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Isham v. Colvin

United States District Court, D. Minnesota

January 30, 2015

Lisa Jean Isham, Plaintiff,
v.
Carolyn W. Colvin, Acting Commissioner of Social Security, Defendant.

Lionel H. Peabody, Esq., for Plaintiff.

Pamela Marentette, Esq., Office of the United States Attorney, for Defendant.

REPORT AND RECOMMENDATION

STEVEN E. RAU, Magistrate Judge.

Pursuant to 42 U.S.C. § 405(g), Plaintiff Lisa Jean Isham ("Isham") seeks review of the Acting Commissioner of Social Security's ("Commissioner") denial of her application for Supplemental Security Income ("SSI"). See (Compl.) [Doc. No. 1]. The parties filed crossmotions for summary judgment [Doc. Nos. 20, 28] that have been referred to the undersigned for a Report and Recommendation pursuant to 28 U.S.C. § 636(b)(1)(B) and (C) and District of Minnesota Local Rule 72.1. For the reasons set forth below, the Court recommends that Isham's Motion for Summary Judgment be granted in part and the Commissioner's Motion for Summary Judgment be denied.

I. BACKGROUND

A. Procedural History

Isham filed her application for SSI on April 28, 2011. (Admin. R.) [Doc. No. 18 at 195].[1] Isham listed an alleged onset date ("AOD") of December 31, 2009, and claimed disability due to depression, anxiety, post-traumatic stress disorder ("PTSD"), dyslexia/illiteracy, attention deficit hyperactivity disorder ("ADHD"), bipolar disorder, foot and ankle pain, asthma, migraines, and deafness in the left ear. ( Id. at 88, 195). Isham's claims were denied initially on July 1, 2011, and again upon reconsideration on October 6, 2011. ( Id. at 111-13, 118-19). Administrative Law Judge Paul Gaughen (the "ALJ") heard the matter on January 11, 2013, and May 1, 2013. ( Id. at 31, 54). The ALJ issued an unfavorable decision on May 17, 2013, and determined Isham was not disabled. ( Id. at 10-23). The Appeals Council denied Isham's request for review on July 9, 2013, rendering the ALJ's decision final. ( Id. at 1-3); see 20 C.F.R. § 416.1481.

B. Isham's Background and Testimony

At the AOD, Isham was 47, making her a younger person. (Admin. R. at 88); 20 C.F.R. § 416.963(c). Her highest grade of school completed is 11th grade, and she previously worked as a cleaner and floor installer. (Admin. R. at 61-63, 69, 240, 251).

1. January 11, 2013 Hearing

Isham believed she was incapable of performing any of her previous jobs. ( Id. at 73). Isham testified she could not concentrate and pay attention to things. ( Id. at 68). She cannot read very well or follow written instructions at a job, and she cannot start something, stay on task, and get it done. ( Id. at 69-70). Isham reported that if she is under pressure or stress, she screams and is mean to herself, which happens almost every day. ( Id. at 71). Usually, she has someone else cook her breakfast, and she does not shower every day. ( Id. at 72). Isham can do housework, laundry, take care of herself, and keep herself clean if she needs to. ( Id. at 73). She testified that she cannot deal with things like the mail and bills. ( Id. at 73).

Isham experiences pain in her ankles, but braces help. ( Id. at 74). She can stand for five to ten minutes at a time. ( Id. at 74-75).

Isham testified she did poorly in school. ( Id. at 76). She went to a special school where she worked at her own pace, and was in special education. ( Id. at 77). Her therapist or case worker helped her fill out the forms required for her Social Security filing. ( Id. at 78).

2. May 1, 2013 Hearing

At the second hearing, Isham testified that her floor layer job required her to run liquid flooring back and forth. ( Id. at 36). She did not receive any vocational or job rehabilitation assistance to do this job. ( Id. at 38). She worked with at least ten other workers, and there was a supervisor for all employees on the shift, plus an additional supervisor just for her, who was also her boyfriend. ( Id. at 38-39).

C. Relevant Medical Record Evidence

Certain records in the Administrative Record concern impairments and illnesses that neither of the parties nor the ALJ base their analysis on, and that the Court does not find relevant-such medical records will not be summarized.

1. Before December 31, 2009

On December 25, 2003, William K. Gitar, MD ("Dr. Gitar"), evaluated Isham at the Essentia Health emergency room for left ankle pain. ( Id. at 517). Isham stated that she fell out of the upstairs window of her residence and admitted to drinking at the time of the incident. ( Id. ). Upon reviewing the x-rays, Dr. Gitar diagnosed Isham with a left ankle sprain and gave her an Ace wrap and crutches to use on an as-needed basis. ( Id. at 518).

Leslie Gibbs, MSEd ("Gibbs"), saw Isham on August 4, 2005, for a Mental Health Diagnostic Assessment. ( Id. at 489). Isham reported feeling depressed and continuing to grieve the loss of her son approximately three years before. ( Id. ). She also reported appetite disturbance, sleeping problems, short-term memory difficulties, crying for no reason, severe mood swings, loss of enjoyment in activities, nightmares, panic attacks, and auditory and visual hallucinations. ( Id. ). Gibbs noted that Isham was "weepy in assessment" and that her "[t]hought process seemed fragmented." ( Id. at 490). Gibbs diagnosed Isham with recurrent and severe major depressive disorder with psychotic features, bereavement, and polysubstance dependence, and assigned a GAF score of 50.[2] ( Id. at 491).

On August 22, 2005, Laura Stresow, RN, CNP ("Stresow"), evaluated Isham for a physical. ( Id. at 463). Isham told Stresow she was anxious, depressed, fearful, and irritable. ( Id. at 464). She also said she attempted suicide twice after the death of her son. ( Id. ). Upon physical examination, Stresow noted bursitis on the anterior surface of Isham's right ankle that was neither hot, red, nor tender.[3] ( Id. ). Stresow recommended Isham follow up with another office visit in one month, continue counseling, and recommended an orthopedic evaluation of the bursa. ( Id. at 465).

Greg Goodrich, LPC, NCC ("Goodrich"), provided therapy to Isham on January 6, 2006. ( Id. at 493). Goodrich diagnosed Isham with recurrent severe major depressive disorder, with bereavement and polysubstance abuse, and assigned a GAF score of 50. ( Id. ). Goodrich recommended Isham see her medical personnel for evaluation for antidepressants. ( Id. ). In his May 26, 2006 termination summary, Goodrich noted that Isham's final diagnosis was depression and alcohol dependence, and her GAF score was 50. ( Id. at 497). He noted that Isham did not follow through with the following: attendance at grief groups, psychotropic medication referral, Alcoholics Anonymous ("AA") meetings, Rule 25 Assessment, or the recommendation that she meet with a native spiritual person.[4] ( Id. ). He noted she was seen by himself and Sue Hall, MSEd, LP ("Hall"), and did not attend further appointments. ( Id. ).

On August 18, 2006, Isham saw David O. Jorde, MD ("Dr. Jorde"), for acute emotional distress. ( Id. at 468). Isham reported she had been crying frequently, had poor concentration, was eating little, getting poor sleep, and had multiple crying spells per day. ( Id. ). Dr. Jorde diagnosed Isham with depression and prescribed Zoloft.[5] ( Id. at 469).

Hall saw Isham on August 18, 2006, for an individual therapy appointment. ( Id. at 494). Hall diagnosed Isham with acute stress disorder, PTSD, history of recurrent and severe major depressive disorder, polysubstance dependence, and personality disorder, and assigned Isham a GAF score of 40. ( Id. ). Isham reported she was continuing to drink alcohol to the point of intoxication and sometimes had blackouts. ( Id. ). She also reported having thoughts such as "I deserve to die, " difficulty concentrating, and difficulty sleeping. ( Id. ). Hall recommended a Rule 25 Assessment, supportive psychotherapy, eye movement desensitization and reprocessing ("EMDR") trauma work, and possibly obtaining an advocate.[6] ( Id. at 495). Hall was scheduled to see Isham on August 31, 2006, however, Isham arrived at the appointment after drinking, and the appointment was rescheduled. ( Id. at 496).

Lorraine L. T. Turner, MD ("Dr. Turner"), treated Isham on January 27, 2007. ( Id. at 470). Dr. Turner noted that Isham had a history of hearing loss in her left ear, depression, alcohol abuse, and migraines. ( Id. ). Isham reported drinking six to twelve beers daily and marijuana use. ( Id. ). Isham also reported chronic daily headaches and vague pain with the popping of her knee and ankle joints when walking or doing other activities. ( Id. at 471). Dr. Turner's physical examination of Isham was normal overall. See ( id. at 472-73). Dr. Turner recommended Isham continue with therapy and follow up in one month. ( Id. at 473).

Isham was seen by Robert W. Stubenvall, MD ("Dr. Stubenvall"), on May 30, 2007, for history of hearing loss. ( Id. at 507). The audiogram showed "mild high frequency neurosensory hearing loss in the right ear with profound left neurosensory hearing loss."[7] ( Id. ).

When Hall left her position, she completed a termination summary. ( Id. at 498). Her final diagnosis of Isham was bereavement; history of mild, recurrent major depressive disorder; polysubstance dependence; and personality disorder. ( Id. ). Hall opined Isham had made progress in therapy and recommended Isham attend her scheduled medical appointments, consider a Rule 25 Assessment and follow those recommendations made based on the assessment. ( Id. ).

On July 2, 2007, Isham was again seen by Stresow. ( Id. at 476). Isham complained of anxiety and difficulty concentrating, headaches, dyspnea, and bilateral ankle pain that had worsened over the last year.[8] ( Id. ). Upon examination, Stresow noted slightly reduced range of motion in the right foot and swelling with moderately reduced range of motion in the left foot. ( Id. at 477). Stresow noted that the area of swelling on the left foot was greater than two inches long and one inch wide with a fluid-filled sac on the anterior portion of the left medial ankle. ( Id. at 478). No erythema was noted.[9] ( Id. ). Stresow prescribed Buspar for anxiety and encouraged Isham to establish medical treatment with a primary doctor.[10] ( Id. ). She also recommended aspiration of the bursa on Isham's left ankle. ( Id. ). Dr. Turner consulted with Dr. Zamzow on August 15, 2007, regarding the bursa. ( Id. at 479). It was recommended the bursa be excised under general anesthesia. ( Id. ).

On December 31, 2007, Isham was seen by Ellie Schoenfeld, MSW, LICSW ("Schoenfeld"), for therapy. ( Id. at 499). Isham continued to be diagnosed with bereavement, polysubstance dependence, recurrent and chronic major depressive disorder, anxiety disorder, physical abuse, and history of personality disorder. ( Id. ). At the time of this appointment Isham's GAF score was 30, with the highest GAF score in the past year being 63. ( Id. ). Isham reported daily and frequent crying, depressed mood, inability to think, recurrent thoughts of death and suicidal ideation without a specific plan, and anxiety attacks. ( Id. ). Further, Isham reported drinking every day, smoking a lot of marijuana, and periodically using other drugs. ( Id. ). Schoenfeld recommended a Rule 25 Assessment and follow through with any recommendations. ( Id. at 500). Schoenfeld further encouraged Isham to leave her abusive relationship and call a crisis line and/or go to the hospital if she was feeling suicidal, and to keep medical appointments. ( Id. ).

On January 11, 2008, Patrick Boyle, CNP ("Boyle"), saw Isham for a medication check. ( Id. at 480). Isham reported it was very difficult for her to meet home, work, and social obligations. ( Id. ). She reported feeling anxious, experiencing fearful and compulsive thoughts and behavior, irritable moods, feelings of guilt or worthlessness, sleep disturbances, fatigue and loss of energy, poor concentration, and indecisiveness. ( Id. ). Isham also reported that she drank twelve to eighteen beers daily and smoked marijuana occasionally. ( Id. ). Boyle talked at length with Isham about alcohol abuse and its depressant effects. ( Id. ).

Mollie A. Stapleton, MD ("Dr. Stapleton"), saw Isham on February 22, 2008, for depression. ( Id. at 482). Isham reported she had been off her medications since July and had been hearing voices. ( Id. ). Additionally, Isham stated she was drinking daily and had memory and attention problems. ( Id. ). Upon examination, Dr. Stapleton noted Isham was agitated, positive for anhedonia, anxious, exhibited compulsive behaviors, had deficient fund of knowledge and language, was fearful, had flight of ideas, was forgetful, had for auditory hallucinations, and had a poor attention span and concentration.[11] ( Id. ). Dr. Stapleton opined that Isham had abnormal comprehension. ( Id. ). Isham was prescribed Effexor and Buspar.[12] ( Id. at 483).

On March 7, 2008, Dr. Stapleton saw Isham for follow-up and a medication check. ( Id. at 484). Isham reported she started taking Effexor and Buspar, but stopped quickly because they made her feel more depressed and "sick." ( Id. ). Isham also reported continued drinking and hearing voices. ( Id. ). Dr. Stapleton asked Isham to return for a follow-up visit in two weeks and encouraged her to make a therapy appointment. ( Id. at 485).

On September 25, 2008, Isham was seen in the emergency room of St. Mary's Medical Center with a cut to her left forearm. ( Id. at 528). She reported cutting herself three days before because she was depressed and frustrated. ( Id. ). John E. Slettedahl, RN, CNP, gave her Cephalexin to help the infection and referred her to a social worker for her depression issues and self-injurious behavior.[13] ( Id. at 528-29).

Dr. Stapleton saw Isham on April 27, 2009, for a rash and cough. ( Id. at 366). Isham reported being assaulted two weeks earlier and was still having headaches. ( Id. ). She stopped taking her medications again because they made her hallucinations worse. ( Id. ). Dr. Stapleton noted that Isham smelled of alcohol and Isham reported drinking to manage her pain. ( Id. ). Upon examination, Dr. Stapleton found Isham to have a depressed affect. ( Id. at 367). Isham appeared to be agitated, was had anhedonia, was anxious, and exhibited compulsive behavior and poor judgment. ( Id. ). Her auditory hallucinations continued. ( Id. ). Dr. Stapleton prescribed Seroquel.[14] ( Id. ).

Dr. Stapleton saw Isham on May 11, 2009, for a follow-up to headaches that arose after the assault, and to treat Isham's depression. ( Id. at 369). Isham reported that Seroquel was helping her sleep, but that she felt groggy in the morning; she was advised to cut the dosage in half. ( Id. ). Upon examination, Isham was not agitated, but was anxious and said she was feeling disconnected from reality. ( Id. at 368).

On May 19, 2009, Dr. Kimberly Schmidt ("Dr. Schmidt") called Dr. Stapleton to inform her Isham was currently in Dr. Schmidt's office and was talking about taking Seroquel to commit suicide. ( Id. at 487). Dr. Schmidt further reported that Isham admitted to drinking three beers and a shot of hard liquor before seeing Dr. Schmidt. ( Id. ). Dr. Stapleton spoke to Isham on speaker phone and Isham agreed to bring her medications into the clinic for disposal. ( Id. ).

On June 19, 2009, Isham was seen by Dr. Turner at St. Mary's Medical Center's intensive care unit ("ICU"). ( Id. at 335). Isham was brought to the emergency room by her partner because he thought her behavior was "funny" and thought her mental status was abnormal. ( Id. ). Isham was transferred to the ICU. ( Id. ). The partner reported that he and Isham had an argument earlier in the day and she left. ( Id. ). When she returned, her partner noted that she was behaving "funny" and her speech was slurred. ( Id. ). Dr. Turner noted Isham was difficult to arouse in the emergency room and had a seizure on the floor in the ICU. ( Id. at 335-36). Upon examination, Dr. Turner noted it was difficult to get any reliable history from Isham as she was intermittently dozing with slurred speech. ( Id. ). Isham admitted to taking some of her father's sleeping pills and drinking some alcohol, but denied taking other drugs. ( Id. at 336). Isham's urine toxicology screen was positive for amphetamines, tricyclics, and THC.[15] ( Id. ). Because Isham refused voluntary hospitalization, Jayme A. Bork, DO ("Dr. Bork"), hospitalized Isham on a seventy-two-hour hold. ( Id. at 334). Dr. Bork discharged Isham on June 23, 2009. ( Id. at 332). Isham's GAF score was 40 on June 21, and 55 on June 23, 2009. ( Id. at 332, 335).

On December 26, 2009, Francis W. Nelson, MD ("Dr. Nelson"), saw Isham at St. Mary's Medical Center's emergency room, when she presented with nausea, vomiting, and abdominal pain. ( Id. at 535). Lab tests revealed alcoholic gastritis.[16] ( Id. at 536). Dr. Nelson recommended no alcohol, no ibuprofen, and no spicy foods, and prescribed Prilosec, Maalox, Zofran, and Phenergan.[17] ( Id. ).

2. After December 31, 2009

On February 1, 2010, Dr. Schmidt saw Isham for intake at Arrowhead Psychological Clinic. ( Id. at 343, 349). Dr. Schmidt's initial diagnosis was bipolar type of schizoaffective disorder, PTSD, alcohol dependence, dependent personality features, and ankle, knee, and hip problems, and Isham's GAF score was 38. ( Id. ). Isham reported she was "super suicidal" and that she had tried to kill herself three times. ( Id. ). She further reported that she was no longer taking any of her medications because they made her "feel stupid." ( Id. at 334). Dr. Schmidt noted that during the intake, Isham acted like a young child, was hard to keep on track, and had difficulty with boundaries and a tendency to be impulsive. ( Id. ). Dr. Schmidt opined that Isham's IQ was likely low. ( Id. ). Isham reported that she had been drinking more frequently and that she wanted to be dead to be with her son Eric, who passed away several years ago. ( Id. at 345). Isham reported that she did not believe she could work, saying "I would probably sit down and cry." ( Id. at 345).

Dr. Schmidt opined that Isham's symptomatology included: angry outbursts; anxiety upon exposure to stimuli symbolizing trauma; auditory hallucinations; avoidance of situations that elicit memories of trauma; depressed mood; difficulty falling asleep; difficulty reading and writing; diminished ability to feel pleasure; distressing and intrusive memories of trauma; feelings of detachment from others; feelings of hopelessness; impaired concentration; low selfesteem; poor comprehension; poor concentration; poor judgment; racing thoughts; difficulty being alone and functioning independently; recurrent dreams of trauma; suicidal ideation without intent to act; and visual hallucinations. ( Id. at 346). Dr. Schmidt further opined a "learning disability is evident." ( Id. ). Dr. Schmidt reported Isham's thought content was characterized by preoccupation with external stressors and her son's death. ( Id. at 347). Further, Dr. Schmidt found Isham's attention and concentration to be characterized by a below-average ability to attend and maintain focus. ( Id. ). Dr. Schmidt recommended Isham attend individual therapy and chemical dependency treatment. ( Id. ).

Between April 21, 2010, and September 12, 2011, Isham saw Schoenfeld for twenty-two individual therapy appointments at Fond du Lac Human Services.[18] ( Id. at 418-43). On October 27, 2010, Isham was admitted to the Center for Alcohol & Drug Treatment for outpatient treatment for alcohol dependence. ( Id. at 390-92). At that time, her GAF score was 45. ( Id. at 392).

On December 6, 2010, Schoenfeld completed a treatment update regarding Isham. ( Id. at 501). Schoenfeld noted that Isham's diagnoses were alcohol dependency, cannabis dependency, recurrent major depressive disorder, anxiety disorder, and victim of physical abuse, and assigned Isham a GAF score of 50. ( Id. ). Isham continued to describe ongoing issues of low mood, feelings of worthlessness, recurrent thoughts of suicide, diminished ability to concentrate, and fatigue. ( Id. ). Additionally, Isham reported she continued to drink alcohol and smoke marijuana, even though she was participating in outpatient treatment. ( Id. ). Schoenfeld recommended Isham continue with individual therapy, continue with sobriety and treatment, utilize community supports such as mental health case management and other stabilization programs, and increase her sober support system. ( Id. at 502).

Dr. Turner saw Isham on December 21, 2010, regarding the hearing loss in Isham's left ear, lower abdominal pain, and headaches. ( Id. at 374). Isham reported she had been sober for two months and was attending outpatient treatment. ( Id. ). Isham was referred to audiology for her hearing loss. ( Id. at 377).

On January 19, 2011, Schoenfeld completed a Social Security Medical Opinion form. ( Id. at 513). In the report, Schoenfeld indicated Isham was diagnosed with major depressive disorder, substance dependency, and anxiety. ( Id. ). She indicated that Isham had mental illness, learning disability, and chemical dependency. ( Id. ). She opined that Isham would not be able to perform any employment in the foreseeable future and that it was unknown if Isham would still have a disabling condition if she stopped her addictive behavior. ( Id. ). Schoenfeld completed a second Social Security Medical Opinion form on April 15, 2011. ( Id. at 514). Schoenfeld's opinion was the same, except that she opined that if Isham stopped her addictive behaviors, there would still be a disabling condition. ( Id. ). Schoenfeld completed a third Social Security Medical Opinion form on December 3, 2011. ( Id. at 515). Her findings were the same as her April 15, 2011 opinion. ( Id. ); see also ( id. at 514).

On March 9, 2011, Isham was seen by George L. Horvat, PhD, LP ("Dr. Horvat"), for a mental health status evaluation and testing. ( Id. at 380). Dr. Horvat observed that Isham was restless, depressed, and tearful at times and displayed difficulty finding the words she wanted to use. ( Id. at 381). Isham stated she was suicidal and had "extreme depression." ( Id. ). She also said her head and ankles were painful, rating the pain as a six. ( Id. ). Isham reported anxiety attacks and said she has to work hard not to hyperventilate. ( Id. ). She further explained she had heard voices since grade school that tell her not to do different things and that she sees vague faces. ( Id. ). Isham told Dr. Horvat she could not follow written instructions because she did not read, but if the instructions were given verbally in basic language, she is able to follow them. ( Id. at 382). Upon examination, Dr. Horvat noted that Isham was distracted and her concentration was scattered. ( Id. ). Dr. Horvat opined that Isham's mood and affect were depressed and that she was preoccupied with thoughts of suicide. ( Id. at 383). When Dr. Horvat asked Isham if she thought she was impaired, she replied, "Yes, my feet. I can't stand on them for long and I can't walk very far. I can't focus. I'm easily bored." ( Id. at 384). Dr. Horvat diagnosed Isham with alcohol dependence, bereavement, PTSD, ADHD, bipolar II, and delusional disorder.[19] ( Id. at 385). Dr. Horvat opined that Isham was not capable of handling her own finances and did not have the mental capacity to understand, remember, and follow directions. ( Id. at 386). Dr. Horvat did think, however, that Isham had the mental capacity to carry out work-like tasks if they were routine, repetitive, and labor intensive, and had the mental capacity to respond appropriately to co-workers and supervisors. ( Id. ). Dr. Horvat further opined that Isham had the mental capacity to tolerate the stress and pressure found in an entry-level, routine, repetitive, labor intensive type of workplace. ( Id. ). Dr. Horvat recommended Isham do the following: go to treatment and attend AA meetings for her alcohol dependence, go to treatment for her grief, and continue to participate in psychiatric treatment. ( Id. ). He also recommended Isham be referred to vocational rehabilitation. ( Id. ).

On June 30, 2011, Sue Solomon, LSW, LADC ("Solomon"), completed a Discharge Narrative for Isham. ( Id. at 393). Isham was being discharged from outpatient treatment as she had been referred to residential treatment to help stabilize her potential use of alcohol and drugs and gain sobriety. ( Id. ).

Isham presented to Kirsten Kortesma, CNP ("Kortesma"), on August 1, 2011, for a physical. ( Id. at 361). Isham told Kortesma she was in alcohol treatment and that it was going well. ( Id. ). Isham stated she had previously taken Effexor and Buspar for depression and anxiety, but that she had not taken any medications since 2009 and asked that she be put on an alternative medication. ( Id. ). Isham complained of ankle pain from falling out of a window ten years earlier. ( Id. ). She said the pain was getting worse, especially when she stood in one spot for too long. ( Id. ). She was prescribed Celexa.[20] ( Id. at 364).

On August 8, 2011, Isham was discharged from the Center for Alcohol & Drug Treatment after successfully completing the program. ( Id. at 412).

Tina M. Posch, MA ("Posch"), saw Isham on September 14, 2011, for a hearing evaluation. ( Id. at 450). The evaluation revealed no usable hearing in the left ear with very poor word recognition. ( Id. ). Posch opined that Isham would benefit from some type of amplification. ( Id. ).

On January 23, 2012, Isham presented to St. Mary's Medical Center's emergency room complaining of lumbar back and coccyx pain after slipping and falling on ice.[21] ( Id. at 547). Isham's x-rays were normal. ( Id. ).

On March 14, 2012, Schoenfeld completed a Mental Functional Limitations form. ( Id. at 552). She opined that Isham had little or no difficulty remembering locations and work-like procedures, but was frequently unable to understand and remember detailed instructions. ( Id. ). Additionally, Schoenfeld found Isham had occasional difficulty carrying out short and simple instructions; was frequently unable to carry out detailed instructions; was frequently unable to maintain attention and concentration for extended periods of time; was occasionally unable to perform activities within a schedule; was frequently unable to maintain regular attendance; was occasionally unable to sustain an ordinary routine without special supervision; was frequently unable to work in coordination with or proximity to others without being distracted by them, make simple work-related decisions, complete a normal workday and workweek without interruptions from psychologically based symptoms, and perform at a consistent pace without an unreasonable number and length of rest periods. ( Id. at 552-53). Schoenfeld noted that Isham had a difficult time with concentration and with "frustrations tolerance." ( Id. at 553).

Regarding social interaction and adaption, Schoenfeld found Isham was occasionally unable to interact appropriately with the general public and to ask simple questions or request assistance; had occasional difficulty accepting instructions and responding appropriately to criticism from supervisors, getting along with coworkers or peers without distracting them or exhibiting behavioral extremes, and maintaining socially appropriate behavior and adhering to basic standards of neatness and cleanliness; was occasionally unable to respond appropriately to changes in the work setting; had occasional difficulty being aware of normal hazards and precautions, and traveling in unfamiliar places or using public transportation; and was occasionally or frequently unable to set realistic goals or make plans independently. ( Id. at 554). Schoenfeld noted Isham "would likely have a difficult time with change and would have a very difficult time working with people who are difficult for her to be around." ( Id. ).

On March 27, 2012, Jeanne Nelson, MSW ("Ms. Nelson") completed a Mental Functional Limitations form.[22] ( Id. at 558). Ms. Nelson found Isham had little or no difficulty remembering locations and work-like procedures and was frequently unable to understand and remember detailed instructions. ( Id. ). Ms. Nelson noted Isham was capable of following detailed/structured work-like procedures with expectations that are clearly defined on a regular routine basis but has difficulty understanding short, simple instructions. ( Id. ). Ms. Nelson further opined that Isham had difficultly remembering detailed instructions, "[h]owever[, ] given reasonable support from professional services on a continuous basis she demonstrate[d] an improvement within recall." ( Id. ).

Regarding sustained concentration and persistence, Ms. Nelson found Isham had occasional difficulty carrying out short and simple instructions; was frequently unable to carry out detailed instructions; was frequently unable to maintain attention and concentration for extended periods of time; was occasionally unable to perform activities within a schedule; was frequently unable to maintain regular attendance; was occasionally unable to be punctual within customary tolerance; was occasionally unable to sustain an ordinary routine without special supervision; was frequently unable to work in coordination with or proximity to others without being distracted by them, to make simple work-related decisions, complete a normal workday and workweek without interruptions from psychologically based symptoms, and perform at a consistent pace without an unreasonable number and length of rest periods. ( Id. at 559). Ms. Nelson noted that Isham often demonstrated difficulty in maintaining concentration and focusing within longer periods of time, and occasionally demonstrated difficulty performing activities within a schedule. ( Id. ). She displayed frustration and was closed off from performing routine tasks and would have difficulty making work-related decisions because she is easily distracted by others and her psychologically based symptoms. ( Id. ).

Regarding social interaction and adaption, Ms. Nelson found that Isham was occasionally unable to interact appropriately with the general public; was frequently unable to ask simple questions or request assistance; had occasional difficulty accepting instructions and responding appropriately to criticism from supervisors, getting along with coworkers or peers without distracting them or exhibiting behavioral extremes, and maintaining socially appropriate behavior, and adhering to basic standards of neatness and cleanliness; was occasionally unable to respond appropriately to changes in the work setting and to be aware of normal hazards and precautions; had occasional difficulty traveling in unfamiliar places or using public transportation; and was frequently unable to set realistic goals or make plans independently of others. ( Id. at 560). Ms. Nelson noted Isham would have difficulty setting realistic goals and making plans independently of others. ( Id. ).

On July 15, 2012, Isham arrived at St. Mary's Medical Center's emergency room via ambulance. ( Id. at 566). Karen A. Lushine, MD ("Dr. Lushine"), reported Isham was found passed out on a sidewalk by a passerby who started CPR.[23] ( Id. ). When paramedics arrived, she was breathing and had a slow pulse, so she was given Narcan, which helped wake her.[24] ( Id. ). Dr. Lushine reported that Isham's urine toxicology was positive for opiates, THC, and amphetamines.[25] ( Id. at 567). She was admitted to the ICU for a multi-drug overdose and discharged from the hospital on July 18, 2012. ( Id. at 562, 566).

Dr. Stapleton saw Isham on December 19, 2012, for a physical. ( Id. at 580). Isham complained of chronic pain in both ankles. ( Id. ). Upon examination, Isham's affect was normal, she was not agitated, and she did not have anhedonia or suicidal ideation. ( Id. at 582). Dr. Stapleton recommended physical therapy for her ankle pain. ( Id. ).

On January 25, 2013, Dean C. Anderson, PT ("Anderson"), saw Isham for a rehabilitation evaluation. ( Id. at 602). Isham presented with left shoulder and bilateral ankle pain. ( Id. ). Isham reported the ankle pain began ten years earlier after she fell from a window and had been worsening. ( Id. ). She said she felt limited in what she was able to do and rated the pain a seven out of ten. ( Id. ). Isham had difficulty putting weight on her feet and ankles in the morning and after being off her feet for a period of time. ( Id. ). She reported that the shoulder pain limited her ability to lift, reach overhead, and to sleep comfortably on her side. ( Id. ). Upon examination, Anderson found Isham had difficulty transferring from a sitting position to standing, but the transition was otherwise normal. ( Id. at 603). Her gait activity was normal after some painreducing steps initially, and there was no noticeable swelling or tissue inflammation noted in her left shoulder or ankles. ( Id. ). Impingement testing and a supraspinatus test was positive and the isometric strength of Isham's ankles were 4 and her left shoulder was 4-/5.[26] ( Id. ). Anderson opined that the evaluation showed a decrease in normal functional status and subjective and objective deficits could be addressed by physical therapy intervention. ( Id. ).

Isham presented to Anderson for physical therapy on January 28, 2013, and again on February 4, 2013. ( Id. at 605-06). She was given bilateral ankle braces and was fitted with Powerstep orthotic inserts and a theraband for her shoulder.[27] ( Id. ).

On March 13, 2013, Anderson completed a discharge summary. ( Id. at 606-07). He noted that Isham was seen for three visits, cancelled twice, and did not show for two appointments. ( Id. at 607). As a result, treatment goals were not met and there was no significant improvement. ( Id. ).

3. Consultative Examinations[28]

a. Physical Consultative Examination

On April 4, 2013, Dr. Neil Johnson, MD ("Dr. Johnson"), conducted a physical examination of Isham. ( Id. at 615-29). After going through Isham's family and medical history, Dr. Johnson performed a physical and neurological examination and concluded that Isham's sensory functions are intact, her reflexes are symmetrical, and noted no disorientation. ( Id. at 617). He concluded that Isham's breath sounds were clear, and he expected her to be able to walk more than her self-reported limitation of one-fourth of a block. ( Id. ). Isham's hearing in her left ear was damaged and hearing in her right ear was mildly damaged. ( Id. ). Dr. Johnson noted she can talk on the phone using her right ear but not her left ear, and she has trouble in a group setting. ( Id. ). Although a crossover microphone hearing aid was suggested, she was not using one at the visit. ( Id. ). Isham could "hear conversational speech at [six] feet without trouble." ( Id. ). Dr. Johnson found discomfort on motion of her ankles and "minimal crepitus of her knees." ( Id. at 618).

Although Isham reported being able to stand less than one minute and walk only onefourth of a block, Dr. Johnson stated that "[p]hysical examination would suggest she should be able to do more than this." ( Id. ). Dr. Johnson found that Isham cannot sit for very long because she likely has ADHD. ( Id. ). Dr. Johnson also noted that Isham has a number of mental health issues, "which appear[] to be her biggest problem in terms of gainful ...


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