United States District Court, D. South Dakota, Central Division
KATHY M. PHILLIPS, Plaintiff,
NANCY A. BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.
OPINION AND ORDER AFFIRMING THE DECISION OF
ROBERTO A. LANGE, UNITED STATES DISTRICT JUDGE.
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
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 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. 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.
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. 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
Phillips's Relevant Personal History
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.
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.
Phillips's Treatment History
Medical and Medical-Psychiatric Treatment
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.
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
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.
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.
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 with a plan to switch to
Tramadol 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.
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,
Levothyroxine,  and Trazadone. AR 424-25.
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,  and Alprazolam.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.
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 at that time.
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,  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.
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 for Phillips's back and
knee pain. AR 418.
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.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.
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. 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.
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 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 and Tramadol for pain, and
Phillips was to follow up in eight weeks. AR 596.
had a follow up appointment with Dr. Huff on November-7,
2012. She reported being unable to tolerate Meloxicam,
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.
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.
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.
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.
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.
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.
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,  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.
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.
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.
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.
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 score of 21, and Adams noted she was in
no acute distress at that time. AR 404. Adams prescribed
Fluoxetine and Trazadone, recommended discontinuing
Celexa and starting Prozac. 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.
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. AR 402.
appointment on September 9, 2Oi3, Phillips reported having
more energy and a good reaction to Wellbutrin,  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. AR 401.
October 2, 2013, Phillips reported having run out of
Wellbutrin a week prior to her appointment and having stopped
taking Statin 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,
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.
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 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.
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.
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 injection but noted Phillips was
sensitive to Mobic. AR 482.
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 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.
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.AR 576.
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.
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.
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,  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 as needed for
stomach pain. AR 570.
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 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.
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.
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.AR 561. Adams apparently then
wrote a Brintellix prescription for Phillips on April 2,
2015. AR 648.
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.
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. AR 19. Dr.
Lim noted that Phillips could not climb ladders at all and
advised Phillips to return in three months. AR 19.
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.
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.
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 for abdominal pain. AR 15.
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.
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