United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION & ORDER
KATHLEEN B. BURKE, UNITED STATES MAGISTRATE JUDGE
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.
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.
March 17, 2015, Cline protectively filed applications for
disability insurance benefits (“DIB”) and
supplemental security income
(“SSI”). 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.
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.
Personal, vocational and educational evidence
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.
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.
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.
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.
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.
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. 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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 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.
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.
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.
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.
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.
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 ...