Searching over 5,500,000 cases.

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.

Jones v. Berryhill

United States District Court, W.D. Arkansas, Fayetteville Division

January 22, 2018

NANCY A. BERRYHILL, Commissioner Social Security Administration DEFENDANT



         Plaintiff, Melissa Michele Jones, [1] 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 filed her applications for DIB and SSI on April 10, 2014, alleging disability since April 10, 2009, due to lipoma, hypertension, diabetes mellitus, osteoarthritis, and bone spurs. (Tr. 94, 103, 115, 128, 150, 153, 159, 162, 237-249). An administrative hearing was held on February 18, 2015, at which Plaintiff appeared with counsel and testified. (Tr. 34-87). By written decision dated July 13, 2016, the ALJ found that during the relevant time period, Plaintiff had an impairment or combination of impairments that were severe. (Tr. 11). Specifically, the ALJ found Plaintiff had the following severe impairments: diabetes, hypertension, cervical lipoma, degenerative disc disease, obesity and reading problems. (Tr. 11). However, after reviewing all of the evidence presented, the ALJ determined that Plaintiff's impairments did not meet or equal the level of severity of any impairment listed in the Listing of Impairments found in Appendix I, Subpart P, Regulation No. 4. (Tr. 14). The ALJ found Plaintiff retained the residual functional capacity (RFC) to:

perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except that she can frequently rotate, flex and extend her neck, frequently reach bilaterally, including reaching overhead, and frequently operate foot controls with her right lower extremity. In addition, she is limited to jobs that do not require complex written communication.

(Tr. 17-18).

         With the help of the vocational expert (VE), the ALJ determined that during the relevant time period, Plaintiff did not have any past relevant work, but that there were other jobs Plaintiff would be able to perform, such as production assembler and newspaper deliverer. (Tr. 24-25).

         Plaintiff then requested a review of the hearing decision by the Appeals Council, which denied that request on August 26, 2016. (Tr. 1-4). Subsequently, Plaintiff filed this action. (Doc. 1). Both parties have filed appeal briefs, and the case is before the undersigned for report and recommendation. (Docs. 11, 13).

         II. Evidence Presented:

         At the time of the administrative hearing held on February 18, 2015, Plaintiff was forty-seven years of age and had completed the eleventh grade, but did not obtain a General Equivalency Diploma (GED). (Tr. 44). The ALJ determined that Plaintiff's work experience did not constitute past relevant work. (Tr. 24-25).

         A review of the pertinent medical evidence reflects the following. On February 26, 2009, Plaintiff went to the emergency department of Siloam Springs Memorial Hospital (SSMH) reporting symptoms of a panic attack with chest pain and midsternal chest pressure. (Tr. 621-626). A chest X-ray revealed no evidence of acute disease. (Tr. 625). Dr. Robert Maul, Jr. diagnosed her with costochondritis and prescribed Norco. (Tr. 622-624).

         The medical evidence continues after the alleged onset date of April 10, 2009. On July 27, 2009, she went to the emergency department of SSMH complaining of left knee pain. (Tr. 604-613). A left knee X-ray revealed moderate joint effusion in association with mild irregularity posterior medial aspect of the tibial plateau. (Tr. 611). She was diagnosed with left knee strain and instructed to follow up with an orthopedic evaluation. (Tr. 606, 608).

         On December 15, 2009, Plaintiff went to the emergency department of SSMH and complained of chest pain that worsened with deep breaths. (Tr. 628-640). An electrocardiogram (EKG) was normal with ST elevation. (Tr. 632). A chest X-ray showed a normal size heart and clear lungs. (Tr. 638). Dr. Robin McAlister diagnosed her with acute chest pain, pleuritis, reactive airways, and hyperglycemia. (Tr. 632).

         On May 3, 2010, Plaintiff returned to the emergency department of SSMH, and she complained of radiating pain after the return of a lipoma on the posterior neck. (Tr. 642-644, 652). Plaintiff had not been taking hypertension or diabetes medications because she reportedly could not afford the medications. (Tr. 643). A computerized tomography (CT) scan of her neck revealed mild thyromegaly and no mass or abscess. (Tr. 644, 652). She was diagnosed with neck pain and cellulitis of the posterior neck. (Tr. 644).

         On May 19, 2010 and June 9, 2010, Plaintiff went to the emergency department of SSMH complaining of chest pain and was diagnosed both times with chest pain. (Tr. 653-675). Plaintiff again reported that she was not taking her diabetes and hypertension medications due to lack of funds. (Tr. 654).

         On June 27, 2010, Plaintiff presented to the emergency department of SSMH complaining of anxiety after witnessing a family fight. (Tr. 676-682). Again, she was noncompliant with her medications. (Tr. 677). Plaintiff was diagnosed with anxiety, hypertension, and diabetes. (Tr. 680).

         Plaintiff's first physical consultative examination was performed on July 7, 2010 by Dr. Tad M. Morgan. (Tr. 436-440). Plaintiff reported smoking eight cigarettes a day and was attempting smoking cessation. (Tr. 436). She stated to Dr. Morgan that her left knee felt unstable on occasion. (Tr. 437). Plaintiff reportedly could walk one block continuously, but then she had to stop and rest for ten minutes. (Tr. 437). An examination showed that she was 71.75 inches tall, weighed 321.25 pounds, and her blood pressure was 140/90. (Tr. 437). Plaintiff had a supple soft tissue mass on her neck, a normal range of motion in her extremities and spine, and a negative straight leg raising exam bilaterally. (Tr. 438-439). Dr. Morgan noted that she had normal reflexes, no muscle weakness or atrophy, and normal gait or coordination. (Tr. 439). Plaintiff could not walk on heel and toes because it made her feet hurt, and she could not squat or arise from a squatting position due to her left knee. (Tr. 439).

         Dr. Morgan diagnosed her with non-insulin dependent diabetes mellitus, recent onset by history; soft tissue mass on the posterior of neck, clinical significance; knee pain with unknown etiology; and chest pain that was non-cardiac by history. (Tr. 440). Dr. Morgan assessed that Plaintiff had mild limitations to walk, stand, lift, or carry. (Tr. 440).

         Plaintiff began going to the Community Clinic in Siloam Springs for medical care. On July 8, 2010, she went to the clinic for diabetes medications and a follow up regarding smoking cessation. (Tr. 569-572). Plaintiff reported she was down to ten cigarettes per day and planned to reduce it to six the next day. (Tr. 569). Plaintiff stopped taking Lorazepam because she stated it made her mean. (Tr. 569). She was not taking any medications because she reportedly could not afford them. (Tr. 569). Her glucose was 276 at the office visit. (Tr. 569). Ms. Vicki Moore, A.P.N. diagnosed her with uncontrolled diabetes and depression with anxiety. (Tr. 569). Ms. Moore prescribed Metformin, Paxil, and Atenolol. (Tr. 570-571).

         On July 15, 2010, Plaintiff returned to the Community Clinic. (Tr. 567-568). Plaintiff reported Paxil was helping. (Tr. 567). She reported having trouble sleeping and would still get dizzy at times. (Tr. 567). Ms. Moore referred the Plaintiff to diabetes education and started Doxepin. (Tr. 568).

         On July 22, 2010, Plaintiff went to the Community Clinic for an initial diabetes education visit. (Tr. 565-566). Ms. Bettie Skelton, R.N., C.D.E. noted that Plaintiff cared for small children, did housework, and was up to walking ten minutes a day. (Tr. 565). Plaintiff reported Doxepin was not helpful, but she had been getting four hours of sleep at night rather than just two hours. (Tr. 565). Plaintiff was instructed to monitor capillary blood glucose (CBG) twice a day and record the results, continue the exercise plan, and stop drinking sugared sodas. (Tr. 566).

         On July 29, 2010, Plaintiff returned to the Community Clinic. (Tr. 563-564). Plaintiff reported she was feeling good, food was beginning to taste better, her exercise was up to 15 minutes, and she was pleased with her weight loss. (Tr. 563). Ms. Skelton wrote that Plaintiff's CBG was uncontrolled, but during the office visit it was down to 205. (Tr. 563). The interim goal for the Plaintiff was a five percent weight loss in 8-16 weeks and to increase activity to 30 minutes a day. (Tr. 563-564).

         On August 17, 2010, non-examining consultant, Dr. Patricia McCarron completed a Physical Residual Functional Capacity Assessment. (Tr. 441-448). Dr. McCarron found that Plaintiff could occasionally lift and/or carry, including upward pulling, ten pounds. (Tr. 442). Dr. McCarron found Plaintiff could frequently lift and/or carry, including upward pulling, less than ten pounds. (Tr. 442). Dr. McCarron assessed Plaintiff could stand at least two hours in an eight-hour workday, sit six hours in an eight-hour workday, and her push and/or pull abilities were unlimited. (Tr. 442). Dr. McCarron found she had no postural, manipulative, visual, or communicative limitations. (Tr. 443-445). Plaintiff's environmental limitations were all unlimited with the exception that she should avoid even moderate exposure to dust, fumes, gases, and etcetera due to a history of chronic smoking. (Tr. 445). Dr. McCarron assessed that the medical evidence records supported a sedentary residual functional capacity with avoidance of even moderate exposure to dust and fumes. (Tr. 448).

         On November 1, 2010, Plaintiff went to the emergency department of SSMH due to complaints of chest pain. (Tr. 481-503, 685-700). Upon examination, she had moderate reproducible chest wall tenderness. (Tr. 484). A chest X-ray revealed no acute disease. (Tr. 484). Her glucose was 392, aspartate aminotransferase (AST) was 71, and alanine aminotransferase (ALT) was 189. (Tr. 484). Dr. Matthew Walter stressed the need for Plaintiff to recheck sugar levels with her primary care physician. (Tr. 484). Dr. Walter diagnosed Plaintiff with chest wall pain, and she reported feeling better upon discharge. (Tr. 484-485).

         On November 26, 2010, Plaintiff returned to the emergency department of SSMH complaining of hyperglycemia due to diabetes. (Tr. 463-480, 701-716). Her glucose level was 534. (Tr. 465). She was diagnosed with uncontrolled diabetes mellitus and acute cephalgia. (Tr. 465). The next day, Dr. Jeffrey Hamby discharged her and prescribed Metformin and Glipizide. (Tr. 466).

         On December 2, 2010, Plaintiff presented herself to Ozark Guidance for mental health treatment. (Tr. 538-542). Ms. Donna Copeland, L.P.C. found Plaintiff had an Axis I diagnosis of major depressive disorder that was recurrent, severe without psychotic features, and full interepisode recovery. (Tr. 542). Notably, Plaintiff was grieving the passing of her mother and other family members. (Tr. 542). Plaintiff had an additional Axis I diagnosis of alcohol abuse, panic disorder with agoraphobia, amphetamine dependence in early full remission, and bereavement. (Tr. 542). The Axis II diagnosis was deferred to Axis I and cluster B traits. (Tr. 542). At Axis III she was found to have diabetes with unspecified complication type II, neck pain, knee pain, and obesity. (Tr. 542). Her global assessment of functioning (GAF) score was 45. (Tr. 542). Ms. Copeland found Plaintiff had social environment, education, access to health care, occupational, and economic problems. (Tr. 542). Plaintiff reported that she had not worked since her mother passed away in 1998. (Tr. 542). The recommended treatment was crisis stabilization, family and individual therapy or counseling, intervention, and medication management. (Tr. 542).

         On December 21, 2010, Plaintiff went to the emergency department of SSMH requesting medication after becoming upset when her children began fighting. (450-462, 717-727). A psychological review of her symptoms showed she was agitated, anxious, and frustrated. Her glucose level was at 430. (Tr. 453). Plaintiff was diagnosed with acute anxiety, uncontrolled diabetes mellitus, and noncompliance with medication. (Tr. 453). Dr. Hamby prescribed her Paroxetine and Glucophage. (Tr. 453).

         On January 4, 2011, Plaintiff returned to Ozark Guidance to complete a master treatment plan with Ms. Copeland and Dr. Ford. (Tr. 549-553). Her diagnosis remained the same from the December 2, 2010 assessment, and Dr. Ford confirmed Plaintiff had depression and anxiety. (Tr. 550-551). The possible need for Plaintiff to take medication was noted. (Tr. 551). The initial plan was for individual therapy or counseling every three weeks, a psychiatric consultation, monthly medication management if needed, and monthly intervention including nursing and nutritional consultations. (Tr.551-552). The long-term goal target date was set for April 4, 2011. (Tr. 550-551).

         On January 25, 2011, Plaintiff underwent a mental consultative examination conducted by Dr. Terry L. Efird. (Tr. 505-509). Plaintiff reported having a history of depression and anxiety symptoms since her mother's death in 1998, anxiety attacks twice a week, crying frequently, and a recognition that her symptoms have become more severe. (Tr. 505). Paroxetine was prescribed through the Community Clinic with no reported side effects. (Tr. 506). She reportedly has been prescribed psychiatric medications for about ten years, and the current medications had been a little helpful. (Tr. 506). Plaintiff reported suicidal ideations on occasion. (Tr. 505). Plaintiff had a history of drug use, but she denied current illegal substance use. (Tr. 506). Dr. Efird noted that her affect was appropriate, mood was generally dysphoric, and an undercurrent of anger or irritability was indicated. (Tr. 506-507). Fund of general information suggested probably average intellectual functioning, she recalled five digits forward and backward, and she performed serial threes at an adequate pace. (Tr. 507).

         Dr. Efird diagnosed Plaintiff with major depressive disorder, moderate; pain disorder without agoraphobia; and her GAF score was 55-65. (Tr. 508). Dr. Efird wrote that Plaintiff endorsed the ability to shop independently, handle personal finances, and perform most activities of daily living adequately, but she was impaired to some extent due to physical pain. (Tr. 508). She reported interacting socially with her friend that lives next door every day and text messaging others daily. (Tr. 508). Dr. Efird found she communicated and interacted in a reasonably socially adequate, intelligible, and effective manner. (Tr. 508). Dr. Efird assessed that she had the capacity to perform basic cognitive tasks required for basic work-like activities. (Tr. 508). No remarkable problems with attention or concentration were noted during the evaluation. (Tr. 508). Dr. Efird noted she generally completed most tasks during the evaluation, had no remarkable problems with persistence, and appeared to have the mental capacity to persist with tasks if desired. (Tr. 508). Plaintiff completed most tasks within an adequate time frame, and no remarkable problems with mental pace of performance were found. (Tr. 508). She could also manage funds without assistance. (Tr. 509). No evidence of malingering was present. (Tr. 508-509).

         On January 31, 2011, non-examining consultant, Dr. Christal Janssen completed a Psychiatric Review Technique and Mental Residual Functional Capacity Assessment. (Tr. 510-526). Dr. Janssen cited Listings 12.04, 12.06, and 12.09 as the categories upon which the disposition was based. (Tr. 510). Listing 12.04 regarded affective disorders, and Dr. Janssen noted Plaintiff had disturbance of mood, accompanied by a full or partial manic or depressive syndrome as evidenced by depressive syndrome. (Tr. 513). Listing 12.06 regarded anxiety-related disorders, and Dr. Janssen noted Plaintiff had anxiety as the predominant disturbance or anxiety experienced in the attempt to master symptoms. (Tr. 515). Plaintiff's anxiety was evidenced by recurrent, severe panic attacks occurring on the average of at least once a week. (Tr. 515). Listing 12.09 regarded substance addiction disorders, and Dr. Janssen noted Plaintiff had behavioral or physical changes associated with the regular use of substances that affected the central nervous system. (Tr. 518). Dr. Janssen assessed that Plaintiff had mild limitations with activities of daily living; mild limitations with social functioning; and moderate limitations maintaining concentration, persistence, or pace. (Tr. 520). No episodes of decompensation were noted. (Tr. 520).

         Plaintiff's ability to maintain attention and concentration for extended periods was moderately limited. (Tr. 524). Dr. Janssen also found she was moderately limited in her ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods. (Tr. 525). Plaintiff's ability to respond appropriately to changes in the work setting and to set realistic goals to make plans independently of others was also moderately limited. (Tr. 525). Dr. Janssen assessed that Plaintiff appeared able to perform semi-skilled work, meaning work where interpersonal contact is ...

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.