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Avery v. Commissioner of Social Security Administration

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

April 2, 2019

ELISA AVERY, Plaintiff,




         Plaintiff 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.

         For the reasons explained herein, the undersigned recommends that the Court AFFIRM the Commissioner's decision.

         I. Procedural History

         Avery protectively filed[1] 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”), [2] 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.

         In his 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. Tr. 1-6.

         II. Evidence

         A. Personal, educational, and vocational evidence

         Avery 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.

         B. Medical evidence

         1. Treatment history

         On 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[3] 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.

         Dr. Li 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. 291.

         In 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.

         Avery 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, 2014, stating:

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.

Tr. 671.

         On 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.

         On 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. Tr. 332.

         On May 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.

         On May 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.

         Avery 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, [4] PND, [5] or 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.

         Upon 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[6] 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.

         Avery 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.

         Pulmonary 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.

         Avery 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.

         On 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[7] 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.

         On 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.

         Avery 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.[8] 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.

         Avery 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.

         Avery 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.

         On 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.

         On 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.

         Avery 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.

         At Dr. 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.[9] 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.

         Avery 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.

         The 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.

         Avery 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.

         On 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.

         On 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. Tr. 967.

         Avery 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.

         Avery 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. Tr. 974.

         During 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.

         During 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.

         Avery 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. 983.

         Avery 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.

         The 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.

         On May 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.[10] 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.

         On 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. 1976.

         Avery 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.

         2. ...

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