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Giordano Ruppert v. Saul

United States District Court, District of Columbia

January 13, 2020

ANDREW SAUL, Commissioner of the Social Security Administration,[1] Defendant.



         Pending before this Court are Plaintiff's [13] Motion for Judgment of Reversal (Pl.'s Mot.) and [13-1] Memorandum in support thereof (“Pl.'s Mem.”); Defendant's [14] [Consolidated] Motion for Judgment of Affirmance/Opposition to Motion for Judgment of Reversal and Memorandum in support thereof (“Def.'s Mot.”); and Plaintiff's [16] Reply.[2] Plaintiff Mary M. Giordano Ruppert (“Plaintiff” or “Ms. Ruppert”) requests reversal of the decision by the Acting Commissioner of the Social Security Administration (“SSA”) to deny Plaintiff disability insurance benefits. Plaintiff alleges that the Administrative Law Judge who issued the decision:

(1) ignored the time off work and time off task required for Ms. Ruppert's required medical treatment; (2) failed to state his specific reasons for deciding that Ms. Ruppert's impairments, alone or in combination, did not meet or medically equal any of the listings in 20 C.F.R. Pt. 404, Subpt. P; (3) failed to find Ms. Ruppert disabled under Listing 4.05 (recurrent arrhythmias) and Listing 12.02 (neurocognitive disorders); (4) misstated the record with regard to the frequency, duration, intensity, and severity of her disabling symptoms; (5) having significantly misstated Ms. Ruppert's daily activities, was left with only the inaccurate and impermissible, sole rationale that her symptoms were unsupported by objective evidence; (6) failed to explain how he reached his conclusions regarding Ms. Ruppert's residual functional capacity in his question to the vocational expert, including working on a regular and continuing basis; and (7) failed to give controlling weight to the well-supported opinions of four of her treating specialists.

Pl.'s Mot. for Reversal, ECF No. 13, at 1-2 (substituting numbers (1)-(7) above for letters (A)-(G) in the original).

         Upon consideration of the pleadings, and for the reasons set forth herein, the undersigned finds that some of Plaintiff's arguments warrant remand of the Defendant's decision. Accordingly, the Court DENIES IN PART AND GRANTS IN PART Plaintiff's Motion for Judgment of Reversal, DENIES Defendant's Motion for Judgment of Affirmance, and REMANDS this matter to the Social Security Administration for further proceedings.

         I. Background

         Plaintiff Mary M. Giordano Ruppert is a 51-year-old female who resides in Washington, D.C. (Administrative Record (“AR”) [10] 50, 78.)[3] She was 44 years old on her disability onset date of October 9, 2012. (AR 78.) She has a master's degree in systems engineering, AR 50, and she was a senior associate for a defense contractor - Booz Allen Hamilton - from July 1990 to October of 2012, with a one year break in 2000-2001, when she served as a vice president of public relations in a public relations firm. (AR 50-51.) On March 10, 2014, Plaintiff filed an application for benefits under Title II of the Act, alleging disability due to Postural Orthostatic Tachycardia Syndrome (“POTS”), post-concussive syndrome, migraines, vestibular cognitive deficit, low blood pressure, diabetes insipius, anxiety, depression, neuropathy, and fibromyalgia. (AR 195-196, 229). Prior to an automobile accident in April 2012, where Plaintiff suffered a concussion, Plaintiff had already been diagnosed with POTS, fibromyalgia, and small fiber neuropathy, but she was working with accommodations, including working at home one day a week and undergoing daily 2.5 hour IV saline infusions to stabilize her blood pressure (where the infusions were sometimes administered at her office). (AR 69-71, 1388.) Plaintiff attempted to return to work after the accident; however, by August 2012, her physicians recommended ceasing work due to her worsening symptoms. (AR 1389.) She continued to attempt to work, but after a possible second concussion in October 2012, she ceased working on October 10, 2012. (AR 1389.)

         Plaintiff's application was denied initially and upon reconsideration. (AR 78-93, 94-110.) Thereafter, Plaintiff requested an administrative hearing, and United States Administrative Law Judge (“ALJ”) Andrew M. Emerson held an administrative hearing, which lasted approximately one hour. (AR 131-133, 45-77.) At the hearing, Plaintiff was represented by a non-attorney representative. ALJ Emerson issued his Decision denying Plaintiff's application. (AR 18-37.) Plaintiff requested a review of ALJ Emerson's decision, but the Appeals Council denied Plaintiff's request for review. (AR 1-7.) As ALJ Emerson's decision constitutes a final agency decision, Plaintiff is entitled to judicial review in this Court under 42 U.S.C. § 405(g).

         A. Evidence Before the ALJ

         The evidence before ALJ Emerson consisted primarily of: (1) medical records spanning from April 2012 through June 2016, including medical records from doctors who treated Plaintiff and reports from state agency physicians who reviewed her records; (2) earnings records; and (3) Social Security Administration (“SSA”) disability reports completed by Plaintiff and her husband. The evidence also included testimony by Plaintiff and by Charlotte Dixon, a vocational expert, during the hearing held by the ALJ.

         1. Plaintiff's Medical Records[4]

         Plaintiff's medical records spanning April 2012 through December 2013, from an unknown source, indicate a diagnosis of Postural Orthostatic Tachycardia Syndrome (“POTS”) and Neurobehavioral Symptoms including pain, nausea, collapse, sudden fatigue with stimuli, difficulty paying attention and remembering things, slowed thinking and brain fog. (AR 391, 393.) Plaintiff was provided IV infusions, speech therapy, physical therapy and acupuncture. (AR 396-408.)[5]

         In late October of 2012, after hitting and reinjuring her head twice that month, Plaintiff went to the emergency room and was diagnosed with concussive syndrome and advised to begin brain rest and to start Lorazepam and Prozac. (AR 380, 434, 698-699, 716.) She used Sumatriptan for migraines, but she could not take Lyrica because it caused dizziness. (AR 434, 699.) In November 2012, Plaintiff was advised by Dr. Rhanni N. Herzfeld, a neurologist from the Neurology Center, to schedule an MRI of her brain and cervical spine, as she had severe neck pain, and she was further advised to undergo a formal neuropsychological assessment and an EEG. (AR 330-331.) On October 23, 2012, Plaintiff reported to Dr. Weiss, her primary care physician, who listed her underlying medical conditions as POTS, diabetes and fibromyalgia, and her current symptoms as recurrent syncope fatigue, nausea, weakness, migraine, chronic pain, dehydration, recurrent viral infections. He indicated that her disability started on October 10, 2012, and the end date was unknown. (AR 1086.)

         Dr. Weiss issued a physician recertification statement on November 27, 2012, wherein he noted that Plaintiff's expected return to work (modified duty) was January 15, 2013. (AR 1085.) Plaintiff was evaluated by Dr. Marilyn Kraus, then-Director of the Concussion Program at Medstar National Rehabilitation Hospital on December 6, 2012, with complaints of fatigue and sleep problems, blurry vision, chest pain and fainting, nausea and incontinence. She reported pain of 5/10 in the back of her head for the previous 7 months. Plaintiff was taking Prozac and Lorazepam. Dr. Kraus noted that Plaintiff was a patient with a complex prior medical history of POTS and diabetes and migraine, who sustained a concussion. Plaintiff was referred to urology and for a balance evaluation/therapy at her physical therapy; she was kept on her medication and prescribed a low dose of Gabapentin. She was scheduled for a follow-up appointment in two weeks. (AR 698-702.)

         On December 6 and 7, 2012, Plaintiff was evaluated by Dr. Jessica Clark, neuropsychologist at MedStar, for possible mild traumatic brain injury. Dr. Clark noted that details provided by Plaintiff were consistent with having suffered a concussion due to a car accident in April 2012, but it was unclear whether Plaintiff's reinjury in October 2012 was a second concussive injury. During the period of August through October 2012, Plaintiff experienced a prolonged course of recovery corresponding with work stress. It was noted that Plaintiff's situation was complicated by a pre-injury history of POTS, diabetes and fibromyalgia. Plaintiff was encouraged to rest and build up to a higher activity level gradually; to follow-up with her physicians regarding her medical issues and with a neuropsychologist who understood the psychological component of her situation; and to try relaxation techniques. (AR 378-383.)

         Plaintiff had a December 18, 2012 follow-up visit with Dr. Kraus, where she reported that her mood had improved but her fatigue was still an issue, along with headache, neck pain, nausea and dizziness. Dr. Kraus recommended that Plaintiff stop Prozac and start Sertraline, continue the Gabapentin, obtain an MRI and EEG, and follow-up with her in four weeks. (AR 703-706.) Plaintiff's MRI indicated that she had mild to moderate foraminal stenosis bilaterally, which had not changed from the previous study and mild right foraminal stenosis at C4-C5 with mild unconvertebral joint arthropathy. (AR 329.) Her EEG was normal. (AR 326.)

         Dr. Weiss issued a physician recertification statement in January 2013, where he noted that Plaintiff's anticipated return to work (modified duty) was September 1, 2013, and further, that Plaintiff was seeing Dr. Hertzfeld and Dr. Kraus and attending physical therapy. (AR 1084.) Plaintiff followed up with Dr. Kraus on January 17, 2013, and she reported feeling a bit better with her POTS under control unless she overdid her activity level. She had switched from Prozac to Sertraline with an improvement in mood and the Gabapentin was helping with sleep. Plaintiff had a vestibular evaluation and started treatments. She was provided with an order for speech therapy. (AR 709-711.) Plaintiff visited Dr. Kraus again on February 21, 2013, where she reported feeling worse, angry, anxious, and hypersensitive to noise. The results of Plaintiff's neuropsychological testing showed average basic attention, variable speed of information processing, low average working memory, variable executive functioning, intact basic attention and verbal learning and memory, and symptoms of depression and anxiety. Plaintiff was diagnosed with cognitive disorder; and told to continue with vestibular therapy and other therapy, reduce Gabapentin, use Alprazolam in lieu of Lorazepam, and increase Sertraline. (AR 712-715.)

         Plaintiff visited Dr. Herzfeld at the Neurology Center again on March 14, 2013, where she reported significant improvement in her occipital headaches but migraines up to three times per week and mood problems occurring after she spent time on the computer. She was diagnosed with post concussive syndrome with gradual improvement but continued hypersensitivity. She was advised to continue brain rest and to increase her dosage of Gabapentin. (AR 324.)

         On March 28, 2013, Plaintiff was examined by Dr. Weiss, who diagnosed her with post-concussive syndrome. Dr. Weiss noted that Plaintiff needed to resolve her cognitive dysfunction, and it would take more than 6 months for any fundamental changes in her medical condition. He noted restrictions in walking, lifting, speaking, sustained mental or physical activities, and continuing anxiety; however, Plaintiff was able to operate a motor vehicle. (AR 1078-1080.) On April 23, 2013, Dr. Weiss wrote a letter in support of Plaintiff's claim for disability, noting that her medical conditions included POTS, chronic fatigue syndrome, fibromyalgia, recurrent syncope, dehydration and autonomic neuropathy. Her overall condition had been improving prior to a car accident in April 2012, when she began to experience migraines, sleep disturbance, nausea and cognitive issues. Dr. Weiss diagnosed her with a traumatic brain injury and prescribed Zoloft, Midodrine, and Gabapentin. Dr. Weiss noted that Plaintiff was restricted in the amount of time she could stand or walk; she frequently collapsed, was sensitive to stimuli and unable to sustain her focus. He noted that Plaintiff had begun to slowly improve with physical therapy and medication and psychological therapy for her anxiety, depression and behavioral issues. He concluded that it was inconceivable that she would be able to return to work any time soon and advocated for full disability. (AR 1173-1174.)

         On May 6, 2013, Plaintiff visited Dr. Kraus, where she reported that she felt better overall in terms of her mood, her mental energy, and her gait, but she was still experiencing overstimulation and she sometimes needed a cane for walking. Plaintiff had reduced her Gabapentin and was using Alprazolam instead of Lorazepam, and she had increased her Sertraline. Her pain was assessed as 8/10, and Dr. Kraus evaluated her as still being very impaired. Plaintiff was using a memory notebook and discussed returning to work on a limited basis. Plaintiff was prescribed Sumatriptan, Zoloft, and Gabapentin. (AR 717-721.) On July 2, 2013, Plaintiff had a follow-up visit with Dr. Kraus, where she reported that her port had been infected and she had been in the hospital for that; her nausea and dizziness were worse; the hypersensitivity was still there; and while they had discussed a return to work at the last visit, with the setback, Plaintiff was not ready to do more yet. Plaintiff's pain was rated a 7/10. Her dosage of Gabapentin was increased, and she remained unable to return to work. (AR 722-725.)

         On or about July 13, 2013, Plaintiff was treated in the Emergency Room at the Community Hospital of the Monterey Peninsula for left arm pain at her PICC line site. (AR 341.) On July 14, 2013, Plaintiff was admitted to the Community Hospital for two days, and she was diagnosed with sepsis and given a 10-day course of Ciprofloxacin, an antibiotic. (AR 354-355.) On October 21, 2013, Plaintiff saw Dr. Kraus, and she described her pain as generalized and rating a 3/10. Plaintiff's balance was unsteady, but her coordination and posture were normal. Plaintiff indicated that she had another port in place for her infusions for her POTS. She noted dizziness was still an issue triggered by overexertion or too much stimuli. Her nausea was also worse, but her cognition was better. Dr. Weiss had taken Plaintiff off Gabapentin because of several aggressive episodes. Plaintiff was referred to another doctor to assess her dizziness; her Sertraline was increased, and she was told to use fish oil. (AR 726-729.)

         On November 4, 2013, Plaintiff consulted with Dr. Dennis Fitzgerald at Medstar Washington Hospital Center regarding her chronic dizziness, and she was scheduled for testing and a return visit. (AR 988-990.) During September through November, 2013, Plaintiff attended speech and language treatment with Ms. Maura Collins. (AR 1280-1285.)

         Dr. Weiss prepared for Plaintiff a Plan of Treatment for the period November 15, 2013 through January 13, 2014, whereby he noted IV hydration for 2-3 hours daily and cleaning and monitoring of the insertion site. (AR 409-410.) Plaintiff's medical records from Coram Specialty Infusion Services show that Plaintiff was previously receiving IV infusions of saline daily and IV infusions of Privigen every 4 weeks, at least at some points throughout 2011 -2013. (AR 514, 518 - 532.)

         On December 11, 2013, Plaintiff was interviewed and examined by Dr. Ross Myerson (Occupational Medicine), who was conducting an independent medical evaluation. Dr. Myerson characterized Plaintiff's conditions as follows: chronic fatigue, brain fog, episodic weakness, POTS, vestibular dysfunction, and recent cognitive problems. He noted that the physicians involved in her care were: Dr. Alan Weiss; Dr. Marilyn Kraus; Dr. Jessica Clark; and speech-language pathologist Maura Collins. Plaintiff had been prescribed Desmopressin Acetate, Midodrine, Sertraline, potassium supplements, Sumatriptan, Alprazolam, and a Port-a-Cath for saline infusions 4-6 times per week. She was seeing an internist practicing integrative medicine, a neuropsychologist and a speech and language pathologist. Dr. Myerson opined that no specific physical functional impairments were identified during his examination or in the medical records nor were the Plaintiff's medical diagnoses supported by his examination or the records. Dr. Myerson concluded that he could not estimate the Plaintiff's abilities, and he believed that the Plaintiff's overall condition was psychiatric in nature with some possible medical issues. (AR 1257-1266.)

         On December 11, 2013, Plaintiff reported for an audiology evaluation at Medstar Washington Hospital Center, with Dr. Rita Ball-Murphy, where she reported hearing loss, tinnitus, ear pain, and problems with balance. The pressure test for Plaintiff's right ear was abnormal, and she was advised to follow-up with an ENT doctor. Her medication list at that time included Ddavp Rhinal Tube Soin, Alprazolam, Zoloft, Sumatriptan, Midodrine Hcl, Klor-con, Normal Saline Flush for two hours daily, and Sertraline. The results of Plaintiff's testing indicated an abnormal right ear (with positive pressure). She was recommended for an ENT and Neurology follow-up. (AR 413-414.)

         Plaintiff visited Dr. Elizabeth Kingsley, cardiologist, for a cardiovascular consultation on December 16, 2013, based on a complaint of a history of postural orthostatic tachycardia syndrome with autonomic neuropathy. Dr. Kingsley noted that Plaintiff had been managing her POTS syndrome for the past 11 years with saline IV treatments 6 days a week and monthly infusions. Dr. Kingsley noted that Plaintiff discontinued her job because of disability; she had post-concussive syndrome; she was hospitalized in July 2013 for septicemia; and she reported to her with chest discomfort, dizziness, balance and vestibular problems. Plaintiff's assessment and plan included hydration, salt tablets, an echocardiogram, treadmill exercise, bone density screening and possibly adding Ritalin to her medications. (AR 421-422.) When tested, Plaintiff's bone density was normal. (AR 424.) On December 20, 2013, Plaintiff consulted with Dr. Fitzgerald about her ears, more specifically her dizziness/loss of balance and the on and off ringing and fullness in her right ear. Dr. Fitzgerald indicated that Plaintiff was going to be scheduled for surgery. (AR 973-975.)

         On January 24, 2014, Dr. Kingsley noted that Plaintiff exhibited physiology (post-exercise drop in blood pressure) compatible with post-exercise vasodilation, and she recommended support hose and avoidance of exercise, especially while standing up. She also suggested salt tablets. Plaintiff's exercise treadmill test had to be stopped early because of Plaintiff's shortness of breath and lightheadedness. (AR 458, 460.)

         During the period from January 2012 through March 2014, there are numerous medical records from Potomac Home Health Care relating to Plaintiff's “port care.” These records regularly indicate that Plaintiff expressed neurological symptoms of dizziness, fatigue and weakness, but they also contain frequent commentary that the patient was not having new pain. (AR 541-637.)

         On February 20, 2014, Plaintiff followed up with Dr. Kraus, and she reported neuropathic pain in her leg and all over, pain in both ears, an upcoming vestibular surgery in March, two migraines per month, more sensitivity to light, being overwhelmed by stimuli, no change in cognition but worse nausea. Dr. Kraus prescribed Ritalin to help with fatigue and concentration. (AR 730-735.) Around March 5, 2014, Plaintiff was admitted to the emergency room at the Johns Hopkins Medical facility with complaints of dehydration from lack of IV fluids and upper chest tightness. (AR 1143-1150.) On April 15, 2014, Plaintiff met with Dr. Weiss, who noted that Plaintiff could not sustain physical or mental activities, must restrict stimuli and stress, and must rest frequently. Plaintiff was diagnosed with low blood pressure and cognitive dysfunction, and given a fair prognosis. Fundamental improvement in her condition was expected to take more than 6 months. (AR 1088, 1093).

         Dr. Weiss's letter dated April 4, 2014 indicates that Plaintiff was unable to concentrate for more than brief periods of time as she had post-concussive syndrome and a possible fistula in her right ear, and she experienced recurrent episodes of collapsing, agitation, and impaired cognitive function. Plaintiff was being treated with multiple medications, including saline infusions, and gamma globulin therapy. Plaintiff had seen a cardiologist who noted post-exercise vasodilation consistent with Plaintiff's POTS and autonomic neuropathy. (AR 1269.)

         On April 29, 2014, Dr. Kraus reported that Plaintiff reported some cognitive benefit from Ritalin and was looking into a Beta blocker for her POTS. Plaintiff noted further that she had a short temper, she was getting migraines 3 times per month, her neuropathic pain was worse, and she still experienced overstimulation. Plaintiff was instructed to continue with Dr. Clark, referred to physical therapy, given an increased dosage for Methylphenidate, and told to follow-up in ten weeks. (AR 872-876.) Medical records from Dr. Kraus dated May 15, 2014 indicate that Plaintiff was close to achieving her maximum medical improvement, and her prognosis was guarded as Plaintiff was still symptomatic. Plaintiff's physical and mental impairments were indicated to be moderate. (AR 1091.)

         During 2014, Plaintiff attended outpatient psychological sessions at MedStar to address her diagnosis of Adjustment Disorder with Mixed Anxiety and Depression, although she canceled several appointments. (AR 736-744.) Plaintiff was treated by Constance Maravell, doctor of oriental medicine (DOM) and licensed acupuncturist, for 7 years, and Ms. Maravell opined that, as of April 24, 2014, Plaintiff could not resume work due to the progressive deterioration of her health since the car accident. (AR 749-864.)

         On approximately June 24, 2014, Plaintiff reported to the emergency room at the Anne Arundel Medical Center suffering from dehydration. Plaintiff reported that she could not get her port to work and missed a day, and she became dizzy and nauseous. (AR 907-931.) On June 27, 2014, Plaintiff reported to Georgetown University Hospital, where she underwent an operation on her right ear in response to her diagnosis of vestibular disorder. (AR 933-967.) On July 17, 2014, Plaintiff followed up with Dr. Fitzgerald, where it was noted that her fistula problems had improved, and Plaintiff was scheduled for a post-op audio test. (AR 968-970.) On July 18, 2014, Plaintiff consulted with Dr. Kraus with complaints of fatigue and sleep problems, decreased hearing and ear pain, nausea, and loss of balance. Plaintiff's pain in her legs and pressure in her ear was rated a 4/10. Plaintiff was referred to a tinnitus clinic, given a prescription for Ritalin twice per day, and scheduled for a follow-up in 12 weeks. (AR 1003-1007.)

         On October 20, 2014, Plaintiff was evaluated by Dr. Jessica Clark, a neuropsychologist, who found that Plaintiff had applied focus and concentration for 30-50 minute periods and reasoning/judgment within normal limits. Dr. Clark noted that Plaintiff was able to drive, and she shared with her husband household activities of cleaning/maintaining her residence, performing routine shopping, and paying bills. Dr. Clark noted that Plaintiff was unable to return to work until her physical status improved. (AR 1096-1098.) On October 29, 2014, Plaintiff was evaluated by Dr. Weiss, and she was able to sit for 4 hours and stand/walk for 2 hours, could use her hands but not sustain an activity and could occasionally lift up to 20 pounds, climb, balance, stoop, kneel and crouch. Dr. Weiss opined that Plaintiff suffered from fatigue and pain that were disabling from working full time at even a sedentary position. (AR 1100-1105.) On December 4, 2014, Plaintiff was admitted to MedStar Washington Hospital Center with dizziness after falling and hitting her head the day before. (AR 1106-1141.) On January 26, 2015, Plaintiff was admitted to Sibley Hospital for vertigo. She was advised to see an endocrinologist to evaluate her fatigue. (AR 1176-1178.)

         In March of 2015, Plaintiff was examined by Dr. Robert R. Jacobs, neuro-optometrist, who opined that Plaintiff's visual symptoms - blurred and double vision, light sensitivity, attention and concentration problems, headaches with reading, which are all common with patients suffering from long term concussion symptoms - intensified when she spent time on the computer or reading. Upon testing, he diagnosed several vision problems, and he recommended that she wear lenses while working on the computer, recommended her for physical therapy to address her symptomology, and anticipated a subsequent program of visual therapy that would eventually allow her to return to work. As a result of his March 2015 examination, Dr. Jacobs opined in a letter dated May 2, 2016, that Plaintiff was not ready to return to work at this time. (AR 1298-1305.) Physical Therapist Heather Carr issued a report on March 23, 2015, whereby she noted that Plaintiff demonstrated poor single leg balance and centering, postural and breathing dysfunction, muscular imbalances and myofascial trigger points on her body. (AR 1470.) On March 29, 2015, Plaintiff was evaluated by Dr. Clark and found to have no restrictions of daily living, moderate difficulties in maintaining social functioning, insufficient evidence of deficiencies of concentration, persistence or pace and no episodes of decompensation. Plaintiff was found to have psychological or behavioral abnormalities associated with a dysfunction of the brain evidenced by mood disturbance and emotional impairment in impulse control. Dr. Clark based her evaluation on observations of the Plaintiff in a controlled office setting, as opposed to objective data. (AR 1185-1187.)

         On May 4, 2015, Physical Therapist Heather Carr reported that Plaintiff was tolerating between 5 minutes and 1 hour of walking, but she had more fatigue and pain on days following the days when she did more walking. She experienced tachycardia and some nausea when moving from supine to sitting and sitting to standing; this improved when she directed her visual attention elsewhere. (AR 1469.)

         On May 13, 2015, Plaintiff had an office visit with Dr. Heechin Chae, at MedStar, who took over for Dr. Kraus. Dr. Chae reviewed Plaintiff's records and medications and noted that Plaintiff complained of blurry vision, numbness, loss of balance, anxiety and depression. Plaintiff's pain was a 7/10. Dr. Chae ordered a sleep study for Plaintiff and he asked her to talk to Dr. Clark and suggested that she pace herself and work on improving her confidence, which had been affected by the loss of her career, leisure activities and her identity because of her injuries. Dr. Chae suggested further that Plaintiff work with her current PT and engage in vision therapy in the future. (AR 1328-1331.) On May 18, 2015, Plaintiff met with Dr, Clark, and they devised a plan for reimplementing strategies for organization and pacing. Plaintiff was scheduled for a follow-up n two weeks because of her low mood. Dr. Clark opined that mood, pacing and management of stress were areas requiring further intervention. (AR 1427-1428.) On June 26, 2015, Plaintiff had a follow-up visit with Dr. Chae, and she reported the same complaints as previously reported. Plaintiff was to taper off the Zoloft and replace it with Wellbutrin, and once that was done, she would engage in a neurostimulant trial. Plaintiff would also participate in speech therapy for her cognitive disorder. (AR 1333-1336.)

         The July 10, 2015 treatment note by Dr. Clark regarding Plaintiff's office visit indicates that Plaintiff was attempting to address her light sensitivity, eye pain and sleep disturbances by wearing an eye mask at night and sunglasses frequently. She was in physical therapy to build her stamina and endurance. Plaintiff reported negative emotions regarding not being able to work at the present time. Plaintiff discussed mentoring young employees at her former place of employment. (AR 1319-1320.) On August 28, 2015, Plaintiff followed up with Dr. Chae, and she reported that the Wellbutrin was working well, and the PT improved her balance, but her sleep was slightly worse. Plaintiff complained of chest pain at rest and with exertion, shortness of breath, dizziness, headaches, nausea and thirst. Her pain was rated an 8/10. Dr. Chae suggested a trial of Amantadine, a neuro-stimulant, to improve frontal lobe function and decrease negative symptoms, and an increase in Wellbutrin. (AR 1337-1340.) Notes from an office visit on October 9, 2015 with Dr. Clark indicated that Plaintiff was struggling with financial stress and relationship issues. (AR 1321.)

         In a report dated September 11, 2015, Plaintiff's Physical Therapist, Heather Carr, indicated that Plaintiff had been making steady progress, but she still continued to have significant impairments with auditory sensitivity, POTS, headaches, neck and jaw pain, which impacted her ability to read, work at a computer, or perform prolonged activity tasks, and as such she was unable to fulfill functional requirements for working. Plaintiff was engaged in physical therapy for at least six months during 2015 with Physical Therapist Heather Carr. (AR 1468.)

         Plaintiff followed up with Dr. Chae again on October 9, 2015, and she reported that while she noticed improvement with Amantadine, she stopped it because it was giving her random twitches. Her pain was rated a 7/10. Plaintiff was going to switch back to Zoloft and continue with the vestibular therapy but hold off on vision therapy. (AR 1343-1345.) Plaintiff also followed up with Dr. Clark on October 9, 2015, where she reported that she had been coping pretty well during the last few months although she was dealing with a lot of stress. They discussed breaking stressors into manageable parts and Plaintiff possibly finding a family therapist. (AR 1431)

         Treatment notes from November 13, 2015 by Dr. Clark indicate that Plaintiff was more positive about her improvement in her physical condition and cognitive process. Dr. Clark encouraged Plaintiff to set reasonable goals for herself, as it was noted that she tended to have very high expectations with resulting negative emotional reactions when these expectations were not met. (AR 1432.) On November 24, 2015, Dr. Gregory J. O'Shanick from the Center for Neurorehabilitation Services conducted an evaluation of Plaintiff. Dr. O'Shanick noted that Plaintiff felt she had reached a plateau and wanted to get better. (AR 1476-1512.)

         Ms. Tanja Hutbacker, Vocational Rehabilitation Services, opined on January 15, 2016, that Plaintiff was unable to return to work at this time due to her symptomatology related to POTS and injuries from her April 2012 concussion. She stated that, on a good day, Plaintiff could perform tasks for about 4-5 hours per day, with 2-3 breaks per day, ranging in time from 5-30 minutes each depending on the level of stress and stimuli during the active periods. The frequency of bad days was dependent on stress and activity. On a bad day, she collapses due to loss of stamina and blood pressure issues. On bad days, she can do about 30 minutes of simple activity followed by a 60 minute break. (AR 1514-1519.)

         On February 8, 2016, Dr. Weiss completed a POTS Residual Functional Capacity (“RFC”) Questionnaire, which indicated that Plaintiff's prognosis was guarded with significant improvement unlikely. Dr. Weiss noted that Plaintiff experienced lightheadedness, extreme fatigue, exercise intolerance, visual disturbances, headaches, muscle pain, weakness, fainting confusion, nausea, constipation, dizziness and self-reported impairment in short-term memory or concentration that is severe enough to cause a substantial reduction in previous levels of occupational, educational, social, or personal activities. Plaintiff also had experienced a racing heart and drop in blood pressure. Plaintiff's workday was frequently interrupted by her fatigue, dizziness or other symptoms that interfered with her attention and concentration. Plaintiff was found to be incapable of even “low stress” jobs because she could not sustain stimuli and exertion for an extended period, and she needed to be able to rest frequently and take unpredictable unscheduled breaks. At one time, she could sit for 45 minutes, stand for 20 minutes, and during the course of the day, she could sit for two hours and stand/walk for less than two hours. Dr. Weiss opined that Plaintiff would likely be absent from work about four days per month. (AR 1405-1409.)

         On May 31, 2016, Plaintiff was admitted to Sibley Memorial Hospital for approximately five days for treatment of a mediport infection. (AR 1550-1562.) On July 17, 2016, Plaintiff was evaluated by Dr. Gregory O'Shanick, who noted her thirteen diagnoses and concluded that her “chronic and permanent neurological, neuromedical and neurobehavioral disorders result in her being unable to engage in substantial gainful employment[.]” (AR 1547.) Dr. O'Shanick opined that Plaintiff was unable to verbally and visually process information in a timely manner or to communicate efficiently. She was at risk for falls and her ability to interact with her co-workers or supervisors was compromised as was her ability to plan, due to her fatigue, hypertension, headache, and her need to be out of work at least three times per month. Id.

         On July 24, 2016, Dr. Jacobs opined that Plaintiff suffers from symptomology that is consistent with her concussion and dysautonomia, and she was showing modest gains since beginning treatment. Dr. Jacobs noted that when Plaintiff was exposed to sustained periods of work on a computer, fluorescent lighting and noisy environments, her condition worsened. Even with controlled exposure to stimuli, she experienced headaches and dizziness. Accordingly, he concluded -based on his clinical observations- that Plaintiff could not endure the exposure required from full and consecutive days of work, which would cause her condition to deteriorate. (AR 1549.)

         2. Function Reports

         Plaintiff filed her Function Report on May 21, 2014, noting limitations in standing, walking, sitting, completing tasks, and concentration. Plaintiff indicated that she had to put her IV bag on for two and one-half hours each morning. In the morning, she awoke at 6:30 a.m., ate breakfast, straightened the house and helped to get her children out the door for school She sometimes walked her children to school. Her day was spent making phone calls, taking a walk, making herself a simple meal, resting in the afternoon, reading for about an hour, and sometimes making dinner. After dinner, she would read, watch television or draw before going to bed at 9:00 p.m. She described being dizzy or fatigued when she tried to dress or wash her hair and using an alarm clock to remind herself of her medications. A nurse would stop by once or twice a week to check on her and she would get a three-hour long injection of gamma globulin. She indicated that she could drive a car and shop for groceries by leaning on the cart for support. She could pay bills, but she was not always accurate. She could shop for short periods online or play games on the computer once a week, watch television once a month, read twice a week, but she did so less often than previously because she would get dizzy and fatigued. She had an alarm on her phone to remind her to go places and usually needed someone to accompany her to places that had a lot of stimuli, such as her son's soccer games and church, as the stimuli made her too weak to drive home. She indicated that she had trouble squatting, bending, standing, reaching, walking, sitting and kneeling because of dizziness and weakness. She indicated further that she had short term memory loss and difficulty understanding, following instructions and with concentration, and that she would write down instructions and read them several times. She had ringing and pain and pressure in her ears. Plaintiff stated that she did not handle stress well - she became weak and collapsed when under stress, or she would get irritable. She had to have a routine to keep herself on task. She sometimes used a cane that had been prescribed. She was taking Ritalin and Zoloft. (AR 243-252.)

         Plaintiff's husband filed a Function Report-Third Party on June 10, 2014. He indicated that his wife was easily fatigued and in near constant pain, weak and unsteady after exertion, with limited mental focus. Stress or too much stimuli caused her to collapse and she often woke up during the night. She could go to her doctor's appointments, occasionally care for the children or make dinner, do light housework, occasionally go grocery shopping, try to walk, but she often needed assistance and always had to plan everything carefully. She struggled to complete tasks and was forgetful and unreliable. She sometimes used a cane, walker or wheelchair. She could follow short instructions but was overwhelmed if instructions were complicated. He estimated that his wife did about 10% of what she used to do. (AR 264-272.)

         3. Testimony at the ...

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