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Markland v. Colvin

United States District Court, E.D. Missouri, Eastern Division

August 31, 2015

SUSAN WILLIAMS MARKLAND, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant

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[Copyrighted Material Omitted]

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         For Susan Williams Markland, Plaintiff: Traci L. Severs , LEAD ATTORNEY, DENNIS W. FOX AND ASSOCIATES, St. Louis, MO.

         For Carolyn W. Colvin, Acting Commissioner of Social Security, Defendant: Nicholas P. Llewellyn, LEAD ATTORNEY, OFFICE OF U.S. ATTORNEY, St. Louis, MO.

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         MEMORANDUM

         David D. Noce, UNITED STATES MAGISTRATE JUDGE.

         This action is before the court for judicial review of the final decision of the defendant Commissioner of Social Security denying the application of plaintiff Susan Williams Markland for a period of disability and disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. § § 401-434. The parties have consented to the exercise of plenary authority by the undersigned Magistrate Judge under 28 U.S.C. § 636(c). For the reasons set forth below, plaintiff's claim is remanded for further development of the record.

         I. BACKGROUND

         Plaintiff Susan Williams Markland, born May 6, 1966, applied for a period of disability and disability insurance benefits under Title II of the Social Security Act on April 27, 2011. (Tr. 126-132.) Plaintiff alleged an onset date of disability of April 13, 2009, due to pancreatitis and L5/S1 herniated disk and nerve damage. (Tr. 160-69.) Plaintiff's claim was initially denied on November 10, 2011. (Tr. 57-58.) On December 9, 2011, plaintiff filed a Request for a Hearing. (Tr. 70-71.) Plaintiff appeared and testified at a hearing before an ALJ on February 6, 2013, and on March 26, 2013, the ALJ found that plaintiff was not disabled. (Tr. 8-25.) Plaintiff exhausted all of her administrative remedies after the Appeals Council denied her Request for Review on March 6, 2014. (Tr. 1-5.) Thus, the decision of the ALJ stands as the final decision of the defendant Commissioner.

         II. MEDICAL RECORD

         A. Medical Records

         On April 21, 2009, plaintiff sought treatment from Musaddeque Ahmad, M.D. for increasing urinary frequency and burning with urination. Dr. Ahmad diagnosed a urinary tract infection and prescribed Darvocet for pain and Bactrim (an antibiotic). Dr. Ahmad also noted that plaintiff had no back tenderness, weakness, fatigue, depression, anxiety, mania, sleep disturbances, or hallucinations. (Tr. 617-18.)

         On May 19, 2009, plaintiff visited Dr. Ahmad for a pain medication refill. Dr. Ahmad continued plaintiff's prescription for Darvocet for plaintiff's pelvic pain. (Tr. 619-20.)

         On September 8, 2009, plaintiff again visited Dr. Ahmad for a pain medication refill. Dr. Ahmad noted that plaintiff complained of moderate to severe right hip pain as well as feeling down and depressed. Dr. Ahmad stopped the Darvocet and prescribed Lorcet Plus for plaintiff's pelvic pain and Elavil for plaintiff's depression. (Tr. 621-23.)

         On October 24, 2009, plaintiff sought treatment from Dr. Ahmad due to not feeling well. Plaintiff complained of diffuse muscle aches, low grade fever, facial pain, headache, nasal congestion, sore throat, and related complaints. Dr. Ahmad prescribed Mucinex DM (a cough suppressant), Amoxil (an antibiotic), Darvocet, and Elavil. Dr. Ahmad also noted that plaintiff had no depression, anxiety, mania,

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sleep disturbances, and no hallucinations. (Tr. 624-26.)

         On February 8, 2010, Plaintiff visited Dr. Ahmad for medication refills. Plaintiff complained of moderate-severe right hip pain that was " no worse, but still there" and was relieved by the current medication treatments. Dr. Ahmad noted that plaintiff also complained of bilateral knee pain and denied lower back pain. Dr. Ahmad decreased the dose for Darvocet and continued the Elavil. (Tr. 627-29.)

         On June 1, 2010, plaintiff saw Dr. Ahmad for a follow-up appointment. Plaintiff again complained of hip pain and bilateral knee pain. Dr. Ahmad also noted that plaintiff complained of mild to moderate chronic lower back pain. Dr. Ahmad continued the Elavil prescription for depression and increased the Darvocet dosage. (Tr. 630-32.)

         On June 15, 2010, plaintiff had a nerve conduction study performed. The computer interpretation of the study stated " consider moderate right L5/S1 radiculopathy" and that " the likelihood of a left L5/S1 radiculopathy or proximal neuropathy is low." [1] (Tr. 645-46.)

         On July 5, 2010, plaintiff saw Dr. Ahmad to discuss plaintiff's MRI results. Dr. Ahmad noted that the MRI of plaintiff's spine showed a " herniated disc in between L5 and S1 protruding towards the right side and causing intervertebral foraminal stenosis" which was consistent with plaintiff's symptoms. The MRI also showed a mass in the pelvic area. (Tr. 633.)

         On December 2, 2010, plaintiff went to the Jefferson Regional Medical Center emergency department with a complaint of abdominal pain. The emergency department physician admitted plaintiff to the medical unit of the hospital. Upon admission, Dr. Ahmad ordered IV fluid, pain control, intravenous Rocephin (an antibiotic), a surgical consultation, and a genitourinary consultation. James Travis Methvin, D.O., performed the surgical consultation examination and saw no need for surgical intervention. Ryan T. Miller, M.D., performed the urology consultation examination and noted that the etiology of plaintiff's abdominal pain was unclear. Dr. Miller determined that the CT scan revealed no evidence of a high-grade obstruction in the right ureter to explain the degree of pain that plaintiff was experiencing. Dr. Miller recommended reevaluation by a general surgeon due to plaintiff's significant abdominal pain being suggestive of either an ulcer or gallbladder disease. (Tr. 271-90.)

         On December 4, 2010, Mohideen A. Jamaluddin, M.D., performed a gastroenterology consultation examination of plaintiff. Dr. Jamaluddin diagnosed possible pyelonephritis and an abnormal CT scan of the pancreas. Dr. Jamaluddin's treatment plan included an endoscopic ultrasound of the pancreas as an outpatient. (Tr. 292-95.)

         On December 4, 2010, Dr. Ahmad discharged plaintiff from the hospital with discharge diagnoses of urinary tract infection, right upper quadrant abdominal pain, history of recurrent urinary tract infection, status post recent ovary mass resection, and history of osteoarthritis of the knee and hip. (Tr. 296.)

         On December 16, 2010, plaintiff saw Dr. Jamaluddin for a consultation examination following her hospitalization. Plaintiff complained of right upper quadrant abdominal pain, and a CT scan revealed a prominent pancreatic duct. Dr. Jamaluddin's plan of care included an endoscopic ultrasound of the pancreas and a stool

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sample to rule out C. diff. colitis, an inflammation of the large intestine resulting from an infection. Dr. Jamaluddin noted that plaintiff's mood and affect were appropriate. (Tr. 225.)

         On January 3, 2011, plaintiff saw Dr. Ahmad for medication refills. Plaintiff complained of right hip pain, bilateral knee pain, and worsening of lower back pain rated as mild to moderate. Dr. Ahmad advised plaintiff to see a pain management physician for her chronic pain management. (Tr. 639-40.)

         On January 18, 2011, plaintiff was again seen by Dr. Jamaluddin for a follow-up examination. Dr. Jamaluddin noted that the CT scan findings were consistent with chronic pancreatitis and that plaintiff continued to have right upper abdominal pain. Dr. Jamaluddin again documented that plaintiff's mood and affect were appropriate. (Tr. 224.)

         On February 8, 2011, plaintiff presented to Abdul N. Naushad, M.D., for pain management of chronic lower back pain, bilateral shoulder pain, and left knee pain. Dr. Naushad noted that plaintiff rated the pain as moderate-to-severe, and when the pain was present it " interferes only with some daily activities." (Tr. 391.) To treat her pain, Dr. Naushad prescribed gabapentin, hydrocodone-acetaminophen, and Mobic. (Tr. 391-94.)

         On February 15, 2011, plaintiff returned to Dr. Naushad's office for further care. Dr. Naushad performed a lumbar transforaminal injection with flouroscopy guidance to relieve plaintiff's pain. Dr. Naushad followed up with telephone call to plaintiff on February 18, 2011 and noted that plaintiff was doing fine and had some tenderness at the injection site. (Tr. 386-87.)

         On February 22, 2011, Dr. Naushad again saw plaintiff because of continued pain after the transforaminal injection. Plaintiff reported, that for her activities of daily living, her physical functioning was " bad" and her mood and sleep patterns were " better." Dr. Naushad performed a second lumbar transforaminal injection with fluoroscopy guidance on March 1, 2011. (Tr. 379-85.)

         On March 8, 2011, plaintiff returned to Dr. Naushad's office for a follow-up appointment with Dr. Naushad for chronic pain. Dr. Naushad noted that plaintiff reported that the pain medications are helping but that she was having more pain " now that I have gone back to work." (Tr. 376.) Plaintiff's physical functioning was " ok," her mood was " better," and her overall functioning was " ok." (Tr. 378.) Dr. Naushad increased the dose for hydrocodone-acetaminophen and added a prescription for orphenadrine for muscle pain. (Tr. 376-78.)

         On March 15, 2011, Dr. Naushad performed a third lumber transforaminal injection with fluoroscopy guidance. (Tr. 373-75.)

         On March 31, 2011, plaintiff was seen by Keely L. Cook, a physician assistant, in consultation with Dr. Aliperti for a new patient examination. Plaintiff was diagnosed with chronic pancreatitis and was prescribed one week of Vicodin for pain. (Tr. 517-18.)

         On April 5, 2011, plaintiff was seen by Dr. Naushad for a follow-up examination. Plaintiff's physical functioning, mood, and overall functioning were all marked as " better." Dr. Naushad also reviewed the narcotic agreement with plaintiff and noted that no hydrocodone was present in plaintiff's urine from a March 8 urine drug screen to monitor medication consistency.[2] (Tr. 370-72.)

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          On April 11, 2011, plaintiff went to the Jefferson Regional Medical Center emergency department complaining of abdominal pain which began two days earlier. The emergency department physician admitted plaintiff to the medical unit with a diagnosis of abdominal pain. (Tr. 307-11.)

         On April 12, 2011, Dr. Ahmad examined plaintiff in the hospital and noted that plaintiff complained of severe, stabbing right upper quadrant abdominal pain radiating to her scapula. Dr. Ahmad also noted that plaintiff denied anxiety, feeling depressed, and emotional problems. Dr. Ahmad ordered consultation with Dr. Jamaluddin, consultation with general surgery, pain control, and an abdominal ultrasound. Dr. Ahmad discharged plaintiff on April 14, 2011 with discharge diagnoses of anemia, acute right upper quadrant and epigastric pain, history of arthritis of the hip and knee joints, history of ovary mass, and rule-out gallbladder dyskinesia. (Tr. 312-22.)

         On May 3, 2011, plaintiff saw Dr. Naushad for a follow-up appointment. Dr. Naushad noted that plaintiff felt the medications were helping, but that the injections were starting to wear off. Dr. Naushad documented that a urine drug screening from April 5th was negative for hydrocodone-acetaminophen. Dr. Naushad also gave plaintiff a written warning for a second inconsistent, negative urine drug screen and gave notice that he ...


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