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Coburn v. Berryhill

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

March 5, 2019

CINDY LYNN COBURN, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          DONALD C. NUGENT, JUDGE

          REPORT AND RECOMMENDATION

          Jonathan D. Greenberg, United States Magistrate Judge

         Plaintiff, Cindy Lynn Coburn, (“Plaintiff” or “Coburn”), challenges the final decision of Defendant, Nancy A. Berryhill, [1] Acting Commissioner of Social Security (“Commissioner”), denying her application for Period of Disability (“POD”) and Disability Insurance Benefits (“DIB”), under Title II 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 that the Commissioner's final decision be VACATED and the case REMANDED for further consideration.[2]

         I. PROCEDURAL HISTORY

         In January 2015, Coburn filed an application for POD and DIB, alleging a disability onset date of December 22, 2009 and claiming she was disabled due to rheumatoid arthritis, diabetes, neuropathy, lupus, and fibromyalgia. (Transcript (“Tr.”) 15, 250.) The application was denied initially and upon reconsideration, and Coburn requested a hearing before an administrative law judge (“ALJ”). (Tr. 15, 125-127, 129-136.)

         On December 21, 2016, an ALJ held a hearing, during which Coburn, represented by counsel, and an impartial vocational expert (“VE”) testified. (Tr. 34-93.) On April 27, 2017, the ALJ issued a written decision finding Coburn was not disabled. (Tr. 15-33.) The ALJ's decision became final on February 2, 2018, when the Appeals Council declined further review. (Tr. 1-6.)

         On March 23, 2018, Coburn filed her Complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 16, 19, 20.) Coburn asserts the following assignments of error:

(1) The ALJ improperly considered the medical opinion offered by the Commissioner's psychological consultant Bonnie Katz, Ph.D.
(2) The ALJ's determination that Plaintiff did not meet Listing 14.06A is not supported by substantial evidence.

(Doc. No. 16.)

         II. EVIDENCE

         A. Personal and Vocational Evidence

          Coburn was born in June 1968 and was 48 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 & 416.963. She has at least a high school education and is able to communicate in English. (Id.) She has past relevant work as a child daycare worker and teacher aide. (Id.)

         B. Relevant Medical Evidence[3]

         At the outset, the Court notes the recitation of the facts in the Commissioner's Brief on the Merits is perfunctory and fails to comply with this Court's Initial Order. In relevant part, that Order (Doc. No. 8) states: “Defendant's brief shall specifically address the legal issues and facts cited by plaintiff and shall cite, by exact and specific transcript page number, all relevant facts in a ‘Facts' section.” (Id. at 3.) (emphasis added). Here, the Commissioner's entire discussion of the lengthy medical record[4] in this case is one and a half pages long, consisting of no more than four short paragraphs. (Doc. No. 19 at 2-3.) The Facts section of the Commissioner's Brief does not address the thorough recitation of the facts set forth in Plaintiff's Brief and, of particular concern, fails entirely to discuss any of the numerous treatment notes, imaging reports, and other medical evidnce from the nearly five year period between Coburn's December 2009 alleged onset date and October 2014. (Id.) The Commissioner does not provide any explanation for failing to discuss the medical evidence for this extended time period.

         As the Court limits its discussion of the medical evidence to the evidence cited in the Fact Sections of the parties' Briefs, the Commissioner's failure to thoroughly address the medical evidence in accordance with this Court's Order is concerning. The Commissioner is in breach of this Court's Order in the instant case and, moreover, has failed to abide by this Court's briefing requirements in other recent social security cases as well.[5] The Commissioner is cautioned that there will be consequences for any further breaches of this Court's Orders.

         1. Physical Impairments

         On January 19, 2010, Coburn presented to rheumatologist Terrance Foley, M.D., with complaints of foot, hip, knee, and shoulder pain. (Tr. 940.) She reported experiencing foot pain for the past several years, and indicated it had become “really severe” during the previous six months.[6] (Id.) On examination, Dr. Foley noted reduced range of motion in Coburn's knees, ankles, right shoulder, and spine; and multiple tender points. (Tr. 937.) He also found normal pulses, normal gait, normal muscle strength, and no edema. (Id.) Dr. Foley assessed “atypical arthralgia, ” prescribed Relafen, and ordered blood work. (Id.)

         The following month, Coburn reported she was “no better.” (Tr. 936.) She complained of morning stiffness, fatigue, muscle cramps in her lower extremities, and tenderness in her feet, heels, and fingers. (Id.) Dr. Foley noted Coburn had positive ANA and stated a diagnosis of inflammatory arthritis should be considered. (Tr. 935-936.) Examination revealed reduced range of motion in her hips, knees, ankles, and spine; tenderness in her bilateral feet; tender points; and normal gait. (Tr. 935.) Dr. Foley assessed osteoarthritis, possible rheumatoid arthritis, positive ANA, and Vitamin D deficiency. (Tr. 936.) He prescribed Tramadol. (Tr. 935.)

         In March and April 2010, Coburn continued to report pain in multiple joints (i.e., her wrists, ankles, hands, feet, hips, and knees), as well as muscle cramps, morning stiffness, and fatigue. (Tr. 933-934, 931-932.) Examination findings included reduced range of motion, tender points, knee crepitus, and normal gait. (Id.) Coburn reported she was able to do her activities of daily living, but with pain. (Tr. 932.) Dr. Foley prescribed Tramadol and Flexeril. (Tr. 931.)

         In September 2010, Coburn indicated she was “doing better” with only mild joint pain and stiffness. (Tr. 930.) She rated her pain on that date a 3-4 on a scale of 10, and indicated she was able to do her activities of daily living with pain. (Id.) On examination, Dr. Foley noted reduced range of motion in Coburn's hips, knees, and spine; knee crepitus; mild tender points; and normal gait. (Tr. 929.) He continued her on her medications. (Id.)

         On March 18, 2011, Coburn reported increased pain and stiffness in her knees, hips, and shoulders, as well as fatigue and morning stiffness. (Tr. 927-928.) Examination revealed reduced range of motion in her hips, knees, and spine; tenderness in her fingers, shoulders, hips, knees, and feet; mild tender points, normal muscle strength; and antalgic gait. (Tr. 927.) Dr. Foley continued Coburn on her medications and ordered x-rays of her knees, which she underwent that date. (Tr. 927, 1043.) The x-rays showed moderate to severe osteoarthritis in Coburn's bilateral feet, including findings of subchondral sclerosis, extensive hypertrophic osteophytosis, and narrowing of the patellofemoral compartments. (Id.)

         On August 9, 2011, Coburn presented to primary care physician Julia Heng, M.D., with complaints of swelling in her legs, feet, and hands. (Tr. 725.) Dr. Heng did not observe edema on that date, but nonetheless prescribed medication. (Id.)

         Coburn returned to Dr. Foley on October 10, 2011. (Tr. 923-924.) She stated she was “better” but still experienced pain and burning in her feet. (Id.) Examination revealed decreased range of motion in her hips and knees, and normal gait. (Id.) Dr. Foley assessed positive ANA and degenerative disc disease, increased her Relafen dosage, and prescribed Gabapentin. (Id.) Coburn returned later that month, with continued complaints of numbness and dysthesias in her bilateral feet. (Tr. 921-922.) Dr. Foley assessed diabetes mellitus, peripheral neuropathy, osteoarthritis, and positive ANA. (Id.) He increased her Gabapentin dosage, and recommended Vitamin B12 injections. (Id.)

         On February 10, 2012, Coburn returned to Dr. Foley with complaints of foot pain, “burning [foot] dysesthesia in a stocking distribution, ” fatigue, and difficulty sleeping. (Tr. 917-918.) Examination revealed reduced range of motion in her hips, knees, and spine; tenderness in her feet; multiple tender points; reduced vibratory sensation; normal muscle strength; and negative straight leg raise. (Id.) Dr. Foley assessed (1) possible connective tissue disorder (“CTD”) with arthralgia, stiffness, and fatigue; (2) probable fibromyalgia with poor sleep, fatigue, and tender points; and (3) probable depression. (Id.) He ordered an electromyography (“EMG”)/nerve conduction study (“NCS”), and blood work; and prescribed Trazodone. (Id.)

         Coburn underwent the EMG/NCS on February 14, 2012, which was within normal limits. (Tr. 1050.) However, the interpreting physician noted that small fiber neuropathy could not be ruled out. (Id.)

         On July 9, 2012, Coburn complained of fatigue, insomnia, and pain in her feet, ankles, hips, and back. (Tr. 913-914.) She rated her pain an 8 on a scale of 10. (Id.) On examination, Dr. Foley noted reduced range of motion in Coburn's hips and knees, multiple tender points, and normal gait. (Id.) He also found Coburn had a “melancholy” affect. (Id.) Dr. Foley assessed osteoarthritis, fibromyalgia, and positive ANA rule out CTD. (Id.) He increased her Trazodone and Gabapentin dosages. (Id.)

         The following month, Coburn continued to complain of pain, particularly in her feet. (Tr. 909-910.) She also reported fatigue, insomnia, numbness, and dysesthesias. (Id.) Examination revealed reduced range of motion, multiple tender points, and a slightly antalgic gait. (Id.) Dr. Foley prescribed Cymbalta. (Id.)

         On February 13, 2013, Coburn stated she was “doing better” and reported improvement with Cymbalta and Trazodone. (Tr. 907-908.) On examination, Dr. Foley noted reduced range of motion in her hips, knees, and spine; and normal gait. (Id.) He assessed undifferentiated connective tissue disorder with positive ANA, fibromyalgia, osteoarthritis, peripheral neuropathy, and insomnia. (Id.)

         Coburn returned to Dr. Foley on June 19, 2013 with complaints of chronic neck, shoulder, and spine pain, which she rated a 5 on a scale of 10. (Tr. 420-425.) She also complained of chronic fatigue and insomnia. (Id.) Examination revealed reduced range of motion in Coburn's hips, knees, and spine; right shoulder tenderness; multiple tender points; and normal gait. (Tr. 423.) Dr. Foley assessed undifferentiated connective tissue disease with positive ANA, rashes, and arthralgias. (Tr. 424.) He also diagnosed osteoarthritis, peripheral neuropathy, and fibromyalgia, each of which had mild or minimal symptoms on current treatment. (Id.) Dr. Foley noted, however, that Coburn's insomnia was “not completely helped with current meds, ” and increased her Trazodone dosage. (Id.)

         On December 16, 2013, Coburn returned to Dr. Foley and reported “feeling low.” (Tr. 414-419.) She complained of poor concentration and memory, dizziness, fatigue, “frequent crying, ” insomnia, morning stiffness, weakness, and peripheral neuropathy with dysesthesias in her feet. (Tr. 414-415.) Coburn stated “she is able to do all activities of daily living but is having difficulty coping with her feelings of depression and fatigue.” (Tr. 414.) On examination, Dr. Foley noted normal muscle strength, normal pulses, normal gait, multiple tender points, and reduced range of motion in her shoulders, hips, knees, and spine. (Tr. 417-418.) Dr. Foley advised Coburn to resume taking Cymbalta, ordered blood work, and “strongly encouraged her to seek counseling and further treatment with psychiatry.” (Tr. 418.)

         On March 27, 2014, Coburn presented to physician assistant Joana Zula, P.A., from Dr. Foley's office with complaints of chronic pain. (Tr. 408-413.) Ms. Zula recorded Coburn's many symptoms, as follows:

The patient has undifferentiated connective tissue disease with positive ANA, rashes, and arthralgias. She is on treatment with Plaquenil. She has chronic neck, shoulder and spine pain. She resumed Cymbalta since the last office visit to help mitigate both the symptoms of pain and depression. She is still dealing with the recent loss of her parents in the fall of 2013. * * * The patient has experienced difficulty concentrating, feeling dizzy, and fatigue ever since this tragedy. She still feels depressed with frequent crying. She denies suicidal ideation. The joint pain is also getting worse, especially the right shoulder in the past 5 months. She has failed multiple NSAIDs, and they have caused gastritis in the past and are intolerable. She doesn't exercise but tried home therapy for the shoulder. She sleeps fair but is still fatigued constantly. She has difficulty falling asleep. She takes trazodone to help her sleep but is inconsistent with this. She is gaining weight. Her last thyroid level was on the high end of normal. She has a history of spontaneous rash. * * * She also has peripheral neuropathy with dysesthesias in the feet. This has been helped with gabapentin but the symptoms are still bothersome. She is able to do all activities of daily living but is having difficulty coping with her feelings of depression and fatigue.

(Tr. 408.) On examination, Ms. Zula noted reduced range of motion in Coburn's right shoulder, bilateral hips and knees, and spine; right shoulder tenderness; multiple tender points; and normal gait, pulses, and reflexes. (Tr. 411-412.) She assessed (1) undifferentiated connective tissue disease with positive ANA; (2) osteoarthritis in multiple sites; (3) peripheral neuropathy, with moderate symptoms on medication; (4) fibromyalgia; (5) depression; (6) chronic debilitating fatigue; and (7) Vitamin B12 deficiency despite injections. (Tr. 412.) Ms. Zula ordered a Vectra DA to monitor Coburn's inflammatory arthritis activity, and an MRI of her right shoulder. (Id.) She also prescribed Synthroid, and strongly encouraged Coburn to seek counseling and treatment with psychiatry. (Id.)

         Coburn underwent an MRI of her right shoulder on April 3, 2014, which showed moderate supraspinatus tendinosis with high-grade partial bursal sided tear of the mid supraspinatus tendon measuring 5 mm in dimension. (Tr. 435.) She also underwent Vectra DA testing, which revealed a score of 42 indicating moderate disease activity despite Plaquenil therapy. (Tr. 402.)

         On April 15, 2014, Coburn returned to Ms. Zula with continued complaints of chronic pain, weakness, fatigue, dizziness, neuropathy, and depression. (Tr. 402-406.) Examination findings and diagnoses were the same as her previous visit. (Tr. 405-406.) Ms. Zula prescribed Arava for treatment of her connective tissue disease, and referred Coburn to orthopedic surgery for evaluation of her right shoulder right rotator cuff tear. (Tr. 406.)

         The following month, Coburn presented to Dr. Foley and reported worsening joint pain, particularly in her right shoulder and left ankle. (Tr. 396-401.) She also continued to complain of fatigue, depression, difficulty concentrating, weakness, and neuropathy in her feet. (Tr. 396-398.) Examination revealed widespread reduced range of motion, tenderness in her right shoulder and left ankle, tender points, and antalgic gait. (Tr. 400.) Dr. Foley assessed (1) undifferentiated connective tissue disease with positive ANA; (2) osteoarthritis in multiple sites; (3) peripheral neuropathy, with moderate symptoms on medication; (4) fibromyalgia; (5) depression; (6) chronic debilitating fatigue; and (7) Vitamin B12 deficiency despite injections. (Tr. 400.) He continued Coburn on her medications. (Tr. 401.)

         In July 2014, Coburn reported continued joint pain and fatigue. (Tr. 390.) She stated her “neuropathy is worse since she is on Arava, ” and rated her pain a 6 on a scale of 10. (Id.) Examination revealed widespread reduced range of motion, tenderness in her right shoulder and left ankle, tender points, and antalgic gait. (Tr. 394.) Ms. Zula prescribed Methotrexate and increased her Gabapentin dosage. (Tr. 394-395.)

         On August 8, 2014, Coburn returned to Dr. Heng. (Tr. 449-450.) She indicated she could no longer give herself B12 injections and requested that Dr. Heng provide them going forward. (Id.) Dr. Heng agreed, and gave Coburn an injection on that date. (Id.) The record reflects Coburn returned to Dr. Heng for B12 injections regularly in August, September, October, November, and December 2014. (Tr. 711, 709, 448, 705, 447, 696, 444-446.)

         On August 25, 2014, Coburn presented to Ms. Zula. (Tr. 383-389.) She reported continued joint pain, fatigue, weakness, insomnia, depression, and neuropathy. (Id.) Examination revealed reduced range of motion in her bilateral wrists, right shoulder, bilateral hips and knees, and spine; tenderness in her bilateral wrists, right shoulder, and left ankle; tender points; and antalgic gait. (Tr. 387.) Ms. Zula ordered an EMG/NCG of Coburn's upper extremities, prescribed Amrix for low back pain, and recommended switching to Methotrexate injections. (Tr. 387-388.)

         Several months later, on November 17, 2014, Coburn returned to Dr. Foley with complaints of significant shoulder, elbow, back and knee pain, along with morning stiffness, constant fatigue, frequent crying spells, and insomnia. (Tr. 377-379.) Dr. Foley ordered a repeat Vectra DA to monitor inflammatory arthritis disease activity, and continued her on her medications. (Tr. 381-382.) Coburn underwent the Vectra DA testing later that month, which revealed a score of 39 indicating moderate disease activity. (Tr. 426.)

         On February 23, 2015, Coburn continued to struggle with the same symptoms. (Tr. 370.) She rated her widespread joint pain a 5 on a scale of 10, and stated she was only able to walk moderate distances. (Id.) Examination revealed no edema; normal strength and pulses; reduced range of motion in her bilateral wrists, right shoulder, bilateral hips, bilateral knees, left ankle and spine; tenderness in her right shoulder, hips, and knees; tender points; and normal gait. (Tr. 373-374.) Dr. Foley assessed undifferentiated connective tissue disease with positive ANA; osteoarthritis; peripheral neuropathy and neuritis with mild to moderate symptoms on medication; fibromyalgia; depression; chronic debilitating fatigue; vitamin B12 deficiency;[7] and insomnia. (Tr. 374-375.) He continued Coburn on her medications and ordered additional Vectra DA testing to monitor her rheumatoid arthritis activity. (Tr. 375.)

         The following month, Coburn reported increased lower back pain, rating it a 7 on a scale of 10. (Tr. 363-364.) She also complained of fatigue, morning stiffness for one hour each morning, dizziness, weakness, poor concentration and memory, dysesthesias, insomnia, depression, and intermittent rashes. (Tr. 364-365.) Examination findings were the same as her previous visit. (Tr. 367.) Ms. Zula ordered an x-ray of Coburn's lumbar spine, and prescribed Lorzone and Vimovo. (Tr. 367-368.) Coburn underwent the x-ray that same day, which showed mild degenerative disc disease and lumbar spondylosis. (Tr. 434.)

         Later that month, Coburn underwent x-rays of her bilateral feet and ankles. (Tr. 432-433.) The foot x-ray showed (1) mild degenerative changes in the tarsal region and left foot; and (2) mild erosive and degenerative changes in the right foot. (Tr. 432.) The ankle x-rays were normal, aside from small plantar calcaneal spurs. (Tr. 433.)

         Coburn subsequently underwent an MRI of her left ankle on April 6, 2015. (Tr. 430.) It showed the following: (1) severe osteoarthritis of the second, third, and fourth tarsometatarsal joints; (2) longitudinal peroneal brevis split tear as the tendon traverses the distal fibula measuring approximately 3cm; (3) mild synovitis in the common peroneal tendon sheath; and (4) mild chronic proximal plantar fasciitis. (Id.)

         On April 28, 2015, Coburn presented to podiatrist Jonathan Sharpe, D.P.M., for evaluation of her bilateral foot pain. (Tr. 649-650.) Examination revealed antalgic gait, bilateral edema, neurologic loss of protective sensation,  motor strength, normal muscle tone, and pain on palpation to the right plantar heel. (Id.) Dr. Sharpe assessed rheumatoid arthritis, degenerative joint disease of the foot/ankle, nontraumatic tendon rupture, Achilles tendinosis, and plantar fasciitis. (Tr. 650.) He prescribed ankle braces and referred Coburn to physical therapy. (Id.)

         Coburn returned to Ms. Zula on June 10, 2015, with reports of continued pain and fatigue. (Tr. 831-837.) Examination revealed reduced range of motion and tenderness in Coburn's fingers, wrists, right shoulder, hips, knees, and ankles; reduced spinal range of motion; tender points; and antalgic gait. (Tr. 835.) Ms. Zula noted Coburn's continued symptoms despite medication and found she “may require biologic therapy for better rheumatoid arthritis disease control.” (Id.) She also found Coburn's ambulation was “severely limited” and that her fibromyalgia symptoms were “debilitating” despite medication. (Tr. 835-836.) Ms. Zula concluded Coburn “is unable to work due to her arthritis condition.” (Id.) She ordered repeat Vectra DA testing and prescribed Wellbutrin to address Coburn's worsening depression. (Id.) Coburn underwent the Vectra DA testing that day, which revealed a score of 43 indicating high moderate rheumatoid activity. (Tr. 824.)

         On July 14, 2015, Coburn returned to Dr. Sharpe. (Tr. 647.) Examination again revealed antalgic gait, neurologic loss of sensation, and  muscle strength. (Id.) Dr. Sharpe encouraged Coburn to start formal physical therapy. (Id.)

         Several days later, on July 16, 2015, Coburn presented to Dr. Heng for follow-up after visiting the ER for a possible stroke earlier that month. (Tr. 669-670.) Dr. Heng noted Coburn had been diagnosed with Bell's palsy, and was receiving outpatient treatment from neurology. (Id.) On that date, Coburn rated her foot pain an 8 on a scale of 10. (Id.) Examination revealed left eyelid weakness but no facial drooping. (Id.) Dr. Heng increased Coburn's Wellbutrin dosage. (Id.)

         On August 5, 2015, Coburn presented to neurologist Joshua Sunshine, M.D., for follow-up regarding her Bell's palsy. (Tr. 774-776.) She complained of multiple symptoms, including neuropathy, tremor, fatigue, reduced vision, muscle pain and weakness, headache, memory problems, depression and anxiety. (Tr. 774.) Coburn denied difficulty performing daily activities, however. (Id.) Examination findings were normal, aside from “low amplitude high- frequency tremor with hand extended.” (Tr. 775-776.) Dr. Sunshine assessed Bell's palsy, essential tremor, and polyneuropathy; and prescribed Mysoline. (Id.)

         On August 12, 2015, Coburn presented to endocrinologist Brian Burtch, M.D., for treatment of her diabetes.[8] (Tr. 748.) She reported neuropathic symptoms in her feet. (Id.) Examination revealed decreased sensation. (Id.) Dr. Burtch assessed (1) type 2 diabetes with neuropathic symptoms uncontrolled; (2) hypertension; (3) dyslipidemia; (4) Hashimoto's disease; and (4) Vitamin B12 deficiency. (Id.)

         Coburn returned to Dr. Foley on September 24, 2015. (Tr. 824-830.) She was tearful and complained of joint pain, leg cramps with standing and walking, fatigue, dizziness, weakness, poor concentration and memory, headache, and dysesthesias and numbness in her feet. (Tr. 825-826, 828.) Examination revealed reduced range of motion and tenderness in her fingers, wrists, right shoulder, hips, knees, and ankles; negative straight leg raise; tender points; no edema; normal muscle strength; and antalgic gait. (Tr. 828-829.) Dr. Foley noted that: “Her ambulation is severely limited. She is working with podiatry and wears ankle braces. She is unable to work due to all her arthritic conditions.” (Tr. 829.) He continued her on her medications, and recommended she begin IV Remicade infusions for her rheumatoid arthritis. (Id.)

         On October 12, 2015, Coburn returned to Dr. Sunshine with complaints of hand tremor and “some tingling in her hands and feet.” (Tr. 770-771.) Examination revealed normal gait, negative Romberg's, normal muscle bulk and tone, normal muscle strength, reduced sensation to Coburn's mid-thighs, and abnormal reflexes. (Tr. 772.) Dr. Sunshine noted improvement in Coburn's Bell's palsy, but continued problems with her neuropathy and tremor. (Id.) He ordered lab work and prescribed Pamelor. (Id.)

         On October 30, 2015, Coburn returned to Ms. Zula with complaints of continued joint pain, which she rated a 7 out of 10. (Tr. 818-819.) Examination revealed widespread tenderness and reduced range of motion in Coburn's joints, swelling in her fingers and wrists, negative straight leg raise, tender points, and antalgic gait. (Tr. 820.) Coburn underwent her first infusion on that date. (Tr. 821.)

         On November 30, 2015, Coburn reported no change in her symptoms after starting infusion therapy. (Tr. 1094.) She rated her pain a 7 out of 10, and complained of continued joint pain, fatigue, and morning stiffness. (Tr. 1094-1096.) Examination findings were the same as her previous visit. (Tr. 1096.) Ms. Zula noted that, despite treatment, Coburn's fatigue was “still profound.” (Tr. 1097.) Coburn underwent her second infusion. (Id.)

         Coburn also presented to Dr. Sunshine on that same date. (Tr. 1073-1074.) She continued to complain of joint and muscle pain, numbness and tingling. (Id.) Dr. Sunshine ordered a skin biopsy of Coburn's left thigh, which showed “significantly reduced epidermal nerve fiber density, consistent with small fiber neuropathy.” (Tr. 1071, 1077.)

         On January 7, 2016, Coburn reported to Ms. Zula that she had not noted any change in her symptoms as a result of the IV infusions. (Tr. 1087-1093.) She complained of joint pain, fatigue, morning stiffness, muscle cramps, weakness, dysesthesia and numbness in her feet, poor concentration and memory, and insomnia; and rated her pain a 7 on a scale of 10. (Tr. 1087- 1089.) Examination again revealed widespread tenderness and reduced range of motion in Coburn's joints, swelling in her fingers and wrists, negative straight leg raise, tender points, and antalgic gait. (Tr. 1091-1092.) Her affect was tearful. (Tr. 1092.) Ms. Zula noted that Coburn's (1) fibromyalgia symptoms were “debilitating” despite treatment; (2) fatigue was “still profound, ” and (3) ambulation was “severely limited.” (Id.) She continued Coburn on her medications, and ordered further Vectra DA testing. (Id.) Coburn underwent the testing several days later, which revealed a score of 45 indicating high rheumatoid arthritis activity. (Tr. 1105.)

         Coburn returned to Dr. Sunshine on January 26, 2016. (Tr. 1075-1076.) She complained of continuing achiness in her hands and feet. (Id.) Examination findings were normal with the exception of abnormal reflexes and reduced pinprick sensation in Coburn's mid-thighs. (Id.) Dr. Sunshine continued Coburn on her medication. (Id.)

         Two days later, Coburn returned to Ms. Zula for IV infusion. (Tr. 1082-1085.) Ms. Zula noted Coburn had “a low grade fever on exam again today, ” as well as chronic fatigue. (Tr. 1082-1083.) Examination findings were the same as her previous visit. (Tr. 1084.)

         On March 24, 2016, Coburn returned to Dr. Foley. (Tr. 1203-1209.) Since her last infusion, she reported “less stiffness and less pain, especially in the feet, hands and wrists.” (Tr. 1203.) However, she continued to complain of “significant ankle pain and swelling and finger IP pain.” (Id.) Dr. Foley noted Coburn's ankle braces had not provided significant relief, and found “her ambulation is severely limited because of the ankles.” (Id.) He also noted Coburn suffered from chronic low back pain, peripheral neuropathy, chronic fatigue, chronic depression, undifferentiated connective tissue disease with positive ANA, and rheumatoid arthritis. (Tr. 1203, 1208.) Examination revealed reduced range of motion in Coburn's fingers, wrists, right shoulder, hips, knees, ankles and spine; tenderness in her PIP joints, right shoulder, hips, knees, and ankles; swelling in her ankles; tender points; antalgic gait; and tearful affect. (Tr. 1207-1208.) Dr. Foley continued her on her medications, including her infusion therapy. (Tr. 1209.) The record reflects Coburn underwent an infusion that date. (Tr. 1202.)

         On May 19, 2016, Coburn again showed widespread tenderness and reduced range of motion in her joints, swelling in her wrists and fingers, tender points, and antalgic gait. (Tr. 1197-1201.) She received an IV infusion on that date. (Tr. 1200.)

         Several days later, on May 24, 2016, Coburn returned to Dr. Heng. (Tr. 1141-1143.) She reported difficulty walking, and rated her pain a 6 on a scale of 10. (Tr. 1141.) Examination revealed “no feeling at all [in her] bilateral feet.” (Tr. 1142.)

         Coburn returned to Ms. Zula on July 14, 2016. (Tr. 1189-1196.) She reported joint pain (particularly in her ankles and fingers), chronic fatigue, morning stiffness, weakness, dysesthesia and numbness in her feet, poor concentration and memory, muscle cramps, and insomnia. (Id.) Coburn was tearful on examination, and showed widespread tenderness and reduced range of motion in her joints, tender points, and antalgic gait. (Tr. 1193-1194.) She underwent an IV infusion that date, and Ms. Zula ordered further Vectra DA testing. (Tr. 1195.) Coburn underwent the testing on July 20, 2016, which revealed a score of 43 indicating moderate rheumatoid arthritis activity. (Tr. 1218.)

         On September 8, 2016, Coburn presented to Dr. Foley. (Tr. 1180-1186.) He noted that, even with six doses of infusion therapy, Coburn “still has significant ankle pain with swelling, and moderate finger PIP, MCP and wrist swelling with pain.” (Tr. 1180.) With regard to her connective tissue disorder with positive ANA, Dr. Foley found Coburn “still has moderate joint pain and swelling as above and moderate fatigue.” (Id.) Examination findings were the same as her previous visit with Ms. Zula. (Tr. 1184-1185.) Dr. Foley noted Coburn “still experiences moderately severe pain associated with synovitis, ” noting her “ambulation is severely limited” and “she is unable to work due to all her arthritic symptoms.” (Tr. 1186.) He recommended a change in Coburn's biologic treatment “because of the poor response to ...


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