United States District Court, W.D. Missouri, Southern Division
ORDER DENYING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT
ROBERT E. LARSEN, Magistrate Judge.
Plaintiff Rebecca Lee seeks review of the final decision of the Commissioner of Social Security denying plaintiff's application for disability benefits under Titles II and XVI of the Social Security Act ("the Act"). Plaintiff argues that the ALJ erred in improperly evaluating the impact of plaintiff's substance abuse problem and by failing to give proper weight to the opinions of two psychologists and a psychotherapist. She further argues that the Appeals Council erred in failing to remand for consideration of new and material evidence. I find that the substantial evidence in the record as a whole supports the ALJ's finding that plaintiff is not disabled. Therefore, plaintiff's motion for summary judgment will be denied and the decision of the Commissioner will be affirmed.
On February 21, 2008, plaintiff applied for disability benefits alleging that she had been disabled since May 1, 2007. At a subsequent administrative hearing she amended her alleged onset date to June 1, 2011, after earning $11, 783.07 in 2009 and $15, 674.54 in 2010 (Tr. 101-102). Plaintiff's application was denied initially. On November 25, 2009, a hearing was held before an Administrative Law Judge. On January 27, 2010, the ALJ found that plaintiff was not under a "disability" as defined in the Act. On May 5, 2011, the Appeals Council granted plaintiff's request for review and remanded her claims for a new administrative decision. A second hearing was held on May 1, 2012. On November 30, 2012, plaintiff was again found not disabled. On March 8, 2013, the Appeals Council denied plaintiff's request for review despite her presentation of additional evidence. Therefore, the November 30, 2012, decision of the ALJ stands as the final decision of the Commissioner.
IL STANDARD FOR JUDICIAL REVIEW
Section 205(g) of the Act, 42 U.S.C. § 405(g), provides for judicial review of a "final decision" of the Commissioner. The standard for judicial review by the federal district court is whether the decision of the Commissioner was supported by substantial evidence. 42 U.S.C. § 405(g); Richardson v. Perales , 402 U.S. 389, 401 (1971); Mittlestedt v. Apfel , 204 F.3d 847, 850-51 (8th Cir. 2000); Johnson v. Chater , 108 F.3d 178, 179 (8th Cir. 1997); Andler v. Chater , 100 F.3d 1389, 1392 (8th Cir. 1996). The determination of whether the Commissioner's decision is supported by substantial evidence requires review of the entire record, considering the evidence in support of and in opposition to the Commissioner's decision. Universal Camera Corp. v. NLRB , 340 U.S. 474, 488 (1951); Thomas v. Sullivan , 876 F.2d 666, 669 (8th Cir. 1989). "The Court must also take into consideration the weight of the evidence in the record and apply a balancing test to evidence which is contradictory." Wilcutts v. Apfel , 143 F.3d 1134, 1136 (8th Cir. 1998) (citing Steadman v. Securities & Exchange Commission , 450 U.S. 91, 99 (1981)).
Substantial evidence means "more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales , 402 U.S. at 401; Jernigan v. Sullivan , 948 F.2d 1070, 1073 n. 5 (8th Cir. 1991). However, the substantial evidence standard presupposes a zone of choice within which the decision makers can go either way, without interference by the courts. "[A]n administrative decision is not subject to reversal merely because substantial evidence would have supported an opposite decision." Id .; Clarke v. Bowen , 843 F.2d 271, 272-73 (8th Cir. 1988).
III. BURDEN OF PROOF AND SEQUENTIAL EVALUATION PROCESS
An individual claiming disability benefits has the burden of proving he is unable to return to past relevant work by reason of a medically-determinable physical or mental impairment which has lasted or can be expected to last for a continuous period of not less than twelve months. 42 U.S.C. § 423(d) (1) (A). If the plaintiff establishes that he is unable to return to past relevant work because of the disability, the burden of persuasion shifts to the Commissioner to establish that there is some other type of substantial gainful activity in the national economy that the plaintiff can perform. Nevland v. Apfel , 204 F.3d 853, 857 (8th Cir. 2000); Brock v. Apfel , 118 F.Supp.2d 974 (W.D. Mo. 2000).
The Social Security Administration has promulgated detailed regulations setting out a sequential evaluation process to determine whether a claimant is disabled. These regulations are codified at 20 C.F.R. §§ 404.1501, et seq. The five-step sequential evaluation process used by the Commissioner is outlined in 20 C.F.R. § 404.1520 and is summarized as follows:
1. Is the claimant performing substantial gainful activity?
Yes = not disabled.
No = go to next step.
2. Does the claimant have a severe impairment or a combination of impairments which significantly limits his ability to do basic work activities?
No = not disabled.
Yes = go to next step.
3. Does the impairment meet or equal a listed impairment in Appendix 1?
Yes = disabled.
No = go to next step.
4. Does the impairment prevent the claimant from doing past relevant work?
No = not disabled.
Yes = go to next step where burden shifts to Commissioner.
5. Does the impairment prevent the claimant from doing any other work?
Yes = disabled.
No = not disabled.
IV. THE RECORD
The record consists of the testimony of plaintiff and documentary evidence admitted at the hearing and presented to the Appeals Council.
A. EARNINGS RECORD
The record establishes that plaintiff earned the following income from 1991 through 2011:
Year Earnings Year Earnings 1991 $ 2, 555.21 2002 $ 853.15 1992 3, 266.69 2003 0.00 1993 0.00 2004 2, 774.00 1994 4, 269.46 2005 2, 566.02 1995 3, 316.20 2006 6, 510.90 1996 0.00 2007 3, 427.111997 79.32 2008 4, 924.48 1998 2, 433.88 2009 11, 783.07 1999 6, 494.42 2010 15, 674.54 2000 10, 758.40 2011 0.00 2001 2, 754.64
(Tr. at 304-320).
B. SUMMARY OF MEDICAL RECORDS
On July 11, 2005, plaintiff was treated by Thomas Kuich, M.D., of St. John's Regional Health Center-Marian Center. Plaintiff admitted to anger episodes, seeing and talking to the dead, and being assaulted by her husband. Plaintiff admitted to drinking alcohol as a teenager and using methamphetamine once every two to three months. The doctor reported that plaintiff appeared at times preoccupied, her affect was depressed, and her intelligence was estimated to be above average. Plaintiff was admitted with a diagnosis of depressive disorder. Plaintiff's medications were Nicotine patch, Haldol (treats schizophrenia), Ativan (also called Lorazepam, treats anxiety and is a Schedule IV controlled substance), and Cogentin. Plaintiff had an acute urinary tract infection on testing dated July 12, 2005. Plaintiff was discharged on July 14, 2005, with recommendation for community resources and treatment (Tr. 750-767).
On December 1, 2005, plaintiff was treated by a clinician at St. John's Regional Health Center Emergency Room with the complaint that she was unable to stop crying. Plaintiff admitted to drinking alcohol 20 years previously and had last smoked methamphetamine in July. Plaintiff indicated she had calmed down after being seen in the ER and discharged (Tr. 768-773).
On April 9, 2007, plaintiff was treated at CoxHealth Emergency Services for right ureteral stone (confirmed by CT scan) with nausea (Tr. 452, 558-571). Plaintiff was admitted to the CoxHealth Hospital by Mark Milne, M.D., of Milne Urology Clinic on April 10, 2007. A scent was placed without complication resulting in dramatic improvement in her right flank pain, and she was discharged on April 11, 2007, with prescriptions for Darvocet-N (narcotic), Levbid (treats bladder spasms), and Pyridium (treats pain and burning from urinary tract infections) (Tr. 452, 460-462, 480-484, 553-557).
On April 13, 2007, plaintiff was treated at CoxHealth Emergency Services for right flank pain and vomiting. Zofran (prevents nausea and vomiting) and Pepcid (reduces stomach acid) were prescribed (Tr. 541-552).
On April 20, 2007, plaintiff was seen by Mark Milne, M.D., who removed plaintiff's ureteral stent. He provided her with an additional antibiotic (Tr. at 454).
May 1, 2007, was plaintiff's original alleged onset date.
On August 16, 2007, plaintiff was treated by Gregory Hunter, M.D., at CoxHealth Emergency Services for complaints of chest pain, slurred speech, headache and nausea. "She has a very odd affect, answering almost every single question with the prefix, Well, you know, the funny thing about that is." Plaintiff denied smoking, doing drugs, or using alcohol. ECG,  CT scans of head and chest x-rays were normal. Plaintiff had no recurrence of her symptoms in the emergency department and she was discharged with a diagnosis of urinary tract infection and headache. She was prescribed Cipro, an antibiotic (Tr. 522-540).
Six days later, on August 23, 2007, plaintiff was treated at CoxHealth Emergency Services for complaints of blood in her urine which was confirmed by urinalysis. Plaintiff was advised to continue her Cipro as prescribed and to follow up with Dr. Milne (Tr. 510-521).
Six days later, on August 29, 2007, plaintiff was treated by Mark Milne, M.D., for reported flank pain, pressure and blood in her urine. Plaintiff stated that she had suffered a heart attack and a stroke since her last visit (which was four months earlier). Urinalysis confirmed blood in her urine. Macrodantin (antibiotic) was prescribed (Tr. 459, 464).
On October 8, 2007, plaintiff was treated at CoxHealth Emergency Services for low back pain radiating down her left leg for three days. Lumbar spine radiographs showed mild degenerative spondylosis. Plaintiff was prescribed Flexeril (muscle relaxer) and Motrin (nonsteroidal anti-inflammatory) (Tr. 499-509).
On October 11, 2007, plaintiff was treated by a chiropractor at Lane Chiropractic. The chiropractor reported that plaintiff had a tight band around the lumbosacral region but no radiating pain (Tr. 437-440, 810-813). Chiropractic adjustment was administered on October 15, 2007, and October 17, 2007, for her complaints of continued low back pain and stiffness (Tr. 440, 813).
On October 17, 2007, plaintiff was treated by Jim Elam, M.D., of St. John's Clinic for complaints of chronic low back pain, nephrolithiasis (kidney stone), history of assault and aggressive behavior, gastroesophageal reflux disease ("GERD"), questionable mood disorder currently not treated, and restless leg syndrome. Plaintiff complained of weight gain, sleeping frequently, depression, mind racing, irritability, and frequent verbal aggression. Dr. Elam reported that plaintiff's back was diffusely tender to palpation in the lumbosacral area extending to the sacroiliac area bilaterally. Plaintiff's gait was normal and there was no evidence of sensory abnormality of the lower extremities. The rest of her exam was normal, and she was observed to be fairly pleasant.
Plaintiff admitted that she does drink, but not heavily, and she was smoking 5 to 10 cigarettes per day. Plaintiff had third-degree assault charges pending due to what she called a "spanking incident" with her child - both of her children had been placed in foster care. Plaintiff reported that she had been seen in the emergency room one month earlier for a heart attack or stroke but was then discharged from the emergency room. Dr. Elam noted that her described symptoms sounded more like a panic attack. "The patient has recently been on Percocet for her back pain.... I have asked the patient to get off of narcotic pain medication for her back. I will be happy to give her tramadol, but that will be the strongest medication I will prescribe for her back. She has taken some issue with this and states she needs something stronger. I have informed her that if she needs something stronger, she will need to find somebody else to take care of her." Dr. Elam's impression was situational disturbance, mood disorder, and low-back pain without sciatica. He refilled her cyclobenzaprine (also called Flexeril, a muscle relaxer). The doctor encouraged plaintiff to continue with chiropractic or physical therapy (Tr. 445-446).
On October 31, 2007, plaintiff was treated by Matthew Stinson, M.D., at Jordon Valley Community Health Center for complaints of depression, crying spells, and change in sleep and eating patterns. Plaintiff reported poor concentration. Dr. Stinson's assessment was depression. He prescribed Celexa (anti-depressant) and recommended continued counseling (Tr. 586).
On November 28, 2007, plaintiff returned to Matthew Stinson, M.D., at Jordon Valley Community Health Center, and complained of vomiting, nausea, dark stool, and increasing fatigue. Dr. Stinson assessed plaintiff with GERD and depression and added Prilosec (reduces stomach acid) to her prescriptions (Tr. 583-585).
On January 9, 2008, plaintiff was treated by Matthew Stinson, M.D. His assessment was increased urinary frequency, resolved; esophageal reflux; urinary tract infection; depression; and sleep-related movement disorder. The doctor prescribed Requip (treats restless leg syndrome), Bactrim (antibiotic), and Mirapex (treats restless leg syndrome) in addition to Celexa (antidepressant) and Prilosec (reduces stomach acid) (Tr. 580-582).
On January 31, 2008, plaintiff was treated by Matthew Stinson, M.D., for recurrent urinary tract infection with symptoms of discomfort and increasing pain. The doctor noted plaintiff had mild suprapubic tenderness. Urinalysis was positive for nitrite. Ciprofloxacin (antibiotic) was prescribed (Tr. 578-579).
On February 7, 2008, plaintiff was examined by Eva Wilson, Psy.D. In the problem and symptoms section, Dr. Wilson reported that plaintiff had her children removed twice by the Division of Family Services ("DFS"), once based on abuse by plaintiff's husband and a second time for abuse by her (Tr. 447). Plaintiff reported that she was unable to work due to depression (Tr. 447). Later, plaintiff reported that she was unable to work due to concentration and identity problems (Tr. 448). Dr. Wilson reported that plaintiff appeared to be in a mildly to moderately depressed mood with affect consistent with mood. Plaintiff's speech was extrapolative and her thought content and perception were discouraged. On the mini-mental status evaluation, plaintiff's scores placed her in the borderline range of intellectual and memory functioning. The doctor indicated that plaintiff did not produce a valid profile on the Minnesota Multiphasic Personality Inventory test because she took a great deal of time to take the test, obsessing over each question and writing words around the questions, and that this indicated plaintiff was either exaggerating her mental state or crying out for help. Dr. Wilson suspected plaintiff was doing both and stated that plaintiff appeared to be impaired at this time by depression and personality problems. Plaintiff tended to lose her identity and be very obsessive. Plaintiff was suffering from depression, which would cause her to have a great deal of difficulty maintaining full-time employment because of her inability to concentrate. The doctor's diagnostic impression was depressive disorder not otherwise specified; major depression, recurrent, severe without psychotic features; borderline personality disorder; rule out borderline intellectual functioning; and history of substance abuse. She assigned a global assessment of functioning ("GAF") of 50. (Tr. 448-449).
On February 20, 2008, plaintiff's urinalysis at Quest Diagnostics showed methicillinresistant staphylococcus aureus ("MRSA") (Tr. 472-475).
On February 21, 2008, plaintiff applied for disability benefits.
One week later, on February 28, 2008, plaintiff was treated by Mark Milne, M.D., of Milne Urology Clinic for significant urinary frequency and pain at end of voiding. Plaintiff had been unable to clear her infection despite rounds of Cipro and Bactrim. Dr. Milne stated that plaintiff was healthy but anxious, and she appeared to be in no acute distress. An abdominal ultrasound was performed and showed a shadowing suspicious for bladder calculus (bladder stone). Urinalysis confirmed continued MRSA infection. Doxycycline (antibiotic) was prescribed (Tr. 458, 465-466, 471, 478, 497-498).
Five days later, on March 5, 2008, plaintiff was admitted to CoxHealth by Mark Milne, M.D., for complaints of bladder stones. Plaintiff's past medical history included possible bipolar disease and MRSA urinary tract infection (Tr. 478-479, 492-494). The following day plaintiff underwent a cystolitholapaxy, which is the breaking up and removal of the bladder stone (Tr. 468-469, 476-477, 490-491, 495-496, 776).
Six days later, on March 14, 2008, plaintiff reported feeling "great" since her surgery (Tr. 458).
On March 31, 2008, plaintiff reported to Mark Milne, M.D., that she felt markedly better following removal of the stone. Plaintiff stopped the antibiotics after surgery. Urinalysis had some bacteria and epithelial cells. Dr. Milne's impression was bladder stone and pseudomonal (a type of bacteria) urinary tract infection (Tr. 457, 467, 489, 779).
On April 11, 2008, plaintiff saw Matthew Stinson, M.D., at Jordon Valley Community Health Center with complaints of depression and dizziness, and she had questions about the effectiveness of her medications. Plaintiff was participating in counseling and "is continuing to see good results." Dr. Stinson assessed fatigue and depression. "Discussed the mind body spirit connection and the possibility of a spiritual component to her disease. Will treat as schizophrenia." He prescribed Abilify (treats schizophrenia, bipolar disorder and depression) and Effexor (anti-anxiety) (Tr. 574-577).
On May 5, 2008, Dr. Stinson treated plaintiff for foot pain and trouble sleeping. Plaintiff reported doing "very well" on Abilify - her energy level had increased and she was dealing with difficulty situations "okay." The doctor noted that plaintiff had tenderness to palpation on her left heel and pain with extreme dorsiflexion (bending the ankle joint by lifting the foot up). Dr. Stinson assessed plantar fasciitis and depression. He prescribed Lunesta (treats insomnia), Abilify (treats schizophrenia), and Celexa (treats depression). He wrote, "Continue pain medicine as needed" however he did not prescribe any pain medicine. Exercises were given to plaintiff for stretching of her plantar fascia (Tr. 605-606).
On May 22, 2008, plaintiff saw Mark Milne, M.D., and reported "some pain" in her right mid back. "She has had an increased amount of lifting over the last 3 weeks helping her mother move." Plaintiff had some tenderness in her back. She was assessed with back pain. "Suspect this is more of a strain on the paraspinous muscle." She was told to take over-the-counter Aleve once a day for ten days. She also had an abdominal scan that day which showed complete resolution of her bladder stone and no kidney stone. (Tr. 621, 777-778).
On June 18, 2008, Elisa Lewis, Ph. D., reviewed plaintiff's medical records and completed a Psychiatric Review Technique (Tr. 592-603). The assessment covered the period from April 1, 2007, to June 18, 2008. The doctor found plaintiff's mental impairments not severe based on affective disorders and personality disorders (Tr. 592). The doctor found plaintiff to have a borderline personality disorder (Tr. 597) and indicated that the degree of limitation was mild in only two areas: (1) social functioning and (2) concentration, persistence, or pace (Tr. 600).
On June 19, 2008, plaintiff saw Matthew Stinson, M.D., with complaints of constipation and chest pain relieved after taking Prilosec (reduces stomach acid). She requested a colonoscopy referral. Her abdomen was tender to palpation in the left lower quadrant. Dr. Stinson diagnosed constipation and depression and referred plaintiff for a colonoscopy (Tr. 605, 607).
On June 9, 2008, Becky Breckner, LPC NCC, of the Center for Resolutions, submitted a statement of her services for plaintiff during the period between 2007 and 2008. Ms. Breckner stated that she had been treating plaintiff since April 23, 2007. Plaintiff was treated on 28 occasions through November 13, 2007, and then resumed her sessions on January 25, 2008 with 18 sessions conducted through June 4, 2008. Ms. Breckner stated plaintiff's chief complaint was depression with extreme difficulty sleeping. Plaintiff reported overwhelming emotions related to her case with the Missouri Division of Children's Services and her marital problems. Plaintiff reported significant weight gain, feelings of fatigue, loss of energy, inability to think and concentrate, and indecisiveness. Plaintiff reported bad days that involved not getting dressed or getting out of bed. Plaintiff made improvement in the earlier year, specifically working with Jordon Valley Clinic on medication management and working through a stressful separation and divorce from her husband. Plaintiff reported that her marriage was characterized by physical, emotional and verbal abuse, which at times caused her to be depressed. Plaintiff reported physical ailments that interfered with her everyday functioning. Plaintiff reported that her lack of resources to meet medical and psychiatric needs on a consistent basis interfered with her ability to hold consistent employment. Plaintiff reported that once the case with the State is closed, she will no longer be able to receive services without paying for them herself. Ms. Breckner indicated this would be an unreasonable expectation on the State's part (Tr. at 590-591).
On August 26, 2008, plaintiff was treated by Dace Miller, M.D., at CoxHealth Systems. Plaintiff underwent a colonoscopy that was normal other than hemorrhoids (Tr. 623-622).
On September 16, 2008, plaintiff was treated in the Emergency Department at CoxHealth Systems for complaints of head and neck pain with nausea and dizziness. Plaintiff reported that her sudden onset headache "[felt] like when I last shot up meth one month ago." She was listed as a smoker. She was given Dilaudid (narcotic) through IV twice and Toradol (non-steroidal anti-inflammatory) once before being discharged. (Tr. 624-631).
The following day, on September 17, 2008, plaintiff was seen by William Graham, M.D., at Jordon Valley Community Health for complaints of headache and depression. Plaintiff reported being at the Cox South ER the previous day with headache, sudden onset, occipital in location and blurry vision, slurred speech, and nausea. By her report all testing at the ER was normal. Plaintiff said she had been discharged with a prescription for Tramadol (narcotic-like pain reliever), which only partially relieved her pain. Dr. Graham's assessment was basilar migraine headache (starting at the base of the brain) vs. vasculitis (inflammation of the blood vessels caused by the immune system attacking blood vessels by mistake) vs. MS and depression. The doctor prescribed ASA/butalbital/caffeine/codeinel (narcotic) for the headache (Tr. 607-608).
The next day, on September 18, 2008, plaintiff returned to the Emergency Department at CoxHealth reporting recurring occipital headache. She said her past medical history included schizophrenia and chronic back pain. Plaintiff was given Toradol (non-steroidal anti-inflammatory), Dilaudid (narcotic) and Phenergan (for nausea) through IV and released (Tr. at 632-647).
On September 19, 2008, plaintiff underwent a head CT which was normal (Tr. 648).
On September 26, 2008, plaintiff returned to the Emergency Department with reports of recurrent severe headaches. A MRI and Cerebral Angiography were done which were normal. She received an IV injection of Dilaudid (narcotic) and Phenergan (for nausea) before being discharged (Tr. 649-658).
On October 9, 2008, plaintiff was treated by Matthew Stinson, M.D. at Jordon Valley Community Health Center for excessive sleepiness, headaches, and depression. Plaintiff admitted to suicidal thoughts over the last month and presented with flat affect. Dr. Stinson spoke with the crisis team who recommended an alcohol and drug screen. He ordered blood work. Dr. Stinson's assessment was amphetamine dependence in remission and headache. He suspected her headache and fatigue were related to depression. Plaintiff was referred to the crisis team (Tr. 609-610).
On October 31, 2008, plaintiff was seen by Matthew Stinson, M.D., to follow up on blood test results which showed Hepatitis C. Plaintiff was vaccinated against Hepatitis A and Hepatitis B and was advised to avoid alcohol. (Tr. at 610-611).
On December 24, 2008, plaintiff was seen in the Emergency Department at CoxHealth for sudden onset of chest tightness with radiation to back and right shoulder. Chest x-rays were normal and her ECG was normal and unchanged from her last one on August 16, 2007. Plaintiff was treated with a GI cocktail (a mixture of medications for stomach acid) and released (Tr. 659-669).
On January 9, 2009, plaintiff was treated by Matthew Stinson M.D., at Jordon Valley Community Health. Plaintiff complained of stomach pain and vomiting "every day for the past three weeks", and expressed concerns about Hepatitis C. "She did elect to consider a treatment for Hepatitis C because she is an alcoholic. She drinks approximately 3 to 4 beers at a time... on the weekend. She has not had any problems during the week." Dr. Stinson's assessment was alcoholic cerebellar degeneration. He ordered blood work and prescribed Ranitidine (treats heartburn and acid indigestion). "Discussed Hepatitis C treatment at length. Will refer for evaluation although I told her that she was probably not a good candidate because of her mood difficulties. I recommended treatment for alcoholism instead." (Tr. 611-612).
On January 22, 2009, plaintiff was treated by Erin Greer, M.D., of the orthopedic department of Ferrell-Duncan Clinic for complaints of bilateral thumb pain and hand numbness. Dr. Greer's findings were consistent with advanced bilateral thumb basal joint arthritis and clinical features consistent with carpal tunnel syndrome. Plaintiff was provided with thumb basal joint injections and splints. Plaintiff's medications were listed as Ranitidine (for GERD), Aleve (over-the-counter non-steroidal anti-inflammatory), Benadryl (antihistamine), Tramadol (narcotic-like pain reliever), Norvasc (treats hypertension and chest pain), aspirin, Robaxin (muscle relaxer), Celexa (treats depression), Spiriva Handihaler (for COPD), Albuterol (for COPD), Premarin (female hormone), and Ketoprofen (non-steroidal anti-inflammatory). Electrodiagnostic studies were recommended (Tr. 798-802).
On February 28, 2009, plaintiff was treated by a staff physician in the Emergency Department at CoxHeath for headaches. She reported a history of schizophrenia and bipolar disorder, and she was listed as a smoker. Plaintiff's CT scan was normal. She was given an injection of Nubain (narcotic), Phenergan (for nausea) and Norflex (muscle relaxer) (Tr. 670-679).
Three days later, on March 3, 2009, plaintiff returned to CoxHealth for treatment of migraine headaches. Plaintiff was treated with Thiamine (vitamin B), Phenergan (for nausea) and Dilaudid (narcotic) and was released (Tr. 680-688).
On April 28, 2009, plaintiff went to the Emergency Room at CoxHealth for complaints of hematuria (blood in the urine) and lumbar pain. She said her pain felt like a kidney stone. The record says "Rx given" however, the record does not appear to indicate what prescriptions or treatment was given. (Tr. 689-695).
Three days later, on May 1, 2009, plaintiff returned to the Emergency Department reporting that her right flank pain had increased. A CT scan showed possible kidney stone and diverticulosis of descending and sigmoid colon. Plaintiff was assessed with a kidney stone and urinary tract infection. She was given Toradol (non-steroidal anti-inflammatory), Zofran (for nausea), Morphine (twice) (narcotic), and Ciproflaxacin (antibiotic)through IV. Plaintiff was discharged with prescriptions for Ciprofloxacin and Tramadol (narcotic-like pain reliever). Plaintiffs medications were listed as Abilify (treats schizophrenia), Celexa (treats depression), Cyclobenzaprine (muscle relaxer), Requip (treats restless leg syndrome), and Trazodone (for anxiety) (Tr. 696-706).
On May 7, 2009, plaintiff was admitted to CoxHealth for worsening back pain and right lower quadrant pain. A CT scan and ultrasound showed an ovarian cyst. Plaintiff admitted to smoking occasionally and a past history of alcohol abuse, but denied other drug use. She also denied headaches and chest pain (Tr. 712, 804). She had no tenderness in her back on exam. Plaintiff was treated for an unrelated condition and was discharged the following morning (Tr. 707-719, 803-808).
On June 11, 2009, plaintiff returned to Ozarks Community Hospital and reported tenderness in both right and left heels. Dr. Bricker recommended stretching and prescribed Mobic (non-steroidal anti-inflammatory) (Tr. at 748).
On August 2, 2009, plaintiff returned to Dr. Bricker at Ozarks Community Hospital complaining about tenderness and pain in both heels. The doctor noted mild gait disturbance and diagnosed plantar fasciitis (see footnote 8, page 11). The doctor injected her right heel with depomedrol and recommended calf stretches (Tr. 747).
On August 7, 2009, plaintiff was evaluated by Matthew Stinson, M.D., for medication recheck on her depression, anxiety, and right knee pain. The doctor noted she had right knee tenderness along the medial aspect of the patella. X-rays showed overgrowth on the bone on the medical side of the knee almost touching the patella. The doctor's assessment was right knee joint pain and depression. He prescribed Lunesta (treats insomnia) and referred plaintiff for orthopedic evaluation (Tr. 612-613).
On September 4, 2009, William Duncan, M.D., an orthopedic specialist at Ferrell Duncan Clinic, treated plaintiff for complaints of recurrent right knee pain which reportedly had been ongoing for many years. Plaintiff denied drug and alcohol use but admitted to tobacco usage. The doctor found plaintiff's gait and station normal with adequate muscle strength and tone. X-rays of plaintiff's right knee showed severe right knee degenerative joint disease with bone-on-bone wear of the medial compartment and an anterior subluxation of the femur relative to tibia. Plaintiff's knee was injected with DepoMedrol. Her prescribed medications were listed as Celexa (treats depression), Abilify (treats schizophrenia), Tramadol (narcotic-like pain reliever), Lunesta (treats insomnia), Requip (treats restless leg syndrome), and Mobic (non-steroidal anti-inflammatory) (Tr. 615-619).
On September 4, 2009, plaintiff was treated at Outpatient Rehabilitation by a clinician for knee pain. A lateral wedge orthotic was recommended to assist with relieving her pain (Tr. 781-783).
On September 6, 2009, plaintiff was admitted to CoxHealth Emergency Systems for right upper quadrant pain. Plaintiff reported increased coffee consumption. She admitted to continued smoking, said she had a history of alcohol use but none at the present, and she denied drug use. Physical and psychological exams were normal. CT scan of the abdomen and pelvis was negative. Plaintiff was given Compazine (for nausea) and Morphine (narcotic) via IV. She was diagnosed with gastritis. Plaintiff was told to avoid caffeine and alcohol and she was given a prescription for Vicodin (narcotic). (Tr. 720-732).
Three days later, on September 9, 2009, plaintiff returned to the Emergency Department for abdominal pain complaints. CT scan of the abdomen was negative. Physical and psychological exams were normal. Plaintiff admitted to continued smoking and a past history of alcohol use but denied current alcohol use and denied any drug use. She was given morphine (narcotic) twice through her IV along with Compazine (for nausea). Plaintiff was assessed with epigastric pain. The clinician suspected plaintiff may have a peptic ulcer and suggested follow up with a primary care physician (Tr. 733-745).
On Friday, October 16, 2009, plaintiff was seen in the CoxHealth Emergency Services for complaints of sore throat and cough. Her cough was described in the record as a "smokers cough." Plaintiff admitted smoking but denied a history of alcohol or drug use. Her physical and psychological exams were normal. Plaintiff was diagnosed with viral syndrome and a strep culture was taken. She was advised not to work until Wednesday, October 21, 2009, or after her symptoms resolved, whichever came first (Tr. 784-793).
On November 5, 2009, plaintiff had a bilateral renal ultrasound which was evaluated by Anbari Martin, M.D., a radiologist at CoxHealth Systems. The ultrasound showed no stone and no hydronephrosis (kidney swelling) (Tr. 827).
On November 19, 2009, Becky Breckner, LPC NCC, of the Center for Resolutions, completed a Medical Source Statement - Mental giving her opinion of plaintiff's ability to do work-related activities on a sustained basis (eight hours a day for five days a week, or an equivalent work schedule). Ms. Breckner opined that plaintiff had no evidence of limitations in the following:
▪ The ability to remember locations and work-like procedures
▪ The ability to understand and remember very short and simple instructions
▪ The ability to understand and remember detailed instructions
▪ The ability to carry out very short and simple instructions
▪ The ability to sustain an ordinary routine without special supervision
▪ The ability to ask simple questions or request assistance
▪ The ability to travel in unfamiliar places or use public transportation
She found that plaintiff was moderately limited in the following:
▪ The ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances
▪ The ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods
▪ The ability to accept instructions and respond appropriately to criticism from supervisors
▪ The ability to maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness
▪ The ability to be aware of normal hazards and take appropriate precautions
▪ The ability to set realistic goals or make plans independently of others
She found that plaintiff is markedly limited in the following:
▪ The ability to carry out detailed instructions
▪ The ability to maintain attention and concentration for extended periods
▪ The ability to work in coordination with or proximity to others without being distracted by them
▪ The ability to make simple work-related decisions
▪ The ability to interact appropriately with the general public
▪ The ability to get along with coworkers or peers without distracting them or exhibiting behavioral extremes
▪ The ability to respond appropriately to changes in the work setting
Ms. Breckner stated that plaintiff has the ability on a sustained basis, i.e., 8 hours per day, 40 hours per week, to make judgments that are commensurate with the functions of unskilled work, i.e., simple work related decisions; she is able to respond appropriately to supervision, coworkers, and usual work situations; and she is able to deal with changes in a routine work setting. Ms. Breckner commented that plaintiff reported needing increased breaks at work due to physical pain and discomfort (Tr. 795-796).
November 25, 2009, was plaintiff's first administrative hearing in connection with her application for disability benefits.
On December 2, 2009, plaintiff was treated by Edward Skeins, M.D., at CoxHealth Emergency Services for complaints of lower abdominal pain radiating into her back. Plaintiff presented looking very uncomfortable and had mild left lower quadrant tenderness. Plaintiff was described as "miserable with pain" by Dr. Skeins. Plaintiff reported a previous ovarian cyst and previous kidney stone, and said this pain was similar to both. CT scans were negative but a left ovarian cyst was confirmed on ultrasound. Plaintiff was "rendered pain free" with injections of Zofran (for nausea), Morphine (narcotic), and Toradol (non-steroidal antiinflammatory). The clinical impression was left ovarian cyst with history of kidney stones, although there were no positive test results on this visit. Dr. Skein recommended plaintiff stop Tramadol (narcotic-like pain reliever) due to the possibility of serotonin syndrome when used with Celexa (treats depression) and to use Hydrocodone (narcotic) for pain instead. He gave her Hydrocodone to use at home (Tr. 828-844).
On December 20, 2009, plaintiff was treated at CoxHealth Emergency Services for migraine headaches. Plaintiff was given Phenergan (for nausea) and Toradol (non-steroidal anti-inflammatory) through IV and was prescribed Phenergan and Fioricet (treats tension headaches, contains a barbiturate and is a Schedule III controlled substance) (Tr. 853-862).
On January 17, 2010, plaintiff was treated at CoxHealth Emergency Services by Gregory Hunter, M.D., for an exacerbation of restless leg syndrome resulting in difficulty sleeping for three nights. She denied any other complaints. She was observed to be alert, pleasant and cooperative. Her physical exam was normal. Plaintiff was given an injection of Valium (treats anxiety and is a Schedule IV controlled substance) and told to follow up with her primary care doctor (Tr. 863-872).
On January 22, 2010, plaintiff was treated by Donna Steward at Jordon Valley Community Health for complaints of back pain radiating down her leg and into her head. The assessment was herniated disc at 1, 5-S1. Non-steroidal anti-inflammatories were recommended along with rest and ice (Tr. 1062-1063).
The following day, on January 23, 2010, plaintiff was treated by Douglas Horn, D.O., at CoxHealth Emergency Services for acute low back pain. Plaintiff was observed to be cooperative and pleasant. Examination showed pain moderate in the lumbar area. Plaintiff range of motion was normal, but painful, with all movement. Plaintiff was given a prescription for Norco (narcotic) and told to follow up with her treating doctor (Tr. 873-876).
Two days later, on January 25, 2010, plaintiff was treated by Matthew Stinson, M.D., at Jordon Valley Community Health for complaints of back pain radiating into her left leg. "Patient had an incident at work where she was lifting multiple things and then went into the kitchen to pick up a bottle and had severe excruciating back pain that would radiate down into her left leg. She has been off work since then. This was 5 days ago.... She has been controlling this with pain medication." Dr. Stinson reported that her back was tender to palpation over the lower lumbar spine and left paraspinal muscles. Plaintiff had a positive straight leg test on the left. Plaintiff was prescribed Prednisone, a steroid, and told to exercise and use anti-inflammatory medication. She was given a work excuse for one week (Tr. 1060-1061).
On January 27, 2010, the ALJ entered the first order denying plaintiff's application for disability benefits.
One week after her appointment with Dr. Stinson, on February 1, 2010, plaintiff returned to see Dr. Stinson for a follow up. Plaintiff reported improvement in her pain although she continued to have pain with flexion of her neck. The doctor noted tenderness over the bilateral hip areas and assessed a herniated disc at La-S 1 central. The doctor recommended plaintiff return to work with a 20-pound weight restriction and continue stretching exercises (Tr. at 1064-1065).
On February 8, 2010, plaintiff reported complete resolution of her back pain and indicated she "might return to work." Plaintiff also stated that Abilify (treats schizophrenia) continued to help with her symptoms and that sometimes she would double her dose. Dr. Stinson noted no back tenderness and indicated that plaintiff may return to work without restriction (Tr. 1066-1067).
One month later, on March 8, 2010, plaintiff was treated by Chad Nall, a physician's assistant at Ferrell-Duncan Clinic, for complaints of right knee pain. Plaintiff reported that she was taking Celexa (treats depression), Abilify (treats schizophrenia), Tramadol (narcotic-like pain reliever), Lunesta (treats insomnia), Requip (treats restless leg syndrome), and Mobic (non-steroidal anti-inflammatory). "We performed a cortisone injection to her right knee last September. This provided her with significant and lasting relief. She reports a gradual return in her painful symptoms over the last 3-4 weeks." Plaintiff was observed to be alert and oriented with appropriate mood and affect. Mr. Nall's assessment was right knee pain and right knee severe degenerative joint disease. He injected her knee with Depo-Medrol and Sensorcaine and recommended follow up as needed (Tr. 877-880)
On April 18, 2010, plaintiff was treated by Juliah Tiedemann, M.D., at CoxHealth South for complaints of pain and possible kidney stone. CT scan was negative for kidney stone or hydronephrosis (kidney swelling). Plaintiff was diagnosed with pyelonephritis (urinary tract infection involving the kidney) and prescribed Cipro (antibiotic) and Percocet (narcotic) (Tr. 887-900).
Four days later, on April 22, 2010, plaintiff was treated by Tommy Trent, D.O., at CoxHealth South for a 1st degree burn on the right hand. Plaintiff was prescribed Vicodin (narcotic) (Tr. 901-909).
On May 3, 2010, plaintiff was treated by Matthew Stinson, M.D., at Jordon Valley Community Health for complaints of kidney pain and possible kidney stone. The doctor noted plaintiff had tenderness to palpation over the right flank. Urine tests revealed no blood in the urine. Dr. Stinson's assessment was dysuria (painful urination) but provided no treatment for that condition, and he increased her dosage of Requip due to continued complaints of restless leg syndrome (Tr. 1068-1069).
One week later, on May 10, 2010, plaintiff was treated by Nurse S. Michael, at the Family Medical Walk-In Clinic for complaints of weakness, severe fatigue, and severe headache. Plaintiff was given an injection of Toradol (non-steroidal anti-inflammatory) and was prescribed an illegible medication. Aleve was recommended for her headache (Tr. 883-886).
On May 12, 2010, plaintiff was treated by Gregory Hunter, M.D., at CoxHealth South for flank pain. CT scan showed no acute abnormality. Plaintiff was prescribed Toradol (nonsteroidal anti-inflammatory) (Tr. 910-927, 940-941).
On May 21, 2010, plaintiff was treated by Joseph Craigmyle, M.D., at CoxHealth South for migraine headaches. Plaintiff was given an injection of Benadryl (antihistamine), Toradol (non-steroidal anti-inflammatory), and Reglan (for nausea) and oral Requip (treats restless leg syndrome) (Tr. 928-939).
Five days later, on May 26, 2010, plaintiff was seen by Matthew Stinson, M.D., for complaints of possible diabetes (she reported a strong family history of diabetes and her own urinary frequency over the past three days which had since resolved) and shoulder discomfort. The doctor reported that plaintiff had pain on active abduction as well as external rotation of both shoulders with a negative cross arm test. The doctor assessed her with subacromial bursitis and suggested anti-inflammatories and avoidance of lifting over her shoulder level for two weeks. The doctor recommended a blood sugar level lab test and urinalysis, and he suggested that plaintiff work on weight loss (Tr. 1070-1071).
On June 21, 2010, plaintiff returned to see Matthew Stinson, M.D., for continued shoulder pain. Joint injections were administered for acute shoulder impingement. The doctor prescribed Tramadol (narcotic-like pain reliever), Lunesta (treats insomnia), and Requip (treats restless leg syndrome) (Tr. 1072-1073).
On July 1, 2010, plaintiff returned to Matthew Stinson, M.D., with complaints of continued shoulder pain and migraine headache. Joint injections were again administered. Dr. Stinson prescribed Imitrex for her migraine and also Flexeril (muscle relaxer), Requip (treats restless leg syndrome), Lunesta (treats insomnia), and Tramadol (narcotic-like pain reliever) (Tr. 1074-1076).
On July 8, 2010, plaintiff was examined by Sharol McGehee, Psy.D., who administered a clinical interview, mental status exam and the Milton Clinical Multiaxial Inventory-Third Edition (MCMI-III). Plaintiff described having hallucinations and delusions. "At one time she believed that her father was God and that she was married to Jesus'. She also believed that her father kicked my husband out of heaven, and he is responsible for the world situation'. She perceives people to be angels. She reportedly spends most of her time struggling with delusions." Dr. McGehee observed that on the day of this exam, plaintiff was oriented to time, place, person and purpose. Plaintiff reported that she had been working at Hobby Lobby for the past 7 1/2 years.
Dr. McGehee reported that plaintiff was actively delusional and met the criteria for a paranoid delusional disorder. Ideas of reference, thought control or thought influence appeared to be present. The doctor opined that plaintiff's behavior could deteriorate into more aggressive acts stimulated by her delusional thinking; that plaintiff was addicted to methamphetamine but had been clean for three years after completing a rehabilitation program at Carol Jones Recovery Center; plaintiff reported using alcohol once a month and then she drinks to get drunk. Plaintiff reported having contracted Hepatitis C by mainlining methamphetamine.
Test results were consistent with paranoid schizophrenia. The doctor opined that plaintiff had both schizotypal and paranoid personality traits and was then experiencing paranoid ...