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Ferris v. Commissioner Of Social Security Administration

United States District Court, N.D. Ohio, Eastern Division

November 8, 2017

POLLY ANNE FERRIS, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.

          MEMORANDUM OF OPINION AND ORDER

          Thomas M. ParkerJ United States Magistrate Judge

         I. Introduction

         Plaintiff Polly Anne Ferris seeks judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying her application for disability insurance benefits (“DIB”) under Title II of the Social Security Act. The parties have consented to my jurisdiction. (ECF Doc. 15.) Because the Commissioner's decision is supported by substantial evidence, it must be AFFIRMED.

         II. Procedural History

         In 2013, Ferris filed an application for DIB, alleging disability beginning on September 30, 2009.[1] (Tr. 283-89). After the Social Security Administration denied her application, she attended a hearing before Administrative Law Judge Joseph G. Hajjar (“ALJ”). (Tr. 141-191, 244-247, 249-251) On July 23, 2015, the ALJ denied Ferris' claim for benefits. (Tr. 121-135)

         The Appeals Council declined to review the case, rendering the ALJ decision the final decision of the Commissioner. (Tr. 1-7)

         III. Evidence

         A. Medical Evidence

         Ferris treated with Dr. James Cannatti at Summit Ophthalmology from 2007 through 2014. She was diagnosed with ocular migraine headaches in November 2012. (Tr. 724, 726, 735)

         In October and November 2011, Ferris complained of diarrhea and hemorrhoids. (Tr. 424) On November 29, 2011, she complained of joint pain and swollen hands to Dr. James Johnston. (Tr. 426) On December 16, 2011, Ferris presented to the emergency room complaining of joint pain and stating that she had a question regarding her hemorrhoids. (Tr. 813) On December 19, 2011, Dr. Johnson prescribed Percocet for her pain and diagnosed irritable bowel syndrome (“IBS”). (Tr. 422)

         On January 13, 2012, Ferris visited her primary care physician, Dr. David Kimbell, MD, with complaints of constipation, bloody stool, joint pain, sleep disturbance, and fatigue. (Tr. 509-511) Dr. Kimbell noted bony deformity and synovitis in Ferris's wrists and hands. (Tr. 510) He noted normal muscle tone, strength, respiratory functions, gait and station. (Tr. 510)

         Ferris met with rheumatologist, Dr. Andrew Raynor, M.D., on January 20, 2012. (Tr. 434) Ferris reported that her joint pain and swelling had responded well to steroid treatment but that she had recently discontinued it. (Tr. 434) Dr. Raynor observed small joint polysynovitis, but normal range of motion of the upper and lower extremities, normal gait, and normal respiratory function. (Tr. 436) He diagnosed inflammatory arthritis and administered injections to Ferris's left wrist and right shoulder. (Tr. 436, 439) X-rays showed mild degenerative changes of the big toes with a small left calcaneal spur, and soft tissue swelling around the fingers and wrists bilaterally (Tr. 437). Her hip joint spaces were well maintained. (Tr. 437) At a follow-up appointment on February 7, 2012, Dr. Raynor diagnosed rheumatoid arthritis (“RA”). (Tr. 443) He observed normal gait, normal respiratory function, and normal range of motion in the upper and lower extremities. (Tr. 443) A chest X-ray performed on February 7, 2012 returned normal findings. (Tr. 609) Dr. Raynor prescribed an anti-rheumatic/immunosuppressant, methotrexate, and advised Ferris of other treatments for rheumatoid arthritis including biologic response modifiers. (Tr. 441, 573)

         Ferris met with Dr. Reynaldo Gacad, a gastroenterologist, on February 3, 2012. (Tr. 399) Ferris complained of excessive bowel movements (five times daily, at times with urgency) who initially diagnosed chronic diarrhea and GERD. (Tr. 399-401) A colonoscopy revealed no abnormalities and samples were biopsied for pathology. (Tr. 402-405) At a follow-up appointment in April 2012, Ferris continued to complain of excessive bowel movements and diarrhea. (Tr. 396-398) Dr. Gacad diagnosed IBS and prescribed medication to treat Ferris's symptoms. (Tr. 398)

         Ferris returned to Dr. Kimbell on February 8, 2012 complaining of constipation, blood in stool and pain in joints. (Tr. 507-508)

         Dr. Raynor prescribed Enbrel, a biologic, in March 2012. (Tr. 445) On March 23, 2012, a bone density/DEXA scan revealed T scores consistent with osteopenia in the left side of Ferris's hip. (Tr. 473) At a visit in May 2012, Dr. Raynor observed normal gait, normal respiratory function, and normal range of motion of the upper and lower extremities. (Tr. 451)

         In May 2012, Dr. Kimbell noted that he was treating Ferris for RA with MTX and Enbrel. He observed hand wrist deformity, synovitis and limited range of motion. Dr. Kimbell diagnosed IBS and anxiety and considered prescribing Lexapro, an antidepressant. (Tr. 504-506)

         In September 2012, Dr. Raynor noted that Ferris continued to have RA activity in her hands and feet but also noted that she was much improved since she started taking Enbrel. Dr. Raynor noted that he would consider a different biologic if Ferris continued to have RA activity at her next visit. (Tr. 453) Dr. Raynor noted pain in Ferris's muscles and joints. Ferris was no longer displaying full range of motion; Dr. Raynor noted “smoldering small joint synovitis wrists and metatarsals.” (Tr. 455) However, he continued to observe normal gait and respiratory function. (Tr. 455) Dr. Raynor adjusted Ferris's medications. (Tr. 453-455)

         At an office visit with Dr. Kimbell in November 2012, Ferris complained of joint pain and swelling throughout her extremities, but no fatigue, sleep disturbance or depression. (Tr. 502) Dr. Kimbell observed synovitis of the right index finger and limited range of motion of both hands. He noted normal muscle tone and strength, normal respiratory function and normal gait. (Tr. 503)

         Ferris followed-up with Dr. Raynor in December 2012. He continued to note smoldering arthritis activity in Ferris's hands and feet. (Tr. 458) He discontinued Enbrel and prescribed Humira. (Tr. 458)

         In February 2013, Dr. Kimbell noted that Ferris continued to suffer from anxiety, IBS and RA. (Tr. 499) He observed synovitis of the right index finger and limited range of motion of both hands. He again observed normal muscle tone and strength, normal respiratory findings and normal gait. (Tr. 501)

         In March 2013, Dr. Raynor noted that Ferris was having recurrent respiratory infections and that she continued to smoke. He ordered a chest X-ray and referred her for a pulmonary assessment. (Tr. 463) Ferris continued to complain of muscle and joint pain. Dr. Raynor noted “smoldering” small joint synovitis of the wrists and fingers. Ferris had normal respiratory findings and gait. (Tr. 465) The chest X-ray revealed stable findings compared to imaging performed in February 2012 with no acute cardiopulmonary process. (Tr. 471-472)

         Ferris met with Dr. Charles Fuenning for a respiratory evaluation on April 25, 2013. (Tr. 419) Dr. Fuenning noted dry inspiratory crackles at end inspiration and end expiratory wheezing. He also observed rheumatoid arthritic changes in the hands. (Tr. 419-420) Dr. Fuenning diagnosed rheumatoid lung (“RL”), chronic obstructive pulmonary disease (“COPD”), and personal history of tobacco use, presenting hazards to health. (Tr. 420) He stressed that Ferris must stop smoking and discussed strategies to accomplish that. He also prescribed an inhaler to treat Ferris's COPD. (Tr. 420) Dr. Fuenning ordered testing which revealed moderate small airway disease with mild restrictive ventilator defect. (Tr. 550) A CT scan of Ferris's chest showed severe emphysema. (Tr. 551)

         In June 2013, Ferris experienced persistent smoldering joint synovitis in her wrists and hands. Dr. Raynor wanted to restart Humira but could not because Ferris continued to smoke. He said he would reevaluate after she met with Dr. Fuenning again. (Tr. 467)

         Ferris returned to Dr. Fuenning on June 27, 2013. She continued to have respiratory difficulty, including coughing and dyspnea. (Tr. 512) Dr. Fuenning noted that Ferris had not quit smoking but had cut back to ½ pack per day. Dr. Fuenning diagnosed small airway disease, emphysema, RA, COPD with exacerbation and RL. (Tr. 514)

         In September 2013, Dr. Raynor noted that Ferris could resume Humira if she stopped smoking and that he would wait to hear from her. Raynor noted continued small joint synovitis, and he felt that she needed a biologic. Ferris received injections in her left shoulder and wrists. (Tr. 619)

         Ferris received physical therapy for her hands in October and November 2013. (Tr. 626-628) At the end of her therapy, Ferris still had pain but indicated that she was more able to manage. (Tr. 627)

         Ferris followed-up with Dr. Raynor in December 2013 and January 2014. (Tr. 648) Ferris still exhibited smoldering small joint synovitis in her wrists and metatarsals, but could not resume Humira because of her smoking. Ferris continued taking prednisone and Methotrexate Sodium. (Tr. 649-651, 647)

         Dr. Raynor restarted Humira in April 2014 even though Ferris had not stopped smoking. Ferris discontinued Humira after one use. Dr. Raynor indicated that she would “rechallenge” and resume the biologic if she stopped smoking. (Tr. 679)

         Ferris returned to Dr. Fuenning on June 26, 2014. She reported that her breathing had improved with medications. (Tr. 866) Dr. Fuenning continued to advise smoking cessation and diagnosed emphysema and COPD. He no longer diagnosed rheumatoid lung. He ordered additional imaging and testing. (Tr. 866-867)

         In July 2014, Dr. Kimbell noted that Ferris was still smoking a pack of cigarettes each day. (Tr. 754) He also noted anxiety and depression with symptoms of sleep disturbance. He observed bony deformity and limited range of motion of the hands without edema. (Tr. 755)

         Ferris returned to Dr. Raynor on July 28, 2014 and reported that she had taken three months of Humira with little benefit. She was advised to take it for an additional six weeks but if no significant improvement she would discontinue and try Rituximab. Dr. Raynor noted continued small joint synovitis. (Tr. 780)

         Ferris met with Dr. Kimbell in October 2014. He noted abdominal pain and treatment for bronchitis. Ferris continued to take Percocet for pain and Enbrel, MTX, and prednisone for RA. (Tr. 750-752)

         From October 2014 through December 2014, Dr. Raynor noted that Ferris had stopped taking Humira in September. She continued to experience pain in her eye, right shoulder, muscles and joints. Dr. Raynor noted smoldering synovitis in her wrists and hands and positive RA factors. Her gait and respiratory findings were normal. Ferris continued to smoke. (Tr. 776-779, 781)

         On January 7, 2014, Ferris returned to Dr. Kimbell who adjusted her medications. He observed limited range of motion in her hands and wrists and diagnosed acute bronchitis and RA and noted that she was “immunocompromised.” (Tr. 803-806)

         On January 20, 2014, Ferris followed-up with Dr. Raynor. Dr. Raynor administered another dose of Rituximab. Dr. Raynor continued to observe smoldering small joint synovitis of the wrists and fingers, now with “multiple rheumatoid nodules.” Ferris had a normal gait and respiratory function. (Tr. 809)

         B. Opinion Evidence

         1. State Agency Non-Examining Sources

         Dr. Kourosh Golestany reviewed Ferris's medical records on August 2, 2013. He opined that Ferris could: lift twenty pounds occasionally and ten pounds frequently; stand/walk for about six hours in an eight-hour workday; sit for about six hours in an eight hour workday; occasionally crawl; never climb ladders, ropes or scaffolds; and occasionally finger with the hangs bilaterally. Dr. Golestany also opined that Ferris must avoid all exposure to unprotected heights and should only work in well-ventilated areas due to her COPD. (Tr. 221-222)

         Dr. John L. Mormol reviewed Ferris's records on December 4, 2013 and rendered the same opinions as Dr. Golestany. (Tr. 236-239)

         On August 7, 2013, Mel Zwissler, Ph.D., reviewed records from Ferris's psychiatric treatment. (Tr. 218-219) Dr. Zwissler opined that Ferris had mild restrictions of activities of daily living and mild difficulties in maintaining social functioning. He opined that she had moderate difficulties in maintaining concentration, persistence or pace, but no repeated episodes of decompensation. (Tr. 219) Dr. Zwissler felt that Ferris's ability to carry out detailed instructions and her ability to perform activities within a schedule, maintain regular attendance and be punctual were moderately limited. (Tr. 223) He further opined that her ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and her ability to perform at a consistent pace without an unreasonable number of length of rest periods were moderately limited. (Tr. 223)

         Bruce Goldsmith, Ph.D., reviewed Ferris's records on December 3, 2013 and affirmed the opinions of Dr. Zwissler. (Tr. 234-235, 239-240)

         2. State Agency Examining Source

         On June 26, 2013, Joshua Magleby, Ph.D., conducted a psychological examination of Ferris. (Tr. 486-492) Dr. Magleby did not review any of Ferris's medical records. (Tr. 486) Dr. Magleby diagnosed persistent depressive disorder, unspecified anxiety disorder, maladaptive behavior (smoking), IBS, COPD and RA. (Tr. 490) He opined that Ferris's ability to understand and carry out simple instructions were similar to other adults of the same age. He felt that her comprehension seemed fair; her memory - fairly average; and her ability to follow more complex instructions - “fairly average for age expectations.” (Tr. 491) Dr. Magleby opined that Ferris's ability to perform simple repetitive tasks appeared good but her ability to perform multi-step tasks seemed “somewhat impaired for age expectation.” (Tr. 491) Finally, he opined that Ferris had never had any significant incidents suggesting that her ability to relate to others was impaired. He also noted that social relating during the examination was appropriate. However, he noted that emotional distress observed during the evaluation might impair her social interactions at times. (Tr. 491)

         3. Treating Sources

         Ferris's treating ophthalmologist, Dr. James Cannatti, completed a medical questionnaire on June 20, 2013. (Tr. 478 - 481) Dr. Cannatti diagnosed arthritis, dry eye syndrome, and ocular migraines. (Tr. 480) Dr. Cannatti opined that Ferris did not have any limitations from an ophthalmic standpoint except that she would need time to take her drops and must avoid dry or dusty environments. (Tr. 481)

         Ferris's treating physician, Dr. David Kimbell, completed a medical questionnaire on July 11, 2013. (Tr. 494-495) He indicated that Ferris had a history of a mental impairment and that he had treated her by prescribing Lexapro. (Tr. 494) He opined that she had functional restrictions including poor coping and trouble with concentration. (Tr. 494)

         Dr. Kimbell completed a second medical questionnaire on October 14, 2013. (Tr. 616-618) In it, he diagnosed rheumatoid arthritis, depression with anxious features and irritable bowel syndrome. (Tr. 617) He indicated that IBS and RA where chronic conditions and that RA was a progressive disease, “with progressive debilitation and chronic pain despite treatment.” (Tr. 618) In describing Ferris's limitations, resulting from her conditions, Dr. Kimbell stated, “chronic pain hands, wrists, worse with activity, requiring narcotic pain medications. New lung involvement with increase dyspnea ...


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