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Phillips v. Berryhill

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

February 6, 2018




         Plaintiff Kathy M. Phillips (Phillips) seeks reversal of the decision of the Acting Commissioner of Social Security (Commissioner) denying her claim for disability insurance benefits and supplemental security income (collectively "social security benefits"). Doc. 17. The Commissioner argues for affirming denial of benefits. Doc. 19. For the reasons explained below, this Court affirms the Commissioner's decision.

         I. Procedural History

         Phillips protectively filed an application for supplemental security benefits and an application for disability insurance benefits on August 23, 2013, alleging disability due to depression, anxiety, lower back pain, and colitis, which she alleged began on August 1, 2012. AR[1] 240, 245, 287. The Commissioner denied Phillips's claims initially on January 3, 2014. AR 168-170. Phillips requested reconsideration of her claims, AR 173-74, and they were denied upon reconsideration on April 18, 2014. AR 175-78. Phillips then sought a hearing before an Administrative Law Judge (ALJ), which was conducted on May 12, 2015.[2] AR 189- 90, 77-115. On June 18, 2015, the ALJ issued his opinion denying Phillips's claims for social security benefits. AR 42-61.

         Phillips then hired a new attorney, AR 38, who appealed to the Appeals Council and submitted new material. AR 9-10, 37. The new material included employment records, additional medical records from Phillips's treatment providers, records from Community Counseling Services, and an additional medical source statement from a treatment provider. AR 6-7. The Appeals Council purportedly considered this new information in stating: "[i]n looking at your case, we considered the reasons you disagree with the decision and the additional evidence listed on the enclosed Order of Appeals Council." AR 2. The Order of the Appeals Council listed as exhibits the new material submitted by Phillips. AR 6-7. The Appeals Council denied Phillips's request for review of the ALJ's decision on September 13, 2016, stating in regard to the new material that "[w]e found that this information does not provide a basis for changing the Administrative Law Judge's decision." AR 1-2. Additionally, the Appeals Council noted that records from Horizon Healthcare dated July 10 to July 13, 2015, did not impact the ALJ's decision on disability, which was evaluated up to June 18, 2015, and advised Phillips that if she wished for the Appeals Council to consider whether she was disabled after June 18, 2015, she would need to apply again.[3] AR 2. By denying Phillips's request for review, the decision of the ALJ became the final decision of the Commissioner, which Phillips now appeals to this Court.

         II. Factual Background

         A. Phillips's Relevant Personal History

         Phillips was born in January of 1963 in Huron, South Dakota, and currently resides there. AR 79, 240, 245. She was married for three years during her thirties, but her former spouse was an alcoholic and both verbally and physically abusive. AR 655. Phillips has one adult son from a different relationship who currently resides in Rapid City. AR 655. Phillips graduated from high school in 1981 and completed a program at Black Hills Beauty College in 1983 and 1984, though she no longer has her cosmetology license. AR 79-80. Phillips spent two years at the University of South Dakota, majoring in social work with a minor in drug and alcohol abuse. AR 79. When she was 31 and attending school at the University of South Dakota, her father visited her, suffered a major heart attack, and passed away in her apartment. AR 655. Phillips has one sister who is two years older and resides in Tombolt, Texas; Phillips and her sister are close and stay in touch regularly via telephone. AR 655. Phillips's mother resides in Huron and Phillips reports the two of them are very close. AR 655.

         From 1997 to 2000, Phillips was an instructor at a center, for persons with disabilities. AR 296. She was later employed as an assembler at Banner Engineering from 2000 to 2002, where she reportedly developed carpal tunnel. AR 84, 296. She also worked as a waitress, casino attendant, and a convenience store clerk previously. AR 296. She began working for Walmart in 2006 and was employed there at the time of her hearing with the ALJ. AR 82, 296. She had worked as a cashier and in the photo lab, but had been moved to a greeter position at the time of her hearing. AR 81, 94, 296. Phillips worked full time at Walmart until August 1, 2012, when she reduced her schedule to 16 hours per week due primarily to her back pain. AR 85, 280. Records show that as of July 2015, Phillips was unemployed, but appears to have started working at a casino, perhaps around August of 2015. AR 16, 18.

         B. Phillips's Treatment History

         1. Medical and Medical-Psychiatric Treatment

         The earliest records detailing Phillips's medical history in the Administrative Record are from Avera Queen of Peace Hospital. Phillips complained about ongoing problems with frequent stools, and on November 5, 2010, she underwent a colonoscopy. AR 496, 498. Dr. Aaron Baas performed the procedure, and listed a post-operative diagnosis of distal esophagitis, a greater than one centimeter rectosigmoid polyp, and chronic diarrhea. AR 498. Dr. Baas also indicated Phillips had a small hiatal hernia. AR 499. The final diagnosis from the pathology report indicated that the colon biopsies were compatible with microscopic colitis with focal features of collagenous colitis. AR 504.

         Records from August and September of 2011 document a routine mammogram where it was observed that Phillips had two nodules on her breasts which were assessed as benign. AR 507-10. A mammogram performed in September of 2013 showed that the two nodules had remained stable since their discovery in 2011. AR 526.

         On November 14, 2013, Phillips complained of having up to 12 loose stools a day with mucus, and wanted to set up a colonoscopy. AR 527. Dr. Baas performed the colonoscopy on December 19, 2013, and found no evidence of colon cancer or polyps, diverticular disease, active colitis, or arteriovenous malformation. AR 533. Random colon biopsies were taken to rule out microscopic or collagenous colitis. AR 533. The pathology report established the final diagnosis as collagenous colitis, which was consistent with the prior colon biopsies. AR 535.

         Treatment records from Whiting Memorial Clinic document a September 2011 visit where Phillips complained of pain near her belly button and it was noted that a hernia had been found during her recent colonoscopy. AR 429. She was referred to Dr. Howe to discuss possible surgery, though Phillips apparently cancelled this appointment due to its cost. AR 425, 429.

         Phillips was seen by Lance S. Lim, M.D., on February 8, 2012, with complaints of pain in her lower back and legs which had been present for the previous few months, with increasing severity over the few days prior to her appointment. AR 425. She reported that the pain radiated into her left thigh, that she was taking Ibuprofen three times daily, and that the pain was most severe when she was at work and slightly relieved when she laid down. AR 425. In addition, she reported that her knees had been hurting for the last two to three years and that antiinflammatory medications did not help. AR 425. She further reported headaches, chronic diarrhea, and on-and-off chest pain that began six months prior to her appointment. AR 425. Dr. Lim noted Phillips to be in no acute distress, with no tenderness in her back on palpitation and an euthymic mood. AR 426-27. Noting that her knees had crepitations, Dr. Lim prescribed Cyclobenzaprine[4] with a plan to switch to Tramadol[5] if that did not work. AR 428. Dr. Lim did not believe the chest pains were cardiac related, but was concerned about the headaches and scheduled a CT scan for the following week. AR 428. He also noted Phillips had no desire to stop smoking, but he explained to her the health risks and costs associated with the habit. AR 428.

         Phillips underwent a CT scan on February 16, 2012, which was read as normal with and without contrast. AR 466. Records in March and May of 2011 document medication refills for Citalopram, [6] Levothyroxine, [7] and Trazadone.[8] AR 424-25.

         On May 22, 2012, Phillips was seen by Leonard Wonnenberg, PA-C, with complaints of increasing back pain over the past couple months. AR 422. She described the pain as being exacerbated with prolonged standing or sitting, indicated she was limited to standing no more than 6 hours daily, reported that the pain began two to four hours after working, and rated the pain as 8/10. AR 422. She explained that the pain began in the lower back and radiated into both hips, and had recently moved up to the upper thoracic area of her back. AR 422. On - physical examination, Phillips had tenderness along the lower back in the lumbar and sacral areas along the paraspinous muscles, but no bony deformity and a straight leg raised was deferred. AR 423. Wonnenberg prescribed Tramadol for 30 days, Lotrisone, [9] and Alprazolam.[10]At that time, an X-ray and bone density scan were recommended, but Phillips deferred those options and continued self-treatment with rest, ice, and heat. AR 424.

         On June 4, 2012, Phillips phoned PA Wonnenberg and reported that Tramadol was not helping with her back pain. AR 424. Wonnenberg ordered a prescription of Relafen[11] at that time. AR 424.

         Phillips returned to PA Wonnenberg on June 22, 2012, and reported that the Relafen had not significantly improved her back pain. AR 418-19. She claimed her legs were fatigued, described again that her back pain went through her thighs with the left thigh experiencing more pain than the right, and claimed right medial knee pain with swelling and crepitus. AR 419. She was not experiencing abdominal pain, diarrhea, or constipation. AR 419. On physical examination, Wonnenberg noted some superior-medial point tenderness in Phillips's right knee with mild swelling, lumbosacral point tenderness, and mild pain on a straight leg raise, with more pain from her left leg than right. AR 419. Wonnenberg switched Phillips from Relafen to Mobic, [12] ordered lab work and an X-ray of her lumbosacral spine and knee, and scheduled a mammogram. AR 421. He noted that a course of steroids was declined by Phillips due to her concern of potential side effects. AR 421. An X-ray, performed that same day, demonstrated mild narrowing of the disc spaces throughout the lumbar spine, which brought up consideration of underlying degenerative disc changes. AR 464. Examination of the right knee was negative for an acute fracture or joint effusion. AR 464.

         Phillips reported to PA Wonnenberg on July 6, 2012, that the Mobic was causing her to experience gas and cramping, and Wonnenberg switched her back to Tramadol. AR 418. During a call on July 31, 2012, he prescribed Norco[13] for Phillips's back and knee pain. AR 418.

         Wonnenberg referred Phillips to Carl Huff, M.D., an orthopedic surgeon, on August 2, 2012. AR 417. Phillips met with Dr. Huff six days later and reported that she was miserable with pain, which she described as constant regardless of her activity or the amount of time she rested, and claimed that it had been worsening over the past six months. AR 599. Phillips reported that she had been relocated to the photo lab from her cashier position at Walmart, because the twisting and repetitive movements of the cashier position increased her back pain. AR 599. She also claimed that her right leg was weak at times. AR 599. Dr. Huff noted that, according to Phillips's provider, X-rays done the previous month were completely negative.[14]AR 599. At that time, Phillips's medications consisted of Citalopram, Levothyroxine, Norco, and Trazodone. AR 599. On physical examination, Dr. Huff noted that Phillips was able to rise with minimal difficulty and walked without a limp. AR 600. He noted moderate tenderness in the midline at L4 and L5 and observed that her paravertebral muscles were quite tender bilaterally. AR 600. With forward flexion, her fingertips reached midway between her knees and ankles, and she was noted to have paraspinal muscle spasm. AR 600. A straight leg raise caused low back pain radiating to the hip and thigh. AR 600. He noted pulses in her feet were normal and there was no muscle atrophy. AR 600. Dr. Huff ordered an MRI due to the claimed chronicity and intensity of her back pain and the apparent lack of response to conservative treatment. AR 601.

         Phillips underwent an MRI on August 16, 2012, which revealed mild degenerative desiccation throughout the lumbar disc spaces as expected for Phillips's age, without significant disc space narrowing. AR 602. The impression of the reviewing radiologist was that Phillips had a normal lumbar spine for her age, and that the minimal degenerative disc desiccation was less than expected with no disc hernia or osteophyte. AR 602. Dr. Huff held a follow up appointment with Phillips on August 20, 2012, and explained her MRI was negative and normal for her age. AR 603. Phillips reported no change in her symptoms and no relief from Tramadol, muscle relaxers, or Hydrocodone.[15] AR 603. On physical examination, Phillips was noted to be tender at the L5 level and over both sacroiliac joints, and a straight leg raise to 90 degrees was negative on the left leg but caused back pain radiating into the thigh with the right leg. AR 604. Dr. Huff assessed Phillips with low back pain and inflammatory arthritis, and noted that because her pain was not explained by the results of the MRI, he would continue with further evaluation including various lab work. AR 604.

         At a follow up appointment to discuss her lab results on August 29, 2012, Phillips reported no change in her symptoms of back and bilateral knee pain and believed that Tramadol and generic Flexeril[16] were not producing pain relief. AR 595. While most of her lab tests were normal or negative, her uric acid level was elevated consistent with gouty arthritis. AR 595. On -physical examination, tenderness was limited to the sacroiliac joints, with mild tenderness of the knees and ankles but no swelling was noted. AR 596. Phillips had foil range of motion of the lumbar spine, hips, knees and ankles, and Dr. Huff assessed her with acute gouty arthropathy. AR 596. He prescribed Allopurinol[17] and Tramadol for pain, and Phillips was to follow up in eight weeks. AR 596.

         Phillips had a follow up appointment with Dr. Huff on November-7, 2012. She reported being unable to tolerate Meloxicam, [18] believed the Tramadol and Allopurinol had not helped alleviate her pain, and reported being very tired of the constant pain. AR 606. Phillips stated that she was unable to continue working as a cashier and had just started as a greeter. AR 606. Despite reporting that her knees ached, Phillips had no mechanical symptoms and no swelling. AR 606. On physical examination of the thoracolumbar spine, Phillips was unable to bend forward to touch her toes and there was diminished segmentation of the lumbar spine. AR 607. Dr. Huff noted that the tenderness was primarily confined to the sacroiliac joint bilaterally, a straight leg raise test was negative, and her hip range of motion was normal without hip pain. AR. 607. A cortisone shot was administered to the sacroiliac joint, and Phillips was to return in three weeks. AR 607.

         Phillips's final appointment with Dr. Huff for which records are present in the Administrative Record took place on December 21, 2012. Phillips reported feeling 75 percent better, though she described being able to work only four hours a day and felt limited with her back, often wearing a back brace. AR 608. She indicated her knees continued to bother her, but the Tramadol was helping. AR 608. Dr. Huff noted she had experienced dramatic pain relief with the cortisone injections of both sacroiliac joints and was almost asymptomatic. AR 608. On physical examination, Phillips's sacroiliac joints were only minimally tender, and she could arise with minimal difficulty and walked without a limp. AR 608. Dr. Huff assessed Phillips with inflammatory arthritis with involvement of the bilateral sacroiliac joints and both knees, discussed limitations and therapeutic exercises with Phillips, and advised her to return if her symptoms worsened or persisted. AR 609.

         Phillips's continued treating with PA Wonnenberg during the time she treated with Dr. Huff. On August 13, 2012, Phillips reported to Wonnenberg that she was experiencing right wrist pain that began with a popping sensation on the lateral aspect of her wrist with immediate pain following. AR 416. At the time of her appointment, she reported the pain was better, rating it as a 1-2/10, and a dull ache along the nonpalmar aspect of digits 2 and 3 of her right hand which she rated as a 3/10. AR 416. Wonnenberg advised Phillips not to work for a week and to be restricted to light duty upon return, wear a wrist splint, and alternate between Tylenol and Ibuprofen. AR 417. An addendum to this record from Wonnenberg indicated Phillips could return to work on "alternative duty and no work at the registry." AR 417.

         Phillips returned to Wonnenberg on September 10, 2012, and reported both that the pain in her wrist was under much better control and that the wrist brace helped considerably. AR 415. Wonnenberg assessed Phillips with gout and advised her that she could return to work without restriction but should continue to wear the wrist brace. AR 416.

         On September 26, 2012, Phillips saw Wonnenberg with complaints of right shoulder pain. She reported experiencing radiating right shoulder pain and a numb tingling in her right metacarpal spaces. AR 413. She reported that working in the fitting room relieved her pain to a degree and that she had stopped taking Meloxicam because of violent diarrhea and had not been using anti-inflammatory medications. AR 413. On physical examination, Wonnenberg noted lateral right shoulder tenderness, slight weakness with arm abduction, minimal pain with internal and external rotation, and 5/5 strength bilaterally. AR 414. An empty can test was negative. AR414. Wonnenberg believed Phillips to have an overuse injury and restricted Phillips from register work for three weeks, though she could return sooner as tolerated. AR 414. He recommended Ibuprofen to Phillips and scheduled her return visit in three weeks. AR 414.

         During her follow up appointment on October 10, 2012, Phillips reported that working in the dressing room helped to prevent exacerbation of her shoulder and hand pain. AR 412. She described her pain as 2/10 that day, but claimed it was typically 3-4/10 at work. AR 412. On physical examination, Wonnenberg noted slight right shoulder pain over the supraspinatus muscle and deltoid area with empty can test against resistance. AR 413. No obvious edema, warmth, or deformities were noted. AR 413. Wonnenberg ordered a physical therapy assessment for her shoulder pain, advised Phillips to continue working the dressing room for a week while progressing back to register work with 1 to 2 hours a day, and suggested Phillips to continue taking Tylenol and Ibuprofen. AR 413.

         Phillips attended physical therapy that same day where her therapist identified pain, range of motion, and strength as impairments, and noted she displayed tendonitis of the biceps. AR 394. Her therapist, Shane Hartman, [19] believed Phillips required skilled rehabilitation therapy in conjunction with a home exercise program, and recommended she attend therapy three times a week for four weeks. AR 394. When Phillips returned to therapy on October 24, 2012, she reported improvement but still had pain with certain "extreme" motions. AR 390. Hartman noted Phillips tolerated her therapy without complaints of pain or difficulty and advised she continue therapy. AR 39l.

         Phillips returned to PA Wonnenberg on November 6, 2012, regarding her shoulder pain and stated she had attended four sessions of physical therapy, but did not attend the prior week. AR 410-11. She had switched to a greeter position at Walmart the prior weekend and described her pain as a 4/10 that day, and stajed that Tramadol was helping somewhat but wanted Hydrocodone. AR 411. On physical examination, Wonnenberg noted mild tenderness on palpitation along the lateral aspect of the supraspinatus muscles, and an empty can test showed pain in the same area. AR 411. She had full range of motion with elbow flexion and extension and no pain with internal and external rotation. AR 411. Wonnenberg restricted her to lifting no more than 15 pounds and four-day work weeks at four hours per day. AR 412.

         At her appointment with Wonnenberg on November 27, 2012, Phillips reported feeling "awesome" since she began working as a greeter and working 16 hour weeks, describing her pain at her appointment as a 1/10. AR 409. She reported doing her at-home exercises and attending physical therapy. AR 409. Wonnenberg recorded that a normal shoulder exam was unremarkable and indicated Phillips could return to work without restriction. AR 409-10.

         Phillips next saw Wonnenberg on March 27, 2013, with complaints of heightened anxiety and back pain. AR 406. She attributed increased anxiety to her son seeing a counselor, and discussed how a new job cleaning apartments was exacerbating her back pain with activities like vacuuming, lifting heavy objects, bending, and general manual labor. AR 406. Wonnenberg noted lower lumbar tenderness extending into the upper gluteus region and sacroiliac region tenderness, no increased edema, no deformity, and normal muscle tone. AR 407. He assessed her with gout, recommended taking Aleve for her back pain, and ordered a refill of her anxiety medications. AR 407-08. Additionally, Wonnenberg supplied a note to Walmart detailing the limitations Phillips was subject to due to her anxiety. AR 408.

         On August 7, 2013, Phillips was treated by Amanda Adams, PA-C, with complaints of worsening anxiety. Phillips stated that she had been under some stress recently because of issues with her son, but was doing ok now, though was drinking six beers a night and had trouble sleeping. AR 403. Phillips had a PHQ-9[20] score of 21, and Adams noted she was in no acute distress at that time. AR 404. Adams prescribed Fluoxetine[21] and Trazadone, recommended discontinuing Celexa[22] and starting Prozac.[23] AR 405. Adams also advised Phillips to stop drinking, to make an appointment with Community Counseling Services, and to return in two weeks for a follow up appointment. AR 404-05.

         On August 21, 2013, Phillips reported that the Fluoxetine was not working and requested Citalopram. AR 401. She was feeling a lack of energy and reported missing a few days of work. AR 401. PA Adams assessed Phillips with anxiety and moderate recurrent major depression and prescribed Citalopram and Bupropion.[24] AR 402.

         At her appointment on September 9, 2Oi3, Phillips reported having more energy and a good reaction to Wellbutrin, [25] though was still having anxiety and claimed an increase in lower back pain recently, which Phillips attributed to her gout flaring up. AR 400. Adams found no tenderness on palpitation, and Phillips had an improved PHQ-9 score of 13. AR 400. Adams felt the back pain described by Phillips sounded more like sciatica than gout and recommended Phillips try home stretching exercises and icing the area, in addition to prescribing Buspar.[26] AR 401.

         On October 2, 2013, Phillips reported having run out of Wellbutrin a week prior to her appointment and having stopped taking Statin[27] and Allopurinol because her last lipid panel and uric acid levels were normal. AR 398. Phillips indicated she had experienced no change in her anxiety level with Buspar, was anxious about an upcoming trip, and was hoping to get some anxiety medications and pain medications for increased back pain. AR 398. On physical examination, Adams noted tenderness on palpitation of the back. AR 398. Adams prescribed a week's dosage of Valium, [28] renewed Phillips's Hydrocodone, gave her a bottle of Wellbutrin, and advised that she restart her Statin and Allopurinol, though Phillips refused because she did not like taking medications. AR 399.

         When Phillips saw Adams on December 2, 2013, she reported her anxiety and depression were under control with Wellbutrin and Citalopram, and that she had discontinued taking Buspar, deeming it unhelpful. AR 627. Phillips described how her anxiety caused her to leave her position at work and calm down in the bathroom, and also made her not want to leave her apartment to do things like shop for groceries and attend doctor appointments. AR 627. Phillips nevertheless had an improved PHQ-9 score of 10, and Adams renewed her Hydrocodone prescription, started her on Naprosyn[29] and gave her more Wellbutrin. AR 627. She advised Phillips to take two Trazadone at night if needed to help with sleep, and wanted her to return in two months. AR 627.

         Phillips reported continued back pain, worsening anxiety and poor sleep at her appointment on January 31, 2014. AR 625. She reported having problems at work lately and was applying for disability. AR 625. Phillips had run out of Wellbutrin the week prior and had decreased her alcohol usage. AR 625. Adams noted Phillips was in no acute distress, had an increased PHQ-9 score of 17, and was assessed with lower back pain, anxiety, and chronic major depression. AR 625-26. Adams refilled Phillips's Hydrocodone, renewed her Trazadone, and discontinued Bupropion and Naprosyn. AR 626. Adams strongly encouraged Phillips to make an appointment with a counselor, but Phillips indicated cost was an issue. AR 626.

         Phillips was treated by Terri Groves, PA-C, on February 2, 2014, for severe lower back pain. Phillips described coughing the day before which caused her back to feel like it "exploded." AR 481. Groves found Phillips to be in no acute distress, found her range of motion of the lumbar spine was decreased due to pain and stiffness, and found no pain on palpitation of the lumbar spine, though noted the right lumbar muscles were taut. AR 481. She prescribed 200 mg of Ibuprofen three times daily, Hydrocodone in the morning and night, and advised no work for the next two days. AR 482. She considered a Toradol[30] injection but noted Phillips was sensitive to Mobic. AR 482.

         Phillips returned to PA Adams on March 10, 2014, and described feeling that her anxiety and depression were under control and that Trazodone was helping her sleep. AR 479. However, Phillips did not think her pain meds worked and only the "steroid injection" from Dr. Huff seemed to help. AR 479. She described how the back pain would shoot down the back of her legs, and her lumbosacral spine was mildly tender on palpitation. AR 479-80. Adams renewed prescriptions for Allopurinol and Hydrocodone, ordered various labs, noted that she wanted Phillips to try Gabapentin[31] for her back pain, and planned to consult with Dr. Lim on whether Phillips would benefit from a steroid injection. AR 480.. Pathology reports from the labs indicated Phillips's cholesterol and uric acid levels were high. AR 492-93.

         Phillips was treated by Dr. Lim on April 17, 2014, requesting a cortisone shot for her back pain. AR 575. She stated the previous shot received from Dr. Huff helped for about two weeks, her hydrocodone was not helping her at this point, and the acetaminophen was bothering her stomach. AR 575. Phillips rated her pain as a 4/10 but indicated that even regular housework would increase it to a 10/10 or close it. AR 575. Dr. Lim noted tenderness on palpitation of the lower back of the right paraspinal region and muscle spasm. AR 575. He administered a cortisone shot and switched Phillips's Hydrocodone prescription to Oxycodone.[32]AR 576.

         Phillips saw PA Adams the following day on April 18, 2014, and reported her back pain was significantly improved since the shot. AR 573. She also complained of neck pain radiating into her shoulder and explained that a chiropractor had previously advised her that she had a herniated disc. AR 573. On, physical examination, Adams found mild tenderness on palpitation to the left side of Phillips's neck and tenderness on palpitation to the cervical spine, but no weakness. AR 574. Adams discontinued the Gabapentin and Ibuprofen 200 mg and refilled her Wellbutrin prescription. AR 574. Phillips was advised to continue with her current medication regimen and to return in three months. AR 574. She was also referred to physical therapy for her neck, but Phillips appears to have cancelled her appointment. AR 574.

         When Phillips returned to Dr. Lim on June 19, 2014, she reported that the shot had only helped for a few days and rated her back pain as 5/10, and said that minimal activity could increase her pain level to 10/10. AR 571. Phillips stated that taking two Oxycodone helped, but reported she had not taken any in a month. AR 571. Dr. Lim noted tenderness on palpitation of the back and increased her quantity of Oxycodone but cautioned Phillips to make the dosage last for 30 days. AR 572. He also renewed her Naprosyn, but emphasized the need to take antiinflammatory medications and advised her to continue with over-the-counter medicine and conservative therapy. AR 572.

         Phillips returned to Adams on August 8, 2014, for a recheck of her depression. She described having two episodes of severe abdominal pain in the previous ten days which she believed was caused by Naproxen. AR 569. She reported discontinuing Naproxen and Omeprazole, [33] and indicated she felt better than she had the previous three days. AR 569. She requested discontinuing Wellbutrin because she did not believe it helped and was fine using only Celexa. AR 569. Adams noted Phillips was in no acute distress, had some mild direct epigastric tenderness on palpitation, and assessed her with gout, anxiety, and epigastric pain. AR 570. Adams restarted Phillips on Omeprazole, discontinued her Wellbutrin and Naproxen, and directed her to take Carafate[34] as needed for stomach pain. AR 570.

         Phillips saw Dr. Lim on October 15, 2014, for back pain and described chronic pain that she rated a 7/10 and that standing, sitting, or walking would push her pain to 8-9/10. AR 565. Phillips also reported having restarted Wellbutrin because her depression had been increasing, and stated she was currently seeing a counselor[35] but had only one session left. AR 565. Phillips described feeling tired, depressed, and hopeless for the last two weeks. AR 565. Dr. Lim described her mood as euthymic and her PHQ-9 score was 16. AR 566. He refilled her Oxycodone, increased her dosage to 100 tablets per month, and directed her to return in three months. AR 566. She was encouraged to see a Dr. Chrisopherson, but Phillips declined because she felt her depression was getting better. AR 566.

         On January 14, 2015, Phillips reported to Dr. Lim that her symptoms were essentially the same and that she was suffering from moderate pain to which she could not give a number. AR 563. Dr. Lim renewed her Oxycodone prescription and advised her to return in three months. AR 564.

         On March 10, 2015, Phillips saw PA Adams for a pap smear and to discuss her depression. Phillips indicated she had recently lost her insurance and was struggling to pay for her medications. AR 560. Phillips was currently on Wellbutrin XR which was helpful but expensive, so Adams changed her to standard Wellbutrin. AR 560-61. Phillips was to inform Adams when she ran out of Celexa at which point Adams would give her samples of Brintellix.[36]AR 561. Adams apparently then wrote a Brintellix prescription for Phillips on April 2, 2015. AR 648.

         Phillips attended an appointment with Dr. Lim on April 15, 2015, for pain management and to discuss her disability claim. Phillips stated that on "lazy days" her pain averaged a 3-4/10, but that at the end of three hours of work she was around an 8/10 which easily.increased to a 10/10. AR 593. She discussed how she felt anxious outside of her environment, especially around rowdy children and people, and described her wish to be in the quietest part of the store while at work. AR 593. In renewing her Oxycodone, Dr. Lim noted that Phillips's back pain was "the same" as it had been and that he did not "envision giving her higher doses [of pain medications] at least in the near future." AR 594. He further stated that "I can't envision her able to complete an 8 hour shift at work." AR 594. Regarding her anxiety, Dr. Lim stated that "As long as patient is in a controlled environment, she will probably be fine. No changes in meds needed." AR 594. Dr. Lim also filled out paperwork for Phillips's lawyer for her disability claim. AR 594.

         Phillips again saw Dr. Lim on July 15, 2015, and explained that she was now unemployed and had been denied disability, though was appealing that decision. AR 18. Phillips stated she was trying to find part-time work and that her pain was at a 4/10, though housework brought it to 8/10, especially bending. AR 18. She could garden for about an hour before "maxing out" and needing to rest. AR 18. Dr. Lim noted that her back was tender on palpitation and identified no muscle spasm. AR 19. Dr. Lim refilled her Oxycodone prescription and discussed Phillips's concern that he had not been specific enough on a question about whether she could climb ladders for her disability claim.[37] AR 19. Dr. Lim noted that Phillips could not climb ladders at all and advised Phillips to return in three months. AR 19.

         At a follow up appointment on October 14, 2015, Phillips reported that her pain was the same and normally around a 4/10, though was currently at 7/10 because she had helped her neighbor the previous day with various tasks. AR 17. She brought paperwork for her disability appeal and explained to Dr. Lim that she was visiting her sister in Texas for two weeks in December which made her anxious and wanted to bring her cat. AR 17. She also described anterior pain in her thighs for the last few months. AR 17. Dr. Lim noted tenderness on palpitation of the right paraspinal region and maintained her prescription of Oxycodone. AR 18. He wrote a note to United Airlines for Phillips to bring her cat on the plane, noted that her anxiety was "essentially fine as long as she is in her usual environment, " and indicated that he may prescribe Diazepam for her flight. AR18.

         Records from Phillips's appointment with Dr. Lim on January 13, 2016, state that she started working at a casino in "August of last year" for four hours on Mondays and Thursdays. AR 16. Phillips stated that it had actually helped her back pain and reported her current pain level to be a 3/10, though stated it averaged 6-7/10. AR 16. Dr. Lim noted tenderness on palpitation of the right paraspinal region, renewed her Oxycodone, and advised her to return in three months. AR 16.

         Phillips was treated by PA Adams for stomach pain, bloating and medication refills on April 12, 2016. Phillips reported doing well with her depression and anxiety, being happy with her Wellbutrin and Gelexa, and not having a gout flare up recently. AR 14. Phillips described sometimes having trouble making it to the bathroom on time, but did not notice blood in her stool. AR 14. She reported that her stomach pain was not affected by food, she often felt bloated, and Omeprazole did not help. AR 14. Adams assessed Phillips with gout-unspecified, hypothyroidism-unspecified, major depressive disorder-recurrent, unspecified, anxiety disorder-unspecified, and pure hypercholesterolemia. AR 15. Adams renewed prescriptions for Levothyroxine, Citalopram, Allopurinol, Wellbutrin XL, and dispensed Bentyl[38] for abdominal pain. AR 15.

         Phillips saw Dr. Lim on April 13, 2016, for her back pain. Phillips reported doing well until four weeks ago when her back pain suddenly started getting worse. AR 13. She described it as radiating down both thighs in the posterior area, starting as a dull ache and then becoming a shooting pain like a spasm, with an average pain level of 5-6/10, and described her current pain level as 5/10. AR 13. Dr. Lim noted no back tenderness on palpitation and restarted a prescription for Cyclobenzaprine and increased the quantity of her Oxycodone. AR 14. Phillips also mentioned that she planned on doing more gardening that year. AR 14.

         Phillips's final appointment with Dr. Lim for which records exist took place on July 13, 2016. Phillips reported experiencing right upper back.and mid back pain, which bothered her more than her chronic lower back pain; Phillips did not know what caused it. AR 11. On physical examination, Dr. Lim noted her upper and middle back exhibited tenderness on palpitation of the right side, and her lower back exhibited tenderness on palpitation, and no muscle spasms were detected. AR 11. Regarding her lower back pain, Dr. Lim recorded it not bothering Phillips as much as before and was a 3/10 that day. AR 12. Phillips reported pain in her right shoulder that she ...

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