Becker v. Social Security Administration

Filing 22

MEMORANDUM AND ORDER IT IS HEREBY ORDERED that Acting Commissioner of Social Security Carolyn W. Colvin is substituted for former Commissioner Michael J. Astrue as defendant in this cause. IT IS FURTHER ORDERED that, pursuant to sentence four of 42 U.S.C. § 405(g), the decision of the Commissioner is REVERSED, and this cause is REMANDED to the Commissioner for further proceedings consistent with this opinion. Because the current record does not conclusively demonstrate that plaintiff is entitled to benefits, it would be inappropriate for the Court to award plaintiff such benefits at this time. Judgment shall be entered accordingly. Signed by Magistrate Judge Frederick R. Buckles on 9/23/13. (KXS)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION
LORRIE BECKER,
Plaintiff,
v.
CAROLYN W. COLVIN, Acting
Commissioner of Social Security,1
Defendant.

)
)
)
)
)
)
)
)
)
)

No.

4:12CV82 FRB

MEMORANDUM AND ORDER
This cause is before the Court on plaintiff’s appeal of
an adverse ruling of the Social Security Administration.

All

matters are pending before the undersigned United States Magistrate
Judge, with consent of the parties, pursuant to 28 U.S.C. § 636(c).
I.

Procedural History

On November 25, 2009, plaintiff Lorrie J. Becker filed
applications for Disability Insurance Benefits pursuant to Title II
of the Social Security Act, 42 U.S.C. §§ 401, et seq., and for
Supplemental Security Income pursuant to Title XVI of the Act, 42
U.S.C. §§ 1381, et seq., in which she claimed she became disabled
on

January

1,

consideration,

2009.
the

(Tr.
Social

178-81,
Security

plaintiff's claims for benefits.

1

182-88.)

On

initial

Administration

denied

(Tr. 75, 76, 79-83.)

Upon

On February 14, 2013, Carolyn W. Colvin became the Acting
Commissioner of Social Security.
Pursuant to Fed. R. Civ. P.
25(d), Carolyn W. Colvin is therefore automatically substituted for
former Commissioner Michael J. Astrue as defendant in this cause of
action.

plaintiff’s request, hearings were held before an Administrative
Law Judge (ALJ) on May 31, 2011, and August 25, 2011, at which
plaintiff testified and was represented by counsel.
expert also testified at the hearings.

A vocational

(Tr. 25-54, 55-68.)

On

September 13, 2011, the ALJ denied plaintiff's claims for benefits,
finding plaintiff able to perform her past relevant work and,
alternatively, that plaintiff could perform other work as it exists
in significant numbers in the national economy.

(Tr. 9-20.)

On

November 16, 2011, the Appeals Council denied plaintiff's request
for

review

of

the

ALJ's

decision.

determination

thus

stands

as

Commissioner.

the

(Tr.
final

1-3.)

The

decision

ALJ's

of

the

42 U.S.C. § 405(g).

Plaintiff now seeks review of the Commissioner’s final
adverse determination arguing that the ALJ’s decision is not
supported

by

substantial

evidence

on

the

record

as

a

whole.

Specifically, plaintiff claims that the ALJ rendered inconsistent
conclusions regarding plaintiff’s severe impairments and erred by
failing to properly consider plaintiff’s chronic pain syndrome and
allegations of headaches and knee pain as severe impairments.
Plaintiff also claims that the ALJ failed to fully and fairly
develop the record in order to obtain medical evidence to support
a determination as to plaintiff’s residual functional capacity
(RFC).

Plaintiff asks the Court to reverse the decision of the

Commissioner and render a fully favorable decision, or remand the
matter for further proceedings.
-2-

Because the ALJ’s decision in this cause is not supported
by substantial evidence on the record as a whole, the matter should
be

reversed

and

remanded

to

the

Commissioner

for

further

proceedings.
II.
A.

Testimonial Evidence Before the ALJ

Hearing Held May 31, 2011
1.

Plaintiff’s Testimony
At the hearing on May 31, 2011, plaintiff testified in

response to questions posed by the ALJ.
At the time of the hearing, plaintiff was fifty-one years
of age.

Plaintiff lived in a home with her fiancé and three

grandchildren whose ages were six, eight and ten. Plaintiff earned
a GED, participated in vocational rehabilitation, received training
in electronics at a technical school, and attended a cosmetology
school.

(Tr. 58-59.)
Plaintiff’s Work History Report shows plaintiff to have

worked as a sorter at the United States Postal Service from 1994 to
1998.

From 1996 to 2005, plaintiff worked as a sales associate at

various retail stores.

From 2001 to 2006, plaintiff worked as a

merchandising and marketing clerk at various wholesalers.

From

August 2006 to October 2009, plaintiff worked as an office clerk at
various businesses.

(Tr. 238.)

Plaintiff testified that she cannot work on account of
her diagnosed conditions of fibromyalgia, Achilles tendinitis,
carpal tunnel, and bulging discs in her back and neck.
-3-

Plaintiff

reported that she takes pain medication but has not undergone any
surgery for her back or carpal tunnel conditions.

(Tr. 61.)

Plaintiff testified that her fiancé worked full time,
resulting in her sometimes being home alone with the grandchildren.
Plaintiff testified that her son comes to help clean the house and
care for the children four or five days a week.

(Tr. 58.)

Plaintiff testified that that she was unaware as to why
her medical records indicated a diagnosis of substance abuse.
Plaintiff testified that she did not abuse her pain medication.
(Tr. 61-62.)

The ALJ determined to postpone the hearing so that

additional evidence could be obtained and presented regarding
allegations of substance abuse.
2.

Testimony of Vocational Expert
Dr. Gerald Belchick, a vocational expert, testified at

the hearing in response to questions posed by the ALJ.
Dr. Belchick characterized plaintiff’s past work as a
merchandiser, office clerk, sales clerk, and sorter as light and
semi-skilled.

(Tr. 64-65.)

It was determined that no further

testimony would be obtained from Dr. Belchick until a supplemental
hearing at which additional testimony from plaintiff would be
adduced.
B.

Hearing Held on August 25, 2011
1.

Plaintiff’s Testimony
At

the

hearing

held

on

August

25,

2011,

plaintiff

testified in response to questions posed by the ALJ and counsel.
-4-

Plaintiff testified that she is the foster parent to her
three

grandchildren

Services.

as

determined

by

the

Division

of

Family

(Tr. 29.)
Plaintiff testified that caring for her grandchildren

causes her a lot of stress because such care is too exhausting for
her by herself.

Plaintiff testified that her son, fiancé and

mother help her care for the children, but that her fiancé cannot
be around the children when he is using drugs and her son cannot be
around

the

problems.

children

unsupervised

because

of

his

drug

abuse

(Tr. 33-35.)
Plaintiff testified that she was previously hospitalized

due to depression.
Plaintiff

(Tr. 53.)
testified

that

she

experiences

migraine

headaches two or three times a week and that such headaches usually
last one to two days but have sometimes lasted as long as a week.
Plaintiff testified that medication taken for the condition helps
most of the time, reducing her debilitation to only one day.
Plaintiff testified that she is able to function when she has mild
migraines.

Plaintiff testified that she has severe migraines two

or three times a month.
continues

to

care

for

(Tr. 39-40.)
her

Plaintiff testified that she

grandchildren

during

her

migraine

episodes and stays in bed while the children are at school.
Plaintiff testified that if she cannot care for her grandchildren,
she calls her fiancé home from work or her mother who lives a few
minutes away.

(Tr. 42.)
-5-

Plaintiff

testified

that

she

has

fibromyalgia

which

causes her to have constant chronic pain all over her body.
Plaintiff testified that she takes medication for the condition
which helps.

(Tr. 44.)

Plaintiff testified that she performs

physical therapy exercises.

(Tr. 38.)

Plaintiff testified that

she has disturbed sleep in that she awakens at least two or three
times a night.

Plaintiff testified that she must keep changing

positions while she sleeps.

(Tr. 45.)

As to her exertional abilities, plaintiff testified that
she can stand for half an hour and sit for three or fours hours as
long as she can change positions.
walk for about twenty minutes.

Plaintiff testified that she can

Plaintiff testified that she does

not engage in any lifting but could probably lift about fifteen
pounds.

(Tr. 38-39.)
As to her daily activities, plaintiff testified that she

wakes up at 4:30 or 5:00 a.m. to take her pain medication, and then
goes back to sleep until 6:30 a.m.

Plaintiff testified that she

then makes coffee, wakes the children and gives them cereal for
breakfast,

and

then

walks

them

to

the

bus

stop.

Plaintiff

testified that she then comes home and rests for about an hour.
(Tr. 33-34, 36.)

Plaintiff testified that she cares for her pets,

consisting of two dogs and five cats.
does laundry and some cooking.

Plaintiff testified that she

Plaintiff testified that she

attends church and some of her grandchildren’s school activities.
Plaintiff testified that her hobbies include gardening.
-6-

Plaintiff

testified that she drives.
2.

(Tr. 36-38.)

Testimony of Vocational Expert
Dr. Belchick testified in response to questions posed by

the ALJ and counsel.
Dr. Belchick characterized plaintiff’s past work as a
merchandiser, office clerk and sales clerk as light and semiskilled; as a sorter as unskilled, medium as actually performed but
light

as

generally

performed;

as

a

babysitter

as

medium

unskilled; and as a housekeeper as light and unskilled.

and

(Tr. 46-

48.)
The ALJ then asked Dr. Belchick to assume an individual
who was restricted to light work at the unskilled level to SVP 3;
that such a person could not work in a setting that includes
constant regular contact with the general public; and that such a
person should not perform work that includes more than infrequent
handling of customer complaints.

Dr. Belchick testified that such

a person could perform plaintiff’s past work as a merchandiser and
as a house cleaner.

Dr. Belchick testified that such a person

could

work

perform

dishwasher,

of

other
which

as

2,000

well,
such

such
jobs

as

kitchen

exist

helper/

locally

and

approximately 96,000 nationally; assembler, of which 2,200 such
jobs

exist

locally

and

approximately

370,000

nationally;

and

packager, of which 2,300 such jobs exist locally and approximately
210,000 nationally.

(Tr. 48-50.)

In response to questions posed by counsel, Dr. Belchick
-7-

testified that unexcused absences from work two or three days a
month is not an acceptable work practice and that employers would
not hire a person with such absences.
III.

(Tr. 51.)

Medical Records

On October 8, 2003, plaintiff was treated at Florissant
Lorazepam2 was prescribed.

Oaks for worsening anxiety.

(Tr. 701-

02.)
In August and October 2005, plaintiff visited Dr. Mark A.
Faron at Florissant Oaks with complaints of anxiety.
Lorazepam were prescribed.
In

November

Zoloft3 and

(Tr. 704-05.)

2006,

plaintiff

visited

Dr.

complaints of neck pain after having sustained a fall.

Faron

Plaintiff

was prescribed Cyclobenzaprine,4 Propoxyphene5 and ibuprofen.
708-09.)

with

(Tr.

In December 2006, plaintiff was referred for physical

therapy for neck pain and cervical spine dysfunction.

(Tr. 710-

11.)
2

Lorazepam (Ativan) is used to relieve anxiety. Medline Plus
(last revised Oct. 1, 2010)<http://www.nlm.nih.gov/medlineplus/
druginfo/meds/a682053.html>.
3

Zoloft is used to treat depression, panic attacks, and social
anxiety disorder.
Medline Plus (last revised Apr. 13, 2012)
<http://www.nlm.nih.gov/medlineplus/druginfo/meds/a697048.html>.
4

Cyclobenzaprine (Flexeril) is a muscle relaxant used to relax
muscles and relieve pain and discomfort caused by strains, sprains
and other muscle injuries.
Medline Plus (last revised Oct. 1,
2 0 1 0 ) < h t t p : / / w w w . n l m . nih.gov/me d l i n e p l u s / d r u g i n f o / m e d s /
a682514.html>.
5

Propoxyphene is used to relieve mild to moderate pain.
Medline
Plus
(last
reviewed
Feb.
1,
2011)<http://
www.nlm.nih.gov/medlineplus/druginfo/meds/a682325.html>.
-8-

Plaintiff visited Dr. Faron on March 6, 2007, for follow
up on anxiety.
her daughter.

Plaintiff reported increased stress on account of
Plaintiff was prescribed Lorazepam.

Plaintiff visited Dr. Faron on

(Tr. 718-19.)

June 25, 2007, with

complaints of pain in her back, neck and shoulder after having been
involved in a motor vehicle incident. Plaintiff was diagnosed with
muscle strain and was prescribed Cyclobenzaprine and ibuprofen.
(Tr. 722-23.)
Plaintiff returned to Dr. Faron on August 30, 2007, with
complaints of back pain radiating down the right leg.
reported that she engages in a lot of lifting.

Plaintiff

Straight leg

raising was positive on the right, and moderately reduced flexion
of the spine and pelvis was noted.

Plaintiff was diagnosed with

sciatica and was instructed to rest and apply heat to the affected
area.

Vicodin6 was prescribed.

(Tr. 726-27.)

Plaintiff continued to complain of sciatic pain to Dr.
Faron on September 11, 2007.

Plaintiff also reported that her

shoulders and left arm go numb.
and Cyclobenzaprine.

Plaintiff was prescribed Vicodin

(Tr. 728-30.)

An MRI of the lumbar spine taken September 21, 2007,
showed mild lumbar spondylosis.
Plaintiff

underwent

(Tr. 731.)
a

6

psychiatric

evaluation

at

The

Vicodin (hydrocodone) (also marketed under the brand name
Norco) is a narcotic used to relieve moderate to severe pain.
Medline Plus (last revised May 15, 2013)<http://www.nlm.nih.gov/
medlineplus/druginfo/meds/a601006.html>.
-9-

Counseling Center at St. John’s Mercy Health Care on January 7,
2008, upon referral by Dr. Faron.

Plaintiff reported to Dr. Arturo

C. Taca, Jr., that she had had panic disorder for about twenty
years.

Plaintiff

trouble sleeping,

reported

having

mood

swings,

irritability,

and sometimes talking too fast.

Plaintiff

reported having a lot of stress due to significant family issues.
Plaintiff’s current medications were noted to include Ativan,
Fioricet7

and

Albuterol.

plaintiff’s mood to
Otherwise,

be

examination

Mental

status

examination

showed

depressed and her affect constricted.
was

unremarkable.

Dr.

Taca

diagnosed

plaintiff with history of major depressive disorder, rule out
bipolar affective disorder.

A Global Assessment of Functioning

Score (GAF) score of 40 was assigned.8

Dr. Taca prescribed

Klonopin9 for plaintiff and referred her for psychotherapy.

(Tr.

695-96, 699.)
7

Fioricet is used to relieve tension headaches. Medline Plus
(last revised Aug. 15, 2013)<http://www.nlm.nih.gov/medlineplus/
druginfo/meds/a601009.html>.
8

A
GAF
score
considers
“psychological,
social,
and
occupational functioning on a hypothetical continuum of mental
health/illness.”
Diagnostic and Statistical Manual of Mental
Disorders, Text Revision 34 (4th ed. 2000). A GAF score of 31-40
indicates some impairment in reality testing or communication
(e.g., speech is at times illogical, obscure or irrelevant) or
major impairment in several areas, such as work or school, family
relations, judgment, thinking, or mood (e.g., depressed man avoids
friends, neglects family and is unable to work; child frequently
beats up younger children, is defiant at home and is failing at
school).
9

Klonopin (Clonazepam) is used to relieve panic attacks.
Medline Plus (last revised July 1, 2010)<http://www.nlm.nih.gov/
medlineplus/druginfo/meds/a682279.html>.
- 10 -

Plaintiff returned to Dr. Taca on January 21, 2008, and
reported a significantly improved mood upon taking Depakote.10
Mental

status

examination

was

unremarkable.

Plaintiff

was

diagnosed with history of major depressive disorder, rule out
bipolar disorder; and a GAF score of 40 was assigned.

Plaintiff

was instructed to continue with Klonopin and Depakote and was
referred for psychotherapy.

(Tr. 698.)

Plaintiff returned to Dr. Taca on February 11, 2008, and
reported that she was not doing well because of the recent loss of
her brother.
headaches.

Plaintiff also reported a recent onset of migraine
Upon examination, Dr. Taca diagnosed plaintiff with

history of major depressive disorder, rule out bipolar affective
disorder.

Plaintiff was assigned a GAF score of 40.

Plaintiff was

instructed to continue with Klonopin and Depakote and was referred
for psychotherapy.

(Tr. 697.)

Plaintiff was admitted to the emergency room at St.
John’s Mercy Medical Center on February 22, 2008, with complaints
of having a headache for three weeks.
migraine headaches was noted.

Plaintiff’s history of

Plaintiff reported being under

increased stress with the recent loss of her brother.
the head was normal.

A CT scan of

Plaintiff was given Toradol,11 Reglan12 and

10

Depakote is used to treat mania in persons with bipolar
disorder, and also to prevent migraine headaches.
Medline Plus
(last revised May 15, 2013)<http://www.nlm.nih.gov/medlineplus/
druginfo/meds/a682412.html>.
11

Plus

Toradol is used to relieve moderately severe pain. Medline
(last
revised
Oct.
1,
2010)<http://www.nlm.nih.gov/
- 11 -

morphine13 and was discharged that same date with reports that she
felt better.

Plaintiff’s medications upon discharge included

Percocet14 and Reglan.

(Tr. 466-82.)

Plaintiff visited Dr. Faron on

March 11, 2008, and

reported having headaches intermittently for about six weeks.

It

was noted that plaintiff was seeing a psychiatrist for anxiety
disorder.

Plaintiff’s current medications were noted to include

Topamax,15 Vicodin and Clonazepam.
continue with her medication.

Plaintiff was instructed to

(Tr. 738-39.)

An MRI of the brain and brain stem taken April 18, 2008,
in response to plaintiff’s complaints of migraine headaches yielded
normal results.
On

(Tr. 451.)

April

28,

2008,

plaintiff

visited

Dr.

Faron

complaining of having persistent, severe migraines for four months.
Plaintiff also reported a four-month history of insomnia for which

medlineplus/druginfo/meds/a693001.html>.
12

Reglan is used to relieve heartburn, nausea and vomiting.
Medline Plus (last reviewed Sept. 1, 2010)<http://www.nlm.nih.gov/
medlineplus/druginfo/meds/a684035.html>.
13

Morphine (MS Contin) is used to relieve moderate to severe
pain.
Medline
Plus
(last
revised
June
15,
2011)
<http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682133.html>.
14

Percocet (oxycodone) is a narcotic used to relieve moderate
to severe pain. Medline Plus (last revised Apr. 15, 2013)<http://
www.nlm.nih.gov/medlineplus/druginfo/meds/a682132.html>.
15

Topamax is used to prevent migraine headaches.
Medline
Plus
(last
revised
May
16,
2011)<http://www.nlm.nih.gov/
medlineplus/druginfo/meds/a697012.html>.
- 12 -

she had been prescribed Imipramine.16

Plaintiff was requesting

refills of Vicodin and Compazine17 inasmuch as she was going on
vacation and needed the medication for her headaches.

Physical

examination, including examination of the extremities, was normal.
Plaintiff was diagnosed with migraine headaches with associated
nausea and was prescribed hydrocodone and Compazine.

(Tr. 343.)

Plaintiff returned to Dr. Faron on June 2, 2008, and
complained

of

having

chest

pain

for

three

weeks.

Physical

examination, including examination of the extremities, was normal.
Plaintiff

was

diagnosed

with

migraine,

generalized

anxiety

disorder, and recurrent depression. Laboratory tests were ordered,
and Duloxetine18 was prescribed.

(Tr. 349-50.)

On June 23, 2008, plaintiff reported to Dr. Faron that
she did not tolerate Cymbalta.
received
diagnoses

any

psychiatric

were

noted

to

It was noted that plaintiff had not

care

recently.

include

allergic

Plaintiff’s

current

rhinitis,

asthma,

migraine, sciatica, headache, and generalized anxiety disorder.

16

Imipramine (Tofranil) is used to treat depression. Medline
Plus
(last
revised
Feb.
15,
2013)<http://www.nlm.nih.gov/
medlineplus/druginfo/meds/a682389.html>.
17

Compazine (Prochlorperazine) is used to control severe nausea
and vomiting, as well as to treat anxiety on a short-term basis.
Medline
Plus
(last
revised
May
16,
2011)<http://
www.nlm.nih.gov/medlineplus/druginfo/meds/a682116.html>.
18

Duloxetine (Cymbalta) is used to treat depression and
generalized anxiety disorder; pain caused by fibromyalgia; and
ongoing bone or muscle pain such as lower back pain or
osteoarthritis. Medline Plus (last revised Feb. 15, 2013)<http:
//www.nlm.nih.gov/medlineplus/druginfo/meds/a604030.html>.
- 13 -

Plaintiff denied any current chest pain.
unremarkable.
affect.

Physical examination was

Plaintiff was also noted to have normal mood and

Plaintiff was referred to psychiatry.

(Tr. 355-57.)

Plaintiff visited psychiatrist Dr. Steven Harvey on July
1,

2008,

and

reported

being

moody

and

having

crying

spells.

Plaintiff reported that she has had mood problems her entire life.
Plaintiff reported that she liked her job. Plaintiff reported that
she travels to Arizona to visit her boyfriend’s mother, and that
she likes to visit places.

Dr. Harvey noted plaintiff to be

pleasant and cooperative, with normal speech and logical flow of
thought.

Plaintiff denied hallucinations or delusions and had no

suicidal or assaultive ideations. Plaintiff was fully oriented and
had intact long term and short term memory.
be anxious, mostly euthymic and stable.
judgment were noted to be fair.

Plaintiff was noted to

Plaintiff’s insight and

Dr. Harvey diagnosed plaintiff

with bipolar disorder-mixed, and a GAF score of 65 was assigned.19
Dr.

Harvey

noted

plaintiff’s

current

medications

Klonopin, Imipramine and Cyclobenzaprine.

to

include

Dr. Harvey instructed

plaintiff to continue with her medications, and Lamictal20 was
19

A GAF score of 61 to 70 indicates some mild symptoms (e.g.,
depressed mood and mild insomnia) or some difficulty in social,
occupational or school functioning (e.g., occasional truancy, or
theft within the household), but generally functioning pretty well,
has some meaningful interpersonal relationships. Diagnostic and
Statistical Manual of Mental Disorders, Text Revision 34 (4th ed.
2000).
20

Lamictal is used to increase the time between episodes of
depression and mania in persons with bipolar disorder. Medline
Plus
(last
revised
Feb.
1,
2011)<http://www.nlm.nih.gov/
- 14 -

prescribed.

Therapy was considered.

return for follow up in three weeks.

Plaintiff was instructed to
(Tr. 566-68.)

On July 22, 2008, plaintiff reported to Dr. Harvey that
she did not start the Lamictal as prescribed but was feeling a lot
better and her mood was okay.

Plaintiff reported that she was

hesitant to start the Lamictal when she felt fine.

Plaintiff

reported that she continued to smoke marijuana and did not see a
problem with it.

Mental status examination was unremarkable.

Plaintiff was noted to be more euthymic and stable.

It was

determined that plaintiff would start Lamictal at a later time.
Dr.

Harvey

instructed

continued

in

plaintiff

to

his

diagnosis

stop

using

and

GAF

marijuana,

score
and

of

65,

further

instructed that plaintiff continue with her other medications.
(Tr. 564-65.)
Plaintiff returned to Dr. Faron on August 19, 2008, and
complained of having headaches and diarrhea associated with stress.
It was noted that plaintiff was scheduled to see her psychiatrist
on September 2, 2008.
and anxious.

Plaintiff reported being depressed, nervous

Plaintiff’s mood and affect were noted to be normal.

Plaintiff was diagnosed with gastroenteritis, asthma, generalized
anxiety disorder, and migraine.

It was noted that plaintiff’s

headaches could be related to stress, and plaintiff was instructed
to

discuss this with her psychiatrist.

Vicodin were prescribed.

(Tr. 363-65.)

medlineplus/druginfo/meds/a695007.html>.
- 15 -

Prochlorperazine and

Plaintiff returned to Dr. Harvey on September 2, 2008,
and reported that she was having problems and had been crying for
four days.

It was noted that plaintiff’s daughter continued to use

drugs and that plaintiff’s son had just been laid off.
status examination was unremarkable.
start Lamictal.

Mental

Plaintiff was instructed to

(Tr. 563.)

On September 8, 2008, plaintiff reported to Dr. Faron
that she had been experiencing bilateral ankle and foot pain for
six weeks, and intermittent left forearm pain for years.
noted

that

Lamictal.

plaintiff

had

seen

Dr.

Harvey

and

Physical examination was unremarkable.

was

It was

prescribed

Plaintiff was

referred to orthopedic surgery for evaluation of possible osteoarthritis.

(Tr. 371-73.)
Plaintiff visited Dr. Craig Aubuchon on September 25,

2008, with complaints of left knee pain and bilateral pain in the
ankles and across the midfoot. Plaintiff reported that her kneecap
gives out occasionally and that she sits most of the time at work
because of knee swelling and pain in her foot when she walks.
was

noted

that

plaintiff’s

medications

included

It

Clonazepam,

Imipramine, aspirin, Cyclobenzaprine, Lamictal, and Albuterol. Dr.
Aubuchon noted plaintiff’s medical history to include emphysema,
reflux,

irritable

bowel,

depression/bipolar,

thyroid

disease,

degenerative arthritis, and headaches. Physical examination showed
plaintiff to appear very healthy and to walk with a normal heel-totoe gait.

Slight tenderness and effusion were noted along the
- 16 -

lateral joint line of the left knee, with grinding noted upon range
of motion.

Tenderness was also noted over the patellar tendon.

Normal strength was noted along the hamstrings and quad.

No

swelling was noted about plaintiff’s ankles or feet, but tenderness
was noted along the tarsometatarsal joints.
about the heel cords as well.

Tenderness was noted

Sensation was intact.

X-rays of the

knee were unremarkable.

X-rays of the feet showed degenerative

changes of the midfeet.

Dr. Aubuchon diagnosed plaintiff with

Achilles tendinitis and chondromalacia of the left foot causing
effusion.

Plaintiff was instructed to participate in physical

therapy and to obtain orthotics to control her midfoot and lessen
the stress.
weeks.

Plaintiff was instructed to return in three to four

(Tr. 335-36.)
Plaintiff returned to Dr. Harvey on September 30, 2008,

who could not determine whether plaintiff was better.

Plaintiff

reported that it takes her three hours to leave the house because
of low energy and low motivation.

Plaintiff reported that she had

more anxiety and that her headaches were worsening.
reported being tired of the pain.

Plaintiff

Dr. Harvey continued in his

diagnosis of plaintiff and instructed her to continue on her
current medication regimen.

(Tr. 561-62.)

On October 16, 2008, plaintiff went to the emergency room
at St. John’s Mercy Medical Center with complaints of migraine
headaches with associated vomiting and chest pain. Plaintiff rated
her pain to be at a level ten on a scale of one to ten.
- 17 -

Plaintiff

was given Compazine, Benadryl and Dilaudid.21

Upon discharge,

plaintiff was prescribed Vicodin. Plaintiff was released to return
to work on October 19, 2008, with no restrictions.

(Tr. 483-99.)

Plaintiff returned to Dr. Aubuchon on October 23, 2008,
and complained of pain in her left shoulder radiating down the
forearm.

Plaintiff also complained of pain in the left greater

trochanter with discomfort and pain upon sitting and upon lying on
her left side.
months.

Plaintiff reported having such pain for several

Physical examination showed limited range of motion about

the left hip with tenderness over the greater trochanter.

No

swelling was noted, and plaintiff had normal strength about the hip
flexors.

Plaintiff had full range of motion about the shoulder

with no tenderness.

Positive impingement test was noted, however,

as well as weakness to supraspinatus testing.
range of motion about her elbow.

Plaintiff had full

X-rays of the left hip, arm and

forearm were normal. Dr. Aubuchon diagnosed plaintiff with rotator
cuff tendinitis over the left shoulder and bursitis of the left hip
over the greater trochanter.

Steroid injections of Depo-Medrol

were administered and plaintiff was instructed to return in one
month.

It was noted that plaintiff was participating in physical

therapy for her lower extremity.

(Tr. 334.)

On October 31, 2008, plaintiff reported to Dr. Harvey
that she was good and that things had improved over the previous
21

Dilaudid is a narcotic used to relieve moderate to severe
pain.
Medline Plus (last revised Aug. 15, 2013)<http://
www.nlm.nih.gov/medlineplus/druginfo/meds/a682013.html>.
- 18 -

couple of weeks.

Mental status examination was normal. Dr. Harvey

continued in his diagnosis of bipolar disorder-mixed and assigned
a new GAF score of 80.22

Plaintiff was instructed to continue with

her current medications and to return in four weeks for follow up.
(Tr. 560.)
Plaintiff returned to Dr. Aubuchon on November 20, 2008,
and complained of continued pain in her left hip and of pain in her
back.

Straight leg raising was positive bilaterally for radiating

pain.

Dr. Aubuchon noted limited range of motion with flexion and

extension.
ankles.

Plaintiff had diminished reflexes in the knees and

Sensation was intact.

noted to be nontender.

Dr. Aubuchon diagnosed plaintiff with back

pain suggestive of sciatica.
was prescribed.

Range of motion about the hips was

Physical therapy for the condition

(Tr. 333.)

On December 8, 2008, plaintiff visited Dr. Faron and
reported that she was participating in physical therapy for her
back. Physical examination was unremarkable. Plaintiff’s migraine
headaches were noted to be controlled with medication, and Vicodin
was prescribed.
controlled

Plaintiff’s asthma condition was also noted to be

with

medication.

Plaintiff

was

prescribed

Cyclobenzaprine for sciatica and was instructed to continue with
22

A GAF score of 71-80 indicates transient symptoms and
expectable reactions to psychosocial stressors (e.g., difficulty
concentrating after family argument) or no more than slight
impairment in social, occupational or school functioning (e.g.,
temporarily falling behind in schoolwork).
Diagnostic and
Statistical Manual of Mental Disorders, Text Revision 34 (4th ed.
2000).
- 19 -

physical therapy.

(Tr. 385-88.)

On December 18, 2008, plaintiff reported to Dr. Aubuchon
that she continued to have back pain and had right knee pain.

Dr.

Aubuchon noted plaintiff’s left shoulder pain to have improved
after the injection. Physical examination of the right knee showed
only slight tenderness over the medial joint line and grinding with
patellofemoral range of motion.

Dr. Aubuchon noted x-rays to show

a little medial joint space narrowing of the right knee.

Dr.

Aubuchon opined that plaintiff may have a degenerative meniscal
tear suggestive of chondromalacia.

Dr. Aubuchon ordered an MRI of

plaintiff’s knee and instructed plaintiff to continue with physical
therapy for her back and shoulder.

Vicodin was prescribed.

(Tr.

332.)
On January 8, 2009, Dr. Aubuchon noted the recent MRI to
show a bucket handle tear of the medial meniscus.

Physical

examination showed significant tenderness at the medial joint line
with a reproduction of symptoms with McMurray’s test.

Plaintiff

had normal strength of the quads and hamstrings and walked with a
normal gait.

Surgical repair by medial arthroscopy was planned.

(Tr. 331.)
Plaintiff visited Dr. Harvey on January 20, 2009, and
reported that she was doing okay.
run out of her medications.

It was noted that plaintiff had

Mental status examination was normal.

Dr. Harvey continued in his diagnosis of bipolar disorder-mixed and
continued his GAF score of 80.

Plaintiff was instructed to restart
- 20 -

her medications and to continue with Lamictal.

(Tr. 559.)

On March 5, 2009, Dr. Aubuchon noted plaintiff to be ten
days post-op.

Examination showed plaintiff able to obtain almost

full extension of the right knee.
stable.

The knee was noted to feel

Physical therapy was ordered.

An x-ray of the right knee

taken that same date showed good cartilage height at both the
medial and lateral joint lines.

(Tr. 329, 330.)

On March 26,

2009, plaintiff reported continued improvement with her right knee
but requested additional pain medication.
noted

about

the

medial

joint

line,

patellofemoral range of motion.
present.

with

no

crepitus

upon

Slight effusion was noted to be

Plaintiff also reported being under a marked amount of

stress due to family issues.
and

Mild tenderness was

plaintiff

treatment.

was

A refill of pain medication was given

instructed

as

to

continued

rehabilitative

(Tr. 328.)
On

plaintiff.

April

14,

(Tr. 327.)

2009,

Darvocet23

was

prescribed

for

On April 15, 2009, plaintiff reported to

Dr. Aubuchon’s office that Darvocet did not control her pain.
Norco was prescribed.

(Tr. 326.)

On April 21, 2009, plaintiff reported to Dr. Aubuchon
that

she

had

chronic

back

pain

which

awakens

her

at

night.

Plaintiff complained of knee pain, aggravated by stepping in a
hole.

Examination showed slight effusion and diffuse tenderness

23

Darvocet is used to relieve mild to moderate pain. Medline
Plus
(last
revised
Mar.
16,
2011)<http://www.nlm.nih.gov/
medlineplus/druginfo/meds/a601008.html>.
- 21 -

about the right knee.

A steroid injection of Depo-Medrol was

administered to the knee. Plaintiff requested pain medication, and
her prescription for Vicodin was renewed.

(Tr. 325.)

On April 21, 2009, plaintiff visited Dr. Daniel Sohn at
Mid County Orthopaedic Surgery and Sports Medicine upon referral
from Dr. Aubuchon.

Plaintiff complained of severe back, neck,

shoulder, and arm pain.

Physical examination showed plaintiff’s

stance, gait and position changes to be normal.
limited

range

of

motion

about

the

back

due

Plaintiff had
to

stiffness.

Tenderness to palpation was noted along the left L-4 spinous
process and in the left gluteus muscle.

Lower extremity strength

was intact, and straight leg raising was negative.

Dr. Sohn

diagnosed plaintiff with low back pain related to facet irritation
and left gluteal myofascial pain.

Plaintiff was prescribed Soma24

and Mobic25 and was instructed to remain active with her usual
activities.

(Tr. 689-90.)

Plaintiff returned to Dr. Faron on April 23, 2009, with
complaints

relating

to

acute

bronchitis.

It

was

noted

that

plaintiff was seeing Dr. Sohn for pain management and Dr. Aubuchon
for orthopaedic issues.

No other complaints were noted. (Tr. 394-

24

Soma is a muscle relaxant used to relax muscles and relieve
pain and discomfort caused by strains, sprains and other muscle
injuries.
Medline Plus (last reviewed Aug. 1, 2010)<http://
www.nlm.nih.gov/medlineplus/druginfo/meds/a682578.html>.
25

Mobic is used to relieve pain, tenderness, swelling, and
stiffness caused by osteoarthritis and rheumatoid arthritis.
Medline
Plus
(last
reviewed
Sept.
1,
2010)<http://
www.nlm.nih.gov/medlineplus/druginfo/meds/a601242.html>.
- 22 -

96.)
On

May

27

and

June

8,

2009,

plaintiff’s prescription for Vicodin.

Dr.

Aubuchon

refilled

(Tr. 323, 324.)

On June 1, 2009, plaintiff returned to Dr. Faron with
complaints relating to acute sinusitis and nausea.
complaints were reported.
8,

2009,

it

was

noted

(Tr. 402-03.)
that

conditions were controlled.

No other

During follow up on June

plaintiff’s

migraine

and

asthma

Plaintiff was instructed to follow up

with psychiatry regarding generalized anxiety disorder.

(Tr. 408-

10.)
During

follow

up

examination

on

June

Aubuchon noted plaintiff to be doing pretty well.

9,

2009,

Dr.

Plaintiff was

instructed to continue with her exercises and to return on an as
needed basis.

(Tr. 322.)

A bone density scan performed June 12, 2009, yielded
normal results.
On

(Tr. 411-12.)

June

17,

2009,

plaintiff

visited

Dr.

Sohn

with

complaints of longstanding pain in her back, neck and shoulder.
Plaintiff reported having poor sleep because of her low back pain.
Plaintiff reported having taken Vicodin for her pain, which was
prescribed by Dr. Aubuchon for her knees, but that she no longer
sees

Dr.

Aubuchon

because

of

her

resolved

knee

condition.

Plaintiff reported that she currently takes Mobic and that taking
Soma did not really help her pain.
limited

range

of

motion.

Examination of the back showed

Tenderness
- 23 -

to

palpation

was

noted

diffusely about the low back, shoulder girdle, neck, elbows, and
knees.

Plaintiff also reported upper extremity numbness

tingling in her hands.

and

Results of nerve conduction studies were

consistent with mild left carpal tunnel syndrome.

Dr. Sohn noted

plaintiff’s diffuse muscle pain to be consistent with fibromyalgia.
Flexeril was prescribed. Plaintiff was instructed to continue with
physical therapy for her neck, shoulder girdle and back; and a
referral was made for carpal tunnel syndrome.

(Tr. 321.)

On July 7, 2009, plaintiff visited Dr. David W. Strege
upon

referral

syndrome.

for

her

complaints

relating

to

carpal

tunnel

Plaintiff complained of intermittent pain and numbness

in the hands, wrists and forearms. Plaintiff reported that wearing
wrist splints did not help the condition.

Dr. Strege noted

plaintiff’s past medical history to include anxiety, depression,
bipolar disorder, and low back problems.

It was also noted that

plaintiff had recently been diagnosed with fibromyalgia.

Upon

physical examination, Dr. Strege determined that plaintiff had
symptoms consistent with mild left carpal tunnel syndrome but noted
that such symptoms were not overly impressive.

Dr. Strege also

opined

resulting

that

plaintiff’s

fibromyalgia.
administered

An
to

symptoms

injection

the

left

of

carpal

could

be

from

Celestone

and

Lidocaine

was

tunnel,

and

plaintiff

was

instructed to return for follow up in four weeks.

(Tr. 319-20.)

Plaintiff returned to Dr. Harvey on July 7, 2009, who
noted plaintiff’s mood to be a lot more stable. Plaintiff reported
- 24 -

that she cries a lot because she is in so much pain.

Mental status

examination was unremarkable. Plaintiff was instructed to continue
with her current medications and to return in three months for
follow up.

Participation in psychotherapy was recommended.

(Tr.

558.)
On July 12, 2009, plaintiff went to the emergency room at
St. John’s with complaints of migraine headaches and of pain in her
back and neck. Plaintiff reported having taken her last Vicodin in
the morning and that her doctor had not yet provided a new
prescription.

Plaintiff was given Toradol, Compazine, Reglan, and

Dilaudid and was discharged that same date. Vicodin was prescribed
upon discharge.

(Tr. 500-15.)

Plaintiff returned to Dr. Faron on July 13, 2009, and
reported that she went to the emergency room the previous evening
due to migraine headaches.
over and was frustrated.

Plaintiff reported that she hurt all
Plaintiff also reported that she was

depressed and that she was instructed by her psychiatrist to
restart Imipramine.

Plaintiff reported having radiating pain in

her hips, back and legs as well as pain in her ankles and heels.
It

was

noted

syndrome.

that

plaintiff

wore

splints

for

carpal

tunnel

Examination of the musculoskeletal system showed no

point tenderness or edema.

Plaintiff was noted to be seeing Dr.

Sohn for sciatica and Dr. Harvey for major depression. Plaintiff’s
symptoms of arthralgia were opined to be related to her depression,
and plaintiff was encouraged to follow up with Dr. Harvey.
- 25 -

(Tr.

420-21.)
On September 2, 2009, plaintiff visited Florissant Oaks
and reported having had moderate migraine headaches for three or
four days.

Plaintiff reported that hydrocodone was the only

medication that helped her condition.

Plaintiff reported being

unhappy with her pain management physician and that she was not
going to see him anymore.

Physical examination was unremarkable.

Plaintiff refused prescriptions for Medrol DosePack and Tramadol,
stating that the medications did not work.
to

continue

with

pain

management.

A

Plaintiff was advised
possible

referral

to

rheumatology was considered as well as possible re-evaluation by a
neurologist,

but

plaintiff

expressed

concern

regarding

Plaintiff was instructed to follow up in December.

costs.

(Tr. 426-27.)

On September 17, 2009, plaintiff reported to Dr. Harvey
that she was under a lot of stress.

Plaintiff reported that she

had been doing pretty well but that her daughter was leaving soon
to go to prison.

Dr. Harvey instructed plaintiff to increase her

dosage of Klonopin and to continue with her other medications as
prescribed.

Plaintiff was assigned a GAF score of 70 and was

instructed to return in six weeks for follow up.
psychotherapy was recommended.

Participation in

(Tr. 556-57.)

Plaintiff visited Dr. Gary Gray from Dunn Physician
Offices

on

September

22,

widespread pain syndrome.
diagnosis

and

opined

2009,

who

noted

plaintiff

to

have

Dr. Gray noted there to be no clear

that

her
- 26 -

condition

was

most

likely

fibromyalgia syndrome.

Plaintiff currently complained of problems

with her hands and feet.

Dr. Gray noted plaintiff’s routine

doctor’s visits to yield normal examinations.
examination
sciatica

was

and

prescribed.

unremarkable.

fibromyalgia,

Plaintiff

and

ibuprofen

Current physical

was

diagnosed

with

Lyrica26

were

and

(Tr. 544-49.)

Plaintiff returned to Dr. Gray on October 9, 2009, with
complaints of back pain radiating to the side and hips, muscle
pain, and foot and ankle pain.

Plaintiff reported ibuprofen and

Darvocet not to help, but that hydrocodone helped.

Dr. Gray

prescribed hydrocodone for plaintiff, noting the medication to be
effective and to be prescribed in good faith to treat a chronic
pain condition.

(Tr. 551-52.)

On October 28, 2009, plaintiff was admitted to the
emergency room at St. John’s after having cut her finger on a
glass.

Plaintiff also complained of pain all the way up her arm

with passive motion.
tendon injury.

It was questioned whether there was possible

Plaintiff’s current medications were noted to

include Percocet, Vicodin, Flexeril, Motrin, Klonopin, Lamictal,
and Tofranil. Physical examination showed plaintiff’s left hand to
have

decreased

range

of

motion

and

tenderness

as

well

as

laceration, but plaintiff was observed to exhibit normal two-point
discrimination, normal capillary refill, no deformity, no swelling,
26

Lyrica is used to relieve neuropathic pain and fibromyalgia.
Medline Plus (last revised Sept. 1, 2009)<http://www.nlm.nih.gov/
medlineplus/druginfo/meds/a605045.html>.
- 27 -

and normal sensation.

Plaintiff requested that she be given

Percocet, stating that Vicodin did not help her pain.

Plaintiff’s

finger was stitched and plaintiff was discharged that same date.
(Tr. 441-49.)
On October 30, 2009, plaintiff continued to complain of
pain

and

immobility

in

her

left

finger.

scheduled surgery for the following week.

Dr.

Michael

Smock

(Tr. 517.)

Plaintiff visited Dr. Gray on November 6, 2009, with
complaints of back pain and ankle/foot pain.

Plaintiff reported

that hydrocodone was only minimally helpful but that oxycodone
taken post-surgery seemed to provide some relief.

It was noted

that plaintiff’s asthma condition appeared stable.

Plaintiff was

instructed to follow up with Dr. Sohn to explore other long-term
medication options regarding her chronic pain. Dr. Gray noted that
all options he was comfortable with prescribing had been exhausted.
(Tr. 529-33.)
On November 13, 2009, Dr. Smock noted plaintiff’s left
finger condition to be consistent with rupture of both flexor
tendons.

Additional surgery was scheduled.
On November 20, 2009, Dr.

complain of increased pain.
little red and swollen.
refilled.

(Tr. 520.)

(Tr. 519.)

Smock noted plaintiff to

Plaintiff’s finger was noted to be a

Plaintiff’s prescription for Percocet was
On November 23, 2009, plaintiff complained

to Dr. Smock of severe pain.

Mild swelling was noted.

was instructed to follow up with hand therapy.
- 28 -

Plaintiff

(Tr. 518.)

On

November 24, 2009, Dr. Smock noted the swelling to have improved
and that plaintiff’s finger looked okay.

Noting plaintiff to take

about eight Percocet a day, plaintiff’s prescription for Percocet
was refilled.

(Tr. 521.)

Plaintiff returned to Dr. Smock on December 1, 2009, and
continued to complain of severe pain.

It was noted that plaintiff

had not yet undergone hand therapy as prescribed.

Plaintiff also

reported that she had severe shoulder and knee pain after having
sustained a fall.
refilled.

Plaintiff’s prescription for Percocet was

(Tr. 522.)
Plaintiff visited Dr. Gray on December 2, 2009, and

complained of pain in her neck, wrist and back after having
slipped.

Plaintiff reported that Dr. Sohn had nothing left to

offer her but more physical therapy for her chronic pain.

It was

noted that there was no clear etiology for plaintiff’s chronic pain
syndrome.

(Tr. 536-37.)

Dr. Gary concluded:

I am not willing to provide more potent
narcotics as this is deferred to her pain
management doctor. She is planning to pursue
disability. I feel she meets criteria from a
psychiatric standpoint. I don’t think she is
emotionally
[c]apable
of
any
meaningful
employment. I cannot in good faith give more
potent pain treatment as there is NOTHING to
support an organic [c]ause of her chronic
pain. She certainly may have acute pain from
the fall warranting short term disability, but
she is on appropriate narcotic therapy from
her hand surgeon.
(Tr. 537.)

- 29 -

Plaintiff visited St. John’s Mercy Sports & Therapy on
December 8, 2009, for initial evaluation regarding hand therapy.
It was determined that plaintiff would participate in therapy three
times a week for four weeks.

(Tr. 686-87.)

Plaintiff returned to Dr. Harvey on December 10, 2009,
who noted plaintiff to have a lot of stressors, including her
daughter being in prison, her alcoholic son having recently been
involved in a motor vehicle accident, her recent tendon injury, and
her anticipated loss of insurance.

Dr. Harvey noted plaintiff to

be doing better with mood stabilizers but opined that plaintiff
needed therapy. Plaintiff was instructed to continue with her same
medication and to return in two months.

It was noted that a

therapist would be sought out once plaintiff’s insurance status was
known.

(Tr. 555.)
Plaintiff visited Dr. Gray on December 24, 2009, who

noted plaintiff to be a chronic pain sufferer with complaints of
neck pain, low back pain, and generalized fibromyalgia-type pain.
It was noted that plaintiff had seen a number of specialists and
had tried a number of medications, all of which were unsuccessful
in relieving her pain.

Dr. Gray noted plaintiff to be desperate

and pleading for someone to help her.

Physical examination showed

tenderness to palpation along paraspinal muscles but was otherwise
unremarkable.

Plaintiff was observed to be in mild distress.

Dr.

Gray diagnosed plaintiff with cervicalgia, lumbar spondylosis and

- 30 -

migraine headaches and prescribed MS Contin, Percocet and Maxalt.27
(Tr. 680-85.)
Plaintiff visited Dr. Gray on February 4, 2010, for
follow up on pain management.

Dr. Gray noted plaintiff to have

chronic neck/back/arm/leg pain and fibromyalgia-type syndrome of
unclear etiology, but that plaintiff’s current medications have
been very effective and have provided plaintiff the best quality of
life that she has had in quite some time.

Plaintiff’s current

medications were noted to include MS Contin, Percocet, Maxalt,
Lamictal, Tofranil, Motrin, and Klonopin. Dr. Gray noted plaintiff
to be more calm, comfortable and pleasant than ever before.

Dr.

Gray described plaintiff as a “new person,” having obtained clear
benefit from a more potent and reasonable pain management regimen.
Plaintiff was instructed to continue on her current medications and
to return in one month for follow up.

(Tr. 674-79.)

An x-ray of plaintiff’s chest taken February 4, 2010,
yielded normal results.

A pulmonary function test performed that

same date in response to plaintiff’s complaints of shortness of
breath yielded essentially normal results, with evidence of a
minimal obstructive ventilatory defect with a moderate diffusion
abnormality.

(Tr. 574, 575.)

On March 15, 2010, plaintiff visited Dunn Physician
Offices after having been involved in a motor vehicle accident
27

Maxalt is used to treat the symptoms of migraine headaches.
Medline Plus (last reviewed Sept. 1, 2010)<http://www.nlm.nih.gov/
medlineplus/druginfo/meds/a601109.html>.
- 31 -

three days prior.

Plaintiff complained of hip and back pain.

was noted that plaintiff walked with a cane.

It

It was noted that

plaintiff had pre-existing pain issues with fibromyalgia and was
chronically

taking

MS

Contin

with

some

Percocet.

Physical

examination currently showed limited range of motion about the hip
due to pain.

Plaintiff was diagnosed with chronic pain disorder

with fibromyalgia, requiring high potency narcotics; and worsening
right hip and back pain due to a recent motor vehicle accident.
Plaintiff was instructed to temporarily increase her dosage of
Percocet due to her recent injury.

(Tr. 666.)

On April 27, 2010, plaintiff visited Dr. Harvey and
reported that her daughter had recently passed away due to acute
morphine intoxication. Plaintiff was noted to be very sad and very
depressed.

Plaintiff reported that she was off of all of her

medications except for Klonopin.
normal.

Mental status examination was

Plaintiff was instructed to continue with Klonopin and to

restart Lamictal. Plaintiff was also instructed to restart therapy
soon.

A GAF score of 70 was assigned.

(Tr. 582.)

Plaintiff visited Dunn Physician Offices on April 6,
2010, for follow up of low back pain and hip pain related to the
motor vehicle accident.
back.

Tenderness was noted about the lumbar

Percocet and Compazine were prescribed, and plaintiff was

referred to physical therapy.

(Tr. 662-63.)

Plaintiff visited Dunn Physician Offices on May 3, 2010,
and complained of arm tingling and numbness relating to the motor
- 32 -

vehicle accident.
and leg pain.

Plaintiff also complained of increased low back

It was noted that plaintiff was leaving for a trip

to Arizona to help her boyfriend “take care of things” after the
death of his mother.

Plaintiff requested an increase in her pain

medications.

Tenderness was noted along the neck to the shoulders

bilaterally.

Plaintiff was also noted to have a limping gait.

An

MRI of the cervical spine was ordered, and a referral to physical
therapy

was

made.

Lamictal

and

Compazine

were

prescribed.

Plaintiff was instructed to continue with her current dose of MS
Contin and was advised to increase her Percocet if necessary during
the trip.

(Tr. 653-54.)
On May 13, 2010, Stanley Hutson, Ph.D., a psychological

consultant with disability determinations, completed a Psychiatric
Review Technique Form (PRTF) in which he opined that plaintiff’s
bipolar disorder resulted in mild restrictions of plaintiff’s daily
activities,

and

moderate

difficulties

in

maintaining

social

functioning and in maintaining concentration, persistence or pace.
(Tr. 583-94.) In a Mental RFC Assessment completed that same date,
Dr. Hutson opined that plaintiff had no significant limitations in
the domain of Understanding and Memory. In the domain of Sustained
Concentration and Persistence, Dr. Hutson opined that plaintiff was
moderately

limited

in

her

ability

to

maintain

attention

and

concentration for extended periods, in her ability to work in
coordination with or proximity to others without being distracted
by them, and in her ability to complete a normal workday and
- 33 -

workweek without psychologically-based interruptions, but otherwise
was

not

significantly

Interaction,
limited

in

Dr.
her

limited.

Hutson

opined

ability

to

In
that

accept

the

domain

plaintiff

of

was

instructions

Social

moderately

and

respond

appropriately to criticism from supervisors, and in her ability to
get along with coworkers or peers without distracting them or
exhibiting behavioral extremes, but otherwise had no significant
limitations.

Finally, in the domain of Adaptation, Dr. Hutson

opined that plaintiff was moderately limited in her ability to
respond appropriately to changes in the work setting, but otherwise
was not significantly limited. (Tr. 595-97.) Dr. Hutson concluded
that

plaintiff

instructions.

had

“the

ability

to

understand

and

remember

She can remember work procedures and can follow

instructions to complete fairly complex activities. She could cope
with a low stress work setting that has few social demands.”

(Tr.

597.)
On June 7, 2010, plaintiff reported to Dr. Gray that she
obtained
protocol.

extensive

relief

with

the

current

pain

management

Dr. Gray noted the pain medication to be effective.

Medrol Dosepack28 and Percocet were prescribed.

(Tr. 646.)

On July 19, 2010, plaintiff reported to Dr. Gray that she
had rib pain and limited range of motion about the left shoulder as

28

Medrol is used to relieve inflammation and to treat certain
forms of arthritis and asthma. Medline Plus (last reviewed Sept.
1,
2010)<http://www.nlm.nih.gov/medlineplus/druginfo/meds/
a682795.html>.
- 34 -

the result of a recent fall, and that her current pain medication
did

not

control

prescribed.

the

related

pain.

Motrin

and

Medrol

were

(Tr. 642.)

Plaintiff visited Dr. Gray on October 14, 2010, who noted
plaintiff to be living with her fiancé and three grandchildren. It
was noted that the children were struggling emotionally with the
recent death of their mother, were undergoing counseling, and
acting out.

It was also noted that they were doing well in school.

Plaintiff reported her symptoms of depression and anxiety to have
worsened since she stopped taking Lamictal, but that she was
scheduled to see Dr. Kabir that day.

Plaintiff also reported the

chronic pain in her legs to continue and that she could stand for
about fifteen minutes.

It was noted that there had been some

improvement in the symptoms.
Gray

diagnosed

plaintiff

Examination was unremarkable.
with

leg

pain,

cervicalgia

fibromyalgia and prescribed MS Contin and Percocet.

Dr.
and

(Tr. 636.)

Plaintiff visited Dunn Physician Offices on October 26,
2010, and complained of migraines, worsening aches in her joints
and muscles, fatigue, and bruising.

Plaintiff’s prescription for

Flexeril was refilled, and Prednisone was prescribed.
tests were ordered.

Laboratory

(Tr. 623-24.)

On November 22, 2010, plaintiff visited Multi-Specialty
Mental

Health

Service

(MMHS)

for

a

psychiatric

evaluation.

Plaintiff reported being more angry during the previous eight
months, having lost her daughter to overdose. No learning disorder
- 35 -

or

other

sign

of

mental

or

physical

disorder

was

observed.

Plaintiff was noted to be taking Lamictal and Klonopin.

It was

noted that plaintiff had had a physical examination within the past
year and that everything was okay.

It was noted that plaintiff was

taking Percocet. As to her social history, plaintiff reported that
she takes care of kids, goes out, and had a best friend who died.
Mental status examination showed plaintiff to have a cooperative
attitude but to speak fast and angrily.

Plaintiff’s mood was noted

to be angry, frustrated and irritable, and her affect was broad.
Plaintiff’s thought processes, memory and judgment were noted to be
fair. Plaintiff’s concentration and insight were noted to be poor.
Plaintiff was considered to have average intellect.

Plaintiff was

diagnosed with bipolar disorder-depressed-moderate and was assigned
a GAF score of 60.29

It was recommended that plaintiff participate

in cognitive behavioral therapy.
On
regarding

November

her

23,

generalized

(Tr. 753-756.)

2010,

plaintiff

visited

pain/fibromyalgia.

Dr.

Dr.
Gray

Gray
noted

plaintiff’s quality of life to have clearly improved with the
treatment

plan.

effective.
Examination

It

was

Plaintiff
was

noted

denied

that
any

unremarkable.

29

the

pain

symptoms

Plaintiff

was

medication
of

was

depression.

diagnosed

with

A GAF score of 51 to 60 indicates moderate symptoms (e.g.,
flat affect and circumstantial speech, occasional panic attacks) or
moderate difficulty in social, occupational or school functioning
(e.g., few friends, conflicts with peers or co-workers).
Diagnostic and Statistical Manual of Mental Disorders, Text
Revision 34 (4th ed. 2000).
- 36 -

generalized anxiety disorder, cervicalgia and fibromyalgia and was
instructed to continue on the current treatment plan.

(Tr. 617.)

Plaintiff returned to MMHS on November 30, 2010, for
therapy.

It was noted that plaintiff’s mood, sleep, and thought

processes were fair.
energy.

Plaintiff reported having no motivation or

Plaintiff was instructed to return in two months.

(Tr.

757.)
Plaintiff visited Dr. Gray on February 23, 2011, who
noted plaintiff’s back pain to be a chronic, intermittent problem
but that effective narcotic pain medication provided good results
and improved plaintiff’s quality of life.

Dr. Gray also noted that

plaintiff tolerated the medication for her headache condition and
experienced no side effects.

Plaintiff’s anxiety was noted to be

stable without the use of Clonazepam.

(Tr. 606-07.)

Plaintiff visited Dr. Marketa Kasalova at Dunn Physician
Offices on March 28, 2011, with complaints of jaw pain after a
dental extraction.
was

noted

that

Plaintiff also reported having headaches.

plaintiff

had

been

diagnosed

with

leg

It

pain,

cervicalgia, fibromyalgia, and dental pain — all for which she was
prescribed Percocet.

(Tr. 599-603, 767-68.)

Plaintiff visited Dr. Kasalova on June 6, 2011, with
complaints of worsening low back pain and neck pain.
reported the pain to radiate into her legs.
reported

numbness

in

her

headaches or chest pain.

left

arm.

Plaintiff

Plaintiff

Plaintiff also
denied

having

Physical examination was unremarkable.
- 37 -

Plaintiff had normal range of motion about the neck. Plaintiff was
diagnosed

with

cervicalgia,

sciatica,

spondylosis, leg pain, and dental pain.

fibromyalgia,

lumbar

Percocet and MS Contin

were prescribed, and plaintiff was referred for physical therapy.
(Tr. 764-65, 780-82.)
On June 7, 2011, plaintiff visited Claire Oglander, MSW,
LCSW, at Catholic Family Services.
score of 60.

(Tr. 793.)

Plaintiff was assigned a GAF

On June 14, 2011, plaintiff failed to

appear for a scheduled appointment with Ms. Oglander.

(Tr. 792.)

On June 20, 2011, plaintiff reported to Ms. Oglander that
her body ached and she was tired all of the time.

Plaintiff

expressed anger, and Ms. Oglander noted plaintiff to be stressed
and overwhelmed. Ms. Oglander continued plaintiff in her GAF score
of 60.

(Tr. 791.)

Plaintiff returned to Ms. Oglander on June 27,

2011, who noted plaintiff not to be making any improvement.

(Tr.

790.)
On

July

20,

2011,

plaintiff

appointment with Ms. Oglander.
Oglander

noted

plaintiff

(Tr. 789.)

not

to

be

Plaintiff’s GAF score remained at 60.

cancelled

a

scheduled

On July 27, 2011, Ms.

making

any

improvement.

(Tr. 788.)

On August 3 and August 10, 2011, Ms. Oglander noted
plaintiff to be making slight improvement.
her GAF score of 60.

Plaintiff continued in

(Tr. 787.)

On August 17, 2011, plaintiff reported to Ms. Oglander
that she felt overwhelmed and scared.
- 38 -

Plaintiff reported that she

could not perform simple housekeeping and that she had no help.
Plaintiff was noted to continue to make slight improvement.

(Tr.

785.)
In a letter addressed to “To Whom it May Concern” dated
August 23, 2011, Ms. Oglander wrote:
It is my professional opinion that any work
Ms. Becker engages in may have a deleterious
effect on her mental health.
Ms. Becker’s
physical limitations, coupled with the stress
she is experiencing raising three young
grandchildren due to the sudden death of her
daughter, may overwhelm Ms. Becker.
Ms.
Becker currently suffers from depression and
anxiety and more stress may exacerbate her
mental condition.
(Tr. 784.)
In a letter addressed to “To Whom it May Concern” dated
August 23, 2011, Dr. Kasalova wrote that plaintiff “has not had any
medical evaluation or treatment for substance abuse” and that the
diagnosis of such had been removed from her record.
IV.

(Tr. 759.)

ALJ’s Decision

The ALJ found plaintiff

to meet the insured status

requirements of the Social Security Act through December 31, 2014.
The ALJ found that plaintiff had not engaged in substantial gainful
activity since the alleged onset date, January 1, 2009.

The ALJ

found plaintiff’s possible left-side carpal tunnel syndrome, lumbar
spondylosis, cervical disc bulging, obstructive ventilatory defect,
allegations of headaches and knee pain, and bipolar affective

- 39 -

disorder to constitute severe impairments, but that plaintiff did
not have an impairment or combination of impairments which met or
medically equaled an impairment listed in 20 C.F.R., Part 404,
Subpart P, Appendix 1.

(Tr. 9-13.)

The ALJ found plaintiff to

have the RFC to
occasionally lift 20 pounds, frequently lift
10 pounds, sit or stand six hours out of an
eight-hour work day, and stand six hours out
of an eight-hour work day. The claimant is
able to understand, remember, and carry out at
least simple instructions and non-detailed
tasks up to and including semi-skilled work at
the specific vocational preference [SVP] level
of three. Additionally, the claimant should
not work in a setting which includes constant/
regular contact with the general public and
should not perform work which includes more
than
infrequent
handling
of
customer
complaints.
(Tr. 13.)
The ALJ found plaintiff able to perform her past relevant work as
a merchandiser and house cleaner.

The ALJ also determined that,

considering plaintiff’s age, education, work experience, and RFC,
vocational expert testimony supported an alternative finding that
plaintiff was able to perform other work as it exists in the
national
packager.

economy,

and

specifically,

dishwasher,

assembler

and

The ALJ thus determined plaintiff not to be under a

disability at any time from January 1, 2009, through the date of
the decision.

(Tr. 13-20.)

- 40 -

V.

Discussion

To be eligible for Social Security Disability Insurance
Benefits and Supplemental Security Income under the Social Security
Act, plaintiff must prove that she is disabled.

Pearsall v.

Massanari, 274 F.3d 1211, 1217 (8th Cir. 2001); Baker v. Secretary
of Health & Human Servs., 955 F.2d 552, 555 (8th Cir. 1992).

The

Social Security Act defines disability as the "inability to engage
in any substantial gainful activity by reason of any medically
determinable physical or mental impairment which can be expected to
result in death or which has lasted or can be expected to last for
a continuous period of not less than 12 months."
423(d)(1)(A), 1382c(a)(3)(A).
disabled

"only

if

[her]

42 U.S.C. §§

An individual will be declared

physical

or

mental

impairment

or

impairments are of such severity that [she] is not only unable to
do

[her]

previous

education,

and

work

work

but

cannot,

experience,

engage

considering
in

any

[her]

other

age,

kind

of

substantial gainful work which exists in the national economy." 42
U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(B).
To

determine

whether

a

claimant

is

disabled,

Commissioner engages in a five-step evaluation process.

the

See 20

C.F.R. §§ 404.1520, 416.920; Bowen v. Yuckert, 482 U.S. 137, 140-42
(1987).

The Commissioner begins by deciding whether the claimant

is engaged in substantial gainful activity.
working, disability benefits are denied.
decides

whether

the

claimant

has

- 41 -

a

If the claimant is

Next, the Commissioner
“severe”

impairment

or

combination of impairments, meaning that which significantly limits
her ability to do basic work activities.

If the claimant's

impairment(s) is not severe, then she is not disabled.

The

Commissioner then determines whether claimant's impairment(s) meets
or equals one of the impairments listed in 20 C.F.R., Subpart P,
Appendix 1.

If claimant's impairment(s) is equivalent to one of

the listed impairments, she is conclusively disabled.

At the

fourth step, the Commissioner establishes whether the claimant can
perform her past relevant work.
disabled.

If so, the claimant is not

Finally, the Commissioner evaluates various factors to

determine whether the claimant is capable of performing any other
work in the economy.

If not, the claimant is declared disabled and

becomes entitled to disability benefits.
The decision of the Commissioner must be affirmed if it
is supported by substantial evidence on the record as a whole.

42

U.S.C. § 405(g); Richardson v. Perales, 402 U.S. 389, 401 (1971);
Estes v. Barnhart, 275 F.3d 722, 724 (8th Cir. 2002).

Substantial

evidence is less than a preponderance but enough that a reasonable
person would find it adequate to support the conclusion.
v. Apfel, 240 F.3d 1145, 1147 (8th Cir. 2001).

Johnson

This “substantial

evidence test,” however, is “more than a mere search of the record
for evidence supporting the Commissioner’s findings.”

Coleman v.

Astrue, 498 F.3d 767, 770 (8th Cir. 2007) (internal quotation marks
and citation omitted).

“Substantial evidence on the record as a

whole . . . requires a more scrutinizing analysis.”
- 42 -

Id. (internal

quotation marks and citations omitted).
To

determine

whether

the

Commissioner's

decision

is

supported by substantial evidence on the record as a whole, the
Court must review the entire administrative record and consider:
1.

The credibility findings made by the ALJ.

2.

The plaintiff's vocational factors.

3.

The medical evidence from treating and
consulting physicians.

4.

The plaintiff's subjective complaints
relating to exertional and non-exertional
activities and impairments.

5.

Any corroboration by third parties of the
plaintiff's impairments.

6.

The testimony of vocational experts when
required which is based upon a proper
hypothetical question which sets forth
the claimant's impairment.

Stewart v. Secretary of Health & Human Servs., 957 F.2d 581, 585-86
(8th Cir. 1992) (quoting Cruse v. Bowen, 867 F.2d 1183, 1184-85
(8th Cir. 1989)).
The Court must also consider any evidence which fairly detracts
from the Commissioner’s decision.

Coleman, 498 F.3d at 770;

Warburton v. Apfel, 188 F.3d 1047, 1050 (8th Cir. 1999).

However,

even though two inconsistent conclusions may be drawn from the
evidence, the Commissioner's findings may still be supported by
substantial evidence on the record as a whole.

Pearsall, 274 F.3d

at 1217 (citing Young v. Apfel, 221 F.3d 1065, 1068 (8th Cir.
2000)).

“[I]f there is substantial evidence on the record as a

whole, we must affirm the administrative decision, even if the
- 43 -

record could also have supported an opposite decision.” Weikert v.
Sullivan, 977 F.2d 1249, 1252 (8th Cir. 1992) (internal quotation
marks and citation omitted); see also Jones ex rel. Morris v.
Barnhart, 315 F.3d 974, 977 (8th Cir. 2003).
The Court now turns to plaintiff’s specific challenges to
the Commissioner’s final decision.
A.

Step 2 Analysis of Severe Impairments
At Step 2 of the sequential evaluation, the ALJ decides

whether the claimant has a severe impairment or combination of
impairments, meaning that which significantly limits her ability to
do basic work activities.30

Plaintiff contends that the ALJ erred

by effectively failing to find plaintiff’s allegations of headaches
and knee impairments to constitute severe impairments at Step 2 of
the analysis, and further erred in failing to find chronic pain
syndrome to be a severe impairment.

The Court addresses each of

these contentions in turn.
1.

Headaches and Knee Impairments
In her written decision, the ALJ stated at Step 2 of the

sequential analysis that plaintiff’s severe impairments included

30

The ability to do most work activities encompasses “the
abilities and aptitudes necessary to do most jobs.” Williams v.
Sullivan, 960 F.2d 86, 88 (8th Cir. 1992).
Examples include
physical functions such as walking, sitting, standing, lifting,
pushing, pulling, reaching, carrying, or handling; capacities for
seeing, hearing and speaking; understanding, carrying out and
remembering simple instructions; use of judgment; responding
appropriately to supervision, co-workers and usual work situations;
and dealing with changes in a routine work situation. Id. at 8889.
- 44 -

“allegations of headaches and knee impairments[.]”

(Tr. 12.)

In

determining plaintiff’s RFC at Step 4 of the analysis, however, the
ALJ found there to be no objective medical records to support
plaintiff’s

claim

that

disabling combination
added.)

Plaintiff

“these

impairments

of impairments.”
contends

that

are

a

part

(Tr. 15.)

these

two

of

her

(Emphasis

findings

are

inconsistent and show the ALJ to have effectively considered
plaintiff’s headaches and knee impairments not to constitute severe
impairments at Step 2.
In Lacroix v. Barnhart, 465 F.3d 881 (8th Cir. 2006), the
claimant made a similar argument, that is, that the ALJ’s Step 4
RFC analysis was inconsistent with the earlier determination made
at Step 2 that plaintiff’s impairments significantly limited her
functional abilities.

The Eighth Circuit soundly rejected this

argument inasmuch as “[e]ach step in the disability determination
entails a separate analysis and legal standard.”

Id. at 888 n.3.

Because plaintiff bases her argument on a contention that the ALJ’s
analysis as to her headaches and knee impairments is inconsistent
between Step 2 and Step 4 of the sequential analysis, her argument
must be rejected on the basis of the Eighth Circuit’s reasoning in
Lacroix.
2.

Chronic Pain Syndrome
Plaintiff also contends that the ALJ erred by failing to

find plaintiff’s chronic pain syndrome to be a severe impairment at
Step 2 of the analysis.

In response, the Commissioner argues that
- 45 -

the ALJ did not err inasmuch as plaintiff failed to claim or
testify that chronic pain syndrome was a basis for her alleged
disability. Instead, the Commissioner argues, plaintiff attributed
her pain to fibromyalgia.

Notably, the ALJ likewise did not

consider plaintiff’s fibromyalgia to be a severe impairment at Step
2.

For the following reasons, the ALJ erred in her analysis and

the matter should be remanded for further proceedings.
The undersigned is aware that, as a general rule, “an ALJ
has no ‘obligation to investigate a claim not presented at the time
of the application for benefits and not offered at the hearing as
a basis for disability[.]’”

Battles v. Shalala, 36 F.3d 43, 45 n.2

(8th Cir. 1994) (quoting Brockman v. Sullivan, 987 F.2d 1344, 1348
(8th Cir. 1993)). An exception to this rule exists, however, where
the evidence of record puts the ALJ on notice of the need for
further inquiry.
case basis.

Id.

This assessment must be made on a case-by-

Mouser v. Astrue, 545 F.3d 634, 639 (8th Cir. 2008)

(citing Battles, 36 F.3d at 45).
The record here is replete with evidence of the existence
of

plaintiff’s

chronic

pain,

including

plaintiff’s

testimony;

consistent complaints of chronic pain to treating physicians and
specialists; observations and diagnoses of chronic pain made by
treating physicians and specialists; and continued and increasing
use of significant narcotic pain medications, including morphine,
hydrocodone and oxycodone, prescribed specifically for plaintiff’s
chronic pain condition.

In addition, a review of the record shows
- 46 -

that on numerous occasions, physicians suggested that plaintiff’s
perception of such severe and chronic pain may be related to her
mental impairment(s).

Indeed, Dr. Gray, plaintiff’s treating

physician who ultimately became plaintiff’s pain specialist, opined
in December 2009 that plaintiff’s “chronic pain syndrome” was
disabling more from a psychiatric standpoint than a physical one.
The ALJ’s decision, however, is silent as to these significant
observations, diagnoses and treatment regimens for plaintiff’s
chronic pain.

Given this substantial and documented evidence, the

question of plaintiff’s chronic pain and chronic pain syndrome was
squarely before the ALJ, obligating her to investigate
impairments further before evaluating plaintiff’s RFC.
Apfel, 187 F.3d 840, 843 (8th Cir. 1999).

these

Gasaway v.

The ALJ erred by failing

to do so.
Upon remand, the Commissioner shall obtain a psychiatric
or psychological evaluation to fully evaluate plaintiff’s mental
impairments as they relate to plaintiff’s diagnosed condition of
chronic pain and determine whether her complaints of pain are
psychological in origin. Dozier v. Heckler, 754 F.2d 274, 276 (8th
Cir.

1985).

Such

evaluation

may

be

made

by

recontacting

plaintiff’s treating psychiatrist or by ordering a consultative
examination.

In addition, although the Commissioner acknowledges

that plaintiff attributed her pain to fibromyalgia and not chronic
pain syndrome, the undersigned notes the ALJ to have nevertheless
dismissed plaintiff’s diagnosed and longstanding impairment of
- 47 -

fibromyalgia in a cursory manner “[g]iven the absence of any
notations regarding how it was concluded that the claimant had
fibromyalgia[.]”
the

ALJ

to

(Tr. 15.)

have

A review of this determination shows

improperly

substituted

her

own

conclusions

regarding the existence of this medical condition for the express
diagnoses of treating physicians.

In such circumstances, an ALJ

commits “egregious error.” Delrosa v. Sullivan, 922 F.2d 480, 48485 (8th Cir. 1991).

If an ALJ questions the existence of a

claimant’s diagnosed condition, the ALJ must, at a minimum, order
a

consultative

decision.
B.

examination

so

that

she

may

make

an

informed

Id. at 485.

RFC Determination
Because the ALJ failed to consider substantial evidence

demonstrating

the

existence

of

chronic

pain

syndrome

and

fibromyalgia and failed to fully and fairly develop the record as
to the effect of such impairments on plaintiff’s ability to perform
work, it cannot be said that the ALJ’s RFC determination is
supported by substantial evidence on the record as a whole.

See

generally Garza v. Barnhart, 397 F.3d 1087 (8th Cir. 2005) (per
curiam). This cause must therefore be remanded to the Commissioner
for further development of the record as to plaintiff’s chronic
pain syndrome and fibromyalgia; for reconsideration of whether such
impairments constitute severe impairments; and for appropriate
consideration as to what effect, if any, such impairments have upon
plaintiff’s RFC when considered in combination with plaintiff’s
- 48 -

other impairments.
Accordingly, for all of the foregoing reasons,
IT IS HEREBY ORDERED that Acting Commissioner of Social
Security Carolyn W. Colvin is substituted for former Commissioner
Michael J. Astrue as defendant in this cause.
IT IS FURTHER ORDERED that, pursuant to sentence four of
42 U.S.C. § 405(g), the decision of the Commissioner is REVERSED,
and

this

cause

is

REMANDED

to

the

Commissioner

proceedings consistent with this opinion.

for

further

Because the current

record does not conclusively demonstrate that plaintiff is entitled
to benefits, it would be inappropriate for the Court to award
plaintiff such benefits at this time.
Judgment shall be entered accordingly.

UNITED STATES MAGISTRATE JUDGE

Dated this

23rd

day of September, 2013.

- 49 -