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Ringering v. Commissioner of Social Security

United States District Court, C.D. Illinois, Springfield Division

August 29, 2019

JULIA RINGERING, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          OPINION

          TOM SCHANZLE-HASKINS, U.S. MAGISTRATE JUDGE

         Plaintiff Julia Ringering appeals from the denial of her application for Social Security Disability Insurance Benefits (Disability Benefits) under Title II of the Social Security Act. 42 U.S.C. §§ 416(i) and 423. This appeal is brought pursuant to 42 U.S.C. §§ 405(g). Ringering filed her application for Disability Benefits on October 9, 2009. The Commissioner denied her claim. This Court reversed and remanded Commissioner's decision for further proceedings. Ringering v. Commissioner of Social Security, Ill. C. D. No. 13-3024 (Ringering I), Opinion entered August 4, 2015 (Case 13-3024 d/e 21) (Ringering I Opinion) included in Certified Copy of Transcript of Proceedings (d/e 6 and d/e 7) (R.), at 528-84. The Commissioner again denied Ringering's application on remand. Ringering has again filed this action for judicial review.

         The parties consented to proceed before this Court. Consent to the Exercise of Jurisdiction by a United States Magistrate Judge and Reference Order entered August 29, 2018 (d/e 12). Ringering filed a Motion for Summary Reversal (d/e 16), and Defendant Commissioner of Social Security filed a Motion for Summary Affirmance (d/e 21). For the reasons set forth below, the decision of the Commissioner is AFFIRMED in part and REVERSED in part. The decision is affirmed except with respect to the physical RFC finding. The case is remanded for development of additional evidence regarding Ringering's physical residual functional capacity.

         STATEMENT OF FACTS[1]

         Ringering was born on January 1, 1970. Ringering completed high school. She worked in various clerical, administrative, and sales positions at automobile dealerships. She also worked as a cashier and in the paint department at a Wal-Mart. She last worked on December 26, 2007. R. 48, 57, 453, 458. Ringering suffers from degenerative disc disease, bipolar disorder, posttraumatic stress disorder (PTSD), and alcohol abuse. R. 29. Ringering filed her application for Disability Benefits on October 6, 2009. She alleged that she became disabled on December 26, 2007. Ringering worked sufficient quarters to remain insured for Disability Benefits through March 31, 2009. R. 27. Ringering is married. Between 2007 and 2009, she lived with her husband and their five children. R. 45.

         On April 23, 2007, Ringering saw psychiatrist Dr. Sanjay K. Nigam, M.D., for a psychiatric evaluation. Ringering reported nightmares, flashbacks, depression, thoughts of suicide and hypersomnia. Ringering reported that she blamed herself for the suicide of her fiancé in April 1995. She reported that she began to seek psychiatric treatment in 1997. She reported episodes of depression in which she experienced increased sleep, low energy, feelings of guilt, poor concentration, weight gain, psychomotor retardation, and lack of motivation. She also reported suicidal ideations. She reported having panic and anxiety attacks. She admitted having three panic attacks on the day of the evaluation. She denied any hallucinations or paranoid delusions. Dr. Nigam noted that Ringering was calm, cooperative, and pleasant. Her personal hygiene was fair. Dr. Nigam diagnosed bipolar disorder, possibly cyclothymia. He assigned her a Global Assessment of Functioning (GAF) score of 55. The GAF score was a measure of a clinician's judgment of an individual's overall level of functioning on a hypothetical continuum of mental health and illness. American Psychiatric Assn, Diagnostic and Statistical Manual of Mental Disorders (4th ed. Text Rev.) (DSM IV-TR), at 32-35.[2] A GAF score from 51 to 60 indicated either “moderate symptoms . . . or moderate difficulty in social, occupational, or school functioning.” Id. at 34. Dr. Nigam changed Ringering's medications. R. 199-201.

         Ringering continued to see Dr. Nigam throughout 2007 and into 2008. On May 9, 2007, and May 21, 2007, Ringering complained to Dr. Nigam of difficulty sleeping and not being motivated to clean the house. R. 202-03. On May 9, Ringering said she was feeling overwhelmed trying to arrange a sleep-over birthday party. On May 9, 2007, Dr. Nigam noted that Ringering's appearance and grooming was fair, her mood was euthymic, her thought process was logical and goal oriented, and her judgment and insight were good. Dr. Nigam gave her a GAF score of 55. R. 202. On May 21, 2007, Ringering said the party was for her son, and she had no problems with the party. She reported that after the party she went golfing and cleaned up the house. She said she got a job at Walmart. Dr. Nigam again noted that Ringering's appearance and grooming was fair, her mood was euthymic, her thought process was logical and goal oriented, and her judgment and insight were good. Dr. Nigam gave her a GAF score of 55-60. R. 203.

         On August 8, 2007, Ringering reported racing thoughts. Dr. Nigam noted that her thought process was logical and goal oriented and her judgment and insight were good. Dr. Nigam again gave her a GAF score of 55. Dr. Nigam recommended counseling. R. 205.

         On September 5, 2007, Ringering again reported feeling anxious and paranoid, and having racing thoughts. Dr. Nigam noted that she had a depressed mood, an appropriate appearance and affect, coherent speech, logical thought processes, normal memory, good judgment and fair insight. R. 206. Dr. Nigam again adjusted her medications.

         On October 8, 2007, Ringering reported that she stopped drinking. She reported that she was sleeping better, but still experienced drowsiness. Dr. Nigam noted that her speech was coherent, her thought process was logical, her memory was normal, her insight was fair, and her judgment was good. Dr. Nigam gave her a GAF score of 60. R. 207.

         On January 4, 2008, Ringering saw Dr. Nigam. Ringering reported that the holidays were not good for her. She reported that she had stress at work at Wal-Mart, and she quit. She reported that she was drinking and was not taking her medications. Dr. Nigam and Ringering discussed the adverse interaction between alcohol and her medications and the effect on her mental illness. Dr. Nigam noted that she was alert and calm, she had a sad mood, her thought process was concrete, her judgment and insight were poor, and her ability to abstract was limited. Dr. Nigam gave her a GAF score of 45. R. 208. A GAF score of 41 to 50 indicated either serious symptoms or any serious impairment in social, occupational, or school functioning. DSM IV-TR, at 34.

         On January 4, 2008, Dr. Nigam wrote a letter To Whom It May Concern regarding Ringering. Dr. Nigam wrote that Ringering was suffering from bipolar disorder with episodes of manic and depressive symptoms. He stated that she required extra support from her family during these episodes. R. 211.

         On February 4, 2008, Ringering saw Dr. Nigam. Ringering reported getting arrested for Driving Under the Influence of Alcohol (DUI) and resisting arrest. Her driver's license was suspended. She reported that the officer shocked her with a Taser. Dr. Nigam stated on that date that Ringering had a good appearance and an improved mood; her cognition was within normal limits; and she had good judgment, fair insight, normal affect, and a logical and goal directed thought process.” Dr. Nigam assigned GAF score of 50 at this visit. R. 209.

         On February 26, 2008, Ringering saw an orthopedic surgeon, Dr. Lukasz Curylo, M.D. because of problems with her neck. On examination, Dr. Curylo found limited range of motion in her neck and decreased strength and sensation in her left arm and fingers. An MRI showed two large disc herniations at ¶ 5-6 and C6-7. The herniations caused neuro-compression and significant canal narrowing. Dr. Curylo discussed treatment options with Ringering, including possible surgery. R. 375. Ringering decided to have surgery on her neck. On or about March 4, 2008, Dr. Curylo performed a cervical fusion operation in which he fused C5-C7 vertebrae. R. 370.[3] Ringering wore a cervical collar after the operation.

         On March 24, 2008, Ringering saw Dr. Curylo for a postoperative follow-up examination. Ringering reported that her numbness was resolved. She said that she was happy with the results. Dr. Curylo stated that Ringering had “Excellent healing with good results.” Dr. Curylo refilled her pain medication prescriptions. R. 370.

         On March 31, 2008, Ringering saw Dr. Nigam. She reported neck pain. She reported trouble sleeping and having racing thoughts. Dr. Nigam noted that Ringering had a better mood, a normal affect, and a logical goal directed, and sequential thought process.” R. 210. Dr. Nigam also stated Ringering had fair judgment and insight. R. 210.

         On May 12, 2008, Ringering saw Dr. Curylo for a second follow-up examination after her surgery. Ringering reported much less pain. She reported that she was taking no pain medication. She complained of mild occasional numbness in her left thumb and first and second fingers. Her symptoms were intermittent. On examination, Dr. Curylo found that the incision was well-healed. He noted no pain in range of motion. Dr. Curylo told Ringering that she no longer needed to wear the cervical collar. Dr. Curylo refilled Ringering's pain prescriptions. R. 371-72.

         On May 22, 2008, Ringering saw a psychiatrist Dr. Kapal Datta, M.D., for a psychiatric evaluation. Ringering rated her depression as a “7 out of 10.” She reported that her anxiety varied. Dr. Datta gave her a GAF score of 60. Dr. Datta adjusted her medications. R. 213-17.

         Ringering saw Dr. Datta several times from May through October 2008. On June 16, 2008, Ringering said she was better and had been walking and riding her bike. R. 218, 221. On July 28, 2008, Ringering said she was doing very well and was cutting down on caffeine. R. 222. In September 2008, Ringering reported that she and her husband filed for bankruptcy relief. In October 2008, Ringering reported that she could not hold a job. Ringering stated that she had been sober since January 2008. R. 218-225, 228-229.

         On September 30, 2008, Ringering was hospitalized after reporting sadness, discouragement, low self-esteem, worthlessness, loss of pleasure, anxiety, and anger. R. 314-17. She was discharged from inpatient care on October 9, 2009. At the time of discharge, Ringering reported some continuing depression, anxiety, and anger, but denied any suicidal ideations. Ringering was assessed with a major depressive disorder and alcohol abuse in initial remission. She was given a GAF score of 60, indicating moderate symptoms or moderate functional limitations. R. 314-17.

         On October 20, 2008, Ringering saw Dr. Datta. She said she was in an intensive outpatient program (IOP). She had attended six sessions. Dr. Datta advised engaging in physical activity. R. 228-29.

         Dr. Shazia Malik, M.D., wrote a letter To Whom It May Concern dated November 4, 2008, stating that Ringering completed 21 hours of a dual diagnoses program for her mental problems and her problems with substance abuse. R. 292.

         On November 17, 2008, Ringering saw Dr. Datta. Ringering said the IOP sessions were helping. She said she was learning how to cope. She was cleaning the house, biking, and taking care of her children. R. 230. Dr. Datta also made a list in his notes that he entitled “Inconsistencies/Discrepancies.” R. 231. Dr. Datta listed under this heading, among other things: Ringering was guarded, she was not able to hold a job, her mother and sister told her she was lazy and did not look after her children, she lost her job in December 2007 and did not like her manager, she stopped attending IOP, she said her insurance would not authorize more care, she said she did not see a psychiatrist in IOP, the IOP records showed that she saw a psychiatrist. R. 231.

         On November 17, 2008, Ringering saw Dr. Curylo about her neck. Ringering reported increasing axial neck pain. She also reported suboccipital pain and intermittent numbness in her left hand. Ringering denied any weakness. Dr. Curylo stated that Ringering may have had adjacent level degeneration with cervicalgia and possibly facet disease superior to the location of her March 2008 fusion. Dr. Curylo referred Ringering to a pain specialist. R. 369.

         On December 8, 2008, Ringering saw Dr. Datta. Dr. Datta noted that Ringering's affect was okay, her mood was much better, and she was sleeping better. R. 234-35. On December 29, 2008, Ringering saw Dr. Datta again. Ringering reported having better energy. Ringering reported that her Christmas was “great.” R. 236-37. On January 26, 2009, Ringering told Dr. Datta that things were better. She said her meds helped her. R. 238.

         On January 26, 2009, Ringering also saw a pain specialist, Dr. Daniel Sohn, M.D. Dr. Sohn noted neck and shoulder girdle myofascial pain. On examination, Ringering's stance, gait, and position were “a little slow.” Ringering was tender to palpation in the neck and shoulder girdles. Her neck range of motion was poor to fair with flexion limited by pain, but extension and rotation were good without discomfort. She had decreased sensation in the upper extremities. Dr. Sohn prescribed physical therapy and medication. Dr. Sohn mentioned that trigger point injections would be considered in the future. Dr. Sohn advised Ringering to remain active with her usual activities. Dr. Sohn advised against bed rest. R. 367-68. Dr. Sohn recommended continuing “appropriate exercises as discussed.” R. 368.

         Ringering continued to see Dr. Datta in 2008 and 2009. R. 213-50. On March 30, 2009, Ringering reported that therapy was helpful. Ringering reported problems at home because of the bankruptcy. She reported negative self-esteem, but she also reported that the medications helped, she was having no anxiety attacks, and her eating and sleeping habits were better. She said that she was cleaning house, visiting with friends, and attending soccer practice with her children. R. 240-41. On May 18, 2009, Ringering reported having lots of anxiety attacks. Ringering reported fighting and anger. R. 242. Dr. Datta listed Ringering's diagnosis as bipolar affective disorder and an adjustment disorder (mixed). Dr. Datta indicated that Ringering was doing much better, and her mood was better. R. 244.

         On April 21, 2009, Ringering saw Dr. Sohn. Ringering reported that the physical therapy hurt. Ringering reported that she continued to follow through on a home exercise program. On examination, Ringering was alert, and in a stable mood. Ringering's head and neck appeared normal. Her range of motion in her neck was decreased in left rotation and extension. She was tender to palpation on the left neck and shoulder. Her upper extremity strength was intact, but she had some pain in her left shoulder girdle with manual muscle testing. Dr. Sohn gave Ringering three trigger point injections. Dr. Sohn also renewed her medications and directed her to continue her exercises. Dr. Sohn again advised Ringering to remain active, avoid bed rest, and continue appropriate exercises. R. 362-63.

         On May 19, 2009, Ringering saw Dr. Sohn again. On examination, Ringering's stance, gait, and position appeared to be normal. She had fair range of motion with pain in the left neck. She was tender on palpation in the left neck and shoulder girdle. Her upper extremity strength was intact. Dr. Sohn administered one trigger point injection. He added valium to her medications, to be taken at night. He again advised her to remain active with her usual activities; he advised against bed rest; and he recommended appropriate exercises that they had discussed. R. 359-60.

         On June 23, 2009, Ringering saw Dr. Sohn. Ringering reported that she had been doing “a lot of travelling for family issues to Florida and Texas.” She said she was tired due to the trips. She reported that the trigger injections had been helpful. She reported that her pain was much better on the left. She reported more pain on the right at this visit. She stated the pain in the right side may have been due to her trips. On examination, her stance, gait, and position changes were normal, the range of motion in her neck appeared to be good. She was tender to palpation on the right neck, but non-tender otherwise. Her upper extremity strength was intact, but her upper extremity sensation was decreased. Dr. Sohn renewed her medications. He advised her to remain active with her usual activities; he advised against bed rest; and he advised to continue her medications and exercises. R. 357.

         On August 17, 2009, Ringering saw Dr. Sohn. Dr. Sohn administered five trigger injections. Ringering told Dr. Sohn that she had been very active over the summer. She had increased pain for the last three weeks. Ringering said that she also has started having headaches and radiating pain down her left arm to the thumb and first and second fingers of the hand. Dr. Sohn recommended that she refrain from overactivity and high impact sports, but also recommended that she continue her usual activities and recommended exercises. Dr. Sohn ordered a nerve conduction study of her left extremity. R. 351-52, 355.[4]

         On September 11, 2009, Ringering saw Dr. Sohn again. Dr. Sohn reported that the nerve conduction study showed normal nerve conduction with some borderline measurements. R. 351. Dr. Sohn ordered an MRI of Ringering's cervical spine. The MRI was conducted on November 17, 2009. The results showed minimal disk bulging of the upper cervical segments without obvious stenosis or cord compression. The results also showed a congenitally narrow spinal canal. R. 378.

         On September 18, 2009, Ringering was admitted to another IOP. Dr. Datta referred her to the program because of his concerns about her manic symptoms and her cravings to drink and engage in promiscuity. Ringering was assessed with low mood, feelings of helplessness, hopelessness, somatic complaints, decreased sleep, decreased appetite, excessive worry, racing thoughts, difficulty concentrating, poor impulse control, irritability, and outbursts of anger. She reported some suicidal ideations. She was given a GAF score of 45, indicating serious symptoms or serious functional limitations. R. 309-10.

         On September 20, 2009, Ringering was examined by psychiatrist Dr. Malik. On examination, Ringering was alert and oriented. Her speech was coherent. Her thought process was logical and goal oriented. Her remote memory was grossly intact. Her intellect was average. Her concentration was fair. Dr. Malik diagnosed bipolar affective disorder, depressed, and alcohol dependence in partial remission. Dr. Malik assigned a GAF score of 55, indicating moderate symptoms or moderate functional limitations. R. 311-12. Dr. Malik planned to continue the intensive outpatient program, recommended AA meetings, and adjusted her medications. R. 313

         Ringering apparently attended the IOP sessions until November 5, 2009. R. 309. At the time of discharge, Ringering was stable without any suicidal or homicidal ideations. She was assigned a GAF score of 65. R. 310. A GAF score of 61 to 70 indicated “some mild symptoms . . . or some difficulty in social, occupational, or school functioning, but generally functioning pretty well . . . .” DSM IV-TR, at 34.

         On November 23, 2009, Ringering saw Dr. Sohn. Dr. Sohn administered an epidural steroid injection into the cervical spine. Ringering underwent a C4-5 Transforaminal Epidural Steroid Injection (TFESI) on November 3, 2009. Ringering reported about a 50% improvement in her pain, but she still had pain in her neck and left shoulder girdle area. Ringering still took 4 to 5 Percocet per day. On examination, Ringering was in a calm and stable mood. Her stance, gait, and position changes appeared normal. Her range of motion was very decreased. Her upper extremity strength was intact. Her left trapezius was very tender to palpation. She reported tingling in three of her left fingers, but her sensation to light touch was intact in those fingers. Dr. Sohn administered a trigger point injection and ordered another C4-5 TFESI. R. 347.

         On November 29, 2009, Ringering saw Dr. Datta. She reported that she was working out on an exercise bike. Her mood was better. Her sleep was okay. She was advised to cut down on caffeine. R. 250.

         On January 12, 2010, Ringering saw Dr. Sohn. Ringering reported that the C4-5 TFESI temporarily caused increased pain, but her pain had dropped from 6/10 to 3-4/10. She reported muscle spasms in her left shoulder girdle muscle that responded well to her medications. On examination, her stance, gait, and station appeared normal. Her range of motion in her neck was decreased to the left. Her upper extremity strength was intact. Her left shoulder active range of motion was good, but with some pain. Her upper extremity sensation was decreased on the left in a C6 distribution. Ringering would not consider more shots at this time. Dr. Sohn prescribed medications and told her to return in two months. R. 341-42.

         On February 21, 2010, state agency psychologist, Dr. S. Hill, Ph.D., completed a Psychiatric Review Technique. R. 254-67. Dr. Hill opined that Ringering's affective disorders and anxiety related disorders were not severe. R. 254. Dr. Hill opined that Ringering had depression. R. 259. Dr. Hill opined that Ringering had mild difficulties maintaining concentration, persistence or pace, but no other functional limitations as a result of her mental condition. R. 264. Dr. Hill noted at the end of the Technique,

Claimant stable at exam of 3/30/09.
Improvements noted
Claimant's allegations, credible.
Impairment not severe.

R. 266.

         On March 4, 2010, Dr. Datta completed a form entitled Social Security Administration Listing of Impairments. R. 269-71. Dr. Datta opined that Ringering became disabled prior to 2008. Dr. Datta opined that Ringering had ongoing symptoms of psychomotor agitation or retardation. Dr. Datta opined that Ringering's condition resulted in marked difficulties maintaining social functioning, and marked difficulties maintaining concentration, persistence, or pace; and repeated episodes of decompensation, each of extended duration. R. 270. Dr. Datta indicated that Ringering had one or two episodes of decompensation. R. 271.

         Dr. Datta checked a box indicating that Ringering's condition met the Social Security Administration's Listing § 12.04 for Affective Disorders. R. 270. The Social Security Administration's analysis of disability considers, at one point, whether a person is so significantly impaired he would be deemed disabled without regard to his age, education, or work experience. 20 C.F.R. §§ 404.1520(d), 416.920(d). To meet this requirement, the claimant's condition must meet or be equal to the criteria of one of the impairments specified in 20 C.F.R. Part 404 Subpart P, Appendix 1 Listing of Impairments. Each impairment identified in the Listing of Impairments is referred to as a “Listing.” Section 12.04 sets forth the Listing for affective disorders such as depression and bipolar disorder.

         On April 23, 2010, a psychologist, Dr. M.W. DiFonso, Psy.D., completed a Psychiatric Review Technique. R. 275-88. Dr. DiFonso opined that Ringering had a history of major depressive disorder. R. 278. Dr. DiFonso opined that there was insufficient evidence in the record to establish any functional limitations from Ringering's mental condition. R. 285. Dr. DiFonso opined that Ringering's statements were only partially credible. Dr. DiFonso opined that Dr. Datta's opinions on the Social Security Administration Listing of Impairments form, R. 269-71, were inconsistent with his treatment notes and not otherwise supported by the record. R. 287. Dr. DiFonso stated that, “No objective findings are presented to substantiate this claim.” R. 287.

         On April 28, 2010, substance abuse counselor Jill Wright from the Montgomery County, Illinois, Health Department conducted a drug/alcohol assessment of Ringering. Wright concluded that Ringering did not present sufficient evidence of current substance abuse to warrant treatment. R. 294.

         On June 10, 2010, Dr. Datta wrote a letter “To Whom it May Concern.” Dr. Datta stated that Ringering had been his patient since May 22, 2008. Dr. Datta stated that Ringering had bipolar affective disorder; major depression, recurrent; episodic hypoglycemia; substance abuse (possibly self-medication to deal with underlying mental issues); and adjustment disorder, mixed. Dr. Datta listed Ringering's medications Seroquel, Pristiq, Lamictal, and Klonopin. R. 290.

         On July 15, 2010, Ringering saw Dr. Sohn. Ringering reported increased neck pain and headaches. Ringering reported that she had been moving and doing a lot of cleaning, scraping, and painting at the new house. On examination, Ringering was pleasant, alert, and in a stable mood. Her range of motion was fair with pain in the neck and shoulder girdle. Ringering was tender to palpation on the left shoulder girdle. Her left upper extremity strength was intact. Dr. Sohn diagnosed a flare-up due to increased activities. Dr. Sohn prescribed Vicodin. R. 333.

         On September 14, 2010, Ringering saw Dr. Sohn. Ringering said she had pain in her neck and left upper extremity. She had still been scraping and painting the new house. On examination, Ringering had a stable mood. Her stance, gait, and position changes appeared normal.

         Her head and neck were stiff with poor range of motion and pain. Ringering was tender on palpation in her left neck and shoulder girdle. Her upper extremity strength was intact. Sensation was decreased in left hand and first three fingers. She was in moderate distress due to the neck pain. Dr. Sohn increased her dosage of Vicodin and ordered an MRI. He recommended continuation of usual activities and appropriate exercises. He recommended against bedrest. R. 328.

         On December 2, 2010, Ringering saw Dr. Datta. Ringering said that she was doing much better. She also said that she was depressed and her mood was not good. She said she was moving into a new house. R. 305.

         On December 2, 2010, Ringering also saw Dr. Sohn. Ringering complained of left neck, shoulder, and arm pain with some residual numbness in the first and second fingers of the left hand. An MRI performed in September 2010 showed the C5-C7 fusion with stenosis at ¶ 4-5 and some narrowing at ¶ 3-4. R. 324, 378. Ringering reported that she had been busy rehabbing her new home. She had been cleaning, scraping wallpaper and painting. Dr. Sohn stated that this activity could be causing her discomfort. Ringering reported that she was sleeping fairly well. R. 324.

         On examination, Ringering's stance, gait, and changes in position appeared normal. She was tender to palpation of the left neck and shoulder girdle. She had pain with flexion, right rotation, and bilateral side bending. Her upper extremity strength was intact. She had some weakness in her fingers. She had some decreased light touch sensitivity in her right thumb and first and second finger. Dr. Sohn administered a T1-2 interlaminar epidural injection. Ringering was also taking Norco for pain. Dr. Sohn recommended continuing her usual activities and appropriate exercises and advised against bedrest. R. 324-25.

         On February 14, 2011, Ringering saw Dr. Sohn. Ringering said that the December 2, 2010 injection helped some with her pain, but her pain was recurring. She reported doing exercises and stretches at home and cutting back on heavy work at home. On examination, Ringering's stance, gait, and changes in position appeared normal. Her range of motion was fair to poor with some pulling and pain in the left shoulder. She was tender to palpation with triggering in ...


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