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Edgington v. Berryhill

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

June 6, 2019

TERESA EDGINGTON, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          JUDGE DONALD C. NUGENT

          REPORT AND RECOMMENDATION

          JONATHAN D. GREENBERG, UNITED STATES MAGISTRATE JUDGE

         Plaintiff, Teresa Edgington, (“Plaintiff” or “Edgington”), 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 AFFIRMED.

         I. PROCEDURAL HISTORY

         In September 2015, Edgington filed an application for POD and DIB, alleging a disability onset date of January 1, 2011 and claiming she was disabled due to panic disorder with agoraphobia, post-traumatic stress disorder, major depressive disorder, fibromyalgia, cervical spine disease with radiculopathy, cervical spondylosis, cervical myositis and foraminal stenosis, lumbar spondylosis with myelopathy, lumbar radiculopathy, and degeneration of intervertebral discs. (Transcript (“Tr.”) 15, 146, 164.) The applications were denied initially and upon reconsideration, and Edgington requested a hearing before an administrative law judge (“ALJ”). (Tr. 15, 98-101, 103-105, 110.)

         On August 4, 2017, an ALJ held a hearing, during which Edgington, represented by counsel, and an impartial vocational expert (“VE”) testified. (Tr 33-67.) On December 28, 2017, the ALJ issued a written decision finding Edgington was not disabled. (Tr. 15-28.) The ALJ's decision became final on May 21, 2018, when the Appeals Council declined further review. (Tr. 1-6.)

         On July 26, 2018, Edgington filed her Complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 12, 14, 16.) Edgington asserts the following assignments of error:

(1) The ALJ committed an error of law and the decision is not supported by substantial evidence as the ALJ improperly concluded that Teresa does not satisfy Listings 12.04, 12.06, and 12.15 for failure to satisfy the “Paragraph B” criteria.
(2) The ALJ erred by not following the requirements of SSR 96-8p when making the RFC finding, and the RFC finding is not supported by substantial evidence.

         (Doc. No. 12 at 2.)

         II. EVIDENCE

         A. Personal and Vocational Evidence

         Edgington was born in January 1969 and was forty-eight (48) years-old at the time of her administrative hearing, making her a “younger” person under social security regulations. (Tr. 27.) See 20 C.F.R. §§ 404.1563(c) & 416.963(c). She has at least a high school education and is able to communicate in English. (Id.) She has past relevant work as a bookkeeper. (Id.)

         B. Relevant Medical Evidence[2]

         1. Mental Impairments

         In February 2010, Edgington presented to Jamie Page, a “Readjustment Counselor” at the Veteran's Administration[3] (“VA”) to establish treatment for increasing depression, anxiety, insomnia, and intrusive thoughts. (Tr. 275-276.) On mental status examination the following month, Ms. Page noted a friendly and cooperative manner with neat appearance, appropriate speech and affect, normal memory function, “relaxed, at ease” motor activity, and good judgment. (Tr. 239-240.)

         In January 2011, however, Edgington called the VA suicide prevention hotline to report increased anxiety, lack of motivation, and depressive symptoms. (Tr. 834.) Edgington stated she “has not answered her phone in approximately one month, has not attended regularly scheduled counseling sessions since the Thanksgiving Holiday, and had not arrived to work since New Years Eve.” (Tr. 835.) She also stated she had been “going down hill” since March 2010, explaining “I'm starting to scare myself.” (Tr. 834-835.)

         The record reflects Edgington met with Ms. Page on at least nineteen (19) occasions in 2011. (Tr. 260-273.) At the majority of these visits, Edgington presented with a depressed mood and affect. (Id.) In January, she reported isolating and intrusive thoughts, insomnia, depression, suicidal thoughts, panic attacks, and nightmares. (Tr. 273-274.) She stated she “lost all of her jobs . . . has not been leaving her house, and she has pulled away from everyone.” (Id.) In February, Edgington was “overwhelmed” and making “limited progress” towards her treatment goals. (Tr. 272.) In March, she indicated she had not left her house for several weeks “due to fear and shame.” (Tr. 271.) The following month, Edgington stated she had put black bags over her windows “fearing someone is looking in at her.” (Tr. 270.) In April, Edgington stated she “has not left the house and laid in bed for three days.” (Tr. 269.) Several weeks later, however, she had a euthymic mood and affect. (Id.) In June, Edgington reported continued depression over the recent death of her mother, but stated she was “getting out more and feeling less anxiety.” (Tr. 267.)

         In August 2011, Edgington reported feeling overwhelmed by foreclosure proceedings and “pending homelessness.” (Tr. 266.) In September, Ms. Page noted as follows:

Veteran presented over the last year with anxiety and depression. Veteran currently reports depression 7/7 days at 9-10/10, avoidance and anxiety at 9/10 on most days. Over the last year, veteran has had increased physical health problems, was contacted by a physically abusive ex-husband . . ., lost her job due to increased PTSD/depression, has been dealing with foreclosure, the death of her mother, the sole provider/caregiver for autistic son, and now managing the care of her father since her mother's death. Veteran's primary coping over the last year has been avoidance. She has gone up to a week without getting out of bed, missing appointments, calling crisis hotline for support, not taking medications, not answer[ing] phone calls and not paying bills. She has continued to keep socially isolated. . .

(Tr. 265.) Edgington reported depression, anxiety, panic attacks, and “some suicidal thoughts.” (Tr. 264.) In November 2011, she continued to report feelings of depression, lack of motivation, and “feeling like a failure, ” stating she “continued to have days [where] she spends all day in bed.” (Tr. 260, 262.) In December, Edgington had a euthymic mood and affect, but rated her depression and anxiety a 7 on a scale of 10. (Tr. 260.)

         During 2011, Edgington also presented regularly to psychiatrist Amal Rubai, M.D. In March 2011, she reported poor energy/motivation, paranoia, panic attacks, nightmares, flashbacks, and severe anxiety. (Tr. 831.) On examination, she was alert and oriented with fair hygiene, cooperative behavior, good eye contact, normal speech and psychomotor activity, reactive affect, organized thought process, fair insight, and “mediocre” judgment. (Tr. 832.) Dr. Rubai noted Edgington “managed to smile” but was tearful at times. (Id.) She diagnosed PTSD, rule out major depressive disorder, and rule out panic disorder with agoraphobia; and assessed a Global Assessment of Functioning[4] (“GAF”) of 50, indicating serious symptoms. (Id.) Dr. Rubai increased Edgington's Paxil dosage, and advised her to restart Ambien and “Ohzine.” (Id.)

         In August 2011, Edgington reported an increase in suicidal thoughts and indicated her medication “wasn't working.” (Tr. 828.) In a visit with Dr. Rubai the following month, she admitted to non-compliance with her medications due to lack of motivation. (Tr. 823.) On examination, she was alert and oriented with fair hygiene and grooming, cooperative behavior, good eye contact, normal speech and psychomotor activity, depressed mood, reactive affect, organized thought process, fair insight, and “mediocre-limited” judgment. (Tr. 823-824.) Dr. Rubai diagnosed PTSD, major depressive disorder, and rule out panic disorder with agoraphobia; and assessed a GAF of 45, indicating serious symptoms. (Tr. 824.)

         In November 2011, Edgington reported feeling better over the last several weeks. (Tr. 806.) She described her mood as “better, ” “above content, ” with “no desire to crawl in bed like I used to.” (Id.) Edgington indicated her sleep was erratic, however, resulting in poor concentration. (Id.) She also continued to report panic attacks and nightmares. (Id.) On examination, Edgington was alert and oriented with good hygiene, calm and cooperative behavior, good eye contact, a smiling mood, “brighter, more reactive” affect, normal speech and psychomotor activity, organized thought process, fair insight, and mediocre judgment. (Id.) Dr. Rubai assessed a GAF of 55 (indicating moderate symptoms), and continued Edgington on her medications. (Tr. 808.)

         In December 2011, Edgington again reported feeling more productive, but continued to complain of panic attacks, erratic sleep, and flashbacks. (Tr. 800.) Examination findings were the same as the previous visit. (Id.) Dr. Rubai assessed a GAF of 55, and increased Edgington's Paxil and Gabapentin dosages. (Tr. 801.)

         Edgington presented to Ms. Page sporadically in 2012, seeing her on five occasions. (Tr. 253-259.) She reported increased depression in January of that year. (Tr. 259.) In March, Edgington stated she experienced depression “50% of the days, several of those days struggling to get out of bed.” (Tr. 257.) Ms. Page described her progress as “stagnant.” (Id.) Later that month, Edgington presented with euthymic mood and affect, but continued to report depression, insomnia, and anxiety. (Tr. 256.) In April, she complained of nightmares/terrors 4 to 5 times per week for the past several weeks. (Tr. 255.) In May, Edgington indicated she had not been out of bed or showered for the previous two weeks. (Tr. 254.)

         Edgington presented to Dr. Rubai in February, April, and May 2012. (Tr. 789-791, 773-775, 752-755.) In February, she complained of increased depression, poor energy and concentration, and panic attacks several times per week. (Tr. 789.) Examination findings were largely normal, aside from restricted affect, fair insight, and mediocre judgment. (Tr. 790.) Dr. Rubai assessed a GAF of 55; continued her on Paxil, Gabapentin, and Ambien; and prescribed Wellbutrin. (Tr. 791.)

         In April 2012, Edgington reported some improvement with Wellbutrin, stating her mood was “pretty good today” and that she had “less [of a] need to lay in bed all day.” (Tr. 773.) She continued, however, to complain of poor sleep, low energy, poor concentration, panic attacks, and nightmares. (Id.) Examination findings were largely normal. (Id.) Dr. Rubai noted Edgington's “mood is again improving, ” but found she still suffered from ongoing moderate PTSD symptoms. (Tr. 774.) She assessed a GAF of 55, and continued Edgington on her medications. (Tr. 775.)

         In May 2012, Edgington stated the previous month had been a “bad month” during which she “stayed in bed most of the time.” (Tr. 752.) She reported her sleep was erratic, but indicated her concentration was improved with no recent panic attacks. (Id.) Examination findings were normal. (Id.) Dr. Rubai noted that Edgington's mood symptoms “vary each visit.” (Tr. 754.) She again assessed a GAF of 55, and continued Edgington on her medications. (Id.)

         In 2013, Edgington only presented to Ms. Page on two occasions. (Tr. 250-252.) In February, she presented with a depressed mood and affect, and indicated she had “been isolating and depressed for the last 6 months or so.” (Tr. 252.) Edgington also reported she had started drinking “a couple times a week to sleep.” (Id.) In October, Edgington again reported feeling depressed and isolated. (Tr. 250.)

         On May 20, 2013, Edgington presented to primary care physician Megan McNamara, M.D. (Tr. 634-638.) She stated she had been “very depressed and [was] only now starting to come out of her depression.” (Tr. 636.) Edgington reported she had recently confided in a friend that she was sexually assaulted while in the military, which “precipitously worsened her mood” and caused her to experienced passive suicidal ideation. (Id.) She had run out of her psychiatric medications. (Id.) Dr. McNamara described Edgington's depression as “moderate-severe” and advised her to re-establish care with psychiatry. (Tr. 637-638.)

         Edgington returned to Dr. Rubai in June 2013, after a year long gap in treatment. (Tr. 628-632.) She indicated she had stopped taking her medications for over six months and admitted to heavy alcohol use, including binge drinking. (Tr. 628.) Edgington reported increased depression and stated she kept her curtains down and avoided leaving the house. (Id.) She complained of poor sleep, daily panic attacks, and “vague auditory hallucinations.” (Id.) Examination findings were normal aside from a depressed mood and hallucinations. (Tr. 629.) Dr. Rubai diagnosed chronic PTSD, recurrent major depressive disorder, and panic disorder with agoraphobia; and assessed a GAF of 51. (Tr. 631-632.) She prescribed Ativan, and advised Edgington to continue with Paxil and Wellbutrin. (Tr. 632.)

         In July 2013, Edgington reported she was avoiding counseling sessions with Ms. Page, and indicated her depression level was “going up.” (Tr. 622.) She indicated she was staying in bed “a lot” and continued to experience panic attacks, but denied auditory hallucinations. (Id.) Examination findings were normal. (Tr. 623.) In October 2013, Edgington described her mood as “pretty bad” and “depressed, ” and complained of poor sleep and concentration. (Tr. 615.) She also reported panic attacks four times per week, recent “anger outbursts, ” and nightmares. (Id.) Aside from a “bad” mood and reactive affect, examination findings were normal. (Tr. 616.) During both of these visits, Dr. Rubai assessed a GAF of 51, and adjusted Edgington's medications. (Tr. 624, 618.)

         In November 2013, Edgington reported some improvement with medication, including better sleep and decreased suicidal ideation. (Tr. 588-590.) She continued to complain, however, of angry mood, avoidant behavior, poor energy, fair concentration, occasional paranoia, daily panic attacks, and nightmares. (Tr. 588.) Examination findings were largely normal, and Dr. Rubai continued Edgington on her medications. (Tr. 590.)

         Edgington did not return to Dr. Rubai until nearly a year later, on October 9, 2014. (Tr. 497-501.) She reported she had stopped taking her medications in February of that year, but restarted in September. (Tr. 497.) Edgington complained of poor sleep, low energy, poor concentration, occasional paranoia, and PTSD symptoms. (Tr. 498.) Dr. Rubai discussed “her pattern of behavior and non-compliance and emphasized importance of ongoing counseling.” (Id.) On examination, Dr. Rubai noted depressed mood, reactive affect, good hygiene and grooming, cooperative behavior, good eye contact, normal psychomotor activity and speech, organized thought process, fair insight, and mediocre-limited judgment. (Id.) She diagnosed chronic PTSD, recurrent major depressive disorder, and panic disorder with agoraphobia; assessed a GAF of 40; and continued Edgington on Paxil, Wellbutrin, and Lunesta. (Tr. 500.)

         On December 3, 2014, Edgington established treatment with social worker Audrey Pace. (Tr. 416-422.) Examination findings were normal, including friendly and cooperative demeanor, normal speech and psychomotor activity, calm mood, full affect, and “no sign of hopelessness, helplessness, and worthlessness.” (Tr. 416.) Edgington admitted to a history of suicidal thoughts that “continues in waves, ” and noted she had been raped and sexually assaulted in the 1980's while serving in the military. (Tr. 417.) She returned to Ms. Pace on December 9, 2014, at which time Ms. Pace concluded Edgington was at a “moderate to high chronic risk of [self] harm.” (Tr. 407.) Mental status examination findings were normal, aside from “some hopelessness, helplessness, or worthlessness.” (Id.)

         Edgington returned to Dr. Rubai on December 11, 2014. (Tr. 401-406.) She reported some benefits from medication, stating “I feel hopeful, not as depressed.” (Tr. 401.) Edgington, however, continued to report poor concentration, occasional paranoia, panic attacks when she has to leave the house, nightmares, and flashbacks. (Id.) Examination findings were largely normal. (Tr. 402.) Dr. Rubai assessed a GAF of 55, and found Edgington's “chronic intermittent suicidal ideation place[s] her at chronic moderate risk.” (Tr. 405.) Shortly thereafter, Edgington presented to clinical psychologist Jennifer Knetig, Psy.D. (Tr. 395.) Dr. Knetig noted Edgington's “affect was initially rather bright, becoming tearful at times over the course of the session, and appeared congruent with a labile mood.” (Id.)

         On January 21, 2015, Edgington called the VA suicide hotline. (Tr. 384-385.) She reported she had not left her house in a month, had been canceling appointments with her therapist, and was struggling with depression. (Id.)

         The following month, Edgington returned to Ms. Pace. (Tr. 368-370.) On examination, Edgington had fair grooming and hygiene, appropriate eye contact, friendly and cooperative demeanor, and normal speech and psychomotor activity. (Tr. 368.) Ms. Pace also noted depressed and cautious affect, an overwhelmed mood, and “some hopelessness, helplessness, or worthlessness.” (Id.) At this visit, Edgington shared the details of her sexual assault while in the military and discussed how that experience continued to cause PTSD symptoms. (Tr. 368-369.) Ms. Pace found Edgington continued to be at a “moderate to high chronic risk of [self] harm.” (Id.)

         The record reflects Edgington reestablished treatment with social worker Ms. Page in 2015, seeing her on 15 occasions between June and December of that year. (Tr. 243-249, 1064-1065.) In June and July, Edgington presented with a depressed mood and affect. (Tr. 249.) In August, she reported “daily feelings of ‘feeling out of control,' shame, intrusive thoughts daily, insomnia, depression, and anxiety.” (Tr. 247-248.) In September, Edgington stated she stayed in bed for three days and “did not shower, get dressed, or do anything.” (Tr. 246.) She reported continued depression anxiety and depression throughout September and October. (Tr. 244-245.) By the end of October, Edgington had a euthymic mood and reported she “has been depressed most days but has forced herself to get up and get at least one thing accomplished.” (Tr. 243.)

         Meanwhile, Edgington returned to Dr. Rubai on August 12, 2015 with continued complaints of poor energy, terrible concentration, and hypervigilance. (Tr. 329.) She indicated her medication was helping with her mood, stating she was “not as weepy.” (Id.) Examination findings were largely normal. (Tr. 330.) Dr. Rubai assessed a GAF of 60 (indicating moderate symptoms) and continued Edgington on her medications. (Tr. 333.)

         The following week, Edgington presented to pain management physician Elias Veizi, M.D. (Tr. 320-326.) On examination, Dr. Veizi noted Edgington was alert and oriented, and found her “recent/remote memory as evidenced through face-to-face interaction and discussion appear grossly intact.” (Tr. 321.) Due to her “diagnosis of fibromyalgia [and] comorbidities of depression and anxiety, ” he recommended Edgington consider an intensive outpatient rehabilitation program (“IOP”). (Tr. 323.)

         Edgington returned to Dr. Rubai in September, October, November, and December 2015. (Tr. 316-318, 301-304, 1159-1162, 1118-1122.) In September, Edgington described her mood as “okay” but continued to complain of poor sleep, low energy, poor concentration, daily panic attacks, and hypervigilance. (Tr. 316.) Examination findings were largely normal. (Tr. 317.) Dr. Rubai assessed a GAF of 60 and adjusted Edgington's medications, prescribing Cymbalta. (Tr. 318.) In October, Edgington reported increased nightmares and daily panic attacks. (Tr. 301.) On examination, Dr. Rubai noted an anxious tone, “okay” mood, and reactive affect. (Tr. 302.) She adjusted Edgington's medications. (Tr. 303.) In November, Edgington indicated that Cymbalta was helping with her anxiety, but reported that a recent health scare had heightened her symptoms. (Tr. 1159.) Examination revealed an anxious tone and affect, and “horrible” mood. (Tr. 1160.) Finally, in December, Edgington again reported experiencing some relief with Cymbalta. (Tr. 1118.) However, she also admitted to “fleeting” suicidal ideation, daily panic attacks lasting up to an hour, nightmares, flashbacks, and anxiety. (Id.) Dr. Rubai assessed a GAF of 60, and adjusted Edgington's medications. (Tr. 1121.)

         Edgington also presented to psychologist Cynthia Vankeuren, Psy.D., in December 2015. (Tr. 1099-1100.) She was “very happy” with Cymbalta, stating it helped with both her physical pain and anxiety/depression and was “life changing.” (Tr. 1099.) Examination findings were normal. (Id.) Dr. Vankeuren noted Edgington had “considerable anxiety that has been debilitating to her.” (Tr. 1100.) She explained that Edgington was considering participating in an intensive outpatient program, but was “anxious about being out of the house for an entire program day.” (Id.)

         On December 7, 2015, Ms. Page wrote a letter on Edgington's behalf, as follows:

Ms. Edgington is a disabled 100% service connected veteran diagnosed with Post Traumatic Stress Disorder (PTSD). Ms. Edgington has been in treatment at the Department of Veterans Affairs for PTSD with this writer since April of 2003.
Ms: Edgington suffers from chronic PTSD and the frequency and intensity of her symptoms continue to interfere with the quality of her life occupationally, socially, and emotionally. The most profound symptoms include daily panic attacks, depression, anxiety, insomnia, flashbacks, nightmares of actual events, difficulties concentrating, memory issues, hyper-startle, and hyper-vigilance.
The area Ms. Edgington has the most difficulties is in interacting/being around people. She has panic attacks most days leaving her home. Her daughter and friend take care of the majority of tasks outside the home including grocery shopping and one of them often accompanies her to appointments. They also remind her to take care of ADL's, remind her about taking medications, and assist her in taking care of the upkeep of her home.
Despite Ms. Edgington's efforts in treatment, her PTSD symptoms continue to interfere with the quality of her life. She is currently involved in weekly individual therapy and will start a women's PTSD treatment group January of 2016.

(Tr. 1058.) Later that month, Ms. Page noted Edgington was depressed, anxious, and agitated; and had only been leaving the house for doctor appointments. (Tr. 1064.)

         Edgington returned to Dr. Rubai on two occasions in 2016. On January 7, 2016, she reported that Cymbalta helped with her mood and pain, but continued to complain of poor energy and concentration, daily panic attacks, “worrying about everything, ” and intrusive thoughts. (Tr. 1086.) Examination findings were normal aside from a “down” mood and reactive affect. (Tr. 1087.) The following month, Dr. Rubai noted a depressed mood, anxious affect, and anxious tone. (Tr. 1333.) She assessed a GAF of 55, and referred Edgington for a consult for possible treatment at the VA's “Day Hospital.” (Tr. 1336.) On February 11, 2016, psychologist Josephine Ridley, Psy.D., found that Edgington met the criteria for participation in the Day Hospital with treatment focusing on “improving overall coping skills and reducing depressive symptoms.” (Tr. 1421.)

         The record also reflects Edgington presented regularly to Ms. Page during 2016. In January, she was disheveled and presented with a depressed mood and affect. (Tr. 1063.) Edgington reported she was “sleeping a lot, not getting out of bed, not eating.” (Id.) In February, she continued to report increased depressive symptoms, including missing appointments, not taking her medications, not returning phone calls, and staying in the house. (Tr. 1062, 1520-1521.) In April, Edgington indicated she had been “very depressed” due to physical health problems and foreclosure proceedings. (Tr. 1518-1519.) In May, she felt depressed and worthless. (Tr. 1518.) In June, Edgington was anxious, depressed, overwhelmed, and not sleeping. (Tr. 1516.) In July, August and September, she reported fear and anxiety over upcoming back surgery. (Tr. 1512-1514.) Following her surgery, Edgington continued to present with a depressed mood and affect. (Tr. 1511.) She reported suicidal thoughts in November 2016, and was flagged as a high suicide risk. (Tr. 1510, 1565-1566.) In December, Edgington stated she was “struggling to get out of the house.” (Tr. 1509.)

         On April 25, 2017, Edgington returned to Dr. Rubai. (Tr. 1561-1566.) She admitted she had taken herself off all her psych medications for about two weeks in March because she “didn't care.” (Tr. 1562.) Her daughter realized Edgington was not taking her medications, and convinced her to resume taking them. (Id.) Edgington remarked “ there was [a] noticeable difference in my attitude on every level when I went back on meds.” (Id.) Specifically, she stated Buspar made her feel “calmer” and Cymbalta helped with both her depression and anxiety. (Id.) However, Edgington continued to report erratic sleep, panic attacks, excessive worrying, flashbacks, and intrusive memories. (Id.) On examination, Dr. Rubai noted good hygiene, fair grooming, cooperative behavior, good eye contact, normal speech and psychomotor activity, improved mood, mild reactive affect, organized thought process, and fair insight and judgment. (Tr. 1563.)

         Dr. Rubai noted a “pattern of noncompliance with meds and follow up.” (Tr. 1565.) She assessed moderate depression/anxiety with avoidance behavior, and noted Edgington's mental health symptoms were more manageable with medication. (Id.) Dr. Rubai noted Edgington had declined participating in the VA's Psychosocial Residential Rehabilitation Treatment Program (“PRRTP”). (Tr. 1566.) She found a GAF of 59 (indicating moderate symptoms) and adjusted Edgington's medications. (Tr. 1565.)

         On May 24, 2017, social worker James Holbrook, LISW-S, recommended removing Edgington's high risk for suicide flag. (Tr. 1548-1549.) He noted she had attended most of her mental health appointments, and had reported “a sustained stabilization of her mood symptoms over the past two months.” (Id.) Mr. Holbrook also concluded Edgington reported “use of sufficient coping skills to remain safe and engage in symptom management.”[5] (Id.)

         2. Physical Impairments

         On October 7, 2011, Edgington presented to primary care physician Megan McNamara, M.D., for evaluation of lower back pain. (Tr. 817-822.) She complained of “very severe, ” aching, constant back pain, as well as numbness radiating to her toes. (Tr. 819.) On examination, Dr. McNamara noted 5/5 muscle strength in Edgington's lower extremities with the exception of her hip flexors which were 4/5 in strength. (Id.) Dr. McNamara could not elicit reflexes in Edgington's right ankle, and straight leg testing was positive on the left. (Id.) She also noted tenderness to palpation in Edgington's bilateral lower spine. (Id.) Dr. McNamara prescribed Naproxen, and ordered X-rays. (Id.)

         Edgington underwent lumbar x-rays on October 17, 2011, which were normal. (Tr. 1053.) Dr. McNamara then ordered an MRI of her lumbar spine, which Edgington underwent on December 3, 2011. (Tr. 821, 1049.) The MRI showed the following: (1) a focal annular tear with diffuse disc bulge and small central disc herniation causing mild central canal compromise at ¶ 5-S1; (2) mild bilateral neural foramen compromise from disc osteophytes; and (3) bulging disc causing mild bilateral neural foramen compromise at ¶ 4-L5 level. (Tr. 1050-1051.)

         In December 2011, Edgington reported she was “feeling much better” and using a supportive pillow which provided “significant relief.” (Tr. 821.) At that time, she was taking Naproxen and Flexeril with “some improvement in symptoms.” (Id.)

         On January 5, 2012, Edgington presented to pain management physician Alfred Beshai, M.D., with complaints of low back pain, bilateral lower extremity pain, and tingling and numbness greater on the left than the right. (Tr. 794-796.) She rated her pain a 7 on a scale of 10, and described it as continuous, sharp, stabbing, and aching. (Tr. 794.) On examination, Dr. Beshai noted limited lumbar spinal range of motion, abnormal reflexes, tenderness in Edgington's lumbar spine, positive straight leg testing bilaterally, and positive Patrick/FABER testing on the left. (Tr. 795-796.) He also found normal gait, normal lumbar lordotic curve, no swelling, 5/5 strength in all muscle groups, and intact sensation. (Id.) Dr. Beshai concluded Edgington was “most likely experiencing neuropathic pain” and recommended injections and physical therapy. (Tr. 796.) He also prescribed Topamax, and recommended she exercise and lose weight. (Id.)

         On May 21, 2012, Edgington presented to pain management specialist Dina Hanna, M.D., for a second opinion. (Tr. 756-757.) On examination, Dr. Hanna noted a slow but non-antalgic gait, normal sensation, 5/5 muscle strength, negative facet loading testing, and positive straight leg testing bilaterally. (Id.) Dr. Hanna also found painful and decreased range of motion in Edgington's lower spine, but noted she was able to do toe and heel walking. (Id.) She diagnosed bilateral lumbar radiculitis at ¶ 4-L5, recommended injections, and prescribed Neurontin. (Id.)

         Edgington returned to Dr. McNamara on July 16, 2012. (Tr. 735-740.) She complained of left knee pain and swelling, and right hand numbness and tingling. (Tr. 738.) On examination of Edgington's left knee, Dr. McNamara noted mild swelling, full range of motion, no tenderness to palpation, negative Lachman's and McMurray's, and no instability. (Tr. 739.) She also found 5/5 muscle strength in her biceps, triceps, and wrists; normal grip strength, and decreased sensation over the 3rd, 4th, and 5th fingers of Edgington's right hand. (Id.) Dr. McNamara diagnosed patellar tendonitis and ulnar neuropathy. (Id.) She recommended knee injections, prescribed an elbow pillow, and referred Edgington to rheumatology. (Id.)

         On August 7, 2012, Edgington presented to rheumatologist Anthony Betbadal, M.D., with complaints of pain in her left knee, bilateral wrists, right elbow, and left hip. (Tr. 712-715.) Dr. Betbadal assessed osteoarthritis, and ordered x-rays. (Tr. 714.) Edgington underwent x-rays of her left knee and bilateral hips on that date, which were normal. (Tr. 1043, 1041.)

         On May 8, 2013, Edgington presented to the emergency room (“ER”) after falling down a flight of stairs. (Tr. 649-656.) She complained of pain in her right arm/shoulder and wrist, which she rated an 8 on a scale of 10. (Tr. 649, 651.) Edgington underwent a CT of her cervical spine, which showed (1) mild scoliosis with straightening of the cervical spine; and (2) degenerative disc disease, more prominent at the C5-C6 level with a moderate disco-osteophytic bulging, bilateral mild to moderate neuroforaminal narrowing, and mild central canal stenosis. (Tr. 653, 1029-1030.) X-rays of her right shoulder and right wrist revealed no acute fracture or dislocation. (Tr. 1031-1032.) Edgington was discharged home with pain medication. (Tr. 653.)

         On May 20, 2013, Edgington presented to Dr. McNamara for follow-up. (Tr. 634-639.) She complained of depression, insomnia, and numbness/tingling in her right arm and shoulder. (Tr. 636-637.) Dr. McNamara diagnosed cervical radiculopathy, and advised Edgington to resume taking Gabapentin. (Tr. 637.)

         Edgington returned to Dr. McNamara in November 2013 with complaints of thumb pain for the previous six weeks. (Tr. 584.) On examination, Dr. McNamara noted swelling and tenderness to palpation of Edgington's left thumb with limited range of motion, mild erythema, and positive Finkelstein's maneuver. (Id.) She assessed possible osteoarthritis, and ordered x-rays. (Id.) Edgington subsequently underwent an x-ray of her left hand, which showed minimal degenerative changes at the interphalangeal joints of the thumb with tiny spurs. (Tr. 1024.)

         On December 30, 2013, Edgington continued to complain of severe left thumb pain, particularly when she tried to close her hand. (Tr. 570-571.) She also reported “significant pain” in her lower lumbar spine, extending down her left leg. (Tr. 571.) Dr. McNamara prescribed a thumb splint, referred Edgington to a hand surgeon, and increased her Gabapentin dosage. (Tr. 572.)

         On January 17, 2014, Edgington presented to Michelle Lee, M.D., for evaluation of her “multiple hand problems.” (Tr. 561-563.) Specifically, she complained of left thumb pain and locking, and right hand numbness. (Tr. 561.) On examination, Dr. Lee noted decreased sensation in Edgington's right hand, full range of motion in her phalangeal joints bilaterally, negative Tinel's and Phalen's in her right hand, and triggering and pain in her left thumb. (Tr. 563.) She diagnosed left trigger thumb and right hand sensation loss, administered a thumb injection, and referred Edgington for an EMG. (Tr. 563, 557-558.) Edgington underwent the EMG on March 17, 2014. (Tr. 548-549.) It revealed evidence of chronic moderate right carpal tunnel syndrome; and mild, subacute right C5 and C6 radiculopathy. (Id.)

         On September 5, 2014, Edgington returned to Dr. McNamara with complaints of worsening back pain radiating down her bilateral thighs to her feet along with associated numbness and tingling. (Tr. 529.) On examination, Dr. McNamara noted tenderness to palpation in Edgington's thoracic and lumbar spines, positive straight leg testing bilaterally, and decreased sensation. (Tr 530.) She referred Edgington for a TENS unit, recommended Lyrica, and ordered thoracic and lumbar x-rays. (Id.) Edgington underwent the lumbar x-ray several weeks later, which was normal. (Tr. 1022.) Her thoracic x-ray showed mild multilevel degenerative changes. (Tr. 1021.)

         On October 16, 2014, Edgington reported “some benefit” from Lyrica, but continued to complain of severe back pain. (Tr. 489.) On examination, Dr. McNamara noted tenderness to palpation in Edgington's entire spine, reduced strength in her right hip, diminished sensation, and a “mild new foot drop on the left.” (Tr. 489-490.) She ordered an “urgent MRI” and prescribed Toradol for pain. (Tr. 490.)

         Two days later, Edgington presented to the ER with complaints of persistent, acute, chronic back pain. (Tr. 471-484.) She underwent an MRI of her lumbar spine, which showed (1) stable degenerative desiccative signal change of the L4-L5 and L5-S1 discs, unchanged since 2011; (2) stable central disc bulges of the L4-L5 and L5-S1 discs, without compressive discopathy; (3) no new acute interim disc protrusions or herniations; (4) normal lower thoracic and lumbar bony spinal canal, no hypertrophic canal stenosis; and (5) normal ...


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