Watson v. Asture

Filing 12

REPORT AND RECOMMENDATIONS For the reasons set forth above, it is the recommendation of the undersigned that the decision of the Commissioner of Social Security be affirmed under Sentence 4 of 42 U.S.C. § 405(g). The parties are advised that they have ten days to file written objections to this Report and Recommendation. The failure to file timely written objections may waive the right to appeal issues of fact. 11 6 1 Signed by Mag Judge David D. Noce on 6/22/09. (KXS)

UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI EASTERN DIVISION MARY WATSON, Plaintiff, v. MICHAEL J. ASTRUE, Commissioner of Social Security, Defendant. ) ) ) ) ) ) ) ) ) ) )

No. 4:08 CV 518 RWS DDN

REPORT AND RECOMMENDATION OF UNITED STATES MAGISTRATE JUDGE This action is before the court for judicial review of the final decision of the defendant Commissioner of Social Security denying the application of plaintiff Mary Watson for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. § 401, et seq. for review and a recommended disposition under 28 U.S.C. § 636(b). decision be affirmed. I. BACKGROUND (Tr. 7.) She is She The For action was assigned to the undersigned United States Magistrate Judge the reasons set forth below, the undersigned recommends that the ALJ's

Plaintiff Mary Watson was born on June 29, 1960. (Tr. 92, 390.) She is married and has three children.

5'2" tall with a weight that has ranged from 135 pounds to 150 pounds. (Tr. 390.) completed high school, three years of college, and completed nursing school at Barnes-Jewish Hospital. (Tr. 99.) for Barnes-Jewish Hospital. (Tr. 30.) She last worked as a nurse

On November 21, 2005, Watson applied for disability insurance benefits, alleging she became disabled on October 15, 2003, on account of fibromyalgia, arthritis, hypothyroidism, asthma, depression, restless leg syndrome, spine surgery for a herniated disk, bunion surgery, migraines, gastroesophageal reflux disease (GERD), hernias, and

inflammatory polyarthropathies.1

(Tr. 44, 79, 93.)

She received a After a

notice of disapproved claims on April 18, 2006. ( T r. 14-23, 27-43.)

(Tr. 50-54.)

hearing on March 28, 2007, the ALJ denied benefits on August 14, 2007. On March 24, 2008, the Appeals Council denied (Tr. 2-4.) MEDICAL HISTORY She plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner. II.

On an unknown date, Watson completed a disability report.

noted suffering from fibromyalgia, arthritis, hypothyroidism, asthma, depression, restless leg syndrome, a herniated disk, hernias, bunions, m i g r a i nes, and GERD. She also complained of fatigue, and pain in her She could not sit, Watson neck, back, knees, head, feet, ankles, and wrists.

stand, or walk for extended periods before feeling the pain.

stopped working on October 15, 2003, on account of the pain and fatigue. Sh e was no longer able to lift patients and perform her duties as a nurse. From 1990 to 2003, Watson worked as a registered nurse on the As part of the job, she Among her medications, Watson delivery floor at Barnes-Jewish Hospital. frequently lifted fifty pounds or more.

took Allegra and Rhinocort for sinusitis, Ambien for sleep, Cymbalta for depression, Darvocet, Glucosomine, and Neurontin for pain, Famotidine for GERD and stomach problems, Relafen as an anti-inflammatory, Skelaxin for muscle spasms, Synthroid for hypothyroidism, and used an Albuterol inhaler, a Flovent inhaler, and Tessalon pearls for asthma. Cymbalta

Fibromyalgia is a condition that causes fatigue, muscle pain, and "tender points." Tender points are places on the neck, shoulders, back, h i p s , arms, or legs that hurt when touched. Fibromyalgia is also associated with difficulty sleeping, morning stiffness, headaches, and problems with thinking and memory. Medline Plus, National Institutes of Health, http://www.nlm.nih.gov/medlineplus/fibromyalgia.html (last visited June 15, 2009). Hypothyroid ism is the diminished production of thyroid hormone, leading to thyroid insufficiency, which is characterized by a low metabolic rate, a tendency to gain weight, a strong desire for sleep, and sometimes myxedema, a skin disorder. Stedman's Medical Dictionary, 755, 1020 (25th ed., Williams & Wilkins 1990). A hernia is the protrusion of a part or structure through the tissues normally containing it. Id., 707. Arthropathy is any disease affecting a joint. Id., 136. -2-

1

and Synthroid caused fatigue, Famotidine caused heartburn, and Relafen caused upset stomach. (Tr. 92-100.) She On an unknown date, Watson completed a disability report appeal. Her back pain had gotten worse since her last disability report. foot and leg. could barely walk at times and had pain and numbness in her lower right She was losing her balance inexplicably, her hands became Among numb, and she had tingling in her right upper arm and shoulder. depression, Allegra, Ambien, Darvocet, Glucosomine,

her medications, Watson took Aciphex for stomach problems, Effexor for Neurontin, Synthroid Rhinocort Nasal Spray for sinusitis, Skelaxin, Synthroid, and used an Albuterol inhaler, a Flovent inhaler, and Tessalon pearls. caused fatigue. Most days it hurt to walk and sit. 134-42.) On January 2, 2002, Watson saw Deborah Parks, M.D. She was six mont h s pregnant, and had been on disability for her pregnancy since a l m o st her first trimester because she was getting dyspeptic with exertion.2 (Tr. 297.) Watson had given birth Her Dr. Parks On August 21, 2002, Watson saw Dr. Parks. Indeed, Watson complained of becoming fatigued easily. Watson would sometimes split the

pain pills because she did not like feeling "under the influence." (Tr.

on May 6, and was having some trouble with post-partum depression. asthma had been good, and she had not needed any inhalers. asthma that was stable, and carpal tunnel syndrome.3

diagnosed her with keratosis, depression, though she was doing well, (Tr. 296.) A On March 6, 2003, Watson saw Dr. Parks for an asthma flare-up. di s ease.

chest x-ray was unremarkable, and showed no active cardiac or pulmonary Dr. Parks attributed the asthma flare-up to environmental She also recommended Watson modify (Tr. 291-93, 309.) The x-ray showed no signs of narrowing or masses. factors, and increased her Flovent. her environment.

On March 13, 2003, Mandar Pattekar, M.D., reviewed an x-ray of Watson's esophagus.
2

Dyspnea is shortness of breath, usually associated with disease of the heart or lungs. Stedman's Medical Dictionary, 480. Keratosis is any lesion on the skin marked by the presence of circumscribed overgrowth. Stedman's Medical Dictionary, 823. -33

There was a small hernia.

The x-ray was in response to Watson's (Tr. 273.)

diagnosed GERD and difficulty swallowing. no evidence of any acute disease. focal infiltrates or consolidation.

On September 20, 2003, an x-ray of the chest was normal and showed The lungs were clear and without (Tr. 271.) The disk at (Tr.

On November 4, 2003, an MRI of Watson's cervical spine revealed no disk abnormalities at C2-3, C3-4, C4-5, C5-6, and C7-T1.4 269-70.) On December 10, 2003, Watson saw Dr. Parks complaining of terrific pain, and difficulties turning her head and raising her arm above her h e a d. Muscle relaxants had been ineffective. Watson thought she was A g o i n g to drop her 6-pound baby after holding him for five minutes. not make lateral turns. C6-7 showed slight degradation and evidence of disk herniation.

physical examination showed Watson was extremely uncomfortable and could She could passively abduct her arms to 90 Dr. Parks degrees, but doing so against resistance provoked pain. not responding to conservative treatment. On January 2, 2004, Watson saw galactorrhea in both breasts.5 (Tr. 289-90.) Dr. Parks, complaining of

suggested Watson see Dr. Dan Riew, an orthopedic surgeon, since she was

Watson reported improvement in her neck Watson reported not being

pain and dysesthesias, but the pain was still severe enough that she was taking Darvocet, Ibuprofen, and Neurontin.6

The human spinal column consists of thirty-three vertebrae. There are seven cervical vertebrae (denoted C1-C7), twelve thoracic vertebrae (den o t e d T1-T12), five lumbar vertebrae (denoted L1-L5), five sacral vertebrae (denoted S1-S5 and fused together into one bone, the sacrum), and four coccygeal vertebrae (fused together into one bone, the coccyx). The cervical vertebrae form part of the neck, while the lumbar vertebrae form part of the lower back. The sacrum is immediately below the lumbar vertebrae. Stedman's Medical Dictionary, 226, 831, 1376, 1549, 1710, Plate 2. Galactorrhea is continued discharge of milk from the breasts between intervals of nursing. Stedman's Medical Dictionary, 628. Dysesthesia is an impairment of sensation, short of anesthesia. It also refers to a condition in which disagreeable sensation is produced by ordinary stimuli. Stedman's Medical Dictionary, 476. Ibuprofen, or Motrin, is an anti-inflammatory drug used to relieve pain (continued...) -46 5

4

able to lift a spatula recently because of weakness in her right arm. Dr. Parks diagnosed her with glactorrhea and disk herniation at C6-7. (Tr. 289, 287.) On January 7, 2004, Watson participated in physical therapy. complained of tingling in her hands and upper extremities. showed some improvement in her range of motion. however, indicated she was in significant pain. closed and heavy breathing. (Tr. 210.) She After physical therapy the Watson She Karen

Seaton, PT, found that Watson was tolerating her medication well, and Her body language, Watson sat with eyes

On January 14, 2004, Watson participated in physical therapy. reported the pain level being 6/10 or 7/10. pain level dropped to 3/10, but the reduction did not last long.

complained of upper extremity symptoms after trying to clean drawers. Watson was tolerating prescriptions well, but was unable to advance through the exercise program because of her increased pain level and acute condition. (Tr. 208.) Her On January 15, 2004, Watson saw Dr. Riew for the first time. 2003. Watson

chief complaints were neck pain and bilateral arm pain since September was unable to carry her 20-month old daughter for To date, Watson had undergone A physical examination She was wearing a soft Dr. Riew diagnosed Xprolonged periods because of the pain.

a conservative course of treatment: physical therapy, massage and ultrasound, and anti-inflammatory medications. showed Watson was "in obvious discomfort." her neck.

collar around her neck because of the pain, and was reluctant to move Her neck pain was worse with flexion. Watson with altered sensation in some of her fingers and forearm, and a right arm smaller than her left arm. Her reflexes were normal. rays showed minimal spondylosis and degenerative disk disease at C6-7.7

(...continued) and swelling. WebMD, http://www.webmd.com/drugs (last visited June 15, 2009). Spondylosis is the stiffening or fixation of the joints within the vertebra. Stedman's Medical Dictionary, 1456. -57

6

There was also mild spurring at C4-5, C5-6, and C7-T1. 8

Dr. Riew

diagnosed her with a herniated nucleus pulposus causing axial neck pain, right-sided radiculopathy, and hyperesthesia around C7.9 She had failed two epidural steroid injections at C7-T1. Watson wanted to try surgery, but Dr. Riew suggested one last epidural injection at C6-7. 33, 241.) On January 19, 2004, Watson participated in physical therapy. was scheduled to have surgery in February. (Tr. 207.) She (Tr. 232-

On January 27, 2004, doctors reviewed a CT scan of Watson's cervical spine. The CT scan revealed normal disk configuration at C2-3, C3-4, C4-5, C5-6, and C7-T1. foraminal stenosis.
10

There was no spinal canal or neural (Tr. 255.)

There was an osteophyte complex at C6-7, but no The facet joints were normal.11

neural foraminal narrowing.

On February 17, 2004, Watson saw Dr. Riew complaining of severe right arm pain and neck pain. A physical examination revealed she had She had paresthesias over the middle X-rays showed mild Dr. full flexion and grip strength.

finger, but otherwise, was neurologically intact.12

spondylosis and a herniated disk at C6-7, causing radiculopathy.

A spur, or calcar, is a small projection from a bone. Medical Dictionary, 227.
9

8

Stedman's

A herniated nucleus pulposus is a slipped disk along the spinal cord. The condition occurs when all or part of the soft center of a spinal disk is forced through a weakened part of the disk. University of Maryland Medical Center, http://www.umm.edu/ency/article/000442.htm (last visited June 16, 2009). Radiculopathy is a disease of the spinal nerve roots. Stedman's Medical Dictionary, 1308. Hyperesthesia is abnormal sensitivity to touch, pain, or other stimuli. Id., 739. The neural foramen is the space through which nerve roots exit the spinal canal to form peripheral nerves. Each foramen is a bony canal formed by the pedicles of two adjacent vertebrae. Medcyclopaedia, http://www.medcyclopaedia.com/?tt_topic=. (last visited June 16, 2009). Stenosis is the narrowing or constriction of any canal. Stedman's Medical Dictionary, 1473. Spinal stenosis refers to the narrowing of the spinal cord. See id. The facet joints are small stabilizing joints located between and behind adjacent vertebrae. See Stedman's Medical Dictionary, 556. Paresthesia is an abnormal sensation, such as burning, pricking, or tingling. Stedman's Medical Dictionary, 1140. -612 11 10

Riew would proceed with the artificial disk replacement at C6-7. 229.) pulmonary masses. On with a February herniated (Tr. 253.) 25, 2004, Watson pulposus underwent and an
13

(Tr.

Chest x-rays showed the lungs were clear, with no evidence of anterior cervical with

arthroplasty with an artificial disk replacement. nucleus

She was diagnosed spondylosis (Tr. 234-35.) The (Tr.

cervical

radiculopathy at C6-7. There were no complications.

next day, an x-ray of her cervical spine showed arthroplasty at C6-7, and mild soft tissue swelling consistent with recent surgery. 250.) On March 4, 2004, Watson saw Dr. Riew, complaining of nausea, vomiting, and constipation following cervical disk arthroplasty. A physical examination showed Tinel's sign over the left calf.14 Her motor strength was normal, and she was able to heel walk, though there was a slightly altered sensation in her foot. problems would resolve. (Tr. 228.) Watson's radicular Yet, Dr. Riew believed her foot

On March 25, 2004, Watson saw Dr. Parks.

symptoms from her herniated disk had improved since the surgery. of spontaneous galactorrhea. for Synthroid and Vioxx.15 ulceration (for which she

she had some burning dysesthesias in her left foot, and another episode She was off all of her medications except Dr. Parks diagnosed Watson with an oral recommended Mylanta), galactorrhea, and

dysesthesias of the left foot, which Dr. Parks attributed to positioning during anesthesia. (Tr. 288.) A physical examination On April 8, 2004, Watson saw Dr. Riew.

showed Watson had some altered sensation to light touch, but otherwise,

An arthroplasty is an operation to restore, as far as possible, the integrity and functional power of a joint. Stedman's Medical Dictionary, 136. T i n e l ' s sign is a sensation of tingling, or of "pins and needles," felt in the distal extremity of a limb, when percussion is made over the site of an injured nerve. Stedman's Medical Dictionary, 1422. Vioxx was used to treat arthritis pain, but is no longer prescribed. WebMD, http://www.webmd.com/drugs (last visited June 16, 2009). -715 14

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had normal sensory motor reflexes. good position. alignment. (Tr. 227)

An x-ray showed the arthroplasty in

Dr. Riew found Watson had excellent motion and good That same day, an x-ray of Watson's cervical (Tr. 240.)

spine showed no signs of fracture or spondylolisthesis.16 arthroplasty.

On May 20, 2004, Watson saw Dr. Riew, three-months after her disk Watson still complained of shoulder pain, but described She still experienced some numbness and tingling in X-rays showed the He it as discomfort.

her arms, but it was intermittent. A physical examination showed Watson had normal motor strength and normal reflexes. artificial disk in good position. Dr. Riew diagnosed her with some neck pain and mild recurrent radicular symptoms that were intermittent. recommended aerobic exercise and a three-month follow-up. (Tr. 225-26.) An x-ray of the cervical spine showed straightening of normal cervical lordosis, and disk prosthesis at C6-7, without any abnormal motion with flexion, extension, and lateral bending.17 reported feeling okay. half-hour. (Tr. 199.) (Tr. 239.) She On June 29, 2004, Watson participated in physical therapy.

On the previous Sunday she had bad pain, but the

day before that she had held her young daughter at church for about a On July 1, 2004, Judy Woehrle, PT, informed Dr. Riew that Watson had shown improved range of motion in her cervical spine, but continued to have pain with elevation of the upper extremities, particularly in both shoulders and in her right arm. Watson expressed a desire to be (Tr. 159.) able to use her arms for reaching, carrying, and lifting.

On August 3, 2004, a note from Judy Woehrle to Dr. Riew indicated Watson missed a few appointments in July because she had gone on vacation. (Tr. 158.)

Spondylolisthesis is the forward movement of the body of one of the lower lumbar vertebrae on the vertebra below it, or upon the sacrum. Stedman's Medical Dictionary, 1456. Lordosis is an abnormal extension deformity - usually in the form of a backward curvature of the spine. Stedman's Medical Dictionary, 894. -817

16

On April 5, 2005, an MRI of Watson's cervical spine revealed normal motion at C6-7 (the location of the prosthetic disk), and minimal degenerative disk disease at C5-6. (Tr. 237.) On August 19, 2004, Watson told Seaton that she was much better, and had recently been able to carry/hold her sleeping, thirty-pound baby for a short walk through a store. 188.) On September 2, 2004, Watson participated in physical therapy. She thought she had turned a corner. working hard on her exercises. She had not taken her pain medication She had also been for the day, and was only having minimal soreness. hands when her arms were overhead. 184.) On September 7, 2004, Watson saw Dr. Riew. Her neck pain had She improved significantly, and she was able to pick up her baby. This was a big improvement. (Tr.

She still complained of tingling in her Seaton observed that Watson's

posture was noticeably better and that she was moving more freely. (Tr.

repo r t e d a sharp pain between the shoulder blades, which lasted for about fifteen minutes. This sensation happened four times over the last month, but did not get worse with activity, and spontaneously resolved. A physical examination revealed she was positive for Tinel's sign, but o therwise, a motor reflex exam and sensory exam were normal. X-rays showed the Bryan disk in good position, and she had excellent motion. Dr. Riew found Watson was doing better with better incorporation of the artificial disk. He noted cubital and carpal tunnel syndrome. Finally, he did not believe Watson's chest pain was back-related. time." (Tr. 223-24.) But even if it was, "the symptoms sound too benign to do anything about it at this That same day, an x-ray of the cervical spine (Tr. 238.) showed normal motion at C6-7 with flexion and extension.

On September 9, 2004, Watson participated in physical therapy. She noted an increase in symptoms following her last physical therapy session. progress. w e a kness. Still, Watson indicated that Dr. Riew was pleased with her After therapy, Watson reported an episode of protracted Jennifer Hirsch, PT, urged her to seek medical treatment.

(Tr. 182-83.)

-9-

On September 10, 2004, Watson saw Dr. Parks, complaining of increasing back pain and chest pain at night. She almost went to the A physical An EKG emergency room because the chest pain was so severe. she had no peripheral swelling. showed no acute changes.

examination showed her lungs were clear, her heart had no murmurs, and Her upper abdomen was tender. Dr. Parks diagnosed chest pain and back pain, Dr. Parks thought Watson might need (Tr. 286.)

likely gastrointestinal in origin. therapy for her depression.

On September 20, 2004, Watson told Jennifer Hirsch that she was "definitely better," and felt like her strength was improving and she was able to do most of her exercises. idea of taking a break from prescription expired. physical therapy. Hirsch discussed with Watson the therapy when her current physical

Watson was a little concerned about ending

(Tr. 180.)

On September 27, 2004, Watson participated in physical therapy. She complained of pain and tingling in the upper thoracic region, particularly when performing her exercises. (Tr. 178.) That same day, Hirsch Jennifer Hirsch wrote to Dr. Riew, noting that Watson had been attending physical therapy twice a week, with slow but steady progress. visits. (Tr. 155.) She was feeling less She was still having joints.18 Dr. Parks a s k ed Dr. Riew to sign a prescription if the doctor approved of more On October 19, 2004, Watson saw Dr. Parks. depressed, and no longer having crying episodes. increasing 285.) On October 25, 2004, a physical therapy note indicated Watson still sighed, from pain, during exercises. Still, Jennifer Hirsch felt as if (Tr. 169.) Watson had met her maximum potential with physical therapy. note. arthralgias, predominantly in the

diagnosed her with arthralgias, GERD, and improved radicular pain. (Tr.

On October 28, 2004, Seaton completed an upper extremity progress Watson suffered from myofacial pain with radicular symptoms. According to the note, Watson did not From June 10, 2004, until October 28, Watson had visited physical therapy twenty-five times.
18

Arthralgia is severe joint pain, but not inflammatory. Stedman's Medical Dictionary, 134. - 10 -

experience pain every day.

But when she did, evenings were the worst. She felt Her

The pain was 5/10 at its worst, and 1/10 at its best.

comfortable with her exercises and felt she could follow up at home. Her posture showed slight improvement in lower cervical flexion. upper extremity strength was 4/5 or 5/5 in all major groups. She showed She

signs of intermittent tenderness adjacent to the cervical spine. In her assessment, Seaton thought Watson had "achieved all goals." at half-intensity in an attempt to further reduce pain. physical therapy. (Tr. 167.) She noted her neck pain instructed her to stop exercising for one to two weeks, then to resume Watson was "to continue her daily activity level as normal," and could discontinue O n April 4, 2005, Watson saw Dr. Riew. There was no radiating pain.

continued to improve, but that she still had some pain at the base. A physical examination showed Watson had She had normal motor strength and (Tr. 222.) (Tr. A She minimally altered sensation to pinprick in the thumb and index finger, but otherwise, sensation was normal. normal reflexes. Dr. Riew recommended aerobic exercise.

O n May 26, 2005, Watson saw Dr. Park complaining of depression. Watson was sleeping well, and Cymbalta was helping with her aches. 283.) On May 31, 2005, Watson had swelling around her kneecap. physical examination good showed of some motion. erythema Dr. with Parks some soft thickening of the bursa, but no effusion in the knee itself.19 maintaine d range prescribed Triamcinolone cream, and Cephalexin.20 (Tr. 283.) tissue Advil,

Erythema is inflammatory redness of the skin. Stedman's Medical Dictionary, 533. Effusion is the escape of fluid from the blood vessels into the tissues or into a cavity. Id., 491. Triamcinolone cream is used to treat a variety of skin conditions, such as rashes and eczema. Cephalexin is an antibiotic used to treat a variety of infections. WebMD, http://www.webmd.com/drugs (last visited June 16, 2009). - 11 20

19

On June 2, 2005, Dr. Parks found Watson's cellulitis overlying the patella to be "dramatically better."21 dime. (Tr. 282.) On June 28, 2005, Gary M. Wassermann, M.D., conducted a bone mineral density study. The study showed Watson had a normal density in (Tr. 303.) the lumbar spine, left femoral neck, and left hip bone. hip pain. She had trouble walking and was exhausted. Her erythema was the size of a

On October 3, 2005, Watson saw Dr. Parks, complaining of knee and Her mood was low. A physical examination showed significant crepitus in the knee, with pain around the femur. true osteoarthritis. weeks. (Tr. 281.) Watson was unable to tolerate the Relafen because of Dr. Parks found marked That same day, David Knee alignment
22

Dr. Parks diagnosed her with fibromyalgia and She wanted Watson to reduce her Darvocet. Dr.

Parks scheduled physical therapy, and recommended a follow-up in six On November 14, 2005, Watson saw Dr. Parks, complaining of hip and kn e e pain. worsening GERD. She was feeling very depressed. crepitus in her left knee. knee, and Effexor for her depression. (Tr. 280.)

She suggested physical therapy for the

A. Rubin, M.D., reviewed an x-ray of Watson's left knee. effusion, and the joints were normal. (Tr. 236.)

was anatomic; there were no fractures or dislocations, there was no On December 1, 2005, Watson participated in physical therapy. Watson's diagnosis was fibromyalgia, with an onset date of six months earlier. Her rehabilitation potential was marked as "good." Her work status was marked as "retired." getting worse all the time. Watson also complained of hip pain,

tailbone pain, and left knee pain dating back six months, with the pain Watson reported pain with all activities, and fatigue after walking for thirty to sixty minutes. Monica Nicastro, MSPT, noted Watson had good rehabilitation potential, but found Watson reported "pain with all movements." (Tr. 376.)

Cellulitis is inflammation of cellular or connective tissue. Stedman's Medical Dictionary, 273. Cr e p i tus, or crepitation, refers to crackling, and can be the noise or vibration produced by rubbing bone or irregular cartilage surfaces together. Stedman's Medical Dictionary, 368. - 12 22

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On January 17, 2006, Watson participated in physical therapy. noted Watson's motivation was fair. "retired." (Tr. 375.)

To

date, she had participated in 10 of 13 scheduled appointments. Nicastro Her work status was marked as In a

On February 10, 2006, Watson completed a function report. meals.

typical day, Watson played card games with her toddler and made simple She might make her kids a snack when they got home from school. At night, she made dinner, and helped By this point she was she might do passive If She tried to rest during the day. "totally exhausted."

her 3-year old shower and get ready for bed. The rest of the day,

exercises or take her children with her to go grocery shopping. needed, she might do the laundry.

Watson took care of her husband and (Tr.

h e r toddler, but noted that her other two children, a 14-year old and 12-year old, helped out a lot, finishing what she tried to start. 101-102, 108.) Before her illness, Watson was able to do whatever she wanted, from work i n g on the delivery floor, to painting, to holding her children while vacuuming. and shower. Now, she was lucky to be able to wash the dishes Her impairments affected her ability to dress without having to stop.

Bending was difficult and showering left her exhausted. Watson's children helped her do She was able to If she went

Watson used to cook real meals, but lately had just been preparing frozen foods and pre-packaged meals. laundry. Cleaning a single room could take all day.

drive a car, but after an hour, her back and hips hurt. help her lift any groceries.

grocery shopping, she preferred to go with her children, so they could Watson like to embroider and do crafts, She used to volunteer but it took a lot of energy and concentration. able to do so.

at her children's school and attend sports activities, but was no longer She only went places she had to go - like to school, to (Tr. 102-06.) things, complete tasks, the doctor's office, or to physical therapy. walk, sit, kneel, climb stairs, remember

Watson's impairment made it difficult to lift, squat, bend, stand, concentrate, follow instructions, use her hands, and get along with others. She could only lift a gallon of milk if she used both hands.

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She could sometimes pick up her daughter, but could not hold her. Watson did not handle stress well. (Tr. 106-09.) A physical examination showed On February 14, 2006, Watson saw Dr. Riew, complaining of neck pain and total body pain from fibromyalgia. normal sensory, motor, and reflexes, except in the thumb and forefinger, and a normal gait other than slow walking from fibromyalgia. Dr. Riew's review of the x-rays showed good incorporation of the artificial disk and excellent preservation of motion and alignment. a follow-up in a year's time. depression. back pain (Tr. 463.) Dr. Riew scheduled

On February 28, 2006, Watson saw Dr. Parks for a follow-up of her She had trouble standing and sitting for long periods, and Dr. Parks diagnosed her with chronic lower with the possibility of some underlying (Tr. 455.) An MRI of the lumbar spine (Tr. 460.) She had and hip pain, h a d migratory joint pain. degenera t i v e disk disease.

revealed multi-level lumbar degenerative disk disease. attended 20 of 29 scheduled appointments. W a t s o n ' s motivation was fair. working."

On March 16, 2006, Watson completed her physical therapy.

Monica Nicastro indicated

Her work status was marked as "not Her pain was about the same,

Watson reported her endurance was better, but that she still Nicastro noted Watson had partially met her minutes, but her pain level for daily

got weak and tired doing certain things. and she still had nausea. goals. on a treadmill for seven

She was able to lift her daughter with less pain and could walk Because of her poor tolerance for (Tr. 357.)

activities remained the same.

exercise, Nicastro recommended Watson try aquatic therapy. of chest pain. and wheezing.

On March 21, 2006, Watson went to the emergency room, complaining Moderate to heavy exertion produced the pain, which was A physical examination showed Watson was anxious Her condition was improved on re-examination. (Tr. However, her chest was non-tender and she was in no m o d e r a t e to severe. respiratory distress.

She was diagnosed with asthma, acute bronchitis, and chest pain. during her examination. (Doc. 339.) - 14 -

327-38.) Dr. Elizabeth McFarland found no acute cardiopulmonary changes The lungs were clear, there were no pleural effusions, and the thoracic spine and bony structures were intact.

On March 23, 2006, Watson completed a functional health status summary. As part of the summary, she indicated having "[q]uite a bit Her In the report, of difficulty" walking two blocks and doing her usual housework. health limited her ability to walk more than a mile. neck, ankles, knees, and right foot. (Tr. 353-56.)

Watson reported pain all over her body - in her hips, shoulders, arms, On March 31, 2006, Watson participated in range of motion testing. Her grip strength, lower extremity muscle weakness, and upper extremity strength were 4/5. same day, Andrew rehabili t a t ion, Determinations. Her effort was good for each. Wayne, to M.D., the a doctor of Missouri (Tr. 387-88.) medicine of That and physical

wrote

Department

Disability

Watson told Dr. Wayne she had mild difficulty with

prolonged driving, and difficulty with prolonged standing and walking. A physical examination showed Watson had a slow gait with a bilateral antalgic pattern. sitting down." She also rocked "back and forth constantly while She had decreased sensation in her left leg, left foot,

right foot, and fingertips. She had typical fibromyalgia tender points. Straight leg raises were mildly positive for lower back pain and she had moderate restriction of motion in her shoulders and lower back. normal motion in the elbows and forearms. She had She did not appear to have

any difficulty breathing. Dr. Wayne diagnosed Watson with fibromyalgia, oste oarthritis in the neck with disk replacement at C6-7, depression reasonably well-controlled with medication, asthma controlled with medication, and a history of migraines. Watson took Aciphex for her In all, G E R D and did "not describe her GI problems as being very severe." Synthroid seemed to be managing her thyroid function as well. fibromyalgia. eight-hour day. Dr. Wayne believed Watson's biggest functioning difficulty was from her Based on her fibromyalgia and other medical issues, Dr. He did not believe she needed an assistive device. He Wayne would limit Watson to two hours of standing and/or walking in an thought she did not have any limitations for sitting or using her upper extremities for fine motor activities. 92.) He thought she could only lift (Tr. 389ten pounds and drive no more than thirty minutes at a time.

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On April 7, 2006, Watson saw Allison Burner, M.A., a licensed psychologist, for a psychological evaluation. and had good eye contact during the exam. denied any hallucinations. significant disorders. Watson was cooperative Her speech was clear and she

Her thought content was rational and

organized, with no evidence of paranoia, phobias, obsessions, or other Watson reported needing help cooking, cleaning, She could not sit, stand, or lay Burner found Watson had good grocery shopping, and doing laundry.

down comfortably for any period of time. some anxiety and depression. score of 60.23 (Tr. 395-98.)

c oncentration and persistence, but found her chronic pain had caused Burner diagnosed her with adjustment disorder with mixed anxiety and a depressed mood, and assigned her a GAF On April 14, 2006, Judith A. McGee, Ph. D., completed a psychiatric review of Watson. Dr. McGee found Watson needed an RFC assessment, and Dr. McGee found had non-mental impairments that required referral.

Watson had depression and adjustment disorder, with mild restriction of her daily activities, moderate difficulties maintaining concentration, but no difficulties maintaining social functioning. episodes of extended decompensation. Dr. McGee Watson had no found Watson's

allegations of depression and difficulty concentrating because of her pain to be fully credible. perform simple work. On April 18, 2006, She believed Watson retained the ability to Angela Hickerson, a disability examiner, (Tr. 399-416.)

completed a physical residual functional capacity assessment. Hickerson found Watson could lift ten pounds occasionally, less than ten pounds frequently, stand and/or walk for about two hours in an eight-hour workday, sit for six hours in an eight-hour workday, and perform

A GAF score, short for Global Assessment of Functioning, helps summarize a patient's overall ability to function. A GAF score has two components. The first component covers symptom severity and the second component covers functioning. A patient's GAF score represents the worst of the two components. On the GAF scale, a score of 55 represents mod e rate symptoms (such as flat affect and circumstantial speech, occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (such as few friends, conflicts with peers or co-workers). Diagnostic and Statistical Manual of Mental Disorders, 32-34 (4th ed., American Psychiatric Association 2000). - 16 -

23

unlimited pushing and pulling.

She could only occasionally climb, Because

crouch, and stoop, and had a limited ability to reach overhead. dusts, and gases.

of asthma, she needed to avoid even moderate exposure to fumes, odors, Hickerson found Watson's fibromyalgia was well But because her (Tr. 417-24.) After the hernia, but documented, and that she had the associated symptoms.

allegations were more restrictive than the totality of the evidence, Hickerson found her allegations only partially credible. On June 22, 2006, Michael E. Presti, M.D., performed an upper endoscopy and a colonoscopy, and took biopsy samples. procedures, he diagnosed Watson with a small hiatal

otherwise normal esophagus, mild gastritis, tethering of the colon, though without any obvious abnormalities of the colon, and internal h e m o r r h o i d s . 24 Dr. Presti advised Watson to continue with her acidDr. Presti also suppression medication for the gastritis and GERD. endoscopy. (Tr. 444-49.) There was no

advised Watson to undergo a follow-up evaluation with an upper and lower On July 14, 2006, an MRI of the abdomen showed a tiny simple cyst in the liver, but otherwise, the liver was unremarkable. mass, lesion, fluid collection, or abnormal enhancement in the abdomen. Biopsies of the small intestine, stomach, large intestine, and colon also showed no pathologies. (Tr. 442, 445, 452.) On September 19, 2006, Robert K. Duddy, DPM, checked the boxes indicating Watson could sit, stand, and/or walk for six hours in an eight-hour workday. Dr. Duddy had successfully performed bunion surgery on Watson on July 19, 2005. (Tr. 426-27, 431-37.) She also physical On October 13, 2006, Watson saw Dr. Parks, complaining of weakness in her lower extremities, feeling week, and being off balance. complained of dysesthesias and chronic headaches. A

examination showed an antalgic gait, that Watson was hyperreflexic throughout, but had full strength in her upper extremities, and 5-/5

A hiatal hernia forms at the opening in the diaphragm where the esophagus meets the stomach. Part of the stomach pushes through this opening causing a hiatal hernia. Most small hiatal hernias do not cause problems. MayoClinic.com, http://www.mayoclinic.com/health/hiatalhernia/DS00099 (last visited June 16, 2009). Gastritis is inflammation of the stomach. Stedman's Medical Dictionary, 635. - 17 -

24

strength in her lower extremities.25 (Tr. 454.)

Dr. Parks diagnosed Watson with

lower extremity pain and weakness, likely due to lumbosacral disease. On October 16, 2006, doctors reviewed an MRI of Watson's lumbar spine. The MRI revealed mild facet arthropathy at L2-3, L3-4, L4-5, and There were also signs of The L5-S1, but no central stenosis at any level. diagnosis was mild lumbar spondylosis.

bulging, disk dessication, and loss of height at L2-3 and L3-4.26 (Tr. 458-59.) On December 4, 2006, Watson saw Dr. Parks. her issues stemmed from fibromyalgia.

Watson had seen a

neurologist recently, and the conclusion was that the vast majority of Dr. Parks counseled Watson to (Tr. 454, 456.) seek "nonpharmacologic means of helping her pain levels." Dr. Parks was going to send Watson back to physical therapy. LPC, saw Watson. household. sit. (Tr. 466.) From December 14, 2006, to January 30, 2007, Linda Medlock, M.Ed. During the December 14 visit, Medlock noted Watson lived at home with her three children, and supervised the She was able to drive, manage family finances, and perform She attended church once month, but it was painful to Her hygiene was light housework.

Her general health was good other than fatigue.

good, her family and peer relationships were good, and she did not have a ny suicidal thoughts. Her appearance was good, her affect and mood Her goals were to keep up with (Tr. 470-77.) were normal, and her speech was normal.

daily activities, to decrease her pain, and to be more functional. Medlock assigned Watson a GAF score of 50.27 follow-up. wa s worse.
25

On February 28, 2007, Watson saw Christine Sigman, M.D., for a Her hypothyroidism had improved, but her fibromyalgia pain At the time, she was taking Albuterol, Allegra, Ambien, the reflexes are

Hyperre f l e x i a is a condition in which exaggerated. Stedman's Medical Dictionary, 745.
26

Disk dessication is the drying out of the intervertebral disks. Stedman's Medical Dictionary, 422. On the GAF scale, a score of 50 represents serious symptoms (such as thoughts of suicide, severe obsessional rituals, frequent shoplifti n g), or any serious impairment in social, occupational, or school functioning (such as the inability to make friends or keep a job). Diagnostic and Statistical Manual of Mental Disorders, 32-34. - 18 27

Atrovent Cytomel, Darvocet, Effexor, Neurontin, Nexium, Rhinocort, Skelaxin, Synthroid, and Vivelle.28 and disorders of the skin. Dr. Sigman diagnosed Watson with hypothyroidism, menopausal and post-menopausal disorders, fibromyalgia, (Tr. 479-81.) From December 11, 2006, to April 16, 2007, Watson participated in physical therapy at Rehab1Network. (Tr. 497-529.) A progress note from March 19, 2007, indicated Watson complained of back pain, with the pain increasing from any prolonged sitting or walking. normal limits. Barb Yemm, PT, observed that Watson's cervical and lumbar range of motion was within Her bilateral upper extremity strength tested at 4+/5, Yemm believed Watson continued to make She had two episodes of (Tr. 512.) "regarding the On without any complaints of pain.

progress with increasing exercise regimen.

i n creased pain following increased activity, but overall continued to see decreasing frequency and intensity of pain. Parks, requesting she respond to a On February 1, 2007, Watson's attorney, Donald Kohl, wrote to Dr. questionnaire claimant's physical capacity to perform tasks necessary to work." March 26, 2007, Dr. Parks completed the questionnaire.

As part of her

responses, she indicated Watson could only walk 200 feet before needing rest, sit for 2 hours continuously, stand 15 minutes continuously, and lift 10 pounds. ALJ's decision. pain. She (Tr. 492-92.) In the request, she noted that she was unable to sit, In September 2007, Watson completed a request for review of the stand, or walk for even short periods without experiencing a lot of She noted problems with fatigue, headaches, and pain in her neck She had not carried her child since she was a small baby. naps because (Tr. 8-9.) she could not help it; her fatigue was and back. took

overwhelming.

Atrovent, or Ipratropium, is a bronchodilator used to treat lung diseases like chronic bronchitis and emphysema. Cytomel is used to treat hypothyroidism. Nexium is used to treat acid-related stomach and throat problems, such as acid reflux or GERD. Vivelle is a hormone used to reduce menopausal symptoms. WebMD, http://www.webmd.com/drugs (last visited June 16, 2009.) - 19 -

28

Testimony at the Hearing On March 28, 2007, Watson testified before the ALJ. worked as a registered nurse. the last fifteen years. impairment. She had last She had not worked any other jobs within

Watson believed her fibromyalgia was her worst Her fatigue and depression were two other Watson saw Dr. Parks and Dr. Parks prescribed medication, Watson called the depression

The pain was worst in her lower back and neck, but was also

present in both her knees.

impairments that prevented her from working. Linda Medlock for her depression. overwhelmin g . fatigue. while Medlock served as her therapist.

She also suffered from hypothyroidism, which produced Watson had GERD as well. (Tr. 27-33.) Watson still Taking Ibuprofen to She had

Watson suffered from asthma, but she did not think the asthma

k e p t her from working.

combat her aches and pains gave her serious stomach issues. stomach attacks nearly every day. not regained her experienced pain. pain.

In February 2004, Watson had received a disk replacement, but had strength following the procedure. On a good day, the pain was 3/10, and on a bad day, On a bad day, Watson took Darvocet to relieve the She tried to avoid taking Watson would also lay down She could not pick up She

it was 7/10 or 8/10.

But taking the pain medication made her dizzy and made it hard

to concentrate because she felt "high." Darvocet because of its side effects.

several times during a day to relieve the pain.

a gallon of milk, because it would cause a lot of pain later on. help. (Tr. 33-37.)

took her children with her to the grocery store because she needed the Her asthma did not keep her from working, but it did produce shortness of breath. pass gas, and belch. Nexium helped. 39.) During the hearing, Gary Weimholt testified as a vocational expert (VE). The ALJ had the VE assume that Watson could lift ten pounds occasionally, less than ten pounds frequently, sit for six hours in an - 20 Watson's depression caused her to get tearful, Her stomach issues happened every night, but Watson was able to sleep okay. (Tr. 37irritable, and short-tempered. Her GERD gave her stomach pain, made her She could not sit for very long, and was unable to go

to church for even an hour.

eight-hour workday, stand and/or walk for two hours in an eight-hour workday, and occasionally climb, balance, kneel, and crawl. The ALJ also had the VE limit overhead reaching and limit exposure to fumes. Finally, he was to assume Watson could understand, remember, and carry out simple instructions. Under these circumstances, the VE testified However, the VE that Watson could not return to her nursing job.

believed Watson could perform some sedentary work - such as glassware and plastic assembly work (DOT # 739.687-066) or pharmaceutical packing jobs (DOT # 559.687-014). national economy. If Watson had to lay down for an hour, either once or twice a day, she would not be able to perform any work in the If Watson also had crying spells, the inability to maintain regular attendance, the inability to complete a workday without i n terruption from psychological symptoms, the inability to perform at a consistent pace, and the inability to deal with normal workday stress, the VE stated she would not be able to perform any work in the national economy. (Tr. 39-43.) III. DECISION OF THE ALJ

The ALJ found that Watson suffered from degenerative disk disease, joint disease, fibromyalgia, and an adjustment disorder, and that these impairments were severe. The ALJ also found Watson suffered from Watson had worked for many (Tr. 17-19.) migraine headaches, reflux disorder (GERD), asthma, and hypothyroidism, but that these impairments were not severe. years despite the asthma, her migraines were infrequent, and medication managed her reflux disorder and hypothyroidism. finding. The ALJ found the medical evidence did not support a disability Watson underwent disk replacement, but post-operative reports MRIs of Watson's lumbar spine showed only mild from Dr. Riew showed normal motor strength, normal reflexes, and mostly normal sensory ability. degeneration. unremarkable. degeneration, and reports from Dr. Parks showed minimal left knee Dr. Sigman found Watson had a normal gait, normal Knee exams were largely therapy for her Watson participated in physical reflexes and neurological results were intact.

fibromyalgia, but a report from the therapist showed good improvement in ambulation, endurance, and trunk and lower extremity strength, and - 21 -

an increased tolerance for daily activities. Dr. Wayne found Watson did not have any limitations in sitting or performing fine motor activities, and concluded Watson could lift up to ten pounds and stand and/or walk for two hours in an eight-hour workday. (Tr. 19-20.) The ALJ found this The The ALJ discounted an opinion from Dr. Parks, which had stated that Watson could only stand fifteen minutes at a time. conclusion was not supported by Dr. Parks's own treatment notes.

ALJ also discounted Watson's allegations of mental disability, because the medical record did not reveal any ongoing mental health treatment. In addition, Watson had told her treating physician and Dr. Wayne that her medication was effective. Dr. McGee, and Alison limitations. Medlock. Psychiatric examinations by Dr. Sigman, did not reveal any serious mental Burner

The ALJ gave almost no weight to the opinion of Linda In addition, Medlock's mental Finally, Watson (Tr. 20.) Watson cared for her

Medlock was a licensed professional counselor, and counselors

are not considered medical sources.

status evaluation of Watson produced normal results. had not undergone any episodes of decompensation. The ALJ found Watson not entirely credible.

three young children, and the ALJ found the ability to care for a young child inconsistent with allegations of a physical or mental disability. The ALJ also noted that Watson reported being able to lift her daughter, despite claiming she could not lift a gallon of milk. She told her physical therapist she was retired, not disabled. She claimed she could not sit for long periods of time, but reported driving, watching television, and reading. Watson complained of flightiness and difficulty concentrating, but she never told any doctors about these side effects. Watson said she needed to lay down during the day, but (Tr. 20-21.) no doctor had told her this was necessary.

The ALJ concluded Watson maintained the RFC to lift ten pounds occasion a l l y , lift less than ten pounds frequently, sit for six hours in an eight-hour workday, stand and/or walk for two hours in an eighthour workday, and occasionally crouch, kneel, crawl, and climb. fu m es. She could not reach overhead on a repetitive basis, and needed to avoid Finally, the ALJ found Watson could understand and carry out Watson was unable to simple instructions and non-detailed tasks. - 22 -

perform her past duties as a nurse.

However, the vocational expert The

found Watson could perform work as a product assembler or packager. in the national economy.

ALJ found this credible evidence that Watson could perform other jobs Accordingly, the ALJ concluded Watson was not (Tr. 20-23.) disabled within the meaning of the Social Security Act. IV. GENERAL LEGAL PRINCIPLES

The court's role on judicial review of the Commissioner's decision is to determine whether the Commissioner's findings comply with the relevant legal requirements and is supported by substantial evidence in the record as a whole. Cir. 2009). Pate-Fires v. Astrue, 564 F.3d 935, 942 (8th "Substantial evidence is less than a preponderance, but is Id. In determining whether the evidence Id. As long as substantial

enough that a reasonable mind would find it adequate to support the Commissioner's conclusion." i s substantial, the court considers evidence that both supports and detracts from the Commissioner's decision. evidence supports the decision, the court may not reverse it merely because substantial evidence exists in the record that would support a contrary outcome or because the court would have decided the case differently. 2002). To be entitled to disability benefits, a claimant must prove she is unable to perform any substantial gainful activity due to a medically determinable physical or mental impairment that would either result in d e a t h or which has lasted or could be expected to last for at least twelve continuous months. 42 U.S.C. §§ 423(a)(1)(D), (d)(1)(A), 1382c(a)(3)(A); Pate-Fires, 564 F.3d at 942. disability. A five-step regulatory See Krogmeier v. Barnhart, 294 F.3d 1019, 1022 (8th Cir.

framework is used to determine whether an individual qualifies for 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4); see also Bowen v. Yuckert, 482 U.S. 137, 140-42 (1987) (describing the five-step process); Pate-Fires, 564 F.3d at 942. Steps one through three require the claimant to prove (1) she is not currently engaged in substantial gainful activity, (2) she suffers from a severe impairment, and (3) her disability meets or equals a listed impairment. Pate-Fires, 564 F.3d at 942. - 23 If the claimant does

n ot

suffer

from

a

listed

impairment

or

its

equivalent, Id.

the

Commissioner's analysis proceeds to steps four and five. RFC to perform past relevant work. work. Id. Id.

Step four

requires the Commissioner to consider whether the claimant retains the The claimant bears the burden of demonstrating she is no longer able to return to her past relevant If the Commissioner determines the claimant cannot return Id. to past relevant work, the burden shifts to the Commissioner at step five to show the claimant retains the RFC to perform other work. In this case, the Commissioner determined that Watson could not perform her past work, but that she maintained the RFC to perform other work in the national economy. V. evidence. DISCUSSION

Watson argues the ALJ's decision is not supported by substantial First, she argues the ALJ failed to evaluate her mental Second, she impairment, and any resulting functional limitations. Parks.

argues the ALJ failed to accord adequate weight to the opinion of Dr. Third, she argues the ALJ erred by failing to recontact her Fourth, she argues the ALJ erred in (Doc. 6.) treating medical providers.

discounting the opinion of Linda Medlock. Mental Evaluation

Watson argues the ALJ failed to evaluate her mental impairment. Federal regulations provide special procedures for the Commissioner to follow in evaluating mental impairments. Sept. 24, 2008). 20 C.F.R. § 404.1520a(a); Tilley v. Astrue, No. 4:07 CV 801 FRB, 2008 WL 4402219, at *13 (E.D. Mo. First, the Commissioner must evaluate the claimant's 20 C.F.R. pertinent symptoms, signs, and laboratory findings to determine whether the claimant has a medically determinable mental impairment. § 404.1520a(b)(1). If the claimant has a medically determinable mental Id. The ALJ does this by rating

impairment, the ALJ must describe the symptoms, signs, and findings that substantiate the impairment. impairment. Second, the ALJ must characterize the severity of the mental 20 C.F.R. § 404.1520a(b)(2). the extent of the claimant's functional loss in the areas of: 1) daily - 24 -

living, 2) social functioning, 3) concentration, persistence, or pace, and 4) episodes of decompensation. 20 C.F.R. § 404.1520a(c)(3). If the claimant's functional loss in the first three areas is only mild, and there have been no episodes of decompensation, the ALJ will generally concluded that a claimant's mental impairment is not severe. § 404.1520a(d)(1). 20 C.F.R. 20 If the ALJ finds the impairment is severe, the ALJ

must determine if the impairment meets a listed mental disorder.

C.F.R. § 404.1520a(d)(2). If the ALJ finds the impairment is severe but d o es not meet a listed disorder, the ALJ performs an RFC assessment. 20 C.F.R. § 404.1520a(d)(3). § 404.1520a(e). At the hearing stage, the ALJ must document the application of these procedures in the decision. 20 C.F.R. If the ALJ fails to follow the appropriate procedure Tilley, 2008 WL 4402219, at *14. f o r evaluating the severity of a claimant's mental impairment, the decision must be remanded. mental impairment. In this case, the ALJ properly evaluated Watson's allegations of In his opinion, the ALJ noted Watson had undergone psyc h ological evaluations by Dr. Sigman, Allison Burner, and Judith McGee, and that these examinations were unremarkable and showed no significant mental limitations. The ALJ also noted that one of Watson's GAF scores indicated only moderate symptoms. no Finally, more the ALJ mild specifically found that Watson had no episodes of decompensation, no difficulti e s maintaining social functioning, than restrictio n s of daily living activities, and no more than moderate difficulties maintaining concentration, persistence or pace. the severity of Watson's mental impairment. More to the point, substantial evidence supports the ALJ's In conclusi o n that Watson's mental impairments were not disabling. well-controlled with medication. disorders. Under the circumstances, the ALJ properly followed the procedure for evaluating

March 2006, Watson told Dr. Wayne that her depression was reasonably In April 2006, Allison Burner found Watson was rational and organized, with no evidence of any significant That same month, Judith McGee concluded Watson had no In December 2006, Linda Medlock episodes of extended decompensation.

found Watson did not have any suicidal thoughts, was able to manage her finances and perform light housework, and had normal speech and affect. - 25 -

There is no evidence in the record that Watson received aggressive mental health treatment, or that she was hospitalized for mental health reasons. e v i d ence She never voiced ALJ's any suicidal thoughts, that delusions, or hallucinations. After reviewing the medical record, substantial medical supports the determination Watson's mental impairments were not disabling. See Jones v. Callahan, 122 F.3d 1148,

1153 (8th Cir. 1997) (ALJ properly concluded that claimant did not have a severe mental impairment, where claimant was not undergoing regular mental-health treatment or regularly taking psychiatric medications, and where his daily activities were not restricted from emotional causes). Weighing Medical Testimony Watson argues the ALJ failed to accord adequate weight to the opinion of Dr. Parks. She also argues the ALJ erred in discounting the opinion of Linda Medlock. The ALJ has the role of resolving conflicts among the opinions of various treating and examining physicians. F.3d 1211, 1219 (8th Cir. 2001). Pearsall v. Massanari, 274 The ALJ may reject the conclusions of Id. Normally, the

any medical expert, whether hired by the government or the claimant, if they are inconsistent with the record as a whole. Casey v. Astrue, 503 F.3d 687, 691 (8th Cir. 2007). generally receives very little weight. 452 (8th Cir. 2000). Still, the opinion of the treating physician is not conclusive in determining disability status, and must be supported by medically acce p t a b l e clinical or diagnostic data. Casey, 503 F.3d at 691. The ALJ may credit other medical evaluations over the opinion of a treating p h ysician if the other assessments are supported by better or more thorough medical evidence, or when the treating physician's opinions are internally inconsistent. Guilliams v. Barnhart, 393 F.3d 798, 803 (8th In Cir. 2005); Cantrell v. Apfel, 231 F.3d 1104, 1107 (8th Cir. 2000). opi nion of the treating physician is entitled to substantial weight. The opinion of a consulting physician, who examines a claimant once, or not at all, Singh v. Apfel, 222 F.3d 448,

determining how much weight to give a treating physician's opinion, the

- 26 -

ALJ must consider the length of the treatment relationship and the frequency of examinations. Casey, 503 F.3d at 692. However, the ALJ discounted this In March 2007, Dr. Parks provided her opinion about Watson's ability to perform certain tasks. notes. opinion, finding it was not supported by the doctor's own treatment Substantial evidence supports the ALJ's decision to discount this opinion. In March 2007, Dr. Parks completed a questionnaire, in which she indicated Watson could only walk 200 feet before needing rest, stand for 15 minutes at a time, sit for 2 hours at a time, and lift no more than ten pounds. However, there is no medical support or analysis behind See Browning v. Sullivan, 958 F.2d 817, 823 Indeed, Dr. Parks had of completing the these summary conclusions.

(8th Cir. 1992) (noting that a conclusory diagnosis letter does not overcome substantial evidence to the contrary). not examined Watson within several months questionnaire.

The questionnaire was completed in response to a letter (Tr. 492.)

from Watson's attorney, requesting that she "respond to the questions set forth on the attached Exhibit A. . . ." In contrast to this opinion, Dr. Parks found Watson had full strength in her upper extremities, and 5-/5 strength in her lower extremities during an exam in October 2006. Two months later, Dr. Parks coun seled Watson to seek "nonpharmacologic means of helping her pain levels," and recommended more physical therapy. There is no evidence from prior visits that Dr. Parks ever found Watson had the type of limitations she indicated in the 2007 questionnaire. In his opinion, the ALJ noted the inconsistencies between Dr. Parks's 2007 letter and her other treatment notes. Accordingly, the ALJ articulated a sufficient reason for discounting the opinions in the 2007 ques t i o n n a ire. 1107. The ALJ also discounted the opinion of Linda Medlock. In discounting her opinion, the ALJ noted that a counselor is not an acceptable medical source, her opinions were inconsistent with the record as a whole, and her opinions were internally inconsistent. See Guilliams, 393 F.3d at 803; Cantrell, 231 F.3d at

- 27 -

During the December 14 visit, Linda Medlock found Watson was in good general health, with a normal appearance, normal affect, and good hygiene. Her family and peer relationships were good, and she did not Yet, Medlock assigned Watson a GAF score have any suicidal thoughts.

of 50, which represented serious symptoms (such as thoughts of suicide), or any serious impairment in social or occupational functioning (such as the inability to make friends or keep a job). Given the clear See Guilliams, internal inconsistency between her findings and the GAF score, the ALJ did not err in discounting the opinion of Linda Medlock. 393 F.3d at 803; Cantrell, 231 F.3d at 1107. Recontacting Physicians Watson argues the ALJ should have recontacted Watson's treating physician if he found the records were inconsistent. A social security hearing is a non-adversarial proceeding, which requires the ALJ to fully and fairly develop the record. Barnhart , 392 F.3d 988, 994 (8th Cir. 2005). Ellis v. But while the duty to

fully develop the record may include the obligation to recontact a treating physician for clarification of an opinion, "that duty arises only if a crucial issue is undeveloped." Id. Under the Code of Federal Regulations, the ALJ will recontact a medical source only where the evidence from a treating physician is inadequate to reach a decision. 20 C.F.R. § 404.1512(e); Goff v. Barnhart, 421 F.3d 785, 791 (8th Cir. 2005). "We will seek additional evidence or clarification from your medical source when the [source's] report . . . contains a conflict or ambiguity that must be resolved, the report does not contain all the necessary information, or does not appear to be based on medically acceptable . . . techniques." recontact a medical source 20 C.F.R. § 404.1512(e). is triggered when the The duty to evidence is

insufficient to make an informed determination - not when the evidence is insufficient to make a favorable determination. Pearson v. Barnhart, No. 1:04-CV-300, 2005 WL 1397049, at *4 (E.D. Tex. May 23, 2005). Watson issue. argues the ALJ should have recontacted her treating physician, but does not specify exactly which treating physician is at In addition, she does not detail which issues she believes - 28 -

remain undeveloped.

In his opinion, the ALJ does not state that the On the

evidence at hand is insufficient to make an informed decision.

contrary, the ALJ described several medical visits during which Watson was found to have normal motor strength, normal sensory ability, mild or minimal degeneration in the knees and back, normal reflexes, and no serious mental limitations. Indeed, the record is over 500 pages long, includes medical visits running from January 2002 to February 2007, and includes testimony from a range of sources, including a vocational expert. There is no evidence that a crucial issue was undeveloped or that the evidence was insufficient to make an informed determination. The ALJ did not err by failing to recontact a treating physician. VI. CONCLUSION

For the reasons set forth above, it is the recommendation of the undersigned that the decision of the Commissioner of Social Security be a f f irmed under Sentence 4 of 42 U.S.C. § 405(g). Report and Recommendation. The failure to file The parties are timely written advised that they have ten days to file written objections to this objections may waive the right to appeal issues of fact.

/S/ David D. Noce UNITED STATES MAGISTRATE JUDGE

Signed on June 22, 2009.

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