Bright-Jacobs v. Barnhart (386 F. Supp. 2d 1295, 2004)

MAGISTRATE JUDGE’S FINAL ORDER

FELDMAN, United States Magistrate Judge.

This is an action to review the determination by the Commissioner of Social Security (“the Commissioner”) that Brenda Brigh1>Jacobs is not entitled to a period of disability, disability insurance benefits (DIB) and/or supplemental security income (SSI) under §§ 216(i), 223(a), and 1614(a)(3)(A) of the Social Security Act, 42 U.S.C. §§ 4160), 423(a), and 1382.

PART ONE HISTORY OF THE CASE

On December 29, 1993, claimant filed an application for disability benefits, alleging she had been disabled since January 15, 1993, apparently due to back surgery and nerve damage and pain. Tr. 46, 117, 121-126, 139, 149, 481. The claim was denied initially on March 26, 1994, and on reconsideration on July 28, 1994. Tr. 129-30, 137-38. On November 6, 1995, a de novo hearing was held before Administrative Law Judge (ALJ) Robert L. O’Steen, who received testimony from the claimant and Vocational Expert (VE) Vivian Hanna. (Tr. 59-116).

In addition to the foregoing, on January 3, 1994, the claimant also filed an application for supplemental security income benefits (SSI), alleging that she had been disabled since January 15, 1993, due to back problems, hiatal hernia. Tr. 139-142, 149. The SSI application was denied initially on March 26, 1994, and on reconsideration, on July 28, 1994. Tr. 143-44, 146-47, 149-51. After the foregoing November 6, 1995 de novo hearing (Tr. 59-116), ALJ O’Steen determined in his June 28, 1996 opinion that since the claimant was able to perform her past jobs, she was not disabled, and not eligible for wage earner’s or SSI benefits. Tr. 46-54. The claimant’s request for review by the Appeals Council was denied on September 12, 1997. Tr. 3-4. A timely appeal to this Court followed.

The ease was docketed as Bright v. Apfel, Civil Action No. 1:97-CV-3509-JEC (NDGa.). On February 24, 1999, Magistrate Judge Gerrilyn G. Brill issued a Report and Recommendation that the Commissioner’s decision be affirmed (Tr. 660-678), which Report and Recommendation was, on April 9, 1999, adopted as the District Court’s Order. Tr. 642.

On April 4, 2000, the Eleventh Circuit Court of Appeals reversed the District Court’s decision of April 9, 1999, and remanded the case to the Commissioner for further proceedings. Specifically, that Court found that the ALJ denied the claimant a full and fair hearing: (1) by failing to consider all of the claimant’s impairments, and (2) by failing to specify the weight he attached to the various medical reports. Tr. 630-38, 679-83. See Bright v. Apfel, 212 F.3d 600, 2000 WL 432431 (11th Cir.2000) (per curium) (not published). Thereafter, the District Court remanded the case to the Commissioner for further proceedings. Tr. 627-629.

On November 18, 2000, the Appeals Council remanded the case to an ALJ for further proceedings. Tr. 636-638.

In the meantime, on October 31, 1997, the claimant filed a second application for SSI benefits, alleging that she was disabled by virtue of disorders of her back— discogenic degenerative, and an affective disorder since April 2, 1994. Tr. 641, 703-06. The application was denied initially on January 28, 1998, and on reconsideration on March 17, 1998. Tr. 641, 646-47, 652-53. As shown hereafter, de novo hearings were held before ALJ James E. Deen, Jr. on January 25, 1999 (Tr. 531-584) and May 14, 2001 (Tr. 535-626) to consider the new application and the remand, and ALJ Deen issued a 49-page partially favorable decision finding that the claimant was disabled and entitled to SSI benefits from September 1, 1997 through October 31, 1999, but not before or after, as she was not disabled before September 1, 1997, and her disability had ceased as of November 1, 1999. Tr. 477-529. In due course, the claimant exhausted her administrative remedies and again appealed the decision to this Court. See Bright-Jacobs v. Barnhart, Civil Action No. 3:03-CV-02 (NDGa.).

As previously noted, the Eleventh Circuit and the District Court remanded the case to the Commissioner, who remanded it to a new ALJ, James E. Deen, Jr. On January 25, 1999, the new ALJ, James E. Deen, held his first hearing on the new application and the remanded decision, and received testimony from the claimant and a new VE, Dr. Phillip Wierson, PhD. Tr. 531-584. He held a second hearing on May 14, 2001, and again heard testimony from the claimant and a third VE, Alice Gardner. Tr. 585-626. Although the claimant’s husband was present as an observer at Deen’s second hearing, he was not called to testify. Tr. 585.

On October 11, 2002, the ALJ issued his 49-page partially favorable decision, finding that the claimant was disabled from September 1, 1997 until October 31, 1999, but not thereafter. Tr. 477-529.

In due course, the claimant appealed that decision to the Appeals Council, which apparently declined further review. Tr. _The claimant then appealed the new partially favorable decision to this Court. [Doc. 1].

PART TWO THE ISSUES

1. Whether the Commissioner’s decision that the claimant can perform his/her past relevant work is supported by substantial evidence;

2. Whether the ALJ denied the claimant a full and fair hearing—

a. whether the ALJ properly determined that the claimant was not enti-tied to benefits before September 1, 1997 because her disability was caused in part by alcoholism; and

b. whether the ALJ properly determined that the claimant’s disability ended on October 31,1999.

PART THREE THE STANDARD FOR REVIEW

The claimant bears the initial burden of proving that he is disabled, which burden is met when he proves that he suffers from a severe impairment that renders him unable to pursue his customary employment. Thereafter, the burden shifts to the Commissioner to prove that the claimant can, nevertheless, perform other types of substantial gainful activity. Freeman v. Schweiker, 681 F.2d 727 (11th Cir.1982). In determining whether a claimant is disabled within the meaning of the Social Security Act, the Commissioner is required to consider:

(1) Objective medical facts or clinical findings;

(2) Diagnosis of examining physicians;

(3) Subjective evidence of pain and disability as testified to by the claimant and corroborated by his wife of other members of his family, his neighbors and others who have observed him; and

(4) The claimant’s age, education and work history....

DePaepe v. Richardson, 464 F.2d 92, 94 (5th Cir.1972); Bloodsworth v. Heckler, 703 F.2d 1233 (11th Cir.1983).

The Commissioner, in reaching his determination, must also follow a sequential evaluation. 20 C.F.R. §§ 404.1520, 416.920 (1986). A claimant presently engaged in substantial gainful activity is declared not disabled and the inquiry ceases. 20 C.F.R. §§ 404.1520(b), 416.920(b) (1986). If the claimant is not engaged in substantial gainful activity, the Commissioner must determine whether he suffers from a severe mental or physical impairment. If the impairment is non-severe, claimant is declared not disabled. 20 C.F.R. §§ 404.1520(c), 416.920(c) (1986). If his impairment is severe, it meets the dura-tional requirements, and it equals or exceeds a “listed” impairment, the claimant is considered disabled. 20 C.F.R. §§ 404.1520(d), 416.920(d) (1986). If the severe impairment does not equal or exceed a listed impairment, the Commissioner must then determine the claimant’s residual functional capacity (i.e. the degree to which a claimant can function, despite his physical or mental impairment(s)). The Commissioner must then evaluate the physical and mental demands of the claimant’s past relevant work, and whether the claimant can meet those demands. If so, there must be a finding of no disability. 20 C.F.R. §§ 404.1520(e), 416.920(e) (1986); Perez v. Schweiker, 653 F.2d 997 (5th Cir.1981). If the claimant cannot perform his past relevant work, then the Commissioner must decide whether the claimant’s impairments) prevent him from doing any other substantial gainful activity (SGA). 20 C.F.R. §§ 404.1520(g) and 416.920(f). In the event the impairments) preclude other SGA, a finding of disability is mandated.

It must also be recognized that hearings before the Commissioner {nee the ALJ and the AC) are nonadversarial in nature, and oblige the adjudicator (AC and ALJ) to ensure that the hearing record is complete. Specifically, it is the adjudicator’s duty to investigate the facts and develop the arguments, both for and against granting benefits. Sims v. Apfel, 530 U.S. 103, 120 S.Ct. 2080, 147 L.Ed.2d 80, 88 (2000); Welch v. Bowen, 854 F.2d 436, 438 (11th Cir.1988); Cowart v. Schweiker, 662 F.2d 731, 735 (11th Cir.1981); Wilson v. Apfel, 179 F.3d 1276, 1278 (11th Cir.1999); Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir.1997). Furthermore, the ALJ must comply with this obligation even if the claimant is represented by counsel. Indeed, this Court’s review of the case is generally limited to a consideration of the evidence in the certified record. Wilson v. Apfel, 179 F.3d at 1279.

When reviewing the Commissioner’s decision, the duty of the Court is not to reweigh the evidence, but rather to determine whether the decision is supported by substantial evidence in the record, and whether the Commissioner applied the correct legal standards. Smith v. Bowen, 792 F.2d 1547, 1549 (11th Cir.1986). Substantial evidence has been defined as “more than a scintilla.. .it means such relevant evidence as the reasonable mind might accept as adequate to support a conclusion.” Walden v. Schweiker, 672 F.2d 835, 838 (11th Cir.1982). This Court must examine the record as a whole, however, and may not affirm the Commissioner’s decision by referring only to those parts of the record which the support the same. Tieniber v. Heckler, 720 F.2d 1251, 1253 (11th Cir.1983). “The substantiality of evidence must take into account whatever in the record fairly detracts from its weight.” Universal Camera Corp. v. NLRB, 340 U.S. 474, 488, 71 S.Ct. 456, 95 L.Ed. 456, 467 (1951) (Frankfurter, J.).

PART FOUR EVALUATION OF THE EVIDENCE

A. THE OBJECTIVE MEDICAL EVIDENCE

The record contains a number of records from Dr. F. Mumiaz, apparently a chiropractor, from May 13, 1986 through December 14, 1993. Tr. 195-249. These records also include medical records from the Pizza Clinic of Chiropractic (Tr. 208, 246-249) and from Dr. Daniel E. Zdonczyr, M.D., a neurologist with the Atlanta Neurological Institute (Tr. 220). None of these dysfunctions are relevant to the instant issues except for a September 28, 1993 notation indicating that the claimant underwent back surgery on August 6, 1993. Tr. 203. The records from such surgery are not included herein. Accordingly, these records will not be discussed further.

Dr. Charles F. Scott, M.D.

On March 20,1991, the claimant saw Dr. Charles F. Scott, M.D. with complaints of rhinitis, a sore throat, severe rash, running nose, lymph gland, bloody cough, after falling on her chest. She weighed 198 pounds. He made no diagnoses. Tr. 351. She returned with complaints of abdominal pain on January 20, 1994. On examination, her liver, gall bladder, renal, aorta and pancreas were all normal. Tr. 345, 348-350. He thought her symptoms suggested gallbladder (?) R/O PUD, gallstones (?). An air contrast barium enema on January 27, 1994 suggested (1) 2 small polyps and (2) large redundant colon. Tr. 331-332, 347-348. She returned on January 21, 1994 (notes are illegible) except (1) scheduled air barium enema, (2) UGI + SBS + 3, (3) (illegible). He also referred her to Dr. Gary L. Richter, M.D., who first saw her on February 25,1994.

Dr. Gary C. Richter, M.D.

Gastroenterologist Dr. Gary C. Richter, M.D. Richter examined the claimant on February 25, 1994. Tr. 300-305. On March 1, 1994, he advised Scott of his findings: (1) history of abnormal barium enema with colon polyps. Schedule colo-noscopy and possibly polypectomy, (2) episodes of abdominal pain, with left flank and back pain, rule out renal in origin, irritable bowel syndrome, (3) symptoms of irritable bowel syndrome, (4) periods of nausea and vomiting, possibly gastroeso-phageal reflux disease. Tr. 297-299.

On March 2, 1994, Richter scheduled an endoscopy for March 16, 1994. Tr. 296. On March 16, the claimant underwent the endoscopy because of dyspepsia, abdominal pain, nausea, and vomiting. The procedure was performed on that date and the only significant finding was a hiatal hernia. He also notified the claimant on March 13, 1994 that her polyps should be removed. Tr. 293. He further notified her that she had elevated cholesterol and triglycerides. Tr. 286-291, 292, 295. See also Tr. 250-266.

On March 25, 1994, Dr. Scott again referred the claimant to Dr. Richter for a colonoscopy based on a history of colon polyps. The claimant tolerated the procedure well, and his findings were (1) suboptimal exam secondary to retained stool, internal hemorrhoids, no polyps seen. Tr. 282-285.

On April 8, 1994, Richter notified the claimant of her borderline cholesterol at 232 and elevated triglyceride level (503). Tr. 279.

On September 22, 1994, she underwent X-rays of her lumbar spine which demonstrated a disc space narrowing with minimal end plate sclerosis at L5-S1, consistent with degenerative disc disease. A minimal scolitic deformity of the lumbosa-cral.

The Fulton County Department of Mental Health

On March 18, 1992, the claimant visited the Fulton County Department of Mental Health. Although most of the notes are illegible, she was apparently depressed. She also abused alcohol as a teenager. Tr. 472-73. She was also evaluated on December 12, 1994. At that time, she was not as depressed, but had suicidal idea-tions, crying spells and feeling of helplessness and hopelessness. Tr. 471. Her list of prescribed medications were: (1) Desyrel 50 mg, 12/12/94 (471), 12/24/94, 1/30/95, 11/30/95; (2) Visteril 25mg 3/18/92 (472), 12/14/94, 1/30/95, 11/20/95. Tr. 470. In addition, the record contains a “To Whom It May Concern” note indicating that on February 9, 1998, she was a resident of its Supportive Living Program. Tr. 1056.

Dr. Tucker, M.D.

On June 13, 1993, she saw Dr. Tucker, M.D., with complaints of lower back pain, stress, incontinence (with cough), leg tingling, can’t feel sex like she used to; can’t tell when time to urinate and defecate. On examination, her abdomen was soft, active bowel sounds, sensation intact in both legs; good sphincter tone. Assessment was left leg numbness, perineal sensation. Tr. 333.

On January 31, 1994, she underwent an upper GI and small bowel X-ray series; and a small sliding hiatal hernia was noted as was gastro-esophageal reflux; no evidence of esophageal ulcer and the balance of her upper GI and SB were normal. Tr. 344-43. On a February 7, 1994 visit, she complained of chest pain with a cough. The diagnosis is illegible, but her weight was 194 pounds. Tr. 340. She returned on February 15, 1994. The complaints are illegible. Assessment was “HH” (hiatal hernia?) w/GERD and ? colon polyps. She weighed 193 pounds. Tr. 341. She may have also returned on February 24, 1994. Tr. 340.

On March 14, 1994, she returned and complaint of? [both her complaints and the assessment are illegible]. She weighed 192 /& pounds. Tr. 339-40. A’May 13, 1994 visit notes “had the ? c/o † appetite”; assessment is illegible. She weighed 190 pounds. Tr. 338.

She returned on August 2, 1994, complaints and assessment are illegible, but she weighed 209 pounds. Tr. 337.

She returned again on August 12, 1994. The doctor noted she weighed 212]6 pounds and was still going to “psych.” Balance of the report is illegible. Tr. 336. A 9/8/94 visit noted her weight at 214 pounds, and that the claimant was going to see Dr. A. Green that day. She apparently had an MRI which showed a three-disc problem. Assessment was “AN” and disc ? Tr. 335.

On June 14, 1993, the claimant visited GMH with complaints of lower back pain for which she had been seeing a chiropractor for the past 1 — -2 months. The LBP radiates down both lower extremities and burning pain in LLE. POS: denies trauma; walks with problem but with some mild ache in L thigh causing occasional limp. Able to control bowel, & bladder. PMH: HTN (past medical history of hypertension). Pt. in NAP back — mild tenderness over pain lumbar areas. 0SLR bilat. but with f ed pain. LE neuro -» PTR’s 2 + + = bilat; motor 5/5X = bilat ind. EHL; 1 position sense on each large toe back pain — possible HNP sensation intact to spine. Tr. 316.

On June 30, 1993, the claimant visited the GMH Orthopedic Clinic with complaints of low back pain for many years, paralysis,' numbness, pain, burning, tingling, sore to the touch from legs and feet to shoulders, alternating L + ®. She also had a history of TB in 1987. She also went to a chiropractor for her lower back pain for several months. .Also possible “sequella”, bulemia, warts? fungal nail infections, vomiting and “a great deal of sleep in her life.” On examination, the doctor noted: reserved? speech, wearing ? on moving NAD. Morning- ? with lying supine. ©• ® SLR for back pain at 40° — L SLR DTRS. 2 + = B at patellar tendon, allutler tendon, EHL, QUADS GAS/SOL, HAMS, ? PTB all 5/5 bilaterally wart on R index finger fungal infx L thumb. X-rays mild facet disc L spine. Imp. ? in pt. with mult, factorial ? and physiologic complaint incl LBP. Tr. 315.

On July 14, 1993, she underwent an MRI of her lower spine. Results showed a left lateral disc herniation at the L5-S1 disc space which could compress both the L5 roots and the SI root; otherwise normal. Tr. 314.

On August 5, 1993, the claimant was admitted to GMH for surgical treatment of her left L5-S1 herniated nucleus pulposus, and underwent a left L5-S1 laminectomy with diskectomy and L5 foraminotomy. She was discharged on August 9, 1993. Tr. 459-463, 465-467. She returned to GMH on October 21, 1993 complaining of lower back pain, neck pain and L ankle pain, after sustaining a fall. After examination, the diagnosis was an ankle strain and lower back musculoskeletal strain, which were treated conservatively. Tr. 468.

Grady Memorial Hospital

On October 21, 1993, she went to GMH with complaints of lower back pain, neck pain, and left ankle pain. She was diagnosed with left ankle strain and lower back strain. Tr. 313.

X-rays of her lumbar, and cervical spine and of her ankle were also made on October 21, 1993. They showed a narrowing of the disc space at L5-S1, otherwise normal. Tr. 312.

On November 30, 1993, the claimant visited Grady Memorial Hospital (GMH) with complaints of increased lower back pain. She previously had surgery with good results, but fell which aggravated her lower back and neck pain. Her neurological signs were all normal except for left ankle reflex and her knees. She was referred to physical therapy. Tr. 311. On that visit, the doctor indicated her lower back and neck pain were improving; and she was directed to undergo more physical therapy. Tr. 464.

She returned again on June 5, 1994 with multiple complaints unrelated to her lower back, including anxiety, ulcers that bleed, stomach pains. As she kept talking nonstop, the doctor referred her to psychiatry for stress control. Tr. 457-458.

On November 17, 1994, the claimant was apparently involved in a motor vehicle collision in which she was a passenger, sustaining blunt trauma. She was taken to the GMH emergency room with complaints of neck and lower back pain radiating into lower left extremity. The report also noted a past medical history for suicidal ideation, and the lumbar laminectomy. On examination, back pain was noted. Straight leg raising was negative. Diagnoses were cervical and lumbar strain. Tr. 454. The hospital also made X-rays of her cervical and lumbar spine. The cervical spine was normal; the lumbar spine was normal except for the laminectomy. Tr. 453.

She returned again on March 5, 1995, with complaints of lower back and lower extremity pain. The examining physician was unable to detect a reason therefor. She also complained of urge incontinence. Past medical history noted (1) Etoh abuse, depression, suicidal ideation, HTW, sinusitis, GERD, GI upset w/NSAIL, PSHX. The physical examination was essentially normal as were lumbar spine X-rays. Tr. 440, 450-451.

She returned again on April 7, 1995 after twisting her ankle. As the ankle appeared swollen, a splint was applied. Diagnosis was ankle sprain. A somatization disorder was also diagnosed. Tr. 448-49.

On August 1, 1995, she underwent a mammogram with normal findings. She also complained of lower back and ankle pain. She also had vision problems. Past medical history noted HTP? Hiatal hernia ? panic attacks. Diagnoses were: (1) LBP: refer pt to orthopedic clinic, (2) anxiety: continue ? meds, (3) visual acuity: opthalmalogy. Tr. 445-447.

She returned to the orthopedic clinic again on August 18, 1995, with a complaint of urinary incontinence, blurred vision, except for myopia and astigmatism. Again, her past medical history included a diagnosis of a somatization disorder. She also had less bowel control. The doctor observed that she ambulated with an unsteady gait, antalgic gait, talks unnecessarily, does not make eye contact, often almost manic at times, flight of ideas? can bend and take off shoes with difficulty, stands from sitting easily — however groaned with any exam. Waddells — ■ TORDS 5/5. The exam was essentially normal. Tr. 441, 443-44.

She returned again on September 7, 1995 with multiple complaints. Her exam was, however, unchanged. The doctor again sent her to physical therapy. Tr. 442.

On September 28, 1995, she returned to physical therapy again on referral from the orthopedic clinic with complaints of severe lower back pain. She was issued a “back book” and instructed in a home exercise program. Tr. 438.

On September 7, 1995, the orthopedic clinic referred her to the pain clinic because of her complaints of chronic pain (no surgically detectable problem). On November 13, 1995, a physician (illegible) replied noting a © MRI in 8/95, showing L5-S1 disc disease. Tr. 958, 986.

On September 13, 1995, she again returned to GMH for a gynecological examination, with complaints of lower back pain. Past medical history included anxiety disorder, pain sensitivity lower back, history of urinary incontinence with and without stress. No significant findings noted. Tr. 959, 996.

On November 13, 1995, the claimant returned to GMH with complaints of chronic lower back, neck and lower extremity pain. Her past medical history included somati-zation. On examination, she had © SLR at 30° on L and 40° on R; severe tenderness on palpation throughout lower back L EHL 4/5, R EHL 5/5. 1 cold sensation L ankle and foot but ? sensation to pinprick patella R 2 + , L 1 + , ankle jerk unable to evaluate pt c/o severe pain when Achilles tendon tapped w/ reflex hammer. This patient is not a good candidate for pp dural steroid injection. Tr. 957, 995.

Dr. John G. Morrow, M.D.

Grady Memorial Hospital

On November 13, 1995, a second physician, John G. Morrow, M.D., reviewed the findings and examined and interviewed the claimant, agreeing she was suffering from a somatization disorder as well as chronic low back pain. She needed to lose weight and continue with physical therapy. Tr. 957, 995.

On April 22, 1996, June 6, 1996 and July 21, 1997, she had her ears examined because of complaints of constant cough, hearing loss and jaw pain. Other than TMJ, no significant findings were noted. Tr. 953, 955, 956, 991, 993, 994.

Dr. Bodie N. Dunlap, M.D.

GMH Psychiatry Emergency Clinic

Apparently, at some date prior to July 18, 1997, she was seen by Dr. Bodie N. Dunlap, M.D. in the psychiatry emergency clinic, admitted and discharged on July 18, 1997. It was noted that she had a history of alcohol abuse until that February. She exhibited depression and anxiety, but was not psychotic. Diagnoses were:

AXIS 1: dysthymia;'

AXIS II: deferred;

AXIS III: arthritis, nausea with narcotics;

AXIS IV: homeless;

AXIS V: 60/unk.

Tr. 990.

On July 21, 1997, she underwent her annual gynecological examination. Results were normal. Tr. 952.

On August 1, 1997, she returned with complaints of chronic stomach pain, chronic diarrhea. Dr. Theodore Antison noted that she had a somatization disorder L/o multiple symptoms, GERD since 1994, gallstones diagnosed in 1996. He referred her to “GI”. Tr. 951, 982.

On August 21, 1997, she was seen in the mental health unit. Apparently, the doctor noted ETOH abuse, but the notes are mostly illegible. Her mental status examination was normal. Diagnoses were:

AXIS I: 300.4;

AXIS II: 0

AXIS III: J, (disc deterioration, hiatal hernia, Briquet’s syndrome/somata-form disorder). She also suffers from depression.

Tr. 947, 987.

On September 16,1997, she underwent a mammogram. Findings were normal. Tr. 945, 984.

On October 8, 1997, she again returned to GMH. She apparently was seen by a social worker. Her mental status exam was normal. Diagnoses were:

AXIS I: 296.32, 300.81;

AXIS II: 0;

AXIS III:(1) disc? (2) Briquet’s syndrome, (3) hiatal hernia, (4) acid reflux.

It was also noted that her application for social security benefits was denied. Tr. 944, 983.

On October 17, 1997, the claimant returned apparently complaining of numbness, ? down L leg. Tr. 1,000.

On October 31, 1997, Drs. Theodore J. Antinson, M.D., Attending Physician, and Dr. Kelly Cobb, M.D., Resident Physician, jointly wrote a “To Whom it May Concern” letter, indicating that the claimant is being treated at GMH for multiple medical and psychiatric problems. Specifically, she suffers from a “somatization disorder (formerly known as Briquet’s syndrome), a chronic disorder characterized by multiple somatic symptoms in multiple organ systems. She is severely disabled by this condition and requires frequent medical followups.”

She also “has significant problems with major depression, panic attacks, arthritis, and gastroesophageal reflux.” Tr. 970.

She returned to the mental health unit on November 5, 1997, and was seen by a social worker (signature illegible). Her mental status examination was essentially normal, although she was hyper verbal, pressured, reclusive, rambling, responds to structures. Diagnoses were:

AXIS I: 296.32, 300.81;

AXIS II: 0;

AXIS III:(1) disc?, (2) Briquet’s syndrome, (3) hiatal hernia, (4) acid reflux.

Tr. 942.

An urgent care center assessment dated November 18, 1997, apparently notes that her cholesterol level is 263; NAD arthritis. She also complained of heartburn and pain. Tr. 938-940. She was referred to GI for the heartburn.

Apparently, on December 17, 1997, and on another occasion, including “_/24/1998 and 5/28/98,” she also had an opthalmalogic examination, including a prescription for eyeglasses. Tr. 937, 938, 1002-03, 1007.

Apparently, on December 31, 1997, she returned with complaints of † epigastric pain, spasms, regur digested food, poor sleep, muscle soreness. The physical exam noted (1) abdomen: BSND soft? epi-gastric area & LLQ. It was also noted that she suffered from (1) somatization disorder, (2) GERD, and (3) back pain. Tr. 946.

Another entry apparently dated 12/31/97 noted that she returned two weeks later for a follow up to her complaint of LLQ pain with episodes of painful defecation. ? tensing of ? muscles, weakness, loss of concentration and blindness, sore throat, tingling in arms & neck like cold chill I ADLs, left leg † aching, extremely anxious, hyper talkative, agitated. She also had (1) a somatization disorder, (2) diarrhea, (3) weakness/hearing, (4) HNT † 2° anxiety ?. Somatization out of control, attempted to explain multiple unexplained complaints? Tr. 948, 985.

A third entry apparently dated December 31, 1997 notes that she returned with a throat inflammation, swelling in L wrist, off & on fire for three weeks, ? tightness in throat “choking,” also had a syncope episode. Her past medical history noted thirteen problems:

1. HTN,

2. GERD,

3. disc disease,

4. gallstones,

5. diarrhea,

6. arthritis,

7. panic attacks,

8. stress incontinence,

9. hemorrhoids/polyps,

10. depression,

11. somatiform/Briquet’s synd.,

12. hearing loss,

13. poor vision.

Tr. 950, 989.

On March 7, 1998, the claimant returned to the orthopedic clinic for a follow up to her chronic lower back pain. The physical exam noted that she walked with L L E extern rotated o/w with L gait, motor 5/5 (B) ue/le, sensory retract/? (B), knee/hip ROM benign, (-) tw? sign, X-rays: ? cervical spondylosis, [illegible character] evid. of instability, lumbar spine with mild DDD/DJD, ? A/P 40 year old female with cervical & lumbar spondylosis, No evid. of radiculapathy? (Tr. 941, 981). The doctor also noted she had a significant psychiatric history, including somatiform disorder.

She returned to the mental health services on May 6, 1998, apparently for group therapy and stress management. Her anxiety had increased, and increased coping skills. However, she hadn’t gotten out of her chair for 3 — 4 days and was wearing a knee brace. The mental status exam, was essentially normal. Diagnoses were:

AXIS I: 296.32, 300.81, 300.19.

Tr. 935.

She returned again on May 13, 1998 for group psychodiscussion — wellness? to decrease depression and impulsivity, and increase knowledge of vitamins A and K. In summary, she only had fair participation and was still depressed. Mental status exam varied from good to poor. Diagnoses were:

AXIS I: 305.00, 300.2, 300.81, 296.32,

AXIS II: 0,

AXIS III: 401.9, 530.81, 553.3, 722.6, 795.5.

Tr. 934,1014.

On May 18, 1998, the Director of Epidemiology telephoned the medical department to advise that the claimant may have been exposed to measles. The claimant, who was present, denied her decongestant for sneezing and runny nose for past 3 months, but had reflux and may have had measles as a child. Tr. 933, 1013.

On May 20, 1998, she underwent an upper endoscopy by Dr. Charles Duck-worth, M.D., Division of Digestive Diseases. He had observed a slight abnormality in her food tube (Barrett’s esophagus) which protects against acid reflux. The biopsy was negative for cancer. Tr. 929-932, 969, 1008, 1010-1012.

On May 28,1998, she underwent another eye examination. The results were normal, with myopia with a history of astigmatism. Tr. 928.

She returned to the Otolaryngology Clinic on June 2, 1998 with complaints of a hearing loss and throat problems. Diagnosis was (1) severe GERD, hiatal hernia (barretts esophagus) followed by GI, (2) long standing moderate to severe SNHL. Tr. 927

She returned to the Mental Health Clinic on June 26, 1998 for group therapy to reduce her depression, reduce suicidal ideation, increase coping and social skills. Her mental status exam was essentially normal. Diagnoses were:

AXIS I: 305.00, 296.32,

AXIS III: 555.3, 401.9, 530.81, 722.6, 795.5.

Tr. 926.

She returned to the Gynecology Clinic on June 30, 1998 for her annual examination. She also complained of abdominal discomfort — diffuse J, abd on L in ? on ® midcycle © bloating. S/P — TVH with en-dometriosis & fibroids. Ovaries remain? IBS barretts esop., anxiety, PMMX — herniated disc, HTN, neuropsych — TVH 1994. Diagnoses were: (1) abdominal discomfort, (2) somatization disorder, (3) HTN, (4) Barretts Esop., (5) IBS. Tr. 925.

She returned to the Mental Health Clinic again on July 10,1998 for group therapy to decrease her depression. Her mental status exam was essentially normal, although it was noted that she was smiling in a dramatic manner while discussing health problems. Diagnoses included:

AXIS I: 296.32, 300.19, 300.81, 305.00,

AXIS III: 795.5, 278.00, 553.3, 401.9, 722.6.

Tr. 923.

On August 5, 1998, she underwent a sonogram examination of her pelvis and vagina. Results showed that she had undergone a hysterectomy with her ovaries intact and normal; and abnormal masses in her pelvis were identified. The examination results were negative. Tr. 920.

On August 13, 1998, she returned to the Gynecology Clinic for a follow up to her June 30, 1998 examination. Assessment was: (1) diffuse lower abdominal discomfort, hx IBS heuro injury, G/w/?. Tr. 919.

She returned to the Orthopedic Clinic on August 18, 1998, with complaints of a soft corn and bony prominence under the 3rd and 4th toes of her right foot with relief from padding. She also has multiple psychological problems. PE showed hot corn w / oip at 4th toe w / prominent callus at PIP, lateral 3rd toe. Diagnosis was: (1) R foot mortous neuroma, (2) R 3rd and 4th toe bony prominence, (3) recommended removal of metatarsal foot pad. Tr. 718A.

On August 24, 1998, she went to GMH complaining that she had rash that itched, night sweats, difficulty walking, has seen ENT and GI concerning her throat/GERD. Diagnoses were: (1) HTN -» borderline high dcast. cont to observe (2) reflux -*■ GI (3) somatization disorder, (4) arthritis[illegible character] stable — -right knee ... worse on walk, (5) rash. Tr. 918, 1009.

On August 24, 1998, she went to the Neurology Clinic with complaints of asthma attacks, whole body numbness R side neck pain, R leg numbness, R neck and R arm pain with intermittent (B)ue “t?,” L leg numbness and side pain, diffuse (B)ve numbness, arm pain, daily non-fluctuating burning in all limbs. Diagnosis included (1) multiple somatic complaints with soma-tization D/O, (2) ], Lankle reflex L/N, S/P L5-S1 laminectomy. Tr. 916.

On September 11, 1998, Dr. Cobb wrote another “To Whom It May Concern” note advising that GMH was currently treating the claimant for fibromyalgia, somatization, D/O, GERD & HTN. He noted that it was a disorder consisting of fibrous tissue, possibly forming benign tumors within one or more muscles causing pain to which may develop muscle debility (weakness). Tr. 913.

He was hopeful that with treatment, albeit with frequent medical evaluation for the next few months, she would improve.

He also noted that she was taking a medication that causes hypersensitivity to sunlight/heat and directing that she avoid outside activities on hot, humid days. Tr. 913-15.

On October __, 1998 , she again returned to GMH with complaints of diarrhea, nausea, fatigue, L side pain, burning in foot, leg and abdomen, burning and tingling in her arms and face, weakness spells, severe reflux? fibromyalgia, hx of C6 fracture. Diagnoses were (1) somatization — off med, (2) GERD (Barretts) [illegible character] cont. operable/ cisa pride, (3) arthritis stable, (4) HTN without TC now will consider?, (5) neuro/weakness. Tr. 912.

On October 14, 1998, she was admitted to GMH, and on October 15, 1998, she underwent surgery on her right foot to excise interdigital nerve of the second web space. Diagnoses were: (1) Morton’s neu-roma, and (2) possible metatarsal phalan-geal joint synovitis right foot. Tr. 972-978.

On October 17, 1998, a physician (signature illegible) referred the claimant to the Orthopedic Clinic because of her complaints of recurrent history of numbness/? down L leg. He also noted she has a somatization disorder. Tr. 943.

On October 26, 1998, she returned to the Medical Clinic with complaints of LLE edema with walking, dizzy spells, increased depressive history, lower abdominal cramp-like pain. Asking for pain medication on examination, Dr. Cobb found low anxiety, heent — clear, CV — RRR w/80, lungs — CTA, abdomen — benign ?, extremities [illegible character] edema. Diagnoses were: (1) somatization, (2) GERD -*■ Barretts -> con ameaozale, GI following ? repeat endoscope, (3) arthritis — back pain, (4) GYN — / drt pap last week; m/s sched to invest abd. 5 X, (5) HTN -» stable, (6) weight vgain — diet / exercise. Tr. 922.

The Fulton County Alcohol & Drug Treatment Center

Commencing on January 5, 1995, the claimant was treated at the Fulton County Alcohol and Drug Treatment Center for her alcohol dependence and depression, with a goal of detoxification. Her treatment commenced on January 17, 1995, and continued daily for six days. Tr. 352-360.

The W.T. Brooks Clinic (Grady Health System)

In connection therewith, she was also treated at the W.T. Brooks Clinic, a part of the Grady Health System. On an unknown date she complained of an illegible problem. The assessment was HTN, dizziness, anxiety / depression, hiatal hernia. The report also noted her previous surgeries, including plytectomies, appendectomy, L5-S1 diskectomy. Tr. 366. She was also seen on December 6,1994 with a complaint of high blood pressure, dizziness and blackout spells. The balance of the report is illegible. Tr. 365. She had a follow-up appointment on December 15, 1994, most of which is illegible, although it notes in general, very anxious, non-stop talking, BP unable to hear, pulse reg. occasionally premature beat not strong, it + reg occasional repuature beat, lungs clear ?, abd. epi-gastric tenderness normal bowel sounds, fundi No ? exudites ? BS 85, UIA WNL. Assessment was anxieties and hypertension. Tr. 364. She again returned on February 14,1995. It, too, is mostly illegible— (C) general extremely anxious, nonstop talking, ? — WNL, throat no redness post?, neck [illegible character] ademopa-thy, lungs no rales, ?, abd. normal bowel sounds, epigastric tenderness. Assessment: URI, hiatal hernia, anxiety. Tr. 362.

South Fulton Medical Center

On June 13, 1993, Dr.__ Tucker admitted the claimant to the South Fulton Medical Center apparently for lower back pain. The doctor noted L leg numbness and a perineal sensation and discharged her. Tr. 333-334.

The record also contains mostly illegible office notes from Dr. Charles Scott, covering the period March 20, 1991 through September 8,1994. Tr. 335-346.

As previously noted, on January 27, 1994, Dr. Charles Scott, M.D., admitted the claimant to the South Fulton Medical Center with complaints of abdominal pain and for an air contrast barium enema. Results showed (1) two small polyps in the mid-transverse colon, and (2) large redundant colon. Tr. 332, 346, 347-50. He readmitted her again on January 31, 1994 for a GI and small bowel X-ray series. Results were (1) a small sliding hiatal hernia, (2) otherwise normal GI and small bowel. Tr. 331.

On February 21, 1994, Dr. Michael Schlossberg admitted the claimant to the South Fulton Medical Center with complaints of lower back pain/flank/ abdominal pain, urinary frequency. Tr. 325. Abdominal X-rays were normal. No other findings are noted. Tr. 318-330.

On March 24, 1994, the claimant was again admitted to the South Fulton Medical Center by Dr. Michael Schlossberg. Complaints were uterine prolapse and stress incontinence. She was discharged on March 31, 1994. While hospitalized, Dr. Schlossberg performed a dilation and curettage, vaginal hysterectomy, interior and posterior repair and enterocele repair. Final diagnosis was (1) “cystocele with stress urinary incontinence, (2) rectocele, (3) enterocele, (4) third degree uterine prolapse, (5) menometrorrhagia, and (6) removal of a small segment of endometrium showing estrogen withdrawal, bleeding, mild chronic cervicits, luomyoma, interi, vaginal mucosa with patchy mild inflation”. Tr. 267-278,1026-1054.

The claimant, who underwent back surgery in 1993 at L5-S1, continued to complain about multiple body problems; was also apparently sent to the South Fulton physical therapy department for 13 treatments (whirlpools, ultrasounds, ?), therapeutic exercises and home exercises on 11/3/93, 11/22/93, 1/5/94, 7/18/94, 7/20/94, 7/22/94, 7/25/94, 7/29/94, 8/1/94, 8/3/94, 8/5/94, 8/10/94. Part of the report is illegible. Tr. 317-330.

Georgia Regional Hos-pital

On November 17,1994, the claimant was admitted, apparently from the South Fulton Mental Health Clinic, to the Georgia Regional Hospital for depression and as a danger to herself. Tr. 369-397. (Tr. 772-811 [duplicate], 1057-1099 [duplicate]). The claimant also indicated she was suicidal. On admission, Dr. A. Ahamed, M.D., noted that her mental status was essentially normal. Tr. 371, 378-79. Her admission diagnoses were:

AXIS I: Major depression, recurrent and dypthemia,

AXIS II: Deferred,

AXIS III: (refers to physical examination.) See Tr. 392-397. Apparently, she also abused alcohol which may have been in remission. Tr. 374, 379. (Tr. 373).

AXIS V: Current GAF 40; highest GAF — 70. Tr. 391.

During her stay, she was apparently seen by Dr. Cray and another physician (signature illegible), in addition to Dr. Ahmad. Her diagnosis on discharge on November 24,1994 was:

AXIS I: Dysthemia # 300.40,

AXIS II: “hold”,

AXIS III: Chronic lumbar back pain, HTN (Hypertension) #724.5, 401.9. She was also no longer suicidal. Tr. 374. (doctor’s signature illegible). Medications were Desyrel 50 Pa RHS Flexeril 10g., Potid, Zoubic 150K, Po-bid; Buspar 5g. Potid and Cayoher 25g. P.O.A.D. Tr. 373.

Dr. E. Clifford Beal, M.D., Psychiatrist

At the request of the Fulton County Alcohol and Drug Treatment Center, she was also treated by psychiatrist E. Clifford Beal, M.D., from June 14, 1994 to September 12, 1994 on 18 occasions, including her initial one-hour interview. Tr. 398. She was upset about her living conditions, inability to care for her children, substance (alcohol) abuse. She was agitated with feelings of hopelessness, helplessness, and inability to sleep. She was also unable to grasp the reality of her situation and follow through with real concrete measures. His diagnoses were: (1) major depression (bipolar) 296.5, with suicidal ideations, (2) possible delusional disorder 297.1, (3) alcohol related disorder 291.9. Tr. 398-99. When he last saw her on September 12, 1994, her prognosis was not good. Indeed, his treatment notes reflect periodic alcoholic drinking binges. Tr. 404-405. Id. The referral note from FCADTC indicated that the claimant was scheduled to undergo an outpatient detox program on January 16,1994 in connection with her alcoholism; and he was requested to recommend medicare benefits. Tr. 399.

Butts County Medical Center

According to the claimant’s former attorney, Michael Brewster, the claimant also visited the Butts County Medical Center on August 25, 1995. The medical records note that she has multiple health problems, and a long history of depression for which she is taking Desyrel 50 mg. and Vistoral 25 mg. The physician (no signature), who apparently saw her, noted that she was oriented in three spheres: her affect/mood was sad, with mild anxiety; her speech was coherent; denied alcohol problem and “HIS” ideation. His/her diagnosis was (1) Dysthemic Disorder, ??????, and she should increase the Desyrel to 75 mg. per day. Tr. 475-76.

Vision Psychological Rehabilitation Program

Commencing on August 28, 1995, the claimant was treated at the Vision Psychological Rehabilitation Program (apparently Dr. ? Allen). The claimant had a list of multiple health problems, including a long history of depression being treated with 50mg. of Desyrel and Vistral 25 mg. She also complained of multiple family stresses. On examination, she was oriented X3, her affect/mood was sad, mild anxiety, speech: coherent; denies alcohol and H/S ideation. Assessment was dysthemic disorder, moderate: increase Desyrel from 50 to 75 mg/day. Tr. 857.

On November 27, 1995, she returned and reported doing better. Apparently, the doctor discontinued her Desyrel. Id. She returned again on August 5, 1996. The doctor reviewed her Visteral and De-synex. Tr. 856. She returned again on August 26, 1996, complaining of being defensive, angry, panicky, overwhelmed. She also reported that the Visteral interfered with her driving, while Desyrel helps her sleep. Every time the doctor attempted to obtain a history, the claimant got more and more agitated. She reported turning to alcohol in the past, but no longer; but her husband abuses alcohol and her children. On examination, she was alert and oriented. Speech coherent; affect anxious; mild agitation; depressed; talks non-stop about her complaints; denies stating she would kill herself. She had trouble understanding and a hearing loss. Assessment was: (1) depression disorder (R/O major depression), (2) anxiety disorder NOS. Tr. 854-55.

Another visit (date unclear _/23/96) notes that the claimant complains of panic attacks, stomach pain, and concern about medications. On examination, she was alert and oriented, speech coherent, affect-anxious, hyperverbal, wringing hands? Assessment was: Desyrel helps with sleep, Effexor beginning to help with depression, anxiety still a problem. Tr. 855. She returned again on October 21, 1996 with complaints of many medical problems, blood pressure fluctuating, headaches associated with back pain; can’t take medicine because of stomach. She is quieting down and more at peace. On examination, she was alert and oriented; anxiety improving; depression improving; focus is on ? about ? physical symptoms. Assessment: mental status improving despite physical pain. Tr. 853. On February 24, 1997, she returned again with many physical complaints: nausea, diarrhea, flu symptoms, talks non-stop with much annotation about meds/physical problems. Apparently, a doctor told her Effexor is not causing her problems and has decreased her anxiety. On examination, she was alert, oriented, speech coherent, c/o panic attacks. Moodanxious. No psychoses. Assessment was: needs to get back on more effective doses of Effexor and use Desyeral to sleep. Tr. 852.

She reported on her May 5, 1997 visit that she was going to have bladder surgery. Still takes Effexor; sleep irregular, but Desyrel helps. On examination, she was alert, oriented, hyperverbal, numerous somatic complaints, feeling more depressed and anxious, and worries about her future. Tr. 852. The last entry, dated 8/19/97, noted that she was told that the doctors at Grady had not given her adequate care. She also has a hiatal hernia, being lactose intolerant, lower gluton problems, irritable bowel syndrome, and probably gallstones. She was also told that the ? meds she is on too much and ? causing more medical problems such as muscle trembling, twitching, sweating, tremors, and feeling very weak. She is scared to eat because of sore throat down to her stomach. Once food is in her stomach, it’s uncomfortable, so she intentionally throws up. She is going to transfer treatment from Grady to DeKalb psychiatrist. On examination, she appeared confused about what she had been told by Grady doctors. She feels many of her meds and improper care are causing problems. Flat mood; anxious affect; no psychotic? voiced or observed. No S/H ideations; poor insight and judgment. Feels GI M.D. and psychiatrists should have been coordinating. Assessment was: depressed, anxious, nervous, medical problems. Tr. 851.

Dr. Khaled Jalil, M.D.

Commencing on October 24, 1996, the claimant visited Dr. Khaled Jalil, M.D. and the Henry County Medical Center on the referral of Dr. Vickie Jones. Tr. 18-32. His initial assessment was to rule out eso-phagitis, as she had complaints of pyrosis and reflux. Tr. 29. On October 25, 1996, he performed a distal esophageal biopsy, which assessments were positive for heli-cobacter pylor, and the gastric mucosa displayed chronic gastritis with focal lymphoid aggregates. Diagnoses were: (1) Grade 2 esophagitis, (2) hiatal hernia, and (3) antral gastritis. Tr. 28, 30-32. She also had follow-up visits on 11/1/96 (Tr. 27), 11/15/96, 12/5/96 and 1/16/97. Tr. 20, 23, 27. On November 18, 1996, she also underwent a colonoscopy because of chronic, persistent diarrhea. Diagnosis was: (1) collagenous colitis, (2) colon polyp, and (3) internal hemorrhoids. Tr. 22. She also had a CT scan of her abdomen and pelvis on January 22, 1997. Her liver, spleen, and pancreas were within normal limits; calcified gallstones were in her gallbladder; normal kidney functions, no retroper-itoneal adenopathy was seen, and the abdominal aorta was normal. Portions of the sigmoid and rectum were incompletely distended, and there was a thickening of the bowel wall. The uterus was absent. Diagnoses were: (1) choleothasis, (2) history of hysterectomy, (3) incompletely distended rectum and sigmoid colon. Tr. 19.

She returned on February 17, 1997 with continued complaints of severe diarrhea, nausea with swelling. Diagnoses were: (1) irritable bowel syndrome, and (2) GERD. Tr. 18.

Sylvan Grove Hospital

Dr. Krishan Gupta, M.D.

She visited the Sylvan Grove Hospital on September 18 and 19, 1995, with complaints of flu-like symptoms — throat, spreading rash and itching and ? numbness. Her physical examination was essentially normal, rule out allergies, and was released by Dr. Maldonado. Tr. 835-840,1122-25.

On February 23,1996, the claimant went to the Sylvan Grove Hospital Emergency Room with complaints of flu-like symptoms. Her physical examination was essentially normal and she was released by Dr. ? to return home. Tr. 832-834, 1119— 1121.

On March 27, 1997, Dr. Vicky James, M.D., referred the claimant to Dr. Krishan Gupta, M.D. because of her stress urinary incontinence, which is aggravated by her low back pain. Dr. Gupta examined the claimant and his diagnoses were (1) stress urinary incontinence, (2) status post-hysterectomy, (3) chronic back problem, and (4) exogenous obesity. He also noted in her past medical history that she had stopped drinking one year previously. Tr. 17. On April 3, 1997, he admitted her to the Sylvan Grove Hospital where he performed a lysroscopy, calibration and dilation of her urethra and Marshall-Marchet-ti procedure as an outpatient. Tr. 16. She returned to the hospital on May 15, 1997 for apparently another outpatient Marshall-Marchetti procedure (M-M). Tr. 14-15, 331-31, 1127-29. She returned again and was admitted on May 20, 1997, and underwent another “M-M” procedure on May 22, 1997. She was discharged on May 24, 1997. Post-operative diagnosis was: (1) stress urinary incontinence, (2) mild to moderate cystoure throcele. Tr. 11-13, 812-22.

On May 29, 1997, Dr. Gupta notified Dr. James that the claimant was (1) post Marshall-Marehetti procedure, (2) low back ache, and (3) cystociles, and was making a good recovery. Tr. 10, 829. She returned on May 30,1997 with complaints of urinary hesitancy and had her foley catheter replaced. Tr. 826-28, 1116-18. She returned on June 5, 1997, and Dr. Gupta removed her foley catheter. Tr. 9. On June 8, 1997, he had to reinsert the foley catheter. Tr. 823-26, 1102-04. A 6/13/97 follow-up visit noted good progress. Tr. 8.

Dr. Vicki James, M.D.

From October 24, 1996 through June 30, 1997, the claimant was treated by Dr. Vicki James, M.D. for hypertension and GI distress. Tr. 840-850. On examination, she found: (1) hypertension with good control, (2) history of hiatal hernia and gastric reflux. She returned on November 21, 1996 and was also diagnosed with gastritis. She returned again on December 4, 1996, and was also diagnosed with (1) irritable bowel syndrome, (2) depression, and (3) seasonal rhinitis. Tr. 849. She returned on January 10, 1997 with multiple complaints, including syncope, atypical chest pain, conjunctivitis and right elbow pain. Her physical examination was essentially normal. Diagnoses were: (1) syncope with angina, (2) conjunctivitis, and (3) right epi-condyditis. Tr. 848. She returned on February 11, 1997, complaining of postnasal drainage, headaches and right elbow pain. Examination was essentially normal. Diagnosis was sinusitis. (Id.). She returned again on February 28, 1997 after being evaluated by Dr. Jalil, who told her she had a hiatal hernia. She reported that she was still having severe nausea and vomiting, which also causes urinary incontinence. She also has anterior chest wall pain. Her examination was essentially normal. Diagnoses were: (1) urinary stress incontinence, (2) hiatal hernia, (3) costochorondrias, (4) irritable bowel syndrome. Tr. 847. She returned on February 11, 1997, complaining of post-nasal drainage, headaches ?, a burning pain in her right elbow. On examination, Dr. James noted tenderness to palpation of the sinuses, more on left, mild injection of the posterior, pharynx and cervical adenopa-thy. Diagnosis was sinusitis. Tr. 848. She returned on March 25, 1997 after having been involved in a motor vehicle accident and diagnosed with muscle strain. Since then, she has been suffering with low back pain. On examination, Dr. James noted tenderness to palpation with no spasms. Diagnosis was acute exacerbation of chronic lumbar disease. Tr. 845. She returned again on April 8, 1997, reporting the pain was better, but with tightness in low back muscles. On examination, James observed spasm or tenderness to palpation. Tr. 844.

On May 2, 1997, she returned with a number of complaints: stomach pain and irritation, chronic diarrhea. The examination was essentially normal. Diagnosis was hypertension under control. Tr. 841.

A June 10, 1997 visit included complaints of low back pain, possibly exacerbated by bladder surgery by Dr. Gupta. On examination, James noted: abdomen— 3 bs, soft mildly exudes, UQ back, decreased ROM © bilateral sacroiliac tenderness © L straight leg raise. Diagnoses were acute exacerbation, chronic low back pain. Id. On her June 30, 1997 visit, the claimant reported that her back was better, but she had to stop taking Reglan because it made her too depressed to care for her children. Another physician told her she had gallstones. The examination was essentially normal. Diagnoses were: (1) degenerative joint disease, osteoarthritis of the spine. Tr. 340.

Spalding Regional Hospital

On March 19, 1997, the claimant was seen in the Spalding Regional Hospital Emergency Room with complaints of pain in her tail bone, apparently after a motor vehicle collision. She also complained of a head injury, (-) hn disc, © chronic lower back pain, more on left, ? H/O ? 1992, S/P laminectomy L5-S1, ?. She complained of tenderness and decreased range of motion lower left extremities. Diagnosis was muscular ? pain, H/O chronic LBP. Degenerative disc disease (physician’s signature illegible). Dr. Anthony Ferrara, M.D. Tr. 911,1022.

On April 28, 1998, the claimant again visited the Spalding Regional Hospital with complaints of trembling and leg weakness. She also complained of chronic low back pain, weak neck, muscle weakness. On examination by Dr. H. Michael Webb, M.D. and Dr. Ronald C. Gay, M.D., which are mostly illegible, show her cranial nerves II — XII were intact, heart-RRR, abdomen — © bowel sounds, soft, tender normal, (-) CUH tenderness, no edema ROM fall. PTRS 2 ©, pulse palatable? diagnosis was neuropathy: X-rays of her lumbar-sacral spine showed mild osteoporosis, vertebral body height and disc spaces are well maintained without fracture or subluxation. Mild spondylosis about the L5 vertebral body, otherwise normal. Tr. 908-10,1020-21.

On June 17, 1999, the claimant visited gastroenterologist Dr. Appaswamy M. Gowda, M.D. with complaints of diarrhea, abdominal pain, nausea and vomiting. Dr. Gowda noted her past medical history and examined her, finding “no jaundice, neck supple, lungs clear, heart sound heard, abdomen soft, diffused moderate tenderness, no mass, no rebound, normal rectal exam with positive occult blood and normal extremities.” Diagnostic impression was abdominal pain, diarrhea, IBD, IBS, PhD, hernia w/reflux, obesity, and hypertension. Tr. 1170.

On June 18,1999, he admitted her to the Spalding Regional Hospital for several procedures. A colonoscopy disclosed internal hemorrhoids and no polyps or constricting lesion. Tr. 1168. He readmitted her on June 23, 1999. At that time, a gallbladder ultrasound revealed that the gallbladder was partially obstructed and filled with multiple gallstones, no dilated bile ducts, otherwise unremarkable. Tr. 1166-67. She also had moderate to severe abdominal tenderness with no masses. Final diagnoses were: (1) abdominal pain, intermittent diarrhea, (3) hypertension, (4) depression, and (5) cholelithiasis. She was discharged on 6/25/99. Tr. 1165-67. During the admission, he also had her examined by Dr. Kusuma S. Rao, M.D., apparently a psychiatrist. He determined that she was alert and oriented X four. She was cooperative, but extremely anxious, nervous and depressed with severe signs of neurovegatitive signs of depression and insomnia, an inability to concentrate, easy irritability and severe panic attack. She exhibited fear of the unknown and feelings of unreality. No auditory or visual hallucinations. She also denied suicidal or homicidal ideations. Her memory was clouded due to her anxiety; her judgment was questionable, but no evidence of any psychosis. Diagnoses were:

AXIS I: depression, severe in nature, without psychotic features, questionable bipolar disorder.

AXIS II: deferred.

AXIS III: 1. cholelithiasis, 2. peptic ulcer disease, 3. high blood pressure, and 4. obesity. Tr. 1163-64, 1174-75.

Apparently, the record also contains Dr. Gowda’s mostly illegible office notes from 6/22/99, 7/16/99, 8/13/99, 10/19/99, 10/29/99. Tr. 1161-62.

On June 14, 2002, she returned to the Spalding Regional Hospital where Dr. David A. Van, M.D. had PA and lateral X-rays of her chest made. Diagnosis was possible infiltrate in the right base arterially, manifested by loss of sharpness in the left hemidiaphram. Tr. 1178. Thereafter, on June 18, 2002, she also underwent an echocardiogram. Results were difficult to study: (1) the left ventricle was normal?, with mild LVH & preserved 1-V function (ff inq), (2) the AD, RD, RV were normal, (3) the valves were not well visualized, and (4) there is no pericardial effusion. Tr. 1178.

IRIS Counseling Alliance

From June 23, 1999 through February 28, 2001, the claimant was treated at the IRIS Counseling Alliance. Tr. 1171-95.

The August 3, 1999 visit noted that the claimant was complaining of multiple problems and had been denied Social Security Disability Benefits. Assessment was mostly illegible, but apparently states that her medications are too high, and the plan was to reduce them? The October 19, 1999 entry notes that the claimant had improved because of an improved family situation. Tr. 1173. On January 15, 2001, the claimant underwent a mental status examination. At that time, she was irritable, sensitive and withdrawn; her facial expression was sad and worried; her appearance was “fat” and poor clothing; motor behavior was decreased; speech was less than normal; her mood and affect were anxious and depressed; sensorillem: memory intact; content of thought was suspicious, feel persecuted, and ideas of guilt. None of which was caused by drinking or withdrawing; her flow of thought was blocking; her fund of information was adequate; her judgment was poor; her intelligence was average; her reliability was truthful; her physical condition noted difficulty falling asleep. There was no alcohol or drug abuse. Diagnoses were:

AXIS I: major depressive disorder;

AXIS II: deferred;

AXIS III: class four?;

AXIS IV: ? and

AXIS V: 60 (doctor’s signature illegible).

Tr. 1171-72. The entry of February 28, 2001 is mostly illegible but appears to state that the claimant is suffering from dysthemia deficit — needs ?; prefers to ? of new group ? She was also referred to neurology. Doctor’s signature is illegible. Tr. 1171. Indeed AA is ideal(?) ? Interview is adequate.

McIntosh Trail Family Practice

Dr. David Van, M.D.

Dr. Vickie Van, M.D.

Emory Clinic

Apparently, commencing in February, 2002, the claimant was treated by Drs. Vickie and David Van and Laura Trice, FNP, at the McIntosh Trail Family Practice. Tr. 1139-1153. On February 16, 2000, she had a pap smear with normal result. Tr. 1151-53. On May 24, 2000, she was treated for a cyst in her groin area. Tr. 1150. She returned on May 26, 2000 with complaints of vomiting, a sore throat, and nausea. Diagnosis was rule out ulcerative colitis, and Barrett’s esophy-gosis. Her cyst was also improving. Tr. 1146-49. She returned again on June 14, 2000 for a physical examination and a check up on her high blood pressure, and Type II diabetes. It was also noted that she had a 2 + pedal pulse on her feet, and her EKG was normal. Diagnoses were: (1) uncontrolled Type II diabetes, (2) seizure disorder, (3) obesity, (4) hype