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Mays v. Colvin

United States District Court, W.D. Arkansas, Fort Smith Division

April 18, 2016

ASHLEY R. MAYS, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner, Social Security Administration, Defendant.


          ERIN L. SETSER, Magistrate Judge.

         Plaintiff, Ashley R. Mays, brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a decision of the Commissioner of the Social Security Administration (Commissioner) denying her claims for a period of disability and disability insurance benefits (DIB) and supplemental security income (SSI) under the provisions of Titles II and XVI of the Social Security Act (Act). 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 protectively filed her current application for DIB and SSI on September 4, 2012, alleging an inability to work since August 3, 2011, [1] due to bipolar disorder and knee problems. (Tr. 57-58, 69-70). For DIB purposes, Plaintiff maintained insured status through December 31, 2015. (Tr. 57, 60). An administrative hearing was held on June 27, 2013, at which Plaintiff appeared with counsel and testified. (Tr. 26-50). Sarah Moore, a Vocational Expert (VE), also testified. (Tr. 50-52).

         In a written opinion dated February 21, 2014, the ALJ found that Plaintiff's bipolar disorder was a severe impairment. (Tr. 11). However, after reviewing the evidence in its entirety, the ALJ determined that the Plaintiff's impairment did not meet or equal the level of severity of any listed impairments described in Appendix 1 of the Regulations (20 CFR, Subpart P, Appendix 1). (Tr. 12). The ALJ found Plaintiff retained the residual functional capacity (RFC) to perform the full range of work at all exertional levels but with the following nonexertional limitations: the claimant can perform simple, routine, repetitive tasks in a setting where interpersonal contact is incidental to the work performed, and she can work under supervision that is simple, direct, and concrete. (Tr. 13). The ALJ determined that Plaintiff had no past relevant work; however, based on her age, education, work experience and RFC, the ALJ determined that there were jobs that exist in significant numbers in the national economy that she could perform. (Tr. 17). Ultimately, the ALJ concluded that Plaintiff had not been under a disability within the meaning of the Social Security Act from August 3, 2011, her alleged onset date, through February 21, 2014, the date of the decision. (Tr. 18).

         Subsequently, on March 4, 2014, Plaintiff requested a review of the hearing decision by the Appeals Council. (Tr. 4-5). Her request was denied on April 30, 2015. (Tr. 1-3). Plaintiff filed a Petition for Judicial Review of the matter on June 2, 2015. (Doc. 1). Both parties have submitted briefs, and this case is before the undersigned for report and recommendation. (Docs. 13, 14).

         The Court has reviewed the transcript in its entirety. The complete set of facts and arguments are presented in the parties' briefs and are repeated here only to the extent necessary.

         II. Evidence Submitted:

         At the hearing before the ALJ on June 27, 2013, Plaintiff testified that she was born in 1983, and had a high school education. (Tr. 27, 30).

         A review of the medical evidence reflects the following. On July 22, 2010, Plaintiff underwent a consultative mental diagnostic evaluation by Robert L. Spray, Jr., Ph.D. (Tr. 297-301). During that evaluation, Plaintiff reported that she had been "mean and really angry" and sometimes "yell[ed] at her son." Dr. Spray noted that Plaintiff was working at Sam's Club as a cashier, but noted she was also assigned other jobs. Plaintiff reported that she had a ten-year-old son, and although she had tried to live independently, they were currently living with Plaintiff's mother. Plaintiff also reported that all she wanted to do was sleep and some days just lie in bed and cry. Plaintiff reported that since she started her medication, she had not had nightmares. Dr. Spray estimated Plaintiff's cognitive functioning to be in the range of 75-80. Dr. Spray noted that Plaintiff communicated adequately, but in somewhat of a child-like voice. Plaintiff reported having friends with whom she went out to eat and to the movies. Dr. Spray noted that Plaintiff appeared to have some difficulty with immediate short-term memory. Plaintiff was noted to have fairly good attention and concentration. She persisted well during the examination; however, Dr. Spray noted Plaintiff might not be able to be as consistent in a job setting. Plaintiff exhibited normal pace during the evaluation; however, Dr. Spray noted that Plaintiff may be distracted by internal dialogue.

         On August 10, 2010, Plaintiff was seen by Dr. Robin L. Ross. (Tr. 305). Dr. Ross' notes reflect Plaintiff's five-year history of severe mood swings and racing thoughts. Plaintiff was noted to be taking Seroquel, which may have been causing some swelling in her lower extremities. Dr. Ross recommended tapering off the Seroquel, and slowly changing Plaintiff's medication.

         On August 11, 2010, Plaintiff presented at River Valley Musculoskeletal Center with complaints of lower leg pain just below the knee. (Tr. 399). After examining Plaintiff and taking x-rays of her left knee, Dr. Thomas Cheyne diagnosed Plaintiff with a probable partial tear, left gastrocnemius. Dr. Cheyne recommended general stretching, light activity, and that Plaintiff remain off work for two weeks.

         Dr. Ross' August 17, 2010, notes reflect that Plaintiff was having trouble sleeping. (Tr. 306). Plaintiff was alert and oriented and had a better mood and affect. Dr. Ross' notes also reflect Plaintiff was completely off Seroquel. Plaintiff reported that another doctor opined that the swelling was caused by Plaintiff's work, and that Plaintiff was off of work until the 25th.

         On August 23, 2010, Plaintiff phoned Dr. Ross' office, reporting that she was feeling very depressed and tearful. (Tr. 307). She stated that Dr. Ross had taken her off of Seroquel, but that her primary care physician thought the Seroquel was not the cause of the swelling in her extremities. She reported that she was confused and did not know what to do. Dr. Ross recommended Plaintiff take Abilify.

         On August 25, 2010, Plaintiff reported that she had not seen much improvement in her left knee. (Tr. 398). Plaintiff's MRI of her knee was normal; however, Dr. Cheyne recommended another MRI of her lower leg if she did not improve soon. He suggested she remain off work for another three weeks.

         On August 26, 2010, Plaintiff reported that she was not sleeping, and that she did not feel like doing anything. (Tr. 307). Plaintiff reported that she was unable to complete activities of daily living, and requested to be placed back on Seroquel. Dr. Ross started Plaintiff back on Seroquel.

         On September 15, 2010, Plaintiff saw Dr. Cheyne with continued complaints of pain in her left knee. (Tr. 397). Dr. Cheyne suggested Plaintiff see Dr. Steven Smith for an evaluation of her knee. Dr. Cheyne recommended that Plaintiff remain off work.

         On September 28, 2010, Dr. Ross' notes reflect that the Seroquel was working well for Plaintiff. (Tr. 307). Her notes also reflect Plaintiff's significant leg pain, and that Plaintiff would see a surgeon later in the week.

         On October 1, 2010, Dr. Smith's notes reflect that he administered an injection in Plaintiff's left knee. His notes also reflect that a MRI showed fluid signal at the patellar retinaculum. At a follow up visit on October 11, 2010, Plaintiff reported that the injection did not help her pain, and Dr. Smith scheduled a left knee arthroscopy. (Tr. 395). On October 19, 2010, Plaintiff underwent a left knee arthroscopy and resection of the suprapatellar plica and debridement of the anterior fat pad performed by Dr. Smith. (Tr. 376).

         On October 29, 2010, Plaintiff was seen by Patrick Walton, Physician Assistant, for a follow up on her left knee post-surgery. (Tr. 394). Plaintiff reported a lot of swelling. Plaintiff reported that her pain was being controlled with her medication, and that she was progressing with her therapy. Plaintiff was noted to be using crutches. Plaintiff's stitches were removed, and she was instructed to continue with therapy. Mr. Walton recommended that Plaintiff be off work for six weeks.

         On November 16, 2010, Plaintiff was seen by Dr. Smith for a follow up on her left knee arthroscopy. (Tr. 393). Dr. Smith noted that Plaintiff was complaining of pain. Plaintiff reported that she did not think she could return to work in two weeks, and Dr. Smith suggested she return to see him in three to four weeks for a repeat examination.

         On November 30, 2010, Plaintiff followed up with Dr. Ross. (Tr. 308). Plaintiff reported that the Seroquel was working well, but that she was experiencing knee pain after her surgery. Dr. Ross' notes reflect that Plaintiff could not work and maintain her mental health. Upon examination, Dr. Ross noted Plaintiff was alert and oriented, with good eye contact, and normal speech. Dr. Ross recommended Plaintiff remain on Seroquel and return in three months.

         On December 16, 2010, Plaintiff reported that her left knee was buckling and giving way. (Tr. 392). Upon examination, Dr. Smith noted significant quadricep atrophy. Dr. Smith also noted that he counseled Plaintiff on rehab exercises, and thought Plaintiff had improved enough to return to work "later on." ...

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