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Balknight v. Commissioner of Social Security

United States District Court, E.D. Michigan, Southern Division

July 31, 2019




          Patricia T. Morris, United States Magistrate Judge


         Plaintiff Yolanda Balknight challenges Defendant Commissioner of Social Security's final decision denying her claims for Title II Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI). The case was referred to me for review. (R. 17); see 28 U.S.C. § 636(b)(1)(B); E.D. Mich. LR 72.1(b)(3). For the reasons below, I conclude that substantial evidence supports the Commissioner's decision. Accordingly, I recommend DENYING Balknight's Motion for Summary Judgment, (R. 21), GRANTING the Commissioner's Motion, (R. 22), and AFFIRMING the Commissioner's final decision.

         II. REPORT

         A. Introduction and Procedural History

         This is not Balknight's first application for disability benefits. See (R. 16, Page ID.199.) Most recently, she sought DIB and SSI in 2012. (Id.) An administrative law judge (ALJ) denied her claims on December 27, 2013, and the Appeals Council declined review. (Id., Page ID.175, 199.) In 2015, this Court upheld the ALJ's decision. See Balknight v. Comm'r of Soc. Sec., No. 2:15-cv-10341, 2015 WL 7247562 (E.D. Mich. Oct. 23, 2015), Rep. & Rec. adopted by 2015 WL 7180388 (E.D. Mich. Nov. 16, 2015).

         Balknight filed her current applications for DIB and SSI on December 23, 2015, (R. 16, Page ID.390), and later alleged that she became disabled on December 1, 2013 (id., Page ID.400). The Commissioner denied the claims. (Id., Page ID.215.) Plaintiff then requested a hearing before an ALJ, which occurred on July 31, 2017. (Id., Page ID. 106-42, 299.) The ALJ issued a decision on September 26, 2017, finding Plaintiff was not disabled during the relevant period. (Id., Page ID.78-94.) On April 12, 2018, the Appeals Council denied review. (R. 11, Page ID.33-35.) Plaintiff sought judicial review on June 8, 2018. (R. 1). The parties have filed cross-motions for summary judgment and briefing is complete. (R. 21, 22, 24.) The case is now ready for resolution.

         B. Standard of Review

         The court has jurisdiction to review the Commissioner's final administrative decision pursuant to 42 U.S.C. § 405(g). The district court's review is restricted solely to determining whether the “Commissioner has failed to apply the correct legal standard or has made findings of fact unsupported by substantial evidence in the record.” Sullivan v. Comm'r of Soc. Sec., 595 F App'x. 502, 506 (6th Cir. 2014) (internal quotation marks omitted). Substantial evidence is “more than a scintilla of evidence but less than a preponderance.” Rogers v. Comm'r of Soc. Sec., 486 F.3d 234, 241 (6th Cir. 2007) (internal quotation marks omitted). “[T]he threshold for such evidentiary sufficiency is not high. . . . It means-and means only-‘such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'” Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019). The Court must examine the administrative record as a whole, and may consider any evidence in the record, regardless of whether it has been cited by the ALJ. See Walker v. Sec'y of Health & Human Servs., 884 F.2d 241, 245 (6th Cir. 1989). The Court will not “try the case de novo, nor resolve conflicts in the evidence, nor decide questions of credibility.” Cutlip v. Sec'y of Health & Human Servs., 25 F.3d 284, 286 (6th Cir. 1994). If the Commissioner's decision is supported by substantial evidence, “it must be affirmed even if the reviewing court would decide the matter differently and even if substantial evidence also supports the opposite conclusion.” Id. at 286 (internal citations omitted).

         C. Framework for Disability Determinations

         Disability benefits are available only to those with a “disability.” Colvin v. Barnhart, 475 F.3d 727, 730 (6th Cir. 2007). “Disability” means the inability

to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than [twelve] months.

42 U.S.C. § 1382c(a)(3)(A). The Commissioner's regulations provide that disability is to be determined through the application of a five-step sequential analysis:

(i) At the first step, we consider your work activity, if any. If you are doing substantial gainful activity, we will find that you are not disabled.
(ii) At the second step, we consider the medical severity of your impairment(s). If you do not have a severe medically determinable physical or mental impairment that meets the duration requirement . . . or a combination of impairments that is severe and meets the duration requirement, we will find that you are not disabled.
(iii) At the third step, we also consider the medical severity of your impairment(s). If you have an impairment(s) that meets or equals one of our listings in appendix 1 of this subpart and meets the duration requirement, we will find that you are disabled.
(iv) At the fourth step, we consider our assessment of your residual functional capacity and your past relevant work. If you can still do your past relevant work, we will find that you are not disabled.
(v) At the fifth and last step, we consider our assessment of your residual functional capacity and your age, education, and work experience to see if you can make an adjustment to other work. If you can make an adjustment to other work, we will find that you are not disabled. If you cannot make an adjustment to other work, we will find that you are disabled.

20 C.F.R. § 404.1520; see also Heston v. Comm'r of Soc. Sec., 245 F.3d 528, 534 (6th Cir. 2001). “Through step four, the claimant bears the burden of proving the existence and severity of limitations caused by [his or] her impairments and the fact that [he or] she is precluded from performing [his or] her past relevant work.” Jones v. Comm'r of Soc. Sec., 336 F.3d 469, 474 (6th Cir. 2003). The claimant must provide evidence establishing the residual functional capacity, which “is the most [the claimant] can still do despite [his or her] limitations, ” and is measured using “all the relevant evidence in [the] case record.” 20 C.F.R. §§ 404.1545(a)(1), 416.945(a)(1).

         The burden transfers to the Commissioner if the analysis reaches the fifth step without a finding that the claimant is not disabled. Combs v. Comm'r of Soc. Sec., 459 F.3d 640, 643 (6th Cir. 2006). At the fifth step, the Commissioner is required to show that “other jobs in significant numbers exist in the national economy that [the claimant] could perform given [his or] her RFC and considering relevant vocational factors.” Rogers, 486 F.3d at 241 (citing 20 C.F.R. §§ 416.920(a)(4)(v), (g)).

         D. ALJ Findings

         Following the five-step sequential analysis, the ALJ determined that Balknight was not disabled. (R. 16, Page ID.78-94.) At step one, the ALJ found that she had not engaged in substantial gainful activity since her alleged onset date. (Id., Page ID.81) At step two, the ALJ concluded that Balknight had the following severe impairments: degenerative joint disease, degenerative disc disease, tarsal tunnel syndrome, carpal tunnel syndrome, obesity, diabetes, peripheral neuropathy, reflex sympathetic dystrophy (RSD), asthma, hypertension, mood disorder, osteoarthritis, and systematic lupus erythematosus. (Id.) The prior ALJ decision, from 2013, included the same severe impairments except for osteoarthritis and systematic lupus erythematosus. (Id., Page ID.157.)

         At step three, the ALJ determined that she did not have an impairment or combination of impairments that met or medically equaled a listed impairment. (Id., Page ID.81-84.) Before proceeding to the final steps, the ALJ found that Balknight had the RFC to perform

sedentary work as defined in 20 CFR 404.1567(a) and 416.967(a) except the opportunity to alternate position for up to 5 minutes approximately every 30 minutes; no climbing of ladders or stairs; occasional stooping; no kneeling, crouching or crawling; frequent handling, fingering and feeling; no exposure to hazards or vibration; no use of foot or leg controls; no concentrated exposure to fumes, dusts or gases; and no exposure to extremes of temperature or humidity. She is limited to simple, routine, repetitive work, and should be able to wear and [sic] orthopedic boot while working.

(Id., Page ID.84.) That RFC matched the earlier RFC from the 2013 ALJ decision. (Id., Page ID.159.) At step four, the ALJ found that Balknight could not perform her past relevant work. (Id., Page ID.167.) Finally, at step five, the ALJ determined that she could perform a significant number of jobs in the national economy. (Id., Page ID.168-69.)

         E. Administrative Record

         1. Medical Evidence

         The first medical report in the record comes from February 2013, roughly 10 months before the disability onset date.[1] (R. 16, Page ID.490.) The report recounts a trip to the emergency room to treat pain and swelling in her left foot. (Id., Page ID.492-93.) She denied any neurological or psychiatric issues. (Id., Page ID.493, 496, 502.) The examination confirmed her complaints of tenderness and swelling but turned up nothing else unusual about her musculoskeletal or neurological functioning. (Id., Page ID.493-94, 497, 503, 514.) X-rays of her ankle likewise were normal aside from a small heel spur. (Id., Page ID.506-07, 510.) On discharge, she could walk without distress. (Id., Page ID.505.) And when she returned the next month, this time complaining of persistent back pain, the examination notes tell that she had “[n]o trouble walking.” (Id., Page ID.516.) Besides tenderness and spasms in her back, the rest of the examination results were normal, including her strength, reflexes, sensory perceptions, and range of motion. (Id., Page ID.517.)

         Her back still hurting a few days later, she went again to the emergency room. (Id., Page ID.527.) On arrival, the notes indicate she had difficulty walking, although her “baseline ambulation status [was] normal.” (Id., Page ID.528.) Back pain was again noted. (Id.) But the other examination findings were normal (including strength, reflexes, senses, and range of motion), and she denied “radicular numbness or tingling, ” radiating pain, and “lower extremity weakness.” (Id.) At an examination a few hours later, her walking was completely normal, as were the other findings except for the continued back pain. (Id., Page ID.527.) CT Scans revealed some disc protrusions and mild degenerative changes leading to mild canal stenosis at the L2-L3 disc level. (Id., Page ID.537.) The cause of her back pain was likely strained muscles or ligaments. (Id., Page ID.532.)

         Respiratory problems brought her back to the hospital, where she was diagnosed with acute asthmatic bronchitis, most likely a seasonal infection. (Id., Page ID.539, 557.) Her examinations during the visit measured strength, tenderness, and range of motion, among other things, and found no abnormalities, although a couple examinations noted distressed breathing and another observed “[t]race pitting lower extremity edema.” (Id., Page ID.540-44, 550, 552, 556-58.) While at the hospital, tests incidentally revealed she had thyroid goiter, although “clinically she is euthyroid, ” (id., Page ID.558, 571, 574), which is medical mumbo jumbo meaning that her thyroid worked normally, 1 J.E. Schmidt, Attorneys' Dictionary of Medicine and Word Finder, E-229 (2013). Additional chest and abdomen scans in 2013 and 2014 were largely unremarkable. (Id., Page ID.606-18.)

         An MRI from August 2013 showed “degenerative disc disease of the lower lumbar spine most pronounced on the left at the L4-L5 level where there is left lateral disc herniation.” (Id., Page ID.581.) That month, she was treated in the emergency room for a pinched nerve. (Id., Page ID.592.) The discharge paperwork explained that a pinched nerve, also called lumbar radiculopathy, “is caused by irritation or pressure on the nerve that goes from the spinal cord to the leg.” (Id.) Despite the pain, her gait was normal and she was ambulatory when she departed. (Id., Page ID.597-98.) A doctor wrote that Balknight wanted “pain control, ” although there had been “no acute change in sx [i.e., symptoms] and no neuro deficits.” (Id., Page ID.601.) The notes also mention that after her MRI she had been referred to “NS, ” who “refused surgery because of obesity.” (Id., Page ID.599.) Aside from back pain evidenced by tenderness and a positive straight leg raise test, [2] she denied problems with her musculoskeletal and neurological systems, and the physical examination found none. (Id., Page ID.599-600.)

         Dr. Sunita Tummala conducted neurological evaluations of Balknight in April and July 2014. (Id., Page ID.649, 651.) To Dr. Tummala, she appeared in “obvious pain.” (Id.) But the results from the neurological examination were normal, as were her strength, (except for a “4/5” rating for her left hip flexor), muscle tone, reflexes, and gait. (Id., Page ID.649-50.) As for her sensory system, in April Balknight experienced “[d]iminished sensation over the median sensory dermatomes” and positive Phalen's and Tinnel's signs; in July, she had “[p]atchy sensory loss over the right leg.” (Id., Page ID.649, 651.) For treatment, Dr. Tummala recommended pain medication and weight loss, among other things. (Id., Page ID.650.)

         Balknight continued to see Dr. Tummala through 2017. (Id., Page ID.1060-67, 1880-87.) During these visits, Balknight complained of depression, back pain, headaches, foot pain, and sensory disturbances in her hands and feet. (Id., Page ID.1060, 1062, 1066.) On examination, a few times her speech was slow and she had patchy sensory loss in her right leg, (id., Page ID.1064, 1066); but no other neurological findings were flagged as abnormal, she had full strength (except her left hip flexor), her muscle bulk and tone were normal, her gait (including heel, toe, and tandem gait) were normal, her reflexes were fine, “[r]apid alternating . . . movements [were] intact, ” and no “finger-to-nose or heel-to-shin dysmetria” were noted. (Id., Page ID.1064, 1066; id., Page ID.1060 (same except no mention of hip flexor, rapid alternating movements, or dysmetria), 1062 (same).) Nerve conduction studies in May 2014 showed reduced or absent sensory responses, which Dr. Tummala interpreted as abnormal and as evidence of “generalized axonal sensorimotor prefer neuropathy.” (Id., Page ID.1460.) In May 2015, Balknight stated that weight loss was a struggle because her back pain prevented exercise. (Id., Page ID.1064.) At a more recent appointment, in February 2017, Balknight continued to complain of bearing “a great deal of pain related to her neuropathy and left leg, ” although her Neurontin effectively managed her neuropathy (but not her leg pain). (Id., Page ID.1877.) During the examination, her motor functioning was normal, she had full strength “in all groups, ” she experienced “patchy sensory loss in a nondermatomal distribution, ” her reflexes were normal, her gait (including casual, heel, toe, and tandem gait) were normal, and the Romberg test-which measures loss of postural control due to deficits in the legs, Gordon F. G. Findlay, et al., Does Walking Change the Romberg Sign?, 18 Euro. Spine J. 1528, 1528 (2009)-was normal. (Id., Page ID.1877).

         She was once again in the emergency room for back pain, in July 2014, apparently after a fall. (Id., Page ID.639, 641.) Her back was tender on examination and had decreased range of motion. (Id., Page ID.643.) Otherwise, she denied problems with musculoskeletal and neurological functioning and her examination results were fine-i.e., normal strength, reflexes, gait, sensation, and negative straight-leg-raise test. (Id., Page ID.639, 642-43.) An imaging study around that time showed mild to moderate stenosis and foraminal narrowing at the L2-L3 disc level, disc bulge and mild to moderate foraminal narrowing at the L4-L5 level, possible “partial impression on the exiting left L4 nerve root, ” and mild stenosis due to epidural fat at the L5-S1 level. (Id., Page ID.605, 647.)

         The following month, Balknight made another visit to the emergency room due to back pain and spasms. (Id., Page ID.667.) The pain was mild and radiated to her lower leg. (Id., Page ID.670.) But according to the intakes, it resulted in no functional limitations and, indeed, she denied any other issues. (Id.) On initial examination, her motor functioning and sensation were normal. (Id., Page ID.667.) A later examination confirmed tenderness but otherwise uncovered no abnormalities, e.g., her strength was normal, her extremities had normal range of motion, her gait was normal, her reflexes were normal, and her sensation was normal too. (Id., Page ID.671.) When she left the hospital, she walked without difficulty. (Id., Page ID.668.)

         The next trip to the emergency room, in September 2014, was for a rash. (Id., Page ID.688.) Aside from that issue, however, she had no other complaints and her examination results were normal, including her gait, musculoskeletal system, her motor functioning, and her sensation. (Id., Page ID.688, 690-91.) Less than two weeks later, her stomach became upset after she took medications without eating. (Id., Page ID.698.) No other complaints (besides anxiety and shortness of breath) were noted. (Id., Page ID.705, 708, 711.) Her physical examination was normal, as she had full range of motion with her back, no tenderness in her back or (by the end of her visit) stomach, and normal strength, sensation, and reflexes. (Id., Page ID.698-99, 706, 709, 712, 717, 734-35, 737.)

         From 2013 through 2014, Balknight also treated with Dr. Siva Sripada for her back pain. (Id., Page ID.750-83.) Balknight claimed that the back pain was severe and intensified by walking, lifting, sleeping, sitting, bending, and standing. (Id., Page ID.752, 754, 756, 758, 762, 764, 772, 774, 776, 778, 780, 782, 1837, 1869, 1874; see also id., Page ID.1843 (complaining of back pain, weakness, painful or stiff joints, leg pain, but no neck pain).) Her mood had also darkened, her relationships deteriorated, and sleep proved difficult. (Id.) But she usually denied new weaknesses or numbness. (Id., Page ID.755, 759, 765, 775, 777, 779, 781, 783; but see id., Page ID.757, 773.) In more thorough reports of her symptoms during fall 2014 appointments, Balknight denied, among other things, weakness, “[t]iredness, ” difficulty sleeping, leg pain, loss of coordination, sensation problems depression, dizziness, and problems thinking or with memory. (Id., Page ID.750-51, 753.)[3]

         During their sessions, Dr. Sripada found some back tenderness but no focal deficits or other abnormalities. (Id., Page ID.776, 778, 780, 782.) Balknight received injections, which provided little relief, and medications. (Id., Page ID.76-61, 764, 766-71, 1867, 1871-73.) In August 2014, her insurance stopped covering her injections. (Id., Page ID.1837.) Dr. Sripada thought that “weight loss would be very beneficial, ” as “there is only so much I can achieve with medication management.” (Id., Page ID.780; see also id., Page ID.756, 762, 772, 774, 778, 782, 1866.) In March 2014, the notes stated, “Ms. Balknight understands clearly that weight loss is the solution to her problems. She has already been evaluated by a surgeon and no recommendations are being made surgically because of her weight.” (Id., Page ID.764.) A few months later, the notes reported, “She needs to have surgery, but her weight is a mitigating factor . . . .” (Id., Page ID.758.)

         Through 2016, Balknight continued receiving treatment from providers at Dr. Sripada's office. (Id., Page ID.1794-828.) In February 2015, she acknowledged that her weight contributed to her pain. (Id., Page ID.1827.) She also stated that Oxycodone was “somewhat controlling her pain.” (Id.) On examination, she had tenderness in her lower back and positive straight leg raises; but her “[s]trength and sensation are preserved in the bilateral lower extremities.” (Id., Page ID.1828.) Subsequent examinations were similar, and on some her deep tendon reflexes were not full, although at times the positive straight leg test results were “mild” or only on one side. (Id., Page ID.1818, 1825.) At some point, she began receiving injections again, which temporarily provided up to 100 percent relief, although often less (usually 20 to 70 percent); her medications, she noted at another time, gave up to 40 percent relief. (Id., Page ID.1794, 1797, 1798, 1800, 1805, 1809, 1812, 1814, 1817.)[4] Later, she stated that “Percocet does help with her activities of daily life, but prolonged standing, sitting and lying flat contributes to exacerbating the pain.” (Id., Page ID.1804.) In June 2015, she noted her depression and told the medical provider that “she spends the majority of her time in the house.” (Id., Page ID.1815.)

         From 2014 to 2015, Balknight saw Dr. Khaled Shukairy. (Id., Page ID.808-20.) She complained about various ailments, including reflux and sinusitis. (Id., Page ID.808, 811.) Often, she denied shortness of breath, neck pain, neck stiffness, muscle pain, and muscle weakness. (Id., Page ID.808, 811, 814, 816-19.) On occasion, she claimed to experience dizziness, (id., Page ID.808, 814, 819), but on others she denied it, (id., Page ID.811). Results from physical examinations showed normal gait, orientation, and posture. (Id., Page ID.809, 812.) In 2014, Dr. Shukairy operated on Balknight to remove vocal-chord polyps. (Id., Page ID.800, 814, 816.)

         The record also contains medical reports from Hamilton Community Health Network (usually signed by Dr. Donald Robinson) spanning from 2013 through 2016. (Id., Page ID.823-906, 1597-1783.) In them, she complained of back pain, numbness, weakness, sensation loss, fatigue, or decreased mobility, and occasionally depression. (Id., Page ID.842, 852, 863, 869, 874, 886, 891, 895-96, 901, 1728-29, 1755-56; but see id., Page ID.1603 (denying fatigue and weakness), 1629 (same), 1635 (same), 1647 (same), 1653 (same), 1658 (same), 1663 (same); 1687-88 (same), 1695 (same), 1701 (same); see also id., Page ID.1599 (denying fatigue), 1622 (same), 1642 (same), 1687-88 (same), 1695 (same), 1715 (same), 1722 (same), 1735 (same), 1740 (same), 1745 (same) 1750 (same), 1755 (same), 1769 (same), 1775 (same), 1781 (same).) The physical examinations sometimes revealed muscle spasms or tenderness, but she often appeared properly oriented, alert, cooperative, and with “normal attention span and concentration, ” her neck was supple, or her extremities had normal mobility, (Id., Page ID.825, 834, 857, 863-64, 869-70, 874-75, 879-80, 887, 891-92, 896, 902, 1600, 1604, 1622-23, 1636, 1643, 1648, 1654, 1659, 1664, 1696, 1702, 1723, 1729, 1741, 1750-51, 1770, 1775-76, 1781; see also id., Page ID.852-53 (same except no report on extremity mobility), 842-43 (same except no report on extremity mobility or orientation); 1715 (same except anxious and no mention of attention span, concentration, orientation, alertness, or cooperation); 1745 (same except depressed affect and no mention of attention span, concentration, orientation, alertness, or cooperation), 1762 (no abnormalities flagged).) The examination results at other appointments, however, showed joint tenderness, undescribed weakness, joint swelling, edema, depression, or decreased range of motion. (Id., Page ID.843, 848, 852-53, 863-64, 870, 875, 880, 887, 902, 1630, 1688, 1709-10, 1736, 1741, 1756, 1770, 1781.) In February 2015, a note states that she was “still unable to have back surgery secondary to her inability to lose 60 pounds.” (Id., Page ID.868.) The notes also indicate that, at least as of October 2014, she spent 16 to 24 hours a day watching television, on a computer, or playing games. (Id., Page ID.1694.)

         A sleep study in February 2015 revealed a “[m]ild case of obstructive sleep apnea and hypopnea.” (Id., Page ID.908.)

         In May 2015, Dr. Matthew Dickson conducted a psychiatric evaluation. (Id., Page ID.910-13.) Balknight claimed to suffer depression, but acknowledged she had never received mental health services. (Id., Page ID.910.) Social interactions were limited because she did not “like people right now.” (Id., Page ID.911.) Though she used to like “going out, ” she currently had no hobbies. (Id.) Most days were spent “in the bed waiting for the day to be over.” (Id.) Household chores were too much to handle, and a relative thus took care of the house. (Id.) She took brief shopping trips and could drive. (Id.) Scheduling and managing appointments were tasks she could do unassisted, and she could also pay bills. (Id.) Dr. Dickinson noticed Balknight's low energy level and general discouragement, but did not detect any cognitive impairment or problems with focus or concentration. (Id.) Overall, Dr. Dickinson concluded that her “mental abilities to understand, attend to, remember, and carry out instructions of work-related behaviors are not impaired, ” although she had a mild impairment in responding appropriately to co-workers and supervisors and adapting to work place changes. (Id., Page ID.912.)

         At her next trip to the emergency department, in April 2015, she complained of sharp back pain radiating to her leg. (Id., Page ID.927.) Yet, the pain imposed no functional limitations (such as a wayward gait or inability to do activities of daily living). (Id.) No other signs or symptoms were noted. (Id.) While her back was tender on examination, all other relevant measures were normal. (Id., Page ID.928, 931.)

         At a May 2015 consultative evaluation with Dr. Samiullah Sayyid, Balknight noted her history of back pain and other impairments. (Id., Page ID.916.) On examination, her neck was supple, she had no motor or sensory deficits, “[t]here was some paresthesia on the tips of the fingers and toes, ” her “[d]eep tendon reflexes are lost altogether in both upper and lower extremities, ” her finger-to-nose test was normal, she could not rapidly alternate her hand movements, her cervical spine was normal with full range of motion, her lumbosacral spine was tender with limited movement, her joints were normal with full ranges of motion except her hips and wrists, she had fine and gross dexterity in her arms, her grip was normal, her gait was normal, she struggled to get on and off the table, and she could not squat or walk on her heels and toes. (Id., Page ID.917-18.) In a supplemental report, Dr. Sayyid noted that Balknight could carry, push, and pull less than ten pounds, and could sit, stand, dress, dial a phone, open a door, make a fist, pick up a coin, pick up a pencil, write, touch finger to finger, and touch finger to nose. (Id., Page ID.919.)

         Her next trip to the emergency room, in May 2015, was for a wrist sprain. (Id., Page ID.943.) On arrival, she noted the pain occurred when she awoke; the intake report also observed that she could move her fingers and wrist without difficulty and no swelling, redness, or bruising was seen. (Id.) She also “denie[d] changes in sensation or strength.” (Id., Page ID.944.) The only abnormality seen during the physical examination was tenderness in her wrist, which retained full range of motion and sensation. (Id., Page ID.944-45.) She walked without assistance, and her back, arms, and legs had full range of movement and all had full range of motion except her right arm, which was “[l]imited.” (Id., Page ID.954-55.)

         At the next month's emergency-room visit, again for back pain, she continued to deny any other symptoms, such as general weakness. (Id., Page ID.966.) The pain minimally limited her functioning. (Id.) Like the last visit, her physical examination results were normal (including normal strength and sensation) and her back was tender; however, one report claimed her gait was antalgic, i.e., pain-avoiding, while another observed it was normal. (Id., Page ID.967, 970.)

         An imaging study completed in June 2015 found the following: the L2-L3 level had “bulging disc and hypertrophic changes of the posterior elements mild canal, ” the L3-L4 level had “severe right and moderate left-sided foraminal stenosis” with probable right L3 nerve-root impingement, the L4-L5 level had “bulging disc and facet hypertrophy with severe bilateral foraminal stenosis” with “bilateral L4 nerve root impingement, ” and the L5-S1 level had “bulging disc and facet hypertrophy with mild right-sided foraminal stenosis.” (Id., Page ID.1515 In July 2015, a mild headache sent her to the emergency room. (Id., Page ID.986.) Aside from mild nausea, the intake form flagged no complaints or concerns, and the physical examination revealed none either. (Id., Page ID.986-87, 991.) When the pain increased to “moderate” in August, she returned to the hospital. (Id., Page ID.1016.) She still denied other symptoms (like numbness or weakness), but asserted she felt stiff in the mornings. (Id.) Her physical examination, too, was completely normal-even her back was fine, without tenderness or spasms. (Id., Page ID.1017, 1020.)

         But a month later, in September, she saw Dr. Sudesh Ebenezer for her back pain. (Id., Page ID.1032.) She was tired, she claimed, and her back hurt, the pain radiated to her legs, her joints ached, her legs swelled, and she was depressed; however, she denied weakness in her limbs, difficulty sleeping, loss of balance, loss of coordination, loss of sensation, and “[p]roblems with [t]hinking.” (Id., Page ID.1033.) No examination notes were memorialized, but Dr. Ebenezer mentioned that operating on Balknight's mild disc herniation at the L4-L5 level “will not likely help her axial low back pain. It could help her left leg radiculopathy however the results of the surgery due to her weight might be in the order of 50%.” (Id., Page ID.1032.)

         In November 2015, a dental infection and a cold caused a return to the emergency room. (Id., Page ID.1036-37.) Aside from a cough and pain, no other symptoms were present-among other things, she denied musculoskeletal pain and stiffness, and sensation problems-and none were found on examination. (Id., Page ID.1040-41, 1044.)

         At the end of 2015, Balknight saw Dr. Ali Karrar at a rheumatology clinic. (Id., Page ID.1589.) At the examination, Balknight's hands and knees were tender to the touch, but her gait was normal, “her neck had full range of motion without pain, ” her thyroid was not enlarged, her higher neurologic functions and cranial nerves were grossly normal, and her motor examination (including “tone, power and nutrition of the muscles”). (Id., Page ID.1590.) Dr. Karrar recommended aerobic exercises and weight loss. (Id., Page ID.1591.) Later examinations produced similar results, and the recommendation often remained the same. (Id., Page ID.1573-74, 1577-78, 1585, 1587.) The findings from the July 2016 examination included, in addition to the above, negative Tinnel's and Phalen's tests and full range of motion in her wrists. (Id., Page ID.1564; see also id., Page ID.1561 (same).) In September 2016, she told Dr. Karrar that her lupus symptoms-including fatigue and joint pain and stiffness-were improving with treatment and (partially) with medication. (Id., Page ID.1560, 1945; see also id., Page ID.1556 (same).) Two months later, her examination results remained the same-with negative Tinnel's and Phalen's and full wrist motion-and Dr. Karrar also observed that she sat “comfortably on the examination table without difficulty or evidence of pain.” (Id., Page ID.1557-58; id., Page ID.1552-53 (same for February 2017), 1946-47 (same for May 2017).)

         During an office visit in January 2016 to treat her diabetes, she denied fatigue, lightheadedness, shortness of breath, anxiety, mental problems, and depression, among other things; she did, however, complain of joint pain. (Id., Page ID.1519.) The examination confirmed joint tenderness, but her extremities had normal mobility, she was cooperative, and her attention and concentration were normal. (Id., Page ID.1520.) Later the same month, she had nausea, a headache, nasal congestion, a cough, and sore throat, in addition to other symptoms. (Id., Page ID.1524.) At that time, she felt weak and complained of back and joint pain. (Id., Page ID.1520.) Her extremities, however, had normal mobility and her mood, concentration, and attention span were all normal, though joint tenderness was produced on examination. (Id., Page ID.1526, 1531.)

         At the emergency room in April 2016, her back pain caused an antalgic gait. (Id., Page ID.1076.) Yet, the “Morse Fall Scale” report during the visit stated she had normal gait. (Id., Page ID.1080.) No other functional limitations were associated with the pain (it was not marked, for example, that she was unable to do activities of daily living). (Id., Page ID.1076, 1080.) And no other symptoms were noted or problems mentioned. (Id., Page ID.1076.) The examination revealed anxiety and back and thigh tenderness; the results were otherwise normal. (Id., Page ID.1077.)

         A month after this visit, she returned with “itching, burning, and hurting all over.” (Id., Page ID.1091.) But she did not complain of other problems, nor did the physical examination uncover any. (Id., Page ID.1092.) She arrived walking, without assistance, and was cooperative. (Id., Page ID.1113.) The rash persisted until a few days later, leading to another visit to the emergency room. (Id., Page ID.1124.) Again, however, she denied other issues and none were found on examination, which revealed normal range of motion for her neck and musculoskeletal system and normal neurological findings. (Id., Page ID.1125-26.)

         Psychiatric treatment notes span from August 2015 through July 2016. (Id., Page ID.1152-74.) She recounted years' long depression, crying spells, and days spent sleeping. (Id., Page ID.1174.) But she had no treatment history. (Id., Page ID.1170.) In the intake records, she noted neurological pain and lupus, but denied all other medical issues, including with her cardiovascular and muscular systems. (Id., Page ID.1171.) The first examination showed Balknight to be cooperative and have coherent speech, mild dysphoria, unremarkable psychomotor behavior, normal muscle tone, normal gait, appropriate attention and concentration, intact memory, intact thought process, appropriate thought content (although with obsessions), full orientation, an adequate fund of knowledge, and impulsive judgment. (Id., Page ID.1172.) At a later visit, she appeared calm and euthymic, with appropriate affect, appropriate speech rate and volume, unremarkable psychomotor behavior, normal muscle tone, normal gait, appropriate attention and concentration, intact memory, appropriate thought content (without obsessions), full orientation, an adequate fund of knowledge, and appropriate judgment (no longer impulsive). (Id., Page ID.1168-69; see also id., Page ID.1152-53, 1158-59.) Sometimes, her obsessions and impulsivity returned (even when her overall thought content and judgment remained appropriate); otherwise the other examination results were the same. (Id., Page ID.1163-64.)

         An ambulance brought Balknight to the emergency room in August 2016 when pain from her wisdom tooth extraction did not abate. (Id., Page ID.1177, 1179.) She denied other issues and the examination results showed her neck and musculoskeletal system had normal ranges of motion; no other abnormalities were flagged. (Id., Page ID.1180-81.)

         Her chief complaint in the emergency room in October 2016 was a cough, coupled with congestion and headaches. (Id., Page ID.1199.) The problems had lasted for two or three days despite her taking over-the-counter medications. (Id., Page ID.1200.) She also mentioned joint pain, but denied back pain, joint swelling, and confusion. (Id.; see also id., Page ID.1204, 1207.) On examination, her neck had normal range of motion, her cardiovascular system was normal, she exhibited no edema, her muscle tone and neurological system were normal, and her mood and affect were normal. (Id., Page ID.1201, 1204-05, 1208.) According to the notes, her symptoms likely stemmed from “a viral infection causing her lupus to flare.” (Id., Page ID.1202.)

         Later that month she saw Dr. Rudrum Muppuri for back and leg pain and peripheral neuropathy. (Id., Page ID.1238.) Also, she had some weakness and numbness in her legs. (Id.) But her leg strength was normal during the examination, her sensation was “grossly intact except decreased sensation on the left lower extremity compared to the right side up to the ankle area, ” and her range of motion was normal. (Id., Page ID.1239.) Tenderness was present on examination. (Id.) Dr. Muppuri advised Balknight to quit smoking and lose weight, which would help with her back and leg pain. (Id., Page ID.1240.) He also scheduled injection treatments and prescribed narcotics. (Id.)

         At the appointments for injections, Balknight repeated many of her complaints. (Id., Page ID.1268, 1358.) After one set of injections, the notes state her pain control was “satisfactory, ” and after others the record indicates she was properly oriented, calm, in no pain, and had no limitations on mobility. (Id., Page ID.1273, 1395, 1449.) After receiving some of the injections, Balknight followed-up in January 2017, regarding her joint and back pain. (Id., Page ID.1342.) The injections provided 60 percent pain relief for two weeks. (Id.) But her pain continued. (Id., Page ID.1344.) No new weaknesses had occurred, and she denied dizziness, shortness of breath, and nausea, among other symptoms. (Id., Page ID.1342.) The physician found Balknight's neck supple, bending with her lumbar spine was reduced, extending with her lumbar spine was not limited, and she had some tenderness in her joints and back, decreased leg strength, normal neurological results, and a negative straight leg raise test. (Id.)

         In the last half of 2016 and into 2017, Balknight received treatment for various issues at the Genesee Community Health Center. (Id., Page ID.1463-1511.) In the sessions, she claimed to suffer from depression, sleep problems, and difficulty concentrating. (Id., Page ID.1483, 1508-09.) She denied fatigue, dizziness, and gait disturbance. (Id., Page ID.1502, 1509.) Some of these same records (and others), however, also state that her lupus caused dizziness and fatigue. (Id., Page ID.1477, 1484, 1489, 1495, 1506.) On examination, Balknight typically had proper orientation, appropriate mood and affect; other examinations showed negative straight leg raise tests, normal memory, normal insight, normal judgment, normal cervical spine, full range of motion with her wrist and fingers, or normal gait. (Id., Page ID.1467, 1472, 1478, 1483, 1489, 1503.) Occasionally, her lumbar spine was tender and had mildly reduced range of motion, her gait was antalgic, or she had severe pain moving her lumbar spine. (Id., Page ID.1496, 1503.) One note states that Balknight reported being offered surgery for her leg pain, but it would have done nothing for her back problems and “[t]hey left the decision up to her.” (Id., Page ID.1499.) Regarding her depression, she reported in March 2017 that it persisted but was improving. (Id., Page ID.1930.) At that appointment, the provider observed Balknight took high doses of medications and planned to reduce one of them; the risk of overdose was “great, ” and Balknight appeared oversedated from the medications. (Id., Page ID.1930-31.)

         In January 2017, Balknight saw an endocrinologist, Dr. Hement T. Thawani. (Id., Page ID.1547.) The examination revealed a minimally enlarged thyroid but no leg edema or gross neurological focal deficits. (Id.) Again in April, her thyroid was mildly enlarged and she had no pitting leg edema. (Id., Page ID.1883.) At that appointment, Dr. Thawani told her that injection therapy “is not a definitive cure for her problem, ” and that she ...

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