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Garrett v. Berryhill

United States District Court, N.D. Ohio, Eastern Division

December 28, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff, Judith A. Garrett (“Plaintiff” or “Garrett”), challenges the final decision of Defendant, Nancy A. Berryhill, [1] Acting Commissioner of Social Security (“Commissioner”), denying her application for a Period of Disability (“POD”) and Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 416(i), 423 et seq. (“Act”). This Court has jurisdiction pursuant to 42 U.S.C. § 405(g) and the consent of the parties, pursuant to 28 U.S.C. § 636(c)(2). For the reasons set forth below, the Commissioner's final decision is AFFIRMED.


         In May 2014, Garrett filed an application for POD and DIB, alleging a disability onset date of March 21, 2014 and claiming she was disabled due to lupus, fibromyalgia, irritable bowel syndrome, chronic obstructive pulmonary disease, hypothyroidism, high blood pressure, depression, and acid reflux. (Transcript (“Tr.”) at 19, 215, 238.) The application was denied initially and upon reconsideration, and Garrett requested a hearing before an administrative law judge (“ALJ”). (Tr. 120-128, 130-136, 137.)

         On February 23, 2016, an ALJ held a hearing, during which Garrett, represented by counsel, and an impartial vocational expert (“VE”) testified. (Tr. 41-88.) On October 5, 2016, the ALJ issued a written decision finding Plaintiff was not disabled. (Tr. 19-39.) The ALJ's decision became final on January 13, 2017, when the Appeals Council declined further review. (Tr. 2-6.)

         On February 23, 2017, Garrett filed her Complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 14, 16.) Garrett asserts the following assignments of error:

(1) The ALJ committed reversible error by failing to consider Ms. Garrett's hypersomnia/narcolepsy under Listing 3.00P and 11.02.
(2) The ALJ violated the treating physician rule, resulting in determinations at Step Four and Five that are not supported by substantial evidence.

(Doc. No. 14.)

         II. EVIDENCE

         A. Personal and Vocational Evidence

         Garrett was born in July 1965 and was fifty (50) years-old at the time of her administrative hearing, making her a “person closely approaching advanced age” under social security regulations. (Tr. 32.) See 20 C.F.R. §§ 404.1563(d) & 416.963(d). She has at least a high school education and is able to communicate in English. (Id.) She has past relevant work as a banking secretary. (Tr. 32.)

         B. Relevant Medical Evidence[2]

         The record reflects Garrett has history of treatment for systemic lupus erythematous (“SLE”), fibromyalgia, and chronic bronchitis.[3] (Tr. 302, 315.) On January 6, 2014, Garrett presented to rheumatologist Matthew Bunyard, M.D., for follow-up regarding her chronic pain and fatigue. (Tr. 328-338.) She reported a variety of symptoms, including weakness, nausea, cough, muscle tenderness, back pain, headaches, dizziness, memory loss, night sweats, easy bruising, rash, and sun sensitivity. (Tr. 329-330.) On examination, Dr. Bunyard noted 5/5 muscle strength, normal pulses, normal reflexes, no edema, and no joint swelling or tenderness. (Tr. 332.) He also noted Garrett's lungs were clear. (Id.) Dr. Bunyard assessed fibromyalgia, noting the “diagnosis seems certain” and Garrett was “on maximum medication.” (Id.) He also diagnosed possible SLE, Vitamin D deficiency, chronic gastrointestinal symptoms, and chronic paresthesias. (Id.) Dr. Bunyard noted Garrett had “high sleep scores” but was unable to complete a sleep study due to “insurance issues.” (Id.)

         Later that month, Garrett presented to primary care physician James Kelly, M.D. (Tr. 711-714.) She reported “multiple things going on, ” including severe fatigue, body aches and swelling, and increased burning and frequency during urination. (Tr. 711.) Dr. Kelly assessed a urinary tract infection, possible upper respiratory infection, and “exacerbation of” her lupus symptoms. (Id.) He also noted Garrett's “fatigue with possible narcolepsy and/or sleep apnea, ” and referred her to a psychiatrist. (Id.)

         On March 6, 2014, Garrett began treatment with Basem Haddad, M.D., for evaluation of her daytime sleepiness. (Tr. 374-376.) She reported “a history of lethargy, daytime sleepiness, total sleep time of 6-8 [hours], and morning headaches.” (Tr. 374.) On examination, Dr. Haddad noted Garrett's lungs were clear. (Tr. 375.) She had normal range of motion, muscle strength, and muscle tone, and her motor and sensory function, reflexes, gait and coordination were all intact. (Tr. 375-376.) Dr. Haddad assessed possible obstructive sleep apnea but noted other conditions needed to be considered, including restless leg syndrome, narcolepsy, and idiopathic hypersomnia. (Tr. 376.)

         Dr. Haddad ordered a polysomnograph, which Garrett underwent on March 23, 2014. (Tr. 377-378.) This test showed no evidence of obstructive sleep apnea, oxygen desaturation, or significant leg movements. (Tr. 378.) After reviewing the results, Dr. Haddad recommended as follows:

1. Excessive daytime sleepiness cannot be attributed to obstructive sleep apnea based on this study and an alternative diagnosis should be sought. Differential diagnoses include insufficient sleep syndrome, narcolepsy, idiopathic hypersomnia, shift work disorder among others.
2. Consider correlation with a multi-sleep latency testing if the clinical suspicion for narcolepsy is high.


         On April 1, 2014, Garrett presented to pain management physician Joseph Abdelmalak, M.D., for consultation regarding her chronic pain. (Tr. 339-350.) She reported “all over body pain, ” explaining as follows:

The patient has had this pain since about 2003. She's seen multiple doctors for her chronic pain and now carries the diagnosis of fibromyalgia. She hurts everywhere and the only areas she doesn't have pain are her bilateral feet and face. The pain is described as a constant pain that is aching, numbness, tingling and cold at times now. Today, the pain intensity is rated as a 5 on a scale of 0-10. The pain intensity is rated 5 on the BEST day and a 10 on the WORST day. The pain is exacerbated by stress and physical activity. The pain is alleviated by medications, heat, and TENs. The patient reports 4-5 hours of uninterrupted sleep per night. She just had sleep study and is seeing sleep specialist who said she does not have sleep apnea but might have narcolepsy. Symptoms interfere with physical activity, work, walking, driving, cooking, household cleaning, lifting and social activities.

(Tr. 339.) On examination, Dr. Abdelmalak found 16 of 18 tender points, noting specifically “tenderness in all cervical paraspinals, SCMs, scalenes, trapezius bilaterally” and tenderness on palpation over all bilateral thoracic and paraspinal muscles. (Tr. 341-342, 343.) Motor strength and tone were 5/5 throughout, and Garrett's reflexes and sensation were normal. (Tr. 342.) Dr. Abdelmalak further noted Garrett could walk on her heels and toes, and tandem gait. (Id.) Her mood was depressed and her affect was flat. (Id.) Dr. Abdelmalak diagnosed fibromyalgia, SLE, and depression. (Tr. 344.) He advised Garrett to exercise and stop smoking, and referred her to physical therapy. (Tr. 343-344.)

         Garrett presented for a Physical Therapy Spine Evaluation on April 8, 2014. (Tr. 888-895.) She reported “progressive complaints of bilateral shoulder and low back pain, ” as well as “constant numbness” in her left ulnar nerve distribution. (Tr. 888.) Garrett rated her neck and low back pain a 5 on a scale of 10 with medication, and an 8 on a scale of 10 without medication. (Id.) On examination, physical therapist Matthew Hixon, P.T., noted Garrett had a reduced lumbar posture and left shoulder depression, and found she ambulated with a “forward flexed posture.” (Tr. 889.) She had limited range of motion in her cervical and lumbar spines, and 4/5 strength in her shoulders, hips, and knees. (Tr. 889-890.) Therapist Hixon also noted tenderness over Garrett's bilateral upper trapezius muscles, and indicated she had difficulty balancing. (Tr. 890.) He found Garrett's problem list included impaired posture, and “impaired joint mobility, motor function, muscle performance, and [range of motion] associated with connective tissue dysfunction [and] spinal disorders.” (Tr. 891.) Therapist Hixon recommended a home exercise program, as well as a six week course of physical therapy. (Id.)

         On April 14, 2014, Garrett returned to Dr. Kelly, with complaints of shoulder radiculitis and diffuse fatigue. (Tr. 694.) On examination, Dr. Kelly noted cervical paravertebral spasms at ¶ 4, C5 and C6 on the left side and “grinding crepitus left shoulder, ” but found no radiculopathy or instability. (Id.) Deep tendon reflexes and motor function were within normal limits. (Id.) Dr. Kelly indicated Garrett's cervical radiculitis had improved but was not resolved, and advised her to continue physical therapy. (Id.)

         The record reflects Garrett presented for physical therapy on at least twelve (12) occasions in April and May 2014. (Tr. 896-910, 364-366, 913-930.) Garrett generally reported continuing pain or soreness in her left shoulder and neck, as well as some numbness and tingling in her bilateral upper extremities. (Id.) At each visit, she rated her pain between a 4 and 6 on a scale of ten. (Id.) Garrett was generally able to complete her exercises without complaints of pain. (Id.) By the end of her course of physical therapy, Therapist Hixon found Garrett had increased range of motion and strength and had made “some progress toward her goals and is occasionally independent with her home exercise program.” (Tr. 929-930.)

         On April 18, 2014, Garrett presented for a mental health evaluation with psychiatrist Alf Bergman, M.D. (Tr. 439-442.) She reported experiencing “chronic or daily episodes of depression, ” including the following symptoms: feeling sad, decreased energy, constant fatigue, decreased sociability, decreased appetite, increased worrying, and occasional hopelessness and thoughts of “being better off dead.” (Tr. 439.) Garrett stated she had never received mental health treatment, or been psychiatrically hospitalized. (Tr. 440.) She also reported pain in her shoulder, lower back, knee, and lower leg, which she described as constant, throbbing, and “moderate in intensity.” (Id.)

         On mental status examination, Garrett was “calm, friendly, downcast, attentive, fully communicative, well groomed, overweight, and relaxed.” (Tr. 441.) Her speech was normal and her language skills were intact. (Id.) Dr. Bergman noted depressed mood and constricted affect. (Id.) Garrett's thinking was logical, her thought content was appropriate, and her short and long term memory was intact. (Id.) Garrett's social judgment appeared intact, and there were no signs of anxiety or “hyperactive or attentional difficulties.” (Id.) Dr. Bergman also noted Garrett's muscle tone, gait, and station were normal. (Id.) He diagnosed major depressive disorder, single episode, moderate; and increased her dosage of Cymbalta. (Tr. 441-442.) Dr. Bergman also suggested Garrett see a sleep specialist or neurologist “to be evaluated for Narcolepsy.” (Tr. 442.)

         Garrett returned to Dr. Bunyard on April 25, 2014. (Tr. 351-363.) On examination, Dr. Bunyard noted Garrett appeared “healthy and well, ” with normal pulses and no edema or joint swelling. (Tr. 353.) He noted she did not have sleep apnea, and that her primary care physician “wonders about narcolepsy.” (Tr. 351.) Shortly thereafter, on April 28, 2014, Garrett presented to Dr. Kelly with complaints of “diffuse fatigue and tiredness” and anxiety/depression. (Tr. 690-693.) Dr. Kelly noted “[w]e will see about narcolepsy.” (Tr. 690.)

         On May 6, 2014, Garrett returned to Dr. Haddad for treatment of her daytime sleepiness. (Tr. 372-373.) He assessed hypersomnia (severe, worsening), but indicated “other possibilities include her depression, fibromyalgia, SLE, narcolepsy, idiopathic hypersomnia, among others.” (Tr. 373.) Dr. Haddad ordered another polysomnograph, which Garrett underwent on May 29, 2014. (Tr. 368-369.) This test found Garrett's “excessive daytime sleepiness cannot be attributed to obstructive sleep apnea, ” and indicated “the findings are suggestive of atypical narcolepsy or idiopathic hypersomnia.” (Tr. 369.) Garrett returned to Dr. Haddad on June 17, 2014. (Tr. 370-371.) He prescribed Provigil/Nuvigil, and advised Garrett to return in six months. (Tr. 371.)

         Garrett returned to Dr. Bergman on June 18, 2014. (Tr. 443-444.) She reported feeling “less sad” and denied recent feelings of worthlessness. (Id.) Garrett also stated she “feels most of her residual symptoms are due to [her] ‘hypersomnia.'” (Id.) Dr. Bergman recommended she continue taking Cymbalta. (Tr. 444.)

         The next day, Garrett presented to orthopedist George Balis, M.D., with complaints of left shoulder pain. (Tr. 402-407.) Dr. Balis noted she had a “painful mass over the dorsum of the left shoulder, ” which had “recently become painful over the last month or so.” (Tr. 404.) On examination, Dr. Balis found Garrett's sitting and standing postures were normal. (Id.) He noted her left shoulder was not swollen, hot or red, but had a 3 cm “firm tender not fluctuant mass over the left acromion.” (Id.) Garrett had good range of motion in the left shoulder, along with “excellent strength” and “excellent grip strength left hand.” (Id.) An x-ray taken that date showed soft tissue mass/swelling over the acromion. (Tr. 405.) Dr. Balis ordered an MRI. (Id.)

         On June 23, 2014, Garrett presented to the emergency room with complaints of central chest pain and “some sensation of numbness down her extremities.” (Tr. 598-606.) On examination, Garrett's reflexes and pulses were normal and she exhibited 5/5 muscle strength in her upper and lower extremities. (Tr. 598-599.) Emergency room physician Lawrence Payne, M.D., noted “there is pain reproducible to the touch [in] the sternal area and she has pain with active use of bilateral upper extremities when testing her chest muscles.” (Tr. 599.) Garrett underwent an EKG in the ER, which was normal; however, her white blood cell count was high. (Id.) A CT scan of her abdomen was normal, as was a chest x-ray. (Tr. 607, 608.) Dr. Payne indicated “at this point I have no indication that her chest pain is being caused by cardiac etiology [and it] appears to be completely musculoskeletal with reproducible pain on palpation.” (Tr. 599.) Garrett wished to follow-up with her primary care physician, and was discharged. (Id.)

         On June 24, 2014, Garrett underwent an MRI of her left shoulder, which revealed (1) minimal rotator cuff tendinosis with no evidence of a tear; (2) mild subdeltoid subacromial bursal thickening; and (3) a likely focal nodular area of subcutaneous fat. (Tr. 408-409.)

         On July 25, 2014, Garrett returned to Dr. Bergman with an increase in her depressive symptoms. (Tr. 445-447.) On examination, Dr. Bergman noted that “signs of mild depression are present, ” including depressed mood and constricted affect. (Tr. 446.) He noted Garrett “continues to feel she has ‘hypersomnia' and wants treatment with stimulant; she wants to continue treatment with Neurologist, not me.” (Id.)

         On August 25, 2014, Garrett underwent a “Functional Capacity Evaluation Assessment for Disability” with physical therapist Marie Soha, P.T. (Tr. 449-456.) Garrett reported whole body pain (including in her neck, shoulder, back, legs, arms, feet, and hands), fatigue and stress/depression. (Tr. 449-450.) She rated her pain a 6 on a scale of 10, and described it as “throbbing, shooting, stabbing, pressing, burning, tingling, aching, tender, exhausting, sickening, frightful, cruel, intense, radiating, numb, cold and dreadful.” (Tr. 451-452.) Garrett indicated her pain was increased by sitting, walking, stress, physical activity, standing, and the weather; and alleviated by rest/bed and lying down. (Tr. 451.) Garrett estimated she could (1) sit for 15 minutes at a time; (2) sit for a total of 2 hours within an 8 hour period; (2) stand for 10 minutes at a time; (3) walk for 10 minutes at a time; and (4) stand/walk for a total of 2 hours in an 8 hour period. (Tr. 452.)

         On examination, Ms. Soha found Garrett had poor posture, and ambulated with a slow cadence, often holding her right upper extremity. (Tr. 454.) Garrett had moderate limitations in her cervical and lumbar spines, and “some give-way weakness” in her lower extremities during manual muscle testing. (Id.) Ms. Soha also noted some edema in Garrett's right lower leg, as well as decreased light touch sensation on her left anterior thigh. (Id.) Ms. Soha then measured Garrett's observed functional tolerances. (Tr. 453.) She found Garrett could sit for a total of 65 minutes at one time without a break; stand/walk for 7 minutes total at one time without a break; and walk for 4 minutes and 20 seconds without a break. (Id.) Ms. Soha further found Garrett could lift and carry 7.5 pounds occasionally, 4.5 frequently, and 3.5 constantly. (Tr. 455.) She noted Garrett demonstrated a poor stair climbing tolerance, and poor ability to balance. (Tr. 449.) Garrett was able to occasionally bend, squat, and reach. (Id.) Based on these results, Ms. Soha placed Garrett at the sedentary physical demand level. (Id.)

         Finally, Ms. Soha assessed Garrett's overall effort and reliability as “fair, ” explaining as follows:

Effort Testing:
1. Poor: Competitive test performance: Client did not display eagerness to begin tests or initiate physical tasks.
2. Good: Heart rate response with activity testing: Client did demonstrate increased heart rate with physical tasks which would be expected to increase cardiovascular demand if normal effort was applied.
3. Poor: Physical signs of effort client displayed during functional lift testing: Self limiting
Reliability of Client Reports:
1. Validity concerns with examples: Unusual/excessive pain behaviors:
2. Poor: Reported vs observed functional tolerances: Client's reports of her functional tolerances for standing and walking were greater than her observed tolerances during this exam. Client's report of her functional tolerance for sitting was less than her observed tolerance during this exam.
3. Good: Discrepancy between perceived abilities: Client's Perception of her functional ability was comparable as indicated on Pain Disability Index, Oswestry and Spinal Function Sort.
4. Good: Client's reports of pain on a 0-10 scale were comparable with those recorded on a 10 cm visual analog scale.
5. Poor: her UAB score indicated HIGH pain behaviors, whereas high pain behaviors may be associated with impaired reliability.

(Tr. 450, 455.) In conclusion, Ms. Soha found Garrett would benefit from further rehabilitation, including in a multidisciplinary chronic pain program. (Tr. 450.)

         On September 15, 2014, Garrett returned to Dr. Kelly. (Tr. 664-669.) She reported back pain with right leg radiculopathy, and also complained of increased depression with anxiety. (Tr. 664.) On examination, Dr. Kelly found lumbar spine paravertebral spasm, tenderness over the right sciatic notch, positive straight-leg raise, and normal motor strength. (Tr. 665-666.) He determined Garrett was “definitely depressed, ” and noted “we did discuss having her see somebody at the ER and be admitted to the hospital if need be due to the depressive symptomatology.” (Id.) Dr. Kelly stated “I am concerned for her well being, ” but indicated Garrett denied suicidal ideation and refused to go to the ER. (Id.)

         On October 16, 2014, Garrett returned to Dr. Bunyard. (Tr. 556-569.) She reported her body pain and fatigue were “still severe” and rendered her “unable to function.” (Tr. 556.) Dr. Bunyard noted Garrett “has had disability disapproved by Liberty Mutual and SSI.” (Tr. 557.) On examination, Dr. Bunyard found normal pulses and no edema, but observed tenderness to touch on Garrett's neck, low back and joints. (Tr. 559.) He also noted joint pain on range of motion, and indicated Garrett had difficulty walking and standing due to pain. (Id.) Dr. Bunyard concluded Garrett would “benefit from a formal, guided, graded conditioning program on land and in water.” (Tr. 560.) He also stated as follows: “I support her disability at this point. I do not believe she can work due to her pain and fatigue.” (Id.)

         Shortly thereafter, on October 22, 2014, Garrett returned to Dr. Kelly. (Tr. 657-663.) She presented with dysphonia; i.e., a “barely audible voice even with straining.” (Tr. 657.) Dr. Kelly strongly advised her to quit smoking as soon as possible “for her own protection and good, ” and referred to her an ear, nose and throat specialist “ASAP.” (Id.) He indicated he was concerned about laryngeal cancer. (Tr. 658.) Dr. Kelly stated he would not be “writing any letters about her disability, ” as he was “not trained in this.” (Tr. 657.)

         On October 30, 2014, Garrett presented to psychologist Sara Davin, Psy.D., for a pain medicine evaluation. (Tr. 570-573.) Garrett complained of “constant ‘extreme and awful' total body pain, ” along with numbness in all her extremities. (Tr. 570.) She also reported sadness, depression, anhedonia, low energy, passive thoughts of suicide, and a sense of worthlessness, helplessness and hopelessness. (Tr. 571.) Garrett stated she spent a total of 22 hours per day reclining in a bed, reclining chair, or sofa. (Id.) On mental status examination, Dr. Davin noted as follows:

The patient was reasonably cooperative. She whispered through most of the interview noting voice changes for unclear reasons and then her voice returned when she was crying. Eye contact was fair. Affect was depressed. Thoughts were logical and relevant without delusional thinking or hallucinations. Somatic preoccupation was extreme. She was not concerned about unanswered medical questions. There was no preoccupation with blame of others. There was no evidence of suicidality. Judgment and insight were fair. Attention span and concentration appeared normal. The patient was oriented to time, place and person.

(Tr. 573.) Dr. Davin concluded Garrett's prognosis was “unclear, ” and discussed with her participating in a Chronic Pain Rehabilitation Program with three to four weeks of “intensity day care.” (Id.)

         Garrett returned to Dr. Haddad on November 4, 2014. (Tr. 579-580.) She stated her symptoms were “a little better” on medication, and denied both cataplexy and hypnogogic hallucinations. (Id.) She did, however, report excessive daytime sleepiness with “occasional sleep paralysis.” (Id.) Dr. Haddad assessed narcolepsy, without cataplexy; and indicated Garrett had shown a “fair response to current treatment.” (Id.)

         Later that month, Garrett presented to Dr. Kelly with complaints of swelling and tenderness over the left lateral posterior elbow area, along with “increased bruisability.” (Tr. 628-630.) On examination, Dr. Kelly noted multiple purpura with bruising on Garrett's bilateral forearms, positive calor over the elbows and wrists, and a 2 inch left elbow bursa with inflammation. (Tr. 628.) He assessed bursitis of the elbow, and advised Garrett to proceed to the ER in case of possible bacterial infection. (Id.) Garrett thereafter presented to the ER, where she was diagnosed with bursitis but “no signs of a septic joint” or infection. (Tr. 594-596.) She was treated with anti-inflammatories and discharged. (Id.)

         In February 2015, Garrett complained of worsening back pain and requested admission to the Cleveland Clinic's Chronic Pain Rehabilitation Program. (Tr. 574.) Dr. Davin approved her request. (Id.)

         On April 28, 2015, Garrett returned to Dr. Bunyard with complaints of continuing and severe joint and muscle pains. (Tr. 980-984.) On examination, Dr. Bunyard noted Garrett “appear[ed] tired.” (Tr. 982.) She had joint pain on range of motion, and tenderness over her neck, shoulders, and hips. (Id.) Dr. Bunyard again noted: “I support her disability at this point. I do not believe she can work (even sedentary work) due to her pain and fatigue. I will write a letter to this point.” (Tr. 984.)

         On May 4, 2015, Garrett presented to neurologist Ika Noviawaty, M.D., for an evaluation of her “loss of consciousness episodes.” (Tr. 1021-1030.) Garrett described her symptoms as follows:

Last year, patient started falling asleep at work for approximately five hours and was asked to get medical evaluation by human resource department. Patient had sleep study done and was diagnosed with sleep apnea and narcolepsy. Nuvigil was started without success. She subsequently started having falls and loss of consciousness episodes with time lapse. The fall was during various situations, like falling off the chair, started talking gibberish at work and then passed out, sudden fall when walking. If coworkers call her, she would wake up. After the last episode few days ago, she felt upper left lip tingling that is still present now. When she woke up from an episode, she usually feels very tired and went back to sleep. Had bruises as the result of the fall. The frequency of passing out is few times/day and fall at least 7-8 times/year. She feels that the frequency had increased in the past year.

(Tr. 1022.) On examination, Dr. Noviawaty found Garrett was alert and oriented to person, place and time, and able to follow one and two step commands, with normal speech and full affect. (Tr. 1024.) She had 5/5 motor strength in her bilateral upper and lower extremities, as well as normal muscle tone, intact sensation, and normal gait. (Tr. 1024-1025.) Dr. Noviawaty determined Garrett “has recent history of loss of consciousness of unclear etiology, focal seizures vs. paroxysmal events.” (Tr. 1025.) She recommended Garrett continue her medications and admission for diagnosis. (Id.)

         Shortly thereafter, on May 14, 2015, Garrett presented to Dr. Kelly for follow up regarding her “global fatigue” and neurological symptoms. (Tr. 1002-1005.) He again strongly advised Garrett to stop smoking, but noted she was “presently unable or unwilling to quit.” (Tr. 1002.) On examination, he noted 1 bilateral edema in her lower extremities, as well as a blunted affect. (Id.) Garrett apparently underwent an electrocardiogram that day, which was abnormal. (Id.) Dr. Kelly advised her to go to the hospital for evaluation. (Id.)

         That same day, Garrett presented to the ER for evaluation of her multiple syncopal episodes and loss of consciousness. (Tr. 934-938.) Examination revealed 1 bilateral lower extremity edema and diffuse abdominal pain and tenderness, but was otherwise normal. (Tr. 935.) Garrett underwent a CT scan of her brain and a chest x-ray, both of which were normal. (Tr. 937.) ER physician Amanda Klukowski, D.O., assessed narcolepsy and hypomagnesemia and discharged Garrett in an “improved” condition. (Tr. 938.)

         On June 1, 2015, Garrett was admitted to the hospital for evaluation of her spells of unconsciousness. (Tr. 1061-1087.) She underwent continuous video electroencephalogram (“VEEG”) during her three day hospital stay to monitor for epileptic seizures. (Id.) Hospital records reflect that, while it was “difficult for [Garrett] to stay awake, ” no epileptic seizures were noted. (Tr. 1085.) A sleep medicine doctor, Bogdan Strambu, M.D., was consulted, who determined as follows:

Patient symptoms are not consistent with narcolepsy and the [polysomnograph/sleep study] findings are not consistent with the severity of her symptoms. The sleep study were done also when the patient had a very irregular sleep pattern. Sleep paralysis is one of Narcolepsy symptoms, although can be present in 25% of normal population. Patient has also severe sleep deprivation and she is sleeping only for 5-7 hours per night that can contribute to her complaints. Narcolepsy can't be ruled out at this time and she will need a [polysomnograph/sleep study] done in outpatient settings after she has a regular sleep schedule for at least 2 weeks and she is sleeping at least 7-9 hours per night. Other causes of hypersomnia likes seizure disorder needs to be ruled out first.

(Tr. 1073.) Garrett was also seen by a psychologist due to “high stress and depression.” (Tr. 1085.) It was recommended she increase her Cymbalta and obtain mental health treatment on an outpatient basis. (Id.) Garrett was discharged in “fair” condition on June 4, 2015. (Id.) Later that month, Garrett requested an appointment with a psychiatrist, ...

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