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Truly v. Berryhill

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

February 15, 2018

JENNIFER M. TRULY, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          SARA LIOI JUDGE

          REPORT AND RECOMMENDATION

          JONATHAN D. GREENBERG UNITED STATES MAGISTRATE JUDGE

         Plaintiff, Jennifer Truly, (“Plaintiff” or “Truly”), challenges the final decision of Defendant, Nancy A. Berryhill, [1] Acting Commissioner of Social Security (“Commissioner”), denying her applications for Period of Disability (“POD”), Disability Insurance Benefits (“DIB”), and Supplemental Security Income (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 416(i), 423, 1381 et seq. (“Act”). This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned United States Magistrate Judge pursuant to an automatic referral under Local Rule 72.2(b) for a Report and Recommendation. For the reasons set forth below, the Magistrate Judge recommends that the Commissioner's final decision be AFFIRMED.

         I. PROCEDURAL HISTORY

         In August 2013, Truly filed an application for POD, DIB, and SSI, alleging a disability onset date of July 31, 2013 and claiming she was disabled due to primary sclerosing cholangitis, liver disease, Grave's disease, ulcerative colitis, an autoimmune hepatitis, the need for a liver transplant, a thyroid disease, spinal scoliosis, and anxiety. (Transcript (“Tr.”) 230, 237, 265.) The applications were denied initially and upon reconsideration, and Truly requested a hearing before an administrative law judge (“ALJ”). (Tr. 132, 136, 142, 149, 154.)

         On June 7, 2016, an ALJ held a hearing, during which Truly, represented by counsel, and an impartial vocational expert (“VE”) testified. (Tr. 42-63.) During the hearing, Truly, through counsel, requested a closed period of disability from July 31, 2013 through August 5, 2015. (Tr. 49.) On July 1, 2016, the ALJ issued a written decision finding Truly was not disabled. (Tr. 19-34.) The ALJ's decision became final on February 16, 2017, when the Appeals Council declined further review. (Tr. 1.)

         On April 21, 2017, Truly filed her Complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 12 & 13.)

         Truly asserts the following assignment of error:

(1) The ALJ erred at step five of the sequential evaluation in finding the plaintiff not disabled.

(Doc. No. 12.)

         II. EVIDENCE

         A. Personal and Vocational Evidence

         Truly was born in April 1984 and was 32 years-old at the time of her administrative hearing, making her a “younger” person under social security regulations. (Tr. 32.) See 20 C.F.R. §§ 404.1563(c) & 416.963(c). She has a high school education and is able to communicate in English. (Id.) She has past relevant work as a server and bartender. (Id.)

         B. Medical Evidence [2]

         From July 31 through August 3, 2013, Truly was hospitalized for abdominal pain, nausea, and jaundice. (Tr. 399.) During her hospitalization, she had an abnormal cholangiogram and elevated liver function testing. (Tr. 400, 402.) She underwent a laparoscopic cholecystectomy (i.e., gallbladder removal). (Tr. 402.) During this procedure, the surgeon voiced concerns Truly possibly had portosystemic encephalopathy (“PSE”). (Tr. 444.) Truly was then transferred to another hospital for further work up. (Id.)

         Truly remained hospitalized from August 3 through 6, 2013. (Id.) During this second hospitalization, Truly underwent a “slew of tests, ” including an ultrasound-guided liver biopsy. (Tr. 445.) The liver biopsy revealed findings consistent with autoimmune hepatitis and primary sclerosing cholangitis (“PSC”) with overlap syndrome. (Tr. 447.) She underwent an endoscopic retrograde cholangiopancreatography (“ERCP”) and stent placement in her liver. (Tr. 445.) Pierre Gholam, M.D., a gastroenterologist and hepatic specialist, diagnosed Truly with PSC with possible overlap syndrome. (Tr. 444.)

         On August 26, 2013, Truly underwent a colonoscopy and a repeat ERCP. (Tr. 510, 511.) During her ERCP, her liver stent was removed, and the procedure revealed improvement in her liver ducts. (Tr. 512.) Her colonoscopy yielded normal findings. (Tr. 510.)

         Truly followed up with Dr. Gholam on November 12, 2013, indicating she was feeling “quite a bit better than when she was first diagnosed.” (Tr. 521.) Her liver enzymes were trending “clearly towards normalization.” (Id.) Truly reported constipation and intermittent abdominal pain. (Id.) On February 4, 2014, an ultrasound of Truly's right upper abdominal quadrant revealed no significant intra- or extra-hepatic biliary dilatation. (Tr. 527.)

         On February 11, 2014, Dr. Gholam indicated Truly's “liver enzymes initially normalized” on her medications, but she subsequently developed abdominal pain and possibly pancreatitis from one of her medications. (Tr. 528.) However, he reported since he adjusted her medications, by prescribing CellCept and Prednisone, she was “back in biochemical remission.” (Id.) Truly reported generalized joint pains and difficulty walking. (Id.) On examination, Truly had tenderness along her lower back and hip joints. (Id.) Dr. Gholam referred Truly to a rheumatologist for evaluation. (Tr. 529.)

         On March 25, 2014, Dr. Gholam filled out a “Chronic Liver Disease Treating Physician Data Sheet, ” prepared by Truly's attorney. (Tr. 614.) On the sheet, Dr. Gholam provided the following information:

• Truly has chronic liver disease, with overlap syndrome, PSC, and autoimmune hepatitis;
• She has portal hypertension, which has not required shunt surgery;
• She is on the following medications: CellCept, Cyproheptadine, Omeprazole, Prednisone, and Ursodiol;
• Her last measured bilirubin, INR, and albumin were normal;
• Her last measured hepatic enzymes were not normal;
• She does not have ascites attributable to liver disease; and
• She does not have end-stage liver disease.

(Tr. 615-620.)

         On May 7, 2014, Truly presented to the emergency room with abdominal pain. (Tr. 738.) A CT scan was suggestive for bowel inflammation and an ovarian cyst rupture. (Id.) She was hospitalized for a gastroenterology consultation and evaluation. (Id.) A colonoscopy revealed an ulcer at the hepatic flexure, but the remainder of her colon and terminal ileum were normal. (Tr. 754.)

         Truly returned to Dr. Gholam on July 1, 2014, and reported continued joint and abdominal pain. (Tr. 713.) On examination, she had diffuse, direct abdominal pain, with normal bowel sounds. (Tr. 717.) Her gait and station were normal, and she had no edema in her extremities. (Id.) Dr. Gholam determined Truly was in “biochemical remission, ” and renewed her medications. (Tr. 719.)

         On July 24, 2014, a CT scan of Truly's abdomen was negative for hydronephrosis. (Tr. 790.) However, the CT scan revealed “rounding of the left hepatic lobe and very subtle micronodularity of the liver contour and prominence of the spleen, which suspects underlying chronic liver disease such as cirrhosis.” (Id.) An August 12, 2014 ultrasound of Truly's liver and abdomen indicated “coarsening of the hepatic echotexture, without focal lesion or perihepatic fluid” and an “unremarkable appearance of the visualized portions of the pancreas and right kidney.” (Tr. 707.)

         Truly returned to Dr. Gholam on October 7, 2014, reporting flank pain, abdominal pain, bloating, loose black stool, and intermittent fever. (Tr. 702.) On examination, she had diffuse right upper quadrant abdominal pain, normal bowel sounds, and normal gait and station. (Tr. 706.) Dr. Gholam listed her PSC and autoimmune hepatitis as “in remission.” (Tr. 711.)

         On December 4, 2014, Truly advised Dr. Gholam she was in her first trimester of pregnancy, and was feeling “poorly in general.” (Tr. 685.) Dr. Gholam noted her “numbers have finally begun to trend towards normalization” with daily Prednisone. (Id.) On examination, she had diffuse abdominal tenderness, with a normal gait and station. (Tr. 688.) Dr. Gholam indicated she was “trending towards biochemical remission, ” and encouraged her to undergo monthly liver function testing and see a high risk obstetrician. (Tr. 690.)

         On December 13, 2014, Truly presented to the emergency room for abdominal pain. (Tr. 817.) An MRI of her abdomen revealed no abnormal fluid collections and an unremarkable spleen. (Tr. 820.) She was prescribed her Miralax for constipation. (Id.)

         On February 17, 2015, Truly reported to Dr. Gholam she still felt “poorly, ” with both abdominal and joint pain. (Tr. 679.) Upon examination, Truly had no extremity edema, was not in distress, and had a normal gait and station. (Tr. 682.) Dr. Gholam noted while Truly was in complete biochemical remission due to high dosages of Prednisone, this was “at the cost of massive weight gain and multiple side effects.” (Tr. 683.) However, Dr. Gholam indicated this was “the only viable option for now until after she completes the pregnancy.” (Id.)

         On March 20, 2015, Truly consulted with psychiatrist Jaina Amin, M.D. (Tr. 622.) She reported she was 29 weeks pregnant, and had been off her CellCept and Abilify since the beginning of her pregnancy. (Id.) She indicated worsening depression, and reported the last two years of her life had been “very stressful and depressing.” (Tr. 623, 622.) She described suicidal thoughts, fear of the future, constant worry, and excessive counting behaviors. (Tr. 623.) During the evaluation, her eye contact, attention, and concentration were all normal. (Tr. 625.) Dr. Amin diagnosed anxiety with obsessional features and moderate, recurrent, major depression. (Id.) She prescribed Seroquel. (Tr. 626.)

         On May 5, 2015, Dr. Gholam noted Truly continued to be in biochemical remission, but it had “come with the price of gestational diabetes.” (Tr. 671.) Truly reported fatigue and swelling. (Id.) On examination, her abdomen was normal, and she had no edema in her extremities. (Tr. 675.) Dr. Gholam advised Truly she would need to remain on Prednisone for two months after the delivery of her child. (Tr. 678.)

         Truly followed up with Dr. Amin on May 15, 2015. (Tr. 629.) She reported her Seroquel dosage was too strong, and she was sleeping poorly at night and tired during the day. (Id.) She denied suicidal ideation, but continued to worry about the future and her health. (Id.) Dr. Amin adjusted her Seroquel dosage. (Tr. 632.)

         On July 21, 2015, Truly reported to Dr. Gholam she had recently been hospitalized for abdominal pain, and her medications were switched back to CellCept and Prednisone. (Tr. 662.) Dr. Gholam noted a recent MRI suggested “diffuse progression of stricturing disease.” (Id.) On examination, her abdomen, gait, and station were all normal. (Tr. 666.) Dr. Gholam began to taper Truly's Prednisone dosage. (Tr. 670.)

         On September 10, 2015, Truly visited the emergency room, reporting nausea, vomiting, diarrhea, and abdominal pain. (Tr. 808.) A CT of her abdomen revealed “no acute changes, ” her “workup was fairly unremarkable, ” and her abdominal examination was “fairly benign.” (Tr. 809, 811.)

         Truly saw Dr. Gholam on November 10, 2015, reporting left-sided pain with loose bowels. (Tr. 652.) On examination, she had left-sided abdominal pain, with normal bowel sounds. (Tr. 655.) Her gait and station were normal, and she had no extremity edema. (Id.)

         A November 17, 2015 ultrasound of her liver revealed the following: (1) a heterogeneous appearance of the liver with mild left-sided intrahepatic biliary dilatation, consistent with Truly's history of autoimmune hepatitis/PSC and (2) a hypoechoic structure in the left hepatic lobe, most likely a cyst. (Tr. 640.)[3]

         On February 4, 2016, Dr. Gholam noted Truly was in “biochemical remission” on CellCept and Prednisone, and was continuing “to feel better and lose weight as we taper Prednisone.” (Tr. 642.) Truly reported chronic musculoskeletal pain and occasional right upper quadrant abdominal pain. (Id.) On examination, her abdomen, gait, and station were normal. (Tr. 645.) ...


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