United States District Court, S.D. Ohio, Western Division, Dayton
M. Rose District Judge
REPORT AND RECOMMENDATIONS 
L. Ovington United States Magistrate Judge
Social Security Administration denied Plaintiff Madina
Fernandes' August 3, 2012 application for Supplemental
Security Income. She brings the present case challenging that
denial. At issue is the decision by Administrative Law Judge
(ALJ) Elizabeth A. Motta, concluding that Plaintiff is not
under a disability and, consequently, not eligible to receive
Supplemental Security Income. Plaintiff contends, in part,
that ALJ Motta failed to properly evaluate the opinions
provided by her treating mental-health professionals and the
opinions of her gastroenterologist, David P. Romeo, M.D. The
Commissioner maintains that the ALJ properly evaluated the
pertinent medical opinions and that substantial evidence
supports the ALJ's decision.
Plaintiff's Vocational Profile and Testimony
was 35 years old on the date she filed her application for
Supplemental Security Income. Being under age 50, she is
considered a younger person under Social Security
Regulations. 20 C.F.R. § 416.963(c). She has a
high-school education and attended college for 3 years. (Doc.
#7, PageID #94). She has no past relevant work.
an administrative hearing held by ALJ Motta, Plaintiff
testified that she is 5 feet 1 inches tall and weighs 190
pounds. She has a driver's license but drives an average
of 2 times a week. She has difficult driving for more than 30
minutes because her back pain becomes severe and her knees
start locking up-“it just gets really painful.”
Id. at 103.
told the ALJ that her medical issues worsened over the years.
Her health problems include daily arthritis pain in her feet.
She underwent knee surgery in 2011 after which she started
noticing more issues with her joints. She has arthritis in
her back, hips, hands, and shoulders. She explained,
“every day I'm in pain.” Id. at 96.
Pain in her hands, especially in her last 3 fingers, makes it
very difficult to use her hands. For example, she cannot
count out paper money. Plaintiff also experiences
“extreme exhaustion” that causes her legs to
“get heavy.” Id. at 98. She estimated
that after she is awake in the morning for 2-3 hours, she
lies down due to pain and sleepiness (“I can barely
keep my eyes open ….”). And as the day goes on,
her pain gets worse.
also has issues with irritable bowel syndrome with daily
diarrhea, 3 times a day. In addition, she will feel the urge
to use the bathroom 3 more times a day but after she reaches
the bathroom, she will not need to go. Id. at 105.
last job (in 2012) was part time. It ended, she noted,
because “I was having a lot of trouble with …
needing breaks and I was ill a lot … and I wasn't
able to come in to work all the time.” Id. at
103. She would call in sick about once a week, and sometimes
she would be late for work due to bathroom issues.
2012, Plaintiff was having issues with Crohn's disease,
knee problems (requiring surgery), anxiety and panic attacks,
and depression. Sometime medication helps her mental health,
but other times she “just feel[s] bad.”
Id. at 100. She has anxiety every day accompanied by
shaking and heart palpitations. She testified, “I get
really nervous around people. I get kind of panicky if
there's too many people around. And then sometimes like
with my depression just all I want to do is sleep. I
don't generally bathe myself when that happens. So I
don't really take care of myself as well as I should.
And, generally, the only time I eat is when my boyfriend
makes me something to eat.” Id. at 107.
stated that she can sit comfortably for about 30 minutes
before she starts getting pain in her hips, knees, and back.
She can stand comfortably for about 20 minutes before her
back, hips, and knees begin to hurt. She can lift and carry 5
pounds. Id. at 108.
does not cook or prepare meals; her boyfriend takes care of
it. Since 2012, she has not done yardwork or gardening.
Sometimes she tries to wash a couple of dishes. Her boyfriend
vacuums and dusts. She does her own laundry once a week and
puts her clothes away. She generally does not go to the
store; her boyfriend does most of the shopping. She does not
go outside her home on a regular basis. She has difficulty
dressing herself and must sit on a stool when she showers.
She does not use a computer or read books, unlike when she
was taking college classes. She eats only once a day because
she can't bring herself “to even care enough to
eat.” Id. at 102.
underwent left knee arthroscopic surgery in December 2011
after which she participated in physical therapy. Plaintiff
went to the emergency room in May 2012 feeling severe
“sharp and crampy” abdominal pain with vomiting
and diarrhea. Id. at 621. She was admitted with an
acute appendicitis and underwent surgery. Id. at
624-29. Five days later, she was released from the hospital
in stable condition. Id. at 630.
2012 treatment notes from treating gastroenterologist David
P. Romeo, M.D., indicate that he had not seen Plaintiff in
over a year. He noted that Plaintiff had lost her
health-insurance coverage in May or June 2012. Id.
at 616. Although she had been asymptomatic on medication, by
late July 2012, her symptoms were recurring. Dr. Romeo
reported that Plaintiff was experiencing a Crohn's
disease flare. She had abdominal pain, cramping, and
“upwards of eight to 10 stools per day including
nocturnal episodes.” Id. He also noted that
there “may be bleeding, ” and Plaintiff had
vomited “on occasion.” Id. She was
understandably “miserable and is tearful over the
situation.” Id. Dr. Romeo diagnosed
Crohn's disease and placed her back on immunosuppressant
therapy. Id. at 617. A month later she was doing
quite well, although she'd experienced an acute illness
with abdominal discomfort and diarrhea. This resolved after a
few days. Id. at 618.
went to the emergency room on early March 2013 with abdominal
pain and diarrhea. She reported that she had stopped taking
her steroid medications a week before. A physician diagnosed
her with Crohn's disease and treated her with medication.
She was discharged with Percocet for pain control, Zofran for
nausea, and Prednisone for Crohn's exacerbation.
Id. at 639-51.
followed up with Dr. Romeo in mid-April. He diagnosed her
with Crohn's disease in endoscopic remission and
prescribed Bentyl. He noted that she had experienced diarrhea
3 to 4 times per day on 8 of the previous 21 days, but on
other days she was constipated. Id. at 664. She was
also experiencing nausea, bloating, and intermittent
abdominal cramping but no ongoing abdominal pain.
2013, Dr. Romeo noted that Dicyclomine was helping with her
abdominal cramping, but “she still has considerable
diarrhea.” Id. at 661. Dr. Romeo reported no
evidence of active Crohn's disease, and thought
Plaintiff's diarrhea may be caused by another problem,
perhaps irritable bowel syndrome. Id. at 662.
2013, Dr. Romeo diagnosed Plaintiff with a history of
Crohn's disease, which was currently stable on
medication. She was, however, experiencing “frequent
diarrhea, controlled with Imodium, which will then lead to
constipation.” Id. at 658. She was also
experiencing nausea and cramping, for which Dr. Romeo
prescribed medications. Id. Plaintiff acknowledges,
“Subsequent treatment notes indicate that the