United States District Court, N.D. Ohio, Eastern Division
R. ADAMS JUDGE
REPORT AND RECOMMENDATION
KATHLEEN B. BURKE UNITED STATES MAGISTRATE JUDGE
Elisa Avery (“Plaintiff” or “Avery”)
seeks judicial review of the final decision of Defendant
Commissioner of Social Security (“Commissioner”)
denying her application for Disability Insurance Benefits
(“DIB”). This Court has jurisdiction pursuant to
42 U.S.C. § 405(g). This matter has been referred to the
undersigned Magistrate Judge for a Report and Recommendation
pursuant to Local Rule 72.2.
reasons explained herein, the undersigned recommends that the
Court AFFIRM the Commissioner's
protectively filed an application for DIB on April 17, 2014,
alleging a disability onset date of April 7, 2014. Tr. 10,
90, 91, 162-165, 181. She alleged disability due to postural
orthostatic tachycardia syndrome (“POTS”),
orthostatic intolerance, vestibular migraines, asthma, and
sinus tachycardia. Tr. 91, 103, 120, 125, 185. After initial
denial by the state agency (Tr. 120-123) and denial upon
reconsideration (Tr. 125-127), Avery requested a hearing (Tr.
129-130). A hearing was held before an Administrative Law
Judge (“ALJ”) on April 12, 2016. Tr. 39-89.
March 1, 2017, decision (Tr. 7-30), the ALJ determined that
Avery had not been under a disability from April 7, 2014,
through the date of the decision (Tr. 10, 24). Avery
requested review of the ALJ's decision by the Appeals
Council. Tr. 159-161. On February 14, 2018, the Appeals
Council denied Avery's request for review, making the
ALJ's decision the final decision of the Commissioner.
Personal, educational, and vocational evidence
was born in 1988. Tr. 45. She lived with her husband and two
minor sons. Tr. 46. Avery has a high school education plus
one year of online college courses. Tr. 47, 186. At the time
of the hearing, Avery was taking one online course. Tr. 77.
The school she was taking the classes through was set up for
students to take one course at a time. Tr. 77. She had one
year to complete and pass the course and, once that was
achieved, she could move on to the next course. Tr. 77.
Because of her health problems, some of Avery's education
involved home schooling. Tr. 48. Avery's work history
involved work at daycare centers as a childcare
provider/teacher assistant and a site supervisor, which
involved managing other childcare providers. Tr. 48-50,
51-53. Avery also worked at a tax service company doing tax
preparation. Tr. 50-51.
November 8, 2013, Avery saw Dr. Yuebing Li, M.D., Ph.D., a
physician in the Neuromuscular Center of the Cleveland Clinic
for her chief complaint of dizziness. Tr. 289-291. Dr. Li
noted that Avery had been seen and evaluated by Dr. Frederick
Jaeger. Tr. 289. Avery relayed that her first symptoms
started when she was a teenager in high school. Tr. 289. One
day in September 2003, Avery passed out and fell backwards
while she was dancing. Tr. 289. She felt her heart beating
fast at that time. Tr. 289. Avery had been sick with a cold
that week. Tr. 289. She was treated at the emergency room
with IV fluid. Tr. 289. Testing and bloodwork was negative.
Tr. 289. Avery reported that, since that time, she had
numerous instances of dizzy spells and loss of consciousness
as well. Tr. 289. Initially, her treatment consisted of
returning to the hospital to receive IV fluids. Tr. 289.
Avery had to be home schooled. Tr. 289. Avery was working
full time when she saw Dr. Li. Tr. 289. In 2004, Avery was
finally diagnosed with POTS. Tr. 289. She had several
tilt-table tests that were positive. Tr. 289. She was treated
with various medications between 2007 and 2011 but had
stopped taking them. Tr. 289. Without medication, Avery's
symptoms continued and remained about the same. Tr. 289. At
the time of her visit, Avery indicated she had four to seven
episodes of dizziness per day, each episode lasting a few
minutes. Tr. 289. Her dizzy episodes were triggered by
multiple factors, e.g., heat, putting arms overhead, standing
up too fast, etc. Tr. 289. Avery reported having episodes of
near syncope four to five times each week. Tr. 290. She had
last passed out in August 2013 and recalled three or four
episodes of loss of consciousness that year. Tr. 290. Avery
relayed that she drank three liters of water per day and
consumed six to eight grams of salt each day. Tr. 290. She
wore compression stockings to the knee level and started
cardiac rehabilitation in July 2013. Tr. 290. She had
recently started taking some midodrine but it was not
helping her much. Tr. 290. Avery reported feeling tired most
of the time; having loss of feeling in her arms and legs;
having pain in her right leg a few times each week for a few
hours at a time; having chronic pain; and having migraine
headaches about twice per week that lasted on average for a
day and sometimes several days. Tr. 290.
concluded that it was clear that Avery had a longstanding
history of POTS, which had started following an infection.
Tr. 291. Dr. Li indicated that Avery had undergone a lot of
behavioral modifications for POTS. Tr. 291. Dr. Li also
indicated that Avery's dizziness might not be totally
explained by POTS, noting that Avery had significant migraine
attacks and that dizziness/vertigo was a common symptom in
individuals with such frequent headaches. Tr. 291. Di. Li
noted that a significant portion of Avery's dizziness was
not postural and did not appear to reflect orthostatic
intolerance; Avery described a feeling of vertigo with
positional changes of her head even when lying in bed. Tr.
291. Dr. Li felt that further evaluation of Avery's
symptoms was warranted and referred her to Dr. Cherian who
specialized in treating dizziness/vertigo. Tr. 291. Dr. Li
also started Avery on Elavil for migraine prevention. Tr.
January and February 2014, Avery returned to see Dr.
Frederick J. Jaeger, Jr., D.O., at the Department of
Cardiovascular Medication, Section of Electrophysiology,
Center for Syncope and Autonomic Disorders, for reevaluation
of recurrent syncope and near syncope, lightheadedness,
migraines, and shortness of breath. Tr. 285-286. During her
February 24, 2014, visit with Dr. Jaeger, it was noted that
Avery tried exercising, augmenting her diet with fluid and
salt, and using compression stockings but she remained
symptomatic. Tr. 285. Avery had a recent episode, which
required hospitalization. Tr. 285. She had been having chest
pain, shortness of breath, tightness, diaphoresis,
lightheadedness and apparent loss of consciousness. Tr. 285.
The episode occurred while Avery was at work and it was
reported that she had had prolonged unresponsiveness despite
a normal heart rate and blood pressure. Tr. 285. During her
February 24, 2014, visit, Avery's vital signs were normal
and she was not tachycardic while in an upright posture. Tr.
285. Dr. Jaeger recommended a loop recorder and consultations
with general neurology and epilepsy. Tr. 285.
saw Dr. Jaeger for follow up on March 31, 2014. Tr. 263-267.
Avery's loop recorder had recently been removed due to an
infection. Tr. 264, 269. Avery felt that she was unable to
work full-time due to weakness, fatigue, palpitations,
lightheadedness, etc. Tr. 264. Dr. Jaeger felt that, if
Avery's full-time schedule was exacerbating her symptoms,
it seemed reasonable for her to cut back on that schedule if
her employer would allow it. Tr. 264. Following the visit, on
April 1, 2014, Dr. Jaeger authored a letter in support of her
desire to work part time (20 hours per week) until May 30,
Mrs. Avery's symptoms are exacerbated by working full
time and feels it would be beneficial to her well being to
reduce her weekly working hours. I agree with Mrs.
Avery's decision and hope that you can accommodate her
change in schedule.
April 22, 2014, Avery attended a physical therapy vestibular
evaluation at the Cleveland Clinic for her dizziness,
headaches, neck pain and POTS. Tr. 268-271. The evaluation
was conducted by Sunni Klein, PT (“physical therapist
Klein” or “Klein”). Tr. 271. The following
problems were observed during the evaluation: decreased range
of motion; decreased dynamic gait; decreased postural
control; decreased knowledge of symptom self-management;
dizziness; imbalance; and pain. Tr. 271. Avery complained of
being unable to lie flat due to spinning sensation. Tr. 271.
Klein noted that Avery's headaches improved with posture
correction and cervical retraction during the visit. Tr. 271.
Klein felt that Avery could benefit from positional testing
to rule out a vestibular component to her symptoms and that
Avery could benefit from physical therapy to address her
impairments and reduce her symptoms. Tr. 271.
April 23, 2014, Avery saw Dr. Jorge Calles, M.D., in the
endocrinology department for consultation for syncope and
orthostasis. Tr. 327-337. Dr. Calles concluded that the
hormonal evaluation did not identify a reason for Avery's
syncope. Tr. 332. Dr. Calles increased Avery's dose of
Florinef. Tr. 332. He recommended that Avery monitor her
blood sugar four times every day and at any time an episode
occurred. Tr. 332. Dr. Calles also recommended a fasting test
to rule out organic hypoglycemia and that Avery measure her
blood pressure at home three to four time every week. Tr.
332. Dr. Calles noted that neurology would be consulted to
rule out epilepsy, but Dr. Calles doubted that was the issue.
18, 2014, Avery sought treatment at the emergency room for
chest pain, shortness of breath, and a racing heart. Tr.
308-317. Avery reported that she had been having near
syncopal events two times each week for the past year. Tr.
310. She indicated that her chest pain was crushing and it
was worse with breathing. Tr. 310. Avery relayed that she
noticed that her heart rate monitor had gone to 191 that day.
Tr. 310. Avery indicated she was experiencing a migraine
during her emergency room visit. Tr. 310. She thought she
lost consciousness the night before. Tr. 310. The emergency
room assessment was slight dehydration and POTS. Tr. 310.
19, 2014, Avery had a physical therapy appointment. Tr.
914-915. Avery had to cancel her therapy appointment the
prior week due to elevated symptoms. Tr. 915. She reported
that she had been at the emergency room because her heart
rate kept shooting up. Tr. 914. Avery indicated she had been
given IV fluids at the hospital. Tr. 914. During her physical
therapy appointment, Avery was feeling better and did not
have a headache. Tr. 914. Because of elevated symptoms, Avery
indicated she had not been as compliant with her exercises.
Tr. 914. Avery indicated that retraction was providing her
with some relief from her headaches and neck stiffness and
being mindful of her posture was helping with her headaches.
Tr. 915. Avery was concerned about her symptoms increasing
when the weather warmed up. Tr. 915. Klein observed that
Avery had a reduced tolerance for exercise during the therapy
session because she was becoming hot and symptomatic of
dizziness. Tr. 916. Avery's symptoms improved with a cold
pack and cold water. Tr. 916. Klein encouraged Avery to
increase the frequency of her cervical exercises because they
seemed to help her headaches, which could be a trigger for
her POTS' symptoms. Tr. 916. Klein also recommended that
Avery look into a cooling vest to help her tolerate exercise
and heat in the summer. Tr. 916.
also had a visit with Dr. Jaeger on May 19, 2014, to follow
up regarding the previous day's emergency room visit. Tr.
501-503. Avery reported feeling less dizzy and there had been
no repeat syncope since the evening before her emergency room
visit. Tr. 501. Avery denied any more palpitations, chest
pains, shortness of breath, orthopnea,  PND,
edema. Tr. 501. Dr. Jaeger noted that Avery was still taking
a low dose of Florinef as well as Cymbalta. Tr. 503. Dr.
Jaeger also indicated that Avery's vital signs showed
obvious orthostatic tachycardia. Tr. 503.
Dr. Jaeger's recommendation Avery followed up with Dr. Li
on May 21, 2014, for consideration of other types of
medication. Tr. 510-514. Examination findings were generally
normal. Tr. 512-513. Dr. Li discontinued midodrine because it
was not helping, noting she was on a low dose and it might
worsen her headaches and increase her heart rate. Tr. 513.
Dr. Li recommended that Avery continue taking Florinef but
noted that it might not be effective for her. Tr. 513. Dr. Li
also recommended that Avery restart Elavil because it had
helped her headaches in the past. Tr. 513. If that did not
work or if Avery could not tolerate it, Dr. Li indicated that
Avery could try an SNRI (e.g., Cymbalta, Effexor, or Prestiq)
as suggested by Dr. Jaeger and, if those were not effective,
they could consider Mestinon. Tr. 513. Dr. Li referred Avery
to Dr. Kara Browning, a physician in his department who
specialized in managing POTS patients. Tr. 513.
saw Dr. Browning on June 25, 2014. Tr. 521-524. Avery
reported being frustrated with the impact of symptoms on her
daily activities and quality of life. Tr. 521.
Notwithstanding her symptoms she was continuing to work full
time with the Head Start Program. Tr. 521. Avery relayed that
her symptoms had worsened since January of that year to the
point of occurring every day. Tr. 521. Dr. Browning
recommended that Avery continue with non-pharmacologic
measures, including more consistent use of compression
stockings, increasing water and salt intake, elevating her
head in bed, graded exercise program, muscle contraction
measures to decrease venous pooling, good sleep hygiene, and
addressing anxiety and depression if present. Tr. 523. As far
as medications, Dr. Browning recommended that Avery stop
taking midodrine because it could be making her migraines
worse. Tr. 523. She recommended that Avery decrease her dose
of Florinef; add Cymbalta; and wean off of amitriptyline
depending on the results of Cymbalta. Tr. 523. Dr. Browning
also recommended that Avery follow up with some of the other
specialists that she had seen. Tr. 523.
function testing performed on August 25, 2014, at MetroHealth
was “consistent with essentially normal
findings.” Tr. 600. Other testing performed that same
day (methacholine challenge test) was indicative of
heightened bronchial reactivity consistent with a diagnosis
of asthma. Tr. 600.
saw Dr. Browning for follow up on August 27, 2014. Tr.
678-680. Avery indicated that her symptoms were worse the
prior week. Tr. 678. She had returned to work full time but
she was not sure she would be able to work a full-time
schedule. Tr. 678. Avery relayed that her legs were feeling
better since taking Cymbalta. Tr. 678. She was having to take
more ibuprofen daily for her headaches and leg and back pain.
Tr. 678. Avery also indicated she was having occasional
episodes of vertigo. Tr. 678. Avery had not had a syncope
episode since her last visit. Tr. 679. Dr. Browning made some
adjustments to Avery's medications. Tr. 680. Dr. Browning
noted that Avery could benefit from counseling. Tr. 680. Dr.
Browning provided Avery with a letter for her employer
regarding continuing with part-time hours. Tr. 673, 680.
Avery was advised to follow up with Dr. Browning in two to
three months or as needed. Tr. 680.
September 11, 2014, Avery met with nurse Karen A. Majewski,
CNP, in the pulmonary department for a follow-up asthma
visit. Tr. 652-656. Nurse Majewski had previously seen Avery
for her asthma in 2012. Tr. 653. Avery was prescribed Qvar.
Tr. 653. She had been doing fairly well with respect to her
asthma since that time. Tr. 653. Avery had stopped her Qvar
about six weeks prior because her breathing was good and she
was tired of taking medications. Tr. 653. Since stopping the
Qvar, Avery noticed some changes in her breathing with
symptoms of chest tightness, shortness of breath, coughing
and wheezing about three times per week. Tr. 653. She was
using saba once per week. Tr. 653. Avery noted that
usual triggers for her asthma included hot and cold air,
weather changes, strong odors, pollens, and stress. Tr. 653.
Nurse Majewski recommended that Avery restart Qvar and saba
as needed. Tr. 654. Nurse Majewski provided Avery with
instructions for monitoring her symptoms and peak flow and
she advised Avery that, if she was stable over the following
two weeks, she could start a trial of a low dose
cardioselective beta blocker. Tr. 655.
September 18, 2014, Avery was transported by ambulance from
work to the emergency room. Tr. 649-652. She complained of a
racing heart. Tr. 649.
followed up with Dr. Calles on September 24, 2014. Tr.
643-648. Avery was having a bad day with dizziness. Tr. 644.
She relayed that her syncope was continuing. Tr. 644. Avery
reported that she had been in the hospital the prior week.
Tr. 644. Avery's neurologist had adjusted her Florinef
and her neurologist and cardiologist were interested in
starting her on Metoprolol. Tr. 644. Dr. Calles noted an
increase in Avery's blood pressure and heart rate with
standing. Tr. 648. Dr. Calles increased Avery's dosage of
Florinef and planned to consult with Avery's other
treating providers regarding proceeding with beta-blockers or
another treatment plan. Tr. 648.
saw Dr. Browning on September 29, 2014, for a test dose of
Metoprolol. Tr. 687. Avery denied shortness of breath, chest
tightness, or discomfort relating to taking the medication
and, on examination, Dr. Browning noted that Avery's
lungs were clear to auscultation and there was no appreciable
wheezing. Tr. 687. Avery relayed that she was having some
difficulty at work with stair climbing which was causing
dyspnea, tachycardia, and dizziness. Tr. 687. Dr. Browning
recommended that they wait and see if the addition of
beta-blockers could help alleviate her symptoms before adding
additional work restrictions. Tr. 687. Because of complaints
of an increase in Avery's migraines, Dr. Browning
adjusted Avery's amitriptyline. Tr. 687. Avery's
Cymbalta prescription remained unchanged. Tr. 687. Dr.
Browning recommended that they hold off on Dr. Calles'
recommendation that Avery start on a trial of pseudoephedrine
until they were able to stabilize her on Metoprolol. Tr. 687.
saw Nurse Majewski on October 9, 2014, for follow up
regarding his asthma. Tr. 639. Avery had been taking her Qvar
and had noted improvement until she became ill with an upper
respiratory infection. Tr. 639. She was able to control her
symptoms during that time with use of saba. Tr. 639. Nurse
Majewski noted that a chest x-ray from February 2014 showed
clear lungs. Tr. 640. Physical examination findings were
normal. Tr. 640. Nurse Majewski assessed mild to moderate
persistent asthma that was not well controlled with improving
exacerbation. Tr. 640. Nurse Majewski continued Avery's
medications. Tr. 641.
November 1, 2014, Dr. Browning provided a “medical
excuse, ” setting forth work restrictions of part-time
work, 20 hours/week, from November 1, 2014, until December
31, 2014. Tr. 672. Avery saw Dr. Browning a few days later on
November 5, 2014. Tr. 695. Avery reported having to take
several sick days because of her symptoms but she was still
interested in working. Tr. 695. Her current work schedule was
four days per week from 8:00 a.m. - 1 p.m. Tr. 695. Avery
noticed some increased fatigue since starting on beta
blockers but she had also noticed less tachycardia. Tr. 695.
Avery was interested in returning to cardiac rehab since her
tachycardia had improved. Tr. 695. Physical examination
findings of Avery's heart and lungs were normal. Tr. 696.
Avery walked with a cane and had an antalgic gait. Tr. 696.
Dr. Browning indicated that Avery could proceed with Dr.
Calles' suggestion of trying pseudoephedrine because of
the alpha receptor effects but Dr. Browning recommended that
Avery use a short acting Sudafed because pseudoephedrine
could exacerbate tachycardia. Tr. 696.
December 4, 2014, Avery saw Julia A. Anisimova, a nurse
practitioner with the neurology department at the Cleveland
Clinic, for complaints of numbness throughout her legs. Tr.
740. Avery described a sensation of “needles going
though out the entire leg.” Tr. 740. She had
experienced some sensory changes in the past but her current
pain was different and had really been bothering her for the
prior week and a half. Tr. 740. She indicated that the pain
was worse with sitting and bending/flexing of her legs. Tr.
740. Cymbalta and amitriptyline had helped initially but her
legs were feeling weaker and she had a decreased tolerance
for walking and standing. Tr. 740. Avery was continuing to
work four days per week from 8:00 a.m. - 1 p.m. Tr. 740. On
physical examination Nurse Anisimova observed normal
strength, tone and bulk in all muscle groups; general intact
sensations (except for some decreased sensation on the inner
aspect of her calves); and intact gait. Tr. 740. Nurse
Anisimova advised Avery to stop taking the Sudafed because it
was not helping and she had noticed her POTS had worsened
since starting. Tr. 740. Nurse Anisimova increased
Avery's Cymbalta and indicated she would discuss with Dr.
Browning testing for small fiber neuropathy by means of a
skin biopsy. Tr. 740.
saw Dr. Browning on January 5, 2015, with complaints of
increased lower extremity paresthesias and pain. Tr. 945-947.
Avery relayed that she was no longer working, explaining that
she had been let go from her employment because of regular
absences for medical symptoms. Tr. 945. Avery relayed that
she wondered if the beta block was contributing to her
fatigue. Tr. 945. Avery had recently had a follow up with
cardiac rehabilitation. Tr. 946. She was wearing compression
stockings, taking in fluids and salt, and performing lower
extremity exercises. Tr. 946. On physical examination, Avery
exhibited minimal to moderate range of motion restrictions in
the lumbar spine; motor examination of the lower extremities
was normal; her muscle bulk and tone were normal; and she had
a positive straight leg raise on the right when sitting or
lying. Tr. 946. Dr. Browning made some adjustments to
Avery's medications and advised Avery to follow up in six
to twelve weeks. Tr. 946.
Browning's request, on January 26, 2015, Dr. Daniel J.
Mazanec, M.D., saw Avery for a consultation regarding back
and leg pain. Tr. 950-956. Avery ambulated with a cane because of
her POTS and her leg symptoms. Tr. 950. She described new,
progressive bilateral lower extremity paresthesias and
weakness with pain. Tr. 955. Avery indicated that her leg
symptoms were increasing. Tr. 950. Also, she indicated that
she had been experiencing bilateral upper extremity numbness
that was non-radicular in distribution and intermittent. Tr.
950. Dr. Mazanec noted there were limited findings on
examination. Tr. 953-955. Dr. Mazanec assessed sciatica and
recommended an MRI of the lumbar spine. Tr. 955.
attended a cardiac rehabilitation session on January 28,
2015. Tr. 957. Avery complained of lightheadedness 17 minutes
into her 30-minute session. Tr. 957. Avery's workload was
reduced which caused her lightheadedness to decrease and
allowed her to continue. Tr. 957. Continued cardiac
rehabilitation was recommended. Tr. 957.
lumbar MRI was performed on February 5, 2015. Tr. 773-775.
The impression was multi-level discogenic and facet
hypertrophic degenerative change; moderate to severe
foraminal stenosis on the right at ¶ 5-S1; and minimal
anterior wedging of the L1 vertebral body without evidence of
marrow edema. Tr. 775.
saw Dr. Browning on February 17, 2015. Tr. 958-959. Avery
indicated her tachycardia had improved with a higher dose of
beta blockers. Tr. 958. Avery relayed that she would rather
have fatigue secondary to beta blocker usage than
tachycardia. Tr. 958. Her asthma was stable on the higher
dose of beta blockers. Tr. 958. Avery noted that she had
started to take Cymbalta at night which helped decrease her
daytime sedation. Tr. 958. Avery was still having problems
performing household chores because of her fatigue and
tachycardia. Tr. 958. Avery discussed the leg and back pain
she was experiencing. Tr. 958. Dr. Browning noted that Avery
had seen Dr. Mazanec at the Spine Center and had undergone an
MRI which showed spondylosis greatest at the L5-S1 without
evidence of central or foraminal nerve root compression. Tr.
958. Avery reported no syncope episodes since her last visit.
Tr. 958. Dr. Browning concluded that Avery's POTS was
stable but she needed cardiac reconditioning to improve her
functional capacity. Tr. 959. Dr. Browning recommended
physical therapy for Avery's lumbar spine issues. Tr.
959. She also recommended that Avery continue to try to
increase her activity, try to wean down her Elavil to see if
her daytime sedation improved; continue non-pharmacologic
measures, and resume cardiac rehabilitation program when able
to tolerate from a spine perspective. Tr. 959.
March 6, 2015, Avery attended a cardiac rehabilitation
session. Tr. 963-964. During the session, Avery complained of
severe lightheadedness, moderate shortness of breath, and
chest tightness 12 minutes into a higher workload. Tr. 963.
Exercise was terminated and Avery was assisted to a chair to
elevate her legs. Tr. 963. Avery's symptoms resolved
after 10-15 minutes. Tr. 963. Avery indicated that she had
undergone a colonoscopy the prior day and had not been able
to eat, which the therapist noted could be related to her
symptoms during the session that day. Tr. 963. The therapist
recommended that Avery continue with exercise at a lower
workload at the next session and gradually increase the
workload to the level of the March 6, 2015, session. Tr. 963.
March 10, 2015, Avery started physical therapy for her low
back pain and lower extremity pain. Tr. 964-968. Physical
therapist Klein observed that Avery had reduced posture,
lumbar mobility and decreased awareness of self-management of
her pain symptoms. Tr. 967. Avery responded well to
extension-based exercises during the session but was limited
due to some complaints of dizziness on exertion due to her
POTS. Tr. 967. The therapist anticipated that Avery would do
well with physical therapy to address her impairments and
reduce her symptoms. Tr. 967. Avery's prognosis was good.
attended cardiac rehab the next day - March 11, 2015. Tr.
968-970. Exercise was stopped 14 minutes into the session
because Avery became lightheaded with chest tightness and was
seeing black spots. Tr. 970. Avery noted that her symptoms
had been occurring more frequently and earlier in the day
since she had reduced her dose of Metoprolol. Tr. 970. She
had no energy but was no longer drowsy. Tr. 970. Avery was
advised to follow up with Dr. Browning. Tr. 970.
attended a second physical therapy session on March 25, 2015.
Tr. 971-972. She relayed that she had passed out the prior
week so she had cancelled an earlier physical therapy
appointment. Tr. 971. Physical therapist Klein noted that
Avery had some improvement in her symptoms with performance
of lumbar extension at home and she had improved her postural
awareness, increased her independence with home exercises,
and had decreased the intensity of her pain. Tr. 972. The
same day, Avery attended a cardiac rehab appointment. Tr.
973-974. Avery stopped exercise on a semirecumbent cycle
after 9 minutes because of chest tightness, lightheadedness,
and flushing. Tr. 974. Avery needed assistance transferring
to a chair to elevate her legs. Tr. 974. Avery expressed
frustration regarding her symptoms, noting that she was
following all of the prescribed advice. Tr. 974. Avery's
symptoms resolved after about 10 minutes but she sat and
rested for about 30 minutes before feeling well enough to
leave. Tr. 974. Avery continued to report worsening of her
symptoms even though she resumed a higher dose of Metoprolol.
Tr. 974. Avery was advised to follow up with her physicians.
an April 8, 2015, cardiac rehab appointment, Avery reported
severe dizziness over the prior week. Tr. 976. Her dizziness
was worse with lifting. Tr. 976. She felt that it was related
to a change in her Metoprolol. Tr. 976. During the April 8,
2015, session, Avery was feeling very drowsy; she was having
a hard time coming up with words; and she was having chest
pain, which she described as someone “squishing”
her. Tr. 976. Avery indicated that her migraines had
improved. Tr. 976. Avery exercised with the fan on, which
helped, and she was wearing compression stocking and drinking
fluids during the session. Tr. 976.
an April 9, 2015, physical therapy session, physical
therapist Klein noted improvement in Avery's pain
symptoms and range of motion since starting therapy and
improved postural awareness and exercises. Tr. 978. Physical
therapist Klein noted that Avery was limited by her POTS'
symptoms with increased exertion. Tr. 978. On April 10 and
April 17, 2015, Avery completed a cardiac rehab session with
no significant complaints. Tr. 979-980.
saw Dr. Jaeger on April 20, 2015. Tr. 980-984. Avery reported
that, since changing her Metoprolol to long-acting, her heart
was racing more frequently and she was very fatigued. Tr.
982. She indicated she had missed cardiac rehab sessions
because she was too exhausted. Tr. 982. She reported near
syncope every day and that her heart raced three to five
times per week with minimal exertion. Tr. 982. Avery had been
called for jury duty and was concerned she would be unable to
participate because of her need for frequent bathroom breaks
due to her increased fluid intake. Tr. 982. Physical
examination findings were normal. Tr. 983. Dr. Jaeger
indicated Avery should try to continue with cardiac rehab and
discuss with her other physicians possible alternatives to
Elavil because it could contribute to reflex tachycardia. Tr.
saw Dr. Calles on May 27, 2015, for follow up regarding her
syncope and orthostasis. Tr. 1780-1786. Avery relayed that
her syncope was continuing but was less intense. Tr. 1780.
She was feeling a little better and smiling. Tr. 1780.
However, she had been at the hospital the prior week due to
two episodes in less than an hour. Tr. 1780. Avery's
neurologist had adjusted her Florinef. Tr. 1781. Dr. Calles
indicated that his hormonal evaluation did not identify a
reason for Avery's syncope. Tr. 1786.
next day, Avery saw Drs. Tariq and Tepper in the neurology
department for consultation regarding her headaches. Tr.
1923-1928. The assessment was that Avery had migraines with
aura. Tr. 1929. Avery's migraines were chronic. Tr. 1929.
They occurred 15 days per month, with there being aura plus
migraines twice weekly. Tr. 1929. The usual duration of
Avery's aura was 3-5 minutes, up to 60 minutes. Tr. 1929.
Avery indicated that her POTS' symptoms had improved and
she was willing to try vestibular and head and neck therapy
again. Tr. 1928. Recommendations included use of a Zomig
nasal spray at the time of a severe migraine attacks;
avoidance of over-the-counter pain medications more than two
days per week; referral for trans magnetic stimulation study;
and referral for vestibular physical therapy and TMJ
dysfunction. Tr. 1928.
29, 2015, Avery attended a cardiac rehab session. Tr. 1939.
She was able to increase her workload during her session. Tr.
1939. Avery continued cardiac rehab sessions and physical
therapy sessions throughout 2015. Tr. 1942-1962, 1984-1988,
1995-1999. At a December 3, 2015, physical therapy
appointment, physical therapist Klein noted that Avery had
significant reduction in her headaches and jaw pain since
getting a bite guard from her dentist. Tr. 1996. But Avery
was getting evaluated for complaints of total body pain and
was having difficulty making regular appointments due to her
symptoms. Tr. 1996. Physical therapist Klein determined that
Avery would be discharged from physical therapy for her
migraines at that time. Tr. 1996.
September 3, 2015, Avery saw Dr. John Morren, M.D., with the
Neurological Institute, Neuromuscular Center, of the
Cleveland Clinic for a consultation regarding ongoing
management for POTS. Tr. 1972-1983. Dr. Morren found that
Avery's current symptoms of presyncope appeared
stable/somewhat improved on her current medications of
Florinef and Metoprolol and nonpharmacological measures. Tr.
1976. Dr. Morren noted Avery's nonrestorative sleep but
also noted that Avery had recently been diagnosed with
obstructive sleep apnea and CPAP therapy was anticipated to
provide significant benefits. Tr. 1976. Dr. Morren
recommended that Avery continue with most of her current POTS
treatment plan. Tr. 1976. He recommended that Avery follow up
with sleep medicine as soon as possible and to start a trial
of Melatonin to try to improve her restorative sleep. Tr.
saw Dr. Jaeger on February 8, 2016. Tr. 2012-2022. Avery last
saw Dr. Jaeger on April 20, 2015. Tr. 2012. Avery stated she
had lightheadedness/dizziness almost daily; she had near
syncope a couple of times per week; her palpitations had
improved with beta blockers; she had chest pain a couple of
times per month; she had shortness of breath with climbing
stairs or walking long distances; she had recently been
diagnosed with obstructive sleep apnea and was wearing a CPAP
nightly; she had edema in her hands, feet, and joints with
bruising on her hands; she had been diagnosed with discoid
lupus, restless leg syndrome, and TMJ since her last visit;
she “had no syncope, orthopnea, PND.” Tr.
2012-2013. Dr. Jaeger reviewed Avery's ongoing treatment
plan; no additional treatment recommendation were made at the
visit. Tr. 2015-2016.