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Heintz v. Berryhill

United States District Court, D. Idaho

March 29, 2019

DAMON HEINTZ, Petitioner,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security Administration, Respondent.

          MEMORANDUM DECISION AND ORDER

          HONORABLE CANDY W. DALE, UNITED STATES MAGISTRATE JUDGE

         INTRODUCTION

         Currently pending before the Court is Damon Heintz's Petition for Review of the Respondent's denial of social security benefits, filed on November 1, 2017. (Dkt. 1.) The Court has reviewed the Petition for Review and the Answer, the parties' memoranda, and the administrative record (AR), and for the reasons that follow, will reverse the ALJ's determination and remand the decision of the Commissioner for consideration of an award of benefits.

         PROCEDURAL AND FACTUAL HISTORY

         Petitioner filed an application for a period of disability and disability insurance benefits under Title II, and a second application under Title XVI for supplemental security income, on August 4, 2014. These applications were denied initially and on reconsideration, and a hearing was conducted on November 10, 2016, before Administrative Law Judge (ALJ) David Willis. The ALJ heard testimony from Petitioner, medical expert Ronald Halston, Ph.D., and a vocational expert. The ALJ conducted a supplemental hearing on June 20, 2017. He heard testimony at that time from Petitioner, medical expert Dawn Crosson, Psy.D., and a second vocational expert. ALJ Willis issued a decision on July 28, 2017, finding Petitioner not disabled.

         Petitioner timely requested review by the Appeals Council, which denied his request for review on September 21, 2017. Petitioner appealed this final decision to the Court. The Court has jurisdiction to review the ALJ's decision pursuant to 42 U.S.C. § 405(g).

         At the time of the alleged amended disability onset date of April 1, 2013, Petitioner was thirty-seven years of age. Petitioner obtained a high school education, [1] and his past relevant work experience includes work as a law enforcement officer, fence and deck fabricator supervisor, and bicycle mechanic. (AR 333, 334.)

         Petitioner reported a history of head trauma. He stated that he previously trained, taught, and fought full contact mixed martial arts and combative defensive tactics. (AR 382.) He also sustained head trauma as a result of multiple vehicle accidents. In 2008, Petitioner was involved in an ATV rollover accident in which a close friend died as a result of the injuries he received. (AR 756.) Petitioner reported being injured in several vehicle and motorcycle accidents that occurred in March, April, and October of 2013. (AR 56, 756, 1126.) At the hearing, Petitioner's representative proposed an amended disability onset date to reflect that Petitioner's mental impairments worsened due to two motor vehicle accidents that occurred in March and April of 2013. (AR 56.) The ALJ agreed, and the disability onset date was amended to April 1, 2013. (AR 56.)

         Petitioner's medical records date back to January 13, 2010, when Petitioner sought care for cervical, thoracic, and low back pain with lower extremity radiation of symptoms, which Petitioner reported were ongoing since a February 2008 ATV accident. (AR 719.) Diagnostic imaging tests revealed degenerative changes of the cervical spine, and mild degenerative change of the lumbosacral spine. (AR 724 -728.) Petitioner reported also suffering from anxiety after the 2008 accident, because he had witnessed his friend's death before paramedics arrived at the accident scene. (AR 724.)

         After the motor vehicle and motorcycle accidents in 2013, Petitioner began complaining of new onset neck pain with radiculopathy, thoracic pain, and low back pain with radiculopathy. (AR 1126.) He sought treatment on November 12, 2013, from the Nevada Comprehensive Pain Center. (AR 1126-1130.)[2] Diagnostic imaging tests revealed mild right foraminal narrowing at ¶ 5-C6, and decreased disc signal and disc height, with moderate foraminal narrowing at ¶ 6-C7; and a normal brain CT. (AR 1136.) An MRI of the brain performed on November 29, 2013, was negative for any abnormality. (AR 797.) He was prescribed Norco and Ibuprofen for pain. (AR 1131.) He was diagnosed also with posttraumatic stress disorder as a result of the 2008 ATV accident. (Id.).

         On January 26, 2014, Petitioner discussed the results of his cervical MRI with health care providers during a visit at the Nevada Comprehensive Pain Center. (AR 1135.) Examination results revealed tenderness to palpitation in his neck, thoracic spine, and lumbar spine, with decreased range of motion in his cervical and lumbar spine. (AR 1137.) Petitioner was diagnosed with cervical facet syndrome, thoracic facet syndrome, lumber facet syndrome, cervical radiculitis/radiculopathy, and thoracic/lumber radiculitis/radiculopathy. (AR 1137.)

         Thereafter, Petitioner moved to Idaho, and established care on March 4, 2014, with Michael Eastman, PA-C, at the Saint Alphonsus Pain Management Center. (AR 788.) Dr. Eastman ordered additional imaging studies at that time. (AR 799-801.) A cervical MRI revealed spondylitic ridging at the C6-C7 level, resulting in mild canal stenosis and mild/moderate bilateral foraminal stenosis with possible mass effect on the existing bilateral C7 roots. (AR 799.) Dr. Eastman referred Petitioner to Helen Holley, Ph.D., for evaluation and treatment of his anxiety and PTSD. (AR 756, 790.)

         At his initial visit with Dr. Holley on March 27, 2014, Petitioner reported that, as a result of his more recent motor vehicle accidents in 2013, he experienced an increase in seizures, nightmares, short-term memory loss, and long-term retrieval difficulties, as well as irritability, insomnia and difficulty concentrating. (AR 784.) Dr. Holley's assessment included a diagnosis of posttraumatic stress disorder, with a history of traumatic brain injury with subsequent seizure disorder, chronic low back pain with radicular symptoms, and degenerative disc disease of the cervical spine. (AR 786.) Dr. Holley treated Petitioner on June 16, July 14, August 11, September 3, and September 30, 2014. (AR 756 - 784, 890.)

         On April 17, 2014, physical therapist Shaun Murphy evaluated Petitioner for his left sided neck pain, radicular symptoms, mid back and low back pain. (AR 938.) Petitioner reported an increase in seizure activity after a motor vehicle accident on October 18, 2013, and an increase in pain along his left side, which included his neck, trunk, arm and leg. (AR 938.) Murphy's examination noted guarded posturing, pain produced in Petitioner's left upper extremity, and diminished sensation along the left side of Petitioner's body. (AR 939.) Murphy noted also that Petitioner had decreased sensation and numbness on the left side of his body from his neck to his lower extremities. (AR 939.)

         Petitioner also saw psychiatrist Jeremy Handy for an initial diagnostic evaluation on June 11, 2014, upon referral from Dr. Holley. (AR 743, 918.) Petitioner reported difficulty sleeping and concentrating, and an increase in anxiety symptoms. (AR 743.) Dr. Handy diagnosed major depressive disorder, posttraumatic stress disorder, centralized anxiety disorder, and attention deficit hyperactivity disorder (ADHD), noting a history of chronic pain, seizures, and head injury. (AR 745.) Dr. Handy began treatment of Petitioner's psychiatric symptoms with medication.

         On June 24, 2014, Petitioner presented to the emergency room seeking a referral to a neurologist for treatment of his seizures, and to a primary care physician. (AR 735.) Petitioner was seen and evaluated, and referred for follow up care. (AR 735.)

         Petitioner's second visit with Dr. Handy occurred on July 9, 2014. (AR 904.) Petitioner stated that his ADHD symptoms had improved with Adderall, but that he had a “couple seizures in the past month.” Petitioner stated that he did not lose consciousness, but that he “blanked out” or had jerking motions over part of his body. (AR 904.) Dr. Handy noted that Petitioner's wife drove him everywhere because of his seizures. (AR 904.) Petitioner reported his depression had improved, and that he had been sleeping better since taking Xanax. Upon examination, Dr. Handy noted Petitioner had no abnormal motor movements, normal gait and station, stable affect, and his speech exhibited a regular rate and volume. (AR 905.)

         At his third visit with Dr. Handy on September 3, 2014, Petitioner reported that the prescribed medications helped alleviate his symptoms of anxiety and depression, as well as improved his PTSD symptoms and insomnia. (AR 747.) However, Petitioner reported that, with the medication, he had experienced several seizures, where he blacked out and had jerking motions over parts of his body. (AR 749.) Petitioner also experienced dizziness, which Dr. Handy observed during the appointment. (AR 902.)

         On September 5, 2014, Petitioner sought care from Certified Nurse Practitioner Kelly Whitehead-Price for a preventative exam. (AR 872.) Petitioner's chief complaint was pain, reported as eight out of ten on the numeric pain intensity scale. Examination findings were noted as normal. (AR 874.) Whitehead-Price recommended pressure point injections to address Petitioner's pain. (AR 872.)

         Petitioner was referred to Dr. James Redshaw at Idaho Neurology, who examined Petitioner on September 19, 2014, and evaluated Petitioner's seizure complaints. (AR 814.) Petitioner's wife reported witnessing the seizures, which involved motor convulsions and loss of awareness, and a postictal phase accompanied by confusion and speech disturbance. (AR 814.) An EEG performed on September 17, 2014, and discussed with Petitioner at his September 19, 2014 visit with Dr. Redshaw, demonstrated right central parietal dysrhythmia at the C4/P4 region. The features were nonspecific and nondiagnostic. (AR 814, 846.) Dr. Redshaw noted that Petitioner's witnessed seizure events reported by his wife were in keeping with a history of complex partial seizures. (AR 815.) Dr. Redshaw prescribed Dilantin, an anticonvulsant medication. (AR 815.)

         On October 1, 2014, Petitioner followed up with Dr. Handy. (AR 900.) Dr. Handy noted that he had increased Petitioner's ADHD medication since his last appointment on September 3, 2014, and Petitioner reported his depression and anxiety symptoms had improved. Petitioner stated also that he had been working on his car in the evenings. (AR 900.) Dr. Handy noted Petitioner walked with a normal gait, had no abnormal motor movements, and his affect was stable. (AR 900.)

         On October 3, 2014, Petitioner followed up with Whitehead-Price for his chronic pain, reporting that he had an acute spasm of his upper neck and shoulders after working on his truck. (AR 866.) Exam findings revealed trapezius muscle spasm, while laboratory results revealed anemia. (AR 869, 874.)

         On November 3, 2014, Petitioner reported to Whitehead-Price that he experienced increased back pain after working on a car and breaking a torque wrench while trying to loosen a nut. (AR 860.) He reported also less extreme bladder urgency, but worsening pain. Upon examination, Whitehead-Price noted Petitioner had an antalgic gait, painful lumbar range of motion, and appropriate mood and affect. (AR 860 - 863.)

         On November 3, 2014, Petitioner saw Michael Eastman, PA-C, [3] complaining of increased pain from the colder weather and exacerbation of his pain after rebuilding the fuel pump and gas system on his vehicle. (AR 887.) Petitioner had a positive test for alcohol, and admitted to Eastman that he had been taking his pain pills more often than as prescribed. (AR 888.) Helen Holley, Ph.D., who appears to have been Eastman's supervisor, signed the progress note that day as well. (AR 886.) On November 14, 2014, Petitioner received trigger point injections for his pain from Dr. Patrick Farrell. (AR 885.)

         On December 1, 2014, Petitioner sought follow up care for pain management and seizures from Whitehead-Price. (AR 855.) Petitioner reported to Whitehead-Price that his pain and mental health symptoms were better controlled, but that his absence type seizures[4] were increasing in frequency and the postictal period was lengthening.

         Petitioner was taken to the Saint Alphonsus Regional Medical Center emergency department on December 5, 2014, by his sister and his wife, after he had awaken feeling shaky, dizzy, and agitated. (AR 838.) The emergency room physician noted no generalized seizure activity, and his impression was that Petitioner's symptoms were related to anxiety and stress. Follow up with neurologist Dr. Redshaw was recommended. (AR 839.)

         At a follow up appointment with Dr. Redshaw on December 9, 2014, Petitioner's wife reported he continued to have “spells, ” with tonic shaking of his limbs. (AR 826.) Upon examination, Dr. Redshaw noted Petitioner was unsteady on his feet. (AR 826.) Because of Petitioner's reported recurrent seizure events, Dr. Redshaw ordered a 48-hour home EEG ambulatory study. (AR 826.)

         On December 21, 2014, Petitioner visited the Saint Alphonsus Regional Medical Center emergency room after a fall while walking his dog. (AR 832.) He reported symptoms of headache, and pain in his cervical, thoracic, and lumbar spine. (AR 832.) Examination revealed diffuse tenderness overlying the cervical, thoracic and lumbar spine. (AR 832.) Imaging studies obtained in the emergency department did not show evidence of a fracture, and a head CT was normal. (AR 834 - 837.)

         After his emergency room visit, Petitioner followed up with Whitehead-Price on December 23, 2014, complaining of chest pain and a non-productive cough. (AR 851, 1007.) Whitehead-Price's orders included a note to research treatment options “given PTSD status patient.” (AR 854.)

         Petitioner returned to see psychiatrist Dr. Handy for a three month follow up appointment on January 7, 2015. (AR 907.) After his last appointment, Dr. Handy noted Petitioner had called the office and reported an increase in anxiety symptoms. During the appointment, Petitioner reported increased PTSD symptoms, difficulties with and an increase in his seizure activity, mental fatigue, drowsiness, and difficulty with clear thoughts and clear speech. Dr. Handy observed during the appointment that, “I have never seen him in this condition where he is dizzy when he is walking, his speech is slow, slightly slurred.” (AR 907.) Dr. Handy adjusted Petitioner's medications, concerned that the effects of Xanax, Oxycodone, Soma, and Dilantin may be having additive effects and causing “foggy brain.” (AR 907.) Dr. Handy noted Petitioner had mild confusion, did not answer questions all the time appropriately, and paused before answering questions, all of which was abnormal. (AR 908.)

         On January 19, 2015, Petitioner sought follow-up care from Whitehead-Price for pneumonia and continued chest pain. (AR 1001.) Petitioner complained of shortness of breath. However, a chest x-ray revealed no abnormalities. (AR 1016.)

         The 48-hour EEG study Dr. Redshaw ordered was performed between January 20 and 25, 2015. (AR 1104.) Although no epileptiform activity was recorded, Petitioner had one clinical event with a total of three combined push button events. (AR 1104.) He was described during the clinical event as “sobbing uncontrollably, body shaking, unable to communicate, difficulty with breathing [and] confused mental status. He was disoriented.” The features were consistent with a nonepileptic event. (AR 962, 1104.)[5]

         Dr. Redshaw's impression of the EEG results was that Petitioner's clinical events appeared to be nonepileptic, and most consistent with a conversion disorder or, less likely, a somatoform disorder. (AR 962.) Dr. Redshaw suspected also that Petitioner exhibited multiple elements of secondary gain. (AR 962.) However, Dr. Redshaw noted that care would focus on continued work with a psychologist to identify the underlying trigger for Petitioner's clinical events and presentation. (AR 962.)

         On January 27, 2015, Whitehead-Price examined Petitioner at his follow-up appointment. Petitioner was complaining of pain in his back and neck, as well as symptoms of pneumonia. (AR 997.) Whitehead-Price continued Petitioner's pain medications.

         At Petitioner's next visit with psychiatrist Dr. Handy on February 18, 2015, the psychiatrist noted Petitioner looked much improved from his prior visit on January 7, 2015. (AR 925.) Dr. Handy noted Petitioner appeared clear minded, healthy, and with good energy. Petitioner reported he continued to experience a lot of anxiety, frequent panic attacks and nightmares. Dr. Handy's mental status examination noted Petitioner had a normal gait and station, no abnormal motor movements, and exhibited a depressed and anxious mood. (AR 926.) Dr. Handy noted also that Petitioner paused in his speech, and had to think about what he was saying, or he could not get the words out, and he noted observing some thought blocking. (AR 926.) Dr. Handy adjusted Petitioner's medication. (AR 927.)

         On February 23, 2015, Petitioner saw Whitehead-Price for a follow-up appointment. (AR 989.) Petitioner reported an increase in his seizures. Petitioner was thought also to be suffering from pneumonia. However, a chest x-ray did not yield abnormal results. (AR 1015.)

         A March 17, 2015 brain MRI without and with intravenous contrast revealed no evidence of an acute intracranial abnormality. (AR 1014.)

         On April 13, 2015, Petitioner saw Jason Gage, Ph.D., for a neuropsychological consultative evaluation to assist with differential diagnosis and treatment recommendations. (AR 942.) Petitioner reported decreased functioning over the past year, with episodes of wandering off, poor coordination, tremors, staring spells, and difficulty with balance and word finding. (AR 948.) At that time, Dr. Gage's diagnosis was “posttraumatic stress disorder and rule out conversion disorder as well as neurocognitive disorders.” (AR 960.) Petitioner would see Dr. Gage several more times, on April 30, May 18, and May 19, 2015, to complete all neuropsychological testing before Dr. Gage dictated a full neuropsychological evaluation report. (AR 942.) Petitioner was accompanied by his wife to all of his appointment with Dr. Gage.

         Later on April 13, 2015, Petitioner saw Dr. Holley for supportive psychotherapy and behavior coping. (AR 1062.) This was his first session with Dr. Holley since December 30, 2014. (AR 1063, 1066.) Petitioner reported having more frequent seizures, which had been videotaped by his wife and which Dr. Holley watched during the session. (AR 1063.) Dr. Holley discussed Dr. Gage's most recent neurological evaluation with Petitioner, and “noted possible conversion disorder as a rule out based on findings.” (AR 1063.) Upon examination, Dr. Holley noted frequent pain behaviors and bilateral hand tremors. She noted also that Petitioner appeared agitated, and that his thought content showed somatic preoccupation and helplessness. (AR 1063.)

         On April 22, 2015, Petitioner saw psychiatrist Dr. James Piktel for an intake appointment upon referral from Dr. Handy.[6] (AR 922.) Dr. Piktel noted “a lot of thought blocking, ” but that Petitioner appeared to be an accurate historian. The chief complaints noted were posttraumatic stress disorder, major depressive disorder, generalized anxiety disorder, ADHD, and chronic pain in the context of traumatic brain injury. (AR 922.) Dr. Piktel's mental status examination noted that Petitioner's speech was articulate, but not coherent, with latency and thought blocking. (AR 923.) Dr. Piktel's assessment was that Petitioner met “the criteria for cognitive disorder not otherwise specified at this juncture, ” based upon a history of traumatic brain injury; posttraumatic stress disorder; major depressive disorder; and generalized anxiety disorder. (AR 923.)

         Whitehead-Price examined Petitioner on April 30, 2015, for a pain management follow-up. (AR 985.) Petitioner described his pain at level eight out of ten. (AR 986.)

         On May 10, 2015, Petitioner sought treatment at the emergency department complaining of worsening back pain radiating from below the base of his skull and down his back and left leg. (AR 1030, 1089.) Petitioner reported difficulty walking and urinary incontinence. (AR 1030.) The emergency department notes document Petitioner's history of traumatic brain injury with residual cognitive deficits. Examination revealed tenderness to the left cervical area and lower thoracic spine. (AR 1032, 1038.) The emergency department discharged Petitioner with a recommendation to follow up with his primary care provider.

         At his follow-up appointment on May 12, 2015, Whitehead-Price noted Petitioner was complaining of pain, and was tender to the touch at his left upper extremity. (AR 980, 982.) Petitioner stated he was awaiting the results of his neuropsychological testing. Whitehead-Price noted that Petitioner continued to exhibit symptoms of delayed communication, and reported episodes of “spacing out.” (AR 980.) Petitioner also reported urinary incontinence. (AR 980.)

         Dr. Gage completed his neuropsychological evaluation on May 19, 2015. (AR 948.) Dr. Gage reported that Petitioner appeared to pause a lot and need time to think during the testing appointments, but that his effort on testing appeared to be good. (AR 950.) Testing revealed average verbal skills, but a significant deficit in verbal memory. Petitioner showed some difficulties with visual memory, poor recognition memory, poor immediate recall, and poor delayed recall. Despite problems with other areas of memory, Petitioner showed “decent attention and working memory.” (AR 950.) Petitioner showed moderate difficulties with verbal fluency, but had good visuospatial skills and perceptual reasoning. (AR 950.)

         Dr. Gage noted Petitioner had the most difficulty with general processing speed, and scored in the first percentile with regard to fine motor dexterity and processing speed on the Grooved Pegboard Test. (AR 951.) However, Petitioner did not demonstrate difficulties with executive functioning. (AR 950.) Further, test results indicated some over reporting of symptoms on the MMPI-2 pertaining to personality and psychopathology. (AR 951.) Dr. Gage's assessment was that Petitioner's poor processing of information secondary to extreme psychological distress constituted the most likely cause of Petitioner's cognitive difficulties. He stated also that the medical findings “seem to be pointing to more of a conversion disorder or nonepileptic psychogenic seizure disorder” to explain the attacks Petitioner had been demonstrating. (AR 952.) Dr. Gage's provisional diagnosis was conversion disorder with attacks or seizures, posttraumatic stress disorder, and major depressive disorder. (AR 954.)

         Dr. Holley treated Petitioner on May 20, 2015. (AR 1058.) Petitioner reported exacerbations in anxiety and depression symptoms triggered by recent onset of daytime urinary incontinence and left side pain in his neck, arm and torso. (AR 1059.) Dr. Holley discussed also the results of Dr. Gage's neuropsychological testing with Petitioner. (AR 1059.) Mental status examination revealed no pain behaviors or hand tremors, normal posture and gait, and a calm demeanor, but she noted Petitioner's thought content showed somatic preoccupation, expectation for chronic disability, and helplessness. (AR 1059-60.) Her assessment included diagnoses of posttraumatic stress disorder, “R/O Conversion Disorder or other Somatoform Condition, ” and histrionic traits. (AR 1060.)

         On May 27, 2015, Dr. James Piktel examined Petitioner and reviewed the results of Dr. Gage's neuropsychological testing. (AR 1050.) Petitioner reported worsening sleep. Dr. Piktel remarked that, “[i]t looks like he has a hard go of it in terms of processing speed and cognitive speed but his executive functioning remains fair.” (AR 1052.) Dr. Piktel's examination revealed articulate, but not coherent, speech with some latency and thought blocking; anxious mood; and fair insight and judgment. (AR 1052.) Dr. Piktel opined Adderall may assist with processing speed. His medication regimen was continued. (AR 1052.)

         Petitioner was seen by Dr. Gage for a follow-up feedback session on June 8, 2015. (AR 966.) Dr. Gage's diagnosis was posttraumatic stress disorder; conversion disorder with attacks (provisional); and major depressive disorder, recurrent, and severe. (AR 966.)[7] Dr. Gage recommended continued psychotherapy, which treatment was limited due to Petitioner's finances. (AR 966.)

         Whitehead-Price also examined Petitioner on June 8, 2015, and discussed Petitioner's chronic conditions. Petitioner and his wife discussed his diagnosis of conversion disorder with Whitehead-Price, along with treatment options. (AR 972.)

         At his next follow-up visit on June 23, 2015, with Whitehead-Price, she indicated his current condition of “dissociative disorder or reaction, unspecified, ” was under fair control; and his cervical and back pain were under fair control. (AR 1218.) However, she noted Petitioner had fallen the week prior to his appointment with her and hit his head, which had increased his pain.

         On June 26, 2015, Dr. Piktel examined Petitioner, noting his history of PTSD, major depressive disorder, generalized anxiety, and chronic pain in the context of a traumatic brain injury. (AR 1049.) Petitioner and his wife reported plans to travel to Salt Lake City for an extended inpatient hospitalization relating to his traumatic brain injury and possible conversion disorder. (AR 1049.) Dr. Piktel noted some thought blocking, anxious mood, and fair insight and judgment. (AR 1049-50.) Dr. Piktel's assessment and impression was cognitive disorder, not otherwise specified; posttraumatic stress disorder; and generalized anxiety disorder. Petitioner's medications were continued. (AR 1050.)

         Dr. Holley saw Petitioner on June 30, 2015, for psychotherapy. (AR 1054.) Her mental status examination revealed that Petitioner presented with his therapy dog, which appeared to calm Petitioner's anxiety. (AR 1055.) Dr. Holley observed no pain behaviors or hand tremors, but noted Petitioner sweated heavily, appeared nervous, and his thought content showed ongoing somatic preoccupation, expectation for chronic disability, and helplessness. (AR 1055.) Dr. Holley's assessment included conversion disorder with depressive symptoms, posttraumatic stress disorder, and histrionic traits. (AR 1056.) The plan was to transition Petitioner into inpatient treatment for conversion disorder. (AR 1056.)

         On July 13, 2015, Petitioner suffered a ground level fall. He sought treatment at Saint Alphonsus Regional Medical Center for severe neck pain, headache, and back pain on July 14, 17, and 19, 2015. (AR 1017, 1026, 1081.) Emergency room notes from the three visits indicate that Petitioner's work-up included a CT scan of the head and neck, which revealed no acute findings. (AR 1022, 1081-84.) Petitioner reported his last seizure was six months prior, and that Dilantin had been working well for seizure management. (AR 1017.) Upon physical examination, it was noted Petitioner ambulated with a cane without difficulty, and that he experienced diffuse muscle tenderness in his back and neck, down to his shoulders bilaterally. (AR 1018.)

         At a follow-up visit on July 23, 2015, Whitehead-Price noted that Petitioner had fallen the week prior and hit his head on a concrete floor, exacerbating Petitioner's pain complaints. (AR 968, 1026.).)

         On July 30, 2015, Petitioner reported to Whitehead-Price that he was experiencing symptoms of fatigue, nausea, body aches, and tremors. (AR 1211.) He reported also being seizure free for six months. Whitehead-Price noted the presence of a cough, dyspnea, and chest pressure. (AR 1212-13.) She ordered laboratory tests and a chest x-ray. Chest x-rays revealed opacity within the medial right upper lobe, and White-head Price diagnosed pneumonia. (AR 1012.

         On August 21, 2015, Petitioner reported shortness of breath, pain when coughing, and dizziness. (AR 1205.) Whitehead-Price's physical exam notes indicated pain was reportedly at a level five out of ten on the pain scale. (AR 1205-1210.)

         After no improvement of his pneumonia symptoms, Petitioner sought additional care from Joshua Holweger, M.D. On October 8, 2015, Dr. Holweger opined that Petitioner was suffering from mild persistent asthma despite normal pulmonary function tests. (AR 1245.) Dr. Holweger noted a flat affect, intermittent eye contact, and slowed thought processing. He considered that Petitioner's conversion disorder associated with traumatic brain injury could be playing a role in Petitioner's symptoms. (AR 1245.) Dr. Holweger began treatment with inhalers. At a follow-up appointment on December 10, 2015, Petitioner reported improvement in his pneumonia symptoms after using the inhalers. (AR 1247.)

         Dr. Piktel ordered a psychiatric inpatient admission for symptoms of depression and attempted suicide on October 26, 2015. (AR 1108, 1117, 1146.) The Saint Alphonsus Behavioral Health Adult Multidisciplinary Team developed a treatment plan for Petitioner dated October 30 - 31, 2015. (AR 1105 - 1107.) The goals of the treatment plan were to decrease suicidal thinking, identify and utilize coping skills, and identify reasons to live and hope for the future. (AR 1107.) Petitioner was discharged on November 5, 2015. (AR 1108 - 1125.)

         At his outpatient therapy follow-up visit with Dr. Holley on December 10, 2015, she recorded Petitioner's recent inpatient hospitalization. (AR 1276-77.) Dr. Holley noted also that Petitioner walked with a cane and leaned on his wife for stability. He appeared agitated, but did not demonstrate pain behaviors or hand tremors. Petitioner described his mood as paranoid. (AR 1277.)

         On December 11, 2015, Whitehead-Price noted Petitioner presented with anxious and fearful thoughts and paranoia during his chronic pain management follow-up visit. (AR 1201.) Petitioner's wife reported that, although his anxiety symptoms had improved, he often accompanied her in the car and stayed in the car while she shopped, because he could not stay home alone or enter the store due to his anxiety. (AR 1201.) Whitehead-Price noted that Petitioner's gait was unstable, and he was using a cane. His right shoulder exhibited pain with range of motion. (AR 1203.) She referred Petitioner to Sarah DeBoard Marion, Ph.D., [8] at Saint Alphonsus Rehabilitation Services.

         Dr. Holley's progress note on January 15, 2016, recorded that Petitioner and his wife reported regression in Petitioner's functioning over the past month. (AR 1272-73.) Petitioner walked with the assistance of a cane. He initially appeared agitated, and demonstrated “occasional pain behaviors in his right ...


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