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Manco v. Berryhill

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

April 8, 2019

CARLA M. MANCO, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.




         Plaintiff, Carla M. Manco, seeks judicial review of the Commissioner's final decision denying her application for social security disability and supplemental security income disability benefits under Title II and Title XVI of the Social Security Act.[1]

         Ms. Manco 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. Alternatively, Ms. Manco 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 court pursuant to 42 U.S.C. § 405(g). The parties have consented to this magistrate judge handling this matter pursuant to 28 U.S.C. § 636(c).

         FACTS [2]

         A. Statement of the Case

         This action arises from plaintiff, Carla M. Manco's, (“Ms. Manco's”), application for SSDI and SSI filed on June 25, 2015, alleging disability since April 15, 2013, due to a learning disability, dyslexia, anxiety, high blood pressure, high cholesterol, and depression. AR281, 288, 372 (citations to the appeal record will be cited by “AR” followed by the page or pages). Ms. Manco also raised issues of being unable to do well with others, memory problems, Methicillin-resistant Staphylococcus aureus (“MRSA”), a cyst on her kidney and neuropathy in her legs, feet, arms, and hands. AR389, 394-95, 401, 433.

         Ms. Manco's administrative law judge hearing was held on June 28, 2017, by Jeffrey Holappa (“ALJ”). AR85. Ms. Manco was represented by other counsel at the hearing, and an unfavorable decision was issued on August 24, 2017. AR6, 85.

         At Step One of the evaluation, the ALJ found that Ms. Manco had not engaged in substantial gainful activity (“SGA”), since the date of her alleged onset of disability, April 15, 2013, and that she met the insured status for her SSDI claim through December, 2021. AR12.

         The ALJ found that Ms. Manco's work at Walgreens in August, 2013, and at Forum Communications in December, 2016, were both unsuccessful work attempts. AR12.

         At Step Two, the ALJ found that Ms. Manco had severe impairments of degenerative disc disease of the cervical spine, small fiber neuropathy, post-traumatic stress disorder (“PTSD”), borderline intellectual functioning, attention deficit hyperactivity disorder, dyslexia, anxiety and depression. AR12.

         The ALJ also found that Ms. Manco had been diagnosed with hypertension, hyperlipidemia, right carpal tunnel disease, obesity, right renal cyst, gastroesophageal reflux disease, and sleep apnea, but determined they were all non-severe. AR12.

         At Step 3, the ALJ found that Ms. Manco did not have an impairment that met or medically equaled one of the listed impairments in 20 C.F.R. 404, Subpart P, App 1 (20 C.F.R. §§ 416.920(d), 416.925, and 416.926) (hereinafter referred to as the “Listings”). AR12. The ALJ considered the mental impairments under Listings 12.02, 12.04 12.06, 12.11, and 12.15 and found that Ms. Manco had moderate limitations in understanding, remembering, or applying information; moderate limitations in interacting with others; moderate limitations with concentration, persistence or maintaining pace; and mild limitations in adapting or managing herself, so did not meet a Listing. AR13-14.

         The ALJ determined that Ms. Manco had the residual functional capacity (“RFC”) to perform:

less than the full range of medium work as defined in 20 CFR 404.1567(c) and 416.967(c) except: the claimant is limited to lifting and carrying 50 pounds occasionally and 25 pounds frequently. The claimant is limited to sitting (with normal breaks) for about 6 hours out of an 8-hour workday. The claimant is limited to standing or walking (with normal breaks) for about 6 hours out of an 8-hour workday. The claimant is limited to pushing and pulling within the same weight limitations as lifting and carrying. The claimant is limited to occasional climbing of ladders, scaffolds or ropes. The claimant is limited to frequent balancing, stooping, kneeling, crouching, crawling and climbing ramps or stairs. The claimant is limited to occasional exposure to work hazards such as unprotected heights and moving mechanical parts. Mentally, the claimant is limited to understanding, remembering and carrying out simple, routine and repetitive tasks. The claimant is limited to making simple work-related decisions. The claimant is limited to occasional interaction with supervisors, coworkers and the general public.


         The ALJ found Ms. Manco's medically determinable impairments could reasonably be expected to produce the symptoms she alleged, but her statements concerning the intensity, persistence, and limiting effects of her symptoms were not “entirely consistent with the medical evidence and other evidence in the record for the reasons explained in this decision.” AR16.

         The ALJ considered the opinions of the State agency medical consultants, who found that Ms. Manco did not have a severe impairment and gave them “only some weight” because evidence admitted at the hearing level has shown the claimant was more limited than originally determined with the development of cervical degenerative disc disease and small fiber neuropathy. AR19.

         The ALJ considered the opinions of the State agency psychological consultants and gave them “great weight.” AR19.

         The ALJ considered the medical source statement completed by Ms. Manco's treating mental health provider, Dr. Fox, who identified multiple areas of “moderate” and multiple areas of “marked” limitations, and accepted the “moderate” limitations. AR19, 810-12. The ALJ rejected all “marked” limitations asserting they were “inconsistent with the mental status examination observations in the record as well as the testing results.” AR19, 810-12 (medical source statement). The ALJ stated Dr. Fox's opinions were “afforded some weight to the extent they support the limitations in the residual functional capacity assessment” determined by the ALJ. AR19.

         The ALJ gave “some weight” to the statement of the consultative psychological examiner, Galen Van Kley, Ph.D., who stated the claimant's employment opportunities would be limited by her intellectual deficits, even though she was capable of learning and retaining new information with repeated exposure. The ALJ's decision stated, “The undersigned accepts that the claimant is capable of performing repetitive tasks and that she is limited, but disabled.” AR19.

         The ALJ noted in the decision that Ms. Manco's treating physician, Dr. Olegario, limited her to lifting no greater than 10 pounds “for now” in July, 2014. AR16.

         Based on the RFC determined by the ALJ, the ALJ first found that Ms. Manco was capable of performing her past relevant work as a hand packager, a medium exertion unskilled occupation, stating, “The undersigned accepts the vocational expert's opinion. Accordingly, the claimant is unable[3] to perform past relevant work as actually or generally performed.” AR21. The ALJ stopped the sequential evaluation at Step 4 and found Ms. Manco not disabled. AR21.

         The Appeals Council denied Ms. Manco's request for review making the ALJ's decision the final decision of the Commissioner. AR1.

         B. Plaintiff's Age, Education, and Work Experience.

         Ms. Manco was born January 31, 1965, and completed the 12th grade in 1983. She stated that she attended special education classes. AR121, 373.

         The ALJ identified Ms. Manco's past relevant work as hand packager, medium exertion unskilled work, DOT# 920.587-018. AR20.

         C. Relevant Medical Evidence.

         1. Olegario Medical Clinic Records

         Ms. Manco was seen on January 22, 2014, to follow-up an emergency room visit due to right sided wrist pain. AR592. Ms. Manco reported at the emergency room visit that she had recently started a new job that required a lot of repetitive activity with her hands, and following examination, she had been assessed with overuse syndrome secondary to repetitive motion and activity with her hands. AR661-62. Examination revealed right wrist pain in a median nerve distribution, and her assessment was carpal tunnel syndrome. AR594. Ms. Manco complained of numbness and tingling as well as pain, and an EMG was obtained that revealed evidence of right median neuropathy at the wrist such as seen in carpal tunnel syndrome. AR547. Karen Garnaas, MD, stated the EMG showed neuropathy at the right wrist characteristic in carpal tunnel syndrome which was of “mild electrophysiologic severity. There is no evidence of a generalized sensorimotor polyneuropathy, cervical radiculopathy, or ulnar neuropathy.” AR547. Ms. Manco had right carpal tunnel surgery on February 27, 2014. AR563, 588.

         Ms. Manco was seen on July 23, 2014, complaining of low back pain and pain between her shoulder blades with symptoms she said were present off and on for years but worsening the past several days. AR577. Examination revealed mid and low back tenderness. AR579. Meloxicam and baclofen were prescribed and she was put on work restrictions with lifting no more than 10 pounds “for now.” The physician stated that there did not appear to be any worrisome spinal symptoms and her symptoms were potentially related to musculoskeletal discomfort. AR579.

         Ms. Manco was seen again on July 29, 2014, with complaints of lower back pain mainly around her right flank. AR574. She said she had had significant pain and was observed to be obviously uncomfortable with, she said, an inability to sit long periods due to pain. AR574. Ms. Manco also reported right sided kidney pain, vertigo, and nausea. AR574. A CT with renal stone protocol was obtained that revealed a probable right ovarian cyst but no kidney stones. AR607.

         Due to Ms. Manco's complaints of mid and low back pain, a lumbar spine x-ray series was obtained on July 30, 2014, that revealed very mild convex right thoracolumbar junction scoliosis and minimal bony spondylosis, but no other abnormal findings. AR606. In previously taken x-rays from April 2011, Tamara Wheeler, M.D., noted “slight spinal curvature” in the left lower thoracic spine and right upper thoracic spine. AR654. Her impression was “scoliotic curvature noted.” AR654.

         Ms. Manco was seen on April 13, 2015, to follow-up on a number of conditions including depression and refilling her Paxil medication. AR570. Her psychiatric history included ADD, anxiety, and depression. AR571. The record showed no barriers to learning, a readiness to learn and learning preferences including one-on-one, telephone instruction, verbal explanation, and written material. AR571. Ms. Manco had normal mood, affect, speech and thought processes. AR572.

         Ms. Manco was seen with her mother on June 3, 2015, to discuss disability. AR566. Ms. Manco was noted to have no learning barriers. AR567. Her mood was depressed, and she had been under stress and was feeling more depressed. AR568. Ms. Manco reported being labeled with a learning disability while growing up and a possibility of dyslexia, and she said she had a difficult time maintaining employment despite help from her mother. AR568. Dr. Olegario stated Ms. Manco had a depressed mood, normal affect, speech and thought processes. AR568. Attention deficit disorder was assessed, and Vyvanse was prescribed. AR569.

         2. AMG Internal Medicine Clinic Records

         Ms. Manco was seen on March 18, 2016, for complaints of pain in both feet with achiness and burning in the balls of her feet into her toes and muscles of her legs. AR837, 840. Ms. Manco rated her bilateral foot pain as 8 out of 10, and she also complained of back, joint and muscle pain. AR838-39. Examination revealed bilateral lower extremity distal tenderness and bilateral hand pain. AR839.

         Ms. Manco was seen on April 18, 2016, with complaints of continued foot and leg pain with pain in the bottom of her feet radiating up her legs and numbness and tingling below both feet. AR833, 836. She also complained of anxiety and stress on the day of the examination. AR833. Examination revealed depressed mood; normal affect, speech, and thought processes; and symptoms “consistent with” neuropathy in both feet, and Lyrica was prescribed. AR836.

         Ms. Manco was seen on June 8, 2016, for complaints of continued bilateral leg pain and numbness. AR830. She rated her leg pain as 7 out of 10. AR831. Ms. Manco complained of a burning discomfort over her distal bilateral lower extremities and had similar symptoms over her hands to a milder degree. AR832. Dr. Olegario noted that back x-rays from the previous year did not show obvious disc disease. AR832. An MRI had been ordered but her insurance company denied coverage. AR832. An EMG was ordered, and gabapentin was prescribed to replace the Lyrica, which she had not tolerated. AR832.

         3. Neurology Associates Records

         Ms. Manco was referred to Neurology Associates and seen on July 18, 2016, for complaints of burning foot dysesthesias over the past year with more recent numbness and tingling in her hands, sometimes radiating up the arms. AR798, 800. Examination revealed some lost sensation in the lower extremities with temperature decreased to lower calves, cool at upper calves, and in the upper extremities pain was sharper at mid hands, temperature cooler at mid forearms. AR803. Ms. Manco was oriented, with intact recent and remote memory, good attention span and fund of knowledge, spontaneous speech, and a full range of affect. AR803. Ms. Manco had normal strength in her wrists, fingers, and hands. She had intact fine-finger movements and finger-nose-finger testing “without tremor or ataxia.” AR803. Her gait was somewhat antalgic but otherwise her heel, toe, and tandem gaits were normal. AR803. Ms. Manco's Romberg's sign was normal. AR803. EMG testing showed minimal evidence of right carpal tunnel syndrome “no definite radiculopathy or large fiber neuropathy.” AR799. Dr. Olegario would “consider skin biopsy for small fiber neuropathy.” AR799. He ordered brain and cervical MRIs and prescribed gabapentin. AR799.

         An EMG of Ms. Manco's upper extremities was obtained on July 18, 2016, and was minimally abnormal on the right with median palmar sensory distal latency “just slightly outside of the normal range” raising the possibility of mild median neuropathy at the right wrist such as seen in carpal tunnel syndrome. AR807. Karen Garnaas, M.D., saw no evidence of a similar process affecting the left upper arm and no cervical abnormalities affecting either upper limb. AR807.

         A cervical spine MRI was obtained on July 21, 2016, which revealed degenerative disc disease with disc protrusions and bulging at ¶ 4-5, C5-6, and C6-7 without significant spinal stenosis, cord compression, or demyelinating disease. AR806.

         A brain and stem MRI was obtained on July 21, 2016, which revealed three small foci of white matter T2 hyperintensity in the left frontal lobe, right frontal lobe and right periatrial white matter, which were nonspecific, although not inconsistent with demyelinating disease. AR805. The suspicion of demyelination was low. AR793.

         Ms. Manco was seen on September 9, 2016, for follow-up and reported continued tightness of the ankles in the morning with some tingling and burning, but overall her symptoms were about 50% improved versus the 8/10 previously reported. AR794. She reported that her symptoms were worse if she was on her feet a lot, and her right knee felt unstable and was randomly giving out. AR794. Ms. Manco also reported her left hand randomly felt swollen and numb, but her hand symptoms seemed less severe since starting gabapentin. AR794.

         Ms. Manco was seen on March 15, 2017, by Becky Emerson, PA-C, to follow up on her neuropathic symptoms felt to be small fiber neuropathy, which could not be ruled out. AR788. Small fiber sensory neuropathy could not be excluded with routine electrodiagnostic studies. AR789. She reported that she felt her symptoms were manageable, but her foot symptoms increased significantly with prolonged standing. AR788. Ms. Manco also said she had fairly mild tightness, numbness, and tingling of her hands up to her shoulders intermittently, and her ankles are always tight with intermittent foot cramps, mild foot to hip numbness, and tingling that comes and goes, and had recently fallen when her right leg gave out. AR788. Ms. Emerson noted that Ms. Manco was pleasant, cooperative, and in no apparent distress. AR788. Ms. Manco was oriented, had intact recent and remote memory, good attention span, good fund of knowledge, and a full range of affect. Ms. Manco had full motor strength in all extremities. Ms. Manco's heel, toe, and tandem gait were normal and her sensation was intact. AR788. Ms. Manco's PHQ-9 score was 3. AR790. She had no barriers to learning. AR792.

         4. Dakota Counseling Institute Records

         Ms. Manco was referred for counseling by her primary care physician and seen on June 10, 2015, by Patricia Fox, Ed.D., for depression, anxiety, and PTSD related to a kidnapping and sexual assault incident. AR611. She complained of symptoms of flashbacks, depression, anxiety, hypervigilance, exaggerated startle response, irritability, panic attacks, poor concentration, low self-esteem, inability to stay focused, and outbursts of anger. AR611. Ms. Manco reported that she had lost a job at a nursing home when a resident grabbed her arm, and she reacted by pushing him away. AR611. Ms. Manco's attention deficit hyperactivity disorder (“ADHD”) assessment revealed 12 out of 18 positive answers for ADHD, her Beck Anxiety Inventory showed moderate anxiety, and her Beck Depression Inventory indicated severe depression. AR611. Ms. Manco was taking Vyvanse and Paxil. AR611.

         Ms. Manco reported she had problems learning in school and attended special education classes through high school. AR612. She had been diagnosed with dyslexia when she was eight years old. AR612. Ms. Manco reported being married four times, physically abused by two of her husbands, and sexually abused by a neighbor when she was eleven years old. AR612. Ms. Manco was observed to be in moderate distress and frequently looked to her daughter, who presented with her, to answer questions. AR613. She spoke rapidly, had good recall, normal attention and concentration, appeared to have fair to poor insight and judgment, and her mood was both anxious and dysphoric. AR613. She was diagnosed with major depressive recurrent moderate, generalized anxiety disorder, sexual abuse of an adult, PTSD, partner relationship problems, and Cluster B traits with a Global Assessment of Functioning assessed at 50; she was scheduled for weekly counseling. AR613.

         Ms. Manco was seen on June 24, 2015, to complete her intake that required more than one appointment due to Ms. Manco answering most of the intake questions with a story. AR614-15. Her thoughts were clear and coherent. Ms. Manco had no difficulty answering questions. AR615. Her intake was completed on June 24, 2015, where Dr. Fox noted she had clear and coherent thoughts. AR615. In addition, she was scheduled for counseling in a week; however, the next day Ms. Manco sought an emergency session and was seen. AR615-16. She presented with scattered thoughts, restricted affect, and an anxious and dysphoric mood. AR616. Ms. Manco had a disagreement with a woman she rented a room from due to some information the property owner received from Ms. Manco's soon-to-be ex-husband. The property owner's husband told Ms. Manco and the property owner that if they could not work things out, Ms. Manco would have to move. Ms. Manco was concerned she was going to lose her place to live. AR616. Dr. Fox noted Ms. Manco was able to ground herself through relaxation breathing and to develop a plan of action. AR616.

         Ms. Manco was seen on July 13, 2015, and reported another altercation with the woman she rented a room from, and this time it had resulted in a physical altercation with the sheriff involved. AR726. Ms. Manco reported, “When she returned Shelly [the property owner] started arguing and then shoved Carla who shoved her back.” AR726. The sheriff “went looking” for the property owner, but the property owner was not charged with anything. AR726. She began looking for a different place to live and stayed with her son but reported she had problems sleeping for fear of the woman. AR726.

         Ms. Manco was seen on July 16, 2015, for an intake appointment into the Care program. AR727. She identified needing help with keeping a job, not being too trusting, and help dealing with her past trauma. AR728. Ms. Manco told Dr. Fox that she had never been diagnosed with a developmental disability. AR729. She reported very few friends, but talked with her mother and children frequently. AR730. She asserted a dyslexia diagnosis when she was eight years old and said she attended special education classes. AR730. Dr. Fox described Ms. Manco as oriented; with good eye contact, average intelligence, and circumstantial but coherent thought process; poor insight and judgment especially in personal relationships; rapid, loud, and pressured speech, slightly restricted affect; anxious and dysphoric mood; and a moderately to severely distressed appearance. AR730.

         Ms. Manco was seen for counseling on July 31, 2015, and again reported another confrontation, this time a verbal argument with a woman who lived next to her husband. Ms. Manco felt harassed and called the police. AR732.

         Ms. Manco was seen for a Care appointment on August 7, 2015, and her affect was slightly restricted, her mood was anxious, and she reported losing her job at the convenience store because the owner told her that “others” were not happy with her work. AR733. Ms. Manco applied for another job at a grocery store. AR733. She was given information about DBT therapy group to help her manage her emotions. AR733.

         Ms. Manco was seen for a Care appointment on August 13, 2015, and her mood was anxious and slightly dysphoric. She reported applying for work, but had failed to pass an assessment test required by Wal-Mart. AR734.

         Ms. Manco was seen for a Care appointment on August 20, 2015. Her mood was euphoric, and she reported she had obtained a part-time job at a liquor store and was scheduled to start the next Monday, working 22 to 25 hours a week. AR735. Ms. Manco also reported that she was reconsidering whether to proceed with her divorce, at the request of her husband, and she felt much of the responsibility for the separation due to her irritability and crankiness. AR735. Ms. Manco reported that negative attitude had changed after she was put on medication. AR735.

         On August 26, 2015, Ms. Manco reported that she and her husband had gone out to eat several times. AR736. She reported keeping herself busy, being able to stay out of conflicts with others, and getting used to life without “drama.” AR736.

         Ms. Manco was seen for a Care appointment on September 8, 2015, and she was cheerful and optimistic about the future and reported that she had applied to become a police officer in Mitchell. AR737. The record stated:

The focus of today's session was to process her interval history. Carla reports that she and her husband Don have applied to become police officers in Mitchell. She took one test and received a letter inviting her to take a more extensive test. She also received a notice from disability services to have a psychological evaluation later this week. She talked about her concerns regarding the test and we spent some time discussing testing strategies. She also expressed concern about her psychological evaluation but was able to dissipate her concerns before the end of the session. She will see Brenda Davenport RN, CNP, for a psychiatric evaluation on 09/11/15. Carla reports that she is getting along with other coworkers and with those who live in the same apartment complex. She sees her husband, Don, frequently. She states that they are communicating well and there has been no arguing as there was in the past. Carla was given a bracelet with the saying “thoughts become things-choose the good ones.” This is to help her stay out of negativity.

         Ms. Manco was seen by Brenda Davenport, RN, CNP, for a psychiatric evaluation on September 11, 2015, and reported she had been working with Dr. Fox for a few months to address mood and anxiety symptoms, but provided a very long and confusing history going into a significant discussion of her history of abuse. AR738. Ms. Manco reported she continues to have nightmares and that her abuser “John” is getting out of prison and “he always finds me.” AR738. Ms. Manco said she enjoyed activities like spending time with her children and fishing with her husband. She had feelings of hopelessness in the past but “not much now.” AR738. Ms. Manco reported improved self-esteem and her energy level was better with the use of Vyvanse, and she said the Vyvanse helps to reduce her mind racing symptoms. AR738. Ms. Manco endorsed some level of psychomotor agitation and vague and passive history of suicidal thinking with no plan or intent. AR738. Her Beck Depression Inventory endorsed severe symptomatology, her Mood Disorder Questionnaire indicated a moderate problem, a bipolar diagnostic scale showed the upper end of low probability, and she had 4 of 10 affirmative criteria for borderline personality disorder. AR739. Ms. Davenport said Ms. Manco did not demonstrate manic symptomatology but seemed influenced by an overly dramatic or emotional family. AR739. The mental status exam revealed no prominent deficits, but her differential diagnoses included major depressive disorder, recurrent, moderate with anxious distress; generalized anxiety disorder per history; probable lower level of intellectual functioning; and she was found to meet the criteria for SMI services. AR742-43. Ms. Davenport observed that Ms. Manco had good eye contact, appropriate grooming, and friendly mannerisms. AR742. Ms. Manco was attentive, had a normal gait, clear speech, and a fairly euthymic mood. AR742. She had logical thought process, average intellect, and appropriate judgment and insight. AR742.

         Dr. Fox saw Ms. Manco for a Care appointment on September 22, 2015, and her mood was slightly anxious but overall optimistic. AR744. She reported going to the emergency room because of boils on her abdomen, but was upset that the ER doctor did not think they needed treatment. AR744. Ms. Manco thought they could extend to her brain, so she was going to see her primary care doctor. AR744. Dr. Fox described her thoughts as clear and coherent and noted she was “doing very well both in her relationships and at work.” AR744.

         Ms. Manco was seen for a Care appointment on November 9, 2015, and her affect was restricted and her mood was very anxious. AR745. She had seen her primary care doctor who did not think she had MRSA. AR745. Ms. Manco reported numerous worries and obsessing over the one-night affair her husband had while they were separated. AR745.

         Dr. Fox saw Ms. Manco for a Care appointment on March 4, 2016, and her thoughts were scattered, speech rapid, and mood anxious. AR748. Dr. Fox noted that she was able to calm down by the end of the session. Ms. Manco had not seen Dr. Fox since November, 2015, and Ms. Manco did not offer a reason why she had not done so. AR748. She reported the anniversary of her kidnapping and rape was coming up and she was having nightmares and flashbacks. AR748. Ms. Manco reported being under a lot of stress at work because they were remodeling, and she could not find things. AR748. She reported that the woman her husband had an affair with while they were separated continued to harass them, and they filed a complaint with the police. AR748.

         Ms. Manco saw Ms. Davenport for a psychiatric appointment on March 29, 2016, and her Paxil dosage was increased, however, Ms. Manco never took the increased dosage due to other medical problems. AR750-51. Ms. Manco had also missed appointments in November and December. AR749. Ms. Manco reported having a lot more anxiety and nightmares. AR749. Ms. Manco reported having a lot more flashback symptoms in the day and being able to reduce her symptoms “very quickly” with a tapping series or technique. AR749. Ms. Manco reported having a lot of pain in her feet and some pain in her hands as well. AR749. Ms. Manco reported working two jobs: one at a grocery store for 22-25 hours every two weeks and one in securities where she was paid “under the table” three days a week. AR749. Ms. Davenport described Ms. Manco as alert and oriented, with clear speech, logical and goal-oriented thought processes, and appropriate insight and judgment. AR750. Her energy level was fair to good. AR750.

         In May, 2016, Ms. Manco told Ms. Davenport that she rarely went to Florida, which she found stressful. She still engaged in her usual fun activities, went fishing with her husband, and had been bonding with her daughter. AR751. Ms. Davenport described Ms. Manco as pleasant, with fairly logical, goal-oriented thought processes and appropriate insight and judgment. AR751. Her energy level was “awesome.” AR751.

         Ms. Manco was seen for a Care appointment on May 20, 2016, and her affect was slightly restricted and her mood dysphoric. AR753. Ms. Manco reported visiting her sister in Florida for her nephew's graduation, but staying with her sister did not go well. She regretted going. AR753.

         Ms. Manco saw Dr. Fox for a Care appointment on June 6, 2016, and her affect was restricted and her mood anxious and dysphoric. AR754. She reported losing her job due to an altercation with a coworker, but blamed her coworker who said she was very angry with her and shouted at her in front of customers, so she walked off the job. Despite calling her boss to explain why she was upset, he fired Ms. Manco the next day. AR754. Ms. Manco reported that she had lost other jobs in the past because of similar problems. AR754.

         Ms. Manco was seen for a Care appointment on June 20, 2016, and her mood was slightly anxious, but also optimistic about the future. AR755. She had found a job as a taxi driver. AR755.

         Ms. Manco saw Kari Rickel, CSW-PIP, for a Care intake appointment on August 1, 2016, and reported working at the American Legion as a bartender and waitress. AR757. She was observed to speak fast with elaborate answers and had some difficulty with focus and concentration, and it took her a half hour to fill out the questionnaire. AR759. Ms. Rickel also noted she appeared to be a good historian. AR759. Ms. Manco was found to continue to qualify for SMI services with a severe mental disability, markedly limited job skills and poor work history, and inability to procure appropriate support services without assistance. AR759.

         Ms. Manco was seen for a Care appointment on August 3, 2016, and her thoughts were scattered and she was quite agitated with restricted affect and extremely anxious mood. AR761. She did not have money to pay for her medications because she lost her insurance because she had not paid her premiums, and she requested samples. AR761. She complained of not being able to concentrate and was not going to be able to do her job because of that. AR761. She was quite agitated and had called her doctor at home, but the doctor's wife would not let her speak to him. AR761.

         Dr. Fox saw Ms. Manco for a Care appointment on August 8, 2016, and her thoughts were somewhat scattered, speech rapid, affect restricted and mood anxious and agitated. AR762. She received assistance applying for the Medical Assistance for Workers with Disabilities program. AR762.

         Ms. Manco saw Ms. Davenport for a psychiatric appointment on August 10, 2016, and reported being out of Vyvanse for three days. AR763. She reported it had been causing her to be argumentative and agitated, and her husband had told her she was psychotic and had issues. AR763. She was working part-time at the American Legion. She reported losing her job at Coborn's because a co-worker got in her face and made her angry. AR763. Her manager witnessed the altercation and also got in her face. AR763. Ms. Davenport stated that Ms. Manco had fairly logical and goal oriented thought processes and fairly appropriate judgment and insight. Her energy level was fair to good and her gait was within normal limits. AR764. Ms. Davenport's plan for Ms. Manco included helping Ms. Manco understand her medical concerns “as she is lower functioning than she appears and is really struggling to understand her own medical needs at this point.” AR764.

         Ms. Manco was seen for a Care appointment on August 24, 2016, and reported being scolded by her boss for failing to serve drinks to her customers. She was angry about the criticism. AR765. Ms. Manco was able to process her thoughts with a guided imagery exercise. AR765.

         Ms. Manco saw Ms. Davenport for a psychiatric appointment on September 22, 2016, and reported she had been able to obtain Vyvanse through an assistance program. She stated her mood and focus were much better, but she continued to be somewhat lower functioning. AR766. Ms. Davenport reported Ms. Manco had logical and goal oriented thought processes and fairly appropriate judgment and insight. AR767.

         Dr. Fox saw Ms. Manco for a Care appointment on October 13, 2016, and her affect was slightly restricted. Her mood was anxious and dysphoric. AR769. She reported her manager fired her from her job at the American Legion. AR769. Her manager had many complaints about her, but she felt he treated her poorly. AR769. Ms. Manco acknowledged that she had lost a number of jobs in the past year and a half, and she blamed her managers rather than looking at her own behavior. AR769. Ms. Manco reported she continued to help her husband deliver newspapers and had a security job where she took money to the ...

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