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Jones v. Berryhill

United States District Court, D. South Carolina

January 3, 2019

Deanna Felicia Jones, 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) 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 or about December 11, 2013, Plaintiff filed an application for DIB in which she alleged her disability began on March 22, 2013. Tr. at 150-51, 160-61. Her applications were denied initially and upon reconsideration. Tr. at 75-76, 92, 95-98, and 100-04. On April 21, 2016, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Tammy Georgian. Tr. at 31-60 (Hr'g Tr.). The ALJ issued an unfavorable decision on October 18, 2016, finding Plaintiff was not disabled within the meaning of the Act. Tr. at 11-30. 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 1-7. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on November 20, 2017. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 46 years old at the time of the hearing. Tr. at 24, 31. She graduated high school. Tr. at 38. Her past relevant work (“PRW”) was as a film processor or machine operator. Tr. at 54. She alleges she has been unable to work since March 22, 2013. Tr. at 150-51, 160-61.

         2. Medical History[1]

         On August 7, 2012, David L. Castellone, M.D. (“Dr. Castellone”), at Palmetto Primary Care Physicians (“Palmetto PCP”) performed a complete physical examination of Plaintiff wherein he noted several normal results, but also ordered several diagnostic tests, including an echocardiogram (“ECG”), mammogram, x-rays, and bloodwork, noting she exhibited abnormal weakness. Tr. at 367-69. Dr. Castellone assessed new weakness, new abnormal ECG, new ankle sprain, stable anxiety, and stable hypertension. Tr. at 369; Tr. at 486-90.

         On August 24, 2012, a mammogram revealed no abnormalities. Tr. at 276, 429.

         On September 4, 2012, Plaintiff presented to Palmetto PCP for a stress test and an ECG based on Plaintiff's hypertension and shortness of breath. Tr. at 282, 378-80. The results were normal. Id.

         On September 5, 2012, Plaintiff presented to Dr. Castellone for follow up of hypertension and reviewed her test results. Tr. at 365-66.

         On January 30, 2013, Plaintiff presented to Dr. Castellone with complaints of worsening right shoulder pain. Tr. at 363-64. Dr. Castellone's examination revealed decreased range of motion (“ROM”) and pain in Plaintiffs cervical spine, but an otherwise normal exam. Id. He assessed new cervical strain or spondylosis and ordered an x-ray and magnetic resonance imaging (“MRI ”) of Plaintiffs cervical spine. Id.

         Also, on January 30, 2013, Plaintiff presented to Palmetto PCP and underwent an x-ray of her cervical spine due to neck pain. Tr. at 288-89, 449. There was no evidence of fracture, subluxation, significant selective disc space narrowing, or focal paravertebral soft tissue swelling, resulting in a negative examination. Tr. at 289.

         On February 8, 2013, Plaintiff presented to Palmetto PCP and underwent an MRI of her cervical spine due to right shoulder and neck pain. Tr. at 287, 437-38. The impression provided “[a]bnormal signal at the C2 and C5 levels, centrally within the cervical cord. The findings can be seen with d[e]myelination such as with [MS]. Other causes of abnormal cord signal such as [Acute Disseminated Encephalomyelitis] and transverse myelitis are less likely considerations, ” with “[n]o high-grade neuroforaminal or spinal canal narrowing.” Tr. at 437-38. She was diagnosed with cervical strain or cervical spondylosis. Id.

         On February 12, 2013, Plaintiff presented to Dr. Castellone for a follow up of cervical strain or spondylosis and reported continued throbbing pain. Tr. at 361-62. Dr. Castellone noted a decreased ROM and pain in her cervical spine, ordered a brain MRI, assessed possible multiple sclerosis (“MS”) and uncontrolled cervical strain or spondylosis, and referred her to neurologist, John Lucas, M.D. (“Dr. Lucas”). Tr. at 362.

         On February 25, 2013, Plaintiff presented to Palmetto PCP and underwent a brain MRI due to numbness in her right arm and leg, blurred vision, tiredness, frequent headaches, and symptoms existing since January 8, 2013. Tr. at 286, 435-36. The impression provided “[f]indings suspicious for [MS].” Tr. at 435. She was diagnosed with “[MS]/possible.” Tr. at 286.[2]

         On February 26, 2013, Plaintiff presented to Dr. Castellone to review her MRI results and reported weakness, dizziness, and headaches. Tr. at 358-60. Dr. Castellone noted Plaintiff had a decreased ROM and pain in her cervical spine, but she had normal gait, her cranial nerves were intact, and she was oriented to time, place, and person. Tr. at 359. He assessed uncontrolled anxiety, new possible MS, and stable hypertension. He referred her to Dr. Lucas and noted she would need a lumbar puncture. Id.

         On March 1, 2013, Plaintiff presented to Dr. Lucas at Palmetto PCP due to an abnormal MRI with possible MS symptoms that began in November 2012 with discomfort in her right shoulder and continued in early 2013, causing numbness in her toes and her right leg to give out. Tr. at 267- 69, 306-08. Plaintiff had two plaques in her cervical spine and had right forearm stenosis. Id. It was noted Plaintiffs mother rapidly declined and passed away in 1986 due to MS. Id. Plaintiff reported she was fatigued all of the time, slept poorly, and had vision loss, pain in her neck and right cervical shoulder, and numbness and tingling sensations in her right arm. Tr. at 267. Plaintiffs physical examination revealed normal results, such as normal cerebellar, basal ganglia function, coordination, stance, and gait. Tr. at 269. Dr. Lucas noted Plaintiffs MRI revealed it was “likely MS, ” and he planned to rule out mimicking illnesses, conduct an Opthal exam, request laboratory tests, [3] and refer to her physical therapy. Tr. at 268, 425-28 (containing lab results revealing high immunoglobulin G and M and Gamma Globulin). Dr. Lucas assessed new MS/possible, bilateral blurred vision, neck pain, and paresthesias. Tr. at 269.

         On March 8, 2013, Plaintiff presented to Dr. Castellone to discuss her lab results. Tr. at 356. Plaintiff reported she was unable to work, but would attempt rehabilitation in an effort to work. Id. Dr. Castellone's examination revealed Plaintiff was tender in her right shoulder, but had normal gait, and was oriented to time, place, and person. Tr. at 356. He assessed new sickle cell trait and anemia. Tr. at 357.

         On March 20, 2013, Plaintiff presented to Dr. Castellone to discuss her leave from work. Tr. at 354. Dr. Castellone noted Plaintiff saw Dr. Lucas for possible MS and she would have a lumbar puncture to address the concern. Tr. at 354. He also noted Plaintiff had severe pain in her right shoulder that occurred especially with work-related lifting activity. Tr. at 354. His physical examination revealed severe right shoulder and cervical spine pain, but noted she had normal gait with intact cranial nerves, and she was oriented to time, place, and person. Tr. at 355. He assessed uncontrolled possible MS, uncontrolled neck pain, uncontrolled radiculopathy, and uncontrolled cervical strain or cervical spondylosis. Id. Dr. Castellone noted Plaintiff reported worsening symptoms and she was advised to perform no work for four weeks due to ongoing issues with possible MS, including obtaining a diagnosis and undergoing the work up with a lumbar puncture. He also noted Plaintiff had severe right shoulder and neck issues with likely disc radiculopathy that interfered with work. Id.

         On March 21, 2013, a lumbar puncture was performed on Plaintiff at Trident Regional Medical Center due to MS. Tr. at 270-75, 374-77, 381-424. and Trident Medical Center Laboratory provided a pathology specimen report of her cerebrospinal fluid. Examination of the cerebrospinal fluid and cell block preparation slide showed the specimen was virtually acellular and no significant inflammation or evidence of malignancy. Id. There were six oligoclonal bands observed in the specimen, with four or more bands shown to be most consistent with MS, resulting in an “Cerebrospinal Fluid Oligoclonal Bands in the Diagnosis of MS.” Tr. at 271. Trident Health System updated Plaintiffs medication list to include citalopram, hydrocodone, lorazepam, losartan, promethazine, and multivitamins. Tr. at 266.

         On April 5, 2013, Plaintiff underwent a nerve conduction study and electromyography (“EMG”) at Charleston Neurology Associates, upon Dr. Lucas' request, that showed normal results for Plaintiffs right extremities. Tr. at 439-44.

         On April 5, 2013, Plaintiff presented to Dr. Castellone for follow up of cervical strain, possible MS, neck pain, and radiculopathy. Tr. at 349. Plaintiff reported insomnia, intermittent back pain with bending, and neck pain. Id. Dr. Castellone noted Plaintiff was tender in her right cervical area, but had normal gait. Tr. at 350. He assessed stable anxiety, uncontrolled possible MS, stable hypertension, uncontrolled neck pain, uncontrolled radiculopathy, and uncontrolled cervical strain or cervical spondylosis. Id. He prescribed Lortab, scheduled her for return visit in one month, and provided a work excuse until late May. Tr. at 350.

         On April 5, 2013, Plaintiff also presented to Valerie Sinkler, M.D. (“Dr. Sinkler”) at Palmetto PCP for possible MS symptoms exhibited by continued numbness in the right side of her body and subjective weakness. Tr. at 351- 53. Dr. Sinkler noted Plaintiff had numbness and weakness in her left hand and leg previously, and she reported numbness in her legs and feet, with tingling sensations. Tr. at 351. Her examination revealed normal results. Tr. at 352-53. Dr. Sinkler noted the diagnosis “at this point [was] probable MS, ” and she suggested solumedrol be administered for three days. Tr. at 353.[4]

         On April 25, 2013, Plaintiff presented to Dr. Lucas to follow up on her possible MS. Tr. at 303-05. She reported numbness in her right arm and back, fatigue, poor sleep quality, dizziness, headaches, and tingling sensations in her trunk. Tr. at 303. She denied vision loss, chest pain, and joint or muscle pain. Id. It was noted Plaintiff had a brain MRI suggestive of MS (no active plaques), two plaques in her cervical spine, right foramen stenosis, and abnormal spinal fluid, with her progression of symptoms reflecting no change since her steroid infusion. Tr. at 303. Upon examination, Plaintiff had normal cerebellar, basal ganglia function, coordination, stance, and gait. Tr. at 304. Dr. Lucas assessed unchanged MS, stopped prednisone, prescribed Neurontin, discussed various medications and oral agents, and noted Plaintiff was working on a decision for treatment. Id.

         On May 6, 2013, Plaintiff presented to Dr. Castellone for follow up of anxiety, cervical strain, hypertension, MS, neck pain, and radiculopathy. Tr. at 341-42. She reported neck and back pain, with numbness in her arm and leg. Tr. at 341. Upon examination, Dr. Castellone noted Plaintiffs right shoulder and neck were tender. Tr. at 342. He assessed new anemia, new rotator cuff syndrome, uncontrolled cervical strain or spondylosis, and uncontrolled MS. Id. He ordered laboratory tests and an MRI to be conducted and prescribed Ativan and Lortab. Id.[5]

         On May 20, 2013, Plaintiff presented to Dr. Castellone for follow up of anemia, cervical strain or spondylosis, MS, and rotator cuff syndrome. Tr. at 339-40. She reported neck, shoulder, arm, and low back pain. Id. Upon examination, Dr. Castellone noted Plaintiffs neck and right shoulder were tender, but she had normal gait and balance. Tr. at 340. He assessed new tenosynovitis, uncontrolled radiculopathy, uncontrolled cervical strain or cervical spondylosis, new anemia, and new MS. Id.

         On May 24, 2013, Plaintiff presented to Andrew McMarlin, D.O. (“Dr. McMarlin”), at Palmetto PCP with right shoulder, neck, and low back pain that existed since December 2012, caused constant radiating pain, and was aggravated by walking, reaching, or pressure. Tr. at 336-38. Dr. McMarlin inspected Plaintiffs shoulders and conducted tests. Tr. at 337. He assessed bilateral muscle spasm, rotator cuff strain, and lumbosacral strain, he administered an injection, and he noted Plaintiffs tenderness may be related to her degenerative disc disease (“DDD”). Tr. at 337-38.

         On June 6, 2013, Plaintiff presented to Dr. Lucas to follow up on her MS. Tr. at 301-02. She reported continued numbness and fatigue, but her “[z]apping pains” had improved and she denied blurred vision, joint or muscle pain, and depression or anxiety symptoms. Tr. at 301. Upon examination, Plaintiff had normal tone, strength, cerebellar and basal ganglia function, coordination, stance, and gait. Id. Dr. Lucas assessed unchanged MS and strongly urged Plaintiff to begin treatment. Tr. at 302.

         On June 24, 2013, Plaintiff presented to Dr. Castellone with complaints of depression and to follow up on lumbosacral strain, muscle spasms, and a right rotator cuff strain. Tr. at 333-35. Dr. Castellone noted Plaintiff saw Dr. Lucas for her MS, her neck had improved, but her legs were weak with parethasias and her lower spine was “bad.” Tr. at 333. Plaintiff reported weakness in her lower extremities and depression. Id. Upon examination, Dr. Castellone noted Plaintiff had a decreased ROM and pain in her lumbar spine, but she had a normal gait. Tr. at 334. He assessed uncontrolled anxiety, stable hypertension, and uncontrolled lumbosacral strain. Id.

         On June 27, 2013, Plaintiff presented to Palmetto PCP and underwent an MRI of her right shoulder due to shoulder pain, limited ROM, pain that radiated to above the elbow, and symptoms occurring since December 2012. Tr. at 285. She was diagnosed with rotator cuff syndrome. Id.

         Also, on June 27, 2013, Plaintiff underwent an MRI of her lumbar spine due to complaints of low back pain and difficulty walking or standing for periods of time, noting she was diagnosed with MS in April 2013 and had numbness in her legs due to MS. Tr. at 284, 432-33. She was diagnosed with lumbosacral strain. Id. The impression provided “[n]o evidence of focal disk herniation or central canal stenosis” and “[m]ild facet arthropathy.” Tr. at 432.

         On July 29, 2013, Plaintiff presented to Dr. Castellone for follow up of hypertension and lumbosacral strain. Tr. at 330-32. Dr. Castellone noted Plaintiffs hypertension was moderate, she saw Dr. Lucas for her MS, and, while the DDD symptoms in her neck had improved, her back was still “bad.” Tr. at 330. Upon examination, Dr. Castellone noted Plaintiff had decreased ROM and pain in her lumbar spine, but normal gait with cranial nerves intact, and she was oriented to time, place, and person. Tr. at 331. He assessed stabled MS, uncontrolled DDD, and improved cervical strain or cervical spondylosis. Dr. Castellone referred Plaintiff to physical therapy for her back and noted she received iron infusions at home. Tr. at 332.

         On August 1, 2013, Plaintiff presented to Dr. Lucas for a follow up of her MS. Tr. at 299. Plaintiff reported her numbness symptoms were still present in her right leg (more than the left), she had numbness in her right hand, she fell the prior week because her right leg gave out, she had low back pains, light headiness, and dizziness. Tr. at 299-300. Plaintiff denied depression or anxiety symptoms. Tr. at 299. Plaintiff's physical examination revealed normal strength, cerebellar and basal ganglia function, coordination, stance, and gait. Tr. at 300. Dr. Lucas assessed unchanged MS and anemia, noting Plaintiff agreed to begin treatment for her MS and selected Copaxone. Id.

         On August 13, 2013, Plaintiff presented to Trident Medical Center with complaints of numbness and weakness on the right side of her face with a frontal headache. Tr. at 259-65. Plaintiff's physical examination was relatively normal with a mild right facial droop, with decreased sensation noted. Tr. at 263. Plaintiff was discharged with the primary impression of Bell's palsy. Tr. at 264.

         On August 27, 2013, Dr. Lucas completed an Attending Physician's Statement of Functionality for Plaintiff to be submitted to Hartford Life Insurance Company for her disability claim as an employee. Tr. at 575-76. Dr. Lucas noted Plaintiff's condition was a result of sickness, she was diagnosed with MS, her subjective symptoms included numbness, weakness, and falls, and pertinent test results to support her condition were a brain MRI on February 25, 2013 with results suspicious for MS and a lumbar puncture test on March 21, 2013, with results consistent with MS. Tr. at 575. Dr. Lucas noted the onset of the condition was in November 2012, he first treated Plaintiff on March 1, 2013, she had been treated four times, most recently on August 1, 2013, and had an upcoming appointment on October 1, 2013. Id. Dr. Lucas also noted Plaintiffs MS had retrogressed and the expected duration of her restrictions or limitations was permanent. Tr. at 576. Dr. Lucas indicated his specialty was neurology. Id.

         On August 30, 2013, Plaintiff presented to Dr. Castellone for follow up of cervical strain or cervical spondylosis, DDD, MS, medication adjustments, and a recent emergency room visit wherein she had right-side facial numbness. Tr. at 327-29. Dr. Castellone noted Plaintiffs neck and shoulder pain from the prior year had improved, but was still an issue. Tr. at 327. Dr. Castellone also noted Plaintiff received injections for her MS, but was “unable to work as weakness [and] also severe pain from neck[, ] shoulder[, ] [and] back” with “bad memory as well.” Id. Plaintiff reported right-side facial numbness. Id. Upon examination, Dr. Castellone noted Plaintiff had decreased ROM and pain in her cervical and lumbar spine, but normal gait with cranial nerves intact, and she was oriented to time, place, and person. Tr. at 328. He assessed paresthesias or right hemifacial, uncontrolled lumbosacral strain, and stable MS. Tr. at 329. He prescribed Lortab, and he ordered an MRI.

         On September 3, 2013, Plaintiff presented to Dr. Castellone for a follow up of parethasias or right hemifacial. Tr. at 325-26. Dr. Castellone noted Plaintiffs MS began months ago, and she had not improved, that she saw Dr. Lucas and had right-sided facial numbness that radiated and caused her to feel dizzy and weak, as well as numbness in her left arm and leg that caused her to drop items. Id. Upon examination, Dr. Castellone noted Plaintiff had a decreased ROM, pain in her cervical and lumbar spine, and decreased grip in her left hand. Tr. at 326. Dr. Castellone noted an MRI had been ordered, “but need[ed] to be done today, patient worsening.” Tr. at 326.

         Later that day, Plaintiff presented underwent a brain MRI due to MS, numbness on the right side of her race, left arm, and toes. Tr. At 283, 430-31. She was diagnosed with paresthesia, right hemifacial. Tr. at 283. The impression provided:

There is a new focus of enhancement and T2 flair signal in the superior cerebellar peduncle on the right in the brainstem, which may simply be better visualized, or represent progression of disease. It is adjacent [to] the internal auditory canal on the right. There is no associated mass effect or hemorrhage. Extensive cerebral white matter changes are otherwise stable in appearance, and are suggestive of demyelinating disease, such as [MS].

Tr. at 431.

         On September 10, 2013, Plaintiff presented to Dr. Lucas to follow up on her MS, paresthesia, and radiculopathy. Tr. at 296-98. Dr. Lucas noted the recent MRI showed a new right cerebellar peduncle MS lesion. Id. Dr. Lucas noted Plaintiff previously had abnormal brain and spine MRIs with abnormal spinal fluid, she had undergone one steroid treatment, and her progression of symptoms were no relapse. Id. Plaintiff denied joint or muscle pain, but indicated she had numbness on the left side of her face and right side of her tongue, she felt “off balance, ” and was “very stressed.” Id. Plaintiffs examination revealed she was crying, she had a slow, ataxic gait (wide based), but no tremors and normal strength. Tr. at 297. Dr. Lucas assessed recurrent MS and paresthesia on right hemifacial, prescribed prednisone, and scheduled a follow up. Id. Dr. Lucas noted Plaintiff had a brainstem MS attack, she had not improved after almost one month, and he would continue to give her a high dose of oral steroids, but explained to her that she had just started Copaxone, so the attack did not mean the medication would not help her. Tr. at 298.

         On September 30, 2013, Plaintiff presented to Dr. Castellone to follow up on complaints of dizziness, fatigue, hypertension, paresthesia or right hemifacial, headaches, and her right ear “popping.” Tr. at 323-24. Plaintiff reported fatigue, headache, lower back pain, and dizziness. Tr. at 323. Dr. Castellone noted Plaintiffs anxiety and depression were not well controlled. Id. He also noted she had an MS relapse, saw a neurologist, and had a bad back “at times.” Id. Upon examination, Plaintiff had no edema, deformities, or cyanosis, normal gait with cranial nerves intact, and she was oriented to time, place, and person. Tr. at 324. Dr. Castellone assessed uncontrolled anxiety, uncontrolled MS, new sinusitis, and uncontrolled DDD, and scheduled a return visit in one week. Id.

         On October 1, 2013, Plaintiff presented to Dr. Lucas for a follow up of MS. Tr. at 293-95. It was noted her progression of symptoms included two relapses to date. Tr. at 293. Plaintiff complained of fatigue, achy leg muscles, numbness in her face and left arm, weakness, light headiness, dizziness, and headache. Id. Plaintiffs examination revealed mild left leg weakness with slight ataxia. Tr. at 294. Dr. Lucas assess uncontrolled MS and worsening fatigue, he ordered bloodwork, [6] prescribed amantadine, continued Copaxone, and scheduled a return visit in one month. Id. Dr. Lucas noted Plaintiff had “only transient improvement with steroids in recent brainstem MS attack” and she could not work. Id.

         On October 7, 2013, Plaintiff presented to Dr. Castellone for a follow up of sinusitis. Tr. at 320-22. Plaintiff reported improved fatigue, muscle aches in her legs and “bad” DDD symptoms, with numbness in her face and left arm, weakness, light headiness, dizziness, and headaches. Id. She described her anxiety and depression as severe, but improving. Id. Upon examination, Plaintiff had normal gait with cranial nerves intact, and she was oriented to time, place, and person. Tr. at 321. He assessed abnormal blood chemistry, improving sinusitis, and uncontrolled DDD, and he referred her to massage therapy. Tr. at 321

         On October 10, 2013, Dr. Castellone completed a statement regarding Plaintiff's ability to work. Tr. at 573. He stated,

I am the primary care physician for [Plaintiff]. She suffers from a new diagnos[i]s of [MS] which is active and under intense treatment by neurology.
In addition to this she has had issues with severe [DDD], lumbar and cervical spondylosis and radiculopathy. She has developed significant anemia. All the above have caused her to develop anxiety and generalized weakness which has caused her to be unable to work now and for the foreseeable future.
She is under my care and a neurologist as well.
Should you have any questions or concerns, please do not hesitate to contact me.

Tr. at 573.

         On November 25, 2013, Plaintiff presented to Dr. Castellone for follow up on bilateral leg stiffness, abnormal blood chemistry, DDD, and sinusitis. Tr. at 317-19. Plaintiff reported back pain, bilateral leg stiffness, and anxiety and depression that she described as severe, but improving. Tr. at 317. Dr. Castellone noted Plaintiff had decreased ROM and pain in her lumbar spine, but normal gait with cranial nerves intact, and she was oriented to time, place, and person. Tr. at 318. He assessed stable anxiety, stable MS, and uncontrolled DDD, and adjusted Plaintiffs medications. Id.

         On January 14, 2014, Plaintiff presented to Dr. Castellone to follow up on anxiety, DDD, and radiculopathy. Tr. at 315-16, 520, 523-32. Plaintiffs anxiety and depression were severe and constant, but improving. Id. Dr. Castellone noted Plaintiff saw Dr. Lucas for her MS and had leg pain or tenderness. Id. Plaintiff reported feeling down, depressed, and hopeless, with little pleasure in the prior month. Id. Upon examination, Plaintiff had tenderness in her extremities, but normal gait with cranial nerves intact, and she was oriented to time, place, and person. Tr. at 521. He assessed new myalgia, unchanged MS, and unchanged hypertension. Id. He refilled Plaintiffs medications and ordered diagnostic tests. Tr. at 521.

         On January 27, 2014, Plaintiff presented to Dr. Lucas for a follow up of MS. Tr. at 290-92, 518-19. Plaintiff reported she still had intermittent numbness in her hands, but her left body numbness had resolved. Tr. at 290. It was noted recent back and muscle pains led to laboratory tests[7] and the rheumatologist's opinion was still pending. Plaintiff denied blurred vision, neck pain, stiffness, muscle pain, and depression or anxiety symptoms, noting there were no new neurological symptoms. Id. Plaintiffs examination revealed she had mild left leg weakness, but her gait was normal. Tr. at 291. Dr. Lucas assessed stable MS, ordered a brain MRI, and scheduled a return visit in three months. Id. He noted he thought Plaintiff “really seem[ed] to be doing better, ” but she described some cognitive complaints that were limiting her ability to work. Tr. at 291-92. He also noted he was awaiting for the rheumatologist's opinion, would repeat an MRI in March, and discussed the 40 mg dosage of Copaxone with Plaintiff. Tr. at 291-92.

         On February 14, 2014, Plaintiff presented to Dr. Castellone to follow up on hypertension, MS, and myalgia. Tr. at 312-14, 515-17. Plaintiffs hypertension was moderate. Id. Dr. Castellone noted Plaintiff saw Dr. Lucas for her MS, had abnormal rheumatologist labs, and would be seeing a rheumatologist soon. Tr. at 515. Plaintiff reported bilateral knee and back pain with occasional anxiety and depression. Id. She reported responding well to her medication, but feeling down, depressed, and hopeless, with little interest or pleasure in the prior month. Id. Upon examination, Plaintiff had normal gait with cranial nerves intact and was oriented to time, place, and person. Tr. at 516. He assessed stable anxiety, stable hypertension, uncontrolled arthritis, uncontrolled myalgia, and uncontrolled cervical strain or spondylosis. Id. He refilled Plaintiffs medications. Tr. at 516.

         Also, on February 14, 2014, Dr. Castellone completed information for Plaintiff to request a disabled placard and license plate application. Tr. at 539-40. He completed a physician statement that certified Plaintiff had the “inability to ordinarily walk one hundred feet nonstop without aggravating an existing medical condition, including the increase of pain” and selected the disability was “[p]ermanent.” Tr. at 540.

         On March 10, 2014, Plaintiff presented for an initial rheumatology visit with Corey M. Hatfield, D.O. (“Dr. Hatfield”), due to pain in both knees, difficulty ambulating, stiffness, loss of balance, lower back pain, fatigue, and insomnia. Tr. at 445-48. Upon examination, Dr. Hatfield noted Plaintiff's strength, balance, gait, and ROM in her right extremities were normal, but her left side was weak. Tr. at 447. He noted Plaintiff had positive or elevated antinuclear antibody (“ANA”), erythrocyte sedimentation rate (“ESR”), and aldolase. Tr. at 448. He also noted Plaintiff had MS and patients with MS could have positive autoantibodies, but the elevated ESR was “most concerning.” Id. He recommended adding naproxen for knee pain and scheduled a return visit in three months to repeat autoimmune labs. Id.

         On March 17, 2014, Plaintiff presented to Dr. Castellone to follow up on anxiety, arthritis, cervical strain or spondylosis, hypertension, and myalgia. Tr. at 309-11, 512-14. She reported fatigue, knee and back pain, tingling sensations in her left hand, and occasional anxiety and depression. Tr. at 309. She reported responding well to her medication, but feeling down, depressed, and hopeless, with little interest or pleasure in the prior month. Id. Upon examination, Dr. Castellone noted Plaintiff was “weak [or] tender all over, ” but her gait was normal, her cranial nerves were intact, and she was alert and oriented to time, place, and person. Tr. at 310. He assessed new insomnia, stable MS, and stable hypertension, but noted Plaintiff reported “worsening symptoms.” Id. He prescribed Naproxen, Norco, Daypro, and Trazodone. Tr. at 311.

         On April 21, 2014, Dr. Castellone completed a treatment form for Plaintiffs medical condition to be submitted to the state agency examiner. Tr. at 495. Dr. Castellone noted Plaintiffs diagnoses included MS, anxiety, and depression; he had prescribed Effexor XR, Trazadone, and Ativan; these medications had helped her condition; and he had not recommended psychiatric care. Id. He also noted Plaintiff was oriented to time, person, place, and situation, her thought process was intact, her thought content was appropriate, and her memory was good, but she was depressed. Id. Dr. Castellone did not indicate whether Plaintiff exhibited any work-related limitation in function due to a mental condition. Id.

         Also, on April 21, 2014, Plaintiff presented to Dr. Castellone for a follow up of hypertension, insomnia, and MS. Tr. at 509-11. Plaintiffs hypertension was moderate. Id. Dr. Castellone noted Plaintiff saw Dr. Lucas for her MS, experienced fatigue and poor sleep, and she was “unable to work, ” such that she was depressed. Tr. at 509. Plaintiff reported fatigue, bilateral knee and back pain, tingling sensations, and stable anxiety. She also reported responding well to her medication, but she felt down, depressed, and hopeless during the prior month. Id. Upon examination, had no edema, deformities, or cyanosis in her extremities, normal gait with cranial nerves intact, and she was oriented to time, place, and person. Tr. at 510. He assessed stable anxiety, stable MS, stable hypertension, stable DDD, stable radiculopathy, stable insomnia, stable cervical strain or spondylosis. Id. Dr. Castellone prescribed Norco and counseled Plaintiff regarding stress management, noting she was “unable to work as totally dis[a]bled [due to] MS, DDD, [and] depression.” Id. Dr. Castellone recommended Plaintiff maintain her current treatment plan. Tr. at 510-11.

         On May 13, 2014, Cleve Hutson, M.D. (“Dr. Hutson”), a state agency medical consultant completed a physical residual functional capacity (“RFC”) assessment. Tr. at 67. He opined Plaintiff could occasionally lift, carry, push or pull twenty pounds and frequently lift, carry, push, or pull ten pounds, but was limited in her left lower extremity to only frequently, due to weakness. Tr. at 68. He also opined she could stand or walk for two hours, sit for about six hours, balance without limit, occasionally climb ramps or stairs, stoop, kneel, and crouch, but never crawl or climb ladders, ropes, or scaffolds, noting these postural limitations were due to Plaintiffs MS with left-sided weakness and numbness. Id. In addition, he opined Plaintiff was limited to frequent reaching overhead with her left upper extremity due to left-side weakness. Tr. at 69. Finally, he opined Plaintiff had environmental limitations, such that she should avoid concentrated exposure to hazards due to MS with leftside weakness. Id. Dr. Hutson explained,

[Plaintiff] alleges that can lift only 5 pounds, squatting, bending, standing, walking and kneeling are difficult because of knee pain. Walking 50 yards requires 10 minutes rest before resuming. On left side can't hold any thing long [second] to numbness. I'll drop it. [Plaintiffs] allegations are supported in the longitudinal record with exams, labs, x-rays and imaging studies along with functional studies.

Tr. at 70.

         On June 13, 2014, Cashton B. Spivey, Ph.D. (“Dr. Spivey”), a state agency consultative examiner performed a psychological evaluation of Plaintiff. Tr. at 501-05. He conducted a clinical interview and administered a Wechsler Adult Intelligence Scale - Fourth Edition (“WAIS-IV”) test, and a Wide Range Achievement Test - Revision Four (“WRAT-4”) test. Id. Dr. Spivey noted Plaintiffs aunt drove her to the evaluation. Id. Plaintiff reported she was participating in the assessment to evaluate her various symptoms, including MS. Id. Dr. Spivey reviewed Plaintiffs history and noted her medications. Id. Plaintiff reported she could dress independently and use a microwave oven, but she did not do most household chores and was not very active during the day. Id.

         On the WAIS-IV exam, Dr. Spivey noted Plaintiffs perceptual reasoning score fell in the low-average range while her other index scores fell in the borderline intellectual functioning range. Tr. at 503. He noted “[o]verall, she appears to be an individual who operates primarily in the borderline intellectual range.” Tr. at 503. On the WRAT-4 exam, Dr. Spivey noted Plaintiffs scores indicated she appeared to function below what would be expected for a 44 year old individual in reading, spelling, and arithmetic, but her math computation fell in the borderline range. Tr. at 504.

         Dr. Spivey concluded, based on the results of the evaluation, Plaintiff appeared to “be an individual of borderline intelligence with academic achievement difficulties” and noted “she may be experiencing a decrement in intellectual functioning as a result of her [MS].” Tr. at 504. Dr. Spivey noted Plaintiff met the diagnoses criteria for major depressive disorder, generalized anxiety disorder, and “rule out possible neurocognitive disorder due to [MS]. (Borderline intellectual functioning).” Id. He also noted Plaintiff believed she was incapable of performing household duties and chores secondary to MS. Id. Dr. Spivey opined Plaintiff “would be capable of understanding simple instructions and performing simple tasks in the workplace, ” but she “would display difficulty understanding complex instructions and performing complex tasks in the workplace.” Id. He also opined “[s]he would display difficulty relating well to others in the workplace due to the magnitude of her reported dysphoria as well as her emotional lability. She would display difficulty with stamina and persistence in the workplace due to complaints of a low energy level, and attention/concentration problems.” Tr. at 505.

         On June 30, 2014, Lisa Clausen, Ph.D. (“Dr. Clausen”), a state agency psychologist consultant completed a psychiatric review technique (“PRT”) assessment and mental RFC assessment. Tr. at 65-67, 70-72. Dr. Clausen opined Plaintiff had mild restriction of activities of daily living (“ADLs”), moderate difficulties in maintaining social functioning, and moderate difficulties in maintaining concentration, persistence, or pace, but no repeated episodes of decompensation. Tr. at 65. In addition, Dr. Clausen noted she gave great weight to the consultative examination performed by Dr. Spivey on June 13, 2014, Plaintiffs reports were credible, and she was considered capable of simple, routine tasks that precluded ongoing interaction with the public. Tr. at 66-67.

         On mental RFC assessment, Dr. Clausen opined Plaintiff had understanding and memory limitations, such that she was moderately limited in her ability to understand and remember detailed instructions, explaining she was “able to understand and remember short and simple instructions, but would have variable difficulties in understanding and remembering detailed instructions.” Tr. at 70-71. Plaintiff was also moderately limited in her ability to carry out detailed instructions, maintain attention and concentration for extended periods, and interact appropriately with the general public and get along with coworkers or peers without distracting them or exhibiting behavioral extremes. Tr. at 71-72. Finally, Plaintiff was moderately limited in her ability to respond appropriately to changes in the work setting and travel in unfamiliar places or use public transportation. Id.

         On July 15, 2014, Plaintiff presented to Dr. Castellone to follow up for anxiety, cervical strain and spondylosis, DDD, hypertension, insomnia, MS, radiculopathy, and sickle cell trait. Tr. at 506-08, 522, 559-61, 571. She reported headaches, sharp pains, shortness of breath with exertion, left-side numbness, and stable anxiety. Tr. at 506. Plaintiffs hypertension was moderate. Id. Dr. Castellone noted Plaintiff saw Dr. Lucas for her MS, experienced fatigue and poor sleep, and she was “unable to work, ” such that she was depressed. Id. He also noted Plaintiff had lower back, left arm, and bilateral leg pain, and reported it was “really getting worse.” Id. Her depression screen noted she had felt down, depressed, or hopeless during the prior month and bothered by little interest or pleasure. Id.

         Upon examination, Dr. Castellone noted Plaintiffs lumbar and cervical spine was tender and her neurological components were “unsteady, ” but she had no lymphadenopathy. Tr. at 507. Dr. Castellone assessed unchanged sickle cell trait, stable MS, stable hypertension, uncontrolled DDD, and uncontrolled radiculopathy. Tr. at 507. He stopped Plaintiffs Effexor, Naproxen, and Daypro, refilled her amantadine, and Zoloft, and counseled Plaintiff to check her blood pressure, continue with Dr. Lucas, and report worsening symptoms. Tr. at 508. Dr. Castellone recommended Plaintiff maintain her current treatment plan. Id. He discussed that Plaintiff “need[ed] [a] cane as uns[t]able.” Id.

         Also, on July 15, 2014, Dr. Castellone completed a medical opinion statement regarding Plaintiffs ability to do work-related physical activities. Tr. at 542-45. Dr. Castellone provided the following limitations: Plaintiff could lift less than ten pounds on an occasional or frequent basis, stand, walk, or sit for less than two hours, sit for thirty minutes before changing positions, stand for ten minutes before changing positions, walk around every ten minutes for ten minutes, but needed the ability to sit at will. Tr. at 542-43. Dr. Castellone opined Plaintiff was “unable to return to work at all.” Tr. at 543. Dr. Castellone also opined Plaintiff would need to lie down at unpredictable intervals during a work shift, approximately every two hours, and noted she “is most comfortable laying down.” Tr. at 544. He noted medical findings, such as an MRI, nerve conduction study, physical therapy, rheumatology report, and x-ray, supported the limitations that he provided. Id. Dr. Castellone noted Plaintiff could never twist, stoop (bend), crouch, or climb stairs or ladders. Tr. at 544. Dr. Castellone noted Plaintiffs impairments affected her physical functions for handling, fingering, and feeling, but not reaching or pushing and pulling. Id. He noted these physical functions were affected due to DDD in Plaintiffs neck, noting it was “very painful for her to perform many common functions.” Tr. at 545. Dr. Castellone noted these limitations were supported by medical findings, such as an MRI, nerve conduction study, and x-rays. Tr. at 545.

         Dr. Castellone noted Plaintiff needed to avoid all exposure to hazards (such as machinery or heights) and avoid even moderate exposure to extreme heat, but she had no environmental restrictions for extreme cold, wetness, humidity, noise, fumes, odors, dusts, gases, or poor ventilation. Tr. at 545. He noted Plaintiff could not operate machinery due to her current medications and increased heat made her pain worse. Tr. at 545. Dr. Castellone noted the earliest date the ...


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