Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Scott v. Berryhill

United States District Court, D. South Carolina

April 5, 2018

Kimberly Rachelle Scott, Plaintiff,
v.
Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant.

          REPORT AND RECOMMENDATION

          Shiva V. Hodges, United States Magistrate Judge

         This appeal from a denial of social security benefits is before the court for a Report and Recommendation (“Report”) pursuant to Local Civ. Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying her claim for Disability Insurance Benefits (“DIB”). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the undersigned recommends that the Commissioner's decision be reversed and remanded for further proceedings as set forth herein.

         I. Relevant Background

         A. Procedural History

         On November 9, 2012, Plaintiff protectively filed an application for DIB in which she alleged her disability began that day. Tr. at 117 and 223-30. Her application was denied initially and upon reconsideration. Tr. at 148-50 and 159-60. On April 12, 2016, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Clarence Guthrie. Tr. at 46-87 (Hr'g Tr.). The ALJ issued an unfavorable decision on May 4, 2016, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 22-45. Subsequently, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 1-6. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on July 13, 2017. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 39 years old at the time of the hearing. Tr. at 50. She graduated from high school and obtained an associate's degree in culinary arts. Tr. at 55-56. Her past relevant work (“PRW”) was as a bus driver, a fast food worker, and a sales clerk. Tr. at 80. She alleges she has been unable to work since November 9, 2012. Tr. at 51.

         2. Medical History

         Plaintiff presented to Blanca I. Durand, M.D. (“Dr. Durand”), on November 5, 2012, for a nine-day history of intermittent vertigo. Tr. at 357. Dr. Durand noted nasal mucosa edema and inferior turbinate hypertrophy, but no other abnormalities. Tr. at 358. She assessed dizziness, benign paroxysmal positional vertigo, Eustachian tube dysfunction, and hypertrophy of nasal turbinates. Tr. at 358-59. She recommended Plaintiff avoid caffeine, follow a low-salt diet, and follow up for Epley maneuver. Tr. at 359. Plaintiff followed up with Michelle L. Dupont, PA-C (“Ms. Dupont”), for Epley maneuver treatment on November 7, 2012. Tr. at 356.

         On November 19, 2012, Plaintiff complained of pain in her back and bilateral knees and shoulders. Tr. at 365. She reported fatigue, weakness, dry eyes and mouth, and skin sensitivity. Id. She indicated she had been very emotional. Id. Rheumatologist Pallavi Sharma, M.D. (“Dr. Sharma”), observed Plaintiff to have right shoulder abduction to 70 degrees and left shoulder abduction to 80 degrees. Tr. at 367. She noted tenderness in Plaintiff's right elbow, but full range of motion (“ROM”) in the bilateral elbows and wrists. Id. She observed active tenderness in Plaintiff's bilateral proximal interphalangeal (“PIP”) and right metacarpophalangeal (“MCP”) joints. Id. She indicated tenderness and crepitus in Plaintiff's bilateral knees and tenderness with full ROM in her bilateral ankles. Id. She noted increased spasm in the lumbosacral spine. Id. Dr. Sharma indicated a complete metabolic profile was normal. Id. She stated Plaintiff had a negative rheumatoid factor, but positive antinuclear antibodies (“ANA”) and Sjogren's syndrome antibodies (“SSA”) greater than eight. Tr. at 367. She assessed Sjogren's syndrome, bilateral knee pain, back pain, fatigue, polyarthritis, and insomnia. Id. She administered Depo-Medrol injections to Plaintiff's bilateral shoulders, referred her for x-rays of her right shoulder and left knee, and instructed her to exercise and to apply warm, moist heat to her back. Id. X-rays of Plaintiff's bilateral shoulders showed mild degenerative change to the acromioclavicular joints. Tr. at 368 and 371. X-rays of Plaintiff's bilateral knees indicated osteoarthritis. Tr. at 369 and 370.

         On January 18, 2013, Plaintiff complained of dry eyes and mouth and pain in her back, feet, hips, and shoulders. Tr. at 362. She reported many fibromyalgia flare ups. Id. She indicated her quality of life had decreased as a result of pain. Id. She reported weakened grip and indicated she experienced hand pain when she drove for long periods. Id. Dr. Sharma observed an erythematous and papulonodular rash on Plaintiff's cheeks and chin. Tr. at 363. She noted 12 of 18 fibromyalgia tender points. Id. She observed mild tenderness in Plaintiff's bilateral shoulders, moderate tenderness in her wrists, and tenderness in her MCP and PIP joints. Id. She indicated moderate tenderness and crepitus in Plaintiff's knees, moderate tenderness and lumbosacral spasm in her back, tenderness in her bilateral trochanteric bursa, and synovitis or deformity in her axial joints. Id. Dr. Sharma instructed Plaintiff to continue to take Plaquenil for Sjogren's syndrome and Duexis for pain and to initiate an aerobic exercise program for fibromyalgia. Id. She increased Plaintiff's Pamelor dosage to 25 mg, prescribed a topical cortisone cream for rash and Flexeril for back pain, and administered a Depo-Medrol injection for bilateral trochanteric bursitis. Id.

         On January 29, 2013, Plaintiff presented to Johns Hopkins Bayview Medical Center for an initial evaluation of Sjogren's syndrome. Tr. at 374. She reported an initial onset of symptoms in July 2012 that included dry eyes and mouth, excessive thirst, exhaustion, trigger fingers, brain fog with impaired memory, diffuse body pain, and stiffness and burning in the joints of her knees, shoulders, hips, ankles, and hands. Id. George Moreno, M.D. (“Dr. Moreno”), observed Plaintiff to have full muscle strength; no focal sensory deficits; full ROM of all peripheral joints; diffuse tenderness over the small joints of the hands, without swelling; and no focal back tenderness. Tr. at 375. He stated the findings were “consistent with early Sjogren's syndrome/undifferentiated connective tissue disease with sicca.” Tr. at 376. He noted that Plaintiff was at increased risk for dental caries and oral infections and recommended that she restrict her sugar intake and optimize her oral hygiene. Id. He advised her to use artificial tears and to increase her consumption of Omega-3 fatty acid to address dry eye symptoms. Id. He stated he would consider adding low-dose Methotrexate or Rituximab for inflammatory arthritis. Id. He indicated Plaintiff should continue to use Cymbalta and Lunesta for fibromyalgia. Id. He stated Plaintiff's brain fog and fatigue might respond to Hydroxychloroquine, Methotrexate, or Rituximab, but acknowledged that the symptoms were difficult to treat in patients with Sjogren's syndrome and that she might not respond to immunosuppressive therapy. Id. He assessed undifferentiated connective tissue disease/early Sjogren's syndrome, inflammatory arthritis, fibromyalgia, brain fog, and fatigue. Id.

         Plaintiff presented to Piedmont Henry Hospital on February 3, 2013, following a syncopal episode. Tr. at 384. She reported pain throughout her body, dizziness, and headache. Tr. at 385 and 388. A physical examination was normal, aside from minimal tenderness over the left mastoid. Tr. at 389. A computed tomography (“CT”) scan of Plaintiff's head showed mild sinus inflammatory disease and left mastoiditis. Tr. at 411. The attending physician diagnosed syncope and mastoiditis, prescribed Allegra and Augmentin, and advised Plaintiff to follow up with her physician on the following day. Tr. at 390.

         Plaintiff followed up with Paul Free, M.D. (“Dr. Free”), on February 7, 2013. Tr. at 402. She complained of dizziness and pain and pressure in her head. Id. Dr. Free noted no abnormalities on physical examination. Tr. at 403. He assessed vertigo, headaches, and syncopal episode and prescribed Prednisone, Meclizine, and Imitrex. Tr. at 403-04.

         On February 21, 2013, Plaintiff reported headaches, unsteadiness, and a spinning sensation. Tr. at 409. She indicated that Imitrex provided only minimal improvement. Id. Dr. Free noted no abnormalities on physical examination. Tr. at 410. He referred Plaintiff for magnetic resonance imaging (“MRI”) of the brain. Id.

         On February 25, 2013, Plaintiff presented to Stephen M. Cohen, M.D. (“Dr. Cohen”), with rectal pain, swelling, drainage, and bleeding. Tr. at 471. Dr. Cohen observed an external opening of an anterior fistula. Id. He performed a fistulectomy on March 15, 2013. Tr. at 485.

         State agency medical consultant Madena Gibson, M.D. (“Dr. Gibson”), assessed Plaintiff's physical residual functional capacity (“RFC”) on March 16, 2013. Tr. at 111-12. She found that Plaintiff could occasionally lift and/or carry 20 pounds; frequently lift and/or carry 10 pounds; stand and/or walk for about six hours in an eight-hour workday; and sit for about six hours in an eight-hour workday. Id. She indicated Plaintiff had no postural, manipulative, visual, communicative, or environmental limitations. Tr. at 112.

         Plaintiff presented to consultative psychologist Gary Kittrell, Ph.D. (“Dr. Kittrell”), for a mental status examination on April 2, 2013. Tr. at 460- 64. She reported chronic anxiety and stress-induced panic episodes. Tr. at 461. She endorsed symptoms of depression that included being easily bored, having poor motivation, anhedonia, restlessness, agitation, excessive worry, and anticipatory anxiety. Id. She indicated her depressive symptoms were exacerbated by pain and personal limitations. Id. She endorsed visual hallucinations, but denied delusions. Id. She reported problems with planning, organizing, multitasking, concentrating, remembering, and maintaining attention. Id. She stated her medication caused side effects that included confusion, nausea, fatigue, and drowsiness. Id. Dr. Kittrell observed Plaintiff to have adequate hygiene and grooming and to be oriented to person, place, and general situation. Tr. at 462. He stated Plaintiff was able to follow three-step directions in providing identification, filling out office forms, and completing various mental status tasks. Id. He noted Plaintiff had below average concentration and memory to presented tasks, as evidenced by her inabilities to repeat five digits backward, to spell “house” backward, and to recite the days of the week backward. Tr. at 462-63. He stated Plaintiff had average cognitive pace, but below average frustration tolerance. Tr. at 463. He indicated Plaintiff's overall social behavior was inadequate, as evidenced by her inability to maintain eye contact or to socially respond in interactions during the interview. Id. He stated Plaintiff had an average general fund of information and below average insight. Id. He noted that Plaintiff had adequate practical reasoning and general hazard recognition abilities. Id. Dr. Kittrell indicated Plaintiff's behavior was consistent with adequate effort and average persistence. Id. He stated Plaintiff demonstrated below average attention and concentration and adequate comprehension. Id. He indicated Plaintiff interacted at an average pace and demonstrated no signs of significant mental confusion. Id. He assessed chronic, complex post-traumatic stress disorder (“PTSD”) and a global assessment of functioning (“GAF') score[1] of 50.[2] Tr. at 464.

         On April 19, 2013, Plaintiff complained of dry eyes and mouth and pain in her bilateral thighs, shoulders, and hips. Tr. at 522. Dr. Sharma noted normal strength, gait, sensation, and muscle tone. Tr. at 523. She indicated Plaintiff had no synovitis, crepitus, or deformity in her extremities. Id. She stated Plaintiff demonstrated 12 of 18 fibromyalgia tender points. Id. She documented significant tenderness in Plaintiff hips, knees, feet, and the MCP and PIP joints of her hands. Id. She noted synovitis or deformity in the sternoclavicular joints, as well as costochondral and entheseal tenderness. Id. She observed Plaintiff to have reduced bilateral shoulder abduction to 80 degrees, bilateral knee crepitus, and positive Faber test. Id. She discontinued Duexis and prescribed Sulindac. Id. She advised Plaintiff to increase her fluid intake, to use Biotin products for oral care, to wear comfortable shoes, to use artificial tears, and to engage in aerobic exercise. Id.

         Plaintiff reported mild rectal discomfort and bright red blood in her stools on April 24, 2013. Tr. at 472. Dr. Cohen noted that Plaintiff's wounds were still healing, but indicated she would need a colonoscopy. Id.

         On April 28, 2013, state agency psychological consultant Vicki Prosser, Ph.D. (“Dr. Prosser”), considered Listing 12.06 for anxiety-related disorders and found that Plaintiff had moderate restriction of activities of daily living (“ADLs”); moderate difficulties in maintaining social functioning; and moderate difficulties in maintaining concentration, persistence, or pace. Tr. at 110-11. She assessed Plaintiff's mental RFC and found that she was moderately limited in her abilities to understand and remember detailed instructions; to carry out detailed instructions; to maintain attention and concentration for extended periods; to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances; to sustain an ordinary routine without special supervision; to work in coordination with or in proximity to others without being distracted by them; to complete a normal workday and workweek without interruptions from psychologically-based symptoms; to perform at a consistent pace without an unreasonable number and length of rest periods; to interact appropriately with the general public; to accept instructions and respond appropriately to criticism from supervisors; to get along with coworkers or peers without distracting them or exhibiting behavioral extremes; to maintain socially appropriate behavior; to adhere to basic standards of neatness and cleanliness; to respond appropriately to changes in the work setting; and to be aware of normal hazards and take appropriate precautions. Tr. at 112-14. Dr. Prosser indicated as follows:

The claimant appears capable of understanding and carrying out instructions and can maintain attention and concentration adequately for 2-hour periods in an 8-hour workday. The claimant can complete a normal 40-hour week of work without excessive interruptions from psychological symptoms, can relate appropriately to coworkers and supervisors on a limited basis and can adapt to a job setting.

Tr. at 114.

         Plaintiff complained of pain in her back and bilateral arms, legs, and knees on July 10, 2013. Tr. at 519. She indicated she had experienced several flare ups of fibromyalgia. Id. She reported numbness and tingling in her arms that interrupted her sleep, bilateral leg pain that radiated to her feet, and severe shoulder pain that affected her ADLs. Id. Dr. Sharma observed Plaintiff to have normal gait, strength, sensation, and muscle tone. Tr. at 520. She noted no crepitus, synovitis, or deformity in Plaintiff's extremities. Id. She indicated Plaintiff had 12 of 18 fibromyalgia tender points. Id. She stated Plaintiff's bilateral shoulders were significantly tender and that she had abduction reduced to 110 degrees. Id. She indicated Plaintiff's bilateral feet were significantly tender. Id. She stated both of Plaintiff's knees showed crepitus. Id. She noted lumbosacral spasm and significant tenderness in Plaintiff's back. Id. Dr. Sharma assessed abnormal kidney function, chronic back pain, bursitis, fibromyalgia, Sjogren's syndrome, and shoulder joint pain. Tr. at 520-21. She instructed Plaintiff to avoid nonsteroidal anti-inflammatory drugs (“NSAIDS”) because of abnormal kidney function; to use warm, moist heat and exercise for her back; to start aerobic exercise for fibromyalgia; and to start Pilocarpine for Sjogren's syndrome. Id. She administered Depo-Medrol injections to Plaintiff's shoulders. Id.

         On August 5, 2013, Plaintiff reported brain fog as a result of poor sleep. Tr. at 536. She endorsed decreased tasks, concentration, and focus. Id. Psychiatric nurse practitioner Jeanette Spence, APRN (“Ms. Spence”), observed Plaintiff to have casual and neat appearance. Id. She stated Plaintiff was alert and oriented times four, but was easily distracted. Id. She described Plaintiff's affect as restricted and her thought content as helpless, hopeless, and confused. Id. She indicated Plaintiff had endorsed passive suicidal ideation. Id. She assessed PTSD and major depressive disorder and indicated a GAF score of 35.[3] Id.

         On August 26, 2013, Plaintiff reported poor sleep and requested that her medications be adjusted. Tr. at 537. She endorsed feelings of inadequacy, self-pity, and self-blame. Id. Ms. Spence observed Plaintiff to appear casual and neat. Id. She indicated Plaintiff's speech was slow at times and that she had slowed motor activity. Id. She described Plaintiff as oriented times four, but indicated her concentration was fair-to-poor and she was easily distracted. Id. She stated Plaintiff's thought process was preoccupied, but goal-directed. Id. She described Plaintiff's thought content as hopeless, helpless, and confused. Id. She indicated Plaintiff was experiencing intrusive thoughts and flashbacks. Id. Ms. Spence referred Plaintiff for a partial hospitalization program assessment. Id.

         On August 29, 2013, Plaintiff reported five flare ups of fibromyalgia since her last visit. Tr. at 515. She complained of pain in her bilateral knees and thighs, hips, shoulders, and bilateral legs. Id. She indicated the injections to her shoulders had improved her quality of life and requested that Dr. Sharma administered injections to her bilateral hips. Id. Dr. Sharma observed Plaintiff to have normal gait, strength, sensation, and muscle tone. Tr. at 516. She noted no crepitus, synovitis, or deformity in Plaintiff's upper or lower extremities. Id. She indicated Plaintiff had 12 of 18 fibromyalgia tender points. Id. She stated Plaintiff's bilateral shoulder abduction was reduced to 70 degrees. Id. She indicated both of Plaintiff's hips and feet were moderately tender. Id. She stated both of Plaintiff's knees showed crepitus and were significantly tender. Id. She indicated Plaintiff's bilateral trochanteric bursa were significantly tender. Id. Dr. Sharma advised Plaintiff to increase her fluid intake, to use Biotin products for oral care and artificial tears, to follow up with an ophthalmologist, and to start aerobic exercise. Id. She prescribed Prednisone, Voltaren gel, and Duexis; instructed Plaintiff to increase her dose of Pamelor and to stop Pennsaid; referred her for x-rays of her bilateral knees; and administered bilateral trochanteric bursa injections. Tr. at 516-17. X-rays of Plaintiff's bilateral knees showed mild degenerative changes. Tr. at 508 and 509.

         On September 4, 2013, Plaintiff reported decreased concentration and focus, poor sleep and appetite, and low energy. Tr. at 538. She indicated she was scheduled to begin the partial hospitalization program the following day. Id. Ms. Spence observed Plaintiff to demonstrate soft and slow speech, to be easily distracted, to have a low mood, and to have hopeless, helpless, and confused thought content. Id. She noted that Plaintiff was experiencing intrusive thoughts and flashbacks. Id. She recommended that Plaintiff continue her current level of care. Id.

         On October 3, 2013, a second state agency psychological consultant, Jeanne Wright, Ph.D. (“Dr. Wright”), considered Listing 12.06 and assessed the same degree of impairment as Dr. Prosser. Compare Tr. at 96-97, with Tr. at 110-11. She also indicated the same limitations in a mental RFC assessment. Compare Tr. at 101-03, with Tr. at 112-14.

         On October 9, 2013, Plaintiff reported four flare ups of fibromyalgia since her prior visit. Tr. at 791. She endorsed dry eyes and mouth and pain and stiffness in her bilateral arms, knees, and hips. Id. She complained of occasional finger locking, but stated the injections had helped her hips and her medications were working well. Id. Dr. Sharma observed Plaintiff to have normal muscle tone, gait, and muscle strength; no synovitis, crepitus, or deformity in her extremities; 12 of 18 fibromyalgia tender points; decreased abduction to 70 degrees in her bilateral shoulders; moderate-to-significant tenderness in her shoulders; moderate tenderness in her wrists and hips; and crepitus and significant tenderness in her knees. Tr. at 792. She discontinued Duexis, decreased Plaintiff's Methotrexate, and prescribed Prednisone and folic acid. Id. She instructed Plaintiff to avoid NSAIDs and to start aerobic exercise.

         On October 25, 2013, Plaintiff reported poor sleep and appetite and low energy. Tr. at 559. She endorsed weekly crying spells, paranoia, intrusive thoughts, and panic attacks. Id. Ms. Spence observed Plaintiff to have poor concentration and slowed motor activity. Id. She stated Plaintiff was easily distracted and had a flat and restricted affect. Id. She indicated Plaintiff appeared neat and casual, was oriented times four, and had normal speech. Id. She described Plaintiff's thoughts as preoccupied and hopeless, helpless, and confused. Id. She assessed a GAF score of 35 to 40. Id.

         On November 22, 2013, Ms. Spence and Elizabeth Jeffords, M.D. (“Dr. Jeffords”), completed a psychiatric/psychological impairment questionnaire. Tr. at 568-74. They indicated Plaintiff had initiated treatment on August 5, 2013, had last been seen on November 22, 2013, and had been presenting for monthly treatment. Tr. at 568. They stated Plaintiff's diagnoses included major depressive disorder and post-traumatic stress disorder. Id. They also indicated a need to rule out borderline personality disorder. Id. They assessed Plaintiff's current GAF score as 35 and indicated her lowest GAF score during the prior year had been 55.[4] Id. They stated Plaintiff's condition was chronic and was not yet stabilized. Id. They identified the following positive clinical findings: poor memory, appetite disturbance with weight change, sleep disturbance, personality change, mood disturbance, emotional lability, delusions, recurrent panic attacks, anhedonia or pervasive loss of interest, psychomotor agitation or retardation, paranoia or inappropriate suspiciousness, feelings of guilt/worthlessness, difficulty thinking or concentrating, passive suicidal ideation, perceptual disturbances, time or place disorientation, social withdrawal or isolation, illogical thinking, decreased energy, obsessions or compulsions, intrusive recollections of a traumatic experience, persistent irrational fears, persistent anxiety, hostility, irritability, pathological dependence or passivity, and blunt, flat, or inappropriate affect. Tr. at 569. They listed Plaintiff's primary symptoms as depression, anxiety, paranoia, labile mood, and hypervigilance. Tr. at 570. They indicated Plaintiff was markedly limited (effectively precluded from performing the activity in a meaningful matter) with respect to the following abilities: to remember locations and work-like procedures; to understand and remember one- or two-step instructions; to understand and remember detailed instructions; to carry out detailed instructions; to maintain attention and concentration for extended periods; to perform activities within a schedule, maintain regular attendance and be punctual within customary tolerances; to sustain ordinary routine without special supervision; to work in coordination with or proximity to others without being distracted by them; to complete a normal workday and workweek without interruptions from psychologically-based symptoms; to perform at a consistent pace without an unreasonable number and length of rest periods; to accept instructions and respond appropriately to criticism from supervisors; to get along with coworkers or peers without distracting them or exhibiting behavioral extremes; to respond appropriately to changes in the work setting; to travel to unfamiliar places or use public transportation; and to set realistic goals or make plans independently. Tr. at 571-73. They indicated Plaintiff would experience episodes of deterioration or decompensation in a work setting that would cause her to withdraw from the situation or experience exacerbation of signs or symptoms. Tr. at 573. They stated Plaintiff had a labile mood, was easily agitated, had a low tolerance for stress and changes, and was unable to remain focused for long periods. Id. They indicated Plaintiff would be absent from work more than three times per month because of her impairments or treatment and was unable to work at the time of the assessment. Tr. at 574.

         On December 20, 2013, Ms. Spence described Plaintiff as hypervigilant. Tr. at 557. Plaintiff reported that she was not sleeping. Id. Ms. Spence observed Plaintiff to demonstrate soft and slow speech; to have poor memory; to be easily distracted; to have a restricted affect; and to endorse hopeless, helpless, and confused thought content. Id. She assessed a GAF score of 35 and added a prescription for Ativan. Id.

         On January 7, 2014, a visual examination showed Plaintiff to have abnormal confrontation visual field. Tr. at 545. Joseph Manno, M.D. (“Dr. Manno”), assessed open angle glaucoma in both eyes. Tr. at 546. He stated Plaintiff “should be able to function in a well lit environment.” Id. He indicated Plaintiff's side vision was affected, but he was unable to assess the extent of the impairment. Id.

         State agency medical consultant Michele Spero, M.D. (“Dr. Spero”), completed a physical residual functional capacity (“RFC”) assessment on January 7, 2014. Tr. at 98-101. She indicated Plaintiff could occasionally lift and/or carry 20 pounds; could frequently lift and/or carry 10 pounds; could stand and/or walk for a total of about six hours in an eight-hour workday; could sit for about six hours in an eight-hour workday; could occasionally balance, stoop, kneel, crouch, crawl, and climb ramps and stairs; could never climb ladders, ropes, or scaffolds; could frequently reach overhead with the bilateral upper extremities; would be limited to jobs requiring limited field of vision; and should avoid all exposure to hazards. Id.

         On January 15, 2014, Plaintiff reported variable sleep, poor appetite, and low energy. Tr. at 556. Ms. Spence observed Plaintiff to have slow and casual speech; to be oriented times four; to be easily distracted; to have poor memory; to be very sad; and to endorse hopeless, helpless, and confused thought content. Id. She noted that Plaintiff was seeing a therapist once a week who was helping her with chronic issues and coping strategies. Id.

         On January 24, 2014, Plaintiff reported fibromyalgia flares. Tr. at 794. She endorsed insomnia, memory confusion, dry mouth and throat, severe pain in her shoulders, and constant pain in her knees, feet, and back. Id. She requested a steroid injection to her shoulders. Id. Dr. Sharma observed Plaintiff to have normal muscle tone, muscle strength, and gait; no synovitis, crepitus, or deformity in her extremities; 12 of 18 fibromyalgia tender points; crepitus in her knees; significant tenderness in her shoulders, knees, feet, and back; and lumbosacral spasm. Id. She prescribed Cymbalta and Prednisone, increased Plaintiff's dosage of Methotrexate, and advised her to avoid NSAIDs, increase her fluid intake, wear comfortable shoes, engage in aerobic exercise, use artificial tears, practice good oral care, and use warm, moist heat for her back. Tr. at 795-96. She administered a Depo-Medrol injection. Tr. at 796.

         On April 14, 2014, Plaintiff reported poor sleep and appetite and low energy. Tr. at 744. Ms. Spence indicated Plaintiff was easily distracted; demonstrated slowed motor activity; had poor memory; endorsed a hopeless mood; had hopeless, helpless, and confused thought content; showed a tearful affect; and endorsed passive suicidal ideation. Id. She assessed a GAF score of 40 and instructed Plaintiff to follow up with her therapist in two weeks. Id.

         On April 25, 2014, Plaintiff complained of dry eyes and mouth, inability to taste, and pain in her knees, ankles, back, shoulder, elbows, feet, and hands. Tr. at 798. She reported many fibromyalgia flare ups. Id. Dr. Sharma indicated Plaintiff demonstrated normal gait and muscle tone and strength and no synovitis, crepitus or deformity in her extremities, aside from her knees. Tr. at 799. She noted significant tenderness in Plaintiff's shoulders, elbows, bilateral MCP and PIP joints, knees, ankles, feet, and back. Id. She observed abduction to 80 degrees in Plaintiff's shoulders, swelling in her knees, and spasm in her lumbosacral spine. Id. She prescribed Lyrica, increased Plaintiff's dose of Methotrexate, and recommended increased fluid intake, oral care, use of artificial tears, aerobic exercise, calcium and vitamin D supplements, and warm, moist heat. Tr. at 799-800.

         On May 14, 2014, Plaintiff reported significant grief following the death of her grandmother. Tr. at 566. Ms. Spence described Plaintiff as having preoccupied thought content and depressed mood, but indicated no other abnormalities on mental status examination. Id. She stated Plaintiff was mildly worse than she had been during the prior visit. Tr. at 567. Plaintiff indicated she would follow up with her therapist. Tr. at 566.

         On July 18, 2014, Plaintiff presented to Edward A. Nielsen, M.D. (“Dr. Nielsen”), after having sustained a fall. Tr. at 576. She complained of pain in her back and knees. Id. Dr. Nielsen observed normal ROM of the left knee, no crepitus or joint instability, and no obvious ligamentous instability, deformity, bruising, effusion, or overlying skin changes. Tr. at 577. He indicated the x-ray of Plaintiff's left knee indicated no acute process, but hinted at osteoarthritis. Id. He prescribed Diclofenac. Id.

         On August 1, 2014, Plaintiff complained of dry eyes and mouth, multiple fibromyalgia flare ups, insomnia, fatigue, memory confusion, pain and numbness in her shoulders and arms, and pain in her back, neck, hip, and ankle. Tr. at 801. She reported that steroid injections to her shoulders had previously provided significant pain relief and requested additional injections. Id. Dr. Sharma observed Plaintiff to have normal muscle tone, strength, and gait and no synovitis, crepitus, or deformity in her extremities, aside from crepitus in her bilateral knees. Tr. at 802. She noted reduced abduction of Plaintiff's bilateral shoulders to 60 degrees and significant tenderness in Plaintiff's shoulders, hands, hips, knees, ankles, feet, and trochanteric bursa. Id. She prescribed Methotrexate, Skelaxin, and a Medrol Dose Pack, increased Lyrica, and administered Depo-Medrol injections to Plaintiff's bilateral shoulders. Tr. at 802-03.

         On August 18, 2014, Ms. Spence noted Plaintiff had poor recent memory; distractible attention/concentration; agitated motor activity; preoccupied, agitated, and easily reactive thought content; fearful perception; constricted affect; and dysphoric and anxious mood. Tr. at 748. She changed Plaintiff's dosages of Latuda and Gabapentin. Tr. at 749. She stated Plaintiff was mildly worse than she had been during the prior visit. Id.

         Plaintiff presented to Tameika Turner-Noland, Ph.D. (“Dr. Turner-Noland”), for a psychotherapy intake session on August 22, 2014. Tr. at 1008-09. Dr. Turner-Noland described Plaintiff as being alert and oriented, having an appropriate affect and euthymic mood, and demonstrating interactive interpersonal communication and intact functional status. Tr. at 1009. Plaintiff described familial stressors related to her husband, mother, and aunt. Id. She followed up for counseling sessions with Dr. Turner-Noland every one-to-two weeks between September 4, 2014, and June 11, 2015. Tr. at 933-1006.

         On September 17, 2014, Ms. Spence noted Plaintiff had poor recent memory, distractible attention/concentration, obsessive thought content, constricted affect, suicidal ideation, and very low, depressed mood. Tr. at 750. She increased Plaintiff's dosages of Latuda and Ativan and indicated Plaintiff desperately needed to see her counselor. Id.

         Plaintiff was hospitalized at Three Rivers Behavioral Health from September 23 to September 26, 2014, for suicidal ideation with plan. Tr. at 663. She was indicated to be a danger to herself with a need for a controlled environment; had failed to response to outpatient treatment; and was experiencing impaired mood, depression, mood swings, and suicidal ideation. Tr. at 663. A mental status examination was normal, aside from anxious mood and flat affect. Tr. at 663. Plaintiff was discharged with a diagnosis of major depressive disorder and a GAF score of 70.[5] Tr. at 664-65.

         Plaintiff followed up with Ms. Spence on September 29, 2014. Tr. at 754. Ms. Spence noted Plaintiff had psychomotor retardation, preoccupied thought content, fearful perception, constricted affect, passive suicidal ideation, and dysphoric mood. Id. She indicated Plaintiff appeared normal, was appropriately dressed, had fair insight and judgment, demonstrated normal speech and flow of thought, and was oriented to person, place, and time. Id. She stated Plaintiff was moderately worse than she had been during her most recent prior visit and changed her dosage of Cymbalta. Tr. at 755.

         On October 31, 2014, Plaintiff complained of severe dry eyes and mouth, insomnia, fibromyalgia flare ups, and pain in her hands, hips, knees, shoulders, and back. Tr. at 805. Dr. Sharma observed Plaintiff to have normal muscle tone, strength, and gait and no synovitis, crepitus, or deformities in her extremities, aside from bilateral knee crepitus. Tr. at 806. She noted reduced abduction to 110 degrees in Plaintiff's bilateral shoulders; significant tenderness in her shoulders, proximal and distal interphalangeal joints, hips, knees, and back; Heberden's and Bouchard's nodes in her hands; and spasm in her lumbosacral spine. Id. She prescribed Sulindac, encouraged Plaintiff to exercise as tolerated, and administered Depo-Medrol injections to Plaintiff's bilateral shoulders. Tr. at 806-07.

         On November 19, 2014, Ms. Spence observed the following abnormalities on mental status examination: poor recent memory with daily forgetfulness, very distractible attention/concentration, preoccupied thought content, dysphoric mood, and passive suicidal ideation. Tr. at 760. She indicated Plaintiff was oriented to person, place, and time and had appropriate dress, affect, and interview behavior and normal general appearance, motor activity, perception, flow of thought, and speech. Id. Plaintiff complained of familial stressors and indicated her mother was living in her home and undermining her authority with her daughter. Id. Despite noting that Plaintiff was mildly worse than she had been during the prior visit, Ms. Spence made no changes to Plaintiff's medications. Tr. at 761.

         On December 10, 2014, Ms. Spence indicated the following abnormalities on mental status examination: poor recent and remote memory, distractible attention/concentration, psychomotor retardation, preoccupied thought content, hypervigilant perception, fair-to-poor judgment, perseverated flow of thought, constricted affect, apathetic interview behavior, passive suicidal ideation, and dysphoric, anxious mood. Tr. at 765. Plaintiff described conflict with her mother. Id. Ms. Spence indicated Plaintiff had been unable to work since 2010 because of physical and emotional disability. Id. She indicated no changes in Plaintiff's condition and made no adjustments to her medications. Tr. at 766-67.

         On January 12, 2015, Ms. Spence observed Plaintiff to have poor recent memory; distractible attention/concentration; normal motor activity, general appearance, thought flow, and speech; orientation to person, place, and time; thought content preoccupied by loss; fair insight and judgment; hypervigilant perception; appropriate affect and behavior; and dysphoric, but stable mood. Tr. at 727. She instructed Plaintiff to adjust her Latuda dosage based on her response and to continue to participate in counseling for coping skills. Tr. at 728-29.

         On February 12, 2015, Ms. Spence indicated the following abnormalities on mental status examination: poor recent memory, distractible attention/concentration, preoccupied thought content, hypervigilant perception, constricted affect, and dysphoric mood. Tr. at 730. She described Plaintiff as having normal general appearance, appropriate dress, normal motor activity, fair insight and judgment, normal flow of thought, appropriate interview behavior, normal speech, and orientation to person, place, and time. Id. Plaintiff complained of feeling tired and defeated by multiple life stressors. Id. She reported that her doctor had instructed her not to drive, but that she felt she had to drive to medical appointments. Id. She indicated she drove slowly and carefully and traveled only five miles. Id. Ms. Spence stated Plaintiff was tolerating her medications well. Id.

         On February 24, 2015, Plaintiff reported dry eyes and mouth, insomnia, fibromyalgia flare ups, and pain in her hands, hips, knees, shoulders, and back. Tr. at 809. Dr. Sharma noted 12 of 18 fibromyalgia tender points; no deformities, cyanosis, clubbing, edema, synovitis, crepitus, or deformity in Plaintiff's extremities; and normal gait and muscle strength and tone. Tr. at 810. She stated Plaintiff was significantly tender in her shoulders, PIP and distal interphalangeal (“DIP”) joints, and knees; had Heberden's and Bouchard's nodes in her hands; and demonstrated lumbosacral spasm in her back. Id. She prescribed Sulindac for pain, increased Plaintiff's dosages of Methotrexate and Lyrica, and administered Depo-Medrol injections to Plaintiff's shoulders. Tr. at 810-11.

         On April 23, 2015, Plaintiff reported feeling depressed and overwhelmed, but sleeping a little better with medication. Tr. at 735. Ms. Spence observed Plaintiff to have poor recent and remote memory, inability to focus, psychomotor retardation, preoccupied and obsessive thought content, hypersensitive and hypervigilant perception, fair-to-poor judgment, perseveration of thought, sad affect, depressed mood, hesitant speech, and passive suicidal thought. Id. She refilled Plaintiff's medications and instructed her to continue to participate in counseling and to try yoga, acupuncture, or massage monthly. Tr. at 733.

         On May 29, 2015, Ms. Spence observed the following abnormalities on mental status examination: poor recent and remote memory; distractible attention/concentration characterized by intrusive thoughts of past trauma; thought content preoccupied by multiple life stressors; hypervigilant perception; and perseveration of thought. Tr. at 741. She changed Plaintiff's dosage of Cymbalta. Tr. at 742.

         On July 24, 2015, Lynn Hicks Snoddy, M.D. (“Dr. Snoddy”), assessed primary open-angle glaucoma, severe stage glaucoma, rheumatoid arthritis in multiple joints, and current use of high-risk medication. Tr. at 717. She indicated Plaintiff had increased intraocular pressure and advised her to follow up in one to two weeks for a ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.