Stedman v. Pierce

          MEMORANDUM OPINION

          GEORGE L. RUSSELL, III, UNITED STATES DISTRICT JUDGE.

         THIS MATTER is before the Court on Defendants Holly Pierce and Wexford Health Sources, Inc.'s (“Wexford”) Motion to Dismiss or in the Alternative, Motion for Summary Judgment (ECF No. 11) and Plaintiff Merrick Stedman's Motion to Amend Pleadings or Consent Request to Defendants to Allow Amendment or in the Alternative Motion for Leave to Amend (“Motion to Amend”) (ECF No. 15).^[1] The Motions are ripe for disposition, and no hearing is necessary. See Local Rule 105.6 (D.Md. 2018). For the reasons outlined below, the Court will grant Defendants' Motion and deny as moot Stedman's Motion to Amend.

         I. BACKGROUND

         A. Factual Background

         Merrick Stedman, a self-represented Maryland prisoner confined at North Branch Correctional Institution (“NBCI”), was transferred to NBCI on July 15, 2015. (Compl. at 5, ECF No. 1). Two days later, Dr. Mahboob Ashraf and Nurse Dawn Hawk evaluated Stedman and diagnosed him with left shoulder pain and tonsillitis. (Id.). Stedman was otherwise in good health. (Id.). However, after drinking the tap water in his cell and noticing that the water “tasted gritty, ” Stedman became concerned that the water was contaminated. (Id.). Because of his concern, Stedman wrote to the Environmental Protection Agency and the City of Cumberland, Maryland asking for water quality assessments. (Id.).

         Stedman first began to get sick on or about November 25, 2015. (Id.). After discovering that the nail on his big toe had started turning grayish-white, Stedman placed a sick-call and received antibiotics for a toe infection. (Id.). Three months after completing the course of antibiotics, Stedman's cellmate was diagnosed with H-pylori. (Id.). On July 3, 2016, Stedman attended sick-call and asked the nurse whether he should be tested for H-pylori in light of his cellmate's diagnosis. (Id. at 5-6). The nurse advised Stedman that he could only contract H-pylori by “playing in feces, contaminated water[, ] or food and that [he] had nothing to worry about.” (Id. at 6).

         Stedman began to feel ill again around September 1, 2016. (Id. at 6). On September 10, 2016, Stedman complained to Nurse Moyer about migraine headaches that were becoming more frequent and more painful. (Defs.' Mot. Dismiss Alt. Mot. Summ. J. [“Defs.' Mot.”] Ex. 1 [“Medical Records”] at 1, ECF No. 11-4). During his visit on September 10, 2016, Stedman's blood pressure was slightly elevated. (Id.). Moyer referred Stedman for follow-up after two weeks of blood pressure checks. (Id. at 2). Moyer also prescribed Stedman Excedrin Migraine for pain relief. (Id.).

         Stedman received blood pressure checks on September 12 and 14, 2016. (Id. at 3- 6). On or about September 15, 2016, Stedman placed a sick-call slip, but did not know that he was scheduled to be seen because his name was not placed on the pass list. (Compl. at 6). Stedman received additional blood pressure checks on September 19 and 21, 2016. (Medical Records at 3-6). During the blood pressure check on September 21, 2016, Stedman reported to Nurse Hawk that he had been feeling dizzy. (Id. at 6). Although Stedman's blood pressure was elevated, his heart rate and respiration were within normal limits. (Id.). According to Stedman's medical records, Hawk notified Stedman's provider about his elevated blood pressure, advised Stedman that he had one blood pressure check left before he would be referred to the provider, and directed Stedman to follow up if his symptoms worsened. (Id.).

         Stedman attended his provider visit the following day with Krista Bilak. (Id. at 7). Bilak reported that Stedman's blood pressure monitoring showed that his blood pressure was consistently high. (Id.). As a result, Bilak educated Stedman about hypertension, added him to the chronic care clinic, and prescribed him Lisinopril.^[2] (Id. at 7-8). Bilak also noted that Stedman complained of heartburn and a recurrent sore throat, so she provided him Tums and took a throat culture. (Id.).

         According to Stedman, his condition continued to decline because of his chest pains. (Compl. at 6). On September 26, 2016, Stedman complained to Nurse Marilyn Evans about a sore throat and night sweats. (Id. at 6; Medical Records at 9). Stedman's tonsils were enlarged and his throat was inflamed and red. (Id.). In Stedman's medical reports, Evans noted that she consulted with Stedman's provider and they were waiting for the results of the throat culture. (Id. at 10). In the meantime, Evans provided Stedman throat lozenges, instructed him to drink fluids, and directed him to submit a sick-call slip if his symptoms changed. (Id. at 10-11). Stedman returned to sick-call on September 30, 2016, complaining of sore throat and dizziness. (Id. at 12). Stedman's medical reports note that his throat was inflamed, he was dizzy, and he was having difficulty swallowing. (Id.). After Stedman's throat culture tested positive for candida albians, Stedman was diagnosed with a yeast infection in his throat and was prescribed an eight-week treatment of Diflucan.^[3] (Compl. at 6; Medical Records at 14; Asresahegn Getachew Aff. [“Getachew Aff.”] ¶ 8, ECF No. 11-5). Stedman alleges that no one could explain to him how it was possible to contract a yeast infection in his throat. (Compl. at 6). Although Stedman's prescription for Diflucan helped clear his yeast infection, Stedman alleges that his health continued to decline. (Id.).

         Stedman saw Bilak again on October 7, 2016 because he continued to feel dizziness upon standing. (Medical Records at 15). Stedman's blood pressure was within normal limits and had minimal changes when he changed positions. (Id.). Bilak directed Stedman to follow up if his condition worsened or did not improve within thirty days. (Id. at 16).

         On October 15, 2016, Stedman submitted a sick-call slip complaining that his chest hurt and he was dizzy. (Id. at 17). Stedman stated he believed something was “seriously wrong” and requested lab work, including blood, urine, and stool testing. (Id.). During his evaluation on October 17, 2016, Stedman advised Nurse Evans that he had been experiencing burning in his chest for approximately one month, and that the burning came on without warning, was not brought on by food or drink, lasted for seconds, and went away on its own. (Id. at 18). Stedman's throat was slightly inflamed, but his physical examination was otherwise unremarkable. (Id.). Nurse Evans referred Stedman to his provider and directed him to return to sick-call if he developed symptoms of infection or his symptoms did not subside. (Id. at 19).

         Stedman was transferred to the care of Defendant Holly Pierce, C.R.N.P. on or about October 20, 2016. (Compl. at 6). Nurse Practitioner Holly Pierce evaluated Stedman on October 25, 2016. (Medical Records at 19). Pierce noted that Stedman complained of fatigue, persistent sore throat, and headache, and that he had a history of high blood pressure. (Id. at 19). Stedman's tonsils were enlarged, but his respiratory and cardiovascular systems were normal. (Id.). Pierce directed that Stedman have blood pressure checks twice a week for three weeks. (Id.). Pierce prescribed Hydrochlorothiazide^[4] (“HCTZ”) to treat Stedman's hypertension, but left Stedman's previous prescription for Prinivil in place. (Id.). Pierce also discontinued Stedman's prescription for Diflucan and instead prescribed Nystatin^[5] to treat his throat. (Id.). Additionally, Pierce ordered another throat culture, a complete blood count with differential, a comprehensive metabolic panel, and a test of Stedman's thyroid levels. (Id.). Stedman was scheduled for follow-up with a provider in two weeks. (Id.). Stedman's throat culture came back normal and his complete blood count showed low neutrophil and high lymphocyte counts. (Id. at 22, 25).

         On October 30, 2016, Stedman met with Nurse Hawk in response to his inquiry about blood pressure checks. (Id. at 23). Stedman advised the nurse that he was supposed to receive blood pressure checks and reported that he felt he had an irregular heartbeat. (Id.). The nurse advised Stedman that blood pressure checks had been ordered and were to begin the following day. (Id.). The nurse also noted that while listening to Stedman's heart for two minutes, his heart rate sped up for approximately two to five seconds on one occasion but then returned to normal. (Id.). The nurse then contacted Stedman's provider for further treatment and orders. (Id. at 23-24).

         After Stedman placed numerous sick-calls complaining about his chest and head, Nurse Practitioner Holly Pierce evaluated Stedman on November 1, 2016. (Compl. at 6; Medical Records at 27). During this visit, Stedman reported that he was suffering from dizziness and heart palpitations. (Medical Records at 27). Stedman's physical exam revealed a slightly elevated heart rate, but his results were otherwise normal.^[6] (Getachew Aff. ¶ 11). Pierce ordered that Stedman's prescription for HCTZ be decreased by half and ordered an EKG. (Medical Records at 27-28).

         Stedman underwent an EKG on November 13, 2016. (Compl. at 6; Medical Records at 29). Stedman's medical records indicate the EKG showed a “left ventricular hypertrophy [“LVH”] with repolarization abnormality, ” but otherwise normal sinus rhythm and no significant abnormalities. (Id.). Stedman alleges that the EKG reader told him he had an abnormal reading and that a provider would speak with Stedman that day. (Compl. at 6- 7). When Stedman did not hear from a provider about his results, he placed a sick-call slip. (Id. at 7). Stedman also placed a sick-call slip on November 23, 2016, requesting the results of his EKG. (Id.). Pierce reviewed the lab results with Stedman on November 17 and 28, 2016, informing Stedman that LVH with repolarization abnormality does not require any treatment.^[7] (Medical Records at 30, 33). According to Stedman, Pierce told him that his EKG results were normal and the EKG technician who told Stedman he had abnormal results “did not know what she was talking about.” (Compl. at 7). Stedman asserts that “[w]hat [Pierce] said, how she said it[, ] and how she looked [were] sketchy” to him. (Id.).

         On December 6, 2016, Stedman submitted a sick-call slip with a note directed to Pierce that read: “I am not requesting to see [Pierce] . . . [but] I need you to listen to what I'm saying to you so that you can provide me with better care.” (Medical Records at 35- 36). In his note, Stedman disputed Pierce's explanation that his dizziness was caused by the blood pressure medication, explaining that that his symptoms of dizziness and difficulty walking began before he started taking the blood pressure medication. (Id. at 36; see also Compl. at 7). Stedman asked Pierce to refer him to a doctor who specialized in his symptoms. (Medical Records at 36).

         Pierce evaluated Stedman on December 8, 2016. (Id. at 37). According to his medical records, Stedman had a hacking cough, a dull tympanic membrane in his right ear, tender sinuses, and moderately enlarged tonsils and left and right turbinate.^[8] (Id.). Stedman said he felt light-headed and explained that his symptoms were aggravated when he got out of bed and when he rose rapidly. (Id.). Pierce prescribed Stedman Zyrtec, Nasacort, ^[9]Prednisone, and Norvasc.^[10] (Id. at 38). Pierce left in place Stedman's prescription for HCTZ, but discontinued the Lisinopril/Prinivil prescription due to Stedman's cough. (Id.). Pierce ordered another throat culture and directed Stedman to follow up in two weeks. (Id.).

         On December 8, 2016, Stedman filed an Administrative Remedy Procedure (“ARP”) against Pierce, alleging that Pierce discussed Stedman's possible medical condition with an officer. (Compl. at 7-8).

         On December 13, 2016, Stedman presented to the medical unit by wheelchair after reporting chest pains and dizziness. (Medical Records at 39). Nurse Tammy Buser provided Maalox and performed an EKG. (Id.). The results of the EKG showed no change from Stedman's previous EKG. (Id. at 39, 41). The following day, Dr. Ashraf evaluated Stedman for ongoing migraine headaches and dizziness. (Id. at 42). Stedman's blood pressure, tympanic membranes, mouth, and throat were normal. (Id. at 42, 43). Dr. Ashraf noted that Stedman's prescription for Lisinopril had been discontinued due to side effects and substituted with Norvasc, but that Stedman had stopped taking Norvasc “because it was not helping him.” (Id. at 42). Dr. Ashraf also noted that Stedman was on 12.5-milligram dose of HCTZ per day, and that Stedman had stopped taking Prednisone^[11] for his allergies because it “made his symptoms worse[n].” (Id.). Dr. Ashraf ordered a blood and lipid panel. (Id.). Later the same day, Stedman submitted a sick-call slip indicating that the pressure in his head worsened and requesting an MRI. (Id. at 46). On his sick-call slip, Stedman complained that the medical department had been playing a “guessing game about [his] possible illness now for approximately 3 months.” (Id. at 47). Stedman also requested to be placed back on daily blood pressure checks. (Id.).

         On December 20, 2016, Pierce and regional medical director Dr. Akal evaluated Stedman. (Id. at 48). Stedman again complained of lightheadedness, but denied having chest pain, ear ache, or headache. (Id.). Stedman states he was surprised to learn during this visit that his sinus issue was the result of mucus draining in the back of his throat, but that Pierce could not say whether this caused Stedman's yeast infection. (Compl. at 8). Stedman had elevated blood pressure during this visit. (Medical Records at 48). Stedman's medical records note that Stedman's EKG showed a normal sinus rhythm with “[l]eft ventricular hypertrophy with repolarization abnormality.” (Id.). Pierce and Dr. Akal referred Stedman to a cardiologist and instructed him to avoid exercise until his cardiology appointment. (Id.). Pierce and Dr. Akal also prescribed Stedman 25 milligrams of Metoprolol Tartrate.^[12] (Id. at 49). Pierce submitted a consultation request for a CT scan on January 5, 2017. (Id. at 50).

         On January 9, 2017, Dr. Barrera evaluated Stedman for nasal drip in the back of his throat. (Id. at 53). Dr. Barrera provided Stedman cold medication and directed him to rest and drink plenty of water. (Id.). On January 13, 2017, a note was entered into Stedman's medical record reflecting the collegial decision to postpone his CT scan until after the cardiology telemedicine was completed. (Id. at 57). On January 14, 2017, the results of Stedman's blood work showed that he had high levels of cholesterol and triglycerides. (Id. at 55). Stedman also tested positive for H-pylori. (Id. at 56). On January 19, 2017, Pierce advised Stedman of the results of his blood work and the collegial decision to delay his CT scan. (Id. at 58). Stedman alleges he was “surprise[d]” at his H-pylori results because he “wasn't even aware that [he] was being tested for the bacteria” and his past concerns about H-pylori had been dismissed. (Compl. at 9). Pierce prescribed Stedman antibiotics to treat H-pylori. (Medical Records at 58). According to Stedman, Pierce instructed him to follow up “in a couple weeks” and provide a stool sample to assess the efficacy of the antibiotic treatment, but despite submitting multiple sick-call slips, Stedman was not re-tested until May 2, 2017. (Compl. at 10).

         On February 8, 2017, Pierce evaluated Stedman for ongoing dizziness and lightheadedness. (Medical Records at 61). Pierce once again advised Stedman that he would be referred to a cardiologist and that he should avoid exercise until that time. (Id.). Stedman's vital signs and physical exam were normal. (Id.).

         Cardiologist Dr. Ashok Chopra evaluated Stedman on February 13, 2017. (Id. at 63-69). Dr. Chopra noted that Stedman's dizziness was likely “due to orthostatic hypotension.”^[13] (Id. at 63). Dr. Chopra directed Stedman stop taking the diuretic and ordered blood pressure monitoring. (Id.). Additionally, Dr. Chopra remarked: “Check Echo and Stress test as marked EKG abnormality. Neuro eval In progress in view of headaches and dizziness.” (Id.). Dr. Chopra directed Stedman to follow up in six weeks, recommended a statin drug^[14] to treat Stedman's elevated lipid levels, and suggested a follow-up lipid panel. (Id.). On that same day, Pierce submitted a consultation request for the additional testing recommended by Dr. Chopra. (Id. at 70). The requests for the echocardiogram and stress tests were approved on February 16, 2017. (Id. at 72).

         On February 18, 2017, Stedman reported to Nurse Baker that he still needed the CT scan of his head. (Id. at 73). Baker advised Stedman that the scan was on hold pending the cardiology consult. (Id.). Baker also advised him that the additional testing requested by Dr. Chopra was pending. (Id.). Baker indicated she would follow up regarding the need for daily blood pressure checks. (Id.). On February 20, 2017, Pierce entered a chart update that Stedman was to receive blood pressure checks three times a week for three weeks.^[15] (Id. at 75).

         Stedman submitted a sick-call slip on February 27, 2017, complaining of increased dizziness, confusion, pressure in his head, and labored breathing. (Id. at 76). Stedman indicated that although his treatment with HCTZ had been discontinued, he had started taking it again the day before submitting his sick-call slip. (Id. at 77). Pierce evaluated Stedman on March 1, 2017 for his ongoing complaints of light headedness. (Id. at 78). Stedman's vital signs were within normal limits and his physical examination was unremarkable. (Id.). Pierce noted that the cardiologist had requested a stress and echo test for Stedman. (Id.). Pierce encouraged Stedman to increase fluids and to avoid exercising and quick movements. (Id.).

         Nurse Cottrell evaluated Stedman on March 12, 2017. (Id. at 80). At that time, Stedman requested an H-pylori test and inquired about the status of his echocardiogram and stress test. (Id.). Stedman also requested a prescription for HCTZ. (Id.). Cottrell referred Stedman to the provider. (Id.). On March 20, 2017, Stedman met with Pierce, who advised him that the echocardiogram and stress tests had been approved and their scheduling was pending. (Id. at 82). Stedman underwent a stress test and echocardiogram on March 22, 2017. (Id. at 83-86). The stress test showed “an appropriate heartrate and blood pressure response to exercise.” (Getachew Aff. ¶ 21). Stedman's echocardiogram showed “mild concentric left ventricular hypertrophy” with an ejection fraction of 65-70%, mild dilation of the left atrium, unremarkable valves, and impaired LV relaxation. (Medical Records at 86).

         On March 30, 2017, Pierce evaluated Stedman for complaints of dizziness, headaches, and heart palpations. (Id. at 91). At that time, Stedman requested a neurology consultation. (Id.). Pierce reviewed the results of the cardiology testing with Stedman and noted a follow-up with the cardiologist had been requested. (Id.). Pierce also reviewed Stedman's history of failed treatment for headaches and renewed the request for CT scan of the head. (Id.). On April 5, 2017, Pierce entered a chart update requesting blood work for Stedman. (Id. at 93).

         On April 6, 2017, Dr. Ashraf evaluated Stedman for complaints of headache pressure, dizziness, and bilateral earache. (Id. at 94). Dr. Ashraf noted that the results of Stedman's echocardiogram and stress test were normal and that Stedman denied any cardiac symptoms or distress. (Id.). Dr. Ashraf also noted that another provider had twice recommended a CT scan of the head, but the requests had been denied on collegial review. (Id.). Dr. Ashraf advised Stedman to take Meclizine and Topamax daily. (Id.). Dr. Ashraf also provided Stedman ear drops and assured him that his providers would continue to treat Stedman's symptoms even if the request for a CT scan was denied again. (Id.).

         Stedman had another EKG on April 23, 2017, which again noted LVH. (Id. at 99- 100). Dr. Ashraf saw Stedman again on April 26, 2017 for Stedman's continued migraines. (Id. at 101). Dr. Ashraf noted that the two previous requests for a CT scan had been denied by the collegial review process, but indicated he would “send a reminder to the collegial” to “reconsider” their denial of the CT scan. (Id.). Dr. Ashraf also noted that the request for consultation with the cardiologist had been approved and that Stedman's providers would follow the cardiologist's recommendations after Stedman's follow-up consultation. (Id.).

         On May 2, 2017, Pierce evaluated Stedman for complaints of ear infection and head pressure. (Id. at 104). At that time, Stedman denied pain or dizziness but complained of pressure behind his eye. (Id.). Stedman told Pierce that the medical staff did not know what they were doing and that he needed to see a neurologist. (Id.). Stedman indicated “he wants off Topamax as he is not taking it.” (Id.). Stedman also stated that he was told he had an ear infection but did not receive the medication and the “painless infection” was out of control. (Id.). Pierce discontinued the Topamax at Stedman's request and placed an order for Excedrin Migraine. (Id.). Pierce did not prescribe an antibiotic. (Id.). Pierce also noted that the cardiology follow-up was pending, and that the request for a CT scan of the head had been denied three times. (Id.). Finally, Pierce requested an optometry exam. (Id.).

         On May 6, 2017, Stedman's laboratory test results showed that his April 27, 2017 and May 3, 2017 stool samples were negative for H-pylori. (Id. at 106-07). On May 8, 2017, Stedman's telemedicine appointment was canceled due to a security issue. (Id. at 108). Pierce requested that the appointment be rescheduled. (Id.).

         On May 22, 2017, Dr. Chopra evaluated Stedman for complaints of fullness in both ears and headaches. (Id. at 109-11). No. acute symptoms were present at that time. (Id. at 109). Dr. Chopra noted that HCTZ had been discontinued as of the last visit, described the results of Stedman's stress test and echocardiogram as “satisfactory, ” and indicated that Stedman's dizziness was not related to cardiac abnormality. (Id.). Dr. Chopra recommended that Stedman lose weight, take a “statin” to treat high cholesterol, receive a follow-up lipid panel in six weeks, and follow up with the cardiologist in four months. (Id. at 111). Dr. Chopra also recommended an ENT evaluation. (Id.). Stedman asked Dr. Chopra whether he had recommended evaluation by a neurologist during Stedman's last visit, but Dr. Chopra advised that the medical staff at NBCI could manage Stedman's symptoms. (Id.). Stedman disagreed, remarking that his symptoms had been present for “years with no relief.” (Id.). Dr. Chopra advised he could recommend a neurologist only after Stedman's consultation with an ENT, if needed. (Id.).

         As a result of the May 22, 2017 consultation, and after discussing Stedman's case with the Regional Medical Director, Pierce placed an order for Pravastatin, discontinued Metoprolol Tartrate, and placed an order for Propranolol. (Id.). Pierce also indicated that referral to an ENT for dizziness was “not indicated” as Stedman was not compliant with his treatment plan in that he declined Topamax and was not taking Meclizine every day as prescribed. (Id.). Additionally, Pierce noted that returning to the cardiologist in four months was “not indicated at this time” for Stedman. (Id.). Pierce directed that Stedman's medications be issued as directly observed therapy (“DOT”) instead of issuing him a blister pack to self-administer. (Id.). Pierce also ordered an x-ray of Stedman's sinuses and noted the optometry exam remained pending. (Id. at 111, 114). Stedman was scheduled for follow-up in one week. (Id. at 111).

         On May 25, 2017, Stedman's laboratory test results showed that his May 23, 2017 stool samples were positive for H-pylori. (Id. at 113). A handwritten note on the results indicates “*wrong test* stool is negative.” (Id.).

         On May 25, 2017, an x-ray of Stedman's face and sinuses showed no abnormalities. (Id. at 115).

         On May 29, 2017, Dr. Ashraf evaluated Stedman for complaints of headache and ear pressure radiating towards the jaw. (Id. at 116). Stedman informed Dr. Ashraf about his frustration that nothing was being done with the CT scan or ENT referral. (Id.). On examination, both of Stedman's ears showed signs of infection. (Id.). Dr. Ashraf prescribed Stedman amoxicillin and Neomycin. (Id.). After Stedman told Dr. Ashraf that he had not received the medicine that had been prescribed to him, Dr. Ashraf called the pharmacy, which indicated that Stedman would receive the amoxicillin that day but that the Neomycin ear drops were non-formulary. (Id.). As a result, Dr. Ashraf submitted a non-formulary drug request for the ear drops the same day. (Id. at 119-20).

         On June 14, 2017, Stedman received an optometry examination. (Id. at 122). The following day, Nurse Practitioner Krista Self evaluated Stedman. (Id. at 123). Self noted that Stedman requested to see an ENT but there was no indication for Stedman to see one. (Id.). Self also noted that while Stedman had various complaints over time, the results of multiple diagnostic studies were unremarkable. (Id.). Self educated Stedman on vertigo, but Stedman disagreed with the diagnosis and plan of care. (Id.). Stedman declined Meclizine to treat vertigo and again requested a consultation with an ENT or neurologist. (Id.).

         On July 14, 2017, Dr. Ashraf evaluated Stedman and informed him that he had tested positive for hepatitis B. (Id. at 127). Dr. Ashraf explained to Stedman the result of the hepatitis test, which required no treatment. (Id.). At that time, Stedman informed Dr. Ashraf about his issues with recurrent head and ear aches. (Id.; see also Getachew Aff. ¶ 26). Examination of Stedman's ears was negative for infection but positive for wax build up. (Medical Records at 127). Dr. Ashraf prescribed Stedman ear drops. (Id.).

         Regional Medical Director Ava Joubert-Curtis examined Stedman on July 17, 2017. (Id. at 132). At that time, Stedman presented an affidavit listing his medical concerns and threatening to file suit. (Id.). Stedman explained his belief that the nurse practitioner had sabotaged his care after he submitted an ARP about medication she was supposed to have prescribed but which he did not receive. (Id.). Dr. Joubert-Curtis noted that she addressed each of Stedman's concerns and highlighted “the elevated [blood pressure] and the evidence of chronic sinusitis on exam (despite neg x-ray of the sinuses).” (Id.). Dr. Joubert-Curtis indicated she would request a CT scan for Stedman's head. (Id.). Examination showed that Stedman's ears were normal, but his sinuses had “very swollen turbinates” and his tonsils were enlarged. (Id. at 134). Additionally, Dr. Joubert Curtis noted:

Headaches appear to be multifactorial, including hypertensive and [c]hronic sinus disease. However due to the nature of the headaches, neg sinus x-rays and headaches when BP appears to be normal, will pursue CT r/o other vascular abno[rmalities]. The hypertension appears to be more of a chronic persistent nature considering the LVH pattern on the EKG. He has seen the Retinal screening specialist. This provider is not able to interpret the findings. However, there does not appear to be any recommendations made. We are stopping the excedrin migraine due to the caffeine in it (elevates BP) and adding ARB [Hyzaar] to help control the BP and will ...