United States District Court, E.D. Missouri, Eastern Division
REPORT AND RECOMMENDATION OF UNITED STATES MAGISTRATE JUDGE
TERRY I. ADELMAN, Magistrate Judge.
This is an appeal from an adverse ruling by the Commissioner of the Social Security Administration ("the Commissioner") denying Claimant Rasida Ramic's applications for disability insurance benefits under Title II of the Social Security Act (the Act"), 42 U.S.C. §§ 401 et seq., and Supplemental Security Income (SSI) under Title XVI, 42 U.S.C. §§ 1381 et seq. Claimant filed a Brief in Support of her Complaint and the Commissioner filed a Brief in Support of the Answer. The case was referred to the undersigned for a report and recommendation pursuant to 28 U.S.C.§636(b).
I. Procedural History
Claimant, who was born on April 6, 1975, filed her applications for benefits on April 29, 2010, alleging a disability onset date of February 28, 2010, due to impairments of her nerves, eyes, and stomach. Claimant's applications were denied initially, and she appealed the denials to an administrative law judge ("ALJ"). (Tr. 82-91.) In response to Claimant's timely request, the ALJ held a hearingon April 25, 2012. (Tr. 43-64.) Claimant appeared with counsel, an interpreter was provided, and the ALJ heard testimony from Claimant and a vocational expert ("VE"). (Tr. 9, 43-64.) At the close of the hearing, Claimant asked for and was permitted to obtain a consultative psychiatric examination. Following the May 22, 2012 examination, Claimant requested a supplemental hearing asserting that the conclusions drawn by the consultative examiner were "baffling." (Tr. 9, 284-85.) In response the ALJ noted that the April 25, 2012 hearing had been thorough and exceeded thirty minutes in length. The ALJ further stated that a supplemental hearing would serve no purpose as he had no further questions for Claimant and her request was based on "erroneous conclusions" regarding the consultative examination. (Tr. 9, 286.) The ALJ then granted Claimant more than six weeks to provide "factually accurate reasons" that might substantiate the need for a supplemental hearing. Id. Claimant failed to respond within the specified time period and the ALJ did not hold a supplemental hearing. (Tr. 9-10, 287.)
On September 25, 2012, the ALJ issued his decision concluding that Claimant was not under a "disability" as defined in the Act. (Tr. 9-25.) On October 25, 2013, the Appeals Council denied Claimant's request for review. Claimant has thus exhausted all remedies and the ALJ's September 25, 2012 opinion stands as the final decision of the Commissioner subject to judicial review pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3).
On appeal Claimant argues that the ALJ erred in assessing Claimant's Residual Functional Capacity ("RFC") by failing to find that Claimant's diagnosed mental impairment was sufficiently severe to constitute a basis for a finding of disability.
II. Application Forms, Work History, Disability and Function Reports
Claimant noted in her Work History and Disability Reports that she had worked as hotel housekeeper, a poultry cutter and most recently as a self-employed housekeeper. (Tr. 12, 46-47, 160-62, 165, & 172.) No additional information regarding the physical demands of her past work were provided in the Reports. (Tr. 179-183.) The application forms indicate that Claimant was self-employed and earned $16, 408.00 in 2010. (Tr. 160.)
In her Function Report dated May 27, 2010, Claimant wrote that she had difficulty sleeping due to chronic pain and needed daily reminders to take her medication. (Tr. 198-199.) She further indicated that because she was unable to concentrate, she could neither clean house nor prepare her own meals and had difficulty driving, frequently becoming lost. (Tr.199-200.) Claimant also indicated that her memory, concentration, understanding and ability to follow instructions were all affected by her symptoms. (Tr. 202.) She primarily stayed at home, rested, took her medicine, played with her children, and watched television. (Tr. 197.) She also wrote that she understood very little English, and was unable to pay bills, count change, handle a savings account or use a checkbook. (Tr. 200.) Claimant stated that she shopped for groceries once a month and went to church weekly but noted that anxiety made it impossible for her to engage in other activities.
In her Disability Report Claimant wrote that she had completed high school. (Tr. 171.) She also reported that she took Citalopram, Laorazepam and Tramadol for her nerves, Hydrocodone with APAP Naproxen for pain, Famotidine for her stomach, "but/apap/cf, " for headaches and "belladonna alk" for unknown reasons. (Tr. 173.)
The record also includes the notes of an agency employee who spoke to Claimant when she filed her applications. The employee noted that Claimant had not made an appointment, was well dressed and groomed and understood little, if any, English. (Tr. 101-02.)
III. Medical Records (Tr. 288-347)
Claimant was seen on November 29, 2007, at Prince Avenue Primary Care (Prince Avenue) in Athens, Georgia for complaints of stomach pain. An abdominal ultrasound performed at that time showed no abnormalities. (Tr. 329.) On December 5, 2007, recurring epigastric pain and continued on Prevacid. (Tr. 347.)
On September 22, 2008, Claimant was seen at Prince Avenue for follow up with respect to gastro-esophageal reflux disease (GERD), and cultured positive for H. pylori infection. Computed tomography ("CT") scans of the abdomen and pelvis showed a hemorrhagic or partially collapsed cyst in the right ovary, mild fatty infiltration of the liver, and fold thickening in the stomach indicating possible gastritis. (Tr. 328, 346.) The examining physician concluded that none of these findings required further treatment apart from continued use of Prevacid as necessary.
On October 7, 2008, Claimant was referred to a specialist for a vision checkup after being diagnosed with blurry vision. (Tr. 352.)
A CT scan of the pelvis performed December 3, 2008, revealed a hemorrhagic collapsed cyst in the right ovary measuring 2.2 cm which was similar to the CT of the pelvis of October 1, 2008, and a possibly new area of cyst or hemorrhagic cyst formation. (Tr. 324.)
On December 4, 2008, Claimant was seen at Prince Avenue for stomach pain. (Tr. 345.) The medical record reflects that that there was a language barrier and that it was difficult for medical professionals to communicate with her. ( Id. ) On December 11, 2008, Claimant was seen again at Prince Avenue complaining of headache. (Tr. 343.) The treating physician assigned diagnoses of ovarian cyst and sinusitis. ( Id. ). A CT of the head performed on that date revealed mild sinus disease involving the left sphenoid sinus, and no other abnormalities. (Tr. 357.)
On February 18, 2009, Claimant presented with anxiety and difficulty sleeping. March 10, 2009 medical records from Prince Avenue indicate that Claimant presented with chief complaints of headache and nerves, was hyperactive and had a hard time sitting still in the emergency room. (Tr. 392-93.) A CT of the brain performed on that date showed no evidence of acute intracranial abnormality. (Tr. 301.)
On March 18, 2009, Claimant was seen again at Prince Avenue for "bad headaches" for which she had also been to the emergency room. (Tr. 308.) She reported having raging fits in which she had broken dishes. (Tr. 310.) Her physician diagnosed her with chronic unresolving headaches, sinusitis, and anxiety and referred her to a neurologist. (Tr. 308-10.)
Claimant was seen on March 24, 2009 by Dr. Anthony DaCunha, M.D., of Physicians South Neurology for complaints of daily headache located in the back of her head and frontal areas. The headaches were associated with blurry vision, dizziness, nausea and intolerance of light, sound and smell. A CT scan of Claimant's head performed at that time was normal. (290.) In addition, electroencephalograms (EEG), a Visual Evoked Potentials (VEP) study, and a Brain Auditory Evoked Potential (BAEP) study all of which were performed a week later showed normal results. (Tr. 292-94.)
Claimant was seen again on April 3, 2009, at the Physicians South Neurology for headaches. (Tr. 289.) A that time a CT of her head showed no abnormalities and a magnetic resonance image ("MRI") of the brain performed on April 7, 2009 also was normal. (Tr. 291.) Medical records from Physicians South Neurology further indicate that Claimant was seen on April 13, 2009, for complaints of headache that had lasted about 6 months. (Tr. 288.) The headaches were associated with blurry vision, dizziness, light, sound and smell intolerance and nausea. ( Id. ) An MRI of the brain performed at this time also was normal. ( Id. )
On April 20, 2009, Claimant saw Dr. Jing Dong to whom she had been referred by Dr. DaCunha for an eye exam and a new eyeglass prescription. (Tr. 95) Claimant complained of blurred vision, both far and near, photosensitivity and numerous headaches in the preceding weeks. (Tr. 295.) After his examination, Dr. Jing Dong noted diagnoses of headache, pingaecula and suspected glaucoma. (Tr. 297.) He patched Claimant's eye for future evaluation and gave her a prescription for eyeglasses. (Tr. 298.) At a follow up appointment on April 25, 2009, Claimant reported continuing problems with her eyes and exhibited symptoms of anxiety. (Tr. 307, 374.) On June 2, 2009, Claimant was seen for new glasses and complaints of left eye pain. (Tr. 305) Dr. Jing Dong noted an increase in Claimant's level of anxiety, prescribed Celexa and approximately one week later increased the dosage. (Tr. 305-306)
October 23, 2009 medical records from St. Mary's Hospital indicate that Claimant presented with nausea, vomiting and complaints of severe cramping pain (10/10). (Tr. 376-378.) On December 7, 2009 Claimant presented with a chief complaint of abdominal pain. (Tr. 364.) Records from this visit indicate that Claimant had miscarried twins in August of 2009, and had had pain and swelling since that time. ( Id. ) A CT of the abdomen revealed no acute difficulties. At a follow-up appointment in late December of 2009 Claimant's prescriptions for medication were renewed and she was assigned the diagnoses of chronic headache, anxiety and mood disorder. (Tr. 303.) On January 1, 2010, Claimant was seen at Prince Avenue for complaints of headache. ( Id. ) She was again diagnosed with headache, anxiety, and mood disorders. (Tr. 304)
A medical certification for Disability Exceptions completed January 2, 2010, indicates that Claimant showed a loss of visual field attributable to neurological rather than ophthalmologic causes. (Tr. 312.) The certification also reflected that had significantly decreased peripheral vision in both eyes. (Tr. 313.)
On March 14, 2011, Claimant presented at the Padda Institute, a general medical practice in Saint Louis, where she complained of a 14lb weight loss in the previous seven to eight months, fatigue and a three- day history of productive cough. Dr. Padda diagnosed an acute upper respiratory infection, prescribed ibuprofen for pain and ordered some diagnostic lab tests. A thyroid panel and urine culture were normal. In addition, a complete metabolic panel and complete blood count ...