United States District Court, D. South Dakota, Southern Division
NIKKI R. FLATEQUAL, Plaintiff,
ANDREW M. SAUL, Commissioner of the Social Security Administration, Defendant.
MEMORANDUM OPINION AND ORDER
VERONICA L. DUFFY UNITED STATES MAGISTRATE JUDGE
Nikki R. Flatequal, 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.
Flatequal has filed a complaint and motion to reverse the
Commissioner's final decision denying her disability
benefits and to remand the matter to the Social Security
Administration for further proceedings. See Docket
No. 1, 13. The Commissioner has filed his own motion seeking
affirmance of the decision at the agency level. See
Docket No. 17.
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. §
Statement of the Case
action arises from plaintiff Nikki R. Flatequal's
(“Ms. Flatequal”) application for SSDI and SSI
filed on February 17, 2016, alleging disability since
December 31, 2015, due to a brain tumor, an open reduction
internal fixation of the left clavicle, left-sided craniotomy
for tumor resection, depression, anxiety, and hip and knee
pain. AR211, 213, 255, 282, 285, 297. Ms. Flatequal's
claim was denied initially and upon reconsideration. AR168,
177, 184. Ms. Flatequal then requested an administrative
Flatequal's administrative law judge (“ALJ”)
hearing was held on March 16, 2018, by Lyle Olson. AR68. Ms.
Flatequal was represented by other counsel at the hearing,
and an unfavorable decision was issued on May 4, 2018. AR12,
One of the evaluation, the ALJ found that Ms. Flatequal was
insured for benefits through June 30, 2021, and that she had
not engaged in substantial gainful activity
(“SGA”) since December 31, 2015, the alleged
onset of disability date. AR17.
Two, the ALJ found that Ms. Flatequal had severe impairments
of a history of left mid-shaft clavicle fracture with
non-union (status post open reduction and internal fixation);
status post left posterior/frontal craniotomy for Grade I
meningioma; degenerative changes, lumbar spine, with
degenerative disc disease most severe at ¶ 5-S1 and
moderate neural foraminal stenosis on the left at ¶ 5-S1
with mild compression of the intraforaminal left L5 nerve
root; status post anterior discectomy and C5-6 fusion with
degenerative retrolisthesis and moderate central spinal
stenosis at ¶ 6-7, with left side radiculopathy;
cervicalgia, headaches; left piriformis syndrome;
fibromyalgia; neurocognitive disorder; major depressive
disorder, recurrent, moderate; and an unspecified anxiety
found that Ms. Flatequal also had additional medically
determinable impairments of osteopenia, hyperlipidemia, and
diverticulitis, but found they were not severe. AR18. The ALJ
found that Ms. Flatequal's borderline personality
disorder was not a medically determinable impairment. AR18.
3, the ALJ found that Ms. Flatequal 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”). AR18-21. The ALJ
considered the mental impairments, and found that Ms.
Flatequal 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, so did not meet
a Listing. AR19-20.
determined that Ms. Flatequal had the residual functional
capacity (“RFC”) to perform:
light work as defined in 20 CFR 404.1567(b) and 416.967(b)
except lift and/or carry 20 pounds occasionally and 10 pounds
frequently, sit with normal breaks for a total of about 6
hours in an 8-hour workday, stand and/or walk with normal
breaks for a total of about 6 hours in an 8-hour workday,
occasionally engage in push/pull actions (i.e., hand
controls) with the left dominant hand (with no resistance
greater than 20 pounds), occasionally climb ramps/stairs,
balance, stoop, kneel and crouch, and never climb
ladders/scaffolds, crawl, 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, interact appropriately
with supervisors and co-workers on an occasional basis and
with the public on a brief and superficial basis only,
respond appropriately to changes in a routine work setting,
and make judgments on simple work-related decisions.
ALJ's subjective symptom finding was that Ms.
Flatequal's medically determinable impairments could
reasonably be expected to cause the alleged symptoms, however
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.”
considered the opinions of the State agency initial level
psychological consultant and gave them “no
weight.” AR25. The ALJ considered the opinions of the
State agency reconsideration level psychological consultant
and gave them “great weight.” AR25. The ALJ
considered the opinion of treating psychiatrist, Michael
Bergan, MD, and gave his opinion “great weight.”
considered the opinions of the State agency medical
consultants from both the initial level and reconsideration
level, and gave them “no weight” because the
opinions were inconsistent with the medical evidence. AR25.
considered the opinion of treating orthopedic physician
Matthew Wingate, MD, and gave his opinion “partial
weight” to the extent the opinion supported a capacity
to perform light exertion work, but rejected the portions of
the opinion which would restrict Ms. Flatequal to sedentary
work. AR26. Dr. Wingate restricted Ms. Flatequal to lifting
10 pounds occasionally, standing or walking to no more than
two hours of an 8-hour workday with alternating sitting and
standing every 30 minutes due to pain, but the ALJ did not
specify which of Dr Wingate's limitations supported light
exertion work. AR26.
considered the opinion of treating physician Scott Dierks,
MD, who the ALJ indicated opined that Ms. Flatequal was
limited to less than a full range of sedentary work, and gave
his opinions only “partial weight” because the
ALJ asserted Dr. Dierks' treatment notes indicated full
range of motion of extremities, appropriate muscle strength,
full sensation and normal gait. AR26-27.
also considered the mental health opinions of treating
physician Scott Dierks, MD, who the ALJ indicated opined that
Ms. Flatequal had marked limitations in her ability to
complete a full work day without extra breaks, and noted that
the opinion was consistent with Ms. Flatequal's alleged
symptoms, but inconsistent with Dr. Bergan's opinions.
The ALJ did not state what, if any, weight he gave Dr.
Dierks' opinions regarding Ms. Flatequal's mental
on the RFC, the ALJ found that Ms. Flatequal was not capable
of performing her past relevant work. AR27.
stated in his decision:
At the hearing, the undersigned asked the vocational expert
to assume a hypothetical for an individual with the residual
functional capacity as previously determined by the
undersigned in this decision. When asked whether such a
hypothetical individual could perform any of the
claimant's past relevant work, the vocational expert
testified such an individual could perform the claimant's
past work at the semiskilled and skilled levels. However, the
undersigned finds that the claimant's mental residual
functional capacity is more consistent with an individual
limited to unskilled work that precludes the mental demands
of the claimant's past relevant work.
AR27. However, the asserted question by the ALJ and asserted
answer by the vocational expert does not appear any where in
the hearing transcript. AR66-114. The vocational expert did
affirm in response to the ALJ's question that Ms.
Flatequal's past work would be excluded. AR108.
5, the ALJ found Ms. Flatequal capable of adjusting to other
work that existed in significant numbers, such as copy
machine operator, DOT# 207.685-014; mail clerk, DOT#
209.687-026; and clerical checker, DOT# 222.687-010, relying
on testimony from the vocational expert regarding the number
of jobs available for each occupation nationally and denied
the claim. AR28-29.
Flatequal timely requested review by the Appeals Council.
AR209. The Appeals Council denied Ms. Flatequal's request
for review, making the ALJ's decision the final decision
of the Commissioner. AR1-5.
Plaintiff's Age, Education and Work Experience.
Flatequal was born in 1966 making her 49 years old at the
onset of disability and turning age 50, a person closely
approaching advanced age, in October, 2016. AR27, 211. She
completed four or more years of college in 1989. AR256. The
ALJ found that Ms. Flatequal had multiple past relevant jobs
at both the skilled and semi-skilled level. AR27.
Relevant Medical Evidence. 1. Avera McGreevy Clinic:
Flatequal saw Dr. Dierks, her primary care physician, on May
4, 2015, and the psychological exam indicated no evidence of
anxiety or depression, but her Celexa dosage was increased
for her depression at her request. AR689-90. When seen again
on May 7, 2015, the treatment note stated she has recently
been seen for depression. AR681. She had been having chronic
abdominal pain, which had been evaluated by a
gastroenterologist with no resolution. AR682-83.
notes for January 4, 2016, indicate that Ms. Flatequal called
and informed the clinic she had fallen on the ice on December
31, 2015, fracturing her skull and collar bone, and a CT scan
obtained as a result revealed a brain tumor. AR420. The CT
scan obtained on December 31, 2015, following her fall
revealed prior post-operative changes from C5-C6 that is
solidly fused and diffuse degenerative changes. AR489. Other
images of the left shoulder revealed a displaced overriding
mid left clavicle fracture. AR489.
Flatequal saw Dr. Dierks on March 5, 2016, following surgery
to repair her collar bone due to some swelling at the
incision site, and she was also scheduled for brain surgery
for her tumor. AR649.
Flatequal saw Dr. Dierks on June 15, 2016, for a physical and
right hip and right knee pain, and she continued to have pain
in her left clavicle. AR872, 874. X-rays were planned for her
hip and knee and the scar on her shoulder was to be excised.
Flatequal saw Dr. Dierks on August 8, 2016, to follow up on
her elevated blood pressure and worsening pain in both hips.
AR844. Dr. Dierks felt that Ms. Flatequal's prior hip
x-ray had shown a little arthritis and she had started on
naproxen initially as needed and now daily. AR849.
Examination revealed pain to palpation and swelling on the
right over the iliac crest, and she was referred to
orthopedics for her hip pain. AR849.
Flatequal saw Dr. Dierks on October 31, 2016, to follow up on
her ongoing hip pain. AR841. She had been to orthopedics and
an MRI did not reveal the cause of the pain, she continued
taking naproxen, and had tried chiropractic treatment without
relief, and was having fatigue. AR841. Examination revealed a
little pain and swelling over the SI joint, the right lower
back, and the paraspinal muscle area. AR842. Naproxen was
stopped and she was referred for physical therapy. AR842.
Flatequal saw Dr. Dierks on June 7, 2017, for neck, hip,
right ankle pain, and a painful lump over her left axilla
area. AR966. Her back pain was bilateral in the lower back
and hip area and was relatively constant but worse with
bending. AR966. Examination revealed tenderness over the C7
to T1 area, trapezius muscle tenderness, a very tender
subcutaneous nodule in her left axilla, tenderness in the
lower back bilaterally over her SI joints, and a focal small
slightly boggy swelling over the right lateral malleolus with
tenderness and bruising. AR971-72. An HLA-B27 blood test was
ordered and x-rays of the lower back and cervical area were
ordered. AR972. Lumbar spine x-rays revealed mild
spondylosis. AR1188. Cervical spine x-rays revealed anterior
interbody fusion at the C5-6 level, degenerative disc changes
at ¶ 4-5 and C6-7, and mild degenerative facet changes.
AR1187. On June 19, 2017, she was seen again, at which time
her depression score was positive and physical therapy was
prescribed for her neck. AR957, 964.
Flatequal saw Dr. Dierks on September 18, 2017, for her
ongoing neck pain and myalgias, following her appointment
with Dr. Wingate, an orthopedic surgeon, who had recommended
EMG testing as well as evaluation for fibromyalgia. AR949.
Gabapentin was prescribed and she was referred to
rheumatology. AR954. A DEXA bone scan obtained on September
20, 2017, revealed low bone density, significantly decreased
since 2015, but not osteoporosis. AR1186.
Flatequal saw Dr. Dierks on November 20, 2017, for a
preoperative exam prior to breast reduction surgery. AR1126.
Dr. Dierks noted that Ms. Flatequal had just had hardware
removed from her collarbone, had been diagnosed with
fibromyalgia, and given her struggles with back and neck pain
he felt the breast reduction surgery was a good plan. AR1126,
1128. Her Tramadol medication was refilled for pain. AR1128.
Flatequal saw physician's assistant Travis
Slaba on November 22, 2017, for significant
clavicle pain following a pop over her left clavicle when
reaching to pick something up. Examination revealed an
inability to shrug her shoulders, significant decreased range
of motion of the left shoulder, and severe discomfort on
palpation of mid clavicle. AR1117. X-rays revealed a left
clavicle fracture. AR1118. A sling, Toradol for pain, and a
referral to the orthopedic clinic were given. AR1118.
Flatequal saw Dr. Dierks on December 20, 2017, to follow-up
on her fibromyalgia, which she reported was worse, and water
therapy was prescribed. AR1096, 1103.
February 6, 2018, Dr. Dierks examined Flatequal and completed
a medical source statement regarding her ability to
physically function during a full-time workday. AR1193-95.
Dr. Dierks opined that Ms. Flatequal would be limited to
lifting less than 10 pounds occasionally or frequently,
standing or walking less than two hours in an 8-hour workday,
and she would need an option to alternate to a standing
position every 30 minutes while sitting. AR1193. Dr. Dierks
stated that Ms. Flatequal was limited in pushing or pulling
in both her upper and lower extremities due to her shoulder,
hip, and back issues, and she was limited to only occasional
reaching, and frequent handling, fingering, and feeling.
February 6, 2018, Dr. Dierks examined Ms. Flatequal and
completed a medical source statement regarding her mental
ability to do basic work activity on a sustained, regular and
continuing basis. AR1189-92. Dr. Dierks identified moderate
limitations in identifying and solving problems, sequencing
multi-step activities, using judgment to make work-related
decisions, ability to keep social interactions appropriate,
complete tasks in a timely manner, ability to ignore or avoid
distractions, sustain an ordinary routine and regular
attendance, and to adapt to change. AR1189-91. Dr. Dierks
also identified marked limitations in Ms. Flatequal's
ability to work a full day without needing more than the
allotted number or length of rest breaks during the day and
in her ability to manage her psychologically based symptoms.
Avera Rheumatology Clinic:
Flatequal saw rheumatologist Jenna King, DO, on November 13,
2017, for evaluation of myalgias. AR900. Ms. Flatequal had
already been started on gabapentin, but reported not noticing
much difference with it, and had been tested for autoimmune
disease and was found to have a negative rheumatoid factor
CCP and HLA-B27. AR900. Ms. Flatequal was suffering from
fatigue, sleep problems, pain, headaches, anxiety/depression,
morning stiffness, tingling in her hands, IBS, spastic colon,
cervical and lumbar osteoarthritis and myalgias. AR900. Ms.
Flatequal was scheduled for a C7 nerve block injection the
following week and a piriformis injection. AR900. Ms.
Flatequal also reported having a lot of disorientation, and
wasn't sure if that was due to the brain surgery for her
tumor, and significant left hip pain. AR901, 903. Examination
revealed full range of motion for all extremities, no joint
swelling, normal reflexes, intact movement, normal sensation,
and 11/18 muscle tender points. AR907. Dr. King's
assessment was fibromyalgia, degenerative joint disease, and
anxiety/depression. AR907. Dr. King stated that Ms. Flatequal
had widespread pain with at least 11 out of 18 muscle tender
points consistent with fibromyalgia, and recommended a
combination of gabapentin, Cymbalta, and Flexeril. AR908.
Avera Neurosurgery Clinic:
Flatequal had brain surgery on March 30, 2016, to remove a
small left posterior frontal dural-based meningioma.
AR468-70, 606, 618. She was discharged from the hospital on
April 3, 2016. AR464.
Flatequal was seen on July 14, 2016, for follow-up to her
tumor surgery and reported having several psychiatric
complaints, which were being addressed by her psychiatrist,
and fatigue, poor energy level, and a sensation of
“disconnect.” AR745. She did not feel she was
able to return to work.AR745. An MRI obtained the same day
revealed no evidence of tumor reoccurrence. AR747.
Flatequal had a 24-hour video EEG on December 27, 2016, due
to spells of alteration of awareness, which was normal.
Flatequal was seen on September 12, 2017, for a nerve
conduction test due to bilateral hand pain and paresthesia,
which revealed no convincing evidence of radiculopathy,
plexopathy or mononeuropathy affecting the extremities.
Flatequal saw neurologist Todd Zimprich, MD, on November 7,
2017, for evaluation of a cognitive disorder with spells of
disorientation, memory difficulties, tremors, and weakness in
the upper extremity, and headaches. AR984. Dr. Zimprich
stated Ms. Flatequal's cognitive disorder was likely due
to mental distraction. AR986. Ms. Flatequal saw Dr. Zimprich
again on November 11, 2017, to test results which failed to
identify an etiology for her neurologic symptoms. AR988. Dr.
Zimprich noted that Ms. Flatequal was anxious with pressured
speech, and she had a low amplitude, high frequency tremor in
her bilateral upper extremities. AR988.
Flatequal saw Dr. Zimprich on November 22, 2017, for
follow-up evaluation of a cognitive disorder with tremors and
headaches, and spells of “disorientation.” AR978.
Ms. Flatequal complained of decreased energy, difficulty
sleeping, depression/anxiety, left hip pain, lightheadedness,
memory loss, headaches, left hand weakness, and left arm and
leg paresthesias. AR978. Dr. Zimprich's assessments
included migraines, stable; tremors, well-managed; meningioma
with no clear residual, but some somatic symptoms may be
associated; and cognitive disorder, likely multifactorial
with a significant element associated with Ms.
Flatequal's psychiatric disease and prior alcohol use,
and may be a mild element associated with the meningioma.
Flatequal was seen on January 4, 2016, at Orthopedic
Institute for a left mid-shaft clavicle fracture. AR702. Due
to swelling and edematous, surgical intervention was not
scheduled. AR702. Follow-up on January 15, 2016, showed
restricted shoulder motion with significant pain with motion.
AR701. Imaging revealed a displaced and shortened mid-shaft
clavicle fracture and surgery was planned. AR701. Ms.
Flatequal underwent an open reduction and internal fixation
of the left midshaft clavicle on January 26, 2017. AR700,
704. Follow-up the following week showed she continued on
pain medication but was doing well. AR699.
Flatequal was seen on March 9, 2016, for follow-up on her
clavicle fracture and continued to do well, and had been
essentially pain free over the clavicle and had full motion.
AR698. On May 25, 2016, Ms. Flatequal was referred for
physical therapy due to left shoulder pain and weakness, and
limited range of motion. AR709. On June 10, 2016, Ms.
Flatequal reported that she had some anterior shoulder
soreness and tingling, but no pain in the shoulder, and her
home therapy was going well. AR812.
Flatequal was seen on October 7, 2016, for right hip/buttock
pain and weakness. AR801. Examination revealed diffuse pain
with palpation over the gluteus musculature. AR801. Imaging
revealed no abnormalities and she was referred for physical
Flatequal was seen on November 4, 2016, for physical therapy
evaluation of right hip/buttock pain and weakness. AR810.
Therapy continued through December  and by December
14, 2016, Ms. Flatequal was not able to tolerate a stationary
bike at level 3 for longer than four minutes. AR811.
Flatequal received a left piriformis injection and a cervical
epidural steroid injection at Avera Hospital on November 14,
2017, by referral from Dr. Wingate. AR1344. She received the
injections for neck and left upper extremity pain that
radiated into her left hand with numbness and tingling to the
fingers. AR1344. Ms. Flatequal's pain was aggravated by
activity. AR1344. Imaging revealed degenerative
retrolisthesis leading to moderate central canal stenosis at
¶ 6-C7 in addition to her prior fusion at ¶ 5-C6.
AR1344. Examination revealed Ms. Flatequal was pacing and
rearranging chairs and her belongings, and she even needed to
get up and do several small tasks during the interview
process. AR1344. Her cervical spine, paraspinous musculature,
trapezius, and rhomboid were all tender to palpation, and the
left greater trochanter into the piriformis and gluteal
musculature were also tender. AR1344.
Flatequal underwent a revision open reduction and internal
fixation of her left clavicle on November 29, 2017, performed
by Dr. Wingate. AR1361. Ms. Flatequal had a plate and screw
removed from her prior clavicle surgery a couple weeks
earlier due to hardware prominence and she refractured her
Flatequal was referred by Dr. Wingate to Midwest Pain
Specialists for a left SI joint injection administered on
December 22, 2017, due to buttock discomfort and SI joint
pain on the left side. AR1044.
Flatequal was seen on March 1, 2018, by Dr. Wingate for
follow-up on her left clavicle. AR1376. She had the plate
removed which had been put in at her initial shoulder
surgery, and following removal she refractured the clavicle.
AR1376. Dr. Wingate stated that he had also been seeing her
for buttock, leg and back symptoms and she had been through
multiple rounds of physical therapy, SI joint injections,
epidural injections, and anti-inflammatory medications.
Flatequal reported that her shoulder was doing well, but was
concerned about her low back and buttock. AR1376. She had
received a L5-S1 transforaminal epidural steroid injection on
February 2, 2018, which had given her 100% relief, but only
for a week. AR1376. She had pain in the L5 distribution and
numbness and tingling all the way down to her foot. AR1376.
Imaging revealed lumbar spondylosis, L5-S1 disc breakdown,
degeneration of facet arthrosis and facet hypertrophy that
causes foraminal stenosis on the left at ¶ 5-S1. AR1376.
Wingate stated Ms. Flatequal “has really been though
everything” and discussed various surgical options.
AR1376. A new lumbar MRI was ordered, and revealed lumbar
degenerative disc disease most severe at ¶ 5-S1 without
significant central canal stenosis and moderate neural
foraminal stenosis on the left at ¶ 5-S1 with mild cord
compression of the intraforaminal left L5 nerve root. AR1376,
March 7, 2018, Dr. Wingate completed a medical source
statement regarding Ms. Flatequal's physical functioning
and stated she was limited to occasionally lifting 10 pounds,
frequently lifting less than 10 pounds, standing and walking
less than two hours in an 8-hour workday, and she must
alternate sitting and standing every 30 minutes to relieve
pain or discomfort. AR1377. Dr. Wingate also limited her to
occasional balancing, kneeling and crouching and frequent
reaching, handling and fingering. AR1378. Dr. Wingate stated
that he had not given her formal restrictions, and his
recommendations were based on diagnosis and her currently
physical state, including a healed clavicle fracture. AR1379.
Avera Behavioral Health
Flatequal was admitted to Avera Behavioral Health on an
involuntary hold following a suicide attempt on July 24,
2015. AR589. Her admission diagnoses included major
depressive disorder, suicide attempt, alcohol intoxication
and use disorder, and unspecified anxiety disorder. AR589.
Her treatment notes indicate that Ms. Flatequal had a history
of a prior suicide attempt and inpatient treatment in 2005.
AR589, 593. Ms. Flatequal requested discharge when the
involuntary hold was lifted on July 26, 2015, and was
released. AR590. She was noted to have limited insight on her
problems, and it was recommended she follow-up with
psychology and counseling. AR590-91.
Flatequal participated in group and individual therapy for
substance addiction at Avera beginning in August, 2015 and
continuing through October, 2015. AR524-58. The initial
diagnostic interview indicated Ms. Flatequal had previously
received treatment for gambling addiction, lack of coping
skills, stress management, and poor impulse control. AR558.
Avera University Psychiatry Associates
Flatequal saw Dr. Bergan at Avera University Psychiatry
Associates on May 24, 2016, for depression. AR728. Ms.
Flatequal reported mood swings, feelings of emptiness, and
periods of impulsiveness. Ms. Flatequal reported prior
suicide attempts by overdose resulting in stomach pumping,
and closing her eyes and turning the wheels of her car
resulting in a crash with both attempts occurring in the
1990's. AR729. She also reported shoulder/neck tension
all the time, and being easily irritated on a daily basis.
AR730. Ms. Flatequal reported a history that included her
parents getting married and divorced twice, her mother
leaving and never returning at age 13, being beat up by four
men in college, giving birth to stillborn twin sons, a
history of gambling addiction, multiple other miscarriages,
inpatient treatment for alcoholism, divorce, and being robbed
and tied up at gunpoint at a casino. AR730. Ms. Flatequal was
diagnosed with major depressive disorder, moderate; alcohol
use disorder, moderate; unspecified anxiety disorder; and
borderline personality traits. AR731. Duloxetine was
prescribed along with her current trazodone, and she was
referred to the STEPPS program. Her mental status exam
revealed dysphoric and anxious mood, fair insight and
Flatequal saw Dr. Bergan on June 28, 2016, and reported
worrying whether a potential job would interfere with her
ability to complete the STEPPS program. AR719.
Flatequal saw Dr. Bergan on October 7, 2016, for follow-up.
AR783. Ms. Flatequal reported she had started the STEPPS
program, but stopped when her father became ill, then
restarted. AR783. She was seeing Chris Pudwill twice a month
at Avera 33rd and Cliff, and she had an appointment with
Carol Kuntz for neuropsychiatric testing. AR783. Dr. Bergan
stated Ms. Flatequal had created a self-fulfilling prophecy
that she can't work, and he did not know whether she
actually could or not. AR785. Dr. Bergen increased her
duloxetine dosage. AR786.
Flatequal participated in the STEPPS therapy program at Avera
from October 24, 2016, through November 29, 2016.
Flatequal was referred for a psychological evaluation at
Great Plains Psychological Services on November 2, 2016, for
an evaluation of cognitive and psychological functioning due
to forgetfulness following her craniotomy and tumor resection
the prior March, and she also complained of left-handed
shakiness, fatigue, brief spells of lightheadedness, numb
tingly left shoulder, as well as multiple joint aches and
Whitten found that her mood/behavior was impaired and her
psychomotor response was questionable. AR755. Dr. Whitten
found no neuropsychological signs of her left hemisphere
lesion lingering. AR756. Dr. Whitten stated that similar
individuals to Ms. Flatequal find returning to work a
struggle, and cautioned the use of opioids, analgesics,
benzodiazepines, and stimulant medications for pain control
due to potential addiction issues. AR756.
Flatequal saw Dr. Bergan on November 3, 2016, for follow-up.
AR774. Ms. Flatequal rated her mood 4/10, energy level was
really bad, concentration not so good, and said her anxiety
was terrible. AR774-75. She reported that she continued to
see Chris Pudwell every two weeks.
Flatequal saw psychologist David Hylland on November 30,
2016, for a psychological evaluation. AR794. Ms. Flatequal
reported she had tried about seven meetings at the STEPPS
program but decided it would not work for her. AR794. She saw
Dr. Hylland again on December 12, 2016, and he had obtained
and reviewed the prior evaluation from Dr. Whitten. AR792.
Dr. Hylland stated the test results showed that Ms. Flatequal
had significant depression with anxiety, and it “shows
that it is going to be very unlikely that she would have any
success trying to carry on any type of occupation because of
her depression and anxiety and her focus on the health that
she has to keep staying on top of.” AR792.
Flatequal saw Dr. Bergan on December 8, 2016, for follow-up.
AR765. Ms. Flatequal rated her mood 5/10, was attending
physical therapy for her hip, and concentration not very
good. AR765-66. She had stopped seeing Chris Pudwell and was
now seeing Dr. Hylland for individual therapy. AR768.
Flatequal saw Dr. Hylland on January 11, 2017, for therapy
and discussed her disability application. AR934. Dr. Hylland
stated, “…which I certainly believe she is
qualified to receive.” AR934. Dr. Hylland stated,
“I hope that she does pursue the appeal of the social
security disability denial because I think she certainly is
incapable of having any type of full time job right now, or
even part time, with her mental state and her physical
Flatequal saw Dr. Hylland on February 8, 2017, and again on
March 8, 2017. AR932-33. At the March appointment, she was
very emotionally upset, very anxious, and quite tearful.
AR932. She had been denied disability again. AR932.
Flatequal was brought to Avera Behavioral Health by the
police on March 30, 2017, due to some anxiety issues. AR1326.
Ms. Flatequal's husband called the police when he felt
she took some pills. AR1326. She said it was a couple of
ibuprofen, and that she was not suicidal. AR1326. Ms.
Flatequal was observed to be quite tearful, worried, and
anxious, and reported she was seeing a counselor. AR1326-27.
Flatequal saw Dr. Hylland for therapy on May 8, 2017, who
stated again that he felt Ms. Flatequal met the criteria for
being disabled from a mental health standpoint and probably
from a ...