United States District Court, E.D. Missouri, Eastern Division
LINDA W. SCHUMACHER, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
MEMORANDUM AND ORDER
TERRY I. ADELMAN, Magistrate Judge.
This is an action under 42 U.S.C. §§ 405(g) and 1383(c)(3) for judicial review of the Commissioner's final decision denying Linda W. Schumacher's application for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401, et seq., and application for supplemental security income under Title XVI of the Act, 42 U.S.C. §§ 1381, et seq. All matters are pending before the undersigned United States Magistrate Judge, with consent of the parties, pursuant to 28 U.S.C. § 636(c). Because the Commissioner's final decision is not supported by substantial evidence on the record as a whole, it is reversed.
I. Procedural History
On July 28, 2010, plaintiff Linda W. Schumacher applied for disability insurance benefits (DIB) and supplemental security income (SSI), claiming she became disabled on December 31, 2004, because of chronic asthma. (Tr. 126-32, 133-36, 174.) Upon initial consideration, the Social Security Administration denied plaintiff's claims for benefits. (Tr. 69-76.) On October 5, 2011, a hearing was held before an administrative law judge (ALJ) at which plaintiff and a vocational expert testified. (Tr. 28-62.) On January 20, 2012, the ALJ issued a decision denying plaintiff's claims for benefits, finding plaintiff able to perform work as it exists in significant numbers in the national economy. (Tr. 10-24.) On December 21, 2012, the Appeals Council denied plaintiff's request to review the ALJ's decision. (Tr. 1-5.) The ALJ's decision thus stands as the final decision of the Commissioner. 42 U.S.C. § 405(g).
In the instant action for judicial review, plaintiff raises numerous claims that the ALJ's decision is not supported by substantial evidence on the record as a whole. Specifically, plaintiff challenges the ALJ's determination regarding her residual functional capacity (RFC), arguing that the ALJ failed to accord proper weight to the opinion of her treating physician, Dr. Robins, and failed to include limitations in the RFC that were supported by the medical records as well as by Dr. Robins' opinion. Plaintiff also contends that the ALJ failed to cite medical evidence to support her RFC determination. Plaintiff also argues that the ALJ should have ordered a consultative examination regarding the extent to which plaintiff's mental impairment affected her ability to work. Finally, plaintiff claims that the ALJ erred in finding her subjective complaints not to be credible. Plaintiff requests that the final decision be reversed and that she be awarded benefits, or that the matter be remanded for further proceedings. For the following reasons, the matter will be remanded for further consideration.
II. Testimonial Evidence Before the ALJ
A. Plaintiff's Testimony
At the hearing on October 5, 2011, plaintiff testified in response to questions posed by the ALJ and counsel.
At the time of the hearing, plaintiff was fifty-two years of age. Plaintiff stands five feet, one inch tall and weighs 127 pounds. (Tr. 35.) Plaintiff left high school in the ninth grade and never obtained her GED. Plaintiff has received no vocational or other training. (Tr. 38.) Plaintiff currently receives unemployment benefits. (Tr. 37.)
Plaintiff's Work History Report shows that plaintiff worked as a school bus driver from June 1999 to approximately November 2004. From March to July 2005, plaintiff worked as a bartender and stocker at an Elks Lodge, as well as performed some clerical work. In 2006 and 2007, plaintiff worked as a housecleaner. From August 2007 to October 2009, plaintiff again worked as a school bus driver. (Tr. 205.) Plaintiff testified that she was placed on medical leave from this last job because of pain, pulmonary irritation, and an inability to take her medication on account of the driving requirements of the job. (Tr. 39.) Plaintiff testified that she was ultimately fired because of her long period of medical leave. (Tr. 36-37.) Plaintiff testified to other short-term or temporary employment positions previously held and, further, that she was terminated from all positions for reasons related to her medical impairments. (Tr. 35, 40-43.)
Plaintiff testified that she was currently unable to work because of significant breathing difficulties. Plaintiff testified that she frequently is out of breath with climbing stairs, walking from her car to the grocery store, and walking through a building. Plaintiff testified that, while at the grocery store, she must lean on a cart for support. Plaintiff testified that temperature extremes also negatively affect her breathing. (Tr. 44.) Plaintiff testified that she uses a nebulizer and takes Albuterol, Singulair, Benadryl, Uniphyl, and Spiriva for her breathing impairments. (Tr. 47-48.)
Plaintiff testified that she also experiences headaches every day and has since her childhood. Plaintiff testified that the headaches sometimes make her sick. (Tr. 44.) Plaintiff testified that she takes Imitrex or Relpax for the condition. (Tr. 50.)
Plaintiff testified that she also has arthritis in her tailbone that sometimes feels like a knife or needle going through her back. Plaintiff testified that the pain sometimes prevents her from standing. Plaintiff testified that she also has pain in her right hip that radiates to her knee, which her doctor suggested may be her ACL. Plaintiff testified that pain in her ankles causes difficulty with standing and walking, and that fibromyalgia pain in her upper back causes pain and twitching in her arms and hands. (Tr. 44-45.) Plaintiff testified that she takes Oxycodone and prescription strength Advil for pain. Plaintiff testified that she also takes Cymbalta for pain, but that it does not help her condition. Plaintiff testified that she takes Valium for restless legs. (Tr. 48-49.)
Plaintiff testified that she has kidney stones and scar tissue in her neck, but no testimony appears in the record that she is affected by these conditions. (Tr. 46-47.)
Plaintiff testified that she has depression and anxiety for which she takes Lexapro. (Tr. 50.) Plaintiff testified that she is uncomfortable in big crowds and does not go anywhere other than the grocery store, drug store, the doctor's office, and the library. Plaintiff testified that she has lost friends and has broken up relationships. Plaintiff testified that she has what she considers "normal" memory problems in that she sometimes forgets words or sometimes forgets where she placed things. (Tr. 52-53.)
As to her exertional abilities, plaintiff testified that she cannot sit for very long because of a "poking" sensation she feels in her hip and buttocks. Plaintiff testified that she must shift from side-to-side while sitting. Plaintiff testified that she can lift a gallon of milk but must use both hands. (Tr. 51-52.)
As to her daily activities, plaintiff testified that she reads books. Plaintiff testified that she goes to the library and to the grocery store but gets help with taking things to the car. Plaintiff testified that she tries to help her sister, who is seventy years of age, and that she able to do some chores for her while sitting, such as vacuuming. (Tr. 53-54.) Plaintiff testified that she has a driver's license and is able to drive. (Tr. 38.)
B. Vocational Expert Testimony
Gary Weinholdt, a vocational expert, testified at the hearing in response to questions posed by the ALJ.
Mr. Weinholdt classified plaintiff's past relevant work as a school bus driver as semi-skilled and medium; as a license clerk and a food order expediter as semiskilled and light; and as a telephone solicitor as semi-skilled and sedentary. (Tr. 57-58.)
The ALJ asked Mr. Weinholdt to consider an individual of plaintiff's age, education, and past work experience and who could perform work at the light exertional level. The ALJ asked Mr. Weinholdt to consider the person to be limited to semi-skilled work and that she must avoid concentrated exposure to extreme heat, extreme cold, humidity, fumes, odors, dust, gases, and poor ventilation. Mr. Weinholdt testified that such a person could perform plaintiff's past work as a license clerk, telephone solicitor, and food expediter. (Tr. 58.)
The ALJ then asked Mr. Weinholdt to consider the individual to have the same exertional and environmental limitations but that she was also limited to unskilled work and could have only occasional contact with supervisors, coworkers, and the public and no transactional interaction with the public. Mr. Weinholdt testified that such a person could not perform the jobs to which he previously testified, but could perform other work such as an electronic accessory assembler, of which 1, 500 such jobs exist in the State of Missouri and 75, 000 nationally; and inspector and hand packager, of which 2, 500 such jobs exist in the State of Missouri and 125, 000 nationally. (Tr. 59-60.)
The ALJ then asked Mr. Weinholdt to assume that, in addition to the limitations set out in the second hypothetical, the person was unable to complete an eight-hour workday at least twice a week because of her physical problems, to which Mr. Weinholdt testified that no work would be available for such a person. (Tr. 60-61.)
III. Medical Evidence Before the ALJ
In December 2003 and January 2004, Dr. D. Helton, D.O., prescribed Vicodin (hydrocodone) for plaintiff's chronic headache pain. Plaintiff was also diagnosed with acute bronchitis; chronic obstructive pulmonary disease (COPD); and cervical, thoracic, lumbar, and sacral somatic dysfunction. (Tr. 236-38.)
In February 2004, Dr. Helton noted that plaintiff continued to smoke, but plaintiff reported that she had not had any recent respiratory problems. Physical examination was unremarkable. Plaintiff was continued in her diagnoses of somatic dysfunction, COPD, and chronic headaches. Plaintiff was prescribed Vicodin and BuSpar and was given samples of Lexapro. (Tr. 235.)
In April 2004, plaintiff reported to Dr. Helton that she experienced shortness of breath with exertion. Plaintiff continued to smoke and reported that she was not ready to quit. Plaintiff was diagnosed with bronchitis and was instructed to avoid smoke, dust, and fumes. (Tr. 232-34.) On April 27, plaintiff requested a refill of pain medication, reporting that the medication helped but that the pain continued to be constant. Plaintiff reported the pain not to prevent her from engaging in daily activities or from working. Plaintiff also reported occasional depressed mood and diminished energy. It was noted that plaintiff stopped taking Lexapro but continued to take BuSpar, which helped her anxiety. Psychiatric examination showed plaintiff to exhibit normal judgment and insight. Memory was intact. No abnormalities of mood or affect were noted. Physical examination was unremarkable except for swollen nasal membranes. Dr. Helton diagnosed plaintiff with somatic dysfunction, chronic headaches, allergic rhinosinusitis, anxiety/ depression, and nicotine addiction. Plaintiff was instructed to restart Lexapro. BuSpar and Lortab (hydrocodone) were prescribed. (Tr. 232-33.)
On May 24, 2004, plaintiff reported doing well on her medication. Plaintiff's prescriptions for Lortab, BuSpar, and Albuterol were refilled. (Tr. 231.) On July 6, plaintiff reported to Dr. Helton that she recently had an asthma attack for which Albuterol provided minimal relief. Scattered expiratory wheezes were noted upon examination. Loratidine was prescribed. (Tr. 230.) Plaintiff's prescriptions for Lortab and BuSpar were refilled in August. (Tr. 229.)
Plaintiff returned to Dr. Helton on November 15, 2004, for medication refills. Plaintiff complained of lumbar pain. Plaintiff also reported that she injured her right ankle when she stepped off of some bleachers. Physical examination was unremarkable. Dr. Helton diagnosed plaintiff with somatic dysfunction, chronic headaches, COPD, generalized anxiety disorder, and depression. Plaintiff's prescriptions for Lortab and BuSpar were refilled. Plaintiff was given samples of Lexapro. (Tr. 226.) Plaintiff's medications were again refilled in April 2005, with samples of Advair given at that time. (Tr. 225.)
Plaintiff's medications were refilled in July 2005, at which time plaintiff was also diagnosed with hypertension. Lopressor was prescribed. Physical examination otherwise was unremarkable. (Tr. 224.) Plaintiff's prescriptions for Advair, Albuterol, Lortab, and Lopressor were refilled in October 2005 and again in February 2006. (Tr. 222-23.)
Plaintiff returned to Dr. Helton's office on March 10, 2006, and complained of dizziness. Plaintiff also reported having difficulty getting her medication refills. Physical examination was unremarkable. Plaintiff was continued in her diagnoses of somatic dysfunction, chronic headaches, COPD, generalized anxiety ...