Bacon v. Colvin

Filing 17

MEMORANDUM AND ORDER : IT IS HEREBY ORDERED that the decision of the Commissioner is reversed and this matter is remanded pursuant to the fourth sentence of 42 U.S.C. § 405(g) for further proceedings. A separate Judgment in accordance with this Memorandum and Order will be entered this same date.. Signed by District Judge Carol E. Jackson on 3/4/16. (KKS)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION
LYDIA M. BACON,
Plaintiff,
vs.
CAROLYN W. COLVIN, Acting
Commissioner of Social Security,
Defendant.

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Case No. 4:14-CV-1621 (CEJ)

MEMORANDUM AND ORDER
This matter is before the Court for review of an adverse ruling by the Social
Security Administration.
I. Procedural History
On March 4, 2011, plaintiff Lydia Bacon protectively filed applications for a
period of disability, disability insurance benefits, and disabled widow benefits, Title
II, 42 U.S.C. §§ 401 et seq., with an alleged onset date of October 21, 2007. (Tr.
166, 172-75). After plaintiff’s applications were denied on initial consideration (Tr.
86-87, 88), she requested a hearing from an Administrative Law Judge (ALJ). (Tr.
100-01).
Plaintiff and counsel appeared for a hearing on December 18, 2012. (Tr. 4878). The ALJ issued decisions denying plaintiff’s applications on April 12, 2013. (Tr.
10-28, 29-47). The Appeals Council denied plaintiff’s request for review on July 16,
2014. (Tr. 1-4). Accordingly, the ALJ’s decision stands as the Commissioner’s final
decision.
II. Evidence Before the ALJ
A. Disability Application Documents

In a Disability Report dated May 31, 2011 (Tr. 193-203), plaintiff listed her
disabling conditions as arthritis — no cartilage in knee; multiple sclerosis; Sjogren’s
syndrome; depression; poor reading ability and math skills; and learning disability.
She reported that she stopped working on October 21, 2007, due to her conditions.
She had previously worked folding uniforms, packing orders in a warehouse, and
checking product for a radio manufacturer. She was prescribed amitriptyline,1
clonazepam,2 Betaseron,3 hydrocodone, medications for the treatment of acid
reflux, high cholesterol, circulatory problems, dry skin and allergies, and vitamin
and mineral supplements. (Tr. 197). In an updated report on August 1, 2011 (Tr.
231-37), plaintiff noted that she had developed weakness on her left side, which
made it difficult for her to balance and she used a cane about once a week. In
December 2011, her additional medications included Ambien and levothyroxine, a
thyroid hormone. (Tr. 248).
In a Function Report dated July 5, 2011, (Tr. 220-30), plaintiff stated that
she lived in a house with adult relatives. In response to a question about her daily
activities, plaintiff stated that she went outside when able and did laundry if she
was not in pain. Pain interfered with her ability to sleep and to complete household
chores. In addition, she could not tolerate heat. Generally, the meals she prepared
were frozen foods. When able, she mowed the grass on a riding mower and
cleaned. She was able to go out alone, drive, and shop, which she did about once a
1

Amitriptyline is a tricyclic antidepressant, sometimes used to treat eating disorders and
post-herpetic neuralgia. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682388.html
(last visited on August 28, 2015).
2

Clonazepam, or Klonopin, is a benzodiazepine prescribed for treatment of seizure disorders
and panic disorders. See Phys. Desk Ref. 2782 (60th ed. 2006).

3

Betaseron, or Interferon Beta-1b Injection, is used to reduce episodes of symptoms in
patients with relapsing-remitting multiple sclerosis. https://www.nlm.nih.gov/medlineplus
/druginfo/meds/a601151.html (last visited on August 28, 2015).

-2-

week. Her hobbies included watching television and working on puzzle books. She
occasionally visited her son and she talked with her family on the computer. She
often dropped things due to arthritis in her hands. Plaintiff had difficulties with
lifting, squatting, bending, walking, kneeling, climbing stairs, memory, following
instructions, and using her hands. She could not lift more than 10 pounds or walk
more than 20 steps before needing to rest for 5 minutes. She occasionally used a
cane. She could pay attention for 30 minutes and could not finish things she
started. She could pay bills, count change and manage a savings account, but had
problems writing checks. She had trouble understanding written instructions but
had fewer difficulties with spoken instructions. She got along well with authority
figures. She could handle changes in routine but not stress. A third-party Function
Report completed by plaintiff’s brother is consistent with her own report. (Tr. 20512).
B. Testimony at Hearing
Plaintiff testified that she left school in the seventh grade. She was able to
read at the fourth-grade level of ability at that time. (Tr. 59). She stated that
reading “aggravates” her and she does as little writing as possible. She is able to
read and write a shopping list, although her spelling is not correct. Contrary to what
she stated in her Function Report, she testified that she could not make change and
only understands how to do addition. Plaintiff worked for eight years repacking
radios. See Tr. 61 (describing the work as taking the radios out boxes, making sure
there was nothing wrong with them, repacking them and sending them down the
line). She next worked for four years filling orders at a Dollar General warehouse,
taking items off of shelves and putting them in totes. Tr. 60. She had a hard time
-3-

meeting completion requirements because she needed help reading the orders. She
last worked in 2007 washing and folding uniforms. She and her husband moved
after she had been in that position for about 6 months and she did not seek further
employment. (Tr. 55, 60, 214). She took care of her husband before his death on
July 4, 2008. (Tr. 55).
Plaintiff testified that she experienced pain in her back and knee. (Tr. 62).
Her left knee “rubs bone to bone.” (Tr. 56). She could stand for about one hour
before she needed to sit down. She was unable to sit comfortably in one position
for more than 20 minutes without shifting her position and she sometimes had to
lie down to relieve knee and back pain. (Tr. 62, 69). She suffered from dry mouth
and severely dry skin caused by Sjogren’s syndrome.4 Plaintiff testified that she
often dropped things; for example, her coffee cup often fell out of her hand. (Tr.
68). As a result of her depression, she generally wanted to stay in her room, but
antidepressant medication helped somewhat. She had never received counseling.
Id. Stress made her multiple sclerosis “act up.”
Plaintiff testified that she shared a two-story home with her brother and her
deceased husband’s brother, both of whom received disability. Her room was on the
first floor. (Tr. 63-64). She swept her own room, but her brother-in-law took care
of everything else, including laundry. He also did most of the shopping and cooking,
although she drove to the grocery store about twice a week and cooked
occasionally. (Tr. 64-66). Her son, who has bipolar disorder and is on disability,
took care of yard work.

4

Sjogren’s syndrome is a disease of unknown cause marked by inflammation of the cornea
and conjunctiva, dryness of the mouth, and connective tissue disease. See J.E. Schmidt
Attorneys’ Dict. of Medicine, Illustrated S-174 (28th ed. 1995).

-4-

The ALJ asked vocational expert Jeffrey F. Magrowski, Ph.D., to address
plaintiff’s vocational history and identify the exertional levels of her past work. (Tr.
72-3). Dr. Magrowski testified that plaintiff’s past work as a uniform folder,
warehouse worker, and radio packer were all performed at the light level and
required the ability to use hands. (Tr. 73-74). The ALJ did not pose any
hypotheticals to Dr. Magrowski.
C. Educational and Medical Records
Educational records show that plaintiff consistently performed below grade
level in grades 1 through 6. (Tr. 242-46). Plaintiff’s scored in the 9th percentile on
the Lorge Thorndike intelligence test when she was 7 years old. (Tr. 245). Her
scores on the Stanford Achievement Test when she was 14 years old were below
the 20th percentile in all subjects.5 (Tr. 244). She left school at age 15 before
completing seventh grade. (Tr. 246).
An x-ray of plaintiff’s left knee taken on April 4, 2008, showed very slight
narrowing at the medial knee joint. There was no evidence of bone destruction. (Tr.
643).
Plaintiff received annual checkups at the Ellis Fischel Cancer Center, following
radiation treatment in 1998 for stage II anal cancer. On April 9, 2008, Steven J.
Westgate, M.D., noted no change since his examination in March 20, 2007. (Tr.
259-60). Plaintiff reported that she had 3 or 4 episodes of mild rectal incontinence a

5

Plaintiff’s percentile scores were: paragraph meaning – 8; language — 2; arithmetic
computation — 18; and science — 10. (Tr. 244).

-5-

month, for which he recommended she use Metamucil. On examination, Dr.
Westgate noted “She looks great[,]” and rated her performance status at 0.6
On August 27, 2008, plaintiff consulted with rheumatologist Chokkalingam
Siva, M.D., for complaints of joint pain. (Tr. 272-75). Plaintiff reported that she had
pain in her shoulders, her left knee, and occasionally her hands, predominantly in
her fingers, with episodic swelling. Plaintiff reported that she had had these
symptoms for several years and was previously diagnosed with osteoarthritis.
Plaintiff’s medical history included hypercholesterolemia, insomnia, and thyroid
disease. On examination, she had no synovitis or effusion of any joints. She had
normal range of motion at all joints and neurologically symmetric muscles in her
arms and legs. Dr. Siva determined that plaintiff had joint pain consistent with
osteoarthritis

of

the

knee

joints.

The

“hand

findings

[a]re

suggestive

of

osteoarthritis,” predominantly in the distal joints of the fingers. Dr. Siva injected
plaintiff’s left knee and prescribed Tylenol and home exercises, in lieu of physical
therapy, which plaintiff stated she could not afford.
Plaintiff received her primary medical care at the SSM Health Medical Group
in Belle, Missouri. On September 2, 2008, plaintiff saw Jane Moore, R.N. (Tr. 39293). Nurse Moore noted that plaintiff’s past medical records showed an elevated

6

“The ECOG Scale of Performance Status (PS) is widely used to quantify the functional
status of cancer patients, and is an important factor determining prognosis in a number of
malignant conditions. The PS describes the status of symptoms and functions with respect
to ambulatory status and need for care. PS 0 means normal activity, PS 1 means some
symptoms, but still near fully ambulatory, PS 2 means less than 50%, and PS 3 means
more than 50% of daytime in bed, while PS 4 means completely bedridden.” J.B. Sorensøn
et al., Performance status assessment in cancer patients, 67 Br. J. of Cancer 773-75 (Apr.
1993). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1968363/ (last visited September 3,
2015).

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erythrocyte sedimentation rate or “sed rate,”7 and mild anemia. Recent blood tests
resulted in a positive ANA8 and negative rheumatoid factor. Plaintiff reported that
she received some benefit from the recent injection of her left knee. She also had
some epigastric discomfort. Blood tests showed continued anemia. (Tr. 433). On
September 9, 2008, Nurse Moore noted that a test for H. pylori was positive and
prescribed antibiotics and Prilosec. (Tr. 390). On October 9, 2008, plaintiff reported
that she still had some mild epigastric discomfort. (Tr. 387-88). She also
complained of significant insomnia. She took Tylenol, ibuprofen, and Vicodin9 for
joint pain. She requested medication for insomnia. A physical examination was
unremarkable. Blood tests on October 24, 2008, showed anemia, elevated
triglycerides and cholesterol, and decreased glomerular filtration rate (GFR), a
measure of kidney function. (Tr. 428-31).
On November 12, 2008, plaintiff told Dr. Siva that the knee injection was
very helpful and she was doing home exercises. He prescribed tramadol,10 Tylenol,
and a topical preparation for pain. (Tr. 315).
A gastric biopsy completed on December 4, 2008, was negative for H. pylori.
(Tr. 425). On December 15, 2008, primary care physician Richard Daugherty, M.D.,
noted that plaintiff had experienced some chest pain and gastric distress, probably
7

The sed rate is a blood test that “indirectly measures how much inflammation is in the
body.” https://www.nlm.nih.gov/medlineplus/ency/article/003638.htm (last visited on Sept.
8, 2015).
8

The ANA test detects antinuclear antibodies. In most cases, a positive ANA test indicates
the presence of an autoimmune reaction. http://www.mayoclinic.org/tests-procedures/anatest/basics/definition/prc-20014566 (last visited on Sept. 8, 2015).
9

Vicodin is a narcotic analgesic indicated for relief of moderate to moderately severe pain.
Dependence or tolerance may occur. See Phys. Desk. Ref. 530-31 (60th ed. 2006).
10

Tramadol is a narcotic prescribed for the treatment of moderate to moderately severe
pain. https://www.nlm.nih.gov/medlineplus/druginfo/meds/a695011.html (last visited Sept.
11, 2015).

-7-

related to reflux. He directed plaintiff to start taking Prilosec, follow a reflux diet,
and stop smoking. (Tr. 384-85).
On February 2, 2009, plaintiff saw Nurse Shannon Wright, A.P.R.N., at the
Belle SSM Health Medical Center. (Tr. 382). Plaintiff reported that she was
experiencing increased anxiety, insomnia and stress, with occasional tearfulness. A
physical examination was unremarkable. Nurse Wright noted that plaintiff took
“intermittent hydrocodone and tramadol for issues related to arthritis.” Blood tests
showed continued anemia and decreased GFR. (Tr. 422, 424). Nurse Wright
prescribed Celexa11 and clonazepam to treat plaintiff’s psychiatric symptoms. At
follow-up on February 16, 2009, plaintiff reported some improvement in sleeping
and anxiety and Nurse Wright increased the dosage of plaintiff’s Celexa. Plaintiff
was noted to be mildly anemic. (Tr. 380). On May 18, 2009, Nurse Wright noted
that plaintiff’s anemia appeared to be significantly improved with vitamin B12
replacement, but she continued to complain of anxiety and depression. Nurse
Wright added trazadone12 to the other medications plaintiff was prescribed. Her
osteoarthritis pain was well controlled with intermittent tramadol and Vicodin. A
physical examination was unremarkable. (Tr. 377-78).
On July 26, 2009, plaintiff saw Dr. Westgate for her annual checkup at the
Ellis Fischel Cancer Center. (Tr. 442-43). She reported that she was still smoking “a
little bit” and continued to have intermittent episodes of rectal incontinence. Dr.
Westgate described plaintiff as “very nonconcerned about this.” She was prescribed
potassium and directed to take Metamucil. Her performance status remained at 0.
11

Celexa, or citalopram, is in the SSRI class of antidepressants. https://www.nlm.nih.gov
/medlineplus/druginfo/meds/a699001.html (last visited on Sept. 18, 2015).

12

Trazadone is a serotonin modulator and is prescribed to treat depression. https://www.
nlm.nih.gov/medlineplus/druginfo/meds/a681038.html (last visited Sept. 18, 2015).

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(Tr. 438-40). A chest x-ray showed minimal atelectasis13 but was otherwise
unremarkable.
On August 19, 2009, plaintiff reported to Nurse Moore that her mood was
significantly improved on Celexa, although she still had insomnia. Her joint pain
was managed “fairly well” with occasional Vicodin and twice daily tramadol, with the
exception of her left knee, which she felt had worsened. (Tr. 374-75). She reported
that Metamucil was having a positive effect. On physical examination, it was noted
that her tongue was extremely dry. With respect to her knees, plaintiff had mild
bony enlargement of the knees with “somewhat fixed” patella, but no laxity,
effusion or click. Her hands demonstrated some mild crepitus, edema and
nodularity, but no increased joint enlargement. Plaintiff’s left knee was injected and
she was prescribed an increased dosage of amitriptyline to address insomnia. She
continued to be anemic. (Tr. 418).
Plaintiff sought emergency treatment on September 3, 2009. (Tr. 501-18).
She reported that she had been sitting at her computer and began to feel light
headed with tingling in her right arm. (Tr. 507). An EKG, chest x-ray, CT scan of
the head, and blood work were all unremarkable. (Tr. 371). She was diagnosed
with hypertension, new onset. (Tr. 506). At follow-up on September 8, 2009, Nurse
Moore noted that plaintiff had been monitoring her blood pressure at home and that
her home readings showed significant improvements. A physical examination was
unremarkable and plaintiff reported that her left knee pain improved following her
most recent injection. Nurse Moore ordered an MRI of plaintiff’s brain. (Tr. 371-72).

13

Atelectasis is the collapse of part or, less commonly, all of a lung. https://www.nlm.nih.
gov/medlineplus/ency/article/000065.htm (last visited on Sept. 8, 2015).

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The MRI completed on September 16, 2009, disclosed multiple foci of
abnormal white matter signal, consistent with chronic ischemic change or a
demyelinating process. (Tr. 305-06). Plaintiff was referred to the Neurology Clinic
at the University of Missouri—Columbia, where she was seen on October 13, 2009.
(Tr. 292-95). She reported episodes of dizziness, needle-like sensations in her
limbs and abdomen, and dull headaches. On examination, she had normal muscle
bulk, tone, and strength. Her reflexes and gait were normal but she had impaired
response to touch on the right side of her body. Plaintiff presently had no functional
impairment. Plaintiff was referred for a rheumatology consultation and further
diagnostic tests. A Magnetic Resonance Angiogram (MRA) of the head and neck
were negative. (Tr. 290-91).
On

November

18,

2009,

plaintiff

returned

to

see

Dr.

Siva

at

the

Rheumatology Clinic. (Tr. 311-14). She reported that she had a positive blood test
for lupus. She also complained of dry mouth. On examination, plaintiff had no
swollen or tender joints and no synovitis. She had full ranges of motion at all joints
and normal muscle strength. She continued to have a nodule on one finger. Dr.
Siva opined that the clinical findings suggested multiple sclerosis, rather than lupus,
and prescribed hydroxychloroquine.14 He also warned plaintiff that the medication
was likely to be less effective if she continued to smoke. He suggested that she

14

Hydroxychloroquine, or Plaquenil, is an antimalarial that is used to treat lupus and
rheumatoid arthritis. https://www.nlm.nih.gov/medlineplus/druginfo/meds/a601240.html
(last visited on Sept. 8, 2015). It has also been prescribed to treat the symptoms of
Sjogren’s Syndrome. See J-E Gottenberg, et al., Effects of Hydroxychloroquine on
Symptomatic Improvement in Primary Sjögren Syndrome, 312(No. 3) JAMA 249 (July 16,
2014). http://jama.jamanetwork.com/article.aspx?articleid=1887760 (last visited on Sept.
18, 2015).

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speak with her primary care physician about decreasing her psychotropic
medications in order to alleviate her dry mouth.
Plaintiff received treatment for upper respiratory symptoms on December 18,
2009, and January 18, 2010. (Tr. 366, 363-64). Her osteoarthritis was fairly well
controlled at this time. She continued to be anemic. (Tr. 409).
Plaintiff returned to the Neurology Clinic on February 2, 2010. (Tr. 283-86).
She reported that she had not had any further episodes of dizziness but
occasionally experienced tingling and pins-and-needles sensations. She continued
to display full strength and a normal gait. At this evaluation, she displayed no
sensory loss. Based on her clinical history, the prior objective evidence of sensory
loss, and the results of imaging studies and blood tests, she was diagnosed with
multiple sclerosis. It was recommended that she start treatment with Betaseron.
The following week, plaintiff’s rheumatologist, Dr. Siva, continued plaintiff’s
prescription for Plaquenil and again recommended that plaintiff stop smoking. (Tr.
306-08).
In May 2010, Nurse Moore noted that plaintiff had had to suspend treatment
with Betaseron while she was treated for a MRSA infection. (Tr. 355-59). Blood
tests showed continued anemia and elevated liver function tests and creatinine15
levels. (Tr. 398, 404-05). A Neurology Clinic note dated May 11, 2010, states that
plaintiff’s tingling sensations had decreased since she started using Betaseron. (Tr.
280-81). Plaintiff similarly reported to Dr. Siva that her arthralgias, fatigue, and
Sjogren’s symptoms had significantly improved. (Tr. 302-04).

15

Elevated creatinine levels signify impaired kidney function or kidney disease.
http://www.medicinenet.com/creatinine_blood_test/article.htm (last visited Sept. 11,
2015).

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On July 26, 2010, oncologist Dr. Westgate noted that plaintiff had radiating
achiness in her hips, consistent with nonspecific radiation fibrosis or bursitis. (Tr.
446-47). Dr. Westgate again told plaintiff that Trental and Vitamin E might relieve
the achiness and incontinence, but that she needed to quit smoking before she
could try this treatment. She stated that she planned to stop smoking soon.
Plaintiff’s performance status was downgraded to 1. (Tr. 487).
On August 17, 2010, Nurse Wright noted that plaintiff had irritation at the
Betaseron injection site. (Tr. 596-97). Plaintiff reported that her arthritis and
dyspepsia were controlled by medication and that she had stopped taking Celexa
and Elavil because her mood was “quite good.” Her anxiety was managed with
clonazepam and she slept through the night. Blood work completed that day
showed continued anemia. (Tr. 495-98).
In September 2010, plaintiff went to the emergency room with a severe
headache. (Tr. 519-25). Imaging studies were negative and she was released with
prescriptions for Vicodin and Compazine.16 At follow-up, Nurse Wright opined that
the headache resulted from plaintiff’s decision to resume taking Celexa at the full
dosage, rather than the half dosage that had been prescribed. (Tr. 593). Plaintiff
also reported chest pressure after eating. An examination was unremarkable with
the exception of elevated blood pressure. Nurse Wright prescribed Celexa, Elavil,
and Prilosec. In October 2010, plaintiff reported that her anxiety, depression and
insomnia were all improved and her chest pain and GERD had resolved. (Tr. 591).

16

Prochlorperazine, also known as Compazine, is used to control severe nausea and
vomiting and to treat the symptoms of schizophrenia and anxiety. http://www.nlm.nih.gov/
medlineplus/druginfo/meds/a682116.html (last visited on Sept. 18, 2015).

-12-

Plaintiff saw Dr. Siva on November 16, 2010. (Tr. 535-37). Her numbness,
tingling, and Sjogren’s symptoms had improved with medication. Dr. Siva noted
that plaintiff was not able to reduce the dosage of her psychotropic medications. On
examination, plaintiff had full ranges of motion and muscle strength and she had no
synovitis or swollen or tender joints. At follow-up with the Neurology Clinic that
same day, plaintiff reported that her symptoms had improved. (Tr. 671-73). A
sensory examination was unremarkable.
On November 17, 2010, Nurse Wright noted that plaintiff was having
difficulty with GERD. Nurse Wright recommended treatment with proton pump
inhibitors, but plaintiff was unable to afford the medication. (Tr. 589). Blood tests
showed some improvement in plaintiff’s anemia. See Tr. 596. On December 21,
2010, plaintiff reported slight improvement in her dysphagia. Nurse Wright provided
plaintiff samples of Dexilant17 to be taken with Zantac, and advised her to quit
smoking. (Tr. 586-87). On January 5, 2011, plaintiff reported overall improvement
in her dysphagia and GERD. (Tr. 584). However, she reported episodes of chest
tightness and palpitations. Cardiac tests completed in January 2011 were normal.
(Tr. 630-31).
Plaintiff underwent an MRI of the brain on January 7, 2011. The number and
distribution of foci were grossly unchanged but there were indications of possible
active inflammation. (Tr. 521-22). An MRI of the cervical spine taken the same day
disclosed moderate cervical spondylosis at C5-C6 with severe left-sided stenosis. A
right-sided disc osteophyte complex at the same level caused moderate right-sided

17

Dexilant, or dexlansoprazole, is a proton pump inhibitor. https://www.nlm.nih.gov/
medlineplus/druginfo/meds/a609017.html (last visited Sept. 14, 2015).

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stenosis. There was mild degenerative disc disease at other levels without
significant stenosis. (Tr. 523-25).
On March 15, 2011, Nurse Wright noted that plaintiff had undergone an
upper endoscopy, during which a mild stricture was dilated. Plaintiff’s GERD was
controlled with Dexilant. (Tr. 579).
On May 23, 2011, Nurse Wright noted that plaintiff had chronic hip and leg
pain. (Tr. 711-12). She had no radicular symptoms or motor weakness. Her anxiety
and depression was generally well treated and Dexilant provided relief for her
ongoing reflux symptoms. On examination, plaintiff had no edema but had crepitus
of the knees. Phalen’s Test was positive for the right hand, with decreased
sensation. Plaintiff declined to undergo nerve conduction studies for carpal tunnel
syndrome. Nurse Wright described plaintiff’s gait as antalgic with prolonged sitting
and noted that she appeared dizzy and had a “bit of shuffle gait.”

Nurse Wright

opined that plaintiff’s osteoarthritis inhibited her ability to work.
Nurse Wright also completed a medical source statement on May 23, 2011.
(Tr. 645-47). She opined that plaintiff could seldom lift or carry any weight less
than 20 pounds and could never lift or carry any weight above 20 pounds. She was
capable of sitting for 1 hour and standing or walking for 3 hours in an 8-hour work
day and needed to alternate between sitting and standing every 30 minutes. She
could only seldom use her feet for operating leg controls. She rarely needed to use
a hand-held assistive device. She could occasionally use her hands to grasp, push
or pull, reach, or handle (though it was noted that she dropped things) and could
never use her hands for fingering. In terms of postural limitations, plaintiff could
occasionally reach overhead or extend her arms out, but could only seldom bend,
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climb, balance, stoop, kneel, crouch, or squat. Plaintiff experienced constant
fatigue, frequent pain, and occasional shortness of breath and vertigo, due to
stiffness and multiple sclerosis flares which caused numbness and near syncope. As
objective

support

for

these

limitations,

Nurse

Wright

cited

plaintiff’s

gait

disturbance, slow ambulation, and shuffling; degenerative changes in her fingers
and the positive Phalen’s test in the right hand; and crepitus in both knees. Blood
tests showed mild anemia with B12 deficiency. See Tr. 705.
At an office visit on June 24, 2011, plaintiff complained of pain in her right
knee and asked for an injection. (Tr. 705-06). She reported no recent flare of her
multiple sclerosis. Her GERD and depression were both well-controlled with
medication. On examination, she had crepitus of the knee with abnormal patellar
tracking, but no synovitis, erythema, or warmth. An x-ray of the right knee showed
mild joint space narrowing, but no joint effusion or acute bony abnormality. (Tr.
708).
Divyajot S. Sandhu, M.D., began following plaintiff through the Neurology
Clinic on July 13, 2011. Plaintiff reported that her multiple sclerosis had been stable
over the last month; her one consistent problem was that she occasionally ran into
things. (Tr. 662-65). During a review of systems, Dr. Sandhu noted that plaintiff
had fatigue, falls, clumsiness, and arthritis. On mental status examination, plaintiff
was alert and oriented, was able to repeat and recall 3 objects, and her abilities to
perform calculations and follow multi-step commands were intact. She had normal
muscle bulk, tone and strength, with slightly decreased sensation on the left side.
Her gait was normal.

-15-

Christine Cruzen18 completed a Physical Residual Functioning Capacity
Assessment (PRFCA) on July 20, 2011. (Tr. 79-85). Ms. Cruzen found that plaintiff
could lift or carry up to 20 pounds occasionally and up to 10 pounds frequently; sit
and stand or walk about 6 hours in an 8-hour day; and had unlimited capacity to
push or pull with her hands or feet.
On July 22, 2011, Kyle DeVore, Ph.D., completed a Psychiatric Review
Technique. (Tr. 649-59). Dr. DeVore concluded that plaintiff met the criteria for
affective disorders (depression), but that her impairment was not severe. He
further found that she had no restrictions in the activities of daily living or
maintaining social functioning, and mild difficulties in maintaining concentration,
persistence or pace. Dr. DeVore noted that plaintiff’s functional limitations were due
to pain and that she reported being able to clean the house, ride a lawn mower,
shop, leave the house, work on a computer, watch television, work on puzzle
books, and visit her son. Her medically determinable impairments of depression and
anxiety were treated with medication. The medical record repeatedly reflected that
she presented with appropriate mood and affect.
Plaintiff was seen at the Ellis Fischel Cancer Center on September 6, 2011.
(Tr. 678-79). She reported that she continued to do fairly well despite her chronic
illnesses and her energy level was described as adequate. Her potassium levels
were low. Dr. Westgate noted that plaintiff had finally quit smoking. (Tr. 685-86).

18

Ms. Cruzen is identified in the form as a Single Decisionmaker (SDM). Missouri is one of
20 states in which nonmedical disability examiners are authorized to make certain initial
determinations without requiring a medical or psychological consultant’s signature. See
Office of the Inspector General, Audit Report, Single Decisionmaker Model — Authority to
Make Certain Disability Determinations without a Medical Consultant’s Signature (A-01-1211218) (Aug. 2013) (available at http://oig.ssa.gov/audits-and-investigations/auditreports/A-01-12-11218).

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She reported that she had tried Trental and Vitamin E to see if that helped her
symptoms of bursitis, arthritis, and perianal fibrosis and tenderness. She stopped
the treatment after 6 months because she had no improvement. Due to the
medications she was taking, she no longer had diarrhea or incontinence and was
struggling with constipation. Overall, she was stable with no evidence of metastatic
disease.
On September 19, 2011, Nurse Wright noted that plaintiff quit smoking in
August 2011. (Tr. 695-96). She ran out of samples of Dexilant and reported
uncontrolled GERD. She also complained of poor sleep and fatigue. On examination,
she was alert, appropriate, and pleasant. She had no edema, synovitis, erythema
or warmth. She returned on October 21, 2011, for evaluation of a finger which she
injured in a fall. An x-ray of her left hand showed degenerative changes. (Tr. 69192). Plaintiff stated that she had not had many multiple sclerosis symptoms, and
had no recent fevers, chest pain, shortness of breath, abdominal pain or other
concerning symptoms. She had recently obtained insurance and was able to take
Prilosec for her GERD. She was given a splint for her finger and a prescription for
hydrocodone for chronic pain and osteoarthritis.
On December 13, 2011, Dr. Siva noted that plaintiff’s affect and mood were
appropriate; her joints were not swollen or tender and showed no synovitis; and
she had normal ranges of motion and muscle strength. Dr. Siva noted that she had
early chronic kidney disease and advised her to monitor her blood pressure. (Tr.
756-58). On December 16, 2011, Nurse Wright noted that plaintiff continued to
experience dyspepsia. (Tr. 856-57). Plaintiff had intermittent numbness in her left
foot and fatigue, but had not had any headaches, falls, chest pain, or shortness of
-17-

breath. She reported uncontrolled insomnia and some anxiety. Blood tests showed
that plaintiff’s creatinine, thyroid stimulating hormone, and liver function tests were
elevated.

(Tr. 870). Nurse

Wright

increased

plaintiff’s

dosage

of Prilosec,

discontinued clonazepam, and prescribed Ambien for sleep. A CT scan of plaintiff’s
abdomen and pelvis disclosed no hepatic masses but did show advanced
atherosclerotic calcifications of the aorta and major abdominal branch vessels. (Tr.
874). On January 16, 2012, plaintiff sought treatment for an upper respiratory
infection. (Tr. 854). She reported that she had cut back on smoking.
On March 1, 2012, plaintiff told Nurse Wright that she had had pain in her
right shoulder for four to five days. (Tr. 851-52). She did not have any weakness in
her grip or altered range of motion and an x-ray showed some mild osteoarthritic
changes. She also reported an episode of chest pain due to uncontrolled GERD, and
some lightheadedness which she attributed to her multiple sclerosis. Finally,
plaintiff had chronic back pain. Nurse Wright prescribed Nexium for GERD and
tramadol for back pain.
Plaintiff was seen at the Neurology Clinic on March 28, 2012. (Tr. 794-98).
Dr. Sandhu noted that plaintiff occasionally experienced a burning pain in her right
calf. In addition, her right leg turned outward and sometimes buckled when she
walked. Possible differential diagnoses included mononeuritis, a new spinal multiple
sclerosis lesion, and lumbosacral plexopathy. An EMG and nerve conduction study
completed on June 13, 2012 were normal. (Tr. 996).
On May 4, 2012, Nurse Wright noted that plaintiff’s dyspepsia was
uncontrolled. She resumed Dexilant. (Tr. 849).

-18-

On June 6, 2012, Dr. Siva noted that plaintiff still complained of low back
pain and arthralgias but no significant joint swelling. He recommended that she
obtain a prescription for Vicodin from her primary care physician. On examination,
she had normal ranges of motion for all joints without synovitis or swelling or
tenderness. She had normal muscle strength. He noted that she continued to take
nonsteroidal anti-inflammatory medications against his advice. She continued to
smoke.
On June 8, 2012, plaintiff saw Nurse Wright with complaints of earache and
elevated blood pressure. (Tr. 847-48). She also complained of fatigue, reflux and
nausea, muscle and joint pain, and depression. On June 10, 2012, plaintiff was
transported to the emergency room by ambulance for complaints of acute
abdominal pain and intermittent chest pain. (Tr. 762-80). At admission, it was
noted that plaintiff had an unsteady gait and back pain with range of motion. (Tr.
763). Chest x-rays showed no acute cardiopulmonary disease. (Tr. 768). A CT scan
of the abdomen and pelvis showed diffuse fatty infiltration of the liver and
degenerative changes at multiple levels of the spine. (Tr. 769).
Plaintiff returned to the Neurology Clinic on July 11, 2012. (Tr. 783-86). She
reported that she had been doing well since her last visit. A recent MRI of her brain
showed no changes when compared to the last MRI. Her neurological examination
was normal; she was oriented and her comprehension and memory were intact. A
motor examination was also normal, with no abnormal movements noted and full
muscle strength and normal tone and bulk. Dr. Sandhu increased her gabapentin19

19

Gabapentin is an anti-epileptic and can be used in multiple sclerosis to control
dysesthesias (pain caused by MS lesions) and the pain caused by spasticity. http://www.
nationalmssociety.org/Treating-MS/Medications/Neurontin# (last visited on Sept. 18, 2015).

-19-

dose from 100 to 200 mg,20 and she was referred to physical therapy for gait
training. (Tr. 786, 794).
On September 7, 2012, plaintiff presented with a lump in her right groin and
pain in her sacroiliac joint. She also complained of needle-like pain in her chest
area, consistent with multiple sclerosis flares. (Tr. 821-24). She had fatigue, fever,
chills, and weakness. On examination, no movement disorder was noted. At follow
up on September 18, 2012, plaintiff complained of swelling, pain, and stiffness in
her right knee, and low back pain that radiated to her right hip and knee. (Tr. 81216). Plaintiff rated her pain at 8 on a 10-point scale. She had trouble straightening
her knee after prolonged sitting. She continued to have tenderness in the right
groin area. On examination, Nurse Wright noted fatigue, chronic muscle weakness,
and crepitus in the right knee. A straight leg test was positive on the right side. Xrays showed mild degenerative changes in the right knee and severe lumbar
spondylosis and osteoporosis. (Tr. 815). An MRI of the lumbar spine confirmed that
plaintiff had degenerative disc disease at multiple levels and disc herniation or
bulges at L1-L2, L2-L3, L3-L4, and L4-L5. She had moderate to moderately severe
nerve impingement on the left side. (Tr. 877-78). The findings at L3-L4 and L4-L5
were more pronounced when compared to a CT scan from January 2012.
On October 10, 2012, Nurse Wright met with plaintiff to review the MRI
findings. (Tr. 801-11). Plaintiff complained of back pain, which she rated at level 8.
Her groin pain was resolved. Her liver function tests were elevated. Nurse Wright
recommended that plaintiff see a spine specialist.
III. The ALJ’s Decision

20

It is unclear from the record when plaintiff began taking gabapentin.

-20-

In the decisions issued on April 12, 2013, the ALJ made the following findings
with respect to plaintiff’s applications for a period of disability and disability
insurance benefits:
1.

Plaintiff met the insured status requirements of the Social Security Act
through December 31, 2012.

2.

Plaintiff did not engage in substantial gainful activity from her alleged
onset date of October 21, 2007, through her date last insured.

3.

Through the date last insured, plaintiff had the following severe
impairments: combination of osteoarthritis, Sjogren’s Syndrome, and
degenerative disc disease of the cervical and lumbar spine.

4.

Through the date last insured, plaintiff did not have an impairment or
combination of impairments that meet or medically equal the severity
of one of the listed impairments in 20 C.F.R. Part 404, Subpart P,
Appendix 1.

5.

Plaintiff has the residual functional capacity to perform the full range of
light work as defined in 20 C.F.R. § 404.1567(b).

6.

Through the date last insured, plaintiff was able to perform her past
relevant work as a folder, a warehouse worker and hand packer. This
work did not require work-related activities precluded by plaintiff’s
residual functional capacity.

7.

Plaintiff was not under a disability within the meaning of the Social
Security Act from October 21, 2007, through December 31, 2012.

(Tr. 32-42).
The ALJ’s findings with respect to plaintiff’s disabled widow’s benefits were
substantially the same, except that the eligibility period for these benefits extended
to July 31, 2015. (Tr. 15).
IV. Legal Standards
The Court must affirm the Commissioner’s decision “if the decision is not
based on legal error and if there is substantial evidence in the record as a whole to
support the conclusion that the claimant was not disabled.”
-21-

Long v. Chater, 108

F.3d 185, 187 (8th Cir. 1997). “Substantial evidence is less than a preponderance,
but enough so that a reasonable mind might find it adequate to support the
conclusion.” Estes v. Barnhart, 275 F.3d 722, 724 (8th Cir. 2002) (quoting Johnson
v. Apfel, 240 F.3d 1145, 1147 (8th Cir. 2001)). If, after reviewing the record, the
Court finds it possible to draw two inconsistent positions from the evidence and one
of those positions represents the Commissioner’s findings, the Court must affirm
the decision of the Commissioner. Buckner v. Astrue, 646 F.3d 549, 556 (8th Cir.
2011) (quotations and citation omitted).
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 death 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); Pate-Fires v. Astrue, 564 F.3d 935, 942 (8th Cir. 2009).

The

Commissioner has established a five-step process for determining whether a person
is disabled. See 20 C.F.R. § 404.1520; Moore v. Astrue, 572 F.3d 520, 523 (8th
Cir. 2009).

“Each step in the disability determination entails a separate analysis

and legal standard.” Lacroix v. Barnhart, 465 F.3d 881, 888 n.3 (8th Cir. 2006).
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.

If the claimant does not suffer from a listed impairment or its

equivalent, the Commissioner’s analysis proceeds to steps four and five. Id.
APrior to step four, the ALJ must assess the claimant=s residual functioning
capacity

(>RFC=),

which

is

the

most
-22-

a

claimant

can

do

despite

her

limitations.@Moore,572 F.3d at 523 (citing 20 C.F.R. ' 404.1545(a)(1)). “RFC is an
administrative assessment of the extent to which an individual’s medically
determinable impairment(s), including any related symptoms, such as pain, may
cause physical or mental limitations or restrictions that may affect his or her
capacity to do work-related physical and mental activities.” Social Security Ruling
(SSR) 96-8p, 1996 WL 374184, *2. “[A] claimant’s RFC [is] based on all relevant
evidence, including the medical records, observations by treating physicians and
others, and an individual’s own description of his limitations.” Moore, 572 F.3d at
523 (quotation and citation omitted).
In determining a claimant’s RFC, the ALJ must evaluate the claimant’s
credibility.

Wagner v. Astrue, 499 F.3d 842, 851 (8th Cir. 2007); Pearsall v.

Massanari, 274 F.3d 1211, 1217 (8th Cir. 2002). This evaluation requires that the
ALJ consider “(1) the claimant’s daily activities; (2) the duration, intensity, and
frequency of the pain; (3) the precipitating and aggravating factors; (4) the
dosage,

effectiveness,

and

side

effects

of

medication;

(5)

any

functional

restrictions; (6) the claimant’s work history; and (7) the absence of objective
medical evidence to support the claimant’s complaints.”

Buckner v. Astrue, 646

F.3d 549, 558 (8th Cir. 2011) (quotation and citation omitted). “Although ‘an ALJ
may not discount a claimant’s allegations of disabling pain solely because the
objective medical evidence does not fully support them,’ the ALJ may find that
these allegations are not credible ‘if there are inconsistencies in the evidence as a
whole.’” Id. (quoting Goff v. Barnhart, 421 F.3d 785, 792 (8th Cir. 2005)). After
considering the seven factors, the ALJ must make express credibility determinations
and set forth the inconsistencies in the record which caused the ALJ to reject the
-23-

claimant’s complaints. Singh v. Apfel, 222 F.3d 448, 452 (8th Cir. 2000); Beckley
v. Apfel, 152 F.3d 1056, 1059 (8th Cir. 1998).
At step four, the ALJ determines whether a claimant can return to her past
relevant work, “review[ing] [the claimant’s] [RFC] and the physical and mental
demands of the work [claimant has] done in the past.” 20 C.F.R. § 404.1520(e).
The burden at step four remains with the claimant to prove her RFC and establish
that she cannot return to her past relevant work. Moore, 572 F.3d at 523; accord
Dukes v. Barnhart, 436 F.3d 923, 928 (8th Cir. 2006); Vandenboom v. Barnhart,
421 F.3d 745, 750 (8th Cir. 2005).
If the ALJ holds at step four of the process that a claimant cannot return to
past relevant work, the burden shifts at step five to the Commissioner to establish
that the claimant maintains the RFC to perform a significant number of jobs within
the national economy.

Banks v. Massanari, 258 F.3d 820, 824 (8th Cir. 2001).

See also 20 C.F.R. § 404.1520(f).
If the claimant is prevented by her impairment from doing any other work,
the ALJ will find the claimant to be disabled.
V. Discussion
Plaintiff argues that the ALJ incorrectly determined her residual functional
capacity (RFC).
A claimant’s RFC is “the most a claimant can still do despite his or her
physical or mental limitations.” Martise v. Astrue, 641 F.3d 909, 923 (8th Cir. 2011)
(internal quotations, alteration and citations omitted). “The ALJ bears the primary
responsibility for determining a claimant’s RFC and because RFC is a medical
question, some medical evidence must support the determination of the claimant’s
-24-

RFC.” Id. (citation omitted). The ALJ should obtain medical evidence that addresses
the claimant’s “ability to function in the workplace.” Lauer v. Apfel, 245 F.3d 700,
704 (8th Cir. 2001) (quoting Nevland v. Apfel, 204 F.3d 853, 858 (8th Cir. 2000)).
“However, the burden of persuasion to prove disability and demonstrate RFC
remains on the claimant.” Id. Even though the RFC assessment draws from medical
sources for support, it is ultimately an administrative determination reserved to the
Commissioner. Cox v. Astrue, 495 F.3d 614, 619 (8th Cir. 2007) (citing 20 C.F.R.
§§ 416.927(e)(2), 416.946 (2006)).
The ALJ determined that plaintiff retained the RFC to perform the full range
of light work. The regulations define light work as “involv[ing] lifting no more than
20 pounds at a time with frequent lifting or carrying of objects up to 10 pounds.” 20
C.F.R. § 404.1567(b). Additionally, “[s]ince frequent lifting or carrying requires
being on one’s feet up to two-thirds of a workday, the full range of light work
requires standing or walking, off and on, for a total of approximately 6 hours of an
8–hour workday.” Social Security Regulation (SSR) 83–10, 1983 WL 31251, at *6
(Dec. 12, 1983). Plaintiff argues that, in determining that she had the capacity to
perform

light

work,

the

ALJ

improperly

assessed

her

multiple

sclerosis,

osteoarthritis, history of anal cancer, depression and anxiety, and learning
disabilities.
Multiple Sclerosis: The ALJ found that plaintiff’s multiple sclerosis was wellcontrolled and therefore was not a serious impairment. (Tr. 16, 35). An impairment
is not severe if it amounts only to a slight abnormality that would not significantly
limit the claimant’s physical or mental ability to do basic work activities. See Bowen
v. Yuckert, 482 U.S. 137, 153 (1987); 20 C.F.R. § 404.1521(a). Severity is not an
-25-

onerous requirement for the claimant to meet, but it is also not a toothless
standard. Kirby v. Astrue, 500 F.3d 705, 708 (8th Cir. 2007) (citation omitted). If
an ALJ incorrectly fails to find an impairment to be severe, the error is harmless if
the ALJ finds the claimant to suffer from another severe impairment, continues in
the evaluation process, and considers the effects of the impairment at the other
steps of the evaluation process. Faint v. Colvin, 26 F. Supp. 3d 896, 910 (E.D. Mo.
2014).
The court finds that the ALJ erred in concluding that plaintiff’s multiple
sclerosis was not a serious impairment. The court further finds that the error is not
harmless because the ALJ did not consider the effects of the multiple sclerosis in
determining plaintiff’s RFC. Plaintiff consistently displayed symptoms of multiple
sclerosis, including fatigue, light-headedness, and needle-like sensation. In July
2011, plaintiff reported that she ran into things and complained of falls and
clumsiness. In December 2011, she reported intermittent numbness in her left foot.
(Tr. 856). In March 2012, it was noted that her right leg turned outward and
sometimes buckled when she walked. She had paresthesias of the right calf and
absent reflexes. (Tr. 794-98). In June 2012, emergency room personnel noted that
plaintiff had an unsteady gait. (Tr. 763). These conditions would affect plaintiff’s
ability to walk and stand and the ALJ was required to consider limitations arising
from multiple sclerosis before determining plaintiff’s RFC.
The only medical opinion evidence in the record was proffered by Nurse
Wright, who opined that plaintiff’s limitations prevented her from working. The ALJ
rejected Nurse Wright’s opinion, in part, because she was not an acceptable

-26-

medical source as defined by the regulations.21 (Tr. 21, 40). Once the ALJ rejected
Nurse Wright’s opinion, she had a duty to further develop the record to obtain
medical evidence regarding plaintiff’s limitations. See Stormo v. Barnhart, 377 F.3d
801, 806 (8th Cir. 2004) (ALJ has independent duty to develop the medical record);
Jackson v. Colvin, No. 4:13-CV-233-NAB, 2013 WL 6571600, at *2 (E.D. Mo. Dec.
13, 2013) (ALJ had duty to develop record where plaintiff was treated for multiple
sclerosis and alleged symptoms consistent with diagnosis). The ALJ should have
obtained a medical source statement from Dr. Sandhu or ordered a consultative
evaluation to determine the effect of plaintiff’s multiple sclerosis on her ability to
work.
Osteoarthritis and other pain: Plaintiff argues that the ALJ improperly
evaluated

the

effects

of

her

osteoarthritis

and

degenerative

disc

disease.

Specifically, plaintiff alleges that the ALJ made factual errors in determining that
plaintiff’s allegations of disabling pain in her knees, hands, and back were not
credible. (Tr. 18, 40).
When evaluating evidence of pain or other subjective complaints, the ALJ is
never free to ignore the subjective testimony of the plaintiff, even if it is
uncorroborated by objective medical evidence. Basinger v. Heckler, 725 F.2d 1166,
1169 (8th Cir. 1984). In considering the subjective complaints, the ALJ is required
to consider the factors set out by Polaski v. Heckler, 739 F.2d 1320 (8th Cir. 1984),
which include: “(1) the claimant’s daily activities; (2) the subjective evidence of the
duration, frequency, and intensity of the claimant’s pain; (3) any precipitating or
aggravating factors; (4) the dosage, effectiveness and side effects of any
21

The ALJ also found that Nurse Wright’s opinion was inconsistent with the record as a
whole. (Tr. 21, 40).

-27-

medication; and (5) the claimant’s functional restrictions.” Masterson v. Barnhart,
363 F.3d 731, 738 (8th Cir. 2004) (citing Polaski, 739 F.2d at 1322). “When
rejecting a claimant’s complaints of pain, the ALJ must make an express credibility
determination, detailing the reasons for discounting the testimony, setting forth the
inconsistencies, and discussing the Polaski factors.” Renstrom v. Astrue, 680 F.3d
1057, 1066 (8th Cir. 2012) (citation omitted). “[A]n ALJ may not discount a
claimant’s subjective complaints solely because the objective medical evidence does
not fully support them.” Id. (alteration in original; citation omitted). When an ALJ
explicitly finds that the claimant’s testimony is not credible and gives good reasons
for the findings, the court will usually defer to the ALJ’s finding. Casey v. Astrue,
503 F.3d 687, 696 (8th Cir. 2007).
The ALJ cited discounted plaintiff’s knee pain, stating that she “navigate[d]
the stairs” of her “three-story home” on a “daily” basis. (Tr. 20, 39). This is a
misstatement of the evidence in the record: plaintiff testified that she lives in a
two-story home with a basement and that her room is on the main floor. The
laundry facilities were in the basement, but she did not do her own laundry. (Tr.
63-64). Thus, there is no evidence that plaintiff navigated stairs on a daily basis.
The ALJ also stated that plaintiff did not take narcotic medications. However, the
record establishes that throughout the period covered by the medical records
plaintiff was routinely prescribed Vicodin and Tramadol, which she used in
conjunction with ibuprofen and Tylenol. (Tr. 389, 315, 382, 377, 438, 374, 366,
364, 662, 692, 851, 823, 812, 801). In addition, plaintiff was administered
injections to treat knee pain. (Tr. 273, 375; see also 705 (requesting injection)).
The ALJ also cited the lack of physical therapy as a reason for discrediting plaintiff’s
-28-

claims. In 2008, Dr. Siva recommended physical therapy to treat plaintiff’s leftknee pain, but she could not afford it. And, in July 2012, Dr. Sandhu ordered
physical therapy to treat plaintiff’s gait imbalance. (Tr. 274). The ALJ also
incorrectly stated that plaintiff did not use a cane. (See Tr. 231, 226, 646). The
ALJ’s credibility determination is flawed as a result of these factual errors.
Plaintiff also complains that the ALJ did not properly account for the clinical
findings in MRIs and CT scans of her spine. In January 2011, an MRI disclosed
moderate cervical spondylosis, severe left-sided stenosis, moderate right-sided
stenosis, and mild degenerative disc disease at other levels of the spine. (Tr. 52324). A CT scan completed in June 2012 showed “degenerative changes at multiple
levels of the spine.” (Tr. 769). In September 2012, Nurse Wright recorded that an
x-ray showed severe lumbar spondylosis and osteoporosis. (Tr. 815). Finally, an
MRI of the lumbar spine in October 2012 showed degenerative disc disease at
multiple levels and disc herniation or bulges throughout the lumbar spine. Two of
the bulges were more pronounced than they had been 10 months earlier and
showed moderate to moderately severe nerve impingement on the left side. On
remand, the ALJ should obtain a medical opinion regarding the significance of these
objective findings.
Nonexertional impairments: Plaintiff argues that the ALJ failed to properly
consider her learning disabilities and depression and anxiety. The ALJ found that
there was no evidence in the record that plaintiff had been diagnosed with learning
disabilities. Her education records show very low academic performance and
plaintiff reports that she cannot read or write well, a condition that negatively
affected her ability to perform her work as an order filler. With respect to
-29-

depression and anxiety, the record reflects that, despite medication, plaintiff
consistently reported that she suffered from insomnia and fatigue. The ALJ should
develop the record to determine whether to include nonexertional limitations in the
RFC determination.
Other conditions: The record establishes that plaintiff had chronic poorlycontrolled anemia and GERD. On remand, the ALJ should address whether these
conditions have an effect on plaintiff’s RFC. As a result of her treatment for anal
carcinoma, plaintiff appears to suffer from diarrhea and incontinence. Plaintiff
routinely reported to Dr. Westgate that she was not concerned by these conditions
and the ALJ did not err in failing to include limitations in the RFC determination. Dr.
Westgate noted that plaintiff had pain in her hips which could be attributed to
radiation fibrosis. The ALJ should address whether this pain imposes restrictions on
plaintiff’s capacity to perform work-related activities.
VI. Conclusion
For the reasons discussed above, the Court finds that the Commissioner’s
decision is not supported by substantial evidence in the record as a whole.
Accordingly,
IT IS HEREBY ORDERED that the decision of the Commissioner is
reversed and this matter is remanded pursuant to the fourth sentence of 42
U.S.C. § 405(g) for further proceedings. A separate Judgment in accordance with
this Memorandum and Order will be entered this same date.
___________________________
CAROL E. JACKSON
UNITED STATES DISTRICT JUDGE
Dated this 4th day of March, 2016.
-30-