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Doshie v. Saul

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

August 28, 2019

ANDREW M. SAUL, [1] Deputy Commissioner of Social Security Defendant.



         Plaintiff, Tangelia Doshie seeks review of the decision by Defendant Social Security Commissioner Andrew M. Saul denying her applications for Disability Insurance Benefits and Supplemental Security Income under the Social Security Act. For the reasons set forth below, the case is reversed and remanded.

         I. Procedural History

         On July 16, 2014, Plaintiff, then forty-five years old, filed an application for a period of disability and Disability Insurance Benefits, alleging that she became disabled on February 1, 2014 due to: “migraine headaches; cervical spine injury and constant pain; a cyst drained from the front lobe of my brain; major depression; asthma; severe peptic ulcers; and anxiety.” (Tr. 69) The Social Security Administration (“SSA”) denied Plaintiff's claims, and she filed a timely request for a hearing before an administrative law judge (“ALJ”). (Tr. 112-13)

         The ALJ conducted a hearing in March 2017 at which Plaintiff and a vocational expert testified.[2] (Tr. 43-67) In a decision dated September 6, 2017, the ALJ found that Plaintiff “has not been under a disability within the meaning of the Social Security Act from February 1, 2014, through the date of this decision.” (Tr. 16) Plaintiff filed a request for review of the ALJ's decision with the SSA Appeals Council, which denied review. (Tr. 1-4) Plaintiff has exhausted all administrative remedies, and the ALJ's decision stands as the SSA's final decision. Sims v. Apfel, 530 U.S. 103, 106-07 (2000).

         II. Evidence Before the ALJ

         A. Testimony

         At the hearing, Plaintiff testified that her depression and anxiety stemmed from trauma in both her early and adult life. (Tr. 51-52) She stated that she was molested throughout her childhood, her grandchild died, and she suffered PTSD from past trauma. Id. Plaintiff previously worked as a “collections escalation forbearance manager” for thirteen years, until the “job ended.” (Tr. 53) Plaintiff “tried to go through the training” to transition from collections work to sales, but she “couldn't grasp the new material.” (Id.) When the ALJ observed that Plaintiff had “a really long work history, very stable, ” Plaintiff explained, “I thought working was helping, I didn't have all of the other physical problems that I have now.” (Tr. 52)

         Plaintiff was employed when she “had my surgery for my brain injury.” (Tr. 52) The surgery and treatment relieved the “swelling and pressure” for a time, but now “it hurts so bad to try to even get out of bed sometimes.” (Id.) In regard to her neck pain, Plaintiff stated: “I need two discs replaced. I have bone spurs, herniated disks with a pinched nerve that I need surgery to fix. Limits me to raising my arms above my head.” (Tr. 55) Plaintiff testified that her knee pain was worse in the right knee than the left. (Tr. 56) Her right knee “stays swollen, it's more painful…goes out more, it's more unstable and causes me to lose my balance more, I fall easily.” (Id.)

         As a result of her “neck issues, ” Plaintiff needed her mother's help to brush her hair and dress “a lot of times.” (Tr. 55) Standing for longer than ten minutes aggravated Plaintiff's back pain. (Tr. 57) Because she needed to stop and rest, Plaintiff's morning routine, which involved brushing her teeth, washing her face, and using eye drops, “took longer than ten to fifteen minutes.” (Tr. 58)

         Plaintiff began using a cane in summer 2016. (Id.) Around the same time, Plaintiff experienced significant weight gain, which she attributed to Seroquel. Plaintiff stated that, at her heaviest, she weighed over 325 pounds, but she lost some of the weight when she discontinued the medication and changed her eating habits. (Tr. 59-60)

         Plaintiff did not like crowds and preferred to be alone or in a small group. (Tr. 51, 61) Plaintiff also testified that she would often “forget the simplest things, like where I put my glasses or what I went in the room for. I have to ask my mother a lot of things, a lot of it simple and then I get upset….” (Tr. 60) Plaintiff stated she had “used marijuana in the past” because “it was supposed to help with anxiety, ” but, in her experience, it “sort of made it worse.” (Tr. 51) Plaintiff denied using cocaine. (Id.)

         The vocational expert testified that Plaintiff's past work as a collection clerk was classified as skilled sedentary work. (Tr. 62) The ALJ asked the vocational expert to consider a hypothetical individual with Plaintiff's age, education, and work history who was:

limited to work at the light exertion level in that they can lift, carry, push or pull [twenty] pounds occasionally, ten pounds frequently. Can sit for six hours in an eight-hour workday, but can only stand or walk for four hours in an eight-hour workday. Can never climb ropes, ladders or scaffolds. Can frequently crouch or crawl. May only frequently reach overhead. May only frequently feel with the upper left extremity.

(Tr. 62-63) The vocational expert testified that such an individual could perform Plaintiff's previous work. (Tr. 63)

         The ALJ asked the vocational expert to consider the same individual “but also add that the individual is limited to simple, routine tasks with minimal changes in the job setting and duties. No. handling of customer complaints and no fast-paced production work.” Id. The vocational expert stated that such an individual could not perform Plaintiff's past work but could perform jobs requiring light, unskilled labor, such as packers, wrappers, product inspectors, and production workers. Id. Finally, the ALJ asked the vocational expert to consider all of the limitations from the second hypothetical and “reduce it down to the sedentary exertion level in that the individual could lift, carry, push or pull ten pounds occasionally, less than ten pounds frequently. They could only stand or walk for two hours in an eight-hour workday.” The vocational expert stated that such an individual could perform the unskilled, sedentary jobs of product inspector and assembler. (Tr. 64)

         B. Relevant Medical Records

         Plaintiff's earliest medical record is from an appointment with her psychiatrist Dr. Walker in February 2014. (Tr. 399) Plaintiff informed Dr. Walker that she was “doing pretty well” but reported “some mild continuing s[ymptoms] of depression.” (Id.) Dr. Walker noted that Plaintiff “took severance from [her] job last June” and was “now looking for work.” (Id.) Dr. Walker diagnosed Plaintiff with major depressive disorder but observed that she was “doing reasonably well given ongoing stressors including father's cancer and treatment. States she has taken and done with current meds.” (Tr. 401) Dr. Walker continued Plaintiff's gabapentin, fluoxetine, and divalproex sodium, and he discontinued her trazodone. (Tr. 399, 402)

         In June 2014, Plaintiff visited her primary care physician, Dr. Simmons, for treatment of pain and spasms in her neck and “burning” in her right shoulder and arm. (Tr. 410) On examination, Dr. Simmons noted tenderness to palpitation and decreased range of motion in Plaintiff's neck. (Id.) Dr. Simmons prescribed baclofen, Voltaren, and tramadol. (Id.) X-rays of Plaintiff's cervical spine performed later that month revealed “moderately severe cervical spondylosis most evidence at ¶ 5-6 and C6-7 with bilateral foraminal narrowing due to posterior vertebral body osteophytes.” (Tr. 415)

         At her follow-up appointment with Dr. Simmons in August 2014, Plaintiff continued to complain of neck spasms and tingling and numbness on her left side, as well as continuous head pain lasting one week. (Tr. 409) Dr. Simmons increased Plaintiff's baclofen and ordered physical therapy and an MRI of Plaintiff's brain and cervical spine. (Id.) The MRI of Plaintiff's cervical spine showed: “prominent degenerative disc disease….The most severe disease is noted at ¶ 5-6 where there is a broad-based right-sided subligamentous disc protrusion that effaces the right side of the cervical spinal cord.” (Tr. 414) The MRI of Plaintiff's brain confirmed “a 3.9 cm cystic mass lesion…in the right frontal lobe, ” which was “slightly increased in size comparison to the prior study done in 2000.”[3] (Tr. 423)

         Plaintiff began physical therapy in early September 2014. (Tr. 428) When Plaintiff returned to Dr. Simmons' office later that month, she complained of continued pain on her right side. (Tr. 478)

         In October 2014, Plaintiff saw Dr. Walker and described her condition as “[p]retty rough. The pinched nerve in my neck is really acting up.” (Tr. 813) Plaintiff reported continued symptoms of depression and her primary complaints were insomnia, “made worse by neck pain, ” and irritability. (Id.) Plaintiff suffered migraines and her “aunt takes her to church, otherwise she tends to isolate.” (Id.) Plaintiff stated that she was in a car accident in January, which caused her to suffer a “thigh contusion and neck injury.” (Id.) In regard to employment, she stated she “doesn't miss work and is too irritable to do the job now.” (Id.)

         Later that month, Plaintiff saw Dr. Chamoun, a neurosurgeon. (Tr. 435-36) Plaintiff primary complaints were “neck pain and bilateral arm numbness and weakness, as well as dizziness and ataxia.” (Tr. 435) Dr. Chamoun reviewed the MRI of Plaintiff's brain and cervical spine and opined that the intracranial cyst “is consistent with benign neuroglial cyst. At this point, there is no significant mass effect from the cyst, and I don't think the cyst is causing her symptoms.” (Tr. 435) Dr. Chamoun referred Plaintiff to Dr. Woodrow at the Spine Center. (Id.) At that time, Plaintiff's medications included baclofen, Voltaren, gabapentin, and hydrocodone/acetaminophen. (Tr. 436)

         In November 2014, Plaintiff informed Dr. Walker that she was “pretty rough still with my neck” but her sleep was “somewhat better.” (Tr. 808) Plaintiff believed her “neck problems [were] aggravated by [a car] wreck, ” and she “reported fatigue/lethargy, sleeping pattern disruption, and chronic pain but no other constitutional issues.” (Tr. 808, 809) Additionally, Plaintiff complained of “frequent headaches, ” and “feeling depressed, anxiety, insomnia, excessive moodiness, and stress….” (Tr. 809) Dr. Walker observed “little benefit at this time from fluoxetine” and prescribed mirtazapine, “which should help her sleep, agitation, and perhaps her pain.” (Tr. 810)

         In December 2014, Dr. Woodrow ordered a cervical x-ray and confirmed “severe joint space narrowing” at C5-C6 and C6-C7. (Tr. 481) Dr. Woodrow examined Plaintiff and noted normal range of motion of the cervical spine and, on motor testing, “normal bulk and tone throughout with 5/5 power throughout the upper and lower extremities bilaterally.” (Tr. 483) Plaintiff rated her pain as a six on a ten-point scale. (Id.) Dr. Woodrow opined that Plaintiff “would benefit from a cervical decompression, likely 2 level ACDF to help with her upper extremity symptoms” but it was “hard to say what will happen with her neck pain per se. It seems a little bit out of proportion to her imaging.” (Id.) Dr. Woodrow ordered a CT scan and epidural steroid injections. (Tr. 484)

         Later that month, Plaintiff saw Dr. Simmons for treatment of sinusitis and cervical nerve route impingement. (Tr. 595) Dr. Simmons noted: “The neck has mild anterior cervical adenopathy” and “tenderness bilaterally with some muscle spasm.” (Tr. 596)

         Also in December 2014, a psychologist, Dr. Bean, performed a consultative evaluation at the request of Disability Determination Services.[4] (Tr. 441-44) During the consultation, Plaintiff reported having “bipolar schizophrenia, ” migraine headaches stemming from her cyst that could last “up to two or three weeks, ” “neck problems, ” and related “problems with her left arm including weakness and numbness.” Id. She stated that she took medication for her migraine headaches, ulcers, mental health issues, insomnia, and anxiety. (Tr. 442) She reported that those medications were not very helpful. Id.

         Plaintiff informed Dr. Bean that she worked for “about 13 years doing customer service and collection work, ” which “she very much enjoyed and she was good at it.” (Id.) Plaintiff explained that, when her former employer eliminated her department in June 2013, they offered her a sales position, but she declined “feeling she was not good for that type of work.” (Id.) Plaintiff accepted a severance package and “has continued to look for work in the customer care and collections field but has been unable to find anything.” (Id.)

         Plaintiff stated that she had “numerous friends” who “g[o]t together at least weekly” to play board games and video games. Id. She also informed Dr. Bean that she enjoyed reading and cooking and was “very active with her church[.]” (Id.) Plaintiff lived with her adult daughter, three grandchildren, and eighteen-year-old son. (Id.) Plaintiff stated that she “[did] her best to keep the house clean” but worked slowly because of the weakness in her arm and hand. Id. Dr. Bean noted that Plaintiff was “able to bathe, dress, and groom herself” but sometimes needed assistance from her daughter. (Id.) Plaintiff could drive and would run errands “for herself and the household.” (Id.) She reported doing light housework but noted that even relatively light items, like a casserole dish, could present a challenge because of her left arm weakness. (Tr. 442-43) She walked “slowly with a somewhat stumbling gait but [did] not use any assistive devices.” (Tr. 443)

         In regard to her mental health, Plaintiff reported she was hospitalized in 2009 with suicidal ideation but she no longer had “thoughts of this sort.” Id. Dr. Bean observed that Plaintiff's affect was primarily dysphoric though “punctuated at times with laughter or smiling related to appropriate content.” (Id.) He opined that her thought processes were “logical and goal directed” with no “delusional content and…no indications of obsessions or compulsions.” (Id.) Plaintiff was well oriented with “[p]ractical reasoning and social judgment skills” intact. (Id.) Dr. Bean summarized his opinion of Plaintiff's capabilities as follows:

It would appear that [Plaintiff] is capable of appropriately and responsibly managing her own finances. She appears to have the capacity to develop and maintain relationships and to interact effectively with others. She appears capable of understanding and performing tasks with appropriate training, monitoring and supervision. Today she does not demonstrate any apparent difficulty with focus, attention, or concentration. ...

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