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Fernandes v. Commissioner of Social Security Administration

United States District Court, S.D. Ohio, Western Division, Dayton

July 24, 2018


          Thomas M. Rose District Judge


          Sharon L. Ovington United States Magistrate Judge

         I. Introduction

         The 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.

         II. Background

         A. Plaintiff's Vocational Profile and Testimony

         Plaintiff 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.

         During 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.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff's 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.

         In 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.

         Plaintiff 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.

         Plaintiff 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.

         B. Medical Evidence

         Plaintiff 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.

         December 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.

         Plaintiff 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.

         Plaintiff 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. Id.

         In May 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.

         In July 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 ...

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