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.

Shrawna D. B. v. Berryhill

United States District Court, N.D. Texas, Dallas Division

April 22, 2019

SHRAWNA D. B., Plaintiff,
v.
NANCY A. BERRYHILL, ACTING, COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, Defendant.

          FINDINGS, CONCLUSIONS, AND RECOMMENDATION

          IRMA CARRILLO RAMIREZ UNITED STATES MAGISTRATE JUDGE.

         By Special Order No. 3-251, this social security appeal was automatically referred for proposed findings of fact and recommendation for disposition. Based on the relevant filings, evidence, and applicable law, the Commissioner's decision should be AFFIRMED.

         I. BACKGROUND

         Shrawna D. B. (Plaintiff) seeks judicial review of a final decision by the Commissioner of Social Security (Commissioner) denying her claims for a period of disability and disability insurance benefits (DIB) under Title II of the Social Security Act (Act), and for supplemental security income (SSI) under Title XVI of the Act. (docs. 1; 14.)

         A. Procedural History

         On April 28, 2015, Plaintiff filed her applications for DIB and SSI alleging disability beginning on September 22, 2012.[1] (doc. 10-1 at 17, 134-35.)[2] Her claims were denied initially on November 9, 2015, and upon reconsideration on February 2, 2016. (Id. at 134-35, 158-59.) On March 8, 2016, she requested a hearing before an Administrative Law Judge (ALJ). (Id. at 205.) She appeared and testified at a hearing on March 6, 2017. (Id. at 74-112.) On April 26, 2017, the ALJ issued a decision finding that she was not disabled, and denying her claims for benefits. (Id. at 17-31.)

         Plaintiff appealed the ALJ's decision to the Appeals Council on June 16, 2017. (Id. at 267-68.) The Appeals Council denied her request for review on March 16, 2018, making the ALJ's decision the final decision of the Commissioner. (Id. at 7.) Plaintiff timely appealed the Commissioner's decision under 42 U.S.C. § 405(g). (See docs. 1; 14.)

         B. Factual History

         1. Age, Education, and Work Experience

         Plaintiff was born on April 10, 1980, and was 36 years old at the time of the hearing. (doc. 10-1 at 30, 79.) She had at least a high school education and could communicate in English. (Id. at 30.) She had past relevant work experience as a data entry operator and child care worker. (Id. at 29-30.)

         2. Medical Evidence

         On May 28, 2014, March 4, 2015, May 12, 2015, and June 23, 2015, Plaintiff met with Sabahat Faheem, M.D., at Crescent Psychiatry. (Id. at 416-23.) In May 2014, she complained of depressed feelings and was not doing well on Citalopram. (Id. at 416.) She had poor energy levels and slept most of the time, but her anxiety had greatly improved and she was not having panic attacks. (Id.) In March 2015, she was doing well on medication, had no depression, and her anxiety and panic attacks were greatly improved. (Id. at 422.) She continued to have low energy, but had fair concentration. (Id.) In May 2015, Plaintiff complained of anxiousness and frequent panic attacks. (Id. at 419.) She felt that her medications were not strong enough, but she denied feeling depressed. (Id.) She stated that her panic attacks interfered with her activities of daily living, and that she had poor sleep, low energy, and fair concentration. (Id.) In June, Plaintiff reported feeling depressed and anxious. (Id. at 413.) She would cry over small things, but she denied having panic attacks or suicidal ideations. (Id.) She was not depressed everyday, but she continued to have poor sleep, low energy, and fair concentration. (Id.) Her mental status exams consistently showed that she was alert, oriented times 4, and cooperative, with logical and well-organized thought processes, good judgment and insight, and no delusional thoughts or hallucinations. (Id. at 417.) Although her mental status exams were mostly identical, her moods were sad, “ok”, anxious, and depressed, and her affect was sad, euthymic, and anxious. (Id. at 414, 417, 420, 423.) Throughout her appointments, she reported that taking care of her special needs son was a stressor for her. (Id. at 413, 416, 419, 422.) Dr. Faheem diagnosed her with major depressive disorder that was either mild or in remission, panic disorder without agoraphobia, hypertension, hyperlipidemia, neuropathy, and carpal tunnel syndrome, and her Global Assessment of Functioning (GAF) score was 50-55. (Id. at 414, 417-18, 420-21, 423.)

         On May 19, 2015, Patrick Baldwin, LCSW, completed a psychosocial assessment for Plaintiff. (doc. 10-2 at 93.) She presented with obsessive compulsive disorder and depression. (Id.) She had a GAF score of 45, and Mr. Baldwin created a plan to decrease her depression. (Id. at 96.)

         Between June 16, 2015 and November 17, 2015, Plaintiff underwent monthly individual therapy sessions with Mr. Baldwin. (Id. at 86-91.) In June, she was depressed with sad affect, and reported that she did not think her medications were working correctly, but she was hopeful she would be doing better soon because her psychiatrist had changed her medications. (Id. at 91.) In July, she reported that her medication was working well and helping to prevent her from becoming overwhelmed with circumstances. (Id. at 90.) She was planning to go on a trip and was looking forward to it. (Id.) She had also been getting out more to socialize with family and friends. (Id.) In August, she presented as depressed with sad affect, and also exhibited psychomotor retardation and appeared fatigued. (Id. at 89.) She was waking up often during the night and not getting enough restorative sleep. (Id.) The symptoms of her depression and anxiety included dysphoric mood, anhedonia, insomnia, fatigue, decreased concentration, and anxiety attacks marked by shortness of breath, heart palpitations, and dizziness. (Id.) In September, she presented as fatigued and reported that she was still getting used to her new medication because her psychiatrist had changed it. (Id. at 88.) The medication made her very drowsy, and she seemed to doze off during the session at times. (Id.) In October, she had bright affect, and reported that she was feeling much better on new medication. (Id. at 87.) She was no longer experiencing mood swings, although she did become irritable with her son at times. (Id.) In November, she continued to do well with her medication and had bright affect. (Id. at 86.) The main stressor in her life at the time was her son failing math. (Id.) Mr. Baldwin continually discussed techniques to help manage her symptoms. (See id. at 86-91.)

         On October 19, 2015, Plaintiff went to Methodist Hospitals (Methodist) to establish care. (doc. 10-2 at 38.) A history of hypertension, type II diabetes, depression, and anxiety was noted. (Id. at 39.) Her mental status examination was grossly normal, and her affect and judgment were normal. (Id. at 41.) She was assessed with type II diabetes and hypertension, and it was noted that her anxiety and depression were managed by psychiatry and counseling. (Id. at 41-42.)

         On November 6, 2015, Matthew Wong, Ph.D., a state agency psychological consultant (SAPC), examined Plaintiff's medically determinable impairments utilizing the psychiatric review technique (PRT) and determined that she had mild restrictions in activities of daily living, moderate difficulties in maintaining social functioning, mild difficulties in maintaining concentration, persistence, or pace, and no repeated episodes of decompensation. (doc. 10-1 at 140.) He found that although she had more than minimal mental limitations, she was able to function in the workplace, with some restrictions, on an effective and sustained basis. (Id.) That same day, he completed a mental residual functional capacity (RFC) assessment based on the medical evidence of record. (Id. at 142-44.) He opined that Plaintiff was no more than moderately limited in the areas of understanding and memory, sustained concentration and persistence, social interaction, and adaptation, and that she was able to understand, remember, and carry out detailed but not complex instructions, make decisions, concentrate for extended periods, interact with others, and respond to changes. (Id. at 143-44.)

         On November 18, 2015, Plaintiff had a follow-up at Methodist for her type II diabetes. (doc. 10-2 at 31-33.) She reported doing better with her diabetes, and that she had started exercising again. (Id. at 33.) She tried to walk at least 30 minutes daily and had walked 2 miles that day. (Id.) She had a gym at her apartment complex and an elliptical machine in her home. (Id.) Regarding her depression and anxiety, it was noted that her conditions had been monitored by Dr. Faheem and Mr. Baldwin, and that her new medication regimen was slowly improving her mood and outlook. (Id.) She denied suicidal or homicidal ideations. (Id.)

         On January 5, 2016, Plaintiff underwent another individual therapy session with Mr. Baldwin. (Id. at 85.) She had a dysphoric mood, sad affect, fatigue, worrying, and psychomotor retardation. (Id.) She reported that her mood swings prevented her from keeping any kind of consistent schedule. (Id.) She took her medications as prescribed, but between her mood swings and fluctuations in her sugar levels, she was unable to maintain any kind of consistency. (Id.) Mr. Baldwin discussed using cognitive behavioral techniques that could help her correct the cognitive distortions that possibly exacerbated her symptoms. (Id.)

         On January 7, 2016, Dr. Faheem completed a mental status report for Plaintiff. (doc. 10-1 at 488.) She noted that Plaintiff had received treatment since May 28, 2014, and that although she was stable on her medications, her mood symptoms worsened with increased stress. (Id.) Plaintiff was alert and oriented times 3 with improved mood and affect. (Id.) She became stressed off and on due to daily stressors and responsibilities, but she had no suicidal ideations or aggressive thoughts. (Id. at 489.) She was unable to do serial sevens and gave only one correct answer. (Id.) Her insight and judgment were fair, and her ability to abstract was intact. (Id.) Her ability to relate to others and sustain work was fair to poor, and Dr. Faheem noted that she could not handle stress well. (Id. at 490.) She further noted that Plaintiff's ability to respond to changes and stress in work settings was poor, and that her prognosis was fair even though she could relapse during stressful times. (Id.) Dr. Faheem reported her diagnoses as major depressive disorder in remission and panic disorder without agoraphobia. (Id. at 487, 489.)

         On February 2, 2016, March 1, 2016, and April 13, 2016, Plaintiff had therapy sessions with Mr. Baldwin. (doc. 10-2 at 84, 108-09.) In February, she reported fatigue, psychomotor retardation, and difficulty walking and tingling in her hands due to diabetes-related neuropathy. (Id.) She was taking Lyrica for neuropathy and Viibryd for depression. (Id.) She reported continued mood swings in spite of taking her medications. (Id.) Plaintiff had started exercising on a treadmill at home, and felt that she was doing something good for her body and mind when she exercised. (Id.) In March, she had depressed mood with sad affect, fatigue, difficulty holding objects due to symptoms of carpal tunnel, sleepiness, and expressions of worry and worthlessness. (Id. at 109.) She reported being diagnosed with a pinched nerve in her neck, which was causing numbness in her legs and arms. (Id.) In April, she had calm affect. (Id. at 108.) She was wearing braces on her wrists due to carpal tunnel syndrome. (Id.) Plaintiff was going to physical therapy for problems in her legs, hands, and wrists, and she was hopeful that her pain levels would improve. (Id.)

         Also on February 2, 2016, Dr. Wong again examined Plaintiff's medically determinable impairments utilizing the PRT and found that she had mild restrictions in activities of daily living, moderate difficulties in maintaining social functioning, moderate difficulties in maintaining concentration, persistence, or pace, and no repeated episodes of decompensation. (doc. 10-1 at 165.) He found that although she had more than minimal mental limitations, she was able to function in the workplace, with some restrictions, on an effective and sustained basis. (Id. at 166.) That same day, he completed a mental RFC assessment based on the medical evidence of record. (Id. at 169-71.) He opined that Plaintiff was markedly limited in her ability to carry out detailed instructions, but no more than moderately limited in the remaining areas of understand and memory, sustained concentration and persistence, social interaction, and adaptation. (Id. at 169-70.) She was able to understand, remember, and carry out only simple instructions, make decisions, concentrate for extended periods, interact with others, and respond to changes. (Id. at 171.)

         On March 9, 2016, Plaintiff had an initial physical therapy examination at Methodist Dallas Medical Center. (doc. 10-2 at 244.) She complained of right hip pain and right upper extremity radicular symptoms. (Id.) She was diagnosed with neuropathy in 2011 and began to have worsening numbness from her knee to her hip in October 2015. (Id.) Prolonged sitting, standing, and bending exacerbated her lower back and hip pain. (Id.) At its worst, her pain was a 10 out of 10; it was a 5 out of 10 at its best. (Id.) She rated her radicular pain in her right arm at an 10 out of 10, but it could be as low as a 2 out of 10. (Id.) She had difficulty due to her shoulder pain and would occasionally sleep upright. (Id.) She was having difficulty cooking, cleaning, and with hygiene, and her son helped her with chores at home. (Id.) She exhibited impaired range of motion, abnormal gait, functional activity tolerance and endurance, and pain. (Id. at 246.) It was determined that she would benefit from physical therapy to help her impairments. (Id.)

         From April 29, 2016 to May 9, 2016, Plaintiff had 4 physical therapy sessions in which she complained of mild pain in her right hip. (Id. at 255-61.) At her last appointment, she continued to have hip pain, but reported no pain in her lower back. (Id. at 261.)

         From May 9, 2016 to February 14, 2017, Plaintiff had several follow-up visits with Dr. Faheem. (Id. at 393-409.) In May, she reported feeling fine except for pain from her carpal tunnel syndrome. (Id. at 406.) Her depression and anxiety had improved and were controlled with medication. (Id. at 406-07.) Her stressor was her special needs son. (Id. at 406.) Her energy level was good, and she denied irritability or angry outbursts, reported good concentration, and denied feelings of worthlessness or guilt as well as suicidal thoughts. (Id. at 407.) Her mental status exam showed that her mood and affect were good, her thought processes were logical and well-organized, her judgment and insight were good, and she was alert and oriented times 4. (Id.) In October, she felt good but was depressed some days and okay on others. (Id. at 402.) Her energy level was good, and she had good concentration, no feelings of worthlessness or guilt, and no suicidal thoughts. (Id. at 403.) Her mental status examination remained the same. (Id.) In November, she felt depressed and as if her medication was no longer working. (Id. at 398.) She had hand and back pain from carpal tunnel syndrome and a slipped disc, she had been crying when listening to the news, and she was feeling depressed because her mother was ill. (Id.) Her energy level was fair and she had good concentration. (Id. at 399.) Her mental status examination remained the same, except her mood was sad and her affect was depressed. (Id.) In February, she felt well and her left hand was doing well following carpal tunnel surgery. (Id. at 394.) She had also started having injections in her back, which provided some relief. (Id.) Her energy level was fair and she had good concentration. (Id. at 395.) Her mental status examination remained the same, except her mood was better and affect was improved. (Id.) She denied feeling anxious or having panic attacks throughout her appointments. (Id. at 395, 399, 403, 407.)

         From June 22, 2016 to September 14, 2016 Plaintiff had monthly therapy sessions with Mr. B a l d w i n . (Id. at 368-72.) She presented with bright affect at one appointment, but as depressed with sad affect at the other appointments. (See id.) In June, she reported that she had been going to physical therapy for her hip pain but it was not helping, and she was still having problems with her carpal tunnel syndrome. (Id. at 372.) In July, Mr. Baldwin observed a depressed mood, sad affect, obvious fatigue, psychomotor retardation, slowed speech, and worrying. (Id. at 371.) Plaintiff discussed upcoming surgeries for her carpal tunnel syndrome and back, and stated that with everything going on, she was having trouble regulating her moods, which was exacerbated by her bipolar disorder. (Id.) In August, she presented with bright affect and explained that she had carpal tunnel surgery the prior week. (Id. at 370.) In September, she was very tired and did not have energy to do things she needed to do. (Id. at 368.) Her carpal tunnel on the left improved following surgery, but she continued to have back pain and was hoping to have surgery for it as well. (Id.)

         On July 20, 2016, Plaintiff underwent left carpal tunnel release surgery. (Id. at 112.) She was alert and oriented times 3, her Phelan's test was positive on the left, and her carpal tunnel test was positive bilaterally. (Id. at 115.) She tolerated the procedure well and was discharged that same day. (Id. at 114.)

         On October 14, 2016, Plaintiff underwent an initial adult mental health assessment at Mental Health Mental Retardation (MHMR) of Tarrant County. (Id. at 63-66.) She reported that she was diagnosed with major depressive disorder, anxiety, panic attacks, and obsessive compulsive disorder in 2012, and her medications were not working. (Id. at 363.) She had poor sleep, varied appetite, declines in her memory, concentration, and functioning, racing thoughts, feeling of worthlessness and hopelessness, and changes in her self-care and relationships . (Id.) She exhibited normal speech patterns, and denied having elevated mood, energy levels, or depressed moods. (Id.) She also denied suicidal or homicidal ideations. (Id.) Although she reported a history of depression, her biggest complaint was that she was not getting enough sleep. (Id. at 366.) She did report significant symptoms consistent with major depressive disorder, however, that did not appear to be remedied by the medications she was taking. (Id.)

         On October 25, 2016, Plaintiff had an appointment with Kayla Corn at MHMR. (Id. at 350.) She stated that she cried a lot and sometimes it started out of nowhere. (Id.) She slept well on her sleeping medications, but did not sleep at all when she did not take them. (Id.) She usually slept about 4-6 hours. (Id.) Her depression and anxiety had been difficult, and her anxiety was high because of calls from her son's school about difficulties he was having with his medications and her mom's breast cancer diagnosis. (Id.) She also stated that she over thought things and that she had obsessive compulsive disorder that really irritated her. (Id.)

         On October 31, 2016, Plaintiff had an initial examination for physical therapy due to pain in her lumbar area, right hip, and right knee. (Id. at 179.) She had to shift her weight when sitting due to pain, and she had to limit sitting and standing due to her pain. (Id.) Her lumbar pain could be at an 2 out of 10 at best and was at an 8 at the appointment. (Id.) Her right hip pain could be a 3 out of 10 at best and was at an 8 at the appointment. (Id.) Her right knee pain did not hurt at its best, but it was at an 10 at the time of the appointment. (Id.) Her pain was aggravated by sitting, standing, walking, using stairs, going from sitting to standing, bending, and voiding, but it was better when she was still. (Id.) Her mental status and cognitive function did not appear impaired. (Id.) She ambulated into the office with an antalgic gait, favoring her right side. (Id.) She had problems in her wrists with decreased range of motion, right hand and finger pain with grasping motions, lumbar pain with palpation and movement, lumbar and thoracic weakness, right knee pain, right hip pain, right lower extremity weakness, and core muscle weakness. (Id. at 181.) It was determined that she would need physical therapy to meet her optimal functional potential. (Id.)

         From November 14, 2016 to January 6, 2017, Plaintiff underwent physical therapy with Tiffany Hunter, P.T., D.P.T. (See id. at 188-232.) She consistently reported pain in her lumbar area, right hip, and right knee, but physical therapy was helping relieve her pain, and at times she had no pain at all. (See id. at 188, 191, 195, 198, 201, 208, 214, 217, 220, 222, 226, 228, 232.) In December 2016, she reported a lot of traveling to visit with her family during the Christmas holiday weekend, and she had no pain. (Id. at 222.) In January 2017, she initially reported that she did not have any pain, but at her next appointment, her pain had increased due to exercising with a balance ball. (Id. at 228, 232.) It was consistently noted that sitting, standing, walking, using stairs, going from sitting to standing, bending, and voiding all aggravated her pain, but her pain was better when she was still. (Id. at 188, 191, 195, 198, 201, 208, 214, 217, 220, 222, 226, 228, 232.)

         On December 28, 2016, Plaintiff saw Kristin Garner, M.D., and Michael Castillo, M.D., with complaints of sharp lower back pain that was mainly in her right buttock and radiated toward the lateral side of her right hip. (Id. at 441-44.) Since 2011, it would come and go, and she had pain when lying down, sitting, stranding, or doing any type of activi t y . (Id.) Heating pads provided mild relief, as did physical therapy, but the relief would be gone when she returned home. (Id.) She was positive for back pain, depression, and nervousness/anxiousness. (Id. at 442.) She had tenderness in the greater trochanter, normal range of motion and normal strength in her right hip, and positive Faber's test. (Id.) A back exam showed tenderness in the sacroiliac area, normal range of motion, normal muscle strength, and normal gait. (Id. at 443.) Dr. Garner assessed her with piriformis syndrome of the right side. (Id. at 444.)

         On January 1, 2017 and May 30, 2017, Plaintiff underwent piriformis injections with Dr. Garner. (doc. 10-1 at 57, 68.) She tolerated the procedures well and there were no complications. (Id. at 59, 69.)

         On February 1, 2017, Plaintiff had another therapy session with Mr. Baldwin. (doc. 10-2 at 367.) She presented as depressed with sad affect and was somewhat anxious. (Id.) She had recently lost a family member, and the funeral was very traumatic for her as it brought back memories of the deaths of grandparents who raised her. (Id.) She had been having frequent crying spells that she was unable to control. (Id.) She also continued to experience severe, disabling back pain from a herniated disc, as well as carpal tunnel pain in her right hand that continued to prevent her from doing many things. (Id.)

         On February 14, 2017, Dr. Faheem completed a mental function questionnaire for Plaintiff. (Id. at 373-78.) She had seen Plaintiff since October 2013, and her diagnoses included major depressive disorder, diabetes, hypertension, neuropathy, and improving carpal tunnel syndrome. (Id. at 373.) The severity of her mental impairment and symptoms was mild, her mood was better, her anxiety had improved, her affect was euthymic, her insight and judgment were fair, and she had no suicidal ideations. (Id.) Her prognosis was fair. (Id.) Her signs and symptoms included decreased energy, generalized persistent anxiety, emotional lability, and somatization unexplained by organic disturbance. (Id. at 374.) Regarding her mental abilities and aptitudes to do unskilled work, Dr. Faheem opined that Plaintiff could perform the following independently, appropriately, effectively, and on a sustained basis: remember work-like procedures, understand and remember very short and simple instructions, carry out very short and simple instructions, make simple work-related decisions, perform at a consistent pace without an unreasonable number and length of rest breaks, ask simple questions or request assistance, and accept instructions and respond appropriately to criticism from supervisors. (Id. at 375.) Dr. Faheem opined that Plaintiff could not maintain attention for 2-hour segments, maintain regular attendance and be punctual within customary and usually strict tolerances, sustain an ordinary routine without special supervision, work in coordination with or proximity to others without being unduly distracted, complete a normal workday and work week without interruptions from psychologically based symptoms, get along with coworkers or peers without unduly distracting them or exhibiting behavioral extremes, respond appropriately to changes in a routine work setting, deal with normal work stress, or be aware of normal hazards and take appropriate precautions, however. (Id.)

         Regarding her mental abilities and aptitudes to do semi-skilled and skilled work, Dr. Faheem opined that Plaintiff could not understand and remember detailed instructions, carry out detailed instructions, set realistic goals or make plans independently of others, or deal with stress of semi-skilled and skilled work. (Id. at 376.) Regarding her mental abilities and aptitudes to do particular types of jobs, Dr. Faheem opined that Plaintiff could interact appropriately with the general public and use public transportation, but she could not maintain socially appropriate behavior, adhere to basic standards of neatness and cleanliness, or travel in unfamiliar places. (Id.) Plaintiff did not have a low IQ or reduced intellectual functioning, and her psychiatric conditions did not exacerbate her experience of pain or any other physical symptoms. (Id.) She opined that Plaintiff would also have difficulty working at a regular job on a sustained basis because she had poor concentration, and she would stay weak and lethargic throughout the day. (Id. at 377.) Plaintiff's impairments were reasonably consistent with the symptoms and functional limitations described in her evaluation. (Id.) Dr. Faheem noted that her condition and functional limitations had slightly improved since June 30, 2016, and found that she could manage benefits in her own best interest. (Id. at 377-78.)

         Also on February 14, 2017, Dr. Hunter completed a physical medical source statement for Plaintiff. (Id. at 379-82.) Her symptoms included decreased wrist range of motion and right hand and finger grasping motions, lumbar pain and weakness, right knee pain, and right hip pain. (Id. at 379.) She had continuous pain in her lumbar and thoracic areas, right knee and hip, and wrists bilaterally. (Id.) Dr. Hunter opined that Plaintiff's symptoms could be expected to last at least 12 months, and that emotional factors contributed to the severity of her symptoms and functional limitations. (Id.) Psychological conditions that affected her physical condition included depression and anxiety. (Id. at 380.) Dr. Hunter estimated that Plaintiff could not walk a city block without rest or severe pain, could sit for 30 minutes before needing to get up, could stand for 20 minutes before needing to sit or walk around, and could sit and stand/walk less than 2 hours total in an 8hour workday. (Id.) She further found that Plaintiff needed a job that permitted her to shift positions at will from sitting, standing, or walking, needed to have periods to walk for at least 5 minutes every 20 minutes, and needed to take unscheduled breaks hourly and for about 10 minutes during a workday due to pain/paresthesias and numbness. (Id.) She did not need to have her leg elevated and did not need a cane or other assistive device to stand/walk. (Id. at 381.) Plaintiff could only occasionally carry less than 10 pounds and never carry more than 10 pounds; she could rarely twist, stoop, bend, crouch, squat, or climb stairs; and she could never climb ladders. (Id.) Dr. Hunter found no limitations in Plaintiff's reaching, handling, or fingering. (Id.) Plaintiff was likely to be off task about 25% of the time or more and be absent 4 or more days per month from work, and her impairments were likely to produce good and bad days. (Id. at 382.) Dr. Hunter concluded that Plaintiff's impairments were reasonably consistent with the symptoms and functional limitations described in the evaluation. (Id.)

         Dr. Hunter also completed a clinical assessment of Plaintiff's pain that same day, and found that her pain was present to such an extent as to be distracting to adequate performance of daily work activities. (Id. at 383.) Physical activity, such as walking, standing, sitting, bending, stooping, and moving extremities would greatly increase her pain to such a degree as to cause some distraction or total abandonment of a task. (Id.) Side effects from her medications could be expected to be severe and to limit effectiveness due to distraction, inattentiveness, and drowsiness. (Id. at 384.)

         Mr. Baldwin also completed a mental function questionnaire for Plaintiff on February 14, 2017. (Id. at 386-91.) He noted that Plaintiff's diagnoses included recurrent major depressive disorder, severe panic disorder, chronic insomnia, herniated disc with chronic pain, and carpal tunnel syndrome with chronic pain. (Id. at 386.) Her GAF score was 40, and her highest GAF score in the prior year was 45. (Id.) Her prognosis was guarded. (Id.) Her signs and symptoms included anhedonia, appetite disturbance, feelings of guilt or worthlessness, generalized persistent anxiety, mood disturbance, difficulty thinking or concentrating, recurrent and intrusive recollections of a traumatic experience, psychomotor agitation or retardation, recurrent obsessions or compulsions, sleep disturbance, emotional withdrawal or isolation, recurrent severe panic attacks, and persistent irrational fear of a specific object, activity, or situation. (Id. at 387.)

         Regarding her mental abilities and aptitudes to do unskilled work, Mr. Baldwin opined that Plaintiff could understand, remember and carry out very short and simple instructions, make simple work-related decisions, ask simple questions or request assistance, get along with coworkers or peers without unduly distracting them or exhibiting behavioral extremes, and respond appropriately to changes in a routine work setting. (Id. at 388.) She could not remember work-like procedures, maintain attention for 2 hour segments, maintain regular attendance and be punctual within customary strict tolerances, sustain an ordinary routine without special supervision, work in coordination with or proximity to others without being unduly distracted, complete a normal workday and workweek without interruptions from psychologically based symptoms, perform at a consistent pace without an unreasonable number and length of rest periods, accept instructions and respond appropriately to criticism from supervisors, deal with normal work stress, or be aware of normal hazards and take appropriate precautions. (Id.) Mr. Baldwin opined that she had none of the mental abilities and aptitudes needed to do semiskilled and skilled work. (Id. at 389.) Regarding her abilities and aptitudes to do particular types of jobs, Plaintiff could interact appropriately with the general public, maintain socially appropriate behavior, adhere to basic standards of neatness and cleanliness, travel in unfamiliar places, and use public transportation. (Id.) She did not have low IQ or intellectual functioning, and her psychiatric condition did not exacerbate her experience of pain or other physical symptoms. (Id.) She could be expected to miss more than 4 days of work per month, her impairment could be expected to last at least 12 months, and her impairments were reasonably consistent with the symptoms and functional limitations described in the evaluation. (Id. at 390.) Mr. Baldwin concluded that Plaintiff would have difficulty working at a regular job on a sustained basis because her physical and psychiatric symptoms prevented her from performing any job duties. (Id.) He noted that her condition and functional limitations had not improved since June 30, 2016. (Id.)

         On February 15, 2017, Stephen L. Hines, M.D., completed a medical source statement for Plaintiff. (Id. at 392.) He noted that her symptoms included anxiety, depression, some right hip pain that was decreasing, and numbness and tingling in her leg. (Id.) Her prognosis was unclear, but appeared to be improving. (Id.)

         On March 7, 2017, Plaintiff had a follow-up appointment after a right piriformis injection on January 17, 2017. (Id. at 446.) She reported great improvement in the pain and that the numbness she was previously feeling had resolved as well. (Id.) She developed sharp pains in the midline lower back that did not radiate a few weeks after the injection, ...


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.