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Eastman v. Berryhill

United States District Court, D. South Dakota, Southern Division

August 7, 2018

JENNIFER L. EASTMAN, Plaintiff,
v.
NANCY A. BERRYHILL, [1] 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.

         INTRODUCTION

         Plaintiff, 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 Act.[2]

         Ms. 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.

         This 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.

         FACTS[3]

         A. Statement of the Case

         This 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.

         Ms. Eastman's claim was denied initially and upon reconsideration. AR268, 276. Ms. Eastman then requested an administrative hearing. AR283.

         Ms. 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.

         At step 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. AR15.

         At step 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.

         The ALJ also found that Ms. Eastman had medically determinable impairments of thyroid cancer, left trapezius strain and cellulitis, which were found non-severe impairments. AR16.

         The ALJ 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.

         The ALJ 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.

         The ALJ 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.

         The ALJ 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.

AR19.

         The 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.

         The ALJ 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.

         The ALJ 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. AR24-25.

         The ALJ 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.

         The ALJ 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. AR25.

         The ALJ 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. AR25.

         Based 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.

         Ms. 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. See AR65-199.
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.

         The 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.

         The 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.

         B. Plaintiff's Age, Education and Work Experience

         Ms. 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.

         The 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.

         The ALJ identified Ms. Eastman's past relevant work as a mail processing clerk, Dictionary of Occupational Titles (DOT) # 209.687-026. AR26.

         C. Relevant Medical Evidence

         1. Sanford Family Medicine

         Ms. 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.

         Ms. 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.

         Ms. 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.

         Ms. 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. AR702.

         Ms. 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.

         Ms. 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.

         Ms. Eastman contacted the clinic on September 15, 2014, and received an orthopedic referral for her hip pain. AR690.

         2. Sanford Family Medicine Clinic Records Submitted to the Appeals Council

         Ms. 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.

         Ms. Eastman was seen on March 30, 2015, with neck and face swelling and tenderness. AR45.

         Ms. Eastman was seen on June 5, 2015, to follow-up on an emergency room visit for cellulitis of the right arm. AR47.

         Ms. 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. AR50.

         Ms. Eastman was seen on March 30, 2016, again to follow-up on an emergency room visit for cellulitis of the left shoulder. AR53.

         3. Sanford Physical Medicine & Rehabilitation Clinic Records Submitted to Appeal Council

         Ms. 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, 804.

         Ms. 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.

         On June 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.

         Ms. 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.

         Ms. 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.

         When 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.

         On 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.

         Ms. 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.

         On 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. AR158.

         Ms. 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.

         On 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.

         Ms. 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.

         On 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.

         4. Sanford Orthopedics & Sports Medicine Clinic

         Ms. 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 discussed. AR690.

         Ms. 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. AR809.

         Ms. 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. AR674.

         5. Sanford Surgical Associates and Sanford Endocrinology Clinic

         Ms. 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.

         Ms. Eastman was seen on August 11, 2014, to follow-up on the thyroidectomy performed in May due to cancer. AR703.

         6. Sanford Hospital

         Ms. 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.

         Ms. Eastman was seen on December 25, 2013, at the emergency room with shortness of breath and nausea, and was diagnosed with anxiety. AR782, 785.

         Ms. 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 physician. AR1014.

         Ms. Eastman was hospitalized on May 28, 2014, for papillary thyroid cancer and a right thyroidectomy was performed. AR720.

         Ms. 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.

         Ms. 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 palpitations. AR1003.

         In 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, 1018.

         In June 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. AR1025.

         In 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. AR1032-33.

         7. Sanford Psychiatry and Behavioral Health Records

         Ms. 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 close. AR524.

         Ms. 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.

         Ms. 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.

         Ms. 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 medications. AR770.

         Ms. 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.

         Ms. Eastman stated she was beading some bookmarks and that this helped her focus. She was looking forward to a visit from her father. AR768.

         Ms. 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. AR767.

         Ms. 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 thyroid. AR761-62.

         Ms. 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.

         Ms. 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.

         Ms. 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 decline. AR693.

         Ms. 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.

         Ms. Eastman was seen on October 10, 2014, and reported increased anxiety, feeling overwhelmed, and having difficulty sleeping; Hydroxyzine was prescribed. AR675.

         8. AMG Midwest Psychiatry Clinic

         Ms. 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.

         Ms. 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 yet. AR1105.

         Ms. 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.

         Ms. 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.

         Ms. 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 education ...


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