United States District Court, Western District of Arkansas, Harrison Division
HONORABLE MARK E. FORD, UNITED STATES MAGISTRATE JUDGE.
Plaintiff, Ivy Marcella Goss, brings this action under 42 U.S.C. §405(g), seeking judicial review of a decision of the Commissioner of the Social Security Administration (“Commissioner”) denying her claim for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social Security Act (hereinafter “the Act”), 42 U.S.C. §423(d)(1)(A), 1382c(3)(A). In this judicial review, the court must determine whether there is substantial evidence in the administrative record to support the Commissioner’s decision. See 42 U.S.C. §405(g).
I. Procedural Background:
Plaintiff filed her application for DIB and SSI on June 9, 2011, alleging an onset date of March 15, 2010, due to kidney disease, fibromyalgia, anxiety and depression, constant chronic pain, sick stomach and vomiting. (T. 151) Plaintiff’s application was denied initially and on reconsideration. (T. 52-54, 55-58, 63-66, 66-67). Plaintiff then requested an administration hearing, which was held in front of Administrative Law Judge (“ALJ”), Ronald L. Burton, on August 23, 2012.
At the time of the hearing, Plaintiff was 39 years of age, she graduated from high school and had one year of college education. (T. 153) Plaintiff’s past relevant work experience included housekeeping from May 2005 to October 2009, a cashier from November 2009 to March 15, 2010, fuel station employee from May 2007 to February 2008, and factory worker at temporary agencies from April 20, 2011 to June 07, 2011. (T. 153)
On February 1, 2013, the ALJ found Plaintiff’s personality and mood disorder severe and her Loin Pain Hematuria Syndrome (“LPHS”), urinary tract infections and flank pain non-severe, as the ALJ determined they caused no more than minimal limitations on the Plaintiff’s ability to perform basic work activities. (T. 13-14) The ALJ determined Plaintiff had the residual functional capacity (“RFC”) to perform a full range of work at all exertional levels, but with the following non-exertional limitations: she could perform where interpersonal contact was incidental to the work performed; complexity of tasks was learned and performed by rote, few variables, and little judgement; and supervision required was simple, direct and concrete. (T. 16)
Plaintiff appealed this decision to the Appeals Council, but said request for review was denied on February 10, 2014. (T. 1-4) Plaintiff then filed this action on April 11, 2014. (Doc. 1) This case is before the undersigned pursuant to consent of the parties. (Doc. 5) Both parties have filed briefs, and the case is ready for decision. (Doc. 8 and 10)
II. Applicable Law:
This Court’s role is to determine whether the Commissioner’s findings are supported by substantial evidence on the record as a whole. Ramirez v. Barnhart, 292 F.3d. 576, 583 (8th Cir. 2002). “Substantial evidence is relevant evidence that a reasonable mind would accept as adequate to support the Commissioner's decision.”
Young v. Apfel, 221 F.3d 1065, 1068 (8th Cir. 2000). “Our review extends beyond examining the record to find substantial evidence in support of the ALJ’s decision; we also consider evidence in the record that fairly detracts from that decision.” Cox v. Asture, 495 F.3d 617, 617 (8th Cir. 2007). The AJL’s decision must be affirmed if the record contains substantial evidence to support it. Edwards v. Barnhart, 314 F.3d, 964, 966 (8th Cir. 2003). The Court considers the evidence that “supports as well as detracts from the Commissioner’s decision, and we will not reverse simply because some evidence may support the opposite conclusion.” Hamilton v. Astrue, 518 F.3d 607, 610 (8th Cir. 2008). If after reviewing the record it is possible to draw two inconsistent positions from the evidence and one of those positions represents the findings of the ALJ, the decision of the ALJ must be affirmed. Young v. Apfel, 221 F.3d at 1068.
It is well-established that a claimant for Social Security disability benefits has the burden of proving his disability by establishing a physical or mental disability that has lasted at least one year and that prevents him from engaging in any substantial gainful activity. Pearsall v. Massanari, 274 F.3d 1211, 1217 (8th Cir. 2001); see also 42 U.S.C. §423(d)(1)(A), 1382c(a)(3)(A). The Act defines “physical or mental impairment” as “an impairment that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques.” 42 U.S.C. §423(d)(3), 1382(3)(c). A Plaintiff must show that his or her disability, not simply their impairments, has lasted for at least twelve consecutive months. Titus v. Sullivan, 4 F.3d 590, 594 (8th Cir. 1993).
If such an impairment exists, the ALJ must determine whether the claimant has demonstrated that she is unable to perform either her past relevant work, or any other work that exists in significant numbers in the national economy. (20 C.F.R. §416.945). The ALJ applies a five-step sequential evaluation process for determining whether an individual is disabled. (20 C.F.R. §404.1520(a)-(f)(2003). Only if the final stage is reached does the fact finder consider the plaintiff’s age, education, and work experience in light of his or her residual functional capacity. See McCoy v. Schweiker, 683 F.2d 1138, 1141-42 (8th Cir. 1982); 20 C.F.R. §404.150, 416.920 (2003).
III. Evidence Presented:
The medical evidence is as follows.
On January 5, 2006, Plaintiff went to Bend Memorial Clinic, Bend, Oregon, with flank pain, hematuria, and fever. The lab results showed an increase in bilirubin, ketones, blood, leukocytes, protein and positive for nitrites. Plaintiff was assessed with acute right pyelonephritis, prescribed Tequin, and advised to take Tylenol and/or Ibuprofen for pain. (T. 481)
Plaintiff was seen at the Bend Memorial Clinic on January 26, 2006, due to a dull, constant pressure in her right flank with an occasional sharp and stabbing pain. The notes indicated Plaintiff was under a considerable amount of stress, she had hematuria and a fever. In July 2005, Plaintiff was diagnosed with pyelonephritis at St. Charles Medical Center. The doctor observed she was tender to palpation on her lower rib cage, back to front. Plaintiff was assessed with muscular sprain, a left adnexal cyst was suspected and hematuria, persistent by treatment for pyelonephritis. An appointment for Bend Urology was scheduled for January 31, 2006. (T. 477)
On August 14, 2006, a surgical pathology report for a colon biopsy and polyp showed multiple fragments of colonic-type mucosa with orderly cylindrical glands showing no architectural or inflammatory change. The basement membrane was of normal thickness and no parasites were identified. The section showed multiple fragments of colonic-type mucosa, many of which demonstrates surface glands with serrated change. (T. 485)
Plaintiff sought mental health treatment in February 2009 to May 2009 with Sherry Adams, licensed social worker at Deschutes County Mental Health (“Deschutes”). During her therapy, Plaintiff did well under the stressors of her life. She continued to work and wanted to go to school for certified nurse assistant. (T. 352, 350) Through the course of treatment, Ms. Adams notes indicated Plaintiff was not giving up and she tried harder. On April 8, 2009, Ms. Adams observed Plaintiff was tired and in a lot of pain. She had been taking pain medication, felt increased agitation, and was not able to focus. (T. 346) Plaintiff called Ms. Adams on September 15, 2009, and informed Ms. Adams she was moving to Washington, due to her granddaughter’s health problems. (T. 335-353)
Plaintiff went to the emergency room at Forks Community Hospital, Forks, Washington, due to sharp, hot pain in her right lower quadrant on December 9, 2009. Plaintiff’s urinalysis showed the presence of blood and her red blood cell, white blood cell and absolute monocyte counts were high. (T. 259) A CT of the abdomen and pelvic showed significant stool without signs of stasis. (T. 270) No urinary tract calcifications or hydronephrosis was seen. The kidneys and bladder demonstrated normal noncontract appearances. The uterus and ovaries were unremarkable and there was no free fluid. (T. 271) The doctor’s impressions were abdominal pain, questionable etiology, and chronic hematuria, questionable etiology. Plaintiff was referred to a urologist. (T. 277) On December 23, 2009, an X-ray of her abdomen showed stool without signs of stasis. (T. 517)
On December 28, 2009, Plaintiff went to the emergency room at Forks Community Hospital due to abdominal pain and distention of her abdomen. (T. 506) Plaintiff’s pelvic ultrasound showed an incidental discovery of endometrial calcifications, which were nonspecific and generally associated with benign processes. The radiologist observed calcifications that might be related to a prior pregnancy or an endometrial polyp, however no convincing signs of a polyp were seen. Otherwise, it was a negative pelvic ultrasound. (T. 269) The doctor found no reason for any distention and diagnosed her with abdominal pain of undetermined etiology, and hematuria. (T. 507)
Dr. Carleen Bensen, urologist at the Forks Community Hospital Bogachiel Clinic, conducted a urology consultation on December 30, 2009. At the time of the consultation, Plaintiff was taking Docusate, Senna, Cephalexin, Mirtazapine and Reglan. During this consultation, Dr. Bensen observed Plaintiff was a very pleasant lady and discussed the fact there was no evidence of any kidney stones. (T. 244) Plaintiff indicated this problem had occurred since she was a child, and was told by her psychologist it was stress related. (T. 248) Plaintiff’s urinalysis showed 250 milligrams per deciliter of blood in her urine. Dr. Bensen began to entertain other diagnoses for gross hematuria and wanted to get an MRI of the abdomen. (T. 244-245)
An MRI taken on December 31, 2009, showed the liver, gallbladder, pancreas, spleen and adrenal glands were unremarkable. The kidneys were unremarkable and both excreted gadolinium contrast. There was no hydronephrosis. The renal pelves were grossly unremarkable, ureters and bowel were not dilated, and there was no intra-abdominal lymphadenopathy or free fluid. The doctor’s impression was an unremarkable abdomen. (T. 266)
On January 19, 2010, Plaintiff’s urinalysis showed presence of blood and her leukocyte esterase and red blood cell counts were high. (T. 257) On January 23, 2010, Plaintiff went to the emergency room at Forks Community Hospital due to flank pain. Plaintiff stated it had gotten worse over the past month, she felt feverish, and had chills and sweats. Plaintiff’s urinalysis showed high traces of blood and bacteria. (T. 253) Plaintiff’s white blood count, mean corpuscular hemoglobin and absolute neutrophil counts were high. ...