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Tammy M. v. Berryhill

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

April 24, 2019

TAMMY M., Plaintiff,
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, Defendant.

         Referred to U.S. Magistrate Judge[1]

          FINDINGS, CONCLUSIONS, AND RECOMMENDATION

          IRMA CARRILLO RAMIREZ UNITED STATES MAGISTRATE JUDGE.

         Tammy M. (Plaintiff) seeks judicial review of the final decision of the Commissioner of the Social Security Administration (Commissioner) denying her claim for supplemental security income (SSI) under Title XVI of the Social Security Act. (doc. 20 at 3.) Based on the relevant findings, evidence, and applicable law, the decision should be REVERSED, and the case REMANDED for reconsideration.

         I. BACKGROUND

         On October 17, 2014, Plaintiff filed her application for SSI, alleging disability beginning on October 17, 2014. (doc. 15-1 at 422, 611-18.)[2] Her claim was denied initially on April 6, 2015, and upon reconsideration on October 29, 2015. (Id. at 492, 507.) On January 11, 2016, Plaintiff requested a hearing before an Administrative Law Judge (ALJ). (Id. at 521.) She appeared and testified at a hearing on March 8, 2017. (Id. at 449-81.) On July 26, 2017, the ALJ issued a decision finding Plaintiff not disabled and denying her claims for benefits. (Id. at 424.)

         Plaintiff timely appealed the ALJ's decision to the Appeals Council on September 29, 2017. (Id. at 585.) The Appeals Council denied her request for review on April 24, 2018, making the ALJ's decision the final decision of the Commissioner. (Id. at 6-12.) Plaintiff timely appealed the Commissioner's decision under 42 U.S.C. § 405(g). (See doc. 1.)

         A. Age, Education, and Work Experience

         Plaintiff was born on September 28, 1969, and was 47 years old at the time of the initial hearing. (doc. 15-1 at 452.) She dropped out of high school in the twelfth grade and does not have a GED. (Id.) She could speak and understand English. (Id. at 634.) She had no past relevant work experience. (Id. at 470-71.)

         B. Medical Evidence

         On August 23, 2014, Plaintiff presented to the emergency room (ER) at Baylor Medical Center (Baylor) with complaints of abdominal pain. (doc. 15-1 at 989). She reported pain in the suprapubic area with urination and stated that her bladder “never hurt this bad before.” (Id. at 991.) She also reported blood in her urine and pain when walking. (Id.) Plaintiff had moderate abdominal tenderness, but there were no apparent or palpable abnormalities. (Id. at 989.) She was assessed with hemorrhagic cystitis and lower abdominal pain. (Id. at 1008.)

         On August 25, 2014, Plaintiff presented to the ER at Methodist Mansfield Medical Center (Methodist) with complaints of lower abdominal pain. (doc. 15-1 at 939.) She appeared in mild distress, but her vitals were normal. (Id. at 942-43.) Her physical examination was unremarkable and she displayed normal range of motion. (Id. at 943.) Plaintiff's back and extremities had no tenderness, her abdomen was soft, and her bowel sounds were normal. (Id. at 943-44.) She was noted to be comfortable and not in acute distress. (Id. at 944.) A CT showed a small hiatal hernia with distal esophagitis. (Id. at 945-46.) Small bilateral kidney stones were observed, but there was no swelling of the kidneys. (Id.) Mild constipation was noted, but there was no obstruction to the gastrointestinal (GI) tract. (Id.) She was discharged the same day and instructed to follow-up with a urologist. (Id. at 946.)

         On the morning of September 22, 2014, Plaintiff arrived by ambulance to the ER at Baylor complaining of low back pain. (doc. 15-1 at 973.) She reported being punched down and choked, and it was noted that she was a victim of domestic violence. (Id. at 974-75.) Physical examination of her neck was negative for obvious evidence of injury or deformity. (Id. at 985.) She had full range of motion of the neck and reported no neck pain. (Id.) Plaintiff reported that she previously had back surgery, but her musculoskeletal examination was normal. (Id. at 975, 985.) She was also noted as being neurovascularly intact with full normal range of motion. (Id. at 985.) Plaintiff's differential diagnoses was reported as contusions, alcohol intoxication, and narcotic abuse. (Id. at 986.) She was assessed with domestic violence, bladder infection, and chronic back pain and discharged that same day. (Id. at 987, 973.)

         On the evening of September 22, 2014, Plaintiff was admitted at Parkland Hospital (Parkland) with a self-inflicted stab wound to the neck. (doc. 15-2 at 148.) She reported being upset about a recent cancer prognosis and “wanted to end her life because she was tired of being sick.” (Id.) She was treated for a five centimeter laceration to the left side of the neck and transferred to inpatient psychiatry. (Id. at 148, 151.) Plaintiff initially refused to speak with the treating psychiatrist, Rebecca Hana, M.D., but eventually accepted treatment. (Id. at 151.) She reported being upset with her ex-husband and felt unsupported by her family. (Id.) She also had recently learned of a bladder mass that could be malignant. (Id.) She reported a history of childhood sexual trauma and two prior suicide attempts. (Id.) Dr. Hanna noted Plaintiff's affect as anxious and insight/judgment as poor. (Id. at 151.) She was unable to assess her mood, thought process, and thought content, however. (Id.) Dr. Hanna's assessment was depression not otherwise specified (NOS) with a Global Assessment of Functioning (GAF) score of 21-30.[3] (Id. at 152.) Plaintiff was noted as being in imminent danger to herself and remained hospitalized for further treatment. (Id.)

         Plaintiff had a psychiatry consult follow-up on September 24, 2014, and reported being in a “good” mood. (Id. at 278.) She denied current suicidal ideation and expressed regret about her recent suicide attempt. (Id. at 277.) Her GAF score had improved to 40. (Id.) Plaintiff was discharged on October 6, 2014[4]; she reported her mood as “good” and was noted as being “future oriented” on that date. (Id. at 333.) She was also noted as appearing logical and having significant improvement in mood. (Id.) Her discharge diagnoses was depression NOS and anxiety NOS, with a GAF of 50. (Id. at 333-34).

         On November 5, 2014, Plaintiff presented to the ER at Parkland complaining of left hip pain. (doc. 15-2 at 352.) She reported worsening hip pain for the past six months, which she rated a 7 out of 10. (Id.) She was observed as having restricted range of motion of her left hip, but was not exhibiting edema. (Id. at 353.) Her straight leg raising was negative. (Id.)

         On December 15, 2014, Plaintiff visited the ER at Baylor complaining of abdominal pain and vomiting. (doc. 15-2 at 391.) She was noted as being distressed and anxious, but denied suicidal ideation. (Id. at 395.) An abdominal X-ray revealed no acute radiographic abnormality of the abdomen or chest. (Id. at 405.) Her bowel gas patterns were noted as normal and no free intraperitoneal air was present. (Id. at 413.) She had a few kidney stones that were unchanged from a prior examination. (Id.) It was also noted that Plaintiff had previous lumbar spine surgery with laminectomies bilaterally at L5, but appeared stable. (Id.) Her diagnosis was a urinary tract infection (UTI). (Id. at 412.)

         On January 6, 2015, Plaintiff presented to the ER at Parkland with complaints of nausea and coughing. (doc. 15-2 at 429.) She also reported headaches, but denied experiencing dizziness or loss of consciousness. (Id. at 431.) Epigastric tenderness was noted but with no rebound; no other abnormalities were observed. (Id. at 429.) She returned back to Parkland two days later complaining of a rash on her face, nausea, and flank pain. (Id. at 439.) Physicial examination of her abdomen revealed tenderness in the lower left quadrant and left flank. (Id.) An abdominal CT revealed bilateral punctate kidney stones without evidence of acute urinary tract obstruction, and post cholecystectomy with two small choledochal cysts. (Id. at 440-41.)

         On February 25, 2015, Plaintiff presented to the ER at Baylor with complaints of lupus, Crohn's disease, fibromyalgia, and recurrent UTIs. (doc. 15-2 at 360.) She was noted as appearing uncomfortable but not in acute distress. (Id. at 361.) Her abdomen showed no edema, cyanosis, or clubbing. (Id.) A comprehensive metabolic panel was unremarkable and hemodynamically stable. (Id.) Her chest X-ray revealed acute pneumonia, but was otherwise unremarkable. (Id.) A h e a d C T showed evidence of chronic maxillary sinus disease. (Id.) She was assessed with pneumonia and designated for inpatient status due to her symptoms and underlying comorbidities. (Id.)

         On March 23, 2015, Plaintiff returned to the ER at Baylor with abdominal pain. (doc. 15-3 at 32-33.) A CT of her abdominal and pelvis showed multiple non-obstructing kidney stones that were noted to be stable. (Id. at 33.)

         On March 31, 2015, Scott Spoor, M.D., a state agency medical consultant (SAMC), completed a physical residual functional capacity (RFC) assessment for Plaintiff. (doc. 15-1 at 487-90.) He noted her medically determinable physical impairments as severe spine disorders and severe essential hypertension. (Id. at 487.) Dr. Spoor opined that Plaintiff could lift and/or carry up to 50 pounds occasionally and 25 pounds frequently; was capable of unlimited push and/or pull, other than shown for lift and/or carry; could stand and/or walk for a total of 6 hours in an 8-hour workday; and could sit for a total of 6 hours in an 8-hour workday. (Id. at 489.) He noted that her statements about impairment related functional limitations and restrictions could not reasonably be accepted as consistent with the objective medical evidence and other evidence in the record. (Id. at 489-90.)

         On April 1, 2015, SAMC Henry Hanna, Ph.D., reviewed Plaintiff's medical record as part of his assessment of her medically determinable mental impairments. (doc. 15-1 at 486.) Dr. Hanna opined that Plaintiff had non-severe affective disorder, but found insufficient evidence to complete a medical assessment of her mental impairments. (Id. at 487-88.)

         On April 2, 2015, Plaintiff presented to the ER at the Medical Center of Arlington (Arlington) complaining of abdominal pain, which she described as sharp and colic in nature and rated a 10 out of 10, and nausea, and vomiting. (doc. 15-4 at 235.) An abdominal and pelvic CT showed colitis and nephrolithiasis. (Id. at 236, 244-45.) Evidence of lumbar spine surgery was seen, but there was no evidence of bowel obstruction. (Id. at 231.) A colonoscopy was performed the following day, which revealed severe colitis in the descending colon, tortuous sigmoid colon, and erythema, as well as possible mild colitis in the rectum. (Id. at 240-41.) She remained in the hospital for eight days and was discharged on April 9, 2015. (Id. at 225.)

         On May 11, 2015, Plaintiff returned to the ER at Arlington complaining of chest, back, and left flank pain. (doc. 15-4 at 205.) An abdominal and pelvic CT showed no evidence of kidney swelling and no obstructing kidney stones. (Id. at 210, 214-15.) A chest X-ray revealed no acute radiographic abnormality of the chest. (Id. at 210, 216.)

         On May 18, 2015, Plaintiff presented to the ER at Parkland complaining of persistent low back pain and left hip pain, which she described as constant and rated an 8 to 9 out of 10. (doc. 15-2 at 467.) She was noted to not be a candidate for surgery. (Id.) Plaintiff reported bruising easily, but her physical examination was unremarkable. (Id. at 467-68.) She was also noted to maintain a normal range of motion. (Id. at 468.) Her treating physician recommended medication and a referral for psychiatry. (Id. at 468-69.)

         On May 21, 2015, Plaintiff presented to the ER at Arlington after passing out and waking up on the floor. (doc. 15-4 at 187.) She reported headaches, weakness, and lightheadedness. (Id.) A brain CT revealed right frontal scalp swelling but was otherwise unremarkable. (Id. at 194.) A lumbosacral spine X-ray showed prior bilateral laminectomy at the L4-5 and L5-S1, but no evidence of fracture or subluxation. (Id. at 196.) Her lumbar discs at all levels were noted as appearing normal. (Id.)

         On May 29, 2015, Plaintiff visited the ER at Parkland complaining of abdominal pain, which she described as “stabbing” in nature, constant, and radiating to her back. (doc. 15-2 at 515, 518.) She also reported experiencing diffuse extremity tremors. (Id. at 515.) An abdominal CT showed kidney stones, but no evidence of obstruction. (Id. at 518-19.) She was noted as having gait instability and lower extremity weakness with twitching. (Id. at 523-24.) A brain CT revealed small right mastoid effusion, but no acute intracranial normality. (Id. at 557.) She remained in the hospital for two days and was discharged on May 31, 2015. (Id. at 497.)

         On July 5, 2015, Plaintiff presented to the ER at Arlington complaining of left flank pain radiating into her abdomen. (doc. 15-4 at 173.) She denied chills, cough, shortness of breath, and headaches. (Id.) Her abdomen was noted as being soft and non-tender, and no peritoneal signs were found. (Id. at 176.) She had full range of motion in her back, but left costovertebral angle (CVA) tenderness was noted. (Id.) She had normal mood and affect and appeared alert and oriented with no motor deficits. (Id.) A renal ultrasound showed a small left kidney stone, but there was no evidence of kidney swelling. (Id. at 178). An abdominal X-ray performed the following day also showed kidney stones, but no other significant findings were noted. (doc. 15-2 at 741.)

         On August 13, 2015, Plaintiff returned to the ER at Arlington complaining of severe right flank pain. (doc. 15-4 at 166.) She was diagnosed with a lower UTI. (Id.) A CT of the abdomen and pelvis showed multiple kidney stones, but no evidence of kidney swelling or obstructive changes of the renal collecting systems. (doc. 15-3 at 715.) No. interval changes since her prior examination were noted. (Id.) The treating physician assessed Plaintiff with acute pyelonephritis, abdominal pain and distention, and severe pain exacerbated by anxiety. (Id. at 755-56.)

         On August 17, 2015, Plaintiff was admitted at Baylor with complaints of flank pain and fever. (doc. 15-3 at 1562.) Her condition was noted as “fair, ” and she was crying, moaning, and screaming with pain. (Id. at 1562-64.) She was diagnosed with a kidney infection/UTI, remained in the hospital for five days, and was discharged on August 21, 2015. (Id. at 1365.)

         On September 25, 2015, Plaintiff presented to Gerald Stephenson, Ph.D., for a mental status examination. (doc. 15-2 at 605.) Dr. Stephenson noted that she had been hospitalized with a self- inflicted laceration to her neck in September 2014. (Id.) She was cooperative and appeared to be forthcoming. (Id.) She reported being disabled based on her history of depression and multiple suicide attempts, and having multiple health issues with chronic pain, neuropathy, and fibromyalgia. (Id. at 606.) Plaintiff said she left work in 2011 because her physical condition made it hard for her t o w o r k . (Id.) She reported being able to perform household chores, but would have to sit down and rest from time to time, and she was able to drive and visit with her friends and family. (Id.)

         Dr. Stephenson reported that Plaintiff's thinking was coherent, logical, and free of loose associations. (Id. at 607.) She denied being suicidal and stated that she had cut herself last year “to try to make the rage go away.” (Id. at 608.) Plaintiff presented with mildly anxious mood with full affect but became more relaxed as the interview progressed. (Id.) Dr. Stephenson estimated her general mental ability in the “average range” and noted that she demonstrated self-awareness. (Id. at 609.) He diagnosed her with pain disorder with physiological pain affecting cognitive efficiency, unspecified depressive disorder associated with chronic pain, and episodic rage that appeared to be her overreacting to precipitating events. (Id.) He also provided a provisional diagnosis of obsessive-compulsive traits associated with anxiety. (Id.) Dr. Stephenson opined that her psychological prognosis was fair, but clouded by multiple physical disorders and chronic pain. (Id.)

         Dr. Stephenson provided the following assessment of Plaintiff's functional capacity:

She understands complex instructions and is able to remember and follow them. It is probable on the basis of her report that she is unable to complete work-related tasks in a timely manner due to chronic pain and a need for periodic periods of rest. She reported being able to perform many household chores but not to be able to tolerate the strain of pulling a vacuum cleaner of only six pounds. She has the ability to relate and to interact appropriately with others, including coworkers, managers and the public. Due to what appears to be a complex of painful and debilitating conditions, she does not appear to be able to cope consistently with the demands of a place of business.

(Id. at 609.) Dr. Stephenson concluded that Plaintiff was capable of receiving funds and understood the ...


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