United States District Court, D. South Dakota, Southern Division
TERESA B. WYMAN, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER
VERONICA L. DUFFY UNITED STATES MAGISTRATE JUDGE
Teresa B. Wyman, seeks judicial review of the
Commissioner's final decision denying her application for
social security disability and supplemental security income
Wyman has filed a complaint and has requested the court to
reverse the Commissioner's final decision denying her
benefits and to enter an order awarding benefits (Docket 17).
Alternatively, Ms. Wyman requests the court remand the matter
to the Social Security Administration for further
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 the parties. See 28
U.S.C. § 636(c).
Statement of the Case
action arises from plaintiff, Teresa B. Wyman's,
application for SSDI and SSI filed on September 21, 2014,
alleging disability since August 1, 2009, due to borderline
personality disorder, fibromyalgia, major depressive disorder
recurrent, depression, migraines, insomnia, anxiety,
post-traumatic stress disorder (“PTSD”),
interstitial cystitis, irritable bowel syndrome with chronic
constipation, right knee arthritis, gastroesophageal reflux
disease (“GERD”), and extreme fatigue. AR27, 227,
237, 281, 283 (citations to the appeal record will be cited
by “AR” followed by the page or pages).
Wyman's claim was denied initially and upon
reconsideration. AR140, 148, 155. Ms. Wyman then requested an
administrative hearing. AR162.
Wyman's administrative law judge hearing was held on
April 18, 2016, by Brenda Rosten (“ALJ”). AR48.
Ms. Wyman was represented by other counsel at the hearing,
and an unfavorable decision was issued on September 2, 2016.
one of the evaluation, the ALJ found Ms. Wyman had not
engaged in substantial gainful activity (“SGA”),
since the date of her alleged onset of disability, August 1,
2009, and that she met the insured status for her SSDI claim
through March 31, 2015. AR26.
two, the ALJ found Ms. Wyman had severe impairments of
obesity, advanced chondromalacia of the right knee,
fibromyalgia, chronic abdominal pain secondary to polycystic
ovary syndrome, major depressive disorder, borderline
personality disorder and PTSD. AR27.
also found Ms. Wyman had medically determinable non-severe
impairments of gastroesophageal reflux disease and migraines.
three, the ALJ found Ms. Wyman did not have an impairment
that met or medically equaled one of the listed impairments
in 20 CFR 404, Subpart P, App 1 (20 CFR § 416.920(d),
416.925, and 416.926) (hereinafter the
“Listings”). AR27. The ALJ found Ms. Wyman had
mild limitations in activities of daily living, moderate
limitations in social functioning, and moderate difficulties
with concentration, persistence or pace. AR28. The ALJ noted
Ms. Wyman received inpatient psychiatric care at Avera
Behavioral Health for one week in June 2015, but found it was
not an episode of decompensation of extended duration. AR28.
evaluating whether Ms. Wyman met or medically equaled a
Listing, the ALJ stated it examined all the listed
impairments and specifically considered Listings § 1.02A
(major dysfunction of a joint -major peripheral weight
bearing joint such as the hip, knee or ankle) and §
1.02B (major dysfunction of a joint-major peripheral joint in
the upper extremity, i.e. shoulder, elbow or wrist/hand). In
evaluating whether Ms. Wyman met or medically equaled a
Listing the ALJ did not state in the decision whether it
considered if Ms. Wyman's fibromyalgia medically equaled
a Listing (for example, Listing § 14.09D in the listing
for inflammatory arthritis), or whether Ms. Wyman's
fibromyalgia medically equaled a Listing in combination with
at least one other medically determinable impairment.
AR27-29. (The commissioner disputes that this sentence
constitutes a material fact).
also considered whether Ms. Wyman met Listings § 12.04
(affective disorders); § 12.06 (anxiety disorders); and
§ 12.08 (personality disorders). AR27. The ALJ found Ms.
Wyman did not meet any of these listings because she failed
to satisfy the “B” or “C” criteria
for these mental impairments. Id. (These facts
regarding the ALJ's consideration of the mental
impairment Listings were not noted or stipulated to by the
parties, but are noted by the court.).
determined Ms. Wyman had the residual functional capacity,
(“RFC”), to perform:
less than the full range of sedentary work as defined in 20
CFR 404.1567(a) and 416.967(a) except: lift and/or carry 10
pounds occasionally and less than 10 pounds frequently. Sit
about 6 hours in an 8-hour workday, and stand and/or walk
combined for about 4 hours in an 8-hour workday. She cannot
operate foot controls with her R lower extremity. The
claimant can never climb ladders, ropes or scaffolds, but can
occasionally climb ramps and stairs using a handrail. The
claimant can occasionally balance, and stoop, and can rarely
(defined as 1-5% of a workday) kneel, crouch, and crawl. She
can have no exposure to work around hazards, such as
unprotected heights and fast and dangerous moving machinery.
Mentally, the claimant is limited to simple tasks. She can
maintain concentration, persistence and pace for 2-hour
segments. She can respond appropriately to brief and
superficial interactions with the general public.
considered the mental medical source statement completed by
Ms. Wyman's treating mental health PA-C, Rachelle
Broveleit, and noted Ms. Broveleit's opinions, if
accepted, would likely support meeting a Listing for Ms.
Wyman's mental health impairments. AR35-36. The ALJ gave
Ms. Broveleit's opinion little weight because she was a
non-acceptable treating medical source,  because her
opinion appeared to be based on Ms. Wyman's subjective
complaints, and because the limitations were disproportionate
to Ms. Wyman's level of treatment. AR36-37. The ALJ also
noted Ms. Broveleit completed the form with Ms. Wyman's
assistance and the conclusions appeared to be based on
subjective complaints and not objective findings. AR36-37.
The ALJ's credibility finding regarding Ms. Wyman's
statements concerning the intensity, persistence and limiting
effects of her symptoms was that they were not
“entirely consistent with the medical evidence and
other evidence in the record for the reasons explained in
this decision.” AR30. The commissioner disputes that
this sentence constitutes a material fact.
on the RFC determined by the ALJ, the ALJ found Ms. Wyman was
not capable of performing any past relevant work. AR37-38.
five, relying on the testimony of a vocational expert, the
ALJ found there was other work Ms. Wyman could perform
including final assembler with 250 jobs in the region,
printed circuit board screener with 300 jobs in the region,
and stone setter with 250 jobs in the region. AR38-39. The
vocational expert defined the region to include North Dakota,
South Dakota and Minnesota. AR39.
Wyman timely requested review by the Appeals Council (AR214),
and submitted new and material evidence to the Appeals
Council consisting of:
a. Medical records from Sanford Clinic Family Medicine:
letters from Ms. Wyman's treating physician dated
September 6, 2016, and October 14, 2016, in which Dr. Jensen
stated that due to Ms. Wyman's complex conditions and
chronic pain she did not recommend that Ms. Wyman work at
this time, and that Ms. Wyman had been unable to work the
last six years due to her medical problems. See
AR16-20. The Appeals Council stated it did not think this
evidence showed a reasonable probability of changing the
outcome of the decision so it did not consider and exhibit
the evidence. AR2.
b. AR20 is blank. Before any of Ms. Wyman's additional
evidence, AR8-20, was presented to the Appeals Council
Officers who declined to review the ALJ's decision, an
SSA employee scanned the blank side of Dr. Jensen's
letter on this one page (AR2-4, 20). Thus, the Appeals
Council only saw AR20 as a blank sheet.
c. Ms. Wyman will attach the entire two page letter from Dr.
Jensen, including the printed side of AR20 to her brief, but
the printed side was not before the Appeals
d. Student Loan Discharge Application and finding of total
and permanent disability by the U.S. Department of Education,
dated November 1, 2016, which included a physician's
certification from Dr. Jensen stating Ms. Wyman was unable to
perform substantial gainful activity and identifying numerous
mental and physical limitations. AR9-12. The Appeal Council
stated because the evidence was dated November 1, 2016, it
did not affect the decision, which was decided September 2,
Appeals Council denied Ms. Wyman's request for review
making the ALJ's decision the final decision of the
Commissioner. AR1. Current counsel then began to represent
Ms. Wyman and this action was timely filed.
Plaintiff's Age, Education and Work Experience
Wyman was born in February, 1974, and completed four or more
years of college. AR237, 279.
identified Ms. Wyman's past relevant work as a secretary,
resident care aide, child monitor, stock clerk and fast food
state agency found Ms. Wyman's work at DSS and Wal-Mart
to be unsuccessful work attempts. AR305.
Wyman also identified part-time work during a six-week
assessment at Goodwill Industries in 2015 arranged by
Vocational Rehab Services. AR342, see also AR360.
Relevant Medical Evidence
Sanford Family Medicine Clinic
Wyman was seen on April 27, 2008, for abdominal pain, fever,
diarrhea and nausea. AR409. She was referred to a specialist
and ultimately diagnosed with biliary dyskinesia or chronic
inflammation of her gallbladder. AR401, 403.
Wyman was seen on November 3, 2008, with continued abdominal
pain and fever. AR441. She reported fatigue, aches all over,
nausea and occasional vomiting, and her gallbladder had been
removed six weeks earlier. AR441. She was taking Prozac for
depression but did not feel it was related to the abdominal
pain, although she had contacted the clinic because she did
not feel the Prozac was working and her dosage had been
increased on October 15, 2008. AR432, 441.
Wyman was seen on April 14, 2009, with continued abdominal
pain symptoms, additional labs were ordered, but Glenn
Ridder, M.D., noted many things had been tried without avail.
AR452. Dr. Ridder wrote, “she is ‘sure' there
is something wrong and I am not so sure.” AR452. Dr.
Ridder then wrote, “May need to go back to the GA doc
for further eval and tx.” AR452. The lab test revealed
abnormal findings in bacteria and mucus, but the record
includes no discussion of the abnormal results. AR458. Dr.
Ridder's office contacted her on April 15, 2009, and told
her the tests were normal. AR466.
Wyman contacted the clinic on July 23, 2009, and requested
that she be switched back to Zoloft from Prozac because
“she feels crazy and not right at all.” AR485.
Her Prozac was discontinued and Zoloft was prescribed. AR485.
Wyman was seen at the Sanford Family Medicine Clinic on
November 9, 2009, for follow-up of depression and anxiety and
her symptoms were not well controlled with her medications.
AR697. Complaints included crying, headaches, poor
motivation, no energy, whole body pain, suicidal ideation
without a plan, and being unable to work with her
fibromyalgia. AR697. The mental status exam was recorded as
normal. AR698. Levaquin, Cymbalta, and Ultram were added with
samples given for each. AR698.
Wyman was seen on November 24, 2009, for her depression and
reported no longer being suicidal, but was not a lot better
yet. AR497. Dr. Ridder stated, “She is having some
improvement with the depression. She is not suicidal any
longer at this time but not a lot better yet.” AR497.
Dr. Ridder found in the mental status exam that she was
oriented, with normal thoughts, speech, affect, and mood.
AR497. He stated, “She is almost smiling.” AR497.
January 12, 2010, Ms. Wyman contacted the clinic to request
samples of Cymbalta because she did not have insurance or any
Wyman was seen on March 8, 2010, and she reported that she
continued to have some suicidal ideation, lethargy and
insomnia. AR694-95. Her mental status exam was again recorded
as normal, but her Cymbalta dosage was increased to see if
symptoms improved. AR695. Dr. Ridder stated that Mr. Wyman
“does look better than I have seen her for quite a
while.” AR695. He described Ms. Wyman as alert,
oriented, and having normal mood and thought content. AR695.
Wyman contacted the clinic on March 25, 2010, and requested
that her Cymbalta dosage be increased because the current
dosage was not helping much and asked for something to help
her sleep because Benadryl and melatonin were not helping.
AR529. Her Cymbalta dosage was increased and Ambien
prescribed for sleep. AR530. Ms. Wyman reported improved
symptoms after adding Abilify on April 15, 2010. AR538.
Wyman was seen on May 26, 2010, for complaints of bilateral
leg pain from hips down. AR691. She said that she had
arthralgia/fibromyalgia for several years and her pain was in
all extremities especially in the legs the last few weeks.
AR691. Her diagnoses at that time included depression,
fibromyalgia, borderline personality disorder, PTSD,
migraine, GERD, and insomnia. AR691. Ms. Wyman said she had
had tenderness and limited range of motion
(“ROM”) of both knees on exam. AR691. Ms.
Wyman's back had good flexion and extension, a normal
range of motion, and some mild diffuse tenderness. AR691.
Wyman was seen on September 30, 2010, for depressive
symptoms, which included depressed mood, agitation,
anhedonia, anxiety, diminished interest in activities,
diminished concentration, fatigue, feelings of worthlessness,
insomnia, recurrent thoughts of death, suicidal thoughts with
a specific plan, and weight gain. AR689. She had stopped
taking Abilify because of side effects. AR689. Her mental
status exam was again recorded as normal; she was alert and
oriented, with normal thought content, speech, affect, and
mood. AR690. Dr. Ridder stated that Ms. Wyman had no pain,
redness, or swelling in her joints. AR689. Dr. Ridder
observed, “she seems to [sic] pleasant to be either
suicidal seriously and is not
convincing that she is ready to go soon to do anything about
it.” AR690. She was referred for both psychiatric and
psychological consults, and urged to present herself to
Behavioral Health Services immediately due to her suicidal
Wyman was seen on March 29, 2011, for follow-up on weight
concerns and right knee pain. AR685. Knee exam revealed
antalgic gait, tenderness, mild effusion, reduced ROM, and
positive Lachman sign. AR686. An x-ray was unremarkable and a
prednisone injection was given. AR686. Following the
injection, her knee had been somewhat better, but was
starting to bother her again by April 28, 2011. AR684.
Wyman was seen on October 2, 2012, for follow-up on her
fibromyalgia and depressive symptoms. AR652. She reported
depressed mood, agitation, fatigue, insomnia, headaches with
neck stiffness and some chest discomfort with stress and
trigger point pain. AR652. Dr. Ridder's notes stated,
“Teresa notes mild generalized fatigue, somewhat
chronic. There's been no weight loss or fever or other
localizing symptoms. Exam shows no specific findings to
suggest a clear cause.” AR652. Ms. Wyman's
musculoskeletal exam showed no pain, redness or swelling on
the joints and her neurologic exam showed no chronic
headaches or neurological abnormalities. AR652-53. Her
extremities were normal. AR652. Her pain was generalized pain
scattered about her trunk and extremities. AR652. Her
medications were adjusted and it was felt her symptoms were
likely related to her fibromyalgia. AR653. Ms. Wyman
contacted the clinic a few days later due to her pain and
asked about Neurontin or Lyrica. AR650. She was referred to
the rheumatology clinic. AR646.
Wyman contacted the clinic on June 3, 2013, regarding a
migraine and was prescribed Imitrex. AR631.
Wyman contacted the clinic on September 19, 2013, complaining
of low back pain, fatigue and nausea and vomiting. AR603.
Examination showed abdominal tenderness and no CVA tenderness
“other than her usual with her fibro.” AR603. Dr.
Ridder noted that “Reviewed her meds and she is not the
greatest at contin [sic] to take them.” AR603.
Wyman was seen by Dr. Jensen on November 19, 2013, to
follow-up her pyelonephritis and reported right knee pain,
fever and nausea, chronic fatigue, increased migraines and
fibromyalgia. AR597. Dr. Jensen increased her Tramadol dosage
and recommended an increased dosage of Neurotin, but Ms.
Wyman refused the increased Neurontin due to problems with
weight gain. AR598. Dr. Jensen noted her mental status as
depressed mood, and Ms. Wyman's PHQ-9 score was 25, which
was in the severe depression range. AR596-97. When seen three
days later, Ms. Wyman still reported pain and pressure in the
left flank, but was much better, which she attributed to the
Wyman saw Dr. Jensen on February 11, 2014, for her
fibromyalgia and Ms. Wyman noted worsening symptoms since
running out of Neurontin. AR581. She said her pain was also
worse with exertion, stress, lack of sleep, and weather
changes. AR581. Her Tramadol was stopped and cyclobenzaprine
added by Dr. Jensen. AR582.
5, 2014, Ms. Wyman contacted the clinic to refill her Imitrex
prescription, and had it refilled again on August 15, 2014.
AR561, 567. She was seen on June 13, 2014, for her
fibromyalgia and reported chronic generalized pain, fatigue,
sleep/mood disturbances, headaches, IBS, multiple tender
points with her pain worse with exertion, stress, lack of
sleep or weather changes. AR566. Dr. Jensen characterized
these as classic fibromyalgia symptoms. AR566. Her Flexeril
was discontinued and Neurontin dosage was doubled. AR567.
Following her appointment with Dr. Jensen, she met with a
nurse to address weight loss. AR565. Her weight at that time
was around 255 pounds. AR565.
Wyman was seen on July 1, 2014, for tension headaches along
with sinus pressure and drainage she said had been continuing
for several days. AR564. She had purulent drainage, a sore
throat, and a productive cough. AR564. Dr. Jensen diagnosed
sinusitis and prescribed antibiotics. Dr. Jensen also
“heartily congratulated” Ms. Wyman on an
excellent job with lifestyle changes and successful
management of her medical condition. AR564.
Wyman contacted the clinic on July 9, 2014, about a
medication she needed and was described as crying and stating
she was suicidal. AR563. Ms. Wyman reported that she was
“going through withdrawal” and was out of
Wyman contacted the clinic on September 29, 2014, after being
seen in the Brookings Orthopedic clinic and requested a
referral for a knee brace. AR559.
Wyman was seen on November 11, 2014, to follow-up on her
ruptured ovarian cyst and left lower quadrant pain. AR818.
She said she had pain, chronically loose stools, and nausea
and fevers. AR818. An abdominal CT scan showed degenerative
spurring of the spine, and no gastric abnormalities, but did
show evidence of a ruptured cyst. AR819. Dr. Jensen felt the
ovarian cyst to be the cause of her abdominal pain. AR820.
Wyman's physical therapy notes from November 5, 2014,
stated that Ms. Wyman has been progressing well in physical
therapy despite four missed appointments due to illness and
other health issues. AR821. She had normal gait patterns, a
normal range of motion in her right knee, and an easier time
climbing stairs. AR821.
Wyman was seen on November 18, 2014, to follow-up on her
ruptured ovarian cyst with ongoing symptoms including pain,
fatigue, nausea, and chronic constipation. AR816. She also
complained of tension in her neck and more frequent
migraines. AR816. Ms. Wyman also continued to have physical
therapy on her knee in November and December. AR816. Her
physical therapy ended on December 8, 2014, when she
cancelled her future appointments because she said that she
kept injuring herself and was in too much pain to continue
with therapy. AR811.
Jensen referred Ms. Wyman for physical therapy beginning
January 20, 2015, due to neck pain and chronic headaches.
AR805. The physical therapist's subjective history noted
a long history of neck pain, headaches, and fibromyalgia
limiting her activities of daily living and ability to work,
but previously she had been able to do housework and
self-care independently. AR805-06. Ms. Wyman reported that
typically she got headaches three times per week, and
numbness and tingling in her hands, right more than left,
especially when waking in the morning. AR806. The physical
therapist's examination revealed limited hip ROM,
positive adduction drop tests bilaterally, limited cervical
rotation to the left, tenderness over the neck, and that she
was very hypermobile. AR806.
Jensen saw Ms. Wyman on July 10, 2015, for follow up after
her inpatient psychiatric treatment at Avera for suicidal
ideation. AR992. Dr. Jensen's note stated, “Patient
had suicidal ideation but is improving with depression and
fatigue since discharge.” AR992. Dr. Jensen's
diagnosis was depression with suicidal ideation. AR992.
Wyman was seen on November 10, 2015, for follow up on her
right knee and medications. AR997. She had been in physical
therapy for her knee from July 24, 2015, through August 21,
2015, having two therapy sessions. AR914-17.
Wyman's migraine medication, Imitrex, was refilled on
February 12, 2016. AR1064. In addition to the Imitrex, Ms.
Wyman's medications at that time included Wellbutrin,
Zoloft, Vyvanse, Ultram, Trazodone, Tylenol, Neurontin,
Celebrex, Zofran, Prilosec, and Ibuprofen. AR1065-66.
Wyman's migraine medication, Imitrex, was refilled again
on April 7, 2016, and again on May 3, 2016. AR1147, 1167.
Wyman saw Dr. Jensen on May 10, 2016, for follow up on her
fibromyalgia and had ongoing symptoms of chronic generalized
pain, fatigue, sleep/mood disturbances, headaches, IBS, and
tender points. AR1172. She reported taking Tramadol at
greater than the prescribed dosage due to pain, that Celebrex
was making her sleepy, and that she was taking the maximum
dosage of Neurotin, which was giving her dry mouth. AR1172.
Ms. Wyman said her pain was worse with exertion, stress, lack
of sleep and weather changes, and Dr. Jensen wrote that her
history was not suggestive of other disorders such as
rheumatoid arthritis, osteoarthritis, or systemic lupus
erythematosus (“SLE”). AR1172. Ms. Wyman's
mental status was normal, as were her extremities. AR1174.
Celebrex was discontinued and Flexeril prescribed, as well as
either Tylenol 650 mg q.i.d. or Tramadol 75 mg q.i.d. AR1175.
September 6, 2016, after the ALJ's decision, but before
the Appeals Council review, Ms. Wyman's treating
physician, Dr. Jensen, wrote a letter regarding Ms.
Wyman's condition and stated Ms. Wyman had been unable to
work the last six years due to her medical problems including
fibromyalgia, borderline personality disorder, PTSD,
migraines, GERD, insomnia, obesity, anxiety, major depressive
disorder, recurrent, chronic pelvic pain, urinary urgency,
and chronic constipation. AR19. Dr. Jensen stated that the
letter was to confirm that Ms. Wyman's medical status had
not changed and that she continued to recommend against
working outside the home. See page two of Dr.
Jensen's letter attached to Ms. Wyman's brief at
Docket No. 18. The letter included in the original transcript
was notated as page one of two, but the transcript provided
by SSA is missing the second page of the September letter,
which shows as a blank page. AR20.
October 14, 2016, Ms. Wyman's treating physician, Dr.
Jensen, wrote a second letter regarding Ms. Wyman's
condition and stated that Ms. Wyman had been a patient of
hers for three years and due to the complexity of Ms.
Wyman's conditions (again listing the same diagnoses as
listed in the September 6, 2016, letter) and chronicity of
her pain, Dr. Jensen did not recommend that Ms. Wyman work at
this time. AR17.
Sanford Orthopedics & Sports Medicine Clinic:
Reynen saw Ms. Wyman for right knee pain on February 21,
2012, at the orthopedic clinic. AR672, 674. Exam revealed Ms.
Wyman's knee was quite large with tenderness, significant
crepitus, and McMurray's testing caused significant
discomfort. AR674. X-rays were essentially normal. AR674. An
MRI was obtained which revealed prominent changes of
osteoarthritis. A knee scope and debridement surgery was
planned. AR671, 732. Paul Reynen, M.D., performed the surgery
and his postoperative diagnosis was articular surface
degeneration of patellofemoral joint and medial compartment.
Reynen saw Ms. Wyman on August 1, 2012, for follow up on Ms.
Wyman's right knee. AR657. She reported being pain free
at the exam, but she stated that the pain increased to 7/10
if she was on her knee too much or if it was bent or straight
too long. Id. Exam confirmed crepitus and physical
therapy was ordered. Id.
Wyman was seen at the Brookings Orthopedic clinic on February
3, 2014, for complaints of right knee pain worse with
extended standing or stairs, and she reported she had three
falls in the last 17 months. AR584. X-rays revealed
significant medial joint space narrowing of the right knee.
AR584, 705. The impression was significant internal
derangement with crepitance of the right knee and an MRI was
ordered. AR584. The MRI revealed moderate medial compartment
arthritis with high-grade cartilage irregularity, and
additional irregularities, but no stress fracture or dead
bone and the knee arthroscopy surgery was planned. AR581,
Wyman was seen at the Brookings Orthopedic clinic on
September 29, 2014, and reported that following her
debridement surgery the prior Spring, her knee had been doing
reasonably well until her knee was struck by a bike, and had
then gotten progressively worse. AR558. Dr. Reynen's exam
revealed discomfort with ROM testing, and tenderness. AR558.
X-rays revealed degenerative changes bilateral knees with
moderate to marked medial joint space narrowing on the right
and mild narrowing on the left. AR700. Spurring was also
noted with the predominant finding of osteoarthritis. AR700.
Physical therapy and a knee sleeve were planned and the knee
was injected with Kenalog and Marcaine. AR558, 827-29.
(October 13, 2014, initial physical therapy evaluation -
rehabilitation potential was fair).
Wyman was seen on December 10, 2015, for right knee pain by
PA Krempges and orthopedist, Chad Kurtenbach, M.D. AR1000,
1002. The PA's examination revealed trace effusion and
tenderness. AR1000. X-rays were obtained and the PA's
impression was bilateral degenerative joint disease right
greater than left, and he recommended conservative treatment
including activity modification, rest, anti-inflammatories,
physical therapy, knee brace, and periodic injections.
AR1001-02. The PA discussed knee replacement with Ms. Wyman
but stated that at her young age, additional replacement
would likely be needed in the future. AR1001. Dr. Kurtenbach
also performed an exam and reviewed the x-ray which revealed
osteoarthritis bilaterally, most significant on the right
knee, and he also discussed treatment options and recommended
conservative treatment including activity modification, rest,
anti-inflammatories, physical therapy, and periodic
injections. AR1002. Dr. Kurtenbach also discussed surgical
knee replacement and noted it was complicated by Ms.
Wyman's young age. AR1002.
Wyman was seen on January 20, 2016, by Dr. Bechtold for right
knee pain. AR1017. She reported swelling, pain at rest and
worse pain with use such as prolonged standing and stairs,
and that her knee pain limited her daily activities. AR1018.
She was quite anxious during the exam and somewhat
hypersensitive to palpation about the knee and ROM, and had
some varus alignment and thrust ambulation, and grinding,
clicking and locking symptoms were present. AR1017. The exam
also revealed swelling, joint tenderness, and positive
McMurray's test and positive crepitation tests. AR1019.
Dr. Bechtold recommended conservative care and discussed a
stationary bike, an elliptical machine, or pool therapy as
excellent exercises to do to relieve joint stress. AR1019-20.
He also recommended Stepping Up To Wellness to help with
weight reduction and improve mobility. AR1020. A total knee
replacement was discussed, but Dr. Bechtold noted that Ms.
Wyman's multiple comorbidities make her highly at risk
for uncertain outcome, and another injection was recommended
and administered. AR1017-18. He stated he would “try to
give her tools to improve her status, but she will definitely
need to take ownership on her own largely.” AR1017. Ms.
Wyman reported on February 6, 2016, that the injection helped
a lot for the first week or so, but her right knee had
started hurting again. AR1039.
March, 2016, Carl Bechtold, M.D., saw Ms. Wyman for
complaints of right knee pain that she claimed prevented her
from walking to her living room from her bathroom or kitchen.
AR1094. He was concerned about her request for knee surgery
because he thought her psychiatric issues and fibromyalgia
were known risk factors for a poor outcome. AR1095. He
characterized Ms. Wyman as “catastrophizing” with
regard to her knee, and he opined that her described pain
severity and dysfunction were not consistent with her amount
of arthritis. AR1095. Ms. Wyman reported her prior injection
helped for about a week and a half, but now she was doing
“horrible” and could not even walk around her
house due to pain. AR1094. Examination by Dr. Bechtold
revealed tearful and anxious affect, very antalgic gait with
a pronounced limp, tenderness to fairly gentle palpation of
the knee, intact but painful strength, but good ROM.
AR1094-95. Dr. Bechtold discussed a total knee replacement,
but stated she had a number of red flags for a poor outcome
including her psychiatric issues and fibromyalgia. AR1095.
Ms. Wyman was very frustrated and crying, and an MRI was
ordered. AR1095. In March, 2016, Matthew Hayes, M.D., stated
the MRI of Ms. Wyman's right knee showed mild to moderate
chondromalacia, small effusion, mild synovitis, tiny debris
in the joint space, mild tendinopathy without tear, and
minimal inflammation. AR1112. Dr. Hayes also stated the MRI
revealed advanced medial compartment chondromalacia with mild
stress changes in the femur, peripheral extrusion of the
meniscus with fraying of the posterior horn/root without
definite acute intrameniscal tear, and mild/moderate
patellofemoral chondromalacia. AR1112. Dr. Bechtold
recommended continued conservative management and the
Stepping Up To Wellness program. AR1118. On March 18, 2016,
Dr. Bechtold stated he saw no new findings to explain the
severity of her pain. AR1118.
Sanford Rheumatology Clinic
Wyman was seen on October 18, 2012, for her fibromyalgia by
rheumatologist, Justina Tseng, M.D. AR646. Exam revealed
tender points bilaterally in the trapezius, elbow, gluteal,
knee distribution and positive anserine bursitis. AR649. Dr.
Tseng's assessment was generalized myalgias, headaches,
tender points, IBS symptoms, and fatigue consistent with
fibromyalgia. AR650. Exercise, sleep hygiene, and stress
management were recommended for her fibromyalgia. AR650.
Wyman was treated in the emergency room for a severe migraine
with vomiting on March 27, 2009. AR389. She stated that she
was getting the headaches monthly. AR389.
Wyman was treated in the emergency room for a migraine, which
was described as recurrent problem on July 5, 2009. AR386.
Wyman contacted the hospital on July 28, 2013, and reported
pain all over her body with painful joints and muscles and
neck pain, causing headache. AR628. She was told to go to the
emergency room. AR629. Ms. Wyman presented to the hospital
and was admitted with a fever and body aches, headache and
shortness of breath. AR612. She was diagnosed with left
pyelonephritis, treated with Levaquin and discharged on July
30, 2013. AR615, 620, 624. Ms. Wyman returned to the
emergency room on August 1, 2013, due to chest symptoms.
AR610. She was diagnosed with atypical chest pain and told to
follow up with her physician. AR611.
Wyman presented to the hospital on October 29, 2013, and was