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Ramirez v. Colvin

United States District Court, N.D. Indiana, Hammond Division

October 31, 2014

CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.


JON E. DEGUILIO, District Judge.

On June 14, 2013, Plaintiff Kathleen M. Ramirez filed her Complaint in this Court seeking review of the final decision of the Defendant Commissioner of Social Security (Commissioner). [DE 1.] The Commissioner filed an Answer on December 17, 2013. [DE 15.] On February 18, 2014, Ramirez filed her opening brief [DE 23], to which the Commissioner responded on April 29, 2014. [DE 26.] Ramirez filed a reply on May 22, 2014. [DE 29.] Accordingly, the matter is now ripe for decision. Jurisdiction is predicated on 42 U.S.C. ยง 405(g).

I. Procedural History

Ramirez filed an application for supplemental security income (SSI) on May 24, 2010. (Tr. 133-136.) Her application was denied initially on August 10, 2010, and again upon reconsideration on November 17, 2010. (Tr. 72-76.) On November 8, 2011, a hearing was held before Administrative Law Judge Melody Paige. (Tr. 40-71.) On February 23, 2012, ALJ Paige issued a decision denying the claim. (Tr. 16-34.) The Appeals Council denied a request for review on April 18, 2013, making the ALJ's decision the final decision of the Commissioner. (Tr. 1-3.)

II. Facts

Ramirez was born on March 2, 1974 and was 37 years old on the date the ALJ rendered her decision. (Tr. 33, 133.) Ramirez alleges a disability onset date of January 25, 2008 for both physical and mental impairments, including bipolar disorder, depression, asthma, and migraine headaches. (Tr. 149-158.) The ALJ found that Ramirez's severe impairments included bipolar disorder, posttraumatic stress disorder (PTSD), asthma, migraines, and obesity. (Tr. 21.)

A. Education and Employment Background

Ramirez has a high school degree and has completed 3 years of college education. (Tr. 51, 139.) Prior to the alleged onset date, Ramirez worked for a couple of years shelving books as a library page, then for fourteen years as a payment service representative for the Chicago Department of Revenue. (Tr. 58-59, 151.) On January 14, 2008, Ramirez was placed on administrative leave from her job at the Department of Revenue after displaying violence in the workplace, and later that month she was discharged from her position. (Tr. 208.)

B. Medical Evidence

Relevant to this appeal are Ramirez's complaints of asthma and migraine headaches, and her treatment for bipolar disorder. At the time of the hearing, Ramirez lived in an apartment with her 8 month old child. (Tr. 49.) She testified that she relied heavily on the assistance of her sister to cook and clean for her on a daily basis due to her medical conditions. (Tr. 53.)

1. Asthma

On October 13, 2009, Ramirez went to the emergency room for an acute exacerbation of her asthma, and was discharged the following day after medication made her feel "markedly better, " and she was instructed to followup with her primary care physician in regards to getting a steroid inhaler. (Tr. 231, 237, 242-43.) On April 27, 2010, Ramirez was again seen in the emergency room for shortness of breath, at which time it was noted she was out of meds. (Tr. 258.) Tests showed her lungs were clear (Tr. 263), she was diagnosed with asthma, and discharged the same day. (Tr. 225.) On August 3, 2010, Ramirez underwent pulmonary testing at St. Catherine, where her asthma was later assessed by state agent Dr. Whitley as being nonsevere. (Tr. 354-361.) This opinion was affirmed by state agent Dr. Mangala Hasanadka on November 17, 2010. (Tr. 457.)

Ramirez's records and testimony indicate she was seen in 2011 at the Hammond Clinic about every three months for asthma problems. Her trouble with asthma is also documented in her various mental health treatment records. (Tr. 56-57, 467-479.) It was noted that cold weather, exercise, heat, humidity, and stress triggered her asthma, and Ramirez testified that she could not climb stairs without becoming winded. Ramirez took asthma medication, including Advair, Singulair, and Proventil which were listed in her prescription records. (Tr. 57, 624, 627-628.)

2. Migraine Headaches

Ramirez has seen neurologist Shahida Ahmad, M.D. for her migraine headaches since as early as 2004 (Tr. 608-610.) In June 2006, he ordered her to stay home from work for approximately twelve weeks due to the side effects from her medication for headaches and bipolar disorder. (Tr. 599.) She was then told to remain off of work another month due to her persistent and severe migraines. (Tr. 598.) Psychiatrist Jayachandran also certified that Ramirez was under his care for the treatment of bipolar disorder and indicated that she was totally incapacitated from early June through September 2006. (Tr. 600.)

On August 24, 2009, Ramirez visited Dr. Ahmad with complaints of an increased number of headaches, occurring almost daily, with severe attacks occurring 3-4 times a month and lasting 2-3 days. (Tr. 217.) Due to not having insurance and an inability to find work, Dr. Ahmad noted Ramirez was unable to get Topamax or Wellbutrin.

On February 22, 2010, Ramirez visited Dr. Ahmad with complaints of an increased number of headaches, this time with pain in her temples and in the back of her head. (Tr. 482.) On both occasions, Dr. Ahmad prescribed Topamax. (Tr. 217, 482.) It was again noted that Ramirez was not able to get her Topamax due to financial difficulties, but once she started taking it again she felt a little better. (Tr. 482.) Dr. Ahmad documented that Ramirez denied any significant problems with her bipolar disorder, and was currently taking Abilify, Seroquel, Wellbutrin, and Topamax daily, and Maxalt infrequently. An MRI study of Ramirez's brain presented no abnormalities except paranasal sinusitis. (Tr. 220.)

In July 2010, reviewing state agent J. Chilton found that Ramirez complained of asthma and migraines, but neither met a listing nor were considered a severe impairment. (Tr. 343.)

On March 12, 2011, Ramirez was evaluated at Community Hospital when she experienced severe headaches after the delivery of her baby. (Tr. 485.) Dr. Anthony Gentile, M.D. noted that her headaches were not typical of post-epidural headaches, prescribed Topamax, and recommended that she followup with Dr. Ahmad. (Tr. 485.) A CT scan of her brain was normal. (Tr. 500.)

In May 2011, Ramirez returned to the care of Dr. Ahmad who noted that Ramirez was experiencing ongoing headaches, and appeared mildly depressed and withdrawn. (Tr. 480-481.) He advised Ramirez to continue taking Topamax and see her psychiatrist as soon as possible.

In July 2011, Ramirez was referred to the Hammond Clinic Specialty Center for her ongoing migraines which were noted as worse since Ramirez had her child. (Tr. 458-479.) She was given Butalbital and Topamax.

Relative to the limitations caused by her migraine headaches, Ramirez testified at the hearing that she needed to take naps during the day and found it difficult to sit, stand, and walk for long periods of time. (Tr. 61.)

3. Bipolar Disorder

Between July 2009 and October 2010, Ramirez had biweekly and then monthly therapy sessions at the Regional Mental Health Center, where she had consultations with psychiatrist Dr. Anissa Rivers and Dr. Eugene Kang, M.D. (Tr. 286-323, 393-455.)

In her July 2009 intake report, Dr. Rivers diagnosed Ramirez with bipolar disorder (moderate, acute, chronic) and PTSD (mild, acute, chronic). (Tr. 393-394.) Dr. Rivers also noted that Ramirez had previously been treated for bipolar disorder for several years by another therapist and psychiatrist. Dr. Rivers opined that Ramirez's current Global Assessment of Functioning (GAF)[1] score was 51. (Tr. 286, 399, 403.)

Throughout Ramirez's therapy sessions, it was noted that Ramirez appeared depressed and tired, tended to isolate herself, and had to practice coping with stress and anger, although some improvement was reported with continued therapy and medication. It was also reported that in dealing with her mental issues Ramirez was doing better at some sessions than others. In ...

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