Michelle K. M. v. Berryhill
| Decision Date | 18 March 2019 |
| Docket Number | Civil Action No. 3:17-CV-3044-BH |
| Parties | MICHELLE K. M., Plaintiff, v. NANCY A. BERRYHILL, ACTING, COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, Defendant. |
| Court | U.S. District Court — Northern District of Texas |
By consent of the parties and the order of transfer dated January 29, 2018 (doc. 16), this case has been transferred for the conduct of all further proceedings and the entry of judgment. Based on the relevant filings, evidence, and applicable law, the Commissioner's decision is REVERSED, and the case is REMANDED for further administrative proceedings.
Michelle K. M. (Plaintiff) seeks judicial review of a final decision by the Commissioner of Social Security (Commissioner) denying her claims for disability insurance benefits (DIB) under Title II of the Social Security Act (Act), and for supplemental security income (SSI) under Title XVI of the Act.
On December 19, 2014, Plaintiff filed her applications for DIB and SSI, alleging disability beginning on October 24, 2014. (doc. 14-1 at 84.)1 Her claims were denied initially on May 8,2015, and upon reconsideration on July 22, 2015. (Id. at 84, 110.) On July 29, 2015, Plaintiff requested a hearing before an Administrative Law Judge (ALJ). (Id. at 132.) She appeared and testified at a hearing on July 6, 2016. (Id. at 33-61.) On October 6, 2016, the ALJ issued a decision finding her not disabled and denying her claims for benefits. (Id. at 17-27.)
Plaintiff timely appealed the ALJ's decision to the Appeals Council on October 17, 2016. (Id. at 179.) The Appeals Council denied her request for review on September 11, 2017, making the ALJ's decision the final decision of the Commissioner. (Id. at 5.) Plaintiff timely appealed the Commissioner's decision under 42 U.S.C. § 405(g). (See doc. 1.)
Plaintiff was born on July 14, 1974, and was 41 years old at the time of the hearing. (doc. 14-1 at 25, 38.) She had at least a high school education and could communicate in English. (Id. at 25.) She had past relevant work experience as a medical assistant. (Id. at 25.)
On July 8, 2014, Plaintiff had x-rays performed on her hips, lumbar spine, right hand, both feet, and sacrum and coccyx. (Id. at 317-22, 462.) X-rays of her hips, right hand, and both feet showed no evidence of fractures or dislocations, unremarkable soft tissues, no erosions, and preserved joint spaces. (Id. at 317-22.) She did have hallux valgus angulation of the first MTP joint in her left foot, however. (Id. at 321.) The x-ray on her spine was performed due to psoriatic arthropathy and showed that the vertebral bodies had normal height, alignment, and density, there was no subluxation or fracture, and the soft tissues had normal appearance. (Id. at 319.) The results of the x-ray of her sacrum and coccyx were unremarkable. (Id. at 462.)
On July 22, 2014, an MRI was performed on Plaintiff's lumbar spine. (Id. at 323.) The results indicated that Plaintiff had a congenitally narrow central canal secondary to short pedicles, multilevel facet osteoarthritis, but no neural foraminal stenosis, and that her central canal was mildly narrowed below the L3-L4 level. (Id. at 324.) MRIs were also performed on her right and left thighs and showed bone marrow edema within the proximal left and right femoral shafts, presumably related to stress or overuse, and no discrete fractures. (Id. at 325-28.)
Also on July 22, 2014, Plaintiff saw Gena Nelson, R.N., for a follow-up appointment and medication management. (Id. at 707.) Plaintiff reported impaired mobility, joint pain, and stiffness. (Id.) She described chronic depressive symptoms that occurred daily, as well as chronic anxiety symptoms. (Id.) She denied having suicidal thoughts or intentions, but stated that she previously had thoughts about there being no point in "going on." (Id.) She expressed feelings of frustration, anxiety, guilt, helplessness, and sadness, and Nurse Nelson discussed coping with chronic pain and depression with her. (Id. at 709.) Nurse Nelson noted that Plaintiff had taken her medication regularly, her behavior had been stable and unremarkable, and she described no side effects, and none were evidenced. (Id. at 707.) Plaintiff appeared friendly, attentive, fully communicative, and casually groomed, but she "look[ed] unhappy," and there were signs of severe depression. (Id. at 708.) Her affect was appropriate, full range, and congruent with her mood; her thinking was tangential and logical; her thought content was appropriate; she had no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic processes; and she denied having suicidal or homicidal ideas or intentions. (Id.) Her cognitive functioning and fund of knowledge was intact; she was fully oriented; her social judgment was fair; her short and long term memory, as well as her ability to abstract and do math calculations was intact; and she had fairinsight into problems. (Id.) There were no signs of hyperactive or attentional difficulties, but there were signs of anxiety. (Id.) Her muscle strength, muscle tone, gait, and station were all normal. (Id.) She was diagnosed with major depressive disorder, generalized anxiety disorder, and insomnia disorder, and she had a global assessment of functioning (GAF) score of 50. (Id. at 709.) Nurse Nelson noted that Plaintiff continued to exhibit symptoms of an emotional disorder that interfered with her day-to-day functioning, and that she was in need of medication management. (Id.) Plaintiff's medications included Cymbalta, Xanax, Ambien, Gamaguard, Tizanidine, and Abilify. (Id. at 709-710.)
On July 31, 2014, Plaintiff underwent a three-phase bone scintigraphy due a disorder of her bone cartilage and an abnormal MRI of her left femur. (Id. at 329.) The results showed mild non-specific increased cortical activity within the femur bilaterally and no focal abnormal activity corresponding to the area of abnormality shown in the recent MRI. (Id.) Plaintiff also underwent a whole body scintigraphy study, which showed scattered areas of increased activity likely due to degenerative disease, but there was no focal abnormal uptake involving the proximal left femur. (Id. at 331.)
On August 5, 2014, Plaintiff saw Robert J. Meador Jr., M.D., with complaints of mixed connective tissue disease (MCTD). (Id. at 650.) She reported that she continued to have severe pain, and that her knees, hips, and toes were still very painful. (Id.) She was having pain with lifting objects and even pressing on the accelerator, felt like she was going to fall a lot, had trouble getting out of the shower, had weakness all the time, had a lot more stiffness in the morning, and broke out in sweats when she had pain. (Id.) She also complained of fatigue, malaise, dry eyes, dry mouth, constipation, back pain, joint pain, muscle cramps, muscle weakness, muscle aches, musclespasms, stiffness, morning stiffness, leg pain with exertion, scalp pain, rashes and dryness, frequent headaches, difficulty walking, weakness, anxiety, and enlarged lymph nodes. (Id. at 651-52.) Dr. Meador determined that her problems included MCTD, unspecified disorder of bone and cartilage, and myalgia and myositis. (Id. at 653-54.) Her medications included Atrovent, Cymbalta, Fiberchoice, Gammagard, ibuprofen, Losartan potassium, melatonin, multivitamins, Noritate, Olux, probiotics, Relpax, Xanax, Zithromax, Zyrtec, Tizanidine, folic acid, Plaquenil, hydrocodone, and Methotrexate. (Id. at 654.)
On August 27, 2014, Plaintiff saw James T. Rester, M.D., at Lake Pointe Medical Partners (Lake Pointe), for myalgia, rash, and hypertension. (Id. at 339.) Her myalgia symptoms had begun 5 months prior to this appointment. (Id.) She was in a lot of pain, which she described as throbbing aches that were intense to dull, but never completely gone, although resting helped. (Id.) She reported trouble working during the day and staying on task; she felt like her mind was foggy and "having short term memory for simple tasks," and she would nod off to sleep at her desk. (Id.) At home, she was limited in washing dishes, sweeping, mopping, bending down to clean or get clothes, and grocery shopping due to her pain. (Id.) She could sleep 12-14 hours on the weekends and still take a nap, and she lost the desire to do many things due to pain. (Id.) Just standing hurt her. (Id.) She listed her symptoms as muscle pain, tendon pain in her ankles, knees, and groin area, pain in the bottom of her feet, lower back spasms that woke her up, pain between her shoulder blades, low grade fevers, and great toe pain bilaterally. (Id.) It also hurt her hands to write sometimes. (Id.) She was becoming depressed and lost in the pain, which had been ongoing since March 2014. (Id.) She also complained of back spasms with some shooting pains into her buttocks intermittently that did not radiate to her legs. (Id.) Her rash affected multiple areas, and it was not associated withcontact with chemicals, plants, perfume, soaps, or lotions. (Id.) Associated symptoms included fatigue, myalgia, and pruritus. (Id.) Regarding her hypertension, associated symptoms included fatigue, and pertinent negatives included chest pain, dyspnea, headaches, irregular heartbeat, nausea, and vomiting. (Id.) Her physical exam was normal, except that she had an obese abdomen with abdominal tenderness and tenderness in her hip, knee, and ankle. (Id. at 342.) Her medications included Atrovent, Cymbalta, Flector, gabapentin, hydrocodone, Losartan, melatonin, Olux, Relpax, Tizanidine, tramadol, Xanax, Zithromax, and Zyrtec. (Id. at 342-43.) She was assessed with fibromyalgia, bursitis, hypertension, and fatigue. (Id. at 343.)
On September 16, 2014, an MRI was performed on Plaintiff's brain due to headaches, imbalance, sleep disturbance, and chronic...
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