United States District Court, D. South Dakota, Western Division
KIMBERLY L. PORTER, Plaintiff,
NANCY A. BERRYHILL, Deputy Commissioner for Operations, performing the duties and functions not reserved to the Commissioner of Social Security,  Defendant.
MEMORANDUM OPINION AND ORDER
VERONICA L. DUFFY, UNITED STATES MAGISTRATE JUDGE
Medical Evidence - Chronological
Claimant and Lay Witness Statements
Issues Before This Court
Standard of Review. .
Disability Determination and the Five-Step Procedure. .
Burden of Proof. .
the ALJ Err in Determining the Alleged Disability Onset Date?
Does the Disability Onset Date Matter?
Law Applicable to Determining Alleged Onset Date
Onset Date After Denial of an Earlier Application
Determination of Onset Date Without Consideration of the Fact
That There Was a Prior Application
the ALJ Err at Step Two in Determining Severe Impairments?
Applicable Law and ALJ Findings
Myofascial Pain Syndrome
the ALJ Fail to Develop the Record as to Pulmonary and
to Obtain 12 Months' of Pre-Application Records
Consultative Examination on Mental Impairments
Consultative Examination on COPD
the ALJ's RFC Assessment Supported by Substantial
Evidence? .... 133
Law Applicable to Formulation of RFC
Back, Hip, Myofascial Pain Syndrome, Complaints of Pain, and
Absenteeism for Physical Therapy Appointments
Nontreating Nonexamining Physicians' Opinions
the ALJ's Step Five Decision Comply with the Law?
Kimberly Porter,  has filed a complaint seeking judicial
review of the Commissioner's final decision denying her
Title II application for a period of disability and
disability insurance benefits and her Title XVI application
for supplemental security income.
Porter now moves this court for an order reversing the
Commissioner's final decision and remanding for further
consideration. See Docket Nos. 18, 19 and 21. Nancy
Berryhill, Deputy Commissioner for Operations
(“Commissioner”) urges the court to affirm her
decision below. See Docket 20.
appeal of the Commissioner's final decision denying
benefits is properly before the district court pursuant to 42
U.S.C. § 405(g). This matter is before this magistrate
judge pursuant to the consent of both parties in accordance
with 28 U.S.C. § 636(c). Based on the facts, law and
analysis discussed in further detail below, the court
reverses and remands for further consideration.
L. Porter filed for concurrent disability benefits on
November 17, 2011, went to hearing on May 29, 2013, and was
denied on June 4, 2013. AR30, 98.
reapplied on August 27, 2013. AR212. The SSA field
office's explained reason for selecting a potential onset
date of June 5, 2013: “prior claim denied by ALJ
state agency initial denial was dated January 2, 2014. AR145.
The reconsideration denial was dated August 1, 2014. AR152.
On August 14, 2014, claimant a requested hearing. AR166.
was accorded on December 30, 2015, with the claimant and her
attorney, Josh Decker, appearing in Rapid City, SD, and ALJ
Michael A. Kilroy presiding from the Billings, Montana, ODAR
location. AR55. On January 22, 2016, the ALJ issued a step
five denial. AR14-23.
by current counsel, Catherine Ratliff, requested Appeals
Council review despite failing to timely appeal the ALJ's
decision. AR10. Porter also submitted a January 17, 2017, MRI
of her knee. AR8, 309.
February 23, 2017, the Appeals Council declined review, after
finding good cause for the claimant's untimely request
for review. AR1. The Appeals Council found that a one-page
medical record, referring to the MRI, from Rapid City
Regional Hospital was dated January 17, 2017, and the ALJ
decided the case through January 22, 2016; therefore, the
evidence did not affect the ALJ's decision. AR2.
Porter's date-last-insured for SSD was December 31, 2016.
was born in 1970. AR212, 214. Her father suffered from
alcoholism and heart disease. A brother suffered from
alcoholism and diabetes. A sister suffered from
diabetes. AR546. Porter did not state the highest
grade she attended in school and merely reported she obtained
a “GED, ” in January 1996. AR64, 233. She never
married. AR212, 214. She had three children born in 1990,
1992, and 1996, and one child was born
has work experience as a childcare provider. AR233, 277.
Porter stated that she performed childcare from 2001 to 2012.
age 18 (1988) to age 32 (2002), Porter's approximate
reported regular earnings were in 1988 ($285), 1989 ($535),
1992 ($463), 1993 ($2307), and 1994 ($49). She had earnings
in 2003 ($7081), 2004 ($9306), 2006 ($7903), 2007 ($8956),
2008 ($7670), 2009 ($9967), 2010 ($9003), 2011 ($5569), and
2014 ($1154). AR220-21.
detailed earnings report shows names of employers since 2000.
AR222. Porter worked for “Maid to Order” in
2003-04, Barry Burgess in 2004, and was self-employed from
2006-2011. AR222-23. She reported that she was a childcare
provider January 2008 to September 2011, working 40 hours a
week, and earning $50 a day. AR233.
described this work in her disability report: she watched,
fed, and taught children. She lifted them, and the heaviest
weight she lifted was 20 pounds. AR234.
Medical Evidence - Chronological
statement of fact: On February 7, 2013, Porter had a
cervical spine soft-tissue neck series, using soft-tissue
technique, which showed straightening of the cervical spine
and degenerative changes particularly at C5-C6. AR776-77.
End disputed statement of fact.
March 14, 2013, Porter saw Jennifer Thielen, PA at the community
health center, for heartburn, smoking cessation, and left
knee pain. AR564. She stated that Prilosec did not help even
when she doubled the dose. Id. She was interested in
stopping smoking. Id. She reported smoking for 20
years, one-half pack a day on average. She denied depression,
but acknowledged irritability at times. Id. She
complained of left knee pain (pointed to the lateral
collateral ligament), going back 5 years when Dr. Den Hartog
did surgery on this knee and shortened the ligament on the
outside of the knee. Id. “She brings my hand
to exactly the area that is hurting her, and it is her IT
band.”Id. She described a feeling of
extreme tightness here.
told PA Thielen that she recently had engaged in 4 months of
physical therapy, ordered by Christina Cote, DO, physiatrist,
said that she was diligent about going to therapy and
following directions, and it did not help; she still dealt
with the pain and stiff feeling. Id. Objectively PA
Thielen noted some tightness of the left IT band compared to
the right, but no instability, pain to palpation or swelling.
Id. PA Thielen assessed esophageal reflux and left
knee joint pain. AR565. She planned a consult with Bryan Den
Hartog, MD, orthopedic surgeon, and an EGD by a
gastroenterologist. Id. PA Thielen prescribed
Dexilant for reflux, and Chantix for smoking
April 17, 2013, Porter saw Bryan Den Hartog, MD, orthopedic
surgeon, for her persistent left knee problems. AR825. Dr.
Den Hartog reported, “We have scoped that twice and
debrided the fairly significant full- or partial-thickness
cartilage defects of both femoral condyles, the trochlear
groove, and the patella.” Id. The last
operation was in 2008 and provided fairly good pain relief
for at least 3 years. The last year and a half the pain had
been gradually recurring and was more significant.
Hartog noted that Dr. Cote had injected cortisone into the
knee 3-4 months earlier and it did not help much, but gave a
little relief. AR825. The knee hurt mostly when Porter tried
to kneel or squat. Dr. Cote had placed her on “those
kinds of restrictions.” Id. Objectively, she
was a thin, well-developed, well-nourished female in no acute
distress. She had a positive patellofemoral grind test. She
did not have instability or effusion. Id. The
x-rays, 4 views, showed “some significant arthritic
changes and change in contour of the femoral condyles on the
left knee. The patella femoral joint is involved as
Hartog assessed mild to moderate degenerative joint disease
(DJD) of the left knee. AR825. He injected
Euflexxa. Id. He explained the medical
reason for Euflexxa was Porter's somewhat refractory
response to cortisone. AR826. She would see Dan Palmer, PA-C,
for the second and third set of injections. Id.
April 25, 2013, Porter saw PA Thielen to discuss smoking
cessation. AR563. Chantix had made her sick. She complained
of moodiness and anxiety issues and presented for evaluation
of possible bipolar disorder. Id.
told PA Thielen, “everyone tells her that she is moody.
She says that her moods are up and down. One minute she can
be happy and the next minute ‘I'm crabby and
cussing everyone out.' ” Id. She had been
on Prozacwhen very young. Chantix worsened these
symptoms. She felt really down some days, but not all the
time. She complained of anhedonia and social withdrawal.
“She says, ‘I come in to town to do what I gotta
do' and gets back home.” Id.
denied suicidal thoughts. She had had some feelings of
hopelessness. She denied flight of ideas, reckless behaviors,
inability to sleep and excessive energy. Id. She
scored 33 on Beck's depression inventory, placing her in
the severe depression category. She had high irritability,
depression with feelings of hopelessness, anhedonia, and
social withdrawal. Id. PA Thielen reported that eye
contact and affect were appropriate, and that Porter was
well-groomed, had well organized and articulate speech, and
had no abnormalities of movement, thought content,
perception, or process. AR563-564.
Thielen counseled Porter on tobacco cessation and encouraged
her to “seek additional medical attention if depression
worsens, or if they begin feeling suicidal.”
Id. PA Thielen stated, “Her symptoms don't
really sounds like bipolar disorder to me. I think she has
more mood lability.” Id. She prescribed
Zyban [Bupropion] to see if it would help
depression, mood lability, and smoking cessation. If that did
not work, PA Thielen stated that she would try a different
antidepressant or add a mood stabilizing medication such as
April 26, 2013, Porter saw PA-C Palmer for Euflexxa #2
injection of the left knee. AR824.
3, 2013, Porter saw PA-C Palmer for Euflexxa #3 injection of
the left knee. AR823.
31, 2013, Porter saw PA Thielen to follow up her complaints
of depression. AR561. She had been on Zyban almost a month.
At first, it helped with smoking cessation. She was down to a
half-pack but was back up from this now. Id. PA
Thielen noted the patient's thought that she smoked from
“boredom. She smokes because she doesn't want to
get out and do anything and just sits a[t] home….She
cries frequently. She reports that her moods are up and down.
She is very irritable. She does have a lot going on right
now.” Porter had had a disability hearing, cried in
front of the judge, and was very anxious about the situation.
“She feels anxious much of the time.” Her
symptoms were anxiety, high irritability, and depression with
feelings of hopelessness, anhedonia, social withdrawal, and
loss of interest in friends and family. Id. She woke
frequently at night and thought she got about 4½ hours
of sleep. AR562.
auscultation, her lungs were clear and respiration was
normal. AR562. PA Thielen reported unremarkable physical and
psychiatric clinical examination except for depressed affect.
She assessed depression with anxiety and emotional lability.
Id. She encouraged Porter to seek additional medical
attention “if depression worsens, or if they begin
feeling suicidal.” Id. She prescribed
Viibryd and told Porter to continue Zyban.
5, 2013, Porter returned to PA Thielen to follow up her
depression. AR328. PA Thielen noted that she had added
Viibryd to Porter's Wellbutrin the previous month in an
attempt to better control her depression. “She states
that this medication combination is working wonderfully for
her. Her boyfriend says ‘You're like a different
person.' ” She previously had been on other
antidepressants: Prozac had adverse side effects, and
Cymbalta didn't work. Id. She stated
that she had not quit smoking completely. Porter said that
the first week or so Viibryd helped with smoking cessation
and now she was smoking a little more again, but less than
before. She was continuing to work on this. Id.
day her Beck depression inventory was 12, consistent with
mild mood disturbance. She woke easily. She had anhedonia but
endorsed no other symptoms of depression. Id. She
was well groomed, had no abnormal movements, an appropriate
affect, and no abnormalities in thought content, perception,
or process. AR329. PA Thielen diagnosed depression with
anxiety, and emotional lability. AR329.
August 6, 2013, Porter sought ER treatment for severe low
back pain with radiation into both legs and saw Kelly
Manning, MD. AR758. Porter told Dr. Manning that she'd
had this for a long time and saw Dr. Cote regularly for the
condition. Id. She felt that the pain was worse.
Id. On exam, her lower back and paraspinals were
tender. Id. Her extremities had no edema, or
evidence of gross weakness. Id. She was alert,
oriented and had normal mood, affect, memory and judgment.
Id. Dr. Manning's impression was radicular low
back pain that was recurrent. She provided analgesics and
encouraged Porter to see her outpatient physician. AR759.
August 23, 2013, Christina Cote, DO, Rapid City Regional
Hospital saw Porter upon Community Health Center's
referral pursuant to contract with the South Dakota
Department of Human Services. AR316. Porter's chief
complaint was chronic pain. Her problem list included chronic
postoperative pain; pain in her ankle and foot; degeneration
of lumbar or lumbosacral disc; other disorders of muscle,
ligament and fascia; myalgia and myositis unspecified;
neuralgia, neuritis and radiculitis, unspecified, acquired
deformities of the knee; lesion of the plantar nerve; hallux
rigidus; and insomnia. Her medications were Bupropion,
Dexilant, Ibuprofen,  Nortriptyline, 
Pennsaid topical drops for the right knee, and
vitamin D. AR316.
a surgical history of arthroscopy in both knees. AR317. On
exam, Porter was five-feet-six and 155.5 pounds. She reported
a pain level of 10. AR318. She reported eight months of
chronic pain, the worst pain today. Id. It was
located in her left hip and left low back, described as a
deep ache and stabbing pain, worse (10/10) with activity. She
had just moved into a new house and had been unpacking and
cleaning. Id. Any activity such as mowing, mopping,
sweeping made pain worse. AR318. Dr. Cote reported that the
patient was oriented, with appropriate mood and affect, and
intact recent and remote memory.
Cote performed a detailed cranial nerve examination and
assessment of tenderness, spasm, bony abnormalities, strength
and reflexes of the cervical and lumbar spine, and
observation of gait and posture. All findings were normal,
and Dr. Cote reported full range of motion, 5/5 muscle
strength, and normal sensation. AR319. Porter's back had
no tenderness or spasms. Id. She assessed myofascial
pain syndrome, neuropathic pain, and chronic postoperative
pain of the right knee. Id. Dr. Cote prescribed
topical Pennsaid for the myofascial pain syndrome and right
knee pain, and Nortriptyline for neuropathic pain.
August 29, 2014, PA Thielen saw Porter for complaints of left
hip pain radiating down her leg for a week, when up and
moving. AR327. Porter reported pain in her low back and, for
2-3 weeks, numbness intermittently down the left leg. The
past week she had had significant pain into her left buttock.
examination, PA Thielen found tenderness to palpation in the
left paraspinous lumbar region, some difficulty with
ambulation secondary to pain, and left sciatic notch
tenderness. AR328. PA Thielen found that straight-leg-raising
on the left was limited by stiffness. Strength and reflexes
were normal. Id. She assessed lumbago with sciatica
and planned an MRI of the lumbar spine. Id. PA
Thielen prescribed Prednisone 40 mg. a day for 5 days; rest,
alternating heat and ice 20 minutes at a time 2-3 times a
day. She prescribed Viibryd, 40 mg. and physical therapy.
Id. PA Thielen noted that Porter saw Dr. Cote for
pain management and encouraged her to discuss this again with
September 4, 2013, Leo Flynn, MD, of Dakota Radiology,
interpreted a non-contrast MRI of the lumbosacral spine,
reporting that degenerative changes at L5-S1 had increased
since 2009 imaging. AR331. At L4-L5, Dr. Flynn saw mild facet
joint degenerative changes and possible minimal left
foraminal disc protrusion. At L5-S1, he reported degenerative
disc changes, loss of disc space height, mild diffuse bulge,
mild left facet arthrosis, posterior annular tearing and a
small left foraminal disc protrusion causing mild foraminal
encroachment which could affect the exiting L5 nerve root.
His overall impression was:
1. Moderate chronic degenerative disc and endplate changes at
L 5-S1 with a small left foraminal disc protrusion. This
appears to be contacting the left L5 nerve root. No.
high-grade spinal stenosis.
2. Suspicious for a very small left foraminal disc protrusion
at L4-L5 close to the existing left L4 nerve root.
AR331, dup. AR641.
September 13, 2013, PA Thielen dispensed
Vicodin for pain. AR327.
September 24, 2013, Porter saw PA-C Palmer for her left knee
pain. AR821. She reported mild relief from the Euflexxa
series and some relief with physical therapy. Id.
She said the pain was mostly in the distal lateral knee.
Id. On examination she had crepitance and a positive
grind test. She had mostly mild tenderness with the most
specific tenderness at distal insertion of the iliotibial
band on the lateral femoral condyle. Id. She had no
instability with varus and valgus stress, or anterior and
posterior drawer. Id.
showed mild medial joint space narrowing and degenerative
changes within the patellofemoral joint. PA-C Palmer assessed
the IT band tendinitis and mild DJD of the left knee.
Id. PA-C Palmer injected cortisone into the
insertions of the IT band. AR822. Following the injection
Porter reported marked relief of pain. Id.
October 15, 2013, Amber Davidson, PA student under PA
Thielen's supervision, saw Porter to follow up her
depression. AR326. Porter stated that she was doing well on
her current medications. She had minimal feelings of
depression and her moods were stable. Id. She had
started Wellbutrin to help her stop smoking but had not had
much luck with this. She had used Quitline in the past and
would try to use it again. Id.
Porter reported continued low back pain with left side
radiculopathy. AR326. Her MRI showed some impingement on the
L5 nerve root. Id. Ms. Davidson said she would refer
Porter to neurosurgery.
Davidson reported her examination showed Porter was in no
acute distress, was oriented to person, place and time, had
normal respiration, normal cardiovascular clinic examination,
and no psychiatric disturbance of note. AR326. Porter was
well groomed, well developed, well nourished, in no acute
distress, alert and oriented. Id. She had well
organized and articulate speech, she answered questions and
readily divulged information, eye contact was appropriate,
there were no abnormal movements, her affect was appropriate,
and she had no abnormalities in thought content, perception
or process. Id. Davidson planned a neurology
consult, encouraged the patient to find a place to walk
indoors, and encouraged her to quit smoking again. AR326.
October 22, 2013, Ashley Pfeiffer, DPT (doctor of physical
therapy), reported an initial evaluation for chronic left
knee and low back pain. AR409. DPT Pfeiffer reported that
Porter presented with significant IT band and lateral quad
tightness and restrictions. AR410. DPT Pfeiffer observed
decreased lumbar active range of motion in all planes, and
poor frontal plane hip weakness. Id. Anterior drawer
and Lachman's tests were negative. Porter had zero
degrees of knee extension, 94 degrees of left knee flexion,
4/5 left knee extension strength, and 4 left knee flexion
Pfeiffer believed Porter's left knee pain appeared
secondary to arthritic symptoms along with restricted lateral
muscle complex and decreased hip and core strength. AR410.
She planned therapy 3 times a week for 6 to 8 weeks, to
include therapeutic exercise, neuromuscular re-education, and
manual therapy, plus modalities for pain control in order to
improve flexibility, range of motion, strength, and function
for Porter's bilateral hips, knees and low back.
October 22, 2013, Porter saw PA-C Palmer for follow-up of
left knee pain. AR820. She said she was markedly better post
injection. She was starting physical therapy. She now
complained more of pain in the anterior knee. “She has
known patellofemoral arthritis, chondromalacia patella. She
completed a Euflexxa series nearly six months ago, and this
did give her some relief … but she is getting
recurrent symptoms.” Id. On exam, she had a
positive patella grind test and crepitance in the
patellofemoral joint, no instability of the knee, and minimal
tenderness at the distal IT band insertion laterally.
Id. PA-C Palmer assessed patellofemoral arthritis
and IT band syndrome, improved. He planned a repeat Euflexxa
series, and noted that she would see a physical therapist for
quad and VMO (vastus lateralis oblique) strengthening and
patellar stabilization. Id.
had physical therapy sessions on October 23 (75 minutes),
October 28 (70 minutes), October 29 (75 minutes), November 1
(75 minutes), November 5 (90 minutes), and November 6 (75
minutes), 2013. AR414, 415, 417, 419, 421, 423.
November 8, 2013, Porter underwent a left L5-S1
transforaminal epidural steroid injection for her L4-L5
radiculopathy by Dr. Trevor Anderson at Black Hills Surgical
Hospital. AR367, dup. at AR396.
November 12, 2013, Porter saw PA-C Palmer at Black Hills
Orthopedic & Spine for her second set of Euflexxa
injections, the first series in the set in her left knee.
November 13, 2013, Porter sought ER treatment for left knee
and left hip pain after a fall, and saw John Hill, MD. AR748.
Her back was not tender. She had mild tenderness with range
of motion of the left knee and left hip. Id. X-rays
of the left knee were normal. AR749. Left hip x-rays showed
calcification in the pelvic soft tissues on the left side,
also shown on a prior CT scan (at AR 751), which were likely
phleboliths. Id. Dr. Hill discharged her with a
prescription for anti-inflammatories and pain medications.
November 16, 2013, Porter sought ER treatment for hip pain
after she had fallen and landed on her left hip. AR740. She
saw Donald Neilson, MD. She reported a history of chronic
left hip pain. There was no weakness or edema, she had normal
pulses, and mild tenderness over the right greater
trochanter. Dr. Neilson treated her with Toradol in the ER
and gave her a prescription for Naprosyn. Id.
November 19, 2013, Porter underwent her second series in the
second set of Euflexxa injections. AR816.
November 20, 2013, Porter had a 70-minute physical therapy
session with DPT Pfeiffer. AR430. She told DPT Pfeiffer that
after another injection she had no change in pain. AR429. DPT
Pfeiffer stated that if no physical therapy gains were seen
after a week she would be discharged. AR430.
November 26, 2013, Porter had a 70-minute physical therapy
session. AR431. DPT Pfeiffer said she would be discharged
after 2 more visits due to no further gains. AR432.
November 26, 2013, Porter saw PA-C Palmer to complete the
Euflexxa series to her left knee and also evaluate left elbow
pain, which she had had for several weeks. AR814. Porter
reported that her elbow was stiff and painful in the morning
and that her left knee was somewhat improved from the
Euflexxa treatment. Id. She reported that a bulging
disc caused some radicular left leg pain, and PA-C Palmer
commented that a bulging disc could also produce left knee
examination, PA-C Palmer found a tender lateral epicondyle,
pain with resisted wrist extension, pronation, and
supination. Porter had full range of motion of the left
elbow. PA-C Palmer assessed lateral epicondylitis of the left
elbow and osteoarthritis of the left knee. Id. He
completed the Euflexxa series. AR815. He discussed treatment
for lateral epicondylitis: stretches, elbow pad, ice, heat,
NSAIDs, and pain cream. Id.
November 27, 2013, Crystal Walton, PA at The Rehab Doctors,
saw Porter after her transforaminal epidural steroid
injection. AR366. Porter stated that “she still cannot
stand or walk or do dishes without having severe pain. The
injection did resolve her pain when she is lying down
… [S]he is in physical therapy and that has not helped
… Her Nortriptyline helps her at night.” The
diagnosis was left L4 and L5 radiculopathy. Id.
November 27, 2013, DPT Pfeiffer wrote a discharge summary.
AR511. DPT Pfeiffer noted Porter could perform home exercises
properly. And the anterior drawer test and Lachman's test
were negative. AR511-12. Subjectively, the patient felt
“confident doing exercises at home.” She also
reported she had had knee surgery with arthroscopic
debridement; she ascended and descended stairs with
significant pain; she was able to walk <5 minutes without
significant pain; she scored 23 on the lower extremity
functional scale; and she was unable to squat without pain.
extension was 0 degrees bilaterally, knee flexion was 120/125
degrees bilaterally. AR512. Knee strength was 4- to 5-/5. DPT
Pfeiffer said the patient had been seen for 12 sessions with
no gains in pain levels or improvement in function. The one
goal she had met was the ability to perform home exercises
properly. Goals for stairs, walking, and squatting were not
met. Since she had plateaued, she was discharged.
20, 2013, Porter saw Kristie Waddell, CNP at community health
for gastroenteritis. AR476-77. Her medications were
Ibuprofen, Vicodin, Dexilant, Nortriptyline, Bupropion, and
Viibryd. AR 476.
Waddell reported a review of systems and clinical examination
that were unremarkable, including gastrointestinal symptoms.
AR477. She prescribed medications and diet for diarrhea.
December 27, 2013, Porter saw Anne Fisher, MD, at the ER for
low back pain after slipping and falling on a patch of ice.
AR722. She smoked half a pack a day. Id. On physical
examination she was sitting in a
semi-Fowler'sposition, had diffuse lower back
tenderness, and reported paresthesias of her feet. DTRs were
2 at the knees and 0 at both ankles. She had no weakness,
normal sensation, and normal mood, affect, memory, and
judgment. Id. Dr. Fisher compared lumbar spine
series (report at AR725) with the September 2013 lumbar MRI.
AR723. She noted narrowing of the L5-S1 disc space, which was
a change. Id. Dr. Fisher treated Porter with IV
Morphine on top of Fentanyl that she received prehospital and
she was able to ambulate. Id. She was discharged
January 5, 2014, Porter underwent a sacroiliac joint
injection at Black Hills Surgery Center. AR525.
January 9, 2014, Porter saw Trevor Anderson, MD, at The Rehab
Doctors on referral from Jonathan Wilson, MD. AR362. Dr.
Anderson reported the history: 9 years ago she woke with back
and leg pain, left greater than right. She had gone to
physical therapy, experienced some improvement, but had
recurrent flare-ups since then. Id. In August 2013
she had to go to the ER with significant pain. Id.
pain diagram Porter indicated aching in her left buttocks;
burning, tingling and numbness in her posterior legs to the
bottom of her feet; and low back pain. AR362. She reported
that pain levels ranged from 4 to 10, affected her sleep, and
that pain was worse with sitting, standing, lifting, bending,
twisting, and walking. Pain was relieved by lying down, ice,
and medications. She described sensations of weakness,
tingling, and numbness in her legs and feet. Activities of
daily living were limited: walking, stairs, picking up
objects off the floor, lifting, reaching, shopping, working
and exercise. Id.
seen Drs. Anderson, Wilson, Cote, and Community Health for
this complaint. AR362.
Anderson noted the radiologist's findings on the
September 2013 lumbar spine MRI. AR362. He noted the November
2013 epidural that allowed Porter to sleep better and lie
down afterward but overall was not terribly helpful.
Id. In further discussion, however, Porter said she
thought she had benefit later on; she said she would consider
a repeat injection. Id.
Anderson noted that Porter had undergone trials of Tylenol,
Ibuprofen, Meloxicam,  Celebrex,  Prednisone, Tramadol,
Hydrocodone, Gabapentin,  Nortriptyline, Pennsaid
gel, epidurals, ice, and physical therapy multiple times, and
a TENS unit. AR362. He noted her history of arthroscopic knee
surgery. Id. She had smoked for 20 years, one-half
pack a day. Id. She denied alcohol use. Id.
review of systems was negative except for depression, low
back and bilateral leg pain. AR363. On examination, she was
able to walk on toes and heels; squat, perform tandem gait,
and had a normal Romberg test. Strength, sensation, and
reflexes were normal. Lumbar range of motion was very limited
throughout with midline lumbar spine pain. Dr. Anderson
observed a left “up-slip.” Id.
Anderson reported normal smooth lumbar pelvic rhythm. AR364.
Porter was tender to palpation over the L5 spinous process,
and over the sacroiliac (SI) joint and piriformis, left
greater than right. Id. The supine piriformis
test provoked on the left greater than right.
The Faber test provoked groin pain. Id.
Straight-leg-raising at 45 degrees caused bilateral calf
pain. Prone extension and reverse
straight-leg-raise did not change her pain. Id.
Dr. Anderson diagnosed L5-S1 radicular symptoms with an SI
joint component. Dr. Anderson recommended a repeat left L5-S1
transforaminal epidural and physical therapy. Id.
Anderson wrote to Dr. Wilson stating, “As you know, she
has stenosis at L5-S1 and bilateral radicular symptoms. She
also has some secondary S1 and piriformis pain.” AR365.
He recommended repeating the epidural and physical therapy.
January 13, 2014, Dr. Anderson performed a left L5-S1
transforaminal epidural steroid injection into the spinal
canal for left L5 radiculopathy. AR338; dup. at AR361, 813.
January 14, 2014, Molly Schwab, PA at community health, saw
Porter to follow up on her Viibryd and Dexilant, which Porter
said were working very well. AR475. Clinical examination was
unremarkable. AR475. The gastrointestinal examination showed
her appetite was not decreased, and she had no nausea,
vomiting, abdominal pain, diarrhea, or constipation.
Id. PA Schwab assessed depression with anxiety, and
esophageal reflux. AR476.
January 24, 2014, Porter reported to PA-C Palmer that she had
been using the TENS and it helped significantly especially
with night pain. AR812. She had been doing PT and had gotten
good strength out of her knee. With the TENS unit she was
able to control her symptoms. The Euflexxa injections seemed
to help better this last series. Id. On exam, PA-C
Palmer found tenderness at the distal insertion of the IT
band on the lateral knee and markedly improved tenderness
along the mid substance and proximal IT band. Id.
PA-C Palmer assessed osteoarthritis of the left knee and IT
band pain, improved. PA-C Palmer told Porter to continue the
TENS and home exercises. She could repeat the Euflexxa series
after May or June if pain recurred. Id.
January 31, 2014, Kevin Sobolik, physical therapist at
ProMotion Physical Therapy, reported a comprehensive
evaluation for Porter, who said she had insidious,
progressive, L5-S1 HNP and radiculitis, with onset 8 years
earlier. AR374. She reported intensification of radiation to
the lower extremities, with exacerbations caused by lifting,
walking too much, twisting, turning wrong, and sleeping
wrong. She reported that she used a home TENS unit, ice, and
relaxation. She reported that she had been to physical
therapy “very often over the last 10 years” and
found some relief from the exercise. Id.
Sobolik reported that Porter stood with no apparent
asymmetry; but supine, her left leg was 1 cm. longer. AR374.
Extension caused low lumbar “pressure” pain.
Bilateral side-bending caused ipsilateral
“pressure.” Forward flexion with hands to knee
increased hip radicular complaints, and with fingertips to
floor she had complete radicular complaints in her left lower
extremity. Id. He found positive
left-lower-extremity neurotension symptoms at 60 degrees on
the straight leg raise. Lumbar range of motion with
side-bending was reduced by 50 percent. Id.
5/5 strength in her bilateral lower extremities, but reported
weakness in the left lower extremity. AR375. Bilateral heel
rise increased her posterior leg radicular complaints. On the
biomechanical evaluation, the left SI joint appeared slightly
reduced in mobility, both superior and inferior glide, which
could be from myofascial guarding. Id. Most all
other lumbar mobility testing was painful. Flexion of the
lower segments increased Porter's radicular complaints,
more so on the left. Sacroiliac testing for pain was
Sobolik's impression was that flexion greater than
extension exacerbated her discogenic radicular symptoms.
AR375. He instructed Porter in 5 exercises for stabilization
and range of motion, and applied inversion traction. Porter
reported “benefit from traction, but not after
performance of this.” Id.
Sobolik listed functional goals that included an “ODI
score” of 25 or less and 75 percent reduction in her
radicular complaints within an eight-week time frame. AR375.
The foundation of care would be progression of core
stabilization. Id. “We will incorporate
primarily extension-based lumbar range of motion and lower
extremity range of motion and neuromobility exercises.”
Id. PT Sobolik listed modalities to introduce at the
next session to address the sacroiliac joint. Id.
reported Porter's most recent disability index scores:
Pain level 8, lumbar Oswestry score 52. AR375. Porter's
“ODI” (Oswestry disability) assessment is at
AR386-87. Porter reported pain levels of 8-9 over the past 24
hours, mild pain at the moment, said that washing and
dressing increased her pain, said she could not lift or carry
anything at all (“have to watch how I move and
lift”), said that pain prevented walking long distances
(AR386), that she could sit “as long as I like
providing that I have my choice of seating surfaces, ”
that pain prevented standing more than 10 minutes (in
addition to other answers related to standing),
and that she slept only ¼ of her normal amount
(AR387). Porter stated that pain prevented more energetic
activities like sports and dancing, that traveling caused
increased pain (“as long as I can have breaks I can
travel but need to stretch…”), and said she
could perform most homemaking duties but pain prevented
physically stressful activities like lifting and vacuuming.
February 3, 2014, Porter sought ER care for cough and
congestion. AR711. James Gilbert, MD, assessed bronchitis
with reactive airway disease. AR712. He discharged her with
Albuterol inhaler, Phenergan with Codeine, and Prednisone for
5 days, with Zithromax. AR711. He encouraged her not to
February 4, 2014, Porter saw Crystal Walton, PA, at The Rehab
Doctors. AR360, dup. at AR 380, 398. PA Walton recorded the
patient's report of effects of epidural infusion: pain
was 8/10 before the epidural infusion, 3/10 immediately
after, 6/10 the next morning, and ranged from 4-6 through day
eleven post-injection. Id. Currently Porter reported
her pain level as 4/10.
said she was very pleased. She had seen a physical therapist
at ProMotion for an evaluation and was no worse after.
Id. PA Walton noted Porter had a diagnosis of left
L5 radiculopathy, and low back pain significantly improved.
PA Walton said that Porter would continue advancing her PT
program as she was able to tolerate. AR360.
Walton discussed the disability form that Porter had brought
in for Dr. Anderson to complete, and said “the
disability company could either order an IME with Dr.
Anderson, an FCE with no guarantee that he could address all
of the questions and that would require a follow-up visit as
well, or he could fill out one of our work forms for the
disability company.” AR360. PA Walton recorded
“Dr. Anderson felt that it would be in her best
interest to contact Myler Disability who sent her this form
and ask them how she should proceed.” AR360.
February 19, 2014, Porter returned to DPT Pfeiffer at the
Physical Therapy Center. AR433. DPT Pfeiffer stated that the
patient had had PT, chiropractic, and injections with little
to no relief. She was not a surgical candidate at this time
so she was looking to therapy to try to offer some relief in
pain and get her core as strong as possible. Id.
Porter told DPT Pfeiffer that she could tolerate sitting 30
minutes or less, standing 15 minutes or less, and walking 20
minutes or less. Id.
examination, Porter had fair “TrA [Transverse
Abdominis] and multifidi” strength testing. She was
unable to lift and was unable to perform her home exercise
program (“HEP”) properly. She had positive
compression, distraction, and Faber tests, negative tests for
lumbar radiculopathy or herniated discs, and normal or
slightly restricted lumbar movements. AR434. Upon palpation,
she had tightness/trigger points in her lumbar paraspinals,
glutes, and piriformis bilat. Lumbar spine movement was
mostly normal and hip and knee strength were 5/5. Her pain
rating was 8, and Oswestry score 58 (meaning, moderate
activity causes significant pain). Id.
said she was unable to perform ADLs without moderate to
severe pain in her back. AR435. DPT Pfeiffer assessed signs
and symptoms consistent with SI dysfunction, her referral
diagnosis. She demonstrated lack of dynamic core stability
especially with higher-level activities, and this contributed
to her symptoms. DPT Pfeiffer noted that trigger points
throughout the lumbosacral region contributed to pain. Due to
Porter's inability to get relief with previous PT
intervention, her rehabilitation potential was low.
Id. DPT Pfeiffer planned “alternative
treatments this round including PRI corrective
exercises.” Id. She planned to also include
lumbar traction and extensive core stabilization in the
therapy program. Id.
February 21, 2014, Porter had 50 minutes of physical therapy.
AR438. On February 24, 2014, she had 63 minutes of therapy.
February 28, Kevin Sobolik reported a physical therapy
evaluation. AR372, dup. at AR 391. The patient reported
progressive lumbar spine pain for the last 8 years with
intensification of radiation to lower extremities. She now
had constant tingling in the left lateral extremity and
bilateral foot numbness, with exacerbations caused by
lifting, walking too much, twisting, turning wrong or
sleeping wrong. Id. She reported the worst pain
level as 10/10 and the best as 3/10. She had a home TENS
unit, and ice and relaxation and more awareness would reduce
exacerbations. She had been to physical therapy at the PT
Center “very often over the last 10 years with some
temporary relief.” Id.
a history of left knee osteoarthritis and depression. She was
on antidepressants and Nortriptyline. AR372.
Sobolik described Porter's pain diagram: aching in her
left knee; pins, needles, numbness in the left low lumbar
region and bilateral lower extremities, to the left heel and
right posterior knee. AR372. Porter had no apparent asymmetry
while standing, but when supine, her left leg was 1 cm.
longer. Extension caused low lumbar “pressure”
pain. Bilateral side bending causes ipsilateral
“pressure.” Id. Forward flexion with
hands and knee increased hip radicular complaints. Fingertips
to floor increased left lower extremity
“complete” radicular complaints. Id.
Porter had positive left-lower- extremity neurotension
symptoms at 60 degrees in the straight leg raise. She had 50
percent of normal lumbar side-bending. Id.
full strength in both lower extremities and subjective
weakness in the left lower extremity. AR372. Bilateral heel
rise induced an increase in posterior lower extremity
radicular complaints. Id. PT Sobolik reported
results of his biomechanical evaluation: the left SI joint
appeared slightly reduced in mobility, both the superior and
inferior glide, which could be myofascial guarding. Most all
other lumbar mobility testing was painful. Id.
Flexion of the lower segments increased radicular complaints,
left greater than right. AR372-73. Sacroiliac testing for
pain was negative. AR373. PT Sobolik stated the physical
therapy impression: Flexion greater than extension
exacerbating discogenic radicular complaints. Id. He
instructed Porter in 5 exercises for stabilization and range
of motion, and applied inversion traction. Porter reported
benefit from traction. AR373.
March 11, 2014, Molly Schwab, PAC at community health,
dispensed Viibryd 40 mg. AR475.
March 12, 2014, DPT Pfeiffer noted that Porter had missed
physical therapy for 2 weeks due to her son having
mononucleosis. She had 45 minutes of therapy on that date.
March 13, 2014, Porter saw Stephen Dick, MD, at the ER, for
complaints of feeling weak, run down, persistent cough, and
persistent problems breathing. AR704. Her lungs were clear,
and she improved considerably after a duo
nebulizer. AR705. Dr. Dick “suspect[ed] her
symptoms are related to the … reactive airway scenario
with her bronchitis.” Id. Her chest x-ray was
read as negative. AR708.
March 19, 2014, DPT Pfeiffer recorded that Porter had missed
her Friday appointment because she was sick and vomiting.
AR447. Porter had 45 minutes of therapy on this day, 45
minutes on March 26, 55 minutes on April 2, 45 minutes on
April 4, 45 minutes on April 8, and 45 minutes on April 18,
March 29, 2014, a chest-x-ray was interpreted as showing no
April 9, 2014, PA Schwab dispensed Viibryd 40 mg. AR474.
April 18, Porter reported trying to do exercises on her own
but said it was difficult to do them consistently. Her
sitting tolerance continued to be 30 minutes or less,
standing tolerance 15 minutes, and walking tolerance 20
minutes. AR462. DPT Pfeiffer again noted “fair TrA and
multifidi strength testing. Unable to lift.”
Id. Sacroiliac joint integrity tests - compression,
distraction, and Patrick's Faber - were positive. DPT
Pfeiffer observed tightness/trigger points of the lumbar
paraspinals, glutes, and piriformis B and normal lumbar spine
movements except for extension, which was slightly
restricted. AR463. Porter had full strength of hips, knees
and ankles, and negative tests for lumbar radiculopathy or
herniated discs. Id.
April 19, 2014, Porter sought ER care for respiratory
complaints. She was noted to be a smoker. AR693. She had a
barky cough and said, “I have been trying to quit
smoking and now my coughing is worse.” AR695. The
impression was acute bronchitis and tobacco abuse. AR694. She
was treated with an Albuterol inhaler, Tessalon Perles,
and a Z-Pak. AR693. She had a full range of motion in
all extremities, no gross weakness or edema, and normal mood,
affect, memory, judgment, grooming and hygiene. AR693, 695.
April 22, 2014, Porter saw CNP Grimsrud for her depression.
AR473. Her medications were Vicodin, Ibuprofen, Dexilant,
Bupropion, Nortriptyline, and Viibryd. Id. CNP
Grimsrud said that Porter had previously seen Molly Schwab,
PA, for depression and GERD. The patient denied concerns
about her current medication. She said she was being treated
for upper respiratory infection with a Z-pak and Tessalon
Perles and was not feeling better. She complained of chest
tightness and wheezing. AR473. Clinical exam, including
psychiatric exam, was negative except for tight, diffuse
wheezes throughout the lungs. AR473-74. CNP Grimsrud ordered
a nebulizer treatment. AR474. She added Prednisone and Advair
Diskus to the medication regimen. Id.
13, 2014, Porter saw Karron Zopp at community health for sore
throat cough, and tenderness under the neck and pain when
swallowing. AR560. Porter still smoked every day.
27, 2014, DPT Pfeiffer wrote a physical therapy discharge
summary. AR508. She stated that Porter had been doing her HEP
regularly, and reported no change in leg or back symptoms.
Id. Objectively she had “fair” strength
testing of the TrA and multifidi. She was able to perform her
HEP properly. Id.
physical therapy examination was normal except for slightly
restricted lumbar extension. AR509. The patient had been seen
for 11 sessions and had been unable to demonstrate any
significant changes in subjective levels of pain or function.
She was compliant with her home strength and stability
29, 2014, Porter saw CNP Grimsrud for her depression. She was
on Bupropion and Viibryd and did not think they were helping.
AR470, dup. AR559. She endorsed high irritability, emotional
lability, and depression. AR471. On examination, she was well
groomed, her speech was organized and articulate, she had
appropriate eye contact and effect, and expressed no
abnormalities in thought content, perception or process.
Id. CNP Grimsrud assessed allergic rhinitis,
depressive disorder NEC, and esophageal reflux. She initiated
Abilify 2 mg a day, and said Porter would be seen in 3 months
or sooner if needed. Id.
laboratory report on this date showed elevated thyroid
stimulating hormone and low Vitamin D, low hemoglobin, mean
corpuscular volume, mean corpuscular Hgb, and mean
corpuscular Hgb concentration, with elevated red cell
distribution width. AR478. Her calcium level and albumin were
low, and alkaline phosphatase was elevated. AR479.
2, 2014, Porter saw Dr. Daniel Hofmann at the ER for back and
leg pain. AR922. She reported she had a history of chronic
back pain treated with injections, and had a TENS unit. She
reported she had been diagnosed with neuropathy in her feet
of unknown cause and had been tried on Gabapentin without
relief. She had had 3 days of exacerbation of her back pain
and parasthesias in her feet. Id. She had a negative
exam. AR922-23. Dr. Hofmann treated her with Toradol IM and a
prescription of Tramadol. AR923. His clinical impression was
exacerbation of chronic low back pain and exacerbation of
neuropathy of the feet. Id.
8, 2014, Porter saw Patrick Tibbles, MD, at the ER, for
several days of worsening cough, and other upper respiratory
symptoms. AR915. She was said to be an ongoing smoker,
“6 cigs packs per day.” Her O2 saturation was
97%. She was using asthma medications without relief. Her
cough was severe and she was unable to sleep. Id. On
physical exam she had very mild pharyngeal erythema and
bilateral rhonchi and wheezing. Id. Chest x-ray was
normal. AR916, 921. She was given a Combivent inhaler and
was admonished to stop smoking. Dr. Tibble's impression
was acute bronchitis, acute bronchospasm, asthma
exacerbation, and ongoing tobacco dependence. AR916. The
remainder of her physical and psychological examinations were
14, Porter sought ER treatment for back pain and coughing.
AR911. She stated that she had just run out of her Tramadol
and Lyrica. AR911-12. She smoked a half-pack a day. AR911. On
physical examination, she had decreased breath sounds
bilaterally, her back was non-tender, her extremities had no
gross weakness or edema, and she had normal mood, affect,
judgment, and memory. AR911-12. She was discharged home with
Lyrica and Tramadol. AR912.
16, 2014, Porter saw CNP Zopp at community health, for cough,
body aches, and fatigue. AR558. She reported going to the ER
2 weeks earlier. She was placed on a Z-Pak but said she had
been coughing non-stop and that she had bad body aches and
chills. Id. CNP Zopp noted her current medications:
Ibuprofen, Nortriptyline, Levothyroxine,  Abilify,
Vitamin D2 50, 000 units twice a week for 8 weeks, Viibryd,
Dexilant, Bupropion, Advair Diskus, and Combivent.
Id. The patient was a “light” tobacco
smoker. She did have a mild fever. Auscultation revealed fine
crackles anteriorly and diminished breath sounds in the bases
bilaterally. Id. CNP Zopp assessed cough, fever, and
simple chronic bronchitis. AR559. She planned a chest x-ray
or other imaging of the chest, Prednisone 40 mg. a day for 5
days, and Tessalon Perles. Id.
18, 2014, Porter saw CNP Grimsrud at community health for
left hip and left pain, which she had had for 5 days. AR557.
She complained of pain with standing and with movement of the
hip. She was on Lyrica, Tramadol, and Ibuprofen through Pain
Management and saw the “Rehab MDs” for
injections. Id. The musculoskeletal examination was
unremarkable with some subjective pain on motion of the left
hip, and a normal range of motion of all extremity joints.
Id. CNP Grimsrud assessed hip joint pain.
Id. She prescribed Meloxicam and instructed Porter
to not take Ibuprofen/Aleve while on this medication. AR558.
30, 2014, Porter saw PA-C Kayla Czmowski at community health
for possible bronchitis. AR555. After her 5-day Prednisone
burst, most of her symptoms had resolved. Id. PA-C
Czmowski assessed “simple chronic bronchitis, ”
prescribed Tessalon and told Porter to increase fluids, rest
and “QUIT SMOKING!” AR556.
30, 2014, PA Walton reported that Porter was last seen at The
Rehab Doctors on February 4, 2014. AR488. PA Walton noted
Porter had a left L5-S1 transforaminal epidural steroid
injection in January 2014, did very well, went to
approximately 8 physical therapy treatments, and did not
really note additional improvement. Id. Recently her
pain came back and “is exactly the same as it was
before.” PA Walton reported her examination: the
patient had some discomfort with left hip maneuvers.
Compression of the SI joint was somewhat painful. Faber was
restricted. SLR was very positive. Id. PA Walton
assessed left L5 radiculopathy, and a hip and SI component.
She planned to schedule another epidural. If Porter continued
to have SI or hip maneuvers [sic], that problem would be
addressed later. Id. PA Walton agreed to call in a
refill of Lyrica. Id.
7, 2014, Porter underwent a left L5-S1 transforaminal
epidural steroid injection, administered by Dr. Anderson.
9, 2014, Porter saw Ashley Rook, PAC at community health, for
her continued bronchitis. AR553. She reported that she
coughed so hard she got light-headed. She was still using
three inhalers and Tessalon. She also had a headache.
Id. She reported she was making an effort to cut
back and hopefully quit smoking, but she was still an
everyday smoker. AR554. She was on Prednisone 40 mg. a day
for 5 days. Id. Her oxygen saturation was 97
percent. Id. Auscultation revealed mild expiratory
wheezes in upper and lower lung fields, normal respiration,
and no accessory muscle use. Her psychometric depression
scale was negative. Id. The assessment was
“simple chronic bronchitis.” Id. PA Rook
renewed the prescription for Prednisone 40 mg for 5 days.
AR555. She continued Tessalon and inhalers. PA Rook
encouraged continued efforts to quit smoking. Id.
14, 2014, Porter saw Clay Smith, MD, at the ER, for severe
back pain involving both the lumbar and thoracic spine after
vacuuming and shampooing carpet earlier that day. AR906.
Porter continued to smoke ½ pack of cigarettes daily.
Id. Dr. Smith ordered Toradol and prescribed a short
course of Tramadol. AR907. His clinical impression was lumbar
and thoracic back pain and atraumatic back pain. Id.
The physical examination demonstrated no extremity edema or
gross weakness, no CVA or midline back tenderness, and normal
mood, affect, memory and judgment. Id.
22, 2014, the laboratory reported low hemoglobin and
hematocrit, mean corpuscular volume, mean corpuscular Hgb,
and mean corpuscular Hgb concentration, with elevated red
cell distribution width. AR568.
22, 2014, Porter sought ER treatment for shortness of breath.
AR902. Chest x-ray was normal. Id. AR 905. Her lungs
were clear, pulmonary vascularity was within normal limits,
and pleural spaces were unremarkable with no evidence of
pneumothorax or effusion. AR902.
26, 2014, Porter sought ER treatment for persistent cough,
wheezing, and shortness of breath. AR894. She had been
camping for several days and was exposed to smoke. She had
been using her inhaler and nebulizers without relief.
Id. On exam, she did not have respiratory distress
or wheezing. Id. Chest x-ray was normal. AR895, 899.
She had unremarkable extremity and psychological
examinations. Id. She was given a Combivent inhaler,
Prednisone, and Azithromycin. AR895. Dr. Tibbles'
clinical impression was acute dyspnea, asthma exacerbation,
acute bronchitis and longstanding tobacco dependence.
28, 2014, PA Walton of The Rehab Doctors reported the L5-S1
transforaminal epidural steroid injection on July 7 helped
Porter's back pain and somewhat helped her leg pain but
did nothing for hip and groin pain. AR487. Pain levels had
fluctuated from 6-9 out of ten since the injection to that
appointment. She reported that she had seen an orthopedist
who told her she had bone-on-bone knee arthritis and would
likely require a knee replacement. Id. Porter had
very positive hip maneuvers on the left and a non-painful
knee exam. Id. PA Walton assessed left hip
degenerative joint disease, left L5 radiculopathy, and low
back pain improved. She scheduled a left hip joint x-ray.
second medical visit on July 28 was to CNP Grimsrud for upper
respiratory symptoms. AR552. She had received 3 5-day steroid
bursts since mid-May and a Z-Pak, plus numerous inhalers and
OTC medications. She continued to smoke daily. She complained
of feeling tired or poorly. Id. CNP Grimsrud
assessed “obstructive chronic bronchitis with acute
bronchitis. AR553. She counseled Porter on cessation of
tobacco. Id. CNP Grimsrud discussed the case with
Dr. Blower and he recommended no further antibiotics or
steroids, but rather a CBC. Id. CNP Grimsrud
wrote, “Due to a medical condition the patient requires
2-3 liters of oxygen at night … and also during
daytime naps.” AR575.
28, 2014, Porter's third medical visit was to the ER
where she saw Dr. Neilson. AR900-01. She complained of
shortness of breath and increasing chest tightness. AR900.
She was a current daily smoker with “no prior history
of asthma or COPD though it is thought at this point she has
some variation of an obstructive pulmonary disease.”
Id. Physical exam revealed diffuse biphasic wheezing
but no respiratory distress. AR900-01. She was given a
nebulizer treatment with significant improvement, though she
still had diffuse rhonchi. AR901. She was given a second
nebulizer treatment and felt significantly better. Clinical
impression was bronchospasm and cough. Id. She had
unremarkable extremity and psychological examinations.
29, 2014, Porter saw Grimsrud for medication follow-up.
AR551. She reported being a “former smoker.” She
reported having a cough and bronchitis for several weeks, had
been on two courses of Azithromycin, currently was on
Prednisone and Zyrtec,  and said she was not feeling better.
The clinical physical and psychiatric examinations were
unremarkable. AR551-52. CNP Grimsrud ordered laboratory
studies. AR552. The laboratory reported elevated TSH and
vitamin D. AR568.
August 11, 2014, David Griffith, MD, interpreted an MRI of
the left hip. AR521-22. He found mild insertional gluteus
medius tendinitis but no evidence of macrotear affecting the
hip; he found a left adnexal cyst that was likely ovarian.
AR522. There were no signs of entrapment neuropathy in the
sciatic nerve region, no perisciatic irritation or scarring,
take off of the hamstring complex was unremarkable, and there
was no muscle atrophy or denervation. AR521.
August 19, 2014, Porter saw PA Walton, who reported (cc:
Jonathan Wilson, MD) that Porter had been seen a week earlier
for continued hip joint pain. Her x-rays had been fairly
unremarkable but an MRI indicated mild insertional gluteus
medius tendonitis, and a left adnexal cyst. Symptoms of left
gluteal and left groin pain were unchanged. PA Walton planned
referrals to physical therapy and gynecology. AR486.
August 22, 2014, Porter sought ER treatment for headache.
AR889. She reported a history of migraines and said she had a
couple a month for over a decade. The headache was behind her
right eye. She was unable to tolerate bright lights.
Id. She was treated with Morphine and Phenergan IM.
AR890. Dr. Hill's clinical impression was acute
cephalgia, and history of migraines. Id.
August 27, 2014, Porter saw CNP Grimsrud for headaches.
AR549-50. She was said to be a former smoker. AR550. She
stated that she used to get frequent migraines but had not
had one in years. She said that she had had this continuous
headache for two weeks. She said it was a migraine at one
point and she sought ER care, and was given morphine.
Id. Porter said The Rehab MD recently took her off
Nortriptyline and that coincided with the start of headaches.
Id. Physical and psychiatric exams were unremarkable
except for headache and diminished breath sounds with
scattered wheezes. Id. CNP Grimsrud prescribed
Amitriptyline 25 mg. at bedtime. AR551.
September 3, 2014, Dr. Pfeiffer reported a physical therapy
evaluation. AR505. The patient complained of left hip pain
and had a history of chronic pain including her low back,
buttock and knee pain. She stated she had tried injections,
PT, massage, and rest, with minimal improvements in pain
levels. She reported significant stiffness and lateral hip
pain that limited her standing and walking. Crystal Walton,
PA, had diagnosed gluteus medius tendinitis and referred her.
the patient ascended and descended stairs with pain and
difficulty, could walk <10 min, tolerate sitting for 30
minutes and stand 5-10 min or less without aggravating pain.
She reported quite a bit of difficulty performing usual
housework activities. Id. She had positive
Ober's test, positive piriformis, SLS 10 sec on R,
and was unable to stand on L. AR506. The Faber test and
Trendelenburg's were positive, and hip
scour was positive. Hip strength ranged from
4- to 5-. Id.
to be achieved by October 15, 2014, were to be able to walk
without significant pain for 15-20 minutes, stand 15 minutes,
report 30% improvement in performing daily housework
activities, and be independent with a finalized HEP.
Id. DPT Pfeiffer stated that Porter presented with
signs and symptoms consistent with the referring diagnosis.
DPT Pfeiffer stated that Porter had significant tightness
throughout the posterior and lateral hip musculature, poor
motor control, and stability of hips and core. AR506. This
was limiting her ability to stand, walk, and perform her
regular ADLs. Rehab potential was fair. Id. She
would be seen twice a week for 6 weeks. AR507.
September 8, 2014, Porter had 45 minutes of physical therapy
and positive findings on the usual tests. (Ober's, Faber,
piriformis, Trendelenburg, SLS, hip scour, and strength
testing of the hip). AR503. She had high irritability with
lateral leg mobilization. AR504.
September 10, 2014, Porter had 45 minutes of physical therapy
and commented, “Weather change makes my knee
sore.” She noted subjective reports that climbing
stairs was painful and difficult and that the patient could
tolerate sitting for 30 minutes. Id. Dr. Pfeiffer
reported positive Ober's, piriformis, Trendelenburg's
and hip scour, “SLR 10 sec on R. Unable to stand on
L.” AR502. She reported hip strength ranging from 4- to
5-. AR502. DPT Pfeiffer assessed slight improvement in
tolerance to mobilization. Id.
September 15, 2014, DPT Pfeiffer reported limitations and
positive tests as before. She provided 45 minutes of physical
September 17, 2014, DPT Pfeiffer stated that Porter continued
to report IT band pain. AR497. She reported limitations and
positive tests as before. AR497-98.
September 24, 2014, PA-C Palmer reported a follow-up visit at
Black Hills. AR810. Regarding her left knee, Porter reported
pain across her lateral hip down to lateral knee. The
Euflexxa series did not seem to affect her knee pain, which
had never been in the joint but was more superior and lateral
to the knee and radiated upward along the IT band over the
greater trochanter in to the lumbar spine region.
Id. Sometimes she got radiating pain down the right
leg but it was more significant on the left. Epidural
injections to her back did not affect the pain; physical
therapy had not really helped. Id. She experienced
numbness at times clear down to her foot. Id.
exam, PA-C Palmer noted mildly positive SLR, tenderness all
along the IT band down to the distal insertion on the lateral
femoral condyle up over the greater trochanter into the
sciatic notch and SI joint. AR810. He noted tenderness from
about L-2-3, L4-5, and L5-S1. PA-C Palmer reviewed the
December 2013 lumbar MRI and said it showed disc herniation
with migration of a loose piece into the lateral foramen that
was impinging on the exiting L4-5 nerve root.
“Certainly this could be reproducing her
discomfort.” PA-C Palmer assessed low back pain,
laterally displaced disc herniation at L4-5; early
degenerative arthritis of the left knee, unresponsive to
Euflexxa. He stated that Porter had “known disc
herniation with foraminal impingement at L4-5 one year ago[,
] not responsive to conservative care. Id. PA-C
Palmer told Porter that he believed the leg pain was
radicular and that a lumbar MRI should be repeated to
re-image the lateral disc herniation at L4-5. AR811. He
wanted her to see Robert Woodruff, MD, orthopedic surgeon at
Black Hills Orthopedic & Spine Center,  to get his
opinion about a possible lumbar microdiscectomy. Id.
September 26, 2014, Stephen Pomeranz, MD, interpreted a
lumbar MRI. AR519-20, dup. at AR887, et seq. He reported a
shallow disc bulge at L5-S1 associated with facet
arthropathy, mild left foraminal ...