United States District Court, S.D. Iowa
For Sandra D Brewer-Kite, Plaintiff: Thomas A Krause, LEAD ATTORNEY, ATTORNEY AT LAW, DES MOINES, IA.
For Commissioner of Social Security, Commissioner, Michael J Astrue, Defendant: Mary C Luxa, LEAD ATTORNEY, U S Attorney's Office, Des Moines, IA.
ROBERT W. PRATT, UNITED STATES DISTRICT JUDGE.
MEMORANDUM OPINION AND ORDER
Plaintiff, Sandra Dee Brewer-Kite, filed a Complaint in this Court on January 29, 2013, seeking review of the Commissioner's decision to deny her claim for Social Security benefits under Title II of the Social Security Act, 42 U.S.C. § § 401 et seq. This Court may review a final decision by the Commissioner. 42 U.S.C. § 405(g).
Plaintiff filed an application for Title II benefits July 15, 2011. Tr. at 150. Plaintiff, whose date of birth is February 20, 1974, (Tr. at 150) was 38 years old (Tr. at 37) at the time of the hearing on August 9, 2012, before Administrative Law Judge JoAnn L. Draper (ALJ). Tr. at 30-63. The ALJ issued a Notice Of Decision -
Unfavorable on August 24, 2012. Tr. at 13-25. The Appeals Council declined to review the ALJ's decision on December 18, 2012. Tr. at 1-6. Thereafter, Plaintiff commenced this action.
In her application, Plaintiff stated she became unable to work because of her disabling condition on July 7, 2011. Tr. at 150. At the first step of the sequential evaluation, the ALJ found that Plaintiff has not engaged in substantial gainful activity after the alleged onset of disability date. The ALJ wrote that work activity which had occurred after the onset date was an unsuccessful work attempt. At the second step, the ALJ found Plaintiff has the following severe impairments: bipolar disorder, cataplexy  (probable), depression and anxiety NOS, personality disorder with aggressive features and substance abuse. The ALJ found that none of these impairments, alone or in combination, were severe enough to qualify for benefits at the third step of the sequential evaluation. Tr. at 18. At the fourth step, the ALJ found
After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform medium work as defined in 20 CFR 404.1567(c) except she can lift and carry 50 pounds or more occasionally and she can frequently lift up to 25 pounds. She can stand and walk six hours out of an eight hour day. She can tolerate occasional exposure to extreme cold and extreme pulmonary irritants. She can never climb ladders, ropes or scaffolds. She is precluded from performing highly detailed complex job tasks. She is precluded from interacting with the general public. She can tolerate occasional interaction with co-workers and supervisors such that her interaction would be short lived, brief and superficial. She is limited to tasks learned in 30 days or less with no more than simple work related decisions and occasional work place changes.
Tr. at 20. The ALJ found that Plaintiff is unable to perform her past relevant work. Tr. at 23. At the fifth step, the ALJ found that Plaintiff is able to do a significant number of jobs, examples of which include laundry folder, industrial cleaner, and final assembler of optical frames. Tr. at 24. The ALJ found that Plaintiff is not disabled nor entitled to the benefits for which she applied. Tr. at 25.
On March 21, 2010, Plaintiff was seen at Broadlawns Medical Center Emergency Department requesting a tetanus shot after she had been bitten and had a bottle broke over her head during a bar fight. Tr. at 267. Plaintiff complained of headache and tail bone pain. Tr. at 268.
Plaintiff was seen at Broadlawns on April 22, 2010, for a followup of a thyroid condition and to refill her medications. Tr. at 394-96. Diagnoses included acute bronchitis, fatigue, generalized anxiety disorder, hypothyroidism, nicotine dependence and obesity. Tr. at 395-96.
On July 4, 2010, Plaintiff was seen at the emergency room at Broadlawns because of right sided tooth pain. Tr. at 274. The nurse wrote that Plaintiff immediately became confrontational and demanded to see Dr. Coppola. The nurse wanted to begin I.V. therapy because she was concerned about infection in Plaintiff's blood stream. Plaintiff said she wanted antibiotics and that she wanted to leave. Plaintiff asked about the possibility of going to the University of Iowa and the nurse offered the
operator's number. The more the nurse offered assistance, the angrier Plaintiff became and at one point threatened to " take it to another level." Tr. at 275.
Plaintiff was seen at the University of Iowa Hospitals and Clinics on July 8, 2010, for her dental care where she underwent extraction of some of her teeth under sedation due to severe dental anxiety. Tr. at 332-43.
When Plaintiff was seen at Broadlawns on July 20, 2010, for thyroid check, it was noted that she was to return to the University of Iowa for follow up of her dental care. Tr. at 391.
On December 30, 2010, Plaintiff was seen at Broadlawns at which time the chief complaint was: " Pt here for med ck and both legs swelling and has a lump in rt thigh. She thinks her Lexapro is not working. Gets bad pains in her wrist and knees hurt. Lt knee gets sharp pains in it." Tr. at 388. Plaintiff's medications were adjusted - dosage of Lexapro was increased, and Prednisone was discontinued. Tr. at 390.
On January 4, 2011, Plaintiff went to Broadlawns because of low back pain. Tr. at 385-87. The diagnosis was paravertebral muscle spasm, and Plaintiff was given a prescription for Flexeril. Plaintiff was also instructed to use ice and heat, and given a note stating when she could return to work. Tr. at 387.
Plaintiff was seen at Broadlawns on March 2, 2011, with a chief complaint of " Pt here to ck out her heart." Tr. at 376. An EKG showed sinus rhythm with no acute changes. Diagnoses included non-cardiac chest pain. Tr. at 378.
On June 9, 2011, Plaintiff saw Kisik Kim, M.D., for an outpatient psychiatric evaluation at Broadlawns Medical Center. Dr. Kim noted that Plaintiff's history included two hospitalizations at the Broadlawns mental health unit in 1993 and 1994, for extreme irritability and impulse control disorder. Plaintiff told the doctor that her children live with their father, and that she lives alone with two pit bull dogs. Dr. Kim wrote:
The patient seems extremely irritable, tense, and ready to explode, literally explode. She does not require much provocation. She yells, screams out, and she has to go outside the office and return, but patient apologized and indicated that she has, in fact, difficulty in controlling her anger. At home, the pit bulls seem to sense when she is angry and this is the reason her children are away with their father.
On psychiatric examination, Plaintiff was flushed and extremely tense. Her speech was coherent and relevant but her mood was labile and she became extremely frustrated. Insight, judgment and impluse control were noted to be poor and the doctor wrote that Plaintiff had an extremely low anxiety tolerance. On Axis I the doctor diagnosed mood disorder and impulse control disorder, not otherwise specified. Tr. at 453. On Axis II the diagnosis was personality disorder the passive-aggresive features. The doctor opined that the global assessment of functioning, both current and for the past year, was 40 . Tr. at 454.
On June 15, 2011, Plaintiff was seen at Broadlawns emergency room because she had passed out while moving furniture. Plaintiff noted one episode of syncope a year before. Tr. at 309. Plaintiff was instructed to return to the emergency room immediately if her symptoms worsen or if new symptoms developed. Tr. at 314. Plaintiff returned to the emergency room on June 16, 2011 with complaints of dizziness, and ringing in her ears. Plaintiff said that she fell, and that she got dizzy when she stood up. Tr. at 302.
A Broadlawns History and Physical report dictated on June 23, 2011, states that while Plaintiff was waiting for an appointment in primary care, she reported that she felt dizzy. Hospital staff brought a wheel chair and as soon as Plaintiff sat down, she lost consciousness for about three seconds. Afterwards, Plaintiff complained of headache, confusion, some chest pain and difficulty breathing. Plaintiff reported that she had blackout spells for years, usually precipitated by dizziness. " She also states she feels 'paralyzed' just prior to this where she can hear voices around her but she just cannot move." Plaintiff said there was never any shaking, tongue biting or loss of bowel or bladder control. Plaintiff said that the frequency of the spells had been increasing over the previous week. It was noted that Plaintiff had received an aortic valve ring in 1997. Tr. at 324. Plaintiff was admitted to the hospital for overnight cardiac monitoring, but the doctor opined that it was possible that the spell could have a psychogenic versus an arrhythmogenic etiology. Tr. at 326. Overnight monitoring did not reveal any cardiac changes. The doctor wrote: " Perhaps related to anxiety disorder with panic attacks. Aggressive psychiatric treatment as outpatient." Plaintiff was scheduled to see a psychiatrist the following week. Tr. at 327.
Plaintiff underwent a psychiatric consultation during the hospitalization on June 24, 2011. It was noted that Plaintiff was being followed in an outpatient setting for mood disorder, impulse control disorder, and personality disorder with passive-aggressive features. Plaintiff also reported being diagnosed with bipolar disorder, anxiety and PTSD. Plaintiff said that she had bouts of loss of consciousness for the previous year and a half. She said that sometimes the spells happen during intense anger, but the previous day she was calm when it occurred. Plaintiff said that her children live with their father because of her blackout spells, but it was noted that the medical chart indicated it was because of her anger outbursts. Plaintiff said she was able to work despite her anger, and that her medication controls the anger when she takes it. " When I take my pills, I do not have anger." Tr. at 328. Plaintiff had one psychiatric appointment with Dr. Kim, but was not satisfied because she was unable to understand the doctor's English. An appointment had been scheduled with Dr. Singh, and Plaintiff said she had been told she would have no problem understanding Dr. Singh's English. Tr. at 329. On Axis I, the diagnosis was bipolar disorder not otherwise specified. On Axis II, the diagnosis was personality disorder with aggressive features by history. Tr. at 330.
Plaintiff saw Manmohan Singh, M.D., on June 29, 2011. Tr. at 397-98. On mental status examination: " She seems hypomanic but not presenting with clear mania or psychosis. Does report a long history of anxiety, depression and denies any thoughts of self-harm. ... She admits to having anger outburst. She has some insight regarding her problem with impaired judgment." Tr. at 397. On Axis I, the diagnosis was bipolar disorder, not otherwise specified. On Axis II, the diagnosis was personality disorder with passive aggressive
features. The doctor and Plaintiff discussed both medication management as well as ways to develop coping skills and stress management. Plaintiff noted a pending appointment with a therapist, and ...