Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Patrick v. Saul

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

August 15, 2019

NICOLE W. PATRICK, Plaintiff,
v.
ANDREW M. SAUL, Commissioner of the Social Security Administration, Defendant.

          MEMORANDUM OPINION AND ORDER

          VERONICA L. DUFFY UNITED STATES MAGISTRATE JUDGE.

         Table of Contents

         INTRODUCTION .................................................................................... 1

         FACTS ................................................................................................... 2

         A. Statement of the Case ................................................................. 2

         1. Initial Application and Proceedings ........................................... 2

         2. ALJ Decision ............................................................................ 2

         3. Appeals Council Review ............................................................ 8

         B. Plaintiff's Age, Education and Work Experience ......................... 10

         C. Relevant Medical Evidence ........................................................ 10

         1. Tschetter & Holm Clinic Records ............................................ 10

         2. Community Counseling Services Records ............................... 23

         3. Chiropractic Treatment Records ............................................. 48

         4. South Dakota Human Services Center (HSC), Yankton, S.D. .... 48

         5. State Agency Assessments ..................................................... 49

         D. Testimony at the ALJ Hearing ................................................... 50

         1. Ms. Patrick's Testimony ......................................................... 50

         2. Ms. Patrick's Mother's Testimony ........................................... 52

         3. Vocational Expert Testimony: ................................................. 52

         E. Disputed Facts .......................................................................... 53

         DISCUSSION ....................................................................................... 53

         A. Standard of Review ................................................................... 53

         B. The Disability Determination and the Five-Step Procedure ........ 55

         C. Burden of Proof ......................................................................... 56

         D. The Parties' Positions ................................................................ 57

         E. Step Two ................................................................................... 57

         F. Step Three ................................................................................ 64

         G. Step Four .................................................................................. 72

         1. Law Applicable to Step Four ................................................... 73

         2. Fibromyalgia .......................................................................... 76

         3. Migraines ............................................................................... 81

         4. Mental Impairments ............................................................... 89

         H. Step Five ................................................................................. 102

         1. Jobs Available “Nationally” ................................................... 102

         2. DOT Descriptions of Jobs and the ALJ's Mental RFC ............ 106

         I. Type of Remand ...................................................................... 108

         CONCLUSION .................................................................................... 109

         INTRODUCTION

         Plaintiff, Nicole Patrick, 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. Patrick 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 Nos. 1 & 19. Alternatively, Ms. Patrick requests the court remand the matter to the Social Security Administration for further proceedings. Id.

         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

         1. Initial Application and Proceedings

         This action arises from plaintiff, Nicole W. Patrick's (Ms. Patrick), application for SSDI and SSI benefits filed on September 14, 2015, alleging disability since September 4, 2015, due to depression, anxiety, fibromyalgia, migraines, and problems with her back and right shoulder. AR201, 209, 244, 268, 276 (citations to the appeal record will be cited by “AR” followed by the page or pages).

         Ms. Patrick's claim was denied initially and upon reconsideration. AR132, 139, 146. Ms. Patrick then requested an administrative hearing. AR153.

         2. ALJ Decision

         Ms. Patrick's administrative law judge (“ALJ”) hearing was held on October 12, 2017, by Lyle Olson. AR48. Ms. Patrick was represented by other counsel at the hearing, and an unfavorable decision was issued on February 6, 2018. AR27, 48.

         At Step One of the evaluation, the ALJ found that Ms. Patrick was insured for benefits through December 31, 2020, and that she had not engaged in substantial gainful activity (“SGA”), since September 4, 2015, the alleged onset of disability date. AR32. At Step Two, the ALJ found that Ms. Patrick had severe medically determinable impairments of migraine headaches; fibromyalgia; major depression, recurrent, moderate, with anxiety; other specified obsessive compulsive and related disorders; dysthymic disorder; and a personality disorder, unspecified. AR32.

         At Step Three, the ALJ found that Ms. Patrick did not have an impairment that met or medically equaled one of the listed impairments in 20 CFR 404, Subpart P, App 1 (hereinafter referred to as the “Listings”). AR33. The ALJ considered Ms. Patrick's mental impairments-singly and in combination--under Listings 12.04 and 12.06, and found that Ms. Patrick had moderate limitations in understanding, remembering, or applying information; moderate limitations in interacting with others; moderate limitations with concentration, persistence or maintaining pace; and moderate limitations in adapting or managing herself. AR33-34. To meet the listing, Ms. Patrick had to demonstrate at least one “extreme” or two “marked” limitations in these areas of functioning, so the ALJ's conclusion she suffered from only “moderate” limitations led to the conclusion Ms. Patrick did not meet the listing. Id.

         Although Ms. Patrick testified she had poor memory and difficulty understanding both written and spoken instructions, the ALJ found the evidence contradicted this testimony. Id. Specifically, her medical records routinely described her as alert and oriented in all spheres. Id. In addition, she was the representative payee for her children's disability payments, she was able to drive, and play card games. Id. The ALJ concluded these activities were consistent with the “moderate” limitations he found to exist. Id.

         In interacting with others, the ALJ noted Ms. Patrick's medical records routinely described her as pleasant and cooperative and she had never been fired or laid off from a job due to problems getting along with others. Id. This evidence was not consistent with Ms. Patrick's testimony that she has difficulty getting along with others, avoids being around people, and struggles to get along with supervisors. Id.

         With regard to concentrating, persisting, or maintaining pace, the ALJ again found a discrepancy between Ms. Patrick's demonstrated abilities and her description of those abilities. Id. While Ms. Patrick stated she has poor concentration and attention, the ALJ noted she displayed normal attention, concentration and focus in mental health sessions, she watches television and movies, plays cards, handles finances, and can drive. Id.

         Regarding adapting and managing oneself, the ALJ noted Ms. Patrick was routinely described as well-groomed in records of office visits, she was able to leave her house unaccompanied, she managed her household, cared for pets, and provided for her two disabled sons. AR34. This did not correlate with Ms. Patrick's self-described limits of not handling changes in her routine well, needing reminders to attend to her personal care, and to take medication. Id.

         The ALJ also concluded Ms. Patrick had failed to establish the existence of a mental disorder over a period of at least two years, and evidence of both medical treatment, mental health therapy, psychosocial support, or a highly structured setting that is ongoing and that diminishes the symptoms and signs of her mental disorders; and marginal adjustment-that is, minimal capacity to adapt to changes in her environment or to demands that are not already part of her daily life. Id.

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

light work as defined in 20 CFR 404.1567(b) and 416.967(b). Specifically, the claimant can lift and/or carry 20 pounds occasionally and 10 pounds frequently. The claimant can sit with normal breaks for a total of about 6 hours in an 8-hour workday, and stand and/or walk with normal breaks for a total of about 6 hours in an 8-hour workday. The claimant can occasionally climb ramps and stairs, balance, stoop, kneel, crouch and crawl, but never climb ladders or scaffolds, work at unprotected heights, or work with dangerous moving mechanical parts. Mentally, the claimant retains the ability to understand, remember and carry out short, simple instructions and interact appropriately with supervisors and co-workers on an occasional basis. The claimant should have no interaction with the public. The claimant can respond appropriately to changes in a routine work setting only and make judgments on only simple work-related decisions. The claimant must work in isolation or in small groups of people not to exceed five or six in number. Lastly, the claimant is limited to goal-oriented work (defined as work where the claimant is given a task or series of tasks to perform and it does not matter when the task is accomplished so long as completed by end of the workday or work shift).

AR34-35. The ALJ stated that this RFC reflected the moderate limitations the ALJ had previously established deriving from Ms. Patrick's mental impairments as discussed above. AR34.

         The ALJ's subjective symptom finding was that Ms. Patrick'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.” AR35.

         The ALJ considered the opinions of the State agency psychological consultants and gave them “less weight” because they found Ms. Patrick's mental impairments nonsevere and did not have the benefit of reviewing additional evidence adduced at the ALJ hearing. AR38. The ALJ considered the opinions of the State agency medical consultants as to Ms. Patrick's physical functioning, and gave those opinions “more weight” but did not explain more than that, stating only that “the record supports the claimant would be able to perform work within a light exertional level.” AR38.

         The ALJ considered the Mental Impairment Questionnaire filled out by Lyle Christopherson, D.O., Ms. Patrick's treating psychiatrist. AR38. Dr. Christopherson had opined Ms. Patrick could not function well without assistance, there was “no way” she could perform her past job, she was completely unable to function independently outside the home, and she would likely miss four or more days of work a month due to her mental impairments. Id. Dr. Christopherson opined Ms. Patrick was “markedly” limited in her ability to attend to activities of daily living, maintain social functioning, and maintain concentration, persistence and pace. Id.

         The ALJ gave Dr. Christopherson's opinions “less weight” because they were “grossly inconsistent with the record as a whole.” AR38. The ALJ stated that Dr. Christopherson's treatment records “routinely describe the claimant as having good eye contact, and open and cooperative, even at times ‘cheerful' with ‘overall appropriate affect.' ” AR38. The ALJ also asserted that many times Dr. Christopherson indicated Ms. Patrick's mental health was “stable” or that she was doing “well.” AR38. The ALJ noted that Ms. Patrick's ability to assist in the caring of her disabled children, mother, and grandmother was not consistent with Dr. Christopherson's opinion. AR38. The ALJ then asserted that overall Dr. Christopherson's treatment notes were not consistent with the severe limitations set forth in his opinion. AR38.

         The ALJ stated that the RFC it determined was supported by the “longitudinal record” and although he accepted that Ms. Patrick's impairments would somewhat erode her functional ability the medical evidence did not support the degree of limitations she alleged. AR38. The ALJ also noted that Ms. Patrick is able to care for her disabled sons and acts as the representative payee for them, attends appointments on her own, and admits to helping her mother and grandmother. AR38.

         Additionally, the ALJ pointed out that Ms. Patrick admitted to having migraine headaches since age nine and fibromyalgia for years prior to the alleged onset date, but “was able to work with these impairments in the past with no mention of remarkable deterioration or worsening of her physical conditions.” AR39. The ALJ stated that “[f]indings upon physical examination do not display any sort of abnormal gait or weakness. Her neurological exams have been described as non-focal and she has not engaged in any sort of physical therapy or injections for her fibromyalgia, which one would expect to see given allegations of disabling pain.” AR39.

         The ALJ considered the testimony of Ms. Patrick's mother and “accepts this testimony and gives it some weight, as it gives insight into the claimant's daily life.” AR37-38. The ALJ then stated that by virtue of her relationship to Ms. Patrick she “cannot be considered a disinterested third-party witness whose testimony would not tend to be colored by affection for the claimant….” The ALJ also stated that “most importantly” more weight could not be given to the witness's statement because it was “not consistent with the lack of more noteworthy treatment and objective findings contained in this case.” AR38.

         Based on the RFC determined by the ALJ at Step Four, the ALJ found that Ms. Patrick was not capable of performing her past relevant work. AR39. At Step Five, the ALJ found Ms. Patrick capable of adjusting to other work that existed in significant numbers such as document scanner, DOT# 207.685-018; laundry worker, DOT# 261.687-014; and routing clerk, DOT# 222.587-038, relying on testimony from the vocational expert regarding the number of jobs available for each occupation nationally and denied the claim. AR40.

         3. Appeals Council Review

         Ms. Patrick timely requested review by the Appeals Council on January 18, 2018, and submitted additional evidence in the form of a letter from Ms. Patrick's treating psychiatrist dated February 7, 2018. AR22-24. The Appeals Council granted review of the ALJ's decision and found that the decision was not supported by substantial evidence because the ALJ did not evaluate Ms. Patrick's complaints of back and arm pain. AR5, 11.

         The Appeals Council stated that Ms. Patrick partially alleged disability based on back and arm pain and provided evidence of treatment for back and arm pain. AR12. The Appeals Council concluded there was no objective medical evidence of an impairment that could cause arm and back pain. The Appeals Council pointed out that physical examination and diagnostic imaging of the spine and arm did not yield evidence of an impairment. AR12. The Appeals Council also noted that Ms. Patrick reported back pain for most of her life, but that back pain did not previously prevent her from working and the record did not indicate any deterioration in back pain. AR12. The Appeals Council then asserted that because Ms. Patrick's treatment for these conditions was “routine and conservative” and “effective” they “would appear to be nonsevere if they were medically determinable.” AR12.

         The Appeals Council adopted the ALJ's findings under Steps 1, 2, 3, 4 and 5 including that “she is not capable of performing past relevant work and that there is not a significant number of jobs the claimant is capable of performing.” AR4. The Appeals Council then concluded Ms. Patrick could perform other jobs that existed in significant numbers identifying the same occupations included in the ALJ's decision, including “laundry worker (DOT# 261.687-014).” AR6. The Appeals Council denied the claim on September 25, 2018, making the Appeals Council's decision the final decision of the Commissioner. AR6.

         B. Plaintiff's Age, Education and Work Experience

         Ms. Patrick was born in July of 1972, making her 46 years old at the time of the denial, and she did not complete high school but received a GED in 1993. AR204, 245. Ms. Patrick reported she worked as a residential aide and a home health aide and had consistent earnings in excess of substantial gainful activity (“SGA”) until the alleged onset of disability. AR37, 222, 333.

         C. Relevant Medical Evidence

         1. Tschetter & Holm Clinic Records

         The earliest treatment record in the appeal file related to Ms. Patrick's physical impairments was for September 22, 2014, when she was seen for constipation, back pain and migraines by William J. Miner, M.D. AR497. Her medications included hydrocodone;[3] Fluoxetine;[4] Seroquel;[5] and Imitrex.[6] AR497. Her past history references a magnetic resonance imaging (“MRI”) scan of her brain that was negative and an MRI of her back. AR497. Examination revealed a flat affect; normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination; and no skin rashes or lesions. AR498. Ms. Patrick's assessments included back pain - 724.5 (Primary), migraine headaches, and hot flashes. AR498. Ms. Patrick's planned treatment included a lumbar epidural. AR498. The epidural was administered at the hospital on September 24, 2014. AR386.

         Ms. Patrick saw Dr. Miner for follow-up on her back pain on October 13, 2014, and reported the epidural had provided some relief, but she still had low back pain and complained of fatigue and headaches. AR494. Ms. Patrick's back pain persisted, she had no falls, spells or new symptoms. AR494. Ms. Patrick also reported that her mood was “ok” and that her bowels were moving. AR494. The record again references prior back and negative brain MRIs. AR494. Examination again found flat affect; normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination, and no skin rashes or lesions. AR495. Ms. Patrick's assessments included irritable bowel syndrome (“IBS”) in addition to back pain. AR495. Dr. Miner told her to continue to take hydrocodone for her back pain and Linzess for her IBS. AR495.

         Ms. Patrick was seen on December 15, 2014, with ongoing complaints of migraines, IBS, and back pain. AR491. Ms. Patrick reported that the Linzess was working well and that she was doing better on Seroquel with no new symptoms, no chest pain, blood pressure was good, stable fatigue, and no spells or falls. AR491. The records again referenced prior back and negative brain MRIs, and examination revealed flat affect; normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination, and no skin rashes or lesions. AR491-92. Ms. Patrick had requested a medication more affordable than Seroquel and it was changed to Topamax. AR491-92. Hydrocodone was continued for back pain. AR492.

         Ms. Patrick saw Dr. Miner on December 30, 2014, with ongoing complaints of migraines and back pain. AR488. Ms. Patrick reported that she was doing “so-so, ” but that her migraines were better. AR488. The records again referenced prior back and negative brain MRIs, and examination revealed flat affect; normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination, and no skin rashes or lesions. AR488-89. Ms. Patrick reported that her lower back pain/fibromyalgia pain was excruciating and affecting her home and work life. AR488. She inquired about another epidural. AR488. Her assessments were radicular lumbar pain and migraine headaches, and another epidural was planned and her Topamax dosage was increased for her migraines. AR489. Ms. Patrick was given the epidural at the hospital on December 31, 2014. AR388.

         Ms. Patrick saw Dr. Miner on February 2, 2015, and reported that her migraines and back pain were worse. AR485. Ms. Patrick also noted that her headaches had improved. AR485. The record again referenced prior back and negative brain MRIs, and examination revealed flat affect; normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination, and no skin rashes or lesions. AR485-86. Hydrocodone was continued. AR486.

         Ms. Patrick saw Dr. Miner on March 2, 2015, and reported ongoing back pain more on the right side and was seeing a chiropractor. AR482. She also completed of extreme fatigue and worsening short-term memory. AR482. The records again referenced prior back and negative brain MRIs, and examination revealed flat affect; normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination; and no skin rashes or lesions. AR482-83. Her Topamax dosage was decreased and labs were ordered due to her fatigue. AR483.

         Ms. Patrick saw Dr. Miner on March 16, 2015, and reported ongoing right sided radicular pain, worsening migraines when taking Singulair. AR477. The records again referenced prior back and negative brain MRIs and examination revealed flat affect; normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination; and no skin rashes or lesions. AR477, 480. Ms. Patrick was assessed with back pain and she received another epidural that same date. AR391.

         Ms. Patrick saw Dr. Miner on April 9, 2015, for ongoing migraines and cold-like symptoms. AR474. The records again referenced prior back and negative brain MRIs, and examination revealed flat affect; normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination; and no skin rashes or lesions. AR474-75. Dr. Miner gave Ms. Patrick samples of Cymbalta for one week then was to change to Brintellix for her migraines. AR475.

         Dr. Miner saw Ms. Patrick on April 27, 2015, for ongoing migraines and the records again referenced prior back and negative brain MRIs, and examination revealed flat affect; normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination; and no skin rashes or lesions. AR471-72. The reasons for her visit included her migraines being worse with Brintellix, and under the history of present illness it stated that “mood much better on brintilix - headaches stable…” AR471. Ms. Patrick was told to wean off Prozac then increase her Brintellix dosage. AR472.

         Ms. Patrick's medical exam records continue to consistently reference a prior MRI of her back and a prior normal brain MRI throughout her treatment notes. Ms. Patrick saw Dr. Miner on May 13, 2015, for ongoing migraines, back pain, anxiety. AR468. She reported she had stopped her Prozac but was feeling very jittery. AR468. Ms. Patrick's assessments included depression with anxiety and her Brintellix dosage was increased again, and fibromyalgia for which she was given Depo Medrol intramuscular injection (Decadron). AR469.

         Ms. Patrick saw Dr. Miner on May 22, 2015, for fibromyalgia and depression with anxiety and reported ongoing back pain with some improvement after the steroid shot and chiropractic care. AR465. Ms. Patrick complained of “n&v” with the higher dosage of Brintellix, but reported improvement with her previous dose. AR465. Her examination showed flat affect; normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination; and no skin rashes or lesions. AR465-66. Her Brintellix was stopped and Wellbutrin prescribed. AR466.

         Ms. Patrick saw Dr. Miner on June 22, 2015, and hydrocodone was continued for back pain. AR459. Ms. Patrick reported that she was doing “so-so, ” and had no issues with her medications, and that her blood pressure was at its goal. AR459. Propranolol was stopped for her migraines, Verapamil prescribed, and a Zofran injection administered. AR460.

         Ms. Patrick saw Dr. Miner on July 21, 2015, for continued back pain and migraines. AR456. She had received an epidural injection the prior day (AR425), and reported increased migraines with dizziness and nausea. AR456. Ms. Patrick also reported that she was tolerating the medication Abilify well, had an ok mood, and had no other new symptoms. AR457. A fentanyl patch was prescribed for her back pain. AR457.

         Ms. Patrick was seen on August 18, 2015, for continued back pain and migraines. AR453. She reported feeling very anxious, having bad headaches the last three days, and said her “back is still hurting, relief with patch-needs refill.” AR453. The fentanyl patches were continued for her migraine headaches and Klonopin prescribed for her anxiety. AR454.

         Ms. Patrick saw Dr. Miner on August 22, 2015, and reported being back at work and feeling extremely anxious and feeling like she could “cry at any moment.” AR450. Her assessments were anxiety and fatigue, and her Abilify dosage was increased and she received a Decadron steroid injection. AR451.

         Ms. Patrick saw Dr. Miner on September 1, 2015, and reported she had quit her job and was feeling very anxious and wanted to discuss social security due to migraines, anxiety, depression, etc. and she was scheduled to see Dr. Christopherson. AR445. Ms. Patrick reported that she was taking Abilify as directed and it seemed to be helping her mood. AR445. Lab tests revealed a positive A ANA SCREEN EIA.[7] AR447.

         Ms. Patrick saw Dr. Miner on September 17, 2015, and reported her mood was better, but her back was “killing” her. AR443. Dr. Miner noted that Dr. Christopherson had discontinued Ms. Patrick's Abilify, and started Prozac and one other medication. AR443. Examination revealed flat affect; normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination; and no skin rashes or lesions. AR443. Hydrocodone was continued for her back pain and a Decadron steroid injection was administered. AR443-44.

         Ms. Patrick saw Dr. Miner on October 2, 2015, for follow-up for back pain. AR441. She reported the back pain comes and goes but it was better, and she had “bad” migraines. AR441. Ms. Patrick returned on November 2, 2015, for her continued back pain and migraines, and Dr. Miner continued hydrocodone as needed for her migraines. AR439.

         Ms. Patrick saw Dr. Miner on February 2, 2016, with reports of right shoulder pain for the last month and an inability to raise her right arm. AR509. She reported that she needed a new prescription for fentanyl and hydrocodone. AR509. She had tried chiropractic treatment for her shoulder. AR509. Ms. Patrick's assessments included low back pain without sciatica and chronic pain syndrome (G89.4) associated with significant psychosocial dysfunction. AR509. Her pain medications were continued and she received a Decadron steroid injection. AR510.

         Ms. Patrick saw Dr. Miner on March 3, 2016, with worsening right shoulder pain, which was worse with movement and better with rest. AR609. Examination revealed pain in the right shoulder muscles, but the joint appeared stable and extremities were without edema or cyanosis. AR610. Her low back pain patches were continued and she received a lidocaine injection in her shoulder. AR610.

         Ms. Patrick saw Dr. Miner on April 4, 2016, with ongoing right shoulder pain, and she complained of vertigo and dizziness upon standing. AR606. She received a Decadron injection and samples of Lyrica were given. AR607. When she was seen a week later her right shoulder pain had improved with treatment, but she reported a migraine for the past three days. AR603. Dr. Miner prescribed Lyrica and she received injections of Reglan, Decadron, and Toradol for her migraine. AR604.

         Ms. Patrick saw Dr. Miner on April 26, 2016, to follow-up on her shoulder and migraines and reported her shoulder was somewhat better, and her headaches were better controlled. AR600. Examination was normal aside from pain in the muscles of the right shoulder and a flat affect. AR601. Ms. Patrick's assessments included abnormal broad-based gait, right shoulder pain, visual distortion, migraine aura, persistent intractable, and tremor. AR601. Dr. Miner continued hydrocodone and provided Lyrica samples. AR601.

         Ms. Patrick saw Dr. Miner on June 2, 2016, for her migraines, back pain and IBS. AR597. She reported that her depression and anxiety had been “up and down” and that she was having “some migraines.” AR597. Ms. Patrick was described as having some significant psychiatric disease but was seeing psychiatry and doing reasonably well. AR597. Examination was normal except for a flat affect and her assessments included migraines treated with Duragesic (fentanyl) patches and chronic pain syndrome treated with Lyrica and a Decadron injection. AR599.

         Ms. Patrick saw Dr. Miner on July 1, 2016, for follow up on her migraines, back pain and IBS. AR594. Dr. Miner noted that Ms. Patrick was overall “doing well” over the last month and admitted to improved arm and chronic pain, stable back pain, and regular bowels. AR594. Ms. Patrick was having some migraines “on and off” quite frequently. AR594. Her medications were continued and she received Toradol and Decadron injections. AR595. Examination was normal aside from a flat affect. AR595. Ms. Patrick's doctor stated, “at this point with her chronic migraines[, ] back pain[, ] psychiatric issues[, ] she is unable to do much more than care for self. Certainly would warrant to be reasonable to have her on disability.” AR595.

         Ms. Patrick saw Dr. Miner again on August 1, 2016, and August 29, 2016, with ongoing migraines, back pain and depression. AR588, 591. On August 1, 2016, Ms. Patrick stated she had good days then bad days and had two really bad weeks. AR591. Ms. Patrick noted to be doing “reasonably well, ” with an improved mood and regular bowels; but ongoing migrainous headaches, back pain, and “some” depression. AR591. On August 29, 2016, Ms. Patrick was noted to be “doing well” with “slightly better” mood and well-controlled pain. AR588.

         Ms. Patrick saw Dr. Miner again on September 26, 2016, for her depression, migraines, and pain and reported that her fibromyalgia had flared up about five to six days ago and she had been depressed for about three days. AR582. Ms. Patrick was noted to be a somewhat rambling historian, but had arthralgias, myalgias, and had a typical fibromyalgia flare. AR582. She had a flight of ideas rambling between her joint pain, nasal congestion, cough, or depression due to her living situation. AR582. She was assessed with fibromyalgia and given prednisone and Decadron injections. AR583-84.

         Ms. Patrick saw Dr. Miner on October 25 2016, and reported worsening migraines and some issues with anxiety, bowels, and chronic headaches. AR580. Examination was normal aside from a flat affect. AR580. Her Lyrica dosage was increased. AR580.

         Ms. Patrick saw Dr. Miner on November 8, 2016, for a two-week follow-up. AR578. Ms. Patrick was assessed with migraine headaches and received Decadron, Toradol, and Reglan injections. AR578.

         Ms. Patrick saw Dr. Miner on December 22, 2016, with ongoing symptoms and her hydrocodone was continued, phentermine was prescribed for her weight, and she received Decadron and Toradol injections. AR574.

         Ms. Patrick saw Dr. Miner on March 9, 2017, and reported not “feeling good, ” being really depressed and having anxiety and her psychiatrist had increased her anxiety medication. AR890. Ms. Patrick also reported that her migraines had increased due to stress and her lower back had been hurting more even with her pain pills. AR890. Examination was normal aside from a flat affect. AR890. She received a Decadron injection. AR891.

         Ms. Patrick saw Dr. Miner on January 12, 2017, for follow-up regarding weight loss. AR894. Ms. Patrick reported headaches, being more depressed and anxious the last two weeks, and some chronic back pain. AR894. Examination showed normal affect, proper orientation, normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination, and no skin rashes or lesions. AR894. Her assessments included migraines, IBS, depression, and fatigue. AR894.

         Ms. Patrick saw Dr. Miner on March 23, 2017, and Dr. Miner assessed Ms. Patrick with migraines without status migrainosus, non-intractable, unspecified migraine type. AR1313. She received Toradol and Decadron injections. AR1313.

         Ms. Patrick saw Dr. Miner on April 10, 2017, and reported being more depressed and anxious and her Obsessive Compulsive Disorder (“OCD”) was worse. AR1310. Her examination was normal except that her affect was flat and she continued with psychiatry. AR1311.

         Ms. Patrick saw Dr. Miner on May 16, 2017, and reported feeling “up and down” and having more migraines. AR1307. Dr. Miner adjusted Ms. Patrick's medications to control her headaches and noted that Ms. Patrick was doing “quite well” with psychiatry. AR1307. Her medications included duragesic or fentanyl patches, hydrocodone, Topamax, Lyrica, Senna, clonazepam, Zyprexa, Prozac, Linzess, Focalin, and Imitrex. AR1307. Examination showed normal affect, proper orientation, normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination, and no skin rashes or lesions. AR1308. The dosage of her fentanyl patches was increased. AR1308.

         Ms. Patrick saw Dr. Miner on June 6, 2017, and the general history noted that her headaches had improved with fentanyl, but since the fentanyl dosage had been increased she reported feeling more hyper, had hives, had difficulty thinking, and was feeling more aggressive toward her mother. AR1305. She denied any abdominal problems, headaches, or changes in vision or hearing. AR1305. Examination showed normal affect, proper orientation, normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination, and no skin rashes or lesions. AR1305.

         Ms. Patrick saw Dr. Miner on July 11, 2017, for follow-up after being discharged from the Human Services Center on July 7, 2017, following 10 days of inpatient mental health treatment. AR964, 1301. Ms. Patrick continued to report back pain, the reason for the appointment included that she had “lots of meds changes doing well, ” and she denied depression, anxiety, bowel changes or headaches. AR1301. Examination showed normal affect, proper orientation, normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination, and no skin rashes or lesions. AR1307.

         Ms. Patrick saw Dr. Miner again on July 25, 2017, and stated that she had been “feeling pretty good, ” denied any depression or anxiety, but admitted to back pain. AR1299. Imitrex was added back to her medications for migraine headaches, and her assessments included backache, unspecified for which Celebrex was prescribed. AR1299.

         Ms. Patrick saw Dr. Miner on August 25, 2017, and was noted to be “feeling okay” and “doing well.” AR1297. Ms. Patrick complained of intermittent headaches and back pain but stated that her back pain was a little better. Examination showed normal affect, proper orientation, normal heart and lung sounds; supple neck; soft abdomen; no edema or cyanosis in the extremities; non-focal neurological examination, and no skin rashes or lesions. AR1297.

         2. Community Counseling Services Records

         Ms. Patrick was seen for an initial examination by Lyle Christopherson, DO, a psychiatrist, on September 16, 2015. AR429. Ms. Patrick stated “I've never had depression like this.” AR429. Ms. Patrick reported being a single mother since her husband committed suicide in 2000, and that she had recently quit her job of eight years. AR429. Dr. Christopherson stated Ms. Patrick was well known to him because he also treated her two boys, both who had some variant of schizoaffective disorder. AR429. Dr. Christopherson also noted a history of chronic back pain secondary to a motor vehicle accident when Ms. Patrick was a teen, fibromyalgia, and migraine headaches. AR429. Ms. Patrick was taking Cymbalta, Prozac, Abilify, Klonopin, fentanyl patches, and hydrocodone. AR429-30.

         In the mental examination section, Dr. Christopherson noted that Ms. Patrick was a female well known to him who always appeared depressed, had some difficulties processing things, and got no joy out of life with “always being in pain and everything hurt[ing].” AR429. Dr. Christopherson also noted that Ms. Patrick was alert and oriented but complained of chronic worry; recent problems with concentration, comprehension, and focus; fatigue even when she wakes up; mild psychomotor retardation; and passive suicidal thoughts. AR431. Dr. Christopherson referred Ms. Patrick to counseling (“Care Program”) and changed her medication regimen to add Prozac in the morning, switch to Rexulti, and taper off Abilify. AR431.

         Ms. Patrick saw Dr. Christopherson on September 29, 2015, and Dr. Christopherson stated under “identifying information” that Ms. Patrick had mood issues, migraine headaches, and chronic pain issues. AR433. Dr. Christopherson stated in his mental status exam that Ms. Patrick “worries right now that she is going to lose her insurance at the end of the month. She has fentanyl patches for pain and it does work for her migraines and she won't be able to afford them. There apparently is no indigent for them. So I don't know what we are going to do about that. Primary care needs to deal with it.” AR433. Neurological examination showed no new neurological deficit. AR433. Ms. Patrick also met with Jennifer Enander, BA, CPRP of the Care Program on September 29, 2015, and Ms. Patrick's PHQ9[8] score was 21.[9] AR434.

         Ms. Patrick saw Dr. Christopherson on October 27, 2015, and she reported only one complaint, that her right leg had a little akathisia, [10] which her doctor felt was from switching medications and should clear over time. AR435. She was doing “fairly well” with her mood, but was always having migraines and had chronic pain issues. AR435. Ms. Patrick showed a stable mood and no suicidality. AR435.

         Ms. Patrick saw Dr. Christopherson on December 14, 2015, for medication management and complained of restless legs, feeling poorly, having no “get up and go, ” not wanting to do anything, and akathisia of the lower extremities. AR517. The doctor stated that Ms. Patrick had done better on Abilify before, but previously they had no samples and there was no indigent program for Abilify, but now they had a large supply of 15mg samples and although she had been on a 10mg dose before, these pills could be cut in half and “hopefully 7.5mg will get her by.” AR518. Ms. Patrick's PHQ9 score had increased to 25. AR518. Ms. Patrick showed no risk factors for suicide, physical violence, substance abuse or psychosis. AR518.

         Ms. Patrick saw Dr. Christopherson on January 12, 2016, for medication management. AR520-21. Ms. Patrick reported that she was a “little stressed” because one of her sons had overdosed. AR521. Ms. Patrick also reported that one of her legs felt jittery due to medication adjustments, which Dr. Christopherson noted should resolve over time. AR521. Ms. Patrick's Klonopin dosage was doubled. AR521. Her PHQ9 score was 23. AR522.

         Ms. Patrick saw Dr. Christopherson on February 16, 2016, and reported tremors and shakiness that began with Rexulti. AR525. Her doctor assured her that her symptoms “would get better” and that “it always gets better, ” and noted that she did not have “full blown tardive dyskinesia[11] but that is, unfortunately, the direction that she is headed….” AR525. Dr. Christopherson noted that otherwise Ms. Patrick was “actually doing fairly well, ” and taking vitamin E to help with her symptoms. AR525. Dr. Christopherson stated that he was hopeful that Ms. Patrick's tremors and shakiness would pass within the next six months. AR525.

         Ms. Patrick saw social worker Tammy Dramstad for an intake evaluation on March 7, 2016. AR618. Ms. Patrick reported living with her sons, ages 25 and 23, in a mobile home a few lots away from her mother and grandparents and was happy with her current home. AR618. She stated “I have so much anxiety and depression.” AR618. Ms. Patrick reported that before June, 2015, she felt more normal, more like herself. AR618. Behavioral observations and examination revealed Ms. Patrick was alert and oriented, had a blunt affect, and described her mood as depressed. AR618. Ms. Patrick also complained of sleep problems, shaky legs, depressed mood, edginess, high anxiety, shortness of breath with anxiety, racing pulse, and feeling a sense of doom with most episodes lasting five to ten minutes. AR619. Ms. Patrick reported that she was no longer able to cook due to the stress, and her mother cooks for them. AR619. Ms. Patrick reported that in June, 2015, she started crying for no reason and felt quite out of it, was not able to do her job, and started feeling anxious and taking more time off. AR619-20. Ms. Patrick reported she completed only the tenth grade, but obtained a GED. AR619-20. She also claimed that she had a learning disability and struggles to retain information. AR620. Ms. Patrick also reported that she worked for a nursing home and assisted living place and worked for the Center of Independence for 8.5 years and home health for 8 years. AR620. Weekly counseling sessions were planned and psychiatric eligibility findings stated her mental impairments caused a poor employment history, inability to perform basic living skills without assistance, inappropriate social behavior, poor eye contact, and a Global Assessment of Functioning (“GAF”) score of 55. AR621-22.

         Ms. Patrick saw Dr. Christopherson on March 23, 2016, and reported being overwhelmed at the simplest things and having tremors. AR625. Ms. Patrick stated that her mother started living with her to help care for her. AR625. Examination revealed falls, tremors, and confusion, and her medication was changed to Lamictal. AR625.

         Ms. Patrick saw a case manager in her home on March 29, 2016, to help her complete disability forms. AR629. Mental status examination revealed proper alertness, flat affect, anxious mood, appropriate fashion, and fair eye contact. AR629. The case worker observed that Ms. Patrick was organized; was able to answer questions with prompting from her mother; and did very well, but was slow at times. AR629. Ms. Patrick indicated that she seldom completed tasks around her home and got assistance from her mom and oldest son. AR629. They met again the next day to continue working on the paperwork and Ms. Patrick's affect was flat and mood anxious. AR630. She continued to need help from her mother answering questions. AR630. Her case manager reported that she “did very well sharing who she is and what she would like to be in the future, ” had a really good outlook on life, and that progress towards her goal was good because she “continues to work on her disability and seems to be okay with people meeting with her in her home.” AR630.

         On April 12, 2016, Ms. Patrick saw her case manager again. Her mental status examination revealed that she was alert, had appropriate affect, and presented herself in appropriate fashion. AR634. Ms. Patrick reported to her caseworker that things went well at her meeting with her lawyer and that she was pleased with her ability to respond to the lawyer's questions. AR635. Ms. Patrick reported that she was doing okay that day but had been anxious and had struggled over the last week. AR635. Ms. Patrick also reported that she is happy when she gets out of the house and performs tasks and that she had a very good day and was able to go to her grandmother's and complete some tasks for her and go out for dinner. AR635. She also noted that she is happy completing tasks that were set out for her by Tammy and that she could complete them with minimal intervention. AR635. She told her case manager that she would like to exercise more because she knew it would help her pain. AR635.

         Ms. Patrick saw Dr. Christopherson on April 18, 2016, and he felt she looked better, but she reported having a bad day and having a migraine. AR637. She reported taking the nasal spray form of Imitrex, because she could not afford the pills, and sometimes it worked and sometimes it did not. AR637. Ms. Patrick continued to complain a lot of jerking and shoulder thrusts and abnormal movements that the doctor felt was associated with neurolyptics.[12]AR637.

         Ms. Patrick had additional case management appointments between April 18, 2016, and May 13, 2016. AR640-46. Mental status examination revealed that Ms. Patrick was alert and properly oriented; had a cooperative and open attitude; exhibited an affect that varied between blunted, anxious and appropriate and mood that varied between anxious and cheerful; showed good eye contact; and verbalized awareness of problems and consequences in terms of insight. AR640, 642-46.

         Ms. Patrick saw Dr. Christopherson on May 3, 2016, and continued to have a high PHQ9 score. AR648. Dr. Christopherson noticed “some kind of jerking motion, ” but the doctor felt she looked a little better. AR648. Dr. Christopherson noted that Ms. Patrick was able to get out and do things, was exercising “a little bit more, ” and had plans to eat out for Mother's Day. AR648. Ms. Patrick was trying to obtain disability and Dr. Christopherson stated, “… it's probably going to be over a year before she gets that. I do believe she will get it. She is certainly not able to work at this time and has been kind of dysfunctional for some time.” AR48. Ms. Patrick felt she may have MS due to her double vision and unsteadiness in her gait but Dr. Christopherson felt it was caused by her medications. AR648.

         Ms. Patrick had additional case management appointments between May 9, 2016, and June 2, 2016. AR650-57. Mental status examination revealed that Ms. Patrick was alert and oriented, had a cooperative and open attitude, exhibited an appropriate affect, had an anxious to cheerful mood, showed good eye contact, and verbalized awareness of problems and consequences in terms of insight. AR650-56. Ms. Patrick's case manager noted that Ms. Patrick did “very well” filing out her disability paperwork. AR652. Ms. Patrick reported that she was doing well, but had some bad days that she was able to work through and did very well. AR654. During this time, Ms. Patrick was making meals that her family enjoyed, doing adult coloring, walking three times a week, going to her cousin's home to visit a newborn baby, caring for her sick mother, and taking her mother to the emergency room. AR650-56.

         Ms. Patrick saw Dr. Christopher on June 7, 2016. AR657. Dr. Christopherson indicated that he thought Ms. Patrick felt “miserable, ” he also reported that Ms. Patrick was looking better with improved tremors. AR657-58. Dr. Christopherson also reported that Ms. Patrick had been tending to her “legally blind” mother who had bronchitis and other medical problems and was helping her elderly grandmother and giving her baths once or twice per week. AR657. Ms. Patrick still alleged headaches, but indicated that the headaches were better. AR657.

         Ms. Patrick had additional case management appointments between June 7, 2016, and July 11, 2016. AR660-667. Mental status examination revealed that Ms. Patrick was alert and properly oriented, had a cooperative and open attitude, exhibited an appropriate affect, had an anxious and cheerful mood, showed good eye contact, and verbalized awareness of problems and consequences in terms of insight. AR660, 663-68. On June 7, 2016, Ms. Patrick reported that she was doing well. AR660. On June 14, 2016, Ms. Patrick reported that she did help her mother cook and she was proud of that. AR663. With less headaches and improved moods, on July 5, 2016, she reported that she had been cooking meals for herself. AR668. On July 11, 2016, Ms. Patrick reported spending more time on her couch and stated that her mother was preparing more of her meals. AR669. On July 11, 2016, Ms. Patrick also reported that she felt she may be slipping further into depression again. AR669.

         Ms. Patrick saw Dr. Christopherson again on July 20, 2016, and he stated in his mental status examination that she was not doing well and had markedly declined, was unable to do the simplest things like making canned soup, and just wanted to sit on the couch and isolate. AR674. Her anti-psychotic medication had been stopped due to side effects, and her Prozac dosage was increased, and Zyprexa and Concerta prescribed. AR674.

         Ms. Patrick saw a case worker on July 20, 2016, to get help with public assistance for her medications. AR672. The case worker found Ms. Patrick's mental status to show that Ms. Patrick was well oriented in all spheres and alert. AR672.

         On August 2, 2016, when Dr. Christopherson saw Ms. Patrick, he stated in his mental status exam that it looked like Ms. Patrick was having a good day versus a bad day and noted that things were better after Ms. Patrick started the medication Concerta. AR681. She tolerated the mediation without difficulty and admitted to doing more. AR681. Her Concerta dosage was increased. AR681.

         Ms. Patrick saw a case worker on August 2, 2016, to review her medications and the case worker stated Ms. Patrick's mental status showed proper alertness, appropriate affect, cheerful mood and appropriate fashion. AR683-84.

         During her therapy visits with her case manager in August, Ms. Patrick reported that despite having some days she struggled she was able to babysit her cousin's children, help her grandmother, go shopping on her own, volunteer at the animal shelter, and do “very well” in public. AR691-93. Ms. Patrick also reported that she felt she successfully handled her rising anxiety when her mother was out of the home for five hours one day. AR692.

         Dr. Christopherson saw Ms. Patrick on September 6, 2016, and stated in his mental status examination that she was worse, with lots of chronic physical aches and Prozac and Concerta were stopped, Fetzima was ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.