United States District Court, W.D. Arkansas, Fort Smith Division
ASHLEY R. MAYS, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner, Social Security Administration, Defendant.
MAGISTRATE JUDGE'S REPORT AND
L. SETSER, Magistrate Judge.
Ashley R. Mays, brings this action pursuant to 42 U.S.C. Â§
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. Â§ 405(g).
protectively filed her current application for DIB and SSI on
September 4, 2012, alleging an inability to work since August
3, 2011,  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).
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).
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).
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
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).
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
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
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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." ...