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Quinones v. Saul

United States District Court, D. South Carolina

December 18, 2019

Evelyn Eickmeyer Quinones, Plaintiff,
Andrew M. Saul, [1]Commissioner of Social Security Administration, Defendant.


          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 he 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 September 10, 2014, Plaintiff filed an application for DIB in which she alleged her disability began on August 11, 2014. Tr. at 188. Her application was denied initially and upon reconsideration. Tr. at 114-17, 118-22. On May 22, 2017, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Mary Ryerse. Tr. at 48-76 (Hr'g Tr.). The ALJ issued an unfavorable decision on September 29, 2017, finding Plaintiff was not disabled within the meaning of the Act. Tr. at 21-47. 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 December 21, 2018. [ECF No. 1]. On October 4, 2019, the undersigned issued an order permitting the Commissioner until October 18, 2019, to file a supplemental brief and advising the parties the court intended to schedule the case for hearing. [ECF No. 18]. Upon reviewing the Commissioner's supplemental brief and notice of supplemental authority (ECF Nos. 19, 20), the undersigned determined a hearing would not aid the court in its decision.

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 58 years old at the time of the hearing. Tr. at 52. She completed college. Tr. at 189. Her past relevant work (“PRW”) was as a caregiver, a life enrichment coordinator, an office assistant, an outreach specialist, and a staff assistant. Tr. at 189. She alleges she has been unable to work since August 11, 2014. Tr. at 188.

         2. Medical History

         Plaintiff presented to Michelle B. Nobles, PA-C (“PA Nobles”), for recurrent episodes of vertigo on August 26, 2014. Tr. at 310-11. PA Nobles indicated she had referred Plaintiff to a neurologist when she initially presented with vertigo one year prior. Tr. at 310. She noted blood work, an electrocardiogram (“EKG”), a computed tomography (“CT”) scan, magnetic resonance imaging (“MRI”), and an electroencephalogram (“EEG”) had all been normal. Id. She stated Plaintiff's providers ultimately concluded Plaintiff's anxiety likely caused the vertigo. Id. She indicated Plaintiff's psychiatrist had adjusted her medications, and her symptoms had improved until Plaintiff developed more frequent vertigo over the prior month. Id. Plaintiff stated she felt dizzy if she looked up or down or moved her head too quickly. Id. She endorsed tinnitus and tiredness, but denied syncope and pre-syncopal episodes. Id. She also reported decreased cognition. Id. PA Nobles noted some fluid in Plaintiff's ears and a severely deviated septum, but indicated no other abnormalities. Id. She assessed recurrent episodes of vertigo, fatigue, bipolar disorder, tinnitus, and hearing loss. Id. She referred Plaintiff to an ear, nose, and throat specialist for evaluation. Id.

         Plaintiff also followed up with psychiatrist Hayne McMeekin, M.D. (“Dr. McMeekin”), on August 26, 2014. Tr. at 322. She reported continued decline and difficulty coping. Id. She endorsed difficulty counting and working with numbers. Id. Dr. McMeekin indicated Plaintiff's work ability had declined. Id. He noted Plaintiff wanted to “go out on disability.” Id.

         On October 21, 2014, Plaintiff reported she had stopped working. Tr. at 321. She indicated she had been very suspicious of others, had scattered thoughts, and was unable to think through problems. Id. Dr. McMeekin indicated a mental status exam was abnormal, as Plaintiff demonstrated racing thoughts and fair attention, concentration, and comprehension. Id. He noted Plaintiff reported work-related stressors and an abusive boss. Id. He assessed a global assessment of functioning (“GAF”)[2] score of 65.[3] Id. He prescribed Lorazepam 0.5 mg and increased Plaintiff's dose of Lamotrigine to 1.5 pills twice a day. Id.

         On December 9, 2014, Plaintiff followed up with PA Nobles for Vitamin B12 deficiency. Tr. at 331. She reported increased energy, but indicated the injections became less effective one week prior to the next scheduled injection. Id. PA Nobles described Plaintiff's affect as normal and noted no abnormalities. Id. She provided Plaintiff with a vial of B12 and syringes for at-home administration. Id. She instructed Plaintiff to continue to take oral Vitamin D and B12 supplements. Id.

         Plaintiff also followed up with Dr. McMeekin on December 9, 2014. Tr. at 351. She reported she was doing a “lot better.” Id. She continued to endorse paranoia, but indicated she was not as obsessive. Id. She reported she had previously reached a psychotic level. Id. She stated she had felt like everyone was against her, but her symptoms had improved since she stopped working. Id. Dr. McMeekin noted the following on mental status exam: neat appearance; cooperative behavior; motor function and speech within normal limits; full affect; anxious mood; scattered thought form; and linear thought process. Id. He assessed a GAF score of 75.[4] Id.

         On December 23, 2014, state agency medical consultant Seham El-Ibiary, M.D. (“Dr. El-Ibiary”), reviewed the record and completed a physical residual functional capacity (“RFC”) assessment. Tr. at 88-90. He provided the following limitations: occasionally lift and/or carry 50 pounds; frequently lift and/or carry 25 pounds; stand and/or walk for a total of about six hours in an eight-hour workday; sit for a total of about six hours in an eight-hour workday; never climbing ladders/ropes/scaffolds; occasionally balancing; frequently climbing ramps/stairs, stooping, kneeling, crouching, and crawling; and avoiding even moderate exposure to hazards. Id. A second state agency medical consultant, George Walker, M.D. (“Dr. Walker”), assessed the same physical RFC on June 3, 2015. Tr. at 105-07.

         On February 2, 2015, Plaintiff presented to Chad Ritterspach, Psy. D. (“Dr. Ritterspach”), for a psychological consultative evaluation. Tr. at 352-54. Dr. Ritterspach noted Plaintiff was cooperative, informative, demonstrated a positive attitude, answered questions freely, spoke articulately, showed normal psychomotor activity, and “appeared to be an accurate source of information about her difficulties.” Tr. at 352. Plaintiff reported her mind raced and she had difficulty remaining “on track.” Id. She stated she was “almost always manic.” Id. She endorsed infrequent depressed mood characterized by self-deprecation. Id. Dr. Ritterspach noted Plaintiff “ha[d] the ability to conform to social standards, comply with rules and regulations, cooperate with authority, and interact with peers” and could “engage in social activity.” Id.

         Plaintiff reported a history of termination from employment for attendance problems related to depression. Id. She endorsed mild difficulty remembering instructions and stated she was unable to maintain concentration throughout the workday or perform tasks independently. Id. She denied a history of conflict with coworkers and supervisors and stated she was able to accept constructive feedback from supervisors. Id. She reported average daily activities that included reading, writing, cooking, a little walking, and watching the news. Tr. at 353. She stated mania affected her ability to drive without getting lost. Id.

         Dr. Ritterspach noted Plaintiff could read, write, follow directions, engage in self-care, prepare simple meals, and engage in social activities. Id. He stated, “[d]ue to mood impairment, ” Plaintiff was “easily distressed and fe[lt] overwhelmed and “d]ue to possible cognitive limitations, ” she required “help with managing money, driving, managing finances, and remembering appointments.” Id.

         Dr. Ritterspach observed the following on mental status exam: appropriate eye contact; articulate speech at normal volume; euthymic mood and affect; logical thought processes; appropriate thought content; ability to follow simple directions; denial of suicidal and homicidal ideation and hallucinations; oriented to time, date, place, and situation; average intellectual functioning; impaired memory for short-term auditory recall; concentration within normal limits; and intact judgment and insight. Id. Plaintiff performed digits correctly up to five digits, remembered recent and remote events, spelled “world” backward, completed serial threes, performed simple math, and interpreted proverbs correctly, but had difficulty recalling three words she had repeated earlier without prompts. Id.

         Dr. Ritterspach diagnosed unspecified mood disorder and indicated “there may be another underlying problem, such as ADHD.” Id. He noted Plaintiff reported mania interfered with her activities of daily living (“ADLs”), causing forgetfulness and disorientation while driving. Id. He stated Plaintiff “would have the ability to interact appropriately with co-workers, supervisors, and the public” in the workplace. Id. He indicated Plaintiff “may have trouble retaining new information as she performs work tasks, ” “may have some problems tolerating work-related stressors, ” and “may be somewhat easily distracted from work tasks, particularly if they are detailed and complex.” Id. He added “[t]he extent of limitations based on racing thoughts and distractibility suggests she would have difficulty in most work settings.” Id. However, he noted Plaintiff's medication was “not helpful at [that] time, ” and stated “she ha[d] the general cognitive/psychological capacity for employment” if she obtained appropriate treatment. Id. He indicated Plaintiff needed assistance to manage her finances in her own best interest. Tr. at 354.

         On February 6, 2015, state agency consultant Craig Horn, Ph.D. (“Dr. Horn”), reviewed the record and completed a psychiatric review technique (“PRT”). Tr. at 85-87. He considered Listing 12.04 for affective disorders and assessed the following degree of functional limitation: mild restriction of ADLs; moderate difficulties in maintaining social functioning; moderate difficulties in maintaining concentration, persistence, or pace; and no repeated episodes of decompensation, each of extended duration. Tr. at 85. He determined Plaintiff had the ability to perform “simple routine tasks away from public.” Id. Dr. Horn also completed a mental RFC assessment. Tr. at 90-91. He found Plaintiff was moderately limited in the following abilities: to carry out detailed instructions; to maintain attention and concentration for extended periods; to work in coordination with or proximity to others without being distracted by them; and to interact appropriately with the general public. Id.

         On April 20, 2015, Plaintiff indicated she had become delusional and paranoid within five days of applying for jobs. Tr. at 359. She indicated she would attempt to work as a telemarketer. Id. Dr. McMeekin described Plaintiff's mental status as “fragile.” Id. He noted the following observations on mental status exam: neat appearance; appropriately oriented; positive eye contact; cooperative behavior; normal motor activity; normal speech; labile affect; anxious mood; scattered thought form; racing thoughts; delusional thought content; startled; and good attention, concentration, recent and past memory, language, insight, and judgment. Id. He indicated Plaintiff was having a delusional episode, as she had become paranoid and delusional while working in a cleaning job and felt like her coworkers did not like her and were stealing her supplies. Id. He prescribed two additional medications and assessed a GAF score of 70. Id.

         On June 3, 2015, a second state agency consultant, Douglas Robbins, Ph.D. (“Dr. Robbins”), completed a PRT and mental RFC assessment. Tr. at 102-04, 107-09. He considered Listing 12.04 and assessed no episodes of decompensation, mild restriction of ADLs, and moderate difficulties in maintaining social functioning and concentration, persistence, or pace. Tr. at 102. He concluded the additional evidence supported a severe, but not listing- level impairment “with moderate functional limitations.” Tr. at 104. In the RFC assessment, he indicated Plaintiff had moderate limitations with respect to the following abilities: to carry out detailed instructions; to maintain attention and concentration for extended periods; to work in coordination with or in proximity to others without being distracted by them; and to interact appropriately with the general public. Tr. at 107-09. He concluded Plaintiff was able to perform “simple routine tasks away from public.” Tr. at 109.

         On June 22, 2015, Dr. McMeekin noted the following on mental status exam: neat appearance; cooperative behavior; motor activity within normal limits; speech within normal limits; full affect; euthymic mood; linear thought process and form; thought content within normal limits; and no perceptual disturbances. Tr. at 372. He indicated Plaintiff's inability to work increased her stressors. Id. He changed Plaintiff medications. Id.

         On July 23, 2015, Plaintiff presented to a Marsha D. Jackson, LMSW, LPCS (“Counselor Jackson”), for counseling. Tr. at 367. She complained of increased depressive symptoms, including hopelessness, isolation, and paranoia of being avoided by others. Id. Counselor Jackson indicated Plaintiff's symptoms were precipitated by a diagnosis of bipolar disorder, loss of her job, foreclosure of her home, and a recent visit to the neurologist. Id. Plaintiff requested intensive treatment for increased negative thoughts. Tr. at 368. She reported a history of suicide attempt years prior and endorsed fleeting thoughts that others would be better off without her, but denied suicidal ideation and plan. Id. Counselor Jackson noted Plaintiff was accompanied to the visit by her husband, who was concerned about her isolation and tearfulness. Id. She assessed a GAF score of 50[5] and indicated Plaintiff was willing to attend a day treatment program. Id.

         Plaintiff followed up with Dr. McMeekin on July 28, 2015. Tr. at 371. Dr. McMeekin noted the following on mental status exam: cooperative behavior; tense and agitated motor activity; depressed, anxious, and angry mood; and scattered thought form characterized by racing thoughts and flight of ideas. Id. He adjusted Plaintiff's medications. Id.

         Plaintiff presented to Carolinas Medical Center Randolph Adult Partial Hospitalization Program (“Partial Hospitalization Program”) for intake on August 3, 2015. Tr. at 390. Lisa Winn, RN (“Nurse Winn”), observed Plaintiff to have appropriate grooming and hygiene and anxious and depressed affect. Id. Plaintiff endorsed depression with increased sleep, binge eating, decreased motivation and interest, lack of energy, poor concentration and focus, and short-term memory loss. Id. She stated she had visited a neurologist, who had diagnosed her with depression-induced dementia, and was scheduled for an upcoming evaluation for possible sleep apnea. Id. Plaintiff endorsed thoughts that “people would be better off without [her]” and a history of two suicide attempts years prior, but denied suicidal intent or plan. Tr. at 390-91. She reported constant paranoia that “people [were] out to get [her]” and were following her. Tr. at 391. She feared being chastised by others. Id. Plaintiff indicated she had been diagnosed with bipolar disorder and had a history of manic behavior characterized by constant movement and talking and impulsive spending. Id.

         On August 5, 2015, Plaintiff presented to the Partial Hospitalization Program for intake with Rodney A. Villanueva, M.D. (“Dr. Villanueva”). Tr. at 391. She reported financial difficulty and hopelessness and expressed “not wanting to be [there]” for the appointment. Id. She endorsed ruminating thoughts prior to falling asleep, decreased interest in activities, feelings of guilt, poor energy level, binge eating, and poor concentration. Id. She reported being followed by others, having her patients' family members accuse her of stealing things, and feeling as if others were annoyed by and jealous of her. Tr. at 392. Dr. Villanueva stated he was not sure if Plaintiff had bipolar disorder. Id. He noted Plaintiff's medications and indicated use of “an antidepressant in the possible setting of bipolar disorder [was] somewhat problematic as it could switch her over into a manic episode.” Id. He indicated “an antipsychotic might be a better choice if she is having mania” and “may be helpful for what may be paranoid delusions.” Id.

         Relying on Plaintiff's report that she sometimes lacked money for medication because of irresponsible spending, Dr. Villaneuva stated “[o]f note, is that the patient can sometimes go 1-2 weeks without medicines because of financial reasons.” Tr. at 393. He acknowledged “[t]he patient may not be consistent with her medications.” Id. He observed the following on mental status exam: neatly dressed; calm and cooperative behavior; good eye contact; no abnormal movements; normal rate and volume of speech; euthymic mood; no suicidal or homicidal ideation; no auditory or visual hallucinations; questionable paranoid delusions; fair insight and judgment; and linear and goal-directed thought process without evidence of loosening of associations or flight of ideas. Tr. at 394. Dr. Villanueva assessed (1) unspecified bipolar and related disorder, by history and (2) unspecified psychotic disorder, consider delusional disorder. Id. He also indicated “[t]here may be some narcissism on the patient's part.” Id. He discontinued Prozac, decreased Lorazepam, prescribed Abilify 10 mg, and continued Lamictal. Id.

         Plaintiff reported she was “much better” on August 13, 2015. Tr. at 364. She endorsed decreased paranoia and stated she had recently reached out to friends. Id. She continued to report racing thoughts that occurred at night, but stated she was able to stop them. Id. Dr. Villaneuva probed Plaintiff's history of paranoid beliefs. Id. He questioned the diagnosis of bipolar disorder because he did not believe Plaintiff had described any true manic episodes. Tr. at 365. He noted the following observations on mental status exam: neatly dressed and well-groomed; cooperative and pleasant; good eye contact; no evidence of psychomotor agitation; speech at normal rate and volume; euthymic mood; affect marked by appropriate smiling; no suicidal or homicidal ideation or auditory or visual hallucinations; paranoid delusions present; linear and goal-directed thought process; no evidence of flight of ideas or loosening of associations; fair insight; and adequate judgment. Id. He continued Plaintiff's medications. Tr. at 366.

         Plaintiff reported “doing really well” during a visit with Dr. Villanueva on August 20, 2015. Tr. at 361. She reported she had declined a job with an afterschool program because she shared a car with her husband and would not have transportation. Id. She indicated she had applied for jobs within walking distance of her home. Id. She reported “a lot less” paranoia. Id. Dr. Villanueva assessed delusional disorder and explained to Plaintiff that people with her diagnosis were often capable of normal functioning. Tr. at 361-62. He noted the following on mental status exam: neatly dressed; calm, cooperative, and pleasant; no evidence of psychomotor agitation; good eye contact; normal rate and volume of speech; euthymic mood; appropriate and smiling affect; no suicidal or homicidal ideation; paranoid delusions present, but occurring “a lot less” often; thought process linear and goal-directed without evidence of flight of ideas or loosening of associations; and adequate insight and judgment. Tr. at 362. Dr. Villanueva continued Abilify and Lamictal, discontinued Ativan, and instructed Plaintiff to use Melatonin for sleep.

         On September 21, 2015, Dr. McMeekin noted the following on mental status exam: neat appearance; cooperative behavior; motor function within normal limits; speech within normal limits; full affect; anxious mood; and scattered thought form characterized by flight of ideas. Tr. at 370. He assessed a GAF score of 65, continued Plaintiff's prescriptions for Ativan and Fluoxetine, and increased Abilify. Id.

         On January 4, 2016, Dr. McMeekin indicated Plaintiff was doing well. Tr. at 369. A mental status exam was within normal limits. Id.

         On February 15, 2016, Plaintiff reported she was no longer delusional. Tr. at 376. She indicated she recently worked in an office, as a cleaner, and as a caretaker. Id. She stated she initially did well in the jobs, but subsequently began to worry about her job performance and others' thoughts of her to the point she became suspicious of her coworkers. Id. She reported she remained at home most of the time, but sometimes left her home to engage in activities like shopping. Id. Plaintiff indicated she was unable to read well because of her short attention span. Id. She reported a sense of dread, anxiety, and failure, but denied being delusional and indicated she could recognize her abnormal thoughts. Id. She stated her medications were working. Id. Dr. McMeekin noted it had been difficult to find medications that were consistently effective and recommended Plaintiff continue her medications. Id.

         On April 25, 2016, Plaintiff indicated she desired to become involved in her mother's church. Tr. at 377. Dr. McMeekin observed Plaintiff to be calm and not as suspicious or overwhelmed as she was when she was working. Id. He noted Plaintiff's symptoms were stable and continued her medications. Id.

         Plaintiff presented to Anthony W. Bracken, M.D. (“Dr. Bracken”), for a cardiology consultation on March 29, 2017. Tr. at 379. She reported recent low diastolic blood pressure readings, but Dr. Bracken indicated a review of her chart failed to yield any abnormal recordings. Tr. at 379-80. Plaintiff also complained of falling asleep during the day and upper right-sided chest discomfort that occurred at rest and upon exertion. Tr. at 380. Dr. Bracken noted no abnormalities on physical exam, but indicated an EKG showed poor R-wave progression, nonspecific T-wave changes, and low voltage in the precordial leads. Tr at 382. He recommended a stress echocardiogram based on Plaintiff's risk factors and advised her to follow up with her primary care physician for daytime somnolence and a possible sleep apnea evaluation. Tr. at 379, 382.

         On April 26, 2017, Counselor Jackson provided a letter specifying she had begun counseling Plaintiff in 2007. Tr. at 388. She stated Plaintiff was a “model client, ” who was “motivated and cooperative concerning recommendations” for treatment. Id. She noted Plaintiff had worked successfully for many years in a hospital, but had accepted a new position in 2011 that had led to increased work stress. Id. She indicated “[b]y 2014, her psychiatric s[ymptoms] became full-blown” and included reduced cognitive functioning. Id. She stated after Plaintiff left the hospital, she “counseled her through countless other attempts at employment.” Id. She noted Plaintiff had attempted and failed many types of jobs. Id. She stated Plaintiff's “severe paranoid ideation . . . took its toll socially and in the workplace.” Id. She indicated Plaintiff “would rather be gainfully employed, but each attempt t[ook] her further into a depressed state.” Id.

         C. The Administrative Proceedings

         1. The Administrative Hearing

         a. Plaintiff's Testimony

         At the hearing, Plaintiff testified she was married and lived with her husband. Tr. at 52. She stated she was 5' 1½” tall and weighed 185 pounds. Tr. at 52-53. She said she earned a master's degree. Tr. at 53. She indicated that since August 2016, she had worked three hours a day, three days a week for Boomerang Transport, transporting Workers' Compensation patients to their appointments and earning a minimum of $22 per ride. Tr. at 53-54. She said she had previously worked for Care Partners. Tr. at 54. She stated she initially worked as a caregiver, but subsequently worked in the office, handling billing and payroll matters. Id. She testified she stopped working as a caregiver because the rushed pace of the job exacerbated her symptoms. Id. She indicated she left the office job because she made mistakes with numbers, causing her to become upset and depressed and to miss work. Id. She said she worked for Eaeic for one week as a scanner for $200. Tr. at 55.

         Plaintiff testified she previously worked for Charlotte Mecklenburg Hospital as an outreach specialist and a staff assistant. Id. She testified she previously worked for Liberty Mutual Insurance as an office assistant. Tr. at 55-56. She stated she also previously worked for wholesale distributor Natural Organics and for chemical distributor Aceto Corporation as a customer service representative. Tr. at 56-57.

         Plaintiff testified that her medications caused dizziness, vertigo, drowsiness, and blurred vision. Tr. at 57. She said she occasionally had problems with high blood pressure and continually had problems with irritable bowel syndrome (“IBS”) and gastroesophageal reflux disease (“GERD”) that were not relieved by medication. Tr. at 58. She denied having recently followed up with Dr. Gaspari for ...

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