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Wren v. Colvin

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

September 7, 2016

PATRICIA A. WREN, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION

          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 applications of plaintiff Patricia Wren for disability insurance benefits and social security income benefits under Titles II and XVI of the Social Security Act (the Act), 42 U.S.C. §§ 401, 1381. 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). (ECF No. 8.) For the reasons set forth below, the decision of the Administrative Law Judge is affirmed.

         I. BACKGROUND

         Plaintiff was born on October 13, 1960. (ECF No. 12 at 197.) She filed her application for Title II benefits on April 15, 2011, and her application for Title XVI benefits on April 30, 2011. (Id. at 194-95.) She initially alleged an onset date of December 31, 2002 (Id. at 497, 504), but amended that to May 15, 2009 (Id. at 11, 643.) She alleges she was unable to work due to knee pain, depression, hepatitis C, asthma, tuberculosis, high blood pressure, and idiopathic thrombocytopenia. (Id. at 649.) Plaintiff's applications were denied on May 31, 2011 (id. at 193), and she requested a hearing before an Administrative Law Judge. (Id. at 231.)

         The ALJ held hearings on September 9, 2011; March 5, 2012; and September 6, 2012, and issued an unfavorable decision on September 12, 2012. (Id. at 100-85, 200- 13.) On December 13, 2012, the Appeals Council granted plaintiff's request for review and remanded the case to the ALJ with instructions to further evaluate plaintiff's RFC based on the assessment of Ollie Raulston Jr., M.D., and to include this more appropriate RFC determination in his hypothetical to the Vocation Expert (“VE”). If needed the ALJ was to obtain additional evidence from a medical expert regarding the severity of plaintiff's impairments. Finally, if there were conflicts between the VE and the Dictionary of Occupational Titles (“DOT”) and other used publications, the ALJ was to explain how he resolved the conflicts. (Id. at 222-23.)

         The ALJ held an additional hearing on October 2, 2013, (Id. at 48-99) and issued a second unfavorable decision on December 9, 2013. (Id. at 11-26.) The Appeals Council chose not to rehear plaintiff's case (Id. at 1-4), and, therefore, the second decision of the ALJ is the final decision of the Commissioner. 20 C.F.R. § 404.984(d).

         II. MEDICAL AND OTHER HISTORY

         On March 29, 2007, plaintiff underwent a disability examination by a state appointed physician, Mary Mullen, M.D. Dr. Mullen found that plaintiff has hepatitis C, post-traumatic stress disorder, and a drug and alcohol dependence. Dr. Mullen, however, opined that plaintiff's disabilities would only be disabling for six to twelve months. (ECF No. 12 at 760-61.)

         On May 22, 2007, plaintiff was seen by Thomas Cabrera, M.D., to whom she was referred through a social services program, Rain, for evaluation and treatment of her hepatitis C. Plaintiff reported abstinence from alcohol and drugs since September 2, 2006. She reported attending Alcoholics Anonymous three times a week and completing counseling for her dependency issues. She reported smoking six packs of cigarettes a week. He found she had hepatitis C, depression (treated with Wellbutrin), acid reflux (treated with Nexium), and a rash. (Id. at 774-75.)

         On June 14, 2007, Dr. Cabrera continued her prescriptions for depression and acid reflux. Plaintiff needed an ultrasound to rule out a gallbladder problem, but due to finances that was not possible at that time. (Id. at 772-73.)

         On August 4, 2008, plaintiff completed an addiction severity index from the Department of Mental Health. It assessed that her chronic medical problems were interfering with her life. Her problems were slight to moderately severe and treatment was probably necessary. (Id. at 782, 787-93.)

         Plaintiff was admitted to in-patient treatment for her addictions from August 4 to September 2, 2008, after being referred by her parole officer. She completed the residential program and it was recommended that she complete an intensive outpatient program, continue counseling, attend a twelve step program five to seven times a week, and follow the directives of her parole officer. (Id. at 785-86.)

         On September 26, 2008, an x-ray of plaintiff's chest showed no active disease in her chest. Her lungs were clear, her heart was within normal size limits, and her bones were normal. (Id. at 882.)

         On October 20, 2008, plaintiff was diagnosed by the Missouri Department of Health with tuberculosis. She was prescribed Rifampin. Her tuberculosis was monitored by the Missouri Department of Health through March 27, 2009. (Id. at 855-72.)

         On October 24, 2008, plaintiff was seen again by the Missouri Department of Health. Her chronic health issues included asthma, acid reflux, and hepatitis C. (Id. at 877-79.)

         On October 28, 2008, medications were ordered for plaintiff. These medications included Benzonatato, a cough suppressant; Loratadine, for allergies; Chantix, for smoking cessation; Veramyst, for allergies; ProAir, for asthma; and, rifampin, for tuberculosis. (Id. at 895.)

         On November 20, 2008, plaintiff completed an addiction severity index from the Department of Mental Health. It evaluated her hepatitis C and tuberculosis as between considerable and extreme and found that treatment was absolutely necessary. Plaintiff reported smoking about one pack of cigarettes a day. (Id. at 796-803.)

         On February 5, 2009, plaintiff was seen at the Montgomery City Medical Clinic. She reported an increase in fatigue, muscle soreness, joint pain, chest and back discomfort. (Id. at 815.)

         On September 17, 2009, plaintiff completed an Addiction Severity Index for the Department of Mental Health. Her medical issues were assessed as only slightly to moderately problematic and her substance abuse problems were moderate and probably needed treatment. Plaintiff was diagnosed with alcohol dependence, cannabis dependence, cocaine abuse in sustained full remission, amphetamine in sustained full remission, and opiate abuse in sustained full remission. (Id. at 834-42.)

         On October 11, 2009, plaintiff visited the University of Missouri Emergency Room for a severe cough worsened by smoking. James Gale Osgood, M.D., prescribed her azithromycin, an antibiotic, and diagnosed acute bronchitis. (Id. at 917-19.)

         Plaintiff was admitted to the McCambridge Center on September 19, 2009 and discharged October 16, 2009. There are no treatment notes ascribed to this in-patient stay. (Id. at 824, 848-49.)

         Plaintiff participated in outpatient treatment at the McCambridge Center from December 12, 2009, to May 10, 2010. Plaintiff stated that she was seeking a way to help her stay off alcohol. (Id. at 823.)

         On April 28, 2011, plaintiff was seen at the University of Missouri's Emergency Room in Columbia, Missouri by Henry W. David, M.D. She complained of chronic chest pain that worsened with exertion. She was given Plavix and aspirin. She was also admitted to the inpatient telemetry unit, where she was seen by Deepa S. Prabhakar, M.D. Dr. Prabhakar ordered several tests, and he recommended she stay overnight for observation. Plaintiff left against medical advice. (Id. at 904-14.)

         On May 5, 2011, plaintiff filed a disability report citing back problems, knee pain, depression, hepatitis C, asthma, tuberculosis, high blood pressure, and idiopathic thrombocytopenia as the conditions preventing her from working. She was taking no prescription medications at the time and did not list any ongoing treatment for any condition. Her last medical visit was to an Emergency Room in Columbia, Missouri for high blood pressure, chest pains, a blood disorder, and headaches on April 28, 2011. (Id. at 648-58.)

         On May 11, 2011, plaintiff completed a function report regarding her disabilities. Plaintiff stated that she used to walk everywhere and complete chores, but could no longer do those because she would “get very tired very fast.” Furthermore, she could only lie down for about four hours due to back pain. She then stated that she can prepare simple meals, do laundry and dishes as needed. She never goes outside unless it is directly to the car, because it causes too much pain and aggravates her asthma. She stated that she could no longer lift, squat, bend, stand, reach, walk, sit, kneel, talk, climb stairs, remember things, complete tasks, concentrate, understand and follow directions, and use her hands. She cannot handle stress anymore and has lost her confidence. (Id. at 694-704.)

         On May 16, 2011, plaintiff's brother completed a third party function report. He stated that he and his sister live together in an apartment and they do light house work, watch TV, and shop together. He stated plaintiff prepares her own simple meals every day and can do indoor chores, including vacuuming and dishes. He stated she was limited in her ability to lift, squat, bend, stand, reach, walk, sit, kneel, remember things, climb stairs, use her hands, and concentrate. He claimed she cannot handle stress; she gets angry and gets headaches. She also is easily confused. He stated she was currently depressed and no longer goes out or socializes. (Id. at 708-15.)

         On May 31, 2011, Marc Maddox, Ph.D., completed a psychiatric review technique form after a telephone interview and review of her records. He diagnosed plaintiff with depression, alcohol abuse, and cannabis dependence. Dr. Maddox determined that plaintiff had mild daily activity and social functioning restrictions, as well as moderate concentration, persistence, or pace restrictions. Dr. Maddox provided a mental RFC assessment. He found she was moderately limited in her ability to understand, remember, and carry out detailed instructions or concentrate for extended periods of time. In all other sections she was listed as not significantly limited. (Id. 923-37.)

         On June 28, 2011, plaintiff provided an updated medication list. It included over-the-counter seasonal allergy relief; adult low-dose aspirin for high blood pressure; and 200mg ibuprofen, three times a day, for her pain. (Id. at 728.)

         On May 31, 2011, Lindsey Struemph, a disability examiner, completed a physical residual function (“RFC”) assessment. Plaintiff's diagnoses included hepatitis C, a history of tuberculosis, asthma, hypertension, back pain, and knee problems. Ms. Struemph assessed that plaintiff could lift 20 pounds occasionally and 10 pounds frequently. She could stand or walk about six hours in an eight-hour day. Plaintiff would have no limitations in pushing, pulling, stooping, kneeling, crouching, or crawling, but should only climb or balance occasionally. Plaintiff has no problems manipulating objects and has no visual or communicative limitations. She should avoid extreme cold, heat, humidity, vibration, respiratory triggers, and work hazards (i.e. heights and machinery). Ms. Struemph noted that plaintiff took no pain relief medication, but could perform personal care, prepare simple meals, do laundry and dishes, ride in a car, go out alone, drive, shop, and manage her finances. Ms. Struemph gave plaintiff's allegations only partial weight. (Id. at 186-92.) Finally Ms. Struemph found, although plaintiff could not perform her past work, she could perform other work and, therefore, was not disabled. (Id. at 193.)

         On November 21, 2011, plaintiff was diagnosed with bronchitis and given a prescription for doxycycline hyclate. (Id. at 956-57, 1087-99.)

         On November 23, 2011, plaintiff was seen by Sandi Reese, APRN-BC at the Kneibert Clinic in Poplar Bluff, Missouri for a follow up visit. Her medications included ibuprofen, promethazine (cough suppressant), Proventil nebulizer (asthma), and albuterol. She continues to smoke and either is uncommitted or has no desire to quit. She reported her asthma and hypertension had improved, and her hepatitis C remained unchanged. Pulmonary tuberculosis, which is partially treated, was added as a new problem. (Id. 1042-45.)

         On December 7, 2011, plaintiff was seen by Nurse Reese for a follow-up visit. Her asthma was reported as improved, but her other conditions-hypertension, hepatitis C, and pulmonary tuberculosis, remained unchanged. New health problems were hematuria, blood in her urine, and gastroesophageal reflux disease. (Id. at 1056-60.)

         On December 19, 2011, plaintiff was seen by Psychiatric Mental Health Nurse Linda Sue Hammonds at the Kneibert Clinic in Popular Bluff, Missouri. Plaintiff asserted she was having problems with depression and mood swings. She has extreme guilt and does not eat enough. She denies suicidal and homicidal thoughts. She continues to have flashbacks about the murder of her six month old daughter by her former husband in 1978. Plaintiff has had at least eleven suicide attempts and hospitalizations since her daughter was killed. Her last attempt was in 2004. Her last alcohol and cannabis use was September 14, 2011. Her Global Assessment of Functioning was between 40 and 45.[1]Nurse Hammonds diagnosed her with affective/bipolar disorder, posttraumatic stress, polysubstance dependency, and antisocial personality disorder. (Id. at 1063-70.)

         On December 19, 2011, plaintiff was seen by Nurse Reese for a follow-up. She was prescribed ibuprofen, promethazine, Proventil, Albuterol, Cipro (an antibiotic), Zantac (for heartburn), haloperidol, and keflex (an antibiotic). She was diagnosed with two additional problems: a urinary tract infection and chronic obstructive pulmonary disease (“COPD”). (Id. 1077-82.)

         On January 6, 2012, plaintiff was seen at the Poplar Bluff Regional Medical Center by Lauren Blackwelder, M.D., to be cleared for admission to an inpatient detox center. (Id. at 1102-06.)

         On January 10, 2012, plaintiff completed a daily activities report. She stated she stopped working because of her limitations. She asserted she always has difficulties with bathing, going to the bathroom, eating, sleeping, making decisions, finishing tasks, and shopping. She reported she often has problems dressing; using the telephone; visiting friends or family; and doing group, church, or club activities. She seldom has problems with taking medicines on time, remembering schedules, doing her personal business or finances, and traveling. She can always make easy meals but will seldom make complicated meals. She defined easy as cereal, sandwiches, and microwave dinners, but any type of prep work was complicated. She limited her standing to ten minutes, sitting to 15 to 20 minutes, and walking to 20 minutes, and she cannot carry anything after a few minutes. She cannot lift, bend, ...


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