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Franklin v. Colvin

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

August 22, 2016

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.



         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 Shannon R. Franklin for disability insurance benefits under Title II of the Social Security Act (the Act), 42 U.S.C. § 401, et seq. The parties have consented to the exercise of plenary authority by the undersigned United States Magistrate Judge pursuant to 28 U.S.C. § 636(c).

         For the reasons set forth below, pursuant to Sentence 4 of 42 U.S.C. § 405(g), the final decision of the Commissioner is reversed and the case is remanded to the defendant Commissioner for further proceedings consistent with this memorandum opinion.

         I. BACKGROUND

         Plaintiff was born on May 30, 1972. (Tr. 148.) He filed his application on June 29, 2012. He alleges he became disabled on November 4, 2011 due to type 2 diabetes, depression, and back, knee, and shoulder problems. (Tr. 148-54, 179.) Plaintiff’s application was denied, and he requested a hearing before an ALJ. (Tr. 99.)

         The ALJ denied his application following a hearing, and the Appeals Council declined further review. (Tr. 1, 15, 51.) Thus, the decision of the ALJ stands as the final decision of the Commissioner.


         Plaintiff saw internist John A. Garcia, M.D. from December 2009 through April 2011 for attention deficit hyperactivity disorder (ADHD), lumbago or pain in the muscles and joints of the lower back, muscle spasms, and anxiety. Plaintiff stated that he had been on Adderall, used to treat ADHD, for years. Dr. Garcia refilled Adderall and prescribed Tramadol, for lumbago; Soma, for muscle spasms; and Valium, for anxiety. On August 3, 2011, plaintiff stated that he was doing well on his medications. (Tr. 228-36.)

         On April 26, 2012, plaintiff was seen at Wayne Medical Center with complaints of shoulder and back pain. Plaintiff had recently moved to the area and was advised that he would receive no medication until his past medical records were reviewed. (Tr. 264-65.)

         On May 4, 2012, plaintiff returned to Wayne Medical Center for chronic lumbar pain. Primary care physician Andrew Gayle, M.D., conducted a physical examination and ordered x-rays. Plaintiff became upset with Dr. Gayle when advised that Dr. Garcia would not prescribe certain medications and stated that he would seek care elsewhere. (Tr. 239-41.)

         On August 28, 2012, plaintiff saw family practitioner Guy Roberts, D.O., for a consultative disability examination. Plaintiff complained of chronic pain and anxiety. Upon examination, plaintiff’s mental status was alert, he was oriented to person, place, and time, and his affect and demeanor were appropriate. When asked why he was unable to work, plaintiff cited pain in his back and shoulders and that he thought he might have diabetes. Dr. Roberts noted that plaintiff’s pain was subjective and that he had never pursued treatment for diabetes. Dr. Roberts’s assessment was chronic pain syndrome and anxiety. He concluded that plaintiff’s physical examination did not warrant disability to any degree. (Tr. 252-56.)

         On August 30, 2012, plaintiff was admitted to Mineral Area Regional Medical Center for severe depressed feelings and suicidal ideations. Internist Parthasarathi Marapareddigari, M.D., diagnosed plaintiff with newly diagnosed type 2 diabetes, depression with suicidal ideation, and anxiety disorder. Plaintiff reported he had been on a downhill slide for several years due to his illnesses, and the loss of his job, automobile, and home. As a result, plaintiff was now considering suicide. Plaintiff attempted suicide as a teen by hanging. Dr. Marapareddigari noted that plaintiff was tearful, expressed suicidal ideation, and appeared depressed. Dr. Marapareddigari prescribed Glucotrol XL and metformin, both used to treat diabetes. Additionally, Dr. Marapareddigari recommended treatment for anxiety with a psychiatrist after plaintiff’s blood sugar was controlled. Plaintiff’s discharge diagnoses were bipolar affective disorder, depressed episode, and uncontrolled diabetes. (Tr. 288-91, 324, 334.)

         On September 3, 2012, plaintiff was transferred to the psychiatric inpatient unit at Southeast Hospital. Plaintiff told psychiatrist John T. Lake, M.D., that he believed he had bipolar disorder after conducting research on it. Plaintiff also complained of pain in his lower back, shoulders, and knees, and expressed hopefulness regarding his recent application for disability insurance benefits. Dr. Lake reported that plaintiff asked what forms he would be willing to fill out for plaintiff and seemed more motivated about that than about getting real treatment. Dr. Lake noted that plaintiff was “very vague about his symptomology, very matter-of-fact, as if he [was] reading it from a textbook.” (Tr. 324.) Plaintiff claimed to be paranoid, but Dr. Lake noted that he did not appear paranoid or suspicious at all, nor did plaintiff describe symptoms suggestive of psychosis. Upon admission, Dr. Lake believed that plaintiff was malingering in order to obtain disability because he did not appear nearly as distressed as he reported. (Tr. 325.)

         Plaintiff was discharged on September 6, 2012. His discharge diagnoses were bipolar affective disorder type 2, depressed episode, and non-insulin dependent diabetes. His discharge diagnosis did not include rule out malingering. By discharge, plaintiff’s mood had improved and stabilized, and he had a low suicide risk assessment. (Tr. 324-27.)

         On October 22, 2012, plaintiff saw psychiatrist Michael Stotler, M.D. Plaintiff reported his recent psychiatric hospitalization. He reported severe social anxiety that interfered with his ability to leave the house and see doctors. His mood cycled quickly from anger to depression to mania with recurrent crying spells and suicidal ideation. Plaintiff reported racing thoughts, paranoia, which he described as people judging him, and self-consciousness, which had caused him to get into fights in the past. On mental status examination, Dr. Stotler observed that plaintiff’s mood and affect was depressed and anxious. He diagnosed bipolar affective disorder, type 1, depressed, moderate; general anxiety disorder; and ADHD. Dr. Stotler assessed a Global Assessment of Functioning (GAF) score of 44, indicating “serious” symptoms. Dr. Stotler increased plaintiff’s Tegretol, an anticonvulsant, and Celexa, an anti-depressant, and changed his anxiety medication from Ativan to Klonopin. (Tr. 285-86.)

         On December 6, 2012, plaintiff saw primary care doctor Thomas Spiro, M.D. Plaintiff’s diabetes was under control. Dr. Spiro prescribed Ultram, for pain; Soma, for muscle spasms; and Xanax, for anxiety. (Tr. 342-43.)

         Plaintiff saw Dr. Stotler again on December 19, 2012. He reported that his anger had decreased and that his moods were much more stable. Tegretol, for bipolar disorder, had provided some relief, and he had some days of feeling better. Plaintiff stated that his depression and anxiety were still severe and that he left the house only if he took extra anxiety medication. Dr. Stotler observed plaintiff’s mood and affect was depressed and anxious. Dr. Stotler increased Klonopin, and added Adderall, for ADHD. (Tr. 283-85.)

         Plaintiff visited Dr. Spiro on December 20, 2012, complaining of chronic pain and anxiety. Dr. Spiro noted that plaintiff’s diabetes was controlled with ...

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