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Symens v. Colvin

United States District Court, D. South Dakota, Central Division

March 4, 2014

HELEN DENISE SYMENS, Plaintiff,
v.
CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.

OPINION AND ORDER AFFIRMING FINAL DECISION

ROBERTO A. LANGE, District Judge.

Plaintiff Helen Denise Symens seeks reversal of the Commissioner of Social Security's decision denying Symens's application for Social Security Disability Insurance (SSDI) benefits. Alternatively, Symens requests that this Court remand the case for a further hearing on issues she has raised. For the reasons explained below, this Court affirms the final decision of the Commissioner of Social Security.

I. Procedural Background

On August 8, 2009, Symens filed an application for SSDI benefits and attendant Medicare under Title II and Title XVIII of the Social Security Act alleging disability since January 10, 2009, due to rheumatoid arthritis, Sjogren's Syndrome, degeneration of her cervical spine, depression, recurrent infections and mouth sores, and side effects from her medications. AR[1] 13, 145, 169. The Social Security Administration denied Symens's application initially on December 22, 2009, AR 74, and again upon reconsideration on March 4, 2010, AR 82. In March 2010, Symens requested a hearing before an Administrative Law Judge (ALJ). AR 86. The ALJ conducted a hearing, AR 33, and issued a decision in May 2011 finding that Symens was not disabled and thus was not entitled to benefits, AR 13-28. Symens then requested that the Appeals Council review the ALJ's decision along with new evidence which request was denied on December 19, 2012. AR 1-6.

II. Factual Background

Symens was born on May 24, 1971. AR 38, 145. She obtained a bachelor's degree in wildlife and fishery sciences from Arkansas Technical University in 1994, and a master's degree in fishery biology from South Dakota State University in 1998. AR 38-39. Symens and her husband Curtis have two children. AR 145, 258.

In 1998, Symens began working as a fish hatchery biologist at the United States Fish and Wildlife Service fish hatchery in Yankton, South Dakota. AR 170, 257. She left her job in Yankton in 2001 to take a position as a fisheries research associate at the University of Arkansas. AR 170, 257. She held this position until 2006, when she and Curtis opened a grocery store in Willow Lake, South Dakota. AR 170, 257. The grocery store encountered financial difficulties and closed in 2008. AR 40, 232, 257. Symens was enrolled in Lake Area Technical Institute's licensed practical nurse program from August 2008 until July 2009. AR 39, 232, 258. She stated that she was unable to complete the program due to pain. AR 39, 232. Symens's most recent work attempt was as a Pampered Chef consultant from April 2010 to June 2010. AR 43, 232.

Symens's relevant medical history begins with a September 23, 2008 appointment with physician's assistant (P.A.) Louann Streff. AR 390. Symens complained of joint pain and P.A. Streff suggested that she take ibuprofen. AR 390. Symens saw Dr. Rebecca Pengilly, her family physician, on September 30, 2008. AR 329. Symens explained that she had developed pain and stiffness in her hands approximately three months ago. AR 329. She also reported pain in her knees and sometimes her ankles. AR 329. Dr. Pengilly examined Symens and found a "little bit" of redness and warmth of the metacarpophalangeal (MCP) joints and a "touch" of swelling of the proximal interphalangeal (PIP) joints. AR 329. Symens hands were tender with flexion and extension. AR 329. Although Symens's knees cracked when she bent them, Dr. Pengilly found no problems at that time with Symens's wrists, elbows, shoulders, ankles, hips, or toes. AR 329. AR 344. Dr. Pengilly assessed Symens as having polyarthralgia and prescribed a short course of Prednisone.[2] AR 329. Symens returned to P.A. Streff on October 1, 2008, complaining of swollen joints. AR 389. P.A. Streff noted some mild swelling in Symens's hands and assessed Symens as having swollen joints. AR 389.

On October 8, 2008, Symens saw Dr. Pengilly for joint pain, reporting pain in her wrists and knees. AR 324. The previous prescription for Prednisone had helped ease Symen's pain, but had not resolved the issue. AR 324. Dr. Pengilly's examination revealed that Symens had tenderness in her MCP joints but not much swelling, and some swelling of her PIP joints. AR 324. Dr. Pengilly noted that Symens's wrists had a full range of motion and were not swollen and that her shoulders and elbows were fine. AR 324. Dr. Pengilly assessed Symens as having polyarthralgia, recommended that she see a rheumatologist, and prescribed Relafen[3] and Ultram.[4] AR 324.

Symens saw P.A. Streff on October 27, 2008, for a follow up on a previous diagnosis of hypothyroidism.[5] AR 388. Symens also complained of problems with her eye and pain in her hands. AR 388. PA. Streff examined Symens but did not find much in the way of joint swelling, noting that there "might be a little bit" of swelling in Symens's hands but "certainly nothing grossly inflamed." AR 388. P.A. Streff assessed Symens as having joint pain and hypothyroidism. AR 388.

Symens saw Dr. Wayne Snyder, her opthamologist, on January 6, 2009. AR 288. Symens had experienced eye trouble in the past, being assessed or diagnosed with retinoschisis, [6] AR 277, 245, 280, possible uveitis, [7] AR 245, 254, and episcleritis, [8] AR 254, 280. Dr. Snyder diagnosed Symens with retinoschisis. AR 292.

Symens revisited P.A. Streff on January 7, 2009, reporting neck pain for which she had seen a chiropractor. AR 386. P.A. Streffs examination of Symens showed tenderness in the paravertebral musculature and around the cervical spine. AR 386. An x-ray revealed no gross bony abnormalities. AR 386. P.A. Streff assessed Symens as having neck pain and prescribed Flexeril.[9] AR 386.

Symens had her first visit with her rheumatologist, Dr. Christine Halligan, on January 12, 2009. AR 456. Symens explained that she developed joint pain shortly after she developed scleritis[10] and that she now had pain in her wrists, elbows, shoulders, knees, ankles, feet, and MCP and PIP joints. AR 456. She described her pain as being worse in the morning but present all day, having swelling in her hands and feet, and having difficulty making a fist. AR 456. Symens stated, however, that her joint pain "essentially resolved" while she was on Prednisone. AR 456. Dr. Halligan's examination of Symens revealed bilateral synovitis[11] in the first, second, and third MCP joints, the second and third PIP joints, and wrists. AR 454. Symens also had diffuse synovitis in her metatarsals. AR 454. Symens's gait and cervical and lumbar range of motion was appropriate for her age and her proximal and distal strength in her upper and lower extremities was intact. AR 454. She was able to make a fist bilaterally and had weak to moderate grip strength. AR 454. Dr. Halligan's impressions from the appointment were that Symens had a positive rheumatoid factor, a new onset of visual changes in her left eye, and inflammatory arthritis. AR 454. Dr. Halligan ordered x-rays, prescribed a course of Prednisone, and started Symens on Methotrexate[12] shortly thereafter. AR 452. Because Symens had complained of a bright light in her left eye, Dr. Halligan had her see Dr. Eric Thomas, an opthamologist, that same day. AR 251, 450. Dr. Thomas's impressions were that Symens had a history of "episcleritis/uveitis" and retinoschisis. AR 252. He stated that "overall things with [Symens's] eyes look to be quite stable.... [s]he does have a mild amount of retinoschisis, however this is very common, and is most likely not related to the rheumatoid arthritis at all." AR 252.

Symens saw Dr. Pengilly on January 23, 2009, for a painful spot in her mouth. AR 322. Dr. Pengilly assessed Symens as having herpes labialis and prescribed Symens Acyclovir.[13] AR 322. Symens saw Dr. Pengilly again on February 4, 2009, for pain in her right foot. AR 321. Symens reported that she was having difficulty walking. AR 321. Although x-rays from the appointment showed a small post calcaneal spur, there was no evidence of fracture, periosteal reaction, or significant arthritic change. AR 318, 321, 332. Dr. Pengilly prescribed Ultram, placed Symens in a walking boot for a week, and referred her to Dr. Shannon Engel, a podiatrist. AR 321. Dr. Engel's February 10, 2009 examination of Symens revealed pain in both feet at the metatarsal phalangeal joints one through five but a normal range of motion in the ankles and subtalar joints. AR 318. Dr. Engel hoped that Symens's rheumatoid arthritis medication would help with the pain and recommended icing, limited activity, and insoles. AR 318.

Symens saw Dr. Halligan again on March 13, 2009. AR 450. She reported that her neck and back were doing fairly well but that she was having severe foot pain and had difficulty standing for prolonged periods. AR 448-49. Symens had some mild tenderness in her fourth and fifth metatarsals on the right but her feet were not swollen and she did not indicate any significant amount of discomfort with palpitation. AR 448. Dr. Halligan observed some tenderness in Symens's wrists and noted that Symens may have some swelling there. AR 448. A joint examination showed no obvious synovitis in Symens's upper or lower extremities. AR 448. Symens's gait and cervical and lumbar range of motion was appropriate for her age and her proximal and distal strength in her upper and lower extremities was intact. AR 448. The x-rays of Symens's hands, feet, and chest from her prior appointment were unremarkable. AR 450. Dr. Halligan's impressions from the appointment were that Symens had episcleritis in her left eye, a positive rheumatoid factor, and inflammatory arthritis. AR 448. She noted that Symens "continues to have joint symptoms despite currently treatment [sic]." AR 448. Dr. Halligan noted that the Methotrexate was not "fully efficacious" at that time and prescribed Humira[14]" and Mobic[15] for Symens's pain. AR 446-47.

Symens returned to Dr. Pengilly on April 3, 2009, because of neck pain. AR 317. Dr. Pengilly noted that a recent x-ray showed "a little bit of narrowing" between C6 and C7 of Symen's spine but was otherwise "ok." AR 317. Symens had a full range of motion in flexion and extension of her neck, but it hurt to turn her head in either direction and she had pain in her strap muscles upon palpitation. AR 317. Dr. Pengilly assessed Symens as having a cervical strap muscle strain with spasms and prescribed Ultram. AR 317. Symens saw Dr. Pengilly again on April 27, 2009. AR 316. Symens reported that she had a fever, neck pain, a headache, fatigue, and nausea. AR 316. Dr. Pengilly assessed Symens as having an upper respiratory infection and prescribed Mobic. AR 316.

Symens visited Dr. Halligan for a reevaluation on May 12, 2009. AR 445. Symens reported that she was eighty to ninety percent improved. AR 445. Although she still had pain in her neck and feet and stiffness in the morning, these problems had lessened. AR 445. Symens showed no obvious synovitis in her upper or lower extremities, some tenderness to palpitation in her right hand MCP, and no tenderness to palpitation in her metatarsals. AR 444. Symens's gait and cervical and lumbar range of motion were appropriate for her age as was her proximal and distal strength in her upper and lower extremities. AR 444. Dr. Halligan's impressions were that Symens had episcleritis in her left eye, a positive rheumatoid factor, and inflammatory arthritis. After noting that Symens was "much improved" on Humira, Dr. Halligan recommended that Symens continue her current protocol. AR 443.

On June 6, 2009, Symens saw Dr. Pengilly for itchy eyes. AR 315. Dr. Pengilly remarked in her notes that Symens had a history of anxiety and depression and that Symens was taking Zoloft.[16] AR 315. Dr. Pengilly assessed Symens as having "[a]llergic conjunctivitis, possibly superimposed fungal infection, " and anxiety with depression. AR 315. She prescribed a short course of Diflucan.[17] AR 315.

Symens saw Dr. Snyder on June 19, 2009, for eye pain. AR 300. Dr. Snyder diagnosed Symens with stable retinoschisis and optic neuritis.[18] AR 302. On June 23, 2009, Dr. Halligan consulted with Dr. Snyder concerning how Symens's arthritis medication was affecting her left eye. AR 442. After Symens had an MRI, Dr. Snyder did not think that she had any swelling of the optic nerve or an underlying infection. AR 442. Thus, he felt that Symens could continue with immunosuppression. AR 442.

Symens saw Dr. Pengilly primarily for herpes labialis on June 24, 2009. AR 314. Symens complained of fatigue, pain and swelling in the right wrist, and pain in the right ankle and foot. AR 314. An examination showed that Symens had a little bit of swelling of the right wrist and pain with flexion or extension and pain on the top of her right foot but no swelling or loss of range of motion. AR 314. Dr. Pengilly assessed Symens as having herpes labialis, rheumatoid arthritis, and right wrist and foot pain that was "possibly secondary" to the rheumatoid arthritis. AR 314. Dr. Pengilly prescribed Valtrex[19] and a Medrol[20] dose pack. AR 314.

Symens visited Dr. Pengilly on July 8, 2009, for ear pain. AR 313. Dr. Pengilly noted that Dr. Halligan had taken Symens off of Methotrexate and Prednisone to allow Symens's cold sores to resolve. AR 313. A wrist examination revealed "a bit" of swelling and some pain. AR 313. Dr. Pengilly prescribed a Medrol dose pack and told Symens to come back in a week to ten days. AR 313. If Symens's cold sores had resolved by that time, Dr. Pengilly would call Dr. Halligan and have her restart Symens on Methotrexate and Prednisone. AR 313. Symens saw P.A. Streff the following day for urinary problems and lower back pain. AR 380. P.A. Streff assessed Symens as having a probable urinary tract infection and prescribed an antibiotic. AR 380. Symens revisited P.A. Streff on July 13, 2009, this time complaining of right ear pain. AR 379. P.A. Streff assessed Symens as having otitis externa and prescribed ear drops. AR 379.

Symens saw Dr. Pengilly for a recheck on July 20, 2009. AR 312. Symens reported swelling in her wrists and "being really achy and tired[.]" AR 312. On physical examination, Dr. Pengilly noted that Symens looked "very tired, " that her wrists were "a bit" swollen and tender, and that her CMP joints were tender but not swollen. AR 312. Although Symens's herpes labialis had resolved, Dr. Pengilly thought that Symens's rheumatoid arthritis had worsened since she stopped taking Methotrexate. AR 312. Dr. Pengilly restarted Symens on Methotrexate and gave her a short course of Prednisone to get her rheumatoid arthritis under control. AR 312.

Symens returned to Dr. Pengilly on August 3, 2009, for neck pain. AR 311. Dr. Pengilly remarked that Symens was trying to go back to school and that "some of [her neck pain] is stress. She also has a history of rheumatoid arthritis and she has still some joint swelling and pain." AR 311. On examination, Dr. Pengilly noted that Symens appeared tired, had some swelling of the MCP joint, and had a limited range of motion in her neck with pain in the cervical strap muscles down into the trapezius. AR 311. Dr. Pengilly prescribed Mobic and Ultram and recommended that Symens see Dr. Halligan. AR 311.

Symens's neck pain persisted and she saw Dr. Pengilly again on August 7, 2009. AR 310. Symens reported pain in her neck, numbness in her hands, and swelling in her wrists and MCP joints. AR 310. An examination showed that Symens had some swelling in her wrists and the MCP joint but that she could flex and extend and her grip was "okay." AR 310. Symens had a positive Phalen's maneuver on both sides with the right being worse than the left. AR 310. She also had a positive Tinel's test on the right and a weakly positive Tinel's sign on the left.[21] AR 310. Dr. Pengilly assessed Symens as having rheumatoid arthritis and bilateral carpal tunnel syndrome.[22] AR 310. She thought that Symens's rheumatoid arthritis was causing the carpal tunnel syndrome. AR 310. Dr. Pengilly prescribed a Medrol dose pak. AR 310. A lab test from August 9, 2009, as well as lab testing at later times showed that Symens had an elevated Creactive proteins (CRP) level, likely related to the rheumatoid arthritis.[23] AR 267; see AR 335, 434, 463-64, 546.

Symens saw Dr. Halligan for a reevaluation on August 12, 2009. AR 441. Symens complained of pain in her wrists, MCP joints, knees, feet, and neck, as well as swelling of her right wrist. AR 440. Symens stated that her pain was worse in the morning or after she had engaged in strenuous activity and that she "was a nursing student but [did] not feel that she would be able to do this due to the degree of fatigue that she has." AR 440. On examination, Dr. Halligan noted aphthous ulcers on Symens's gums, no obvious synovitis in her upper or lower extremities, no tenderness upon palpitation in the MCP and PIP joints, and no tenderness over fibromyalgia trigger points. AR 439-40. Symens had excellent grip strength, her gait and cervical and lumbar range of motion were appropriate for her age, and her proximal and distal strength in her upper and lower extremities was intact. AR 439. In her notes from the appointment, Dr. Halligan stated:

I discussed with the patient I think it is likely that she [has] rheumatoid arthritis as the cause of her multiple joint symptoms. I see no evidence of synovitis on her examination. I have discussed with the patient that her degree of pain seems to be out of proportion to what her physical examination would explain. She believes the prednisone has helped her only 50%. AR 439. Dr. Halligan remarked that she wanted to see whether Symens showed signs of synovitis when Dr. Pengilly started her on Prednisone. AR 438. Dr. Halligan took Symens off of Methotrexate due to Symens's aphthous ulcers, but recommended that Symens continue with the Humira, use Prednisone for pain, and begin taking Arava.[24] AR 438. Dr. Halligan also ordered several lab tests and cervical spine x-rays. AR 438. Symens's spine x-rays showed "[f]ocal disc space narrowing at C6-C7 with straightening of the normal cervical lordosis in neutral position but no subluxation as described[, ]" AR 484.

In conjunction with her application for disability benefits, Symens completed a disability report on August 23, 2009. AR 168. Symens stated in the report that her pain and fatigue made it difficult for her to concentrate and limited her ability to do household chores and engage in physical activity. AR 169, 180. She described her pain as being so severe on some days that'it prevented her from doing anything around her house. AR 180. Symens's application stated:

I told my doctor that I had been thinking of applying for SSDI, and she said she thought I could work. To be honest, I just cried, and said I am not the kind of person to just quit work and my dreams, but it is hard when I can't walk without pain and have trouble getting out of bed due to fatigue.

AR 180.

Symens saw P.A. Streff on August 24, 2009 for urinary problems. AR 378. Symens also complained of an increase in joint pain and swelling. AR 378. P.A. Streff prescribed Diflucan. AR 378.

Symens saw Dr. Pengilly on September 9, 2009, because she was concerned that she had a urinary tract infection. AR 347. An exam showed that Symens had a "little bit" of swelling in her left wrist but that the rest of her extremities were normal. AR 347. Dr. Pengilly assessed Symens as having a history of urinary irritation with nausea and rheumatoid arthritis. AR 347. Dr. Pengilly noted that Symens had been prescribed Cipro while in California and had been taking it for ten days and prescribed Zofran.[25] AR 347. Symens continued to have urinary problems and saw Dr. Karam Pathan, a urologist, on September 24, 2009. AR 352. Dr. Pathan examined Symens and found that her extremities were normal. AR 353. He assessed Symens as having recurrent urinary tract infections and ordered several tests. AR 353.

Symens completed a function report on September 30, 2009. AR 197. She indicated that she cared for her two children, ages six and nine, and described her activities as including washing dishes, doing laundry, mowing, cooking basic meals, getting groceries when she was in town, paying bills, and helping her children with their homework and preparing them for bed. AR 197, 199, 200. Symens stated, however, that her pain and other symptoms sometimes made it difficult or impossible to do some of these activities. AR 197, 199, 200. She also described needing to rest frequently throughout the day, AR 197, being unable to lift more than eight pounds, and only being able to walk twenty to thirty minutes before needing to rest, AR 202.

Symens returned to Dr. Pathan on October 8, 2009, for a cystoscopy.[26] AR 354. The cystoscopy showed proximal narrowing in the urethra and descent in the bladder floor. AR 354. Dr. Pathan remarked that the combination of these conditions and Symens's immune suppressive medication presented an ideal situation for recurrent urinary tract infections. AR 354.

Symens saw P.A. Streff on October 13, 2009, for flu symptoms and ongoing nausea. AR 426. P.A. Streff prescribed Tamiflu and Zofran. AR 426. Symens saw P.A. Streff again on October 27, 2009, this time for neck pain. AR 425. An exam revealed palpable muscle spasms in Symens's upper trapezius. AR 425. P.A. Streff prescribed Flexeril. AR 425.

Symens saw Dr. Halligan for a reevaluation on November 5, 2009. AR 436. Symens reported intermittent paresthesias in her hands and feet and swelling in her hands. AR 435. On examination, Symens had no obvious synovitis, a normal range of motion, an appropriate gait, and intact strength in her upper and lower extremities. AR 434. She was not tender over fibromyalgia trigger sites. AR 434. Although Dr. Halligan told Symens that rheumatoid arthritis was likely causing Symens's symptoms, she expressed some concern that Symens may have "some noninflammatory muscle and joint pain." AR 432-33. Dr. Halligan diagnosed Symens as having rheumatoid arthritis, paresthesias, and a history of retinoschisis. AR 432. She recommended that Symens continue taking Humira and Arava, and that she take Tramadol as needed for her pain. AR 433.

Symens visited P.A. Streff on November 9, 2009, complaining of considerable right foot pain. AR 424. An examination of Symens's extremities showed tenderness but no swelling. AR 424. X-rays of Symens's foot showed a small posterior calcaneal spur but no evidence of arthritic change, fracture, or periosteal reaction. AR 415, 424. P.A. Streff assessed Symens as having foot pain and told her to continue taking her current medications. AR 424.

Several doctors conducted assessments of Symens in relation to her application for SSDI benefits. At the South Dakota Department of Human Services' behest, Symens saw psychologist Frank Dame on December 14, 2009. AR 256. Symens reported that her rheumatoid arthritis caused her constant chronic pain and that her activities were restricted because ofjoint pain and stiffness in the feet, ankles, hands, wrists, neck, and knees. AR 258. She stated that she could not comfortably bend, stoop, lift, carry, stretch, walk for more than 100 yards, or sit for longer than fifteen to twenty minutes. AR 258. Symens said that she was painful and stiff in the morning and that her wrist pain impaired her ability to dress. AR 259. She reported going back to bed after getting her children ready for school and then getting up and showering, dressing, vacuuming, and doing laundry and book work. AR 259. Symens noted, however, that she was only able to engage in those tasks for twenty to thirty minutes, that she required twenty minutes of rest afterwards, and that she felt "intense pain in her hands and neck" after more than thirty minutes of activity. AR 259. Symens shopped for groceries despite her pain and prepared dinner three times a week. AR 259. On other days Symens relied on prepared foods or sandwiches and soup. AR 259. Dr. Dame noted that Symens had to stand and stretch several times during the appointment, but found that Symens's concentration and attention were "only mildly and periodically impaired[.]" AR 259-60. When discussing Symens's mental status, Dr. Dame remarked: "In her emotional presentation there was evidence of depression, some anxiety and the former appeared to reach clinically significant levels of severity." AR 259. Dr. Dame concluded that "the results of the present examination indicate that [Symens] is seriously disabled by virtue of the medical diagnosis of rheumatoid arthritis." AR 261.

Dr. K. Terry, a non-examining state-agency physician, completed a physical residual functional capacity (RFC) assessment of Symens on December 16, 2009. AR 356-363. Dr. Terry found that Symens could lift 20 pounds occasionally, lift 10 pounds frequently, and could stand and/or walk for approximately six hours or sit for about six hours within an eight-hour work day. AR 357. He noted that Symens did have some postural limitations, however, finding that Symens could only occasionally climb, stoop, kneel, crouch, and crawl. AR 358. In the "additional comments" section of the RFC form, Dr. Terry noted that Symens had shown normal strength and gait during a March 2009 appointment and a functional range of motion during a November 2009 appointment. AR 363. Dr. Terry stated that Symens's rheumatoid arthritis medication had improved her symptoms and that although he found her statements mostly credible, she was expected to continue to improve. AR 363.

On January 12, 2010, Symens saw Dr. Eric Peterson, an orthopedic surgeon, for evaluation of her right wrist. AR 430. Symens reported pain in her right wrist and thumb and weakness when trying to open bottle caps or buttoning buttons. AR 430. An examination showed that Symens had a positive Finkelstein's test[27] on the right, "5/5" strength against resistance in her wrist, and full active motion in her hand and arm motions. AR 430. Dr. Peterson also noted an equivocal cyst on Symens's right wrist. AR 430. He diagnosed Symens with, among other things, right de Quervain's tenosynovitis, and recommended a steroid injection and physical therapy.

On January 20, 2010, Symens saw Dr. Greg Mumm, one of Dr. Halligan's associates. AR 557. Symens reported joint pain, morning stiffness with pain worsening at the end of the day, episodic paresthesias in her hands and feet, and pain in her right hip while driving. AR 557. Dr. Mumm noted that Symens's lab work from earlier that month was all within normal limits and that her hand and foot x-rays from January 2009 showed no evidence of erosive disease. AR 557. An examination revealed a positive Finkelstein's test and mild tenderness in Symens's hands and right hip. AR 558. There was no definite synovitis, however, and Symens had a normal range of motion in her hands, wrists, elbows, shoulders, hips, ankles, and knees. AR 558. She also had a negative Phalen's maneuver and normal fine touch sensation and motor strength. AR 559. Dr. Mumm's impressions were seropositive rheumatoid arthritis with persistent joint pain and episodic ...


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