Smith v. Saul

          MAGISTRATE JUDGE'S REPORT AND RECOMMENDATION

          HONORABLE MARK E. FORD UNITED STATES MAGISTRATE JUDGE.

         Plaintiff, Sherri R. Smith (“Smith”), brings this action under 42 U.S.C. § 405(g), seeking judicial review of a decision of the Commissioner of Social Security Administration (“Commissioner”) denying her claim for a period of disability and disability insurance benefits (“DIB”) under Title II of the Social Security Act (“the Act”), 42 U.S.C § 423(d)(1)(A). In this judicial review, the Court must determine whether there is substantial evidence in the administrative record to support the Commissioner's decision. 42 U.S.C. § 405(g).

         I. Procedural Background

         On July 7, 2016, Plaintiff filed this application with an alleged onset date of April 15, 2016, due to heart murmur, hand and feet numbness, high blood pressure, and throat and neck pain. (ECF No. 11, pp. 25, 222). Plaintiff was 51 years old at the time of her application, possessed a twelfth-grade education, and had past relevant work (“PRW”) experience as a customer service representative/teller and new accounts representative. (Id., pp. 35, 75). Her application was denied initially on November 4, 2016, and again upon reconsideration on March 20, 2017. (Id., p. 25). Plaintiff filed a written request for hearing on May 17, 2017, and the hearing was held on September 5, 2017, before the Hon. Alexis Murdock, Administrative Law Judge (“ALJ”). Plaintiff was present and represented by counsel, David Harp. (Id.).

         On December 21, 2017, the ALJ found Plaintiff's major depressive disorder, anxiety, panic disorder with agoraphobia, PTSD, osteoarthritis, DDD of the cervical spine, DDD of the lumbar spine, hypertension, chronic tension headaches, TMJ^[2], and Eagle's Syndrome^[3] or elongated styloid process syndrome to be severe. (Id., p. 28). However, her alleged vertigo improved with medication and her foot pain with bunion did not meet the durational requirements for a severe impairment. (Id.). The ALJ ultimately concluded Plaintiff did not have an impairment that met or medically equaled the severity of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Id., pp. 28-30). The ALJ then found Plaintiff capable of performing light work, except as follows: “the claimant can understand, remember, and carry out more than simple instructions and tasks, but no complex instructions or tasks; can regulate her emotions, control behavior, and maintain well-being in a work setting with those instructions and tasks, as long as there are no fast-paced production requirements, such as assembly-line work; and can learn and recall in a work setting with those instructions and tasks.” (Id., p. 30). Although the Plaintiff could not perform her PRW, the ALJ found she was capable of performing work as a content checker, mail room clerk, and office helper. (Id., p. 35-36).

         The Appeals Council denied Plaintiff's request for review on July 24, 2018. (Id., pp. 5-10). Plaintiff filed this action on August 31, 2018. (ECF No. 1). Both parties have filed appeal briefs (ECF Nos. 14, 15), and this matter is ready for Report and Recommendation.

         II. Relevant Evidence

         Plaintiff presents a history of mental and physical complaints dating from the late 1990's, when she was initially treated for feelings of tiredness, depression, and complaints of back pain. (EFC No. 11, p. 301). She also received estrogen replacement therapy due to ovary failure at the age of 26 (Id., p. 301), and she was diagnosed and treated for clinical depression with underlying anxiety by Dr. Baker (Id., pp. 304-306, 308). She continued to meet with Dr. Baker in the late 1990's and 2000's and was prescribed Xanax, Zoloft, and Paxil at differing times. (Id., pp. 303-306, 308).

         On September 23, 1998, Plaintiff self-initiated an increase in her Paxil and stopped taking Xanax. (Id., p. 305). On February 19, 1999, she made another self-initiated adjustment, increasing her Estrace dosage, which she stated made her feel “much better.” She was also doing “very well” on Paxil at that time. (Id., p. 306).

         In April 2000, Plaintiff stopped taking Estrace, Provera, and Paxil on her own, but Dr. Baker restarted her on a hormone regimen due to persistent hot flashes. (Id., p. 311).

         In 2009, Plaintiff went to Dr. Kareus for an evaluation of neck pain, which she claimed had been present for three years. (Id., pp. 409-411). No. bone or joint abnormalities were detected, although she did exhibit a decreased range of motion in the neck. This led Dr. Kareus to diagnose degenerative cervical spine disease, pending x-rays. (Id., p. 411). At that time, Plaintiff exhibited a normal attention span with normal concentration, affect, and behavior. Physical therapy or chiropractic therapy was recommended, and Plaintiff was treated at Back in Action Chiropractic on numerous occasions in 2010 with mixed results. (Id., pp. 409-449).

         On November 12, 2013, Plaintiff saw Dr. Donald Chambers for an initial evaluation. (Id., p. 451). She had a calcification in her neck and either mitral or aortic valve insufficiency. She reported that her mind raced all the time, she experienced hot flashes, she was consistently late to work, and off work too often. She was considering quitting. Dr. Chambers prescribed Trileptal^[4], advised her not to stop working, and stated he felt he could help her problems.

         Between 2014 and 2017 Plaintiff went to Ozark Wellness Clinic where she was treated for a variety of impairments, including: anxiety; depression; stress; dizziness; pain in her back, shoulders, neck, temples, jawbone, head, teeth; and, numbness in her body and hands. (Id., pp. 331-354, 383-400, 454-468). At one of her most recent visits, on July 31, 2017, Plaintiff complained of chronic head, neck, and shoulder pain; muscle weakness; tenderness in the balls of her feet; and, dizziness. She admitted that foot massages and saltwater baths helped her feet, and Valium^[5] was effective in treating her vertigo and Eagle syndrome symptoms. Because she did not have insurance, her pectus excavatum^[6] could not be treated. Nurse Yvonia Finley noted it would eventually cause a cardiac issue and pressed the need for treatment. (Id., p. 456).

         On May 22, 2015, Plaintiff went to Cooper Clinic for lab work where she complained of pain in her right flank, neck, and eyes with a swollen tongue. (Id., pp. 321-329). The doctor noted that her tongue appeared normal. She was ...