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Evans v. Berryhill

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

March 21, 2018

JENNIFER EVANS, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          JUDGE JOHN R. ADAMS

          REPORT AND RECOMMENDATION

          JONATHAN D. GREENBERG, UNITED STATES MAGISTRATE JUDGE.

         Plaintiff, Jennifer Evans, (“Plaintiff” or “Evans”), proceeding pro se, challenges the final decision of Defendant, Nancy A. Berryhill, [1] Acting Commissioner of Social Security (“Commissioner”), denying Evans' applications for Period of Disability (“POD”), Disability Insurance Benefits (“DIB”), and Supplemental Security Income (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 416(i), 423, 1381 et seq. (“Act”). This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned United States Magistrate Judge pursuant to an automatic referral under Local Rule 72.2(b) for a Report and Recommendation. For the reasons set forth below, the Magistrate Judge recommends the Commissioner's final decision be AFFIRMED.

         I. PROCEDURAL HISTORY

         In January 2015, Evans filed applications for POD, DIB, and SSI, alleging a disability onset date of January 1, 2012 and claiming she was disabled due to bipolar disorder, post-traumatic stress disorder (“PTSD”), anxiety, herniated discs, “bad knees, ” and fibromyalgia. (Transcript (“Tr.”) 14, 207, 209, 236.) The applications were denied initially and upon reconsideration, and Evans requested a hearing before an administrative law judge (“ALJ”). (Tr. 150-156, 166-177, 178.)

         On October 14, 2016, an ALJ held a hearing, during which Evans, represented by counsel, and an impartial vocational expert (“VE”) testified. (Tr. 63-89.) On October 28, 2016, the ALJ issued a written decision finding Evans was not disabled. (Tr. 14-27.) The ALJ's decision became final on March 22, 2017, when the Appeals Council declined further review. (Tr. 1.)

         On May 18, 2017, Evans, filed her pro se Complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 17, 18.) Evans asserts the following assignments of error:

(1) The Administrative Law Judge appears to have abused his or her discretion.
(2) The decision is not supported by substantial evidence.
(3) We receive new and material evidence on the decision is contrary to the weight of all the evidence now in the record.

(Doc. No. 17.)

         II. EVIDENCE

         A. Personal and Vocational Evidence

         Evans was born in March 1974 and was forty-two (42) years-old at the time of her administrative hearing, making her a “younger” person under social security regulations. (Tr. 25.) See 20 C.F.R. §§ 404.1563(c) & 416.963(c). She has at least a high school education and is able to communicate in English. (Id.) She has past relevant work as a consultant (sedentary, skilled, SVP 8); chief payroll supervisor (sedentary, skilled, SVP 8); and payroll clerk (semiskilled, SVP 4). (Tr. 25.)

         B. Medical Evidence

         1. Mental Impairments

         On February 5, 2013, Evans underwent an Adult Diagnostic Assessment with social workers Martha Yeager, BA, LSW and Don Cook, MSW, LISW-S. (Tr. 286-294.) She reported a history of substance abuse, including heroin, crack cocaine, and marijuana. (Tr. 288.) Evans desired treatment in order to become sober, address her heroin withdrawal issues, and decrease her depression symptoms. (Tr. 286.) She reported feeling terrible and indicated she had “to be clean, per Public Defender, to avoid a jail sentence” on four felony charges for writing bad checks. (Tr. 286, 289.) Evans stated “she has not done [any activities of daily living] because she cannot get out of bed unless she does drugs.” (Tr. 286.) She attributed her drug use to her fibromyalgia and back pain. (Tr. 292.)

         With regard to her mental health symptoms, Evans reported increased depression over the past year and stated she “feels useless and hopeless all the time, cries all the time every day, no energy and motivation.” (Tr. 290.) She also complained of anxiety attacks “a couple of times per week, ” which had been worsening over the past year. (Id.) Evans stated she could not relax, and reported constant fidgeting and racing thoughts. (Id.) She also reported mood swings and sleep problems. (Tr. 291.) Evans indicated she “gets too overwhelmed to function.” (Tr. 292.) Evans was diagnosed with depression psychosis, unspecified, and combined drug dependency, unspecified; and assessed a Global Assessment of Functioning (“GAF”) of 55, [2] indicating moderate symptoms. (Tr. 293.)

         Several weeks later, Evans underwent an Initial Psychiatric Evaluation with Kathleen Christy, APRN-BC. (Tr. 296-300.) Evans reported she was “weaning herself off heroin.” (Tr. 296.) She indicated she was “having problems sleeping at present with racing thoughts, can't relax, appetite comes and goes, concentration: not good at all.” (Id.) Ms. Christy stated Evans was “very focused on fibromyalgia and believes that if she was not in pain she would not need drugs.” (Id.) On mental status examination, Evans was cooperative but agitated, restless, and withdrawn. (Tr. 297.) Ms. Christy noted average eye contact and demeanor, pressured speech, a tangential thought process, and an angry, irritable, and depressed mood. (Id.) In addition, Ms. Christy found obsessional, guilty, preoccupied, and paranoid thought content. (Id.) She diagnosed postraumatic stress disorder (“PTSD”) and combined drug dependency; and offered a differential diagnosis of “rule out” bipolar disorder. (Tr. 298.) She assessed a GAF of 55, indicating moderate symptoms. (Id.) Ms. Christy prescribed Seroquel. (Tr. 299.)

         The record reflects Evans presented for mental health treatment on several occasions between March and December 2013. On March 4, 2013, Evans' Seroquel dosage was increased and she was prescribed Neurontin and a trial of Cymbalta. (Tr. 338-339.) Ten days later, it was noted Evans was “in Lake County jail.” (Tr. 336.) It appears she was released on May 29, 2013 and presented for a counseling session on June 25, 2013. (Tr. 328.) She had not attended AA meetings and reported using drugs since her release. (Id.) Evans' speech was pressured and Ms. Christy described her as “markedly ill.” (Tr. 328-329.) The following month, Evans was attending AA once per week and doing community service projects. (Tr. 326.) Ms. Christy continued to describe her as “markedly ill.” (Tr. 327.)

         Evans regularly presented for mental health treatment in 2014, presenting to Ms. Christy on at least eight (8) occasions. (Tr. 320-321, 318, 316-317, 314-315, 312-313, 310-311, 308-309, 306-307, 304-305.) During each visit, in response to the question “how mentally ill is the patient at this time, ” Ms. Christy described Evans as “markedly ill.” (Id.) Records from these visits are handwritten and often difficult to read but they appear to indicate Evans' medication was adjusted several times. In July 2014, her Geodon dosage was increased. (Tr. 316.) In August 2014, Evans was “more depressed” and prescribed Wellbutrin. (Tr. 312.) The following month, Evans was depressed with low energy and continued on her medications. (Tr. 310.) In October 2014, Ms. Christy increased her Geodon dosage and prescribed Trazodone. (Tr. 306.) Throughout most of this time period, Evans is described as “stable.” (Tr. 317, 313, 309, 307.) By December 2014, however, Evans was “symptomatic” with slightly pressured speech and reports of sleep problems and forgetfulness. (Tr. 304-305.)

         In 2015, Evans presented for mental health treatment on numerous occasions, both to physician assistant Pushpalatha Venkatarman, P.A., and professional clinical counselor Stephen J. Roos, PCC-S, LCDC III. On March 6, 2015, Evans presented to Ms. Venkatarman with complaints of impaired balance, difficulty concentrating, impaired memory, and racing thoughts. (Tr. 466-467.) On examination, Ms. Venkatarman noted depressed, sad, and tired mood, and slurred thought process. (Id.) She diagnosed bipolar disorder, unspecified; assessed a GAF of 60, indicating moderate symptoms; and prescribed Propranolol to address Evans' balance issues. (Id.) In response to the question “how mentally ill is the patient at this time, ” Ms. Venkatarman answered “moderately ill.” (Id.)

         Several weeks later, on March 26, 2015, Evans was “feeling better with propranolol” and “able to walk straight.” (Tr. 464-465.) She continued to complain of racing thoughts but stated her mood swings were well-controlled. (Id.) On examination, Evans was happy, cheerful, and cooperative. (Id.) Ms. Venkatarman described her as alert and oriented but mildly depressed with short term memory problems. (Id.) She again diagnosed bipolar disorder, unspecified; assessed a GAF of 60; and described Evans as “moderately ill.” (Id.)

         In April 2015, Evans reported “being stable with her current medication.” (Tr. 461-462.) She was not having significant mood swings or feeling restless, and was “still looking for a job, [but] finding it difficult . . . because of felonies.” (Id.) On examination, Evans was cooperative with logical thought process and mild mood swings and mild depression. (Id.) She answered questions appropriately but indicated problems with short term memory. (Id.) Ms. Venkatarman described Evans as “moderately ill” and continued her on her medications (Neurontin, Cogentin, Wellbutrin, Trazadone, and Propranolol). (Id.)

         In July 2015, Evans was again noted as “stable with current medication.” (Tr. 459-460.) She reported having difficulties with her memory and feeling restless. (Id.) Ms. Venkatarman noted Evans' thought process was “fair” and indicated her anxiety and depression was situational. (Id.) She diagnosed bipolar disorder and prescribed Geodon. (Id.)

         On September 3, 2015, Evans presented to counselor Mr. Roos with complaints of racing thoughts, memory loss and “issues with PTSD and abusive relationships in the past.” (Tr. 586-587.) She also reported chronic pain due to fibromyalgia and back pain from a car accident in high school. (Id.) On examination, Evans was cooperative with average eye contact and motor activity, clear speech, logical thought process, and an average estimated intelligence. (Id.) She did not report any impairment in memory, attention, or concentration. (Id.) However, Mr. Roos also noted Evans was withdrawn with a constricted affect and depressed and anxious mood. (Id.)

         Evans returned to Mr. Roos on September 7 and October 1, 2015. (Tr. 584-585, 613-614.) On September 7, 2015, Evans had a euthymic mood and was not described as depressed or anxious. (Tr. 584-585.) She did, however, have a constricted affect and reported memory impairment. (Id.) On October 1, 2015, Evans reported doing community service at a local dog shelter and “look[ed] and sound[ed] very positive at this time.” (Tr. 613.) She did not report memory impairment during this visit. (Tr. 614.)

         On October 28, 2015, Evans returned to Ms. Venkatarman. (Tr. 611-612.) She indicated decreased restlessness and memory impairment, but continued to complain of depression and anxiety. (Id.) Ms. Venkatarman described her as “moderately ill” and continued her on her medications. (Id.)

         On November 6, 2015, Mr. Roos noted Evans was “doing well, both in sobriety and emotionally.” (Tr. 609-610.) Mental status examination findings were normal, with the exception of a constricted affect. (Id.) Several weeks later, on November 20, 2015, Evans “said she continues to be stable on her medication regime, ” but complained of constant neck and back pain. (Tr. 607-608.) Mental status examination findings were normal aside from a preoccupied demeanor and constricted affect. (Id.) Evans did not report memory impairment during either of her November visits. (Tr. 607-610.)

         Evans' condition fluctuated during her three sessions with Mr. Roos in December 2015. (Tr. 601-606.) On December 4, 2015, she was anxious and under stress due to her boyfriend's alcohol use. (Tr. 605-606.) At this visit, Evans was withdrawn and preoccupied with a constricted affect and depressed, anxious mood. (Id.) On December 18, 2015, however, Evans was “doing well” and “very happy” due to an upcoming visit with family. (Tr. 603-604.) Mental status examination findings were normal. (Id.) By the end of December 2015, Evans was again preoccupied and anxious with a constricted affect. (Tr. 601-602.) She did not report memory impairment during any of her December visits. (Tr. 601-606.)

         On January 8, 2016, Evans returned to Ms. Venkatarman. (Tr. 598-599.) She was “stable on her meds, ” but did report occasional auditory/visual hallucinations, mild depression and anxiety, and short term memory problems. (Id.) Later that month, Evans presented to Mr. Roos as “slightly withdrawn, ” preoccupied and “struggling in several areas.” (Tr. 596-597.) She reported feeling “preoccupied with being approved for disability, ” but indicated she wanted to return to school to study chemical dependency counseling. (Id.) Evans did not report memory impairments during her January visits with Mr. Roos. (Tr. 596-597, 594-595.)

         In February 2016, Evans “made the difficult decision to change where she lives and with whom she associates.” (Tr. 590-591.) She was withdrawn and preoccupied, and “said she wants to have the disability money to pay off court costs and restitution” stemming from her previous felony convictions. (Id.) The following month, Mr. Roos noted Evans had “greatly improved her situation” by “moving into a sober environment.” (Tr. 699.) Mental status examination findings were normal apart from a preoccupied demeanor and constricted affect. (Tr. 699-700.)

         Treatment records reflect Evans' living situation caused significant stress over the next several months. On March 25, 2016, Evans was preoccupied, tired, anxious and stressed. (Tr. 697-698.) She reported difficulty finding housing, reporting she had been “staying with various people for days at a time.” (Id.) Evans reported difficulty sleeping and “not eating very well, ” and was withdrawn and anxious with a constricted affect. (Tr. 695, 697-698.)

         Evans continued to struggle with her housing situation in April 2016, “staying temporarily at random, unstable, and often dangerous places.” (Tr. 693-694.) On April 8, 2016, Ms. Venkatarman and Mr. Roos each completed a “Certification of Disability, ” stating Evans was “disabled according to the HUD definition.” (Tr. 718, 715.) In these Certifications, they described Evans as “a person with a mental impairment that impedes the ability to live independently, is expected to be of indefinite duration, and is of such a nature that could be improved by more suitable housing conditions.” (Id.)

         On May 12, 2016, Evans returned to Ms. Venkatarman for follow-up. (Tr. 701-703.) She reported her mood swings were “well controlled” and denied hypomanic/manic symptoms and depressive episodes. (Id.) Evans indicated “when she was dehydrated she was having delusions, hallucinations but feeling fine now.” (Id.) On examination, Ms. Venkatarman noted Evans was alert and oriented to person, place and time with clear speech and fair thought process. (Id.) She also noted “occasional” auditory and visual hallucinations, and anxiety. (Id.) Ms. Venkatarman prescribed Vistaril, and continued Evan's other medications. (Id.)

         On May 20, 2016, Evans reported to Mr. Roos that she had obtained housing at a halfway house. (Tr. 681-682.) Mr. Roos noted she was anxious and preoccupied with a constricted affect. (Id.) Evans did not report any memory impairment during this visit. (Id.)

         Evans next returned to Mr. Roos on July 15, 2016. (Tr. 679-680.) He noted Evans was “somewhat withdrawn and in pain from a chronic back ailment and fibromyalgia, ” stating she “in obvious physical pain today.” (Id.) Evans reported her probation was extended “because she has not paid court costs, ” and indicated she “desperately hopes for positive movement regarding disability payments, so she can be free of the legal system and have enough money to find a place to live.” (Id.) On examination, she was withdrawn and preoccupied with a depressed mood and constricted affect. (Id.) Mr. Roos noted a logical thought process and indicated Evans did not report any memory impairment. (Id.)

         On August 8, 2016, Evans returned to Ms. Venkatarman. (Tr. 711-712.) She stated her mood swings were well controlled and her restlessness was “getting better, ” but she was stressed and depressed due to her financial problems. (Id.) On examination, Ms. Venkatarman noted occasional auditory/visual hallucinations and situational anxiety. (Id.) She adjusted Evans' medications, discontinuing Trazadone and increasing her Vistaril dosage. (Id.)

         Later that month, Evans presented to Mr. Roos and indicated she would be moving in with her boyfriend. (Tr. 709.) She stated she had “few housing options at this time because she has no income, ” and “will naturally not be going to school at this time” for chemical dependency counseling classes. (Id.) On examination, Evans had average eye contact and motor activity, clear speech, and logical thought process with an anxious mood and constricted affect. (Id.) She did not report any memory impairment. (Id.)

         On November 14, 2016, Evans returned to Ms. Venkatarman. (Tr. 771-772.) She denied manic/hypomanic symptoms and depressive episodes, but reported “problems with memory, concentration, [and] ongoing [visual hallucinations] [that] come in the way of her attention.” (Id.) Ms. Venkatarman increased Evans' dosages of both Vistaril and Benztropine. (Id.)

         On February 13, 2017, Evans reported feeling “pretty good.” (Tr. 775-776.) She again denied manic/hypomanic symptoms and depressive episodes but stated she was “still having [auditory/visual hallucinations], making her daily functioning difficult.” (Id.) Evans also indicated she was having memory and concentration problems. (Id.) On examination, Ms. Venkatarman found Evans was alert and oriented to person, place and time, with clear speech and fair thought process, insight, and judgment. (Id.) She also determined Evans' mood/affect, thought content/perception, and cognition (orientation, memory, concentration, fund of knowledge) were all within normal limits. (Id.) Ms. Venkatarman changed Evans' diagnosis to schizoaffective disorder, bipolar type, noting Evans had a history of manic, depressive episodes and hallucinations “during the course of manic, depressive episodes and in between.” (Id.) She continued Evans on her medications. (Id.)

         2. Physical Impairments

         The first medical record cited by the parties relating to Evans' physical impairments is dated October 16, 2014, over two and a half years after her January 2012 onset date. (Tr. 505-510.) On that date, Evans began treatment with primary care physician Elizabeth Turbett, M.D., presenting for a comprehensive physical exam. (Id.) Evans complained of back pain and “all over pain.” (Tr. 505.) She reported suffering from scoliosis, lower back pain, and “bulging discs.” (Id.) Evans stated she had been treated by a “Dr. Lee, ”[3] who diagnosed her with fibromyalgia and prescribed Lyrica. (Id.) She stated she “does not exercise because it hurts to walk” and requested an increase in her Lyrica dosage. (Id.) On examination, Dr. Turbett noted as follows:

Musculoskeletal: Gait is normal with toe and heel walking and no foot drop . Extremities: Full Range of motion and strength throughout. Inspection of the cervical spine reveals normal findings. There is no tenderness to palpation. Range of Motion: normal flexion, extension, rotation and lateral bending. Inspection of the lumbar spine reveals normal lumbar lordosis. There is minimal tenderness of the lumbar area. Range of motion of lumbar spine is limited in flexion and extension. The lumbar spine is stable. Bilateral Straight leg raise is negative. * * *

(Tr. 507.) Dr. Turbett also noted normal motor strength and tone, normal reflexes, and no edema. (Id.) She diagnosed backache, unspecified; “unspecified myalgia and myositis;” and gastroesophogeal reflux disease (“GERD”). (Tr. 508.) Dr. Turbett continued Evans on her current medications and dosages, and advised her to exercise five times per week for twenty minutes each time. (Tr. 509.)

         Evans returned to Dr. Turbett on December 4, 2014 with complaints of urinary frequency. (Tr. 497-499.) Dr. Turbett diagnosed a urinary tract infection and prescribed antibiotics. (Id.) She also increased Evans' Lyrica dosage. (Id.)

         Later that month, on December 22, 2014, Evans presented to Louis DeMicco, D.O., with complaints of neck and back pain. (Tr. 665-666.) She reported that “10 years ago she had an MRI of the lumbar spine and had some herniated disc, ” and was treated with nerve blocks. (Id.) On examination, Dr. DeMicco noted pain with rotation and flexion in Evan's neck, and pain to palpation in her lumbar spine. (Id.) He also noted good muscle strength in her upper and lower extremities, and negative straight leg raise. (Id.) Dr. DeMicco assessed cervical neck pain, thoracic back pain, lumbar back pain, and history of lumbar disc disease. (Id.) He referred her for physical therapy and chiropractic care. (Id.) Dr. DeMicco indicated Evans was “going to stick with her over the counter medications, ” noting she alternates between Ibuprofen and Naproxen. (Id.)

         Evans presented for physical therapy on December 29, 2014. (Tr. 664.) She complained of neck and upper back pain that “at times can cause her significant discomfort.” (Id.) The physical therapist (whose name is illegible) noted pain to palpation along her cervical and thoracic spines, as well as reduced muscle strength. (Id.)

         On January 22, 2015, Evans returned to Dr. DeMicco for follow up. (Tr. 663.) She reported doing physical therapy twice per week and indicated it was helping her lower back pain. (Id.) On examination, Dr. DeMicco noted pain and tenderness along Evans' lumbar spine. (Id.) Straight leg raise was negative. (Id.) He recommended Evans continue her chiropractic care and physical therapy, while he attempted to get insurance approval for an MRI of Evan's lumbar spine. (Id.)

         The record reflects Evans returned for physical therapy on February 16, 2015. (Tr. 662.) She indicated that, since beginning therapy, “she has improved and was feeling better until she fell on ice about four days ago.” (Id.) The therapy again noted pain to palpation along Evans' cervical and thoracic spines, as well as reduced muscle strength. (Id.)

         On February 23, 2015, Evans returned to Dr. DeMicco. (Tr. 661.) She indicated she had been doing physical therapy twice per week and saw a chiropractor once per week. (Id.) Evans stated her pain was an 8 on a scale of 10 in her lumbar back, and a 6 out of 10 in her neck and mid back. (Id.) Dr. DeMicco noted tenderness across Evans' cervical and lumbar spines, but stated she was neurologically intact with negative straight leg raise testing. (Id.)

         Evans returned to Dr. Turbett on March 3, 2015. (Tr. 494-496.) She “first complained about back pain, but she has had this for many years.” (Tr. 494.) Evans also reported urinary frequency and urgency, burning with urination, and nausea. (Id.) Dr. Turbett diagnosed a urinary tract infection and prescribed antibiotics. (Tr. 495-496.)

         Three days later, on March 6, 2015, Evans presented to the emergency room (“ER”) with complaints of “general weakness, ” lightheadedness, and slurred speech. (Tr. 373, 377, 392.) A chest x-ray taken that date was compatible with right lung infection or inflammation. (Tr. 426.) An EKG showed sinus tachycardia. (Tr. 390.) She was diagnosed with an acute lower urinary tract infection and pneumonia, prescribed antibiotics, and discharged home. (Tr. 373, 431.)

         On March 23, 2015, Evans returned to Dr. DeMicco for follow up regarding her neck and back pain. (Tr. 660.) She stated both her neck and back were still “bothering her, ” and indicated her pain was a 6 on a scale of 10. (Id.) On examination, Dr. DeMicco noted “some tenderness across the cervical and lumbar spine with pain with range of motion.” (Id.) He also found she was neurologically intact with negative straight leg raise. (Id.) Dr. DeMicco recommended she continue with therapy and chiropractic care, but stated “her pain does not seem to be improving despite the therapy.” (Id.)

         Evans presented for physical therapy on April 2, 2015. (Tr. 659.) She reported she was “feeling better” but continuing to have difficulty with bending and lifting activities. (Id.) The physical therapist noted signs and symptoms “indicative of [major muscle] spasms along upper and mid back, as well as overall deconditioning.” (Id.)

         On April 13, 2015, Evans returned to Dr. DeMicco. (Tr. 658.) She reported physical therapy and chiropractic care “does help.” (Id.) On examination, Dr. DeMicco noted tenderness, muscle spasm, and pain with range of motion. (Id.) He indicated Evans was going to continue with over the counter pain medication, physical therapy, and chiropractic treatment. (Id.)

         Evans presented to Dr. Turbett on April 14, 2015. (Tr. 487-490.) She complained of cough, dysuria, and urinary frequency. (Tr. 487.) A chest x-ray taken that date showed “clearing of diffuse pneumonitis in the right lung” as compared to the March 6, 2015 x-ray. (Tr. 358, 485.) Dr. Turbett assessed urinary tract infection and pneumonia, and prescribed antibiotics. (Tr. 488-489.)

         Evans returned to physical therapy on May 1, 2015. (Tr. 657.) She reported “feeling better” but stated she continued to have difficulty with head turning. (Id.)

         On May 11, 2015, Evans presented to Dr. DeMicco with complaints of continuing pain in her neck and lower back, which she rated a 6 on a scale of 10. (Tr. 656.) Examination revealed tenderness across Evans' neck. (Id.) Straight leg raise testing was, again, negative. (Id.)

         On August 5, 2015, chiropractor Justin Wirick, D.C., submitted a letter regarding Evans' physical impairments, follows:

Ms. Jennifer Evans was under my care for full spine complaints January 2015 through May 2015. At that time, she exhibited consistent lower [lumbar spine] dystxn and recurrent pain that interfered with her abilities to perform her daily activities. She ceased treatment in May 2015 because she ran out of medical benefits; however, her symptoms had not stabilized at that time. I cannot comment on her current physical status since 3 months have passed since last eval[uation], however she was functionally compromised [due to] lumbar-based [symptoms] in May 2015.

(Tr. 655.)[4]

         On August 21, 2015, Evans returned to Dr. Turbett with complaints of “fibromyalgia aned all over pain” that seemed to be worsening. (Tr. 479-481.) She stated she walks every day, but cannot stand or sit for prolonged periods. (Tr. 479.) Evans requested an increase in her Lyrica dosage because “she does not feel it is as effective and has pain all over on some days.” (Id.) Evans also requested “a letter for her lawyer stating she has significant disability and is unable to work.” (Id.) Dr. Turbett indicated “I have previously received notice from her lawyer and stated I would not do testing to determine her disability and told her the same thing today.” (Id.)

         On examination, Dr. Turbett found “no pain at random trigger points when done as part of rest of exam.” (Tr. 480.) She also noted no tenderness to palpation of the lumbar spine, normal strength, and negative bilateral straight leg raise. (Id.) Dr. Turbett assessed backache, unspecified; and “unspecified myalgia and myositis.” (Id.) She increased Evans' Lyrica dosage and referred her to a chiropractor. (Id.)

         Evans returned to Dr. Turbett on November 24, 2015 for a comprehensive physical exam. (Tr. 616-620) She complained of back pain and “all over pain.” (Tr. 616.) On examination, Dr. Turbett noted:

Musculoskeletal: Gait is normal with toe and heel walking and no foot drop . Extremities: Full Range of motion and strength throughout. Inspection of the cervical spine reveals normal findings. There is no tenderness to palpation. Range of Motion: normal flexion, extension, rotation and lateral bending. Inspection of the lumbar spine reveals normal lumbar lordosis. There is minimal tenderness of the lumbar area. Range of motion of lumbar spine is limited in flexion and extension. The lumbar spine is stable. Bilateral Straight leg raise is negative. * * *

(Tr. 618.) She also noted normal muscle strength and tone and no edema. (Id.) Dr. Turbett assessed GERD; dorsalgia, unspecified; fibromyalgia; and hypercholesterolemia. (Tr. 619.) She continued Evans on her medications and encouraged her to exercise five times per week. (Tr. 619-620.)

         The record reflects Evans presented for physical therapy on February 18, 22, and 24, 2016. (Tr. 726-728.) On each of these visits, she rated her pain a 7 on a scale of 10. (Id.) She reported difficulty sleeping and “having a hard time doing chores around the house.” (Tr. 726, 727.)

         On March 1, 2016, Evans presented to the ER with complaints of chest pain that radiated down her left arm, weakness, cough, and shortness of breath. (Tr. 622, 627, 637.) A chest x-ray taken that date showed no acute findings. (Tr. 640, 652.) Evans was diagnosed with acute bronchitis; prescribed antibiotics, prednisone and albuterol; and discharged home. (Tr. 622, 640, 642.)

         Evans presented for physical therapy on four occasions in March 2016. (Tr. 722-725.) On each visit, she rated her pain a 7 or 8 on a scale of 10. (Id.) Evans reported difficulty lifting and turning her neck. (Tr. 724, 725.) By mid-March, she reported improved sleep. (Tr. 722.)

         On March 29, 2016, Evans presented to Dean Pahr, D.O., for evaluation of her back pain. (Tr. 766-767.) She reported she had been “hurting a very long time chronically, ” and rated her pain a 7 on a scale of 10. (Id.) Examination findings were normal. (Id.) A lumbosacral spine x-ray taken that date was unremarkable. (Tr. 768.) Dr. Pahr assessed lumbar radiculitis, fibromyalgia, and chronic pain syndrome. (Tr. 767.)

         On April 22, 2016, Evans presented to the ER with complaints of shortness of breath, fever, sweating, nausea, dizziness, blurry vision, weakness, and visual hallucinations. (Tr. 729, 730, 736, 744.) A chest x-ray taken that date was normal. (Tr. 749-750.) Evans was diagnosed with acute urinary tract infection, prescribed antibiotics, and discharged home in stable condition. (Tr. 750.)

         Evans returned to Dr. Turbett on May 3, 2016. (Tr. 670-672.) She complained of urinary frequency and irritation. (Id.) Dr. Turbett diagnosed a urinary tract infection, and prescribed antibiotics. (Id.)

         Evans returned to physical therapy on July 7 and 14, 2016. (Tr. 720-721.) She rated her pain a 6-7 on a scale of 10, and stated “she has difficulty working ...


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