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Castro v. Berryhill

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

June 18, 2018

JOYCE CASTRO, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         This action is before the court for judicial review of the final decision of the defendant Commissioner of Social Security denying the application of plaintiff Joyce Castro for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401-434. 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 final decision of the Commissioner is affirmed.

         I. BACKGROUND

         Plaintiff was born on December 7, 1950 and was 65 years old at the time of her hearing. She filed her application on October 21, 2013, alleging a February 15, 2013 onset date. (Tr. 120, 479, 665.) She alleged disability due to high blood pressure, diabetes, leaking heart valve, high cholesterol, asthma, chronic obstructive pulmonary disease (COPD), depression, laryngitis, and a heart murmur. (Tr. 337.) Her application was denied, and she requested a hearing before an ALJ. (Tr. 239-49.)

         On April 13, 2016, following a hearing, an ALJ found that plaintiff was not disabled as defined in the Act. (Tr. 120-29.) She moved the Appeals Council to allow her to present new and material evidence, medical records from Mercy Hospital-Washington from November 12, 2013 to November 5, 2015. (Tr. 9.) On May 19, 2017, the Appeals Council denied her request for review, starting that it found no reason under the rules to review the ALJ's decision. (Tr. 1-5, 295-98.) Thus, the decision of the ALJ stands as the final decision of the Commissioner.


         The following is a summary of plaintiff's medical history relevant to this appeal. On October 28, 2013, plaintiff was seen at Mercy Hospital to establish care. She stated that she was applying for disability. Deborah Beste, N.P., examined plaintiff and diagnosed hypertension, diabetes, asthma, mitral valve prolapse, tobacco use disorder, marijuana abuse, depression, gastro esophageal reflux disease (GERD), rib pain, and chronic laryngitis. She had smoked a pack of cigarettes every day for 46 years. She was prescribed Celexa, an antidepressant, and Lisinopril, for high blood pressure, and instructed to return in two weeks. (Tr. 420-34.)

         Plaintiff returned to Mercy Hospital on November 14, 2013 for follow-up and complaints of hoarseness. Her blood pressure was elevated and needed better control. A laryngoscopy was ordered. She also complained of headaches and some chest pressure. (Tr. 671-77.) She was seen again on November 20, 2013. She stated that she had stopped taking Celexa because it made her nauseated, that she did not want to take anything more for her depression, and that she did not want to go to counseling. (Tr. 665.) On July 28, 2014, she was seen for an earache. Her blood pressure was elevated. She reported that she had run out of her blood pressure medication months earlier. She was restarted on Atenolol, used to treat high blood pressure. (Tr. 638-49.)

         On January 13, 2014, plaintiff underwent a consultative psychological evaluation by Paul Rexroat, Ph.D., a psychologist, for her depression. (Tr. 501-04.) She reported that anxiety was not a problem for her and that she had never received treatment from a mental health professional. She reported feeling sad, lonely, and worthless, as well as being easily irritated even though she still liked being around other people. She described being forgetful and having trouble concentrating. She believed she had been intermittently depressed for fifteen years. (Tr. 502.)

         Upon examination, plaintiff was not suspicious, anxious, tense, or weepy. She exhibited a normal range of emotional responsiveness and a normal affect, and was alert and cooperative. She had normal, coherent, and relevant speech, and exhibited adequate social skills. She was well oriented to person, place, time, and situation. She appeared to have normal memory and average intelligence. She was able to solve simple math problems, count backwards, and perform normal abstract verbal reasoning. (Tr. 502-04.)

         Dr. Rexroat believed plaintiff had mild limitations in activities of daily living and in social functioning. He indicated that plaintiff was able to sustain concentration, persistence, and pace with simple tasks. Dr. Rexroat diagnosed moderate recurrent major depression and cannabis abuse. He assigned plaintiff a Global Assessment of Functioning (GAF) score of 62, indicating mild symptoms. He concluded her prognosis was “guarded” because of her depression. (Tr. 503-04.)

         On January 13, 2014, a carotid duplex study, an ultrasound that looks for blockages in the carotid arteries, showed mild atherosclerosis in the left and right proximal internal carotid arteries. (Tr. 966.) Following an abnormal EKG, additional heart imaging revealed normal systolic function. (Tr. 958.)

         On January 14, 2014, plaintiff underwent a laryngoscopy for excision of a bilateral cord polyp. (Tr. 945, 948-49, 951.)

         On January 25, 2014, plaintiff saw Raymond Leung, M.D., an internist. Dr. Leung diagnosed hypertension, diabetes, heart murmur, neck and back pain with decreased range of motion in the cervical and lumbar spines, and asthma and COPD. Dr. Leung did not provide an opinion regarding plaintiff's physical abilities. (Tr. 507-10.)

         Cervical spine imaging on March 19, 2014, showed mild to moderate multilevel degenerative change, and mild reversal of the normal cervical lordosis. Lumbar imaging revealed mild multilevel degenerative change. (Tr. 515-16.)

         On March 21, 2014, state-agency medical consultant, Kyle W. Devore, Ph.D., a clinical psychologist, reviewed the record. He opined that plaintiff had mild restrictions in activities of daily living; no difficulties maintaining social functioning; mild difficulties maintaining concentration, persistence, or pace; and no repeated episodes of decompensation. Dr. Devore concluded that plaintiff did not have a severe mental impairment because she had no more than mild limitations in any functional area. (Tr. 228-30.)

         On September 2, 2014, plaintiff saw Arjun Singh, M.D., an internist, for anxiety and back pain. Plaintiff described her anxiety as an 8/10 with medication and 10/10 without medicine. Dr. Singh prescribed Xanax, a short acting drug used to treat anxiety, and recommended that she obtain counseling and treatment with a psychiatrist. Plaintiff saw Dr. Singh every two weeks during September and October 2014 for anxiety. (Tr. 538-543.)

         A coronary angiography on September 5, 2014, demonstrated severe two vessel coronary artery disease. She received percutaneous coronary intervention, a non-surgical procedure used to treat narrowing of the coronary arteries of the heart found in coronary artery disease, with excellent results. (Tr. 912, 925.)

         Plaintiff sought emergency treatment on October 20, 2014, for chest pain, anemia, and gastrointestinal bleeding. (Tr. 852.) An upper G.I. endoscopy confirmed iron deficiency anemia secondary to chronic blood loss. She received a transfusion and intravenous Protonix, used to treat heartburn. She was diagnosed with GERD. (Tr. 772, 777, 815.)

         On November 24, 2014, plaintiff reported having anxiety spells every few days for several months. Dr. Singh continued her on Xanax and saw plaintiff on a monthly basis through October 23, 2015. (Tr. 519-22, 526-37.)

         An echocardiogram administered on September 16, 2015, revealed, among other things, normal left ventricle size and function, with an estimated ejection fraction, a measurement of the percentage of blood leaving the heart each time it contracts, of 60%, which is considered normal; impaired relaxation; mild left atrial enlargement; and thickened aortic valve with severe stenosis or narrowing. (Tr. 754.)

         A heart catheterization on September 25, 2015, demonstrated moderate aortic stenosis or narrowing; patient stents, systemic hypertension; mildly elevated filling pressures; and anemia. (Tr. 721.)

         On November 5, 2015, a small intestinal endoscopy confirmed iron deficiency anemia and gastrointestinal hemorrhage. (Tr. at 710, 714.) A heart catheterization of March 24, 2016, revealed moderate to severe aortic stenosis, normal cardiac output, one ...

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