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Phalin v. Commissioner of Social Security

United States District Court, N.D. Ohio

April 27, 2018



          Thomas M. Parker, United States Magistrate Judge

         I. Introduction

         Plaintiff, Melinda Phalin, seeks judicial review of the final decision of the Commissioner of Social Security denying her application for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social Security Act (“Act”). The parties have consented to my jurisdiction. ECF Doc. 14.

         Because the ALJ did not correctly apply the applicable legal standards, the final decision of the Commissioner must be VACATED and the case REMANDED for further proceedings.

         II. Procedural History

         On March 26, 2014, Phalin applied for disability insurance benefits and supplemental security income, alleging disability beginning September 1, 2011. (Tr. 142-149) The claim was denied initially on July 11, 2014 (Tr. 87-92) and after reconsideration on November 3, 2014. (Tr. 99-110) Phalin requested a hearing on November 13, 2014. (Tr. 111) Administrative Law Judge (“ALJ”) Susan Giuffre heard the case on February 23, 2016. (Tr. 30-52) The ALJ found Phalin not disabled on April 8, 2016. (Tr. 14-24) The Appeals Council denied Phalin's request for review, rendering the ALJ's decision final. (Tr. 1-3) Phalin instituted this action to challenge the Commissioner's final decision.

         III. Evidence

         A. Personal, Educational and Vocational Evidence

         Phalin was born on May 25, 1982 and was 33 years old at the time of the hearing. (Tr. 142) She lived with her mother, her mother's fiancé, and her two small children. (Tr. 36-37) Phalin completed high school and had past work experience as a cashier/clerk. (Tr. 23, 34-36)

         B. Relevant Medical Evidence [1]

         On October 14, 2011, Phalin saw Nurse Practitioner Mary Griffith for a refill of her prescriptions. She complained of pain in her lower abdomen. Phalin reported blood sugar ranging from 90-150 mg/dl. Ms. Griffith diagnosed diabetes type I, uncontrolled. (Tr. 219-220)

         At follow-up appointments with Ms. Griffith in January, April, and May 2012, Phalin had normal foot examinations. (Tr. 492-493, 496) In May 2012, Phalin learned that she was pregnant. (Tr. 491)

         In October 2012, treatment notes show an A1c level of 4.5. (Tr. 364) A treatment note from December 2012 states that Phalin was not at risk for falling. (Tr. 385) Phalin had normal foot examinations with Nurse Griffith in December 2012 and March 2013. (Tr. 489-490) At a doctor's appointment in June 2013, Phalin reported that her blood sugars were well controlled during pregnancy due to persistent nausea and very little eating. (Tr. 333)

         Phalin met with Todd Wagner, M.D., on March 28, 2013 complaining of lower extremity pain and paresthesias. Phalin's A1c level was 9.2%. Dr. Wagner adjusted Phalin's dosage of Gabapentin and counseled her that it might not take effect for two to three weeks. (Tr. 487)

         In April 2013, Dr. Wagner referred Phalin to Nurse Practitioner Colleen Pomaro at the MetroHealth Medical Center's endocrinology clinic. (Tr. 369-370) Treatment notes indicate that Phalin was initially diagnosed with type 1 diabetes mellitus in 1996 at age 14. Metformin had been prescribed after one month due to lack of improvement. Phalin denied having ever been instructed on diabetic diet or engaging in any regular exercise. (Tr. 370) A foot examination was normal, with Phalin having intact sensation, normal pulses, and normal monofilament testing. (Tr. 372) Nurse Pomaro diagnosed type 1 diabetes mellitus of 17 years duration, complicated by DPN (“diabetic peripheral neuropathy) and changed plaintiff's insulin medication. (Tr. 374)

         On April 26, 2013, Phalin followed-up with Nurse Pomaro. (Tr. 360) Phalin reported constant fatigue, numbness and tingling of legs and feet. (Tr. 361) She reported small changes in diet and decreasing her cigarette use. (Tr. 365) A foot examination was normal. (Tr. 364) Nurse Pomaro continued the same dose of insulin. (Tr. 365)

         In May 2013, Phalin went to the emergency department for chest pain and a rash. (Tr. 345) An EKG was normal. (Tr. 346) Neurologic and extremity examinations were unremarkable. (Tr. 345) In June 2013, Phalin established care with Dr. Corinna Falck-Ytter at MetroHealth Medical Center. Phalin reported that she would like to improve her diabetes self-management. She was “most troubled” by severe pain in both feet. (Tr. 333) She carried her daughter around a lot. (Tr. 334) She reported checking her insulin four times daily and using 10 units of Novolog before she ate and 20 units of Lantus at night. (Tr. 333) Dr. Falck-Ytter diagnosed type 1 diabetes mellitus, with complications, uncontrolled. He counseled Phalin to stop smoking and to learn carb counting again. He set an A1c goal of less than 7%. (Tr. 335)

         Phalin returned to Dr. Falck-Ytter in July 2013 with complaints of ongoing loose stools and “a lot of foot pain.” Phalin was still smoking but had been working hard on eating better. (Tr. 327) Dr. Falck-Ytter noted that Phalin was not at risk for falls. (Tr. 326) Phalin did a “tremendous job of getting her readings improved” and reported that her A1c readings were around 7% or less now. (Tr. 328) Dr. Falck-Ytter prescribed Lyrica for neuropathy. (Tr. 328)) She referred Phalin to physical therapy. (Tr. 320)

         Plaintiff was ambulating independently at physical therapy in August 2013. (Tr. 305)

         Phalin returned to Dr. Falck-Ytter on October 15, 2013. Phalin complained of continued pain in her feet and nausea. (Tr. 270) She also complained of difficulty eating and insulin intake due to gastroparesis. Dr. Falck-Ytter noted that Phalin had poor diet choices and did not exercise. Dr. Falck-Ytter recommended that Phalin visit a diabetes website and attend smoking cessation classes. She also ordered a gastric emptying study. (Tr. 271) The results of the gastric emptying study were normal with 7% retention after 4 hours. (Tr. 275)

         Treatment notes in November 2013 and February 2014 indicate that Phalin was not at risk for falling. (Tr. 237, 262)

         Plaintiff went to the emergency department complaining of lower abdominal pain on December 10, 2013. Phalin reported that her sugars had been well maintained except for an incident of low sugar that morning. (Tr. 250) Neurological and extremity examinations were normal. (Tr. 251) Phalin was discharged with a diagnosis of yeast infection. (Tr. 252)

         Phalin went to the emergency room on July 4, 2014 complaining of suprapubic pain after discovering that she was pregnant. (Tr. 787) Phalin's gait was documented as steady, without assistance. (Tr. 553) Neurological and extremity examinations were normal. (Tr. 789) Phalin was diagnosed with abdominal pain and pregnancy. (Tr. 790)

         On July 7, 2014, Phalin presented for a maternal fetal medicine consultation. (Tr. 561) She had an elevated A1c level and was counseled that uncontrolled diabetes could cause risks to her pregnancy and to her long-term health. (Tr. 561) Phalin was not at risk for falls. (Tr. 560) Phalin maintained good control over her blood sugars during her pregnancy. (Tr. 749, 758-759, 761, 784, 984, 1030, 1103, 1282, 1310, 1342, 1681)

         In August 2014, Phalin went to the emergency department complaining of headaches and right flank pain. She was concerned about developing preeclampsia. (Tr. 618) Phalin reported that her blood sugar was well controlled. Examination was generally normal and Phalin had a normal gait. There was no sign of acute abdominal pathology. (Tr. 619)

         Phalin went to the emergency department again in early September 2014 complaining of nausea and vomiting. (Tr. 636) Examination was generally unremarkable except for mild epigastric pain and abdominal tenderness. (Tr. 638) She was able to move all extremities and had no focal neurological deficits. (Tr. 638) The attending doctor concluded that Phalin's vomiting was pregnancy related. (Tr. 639)

         At an obstetrics appointment on September 2, 2014, Phalin reported being independent in her activities. (Tr. 670)

         Phalin returned to the emergency department on September 18, 2014 with complaints of abdominal pain. (Tr. 689) Examination showed normal range of motion of all extremities and intact strength and sensation. (Tr. 690) The attending physician believed that Phalin's symptoms were likely secondary to cholelithiasis (gallstones.) (Tr. 690)

         On September 26, 2014, Phalin underwent laparoscopic open cholecystectomy (Tr. 728-729, 930) after an ultrasound showed cholelithiasis and gallbladder polyp. (Tr. 738)

         Treatment notes from October and December 2014 show that Phalin was not at risk for falls. (Tr. 877, 1049, 1253)

         In April 2015, Phalin went to the emergency room with complaints of headache and chest pain. (Tr. 1620) She reported that her sugars had been high despite being compliant with insulin. (Tr. 1621) Examination showed full range of motion in her extremities and normal strength and sensation. (Tr. 1622) Phalin was discharged after her blood sugar returned to normal. (Tr. 1623)

         In October 2015, Phalin began treating with Nurse Practitioner Susan Lyons. (Tr. 1681) Phalin reported painful neuropathy and retinopathy. She stated that her best glucose levels had been during her pregnancy when she counted carbohydrates and used NPH and Lispro. Phalin reported caring for her 9 month old infant at home. (Tr. 1681) Phalin had a normal neurological exam with no obvious sensory or motor deficits; she had normal reflexes in her upper and lower extremities. (Tr. 1683) Ms. Lyons noted that Phalin's diabetes was “uncontrolled with apparent improvement over the past couple of months.” (Tr. 1683)

         Phalin followed up with Nurse Lyons on November 5, 2015. She continued to complain of painful neuropathy. Neurontin and Lyrica had not alleviated leg pain. (Tr. 1688)

         Phalin was referred to Dr. Nicholas Zakov at Retina Associates of Cleveland for diabetic macular edema (fluid on eye) and blurred vision more in the left eye. (Tr. 824-829) Dr. Zakov diagnosed diabetes, type I, with ocular complications. (Tr. 827) A fluorescein angiogram showed leakage in both eyes from patches of microaneurysms. (Tr. 825) Dr. Zakov explained to Phalin that she had diabetic retinopathy and that this could be a serious, progressive and blinding ...

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