United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION & ORDER
KATHLEEN B. BURKE UNITED STATES MAGISTRATE JUDGE
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.
September 15, 2014, Thompson protectively filed an
application for Disability Insurance Benefits
(“DIB”). 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.
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.
Personal, vocational and educational evidence
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.
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.
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”). 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.
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. Tr. 292.
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.
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.
Dr. Singh's referral, on April 1, 2014, Thompson saw
Kutaiba Tabbaa, M.D.,  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.
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.
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.
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.
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. 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.
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.
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.
17, 2015, Thompson saw Marline Sangnil, M.D., and Mary Vargo,
M.D., of the PM&R department. 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.
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.
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
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.
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.
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.
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.
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.
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.
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. Tr. 411. Ms. Martinez noted that Thompson
was scheduled for appointments with Ms. Martinez as well as
Carol Cardello. Tr. 411.
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. Tr. 385-386.
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.
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.
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.
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.
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