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Freeman v. Colvin

United States District Court, W.D. Missouri, Western Division

September 6, 2016

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



         Plaintiff Calvin Freeman appeals the Commissioner of Social Security's final decision denying his application for disability insurance benefits and supplemental security income. The decision is reversed and the case remanded.

         I. Background

         Freeman was born in 1959 and has worked as a cook, housekeeper, and janitor. He alleges he became disabled beginning on June 21, 2013.

         A. Medical history

         1. Respiratory issues

         Freeman has chronic obstructive pulmonary disease, asthma, and other respiratory conditions. From July 2012 to April 2014, he has gone to the emergency room or been admitted to the hospital about 22 times for shortness of breath, including shortness of breath that caused him to wake up at night; wheezing; dyspnea; tachypnea; cough; pneumonia; or acute asthma exacerbation. From November 2012 to October 2015, he was seen by a doctor or at a clinic at least 12 times concerning breathing difficulties or in follow-up to his hospital visits. He has been prescribed inhalers, steroids, and other medications for both short- and long-term treatment. Although a provider noted in March 2014 that Freeman reported walking two or three miles per day, in June 2014, another provider observed that Freeman's shortness of breath caused him significant distress when walking inclines and stairs, and in March 2015, Freeman failed a stair-walk test.

         2. Psychiatric issues

         At a November 2012 clinic visit relating to uncontrolled asthma, the provider noted Freeman had a depressed mood and affect. In June 2013, Freeman went to the emergency room because he was having thoughts of suicide. He reported hearing voices telling him to hurt himself by drinking bleach. After a 12-day stay, he was discharged with diagnoses of depression and cocaine abuse, and prescriptions for psychotropic medications. In July 2013, he went to a clinic to start the process for receiving psychiatric services, and was referred for medication management and therapy. At a subsequent intake visit, examination revealed he had blocking thought processes, poor impulse and anger control, and flat affect. He was diagnosed with severe depression and paranoid schizophrenia, and referred for a complete psychiatric evaluation. Freeman saw Dr. Nallu Reddy, a psychiatrist, at the end of July, reporting that he was afraid of sounds and hearing voices telling him to hurt himself. His mood was depressed. Dr. Reddy diagnosed paranoid schizophrenia and prescribed medications. At a medical appointment in August 2013, the provider noted Freeman was having leg tremors and thought they might be associated with Haldol, which Dr. Reddy had prescribed. The Haldol was later discontinued.

         At a visit with Dr. Reddy in February 2014, Freeman reported that he liked his current combination of medications, Celexa and Seroquel, and was not having side effects; he was happy and smiling at the visit. At an April 2014 visit, Freeman told Dr. Reddy that during a recent hospitalization, he had been given Haldol instead of Seroquel, causing leg weakness, and that he wanted to return to his prior to combination of medications. Dr. Reddy prescribed Celexa and Seroquel, and continued Freeman's diagnosis of paranoid schizophrenia. At an August 2014 visit, Dr. Reddy noted Freeman was going through multiple medical problems, including asthma, hypertension, and heart problems, and was having specialist appointments. The doctor discussed options for other medications in place of the Seroquel, which was causing Freeman to gain a great deal of weight, but Freeman said the Seroquel helped with sleep and the voices. The doctor continued the diagnosis of paranoid schizophrenia, and renewed the prescriptions for Celexa and Seroquel. He noted Freeman would continue therapy, and encouraged him to have goals such as attending the clinic's day program at least twice a week.

         At his late-August 2014 annual evaluation for community support services at Swope Clinic, Freeman reported to his case manager that he experienced auditory hallucinations with commands to hurt himself, paranoia, depression, and other symptoms, and that he was stressed by his health and having several appointments with different providers. The case manager noted Freeman had blunt affect with low anger control. The evaluation summary included treatment recommendations, with which Freeman agreed, including continuing to receive community support services at the rehabilitative level, and seeing his psychiatrist, primary care physician, specialists, therapist, home healthcare nurse, and a nutritionist, and continuing to take prescribed medications. Dr. Reddy approved the evaluation report.

         At an October 2014 therapy session, Freeman was experiencing paranoia, depression, and insomnia. He said he had not been feeling well lately due to deaths in the family and had just returned from a family-member's funeral in another state. He said he had been out of medications for six days and was starting to hear voices and feeling irritable. He said he was spending most of his time in the house because he did not like to be around people. The counselor noted that Freeman was receptive to therapy and to working on his mental health issues. Freeman told the counselor that he had been practicing daily living skills to improve his daily functioning. The following week, Freeman saw Dr. Reddy for medication follow up. After discussing medication alternatives, Freeman was continued on Celexa and Seroquel. The doctor continued Freeman's diagnosis of paranoid schizophrenia, and instructed him to continue attending therapy to learn coping skills, participating in the community support program for assistance with independent living, and seeing his primary care doctor, eye doctor, and dentist for his physical issues.

         From July 2013, when Freeman was discharged from his 12-day hospital stay for suicidal ideation, through his September 2014 annual case management review, Dr. Reddy and his other mental health care providers gave Freeman GAF scores of 50, 32, 38, 42, 45, 45, 46, and 34, in order. Tr. 350, 239, 709, 889, 886, 860, 845-46, and 862.

         3. Other issues

          In 2014, Freeman had episodes of dizziness and fainting. He went to the emergency room in May after a fainting episode, and followed up with doctors at least four times. He was referred for neurological and cardiac evaluations, and had a chest CT, two EEGs, and other tests, all of which were essentially negative. In November, suspecting that one of Freeman's psychiatric medications, Seroquel, could be contributing to his symptoms, a cardiologist recommended he speak with his psychiatrist about it.

         Freeman complained of knee pain starting in December 2013. At a consultation in January 2014, Dr. James Bogener, an orthopedic surgeon, observed swelling in the right knee and bilateral chondral loss in the medial aspect of both knees. He recommended physical therapy and prescribed an anti-inflammatory. Freeman saw Dr. Bogener again in March 2014, complaining of patellar pain. An MRI showed mild patellofemoral arthritis and possible bilateral meniscal tears in the knees. The doctor ...

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