United States District Court, D. South Dakota, Southern Division
JENNIFER L. EASTMAN, Plaintiff,
NANCY A. BERRYHILL,  Deputy Commissioner for Operations, performing the duties and functions not reserved to the Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION
VERONICA L. DUFFY, UNITED STATES MAGISTRATE JUDGE.
Jennifer L. Eastman, seeks judicial review of the
Commissioner's final decision denying her application for
supplemental security income disability (“SSI”)
benefits under Title XVI of the Social Security
Eastman has filed a complaint and has requested the court to
reverse the Commissioner's final decision denying her
disability benefits and to enter an order awarding benefits.
See Docket No. 13. Alternatively, Ms. Eastman
requests the court remand the matter to the Social Security
Administration for further proceedings.
appeal of the Commissioner's final decision denying
benefits is properly before the district court pursuant to 42
U.S.C. § 405(g). This matter was referred to this
magistrate judge pursuant to 28 U.S.C. § 636(b)(1)(B)
and the October 16, 2014, standing order of the Honorable
Karen E. Schreier, district judge.
Statement of the Case
action arises from plaintiff, Jennifer J. Eastman's,
application for SSI filed on February 13, 2014, alleging
disability since January 4, 2013, due to PTSD, anxiety, panic
attacks, depression, learning disability, neurological muscle
spasm disorder, with spasms in her back and hips, and
degenerative disc disease. AR335, 363, 380-81.
Eastman's claim was denied initially and upon
reconsideration. AR268, 276. Ms. Eastman then requested an
administrative hearing. AR283.
Eastman's administrative law judge (ALJ) hearing was held
on May 17, 2016, by Brenda Rosten. AR202. Ms. Eastman was
represented by other counsel at the hearing and an
unfavorable decision was issued on August 16, 2016. AR10.
Plaintiff's current counsel then appeared to appeal her
hearing-level denial. AR333.
one of the evaluation, the ALJ found that Ms. Eastman had not
engaged in substantial gainful activity (“SGA”)
since the date of her SSI application, February 13, 2014.
two, the ALJ found that Ms. Eastman had severe impairments of
mild degenerative disc disease of the cervical spine and
lumbar spine, osteopenia of the left knee, affective disorder
and anxiety disorder. AR15.
also found that Ms. Eastman had medically determinable
impairments of thyroid cancer, left trapezius strain and
cellulitis, which were found non-severe impairments. AR16.
also stated that there were references in the record to an
intellectual/learning disability, but found that it did not
represent a medically determinable impairment as there was no
definitive diagnosis of this condition or an indication of a
cognitive defect in the record. AR16.
also stated in the decision, “that the claimant's
alleged intellectual disability does not meet the
requirements of medical listing 12.05, as there is no
evidence of deficits in adaptive functioning before age 22.
The claimant reported that she was in special education and
had difficulties in math and reading. This is consistent with
the claimant's educational records, which show a full
scale IQ of 64 and a grade point average of 2.7 (Exhibit
15E/3). However, the claimant testified that she graduated
high school and had a driver's license. She also reported
that she could read the newspaper to some extent. The
claimant also worked for the post office at substantial
gainful activity levels prior to the alleged onset date. The
undersigned notes that although the claimant's
intellectual disability is a non-medically determinable
impairment in this record, her alleged limitations fall
within the very simple, unskilled work that is set out in the
residual functional capacity below.” AR16-17.
found that Ms. Eastman did not have an impairment that met or
medically equaled one of the listed impairments in 20 CFR
404, Subpart B, App 1 (20 CFR §§ 416.920(d),
416.925, and 416.926) (hereinafter referred to as the
“Listings”). AR17. The ALJ found that Ms. Eastman
had mild limitations in activities of daily living, moderate
limitations in social functioning, and moderate difficulties
with concentration, persistence or pace. AR18. The ALJ noted
a short-term psychiatric hospital stay, but no episodes of
decompensation of extended duration. AR18.
determined that Ms. Eastman had the residual functional
capacity (“RFC”) to perform:
A range of light work as defined in 20 CFR 416.967(b).
Specifically, she can lift and/or carry 20 pounds
occasionally and 10 pounds frequently. The claimant can sit
for about 6 hours in an 8-hour workday, and stand and/or walk
combined about 6 hours in an 8hour workday. She should never
climb ladders, ropes or scaffolds, but can occasionally climb
ramps and stairs, and occasionally stoop, kneel, crouch and
crawl. The claimant should have no more than occasional work
around hazards (such as unprotected heights and fast and
dangerous moving machinery). Mentally, the claimant is
limited to simple tasks. She is able to maintain
concentration, persistence, and pace for two-hour segments.
She can respond appropriately to brief and superficial
interactions with the general public.
ALJ's credibility finding regarding Ms. Eastman's
statements concerning the intensity, persistence and limiting
effects of her symptoms was that they were not
“entirely consistent with the medical evidence and
other evidence in the record for the reasons explained in
this decision.” AR20.
considered the opinions of the state agency psychological
consultants who determined that Ms. Eastman could understand,
remember, and carry out two-step instructions on a consistent
basis, and could sustain a basic level of attention and
concentration for two-hour segments if she was in a routine
work environment and that Ms. Eastman would require reduced
contact with the public, was not capable of working in a
crowd of people, and she would require a routine work
environment but was capable of responding appropriately to
basic changes in the work setting, if it was routine. AR24.
The ALJ gave the opinions “considerable weight”
because their assessments were consistent with the record as
a whole, specifically that over time Ms. Eastman's
symptoms improved with medication and counseling and she was
capable of maintaining activities of daily living and some
outside activity, citing Exhibit 20F/1. AR24.
considered the third-party statement completed by Ms.
Eastman's husband and stated that she
“accepts” his observations, but gave them little
weight, asserting that they were based on casual observations
and not objective medical testing or clinical observations.
considered the psychological report prepared by psychologist,
Mary Honer, Ed.D, in 1993, and noted that the report
reflected that Ms. Eastman had a full scale IQ of 64, and
that she had been in special education since elementary
school, but gave the opinion “little weight”
acknowledging that it supported “some type of
intellectual or learning disability” but asserted it
was not consistent with Ms. Eastman's work and tasks as
an adult, that it did not contain a specific diagnosis and it
was prepared for school purposes. AR25.
stated the RFC was based on the treatment record, Ms.
Eastman's testimony, and her reported activities of daily
living, and given Ms. Eastman's degenerative disc disease
and osteopenia the ALJ stated “the undersigned has
limited her to a light exertional level, with occasional
postural limitations” and height and hazard
restrictions were incorporated into the RFC due to Ms.
Eastman's reported dizziness due to her medications.
stated that due to Ms. Eastman's mental limitations, she
limited her to simple tasks for which she could maintain her
concentration, persistence and pace for two-hour segments and
to only brief and superficial interactions with the public.
on the RFC determined by the ALJ, the ALJ first found that
Ms. Eastman was capable of performing past relevant work as a
Mail Processing Clerk (AR25), but then stated in the
explanation section that Ms. Eastman “cannot”
perform her past work as a Mail Processing Clerk. AR26. The
ALJ found that Ms. Eastman was not disabled at step 4. AR26.
Eastman timely requested review by the Appeals Council
(AR333), and submitted additional new and material evidence
after notifying the Appeals Council that the record had not
been fully developed (AR442), consisting of:
a. Medical records from Sanford - Physical Medicine and
Rehabilitation Clinic for March 7, 2012, to April 26, 2016.
b. Medical records from Sanford - Family Medicine Clinic for
March 6, 2015, to May 10, 2016. See AR42-64.
c. Medical records from AMG Midwest Psychiatric Clinic for
January 12, 2016, to June 27, 2016. See AR32-42.
Appeals Council acknowledged receiving the evidence submitted
by Ms. Eastman, but stated that it did not consider and
exhibit the evidence because it found the “evidence
does not show a reasonable probability that it would change
the outcome of the decision.” AR2.
Appeals Council denied Ms. Eastman's request for review
making the ALJ's decision the final decision of the
Commissioner. AR1. Ms. Eastman then timely filed this action.
Plaintiff's Age, Education and Work Experience
Eastman was born in October of 1976, and completed the 12th
grade in 1995 with attendance in special education classes
from kindergarten to the 12th grade at Bolsa School in
California. AR335, 364.
appeal record contained Ms. Eastman's high school
transcript that included a psychological report with Wechsler
IQ testing performed in 1987 and 1993. AR432. The report
indicated that IQ testing administered in 1987 revealed a VIQ
or verbal IQ of 57, and a PIQ or performance IQ of 89, and
that upon retesting in 1993 the VIQ was 54, PIQ was 80 and
full scale IQ was 64. AR432. The transcript indicated a 2.7
GPA, and that she had “MET D/STD” proficiency
standards in reading, mathematics, and English, but many of
the listed classes included the designation “SE”
or special education following the class name. AR430. The
report indicated that Ms. Eastman had been in special
education classes since elementary school and was only
mainstreamed for physical education. AR433. The psychologist
stated that Ms. Eastman's cognitive ability was in the
overall deficient range with verbal scores significantly
lower than performance scores suggesting a communication
handicap, and her greatest weakness involved auditory
processing, receptive and expressive language and memory.
AR433. Ms. Eastman's Individualized Education Program
(IEP) stated that she met the Title 5 eligibility due to a
learning disorder. AR435. The IEP stated that her proficiency
tests in math, reading, and English would be given with no
time limits, in a small classroom setting, and with needed
assistance given because regular testing exceeded her current
level of functioning. AR435. The transcript also contained
scores from Wide Range Achievement Testing, and
Woodcock-Johnson Testing, which were consistent with the
intellectual impairment shown in the IQ test results. AR432.
identified Ms. Eastman's past relevant work as a mail
processing clerk, Dictionary of Occupational Titles (DOT) #
Relevant Medical Evidence
Sanford Family Medicine
Eastman was seen at the Sanford Family Medicine Clinic on May
5, 2013, for muscle spasms in her neck, back and shoulder and
her assessments included trapezius muscle strain, stress and
adjustment disorder, and anxiety reaction. AR466. Citalopram
was prescribed for her dysthymia symptoms and counseling was
encouraged. AR467. She was seen again on June 28, 2013, with
continued neck and shoulder symptoms for which she had been
receiving physical therapy. AR473. An exam revealed cervical
tenderness with an x-ray showing straightening of the
cervical spine and mild degenerative changes, and flexeril
was prescribed. AR473-74, 478, 839-40. Ms. Eastman received
five physical therapy sessions from May 23, 2013, to June 7,
2013, for neck/shoulder pain. AR606. Continued therapy was
recommended and completed through 10 sessions when further
therapy was again recommended due to ongoing pain and
limitations. AR606, 613, 636-37.
Eastman was seen on January 3, 2014, for anxiety (following
an emergency room visit on Christmas day), which she had been
dealing with since she had a dilation and curettage (D&C)
procedure for a miscarriage and the uterine artery was cut
and she nearly bled out. AR493. She ended up having an
emergency hysterectomy. AR493. Ms. Eastman also complained of
ongoing back pain. AR493. She had been on a number of anxiety
medications for short periods and had started counseling
following the emergency room visit. AR493. The doctor thought
her back symptoms may be related to stress and prescribed
valium pending an appointment with psychiatry. AR496.
Eastman was seen on April 2, 2014, for neck pain with
tingling and spasms in her left shoulder. AR765. Following
examination, a cervical spine MRI was ordered which revealed
some mild disc protrusion without spinal stenosis. AR764-65.
Eastman was seen on August 19, 2014, for chronic neck and hip
pain. AR702. Voltaren was prescribed for pain and behavioral
health was involved to help with her chronic pain and
long-term goals of functioning and maximum pain relief.
Eastman reported on August 22, 2014, that the Voltaren
prescribed for her neck pain was not helping, and she had
been to the emergency room due to dizziness, headache and
neck pain; Ultram was prescribed. AR696-97.
Eastman was seen on September 2, 2014, for follow-up for
chronic pain including headaches, back and neck pain. AR694.
Examination revealed diffuse paraspinous muscle tenderness,
stiffness was apparent, and range of motion limited with
pain. AR694. Her left leg was also noted to be one inch
shorter than her right. AR694.
Eastman contacted the clinic on September 15, 2014, and
received an orthopedic referral for her hip pain. AR690.
Sanford Family Medicine Clinic Records Submitted to
the Appeals Council
Eastman was seen on March 6, 2015, for a 60-pound increase in
her weight and fatigue and depression. AR43. Her assessments
at that time were obesity, major depressive disorder, panic
disorder with agoraphobia and moderate panic attacks, PTSD,
and tachycardia. AR43.
Eastman was seen on March 30, 2015, with neck and face
swelling and tenderness. AR45.
Eastman was seen on June 5, 2015, to follow-up on an
emergency room visit for cellulitis of the right arm. AR47.
Eastman was seen on February 5, 2016, complaining of
worsening problems with her memory. AR50. She reported that
she had problems learning since she was a child and she
graduated high school, but was told she was at the fifth
grade level. AR50. She said she had worked at numerous jobs,
but could never keep her job very long because she
couldn't keep up. AR50. The doctor felt her memory
problems were more related to her anxiety and problems
learning but did refer her for neuro psychiatric testing.
Eastman was seen on March 30, 2016, again to follow-up on an
emergency room visit for cellulitis of the left shoulder.
Sanford Physical Medicine & Rehabilitation Clinic
Records Submitted to Appeal Council
Eastman was seen on March 3, 2012, for bilateral numbness,
tingling and swelling in the upper extremities, which she
believed was due to repetitious activity at her post office
job and was diagnosed with arm pain and carpal tunnel of the
right wrist based on nerve conduction studies. AR70-71, 76,
Eastman was seen on April 30, 2014, for an initial
consultation regarding neck and upper back pain, which had
persisted for over one year with physical therapy,
chiropractic, and clonazepam treatments. AR80-81. Examination
revealed tenderness in the cervical paraspinal muscles. AR81.
A cervical spine MRI obtained on April 8, 2014, was reviewed
and revealed left C4-5 disc protrusion with mild
neuroforaminal stenosis, C5-6 disc bulge, and straightening
of the cervical lordosis, as well as thyroid nodule. AR81,
831-32. Trigger point injections were administered. AR81,
757. On June 2, 2014, Ms. Eastman reported that the TPI was
wearing off and she had the same pain as before. AR93, 716.
19, 2014, Ms. Eastman contacted the clinic again and reported
that her neck pain was terrible again; she couldn't lie
down and had terrible muscle spasms. AR97, 715. Ms. Eastman
was late for her appointment the next day and could not be
rescheduled until July 8, 2014, for another injection.
AR98-99. Ms. Eastman contacted the clinic again on June 23,
2014, and reported she couldn't take her neck pain much
longer, and was scheduled to start radiation treatment so she
wanted an injection for her neck before the radiation
treatment, but her doctor was out of town so an injection
could not be done. AR100, 714.
Eastman was seen on June 24, 2014, for her ongoing neck pain
and received trigger point injections again. AR102, 710. She
also received chiropractic treatment for her neck from July
31, 2014, to August 21, 2014. AR664-671.
Eastman was seen on November 3, 2014, for low back pain with
radiation to her leg. AR117. Examination revealed tenderness
to palpation over the lumbar paraspinal muscles, and limited
range of motion in flexion and extension. AR118. A lumbar MRI
revealed an L5-S1 annular tear without obvious nerve root
impingement. AR118. An epidural steroid injection was
administered at ¶ 5-S1, and physical therapy prescribed.
AR118, 136. Ms. Eastman reported on November 25, 2014, that
the injection helped 100% with her hips, but was still
getting occasional left leg pain and had pressure in her
back. AR138. She also asked about other possible treatment
for her neck. AR138. However, on December 17, 2014, Ms.
Eastman reported that her pain had not improved much since
the injection and she was having more back pain than hip
pain, and was having leg pain also. AR139.
seen on November 11, 2014, for a lumbar epidural injection
due to back and left leg pain, the physical exam note
included “Mental Status: normal.” AR946, 948.
November 19, 2014, Mark Ponstein, a physical therapist saw
Ms. Eastman for therapy due to left knee pain and stated that
Ms. Eastman did not have an antalgic gait, but noted she had
a slightly externally-rotated gait pattern. AR982, 983. Ms.
Eastman rated her left knee pain on average at 5-6/10. AR983.
She had slight pain deep in the knee on the left and no pain
on the right during resisted testing with knee extension at 0
degrees. AR983. After having her sitting posture corrected
for her low back and left leg symptoms went from 3-4/10 down
to 0/10. AR983. Ms. Eastman was educated on proper seated
position with a lumbar roll and educated to possibly lie on
her stomach more throughout the day instead of sitting in a
flexed position on her bed watching TV to help her low back
and left hip pain. AR984.
Eastman was seen on December 24, 2014, and reported that
overall she had received about 20% relief from the epidural
in her back. AR140. She continued to have low back pain with
radiation to the left leg, which was worse with prolonged
postures, bending and twisting, or getting out of her car,
and better with rest. AR140. Examination revealed continued
tenderness to palpation of the paraspinal muscles and the
slump sit test caused typical pain on the left, and an
additional epidural injection was planned and administered on
January 13, 2015. AR141, 153, 954.
January 19, 2015, Ms. Eastman contacted the clinic and
reported that the epidural had helped with the nerve pain
down her leg, but the back pain continued and increased.
AR155. She also reported that her back had “popped
out” and she feels something moving in her lower back.
AR155. On March 9, 2015, Ms. Eastman reported that she just
wanted to lay down all the time to make the back pain better
and sitting or standing for long periods hurt her hips more.
Eastman was seen on April 15, 2015, and had continued low
back pain with left sided leg pain and swelling in her legs,
and she reported that the epidural had not helped AR160.
Lumbar and thoracic spine MRIs were recommended. AR161.
April 22, 2015, Edward Czarneck, M.D., stated that Ms.
Eastman's lumbar MRI showed a disk desiccation and small
right protrusion at ¶ 5-S1 without definite spinal
stenosis or nerve root impingement. AR992. The MRI also
revealed minimal disk bulging at ¶ 4-5. AR992.
Eastman was seen on April 29, 2015, following the MRIs; the
thoracic MRI was unremarkable, and the lumbar MRI was
unchanged showing continued L5-S1 disk abnormality. AR181.
Treatment options including Lyrica, acupuncture, and a
surgical consultation were discussed. AR181. On May 27, 2015,
Ms. Eastman reported ongoing low back and leg pain and was
having difficulty lifting Pampers and other items. AR193.
April 12, 2016, the clinic contacted Ms. Eastman to schedule
recheck and possible additional injections. AR195. Ms.
Eastman returned the call and reported that her last
injection had been in January 2016 and she had received 0%
pain relief. AR196. Ms. Eastman's insurance would not
authorize the treatment because the last injection had not
helped, and she was scheduled to see the doctor to discuss
long term treatment, but missed the appointment. AR198-99.
Sanford Orthopedics & Sports Medicine Clinic
Eastman was seen on September 16, 2014, for bilateral hip
pain and reported a prior growth plate injury when she was 12
that created a leg length discrepancy and alters her gait
contributing to the hip pain. AR688. X-rays of the hips
revealed no fracture or dislocation but noted apparent leg
length discrepancy, and shoe lifts and physical therapy were
Eastman was seen on October 1, 2014, for left knee pain
following an injury 9 days earlier, and an x-ray revealed no
acute fracture, old healed fractures, and osteopenia; an MRI
was ordered. AR675, 678-79. The MRI revealed a small knee
effusion and ruptured popliteal cyst, edema, and slight
lateral subluxation of the patella without bone contusion.
Eastman contacted the orthopedic clinic on October 14, 2014,
and requested an order for a different left knee brace than
ordered by the doctor due to insurance coverage issues.
Sanford Surgical Associates and Sanford Endocrinology
Eastman was seen on July 15, 2014, post-surgery and one week
of radiation treatment for her thyroid cancer. AR705. She
reported fatigue and weight gain, which was felt to be
related to her psychiatric medication. AR705.
Eastman was seen on August 11, 2014, to follow-up on the
thyroidectomy performed in May due to cancer. AR703.
Eastman was discharged from physical therapy for a trapezius
strain following 14 sessions of therapy on July 10, 2013.
AR790-91. At discharge she reported ongoing pain rated 2/10
with medication. AR791.
Eastman was seen on December 25, 2013, at the emergency room
with shortness of breath and nausea, and was diagnosed with
anxiety. AR782, 785.
Eastman was seen on April 14, 2015, in the emergency room
with left leg swelling and pain. AR1012. Examination revealed
mild left leg swelling, NVI distally and venous Doppler was
obtained that was negative. AR1014, 1018. She was told to
elevate it, use ice, and follow-up with her primary care
Eastman was hospitalized on May 28, 2014, for papillary
thyroid cancer and a right thyroidectomy was performed.
Eastman was seen on September 21, 2014, in the emergency room
following an injury to her left knee two days earlier when
she fell off a chair, and reported pain and swelling. AR685.
Examination revealed decreased range of motion, swelling, and
tenderness in the knee, and her musculoskeletal exam also
revealed edema and tenderness. AR686.
Eastman was seen on February 11, 2015, in the emergency room
for palpitations and some dizziness. AR998. She was treated
with IV fluids, Ativan, Toradol, and Pheregan and released
feeling better. AR1003. The review of systems section of the
note included “Back: no pain.” AR998. She had
full strength in her arms and legs. AR1001. Matthew Finke,
M.D., stated her physical exam was unremarkable, her EKG and
chest x-ray showed no abnormalities, and his assessment was
April 2015, Courtney Merkwan, M.D., saw Ms. Eastman for lower
extremity edema and pain. AR1012. He noted that she had
normal motor abilities, muscle tone and strength. AR1013. The
review of systems section of the note included
“Musculoskeletal/Extremities: 门 swelling and pain,
back pain.” AR1913. A Doppler study of Ms.
Eastman's left leg was normal, and Dr. Merkwan indicated
that Ms. Eastman's pain was likely from her back. AR1014,
2015, Ms. Eastman sought treatment for what she thought was a
small bug bite or pimple on her upper arm. AR1021. She said
she had been “working out in the garage painting for
the last 2 days . . . .” AR1021. Kristen Busse, M.D.,
diagnosed cellulitis and also observed Ms. Eastman had a
normal mood, affect, behavior, judgment, and thought content.
March 2016, Matthew Finke, M.D., saw Ms. Eastman at the
emergency room for complaints of shoulder pain after she had
a tetanus immunization. AR1033. He diagnosed cellulitis, and
also noted that she had 5/5 strength in her arms and legs.
Sanford Psychiatry and Behavioral Health Records
Eastman was referred for therapy due to issues with PTSD and
anxiety and reported to her therapist on December 24, 2013,
that she lived with her spouse and four children, ages 17,
14, 11, and 5. AR524. She had a twin sister to whom she was
Eastman was seen on January 17, 2014, for psychiatric
evaluation and reported that she had previously been in the
hospital for a dilation and evacuation (D&E) procedure
for fetal demise at 16 weeks gestation, and in the recovery
room had experienced severe bleeding, apparently due to a
nick in the major artery, and had been rushed back into
surgery for an emergency hysterectomy thinking she was going
to die. AR777. She explained she lost the fetus and the
chance to have another baby both and had been depressed and
dysphoric since that time. AR777. Ms. Eastman's GAF was
assessed at 40 to 45, and Cymbalta was prescribed along with
valium and counseling. AR778. When she was seen a week later
she reported she was already feeling less depressed,
functioning a little better, and having less anxiety. AR774.
Eastman was seen on January 29, 2014, for counseling and
reported attending a friend's funeral and having a panic
attack, and that she continued to have pain with her anxiety.
AR773. She reported she was considering filing for
disability, and her counselor stated she supported Ms.
Eastman filing for disability given her circumstances. AR773.
Eastman was seen on February 26, 2014, for a psychiatric
visit and reported improved sleep, depression, and less
crying, but afternoon anxiousness, off and on irritability,
flashback nightmares, and she was forgetful and having memory
lapses. AR770. She was observed to be slightly psychomotor
slowed, and valium in the afternoon was added to her
Eastman was seen on March 11, 2014, for counseling and
reported that she continued to do a bit better, but still
struggled with nightmares at times, continued to avoid
crowds, and filed for disability. AR768.
Eastman stated she was beading some bookmarks and that this
helped her focus. She was looking forward to a visit from her
Eastman was seen on March 26, 2014, for a psychiatric visit
and reported that her sleep was better, memory was slowly
improving, family interactions were slowly getting better,
energy level was fair, was not having mood swings or racing
thoughts, but was irritable at times, and having episodic
sadness and mourning. AR767. She also reported shooting
neuropathic-sounding pain in her neck and shoulders, and was
observed to be moving a little slowly due to the pain. AR767.
Ms. Eastman was continuing twice weekly counseling sessions.
Eastman was seen on April 22, 2014, for a psychiatric visit
and was tearful when discussing the surgical event that
resulted in an emergency hysterectomy, and also mentioned her
neck pain and the nodules which had been found in her
Eastman was seen on May 27, 2014, for a psychiatric visit and
counseling and reported feeling better since Wellbutrin had
been prescribed. AR730-32. She reported that she felt
Cymbalta was working well for her, but mirtazapine was
causing weight gain, and clonazepam was working well for her
with fewer less intense panic attacks. AR762.
Eastman was seen on June 30, 2014, for a psychiatric visit
and counseling and her medications were continued unchanged.
AR709. She presented as being quite anxious in counseling and
was having trouble sleeping. AR709.
Eastman was seen on September 8, 2014, and reported fatigue
secondary to thyroid surgery, chronic neck pain, feeling like
isolating and not wanting to get out of bed, feeling
overwhelmed, and was having nightmares from the event
resulting in her PTSD in January 2014. AR690-91. Prazosin was
prescribed for her nightmares, and Wellbutrin continued, but
not increased secondary to her thyroid condition. AR691. Ms.
Eastman was also seen that day for counseling, and reported
that her functioning had declined, she was tearful, having
difficulty getting up in the morning and was feeling pain all
the time. AR693. The counselor felt Ms. Eastman may require
at least a partial hospitalization due to her mental health
Eastman was seen for counseling on September 30, 2014, due to
anxiety, depression, and PTSD. AR680. Ms. Eastman had been to
Avera and had started the partial hospitalization program,
but had not participated very long because she became
overwhelmed. AR680. She had been receiving radiation for
cancer and was scheduled for more in January. AR680. She
reported her church was supportive and she had friends coming
over on a regular basis to check on her. AR680. She also
connected with the American Cancer Society, which was
providing some support. AR680.
Eastman was seen on October 10, 2014, and reported increased
anxiety, feeling overwhelmed, and having difficulty sleeping;
Hydroxyzine was prescribed. AR675.
AMG Midwest Psychiatry Clinic
Eastman was seen on January 19, 2015, for an intake
evaluation for depression and anxiety. AR1111-12. Her
symptoms included low energy, depressed mood, anhedonia,
irritability, fluctuating sleep, crying spells, poor
concentration, and suicidal ideation without a plan or
intent. AR1112. Tony Sorensen, Psy.D., stated that Ms.
Eastman was oriented, had intact memory, and an age
appropriate fund of knowledge. AR1111. Her thoughts were
logical, she had intact computation and abstract reasoning.
AR1111. Dr. Sorensen estimated that she had average
intelligence. AR1112. Her mental status exam also revealed
restricted affect and depressed mood. AR1112-13. She was
taking Wellbutrin, clonazepam, and hydroxyzine. AR1112. Dr.
Sorensen recommended at least weekly therapy and medication.
AR1113. Ms. Eastman began psychotherapy and had counseling on
January 22, 2015, and January 29, 2015, with similar symptoms
and exam. AR1107, 1110.
Eastman was seen for a psychiatric visit on February 5, 2015,
and had transferred care to the Avera clinic because Avera
was paying her medical expenses and they encouraged her to
utilize Avera providers. AR1099. Ms. Eastman reported she
continued to struggle with unpredictable symptoms, some days
better than others. AR1099. She reported her mood was down, a
lack of interest, low energy, low motivation, and her anxiety
was always high with episodic panic attacks and anticipatory
anxiety. AR1100. She reported decreased and restless sleep
with nightmares and that she wakes in a panic attack at least
once per week. AR1100. She had been scheduled to start the
Avera Partial Hospitalization program in September 2014, but
couldn't do it as she felt she couldn't trust Avera.
AR1100. Ms. Eastman's medications were unchanged and she
was to continue with counseling and consider the partial
hospitalization program at some point in the future, but not
Eastman was seen for a psychiatric visit on March 9, 2015,
and reported that her mood was down, irritable and varying
from day-to-day and she had gained weight and was fatigued.
AR1088. Her weight had increased from 160 pounds in 2013 to
196 pounds on exam. AR1088. She was to taper off Cymbalta and
replace it with generic Prozac since she was only doing
marginally on Cymbalta. AR1091.
Eastman continued counseling sessions about weekly from
January 29, 2015 through March 26, 2015, with varied but
similar symptoms. AR1082, 1084, 1086, 1093, 1095, 1097, 1107.
On March 26, 2015, she reported that she had attended a
sporting event for her son but felt so overwhelmed the first
day she did not attend the second day. AR1082.
Eastman's counseling sessions continued and in the April
6, 2015, session it was noted she had been in Avera
Behavioral Health for two days after overdosing on two
medications. AR1080. At her session on April 16, 2015, Ms.
Eastman wanted to write a letter to the physicians who had
performed her D&E procedure, but was frustrated and
discussed her difficulty and embarrassment over her
difficulty writing and acknowledged she was in special