PAUL ZOSS, Magistrate Judge
APPENDIX A — MEDICAL RECORDS SUMMARY
I. INTRODUCTION
The plaintiff Kara McGee ("McGee") appeals a decision by an administrative law judge (" ALJ") denying her Title II disability insurance ("DI") benefits. McGee argues the ALJ erred in (1) improperly discounting her treating physicians' functional capacity assessments; (2) failing to make a proper Polaski analysis; and (3) relying on a faulty hypothetical question. McGee argues that because of these errors, the Record does not contain substantial evidence to support the ALJ's decision denying her claim for benefits. ( See Doc. No. 14) II. PROCEDURAL AND FACTUAL BACKGROUND A. Procedural Background
On November 30, 1998, McGee filed an application for DI benefits, alleging a disability onset date of November 1, 1998. (R. 30, 150-52) The application was denied initially and on reconsideration. (R. 135-36, 137-40, 143-47)
McGee requested a hearing, and a hearing was held before ALJ John P. Johnson in Waterloo, Iowa, on May 3, 2000. (R. 67-116) Attorney Richard Vickers represented McGee at the hearing. McGee testified at the hearing, as did Delores Gray White, Jennifer Sue Keeling, and Vocational Expert ("VE") Steven Moats. On November 16, 2000, the hearing was reconvened to take testimony from Paul From, M.D., and additional testimony from McGee. (R. 117-134)
On April 18, 2001, the ALJ ruled McGee was not entitled to benefits. (R. 27-41) On June 7, 2001, McGee requested review by the Appeals Council (R. 21-22), and on April 12, 2002, the Appeals Council denied McGee's request (R. 9-10), making the ALJ's decision the final decision of the Commissioner.
McGee filed a timely Complaint in this court on June 26, 2002, seeking judicial review of the ALJ's ruling. (Doc. No. 3) On September 9, 2002, the parties consented to jurisdiction by the undersigned United States Magistrate Judge, and Chief Judge Mark W. Bennett transferred the case to the undersigned. (Doc. No. 6) McGee filed a brief supporting her claim on February 27, 2003. (Doc. No. 14) On April 21, 2003, the Commissioner filed a responsive brief. (Doc. No. 18) The court now deems the matter fully submitted, and pursuant to 42 U.S.C. § 405(g), turns to a review of McGee's claim for benefits.
B. Factual Background
1. Introductory facts and McGee's daily activities
At the time of the hearing, McGee was a 38-year-old widow living in Clarksville, Iowa. (R. 71) She was 5"2" tall, and weighed 220 pounds. (R. 85) She had a valid, unrestricted driver's license, and drove about 150 miles each week. ( Id.)
In 1986, she received her G.E.D. (R. 71) She also received some training to be a nurse's aide, but worked as a nurse's aide for only about two weeks. (R. 72) For the remainder of her fifteen-year employment history, she provided child care to as many as ten children at a time. ( Id.) Because of health problems, for the eighteen months preceding the ALJ hearing, McGee cared for just two children, and McGee's mother and a neighbor helped watch them because McGee was not able to watch them on her own. (R. 72, 76-77) She received $60 per week for watching the children. (R. 79-80) One of the children was seven months old, and the other was three-and-one-half years old. (R. 78)
McGee explained that she had an ileostomy in 1978, when she was about 16 years-old. (R. 73, 87) About four years before the hearing, she developed insulin-dependent diabetes. (R. 73, 88) She also has arthritis, and she recently discovered she has "liver failure." (R. 73) She has migraine headaches two or three times a week, but takes medicine to control the condition. (R. 74, 88) She also suffers from depression. (R. 74) In the past, she has had carpal tunnel syndrome. (R. 75) She suffers from ulcerated colitis, or Crohn's disease. (R. 79, 89) She also has had her gall bladder removed. (R. 79)
She testified that when she feels a migraine headache coming on, she takes the medication and lies down in her room for twenty minutes to an hour, and the headache usually goes away. (R. 88)
McGee testified that she spends about a day-and-a-half each week in doctors' offices, emergency rooms, and hospitals. (R. 76) She frequently suffers from dehydration, and has had a port installed in her chest so she can receive intravenous fluids more easily. (R. 82-83) Shortly before the hearing, she had a procedure where they injected her spine to treat pain in her back and hips. (R. 81) She also had another procedure where her doctor cleaned out a pocket of pus that had formed at her rectum, a recurring side-effect of her ileostomy. (R. 82)
McGee described her typical day as follows. She gets up in the morning between 7:00 a.m. and 7:30 a.m. (R. 93) She eats breakfast, and then spends the morning watching television with the two children she cares for. (R. 94) The children then have lunch. She puts them to bed for a nap at about 1:00 p.m. ( Id.) While the children are napping, McGee usually lies down with them. (R. 77, 94) The children ordinarily sleep until someone picks them up, between 3:30 p.m. and 4:00 p.m. (R. 94) After the children leave, McGee cleans up the house if she feels up to it, and then cooks supper, does the dishes, and watches television. (R. 95) She attends church every Sunday. ( Id.)
McGee's ostomy runs continuously, and she has to empty the bag about twenty times a day. (R. 77) It takes her five to ten minutes to empty the bag. ( Id.) McGee is unable to stand on her feet for long periods of time because of pain in her hips and back. ( Id.) When asked if she can lift the children she watches, she testified she can lift the baby, who weighs sixteen pounds, but she cannot lift the older child. (R. 78, 91) Sometimes she can do housework, but other times she cannot do anything. (R. 78) She goes to bed at about 8:30 p.m., but has problems sleeping. (R. 93-94)
McGee can walk about three or four blocks at a time, until her hips start hurting. (R. 90) She can stand for about twenty minutes at a time. ( Id.) Her knees give her problems when climbing stairs, bending, stooping, kneeling, or squatting. ( Id.) Her hands go to sleep if she writes for more than a half hour. (R. 90-91) She can sit for "a couple hours." (R. 91) Her back hurts when she reaches her arms over her head. (R. 92) She has some difficulty remembering things. ( Id.) When faced with stress, she cries easily. ( Id.)
At the time of the hearing, McGee was taking the following medications on a daily basis: opium and liquid potassium, for ostomy maintenance; Celebrex, for arthritis; Neurotin, for diabetic neuropathy; Paxil, for depression; Prevacid, for ulcers; Demadex, as a "water pill;" Propranolol, for blood pressure and migraines; Trazodone, as a sleeping pill; Insulin N and Humalog, for diabetes; Zyrtec and Flonase, for allergies; Buspar, for anxiety; and non-prescription magnesium, Metamucil, and aspirin. (R. 74-75; 221) She also was taking Imitrex, on an as-needed basis, for migraines. (R. 75)
McGee's mother, Delores Gray White, also testified at the hearing. At the time of the hearing, White had been living with McGee for about one year. (R. 95-96) White had moved in with McGee after McGee's husband had died, and because both White and McGee are disabled, they decided they could help each other. (R. 96) White believes McGee is "goin' down hill, quite a way." ( Id.) White testified that both she and her daughter work together to care for the children. (R. 97)
McGee also called Jennifer Sue Keeling, an acquaintance, as a witness at the hearing. (R. 99) Keeling has known McGee since 1993. (R. 100) At the time of the hearing, McGee was babysitting for Keeling's two youngest children. ( Id.) Keeling testified that about once a week, she has to find alternative childcare arrangements for her children because McGee is having physical problems. ( Id.) According to Keeling, McGee is not physically capable of caring for more than her two children. (R. 104) In order to keep her two children with McGee, Keeling makes many allowances that most parents would not make. (R. 106-07)
2. McGee's medical history
A detailed chronology of McGee's medical history is attached to this opinion as Appendix A. The earliest medical documentation in the Record relating to her claim of disability is a March 1997 report of a hospitalization for dehydration at the Waverly Municipal Hospital. (R. 223-39) McGee gave a history of a permanent ileostomy secondary to a total colectomy for ulcerative colitis. (R. 223) She came to the hospital because she had lost large volumes of fluid through her ileostomy and from vomiting. (R. 225) Her condition was brought under control after a three-day hospitalization. ( Id.)
Later in March 1997, McGee again was seen at the Waverly Municipal Hospital, for Type I insulin dependent diabetes mellitus. (R. 241) She was referred for self management education. ( Id.)
In April 1997, McGee was admitted to the Waverly Municipal Hospital for two days for "dumping syndrome and dehydration." (R. 246) Her condition was brought under control with IV fluids. ( Id.) She was hospitalized again in July 1997, for the same problem. (R. 255) In the records of that hospitalization, her diabetes is described as Type II, controlled with diet and oral medication. ( Id.) She was discharged after two days, but a day later she was readmitted for three days because of weakness and severe diarrhea. (R. 263)
On August 22, 1997, McGee was seen at the hospital for headaches and dizziness. (R. 265) A CT scan of her head was negative. (R. 267)
McGee was hospitalized for dehydration on September 9, September 28, and December 31, 1997, and January 1, 1998. On January 22, 1998, she was seen by Dawn Morey, D.O. for complaints of abdominal pain. (R. 293) Dr. Morey observed lesions on the periphery of McGee's stoma, and ordered an upper GI panendoscopy with biopsy. ( Id.) The test was performed, and Dr. Morey determined that McGee had a gastric ulcer and small papilloma on her stoma, and gastroparesis. (R. 289) McGee saw Dr. Morey again on January 26, 1998. (R. 493) On January 28, 1998, Dr. Morey performed an endoscopy, and diagnosed McGee as suffering from a lymphoid hyperplasia in the small bowel. (R. 298)
On February 3, 1998, McGee went to the hospital complaining of "dramatic diarrhea with dehydration." (R. 309) On February 4, 1998, she had an abdominal X-ray, and it appeared she had a partial small bowel obstruction. (R. 305) This diagnosis was supported by a CT scan on February 5, 1998. (307) On February 20, 1998, a revision of ileostomy surgery was performed on McGee to open up her small bowel. (R. 310-13) After the surgery, McGee developed an allergic reaction to the stoma appliance, but the reaction resolved after treatment. (R. 491-93)
On April 27, 1998, McGee was seen for right leg pain by Lee O. Fagre, M.D., at the Waverly Municipal Hospital. (R. 314-16) A CT scan showed mild to moderate degenerative changes in her lower spine, with no herniations but some bulges, most prominently at L4-5 and L5-S1. (R. 316)
On March 8, 1998, McGee was admitted to the hospital complaining of marked output from her ileostomy and dehydration. (R. 317) She was hospitalized for three days, and treated with intravenous fluids and antibiotics. The final diagnosis was gastroenteritis with marked output from ileostomy causing dehydration, leukocytosis, urinary tract infection, non-Insulin-dependent diabetes mellitus, hypertension, hyperlipidemia, and gastroesophageal reflux disease. (R. 317) On June 19, 1998, McGee was admitted to the hospital for three days because of chronic dumping syndrome, with secondary dehydration and underlying abdominal pain. (R. 341) Drs. Morey and Fagre decided to refer McGee to the University of Iowa Hospitals and Clinics for a consultation. ( Id.)
On July 6, 1998, McGee was seen at the Center for Digestive Diseases at the University of Iowa. (R. 355-59) In a report, Robert W. Summers, M.D., a doctor with the Center, recited the following medical history:
[McGee's] past medical history is significant for a history of ulcerative colitis since the 1970s. The disease required colectomy, ileostomy and later revision of the ileostomy in February of 1998; history of adult diabetes mellitus since April of 1995; history of obesity; history of hypertension since February of 1996; history of hyperlipidemia.
(R. 355) Dr. Summers made the following assessment:
Intermittent crampy abdominal discomfort with high ostomy output. At this time based upon her history of multiple abdominal surgeries for her Crohn's disease, there was a concern that the patient may have recurrent bowel obstruction. Thus, the patient has been scheduled for a small-bowel series. These tests will help us rule out Crohn's disease as well as to evaluate for possible evidence of a bowel obstruction. In the meantime, the patient was encouraged to force fluids. Interestingly to note, the patient's electrolytes obtained yesterday were all within normal limits.
(R. 356) The findings from an "upper G.I. with small bowel series" were "suggestive of gastritis and prior ulcer disease. No active Crohn's disease identified. No evidence for stricture." (R. 357) A gastrointestinal endoscopy indicated "normal ileoscopy without evidence of inflammatory bowel disease or stenosis." (R. 358) A biopsy of the ileum was normal. (R. 359)
On July 12, 1998, McGee went to the Waverly Municipal Hospital, complaining that she felt weak and clammy. (R. 360) The following day, she returned, complaining of leg cramps. (R. 419) She went to her doctor complaining of anxiety, dehydration, and bowel problems on July 15, 21, and 27, August 5, 14, and 27, and September 3, 1998. (R. 415-18) She was hospitalized on September 3, 1998, for more aggressive therapeutic intervention, including the administration of IV fluids. (R. 375) The assessment of Joseph Berdecia, M.D. was "probable transient viral gastroenteritis." (R. 378)
On September 10, 1998, McGee complained to her doctor of headaches. (R. 416) She was diagnosed as suffering from acute sinusitis. ( Id.) She returned to her doctor with the same complaint the next day. ( Id.) On September 17, 1998, she complained to her doctor of left arm irritation. (R. 413) She was diagnosed as suffering from dermatitis at her IV site. ( Id.) She went to the hospital on the following day for physical therapy to treat the arm pain. (R. 379-82) On September 21, 1998, McGee was seen by her doctors for diarrhea. (R. 414) On September 24, 1998, she was seen for a headache. (R. 413) On October 3 and 28, 1998, she again was seen for bowel problems. (R. 414, 383-85) Her claimed disability onset date is November 1, 1998.
On November 3, 1998, McGee was hospitalized for diarrhea and dehydration. (R. 389) She was discharged the following day. ( Id.) On November 6, 1998, she was seen in the emergency room for migraine headaches. (R. 390-91) On November 11, she was hospitalized for dehydration, severe hypertension, colitis, diarrhea, migraine headaches, diabetes, and depression. (R. 393) Dr. Berdecia noted that McGee's husband had died recently, and she was going through a grieving process. ( Id.) The doctor prescribed oral Prelone, Naprosyn liquid, Lotrel, Propulsid, Prozac, and Prevacid. McGee also was told to take Midrin as needed for headaches. ( Id.) She was discharged on November 15, 1998. ( Id.)
On November 18, 1998, McGee was seen by her doctor for high output from her ostomy. (R. 407, 411) She also was having problems with her blood sugar. (R. 407) On December 2, 1998, she saw her doctor because of colitis, poor control of her diabetes, headaches, and sleeping problems. (R. 406) On December 4, 1998, she called her doctor about sinus headache pain. ( Id.) She called again on December 10, 1998, complaining of a severe headache and a shaky feeling, and her medication was adjusted. (R. 404-05) She saw her doctor about her headaches again on January 6, 1999. (R. 597) A CT scan on January 8, 1999, confirmed that she was suffering from acute sinusitis. (R. 596)
On January 11, 1999, McGee again was hospitalized for dehydration from high ostomy output. (R. 423) She was treated with aggressive IV fluid hydration and antibiotics, and was discharged the following day. ( Id.) She reported headaches again on January 13 and 15, 1999. (R. 595-96)
On January 15, 1999, Dr. Berdecia wrote to the Iowa Department of Transportation, stating McGee had a permanent handicap because of her diabetes, severe hypertension, and colitis. (R. 424)
From January 17 to 19, 1999, McGee was hospitalized for dehydration. (R. 425-33, 631) She was rehydrated, and her insulin-dependent diabetes was treated. (R. 426) Dr. Fagre stated McGee was "well known to this service with a long standing history of recurrent gastroenteritis and a dumping syndrome from an ileostomy due to ulcerative colitis." ( Id.) On January 22, 1999, she was again admitted to the hospital for high ostomy output and headaches. (R. 434-39, 627) On January 25, 1999, after reviewing the results of laboratory tests, Dr. Berdecia diagnosed McGee as suffering from hypotension, hypokalemia, diabetes, and colitis. (R. 446) She was transferred to the Mayo Clinic. (R. 450)
From January 25 to 29, 1999, McGee was examined at the Mayo Clinic. (R. 447-57) Several tests were performed to identify the cause of her increased ileostomy output, but all were negative except for a suggestion of bacterial overgrowth. She was put on an antibiotic cycle to treat the bacteria. (R. 451) The Mayo doctors determined that McGee's diabetes was not well controlled because she had not been following her diabetic diet. McGee was given instructions about her diet, and her medication was adjusted. ( Id.) She was discharged with no functional restrictions. (R. 452) Lisa A. Boardman, M.D. wrote the following in McGee's discharge report:
My impressions and recommendations are as follows:
• Increased ileostomy site output
Mrs. McGee had had an ileostomy placed approximately 20 years ago, and in March 1997 she underwent an ileostomy revision. She has since had increased output from her stoma with multiple admissions for diarrhea which has resulted in hypomagnesemia, hypokalemia, and dehydration. She came to Saint Marys Hospital on January 26, 1999, and had an esopha-gogastroduodenoscopy which revealed that she had no evidence of mucosal disease within the first section of the small intestine; however, an aspirate grew 100,000 colony-forming units consistent with bacterial overgrowth. As well, she underwent an ileostomy which showed normal small bowel mucosa. She had a CT scan of the abdomen and pelvis on January 26, 1999, which was normal. Her small bowel follow-through on January 27, 1999, showed normal bowel without evidence of mechanical obstruction. It was believed that the portion of the increased stool output that was associated with dehydration was related to her diet. For this reason, she was instructed on the use of Ceralyte as well as magnesium and potassium replacements orally. She was also instructed to follow her diabetic diet more carefully. She will use Ceralyte sipping solution in order to try to maintain her electrolyte balance. It was also recommended that if she notices that her stool output increased significantly that she have laboratory tests done to determine if she is developing electrolyte imbalances. We also recommended that she follow her stool output by measuring it on a daily basis. A fluid restriction of 1.5 liters also led to a great decrease in her stool output to approximately 1.5 liters a day.
• Bacterial overgrowth
It was felt that the bacterial overgrowth is a component of her increased stool frequency, and she was begun on Ciprofloxacin 500 mg twice a day for the first five days of the month alternating with another antibiotic for the first five days of the other month. She may need to be on this chronically, but after three months of antibiotic therapy, she will have a trial without antibiotics to determine the need for long-term antibiotic treatment.
• Diabetes mellitus
She was evaluated by the Diabetes Service who simplified her regimen. They also recommended discontinuation of Glucophage because this may aggravate diarrhea. She had a glycosylated hemoglobin of 6.6 on admission.
• Ulcerative colitis
She is not having any apparent difficulty in terms of pouchitis or extraintestinal manifestations of ulcerative colitis since her colectomy.
• Electrolyte imbalances
This was, again, felt to be related to the increased output through her stoma; and she is to follow the measures as outlined above.
(R. 447-48)
On January 30, 1999, the day after her discharge from the Mayo Clinic, after staying up late the night before at a concert, McGee was admitted to the Waverly Municipal Hospital with dehydration, hypertension, low borderline potassium, and low magnesium. (R. 458-68, 619-20, 594) She was given IV fluids, magnesium, and potassium. On February 9, 1999, she was admitted to the hospital for vomiting and abdominal pain. (R. 472-73) She was rehydrated with IV fluids. (R. 472) Tests suggested possible kidney problems. ( Id.) She was referred for counseling and possibly a psychiatric evaluation for depression. ( Id.)
On February 12, 1999, she was seen at the Waverly Municipal Hospital emergency room, complaining of abdominal pain. (R. 478) She was given IV fluids, Demerol, and Vistaril. ( Id.) At a follow-up visit with Dr. Berdecia on February 17, 1999, she reported she was feeling better, but was still having problems with output. (R. 593) She returned to her doctor on February 24, 1999, complaining of swollen legs. (R. 592)
On March 2, 1999, a licensed mental health counselor reported she had visited with McGee twice, and McGee appeared to be struggling with grief over the death of her husband. (R. 485) On March 3, 1999, McGee saw her doctor about her diabetes, hypertension, and sleeping difficulties. (R. 592) On March 10, 1999, she saw her doctor for severe abdominal pain and sinusitis. (R. 591) A pelvic CT performed on March 12, 1999, was negative. (R. 487) She returned to her doctor on March 19, 1999, with continued complaints of pelvic pain, and unusual headaches. (R. 590) On March 22, 1999, she saw her doctor again about constant, dull, upper-quadrant pain, with occasional sharp pain and a persistent headache. (R. 591) On March 23, 1999, she complained to her doctor about continued pelvic pain, difficulty breathing, and knee and joint pain. (R. 590)
On March 29, 1999, John A. May, M.D. completed a Physical Residual Functional Capacity Assessment for DDS. (R. 494-501) He determined McGee could lift fifty pounds occasionally and twenty-five pounds frequently; stand and/or walk for about six hours in an eight-hour workday; and sit, with normal breaks, about six hours in an eight-hour workday. She had no limitations on her ability to push or pull. She also had no postural, manipulative, visual, communicative, or environmental limitations. Dr. May concluded McGee's allegations were "consistent and credible." (R. 502) He stated, "She is currently taking care of children in her home. No limitations have been placed by her treating sources. The RFC is a reflection of the body of evidence contained within the file." ( Id.)
On April 7, 1999, McGee saw her doctor about crying spells, apparently resulting from continuing grief over the loss of her husband. (R. 589) She was diagnosed as suffering from an adjustment disorder with depressed mood, and her medication was adjusted. ( Id.) On April 27, 1999, she saw her doctor about elevated blood sugar, dysmenorrhea, and headaches. (R. 588) Her medication again was adjusted. ( Id.) She returned to the doctor the same day for burning and shooting pain in her head. She was given Nubain and Vistaril. ( Id.) On the following day, April 28, 1999, she called to report that she had awakened with a "terrible" headache. ( Id.) On April 29, 1999, she called to report her headache was severe, and her face felt like it was burning. (R. 587) On April 30, 1999, she called her doctor about her headaches, and then went to the emergency room. She was sent home with instructions to rest. (R. 506) An MRI of her head and an EEG, both performed on May 5, 1999, were normal. (R. 511-13) On May 7, 1999, McGee saw Brian Sires, M.D., a neurologist, about the headaches. (R. 514-15) Dr. Sires recommended McGee's hormone replacement regimen be changed or discontinued. (R. 514) He commented, "I understand [Dr. Berdecia has] already initiated this." (R. 514) McGee's headaches continued throughout May and June 1999, with frequent visits to her doctor and to the hospital.
On July 27, 1999, Gary J. Cromer, M.D. completed a Physical Residual Functional Capacity Assessment for DDS. (R. 523-30) He determined McGee could lift twenty pounds occasionally and ten pounds frequently; stand and/or walk for about six hours in an eight-hour workday; and sit, with normal breaks, about six hours in an eight-hour workday. She had occasional postural limitations, but no limitations on her ability to push or pull, and no manipulative, visual, communicative, or environmental limitations. Dr. Cromer concluded as follows:
Subjective reports reveal numerous inconsistencies. Claimant has a history of dietary noncompliance that was determined to be the primary factor in causing her GI symptoms. Despite her ongoing GI allegations, she hasn't been hospitalized for same since 2/99 while gaining 25#. She has exhibited drug-seeking behavior and overuse of narcotics, and has been non-compliant in following up with her neurologist regarding her headaches. These inconsistencies have eroded claimant's credibility.
(R. 531)
On August 18, 1999, Glenn F. Haban, Ph.D. completed a psychological evaluation of McGee for DDS. (R. 533-36) His diagnosis was as follows: "Ms. McGee is currently functioning within the normal range for orientation and cognitive capacity. The mental status examination suggests bereavement. No other Axis One Disorders were identified." (R. 535)
On August 31, 1999, McGee was seen at the Waverly Municipal Hospital for bleeding spots on her stoma. (R. 642) McGee reported that the spots had been present for several weeks. ( Id.) She also reported that her ostomy appliance was not fitting well, and was leaking on occasion. ( Id.) Dr. Morey noted McGee's ostomy output was better, but also observed there was granulation tissue on the ostomy with bleeding. ( Id.) Dr. Morey had McGee return to the hospital on September 2, 1999, so the granulation tissue on the stoma could be excised and sutured. McGee was told to follow up with an ostomy nurse to get a better fitting ostomy appliance. ( Id.)
On September 24, 1999, Dr. Berdecia wrote the following to McGee's attorney:
This letter is concerning Ms. Kara McGee. . . . This lady has had extensive medical problems that include the following: She has problems with Severe Hypertension, Insulin Dependent Diabetes, has been diagnosed with Colitis at an early age of 16. This lady indeed was one of the very first patients that underwent a colostomy procedure in Iowa City about twenty plus years ago. By their own recommendation they never expected her to last this long with a colostomy because of her medical problems. She has bouts where she has multiple problems that include chronic and persistent diarrhea that over the last two years have required multiple hospitalizations with the problem of developing severe problems with electrolyte imbalance. She has not only been seen in Iowa City [but] also has been seen in Mayo Clinic as you could probably surmise from copies of her medical records. She is on multiple medications for treatment of the above mentioned conditions as well as the medications she requires because of recurrent migraine headache. Obviously in terms of being able to obtain employment with all these medical conditions it would be extremely hard if not impossible at best since this will be a kind of person that obviously will spend most time out at any work place.
(R. 679)
On September 30 and October 1, 1999, tests were performed on McGee's gallbladder and liver. (R. 571, 573) She was found to have three gallstones, and probable diffuse fatty infiltration of the liver. On October 8, 1999, after another episode of abdominal pain, her gallbladder was removed. (R. 556-58)
On October 4, 1999, Beverly Westra, Ph.D. completed a Psychiatric Review Technique form and a Mental Residual Functional Capacity Assessment form. (R. 539-47, 551-54) Dr. Westra concluded McGee had an adjustment disorder with depressed mood (R. 542), but she otherwise had no psychiatric problems. Dr. Westra found McGee would be limited slightly in the activities of daily living and maintaining social functioning, and often would be deficient in concentration, persistence, or pace. (R. 546) She found McGee's mental functioning was not significantly limited, except for moderate limitations in the ability to understand, remember, and carry out detailed instructions, and the ability to maintain attention and concentration for extended periods. (R. 551) Dr. Westra concluded McGee's "[a]ttention and concentration would be adequate for most simple tasks, but moderately impaired for highly complex or detailed information and for sustained attention for prolonged periods of time." (R. 555)
On November 1, 1999, Dr. Morey surgically placed an "L internal jugular Titan port" in one of McGee's veins because of the "[n]eed for long term IV access." (R. 559) On November 6, 1999, McGee went to the hospital complaining of headaches, and she saw her doctor on November 10, 1999, still complaining of headaches. (R. 577, 666) On November 12, 1999, she went to the hospital for dehydration, and was given IV fluids through her port. (R. 638) On November 15, 1000, she saw her doctor for headaches and dizziness. (R. 576)
On November 18, 1999, McGee was seen by Suresh Reddy, M.D., a gastro-enterologist, for abnormal liver enzymes. (R. 644-45) Dr. Reddy's diagnosis was as follows:
Elevated liver enzymes with liver biopsy showing fatty liver. Intraoperative cholangiogram apparently was abnormal, showing some strictures in the bile ducts, suggestive of P.S.C.
(R. 645)
On November 21, 1999, McGee was seen at the Waverly Municipal Hospital for increased ostomy output during the previous two days, and for achiness, sweating, headaches, and nausea. (R. 646) She was told to rehydrate orally. (R. 647) She saw Dr. Fagre on November 27, 1999, for vomiting, diarrhea, body pain, fever, chills, sweats, and difficulty urinating. (R. 575) She was sent to the hospital, where she was re-hydrated, and she was discharged on November 29, 1999. (R. 651)
On December 8, 1999, Dr. Reddy evaluated McGee for profuse diarrhea and increased ostomy output since her gallbladder surgery. (R. 653) He referred her to Dr. Reedy for an ERCP. After the procedure, Dr. Reddy diagnosed multiple strictures in the intrahepatic duct suggestive of sclerosing cholangitis. (R. 655) Dr. Reddy commented that there are no specific medications available to treat the condition. ( Id.) In a follow-up report, Lawrence Liebscher, M.D. presented several possibilities that could explain this problem, but reached no conclusions. (R. 654) In a pathology report from the Mayo Clinic dated December 14, 1999, the pathologist noted "histologic findings are consistent with small duct primary sclerosing cholangitis, stage 2-3." (R. 667)
ERCP is shorthand for Endoscopic Retrograde Cholangiopancreatography, which is a diagnostic procedure used primarily to examine the bile ducts, gallbladder, duodenum, and pancreatic duct.
In an opinion letter dated December 14, 1999, Roger L. Skierka, M.D., one of McGee's treating physicians, wrote the following:
Kara is a young lady who has a long history of a diagnosis of ulcerative colitis. As a young child she did have surgical removal of a large section of her colon. Since that time she has had a colostomy bag to help with her bowel movements. Complications of that include arthritis from which she is currently suffering. She also has a history of liver changes. She recently underwent a cholecystectomy to remove her gallbladder and subsequently had elevated liver function tests at that time. She recently had a liver biopsy which the results are pending but it did show some chronic signs of change secondary to what was presumed to be the ulcerative colitis.
The patient is also suffering from diabetes mellitus for which she does require insulin. Although her blood sugars have currently been under good control she has had a history of poor control over this problem.
She also suffers from depression and anxiety attacks as well. She is on an extensive amount of medicines for the GI upset secondary to the ulcerative colitis. We have a very difficult time managing her medical problems but with the assistance of specialists in Waterloo and with verbal assistance from Iowa City and Mayo[,] we have been able to maintain good relationships with her and keep her out of the hospital for an extended period of time.
We are requesting at this time any assistance you can give us in regards to this [patient's] medical problems and her inability to function in an employment status. Because of her diabetic problem, arthritis and other problems associated with her ulcerative colitis[,] we do not feel that she is capable of working outside of the home.
Although she is attempting to do everything she can to maintain her own ability to function on her own, she is having a very difficult time. Any assistance that can be given at this time would be deeply appreciated.
(R. 657-58)
On April 5, 2000, McGee went to the hospital because of dehydration after twenty-four hours of vomiting. (R. (671-72) On April 10, 2000, Dr. Morey performed a "[r]ectal exam under anesthesia and curettage of abnormal mucosa versus granulation tissue." (R. 675)
On April 19, 2000, Dr. Skierka wrote another letter, and supplemented his earlier opinions as follows:
She did have her gallbladder removed several months ago secondary to an acute inflammatory reaction of that organ. It was in hopes that this would help resolve some of the liver problems as the two are closely related. Unfortunately after discussing this in detail with him, the Gastroenterologist Dr. Reddy, stated that he felt the patient was going to eventually develop more liver complications secondary to the ulcerative colitis. In light of this we do have to monitor her liver function tests on a 6 month basis and maintain close regulation of that to help avoid any problems. She also subsequently has type I or insulin dependent diabetes. Her numbers have been under decent control recently. She takes a significant amount of insulin to help control this diabetic problem. She is suffering from depression at this time. Because of her medical problems she is on a lot [sic] of different medicines at this time. She has frequent physician visits both to primary care physicians such as myself and to specialist[s] such as the surgeon. The surgeon recently did a procedure on the patient to remove a cyst in her abdominal region.
It was an infectious agent in a fistula forming body. This is just another complication that this [patient] has to endure due to her chronic ulcerative colitis and the manifestations of that disease. She is now starting to develop the arthritis that is also associated with the ulcerative colitis. She also has a subsequent risk of developing cancer associated with the ulcerative colitis.
* * *
In light of her many medical problems and the need to frequently visit physicians for these problems it is felt that any assistance that can be provided for this patient would be greatly appreciated by both the medical professionals and also by the patient. . . . She is . . . unable [to do] most types of manual labor due to the arthritis and the chronic problems that she suffers from.
(R. 677-78) Dr. Skierka wrote a third letter on November 1, 2000, stating, in part:
It is my medical opinion that this woman does have significant disability due to her chronic medical problems. Taken individually, I am sure most people could handle hypertension without any problem or diabetes without any problem or depression. Unfortunately this woman has a combination of many medical problems that have caused a significant debilitation.
(R. 688)
On August 23, 2000, after the initial administrative hearing in this case, Paul From, M.D., an internist, reviewed the medical records in the case at the ALJ's request and answered certain interrogatories. (R. 681-86) In his answers, Dr. From stated that McGee has severe impairments, but no specific impairment meets the Listing criteria. He stated, "There is no documentation that the impairment is disabling other than for statement[s] from 2 attending physicians. These opinions differ somewhat from listed objective criteria in previous evaluations." (R. 682) He further stated when "compliance [with the prescribed treatment] was good, the problems with ileostomy output and electrolyte imbalance seemed to be under fairly good control. However, the development of depression and then the cholangitis later occurred. The attending physicians do not comment upon non-compliance, but this is readily apparent in other documents in [the Record]." (R. 683)
On November 16, 2000, at the request of McGee's attorney, Dr. From testified before the ALJ. (R. 119-32) Dr. From testified he is board certified in internal medicine. (R. 120-21) He was retained by the Social Security Administration to review McGee's medical records and to answer interrogatories, as discussed above. (R. 121-22) According to Dr. From, McGee's impairments, even when viewed in combination, do not meet the requirements of the Listings. (R. 122) Dr. From testified that from his review of the medical records, it appeared the high output from McGee's ileostomy was caused by dietary noncompliance and bacterial overgrowth of the small bowel. (R. 125) To support his testimony that McGee had not complied with dietary restrictions, Dr. From could point only to his recollection that he had read about this problem "more than one time" when he had reviewed McGee's medical records. (R. 127)
The only reference the court can locate in the Record that mentions dietary non-compliance is in a report from the Mayo Clinic, where Dr. Boardman stated, "It was believed that the portion of the increased stool output that was associated with dehydration was related to her diet," and McGee was "instructed to follow her diabetic diet more carefully." (R. 447) Besides this one instance, the court finds no other support for the statement by medical consultant Dr. Cromer that McGee "has a history of dietary noncompliance that was determined to be the primary factor in causing her GI symptoms." (R. 531)
McGee testified in response to Dr. From's testimony that she had followed the dietary restrictions given to her by her doctors, and she had never been told by a doctor that she had been noncompliant. (R. 132-33)
3. Vocational Expert's Testimony
The ALJ asked the VE the following hypothetical question:
My first assumption is that we have an individual who is 38 years old. She was 36 years old as of the alleged onset date of disability. She's a female. She has a high school general equivalency diploma and past relevant work, and we're gonna limit that to the childcare worker. And she has the following impairments: She is status post ileostomy, secondary to the total colectomy with dumping syndrome and colitis; Insulin dependent diabetes mellitus, hypertension, gastro-esophageal reflux disease, obesity, status post gallbladder surgery, reactive airway disease, degenerative changes of the lumbar spine, history of migraine headaches and an adjustment disorder with depressed mood. As a result of a combination of those impairments, she has the residual functional capacity as follows: She cannot lift more than 20 pounds, routinely lift 10 pounds, with no standing [of] more than 60 minutes at a time. Walking of two to three blocks at a time. No repetitive bending, stooping, or squatting. No continuous kneeling, crawling or climbing. This individual should not be exposed to excessive heat, humidity or cold or more than moderate levels of dust or fumes. She is not able to do very complex or technical work, but is able to do more than simple, routine, repetitive work, which does not require constant attention to detail. She should not work at more than a regular pace and that's using three speeds of pace being fast, regular and slow. And she should not work at more than a moderate level of stress. Would this individual be able to perform any jobs she previously worked at, either as she performed it, or as it is generally performed within the national economy and if so, would you please specify which job?
(R. 110-11) The VE responded this person would be able to perform McGee's past work as a childcare provider. (R. 111)
The ALJ next asked the VE the following hypothetical question:
My next hypothetical would be an individual with the same age, sex, education, past relevant work and impairments as previously specified. And this would be an individual who would have the residual functional capacity as follows: This individual could not lift more than 15 to 20 pounds, routinely lift 10 pounds, with no standing of more than 20 minutes at a time, no sitting of more than two hours at a time and no walking of more than three to four blocks at a time. With no repetitive bending, stooping, squatting, kneeling, crawling or climbing. No repetitive gross or fine manipulation for periods of time exceeding a half hour at a time, with no repetitive work with the arms overhead. This individual is not able to do very complex or technical work, but is able to do more than simple, routine repetitive work which does not involve a stress level of more than a mild to moderate degree of stress. Would this individual be able to perform any jobs she previously worked at either as she performed it, or as it generally performed within the national economy?
(R. 111-12) The VE responded this individual also would be able to perform work as a childcare provider. (R. 112) The VE further testified this individual could perform a number of jobs within the economy, for example, as a courier messenger, a surveillance monitor, or a parking lot cashier. (R. 113) The VE clarified that if the individual required frequent, unscheduled breaks from regular work activity, then normal employment would be eliminated, although scheduled breaks would not eliminate these jobs. (R. 113-14)
On cross-examination by McGee's attorney, the VE testified the individual in the ALJ's hypothetical would not be employable if the individual had the following additional problems:
[T]his person also was suffering from depression and was on several types of medications; the same medications . . . that have previously been introduced into evidence. And you also assume that this person would miss at least one day and maybe one and a half days of her week, seeking medical attention because of [her] condition, and also [, it is] necessary for this person to take unscheduled breaks up to once an hour to perform a personal function such as changing her bag[.]
(R. 114) The VE testified that the last two parameters would preclude employment. ( Id.)
4. The ALJ's conclusions
In his decision, the ALJ reviewed McGee's medical records in detail, and then commented that he gave "little weight" to Dr. Skierka's opinion on the severity of McGee's limitations. (R. 35) The ALJ stated the following:
[McGee] has no ongoing treatment for liver disease and was noted to be asymptomatic and the elevation of her liver enzymes was not significant. Her complaints of migraine headaches had stabilized by November 1999. Objective medical evidence showed only mild to moderate degenerative changes in her spine, and the claimant reported significant relief following facet and epidural injections. There is no objective evidence of a recurrence of the claimant's ulcerative colitis, and she was able to control her diarrhea without emergency room or physician treatment from February 1999 until November 1999. The medical records show she increased her weight from February 1999 until November 1999 by 27 pounds, indicative of little difficulty assimilating food.
(R. 35-36)
In commenting on McGee's testimony, the ALJ found her subjective complaints "to be not fully credible, and her symptoms to be not as limiting as alleged." (R. 37) As support for this conclusion, he stated the following: "The undersigned finds nothing in the evidence of record to indicate that the claimant returned to Dr. Sires after his recommendation that she discontinue her hormone therapy. Her list of current medications does not show any hormone replacement medications, and her headaches stabilized after she was examined by Dr. Sires." (R. 38)
This simply is not true. After McGee saw Dr. Sires on May 7, 1999, she complained of headaches on May 9, 13, and 14; June 18 and 28; and November 6, 10, 15, and 21, 1999.
The ALJ found as follows:
Based on the claimant's testimony, the undersigned finds that she retains the following residual functional capacity: She can occasionally lift and carry 20 pounds and can frequently lift and carry 10 pounds. She can stand for 60 minutes and walk 2 to 3 blocks. She can do no continuous kneeling, crawling, and climbing and can not repetitively bend, stoop, and squat. She should avoid exposure to excessive heat and cold temperatures and should avoid more than moderate exposure to dust and fumes. She is not able to do very complex technical work but is able to perform more than simple, routine, repetitive work. She can work at no more than a regular pace, at more than a moderate stress level, and in jobs not requiring constant attention to detail.
(R. 38-39) The ALJ found McGee had the physical and mental capacity to work as a child care provider, and she therefore was not prevented from performing her past relevant work. (R. 40) Based on these finding, the ALJ concluded McGee was not disabled within the meaning of the Social Security Act at any time through the date of his opinion, and therefore was not entitled to DI benefits. (R. 30, 39)
III. DISABILITY DETERMINATIONS, THE BURDEN OF PROOF, AND THE SUBSTANTIAL EVIDENCE STANDARD A. Disability Determinations and the Burden of Proof
Section 423(d) of the Social Security Act defines a disability as 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. § 423(d)(1)(A); 20 C.F.R. § 404.1505. A claimant has a disability when the claimant is "not only unable to do his previous work but cannot, considering his age, education and work experience, engage in any other kind of substantial gainful work which exists . . . in significant numbers either in the region where such individual lives or in several regions of the country." 42 U.S.C. § 432(d)(2)(A).
To determine whether a claimant has a disability within the meaning of the Social Security Act, the Commissioner follows a five-step process outlined in the regulations. 20 C.F.R. § 404.1520 416.920; see Kelley v. Callahan, 133 F.3d 583, 587-88 (8th Cir. 1998) (citing Ingram v. Chater, 107 F.3d 598, 600 (8th Cir. 1997)). First, the Commissioner must determine whether the claimant is currently engaged in substantial gainful activity. Second, he looks to see whether the claimant labors under a severe impairment; i.e., "one that significantly limits the claimant's physical or mental ability to perform basic work activities." Kelley, 133 F.3d at 587-88. Third, if the claimant does have such an impairment, then the Commissioner must decide whether this impairment meets or equals one of the presumptively disabling impairments listed in the regulations. If the impairment does qualify as a presumptively disabling one, then the claimant is considered disabled, regardless of age, education, or work experience. Fourth, the Commissioner must examine whether the claimant retains the residual functional capacity to perform past relevant work.
Finally, if the claimant demonstrates the inability to perform past relevant work, then the burden shifts to the Commissioner to prove there are other jobs in the national economy that the claimant can perform, given the claimant's impairments and vocational factors such as age, education and work experience. Id.; accord Pearsall v. Massanari, 274 F.3d 1211, 1217 (8th Cir. 2001) ("[I]f the claimant cannot perform the past work, the burden then shifts to the Commissioner to prove that there are other jobs in the national economy that the claimant can perform.") (citing Cox v. Apfel, 160 F.3d 1203, 1206 (8th Cir. 1998)).
Step five requires that the Commissioner bear the burden on two particular matters:
In our circuit it is well settled law that once a claimant demonstrates that he or she is unable to do past relevant work, the burden of proof shifts to the Commissioner to prove, first that the claimant retains the residual functional capacity to do other kinds of work, and, second that other work exists in substantial numbers in the national economy that the claimant is able to do. McCoy v. Schweiker, 683 F.2d 1138, 1146-47 (8th Cir. 1982) ( en banc); O'Leary v. Schweiker, 710 F.2d 1334, 1338 (8th Cir. 1983).
Nevland v. Apfel, 204 F.3d 853, 857 (8th Cir. 2000) (emphasis added); accord Weiler v. Apfel, 179 F.3d 1107, 1110 (8th Cir. 1999) (analyzing the fifth-step determination in terms of (1) whether there was sufficient medical evidence to support the ALJ's residual functional capacity determination and (2) whether there was sufficient evidence to support the ALJ's conclusion that there were a significant number of jobs in the economy that the claimant could perform with that residual functional capacity); Fenton v. Apfel, 149 F.3d 907, 910 (8th Cir. 1998) (describing "the Secretary's two-fold burden" at step five to be, first, to prove the claimant has the residual functional capacity to do other kinds of work, and second, to demonstrate that jobs are available in the national economy that are realistically suited to the claimant's qualifications and capabilities). B. The Substantial Evidence Standard
Governing precedent in the Eighth Circuit requires this court to affirm the ALJ's findings if they are supported by substantial evidence in the record as a whole. Krogmeier v. Barnhart, 294 F.3d 1019, 1022 (8th Cir. 2002) (citing Prosch v. Apfel, 201 F.3d 1010, 1012 (8th Cir. 2000)); Weiler, supra, 179 F.3d at 1109 (citing Pierce v. Apfel, 173 F.3d 704, 706 (8th Cir. 1999)); Kelley, supra, 133 F.3d at 587 (citing Matthews v. Bowen, 879 F.2d 422, 423-24 (8th Cir. 1989)); 42 U.S.C. § 405(g) ("The findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive. . . ."). Under this standard, "[s]ubstantial evidence is less than a preponderance but is enough that a reasonable mind would find it adequate to support the Commissioner's conclusion." Krogmeier, id.; Weiler, id.; accord Gowell v. Apfel, 242 F.3d 793, 796 (8th Cir. 2001) (citing Craig v. Apfel, 212 F.3d 433, 436 (8th Cir. 2000)); Hutton v. Apfel, 175 F.3d 651, 654 (8th Cir. 1999); Woolf v. Shalala, 3 F.3d 1210, 1213 (8th Cir. 1993).
Moreover, substantial evidence "on the record as a whole" requires consideration of the record in its entirety, taking into account both "evidence that detracts from the Commissioner's decision as well as evidence that supports it." Krogmeier, 294 F.3d at 1022 (citing Craig, 212 F.3d at 436); Willcuts v. Apfel, 143 F.3d 1134, 1136 (8th Cir. 1998) (quoting Universal Camera Corp. v. N.L.R.B., 340 U.S. 474, 488, 71 S.Ct. 456, 464, 95 L.Ed. 456 (1951)); Gowell, id.; Button, 175 F.3d at 654 (citing Woolf, 3 F.3d at 1213); Kelley, 133 F.3d at 587 (citing Cline v. Sullivan, 939 F.2d 560, 564 (8th Cir. 1991)).
In evaluating the evidence in an appeal of a denial of benefits, the court must apply a balancing test to assess any contradictory evidence. Sobania v. Secretary of Health Human Serv., 879 F.2d 441, 444 (8th Cir. 1989) (citing Steadman v. S.E.C., 450 U.S. 91, 99, 101 S.Ct. 999, 1006, 67 L.Ed.2d 69 (1981)). The court, however, does "not reweigh the evidence or review the factual record de novo." Roe v. Chater, 92 F.3d 672, 675 (8th Cir. 1996) (quoting Naber v. Shalala, 22 F.3d 186, 188 (8th Cir. 1994)). Instead, if, after reviewing the evidence, the court finds it "possible to draw two inconsistent positions from the evidence and one of those positions represents the agency's findings, [the court] must affirm the [Commissioner's] decision." Id. (quoting Robinson v. Sullivan, 956 F.2d 836, 838 (8th Cir. 1992), and citing Cruse v. Bowen, 867 F.2d 1183, 1184 (8th Cir. 1989)); see Hall v. Chater, 109 F.3d 1255, 1258 (8th Cir. 1997) (citing Roe v. Chater, 92 F.3d 672, 675 (8th Cir. 1996)). This is true even in cases where the court "might have weighed the evidence differently." Culbertson v. Shalala, 30 F.3d 934, 939 (8th Cir. 1994) (citing Browning v. Sullivan, 958 F.2d 817, 822 (8th Cir. 1992)); accord Krogmeier, 294 F.3d at 1022 (citing Woolf, 3 F.3d at 1213). The court may not reverse "the Commissioner's decision merely because of the existence of substantial evidence supporting a different outcome." Spradling v. Chater, 126 F.3d 1072, 1074 (8th Cir. 1997); accord Pearsall, 274 F.3d at 1217; Gowell, supra.
On the issue of an ALJ's determination that a claimant's subjective complaints lack credibility, the Sixth and Seventh Circuits have held an ALJ's credibility determinations are entitled to considerable weight. See, e.g., Young v. Secretary of H.H.S., 957 F.2d 386, 392 (7th Cir. 1992) (citing Cheshier v. Bowen, 831 F.2d 687, 690 (7th Cir. 1987)); Gooch v. Secretary of H.H.S., 833 F.2d 589, 592 (6th Cir. 1987), cert. denied, 484 U.S. 1075, 108 S.Ct. 1050, 98 L.Ed.2d 1012 (1988); Hardaway v. Secretary of H.H.S., 823 F.2d 922, 928 (6th Cir. 1987). Nonetheless, in the Eighth Circuit, an ALJ may not discredit a claimant's subjective allegations of pain, discomfort or other disabling limitations simply because there is a lack of objective evidence; instead, the ALJ may only discredit subjective complaints if they are inconsistent with the record as a whole. See Hinchey v. Shalala, 29 F.3d 428, 432 (8th Cir. 1994); see also Bishop v. Sullivan, 900 F.2d 1259, 1262 (8th Cir. 1990) (citing Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir. 1984)). As the court explained in Polaski v. Heckler:
The adjudicator must give full consideration to all of the evidence presented relating to subjective complaints, including the claimant's prior work record, and observations by third parties and treating and examining physicians relating to such matters as:
1) the claimant's daily activities;
2) the duration, frequency and intensity of the pain;
3) precipitating and aggravating factors;
4) dosage, effectiveness and side effects of medication;
5) functional restrictions.
Polaski, 739 F.2d 1320, 1322 (8th Cir. 1984). Accord Ramirez v. Barnhart, 292 F.3d 576, 580-81 (8th Cir. 2002).
IV. ANALYSIS A. Opinions of Treating Physicians
McGee argues the ALJ erred in improperly discrediting or ignoring the opinions of McGee's treating physicians. The court agrees. "A treating physician's opinion should not ordinarily be disregarded and is entitled to substantial weight. Ghant v. Bowen, 930 F.2d 633, 639 (8th Cir. 1991). By contrast, `[t]he opinion of a consulting physician who examines a claimant once or not at all does not generally constitute substantial evidence.' Kelley v. Callahan, 133 F.3d 583, 589 (8th Cir. 1998)." Jenkins v. Apfel, 196 F.3d 922, 925 (8th Cir. 1999).
In Prosch v. Apfel, 201 F.3d 1010 (8th Cir. 2000), the Eighth Circuit Court of Appeals discussed the weight to be given to the opinions of treating physicians:
The opinion of a treating physician is accorded special deference under the social security regulations. The regulations provide that a treating physician's opinion regarding an applicant's impairment will be granted "controlling weight," provided the opinion is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] record." 20 C.F.R. § 404.1527(d)(2). Consistent with the regulations, we have stated that a treating physician's opinion is "normally entitled to great weight," Rankin v. Apfel, 195 F.3d 427, 430 (8th Cir. 1999), but we have also cautioned that such an opinion "do[es] not automatically control, since the record must be evaluated as a whole." Bentley v. Shalala, 52 F.3d 784, 785-86 (8th Cir. 1995). Accordingly, we have upheld an ALJ's decision to discount or even disregard the opinion of a treating physician where other medical assessments "are supported by better or more thorough medical evidence," Rogers v. Chater, 118 F.3d 600, 602 (8th Cir. 1997), or where a treating physician renders inconsistent opinions that undermine the credibility of such opinions, see Cruze v. Chater, 85 F.3d 1320, 1324-25 (8th Cir. 1996). Whether the ALJ grants a treating physician's opinion substantial or little weight, the regulations provide that the ALJ must "always give good reasons" for the particular weight given to a treating physician's evaluation. 20 C.F.R. § 404.1527(d)(2); see also SSR 96-2p.
Prosch, 201 F.3d at 1012-13. See Wiekamp v. Apfel, 116 F. Supp.2d 1056, 1063-64 (N.D. Iowa 2000). See also Rankin v. Apfel, 195 F.3d 427, 429 (8th Cir. 1999) (where physician's conclusion is based heavily on claimant's subjective complaints and is at odds with the weight of objective evidence, ALJ need not give physician's opinion the same degree of deference) (citing Haggard v. Apfel, 175 F.3d 591, 595 (8th Cir. 1999)). Dr. Berdecia and Dr. Skierka, both treating physicians, are of the opinion that McGee has significant functional limitations that, if accepted as true by the ALJ, would have precluded all employment. The ALJ simply ignored the opinions of Dr. Berdecia without comment, and decided to give "little weight" to the opinions of Dr. Skierka with no real justification. Instead, the ALJ relied on evidence from Dr. From, a non-treating, non-examining physician.
Dr. From's conclusions were based primarily on his belief that McGee's continuing problems were caused by dietary noncompliance. In the voluminous Record, there is only one reference to dietary noncompliance by a treating physician. Dr. Boardman simply stated it was believed that a portion of McGee's increased stool output was related to her diet, and McGee was "instructed to follow her diabetic diet more carefully." (R. 447) This is a thin thread upon which to ignore the substantial evidence in the Record supporting the opinions of McGee's treating physicians.
In light of contrary evidence from McGee's treating physicians, the opinions of Dr. From, a consulting physician, cannot constitute substantial evidence to support the ALJ's denial of benefits. See Jenkins, 196 F.3d at 925 (citing Kelley, 133 F.3d at 589).
The opinions of McGee's treating physicians provided substantial evidence that she is disabled under the provisions of the Social Security Act.
B. The Polaski Standards and the ALJ's Hypothetical Questions
Although the court does not need to reach these issues, it is apparent on the Record that the ALJ improperly discredited McGee's testimony concerning her functional limitations. Without even giving lip-service to the Polaski standards, the ALJ concluded, with little support, that McGee's testimony was "not fully credible." This is just the type of reasoning the court in Polaski was attempting to prevent. An ALJ may not discredit a claimant's subjective allegations of disabling limitations without justification, even where there is a lack of objective medical evidence, unless such allegations are inconsistent with the Record as a whole. Here, far from being inconsistent with the Record, substantial objective evidence supports McGee's testimony.
McGee testified that she must change her ostomy bag twenty times each day, and it takes from five to ten minutes to complete the procedure. She also testified she spends an average of a day-and-a-half each week in doctors' offices and hospitals. She testified that she suffers from disabling migraine headaches two to three times a week. All of this testimony is supported, or at least is uncontradicted, in the Record. The VE testified that an individual with these restrictions would be unemployable. Therefore, this evidence, if accepted, would have established that McGee is disabled under the Social Security Act. The ALJ's rejection of this evidence was virtually without justification.
Although McGee can control these headaches with medication, she testified that when she feels a migraine headache coming on, she must take the medication and then lie down for twenty minutes to an hour before the headache goes away.
It is difficult to determine how the ALJ could have looked at this Record, seen what McGee has to go though to live her life, read the opinions of her treating physicians, and then decide she is not disabled. It is patently obvious that no one with McGee's medical problems and the resulting functional limitations would be employable anywhere in the national economy.
Similarly, the only appropriate hypothetical question asked of the VE was the question asked by McGee's attorney. The VE's response to the hypothetical question was that the individual described in the question would be precluded from all employment.
For these reasons, the court finds McGee is disabled and is entitled to benefits from her alleged disability onset date of November 1, 1998.
V. CONCLUSION
Having found McGee is entitled to benefits, the court may affirm, modify, or reverse the Commissioner's decision with or without remand to the Commissioner for a rehearing. 42 U.S.C. § 405(g). In this case, where the record itself "convincingly establishes disability and further hearings would merely delay receipt of benefits, an immediate order granting benefits without remand is appropriate." Cline, 939 F.2d at 569 (citing Jefferey v. Secretary of H.H.S., 849 F.2d 1129, 1133 (8th Cir. 1988); Beeler v. Bowen, 833 F.2d 124, 127-28 (8th Cir. 1987)); accord Thomas v. Apfel, 22 F. Supp.2d 996, 999 (S.D. Iowa 1998) (where claimant is unable to do any work in the national economy, remand to take additional evidence would only delay receipt of benefits to which claimant is entitled, warranting reversal with award of benefits).
Accordingly, for the reasons discussed above, the Commissioner's decision is reversed, and this case is remanded to the Commissioner for a calculation and award of benefits. Plaintiff's counsel is directed to submit a timely application for attorney fees in accordance with Local Rule 54.2(b). IT IS SO ORDERED.
MEDICAL RECORDS SUMMARY McGee vs. Barnhart, Case No. C02-3042-PAZ
DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Diagnosis: DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Diagnosis: Impression: Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Diagnosis: Assessment Recommendation DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan Assessment Plan Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Final Diagnosis Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Final Diagnosis Final Diagnosis DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment/Plan Impression DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Impression Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan Assessment Plan Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan Assessment Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Preliminary Assessment Plan Assessment Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Diagnosis Assessment 12/20/96 Waverly Municipal Hospital Sprained right Pt referred by Dr. Pattee. Pt R. 633-34 Physical Therapy Department ankle has aching and pain going up Michael R. Kaus, P.T. side of rt. calf. : Ankle sprain. Work on strengthening ankle and nerve perception in ankle joint. 03/22/97 Waverly Municipal Hospital Dehydration Pt is a 35-yr-old female who thru Lee O. Fagre, M.D. secondary to had a total colectomy for 03/24/97 gastroenteritis; ulcerative colitis. Pt lost large R. 223-39 diabetes volumes of fluid through her ileostomy and vomiting. Brought dehydration and blood sugar under control; switched pt to oral meds after 1 day. X-ray of supine and upright abdomen showed little bowel gas; suggestion of a couple of mildly dilated loops of small bowel that could be a mild ileus. Chest X-ray normal. Final Gastroenteritis, poorly controlled with dehydration; poorly controlled diabetes mellitus; Permanent ileostomy secondary to total colectomy for ulcerative colitis. Rx for Rezulin, Bentyl and some insulin; continue Glyburide. 03/31/97 Waverly Municipal Hospital Diabetes Primary diagnosis: Insulin R. 241 Lee O. Fagre, M.D. dependent diabetes mellitus. Current meds: Glyburide, Rezulin, Insulin, blood pressure medication. Pt referred for "In Control" Diabetes Self Management Education. 04/24/97 Waverly Municipal Hospital Diabetes; Pt has ileostomy for significant thru Lee O. Fagre, M.D. gastroenteritis large bowel problems. 04/25/97 w/dumping Pt "ends up draining out R. 242-48 syndrom and through her ileostomy every dehydration once in a while and gets what appears to be a dumping syndrome and dehydrates." Pt admitted for IV fluids to rehydrate. Pt given Kaopectate, Lomotil, Codiclear DH cough syrup; continue sliding scale Insulin. 07/17/97 Waverly Municipal Hospital Vomiting w/dry Pt has an ileostomy for thru Michael Berstler, M.D. heaves; frequent ulcerative colitis; diabetes 07/18/97 loose stools mellitus Type II; was on R. 249-58 Insulin, now on oral meds. Current meds: Lomotil, Rezulin, Glyburide, Lotensin. : Probable gastroenteritis with frequent stools and nausea with dehydration about 5-7%. Blood sugar 177 presently. Diet and oral medication controlled. Hypertension. Hyperlipidemia. : Pt admitted for IV hydration and monitoring of sugars. 07/19/97 Waverly Municipal Hospital Weakness, Pt was placed back on IV thru John Brunkhorst, M.D. diarrhea fluids. Cultures negative. Pt 07/21/97 still having a lot of output R. 259-63 from her ileostomy. Pt was rehydrated and discharged on Cipro, Lomotil, and Kaopectate. Acute gastroenteritis, old ileostomy. Pt will be followed on an out-patient basis. 08/22/97 Waverly Municipal Hospital Headache, CT of head — Negative. R. 264-67 Robert Choi, M.D. dizziness G. E. Raecker, D.O. 09/09/97 Waverly Municipal Hospital Diabetes, Pt complains of dizziness. IV R. 268-74 Lee O. Fagre, M.D. dehydration started. Dizziness much better. Pt discharged to home with a friend. 09/28/97 Waverly Municipal Hospital Lower Pt complaints as noted at left; R. 275-80 Kelly Schmidt, M.D. abdominal also increased ileostomy cramping and output (4 gals yesterday), urinary very watery. Current meds: frequency for Rezulin, Glyburide, Lobid, past 2 days Duract, Amitriptyline. Pt did not know her meds and did not have them with her; may be some confusion with the meds. Pt hydrated in E.R.; symptoms improved and she was discharged. High ileostomy output, mild dehydration, urinary tract infection. : Pt will return if high ileostomy output continues more than 24 hours. Rx for Bactrim DS. 12/31/97 R. Waverly Municipal Hospital John Dehydration Pt admitted for rehydration. 281-83 Brunkhorst, M.D. 01/01/98 R. Waverly Municipal Hospital John Gastroenteritis Pt admitted for observation; given 284-88 Brunkhorst, M.D. IV fluids. Pt has an ileostomy from Crohn's Disease. Every time she gets a little diarrhea, she puts out a lot of fluids and gets dehydrated. 1. Acute gastroenteritis, secondary to flu. 2. Crohn's Disease ileostomy. 01/22/98 Dawn Morey, D.O. Abdominal pain; Pt complains of abdominal pain; has R. 293 opinion letter some little blister-type areas on stoma that bleed when she rubs them. : Abdominal pain, rule out peptic ulcer disease. Also need to make sure she doesn't actually have Crohn's disease rather than ulcerative colitis. : Upper GI panendoscopy with biopsy, w/concurrent biopsy of lesions on stoma. 01/22/98 R. Dawn Morey, D.O. Abdominal and left Consultation for Dr. Fagre. Pt has 493 upper quadrant pain had recurrent pain and loose stools with dehydration for three weeks. No notes re what treatment was given. 01/23/98 R. Waverly Municipal Hospital Dawn Upper GI Pt admitted for upper GI 289-92, 294 Morey, D.O. pan-endoscopy pan-endoscopy with biopsy, and biopsy and fulguration of lesions on stoma. Post-Op Diagnosis: Gastric ulcer and small papilloma on stoma. Gastroparesis. 01/26/98 R. Dawn Morey, D.O. Abdominal pain Pt continues to have abdominal 493 pain and cramping, loose stools, diarrhea, poor appetite. "Schedule scope through ileostomy." 01/27/98 R. Waverly Municipal Hospital Lee O. Lab studies Screen for elevated lead 295-97 Fagre, M.D. level; results normal. 01/29/98 R. Waverly Municipal Hospital Dawn Endoscopy Procedure: Small bowel endoscopy 298-300 Morey, D.O. with mucosal biopsies. Postoperative Diagnosis: Diarrhea, plus lymphoid hyperplasia with the small bowel. 02/03/98 R. Waverly Municipal Hospital Michael Diarrhea with Pt has history of ulcerative 308-09 Berstler, M.D. dehydration colitis with ileostomy and has had almost irritable ileostomy symptoms of dramatic diarrhea with dehydration. : Rx for Prilosec, Nubain, Propulsid. If meds don't help, evaluate for toxicity reaction to meds and for autonomic dysfunction. 02/04/98 R. Waverly Municipal Hospital Lee O. Right upper Flat and upright abdominal 301-06 Fagre, M.D. quadrant pain X-rays. Impression: Partial small bowel obstruction. Postoperative changes of right abdomen. Follow-up suggested. 02/05/98 R. Waverly Municipal Hospital J. R. Right upper CT scan of abdomen with and 307 Hooyman, M.D. quadrant pain without contrast: Impression: Mechanical small bowel obstruction at the level of the ileostomy. 02/10/98 R. Dawn Morey, D.O. Follow-up exam re Upper GI scope showed gastric ulcer 492-93 abdominal pain and gastro-paresis. Small bowel endoscopy was done to rule out ulcerative colitis. : Abdominal pain and partial bowel obstruction. : Obtain CT scan films to review and then proceed with revision of her ostomy. 02/17/98 R. Dawn Morey, D.O. Scheduled revision of 492 ileostomy for 2/20/98. 02/20/98 R. Waverly Municipal Hospital Dawn Revision of Postoperative diagnosis: Partial 310-13 Morey, D.O. ileostomy bowel obstruction secondary to constriction at ileostomy site. Current meds: Rezulin, Lopid, Lo-Trol. 02/22/98 Dawn Morey, D.O. Pain and itching Pt changed the ostomy R. 492 at ostomy site appliance because it was leaking and there was redness and discomfort at the skin site under the wafer. : Contact dermatitis. : Changed the ostomy appliance. Pt given injection of Solu-Medrol and a Medrol dose pack. Pt to take Dramamine and use ice on the area for the itching. 02/27/98 Dawn Morey, D.O. Follow-up re Pt had a revision of her R. 491-92 ostomy ostomy on 2/20/98; developed allergic reaction w/contact dermatitis under her stoma appliance. Leaking has stopped; tenderness is gone; ostomy is working well; belly pain is gone and the ostomy output is doing well. : Status post revision of ileostomy; contact dermatitis, resolving. : Recheck in a month. 03/23/98 Dawn Morey, D.O. Follow-up re Localized dermatitis is R. 491 ostomy resolved; pt can apply her normal appliance without difficulty. : Status post revision of the ileostomy; gastric ulcer. : Continue Prilosec. 03/28/98 Covenant Clinic Sinus infection, Erythromycin has not helped R. 419 sore throat, nasal pt's symptoms. : congestion, 1. Acute sinusitis on the headache right. 2. Possible URL 3. Headache secondary to the sinuses. : Pt given Rocephin shot. Pt had to take liquid Erythromycin because of her colectomy and even that gave her loose bowels. Rx for Midrin. 04/27/98 Waverly Municipal Hospital Right leg pain; X-ray: AP, lateral, both R. 314-16 Lee O. Fagre, M.D. CT and X-ray of oblique views of the lumbar lumbar spine spine. Impression: Mild to moderate degenerative changes involving lower L-2 spine. CT of L-S spine without intravenous contrast. Impression: No disc herniations. Disc bulges present, most prominent at L4-5 and L5-S1. Spinal canal narrowing is greatest at L4-5, mild due to combination of mild disc bulge with degenerative change. 05/08/98 Waverly Municipal Hospital Large output Pt feeling poorly and dehydrating. thru Lee O. Fagre, M.D. from ileostomy Pt was put on IV 05/10/98 tube; dehydration; fluids and IV antibiotics; R. 317-26 gastroenteritis turned out to be urinary tract infection. Chest X-ray: Normal. Pt put on Kaopectate, Lomotil, Lopid, Lotrel, Rezulin, Ibuprofen, Prevacid. : 1. Gastroenteritis with marked output from ileostomy causing dehydration. 2. Leukocytosis. 3. UTI. 4. Non Insulin dependent diabetes mellitus. 5. Hypertension. 6. Hyperlipidemia. 7. Gastroesophageal reflux disease. 05/23/98 Covenant Clinic Rash Pt seen yesterday because of R. 419 onset of rash. Pt had UTI and was put on Macrodantin. Now she has little spots which got worse overnight. : Cellulitis on arms, right axilla and abdomen. : Rx for Keflex. Culture the rash. 05/26/98 Waverly Municipal Hospital Lab studies Organism: Staph aureus R. 332-34 Lee O. Fagre, M.D. 05/27/98 Waverly Municipal Hospital Cellulitis Pt admitted with staphylococcal thru Lee O. Fagre, M.D. cellulitis that was 05/29/98 treated with IV antibiotics. R. 327-31 After a few days of IV treatment and soaks, erythema and abscess draining went down. Pt discharged with good cleansing techniques and Rx for Keflex. Pt to keep tight control of her diabetes. : 1. Cellulitis with staphylococcal aureus abscesses. 2. Diabetes mellitus, poorly controlled. 3. Hypertriglyceridemia. 4. Hypertension. 5. Degenerative joint disease. 06/19/98 Waverly Municipal Hospital Abdominal pain; Pt was brought in for chronic thru Lee O. Fagre, M.D. leg cramps; dumping syndrome with 06/22/98 dehydration secondary dehydration and R. 335-39; underlying abdominal pain. 340-45 High ostomy output. Question whether Pt has Crohn's disease instead of ulcerative colitis which may be causing her current problem. Pt scheduled to go to Iowa City as an outpatient. : 1. Dumping syndrome. 2. Diarrhea. 3. Vomiting. 4. Colostomy. 5. Diabetes mellitus. 6. Inflammatory bowel disease. 07/05/98 Waverly Municipal Hospital Right knee pain, Pt complains of right knee R. 349-54 Francis Coyle, M.D. chills, abdominal pain. Pt returns in the afternoon pain complaining of chills. Diagnosis: Diabetes and post ileostomy. Pt to go to Iowa City tomorrow. 07/06/98 University of Iowa Hospitals Consultative Pt was interviewed and examined R. 355-56 and Clinics examination at the Center for Robert W. Summers, M.D. report Digestive Diseases on Pamela Pick, M.D. 07/06/98. Diagnoses: 1. History of ulcerative colitis, status post revision of ileostomy in February of 1998. 2. History of adult onset diabetes mellitus. 3. History of hypertension. 4. Obesity. Pt presents for evaluation of increased ileostomy output associated with abdominal cramps. Pt has required two hospitalizations in May and one in June for IV fluid hydration. She has also received IV fluid as an outpatient every other week for the past month. Pt noted that fluid "squirts" out of her ostomy site. Rezulin and Glyburide were discontinued over 11/2 mos. ago, hoping high ostomy output was secondary to diarrhea caused by the meds, but symptoms have continued. Neither Lomotil nor Donnatal has provided much relief. Glucose levels still range between 103 and 176. Current meds: Lotensin, Lopid, Lotrel, sliding Humulin insulin scale, Lomotil, Donnatal. : Intermittent crampy abdominal discomfort with high ostomy output. Due to Pt's multiple abdominal surgeries for her Crohn's disease, there is a concern she may have recurrent bowel obstruction. Pt is scheduled for a small bowel enteroscopy. 07/07/98 University of Iowa Hospitals Upper GI with Evaluate for stricture or R. 357-59 and Clinics small bowel active Crohn's disease. : Robert W. Summers, M.D. series; Gastritis: prior Enteroscopy; ulcer disease. No active Ileum biopsy Crohn's disease; no evidence for stricture. Enteroscopy via ileal stoma showed normal ileoscopy without evidence of inflammatory bowel disease or stenosis. Ileum biopsy: No diagnostic abnormality. 07/12/98 Waverly Municipal Hospital Weakness, "I feel like crap." Pt presents R. 360-65, D. J. Rathe, D.O. clammy with w mo. history of ileostomy 369 with output that does not seem to be digested at all. Symptoms started in January 1998. Pt was evaluated at the University of Iowa Hospitals. She was told to measure her outputs for four days and then begin a medicine which she mixes with Ensure. Pt is not sure what the medicine is and she left it at home. : Weakness, diaphoresis with high ileostomy outputs. Pt will begin her medication regimen per Iowa City, and follow up with Dr. Berdecia in 3-5 days for urinalysis recheck. 07/13/98 R. Covenant Clinic Charley horses in Pt called complaining of Charley 419 legs Horses in legs for past two days and doesn't feel like doing anything. Rx for Norflex. 07/14/98 R. Waverly Municipal Hospital Joseph Diarrhea, leg Laboratory studies 366-68 Berdecia, M.D. cramps, weakness performed. 07/15/98 R. Covenant Clinic High output "They were not able to find 418 through ostomy anything wrong with her in Iowa City. She is still having problem with this." : 1. Leg pain, possible restless leg syndrome. 2. Possible re-exacerbation of inflammatory bowel disease. : Rx for Skelaxin. Pt given shot of Depo Medrol. 07/21/98 Covenant Clinic Abdominal Pt still having some R. 418 cramping cramping, but better since started on Levsin. "[T]hings are running right through her in the ostomy." : Exacerbation of inflammatory bowel disease. : Pt given samples of Levsin sublingual. 07/27/98 Covenant Clinic Ulcerative colitis Pt has had problems last two R. 418 and diabetes days with high output of her ostomy. : 1. Inflammatory bowel disease. 2. IDDM 3. Muscle pain in legs. : Rx for Belladonna suppositories. Continue Levsin sublingual and Metamucil. Pt given samples of Allegra. 08/05/98 Covenant Clinic High output Pt continues to have high output R. 417 from ostomy from ostomy. Tincture of Opium did not seem to help, but she was taking too much of the medication and was given a syringe to measure it correctly. Levsin sublingual doesn't seem to be working. : 1. Inflammatory bowel disease, chronic. 2. Abdominal pain, secondary to # 1. : Pt will take Tincture of Opium and Propulsid. 08/14/98 R. Covenant Clinic High ostomy : 1. ulcerative 417 output colitis; 2. rhinitis; 3. high output from ostomy. : Continue Propulsid and Levsin sublingual. Pt given Claritin samples. 08/27/98 R. Covenant Clinic Anxiety; follow-up Colitis appears fairly stable al 415 re colitis this time. Pt is having quite a bit of problem with anxiety. : 1. Hypertension poor to fair control. 2. IDDM 3. Dysmenorrhea. 4. Anxiety. Rx for Alesse BCP. Increase Lotrel; continue Buspar. 09/03/98 R. Covenant Clinic Dizziness, : 1. Dehydration. 2. 415-16 dehydration, Colitis exacerbation. 3. high ostomy Hypertension, under better control. output : Pt given one liter of lactated ringers with Phenergan. Increase Propulsid; use Tincture of Opium. Addendum: Pt sent to hospital as fluid hydration was attempted in office. 09/03/98 Waverly Municipal Hospital Joseph Weakness, Pt was given IV fluids in office, thru Berdecia, M.D. dizziness, but continued not to feel well. Pt 09/04/98 nausea, high admitted to hospital for more R. 370-78 output from aggressive and therapeutic ostomy intervention. Current meds: Sliding scale Humulin R, Lo-Trol, Propulsid, Levsin, Bu-Spar. Abdominal X-ray showed little bowel gas, no evidence of mechanical bowel obstruction, no pneumoperi-toneum. : 1. Severe dehy-dration. 2. Exacerbation of colitis with high output of ostomy. 3. Rule out infectious process. : Pt admitted to medical floor; given two liters of lactated ringers bolus over two hours, and Phenergan for nausea and vomiting. Cultures are negative. : Probably transient viral gastroenteritis. 09/05/98 R. Covenant Clinic Medication refill Pt given four boxes of Lotrel 416 samples. 09/10/98 R. Covenant Clinic Headache Pt complains of headache. 416 Tylenol gave no relief. : 1. Acute sinusitis 2. Colitis 3. IDDM. : Rx for Toradol and Cefzil; refill Lotrel. 09/11/98 R. Covenant Clinic Follow-up re Pt seen two days ago for acute 416 headache sinusitis. Today complains of severe headache. Pt given Compazine injection and Ultram samples. 09/17/98 R. Covenant Clinic Left arm Pt developed dermatitis at IV 413 irritation site. She was advised to use Triamcinolone, which made symptoms worse. Rx for Medrol Dospak and liquid Vicodin; continue Allegra. 09/18/98 Waverly Municipal Hospital Left arm pain Pt referred to physical therapy R. 379-82 Joseph Berdecia, M.D. Ron L. by Dr. Berdecia for evaluation Ragsdale, P.T. of arm pain. Pt scratched her arm a few days ago, developed a rash, was told to use ointment and then wrap arm with cellophane. She complied and symptoms greatly increased; she now has general dermatitis in her forearm. There is no other type of wound dressing that would be better than the Silvadene she is using. Some Lidocaine or Marcaine could be put into the ointment to help decrease her pain. 09/21/98 R. Covenant Clinic Diarrhea : 1. Chronic diarrhea. 2. 414 Mild dehydration. Pt is to go home and drink a lot of fluids. 09/22/98 R. Covenant Clinic Medication Pt to use Zonic and regular dose 413 review of NPH insulin. 09/24/98 R. Covenant Clinic Headache Pt seen for severe headache. Rx 413 for Compazine. : Migraine headache. 09/30/98 R. Covenant Clinic Dermatitis Pt seen for follow up of severe 414 dermatitis on right upper extremity. : 1. Dermatitis of upper extremity. 2. IDDM. 3. Ulcerative colitis. Continue Lotrel and regular insulin. DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Assessment Assessment Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan Assessment Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan Assessment Plan Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Assessment Plan Diagnosis DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Final Diagnosis: Plan Assessment Plan Diagnosis: DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan Summary Diagnoses DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Impression Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Opinion Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan occasionally frequently DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Current meds Conclusion DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan Meds DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Impression Plan Assessment Plan Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan Exertional Limitations occasionally frequently Postural DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Limitations occasionally Conclusions DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Ratings of job-related skills DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Tests Administered Clinical Interview DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Plan Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Impression slight often never moderately not significantly limited DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Conclusion DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Recommendation Assessment DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Assessment Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Current meds Assessment/Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Impression Plan Impression DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Plan Assessment Plan Procedure Assessment Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Procedure Impression DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Plan Impression DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS Assessment/Plan DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS DATE MEDICAL COMPLAINTS DIAGNOSIS, PRACTITIONER/ TREATMENT FACILITY COMMENTS 10/03/98 Covenant Clinic Ulcerative colitis Pt is "sort of R. 414 immunocom-promise[d] because of this chronic diarrhea she has secondary to the colitis." Pt had boils all summer, all over her body. She took Rocephin and was put on IV antibiotics. Pt has small boil on right supraclavicular area. : 1. Boil 2. Chronic colitis. 3. Hypertension under well control. Rx for Rocephin and Keflex. Continue hot packs. 10/05/98 Covenant Clinic Shoulder pain Pt seen for complaint of shoulder R. 412 pain. The area looks like a boil. : Carbuncle. Rx for Trovan given. 10/06/98 Covenant Clinic Medication Pt had a reaction to liquid R. 412 reaction Vicodin. Pt switched to liquid Motrin; Rx for liquid Benadryl for the reaction. 10/07/98 Covenant Clinic Follow-up re Pt also complains of dry skin, R. 412 carbuncle especially on hands. : Furuncle. Continue Trovan. 10/16/98 Covenant Clinic Medication refill Refilled Triamcinolone, R. 412 Zylocaine, and Zinc Oxide 10/21/98 Covenant Clinic Itchy arm; : 1. Dermatitis. 2. IDDM. R. 411 break-through 3. Metrorrhagia. : Switch to bleeding on birth Ortho-Cyclen BCP. Continue Lotrel. control pills Increase Humulin. (Ortho-Tricyclen) 10/28/98 Waverly Municipal Hospital High ostomy Pt "not feeling well." She R. 383-85 Joseph Berdecia, M.D. output; leg has been having very high cramps output from ostomy and a lot of cramping and "charley horses" in her legs. : 1. Dehydration. 2. Colitis exacerbation. : Pt given one liter of lactated ringers, Bentyl, Solu-Medrol. Pt to start Pediapred; continue all other current meds. 10/29/98 Covenant Clinic Medical refill Rx for Cefzil. R. 411 11/01/98 McGee's Claimed Disability Ileostomy for R. 31, Onset Date ulcerative 150 colitis, hypertension, Type I diabetes 11/03/98 Waverly Municipal Hospital Diarrhea, Pt was admitted to observation thru John Brunkhorst, M.D. dehydration bed w/diarrhea. Pt has 11/04/98 an ileostomy and is R. 386-89 dehydrated. : 1. Dehydration. 2. Insulin dependent diabetes mellitus. 3. Ulcerative colitis. Pt improved overnight and was discharged. No change in current meds; added Xanax. 11/06/98 Waverly Municipal Hospital Migraine Pt seen in E.R.; given R. 390-91 Joseph Berdecia, M.D. headache injections for migraine headaches. : Migraine headache. : Rx for Nubain and Compazine. 11/11/98 Covenant Clinic Not feeling well Pt not feeling well. History R. 411 and physical done for hospital admission. 11/11/98 Waverly Municipal Hospital Weakness Pt lost her husband recently thru Joseph Berdecia, M.D. because of a sudden death to 11/15/98 septicemia. Over the last few R. 392-403 days, she has had rather large amounts of output, has not been able to eat, and feels sick, weak, and dizzy at times. Pt admitted to medical floor; started on lactated ringers. : Dehydration, now resolved; severe hypertension, stable; Colitis exacerbation; Diarrhea, doing better; Migraine headaches; IDDM, stable; Adjustment disorder with depressed mood. : Ordered blood cultures and lab studies; started Pt on Solu-Medrol. 11/18/98 Covenant Clinic High output Pt's blood sugars are slightly R. 407, from ostomy better. Switch Pt from regular 411 insulin to Humalog to get better control of her sugars. Pt slept well in the hospital when taking Halcion. : 1. Hypertension. 2. IDDM poor control 3. Insomnia. : Rx for Halcion, switch to Humalog, continue NPH. Pt to have BP checked every Friday. 11/19/98 Covenant Clinic Blood sugar too high Pt called to report her blood sugar R. 407 was too high. Pt told to increase Humalog. 11/20/98 Covenant Clinic Blood pressure BP 140/98. Rx for Demadex. R. 407 check 11/23/98 Covenant Clinic Sore throat, Pt called complaining of a sore, R. 407 cough, fever raw throat; cough; fever, for three days. Rx for Trovan. 12/02/98 Covenant Clinic Diabetes Pt's diabetes has been poorly R. 406 Mellitus controlled as well as her colitis. Pt is doing fairly well, but still has headaches and problems sleeping. : 1. IDDM. 2. Hypertension. 3. Headaches by history. : Increase Humalog and NPH. Decrease Prozac. Continue Cardura and Lotrel. 12/04/98 Covenant Clinic Sinus pain Pt called with complaints of sinus R. 406 pressure and pounding. Rx for Allegra-D and Omnicef. 12/05/98 Covenant Clinic Pedal edema Pt given Rx for Demadex for pedal R. 406 edema. 12/07/98 Covenant Clinic Medication Refilled Zyrtec liquid. R. 406 Refill 12/10/98 Covenant Clinic Headache Pt complains of severe headache R. 404 and feeling shaky. She has been taking Prozac and Omnicef for the last couple of weeks. : 1. Acute sinusitis. 2. Medication side effect. 3. Headache. : Rx for Rocephin and Vantin; reduce Prozac. 12/16/98 Covenant Clinic Follow-up re Pt still has a headache. Pt R. 404-05 headache quit taking Prozac because it made her jittery. : IDDM, poorly controlled; acute sinusitis, better; hypertension. : Increase Humalog, continue regular dose of NPH and Cardura, increase Demadex. 01/06/99 Covenant Clinic Follow-up re Pt is seen for follow-up after R. 597 headache being diagnosed with acute bronchitis, reactive airway that is doing somewhat better, and severe headaches with dizziness. : 1. Acute pansinusitis 2. IDDM doing somewhat better. 3. Sacroiliitis 4. Hypertension. : Continue Lotrel, Glucophage, Humalog and Humulin N. Rx for Vantin and Kenalog spray. 01/06/99 Covenant Clinic Letter to Mayo Referral to the Mayo Clinic R. 421-22 Joseph Berdecia, M.D., Ph.D. Clinic for evaluation of problems with high output of Pt's ostomy. 01/08/99 Covenant Clinic Coughing, chest : 1. Acute bronchitis R. 596 pain, headache 2. RAD. 3. Pansinusitis. : Pt given Rocephin and breathing. Rx for Atrovent, Albuterol, and Vanceril double strength. CT confirmed acute sinusitis in right asthenoid, right and left maxillary sinuses. 01/09/99 Covenant Clinic Follow-up re Pt came in for a repeat R. 596 bronchitis Rocephin injection. She appears to have better air movement. 01/11/99 Waverly Municipal Hospital Dehydrated Pt "not feeling well." Pt was thru Joseph Berdecia, M.D., Ph.D. admitted after failing out-patient 01/12/99 treatment and R. 423, becoming quite dehydrated 625-26, because of high ostomy 629-30 output. : 1. Acute bronchitis 2. Failed out-patient treatment. 3. Acute pansinusitis. 4. High ostomy output decreased. 5. Reaction airway disease, doing better. : Pt discharged home to continue with respiratory treatments. She will continue as an outpatient with IM antibiotic treatments. Start on Flonase nasal spray. 01/13/99 R. Covenant Clinic Follow-up re Pt doing fairly well after 596, 632 bronchitis; ankle hospitalization. Pt sprained her and knee sprain ankle and knee. Pt still having problems with headaches, still using her respiratory machine. Chest X-ray: Very shallow inspiration probably related to Pt's size. Heart size normal. Lungs clear. : Acute bronchitis; Pansinusitis. 01/14/99 R. Covenant Clinic Follow-up re Pt returns for follow-up; also had 596 bronchitis problems with vomiting today. sinusitis : 1. Acute bronchitis 2. Pansinusitis. 3. Nausea. : Pt given Compazine and Rocephin. 01/15/99 R. Covenant Clinic Joseph Berdecia, Letter to Iowa Pt's handicap is permanent. 424 M.D. Ph.D. Department of : IDDM, severe Transportation hypertension, colitis. 01/15/99 R. Covenant Clinic Follow-up re Pt still having severe headaches. 595 bronchitis and Stadol is the only thing that sinusitis controls her pain. Pt given injection of Rocephin. Scheduled follow-up CT. Refilled Stadol. 01/16/99 R. Covenant Clinic Follow-up Pt came in for a shot of Rocephin 595 medication per Dr. Berdecia's order. 01/17/99 Waverly Municipal Hospital Lee Dehydration Pt was admitted with thru Fagre, M.D. gastroenteritis. Pt was rehydrated 01/19/99 R. and her insulin dependent diabetes 425-33, 631 mellitus was treated. Pt's bowels were slowed down a bit. 1. Gastroenteritis 2. Dehydration, improved. 3. Insulin dependent diabetes mellitus. 4. Status post ileostomy with dumping syndrome. 5. Acute sinusitis resolving. 6. Resolving bronchitis. 7. Hypertension. : Metamucil wafers, Lomotil liquid, Humulin, Humalog, Glucophage, Lotrel, ACE inhibitor. 01/22/99 Waverly Municipal Hospital Joseph Weak, headache Pt had been doing well last few days thru Berdecia. M.D. until 01/21, when she started having 01/23/99 R. multiple episodes of high output 434-39, 627 through her ostomy, and headache. : 1. Orthostatic hypotension. 2. Dehydration. 3. Pansinusitis. 4. IDDM. : Pt given one liter of lactated ringers; put on full liquid ADA diet of 1800 calories; restarted on Zosyn; restarted her home meds. 01/25/99 R. Waverly Municipal Hospital Joseph Laboratory Hypotension, 440-46, Berdecia, M.D. results hypokalemia, IDDM, colitis, old 621-23, 627 ostomy. 01/25/99 Covenant Clinic Vomiting, back Pt threw up all day yesterday R. 595 pain and is having some back pain. Pt's lab studies showed low potassium and abnormal urinalysis. : 1. Hypokalemia. 2. Urinary tract infection. : Pt given Rocephin and Toradol for headache. Rx for Ceftin and K-Dur. 01/26/99 Mayo Clinic Evaluation Chief complaint: Severe dehydration thru with high output 01/29/99 from ileostomy. R. 449-57 : 1. Increased ileostomy output, secondary to bacteria overgrowth and excessive intake of simple carbohydrates. 2. Dehydration, secondary to #1. 3. Diabetes mellitus type 2. 4. History of ulcerative colitis, status post total colectomy with ileostomy. 01/29/99 Mayo Clinic Report from Pt was admitted to Gastroenterology R. 447-48 Lisa A. Boardman, M.D. evaluation at Service at Mayo Mayo Clinic Medical Center. Reviews Pt's history of high output through stoma and dehydration. "It was believed that the portion of the increased stool output that was associated with dehydration was related to her diet." Pt instructed in use of "Ceralyte," and magnesium and potassium replacements. Pt told to follow diabetic diet more carefully. Pt to measure stool output on a daily basis. Bacterial overgrowth is likely a component of her increased stool frequency, and Pt was started on ciprofloxacin. Pt "may need to be on this chronically, but after three months of antibiotic therapy, she will have a trial without antibiotics to determine the need for long-term antibiotic treatment." Recommended discontinuing Glucophage because it may aggravate diarrhea. Pt's electrolyte imbalance was felt to be related to the increased output through her stoma. 01/29/99 Covenant Clinic Medication Rx for Amitriptyline. R. 594 Refill 01/30/99 Waverly Municipal Hospital Weakness, Pt was admitted with thru Joseph Berdecia, M.D. hypertension problems with hypertension, 01/31/99 low borderline potassium, R. 458-68, low magnesium level. Pt 619-20 given an IV fluid bolus followed by IV magnesium and potassium supplementation. Restarted meds. : 1. Dehydration. 2. Orthostatis hypertension 3. Electrolyte imbalance. : Pt to have IV hep locked; change her electrolyte at home to K-Dur, continue Mag Sulfate supplementation and her other meds. 02/02/99 Covenant Clinic Dehydration Pt had to be hospitalized R. 594, "after getting dehydrated 617 after being up all [night] at a concert." Pt advised "to take better care of herself." : 1. Hypertension 2. IDDM 3. Dehydration doing better. Rx for K-Tabs. Mayo recommended cycling Pt with Cipro, Amoxicillin and Bactrim. 02/08/99 Waverly Municipal Hospital Lab results R. 469-70, Joseph Berdecia, M.D. 616 02/09/99 Waverly Municipal Hospital Vomiting, Pt was admitted with nausea, thru Joseph Berdecia, M.D. abdominal pain vomiting, and not feeling 02/10/99 well. Pt rehydrated with IV R. 471-77, fluid; showed increase in her 613-14 creatinine levels for first time. Recommended that Pt have some counseling and possibly a psychiatric evaluation for depression. Renal ultrasound was negative. : 1. Colitis exacerbation 2. Diarrhea. 3. Dehydration. 4. Uremia. : Continue workup for kidney problems on out-patient basis. Schedule appt at Cedar Valley Mental Health for further counseling and treatment. Pt to resume home meds except for Lotrel. Rx for Serzone, Asacol, Potassium chloride liquid, and Atarax. 02/12/99 Waverly Municipal Hospital Abdominal pain Pt complains of abdominal R. 478, Francis Coyle, M.D. pain. Given Demerol and 481-83 Vistaril. 02/13/99 Allen Memorial Hospital Abdominal pain, Pt seen in E.R. at Waverly R. 479-80, Suresh K. Reddy, M.D. vomiting, Hospital for acute onset of 488, 612 increased ostomy abdominal pain, vomiting, output and increased output from her ostomy. Pt given IV fluids, Demerol, and Vistaril; transferred Pt to Allen Memorial Hospital for further management of symptoms. By the time Pt got to Allen Memorial Hospital, her symptoms were better. : 1. Intermittent episodes of abdominal pain, nausea, vomiting and diarrhea causing dehydration. Etiology unclear. Pt diagnosed w/bacterial over-growth which could be causing her symptoms. 2. History of ulcerative colitis, status post colectomy with ileostomy. : Rx for Cipro. Drink electrolyte solutions such as Pedialtye or Gatorade. Limit intake of fluids to 1.5 to 2 liters a day. 02/17/99 Covenant Clinic Follow-up re Pt feeling somewhat better R. 593 abdominal pain today, but still having problems with output. : 1. Bacterial overgrowth of gastric fluid. 2. IDDM, w/sugars between 90 and 150. 3. Adjustment disorder with depressed mood. 4. Headaches by history. : Stay on Cipro. Pt given samples of Phrenilin Forte. Continue Serzone, Lotrel, Prevacid, Magnesium supplementation and hypopotassium supplementation. Pt given one spray of Stadol nasal spray for severe headache; may repeat in one hour with one refill. 02/24/99 Covenant Clinic Swollen legs Pt has been developing R. 592 problems with leg edema. : 1. Leg edema. 2. Hypertension 3. IDDM. : Pt given Humulin Pen to use. Rx for Neurontin. Juzo stockings were ordered. 02/24/99 Covenant Clinic Letter to Meyer Recommendation for Pt to R. 484 Joseph Berdecia. M.D., Ph.D. Pharmacy use compression hose to present complications from Chronic Venous Stasis. 03/02/99 Cedar Valley Mental Health Center Report from Counselor met w/Pt twice. Pt R. 485 Pat Jebe, LMHC mental health appears to be struggling with some evaluation grief over husband's death. Pt continues to take Serzone; sees no changes but reports she feels quite well. It has been over three weeks since she has felt the need to be hospitalized. Pt "does appear to be very active and seems to have many interests/projects going on at this time." Scheduled follow-up. 03/03/99 Covenant Clinic Hypertension, Pt feeling better, but still R. 592 diabetes, edema staving up at night. : 1. Hypertension 2. IDDM. 3. Pedal edema. 4. Adjustment disorder. : Continue Juzo hose. Rx for Avapro. Increase Serzone. 03/10/99 R. Covenant Clinic Abdominal pain Pt complaining of severe low 591, 611 abdominal pain over the ovaries, that goes around to her back. : 1. Abdominal and pelvic pain. 2. Sinusitis. : Rx for Toradol, Rocephin, Flagyl. Scheduled Pelvic CT. 03/12/99 Waverly Municipal Hospital Radiology report CT of pelvis without R. 486-87, Joseph Berdecia, M.D. from pelvic CT contrast. : "There is 489 a questionable indistinctness in the mid pelvis at the uterine fundus that is probably simply due to adjacent fluid filled bowel loops. It would seem unusual that if this were free fluid that it does not accumulate in a more dependent portion of the posterior pelvis. An ileostomy is identified. I do not identify abnormal bowel wall thickening." Addendum to CT: Comparison with previous Mayo Clinic exam shows no remarkable change in appearance of the pelvis. 03/19/99 Covenant Clinic Pelvic pain Pt still having pelvic pain. R. 590 Pelvic CT did not show any masses. Pt having some unusual headaches. : 1. Pelvic pain 2. Rhinitis. 3. Hypertension : Continue Avapro. Rx for Nasonex and Micronor. 03/22/99 Covenant Clinic Upper quadrant Pt complaining of constant, R. 591 pain dull upper quadrant pain, and occasional sharp pain. Persistent headache. No treatment notes. 03/23/99 Covenant Clinic Pelvic pain; knee Pt complains of having some R. 590 and joint pain; difficulty with her breathing breathing and still having some pelvic problems pain. Xanax helps Pt sleep. Pt having a lot of knee pain and joint problems. Celebrex helped with the joint pain. : 1. Acute reactive airway disease. 2. IDDM. 3. Pelvic pain. : Rx for Celebrex, Xanax, Vicodin ES, Progesterone tablet. Continue Humalog, Micronor tablet. 03/29/99 John A. May, M.D. Physical Pt may lift and/or carry 50 R. 494-501 Residual lbs, including upward Functional pulling, and 25 Capacity lbs ; stand and/or Assessment walk about 6 hrs in an 8-hr workday (with normal breaks); sit about 6 hrs in an 8-hr workday (with normal breaks); and is unlimited in her ability to push and/or pull (including operation of hand and/or foot controls), other than as shown for lift and/or carry. Pt has no postural, manipulative, visual, communicative or environmental limitations. 03/29/99 John A. May, M.D. Medical Pt "alleges ileostomy, ulcerative R. 502-03 Consultant colitis, hypertension and Review diabetes mellitus." Medically determinable impairment is ulcerative colitis with ileostomy, hypertension, diabetes mellitus, Type II and obesity; severe based on impairment findings, symptoms, and consistency of evidence. Pt has migraine headaches, abdominal cramps, swelling of legs, and less energy than she used to have. : Serzone, Neurontin, Prevacid, Accupril, Phenergan, Stadol, insulin, Naprosyn and Prozac. "The claimant's allegations are consistent and credible." : "This claimant has a long history of colitis with ileostomy in the late 70's. This was revised in 2/98. She has been hospitalized in 1998 due to diarrhea and dehydration. Her weight and hemoglobin have remained stable. GI studies reveal no recurrence of her colitis. She has diabetes mellitus, hypertension, and migraine headaches which are controlled by medication. She is currently taking care of children in her home. No limitations have been placed by her treating sources." 03/30/99 Covenant Clinic Preeti Report from Pt referred for evaluation. Exam R. 504 Srivatsa, M.D. evaluation for was unremarkable. Pt given samples pelvic pain and of Voltaren; recommended possible irregular menses Depo Provera or Provera to control bleeding. 04/07/99 Covenant Clinic Crying spells Pt complains there is "something R. 589 wrong with her." Pt took father-and mother-in-law to cemetery last week to look at her husband's grave. Sine then, Pt has had difficulty sleeping and has frequent crying. Pt still having difficulty dealing with her husband's sudden death. : 1. Adjustment disorder with depressed mood. : Switch to Zoloft, increase Xanax. 04/08/99 R. Covenant Clinic Medication Rx for Demadex, Prevacid. 589 Refill 04/12/99 Covenant Clinic Blisters on arm Pt has scratch on forearm R. 589 that she has rubbed and now has an open blister, like sunburn. : Cellulitis from scratch on left forearm. : Dressed Pt's arm with Bactroban, which she didn't like, so Rx for Silvadene was given to Pt. 04/15/99 Covenant Clinic Medication Pt requested refill on Stadol R. 588 Refill Nasal Spray. Meyer Pharmacy called to state Pt had got gotten a refill seven days ago and Dr. only wanted her to refill it every two weeks. Pt was told to make it last until the end of the week. 04/22/99 Covenant Clinic Medication Rx for Hydrocodone/Apap. R. 588 Refill 04/27/99 Covenant Clinic Elevated blood Pt is on Danazol for dys-menorrhea; R. 588 sugar Danazol is raising Pt's blood sugars. : 1. IDDM poorly controlled. 2. Dysmenorrhea better but still having pain. 3. Headaches. : Rx for Zomig and Nasonex spray. Increase Humulin-N, Humalog, and Zoloft. 04/27/99 Covenant Clinic Headache Pt comes in for a second visit R. 588 today complaining of headache. Zomig caused a lot of burning and shooting pain. The only way to get rid of the headache was to give Pt Nubain and Vistaril. Pt told not to take Zomig. 04/28/99 Covenant Clinic Headache Pt called to report she woke up R. 588 with a terrible headache. Zomig did not help. Danazol dose was cut in half and Stadol spray refilled. 04/29/99 R. Covenant Clinic Severe headache, Pt told to use Stadol now, and 587 burning in face again in one hour if not better. 04/30/99 R. Covenant Clinic Headache Pt called stating her headache was 587, 607, back. She has used eight squirts of 609-10 Stadol since 3:30 p.m. yesterday with no relief. "Faxed golden rod to WMH for Solu Medrol 100 mg IM, Nubain 20 mg IM and Compazine 10 mg IM." Pt scheduled for EEC, MRI of head, lab studies. Pt given Nubain and Vistaril. 04/30/99 R. Waverly Municipal Hospital Joseph Headache Pt went to E.R. with "headache 505-10 Berdecia. M.D. since yesterday." Pt given Solu Medrol, Nubain and Compazine. Pt instructed not to drive; go home and rest. 05/03/99 R. Covenant Clinic Headache Pt having intractable headaches. Pt 587 counseled concerning her use of Stadol, which is only medication that seems to help. Pt will try Fiorinal with codeine. 05/03/99 R. Covenant Clinic Medication Pt called requesting more Stadol, 587 Refill still complaining of terrible headache. Pt has filled eight bottles of Stadol in March and seven bottles in April. Rx for Fiorinal with codeine 05/04/99 R. Covenant Clinic Medication Rx for Topicort, Lidocaine, Zinc 587 Refill Oxide Cream. 05/04/99 Covenant Clinic Nausea Pt presents feeling shaky and R. 586 nausea, hurts all over, feeling hot and cold at times. : 1. Acute sinusitis. 2. Headaches recurrent. : Rx for Depo Medrol, Rocephin, and Toradol. 05/05/99 Waverly Municipal Hospital Report from MRI of head with and R. 511-13 Joseph Berdecia, M.D. MRI of head and without contrast was normal. EEC EEC normal, awake and asleep. 05/07/99 Cedar Valley Medical Headaches Pt seen for evaluation of R. 514-15 Specialists, P.C. severe headaches which historically Brian Sires, M.D. seem to be related to hormone manipulation for her menstrual periods. Also possible muscle contraction component. Recommended Pt's hormones be changed or discontinued. Pt sent to physical therapy for massage techniques. 05/09/99 Waverly Municipal Hospital Headache, Pt has no vision disturbance, R. 516-18 David J. Rathe, M.D. irregular and though she is photophobic elevated blood and phonophobic with headaches. sugars, Pt has difficulty dizziness, sleeping due to headaches. Pt depression has been under stress recently and in recent past; husband died 11/98. Pt has been having problems with depression and has been scratching herself until she bleeds. : Zoloft, Percocet, Cipro, insulin Humulin, Humalog and Regular. : 1. Chronic cephalgia with acute exacerbation. 2. Diabetes Type II, elevated glucose. : Pt to use her own headache pill; return to E.R. if headaches worsen. 05/10/99 R. Covenant Clinic Arm itching Pt has scratched her arms with 586 scissors because they were bothering her so much. : 1. Dermatitis. 2. Cellulitis of the upper extremity. : Rx for Keflex. Pt given a mix of Triam-cinolone/Silvadene to apply to affected areas. 05/11/99 R. Covenant Clinic Medication Rx for Phrenilin Forte. 586 Refill 05/12/99 R. Covenant Clinic Medication Rx for Topicort, Lidocaine, Zinc 586 Refill Oxide Cream. 05/13/99 R. Waverly Municipal Hospital Joseph Headache Pt went to E.R. with complaints 519-22 Berdecia, M.D. of headache all over her head. MRI of head was normal. 05/14/99 R. Covenant Clinic Headache Pt has "terrible headache"; does 585 not feel well. : 1. Headache. 2. muscle cramps. 3. Ileostomy because of severe colitis. 4. Adjustment disorder. : Rx for Xanax, Stadol, Vista-ril, Neurontin; increase Avapro. 05/20/99 R. Covenant Clinic Follow-up re : 1. Hypertension 2. 585 hypertension, Colitis. 3. IDDM. : Rx for diabetes Cipro, Avapro. Continue insulin dosage. Pt is off Danazol and her sugars are coming down. 05/26/99 R. Covenant Clinic Sore throat Pt complains of sore throat, 585 sinus congestion and pressure. Rx for Cefzil and Pan Mist LA. 06/02/99 R. Covenant Clinic Medication Rx for Vistaril and Stadol. 585 Increase Levoxyl. 06/07/99 R. Covenant Clinic Nasal drainage Pt still having problems with 584 colitis. Exam shows red throat and "copious amounts of postnasal drainage." Refilled Kenalog spray; continue other current meds. 06/08/99 R. Covenant Clinic Medication Given Rx for "Palgic DS" for nasal 581, 583, problems and sinus. 584 06/08/99 R. Covenant Clinic Medication Rx for Tincture of Opium. 584 Refill 06/09/99 R. Covenant Clinic Medication Rx for Phrenilin Forte and 581, 583 "Palgic DS." 06/15/99 R. Covenant Clinic Medication Rx for Lotrisone Cream, Phrenilin 581, 583 Refill Forte, Hydroxyzine Syrup. 06/18/99 R. Covenant Clinic Headache and Phrenilin Forte not helping. Rx 581, 583 nausea for Compazine. 06/26/99 Covenant Clinic Medication Rx for Phrenilin Forte. R. 581, Refill 583 06/28/99 Covenant Clinic Headache Pt is seen for follow up on R. 581 diabetes; complains of frequent headaches and menstrual pain. : 1. IDDM stable. 2. Migraine headaches. 3. Hypertension 4. Dysmenorrhea. : Take Prempro and Phrenilin Forte. 06/28/99 Covenant Clinic Medication Rx for liquid KCL R. 584 07/07/99 Covenant Clinic Medication RX for Stadol Nasal Spray. R. 582 Refill 07/08/99 Covenant Clinic Medication Rx for Tincture of Opium R. 581, Refill and Silvadene. 583 07/12/99 Covenant Clinic Medication Rx for Tincture of Opium. R. 582 Refill 07/27/99 Gary J. Cromer, M.D. Physical : Pt R. 523-530 Residual may lift and/or carry 20 lbs, Functional including upward pulling, Capacity and 10 lbs Assessment ; stand and/or walk about 6 hrs in an 8-hr workday (with normal breaks); sit about 6 hrs in an 8-hr workday (with normal breaks);and is unlimited, in her ability to push and/or pull (including operation of hand and/or foot controls) other than as shown for lift and/or carry. : Pt can climb ramps/stairs. balance, stoop, kneel, crouch and crawl. Pt cannot climb ladders/ropes/scaffolds. No other limitations. 07/27/99 Gary J. Cromer, M.D. Medical Pt "alleges disability due to R. 531-32 Consultant ileostomy for ulcerative Review colitis, hypertension, diabetes, Comments and back pain from arthritis. AOD is 11/01/98." : "Claimant has documented medically determinable impairments with history of ulcerative colitis now status post total colectomy without extraintestinal manifestations, moderate obesity, diabetes and hypertension and headaches. Her diabetes and hypertension are nonsevere. She has not documented a medically determinable impairment to support her allegation of back pain from arthritis." Remaining impairments are severe but do not meet listing requirements. "Subject reports reveal numerous inconsistencies. Claimant has a history of dietary noncompliance that was determined to be the primary factor in causing her GI symptoms." Pt has gained 25 pounds. "She has exhibited drug-seeking behavior and overuse of narcotics, and has been noncompliant in following up with her neurologist regarding her headaches. These inconsistencies have eroded claimant's credibility." 08/10/99 Covenant Clinic Medication Rx for Amoxil. R. 580 Refill 08/18/99 Covenant Clinic Medication Rx for Nystatin Swish and R. 580 Refill Swallow. 08/18/99 Glenn F. Haban, Ph.D. Psychological Pt referred for evaluation to R. 533-36 Evaluation help determine eligibility for Social Security Benefits. Pt arrived on time, dressed casually, and was neat and clean with good hygiene. Weight somewhat above average for her height. Steady gait. "Numerous scratches and sores were noted on her left forearm." "No unusual thought content or preoccupations were expressed." Affect was appropriate; "social presentation was somewhat dramatic." "The results of the cognitive status screening found Ms. McGee to be within the normal range for orientation and elemental cognitive capacity. She was grossly intact for simple attention processes, but borderline for more complex attention and problem solving skills. Her functioning was intact for memory functioning, verbal similarities and differences, performs mathematical calculations. She was intact for abstract reasoning and concept formation." Pt "is currently functioning within the normal range for orientation and cognitive capacity. The mental status examination suggests bereavement. No other Axis One Disorders were identified." Pt can manage her own funds. — in the following areas: concentration/attention and calmness/ patience are poor to adequate; self-confidence is poor; social skills and dealing with public are adequate to excellent; taking supervision is excellent; work stresses, independence, making decisions, handling money, understanding complex job instructions, reliability, persistence, and accuracy in work are all adequate. [Excellent means no impairment. Adequate means "Performs well enough to meet community-work expectations." Poor means "Is impaired to the extent that behavior is not dependable or c[onsistent]."] : Mental Status Checklist for Adults; Cognitive Capacity Screening Examination. : Pt reports she is unable to work due to nervousness and mood changes that have increased since her husband died last year. Pt continues to be involved in pleasurable activities such as going to the fair, visiting with others, and cooking, but her activity is limited by pain. Pt has 10 years of formal education and a GED. She quit school due to medical problems. Pt was trained as a nursing assistant, but quit due to back injury and difficulty working with older patients, who would die. Pt worked in child care for the past 4 years and was able to care for about 10 children. "She feels she can no longer do this job due to her nervousness. She continues to care for one child on a part-time basis. She is not looking for work and feels unable to work due to her emotional condition." 08/25/99 Jay P. Ginther, M.D. Epicondylitis Pt had good results with injections R. 537 to right medial epicondylar area along with using a brace and taking Ibuprofen on a regular basis. Pt is doing well on the right overall. Left medial epicondyle is tender; Pt has multiple areas of abrasion on the dorsum of the left forearm from scratching. She has been scolded for this by the Medi Health counselor. : Inject left medial epicondylar area with Marcaine and Depo-Medrol. She was given a brace and refilled her Ibuprofen. 08/25/99 Covenant Clinic Medication Rx for Amoxil. R. 580 Refill 08/26/99 Covenant Clinic Cat bite Pt got bitten by her cat. Rx R. 580, for Amoxicillin. 608 08/31/99 Waverly Municipal Hospital Spots on stoma Pt is seen for bleeding spots R. 642 Dawn Morey, D.O. on stoma, present for several weeks. Ostomy appliance does not fit well and leaks occasionally, although output is much better. : Granulation tissue on the ostomy with bleeding. Ulcerative colitis. : Pt to see ostomy nurses for possible change in stoma appliance. 09/01/99 Covenant Clinic Medication Rx for Stadol Nasal Spray R. 580 Refill 09/02/99 Dawn Morey, D.O. Report from Pt seen because of granulation R. 548, referral re tissue on ostomy that 642 granulation bleeds. Appliance removed; tissue on ostomy several areas excised and sutured. Pt to follow up with ostomy nurse to get a better fitting ostomy appliance. 09/24/99 Covenant Clinic Opinion Itr to Pt has "extensive medical R. 679 Joseph Berdecia, M.D., Ph.D. Pt's attorney problems" including severe hypertension, insulin dependent diabetes, and colitis since age 16. Pt has bouts of multiple problems that include chronic and persistent diarrhea requiring multiple hospitalizations over the past two years, with developing severe problems with electrolyte imbalance. Pt is on multiple meds for treatment of these conditions as well as headaches. Dr. opines Pt will be unable to obtain employment due to frequent absences from work to deal with her medical problems. 09/30/99 Waverly Municipal Hospital Report from Impression: 1. cholelithiasis R. 571-572, John Halloran, M.D. gallbladder without ultrasonographic 604-05 ultrasound evidence of cholecystitis. 2. No evidence of biliary ductal dilatation. 3. Probable diffuse fatty infiltration of the liver. 10/01/99 Allen Memorial Hospital Report from NM : 1. No evidence R. 573 Lawrence Liebscher, M.D. Hepatobiliary for acute cholecystitis. 2. scan Low gallbladder ejection fraction which is a nonspecific finding but could be secondary to chronic cholecystitis or biliary dyskinesia. 10/04/99 Covenant Clinic Medication RX for Tincture of Opium R. 579 Refill and Hydrocodone. 10/04/99 Beverly Westra, Ph.D. Psychiatric Pt has disturbance of mood, R. 539-47 Review accompanied by a full or Technique partial manic or depressive syndrome as evidenced by a diagnosis of adjustment disorder with depressed mood. Pt has a degree of limitation in activities of daily living and difficulties in maintaining social functioning. Pt has deficiencies of concentration, persistence or pace resulting in failure to complete tasks in a timely manner (in work settings or elsewhere). Pt has episodes of deterioration or decompensation in work or work-like settings. 10/04/99 Beverly Westra, Ph.D. Mental Residual Pt is limited in R. 551-54 Functional ability to understand, remember, Capacity and carry out detailed Assessment instructions; maintain attention and concentration for extended periods. Pt is in any other area. 10/04/99 Beverly Westra, Ph.D. Medical Pt alleges disability due to R. 555 Consultant ileostomy, ulcerative colitis, Review hypertension, diabetes mellitus; Comments after filing initial claim, had treatment for depressed mood by family physician, and consultative exam on 8/18/99. Family doctor diagnosed Adjustment Disorder with Depressed Mood shortly after death of Pt's husband. Dr. Haban assessed Pt on 8/18/99, and diagnosed Bereavement 9 mos after her husband's death. This doctor feels Adjustment Disorder with Depressed Mood (chronic) would be the most appropriate diagnosis. No evidence of limitations re activities of daily living or social functioning. "Attention and concentration would be adequate for most simple tasks, but moderately impaired for highly complex or detailed information and for sustained attention for prolonged periods of time." : Pt has medically determinable impairment of Adjustment Disorder with Depressed Mood, severe, but not of listing-level severity. Impairment results in some mild to moderate limitations. "Allegations are credible and consistent[.]" 10/04/99 R. Covenant Clinic John B. Referral Referral to Dr. Morey for 570 Brunkhorst M.D. evaluation and treatment of gallstones. 10/07/99 R. Dawn Morey, D.O. Report from Pt seen for abdominal pain that 549-50 evaluation re began suddenly last week when Pt abdominal pain was in the bathtub. Pt got nauseated suddenly and began throwing up profusely. Pt was taken to E.R. and admitted for work up. Pt continues to have pain in right upper abdomen, radiating through to her back and somewhat up into her chest. Ultrasound shows cholelithiasis. : Cholelithiasis, cholecystitis. : Cholecys-tectomy with cholangiogram. 10/08/99 R. Waverly Municipal Hospital Dawn Cholecystectomy Post-op Diagnosis: 556-58, 569 Morey, D.O. Cholelithiasis, cholecystitis 10/19/99 R. Waverly Municipal Hospital Dawn Post-op check Pt is doing fairly well. Recheck 640-41 Morey, D.O. in a month and order liver function tests at that time. : Status post open cholecystectomy. 10/22/99 R. Covenant Clinic Not feeling well; Pt is just not feeling well; 578-79, 602 crying for three days husband died one year ago. "This time of year I would expect her to have these feelings of depression and sadness." Pt sent to Mental Health Center. Pt would like something for sleep as the Ambien is not working and would like to be evaluated as to why she hasn't had a period for over a year. : Insomnia, secondary to depressive affect. She also has amenorrhea. Pt to continue current meds. Rx for Restoril. 10/25/99 Covenant Clinic Post-operative Pt has pain in lateral aspect R. 578 pain of the surgical wound she got from the cholecystectomy. : Post-ophematoma. Pt given Percocet. 10/28/99 Waverly Municipal Hospital Incisional pain Pt is evaluated for pain in R. 640 Dawn Morey, D.O. lateral aspect of her incision. Dr. Skierka injected a local which helped discomfort temporarily. : Abdominal wall tenderness, status post open cholecystectomy. : Recommended ultrasound to rule out hernia. Ultrasound shows a 6 mm area of fluid collection at site of tenderness; looks homogeneous and was injected with some local anesthetic. Pt to take Motrin liquid and take it easy for a few days. 10/30/99 Waverly Municipal Hospital Pain in incision Pt seen for pain in the R. 568 Lee Fagre, M.D. incision along the lateral aspect. Area has been injected twice and ultrasound showed no gross abnormalities. Small palpable mass along gallbladder scar was injected with Marcaine. "I think she needs a pain doctor to take care of it." 11/01/99 Waverly Municipal Hospital Placement of L Pt has difficulty with IV R. 559-64, Dawn Morey, D.O. internal jugular access. Post-op Diagnosis: 639 Titan port Need for long term IV access, right upper quadrant incisional pain. Pt had a port placed this morning and developed a rash, itching and general anxiety with pain in the left lateral incision. It was recommended the Pt see a GI specialist to evaluate the cholangiogram pictures and abnormal liver function tests. 11/01/99 Waverly Municipal Hospital Chest X-ray Portable Chest X-ray: Left R. 567 Driss Cammoun, M.D. jugular line with the distal segment is difficult to identify but could project near the SVC. No pneumothorax. Lungs are low volume. Heart is of normal size. Pulmonary vascularity is normal. No evidence for pleural disease. 11/04/99 R. Covenant Clinic Matt Consult request A consult was requested for Pt 565 Sowle, PA-C with Dr. Federhofer for right-sided pain at incision site. 11/04/99 R. Covenant Clinic Matt Consult request A consult was requested for Pt 566, 601 Sowle, PA-C with Dr. Reddy re abdominal pain. 11/06/99 R. Waverly Municipal Hospital Headaches Pt has history of multiple 666 Branimir Catipovic, M.D. headaches. Recently she got a porta cath because of her need for IV medication. She had a very bad headache treated with Vistaril and Demerol. : Celebrex, Luvox, Neurontin, Avapro, Prevacid, Ambien, Cipro, Demadex, Magnesium, Phrenilin, insulin. : Headache. Pt will be given Vistaril and Demerol. 11/08/99 R. Covenant Clinic Sore throat, cough, Pt called in to report 577 earache, no fever symptoms. Rx for Suprax. 11/09/99 R. Waverly Municipal Hospital Dawn Port check Pt is seen for check of a port 639 Morey, D.O. that was placed recently. No evidence of infection. 11/10/99 R. Covenant Clinic Headache Pt complains of bad headache 577 radiating around to the front of her head. She is not having blurred vision now, but did earlier in the day. Pt given an injection of Toradol. 11/12/99 Waverly Municipal Hospital Dawn Fluid hydration Pt in for fluid hydration. R. 638 Morey, D.O. Swelling and pain were noticed at the port site. : Extravasation, most likely from dislodged Huber needle. : Let swelling go down and reevaluate. 11/15/99 Waverly Municipal Hospital Dawn Evaluation of port Pt in for re-evaluation of port. R. 638 Morey, D.O. Swelling is gone and port is easily accessed. Scheduled portagram contrast study. 11/15/99 Covenant Clinic Medication Refilled Cipro R. 576 Refill 11/15/99 Covenant Clinic Dizziness, Advised Pt to take Valium for the R. 576 headache dizziness. Refilled Valium. Pt to see Dr. Morey today. 11/16/99 Covenant Clinic Blood pressure BP 140/98. In light of Pt's R. 576 check headaches, she was started on Propranolol. Pt also has rash on left arm which she scratched and it has broken out. She was given samples of Bactroban, Maxalt, and Imitrex. Triamcinolone ointment and cream was also used. Extensive workup was done including CT scan and MRI of the head to try to find cause of headaches. 11/16/99 Covenant Clinic Phone Call Pt's counselor called and would R. 576 like to try Pt on Trazodone for sleep. Rx for Trazodone. 11/16/99 Waverly Municipal Hospital Stephen Portagram Impression: No radiographic R. 736 Frazier, M.D. evidence of obstruction of the Porta-Cath. 11/17/99 Covenant Clinic Medication Refilled Imitrex R. 576 Refill 11/18/99 Cedar Valley Medical Abnormal liver Pt seen for evaluation of abnormal R. 644-45 Specialists, P.C. Suresh enzymes liver enzymes and abnormal Reddy, M.D. intraoperative chol-angiogram. : 1. Elevated liver enzymes with liver biopsy showing fatty liver. Intraoperative chol-angiogram apparently was abnormal, showing some strictures in the bile ducts, suggestive of P.S.C. : Obtain intraoperative cholan-giogram films and have pathologist review liver biopsy slides to see if there is any evidence of P.S.C. 11/21/99 Waverly Municipal Hospital D. J. Achy; body sweats; Pt has been ill since 11/17, with R. 646-47 Rathe, D.O. headache; increased increased watery output of ostomy output colostomy as soon as she drinks something. It has slowed down over the last two days, but today she is quite achy and has had body sweats. She feels cold and nauseated and has a headache. : 1. Diarrhea. 2. Myalgias. 3. Sweats. : Continue oral rehydration; may start small amounts of food; may take Tylenol for aches and pains. 11/24/99 Covenant Medical Center Pinpoint, sharp, Pt's chief complaint is R. 648-49 Robert Federhofer, D.O. burning pain pinpoint, sharp, burning pain, worse with palpation, over area that would be approximately the distal caudad 1 cm of the surgical scar. Pain started when staples were removed after cholecystectomy done a month ago. : Scar neuroma along intercostal nerve. : Pt will undergo a series of intercostal nerve blocks starting at the cutaneous portion and trapped in the nerve. : Betadine prep. Injected Marcaine. 11/27/99 Covenant Clinic Vomiting, : Possible sepsis. R. 575, Lee Fagre, M.D. diarrhea, body : Recommended Pt go to 599 pain, fever, the hospital and get some chills, sweats, out-patient lab work done. difficulty urinating 11/27/99 Waverly Municipal Hospital Urinary tract Pt was admitted for rehydration. thru R. L. Skierka, M.D. infection, Pt was discharged 11/29/99 gastroenteritis home and is to continue her R. 651 meds except for Ciprofloxacin. Follow up with Dr. Reddy. 12/01/99 Covenant Medical Center Follow-up re Pt shows marked improvement R. 650 Robert Federhofer, D.O. neuroma along with initial injection of intercostal nerve intercostal nerve branches at the scar. The area is less sensitive to touch, but Pt has burning pain with more aggressive palpation and compression. Treated with Neurontin. : Injected lateral distal portion of the scar and intercostal nerve with Marcaine and Aristocort. 12/06/99 Covenant Clinic Roger Referral Pt is referred to Dr. Reddy for R. 652 Skierka, M.D. evaluation and treatment of persistent diarrhea. 12/07/99 Covenant Clinic Left third finger Pt complaints of pain in her left R. 575 third finger. She is unable to bend it. She also has left hip pain with radiation down laterally. No treatment notes. 12/08/99 Cedar Valley Medical Evaluation re Pt is referred for evaluation of R. 653 Specialists. P.C. Suresh diarrhea and profuse diarrhea and increased Reddy, M.D. increased ostomy output from her ostomy since her output gallbladder surgery. : 1. Increasing output from the ileostomy probably related to recent cholecystectomy causing some post-surgical diarrhea. 2. Abnormal intraoperative cholangiogram suggestive of possible sclerosing cholangitis but films are not of high quality to make a definitive diagnosis. : Continue Metamucil and Tincture of Opium to control diarrhea. Take Pedialyte to prevent dehydration. Recommended Pt have a formal ERCP to obtain a better cholangiogram picture to make a definitive diagnosis whether she has sclerosing cholangitis or not. 12/10/99 Allen Memorial Hospital ERCP Postoperative Diagnosis: 1. R. 655-56 Suresh Reddy, M.D. Normal pancreatic duct. 2. Normal extrahepatic biliary system. 3. Multiple strictures in the intrahepatic duct suggestive of sclerosing cholangitis. Pt's liver enzymes are only mildly elevated. There are no specific meds available for this. Actigall or Colchicine will be tried. 12/10/99 Lawrence Liebscher, M.D. Follow-up re ERCP was performed by R. 654 Abnormal liver Dr. Reddy. : The enzymes intrahepatic bile ducts appear diffusely narrowed with some areas of focal stricture, possibly due to under-filling, but an inflammatory process is possible. Cholangitic hepatitis is possible, although no focal areas of dilatation and only a few areas of focal stricture are present, which would not be typical for sclerosing cholangitis. The extrahepatic bile ducts appear normal. 12/14/99 Covenant Clinic Opinion letter Pt has long history of ulcerative R. 657-58 Roger L. Skierka, M.D. colitis. A large section of her colon was removed as a child; she has a colostomy bag to help with bowel movements. Complications include arthritis. She has a history of liver changes and recently underwent a cholecystectomy to remove her gallbladder. A liver biopsy is pending, but showed some chronic signs of change secondary to what was presumed to be ulcerative colitis. Pt suffers from diabetes mellitus and requires insulin. Pt suffers from depression and anxiety attacks. She is on an extensive amount of medicine for GI upset secondary to ulcerative colitis. "Because of her diabetic problem, arthritis and other problems associated with her ulcerative colitis we do not feel that she is capable of working outside of the home. Although she is attempting to do everything she can to maintain her own ability to function on her own, she is having a very difficult time." 12/14/99 Mayo Clinic Pathology report Needle biopsy of live: R. 667-68 Herschel A. Carpenter, M.D. "Consistent with small duct primary sclerosing cholangitis, stage 2-3." 12/31/99 Waverly Municipal Hospital Roger Sweating, cough Normal chest X-ray R. 669 L. Skierka, M.D. 01/11/00 Waverly Municipal Hospital A. E. Back and lower Pt underwent facet injection at R. 670 Delbridge, M.D. extremity pain L4-5 bilateral, L5-S1 bilateral, and an epidural injection under fluoroscopic control. 04/05/00 Waverly Municipal Hospital Traci Vomiting, Pt comes in the hospital after 24 R. 671-72 Skierka, M.D. diarrhea hours of vomiting and straight water from her ostomy bag. : 1. Vomiting and diarrhea with dehydration. Pt was placed in an observation bed and was given a couple of liters of fluid. 04/06/00 Waverly Municipal Hospital Roger Pre-surgical Pt approved for surgery with R. 673-74 L. Skierka, M.D. work-up general anesthesia on 04/10/00. 04/10/00 Waverly Municipal Hospital Dawn Rectal pain and Procedure: Rectal exam under R. 675 Morey, D.O. drainage anesthesia and curettage of abnormal mu-cosa versus granulation tissue. 04/19/00 Cedar Valley Mental Health Center Opinion letter Pt has diagnosis of depression; R. 676 Pat Jebe, LMHC treated with Paxil and Trazodone. Pt's "numerous ailments require that she take a number of meds, is frequently seen by various medical health professionals and she has needed to be hospitalized a number of times over the recent year or so. Though [Pt] has insurance, she has a high deductible, and her co-payment is more than she can afford, as is her high monthly insurance bill. She cannot always afford to buy her meds, and she tends to go without them as well as postponing needed appointments with medical personnel, as she cannot afford to pay for these services. Due to [Pt's] numerous chronic illnesses and her limited income, I feel that she should seek out assistance through SSI income. She cannot possibly continue to shoulder the medical bills that she will certainly face in the future, and the stress of this situation undermines her mental health. I understand that [Pt] is to have a hearing regarding her SSI benefits in a few weeks, and it is my hope that she will be eligible." 04/19/00 Covenant Clinic Opinion letter Pt has a long history of R. 677-78 Roger L. Skierka, M.D. chronic medical problems. Because of her ulcerative colitis, Pt is at increased risk for complications such as liver failure. Her liver function tests have recently gone up showing she is having some signs of complications with her liver. Even after having had her gallbladder removed, the gastroenterologist, Dr. Reddy, felt Pt eventually would develop more liver complications secondary to ulcerative colitis. Pt's liver function tests are monitored on a six-month basis. Pt also has Type I diabetes and she is suffering from depression. "Because of her medical problems she is on a lot of different medicines at this time. She has frequent physician visits both to primary care physicians such as myself and to specialists such as the surgeon." Pt recently had a cyst removed in her abdominal region and is starting to develop arthritis; both are complications of chronic ulcerative colitis. Pt has a subsequent risk of developing cancer associated with the ulcerative colitis. Pt also helps care for her mother, which is burdensome, but she seems to be maintaining okay. "In light of her many medical problems and the need to frequently visit physicians for these problems it is felt that any assistance that can be provided for this patient would be greatly appreciated by both the medical professionals and also by the patient. The medicines she takes are not inexpensive and some of them are not provided by drug companies for free. Although we can supply her with some medicine on an infrequent basis without cost to the patient, most do have to be provided through a pharmacy. She is also subsequently unable to do most types of manual labor due to the arthritis and the chronic problems that she suffers from. It is therefore felt that, again, if any assistance can be administered for this patient, it would be greatly appreciated. It will also help reduce the stress in her life which will also help reduce the amount of time that she does have to seek medical attention. In the long run I think it will actually help save money and also help this patient." 08/23/00 Paul From, M.D. Answers to Pt has severe impairments, R. 681-86 interrogatories but no specific impairment with attached meets the listing criteria. summary "There is no documentation that the impairment is disabling other than for statement[s] from 2 attending physicians. These opinions differ somewhat from listed objective criteria in previous evaluations." "On December 10, 1999, Dr. Reddy did find evidence of sclerosing cholangitis. Symptoms and findings seem to change somewhat in 1999." Pt's problems "appear to be those of a socioeconomic nature rather than true medical problems." "There are very few laboratory findings although the events of multiple problems do continue and increase throughout these documents." Opines if Pt were in compliance with prescribed treatment, her ostomy output would be "under fairly good control." "However, the development of depression and then the cholangitis later occurred. The attending physicians do not comment upon non-compliance, but this is readily apparent in other documents in [the Record]." 11/01/00 Covenant Clinic Opinion letter "We have been making an R. 687-88 Roger L. Skierka, M.D. attempt to obtain Social Security benefits for this patient due to her chronic medical problems which have resulted in her disability to perform most activities of daily living." Per Pt's report, she used to be able to manage a day care setting with several children. At this point she has a very difficult time managing 2-3 children for a short period of time. Pt's past medical history is significant for ulcerative colitis and significant number of surgical procedures done. Pt has type I diabetes mellitus, hypertension, history of dysmenorrhea, history of migraine headaches, history of ovarian cysts; and degeneration of her spine due to arthritis, most likely from the ulcerative colitis. Pt has abnormal liver function due primarily to ulcerative colitis. Pt suffers from significant depression and has chronic pain. "It is my medical opinion that this woman does have significant disability due to her chronic medical problems. Taken individually, I am sure most people could handle hypertension without any problem or diabetes without any problem or depression. Unfortunately, this woman has a combination of many medical problems that have caused a significant debilitation."