United States District Court, D. Oregon, Medford Division
OPINION AND ORDER
JANICE M. STEWART, Magistrate Judge.
Plaintiff, Melissa Dodds ("Dodds"), seeks judicial review of the final decision by the Social Security Commissioner ("Commissioner") denying her application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act ("SSA"), 42 USC §§ 1381-1383f. This court has jurisdiction to review the Commissioner's decision pursuant to 42 USC § 405(g) and § 1383(c)(3). All parties have consented to allow a Magistrate Judge to enter final orders and judgment in this case in accordance with FRCP 73 and 28 USC § 636(c). For the reasons set forth below, that decision is reversed and remanded for the calculation and payment of benefits.
Dodds protectively filed her applications on May 27, 2010. Tr. 215-37. Her applications were denied initially and on reconsideration. Two hearings were held before Administrative Law Judge ("ALJ") Phillip J. Simon on June 25 and November 29, 2012. Tr. 35-71. The ALJ issued a decision on December 28, 2012, finding Dodds not disabled. Tr. 15-34. Therefore, the ALJ's decision is the Commissioner's final decision subject to review by this court. 20 CFR §§ 416.1481, 422.210.
Born in 1961, Dodds was 50 years old at the time of the hearing. Tr. 38. She has completed a GED and has past relevant work experience as a cashier, checker, fast food worker, and fast food services manager. Tr. 26. Dodds alleges she has been unable to work since December 31, 2007, due to the combined impairments of pancreatitis, psychosis, Hepatitis C, ascites, chlamydia, gallbladder surgery removal, and depression. Tr. 271.
I. Medical Records
The extensive medical record is replete with visits by Dodds to the emergency room ("ER") for treatment due to alcohol abuse, mental health issues and physical problems.
On May 3, 2008, Dodds was seen in the ER after cutting herself. Tr. 446. She reported a 10-20 year history of cutting on herself and admitted to daily suicidal thoughts. Id.
On April 29, 2009, Hala Ahmed, M.D., recorded Dodds's admission to continued alcohol abuse and self-mutilation and diagnosed depression/personality disorder and alcohol dependence. Tr. 663. Noting that Dodds had no insurance and could not afford the counseling she needed, Dr. Ahmed prescribed Fluoxetine. Id.
On June 25, 2009, Dodds was brought by the police to a hospital Emergency Room ("ER") with depression and suicidal ideation due to drinking for the past several days after her fiance left her. Tr. 443. A drug screen was positive for marijuana. Tr. 444.
On October 18 and 21, 2009, Dodds was seen in the ER with anxiety and vomiting from acute alcohol withdrawal. Tr. 535, 438.
On November 10, 2009, Dodds was seen in the ER for acute intoxication after drinking "only 30-40 shots of whiskey" that day. Tr. 435. She stated that she typically drinks between one-half and one gallon of whiskey daily. Id.
On January 18, 2010, Dodds was seen in the ER for acute alcohol intoxication after making suicide threats on the emergency dispatch line. Tr. 430, 432.
Dodds began to miss work at her part-time job in March 2010. Tr. 671-72. She was seen in the ER on April 10, 2010, with nausea and vomiting after being sober for six days. Tr. 427. On April 15, 2010, Dodds told Dr. Ahmed that her last drink had been ten days ago. Tr. 1023. He prescribed Zantac for abdominal pain.
On April 21, 2010, Dodds presented to the ER with numbing and tingling of her abdomen. Tr. 422. She had weakness on straight leg raising, walked very slowly, and complained of progressive bilateral lower extremity weakness. Tr. 424. Dodds had a cholecystectomy the next day and was discharged two days later. Tr. 410-11.
On April 27, 2010, Dodds saw Dr. Ahmed for abdominal pain, fatigue, and nausea. Tr. 656. When she was seen two days later in the ER for abdominal pain, she reported that she had not had alcohol for several weeks. Tr. 403.
On May 2, 2010, Dodds was seen in the ER for severe abdominal pain and fluids leaking from her abdominal incision sites. Tr. 394. She was depressed and crying and admitted that she had started drinking heavily again to relieve the pain. Id. She was admitted for pain management with Oxycontin and morphine; received Lasix, Aldactone, and Inderal for ascites; and was prescribed thiamine, folic acid, Ativan, and Librium for alcohol abuse. Tr. 396. On May 6, 2010, Dodds was discharged with the diagnosis of a urinary tract infection - resolved, ascites - resolved, acute pancreatitis secondary to gallstones and alcohol abuse. Tr. 391.
On May 9, 2010, Dodds was again seen in the ER for abdominal pain. Tr. 366-70. Describing Dodds as "disruptive, " the ER physician found "no emergent medical condition requiring treatment or admission." Tr. 366. Two days later, Dodds was back in the ER with abdominal pain. Tr. 383. She did not remember her cholecystectomy in April 2010, reported drinking "about a half gallon of vodka every day" to treat her pain and was not eating. Id. The ER physician noted she was "writhing on the stretcher in pain. She will answer the questions once her pain is controlled, but otherwise not a great historian." Tr. 383-84. She was diagnosed with alcohol induced acute pancreatitis, gastroesophageal reflux disease ("GERD"), alcoholic hepatitis, and severe malnutrition. Tr. 386. She was discharged after a week (Tr. 1174), but was admitted to the ER the next day (May 19, 2010) with acute abdominal pain, acute pancreatitis, alcoholism, and anemia. Tr. 378-81. Dodds returned again on May 21, 2010, with severe abdominal pain from alcohol induced pancreatitis. Tr. 457. Two days later she returned again with weakness and fatigue. Tr. 460. Her color was poor; she was tearful and very slow; and her lower extremities were swollen. Id. Three days later, on May 26, 2010, she was admitted due to abdominal pain and an altered mental state and placed on a psychiatric hold. Tr. 466. The next day she filed her DBI and SSI applications at issue here. On May 30, 2010, she was discharged to the Crisis Resolution Center ("CRC"). Tr. 469.
Dodds was seen in the ER on June 19, 2010, for abdominal pain. Tr. 643. She had stopped taking her medications ten days previously, including Methadone, Ranitidine, Ativan, folic acid, and thiamine. Id. She was prescribed Phenergan and Percocet, but did not fill the prescriptions and left against medical advice. Tr. 648. She returned the following day with abdominal pain and vomiting. Tr. 648, 729.
On June 23, 2010, Dodds reported to Dr. Ahmed not drinking any alcohol since May 25, but still had continuing abdominal pain with vomiting and nausea, insomnia, and fatigue. Tr. 653. Dr. Ahmed gave her a release to return to work part-time in one week. Tr. 655.
On August 5, 2010, Dodds saw Bruce Towers, PA-C, at the same clinic as Dr. Ahmed, for nausea and vomiting. Tr. 1009. He prescribed some additional medications. Tr. 1012.
On August 11, 2010, Dodds completed an Oregon Department of Human Services form stating she had been clean and sober since May 25, 2010, noting her prior daily use of alcohol, methamphetamine, and marijuana. Tr. 305. She also noted her incarceration for distribution and driving under the influence. Id.
However, on September 3, 2010, when Dodds was seen in the ER requesting a refill of her Methadone, she admitted drinking alcohol in the past week. Tr. 675. On September 23, 2010, Dodds reported constant pain at 8/10 and that she had run out of medication and drank alcohol. Tr. 1005. PA Towers noted depression, anxiety, fearfulness, inability to focus, and insomnia. Tr. 1006.
On October 31, 2010, Dodds was brought by the police to the ER very intoxicated and threatening to drink herself to death after being fired from her job due to alcohol inebriation. Tr. 685. She was discharged from the hospital on November 5, 2010. Tr. 696.
On November 15, 2010, she was again brought to the ER intoxicated. Tr. 714. She had a suicide note, stated she was going to kill herself, and was angry, argumentative, and combative. Id. She refused admission to CRC and medications to manage alcohol withdrawal and stated she would return home and drink alcohol. Tr. 716. Two days later, she was brought to the ER by ambulance because she was too intoxicated to walk with a blood alcohol level over 300, but she left against medical advice. Tr. 711-12.
On November 20, 2010, Dodds returned to the ER reporting rape and assault, admitting she had been drinking alcohol, and threatening suicide. Tr. 708. She was a very poor historian, essentially refusing to answer questions. Tr. 739. Jennifer Wabin, M.D., noted that Dodds was uncooperative, with poor eye contact, a poor mood, an irritable affect, poor insight, ppoor judgment, and poor impulse control, and assessed a Global Assessment of Functioning ("GAF") score of 35. Tr. 740. On November 22, Dr. Wabin noted that Dodds stated "that she cannot be helped and she doesn't see any no point in talking." Tr. 760. She was discharged on November 24, 2010, with a GAF of 45. Tr. 752.
On December 6, 2010, Dodds was seen in the ER acutely intoxicated but denied suicidal ideation. Tr. 754. She returned intoxicated on December 9 and left against medical advice before mental health personnel could evaluate her. Tr. 756-59. The next day Dodds returned to the ER intoxicated, stating she wanted to die. Tr. 769. On December 20, 2010, she returned to the ER with abdominal pain and alcohol withdrawal symptoms. Tr. 772. She was shaky, weak, and dizzy, and was admitted for treatment. Tr. 777.
On January 31, 2011, Dodds was arrested, intoxicated, taken to detox, and then brought to the ER due to shaking and pain. Tr. 792.
On February 12, 2011, she returned to the ER with abdominal pain and nausea and admitted to drinking five half gallons of whiskey per week. Tr. 794. The following day she returned with abdominal pain and vomiting after she had been drinking. Tr. 797. The next day, she was again seen in the ER for abdominal pain and vomiting. Tr. 812. Two days later she returned with convulsions, abdominal pain and visual hallucinations, and was admitted. Tr. 804, 1116. However, on February 18, 2011, she left against medical advice. Tr. 817.
On May 15, 2011, Dodds was seen in the ER, intoxicated and complaining that no one would help her stop drinking. Tr. 1110. She reported that she had been sober for two months, but resumed drinking when her father died. Id. She claimed five personalities inside her made it more difficult to get well. Id. The physician noted an "rather abrupt change in her entire demeanor" which Dodds said was a different personality coming out. Tr. 1111.
On May 17, 2011, Dodds was back in the ER due to depression, suicidal ideation, and intoxication with a blood alcohol level of 416. Tr. 823-25. She was scheduled to start a rehabilitation program in the morning. Tr. 823. On May 20, 2011, Dodds was brought to the ER by ambulance because of suicidal ideation. Tr. 828. She was inebriated, "extremely disheveled, " tangential and confused. Tr. 832. She was admitted on a psychiatric hold until an ...