United States District Court, E.D. Missouri, Northern Division
BRANDY M. SEVERNS, Plaintiff,
NANCY A. BERRYHILL,  Acting Commissioner of Social Security, Defendant.
D. NOCE, UNITED STATES MAGISTRATE JUDGE.
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.
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).
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).
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).
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).
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).
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.
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.
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).
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.
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).
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).
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).
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.
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).
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).
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).
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).
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).
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.
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 ...