United States District Court, W.D. Arkansas, Fayetteville Division
MAGISTRATE JUDGE'S REPORT AND
ERIN L. WIEDEMANN UNITED STATES MAGISTRATE JUDGE
Pauline Atkins, 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 supplemental security
income (SSI) benefits under the provisions of Title 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).
protectively filed her current application for SSI on April
28, 2015, alleging an inability to work due to mental
retardation and cirrhosis of the liver. (Tr. 67, 201). An
administrative hearing was held on December 4, 2017, at which
Plaintiff appeared with counsel and testified. (Tr. 40-65).
written decision dated January 18, 2018, the ALJ found that
during the relevant time period, Plaintiff had an impairment
or combination of impairments that were severe. (Tr. 23).
Specifically, the ALJ found Plaintiff had the following
severe impairments: cirrhosis of the liver, hepatitis C,
borderline intellectual functioning and major depressive
disorder. 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. 24). The ALJ
found Plaintiff retained the residual functional capacity
lift and carry 10 pounds occasionally and less than 10 pounds
frequently; stand and/or walk 2 hours in an 8-hour workday;
sit, for 6 hours in an 8 hour work day; and push and/or pull
10 pounds occasionally and less than 10 pounds frequently. In
addition, the claimant retains the ability to understand,
remember and carry our (sic) simple jobs (sic) instructions
and to make decisions/judgments in simple work related
situations. The claimant is also able to respond
appropriately with co-workers, supervisors and the public and
has the ability to respond appropriately to minor changes in
the usual work routine.
(Tr. 27). With the help of a vocational expert, the ALJ
determined Plaintiff could perform work as a circuit board
assembler and a toy stuffer. (Tr. 32).
then requested a review of the hearing decision by the
Appeals Council, which after reviewing additional evidence
submitted by Plaintiff, denied that request on June 21, 2018.
(Tr. 1-6). 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.
Court has reviewed the entire transcript. The complete set of
facts and arguments are presented in the parties' briefs,
and are repeated here only to the extent necessary.
time of the administrative hearing held on December 4, 2017,
Plaintiff, who was forty-four years of age, testified that
she had an eighth grade education. (Tr. 44). The record
revealed Plaintiff had no past relevant work. (Tr. 43).
pertinent medical evidence before the ALJ during the relevant
time period reflects the following. On May 15, 2015,
Plaintiff was seen by Judith K. Lane, APRN, CNP, to establish
care. (Tr. 309-318, 338-341). Nurse Lane noted Plaintiff was
recently released from prison and was living in a drug rehab.
Plaintiff was imprisoned for about three years. Prior to her
imprisonment, Plaintiff reported she drank twelve beers a day
and used IV meth. Plaintiff reported she had Hepatitis C with
known cirrhosis. Plaintiff reported that prior to her
imprisonment, she worked as a farmhand. Plaintiff reported
right elbow pain for the past two years. Plaintiff also had a
long history of gastroesophageal reflux disease (GERD). Upon
examination, Nurse Lane noted no erythema or swelling of the
right elbow with full range of motion with tenderness along
the epicondyle. Plaintiff was noted to have a normal mood and
affect with normal thought content. Plaintiff was assessed
with Hepatitis C, right elbow pain, a rash, hematuria and
6, 2015, Plaintiff was seen in the emergency room complaining
of vaginal bleeding for two years and right flank pain with
burning with urination for one month. (Tr. 319-338, 341-347).
Plaintiff also reported dyspnea. Plaintiff was assessed with
a urinary tract infection and right lower quadrant pain.
Plaintiff was noted to have a normal mood and affect, and
normal judgment and thought content. Plaintiff was admitted
and underwent testing. Plaintiff was prescribed medication
and discharged home on June 7th.
2, 2015, Plaintiff underwent a consultative mental diagnostic
evaluation and intellectual assessment performed by Dr.
Cynthia W. Dupuis. (Tr. 349-356). Plaintiff arrived alone by
way of public transportation. Plaintiff reported an inability
to work because she did not comprehend well. Plaintiff
reported she also worked too slowly. Plaintiff denied
symptoms of depressed mood, anxiety, hallucinations or
delusions. Plaintiff reported she went to school through the
sixth grade, noting she repeated the sixth grade three times.
Plaintiff reported that she began using illegal substances at
a very early age. Plaintiff was jailed in July of 2012, and
remained incarcerated until April of 2015. Dr. Dupuis noted
Plaintiff presented with a normal mood and affect and logical
and goal directed thought processes. Plaintiff spoke
extremely slowly at times but exhibited an average work pace.
Plaintiff exhibited no difficulty following directions and
evidenced concentration, persistence and focus on all tasks.
Dr. Dupuis noted Plaintiff completed the Wechsler Adult
Intelligence Scale - Fourth Edition and received a Full Scale
IQ of 74, Verbal of 72, and Perceptual Reasoning of 82. Dr.
Dupuis noted Plaintiff's ability to sustain attention,
concentrate and exert mental control was in the borderline
range. Dr. Dupuis noted Plaintiff's report that she could
complete chores, cook meals, manage money and obtain a
driver's license. Dr. Dupuis noted Plaintiff reported a
slow work pace led to an employment termination, but
Plaintiff also reported she was also using methamphetamines
at that time. Dr. Dupuis opined that Plaintiff had the
ability to cope with the typical mental/cognitive demands of
skill-appropriate work if she remained substance free. With
respect to adaptive functioning, Plaintiff reported the
ability to drive, prepare simple meals, clean her room,
participate in karaoke at the drug rehabilitation center, and
sit in groups to talk. Dr. Dupuis reported no evidence that
Plaintiff had difficulty understanding instructions given by
the examiner. Dr. Dupuis indicated no limitations were
observed in Plaintiff's ability to attend and sustain
concentration on basic work-like tasks. Dr. Dupuis opined
Plaintiff was also able to persist and work at a normal and
2, 2015, Plaintiff was also seen by Dr. Shaletha D. Jones for
a follow-up for chronic issues. (Tr. 362-384, 404-420). Dr.
Jones noted Plaintiff was recently released from prison after
being incarcerated for three years. Prior to her
incarceration, Plaintiff had a history of alcoholism and IV
drug use. Plaintiff reported she had been clean for three
years. Plaintiff reported dyspnea on exertion, and bilateral
leg swelling for the past four years that had worsened over
the past three to four months. Plaintiff reported she was
unable to walk across the street without becoming short of
breath. Plaintiff reported she saw a cardiologist before she
went into prison but did not remember the diagnosis. While
incarcerated, Plaintiff reported she had started
spironolactone and Lasix but stopped taking the medication as
she felt it was not working. Plaintiff reported back pain.
Plaintiff had not tried physical therapy. Plaintiff denied
numbness, tingling or weakness. Plaintiff reported she had
recently been treated for a urinary tract infection.
Plaintiff indicated her gastroesophageal reflux was
controlled with medication. A musculoskeletal examination
revealed edema and tenderness. Plaintiff had a normal mood,
affect, behavior, judgment and thought content. Plaintiff was
assessed with Hepatitis C, unspecified hematuria, GERD,
dyspnea with exertion, and lumbar back pain. Plaintiff was
prescribed medication and referred for physical therapy.
9, 2015, Plaintiff underwent an echocardiogram that revealed
normal systolic function and an ejection fraction estimated
at sixty percent. (Tr. 391-397, 421-428).
17, 2015, Plaintiff was seen by Laroya Jenkins, PT, for a
physical therapy evaluation. (Tr. 429-461). After an
evaluation, Plaintiff's goals were set. It was
recommended Plaintiff attend one to two weeks of therapy for
therapy treatment notes dated July 22, 2015, indicate
Plaintiff reported no back pain but she had left foot/ankle
burning after working at a car wash all day. (Tr. 462-465).
Plaintiff also reported a mild rash in the same area as where
she felt burning. Plaintiff tolerated the session well and
was able to demonstrate the exercise program.
23, 2015, Dr. Jerry Thomas, a non-examining medical
consultant, opined Plaintiff did not have a severe physical
impairment. (Tr. 71-72). On September 24, 2015, after
reviewing the records, Dr. ...