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Fleming v. Colvin

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

August 26, 2016

RHONDA L. FLEMING, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION

          SHIRLEY PADMORE MENSAH UNITED STATES MAGISTRATE JUDGE

         This is an action under 42 U.S.C. §§ 405(g) and 1383(c)(3) for judicial review of the final decision of Defendant Carolyn W. Colvin, the Acting Commissioner of Social Security, denying the application of Plaintiff Rhonda L. Fleming (“Plaintiff”) for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq., and for Supplemental Security Income (“SSI”) under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381, et seq. (the “Act”). The parties consented to the jurisdiction of the undersigned magistrate judge pursuant to 28 U.S.C. § 636(c). (Doc. 8). Because I find the decision denying benefits complies with the relevant legal requirements and is supported by substantial evidence, I will affirm the Commissioner's denial of Plaintiff's application.

         I. Procedural Background

         On June 19, 2012, Plaintiff applied for DIB and SSI, alleging that she had been unable to work since January 28, 2011, due to glaucoma, emphysema, and depression. (Tr. 124-36, 154). Her applications were initially denied. (Tr. 52-67). On March 5, 2013, after a hearing, the Administrative Law Judge (“ALJ”) issued an unfavorable decision on Plaintiff's claims. (Tr. 10-16). Plaintiff requested review by the Social Security Administration's Appeals Council, but on June 15, 2015, the Appeals Counsel denied the request for review. (Tr. 1-3). Plaintiff has exhausted all administrative remedies, and the decision of the ALJ stands as the final decision of the Commissioner of the Social Security Administration.

         II. FACTUAL BACKGROUND [1]

         A. Plaintiff's Testimony Before the ALJ

         Plaintiff was 54 years old as of the date of the hearing before the ALJ. (Tr. 26). Her last job involved part-time work doing home health care, and she testified that she was laid off due to lack of work. However, she also testified that it was getting hard to work because the patients were mean and she could not deal with that with her depression. (Tr. 28). She testified to several physical problems that prevent her from working, including her emphysema making her out of breath; trouble standing some days; a need to sit down to catch her breath when doing anything physical; inability to walk more than half a block without sitting down; problems with her left wrist; and vision problems related to glaucoma. (Tr. 29-31, 49-51). She also testified that she has a hard time trying to concentrate; that she has depression that causes crying spells almost every day; that she has anxiety that makes her heart beat faster and her hands get shaky, which is when she has trouble trying to concentrate; that she has panic attacks a couple of times a month; and that she has bad days about ten times a month when she does not leave the house at all and does not do anything. (Tr. 41-47). On a typical day, she gets up, watches the news, makes her bed, and tries to clean; it takes her a day to clean a room. (Tr. 36). Aside from going to doctors and to the grocery store once a month, she rarely goes out. (Tr. 36, 45).

         B. Plaintiff's Medical Records

         On February 14, 2011, Plaintiff saw her primary care physician, Dr. Sanjay Sharma, D.O., and reported symptoms of sweating, shaking, nausea, and blurred vision. She reported “significant anxiety.” It was noted that she was already taking Prozac, and she was started on Ativan. (Tr. 225-27). Plaintiff reported that she exercised by walking and using weights and an exercise ball. (Tr. 235). She reported a general ability to do usual activities. (Tr. 236).

         On March 22, 2011, Plaintiff returned to Dr. Sharma. She was in tears and reported living with a gentleman who she said was very manipulative and had a lot of control issues. She reported sweats coming in from nowhere and poor sleep. (Tr. 260). Her mood was sad, but her mental status examination was otherwise normal. Dr. Sharma diagnosed adjustment disorder with mixed anxiety and depressed mood, started her on Xanax, and referred her to a psychiatrist. (Tr. 261).

         On April 11, 2011, Plaintiff returned to Dr. Sharma and reported that she had been feeling much better since she had been on Xanax. Dr. Sharma noted that Plaintiff still felt like seeing a psychiatrist because of ongoing issues, but “all in all she is doing much better.” Also, he noted that “most of her issues revolve around her controlling partner.” (Tr. 258).

         On July 6, 2011, Dr. Sharma noted that Plaintiff “has been doing well and has no complaints.” Dr. Sharma noted that Plaintiff “is doing better except when she is not on Xanax her anxiety is worse” and stated, “Most of her anxiety is associated with issues related to her fiancé.” It was noted that she did exercise by walking and using weights and an exercise ball. (Tr. 256). Her mood was anxious but her mental status examination was otherwise normal. (Tr. 257).

         On October 3, 2011, Plaintiff returned to Dr. Sharma for follow up, but no mental symptoms were discussed; her Xanax prescription was refilled. (Tr. 252-53).

         On April 9, 2012, Plaintiff returned for follow-up and reported “going through some significant stress in life which is related to her family cabin that burned down, ” as well as issues with her boyfriend and finances. She reported anxiety. (Tr. 251). She was out of Xanax, and Dr. Sharma prescribed some. (Tr. 250-51).

         On June 4, 2012, Plaintiff went to Dr. Sharma to have disability paperwork filled out. She reported not doing well with her depression. Dr. Sharma noted that she had stress with her boyfriend, as well as financial stress. Dr. Sharma noted that Plaintiff complained of anxiety, depression, crying spells, irritability, insomnia, depressed mood, lack of interest in pleasurable things every day for more than several months, fatigue, concentration issues, and irritability all the time. She was in tears and had a depressed mood, and Dr. Sharma diagnosed major depressive disorder, single episode, moderate. Dr. Sharma recommended a psychiatric consult. (Tr. 307).

         On June 13, 2012, James W. Morgan, Ph.D., reviewed Plaintiff's records and found that Plaintiff had a medically determinable impairment of anxiety that resulted in no restriction in activities of daily living, mild difficulty in social functioning, mild difficulty in concentration, persistence or pace, and no episodes of decompensation. (Tr. 55-56, 63-64).

         On August 9, 2012, Plaintiff saw Dr. C.J. Jos, M.D., for an initial psychiatric evaluation. Dr. Jos noted that Plaintiff reported a history of depression on and off for the last 20 years, consisting of depressed mood, crying spells, occasional suicidal thoughts, constant anxiety, and being nervous and anxious. (Tr. 293). He noted that Plaintiff had a “quite anxious” mood and affect and had “fair” concentration; her mental status examination was otherwise normal. (Tr. 293-94). He diagnosed generalized anxiety disorder, major depression (recurrent), and personality disorder with compulsive traits; he assigned Plaintiff a Global Assessment of Functioning (“GAF”) score of 65;[2] he prescribed Xanax, Elavil, and Prozac; and he told Plaintiff to follow up in one month. (Tr. 294).

         On September 7, 2012, Plaintiff reported to Dr. Jos that overall she was doing better and using her medications responsibly; Dr. Jos noted a fair mood and affect; assigned a GAF of 65; continued her medications; and advised Plaintiff to come back in three months and call if any issues came up before that. (Tr. 291-92).

         On October 8, 2012, Plaintiff returned to Dr. Sharma and reported that she had seen a psychiatrist, that he continued her medications, and that she was feeling better. She reported being able to do usual activities, being in a good general state of health, and having no fatigue or weakness. She reported exercising using weights and walking. (Tr. 305).

         On November 15, 2012, Plaintiff saw Dr. Jos and “reported she was having a lot of stress related to her boyfriend, ” but that the medications were helping her (Tr. 289). Her mood and affect were fair, and her GAF was 65. She was advised to come back in three months but to call before then if needed. (Tr. 288).

         On February 7, 2013, Plaintiff returned to Dr. Jos, with her chief complaint being depression. Dr. Jos noted that Plaintiff “reported she was still under a lot of stress related to her boyfriend whom she thought was taking advantage of her” and that she “also felt her daughter was taking advantage of her.” (Tr. 287). She was taking her medications responsibly and denied any side effects. Her mood and affect were depressed and she had “mild ideas of hopelessness and helplessness.” She did not want a follow-up appointment with a counselor, but preferred to have a number to call in case there ...


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