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Severns v. Berryhill

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

September 6, 2017

NANCY A. BERRYHILL, [1] Acting Commissioner of Social Security, Defendant.



         This action is before the court for judicial review of the final decision of the Commissioner of Social Security that the plaintiff, Brandy M. Severns, is not disabled under Title II or Title XVI of the Social Security Act and thus not entitled to disability insurance benefits (“DIB”), 42 U.S.C. §§ 401 et seq., or supplemental security income (“SSI”). 42 U.S.C. §§1381-1383(f). 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, the decision of the Commissioner is affirmed.

         I. BACKGROUND

         Plaintiff was born on June 2, 1973. (Tr. 163). She filed applications for DIB and SSI in March 2013. (Tr. 163-76). She alleged an onset date of August 1, 2010, claiming disability based on degenerative disk disease, restless leg syndrome, non-malignant endometrian disease, depression, back issues, pain throughout body, hyperthyroidism, and high blood pressure. (Tr. 229). These initial applications were denied on May 20, 2013, and she requested a hearing before an administrative law judge (“ALJ”) in June 2014. (Tr. 104-19). Plaintiff appeared before the ALJ on January 28, 2015. (Tr. 29). On February 27, 2015, the ALJ determined that plaintiff was not disabled. (Tr. 14-24).

         Plaintiff appealed the ALJ's decision, and the Appeals Council denied her request for review on May 17, 2016, making the decision of the ALJ the final decision of the Commissioner of Social Security. (Tr. 1-5).

         A. Medical Record

         On August 15, 2011, Plaintiff was evaluated by physical therapist Jennifer Hu, DPT. (Tr. 277-78). Dr. Hu opined that plaintiff was able to perform functional tasks while walking, standing, and sitting; was able to reach overhead without difficulty; was unable to squat due to fear of losing balance; and was unable to bend forward to touch the floor. (Tr. 277). She also found plaintiff able to perform light lifting of less than or equal to 10 pounds. (Tr. 277).

         On November 30, 2011, plaintiff began treatment with Hope Tinker, MD, and Leann Williams, Family Nurse Practitioner-BC, for cervical motion tenderness and dysfunctional uterine bleeding. (Tr. 279-80).

         On March 19, 2012, she saw Courtney Barr, MPH, MD, for heavy vaginal bleeding. (Tr. 319). Dr. Barr diagnosed plaintiff with menorrhagia, and treatment options were discussed with her including ablation procedures, IUDs, a hysterectomy, and hormone injections. (Tr. 322). Plaintiff decided to consider options elsewhere before making a decision. (Tr. 322).

         From February 12, 2013 to August 5, 2013, Dr. Tinker and Nurse Practitioner Williams treated plaintiff for hypertension, back pain, hypothyroidism, elbow pain, menorrhagia, chest pain, high blood pressure, and depression. (Tr. 376-81). The treatment plan discussed included prescriptions of Narflex, Paxil, and Lisinopril along with an elbow strap and ice. (Tr. 376-81).

         On May 4, 2013, plaintiff saw Dennis Velez, MD, for a consultative examination. (Tr. 337-43). Plaintiff was tender to palpation of the lumbosacral spine, with limited range of motion. (Tr. 342). However, Dr. Velez did not find any limitations in her ability to sit, stand, walk, lift, or carry. (Tr. 342). He also did not find plaintiff to have any manipulative limitations or verbal or written communication problems. (Tr. 342).

         On May 28, 2013, plaintiff complained of back and lumbar pain at an urgent care clinic. (Tr. 413-18). She had a lumbosacral spine x-ray that revealed mild lumbar spondylosis. (Tr. 417). Keith Groh, MD, recommended that she follow up with a neurosurgery clinic as needed. (Tr. 416).

         On June 6, 2013, on referral from Dr. Groh, plaintiff was evaluated by Thorkild Norregaard, MD, at the University of Missouri Neurosurgery Clinic, with back pain and left-sided radicular leg symptoms. (Tr. 388-91). Dr. Norregaard diagnosed her with neurogenic claudication, lumbago, left lower extremity radiculopathy, and new-onset seizures. (Tr. 391). He recommended an MRI of the lumbar spine on suspicion of degenerative disc disease and possible neuro foraminal stenosis. (Tr. 391). A week later, plaintiff had an MRI and was examined by Kimberly McBride Johnson, PA, who did not find significant disc abnormality and recommended that she continue conservative management with Naproxin and Flexeril. (Tr. 393).

         On October 18, 2013, plaintiff returned to the urgent care clinic reporting back and right hip pain due to a fall two weeks prior. (Tr. 420). She was prescribed acetaminophen-hydrocodone and prednisone. (Tr. 419-22).

         On December 15, 2013, plaintiff was examined at the Missouri Orthopaedic Institute by Mark Drymalski, MD. (Tr. 395). Dr. Drymalski reviewed plaintiff's MRI and found multi-level degenerative disc disease, slight-to-moderate decreased disc space height, mild foraminal stenosis bilaterally at ¶ 5-S1, broad based disc bulge at ¶ 4-5, and central disc protrusion at ¶ 5-S1. (Tr. 397). Dr. Drymalski prescribed a Gabapentin titration for chronic pain, Robaxin, and recommended referrals as necessary. (Tr. 398). He also recommended avoiding opioids for chronic pain. (Tr. 398).

         On February 26, 2014, plaintiff saw Rick Bonnette, DO, at Family Health Care for decreased back mobility. (Tr. 351-53). Dr. Bonnette determined that plaintiff could only forward flex 45 degrees before experiencing pain. (Tr. 351). He advised plaintiff to continue taking previously-prescribed medication, to lose weight, and to quit smoking. (Tr. 352).

         On May 8, 2014, plaintiff had a follow-up appointment with Dr. Drymalski for her chronic back pain and right leg pain. (Tr. 399). Dr. Drymalski prescribed Flexeril, a continuation of Gabapentin, and a referral for stress urinary incontinence. (Tr. 401).

         Plaintiff saw Dr. Bonnette again on June 10, 2014, for a swollen and painful neck. (Tr. 363). He refilled her prescription of Bactrim and recommended continuing a muscle relaxer, Mobic. (Tr. 367). He also advised plaintiff to sleep with her neck supported in a neutral position, try some neck exercises, and use moist heat on the affected area. (Tr. 367). Dr. Bonnette also suggested plaintiff get x-rays of her cervical spine and see pain management doctors. (Tr. 367).

         On July 22, 2014, plaintiff saw Christopher O'Connell, MD, at the University of Missouri Health Care Psychiatry Clinic for an initial depression and anxiety evaluation. (Tr. 402). Dr. O'Connell found that plaintiff had symptoms suggestive of anxious depression and prescribed her Zoloft, Trazodone, and Xanax. (Tr. 405).

         The same day, plaintiff was treated at the urgent care clinic for knee pain after another fall. (Tr. 423). The doctors ordered an x-ray, prescribed Norco for the pain, and instructed her to ice her knee and wear a knee brace. (Tr. 425).

         On July 31, 2014, plaintiff returned to the Missouri Orthopaedic Institute for a follow-up with regard to her chronic low back and right leg pain. (Tr. 406). Dr. Drymalski ordered an x-ray of her right knee and recommended she continue taking Flexeril, Mobic, and Gabapentin. (Tr. 408). Dr. Drymalski noted plaintiff was “continu[ing] to do well from a medication standpoint.” (Tr. 406).

         On September 2, 2014, plaintiff had a follow-up appointment with Dr. O'Connell for anxiety and depression on September 2, 2014. (Tr. 410). Dr. O'Connell increased her Zoloft and Trazodone prescriptions. (Tr. 412). He observed that plaintiff had normal cognition, memory, language, and fund of knowledge. (Tr. 411). He noted that her symptoms were improving and she was open to increased medication and therapy. (Tr. 411).

         In January 2015, Dr. O'Connell wrote a letter stating that he had been plaintiff's doctor since July 2014 and that her diagnoses were Major Depressive Disorder, Panic Disorder with Agoraphobia, and Generalized Anxiety Disorder. (Tr. 427). The letter explained that plaintiff's disorders may be aggravated by triggers, including stress and physical pain, and that plaintiff was impaired to return to work. (Tr. 427).

         In January 2015, Dr. Drymalski submitted a Physician's Assessment form confirming plaintiff's diagnoses of failed back syndrome, right SI joint pain, and lumbar spondylosis. (Tr. 428). He noted that plaintiff can sit for one hour at a time before needing to get up, and stand 30 minutes at a time before needing to sit down. (Tr. 429). Further, he noted that he “would not expect chronic back pain to affect punctual [work] attendance.” (Tr. 430). He clarified this letter six months later, in August 2015, after the ALJ's ...

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