she can walk, drive a car or ride in a car for about 30 minutes each. She can shop in stores for groceries for 45 minutes to an hour. Her hobbies include reading and watching television. Plaintiff's condition does not affect her ability to concentrate, understand, follow instructions or get along with others. She is able to handle stress, but sometimes it is difficult for her to handle changes in routine (Tr. at 196-203).
B. SUMMARY OF MEDICAL RECORDS
Plaintiff submitted medical records beginning about two years before her alleged onset date.
On November 16, 2009, plaintiff was seen by Teresa Walker, M.D., at ReDiscover Mental Health (Tr. at 799). Plaintiff's hygiene and grooming were normal. Her mental status exam was normal except that she was irritable and angry. Insight and judgment were normal, memory was normal, concentration was intact. Plaintiff was diagnosed with generalized anxiety disorder ("GAD"), mood disorder, severe occupational and medical problems and was assessed with a Global Assessment of Function ("GAF") Score of 45.
On December 4, 2009, plaintiff was seen by Dr. Walker at ReDiscover Mental Health (Tr. at 796). Plaintiff reported that she may need another surgery or chemotherapy. Her mental status exam was normal - good grooming, good hygiene, good eye contact, regular speech normal psychomotor activity, no suicidal or homicidal ideation, normal thought process, full affect, congruent mood, normal insight and normal judgment. She was assessed with generalized anxiety disorder with a GAF of 45. She was continued on Ativan (for anxiety) and Nortriptyline (antidepressant).
On January 8, 2010, plaintiff saw Dr. Walker at ReDiscover Mental Health (Tr. at 795). Plaintiff indicated that she had been seeing her primary care physician for recurrent colds. Plaintiff said she was not sure about kidney cancer issues. "Now worried about youngest daughter - charged with theft of cell phone case." Plaintiff was not sleeping well due to kidney surgery. On exam, Dr. Walker noted that plaintiff's grooming was good, hygiene was good, eye contact was good, psychomotor activity was normal, speech was normal, no suicidal or homicidal ideation reported, thought process was normal, affect was full, mood was normal, insight was normal, judgment was normal. No abnormal findings were noted. Plaintiff was assessed with generalized anxiety disorder with a GAF of 45. Her Ativan was refilled and she was told to try Melatonin.
On February 4, 2010, plaintiff saw Dr. Walker at ReDiscover Mental Health (Tr. at 791-794). Plaintiff reported a lot of stressors with three daughters, ages 20, 17 and 16. "Cars were totaled, kids ok." Plaintiff had undergone surgery due to renal cancer and was not sure if she was going back to work or not. Plaintiff reported worrying all the time about the recurrence of cancer. "Her mood is generally OK. Has a lot of health issues." Plaintiff reported eating well but she was unable to gain weight. Her motivation was OK. She was irritable but less depressed, less tearful than she was. "A lot of anxiety/worry - panic feelings. Tormented that maybe 1 cell in kidney will start cancer." No mood disturbance was noted. No thought disturbance was noted. Plaintiff continued to smoke. "Enrolled in Longview in some program with daughter. Excited to get her CNA. Works for family to care for elderly parents. Very tired with school." Plaintiff's mental status exam was entirely normal: grooming and hygiene were good, eye contact was good, psychomotor activity was normal, speech was normal, no suicidal or homicidal ideation, thought process was normal, affect was full, mood was normal, insight was normal, judgment was normal. Dr. Williams assessed generalized anxiety disorder. "Very happy with job/school." She assessed a GAF of 55 and refilled plaintiff's medications.
Almost a year later, on January 19, 2011, plaintiff was seen by attending physician Douglas Tietjen, M.D., at St. Luke's Hospital East where she underwent a CT scan of her pelvis (Tr. at 305-309). The scan was normal except multiple nonobstructing kidney stones were observed, with the largest measuring 3 mm. Plaintiff's bowel was unremarkable without evidence of obstruction or acute inflammatory changes. Plaintiff had chest x-rays which were normal as to heart and lungs.
Seven months later, on August 14, 2011, plaintiff was seen in the emergency department at St. Luke's Hospital East for vomiting, gradual and worsening headaches and high stress (Tr. at 303). She had run out of her Fioricet (a schedule III controlled substance, treats tension headaches) two days earlier, and her headache had started the day before. Plaintiff continued to smoke. On physical examination, it was noted that plaintiff appeared anxious, had pharyngeal erythema (i.e., her throat was red), and tachycardia (a faster-thannormal heart rate at rest). The rest of her physical and psychological examination was normal. She was assessed with sinus infection and headache. She was prescribed an antibiotic.
Two days later, on August 16, 2011, plaintiff was seen in the emergency department and was then admitted under the attending physician, Heather Kort, D.O., to St. Luke's Hospital East, for chest pain and headache (Tr. at 276-301). Plaintiff indicated her symptoms were mainly related to her headache. She developed chest pain as well as nausea and vomiting associated with her headache. She then began having "new neck and back stiffness." A further review of systems was done and plaintiff denied any other symptoms. She did report previous diagnosis of fibromyalgia, Meniere's disease,  high blood pressure, high cholesterol/triglycerides, and prior surgery for renal cell carcinoma. She specifically denied fatigue (Tr. at 290).
Plaintiff was still smoking and had indicated that she had tried to quit. She reported having suffered with migraines during her entire life. She said she was using Fentanyl patches and Oxycodone four time a day for fibromyalgia pain and that her fibromyalgia pain was "well controlled" on this medication. Plaintiff reported that she was married with two teenaged daughters at home, and she was disabled. CT scan of her head was entirely normal.
All of her tests were normal except it was noted that she had questionable mitral stenosis. She had normal left ventricular systolic function with an estimated ejection fraction of 60%. Because plaintiff had no history of rheumatic fever, it was decided that she would follow up with another echocardiogram as an outpatient. Her chest pain was noted to be "likely noncardiac in nature."
Plaintiff was discharged on August 19, 2011, with prescriptions for Atenolol (treats high blood pressure and chest pain), Fioricet (a schedule III controlled substance, treats tension headaches), Fentanyl patch (schedule II controlled substance, treats pain), Nicoderm (over-thecounter nicotine, used to help stop smoking), Nortriptyline (antidepressant), Prenatal vitamins, Simvastatin (reduces cholesterol), "Soma per home medications", Topamax (prevents migraine headaches), Roxicodone,  and Restoril. She was instructed to follow a low-fat diet.
September 10, 2011, is plaintiff's alleged onset date.
On September 13, 2011, plaintiff was seen by Sanjaya Gupta, M.D., at St. Luke's Hospital East for a follow up on suspected mitral valve stenosis (Tr. at 270-271). She had another echocardiogram done which showed normal left ventricular systolic function with an estimated ejection fraction of 65% and severe rheumatic mitral stenosis which had worsened since her hospital stay the month before.
On September 23, 2011, plaintiff applied for disability benefits.
On September 27, 2011, plaintiff was admitted under the attending physician, Matthew Deedy, M.D., to St. Luke's Hospital East for rheumatic mitral stenosis (Tr. at 265-268). A TEE procedure was performed. Carlos Rivas-Gotz, M.D., found that plaintiff had normal left ventricular systolic function with an estimated ejection fraction of 60%. She had moderate rheumatic mitral stenosis at rest.
On September 29, 2011 - six days after plaintiff filed her disability application - she was seen by either Francisco Judilla, M.D., or Robert Williams, D.O., at Doctors Hospital for lower back pain and fibromyalgia (Tr. at 412-415). Dr. Williams's name appears at the beginning of the record, but it is electronically signed by Dr. Judilla. As to her lower back pain, the doctor wrote, "Underlying diagnosis or cause is unknown." Plaintiff described her pain as an 8 out of 10; "when present it interferes with most, but not all, daily activities.... Patient's statement regarding effect on life: problems at home - inability to do housework; problems at work - inability to work." Plaintiff also reported pain in her hips and knees. She rated this pain a 9 out of 10. She reported pain in her buttocks which she rated a 7 out of 10. She reported fatigue, generalized aching, restlessness, and sleeping problems. She reported chest pain at rest or with exercise, constant leg cramps and pain when walking a short distance, muscle tenderness, loss of muscle strength, back pain, constant joint pain, constant joint stiffness, constant joint swelling, constant weakness, headache, and easy bruising. Her past health history indicated a negative psychiatric history.
This record states that a "mirror fell and cut her R leg and had 18 staples Aug 2011." However, the emergency room records dated August 16, 2011, do not reflect any cut - plaintiff went to the hospital on that day complaining of a severe headache. This record shows plaintiff's "current or most recent occupation" as "student/works part time for cardiologist." Plaintiff continued to smoke and said she was exposed to second-hand smoke. Her current exercise level was "exercise regularly, 20 minutes or more, once or twice weekly and exercise regularly, 20 minutes or more, 3 or more times per week."
On exam plaintiff had normal breath sounds. Her cervical spine was normal. Her thoracic spine was normal. She had tenderness and muscle spasm in her lumbar spine. Her judgment and insight were normal, mood and affect were normal and appropriate. Dr. Judilla wrote, "PCP wants Pain doctor [to] take care of narcotic. Pt understand[s] that we do routine Drug test & only 1 doctor prescribe[s] narcotics. Pt will retain PCP." Dr. Judilla ordered an MRI of plaintiff's lumbar spine, left knee, and bilateral hips. He ordered an EMG. He told her to follow up in one week.
The following day, on September 30, 2011, plaintiff saw James Stewart, M.D., at St. Luke's Hospital for mitral stenosis. (Tr. at 322-325, 350-353, 378-409). She complained of increased chest pain and shortness of breath - she was unable to walk across a room without getting out of breath. "Mrs. Williams works with special needs children." Plaintiff continued to smoke a pack of cigarettes per day. Plaintiff voiced her desire to quit and said she would be willing to try a nicotine patch.
Plaintiff denied easy bruisability. "She does state that 2 weeks ago she did sustain an injury from a mirror on her right shin, where she did receive 18 staples. These staples have been removed. She does have a Tegaderm in place that is clean, dry, and intact." A Tegaderm is a waterproof dressing used to protect wounds. Plaintiff denied depression but reported anxiety. "She does have partial upper dentures. She is missing teeth. Her dentition is poor. She states this is secondary to chemotherapy that she [underwent] from her renal cell cancer."
Plaintiff had normal breath sounds in the bilateral upper lobes but diminished breath sounds in the bases. She had no edema in her extremities. Dr. Stewart discussed with plaintiff the likely need for a mitral valve replacement. "She expressed concern about postoperative pain management."
Plaintiff was admitted to the hospital. On October 3, 2011, she had a coronary angiography which showed no occlusive coronary disease. "She had not had dental care for some time and was planning to have her upper teeth extracted. Because this was a risk for potential infection, she was seen by the facial surgery team and underwent extraction of all of her upper teeth on 10/04. We did keep her an extra day yesterday because of significant discomfort with this. Today, she is feeling better, but has been using IV Dilaudid every 2 hours."
Cardiac catheterization which showed no blockages in her coronary arteries and ruled out coronary artery disease. "The patient has been having increased low back pain secondary to being bed bound and also only able to use IV medication for her chronic low back pain in preparation for surgery. For this reason, the pain management team has been consulted. At home, the patient is usually on fentanyl patch 100 mcg an hour, oxycodone 30 mg 4 times a day and Fioricet. At this time the patient is only able to take morphine IV for her pain along with the fentanyl patch and this is not enough to alleviate her chronic back pain. The patient states that the pain started about 10 years ago after a motor vehicle accident." Plaintiff's pain medications in the hospital included Topamax (prevents migraine headaches) twice a day, Roxicodone every 6 hours, Nortriptyline (antidepressant) once a day, Fioricet 4 times a day, Fentanyl patch, morphine every 2 hours, Percocet every 6 hours, and Fentanyl IV every 3 hours. On exam plaintiff had two positive trigger points. Plaintiff's IV morphine, Percocet, Fentanyl, Roxicodone and Fioricet were all discontinued until after her mitral valve replacement. She was started on IV Dilaudid. "The patient has had an adverse reaction to epidural steroid injection in the past and has been advised not to get them again."
Plaintiff was discharged on October 6, 2011. Her Oxycodone and Fioricet were discontinued and she was given a prescription for Dilaudid along with a Fentanyl and Lidocaine (anesthetic) patch. "We spent 5 minutes talking about the hazards of smoking and the benefits of cessation."
From October 10, 2011, through October 30, 2011, plaintiff was admitted to St. Luke's Hospital to undergo a mitral valve replacement (Tr. at 314-321, 346-348, 354-376). Her surgery was postponed due to plaintiff's blood work showing an infection. She was seen by Steven Prstojevich, M.D., D.D.S, who evaluated her mouth and, despite plaintiff indicating she was in extreme pain where her teeth had been removed, found that her mouth was healing as expected and was not the cause of her infection. Plaintiff denied joint pains or muscle aches (Tr. at 359). Urinary tract infection was ruled out (Tr. at 358). Plaintiff subsequently underwent a mitral valve replacement on October 14, 2011. She was assessed by Sonali Agarwal, M.D., of the Pain Management Team on October 18, 2011 (Tr. at 360-361). Plaintiff reported that her pain was not being controlled; she was then on Fentanyl patch (a schedule II controlled substance, an opioid pain reliever), Lidocaine patch (anesthetic), Nortriptyline (antidepressant), Fioricet (a schedule III controlled substance which treats tension headaches), and Dilaudid (a schedule II controlled substance, an opioid pain reliever) (Tr. at 361). The pain was on her chest at the incision site and in her upper gums. All of her pain was rated a 9 out of 10. Her oral Dilaudid was increased; IV Dilaudid was started.
A pacemaker was put in place on October 24, 2011 (Tr. at 373-374). She had a normal ejection fraction (Tr. at 364). "She also has had difficulty with pain management and the pain management team was consulted. They did make changes to her regimen and she is now well-controlled.... Much of her post-operative stay has been awaiting her INR to become therapeutic. This has happened today and she is ready to be discharged to home with home health." Plaintiff had been ambulating the halls independently. "Again her pain has been well-controlled and she is tolerating a regular diet." When discharged, plaintiff was told not to lift more than 10 pounds for the next 6 weeks, not to drive for 1 to 2 weeks "or while she continues with pain medications." Plaintiff was discharged with prescriptions for Fentanyl patch (schedule II controlled substance, an opioid pain reliever), Lidoderm patch (anesthetic), Loratadine (antihistamine), Oxycodone (schedule II controlled substance, an opioid pain reliever), Protonix (treats excess stomach acid), Topamax (prevents migraine headaches) as needed, Wellbutrin (antidepressant), and Warfarin (blood thinner).
Plaintiff was again hospitalized from November 7, 2011, through November 11, 2011, due to a low INR, meaning her blood was clotting too quickly (Tr. at 328-344). This had been reported by a home health nurse. "Before surgery she used to walk 1 mile per day, post op activity is limited [due to] pain." Plaintiff reported pain in her breast area where the pacemaker was inserted. She denied shortness of breath or chest pain. On exam her gait was stable, she had no edema in her legs, her upper breast area was "excruciatingly tender to touch." Her lungs were clear and she denied shortness of breath (Tr. at 336). "She hd noticed swelling and pain in her left breast on Sunday and it has been getting worse since that time. She attributes the pain to doing too much and working too much with her arms." Plaintiff had been folding laundry and unloading the dishwasher when her pain began (Tr. at 342). Plaintiff reported that she is a "special education teacher." (Tr. at 342). She complained that her current pain medication (which included Fentanyl patch [opioid], Lidoderm patch [anesthetic], Nortriptyline [antidepressant], and Oxycodone [opioid]) was not controlling her pain (Tr. at 342-343). Gillian Jones, M.D., wrote, "We would recommend a plastic surgery consultation for possible breast implant problems. The patient is scheduled to have an ultrasound.... We will follow up on that and recommend possible CT scan for further evaluation of the implants. There is no obvious abscess or fluid collection to drain. It would be inappropriate at this time to make an incision on a patient with implants." (Tr. at 341).
Plaintiff was seen by Pain Management while in the hospital. "I agree with current treatment. I would not recommend an increase in her opioids and also would not give but limited IV doses." (Tr. at 339). Plaintiff was treated with IV Heparin (blood thinner) and was discharged in stable condition. "Her pain has been under adequate control with her regimen per Pain Management.... She will be sent home on her pain medication regimen per Pain Service. I have also given her their number for outpatient follow up as she is unhappy with her pain management service that she is currently at." Plaintiff's discharge medications included Fentanyl patch (opioid), Lidocaine patch (anesthetic), Loratadine (antihistamine), Norco,  Nortriptyline (antidepressant), Oxycodone (opioid), Topamax (prevents migraines), Wellbutrin (antidepressant) and Warfarin (blood thinner).
On December 1, 2011, plaintiff was seen by Francisco Judilla, M.D., at Doctor's Hospital for a medication follow up (Tr. at 416-419). Plaintiff reported difficulty carrying out usual activities, fatigue, generalized aching, restlessness and sleeping problems. She described constant chest pain at rest or with activity, constant leg pain when walking a short distance, constant limitation of a joint, constant loss of muscle strength, intermittent muscle tenderness, constant back pain, constant joint pain, constant joint stiffness, constant joint swelling, constant weakness, easy bruising, headache, and numbness. Her pain medications included Fentanyl patch (opioid), Esgic,  Loratadine (antihistamine), Nortriptyline (antidepressant), Oxycodone (opioid), and Temazepam. "Currently smokes an average of 7 per day." Dr. Judilla noted that plaintiff's gait was normal. "Patient able to undergo exercise testing and/or participate in exercise program." Her cervical spine was normal. She had tenderness and muscle spasm in her thoracic and lumbar spine. Plaintiff's judgment, insight, memory, mood, affect, speech, fund of knowledge, and "capacity for sustained mental activity" were all noted to be normal. She was continued on her medications. "Pt does not have PCP. Prescribe meds till she find[s] PCP." Dr. Judilla noted that plaintiff's heart surgeon put her on a high dose of narcotics. Dr. Judilla intended to begin decreasing her narcotics and indicated, "We will continue decreasing narcotics on next visit."
On December 14, 2011, plaintiff returned to see Dr. Judilla and complained of lower back pain (Tr. at 420-423). Plaintiff indicated her pain was a 5 out of 10 and had gotten worse. "Functional impairment is mild - the patient is aware of it when present but it doesn't interfere with daily activities. Need for pain meds has not changed." Plaintiff indicated that she had not consulted with a medical provider "outside this group" regarding the pain since her last visit. Plaintiff reported constant chest pain, leg cramps and pain, limitation of use of a joint, loss of muscle strength, back pain, joint pain, muscle pain, joint stiffness, joint swelling, and weakness, and she reported intermittent muscle tenderness. Plaintiff gait was observed to be normal. "Patient able to undergo exercise testing and/or participate in exercise program." Her cervical spine was normal. She had tenderness and muscle spasm in her lumbar spine. She had mild tenderness in her sacroiliac joint which was observed to be "stable." She had normal insight, normal judgment, normal mood, normal affect, normal fund of knowledge. Dr. Judilla noted that plaintiff's "lower back pain is stabilized with meds." He kept her on the same medications but decreased the dose of her Fentanyl patch (opioid) and increased her Esgic (barbiturate) from every 6 hours to every 4 hours as needed for pain. He refilled her Oxycodone (opioid).
On December 28, 2011, plaintiff saw Dr. Judilla for a follow up on lower back pain (Tr. at 424-427). Plaintiff reported that her lower back pain radiated into her left leg, interfered with her sleep and mobility, but interfered "only with some daily activities." Her pain was now constant which was an increase in frequency. Plaintiff was listed as a nonsmoker and was off the nicotine patch. On exam plaintiff had normal breath sounds. Her gait was mildly antalgic. Her cervical spine was normal. She had tenderness and muscle spasm in her lumbar spine. Her sacral spine was normal to inspection but with moderate tenderness. Her sacroiliac joint was normal and stable. Tenderness was present in her right knee and lower leg, although an x-ray on that day showed that her knees were normal (Tr. at 432-433). X-ray of her lumbar spine showed loss of lumbar lordosis (loss of curvature of the spine) but no other abnormality (Tr. at 434). Her lumbar vertebrae were properly aligned, discs were normal, soft tissues were normal, sacroiliac joints were normal. Dr. Judilla observed that plaintiff's judgment was normal, insight was normal, mood and affect were normal and appropriate, fund of knowledge was normal. Dr. Judilla again decreased the dosage of plaintiff's Fentanyl patch and recommended plaintiff have a CT scan of her lumbar spine. "Patient understands that we need to decrease her meds on next visit the dosage & number of pills."
On January 11, 2012, plaintiff saw Dr. Judilla for medication refills, follow up on chest and lower back pain, and a new complaint of having broken her middle toe on her right foot (Tr. at 428-431). Plaintiff described her back pain as an 8 out of 10 and said it interfered with most of her daily activities. On exam her lungs and heart were normal. Gait was normal. "Patient able to undergo exercise testing and/or participate in exercise program." Her cervical spine was normal. She had tenderness and muscle spasm in her lumbar spine. Sacroiliac joint was normal and stable. She had mild tenderness in her knees. Her judgment was normal, insight was normal, mood and affect were normal and appropriate to the situation, fund of knowledge was normal. She was assessed with "other and unspecified disorders of joint: pain in joint pelvic region and thigh" and lumbar radiculopathy. "Plan was to decrease 3 pills for pain to 1-2 different pill. Pt. refuses to go to 2 pills from 3 different pills. Discussed with pt. that I am not helping her anymore so she will look for another Doctor (PCP/Cardiologist) for her meds." Dr. Judilla prescribed two weeks' worth of medications.
On January 24, 2012, plaintiff saw Sanjaya Gupta, M.D., at St. Luke's Hospital for a follow up (Tr. at 437-438). She had a normal ejection fraction of 60%. Her entire cardiac exam was normal.
On January 26, 2012, plaintiff saw Pamela Davis, D.O., at Pleasant Hill Medical Clinic to establish care and get refills on her medications (Tr. at 763-766). Plaintiff reported "chronic low back pain from some disc bulges" although a month earlier her lumbar spine xrays showed no disc bulges. She reported a history of migraine headaches. Plaintiff denied shortness of breath. Although she had consistently denied depression in the past, she reported depression and generalized anxiety disorder as past diagnoses. On exam bilateral decreased breath sounds were observed. Plaintiff's heart exam was normal. Muscle tone, muscle strength, gait, stance, and balance were all normal. Psychiatric exam was entirely normal. Plaintiff was assessed with migraine headache and chronic pain. Dr. Davis prescribed Oxycodone (opioid), Fentanyl patch (opioid), Nortriptyline (antidepressant), and Esgic (barbiturate). "Pt verbally agreed to chronic pain agreement with myself as the only prescriber, no lost or stolen prescriptions and random drug screening."
Five days later, on January 31, 2012, plaintiff returned to see Dr. Davis to discuss her medications (Tr. at 759-762). "When she came in last Thursday, 1/26/12 she was given a refill of her Esgic (barbiturate), however, she believes that her dosage was not correct. She doesn't believe that she was given enough pills for her to be dosed 2 tabs three times/day which is what she had been on previously. She is currently having a migraine." Examination of heart and lungs was normal. Balance, gait and stance were normal. Appearance, attitude, mood, affect, thought process and thought content were normal. "I explained to patient that this is a rescue medicine not to be taken on a schedule as it is dependent and produces rebound headache when used as she is using it. Will give her some phenergan [for nausea] and take a couple of Tylenol when she has headache and wean off the regular use of the butalbital (Esgic, a barbiturate)."
On February 10, 2012, plaintiff returned to see Dr. Davis for cold symptoms and headache (Tr. at 755-758). Plaintiff also complained of anxiety. "She has tried to reduce her number of Esgic Plus and she gets panicked when she runs low." Physical exam was normal, including gait and stance. She was assessed with sinus infection was given an antibiotic and additional Esgic pills, and she was told to use Tylenol or Ibuprofen for pain and fever reduction.
On February 20, 2012, plaintiff saw Dr. Davis to follow up on her right middle toe (Tr. at 751-754). Plaintiff had stubbed her toe three weeks earlier, went to the emergency room the day before, and was told that it was broken. "She also wants to talk about chronic migraine headaches." Plaintiff had been trying to taper her Esgic to as needed but she said her headaches were becoming more severe. She said she was waiting to hear back from a neurologist about an appointment. Plaintiff had no chest pain or discomfort, no shortness of breath. She was assessed with closed fracture of her toe and migraine headache. She was prescribed Topamax (prevents migraines) and she was given a refill of Esgic Plus (barbiturate). "Will continue to wean the butalbital [Esgic] now to two a day and she will make an appt with neurology to discuss additional treatment."
On February 28, 2012, plaintiff saw Susan Opper, M.D., at St. Luke's for pain management (Tr. at 492-494). "The chief complaints are chest wall pain, chronic history of fibromyalgia, and lower back pain on chronic opioid therapy.... In regards to her chronic low back pain, for which she previously was seen at the Headache and Pain center, up until January of 2012, the patient does state that at this point in time the Headache and Pain ...