United States District Court, D. Colorado
MICHAEL E. HEGARTY, UNITED STATES MAGISTRATE JUDGE.
Gwendolyn Ann Poole, appeals from the Social Security
Administration (“SSA”) Commissioner's final
decision denying her application for disability insurance
benefits (“DIB”), filed pursuant to Title II of
the Social Security Act, 42 U.S.C. §§ 401-33, and
her application for supplemental security income benefits
(“SSI”), filed pursuant to Title XVI of the
Social Security Act, 42 U.S.C. §§ 1381-83c.
Jurisdiction is proper under 42 U.S.C. § 405(g). Because
the ALJ failed to address all of Ms. Poole's severe
impairments at step three, I reverse the decision of the ALJ
and remand the case to the Commissioner for further
Ms. Poole's Conditions
Poole was born on September 20, 1966; she was forty-six years
old when she filed her application for DIB and SSI. [AR 77].
Ms. Poole claims she became disabled on October 22, 2012 due
to physical impairments. [Id.]
Poole first sought treatment for lower back pain in May 2005.
[AR 307]. After lumbar epidural steroid injections and
physical therapy failed to relieve her pain, she underwent
back surgery on January 27, 2006. [AR 314-22, 340-42]. During
the surgery, disc material impinging on Ms. Poole's nerve
root was found and successfully removed. [AR 341].
December 30, 2007, Ms. Poole was rear-ended by a drunk
driver. [AR 354]. After the accident, she experienced
migraines, upper and mid back pain, and tingling in her arms.
[Id.] For three years, Ms. Poole received
osteopathic manipulation, chiropractic treatment, and various
prescriptions for painkillers. [AR 394]. On December 9, 2010,
Ms. Poole was referred to Uptown Brain Injury and Pain
Management to address her recurring symptoms. [Id.]
There, Dr. Alexander Feldman noted reduced range of motion
(“ROM”) in the lumbosacral spine and cervical
spine, as well as reduced size of the left calf muscles and
positive leg raising tests. [AR 395]. Ms. Poole was then
referred for a lumbar spine MRI at Denver Integrated Imaging
North. [AR 389]. This test showed increased disc extrusions
and disc bulge with compression of nerve roots in her spine.
[AR 400]. Though the MRI revealed reduced spinal stenosis, a
new foraminal narrowing was found. [Id.] In May
2011, an MRI was completed on her cervical spine, which
demonstrated mild degeneration yet no accessory ligament
tears. [AR 386]. She attended physical therapy for four
months in 2011. [AR 402-24].
Poole began to experience symptoms of hypothyroidism in
February 2012. [AR 432]. Throughout 2013 and 2014, Ms. Poole
was formally diagnosed and treated at Aurora South by Dr.
Michael Holder and Dr. Kalindi Batra for hypothyroidism,
hypertension, obesity, sinusitis, migraines, and back pain.
[AR 438-98]. Regarding her migraines and back pain, she
displayed no focal neurological deficits, normal sensation,
reflexes, muscle strength, and tone in February 2013. [AR
497]. Further, in November 2013, Ms. Poole walked with a
normal gait and still had normal sensations and reflexes. [AR
466]. She was prescribed Armour to treat her hypothyroidism
symptoms, which included weight gain, hair loss, and fatigue.
[AR 462, 564]. However, her most recent bloodwork labs have
all demonstrated normal baselines of TSH/FT3/FT4 and an
ultrasound showed only mild enlargement of the thyroid, which
do not represent a true diagnosis of hypothyroidism. [AR 468,
564]. Also, on April 30, 2014, Ms. Poole elected to stop
taking her hypertension medication. [AR 446]. Despite her
high blood pressure, Dr. Batra noted that she did not have
any hypertensive risk factors or target end organ damage.
and August 2014, Ms. Poole visited two different emergency
care centers with complaints of low back and left hip pain.
[AR 542, 689]. Both times her doctors gave her Percocet and
ordered x-rays of her left hip and lumbosacral spine.
[Id.] Her left hip x-ray demonstrated
“moderate to severe degenerative changes in the
hip” but no apparent fractures or malalignment. [AR
543]. The x-ray of her lumbar spine showed mild degenerative
dislocations, foraminal narrowing, and a bulging disc on her
S1 nerve. [AR 546].
August 7, 2014, Ms. Poole first visited the Hidden Lake
Medical Offices to address her chronic back pain. [AR 560].
There, Dr. Emily Merrick noted Ms. Poole had full ROM,
negative straight leg raising tests, and her lower extremity
strength was rated a 5/5. [AR 561]. Though her left lower
back and left hip were tender, the doctor opined that Ms.
Poole appeared to be in no pain and she should stop taking
Percocet. [Id.] Ms. Poole saw Dr. Janisse Rears four
days later, who consulted her on chronic pain syndrome and
symptom management. [AR 559]. Dr. Rears offered steroid
injections for her hip pain and recommended increasing
activity by five minutes per week to promote weight loss. [AR
560]. In response, Ms. Poole declined steroid injections and
stated she cannot increase the time she spends exercising.
Poole had her initial visit with Dr. Karen Ksiazek at Exempla
Spine Care on August 26, 2014. [AR 548]. She explained that
after eventually agreeing to a left hip injection, her
average pain level was a five out of ten, with tingling and
numbness in her left leg and stabbing pain in her right
thigh. [AR 548, 550]. She had restricted ROM in her spine and
a positive right leg slump test. [AR 550]. However, her
straight leg raises were negative bilaterally, she had
significant compression of nerve roots, and a normal heel-toe
walk. [AR 550-51]. Dr. Ksiazek recommended physical therapy,
spine and hip injections, and possible orthopedic correction
of her left hip. [AR 549].
Rears submitted a Colorado Department of Human Services Med-9
Form in March 2015. [AR 577]. She opined that Ms. Poole was
“not totally disabled” but had a physical
impairment that would last for six months. [Id.] She
stated that Ms. Poole's chronic lower back pain limited
her to light physical exertion. [Id.]
March 7, 2015, Ms. Poole spent the night in an emergency room
due to chest pain and a racing heart. [AR 742]. Her EKG
results showed an irregular sinus rhythm, but overall she had
no focal neurological deficits, normal ROM, no back pain, and
full (4/4) strength. [AR 744, 758]. Her doctor noted that she
was “a bit melodramatic in describing” her
symptoms. [AR 758]. She was diagnosed with atrial
fibrillation and discharged the next morning. [Id.]
her hospitalization, Ms. Poole visited Dr. Kristin Sterrett
at Hidden Lake Medical Offices. [AR 627]. Ms. Poole refused
to see their endocrinologist, and Dr. Sterrett noted that she
was unlikely to accept evidence-based medical care in the
April 7, 2015, Ms. Poole revisited Dr. Ksiazek for back and
neck pain. [AR 734]. She described her current pain as a 4/10
but her average pain as a 5/10. [Id.] Dr. Ksiazek
noted only mild cervical spine spasms and recommended x-rays
and physical therapy. [AR 736-37]. An x-ray of her cervical
spine on April 8 demonstrated mild degenerative disc disease
but no fracture. [AR 679]. A left shoulder x-ray showed no
fracture or dislocation and only mild osteoarthritic changes.
October 16, 2015, Ms. Poole mentioned to Dr. George Robinson
at Rock Creek Medical Offices that she does not take her
medication for atrial fibrillation and hypothyroidism
anymore, as she wishes to self-regulate. [AR 616]. For her
chronic pain, she described her left hip pain as worsening;
she cannot sit cross-legged and has difficulty putting on her
shoes. [AR 615]. She relayed to the doctor that she receives
hip injections every three months, but their effectiveness
has diminished over time. [AR 616]. Further, in that same
month, an x-ray of her hips showed “bone on bone,
” but only minimal degenerative changes. [AR 616,
650-51]. Dr. Robinson performed a total left hip replacement
on February 1, 2016. [AR 600-05]. Six weeks after the
surgery, on March 15, Ms. Poole reported that “a lot of
her preoperative pain is improved.” [AR 593]. She still
experienced back issues and felt as if her legs were
different lengths, so Dr. Robinson recommended continued
physical therapy to strengthen her hip muscles. [AR 593-94].
Poole visited Dr. Ksiazek on February 16, 2016 to address her
continued back pain. [AR 725-26]. The doctor ordered an MRI
of her lumbar spine, which demonstrated shallow disc
displacement, central disc protrusion, and anterior
spondylosis. [AP 798-99]. After this test, on March 29, Dr.
Ksiazek submitted a form regarding Ms. Poole's ability to
perform work-related activity. [AR 724]. She stated that Ms.
Poole could sit for only one hour, stand for fifteen minutes,
and could not walk more than a quarter mile with an aid.
one month later, Dr. Ksiazek submitted to the SSA a Medical
Source Statement of Ability to Do Work Related Activities.
[AR 790-96]. She opined that Ms. Poole could occasionally
lift up to fifty pounds, occasionally carry up to twenty
pounds, and frequently carry ten pounds. [AR 790]. Further,
she stated that Ms. Poole could sit for up to seven hours
within a day and for forty-five minutes at a time, stand for
two hours within a day and for twenty minutes at a time, and
walk for three hours but only forty minutes at a time. [AR
791]. Dr. Ksiazek opined that Ms. Poole had some limitations
on the use of her left foot, left arm, and shoulders, but
could still occasionally climb stairs, balance, kneel and
crawl. [AR 793]. Also, she recommended Ms. Poole never climb
ladders and avoid the extreme ...