Moraine v. Social Security Administration (695 F. Supp. 2d 925, 2010)

ORDER ADOPTING REPORT AND RECOMMENDATION

JOHN R. TUNHEIM, District Judge.

The above-entitled matter comes before the Court upon the Report and Recommendation of United States Magistrate Judge Raymond L. Erickson, dated February 16, 2010, and no objections having been filed to said Report and Recommendation.

Based upon the Report and Recommendation of the Magistrate Judge, and all of the files, records and proceedings herein,

IT IS HEREBY ORDERED that:

1. The Plaintiffs Motion for Summary Judgment [Docket No. 24] is denied.

2. The Defendant’s Motion for Summary Judgment [Docket No. 29] is denied.

3. This matter is remanded to the Commissioner for further proceedings, in accordance with this Report, pursuant to Sentence 4 of Title 42 U.S.C. § 405(g), and that Judgment should be entered accordingly.

4. Pursuant to the holding in Shalala v. Schaefer, 509 U.S. 292, 297, 113 S.Ct. 2625, 125 L.Ed.2d 239 (1993), Judgment is entered accordingly.

REPORT AND RECOMMENDATION

RAYMOND L. ERICKSON, Chief U.S. Magistrate Judge.

I. Introduction

The Plaintiff commenced this action, pursuant to Section 205(g) of the Social Security Act, Title 12 U.S.C. § 105(g), seeking a judicial review of the Commissioner’s final decision which denied her application for Disability Insurance Benefits (“DIB”). The matter is now before the Court on the parties’ cross-Motions for Summary Judgment. The Plaintiff appears pro se, and the Defendant appears by Lonnie F. Bryan, Assistant United States Attorney. For reasons which follow, we recommend that the parties cross-Motions for Summary Judgment be denied, and that this matter be remanded to the Commissioner for further proceedings, not inconsistent with this Report.

II. Procedural History

The Plaintiff applied for DIB on March 26, 2007, at which time, she alleged that she had become disabled on March 6, 2007. [T. 9, 128, 130], The Plaintiffs date, on which she was last insured for DIB, was September 30, 2008. [T. 9, 131]. Her claim was denied upon initial review, and upon reconsideration. [T. 9, 45-54]. The Plaintiff timely requested a Hearing before an Administrative Law Judge (“ALJ”) and, on June 18, 2008, a Hearing was conducted, during which the Plaintiff appeared personally, and by Laura K. Ross, Esq. [T. 9, 22-44], Thereafter, on July 19, 2008, the ALJ issued a decision, which denied the Plaintiffs claim for benefits. [T. 6-17], The Plaintiff requested an Administrative Review before the Appeals Council, and on September 22, 2008, the Appeals Council declined to review the matter further. [T. 1-5, 18-21], Thus, the ALJ’s determination became the final decision of the Commissioner. See, Grissom v. Barnhart, 416 F.3d 834, 836 (8th Cir.2005); Steahr v. Apfel, 151 F.3d 1124, 1125 (8th Cir.1998); Johnson v. Chater, 108 F.3d 942, 943-44 (8th Cir.1997).

Although not formally a part of the Record, it appears that the Plaintiff filed a second application for DIB, which was approved on the initial level of review. See, Plaintiffs Motion for Summary Judgment, Docket No. 21, at p. 3 of 3. The Commissioner advises that the official records reflect that the Plaintiff filed a second application for DIB on November 13, 2008, which was granted at the initial level of administrative review, based upon a finding that the Plaintiff became disabled on July 18, 2008, which is the date that the Plaintiff identified as the alleged onset date in her application, and which is one (1) day before the date of the ALJ’s Decision in this case. See, Defendant’s Memorandum in Support of Motion for Summary Judgment, (“Defendant’s Memorandum”), Docket No. 30, at p. 23 of 24. We make note of this procedural development only to be satisfied that we have continued jurisdiction over the subject matter of this action and, concluding that a period of disability remains in dispute, we are satisfied that we continue to be presented with an actual “case or controversy.” See, e.g., Defenders of Wildlife, Friends of Animals and Their Environment v. Hodel, 851 F.2d 1035, 1038 (8th Cir.1988) (“Article III of the Constitution limits the power of the federal courts to actual ‘cases’ and ‘controversies.’ ”), citing United States Constitution, Article III, Section 2; see also, McClain v. American Economy Ins. Co., 424 F.3d 728, 731 (8th Cir.2005), quoting Friends of the Earth, Inc. v. Laidlaw Envtl. Servs. (TOC), Inc., 528 U.S. 167, 180-81, 120 S.Ct. 693, 145 L.Ed.2d 610 (2000) (“[T]o satisfy Article Ill’s standing requirements, a plaintiff must show (1) it has suffered an ‘injury in fact’ that is (a) concrete and particularized and (b) actual or imminent, not conjectural or hypothetical; (2) the injury is fairly traceable to the challenged action of the defendant; and (3) it is likely, as opposed to merely speculative, that the injury will be redressed by a favorable decision.”).

III. Administrative Record

A. Factual Background. The Plaintiff was fifty (50) years old on the alleged onset date. [T. 15]. The Plaintiff graduated from high school, had two (2) years of post-secondary education, and has past work experience as an accounting clerk and personnel recruiter. Id. As related by the Plaintiff, she stopped working on or about March 6, 2007, due to her disability.

1. Medical Records. On April 3, 2006, the Plaintiff was seen at the Apple Valley Medical Center (“AVMC”), for complaints of headaches and a sore throat. [T. 267]. She was tested for Strep throat, which came back negative. [T. 281], Shortly thereafter, on April 21, 2006, the Plaintiff presented at AVMC with complaints of a sore throat. [T. 266].

On May 24, 2006, the Plaintiff saw Dr. Reetu Syal for hot flashes, fatigue, and symptoms of menopause. [T. 297]. Dr. Syal noted that the Plaintiff had underwent a vaginal hysterectomy one (1) year earlier, that the Plaintiff was taking Lexapro, and that she had a history of gestational diabetes. Id. The Plaintiff advised that she wished to proceed with hormone replacement therapy to treat her menopausal symptoms, and Dr. Syal prescribed Premarin at that time. Id. Dr. Syal also ordered hemoglobin and thyroid tests, so as to rule out other possible sources of the Plaintiffs fatigue. Id.

The Plaintiff was seen by Dr. Ingrid Wilbrand-Conley on August 22, 2006, for symptoms of menopause and significant hot flashes, which had improved slightly since she started taking Premarin, but she reported that she was experiencing nausea during hot flashes. [T. 296]. Dr. Wilbrand-Conley observed that the Plaintiff was well-developed, well-nourished, and in no acute distress. Id. The Plaintiff further reported that she was experiencing a lot of stress in her life, which had contributed to a slow increase in her weight over the last few years. Id. Dr. Wilbrand-Conley ordered a TSH cascade, and hemoglobin and glucose tests, and advised the Plaintiff to contact her primary care physician if her stress increased. Id. She was also prescribed Climara. Id.

On September 29, 2006, the Plaintiff saw Dr. Wilbrand-Conley for her annual examination, at which time, the Plaintiff reported that her stress level continued to increase, that she had “a lot of things going on in her life,” and that the Lexapro was helping, but it was not completely addressing her stress level. [T. 294]. The Plaintiff reported several bouts of abdominal pain, which was associated with diarrhea, over the last couple of months which, at times, required up to seven (7) trips to the bathroom. Id. Dr. Wilbrand-Conley believed that the Plaintiff might have irritable bowel syndrome (“IBS”), and recommended that she set up a consultation with a gastroenterologist for a colonoscopy, so as to evaluate the Plaintiff for the existence of IBS. Id. Dr. Wilbrand-Conley also recommended that the Plaintiff quit smoking and decrease her use of caffeine. Id.

Dr. Patrick M. O’Reilly saw the Plaintiff on October 5, 2006, following a referral from Dr. Wilbrand-Conley for diarrhea and abdominal pain. [T. 308]. The Plaintiff told Dr. O’Reilly that, on July 2, 2006, her mentally ill sister came to her house and threatened to kill her. Id. The Plaintiffs sister remained at the house for about forty-five (45) minutes and, upon leaving, she drove into a police car. Id. The Plaintiff reported that, ever since that day, she has had abdominal pain and diarrhea, typically seven (7) or eight (8) times per day. Id. The Plaintiff described cramping pain in the lower abdomen, intermittent sharp left lower quadrant pain, gas and bloating, incomplete evacuation, and relief from the abdominal pain following a bowel movement. Id. The Plaintiff further reported that the intake of any food or drink resulted in prompt diarrhea. Id. Other symptoms included increased weakness and dizziness, increased difficulty sleeping, and nightmares. Id.

The Plaintiff was not in acute distress, and a physical examination was normal, with Dr. O’Reilly noting that her abdomen was soft, nontender, and nondistended, and that her bowel sounded normal. Id. Dr. O’Reilly observed that the Plaintiff had not lost any weight and had, in fact, gained five (5) to six (6) pounds. Id. He believed that the Plaintiff may have post traumatic stress disorder (“PTSD”), as a result of the incident with her sister. Id. Dr. O’Reilly further observed that the Plaintiff was exhibiting symptoms of irritable bowel syndrome, and opined that she may have underlying etiologies, such as colitis or infection. Id. He ordered stool cultures and laboratory work, and concluded that, if the results of those tests turned out to be unremarkable, then a colonoscopy would be ordered. [T. 308-309].. On October 12, 2006, the Plaintiff presented with complaints of diarrhea and abdominal pain of unknown etiology, at which time Dr. Arnold M. Brier performed a colonoscopy and rectal biopsy. [T. 299, 307]. Dr. Lisa L. Lyons, who was the attending pathologist, concluded that the results appeared typical of the collagenous colitis form of microscopic colitis. [T. 299]. Dr. Lyons advised that the diagnosis would be further supported if there was a history of chronic, watery diarrhea. Id. Thereafter, on October 24, 2006, Dr. Brier diagnosed the Plaintiff with microscopic colitis. [T. 263],

On October 27, 2006, the Plaintiff saw Amy C. Heilman, P.A.-C. (“Heilman”), for a followup regarding her recent diagnosis of microscopic colitis. [T. 305-306]. Heilman noted that the Plaintiff had a history of diarrhea since July, which the Plaintiff reported as occurring between two (2) and twelve (12) times daily, with cramping. [T. 305]. Heilman noted that the Plaintiff was previously taking NSAIDs, but had recently switched to Tylenol, that laboratory testing and stool cultures were normal, and that the Plaintiff was currently taking Lexapro and Prempro. Id. She prescribed Asacol as a treatment for the collagenous colitis, advised the Plaintiff to limit intake of caffeine and dairy products, and directed the Plaintiff to follow up with her in two (2) to three (3) months for a reassessment of her symptoms.

The Plaintiff sought urgent care treatment at AVMC on December 6, 2006, with complaints of swollen hands, mouth and throat, and facial tingling and, while there, she was seen by Dr. Decker. [T. 275]. The Plaintiff reported that she was taking Entocort, Asacol, Lexapro, and Premarin, and a medical history of microscopic colitis and depression were noted. Id. A review of the Plaintiffs systems revealed that the Plaintiff was experiencing red, burning eyes, swelling and tingling in the throat, shortness of breath, nausea and dizziness. Id. The Plaintiff believed that Entocort was causing an allergic reaction, and Dr. Decker noted that she looked extremely agitated, but that he observed no problems with speaking or breathing. [T. 276]. Dr. Decker strongly doubted that the Plaintiff was experiencing an allergic reaction, but he prescribed Benadryl. Id.

Dr. Wilbrand-Conley saw the Plaintiff for a reevaluation on December 21, 2006, at which time, she noted the Plaintiffs recent diagnosis of microscopic colitis following complaints of persistent diarrhea. [T. 293]. Dr. Wilbrand-Conley noted that the Plaintiff was currently taking Lexapro and Premarin, and that she had been treating the microscopic colitis with Asacol and Entocort, with some improvement to her symptoms of abdominal pain and diarrhea, but that those medications were discontinued due to side effects. Id. The Plaintiff reported that she was currently asymptomatic, and that she was not having any problems with diarrhea or cramping pain. Id.

On December 26, 2006, the Plaintiff presented at AVMC urgent care with a sore throat that had lasted approximately two (2) weeks. [T. 272], The Plaintiff reported symptoms of nasal congestion, ear pain, cough, and headache. [T. 272, 274]. The Plaintiff also reported that she was taking Lexapro, Premarin, and that she had just finished taking Entocort. [T. 272], The Plaintiff was advised to get plenty of rest and fluids. Id.

Shortly thereafter, on January 4, 2007, Dr. John E. English, who was the Plaintiffs primary care physician, saw the Plaintiff for a consultation regarding her recent diagnosis of microscopic colitis, and because she had seen no improvement in the sore throat, headache, and cough, since she was seen in the urgent care clinic the previous week. [T. 269, 277-280]. Dr. English ordered a number of laboratory tests. [T. 277-280].

On January 26, 2007, the Plaintiff presented at AVMC for complaints of a sinus infection, which was not going away with medication. [T. 268], Dr. English also ordered x-rays of the Plaintiffs right shoulder following a fall, which revealed no definite evidence of an acute fracture or dislocation. [T. 330].

Dr. Wilbrand-Conley saw the Plaintiff on March 8, 2007, at which time, the Plaintiff reported lumps in her breasts. [T. 298]. Dr. Wilbrand-Conley ordered a mammogram, and Dr. Frank P. Maguire concluded that the results were normal, with no signs of malignancy. Id.

Dr. Hansen saw the Plaintiff on March 15, 2007, for a followup visit on her diagnosis of microscopic colitis. [T. 301], Dr. Hanson noted a past medical history of hysterectomy, tonsillectomy, and no known family history of gastrointestinal malignancies. Id. The Plaintiff was in no acute distress, had a regular heart rate and rhythm, and she exhibited an appropriate mental status and normal gait. Id. The Plaintiff reported that she had not felt well since the previous Summer. Id. Dr. Hansen noted that the Plaintiff had tried Asacol, which did not help, and that she had also tried Entocort, which had improved her symptoms, but that she had stopped using it after three (3) weeks, due to a funny sensation in her tongue. Id.

Since the Plaintiff began using Asacol again, her stools had worsened, and she was feeling fatigue and malaise, and she reported that it had gotten so bad that “it is actually affecting her job, to the point where she lost her job yesterday.” Id. Dr. Hanson noted that the Plaintiff was experiencing stress and situational depression as a result, and that she had not noticed significant depression before her illness began in the Summer. Id. The Plaintiffs weight remained stable. Id. Dr. Hanson advised the Plaintiff to follow up with her primary care physician within the next month, before returning to see him in one (1) month’s time. [T. 301-302]. Dr. Hansen discontinued Asacort, prescribed Entocort, and told the Plaintiff to report back to him if her symptoms worsened, or if she was unable to tolerate the Entocort. [T. 302],

On April 24, 2007, Dr. Hanson saw the Plaintiff again, at which time, the Plaintiff presented as stressed and tearful, with complaints of joint aches, headache, weakness, and nausea. [T. 334]. The Plaintiff was taking Ensure, Entocort, Premarin, and Lexapro. Id. Dr. Hansen noted that the Plaintiff had experienced significant stressors in the past year, and that he believed that her psychosocial stressors were playing a role in her physical illness. Id. He further noted that the Plaintiff had not shared her personal situation with any of her other health care providers. Id. Dr. Hanson advised the Plaintiff to contact a psychologist to discuss cognitive and drug therapy, and opined that he didn’t think Lexapro was the best drug for her. [T. 334-335]. Dr. Hanson prescribed Questran, and ordered a CT scan of the Plaintiffs abdomen, which revealed normal results. [T. 335-336].

The Plaintiff saw Stephen M. Hjemboe, Ph.D., L.P., a couple of days later, on April 26, 2007, for treatment of PTSD stemming from the incident with her sister, occurring during the Summer of 2006. [T. 366-372], The Plaintiff related symptoms of intense fear, guilt, muscle and joint pain, headaches, and fatigue. [T. 366]. The Plaintiff reported prescriptions for Imipramine, Provigil, Lexapro, Premarin, and Entocort. [T. 367].

As related by the Plaintiff, she was experiencing symptoms of mild depression, insomnia, decreased interest in activities, decreased energy, increased sexual problems, decreased concentration, memory problems, crying, panic attacks, dizziness, anxiety, and nightmares. [T. 369-370]. Dr. Hjemboe concluded that the Plaintiffs complaints were consistent with post traumatic stress disorder (“PTSD”). [T. 370]. The Plaintiff saw Dr. Hjemboe again on May 2, 2007, and May 9, 2007, for additional counseling sessions related to her symptoms of PTSD. [T. 364-365].

The Plaintiff was seen by Stephanie Elko, P.A.-C (“Elko”), on May 24, 2007, for a follow-up visit regarding her collagenous colitis diagnosis, at which time, she presented with continued complaints of “muscle aches, joint aches, fatigue, nausea with emesis, weakness and headaches.” [T. 332-333]. The Plaintiff reported prescriptions for Entocort, Questran, Premarin, and Lexapro. [T. 333], The Plaintiffs bowel movements had improved, with only approximately three (3) per day, but she was still reporting occasional abdominal pain in the form of a dull ache. [T. 332],

Elko noted that, on her prior visit of April 24, 2007, the Plaintiff reported complaints of joint aches, muscle aches, headaches, weakness, and nausea, and that she was having five (5) to eight (8) bowel movements a day. Id. Elko noted that the Plaintiff had been experiencing significant stress in her life over the past year, and that Dr. Hanson had referred her to a psychologist to help with her stress and depression and, at that time, he felt that several of her physical symptoms were secondary to her stress. Id. Elko concluded that the Plaintiff was experiencing improved bowel movements, and that she was dealing well with psychosocial stressors. [T. 333].

The Plaintiff exhibited right upper quadrant discomfort in the abdomen, which was tender to palpation, and which was aggravated by movement. Id. Elko concluded that this was likely secondary to a possible abdominal wall strain, as reported by the Plaintiff. Id. The Plaintiff wondered if the Entocort was playing a role in her muscle and joint aches, and asked that it be discontinued. Id. Elko prescribed a taper of the Entocort and Tylenol, as needed for abdominal pain, and encouraged the Plaintiff to continue with her psychologist and her drug therapy. Id. Elko reported that she discussed at length with the Plaintiff, that improvement in psychosocial stressors might result in an improvement of her physical symptoms. Id. Dr. Hj emboe saw the Plaintiff again on June 5, 2007, for therapy related to the Plaintiffs stress and PTSD issues. [T. 363]. At that time, the Plaintiff reported memory problems and a decrease in energy, which would hit her suddenly. Id. On June 26, 2006, the Plaintiff was seen at AVMC with complaints of a sore left leg from a bug bite. [T. 324]. A few weeks later, on July 16, 2007, the Plaintiff was seen at AVMC again, with complaints that she had been experiencing leg and arm aches, and fatigue, for many months without improvement. Id. Diagnoses of colitis, bursitis of the left shoulder, and fatigue, were noted in the medical records. Id.

On July 26, 2007, the Plaintiff was seen by Dr. Hansen for a followup visit regarding her collagenous colitis. [T. 331]. Recent laboratory tests of her liver, hemoglobin, and thyroid function, were normal. Id. The Plaintiff was in no acute distress, with a normal mental status and normal gait. Id. Dr. Hansen observed that the Plaintiffs significant psychosocial stresses appeared to be well-controlled. Id. He noted that the only thing that had controlled her colitis was Entocort, and that she had tried Asacol and sulfasalazine, which caused her to have systemic side-effects of headaches and weakness. Id. He noted that she had also taken Questran, which had decreased her bowel movements, but it was stopped for a reason that was not apparent. Id. He prescribed Questran, advised that they would taper the Entocort if her stools decreased in frequency, and directed the Plaintiff to contact his office in two (2) to three (3) weeks. Id.

The Plaintiff was seen at AVMC on August 6, 2007, at which time, she received flu test results. [T. 323]. Diagnoses of microscopic colitis and fatigue were noted. Id. Chantix was discussed with the Plaintiff at that time, but her insurance would not cover a prescription for the medication. Id. Two (2) days later, on August 8, 2007, the Plaintiff contacted AVMC again. Id. Apparently, Dr. English had recently prescribed Amitriptyline for the Plaintiffs pain, and she reported it was not working, and that she was experiencing a racing heart, migraines, vomiting, and a possible allergic reaction. Id.

The Plaintiff had another session with Dr. Hjemboe on August 15, 2007, at which time, the Plaintiff reported numerous physical symptoms. [T. 362]. Dr. Hjemboe concluded that the Plaintiff had “resolved her recent stress reaction.” Id. The Plaintiff advised that she was looking for another doctor, because she was not confident in the- expertise, or the advice, that she was receiving, explaining that a nurse had recently told her that she was on the wrong medication. Id. The Plaintiff believed that her physical symptoms were related to fibromyalgia. Id. Dr. Hjemboe observed that the Plaintiffs symptoms began at the time of the traumatic incident with her sister, and that the Plaintiff was presently very concerned with her medical care and the chronicity and intensity of her symptoms. Id. She left the appointment complaining of a severe headache. Id.

On September 12, 2007, the Plaintiff presented to a counseling session with a significant increase in anxiety. [T. 525]. Dr. Hjemboe opined that the Plaintiffs symptoms of PTSD had returned. Id. Dr. Hjemboe further concluded that the Plaintiff probably had some somatizing tendencies, although she seemed to process “her emotions very effectually on. a conscious level.” Id. Shortly thereafter, on September 20, 2007, the Plaintiff was treated at the Millner Family Chiropractic Clinic, where she received x-rays, which indicated spinal deterioration. [T. 426].

On December 12, 2007, the Plaintiff saw Dr. Orandi at AVMC, at which time, she reported pain in all of her muscles and joints, migraine headaches, and muscle spasms. [T. 442]. The Plaintiff reported that the carisoprodol was helping with the muscle spasms, but her main concern was getting her pain under control. Id. Diagnoses of colitis and fibromyalgia were noted, and Dr. Orandi referred the Plaintiff to a fibromyalgia clinic. Id. Multiple trigger points were observed in a physical exam. Id. Dr. Orandi prescribed a trial of Ultram, and advised the Plaintiff to continue taking Soma. Id.

Dr. Hjemboe saw the Plaintiff on December 31, 2007, at which time, he noted that the Plaintiff was sleep-deprived, and expressed some concern that she may have a sleep disorder. [T. 524], He recommended that she see another doctor, in order to address the sleep issues that she was having. Id. He noted that the Plaintiffs fears were growing, and that her fatigue seemed to be fueling them. Id. The Plaintiff reported that she fears going out in public, and not being able to get home, and that she fears driving, as a result of the fatigue she experiences. Id.

The Plaintiff was seen by Dr. Kenneth Britton on January 18, 2008, on a referral from Drs. Orandi and English, for treatment of pain for a presumptive diagnosis of fibromyalgia. [T. 568]. He noted the Plaintiffs past medical history of generalized myofascial pain, bowel complaints, restless legs, headaches, childhood physical abuse, and a “dramatic worsening in her chronic myofascial pain complaints and other symptoms over the past year and a half.” Id. Dr. Britton conducted a physical examination of the Plaintiff, which was “essentially within normal limits with the exception of very significant generalized myofascial pain.” Id. He found significant allodynia in essentially all regions, with no discrete focal orthopedic or neurological abnormalities. Id. Dr. Britton indicated that he also reviewed a number of her medical records that were sent to him. Id.

Following his review of her medical records and physical examination, Dr. Britton concluded that it was his impression that the Plaintiff did in fact have fibromyalgia syndrome. Id. He conducted a full workup in order to exclude other possible causes of her symptoms, all of which were negative. Id. He prescribed Lyrica and referred the Plaintiff to their comprehensive chronic pain program for fibromyalgia, for treatment and physical therapy. Id.

The Plaintiff saw Dr. Wilbrand-Conley on February 18, 2008, for an annual examination. [T. 451]. Dr. Wilbrand-Conley opined that the Plaintiff was “plagued with fibromyalgia, [and] collagenous microscopic colitis.” Id. She noted that the Plaintiff was experiencing excessive fatigue, muscle pain, pain in her neck, pain in the lower abdomen, diarrhea, hot flashes, and depression, and that she was taking Premarin, Lyrica, and Lexapro. Id. The examination revealed no gynecological abnormalities. Id.

On February 20, 2008, the Plaintiff saw Dr. Britton, at which time, he reported that the Plaintiff was experiencing myofascial pain, and that she appeared to be in no distress. [T. 567], Following the examination, Dr. Britton prescribed continued physical therapy. Id. About one (1) week later, on February 27, 2008, the Plaintiff was seen by Dr. Hansen, at which time, he noted that he had been seeing her regularly since her diagnosis in October of 2006, and that the Plaintiff had been refractory to all medical therapy. [T. 455]. The Plaintiff' reported that she had recently been diagnosed with fibromyalgia, and that she was experiencing eight (8) to ten (10) bowel movements a day. Id. Dr. Hanson noted that the Plaintiff was in no acute distress, with a normal mental status and gait, and a review of the Plaintiffs systems was “[r]emarkable mostly for fatigue, depression and anxiety,” with all other systems normal. Id. He noted that her current medications were vitamins, Ensure, Premarin, and Lexapro. Id.

Dr. Hanson noted that the Plaintiff had used Pepto Bismol intermittently without benefit, and that she was unable to tolerate the use of Asacol, sulfasalazine, Questran, or Entocort. Id. Dr. Hansen concluded that he suspected the Plaintiff had symptoms of collagenous colitis, which were combining with the effects of clinically severe depression and anxiety, and he recommended that she pursue treatment of the depression and anxiety more aggressively. Id. He further recommended that the Plaintiff use Pepto Bismol chewable tablets, and Imodium, as needed. [T. 456],

On March 14, 2008, the Plaintiff presented at AMVC with complaints of depression; racing heart; pain in the muscles of her right shoulder, armpit, and chest; and an increase in stress related to a death in her family. [T. 499]. A physician noted diagnoses of depression, anxiety, and fibromyalgia, and prescribed Wellbutrin, Soma, Lexapro, and physical therapy. Id.

Mark Winkler, PA-C (“Winkler”), saw the Plaintiff on March 21, 2008, at which time, the Plaintiff presented with nausea, vomiting, myofascial pain, inability to focus, and blurred vision. [T. 566]. Winkler prescribed Neurontin and noted that the Plaintiff should see an eye doctor for the blurred vision, which was likely a sideeffect from her medication. Id.

Dr. Britton saw the Plaintiff on April 18, 2008, at which time, the Plaintiff reported that she was not tolerating Neurontin well. [T. 565]. He opined that the medications were not making a valuable difference in treatment, and that, most recently, the Plaintiff had been unable to tolerate Neurontin. Id. At this time, the Plaintiff told Dr. Britton that she had seen a television report on nephrogenic systemic fibrosis, and she was convinced that she had the condition, because she was experiencing blisters and pustules on her skin. Id. Dr. Britton noted that the medical records from AVMC showed normal renal function, and he concluded that it did not appear to be a correct diagnosis. Id. Dr. Britton discontinued the Plaintiffs prescription for Neurontin. Id.

On May 22, 2008, the Plaintiff saw Dr. Peter M. Parten following a referral from Dr. Britton, in relation to the Plaintiffs complaints of left shoulder pain, which had persisted for the last fifteen (15) years, with worsening over the last two (2) years. [T. 489], The Plaintiff rated her pain as a seven (7) on a scale of ten (10), and she characterized the pain as stabbing, aching, and intermittent. Id. Following x-rays, Dr. Parten diagnosed the Plaintiff with left shoulder impingement syndrome, and scapular winging. Id. He recommended physical therapy for the left shoulder and administered a subacromial injection of Lidocaine and Depo-Medrol. Id.

On May 30, 2008, the Plaintiff was seen at AVMC, at which time, the Plaintiff requested a prescription for pain care. [T. 497]. Diagnoses of anxiety, depression, fibromyalgia, and chronic pain, were noted, and Effexor and Skelaxin were prescribed. Id.

On June 2, 2008, Dr. Hjemboe saw the Plaintiff, at which time, he noted that the Plaintiff was now treating for fibromyalgia, and still experiencing pain and fatigue. [T. 523]. The Plaintiff reported that she had discovered skull and nerve damages, which she attributed to childhood abuse. Id. The Plaintiff reported feeling scared while driving by herself. Id. The Plaintiff further reported that Dr. Hanson believed her physical ailments were psychological in origin, and that she should pursue more aggressive treatment for the depression. Id.

On June 13, 2008, the Plaintiff was seen by Martha Hultgren, PT, at which time, the Plaintiff presented with shoulder pain and upper extremity weakness. [T. 560-563]. She noted that the Plaintiff had been referred by Dr. Parten, for therapy related to impingement syndrome, and the scapular winging of her shoulder. [T. 563]. The Plaintiff described the pain as sharp and achy, with stiffness, and she reported symptoms while pulling, pushing, lifting, reaching behind her back, and sleeping. Id. Hultgren noted a past medical history of fibromyalgia, shoulder dislocation, migraines, bone spurs, joint pain, hip problems, and microscopic colitis. Id.

2. Assessments. In addition to the foregoing medical records, a number of assessments are contained in the Administrative Record. On June 21, 2007, Dr. Carl M. Leigh, who is a State Agency Physician, completed an assessment of the Plaintiffs physical residual functional capacity (“RFC”). [T. 338-345]. He noted that the Plaintiff alleged a disability as of March 6, 2007, due to diarrhea, pain, cramping, fatigue, malaise, and weakness, associated with collagenous colitis. [T. 339]. Dr. Leigh observed that the Plaintiff reported considerable variability, with respect to her functional capacity, between her good and bad days. [T. 343].

However, in spite of this variability, Dr. Leigh concluded that the Plaintiffs daily living activities were fairly extensive, which included getting the children off to school, cooking simple meals, doing dishes, doing laundry, and doing light housework. Id. Dr. Leigh also advised that the Plaintiffs allegations appeared to be “seriously out of proportion to the objective findings.” Id. For example, Dr. Leigh noted that the Plaintiff alleged that she cannot take her children to the park, which is three (3) blocks away, because she fears she will not be strong enough to make it back. Id. However, Dr. Leigh advised, that if the Plaintiffs symptoms of pain, weakness, and fatigue, were that debilitating, he would expect the Plaintiff to seek changes in medication, or other treatment modalities. Id.

Overall, Dr. Leigh concluded that the Plaintiffs allegations of symptoms, and functional limitations, were found to be only partially credible. Id. Dr. Leigh concluded that the Plaintiff would be limited to lifting or carrying 20 pounds occasionally; lifting or carrying 10 pounds frequently; standing or walking for 6 hours in an eight (8) hour workday; and sitting for about six (6) hours in an eight (8) hour workday; and that she would be able to do unlimited pushing and pulling. [T. 339], He further concluded that the Plaintiff had no postural, manipulative, visual, communicative, or environmental limitations. [T. 340-342],

On October 3, 2007, the Plaintiff was examined by Dr. Alford Karayusuf in relation to her claim for Social Security Disability benefits. [T. 380-382]. At the time of the examination, the Plaintiff was fifty-one (51) years old, and one hundred thirty-five pounds. [T. 380]. He noted that her chief complaints were fatigue, diarrhea, which occurred approximately ten (10) times per day, and pain. [T. 380]. The Plaintiff stated that she has no control over the fatigue, which hits her like a brick wall, and that it hurts to sit and to stand. Id. She reported that there are times when she does not have strength to keep standing or holding her head up. Id.

Dr. Karayusuf found the Plaintiff to be “a very somatically preoccupied woman.” Id. The Plaintiff cried profusely numerous times during her interview, although he had some difficulty establishing whether or not the Plaintiff was being treated for depression. [T. 380], She would not indicate that she was depressed, and continued to emphasize that her problems were physical, although she acknowledged feelings of sadness. Id. Dr. Karayusuf related that the Plaintiff had been previously involved in counseling that was related to sexual and physical abuse, and that was committed by her father during her childhood. Id.

The Plaintiff reported difficulty sleeping due to her headaches, diarrhea, and neck pain, but she had no changes in her appetite. [T. 381]. Dr. Karayusuf observed that the Plaintiffs concentration and memory were diminished, she was distracted and unfocused, she constantly worried, her thoughts were always racing, and she was extremely apprehensive about the recent release of her sister from the St. Peter State Hospital, because she believed that her sister’s mental health had not improved, and that her sister would try to kill her again. Id. Dr. Karayusuf stated that the Plaintiff was oriented to time, place and person; that her memory was intact; that she had average intelligence; and that she had minimal insight. [T. 382].

Dr. Karayusuf recounted that the Plaintiff lived with her husband, and two (2) children, and that she had four (4) grown children, who did not live at home. Id. With respect to her daily living, Dr. Karayusuf reported that the Plaintiff would generally get up at 6:00 o’clock a.m., and go to bed at 8:00 o’clock p.m., that she bathed every two (2) to three (3) days, made her bed every day, and cooked for herself. [T. 381]. The Plaintiff advised that she did not do her own grocery shopping. Id. Dr. Karayusuf also noted that the Plaintiff drove when she needed to get around, and that she was capable of finding her way around. Id. The Plaintiff stated that she engaged in light housework, including dusting, sweeping, cleaning, and doing the dishes and laundry. Id. The Plaintiff would not say how often she engaged in those activities. Id. Dr. Karayusuf further stated as follows: “[The Plaintiff], for reasons that are not clear to me at all, would not answer questions about the frequency of dusting, vacuuming, laundry and washing dishes,” but “[s]he would only say, T have to push myself to do these things.’ ” Id. The Plaintiff reported that she was able to concentrate on television programs, and that she watched about two (2) hours of television per day. Id.

Following his examination, Dr. Karayusuf diagnosed the Plaintiff with major depression, which he characterized as recurrent, with cyclothymic and possibly even bipolar features. [T. 382]. He also concluded that the Plaintiff exhibited elements of PTSD, which had cleared up over the years. Id. He went on to provide the following assessment of the Plaintiffs work-related abilities:

She is able to understand, retain and follow instructions. She is not able to interact with the public due to her emotional lability and pressured speech. She is restricted to brief, superficial interactions with fellow workers and supervisors. Within these parameters and in the context of performing simple, routine, repetitive, concrete, tangible tasks, she is able to maintain pace and persistence.

She is able to manage benefits.

Id.

On October 26, 2007, Thomas L. Kuhlman, Ph.D., L.P., who is a State Agency medical consultant, completed a Psychiatric Review Technique Form, and a Mental RFC Assessment. [T. 386-403]. First, Dr. Kuhlman found that the Plaintiff had an affective disorder — namely, a depressive syndrome, which was characterized by a pervasive loss of interest in almost all activities, appetitive disturbance, sleep disturbance, psychomotor agitation or retardation, decreased energy, feelings of guilt or -worthlessness, and difficulty with concentration or thinking. [T. 389]. He also found the Plaintiff to suffer from an anxiety-related disorder, which was evidenced by a recurrent and intrusive recollection of a traumatic experience, that was a source of marked distress for the Plaintiff. [T. 391]. Lastly, Dr. Kuhlman believed the Plaintiff suffered from a somatoform disorder, which was evidenced by an “[u]nrealistic interpretation of physical signs or sensations associated with the preoccupation or belief that one has a serious disease or injury.” [T. 392].

Dr. Kuhlman advised that those mental disorders would result in a moderate limitation on daily living activities, a mild limitation in maintaining social functioning, moderate difficulty in maintaining concentration, persistence and pace, and with no episodes of decompensation. [T. 396]. Dr. Kuhlman went on to note that, while the Plaintiff was alleging only physical impairments, she minimized her mental impairments. [T. 398]. He further noted that she acted as a parent and homemaker, except when her physical symptoms impaired her, she was independent in hygiene and self-care, and she managed her finances adequately. Id.

In completing his RFC assessment, after considering all the evidence in the case record, Dr. Kuhlman noted his assessment was predicated on the conclusion “that the statements of [the Plaintiff] regarding alleged symptoms and their effect on functions are deemed only partially credible.” [T. 402], Dr. Kuhlman concluded that the Plaintiff had sufficient mental capacity to concentrate on, to understand, and to remember routine, repetitive, and three (3) to four (4) step uncomplicated instructions, but that she would be markedly impaired for detailed or complex, technical instructions. Id. He also concluded that the Plaintiffs ability to carry out routine, repetitive, and three (3) to four (4) step tasks, with adequate persistence and pace, would not be significantly limited, but that it would be markedly limited for detailed or complex, technical tasks. Id.

Dr. Kuhlman further advised that the Plaintiffs ability to handle co-worker, and public contact, was reduced, but she would be able to handle brief, superficial contact, and that the Plaintiffs ability to tolerate and appropriately respond to supervision would be reduced, but adequate to handle ordinary levels of supervision, as found in customary work settings. Id. Lastly, Dr. Kuhlman concluded that the Plaintiffs ability to handle stress and pressure in the workplace was reduced, but he concluded that it would be adequate to handle the stress of routine, repetitive steps, or a three (3) to four (4) step work setting, and that she would not be able to handle the stresses associated with a detailed or complex work setting. Id. Dr. Kuhlman noted that his mental RFC assessment was consistent with Dr. Karayusufs evaluation. Id.

On October 29, 2007, Dr. Gregory H. Salmi, who is a State Agency physician, concluded that, after reviewing Dr. Leigh’s assessment of June 21, 2007, and all of the medical records in the file, following the Plaintiffs request for Reconsideration, he found that there were no new allegations, and that the medical records revealed no worsening of symptoms. [T. 405-407]. Accordingly, Dr. Salmi affirmed the assessment of June 21, 2007, as written. [T. 406].

On June 5, 2008, Dr. Stolpman, who is one of the Plaintiffs treating physicians, completed a physical and mental medical assessment of the Plaintiffs ability to do work-related activity. [T. 500-508]. With respect to the physical assessment, Dr. Stolpman noted that it was his opinion that the Plaintiff would be limited in her work-related activities by her fatigue, migraine headaches, depression, weakness, joint pain and fibromyalgia, based upon his review of her medical history and examinations. [T. 504], He concluded that the Plaintiff would be limited to carrying ten (10) to fifteen (15) pounds occasionally, and five (5) pounds frequently; standing or walking for one (1) hour in an eight (8) hour workday, and less than one (1) hour without interruption; sitting for four (4) to six (6) hours in an eight (8)-hour workday, and less than one (1) hour without interruption. [T. 501-503]. He further concluded that the Plaintiff could never climb or crawl, and that she could only occasionally balance, stoop, crouch, kneel, reach, push, or pull. [T. 502-503]. He found that the Plaintiff would have environmental restrictions, due to her allergies and fibromyalgia, and would have to avoid moving machinery, temperature extremes, chemicals, dust, noise, fumes, and humidity. [T. 503].

With respect to his mental assessment, Dr. Stolpman noted that the Plaintiffs symptoms included poor concentration and memory, depression, fatigue, and a limited capability of dealing with stress. [T. 506-507]. In particular, Dr. Stolpman concluded that the Plaintiff would experience extreme limitations in dealing with work stress; marked limitations in maintaining attention and concentration; marked limitations in understanding and carrying out complex job instructions; and a marked limitation in demonstrating reliability. [T. 506-507], He further concluded that the Plaintiff would experience moderate limitations in following work rules; using judgment; functioning independently; in her ability to understand and carry out detailed but not complex job instructions; and in her ability to behave in an emotionally stable manner. [T. 506-506]. Dr. Stolpman noted that his own treatment, which had only lasted about four (4) months, had been insufficient to form a basis for his assessments, and he based his opinion on the medical records that were available. [T. 508].

On June 16, 2008, Dr. Hjemboe completed a medical assessment of the Plaintiffs mental ability to do work-related activity, in relation to her disability claim. [T. 542-544]. Dr. Hjemboe noted a medical history of depression, anxiety, PTSD, and a vulnerability to stress. [T. 542], He opined that stress and energy are chronic problems for the Plaintiff, which is influenced by chronic physical ailments. Id. He found that the Plaintiff would have marked difficulty in dealing with work-related stress, and that she would experience a moderate limitation in her ability to maintain concentration and attention, in understanding and carrying out complex job instructions, and behaving in an emotionally stable manner. [T. 542-543].

3. Other Records. On April 13, 2007, the Plaintiff completed a Function Report, in which she described how her impairments limited her daily living activities, which may be summarized as follows. [T. 151-162],

The Plaintiff reported muscle and joint pain, headaches, and dizziness, and other aches and pains all over her body, which affected her ability to sleep. [T. 152], The Plaintiff related that she cared for her two (2) youngest children, who were ages six (6) and nine (9), and that she cared for two (2) dogs, by letting them outside and feeding them. Id. She did not need reminders to take care of personal needs and grooming, and she has no problems with her personal care, although it takes her a lot longer than it used to, to complete those tasks. Id. The Plaintiff reported that her husband and children had to remind her to take medications, and she had to get a pill box in order to keep track of the medications that she was taking. [T. 153].

The Plaintiff advised that she is able to drive a car, although, if she felt too sick or dizzy, she would not drive, but that her children were able to take the bus to school on those days. [T. 154], She advised that she went shopping about once a week, although it was becoming less frequent. Id. When she was not feeling dizzy or having a headache, she would pays bills and handle a savings account. Id. She further reported that her ability to handle money had declined since her condition began. [T. 155],

The Plaintiff stated that she would generally get up at 6:00 o’clock a.m. every day, at which time, she would try to get a few things done before awakening her two (2) children. [T. 151]. The Plaintiff advised that, on those mornings that she felt well enough, she might do a load of laundry before getting her children’s clothing ready for the day. Id. After the Plaintiff got her children up in the morning, she made them breakfast, made sure they got ready for school, and then brought them to school. Id. If she had a good day, the Plaintiff would get groceries, or do other shopping. Id. On bad days, she would just stay home and rest. [T. 159].

According to the Plaintiff, she prepared only simple meals for her family. [T. 153, 161]. The Plaintiff reported that she would take out the trash, do light cleaning, and do the laundry and dishes. [T. 153]. However, she noted that she had hired someone to help with the cleaning. Id.

With respect to hobbies, the Plaintiff reported that she loved to spend time with her children but, since her illness, she was no longer able to play with her children, and just watched instead. [T. 155]. The Plaintiff further stated that she could not walk to the park with her children, which is only three (3) blocks away, because she was afraid that she would not have enough strength to make it back home. [T. 160]. The Plaintiff stated that she rarely goes anywhere with friends or family anymore. [T. 156].

With respect to work-related abilities, the Plaintiff reported that she was able to follow instructions very well, that she followed spoken instructions “pretty good,” and that she got along very well with authority figures. [T. 156-157]. However, she advised that she had a hard time dealing with stress since the onset of her illness. [T. 157], She reported that one (1) of the reasons she quit working was because she would become overwhelmed with completing tasks. [T. 161]. The Plaintiff further reported that she often loses track of what she is doing, and that it takes her a long time to complete tasks because she has a hard time concentrating. Id. In addition, the Plaintiff asserted that her condition affected her ability to lift, stand, walk, hear, climb stairs, and see. [T. 156]. She further reported symptoms related to her memory and her ability to complete tasks and to concentrate. Id.

On August 7, 2007, the Plaintiff submitted a communication, in which she advised that her symptoms were becoming worse, and that she had recently been diagnosed with fibromyalgia. [T. 184-199]. She further advised that she was no longer able to complete simple tasks, and that she needed help with cleaning, laundry, groceries, lawn work, and caring for her children. [T. 193]. She reported that she was afraid to leave her home, because of the diarrhea and fatigue. [T. 194], She noted that she was afraid that if she left, she would not be able to make it home. Id. She further noted that she had missed appointments because she was too weak to drive. Id. She reported that she was waking up several times each night with pains in her legs, arms, back, head, and stomach. Id.

On August 16, 2007, the Plaintiffs husband filled out a Function Report Form. [T. 200-212]. Her husband reported that, on some days, while he was at work, she was able to get dishes and housework done, but on other days all she could do was rest. [T. 200]. He also stated that the Plaintiff wakes up several times a night with pain and headaches. [T. 201]. He reported that the Plaintiff cared for their children, cared for their dogs, and prepared daily meals, but that she received a lot of help from her mother, and from her grown children. [T. 201-202], He further indicated that the Plaintiff was able to do laundry and dishes on some days, depending on her energy level, but on other days, she would do no household chores, and that, as a result, they had someone to help with the cleaning. [T. 202]. According to the Plaintiffs husband, she was able to drive, depending on her symptoms. [T. 203]. He noted that the Plaintiffs mother had been at their house three (3) times that week, in order to help complete chores around the house, such as picking up groceries, washing dishes, cleaning, and getting food ready for the children. [T. 207].

The Record also contains the Plaintiffs application for a disability parking certificate, dated May 30, 2008, in which Dr. Stolpman reported that the Plaintiffs ability to walk was severely limited by fibromyalgia and weakness. [T. 495].

1. Evidence Presented to the Appeals Council.

As we have noted, following the ALJ’s decision, the Plaintiff requested review by the Appeals Council and, at that time, she submitted additional evidence. [T. 1]. In denying the Plaintiffs request for review, the Appeals Council advised that it had considered the additional evidence submitted by the Plaintiff, but that it had concluded that the evidence was not material to the ALJ’s decision. [T. 2], In particular, the Appeals Council concluded, as follows:

The contentions do not raise any new issue of law or fact. Essentially, the contentions are directed toward the Administrative Law Judge’s evaluation of the evidence and testimony and consequently, the ultimate issue of “disability.” The Appeals Council finds that the Administrative Law Judge fully considered and evaluated the evidence and reached the appropriate conclusions on the issues.

Id.

Among the documents that the Appeals Council received were receipts for food deliveries, which were dated July 18, 2008. [T. 4, 252-256]. The Plaintiff also submitted a list of her treating physicians, and an informational sheet on fibromyalgia. [T. 250, 262],

In addition, the Plaintiff submitted a physical therapy plan, which is dated February 20, 2008, and which was developed by Mathew Vraa (“Vraa”), who is a Physical Therapist. [T. 569]. On that day, the Plaintiff presented with headaches, abdominal pain, and upper thoracic and low back pain. Id. Vraa noted some visual restrictions, and recommended that she see an ophthalmologist, in light of significant status changes in the last several weeks. Id. In addition, the Plaintiff submitted physical therapy exercise instructions; records indicating that the Plaintiff was scheduled to have an MRI Scan of her left shoulder, at the direction of Dr. Parten on August 8, 2008; and a form indicating that Dr. Par-ten recommended physical therapy, on May 22, 2008, following the Plaintiffs diagnosis for left shoulder impingement sjmdrome and scapular winging. [T. 570-574].

The Plaintiff also submitted a letter from Dr. Scott Millner, who is a Chiropractor. The letter is dated August 19, 2008, and contains Dr. Millner’s report that he first saw the Plaintiff on September 19, 2007, for chronic discomfort, and that x-rays taken at that time revealed a reversed cervical curve, and moderate to severe degeneration of her cervical spine. [T. 575]. He noted that the Plaintiffs symptoms were neck pain, shoulder pain, upper back pain, and overall muscle soreness. Id. Dr. Millner advised that he had performed a Bio-Impedence Analysis of the Plaintiff which, he advised, was a test to help measure cell health, hydration, metabolism potential, body composition, and BMI. [T. 575-579]. The tests showed signs of low metabolism and increased cell breakdown, which were being treated with improved nutrition, and decreased stress levels. [T. 575].

2. Evidence Submitted to the Court.

At the time that the Plaintiff filed her Complaint, she also filed numerous documents with the Court. Some of the documents were already a part of the Administrative Record. However, those documents, which were not a part of Administrative Record, may be briefly summarized.

The Plaintiff was she was seen by Dr. Britton on August 18, 2008, for a follow-up examination that was related to the Plaintiffs diagnosis for fibromyalgia and chronic myofacial pain, at which time, he also conducted an assessment of her physical ability to do work-related activities. See, Exhibit 1 to Complaint, Docket No. 1-1, at p. 2 of 28. Dr. Britton noted that she had not tolerated medications, and that he did not have any further recommendations by way of additional treatment. Id. The Plaintiff was found to be positive at multiple trigger points. Id. at p. 1 of 28. Dr. Britton went on to conclude that the Plaintiff suffered from cervical disc degeneration, lumbar disc degeneration, fibromyalgia and chronic pain, and he recommended follow up visits as needed, and for any significant changes. Id. at p. 1 of 28.

On that same day, Dr. Britton also completed a Medical Assessment of the Plaintiffs physical ability to do work-related activities, in which he advised that the Plaintiffs impairments affected her ability to lift or carry items, to stand and walk, and to sit. Id. at pp. 3-6 of 28. Dr. Britton also expressed his opinion that the Plaintiff could carry ten (10) pounds occasionally and two (2) pounds frequently; that she could stand or walk for a total of four (4) hours, in an eight (8)-hour workday, and less than one (1) hour without interruption; and that she could sit for four (4) hours in an eight (8)-hour workday, and less than one (1) hour without interruption. Id. at pp. 3-4. He further opined that, as a result of the Plaintiffs impairments, she could never climb, balance, stoop, crouch, kneel, or crawl. Id. at p. 4 of 28. He believed that the Plaintiff could occasionally reach, handle, feel, push and pull, and that she could constantly see, hear, and speak. Id. at p. 5 of 28. He also noted that the Plaintiffs impairment would require restrictions related to heights, heavy machinery, temperature extremes, chemicals, dust, noise, fumes, humidity, and vibrations. Id. He concluded that the fatigue that the Plaintiff experienced would also limit her ability to work an eight (8)-hour work day, five (5) days per week. Id. at p. 6 of 28.

Accordingly, Dr. Britton made the following assessment of the effects of the Plaintiffs impairments:

Work restrictions I believe within a reasonable degree of medical certainty that she is unable to engage in any significant gainful activity due to the fibromyalgia, degenerative disk [sic] disease, and resultant chronic pain. I believe that she is permanently and totally disabled and that the prognosis for any significant change is very poor.

Id. at p. 1 of 28.

The Plaintiff also submitted an initial physical therapy evaluation, which was prepared on January 25, 2008, by Vraa on the referral of Dr. Britton. Id. at p. 9 of 28. Vraa advised that the Plaintiff had been having pain for approximately two (2) to three (3) years, but he noted that a review of her history showed that she was having symptoms, markers, and warnings signs, which were not picked up on, for chronic hyperirritability and neural issues. Id. He further advised that it was his opinion that the Plaintiff had psychological issues that added an overlay to her pain issues. Id. The Plaintiff underwent physical therapy and, following treatment, Vraa instructed the Plaintiff on a home exercise program. Id.

The Plaintiff also submitted medical records reflecting that she had a physical therapy session with Vraa on May 16, 2008, at which time, the Plaintiff presented with pain in the shoulder, low back, and the left hip. Id. at p. 19 of 28. He noted that the range of motion in her left shoulder was good. Id. He also concluded that they should pursue treatment of the left shoulder more aggressively, and referred the Plaintiff to Dr. Peter Parten of Summit Orthopedics. Id.

On September 4, 2008, the Plaintiff appeared for a physical therapy session with Vraa, at which time, she presented diagnostic imaging of her shoulder, from Summit Orthopedics. Id. at p. 22 of 28. Vraa noted that it had been approximately four (4) months since their last session. Id. The treatment did not include a home exercise treatment, but they discussed getting the Plaintiff back into a home walking program. Id.

On October 23, 2008, the Plaintiff presented at a physical therapy session with chief complaints of increased pain and weakness in the legs, and lower back and neck, problems with concentration and completing tasks, mental issues, and facial pain. Id. at p. 23 of 28. A review of the Plaintiffs systems revealed neck stiffness, muscle spasms in the neck, and muscle aches in the neck and shoulder. Id. Vraa noted that the Plaintiff suffered from generalized pain, which was characterized by a pressure, burning, sharp cramping, and numbness qualities, that were present constantly. Id. He further noted that she suffered from muscle aches; facial, neck, and limb pain; as well as symptoms in her hands, wrists, elbows, arms, shoulders, midback, lower back, hip, knee, ankle, and foot. Id. Vraa advised that the Plaintiff lacked a good compensation mechanism for dealing with stress, and exhibited general neural irritation which, he concluded, was possibly due to high anxiety or poor stress compensation. Id. Vraa further concluded that the Plaintiffs gastrointestinal symptoms were possibly due to nervous system issues, emotional issues, stress, and lack of sleep. Id. at p. 24 of 28.

Vraa further noted that the Plaintiff would be seeing her general practitioner the next day, and stated that the Plaintiff would ask about getting additional testing. Id. He advised that they would see about getting the Plaintiff back on a low dose of Lyrica, since it had been beneficial in the past. Id. Vraa further noted that the Plaintiff has previously had three (3) bouts of shingles which, he opined, was likely due to her lack of ability to handle stress. Id.

On October 24, 2008, the Plaintiff was seen by Winkler, at which time, the Plaintiffs chief complaint was chronic generalized pain. Id. at p. 25 of 28. Winkler noted diagnoses of fibromyalgia, psychiatric disorders, and chronic pain syndrome. Id. at p. 26 of 28. A review of the Plaintiffs systems revealed that her systems were normal, although the Plaintiff was positive at multiple trigger points. Id. Winkler prescribed Lyrica, and referred the Plaintiff to the Minnesota lung and sleep center. Id.

The Plaintiff was seen by’ Vraa for physical therapy again, on October 21, 2008, at whi