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Howell v. Commissioner of Social Security

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

January 9, 2018

TAMMY H. HOWELL, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          Judge, Christopher A. Boyko

          REPORT AND RECOMMENDATION

          JAMES R. KNEPP, II UNITED STATES MAGISTRATE JUDGE

         Introduction

         Plaintiff Tammy Howell (“Plaintiff”) filed a Complaint against the Commissioner of Social Security (“Commissioner”) seeking judicial review of the Commissioner's decision to deny supplemental security income (“SSI”). (Doc. 1). The district court has jurisdiction under 42 U.S.C. §§ 1383(c) and 405(g). This matter has been referred to the undersigned for preparation of a report and recommendation pursuant to Local Rule 72.2. (Non-document entry dated February 16, 2017). Following review, and for the reasons stated below, the undersigned recommends the decision of the Commissioner be reversed and remanded for further proceedings.

         Procedural Background

         Plaintiff filed for SSI in June 2014, alleging a disability onset date of January 1, 2013.[1] (Tr. 149). Her claims were denied initially and upon reconsideration. (Tr. 80, 96). Plaintiff then requested a hearing before an administrative law judge (“ALJ”). (Tr. 112). Plaintiff (represented by counsel), and a vocational expert (“VE”) testified at a hearing before the ALJ on July 28, 2016. (Tr. 40-64). On August 12, 2016, the ALJ found Plaintiff not disabled in a written decision. (Tr. 21-34). The Appeals Council denied Plaintiff's request for review, making the hearing decision the final decision of the Commissioner. (Tr. 1-4); see 20 C.F.R. §§ 416.1455, 416.1481. Plaintiff timely filed the instant action on February 15, 2017. (Doc. 1).

         Factual Background

         Personal Background and Testimony

         Plaintiff was born in June 1967, and was 49 years old at the time of the ALJ hearing. See Tr. 44, 149. Plaintiff had an eighth-grade education in special education classes, and a GED. See Tr. 45, 52. Plaintiff was divorced, and lived with a friend, but did not pay rent. (Tr. 45). Plaintiff testified she had last worked doing assembly work in 2005. (Tr. 46-47).

         Plaintiff described why she felt she was disabled:

At this time it's my neck, my shoulder and my back with all the pain that I have throughout the day, and all the breaks that I take throughout the day when I'm doing something. I don't believe I could do a job. And then with my mental problems I'm afraid that I might have an anger outburst and hurt someone.

(Tr. 48). For treatment, Plaintiff took pain medicine for her back, and went to physical therapy for her neck and shoulder. Id. She anticipated an MRI after physical therapy concluded. Id.

         Plaintiff also testified to problems with her left knee. (Tr. 52). She got migraine headaches at least once per week. Id. When the migraines occurred, she took medicine and laid down, and was “usually out for two days”. Id. Plaintiff also had COPD. (Tr. 54-55).

         Plaintiff testified that for her mental health treatment, she took Valium and Ativan, saw a counselor once per week, and saw a psychiatrist once or twice per month. (Tr. 49). She thought these measures were helping. Id. She had been in counseling for two years to address anger and depression. (Tr. 54-55).

         Plaintiff estimated she could stand in one place for ten minutes before having to move due to “sharp pains in [her] lower back that run[] up to the middle of [her] back.” (Tr. 49). At that point, she would have to “[e]ither shift or sit down.” Id. She would have to sit for twenty minutes before standing back up. Id. Walking was “[a]bout the same” as standing. Id. Plaintiff used a cane sometimes, when her back was “really, really hurting or [her] sciatic nerve[] [pain was] really bad.” (Tr. 49-50). Plaintiff estimated she could sit for half an hour, but would have pain during that time. (Tr. 50). She could lift “[n]o more than five pounds”, and could lift a gallon of milk with her left hand. Id. Plaintiff also testified to difficulty bending, kneeling, crouching, as well as reaching overhead or out in front of her with her right arm. (Tr. 51). She had trouble with grip in her right hand. Id. Plaintiff testified as to how she got through her days:

I stand for a little while, I can stand for about 10, 15 minutes, then I sit down or shift my weight to this side. I don't stand a lot permanent on my feet. When I'm sitting I can only sit for 20 minutes then my back starts hurting so I get up and walk around a little bit to relieve that. Still I have pain.

(Tr. 53). She spent the most time in the recliner. Id.

         Plaintiff's roommate did most of the household work, but she testified she folded clothes, loaded the dishwasher, and cleaned her bathroom. Id. Plaintiff also shopped for groceries, and went to doctor appointments. (Tr. 54).

         Relevant Medical Evidence

         Physical Health

         In May 2014, Plaintiff went to the emergency room with right back and arm pain. (Tr. 249). On examination, Plaintiff had decreased range of motion, pain and spasm in her cervical spine, and tenderness around her right scapula. (Tr. 250). She was assessed with musculoskeletal pain, and discharged with prescription medication. (Tr. 252).

         Plaintiff then saw Sherry Adkins, M.D., at Family Health Center for a follow-up visit. (Tr. 272-74). She requested a rheumatology referral, wanted to change her anxiety medication, and wanted a cane due to knee pain. (Tr. 272). She reported back, neck, and knee pain. Id. On examination, Dr. Adkins found some tenderness in Plaintiff's right arm. (Tr. 273). She assessed Plaintiff with uncontrolled anxiety, discussed medication options, and referred her to a psychiatrist. Id. She also assessed bilateral knee pain, which she found most consistent with bursitis, and referred Plaintiff for an orthopedic consultation. (Tr. 273-74).

         In June 2014, Plaintiff saw Eric Koperda, M.D., at Family Health Center. (Tr. 275). Her physical examination was normal. (Tr. 276). Plaintiff reported she was unable to reach a psychiatrist, and Dr. Koperda repeated the referral. Id. Dr. Koperda also assessed bilateral pedal edema, which Plaintiff reported was worse at the end of the day. Id. He noted he would “oblige pt with cardiac workup” due to family history of coronary artery disease. Id.

         An echocardiogram performed later that month showed: 1) the left ventricular systolic function was in the lower limit of normal to mildly reduced; 2) the right ventricular cavity size was mildly enlarged; 3) the right atrial cavity size was mildly dilated; 4) mild mitral regurgitation; and 5) mild to moderate tricuspid regurgitation. (Tr. 290). A bone density scan showed osteoporosis in Plaintiff's lumbar spine. (Tr. 286).

         In July 2014, Plaintiff saw Rodel Cacas, M.D. at Wilmington Physicians Group, LLC, to establish care. (Tr. 333). She reported depression, anxiety, COPD, osteoporosis, sciatica, and PTSD. Id. Plaintiff reported arthralgias/joint pain, and joint stiffness, but no muscle aches or weakness. (Tr. 335). On examination, Dr. Cacas noted normal muscle strength and tone, no tenderness, and full range of motion. (Tr. 336). Her psychiatric examination was normal. Id. Dr. Cacas assessed, inter alia, PTSD, an inflamed sacroiliac joint, and carpal tunnel syndrome. Id.

         Plaintiff returned to Dr. Cacas in August 2014 for a sacroiliac joint injection. (Tr. 329-32).

         In a visit to a urologist in September 2014, Plaintiff denied back pain, joint pain or swelling, or neck pain, but was noted to have osteopenia. (Tr. 347). Her physical and psychiatric examinations were normal. (Tr. 348).

         In October 2014, Plaintiff returned to Dr. Cacas with neck, shoulder, and back pain. (Tr. 324-28). She reported the pain had been worsening for a few week, and that it had waxed and waned for years. (Tr. 326). She reported Advil did not help, and the sacroiliac injection “did not help much”. Id. Her muscle tone, strength, and range of motion were normal, but she had tenderness in seventeen out of eighteen fibromyalgia points. (Tr. 327). Dr. Cacas assessed “[p]rimary fibromyalgia syndrome”, and started Plaintiff on trial medication. Id. Her psychiatric examination was normal. Id.

         Later that month, Plaintiff returned to Dr. Cacas for follow-up. (Tr. 319-23). She reported pain through her shoulders, lower back, and buttock, and that she was “[h]aving a flare” and “having difficulties getting around.” (Tr. 321). Dr. Cacas again assessed primary fibromyalgia syndrome, noting the same seventeen out of eighteen positive points. (Tr. 322). He noted Plaintiff did not tolerate previously prescribed medication, and started Plaintiff on a trial of Tylenol 3. Id. Her psychiatric examination was again normal. Id.

         Plaintiff returned to Dr. Cacas again at the end of October 2014. (Tr. 315-18). Dr. Cacas again noted Plaintiff reported arthralgias/joint pain, but no muscle aches or weakness, (Tr. 317). She also reported anxiety and emotional lability but no emotional problems/concerns or depression. Id. On examination, Dr. Cacas found tenderness and limited range of motion. Id. Her mental status was anxious and depressed. (Tr. 318). Dr. Cacas again assessed primary fibromyalgia syndrome, and noted he would “fill paperwork”. Id.

         In December 2014, Plaintiff had MRIs of her right elbow and left knee. (Tr. 461-62). In her elbow, she had a tendon tear; in her knee, she had an oblique undersurface tear of the medial meniscus posterior horn-body junction and adjacent posterior body segment, small areas of low-grade articular cartilage loss, and small knee joint effusion. Id. That same month, Plaintiff saw Andrea Manhart, D.O., about migraines. (Tr. 483-88). Her examination (mental and physical) was essentially normal. (Tr. 487). She was assessed with migraines and prescribed medication. (Tr. 487-88). A follow-up brain MRI showed no acute abnormality. (Tr. 460).

         In March 2015, Plaintiff returned to Dr. Manhart regarding her headaches. (Tr. 479-83). Dr. Manhart assessed migraines, neck pain, and muscle tension; she prescribed medication. (Tr. 482-83).

         In April 2015, Plaintiff saw Dr. Cacas “to fill out disability paperwork.” (Tr. 523). Plaintiff again reported arthralgias and joint pain, but no muscle aches, weakness, or joint stiffness. Id. On examination, Dr. Cacas noted Plaintiff had normal tone and strength, but “tenderness” in her joints, bones and muscles. (Tr. 524). Dr. Cacas continued to assess, inter alia, primary fibromyalgia syndrome. Id.

         Plaintiff returned to Dr. Cacas in May 2015. (Tr. 514-19). Plaintiff reported arthralgias and joint pain, but no muscle aches, weakness, or joint stiffness. (Tr. 518). She had normal muscle tone, and strength, but some tenderness. Id. Dr. Cacas assessed lateral epicondylitis (“tennis elbow”). Id. Later that month, Plaintiff underwent surgery on her elbow. (Tr. 455-56).

         In June 2015, Plaintiff saw a physician's assistant at Wilmington Physicians Group regarding her elbow. (Tr. 421). Notes indicate an appropriate range of motion and normal sensation. (Tr. 424). Plaintiff reported still having some pain, but that she felt better than prior to the surgery. (Tr. 425).

         In July 2015, Plaintiff underwent multiple sessions of chiropractic care with Randall Fick, D.C., D.A.B.C.O. (Tr. 350-51). She complained of pain and stiffness in her neck, back, and shoulder. (Tr. 350). Dr. Fick found reduced range of motion in the lumbar and thoracic spines, as well as myospasm in the mid thoracic multifidus and the suboccipitals. Id.

         Plaintiff again saw a physician's assistant at Wilmington Physician's Group about her elbow. (Tr. 415-20). Plaintiff had appropriate range of motion and normal sensation, Tr. 418, but reported increased pain, Tr. 420. The physician's assistant found it “somewhat concerning” that she still had swelling, and performed a corticosteroid injection to address the swelling. Id.

         Plaintiff returned to Dr. Cacas in July 2015, reporting right elbow and shoulder pain. (Tr. 511-13). Plaintiff reported severe pain right after the steroid injection, and that it was not improving. (Tr. 511). On examination, Plaintiff had some musculoskeletal tenderness. (Tr. 512). Dr. Cacas assessed cubital tunnel syndrome, status post surgery and corticosteroid shot, and prescribed medication pending orthopedic follow-up. Id.

         In August 2015, Plaintiff returned to Dr. Cacas with right shoulder pain. (Tr. 501-07). She reported reaching movements were the worst, and that she was “[h]aving a hard time in general as it is very aching [sic]”. (Tr. 505). On musculoskeletal examination, Dr. Cacas noted full range of motion, but with tenderness. Id. He ordered x-rays of Plaintiff's shoulder and neck. (Tr. 506). The shoulder x-ray was normal. (Tr. 454).

         In February 2016, Plaintiff returned to Dr. Cacas regarding neck and back pain. (Tr. 496-500). On examination, Dr. Cacas noted full range of motion and tenderness. (Tr. 499). Dr. Cacas assessed, inter alia, fibromyositis/fibromyalgia and neck pain. (Tr. 499-90). A follow-up x-ray of Plaintiff's neck showed degenerative changes at ¶ 5-6 and C6-7, as well as loss of the normal cervical lordosis. (Tr. 453).

         A March 2016 bone density analysis showed “[o]steoporosis but values are essentially stable as compared to prior exams.” (Tr. 452). Later that month, Plaintiff underwent an abdominal and pelvic CT scan due to abdominal pain. (Tr. 447). It showed no pancreatic edema, a 2 centimeter low density mass of the left adrenal, and low-density mass lesions of bilateral kidneys, most likely representing cysts. Id. Her appendix looked normal, and she had left colon diverticulosis without acute phlegmon. Id.

         Plaintiff returned to Dr. Cacas for follow-up in April 2016. (Tr. 490-94). Plaintiff reported musculoskeletal symptoms in her neck, shoulders, elbow, knee, foot, ankle, and lower back. (Tr. 493). She again reported arthralgias and joint pain, but no muscle aches or weakness, and no joint stiffness. (Tr. 494). On musculoskeletal examination, Dr. Cacas noted tenderness, ...


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