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Cline v. Commissioner of Social Security

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

July 31, 2019

JODI CLINE, Plaintiff,



         Plaintiff Jodi Cline (“Plaintiff” or “Cline”) seeks judicial review of the final decision of Defendant Commissioner of Social Security (“Defendant” or “Commissioner”) denying her applications for social security disability benefits. Doc. 3. This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned Magistrate Judge pursuant to the consent of the parties. Doc. 13.

         For the reasons explained herein, the Court finds that that the Administrative Law Judge (“ALJ”) either overlooked, inaccurately read, and/or made misstatements regarding medical evidence. Therefore, the Court is unable to conduct a meaningful review to assess whether the ALJ's decision to assign little weight to the opinion of Cline's treating neurologist Dr. Baddour and/or the RFC assessment are supported by substantial evidence. Accordingly, the Court REVERSES and REMANDS the Commissioner's decision for further proceedings consistent with this opinion.

         I. Procedural History

         On March 17, 2015, Cline protectively filed applications for disability insurance benefits (“DIB”) and supplemental security income (“SSI”).[1] Tr. 15, 69, 105, 133, 134, 229-235. Cline alleged a disability onset date of November 21, 2014. Tr. 15, 69, 86, 229, 290. She alleged disability due to brain cyst, fibromyalgia, feet pain with swelling, migraines, back pain, being tested for multiple sclerosis, balance issues, problem with choking, bladder won't empty all the way, trigeminal neuralgia, standing limitations of 20-30 minutes, walking limitations of 15-20 minutes, sitting limitations of 1-2 hours, lifting limitations of 8-10 pounds, grip issues in both hands, cannot open two liter of pop, shortness of breath, sleeping problems with chronic fatigue, tingling in arms and fingers, acid reflux/ulcers, restless leg syndrome, depression, crying spells 6-7 times per day, foggy thinking, general anxiety, and social anxiety. Tr. 69, 105, 136.

         After initial denial by the state agency (Tr. 135-142) and denial upon reconsideration (Tr. 145-149), Cline requested a hearing (Tr. 151-152). A hearing was held before the ALJ on June 30, 2017. Tr. 36-68. On December 4, 2017, the ALJ issued an unfavorable decision (Tr. 12-35), finding that Cline had not been under a disability, as defined in the Social Security Act, from November 21, 2014, through the date of the decision (Tr. 28). Cline requested review of the ALJ's decision by the Appeals Council. Tr. 219-223, 336-340. On May 31, 2018, the Appeals Council denied Cline's request for review, making the ALJ's decision the final decision of the Commissioner. Tr. 1-6.

         II. Evidence

         A. Personal, vocational and educational evidence

          Cline was born in 1971. Tr. 229. She has three children - 2 adults and one minor. Tr. 41, 1530. Cline completed high school and two years of college. Tr. 41. She was unable to finish her nursing degree. Tr. 41. She worked in the past as a home health aide. Tr. 42. Cline estimated having last worked in 2014. Tr. 42.

         B. Medical evidence

         1. Treatment history

         In 1994, Cline had brain surgery for a left-sided arachnoid cyst. Tr. 510. As far back as 2007, and continuing until 2014, Cline complained of headaches. Tr. 509, 511, 957. She first consulted with neurologist Dr. Raymond Baddour, M.D., in 2007 for evaluation of her headaches. Tr. 883. On April 9, 2014, Cline sought emergency room treatment at The Ohio State University Wexner Medical Center for jaw pain and a headache. Tr. 957. Cline reported having seen both her dentist and her primary care physician for her left-sided jaw pain, which had started the prior December but had waxed and waned. Tr. 957. She had been diagnosed with TMJ. Tr. 957. The emergency room physician noted that Cline was scheduled to see Dr. Gregory Ness, DDS, on April 16, 2014, and did not feel that there was anything that could be done at the emergency room to help Cline with her problems. Tr. 959, 1149. When Cline saw Dr. Ness on April 16, 2014, he suspected neuropathic pain consistent with trigeminal neuralgia and recommended that Cline follow up with her neurologist. Tr. 1150-1153.

         Upon an order from Dr. Baddour, on June 3, 2014, Cline had a brain MRI due to severe left jaw and facial pain with headaches. Tr. 506-507. The MRI showed a benign vascular malformation consistent with venous hemangioma involving the left cerebellum hemisphere; status post previous left parietal craniotomy with a focal area of encephalomalacia or cortical atrophy deep to the craniotomy site and no enhancement present at the surgical site; and no focal signal abnormality or abnormal enhancement observed along the course of the trigeminal nerve. Tr. 507.

         On June 10, 2014, Cline sought emergency room treatment at Shelby Hospital for the pain to the left side of her face, cheek and jaw. Tr. 921. She explained that Dr. Ness at OSU had diagnosed her with trigeminal neuralgia, and she had been taking baclofen but she was no longer getting any relief. Tr. 921. She reported having an appointment scheduled with an oral surgeon at OSU but could not get in sooner. Tr. 921. Cline's diagnosis was facial pain and she was discharged home in stable condition. Tr. 923. Cline returned to the emergency room on June 15, 2014, complaining “I'm sick all over.” Tr. 917. Her symptoms included nausea and vomiting. Tr. 917. She had not taken Percocet or Vicodin for three days. Tr. 917. Cline was not interested in any more pain pills so the emergency course of treatment was to help Cline with her withdrawal symptoms. Tr. 920. She was discharged home in stable condition. Tr. 920.

         Cline saw Dr. Daniel M. Prevedello, M.D., at The James Skull Base Surgery Clinic on July 15, 2014, for a consultation regarding her left-sided facial pain. Tr. 537. Cline noted that her headaches may be related to her history of left frontal arachnoid cyst that had been operated on. Tr. 537. Dr. Prevedello's physical examination showed normal range of motion, no edema, normal strength and reflexes, no cranial nerve deficit, normal muscle tone, and normal gait and coordination. Tr. 540. Dr. Prevedello noted Cline had no pain when he touched her face on the left side. Tr. 540. Cline explained that her face usually gets irritated by touching but she had taken a Percocet earlier in the day. Tr. 540. Dr. Prevedello recommended additional diagnostic testing to better evaluate the relationship of the trigeminal nerves with the vascularity at the posterior fossa. Tr. 540. Dr. Prevedello explained to Cline that her cyst was not the cause of her facial pain. Tr. 540-541. He felt that Cline's pain was slightly atypical and recommended that she return in one week. Tr. 541.

         Cline had the additional testing recommended by Dr. Prevedello completed on July 22, 2014. Tr. 549-553. Cline then followed up with Dr. Prevedello on July 22, 2014.[2] Tr. 560-567. Dr. Prevedello indicated that the MRI sequence showed an ectatic vessel which might explain her facial pain. Tr. 567. Dr. Prevedello also indicated that Cline had initially done very well with Tegretol but she developed a rash and had to switch to Dilantin which was not controlling her pain as well. Tr. 567. Dr. Prevedello felt that surgery could benefit Cline but both he and Cline felt that they should exhaust medical therapy as a means of managing her condition. Tr. 567. Thus, Dr. Prevedello recommended that Cline taper off of Dilantin (under the guidance of her neurologist) and try a different class of antiepileptic medication, like Gabapentin, before considering surgery. Tr. 567. Dr. Prevedello indicated he would see Cline for follow up in three months, noting that Cline should call sooner if her pain became too unbearable. Tr. 567.

         Cline saw Dr. Baddour on August 12, 2014. Tr. 846. During that visit, Dr. Baddour noted diagnoses of fibromyalgia, tension-vascular headaches, restless leg syndrome, and trigeminal neuralgia. Tr. 846. On physical examination, Dr. Baddour noted no deficits to pinprick over the face. Tr. 846. Dr. Baddour advised Cline to start to taper Dilantin and start on Gabapentin for trigeminal neuralgia. Tr. 846. He also continued Percocet to be taken as needed as well as Maxalt for headaches, Zofran for nausea, and Requip for restless leg syndrome. Tr. 846.

         On October 16, 2014, Cline saw Dr. Robert Secor, M.D., her primary care physician, for an office visit. Tr. 618, 1226-1227. Dr. Secor noted present illnesses of allergies, trigeminal neuralgia, and fibromyalgia. Tr. 1226-1227. Other than an abnormal heart sound being noted, physical examination findings were normal. Tr. 1227. Prescriptions for Neurontin and Percocet were provided. Tr. 1227.

         During a November 11, 2014, visit, Dr. Baddour noted that Cline's tension-vascular headaches and her right occipital neuralgia had subsided. Tr. 844. Physical examination findings were unremarkable. Tr. 844. Dr. Baddour noted that Gabapentin was helping but was concerned that it could be causing some lower extremity swelling so adjustments were made to Cline's medication. Tr. 844. Also, Cline planned on getting compression stockings for her lower extremity swelling. Tr. 844.

         Cline saw Dr. Prevedello on November 25, 2014. Tr. 574-579. Dr. Prevedello's physical examination showed normal range of motion, no edema, normal strength and reflexes, no cranial nerve deficit, normal muscle tone, and normal gait and coordination. Tr. 578. He noted that Cline's left-sided facial pain was exacerbated by brushing of her teeth. Tr. 578. Dr. Prevedello recommended trigeminal nerve decompression surgery and planned to proceed with the surgery in January. Tr. 578-579.

         On January 9, 2015, Cline underwent microvascular decompression of the left trigeminal nerve, which was performed by Dr. Prevedello. Tr. 612-618. She was discharged home with instructions to have her staples/sutures removed within 10-14 days. Tr. 618. On January 21, 2015, Cline saw Dr. Secor for a post-operative visit and removal of her sutures. Tr. 1228-1230. Cline returned to see Dr. Prevedello on February 10, 2015, for a post-operative visit. Tr. 1023-1209. Cline was doing well one-month post-op. Tr. 1028. She felt her left V2 distribution pain was improved but not entirely resolved. Tr. 1028. Thus, Dr. Prevedello recommended that Cline continue taking her Neurontin and then consider tapering off if possible after two more months. Tr. 1028. She was still reporting daily headaches. Tr. 1028. Dr. Prevedello planned to compare old imaging with new imaging to see if Cline's arachnoid cyst was growing. Tr. 1028.

         When Cline saw Dr. Baddour on March 24, 2105, she relayed that she had not recently had any significant headaches. Tr. 840. A six-day Prednisone taper in combination with other medications had helped her headaches. Tr. 840. Also, a prior right occipital injection had been of benefit in reducing her headaches for about two days. Tr. 840. The surgery in January had helped reduce Cline's trigeminal neuralgia pain but she was still experiencing trigeminal neuralgia pain daily. Tr. 840. Cline complained of restless leg syndrome and musculoskeletal low back pain. Tr. 840. On physical examination, Dr. Baddour observed 5/5 motor strength in foot dorsiflexors bilaterally and quadriceps bilaterally, deep tendon reflexes absent in the right ankle otherwise in the lower extremities, plantar responses were downward bilaterally, negative straight leg raise bilaterally, no edema in lower extremities, and upper lumbar paraspinal muscle tenderness. Tr. 840. For her restless leg syndrome and back pain, Dr. Baddour recommended a six-day Prednisone taper and possibly a lumbar MRI if her back symptoms persisted. Tr. 840-841.

         Cline followed up with Dr. Prevedello on April 14, 2015. Tr. 1029-1034. On physical examination, Dr. Prevedello observed grossly normal range of motion, no dependent edema in arms/legs, normal mood and affect, motor strength was 5/5, sensation intact in bilateral C2-T2 and L2-S2, and reflexes were present and equal (). Tr. 1033. Dr. Prevedello indicated that Cline continued to experience pain in the left V2 distribution but reported that she was far better than she had been before her surgery and she was continuing to improve. Tr. 1034. Cline complained of a variety of other issues that had been occurring over the past month, including tingling in her hands and feet, burning and jabbing sensation in her low back, and dropping things. Tr. 1034. Dr. Prevedello recommended testing to rule out spinal cord or nerve root compression and a lumbar puncture to rule out MS. Tr. 1034.

         Cline saw Dr. Baddour on April 28, 2015, and she complained of right-sided facial neuropathic pain that started earlier in April 2015. Tr. 1374. The pain was localized to the V2 and V3 distributions of the trigeminal nerve and was exacerbated by eating, cold ambient temperature, or wind blowing across her face. Tr. 1374. Prednisone helped with her facial pain but the medication was wearing off later in the day, making her pain more pronounced. Tr. 1374. Cline reported some recent gait imbalance but related it to having tried increasing her Gabapentin to help reduce her facial pain. Tr. 1374. The increased dose did not help so she was no longer increasing it. Tr. 1374. Cline reported fluctuating low back pain and chronic tingling in her hands and feet that had been present for years. Tr. 1374. Physical examination showed 5/5 motor strength in the biceps and quadriceps bilaterally, no deficits to soft touch in the hands, no deficits to pinprick over the face or occipital head region, plantar responses were downward bilaterally, deep tendon reflexes were in the upper extremities, at the knees, and at the ankles. Tr. 1374. Dr. Baddour ordered a head MRI to assess Cline's new reports of right-sided trigeminal neuralgia. Tr. 1375.

         On May 12, 2015, Cline saw Dr. Prevedello along with a resident Dr. Wenya Bi, M.D., Ph.D., for follow up. Tr. 1120-1125. Cline was unable to obtain the spinal MRI to rule out spinal cord or nerve root compression due to insurance reasons. Tr. 1124. However, she was able to have the lumbar puncture procedure performed that day. Tr. 1124. Cline explained her new onset of right-sided facial pain, which she described as similar to prior symptoms on her left side. Tr. 1124. Physical examination findings showed grossly normal range of motion, no dependent edema in arms/legs, mood and affect were normal, sensation was intact to fine and crude touch in bilateral V1-3 distributions, extremities moved with full strength, and independent ambulation. Tr. 1124-1125. Additional testing was ordered to evaluate for evidence of MS or demyelinating disease and Cline was advised to follow up with her neurologist for possible neuropathy. Tr. 1125. The following day, Cline sought emergency room treatment at Shelby Hospital for a spinal headache which she stated had started immediately after she had the spinal tap the day before. Tr. 1348. Cline was discharged home the same day in stable condition. Tr. 1351.

         On May 21, 2015, Cline saw rheumatologist Scott R. Burg, D.O., at the Cleveland Clinic for a consultation regarding her foot and back pain. Tr. 1192-1197. On physical examination, Dr. Burg observed deep tendon reflexes 2 and symmetric in all extremities; normal sensory exam; normal 5゚ muscle strength; normal bulk and tone; no visible abnormalities in the cervical spine; full range of motion in the cervical spine; and no tenderness to palpation in the cervical spine; no visible abnormalities in the thoracic spine; slight tenderness in the lower parathoracic region; no visible abnormalities in the lumbar spine; full range of motion in the lumbar spine with slight lumbar spine tenderness to palpation; negative straight leg raise; adequate heel and toe walking; normal inspection of upper and lower extremities. Tr. 1194-1195. Dr. Burg noted that Cline had multiple medical problems along with complaints of chronic lower thoracic and lumbar pain in addition to burning pain in her feet. Tr. 1196. Dr. Burg encouraged Cline to discuss the burning pain with her neurologist if she had not done so already. Tr. 1197. Dr. Burg did not see evidence of an inflammatory synovitis and he could not say whether she had fibromyalgia alone. Tr. 1197. He recommended additional testing and follow up with him in three weeks. Tr. 1197.

         On May 22, 2015, Cline had a brain MRI performed as ordered by Dr. Baddour. Tr. 1345-1346. The MRI was similar to the March 2014 imaging except there was a small amount of fluid present in the left mastoid air cells non-specific in its appearance that was not present on the previous MRI. Tr. 1346.

         During a May 28, 2015, visit with Dr. Baddour, Cline complained of burning and stinging pain in her feet and Dr. Baddour noted slight decreased vibration sensation in the feet. Tr. 1372, 1373. He observed 5/5 motor strength in the quadriceps and dorsiflexors bilaterally, no deficits in pinprick over the face, plantar responses were downward bilaterally, deep tendon reflexes were absent at the knees and right ankle and trace at the left ankle. Tr. 1372. Dr. Baddour ordered additional testing to assess for neuropathy and noted that EMG/nerve conduction studies of the lower extremities would be considered if her lower extremity symptoms persisted and depending on other analyses. Tr. 1373.

         During a visit with Dr. Baddour on June 23, 2015, Cline complained of right occipital neuralgia pain that had been prominent over the prior five days and she was having occasional neck pain. Tr. 1371. Physical examination findings were unremarkable. Tr. 1371. Dr. Baddour prescribed Prednisone and Dilantin and ordered cervical x-rays to assess her occasional neck pain. Tr. 1371.

         Cline saw Dr. Prevedello on June 29, 2015, for follow up regarding her spinal tap and other testing. Tr. 1139-1144. Cline relayed that her face pain had “improved tremendously and she [was] very satisfied with the result.” Tr. 1143. Physical examination findings showed normal range of motion, no edema, normal strength and reflexes, no cranial deficit, normal muscle tone, normal gait and normal coordination, and mood, affect and judgment were normal. Tr. 1143. Dr. Prevedello informed Cline that the results from the lumbar puncture showed no abnormality and instructed her to follow up when necessary. Tr. 1144.

         On July 30, 2019, Cline had a cervical spine x-ray taken, which showed mild disc disease and facet arthropathy in the lower cervical spine and minimal osseous foraminal narrowing at C5-C6 on the right. Tr. 1338.

         During an August 3, 2015, visit, Dr. Baddour noted that an MRI and other testing performed at OSU did not suggest the presence of demyelinating disease. Tr. 1370. Physical examination findings were unremarkable. Tr. 1369. Dr. Baddour noted Cline's complaints of stinging in her feet as well as her other complaints of pain. Tr. 1370. On August 14, 2015, and September 11, 2015, Dr. Baddour administered trigger point injections in Cline's right upper cervical paraspinal muscles due to Cline's reports of neck pain and right occipital neuralgia pain. Tr. 1367-1368.

         Cline saw her primary care physician Dr. Secor on August 6, 2015, for cold symptoms, a lump on her back and multiple aches. Tr. 1391. Cline was interested in seeing a specialist regarding her muscle and joint aches. Tr. 1391. Dr. Secor referred Cline to a rheumatologist for assessment of polyarthritis. Tr. 1394.

         Cline saw Dr. David G. Stainbrook, Jr., D.O., in August and September 2015 for her joint pain and osteoarthritis. Tr. 1158-1164, 1165-1173. During the August 27, 2015 visit, Dr. Stainbrook assessed fibromyalgia syndrome based on history, which he noted was supported by this examination that day. Tr. 1165. Dr. Stainbrook noted that Cline could benefit from a psychological evaluation and treatment of any underlying depression and/or anxiety disorder and evaluation by chronic pain management. Tr. 1165. Dr. Stainbrook prescribed Savella and provided Cline with a referral for physical therapy. Tr. 1165. Dr. Stainbrook also assessed osteoarthritis, back pain, lumbar disc degenerative disease, lumbar spine osteoarthritis, cervicalgia, cervical disc disease, osteoarthritis of the cervical spine, arthralgia of hip, osteoarthritis of hip, arthralgia of the ankle and/or foot, osteoarthritis of ankle and foot, vitamin D deficiency, occipital neuralgia, trigeminal neuralgia, migraine headache, fatigue, overweight, and disorder of bone and cartilage, unspecified. Tr. 1165-1166, 1170-1171. Dr. Stainbrook's physical examination findings during the August 27, 2015, visit were generally normal, including a normal gait, except he noted some abnormal findings, including an obese abdomen; cervical spine tenderness and severely reduced cervical spine range of motion; thoracic spine tenderness; lumbar spine tenderness; left hip tenderness with mildly reduced range of motion; tenderness and pain in the hips with decreased range of motion; right and left TMJ positive for crepitus; MTP1 and MTP5 in the feet bilaterally positive for pain and decreased range of motion; and soft tissue discomfort noted in various areas with 18 out of 18 total tender points. Tr. 1169-1170. Bilateral foot x-rays were taken on August 27, 2015. Tr. 1188. The impression was no acute osseous abnormality, no erosive osseous changes, mild right hallux valgus deformity with bunion formation and associated right first MTP joint degenerative changes, and tiny plantar and retrocalcaneal enthesophytes bilaterally. Tr. 1188-1189.

         During Cline's September 9, 2015, visit, Dr. Stainbrook diagnosed Cline with osteoarthritis, cervical degenerative disease, osteoarthritis of the cervical spine, hip and ankle and foot, lumber disc degenerative disease, vitamin D deficiency, trigeminal neuralgia, occipital neuralgia, fibromyalgia, positive ANA, calcaneal spur and arthralgia of the ankle and/or foot. Tr. 1158-1159. Physical examination findings included left knee being positive for normal crepitus, gait was normal, and there was soft tissue discomfort noted in various areas with 18 out of 18 tender points. Tr. 1161-1162. There were no range of motion limitations noted. Tr. 1161-1162. Cline had not started Savella yet because prior authorization was required. Tr. 1159. She planned to follow up with her pharmacy that day. Tr. 1159. She was going to start physical therapy the following week. Tr. 1159.

         On September 16, 2015, Cline had an initial physical therapy evaluation. Tr. 1177-1179. She rated her symptoms at a 5/10 and indicated they varied between 3/10 and 8/10. Tr. 1177. The physical therapist noted the following regarding lumbar spine testing “flexion 50%, extension and lateral flexion in either direction 25% limited.” Tr. 1178. As far as the cervical spine, the therapist noted “flexion, extension and rotation in either direction 50% limited with lateral flexion 25% limited.” Tr. 1178. The therapist indicated that Cline's signs and symptoms appeared consistent with “impaired joint mobility, motor function, muscle performance and range of motion associated with connective tissue dysfunction.” Tr. 1179. Cline attended therapy from September 16, 2015, through November 4, 2015, for a total of 11 sessions. Tr. 1326-1336. Although she attended 11 sessions, Cline did not show for her final session so a final assessment was not performed. Tr. 1326. The therapist noted that, during the sessions, Cline continued to have good and bad days depending on her activities and stress level. Tr. 1326.

         Cline saw Dr. Baddour on November 3, 2015. Tr. 1365-1366. It was noted that Cline was seeing a rheumatologist, Dr. Stainbrook, for fibromyalgia and osteoarthritis. Tr. 1365-1366. Savella and aquatic therapy had been of modest benefit. Tr. 1365. Cline reported fatigue for which she received a B12 injection. Tr. 1365. She was still having tension-vascular headaches but they had diminished in frequency. Tr. 1365-1366. Physical examination findings were unremarkable. Tr. 1365.

         Upon Dr. Baddour's referral, on December 2, 2015, Cline saw Dr. Devon S. Conway, M.D., at the Cleveland Clinic for a consultation regarding the possibility of MS. Tr. 1216-1220. During the visit, Cline relayed that she was friends with another patient of Dr. Conway's and that friend had suggested that Cline see Dr. Conway about the possibility of MS. Tr. 1216. Dr. Conway found that Cline's neurological examination was unremarkable. Tr. 1220. He concluded that MS was not likely. Tr. 1220. Dr. Conway indicated that a possible alternative diagnosis might be peripheral neuropathy but he noted that Cline did not have significant sensory deficits on examination. Tr. 1220. In light of the lack of clear explanation for Cline's symptoms, Dr. Conway felt that an EMG and/or QSART[3] might be worth pursuing. Tr. 1220. Cline wanted to have the testing performing locally so Dr. Conway noted he would defer to Dr. Baddour. Tr. 1220.

         On January 7, 2016, Dr. Baddour administered another B12 injection to help Cline with her fatigue. Tr. 1364. Cline saw Dr. Baddour on February 3, 2016. Tr. 1362-1363. Cline relayed that she had a recent fall. Tr. 1363. She reported stinging pain in her feet and occasional weakness and occipital pain in her hands. Tr. 1363. Dr. Baddour indicated that an EMG/nerve conduction study would be ordered to assess for possibly polyneuropathy. Tr. 1363. Dr. Baddour's physical examination findings were generally unremarkable. Tr. 1362. On physical examination, Dr. Baddour observed decreased vibration in the feet and deep tendon reflexes were absent in the knees. Tr. 1362.

         On March 27, 2016, Cline presented to the Shelby Hospital emergency room with complaints of left-sided cheek/facial spasms. Tr. 1271. Physical examination findings were unremarkable. Tr. 1274. Her diagnosis on discharge was chronic pain in face. Tr. 1275. She was discharged home in stable condition with prescriptions of Prednisone and Oxycodone with acetaminophen. Tr. 1279. The next day, Cline followed up with Dr. Baddour. Tr. 1361. Cline relayed that she was experiencing an exacerbation of severe trigeminal neuralgia pain in the left V2 and V3 distributions that started five days prior. Tr. 1361. Dr. Baddour noted that, following Cline's visit to the emergency the day before, she was started on Prednisone and given narcotics. Tr. 1361. Cline reported that her pain was slightly reduced but still severe. Tr. 1361. She described her pain as burning, sharp, and intermittent. Tr. 1361. Physical examination findings were unremarkable. Tr. 1361.

         On April 9, 2016, Cline returned to the emergency room at Shelby Hospital. Tr. 1258-1269. Cline complained of sharp pain to the right side of her face and ear. Tr. 1258. She relayed that she had called her neurologist the day before and had her Dilantin increased. Tr. 1258. Physical examination notes indicate that Cline was not in acute distress. Tr. 1260. She was treated in the emergency room with Dilaudid and Phenergan and discharged home in stable condition. Tr. 1262, 1267.

         Cline returned to see Dr. Prevedello on April 19, 2016. Tr. 1416-1424. Physical examination findings showed normal range of motion, no edema, normal strength and normal reflexes, no cranial nerve deficit, normal muscle tone, normal gait and coordination, normal mood, affect and judgment, and she was neurologically intact. Tr. 1421. Dr. Prevedello indicated that a recent brain FIESTA sequence MRI did not reveal any specific abnormality. Tr. 1414, 1420, 1421. Dr. Prevedello discussed with Cline the possibility of redoing the microvascular decompression procedure or consulting with Dr. John McGregor regarding other possible treatments, e.g., glycerol balloon, radiofrequency, gamma knife. Tr. 1422.

         Cline saw Dr. Baddour on May 5, 2016. Tr. 1358-1359. Physical examination showed motor strength 5/5 in the hands bilaterally and there were no deficits to soft touch in the hands. Tr. 1359. Cline had not had any severe tension-migraine type headaches recently. Tr. 1359. Cline's facial pain had ...

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