United States District Court, M.D. Pennsylvania
WILLIAM J. NEALON, District Judge.
On June 15, 2013, Plaintiff, Debbie Santos, filed this instant appeal under 42 U.S.C. § 405(g) for review of the decision of the Commissioner of the Social Security Administration ("SSA") denying her applications for disability insurance benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI, respectively, of the Social Security Act, 42 U.S.C. §§ 1461 et seq., 1381 et seq. (Doc. 1). The parties have fully briefed the appeal, and the matter is now ripe for review. For the reasons set forth below, the decision of the Commissioner denying Plaintiff's applications for DIB and SSI will be vacated.
Plaintiff protectively filed her applications for DIB and SSI on February 23, 2012. (Tr. 17). This claim was initially denied by the Bureau of Disability Determination ("BDD") on May 2, 2012. (Tr. 17). On May 14, 2012, Plaintiff filed a written request for a hearing before an administrative law judge. (Tr. 17). Two (2) separate hearings were held on October 1, 2012, and January 9, 2013, before administrative law judge Sharon Zanotto ("ALJ"). (Tr. 17, 34, 82). At the October 1, 2012 hearing, Plaintiff testified. (Tr. 82). At the January 9, 2013 hearing, Plaintiff and vocational expert Brian Bierley ("VE") testified. (Tr. 34). On January 14, 2013, the ALJ issued a decision denying Plaintiff's claims because, as will be explained in more detail infra, Plaintiff's impairments did not meet or medically equal any impairment Listing, and she could perform less than a full range of light work, with avoidance of concentrated exposure to dust, fumes, odors, gases and chemicals, avoidance of hot and cold temperatures, only occasional interaction with supervisors, and no interaction with coworkers or the public. (Tr. 20-22).
On March 11, 2013, Plaintiff filed a request for review with the Appeals Council. (Tr. 10). On April 17, 2013, the Appeals Council concluded that there was no basis upon which to grant Plaintiff's request for review. (Tr. 1-5). Thus, the ALJ's decision stood as the final decision of the Commissioner.
Plaintiff filed the instant complaint on June 15, 2013. (Doc. 1). On August 15, 2013, Defendant filed an answer and transcript from the SSA proceedings. (Docs. 8 and 9). Plaintiff filed the brief in support of her complaint on September 27, 2013. (Doc. 10). Defendant filed a brief in opposition on November 15, 2013. (Doc. 13). Plaintiff filed a reply brief on November 25, 2013. (Doc. 14).
Plaintiff was born in the United States on March 18, 1978, and at all times relevant to this matter was considered a "younger individual." (Tr. 94, 272). Plaintiff did not obtain her high school diploma or GED, and can communicate in English. (Tr. 275, 277). Her employment records indicate that she previously worked as a candy packer, certified nurse's assistant, and a cashier. (Tr. 277).
The records of the SSA reveal that Plaintiff had earnings in the years 1994 through 2011. (Tr. 149). Her annual earnings range from a low of no income in 2010 to a high of twenty-five thousand three hundred eighty dollars and thirty-eight cents ($25, 380.38) in 2002. (Tr. 264). Her total earnings during those seventeen (17) years were one hundred forty-eight thousand fifty-six dollars and fifty-two cents ($148, 056.52). (Tr. 264).
Plaintiff's alleged disability onset date is December 22, 2011. (Tr. 272). The impetus for her claimed disability is a combination of the following: asthma, breathing problems, depression, heart problems, anxiety, panic disorder, blood clot disorder, and ovary problems. (Tr. 276). In a document entitled "Function Report - Adult" filed with the SSA in March of 2012, Plaintiff indicated that she was married, and lived with and cared for her husband, five (5) sons and pets. (Tr. 292-293). She indicated that she needed help caring for her family and pets because she would "get tired[, ] overwhelmed[, and her body would] shut down." (Tr. 293). She was able to care for her personal needs. (Tr. 293). She also noted that she could prepare meals on a weekly basis, but preferred to cook "easy oven things." (Tr. 294). She was able to clean her house and do laundry. (Tr. 294). Aside from doctors' visits, school meetings, and a monthly grocery store outing, she "hardly ever" went outside, and needed someone to accompany her because she had a phobia of being alone. (Tr. 294-296). She indicated that she would drive and walk when she went out. (Tr. 295). However, she could only walk about one (1) block, or for five (5) to ten (10) minutes, before she would become short of breath. (Tr. 297).
Regarding concentration and memory, Plaintiff stated that she could pay attention for twenty (20) to thirty (30) minutes, but could not complete tasks, could not follow written or spoken instructions well, and needed reminders to take care of her personal needs and to take medicine. (Tr. 294, 297). She could pay bills, count change, handle a savings account, and use a checkbook. (Tr. 295).
Socially, Plaintiff indicated that she no longer had any hobbies or interests, and did not spend time with others. (Tr. 296). She had problems getting along with others, including friends, family, neighbors and authority figures, because of her "different personalities." (Tr. 297-298). In the function report, when asked to check items which her "illnesses, injuries, or conditions affect, " Plaintiff did not check using hands. (Tr. 297).
In her Supplemental Function Questionnaire, Plaintiff indicated that her pain began on October 18, 2011, was caused by asthma, and was located in her "chest, lungs, hands, arms, legs, [and] head." (Tr. 300). She noted that the following activities caused her pain: "clean[ing], laundry, cooking, dressing [her] kids [and]  put[ing] their shoes on." (Tr. 300). her pain occurred every day, would last for fifteen (15) to twenty (20) minutes on and off throughout the day, and was worse when she was attending to her family's needs. (Tr. 300). She stated that her eating habits had changed because of her pain, and that while she lost and gained weight from her medication, she was purposefully trying to lose weight, as she stated, "140 [pounds] is my goal." (Tr. 301). To relieve her pain, she took Vicodin, which would help for a "couple hours." (Tr. 301). She did not wear or use any devices such as a brace or a TENS unit to relieve her pain. (Tr. 301). She indicated that she was referred to a psychiatrist to help her cope with her pain. (Tr. 301).
At her October 1, 2012 hearing, Plaintiff testified that she did not perform chores around the house, but rather her husband was the one who cooked, cleaned, did the laundry, and took care of their sons since she became sick. (Tr. 123). She was unable to walk more than two (2) flights of stairs without resting. (Tr. 125). She stayed in bed most days, staring at her fish in a nearby fish tank. (Tr. 129-130). She testified that she had issues getting along with supervisors and coworkers because she often felt insubordinate, and if she did not like what was said to her at work, she would yell at whomever was speaking to her. (Tr. 132). She also stated that she had difficulty concentrating, and needed reminders to take her medicine and attend appointments. (Tr. 132-133). With regards to sleep, she testified that she had insomnia due to nightmares and urinary frequency. (Tr. 133-134). Finally, she testified that she often had suicidal thoughts and thoughts about harming her children. (Tr. 135).
At her second hearing on January 9, 2013, which was conducted after Plaintiff submitted additional medical records, Plaintiff testified that due to a combination of asthma, urinary frequency and incontinence, and mental health issues, she was unable to work since she was terminated from her job as a certified nurse's assistant at Claremont Nursing home in December of 2011. (Tr. 40-43, 64). She stated that she received food stamps and medical and cash assistance, and that her husband did not work in order to take care of her and the children. (Tr.43). Plaintiff indicated that she could not work primarily because she experienced frequent panic attacks that caused her to become physically and verbally violent towards herself and others, including pulling her own hair, scratching herself, and yelling at her children. (Tr. 43-46, 68). She was diagnosed as having panic attacks by Dr. De La Cruz and Dr. Robin Miller, which occurred about two (2) times per day before her father's death in March of 2012, and increased to four (4) to five (5) times a day after his death. (Tr. 46, 48). She stated that since March of 2012, a counselor from Child and Youth Services ("CYS") would visit her once a week to counsel her and her children, and a caseworker would visit her once a month to discuss the family's evaluation for that month. (Tr. 55-56). Regarding medications, she used a nebulizer, rescue inhaler, Symbicort and occasional Prednisone tapers for her asthma, and Cymbalta, Xanax and Lithium for her mental health issues. (Tr. 66, 69).
On December 28, 2011, Plaintiff presented to the emergency room ("ER") at Holy Spirit Hospital for a cough and chest congestion. (Tr. 448). Plaintiff was alert, oriented, and cooperative, in moderate distress, and denied having any thoughts of hurting herself or others. (Tr. 450, 457). Her chest x-ray was negative for any findings. (Tr. 453). Her physical exam noted bilateral expiratory wheezing, and she was diagnosed with bronchitis. (Tr. 454, 457). Plaintiff was given a nebulizer breathing treatment with Albuterol and Atrovent, and her bilateral expiratory wheezing diminished as a result. (Tr. 454-455).
On December 30, 2011, Plaintiff again presented to the ER at Holy Spirit Hospital for a severe cough with accompanying sweating and chills. (Tr. 503-505). Plaintiff was noted to be alert, anxious, and in severe distress. (Tr. 505). Her past medical history noted asthma, depression, anxiety, Chronic Obstructive Pulmonary Disease ("COPD"), and stress incontinence. (Tr. 507). Bilateral wheezing was noted. (Tr. 508). The principal diagnosis from this visit was asthma with an acute exacerbation, and her secondary diagnoses included anxiety, depressive disorder, and stress incontinence. (Tr. 503). As a result, she was admitted to the Medical-Surgical floor, and given nebulizer treatments, a cough suppressant, and intravenous ("IV") medrol. (Tr. 508). The assessment notes from this visit state that Plaintiff had acute bronchitis versus COPD exacerbation, that her depression and anxiety were uncontrolled, and that she understood and agreed with the treatment plan. (Tr. 508). Her medications upon discharge on December 31, 2011 included the following: Robitussin, Medrol dose pack, Avelox, Ativan, Combivent inhaler, and Effexor. (Tr. 510).
On January 4, 2012, Plaintiff had a follow-up appointment with Vanitha Abraham, M.D. to assess her asthma and bronchitis. (Tr. 535). She reported that she had a cough, and awakened with dyspnea, a wheeze, a dry cough, and hoarseness. (Tr. 535). It was noted that she was oriented to time, place, person, and situation. (Tr. 536). She was given an in-office nebulizer treatment, and was sent home with a nebulizer machine and asthma medication. (Tr. 536).
On January 25, 2012, Plaintiff presented to the Dillsburg Family Health Center, and was seen by Dr. Abraham for complaints of a cough. (Tr. 533). She was noted as being very upset and panicky, and was "freaking out." (Tr. 533). Plaintiff was prescribed Methylprednisone for her cough. (Tr. 534).
On January 27, 2012, Plaintiff presented to Dillsburg Family Health Center, where she was examined by Dr. Abraham for complaints of a productive cough and a recent bout of bronchitis. (Tr. 531-532). She was noted as being oriented to time, place, person and situation, and demonstrated the appropriate mood and affect. (Tr. 531). Upon Dr. Abraham's recommendation, Plaintiff was immediately transferred and admitted to the Intensive Care Unit ("ICU") at Holy Spirit Hospital for breathing difficulties and severe chest pain that had been occurring for four (4) months. (Tr. 466, 469, 532). She was seen by Rajwinder Nagra, M.D. (Tr. 472). Her past medical history indicated she had asthma and depression. (Tr. 469). Her exam noted that she was anxious and tearful, but also that she was alert and in no apparent distress. (Tr. 469, 471). Plaintiff denied having any suicidal or homicidal thoughts. (Tr. 471). She had acute bilateral expiratory wheezing, and a low pulse oxometry reading. (Tr. 470, 472). Her medications list included Xanax, Symbicort, Ambien, Prednisone, Avelox, and Promethazine. (Tr. 471). After multiple pulmonary tests, she was again diagnosed with bronchitis with an acute exacerbation of chronic obstructive asthma. (Tr. 466, 472). Her secondary diagnoses included acute respiratory failure, major depressive disorder that was recurrent and severe without psychotic features, a cardiac dysrhythmia, and abnormal glucose. (Tr. 466, 470). On January 28, 2012, Plaintiff had a psychiatric consultative examination while admitted to Holy Spirit Hospital. (Tr. 473-473). The examination indicated that Plaintiff was oriented to time, place and person, had an intact memory, was anxious and depressed, and had normal speech and a coherent thought process. (Tr. 474). She denied hallucinations, and suicidal and homicidal ideations. (Tr. 474). She was diagnosed with recurrent and severe major depressive disorder without psychotic thoughts. (Tr. 474). On January 29, 2012, Plaintiff was placed on a continuous invasive mechanical ventilator with the insertion of an endotracheal tube for less than ninety-six (96) consecutive hours. (Tr. 467). She remained in the hospital until February 4, 2012. (Tr. 466, 476). Her discharge papers stated that she was diagnosed with the following: acute bronchial asthma exacerbation, anxiety, major depressive disorder, non-sustained ventricular tachycardia, hypertension, and dysfunctional uterine bleeding. (Tr. 477). Her medications upon discharge included the following: Avelox, Xanax, Ambien, Symbicort, Atrovent, Prednisone, Wellbutrin, and Cardizem. (Tr. 477). She was instructed to follow-up with Dr. Thevenin-Smaltz in one (1) week and Dr. Long in two (2) weeks. (Tr. 477).
On February 6, 2012, Plaintiff presented to Dillsburg Family Health Center for a follow-up after her recent hospitalization at Holy Spirit. (Tr. 528). She reported that she was weak and not able to walk. (Tr. 528). She noted that she was irritable, fearful, anxious, and depressed, and had difficulty concentrating, an inability to focus, mood swings, psychiatric symptoms, and sleep disturbances. (Tr. 529). She was negative for suicidal ideation. (Tr. 529). Her psychiatric exam noted that she exhibited compulsive behavior and poor judgment, did not behave appropriately for her age, did not interact appropriately, did not have pressured speech, and did not demonstrate the appropriate mood or affect. (Tr. 529). The assessment plan was to continue with the asthma and anxiety medication she was already taking. (Tr. 530).
On February 11, 2012, Plaintiff presented to the ER at Holy Spirit Hospital for right arm numbness, swelling, and mottling, and was seen by Amy Fajando, M.D. (Tr. 436, 728). Her assessment indicated that her breathing was normal, her airway was patent, she was alert, oriented and cooperative, and she did not have any thoughts of hurting herself or others. (Tr. 438). She also was noted as having intact sensation and motor skills, normal speech, and normal cognition. (Tr. 444). Plaintiff reported that she felt anxious. (Tr. 446). The physician's notes, including diagnoses and treatment recommendations, are largely illegible. (Tr. 443-446).
On February 14, 2012, Plaintiff presented to the ER at Holy Spirit Hospital with a history of asthma, depression and a prior deep vein thrombosis ("DVT") in her right arm, and complaints of stabbing chest pain from her left shoulder blade into her chest wall with accompanying nausea, sweating, and shortness of breath rated as a ten (10) on a scale of one (1) to ten (10). (Tr. 425, 433). She denied any recent thoughts of hurting herself. (Tr. 426). The physical exam indicated that Plaintiff was not in acute distress, was alert, had a normal mood and affect, had normal breathing sounds, a regular heart rate, and a normal complete blood count (CBC). (Tr. 426, 434). The clinical impression indicated that Plaintiff was diagnosed with anxiety and discharged the same day. (Tr. 434).
On February 28, 2012, Plaintiff had an appointment at Dillsburg Family Health Center for a follow-up visit regarding anxiety and a prior DVT. (Tr. 525). She reported that she had been experiencing anxious, fearful and compulsive thoughts, a decreased need for sleep, a depressed mood, difficulty concentrating, difficulty falling and staying asleep, a diminished interest in pleasure, excessive worry, fatigue, loss of appetite, poor judgment, racing thoughts, restlessness, hopelessness, and paranoia. (Tr. 525). She was irritable, did not behave appropriately for her age, and did not exhibit the appropriate mood or affect. (Tr. 527). She exhibited normal judgment, and reported that she did not have suicidal ideations. (Tr. 527.). Her anxiety was associated with headache, nausea, sweating and trembling. (Tr. 525). The treatment recommendations from this visit included psychotherapy, a selective seratonin reputake inhibitor ("SSRI"), a tricyclic antidepressant, an antipsychotic, a suicide risk assessment, and an anxiolytic. (Tr. 525). Her medications list from this visit included Ambien, Avelox, Combivent, Coumadin, Lorazepam, Lovenox, Polymyxin, Prenisone, ProAir, Promethazine, Symbicort, Wellbutrin, and Xanax. (Tr. 525-526).
On March 1, 2012, Sylvestre De La Cruz, M.D. performed an adult psychiatric evaluation on Plaintiff. (Tr. 549). Dr. Cruz noted that Plaintiff's affect was depressed, and her mood was restricted. (Tr. 549). She denied experiencing any suicidal and homicidal thoughts, delusions, or hallucinations. (Tr. 549). Plaintiff noted that her panic attack symptoms consisted of sweating, shaking, fidgeting, and chest tightness. (Tr. 547-548). The mental status examination noted that Plaintiff was kempt in appearance, cooperative during the interview, and was oriented in time, place, and person. (Tr. 548). She had grossly intact immediate, recent and remote memory, and coherent and goal-directed speech. (Tr. 548-549). She had fairly good eye contact, was organized in thinking, was of average intelligence, and exhibited sound hypothetical judgment. (Tr. 548-549). Her Global Assessment Function ("GAF") score at this visit was between a fifty-five (55) and sixty (60), and her prognosis was fair. (Tr. 549-550). This evaluation resulted in diagnoses of panic disorder without agoraphobia, and major depressive disorder that was recurrent and moderate to severe without psychotic features. (Tr. 549).
On March 14, 2012, Plaintiff was evaluated by consultative examiner James Long, M.D. (Tr. 555). The notes from this exam state that Plaintiff was oriented to time, place, person, and situation. (Tr. 562). He opined that Plaintiff had no limitations in lifting, standing and walking, sitting, pushing and pulling, postural activities, or other physical functions. (Tr. 554-555). He indicated that with regards to environmental restrictions, she would need to avoid areas with poor ventilation due to her asthma. (Tr. 555).
On March 30, 2012, Plaintiff presented to the ER at Holy Spirit Hospital with complaints of shortness of breath, coughing, and wheezing. (Tr. 661). Dr. Luke Chetlen evaluated Plaintiff, and found her to be "tachypneic with increasing work of breathing and with poor air movement." (Tr. 661). She was emergently intubated. (Tr. 661). Her assessment noted that she was critically ill, was in respiratory failure, had an acute exacerbation of asthma, and a history of anxiety, a DVT in her upper right extremity, and hypertension. (Tr. 662). She was admitted to the ICU under the care of Dr. Foster, and was placed on full ventilator support, given IV antibiotics and solu-medrol, and a Nicoderm patch. (Tr. 662).
On April 1, 2012, while still hospitalized, Plaintiff was evaluated by pulmonologist Henry Ostman, M.D. (Tr. 665-667, 669). During this examination, Plaintiff reported that she had episodic shortness of breath, chest pain, and wheezing, but the exam was negative for all other findings. (Tr. 666). Dr. Ostman noted that he heard no wheezing either inspiratory or expiratory, and no dullness to percussion. (Tr. 666). Plaintiff's speech was fluent and eloquent, and her gaze was intact. (Tr. 666). On April 2, 2012, Plaintiff was discharged from the hospital. She was diagnosed by Richard Schreiber, M.D. with the following: acute hypoventilatory respiratory failure, acute severe asthma, anxiety, depression, GERD, DVT of the right upper extremity, hypertension, and possible allergies. (Tr. 668). Plaintiff's discharge medications included the following: Xanax, Ambien, Symbicort, Flovent, Combivent, Prednisone, Flonase, Ventolin, Prozac, Cardizem, the Nicotine patch, and Vicodin. (Tr. 668).
On April 17, 2012, Plaintiff presented voluntarily to the emergency room ("ER") at Holy Spirit Hospital, and was subsequently admitted to Holy Spirit Behavioral Health, after experiencing homicidal and suicidal thoughts while driving erratically with her children in the car due to an argument with her husband. (Tr. 715, 719). She was examined by Robin Miller, M.D., who found that Plaintiff was awake and alert, appeared to be her stated age, had an elevated affect and mood, was difficult to interrupt, had pressured speech, was in a hypomanic state, had intact short and long-term memory, did not show evidence of psychosis, was oriented in all spheres, and had fair insight and judgment. (Tr. 572, 716). She reported that she had an extremely high energy level, would "run around the house doing all the chores in a very high energy way, " was sleeping well, denied having auditory or visual hallucinations or paranoia, and had poor appetite. (Tr. 571). She rated her depression at a four (4) out of ten (10). (Tr. 571). Dr. Miller gave Plaintiff a GAF score of twenty (20) to twenty-five (25), and noted that her GAF ...