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Thompson v. Commissioner of Social Security

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

December 28, 2017

LISA THOMPSON, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          MEMORANDUM OPINION & ORDER

          KATHLEEN B. BURKE UNITED STATES MAGISTRATE JUDGE

         Plaintiff Lisa Thompson (“Plaintiff” or “Thompson”) seeks judicial review of the final decision of Defendant Commissioner of Social Security (“Defendant” or “Commissioner”) denying her application for social security disability benefits. Doc. 1. This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned Magistrate Judge pursuant to the consent of the parties. Doc. 14. For the reasons explained below, the Court AFFIRMS the Commissioner's decision.

         I. Procedural History

         On September 15, 2014, Thompson protectively filed an application for Disability Insurance Benefits (“DIB”).[1] Tr. 17, 44, 98, 147-153. Thompson alleged a disability onset date of March 10, 2012. Tr. 17, 44, 88, 100. She alleged disability due to back injury, depression, obesity, hyperlipidemia, and ischemic heart disease. Tr. 44, 88, 99, 110, 117, 171. Thompson's application was denied initially (Tr. 110-113) and upon reconsideration by the state agency (Tr. 117-123). Thereafter, she requested an administrative hearing. Tr. 124-125. On August 31, 2016, Administrative Law Judge Pamela Loesel (“ALJ”) conducted an administrative hearing. Tr. 40-87.

         In her October 17, 2016, decision (Tr. 14-39), the ALJ determined that Thompson had not been under a disability within the meaning of the Social Security Act from March 10, 2012, through the date of the decision (Tr. 17, 35). Thompson requested review of the ALJ's decision by the Appeals Council. Tr. 12-13. On December 12, 2016, the Appeals Council denied Thompson's request for review, making the ALJ's decision the final decision of the Commissioner. Tr. 1-4.

         II. Evidence

         A. Personal, vocational and educational evidence

         Thompson was born in 1973. Tr. 34, 147. At the time of the hearing, Thompson was 43 years old and was living with her 11 year old daughter and her brother. Tr. 46, 48, 50. Thompson's mother had recently passed away and they were living in her mother's house. Tr. 50. Thompson has an adult son who lived nearby her home. Tr. 50. Thompson last worked in 2012 performing home healthcare work. Tr. 56-58, 171. Her home healthcare work involved lifting and transferring patients and assisting them with range of motion exercises. Tr. 56-58. She stopped working because her back pain made it hard for her to perform her duties. Tr. 171. Thompson's past work also included hospice and skilled nursing facility work. Tr. 59-60. Thompson completed school through the 11th grade. Tr. 172. She has been working on obtaining her GED. Tr. 68. She received some vocational training through Vocational Guidance Services for clerical work. Tr. 67, 172. She also tried taking classes at Bryant and Stratton for paralegal work but she was unable to complete the classes because she was ashamed to admit that she needed some help. Tr. 66-67.

         B. Medical evidence

         1.Treatment history

         a. Physical impairments

         On February 8, 2013, Thompson was seen by Anita Singh, M.D., at Metro Health Brooklyn Health Center with complaints of back pain for a week. Tr. 319-321. Thompson also requested an increase in her prescription for Elavil (Amitriptyline) because her then current dosage was not helping with her insomnia. Tr. 320. Thompson described her back pain as sharp, excruciating, chronic and radiating into her right buttock and right upper thigh. Tr. 320. She did not have weakness or sensory changes but her pain was made worse by forward flexion, lateral flexion, rotation, sitting and standing. Tr. 320. Thompson felt that her pain was caused by overuse of her back muscles and exacerbation of a prior back injury from 2005 that occurred when she was lifting a patient. Tr. 320. Thompson had gotten “fair relief” with use of NSAIDs, Tramadol, a heating pad and bed rest. Tr. 320. On examination, Thompson exhibited tenderness at the L4-L5 area and in her right paraspinal muscles and straight leg raising was negative. Tr. 320. Thompson was diagnosed with lumbago and sleep disturbance. Tr. 321. She received a Toradol injection and her Elavil was increased. Tr. 320-321. Thompson also had an x-ray of her lumbar spine taken in February 2013. Tr. 300. The x-ray showed that Thompson's alignment was intact with no acute bony abnormalities and mild to moderate degenerative disc disease at the L4-5 and L5-S1 level. Tr. 300.

         Upon Dr. Singh's referral, on September 23, 2013, Thompson saw Shu Que Huang, M.D., of the Department of Physical Medicine and Rehabilitation (“PM&R”).[2] Tr. 300-303. Dr. Huang recapped Thompson's reports of her past and present back problems, noting that Thompson indicated that beginning in 2005 she started experiencing intermittent low back pain along with right leg pain to the foot; she had some pain free weeks followed by painful weeks; she did not know what triggered her flare ups; she had tried Motrin and Aleve without relief; she was allergic to opioids; she tried physical therapy and chiropractic treatment in 2005 without relief; and she had tried Lyrica and Cymbalta back in 2005 but had to stop because the medicine made her feel “out of it.” Tr. 300. Thompson also indicated that she recently started having some soreness in her neck but noted that she had recently started computer classes and, thus, her neck stiffness might be attributed to spending prolonged time stooped at a computer. Tr. 300. On examination, Dr. Huang observed 1 reflexes in Thompson's bilateral extremities; normal sensation in dermatomes of upper and lower extremities; and 5/5 strength in upper and lower extremities. Tr. 302. On examination of Thompson's neck, Dr. Huang observed that Thompson's cervical lordotic curvature was decreased in her neck; her range of motion was mildly limited with pain in rotation; she had tenderness bilaterally in her “cervical paraspinals and traps[;]” and Spurling's was negative. Tr. 302. On examination of Thompson's back, Dr. Huang observed that Thompson's lumbar lordotic curvature was increased; there was no evidence of scoliosis; flexion and extension range of motion was normal but with pain more-so with extension and lateral bending; there was tenderness at the bilateral lumbosacral paraspinals; there was no evidence of spasm or trigger points; straight leg raise caused low back pain; and FABER caused low back pain. Tr. 302. Dr. Huang's assessment was that Thompson had chronic spondylogenic low back pain with nerve irritation, noting that her pain may be discogenic in nature and that her neck pain was likely myofascial in nature from computer work. Tr. 302. Dr. Huang referred Thompson to physical therapy for core strengthening and a TENs unit trial; discontinued Motrin and started Thompson on Voltaren and Neurontin; provided her with information on neck stretches; and advised her to return in two months. Tr. 302.

         On October 2, 2013, Thompson started physical therapy. Tr. 293-298. Thompson's physical examination findings were generally normal with some abnormal findings noted, including increased lumbar lordosis, poor abdominal strength, and tenderness to palpation in the lumbosacral area. Tr. 297. The physical therapist noted an Oswestry score of 41/50 80%-100%, meaning that she was either bed bound or exaggerating her symptoms. Tr. 297. During an October 7, 2013, physical therapy session, Thompson had no pain. Tr. 291. The physical therapist added lower extremity stretches and practiced flexion exercises. Tr. 291. Thompson tolerated treatment well. Tr. 291. The physical therapist recommended a continued need for physical therapy.[3] Tr. 292.

         On February 4, 2014, Thompson was seen at an express care clinic with complaints of low back pain that was worse than usual. Tr. 282-285. Thompson relayed that her back pain was traveling up her back and causing neck pain. Tr. 282. Thompson described her pain as achy and sharp. Tr. 282. Thompson was out of her usual medications and had not tried anything for pain relief. Tr. 282. Positional changes did provide Thompson with pain relief and she had less pain when standing. Tr. 282. On examination, Thompson was in no acute distress but appeared uncomfortable; she exhibited full range of neck motion but with spasm on the right side; there was no visible deformity in her back; she had no midline tenderness in her back; she was negative for palpable spasm in her back; her gait was normal; her ankle reflexes were 2 bilaterally; her lower leg sensation was intact; her strength was intact 5/5 in her upper and lower extremities. Tr. 284. Thompson received a Toradol injection and new prescriptions. Tr. 284-285. She was advised to follow up with her primary care physician if her symptoms persisted. Tr. 285.

         On March 14, 2014, Thompson saw Dr. Singh at Metro Health Brooklyn Health Center for an evaluation of hyperlipidemia. Tr. 274-278. During the visit, Thompson also requested a referral to the pain clinic for her chronic back pain. Tr. 275. She indicated that she tried physical therapy without much relief. Tr. 275. She reported that Neurontin was helping with her pain. Tr. 275. Also, Thompson relayed that she was trying to lose weight and exercise. Tr. 275. On examination, Thompson exhibited bilateral lumbar paraspinal tenderness. Tr. 276. There were no abnormal neurological findings and Thompson's straight leg raising was negative. Tr. 276. Thompson was provided a prescription for Mevacor and advised to follow a low fat, low cholesterol diet and engage in regular, aerobic exercise. Tr. 277. A pain clinic service request was made. Tr. 277.

         Upon Dr. Singh's referral, on April 1, 2014, Thompson saw Kutaiba Tabbaa, M.D., [4] a pain management physician. Tr. 259-266. Thompson explained that physical therapy seemed to help but the pain was too unbearable. Tr. 260. Thompson reported that she took Neurontin, Voltaren, and Elavil and the medication seemed to help but she did not want to take too many pills. Tr. 260. Dr. Tabbaa's cervical exam showed no pain with flexion, extension, or rotation and the cervical paravertebral exam was normal. Tr. 264. Dr. Tabbaa's lumbar exam showed no pain with flexion but extension and rotation were mildly painful. Tr. 264. The cervical paravertebral exam revealed tenderness on the right to palpation. Tr. 264. Dr. Tabbaa's neurological examination revealed normal reflexes, sensation, strength, coordination and gait. Tr. 264. In addition to his physical examination, Dr. Tabbaa reviewed the February 2013 lumbar x-ray findings. Tr. 264. Dr. Tabbaa concluded that Thompson's symptoms appeared consistent with facet joint arthritis. Tr. 264. Dr. Tabbaa encouraged weight loss, provided Thompson with a prescription for pool therapy, scheduled Thompson for medial branch blocks at ¶ 4-L5 and L5-S1, and he advised Thompson to continue taking Voltaren for arthritis/pain relief. Tr. 264. Dr. Tabbaa also prescribed Lorazepan (Ativan). Tr. 265.

         On April 17, 2014, Thompson received her first lumbar medial branch block on the right at ¶ 3, L4, L5, and S1. Tr. 257. During a follow-up visit with Dr. Tabbaa on May 20, 2014, Thompson reported that she felt great following the lumbar block but had gradually worsening lumbar and hip pain. Tr. 257. Thompson described her pain as sharp, crampy, and intermittent and made worse by rotation and standing. Tr. 257. On examination, Dr. Tabbaa observed normal strength in all extremities, normal deep tendon reflexes, and normal sensation in all extremities. Tr. 257. Dr. Tabbaa observed some positive findings, including limitation of motion on extension and marked tenderness to palpation over the paraspinal muscles. Tr. 257. Dr. Tabbaa reminded Thompson of the importance of protecting her back and maintaining a regular program of improving strength and flexibility. Tr. 258. Dr. Tabbaa recommended bilateral L4-5 and L5-S1 facet injections and physical therapy. Tr. 258. He prescribed Zanaflex. Tr. 258.

         On June 18, 2014, Thompson was seen at an express care facility complaining of problems with her back. Tr. 249-252. Her symptoms included left flank pain. Tr. 250. Thompson's general appearance on examination was noted to as “healthy, alert, mild distress, oriented.” Tr. 250. A musculoskeletal examination revealed a full range of motion; a steady gait; and tenderness over the sacral spine with muscular pain over the left and right flank area. Tr. 250. Thompson was prescribed Voltaren and Lidocaine and she was advised to contact pain management to request an earlier appointment for her injection. Tr. 250. She was also advised to seek relief through pillow positioning and heat therapy. Tr. 250.

         On September 16, 2014, Thompson saw Dr. Tabbaa for follow up. Tr. 246-249. Thompson had a facet joint injection on June 24, 2014, which she reported alleviated her pain for about a month. Tr. 246. She continued to have gradually worsening lumbar pain that she described as constant and throbbing and worse with forward flexion, cold weather and generally all activity. Tr. 246. Thompson also complained of numbness in her right leg. Tr. 246. She felt that the Volteran, Motrin and Lidocaine were not working to relieve her pain. Tr. 246. Thompson explained that she had several allergies to pain medication. Tr. 246. On physical examination, Dr. Tabbaa observed that Thompson was in no distress; she had no abnormal curvature in her back; range of motion in her back was normal; she had normal strength in all extremities; deep tendon reflexes were normal and sensation was normal in all extremities; there was tenderness to palpation over the paraspinal muscles. Tr. 247. Dr. Tabbaa reinforced the importance of protecting her back and maintaining a regular program of improving her strength and flexibility; he recommended pool therapy; and recommended bilateral medial branch blocks at the L3-S1. Tr. 248.

         On November 6, 2014, Thompson received her second bilateral L3, L4, L5 and S1 lumbar medial branch block. Tr. 348-351, 368. During a February 3, 2015, follow-up visit with Dr. Tabbaa, Thompson reported getting good relief from the medial branch block for two weeks. Tr. 343, 362. On physical examination, Dr. Tabbaa observed bilateral paraspinal tenderness in the lumbar region. Tr. 344, 362. Dr. Tabbaa prescribed Zanaflex and he recommended radiofrequency ablation. Tr. 346. Dr. Tabbaa also recommended a weight management referral, noting he discussed with Thompson the importance of pool therapy and weight loss.[5] Tr. 346, 365. Thompson underwent the lumbar medial branch radiofrequency rhizotomy at the L3, L4, L5, and S1 areas on the right on March 30, 2015, and on the left on April 9, 2015. Tr. 352-353, 355-356.

         On May 24, 2015, Thompson was seen at the emergency room. Tr. 427-439. She complained of low back pain that was radiating into her legs bilaterally. Tr. 427, 429. Thompson relayed that her back problem was chronic but she woke up that morning and her pain was worse. Tr. 427. On physical examination, the following was observed - Thompson could move all four extremities and there was no midline thoracic spine tenderness but there was diffuse lumbar tenderness; straight leg raise was negative bilaterally; Thompson had 5/5 strength bilaterally in her lower extremities upon knee flexion/extension, ankle dorsiflexion, and ankle plantar flexion; Thompson had no sensory deficits to light tough; her reflexes were normal and equal; she had a normal gait; and there were no acute focal neurological deficits. Tr. 431. Thompson was treated in the emergency room with a Toradol injection and Flexeril tablet. Tr. 431. She showed improvement following administration of the medication and was discharged in stable condition. Tr. 431-432. On discharge, Thompson was provided with prescriptions for Naproxen and Zanaflex. Tr. 432.

         Two days later, on May 26, 2015, Thompson saw Dr. Tabbaa for a follow-up visit. Tr. 423-426. On examination, Dr. Tabbaa observed normal range of motion in Thompson's back; normal strength in all extremities; normal deep tendon reflexes and normal sensation in all extremities; and tenderness to palpation over Thompson's paraspinal muscles. Tr. 425. Dr. Tabbaa noted that Thompson was experiencing the same pain she had been having despite undergoing a radio frequency procedure. Tr. 425. He recommended a lumbar MRI for radicular right leg pain. Tr. 425. He also recommended physical therapy and a consultation for a disability assessment, noting that Thompson was applying for disability. Tr. 425. On June 11, 2015, the lumbar MRI was performed. Tr. 442. The results showed mild degenerative changes with posterior disc bulging at ¶ 3-4, L4-5, and L5-S1 along with facet hypertrophy and bilateral foraminal impingement most evident at ¶ 5-S1. Tr. 442. There was no disc extrusion or critical canal stenosis. Tr. 442.

         On June 17, 2015, Thompson saw Marline Sangnil, M.D., and Mary Vargo, M.D., of the PM&R department.[6] Tr. 416-420. Drs. Sangnil and Vargo took a history regarding Thompson's back problems, considered the June 11, 2015, MRI findings, and performed a physical examination. Tr. 416-420. Findings from the back examination included a normal lumbar lordotic curvature; no evidence of scoliosis; very limited range of motion (flexion 20 degrees, extension 0, lateral rotation 0 bilaterally); tenderness throughout the lumbar spine paraspinals and midline; and straight leg lifting in both legs caused pain at 10 degrees. Tr. 419. The neurological motor examination was limited in some respects due to pain. Tr. 419. Thompson's sensation was intact to light touch in her upper and lower extremities bilaterally. Tr. 419. Thompson's reflexes were normal throughout her upper and lower extremities. Tr. 419. With respect to Thompson's gait, Drs. Sangnil and Vargo observed that Thompson was only able to take three steps and then had to sit down. Tr. 419. Also, they observed that Thompson was only able to lift five pounds for about three minutes before sitting down. Tr. 419. Dr. Vargo noted that Thompson's reactions to pain seemed to have become exaggerated. Tr. 420. Also, Dr. Vargo observed that Thompson had had limited physical therapy and had not had a “psychology approach for pain management coping strategies[.]” Tr. 420. Drs. Sangnil and Vargo indicated that imaging revealed lumbar degenerative changes with mild bilateral neural foraminal impingement most evident at ¶ 5-S1 and noted that the examination was limited due to pain. Tr. 420. They advised Thompson to fax the disability paperwork to their office, follow up with pain management, and they recommended that she see a psychologist and physical therapist. Tr. 420.

         Thompson sought treatment at an express care clinic on October 4, 2015, for her back pain. Tr. 403-404. Thompson indicated that her pain was not any different that day than it had been. Tr. 404. She was seeking documentation regarding her history of back pain. Tr. 404. The express care clinic advised Thompson that she would need to see her primary care physician regarding her request and that the next open appointment was on October 7, 2015. Tr. 404. Instead of waiting to be seen in the express care clinic, Thompson opted to see her primary care physician on October 7, 2015. Tr. 400-403, 404. During her October 7, 2015, visit with Dr. Singh, Thompson complained that her back pain was not improving and was getting progressively worse. Tr. 401. She reported pain radiating into her legs bilaterally and that she had fallen a couple of times. Tr. 401. Physical examination findings were normal. Tr. 402. The diagnosis was spondylosis of lumbosacral joint. Tr. 402. The recommended plan was for Thompson to follow up with the PM&R department. Tr. 402.

         On November 18, 2015, Thompson saw Drs. Sangnil and Vargo again for a disability evaluation. Tr. 391-396. She presented with her disability forms. Tr. 391. An updated evaluation was performed by Drs. Sangnil and Vargo because they felt their prior evaluation “was a relatively long time ago (6/17/15)[.]” Tr. 395. Thompson relayed she was unable to work due to her back pain, which she described as starting in her low back and radiating down the back of her legs to her feet and causing difficulty with ambulation. Tr. 391. Thompson reported that sitting and standing for more than 20 minutes causes pain. Tr. 391. She reported numbness/tingling in her lower extremities and weakness in her extremities. Tr. 391. Findings from the back examination included a normal lumbar lordotic curvature; no evidence of scoliosis; limited range of motion (flexion 30 degrees, extension 0, lateral rotation 0 bilaterally); tenderness throughout the lumbar spine paraspinals and midline; and straight leg lifting in both legs caused low back pain. Tr. 394. Thompson's FABER's and Gaenslen's testing was positive. Tr. 394, 395. The neurological motor, sensory and reflex examination of upper and lower extremities was normal. Tr. 394. Thompson's gait was slow and antalgic. Tr. 394. Drs. Sangnil and Vargo indicated that imaging revealed lumbar degenerative changes with mild bilateral neural foraminal impingement most evident at ¶ 5-S1 and that the examination revealed bilateral sacroiliac joint pain, which could be factoring into Thompson's back pain. Tr. 394. Dr. Sangnil completed Thompson's disability forms that day.[7] Tr. 395. Thompson was advised to continue to follow up with pain management and that consideration should be given to sacroiliac joint injections. Tr. 395.

         b. Mental impairments

         On April 23, 2012, Thompson was seen at Metro Health Brooklyn Health Center with complaints of insomnia, being under a lot of stress, and elevated blood pressure. Tr. 328. Thompson reported losing her job and trying to get back into school. Tr. 328. She had tried Ambien and Elavil with some success. Tr. 328. Thompson was provided a prescription for Elavil. Tr. 330. In May 2012, Thompson returned to Metro Health Brooklyn Health Center to obtain a physical for a STNA position. Tr. 325. At that time, Thompson denied any other concerns or issues, including psychiatric concerns. Tr. 325.

         Starting around October 2012, Thompson began seeing Dr. Griggins, Ph.D., with Parma Health Ministry, for psychological counseling. Tr. 212-234. Thompson reported having anger problems and feeling somewhat depressed. Tr. 233. She indicated she had never been unemployed until recently and was unable to find work. Tr. 234. She was trying to finish her GED and take courses to become an EKG technician. Tr. 234. Thompson was taking Elavil to help her sleep. Tr. 233.

         During a February 8, 2013, visit at Metro Health Brooklyn Health Center, Thompson requested and received an increase in her Elavil prescription because she felt that the medication was not helping her with her insomnia. Tr. 320. On June 27, 2013, Thompson saw Dr. Singh again at Metro Health Brooklyn Health Center. Tr. 311-314. Thompson relayed that she was having problems with insomnia, anhedonia, and fatigue and she was feeling hopeless, having excessive guilt, and feeling depressed. Tr. 312. Her symptoms had started about a week earlier and were gradually worsening. Tr. 312. She reported she had “a lot going on - [her] son just went to jail yesterday.” Tr. 312. On physical examination, Dr. Singh observed that Thompson's mood was stable and her speech was appropriate. Tr. 313. Thompson was continued on Elavil and advised to take it every day. Tr. 314. Thompson saw Dr. Singh on August 9, 2013, for medication monitoring. Tr. 307. Thompson's insomnia was well controlled with Elavil and she wanted a refill. Tr. 307-308. She denied suicidal and homicidal ideation and her mood was stable. Tr. 308. Dr. Singh continued Thompson on Elavil. Tr. 310.

         In September 2013, Thompson saw Dr. Griggins. Tr. 216. Dr. Griggins noted that Thompson was doing very well. Tr. 216. She was receiving computer training services through VGS; she was in a good relationship with a male friend; and she was distancing herself from her son and involving herself less in his relationships and problems. Tr. 216. However, in April 2014, Thompson reported being stressed about having no job and no money. Tr. 214. She was concerned she might be evicted from her Section 8 housing. Tr. 214. She was more stressed and getting more angry with the people that she needed help from. Tr. 214. Dr. Griggins suggested that Thompson start seeing him more regularly again since she was engaging in self-defeating behaviors. Tr. 214. Thompson cancelled two appointments with Dr. Griggins in May 2014. Tr. 213. In July 2014, Thompson was coping with her father's death and the death of her daughter's 15-year old friend. Tr. 213. She also reported that she was not having luck through VGS and was thinking about going back to being a STNA but she could not afford the $500 fee associated with repeating the STNA courses and exam. Tr. 213. Dr. Griggins encouraged her to call nonprofits to see if training was available at a lower rate since VGS would not cover the costs. Tr. 213. Thompson continued to see Dr. Griggins through at least July 2014. Tr. 213.

         On March 17, 2015, Thompson saw Dr. Singh for a follow-up visit. Tr. 339-342. Thompson reported she was stressed out due to housing related matters and she was having a difficult time sleeping. Tr. 339. She was living with her brother and looking for her own housing and a job. Tr. 339. Thompson was interested in increasing her Elavil dose. Tr. 339. She reported having a good support system and she denied suicidal and homicidal ideation. Tr. 339. On examination, Dr. Singh observed that Thompson was alert, pleasant, cooperative and her mood and affect were stable. Tr. 341. Dr. Singh increased Thompson's Elavil dose. Tr. 342.

         On September 22, 2015, Thompson presented to Metro Health for a mental health assessment that was conducted by Jane Martinez, LISW. Tr. 405-415. Thompson relayed that she had been evaluated at Metro for her back pain and was told that there was nothing wrong with her and was advised to see a psychiatrist. Tr. 405. She reported feeling depressed for about 4 years. Tr. 405-406. Approximately three or four years earlier her son was stabbed around Mother's Day. Tr. 406. He survived. Tr. 406. Around that same time, her mother was very ill with COPD and emphysema. Tr. 406. She reported wanting to stay home and not talking with anyone. Tr. 406. Her appetite fluctuates. Tr. 406. Thompson never attempted suicide but reported suicidal ideation. Tr. 406. Thompson's stressors included lack of work and having to support herself and her daughter. Tr. 406. She was evicted in February 2015. Tr. 406. She reported having problems falling asleep and staying asleep. Tr. 406. Thompson also reported problems with irritability, aggression, and anxiety. Tr. 407. Because of her anxiety, Thompson indicated she was unable to concentrate at times. Tr. 407. Ms. Martinez diagnosed dysthymic disorder and cannabis abuse and assessed a GAF score of 51-60.[8] Tr. 411. Ms. Martinez noted that Thompson was scheduled for appointments with Ms. Martinez as well as Carol Cardello. Tr. 411.

         On November 30, 2015, Thompson saw Carol Cardello, CNS, for pharmacologic management. Tr. 383-386. Thompson reported depression in the context of chronic pain. Tr. 384. Thompson indicated she had applied for disability. Tr. 384. She had obtained some secretarial training but was unable to find work or sit for long periods of time. Tr. 384. Ms. Cardello noted that Thompson was reluctant to try new medications but was receptive to trying an antidepressant. Tr. 385. On examination, Ms. Cardello observed that Thompson was adequately groomed; cooperative; oriented to time, person and place; her speech was spontaneous with a normal rate and flow; she had racing and paranoid thoughts; she had occasional auditory hallucinations - voices that were self-deprecating, not commanding; her mood was depressed and irritable; her affect was full; her memory was within normal limits; her attention and concentration were sustained; and her judgment and insight were fair. Tr. 385. Ms. Cardello felt that Thompson could benefit from antidepressant medication and counseling. Tr. 395. She diagnosed depression due to general medical condition, prescribed Effexor, and recommended that Thompson resume counseling.[9] Tr. 385-386.

         On December 16, 2015, Thompson saw Ms. Martinez for counseling. Tr. 376-378. Ms. Martinez noted that Thompson was making progress towards her treatment goals - she was attending appointments; she acknowledged needing professional help; her medication was helping with her hallucinations; and she was looking for a case manager. Tr. 377. On examination, Ms. Martinez observed that Thompson was well groomed; cooperative; oriented to time, person and place; her speech was spontaneous with a normal rate and flow; her thought process was logical and organized; there were no abnormal/psychotic thoughts; her insight and judgment were fair; her memory was within normal limits; her attention and concentration were sustained; her mood was euthymic; and her affect was full. Tr. 378. Ms. Martinez's impression was that Thompson's symptoms were in partial remission. Tr. 378.

         On July 8, 2016, Thompson saw Ms. Cardello. Tr. 677-679. Thompson reported doing okay after having lost her mother a few weeks prior. Tr. 678. Thompson was continuing to see a counselor. Tr. 678. Thompson was taking Benadryl to help her sleep and she reported benefits from taking Effexor. Tr. 678. Thompson presented disability paperwork and paperwork to erase a loan. Tr. 678. Ms. Cardello advised Thompson that the paperwork would need to be completed at a different visit or outside of the current session. Tr. 678. Thompson had needed assistance from mobile crisis for "flipping out" at home. Tr. 678. She had been evicted from her home and was living with her brother. Tr. 678. Thompson reported feeling more stable and she denied suicidal ideation. Tr. 678. Ms. Cardello observed that Thompson's mood was sad and grieving and her thoughts were racing. Tr. 678. Other objective physical examination findings were that Thompson was adequately groomed; cooperative; oriented to time, person and place; there were infrequent voices; rate and flow of speech were normal; affect was full; attention and concentration were sustained; memory was within normal limits; and judgment and insight were fair. Tr. 678. Ms. Cardello's impression was that Thompson was less anxious but grieving the loss of her mother. Tr. 679. Ms. Cardello diagnosed depression due to general medical condition and she recommended that Thompson continue Effexor, use Benadryl for sleep, and continue counseling. Tr. 679.

         2.Opinion evidence

         a. Treating

         Physical impairments

         On November 18, 2015, Dr. Sangnil completed a form entitled Medical Source Statement: Patient's Physical Capacity. Tr. 445-456. Dr. Sangnil opined that Thompson was restricted to lifting/carrying 5 pounds occasionally and 5 pounds frequently; standing/walking for a total of 5 minutes, noting that Thompson can only take a few steps before she has severe pain; and sitting a total of 25 minutes. Tr. 445. In support of exertional limitations, Dr. Sangnil noted that Thompson had lumbar degenerative changes with mild bilateral foraminal impingement most evident at ¶ 5-S1. Tr. 445. Dr. Sangnil opined that Thompson could rarely climb, stoop, crouch, kneel and crawl and she could occasionally balance. Tr. 445. Dr. Sangnil opined that Thompson could rarely reach or push/pull and she could frequently perform fine and gross manipulation. Tr. 446. Dr. Sangnil opined that Thompson's impairments caused environmental limitations, including heights and moving machinery. Tr. 446. Dr. Sangnil indicated that Thompson had not been prescribed a cane, walker, brace, TENS unit, breathing machine, oxygen or wheelchair. Tr. 446. Dr. Sangnil opined that Thompson would need to alternate between sitting, standing, and walking at will. Tr. 446. She rated Thompson's pain as severe and indicated that Thompson's pain would interfere with concentration and cause absenteeism. Tr. 446. Dr. Sangnil opined that Thompson would need to elevate her legs at will at 45 degrees. Tr. 446. Also, Thompson would require unscheduled rest periods during an 8-hour workday in addition to the standard breaks and lunch and she would require an additional 8 hours of rest on an average day. Tr. 446.

         Mental impairments

         In July 2016, Ms. Cardello and Howard Gottesman, M.D., completed a form entitled Medical Source Statement: Patient's Mental Capacity. Tr. 689-690. Dr. Gottesman signed the form on July 14, 2016, and Ms. Cardello signed the form on July 25, 2016. Tr. 690. They noted that Thompson had been under their care since November 30, 2015. Tr. 690.

         Ms. Cardello and Dr. Gottesman opined that Thompson could constantly, meaning her ability to perform the activities was unlimited, understand, remember and carry out simple job instructions; maintain appearance; and leave her own home. Tr. 689-690. They opined that Thompson could frequently, meaning she had the ability to perform the activities for up to 2/3 of a workday, follow work rules; respond appropriately to changes in routine settings; interact with supervisors; work in coordination with or proximity to others without being distracted; work in coordination with or proximity to others without being distracting; understand, remember and carry out detailed, not complex job instructions; socialize; behave in an emotionally stable manner; and relate predictably in social situations. Tr. 689-690. They opined that Thompson could occasionally, meaning she had the ability to perform the activities for up to 1/3 of a workday, use judgment; maintain attention and concentration for extended periods of 2 hour segments; maintain regular attendance and be punctual within customary tolerance; deal with the public; relate to coworkers; function independently without ...


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