Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Rini v. Commissioner of Social Security

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

May 17, 2019

CYNTHIA A RINI, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.

          JUDGE JAMES S. GWIN

          REPORT AND RECOMMENDATION

          KATHLEEN B. BURKE, UNITED STATES MAGISTRATE JUDGE

         Plaintiff Cynthia Rini (“Rini”) seeks judicial review of the final decision of Defendant Commissioner of Social Security (“Commissioner”) denying her application for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”). Doc. 1. This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This matter has been referred to the undersigned Magistrate Judge for a Report and Recommendation pursuant to Local Rule 72.2(b)(1).

         For the reasons stated below, the undersigned recommends that the Commissioner's decision be AFFIRMED.

         I. Procedural History

         In July and September 2015, Rini filed applications for DIB and SSI, respectively, alleging a disability onset date of January 1, 2010. Tr. 11. She alleged disability based on the following: ADHD, anxiety, sleep disorders, fibromyalgia, and severe recurrent major depression. Tr. 263. After denials by the state agency initially (Tr. 100, 101) and on reconsideration (Tr. 126, 127), Rini requested an administrative hearing. Tr. 158. A hearing was held before an Administrative Law Judge (“ALJ”) on June 28, 2017. Tr. 28-75. At the hearing, Rini amended her alleged onset date to February 1, 2014. Tr. 44-45. In her November 30, 2017, decision (Tr.11-21), the ALJ determined that there are jobs that exist in the national economy that Rini can perform, i.e., she is not disabled. Tr. 20-21. The Appeals Council denied Rini's request for review, making the ALJ's decision the final decision of the Commissioner. Tr. 1-3.

         II. Evidence

         A. Personal and Vocational Evidence

         Rine was born in 1974 and was 39 years old on her alleged onset date. Tr. 259. She has an associate's degree. Tr. 31. She worked in quality assurance as a software tester for thirteen years at Progressive Insurance and as a solutions analyst selling software for a technology company; she last worked in 2016 selling fragrances at a kiosk in a mall. Tr. 32, 33-34, 43, 68.

         B. Relevant Medical Evidence[1]

         In February 2012, Rini restarted treatment with Douglas McLaughlin, D.O., for depression, anxiety, and ADHD; she had not seem him for about a year. Tr. 302. She reported that she had not worked in two years and that she needed to get a job and stay focused. Tr. 302. She was taking Klonopin and Prozac but had run out of her Ritalin and wanted to restart it. Tr. 302. She also reported erratic sleep patterns. Tr. 302. Upon exam, she was alert and oriented, calm and pleasant, and “seem[ed] dysthymic, mood ‘a little bit seclusive [sic] to home.'” Tr. 302. She received support from friends and had a good sense of humor about her. Tr. 203. She denied suicidal or homicidal ideation, hallucinations, and paranoid thinking. Tr. 302. Dr. McLaughlin renewed her medications and restarted her on Ritalin. Tr. 302.

         In July 2013, Rini returned to Dr. McLaughlin stating that she needed help with her fatigue. Tr. 306. She reported that she had been diagnosed with delayed sleep phase syndrome in 2009 and asked about treatment options other than stimulants. Tr. 306. She expressed concern over losing her new job; she worked 8-5pm in information technology (IT) for a technology company. Tr. 306. She was compliant with her Prozac and Klonopin (which she took sparingly) and she had stopped taking Ritalin. Tr. 306. She did not have a therapist and was “not interested” in therapy. Tr. 306. Upon exam, she had an euthymic mood, full and appropriate affect, normal concentration, intact memory, intact associations, and clear, distinct speech. Tr. 306. Dr. McLaughlin diagnosed depression and insomnia, discontinued her Ritalin, started a trial of Nuvigil for her sleep disorder, and assessed a global assessment of functioning score (GAF) of 51-60.[2] Tr. 306-307. He recommended she follow up as needed.

         Rini returned to Dr. McLaughlin in February 2014. Tr. 310. She reported that she had lost her job in the fall. Tr. 310. She asked about pursuing disability and stated that she could not work or focus and had been late to work. Tr. 320. She was working a few hours a week selling perfume. Tr. 320. She last took Nuvigil several months earlier after she had lost her job, noting it was expensive but effective. Tr. 320. She did not have a therapist and was not interested in therapy. Tr. 310. Upon exam, she was calm, cooperative, and pleasant; her memory was mildly impaired; her concentration was poor and she was easily distracted; she had intact associations and an appropriate fund of knowledge; her mood was anxious and distressed but she “maintains sense of humor and sarcasm;” and her affect was “full and appropriate to topic.” Tr. 311. The treatment note states that her speech was clear and distinct and her thought process was logical, coherent and rational; it also states that her speech was pressured with tangential/disorganized thought process. Tr. 311. Dr. McLaughlin diagnosed mood and anxiety symptoms, ADHD, and sleep disorder and assigned a GAF of 45.[3] Tr. 311.

         Rini failed to show for her April 2, 2014, appointment with Dr. McLaughlin and returned on April 28. Tr. 314, 216. She was no longer pursuing disability, having started a part-time job at a mall. Tr. 316. She stated that she needed help with her medication; she was still tired with poor focus. Tr. 316. Her examination findings were the same as her prior visit and she again received a GAF score of 45. Tr. 317-318. Dr. McLaughlin increased her Prozac, continued her Nuvigil, added a trial of Trazadone for sleep, and recommended she taper, then discontinue, her Klonopin. Tr. 317. She was to follow up in four weeks. Tr. 317. She was not interested in therapy. Tr. 316.

         Rini returned to Dr. McLaughlin on September 3, 2014. Tr. 320. She reported doing okay but needing to talk about a few things. Tr. 320. She was not pursuing disability, was no longer working, and was on unemployment. Tr. 320. She was not interested in therapy. Tr. 320. Her mood was “not bad today” and she was calm, cooperative, and pleasant. Tr. 322. She reported that her insomnia persisted and that she had discontinued Trazodone on her own because it had not helped. Tr. 320. She asked to restart ADHD medication because she felt distracted. Tr. 320. Upon exam, her memory was mildly impaired; her concentration was poor and she was easily distracted; she had intact associations and an appropriate fund of knowledge; her mood was anxious and distressed but she “maintains sense of humor and sarcasm;” and her affect was “full and appropriate to topic.” Tr. 311. The treatment note states that her speech was clear and distinct and her thought process was logical, coherent and rational; it also states that her speech was anxiety driven and pressured with tangential thought content “per her usual.” Tr. 321. Her behavior was “restless, laughs out loud.” Tr. 321. Dr. McLaughlin wrote, “referral to therapist again today-[patient] agrees to go to new therapist.” Tr. 321. He assigned a GAF of 45, added Seroquel for sleep and anxiety, and asked for her to return in four weeks. Tr. 321-322.

         Rini returned to Dr. McLaughlin on January 28, 2015. Tr. 325. She reported doing better and sleeping better with Seroquel. Tr. 325. She had no therapist and was not interested in therapy. Tr. 325. She was again asking for ADHD medication. Tr. 325. She was planning on moving in with her boyfriend. Tr. 325. Her exam findings were as her prior visit, other than her behavior was listed as “restless, laughs out loud, giggles-baseline.” Tr. 325-326. Her medications were continued and she was to follow up as needed. Tr. 326.

         Rini returned to Dr. McLaughlin on June 24, 2015. Tr. 329. She stated, “I'm doing better.” Tr. 329. She was considering disability again; she was not working full time and worked part time selling perfume at a mall (5 hours a day “here and there”). Tr. 329. She stated, “I can't wake up and get to work. I have so many physical issues...I can't work.” Tr. 329. She was still planning on moving in with her boyfriend in a different town. Tr. 329. Her exam findings were the same as her prior visit. Tr. 330. Dr. McLaughlin continued her medications and advised she follow up with her primary care physician after reviewing her recent bloodwork. Tr. 330.

         Rini saw Dr. McLaughlin on October 19, 2015. Tr. 348. She had had a recent fibromyalgia diagnosis. Tr. 348, 393. She was working with an attorney pursuing disability. Tr. 348. She reported her anxiety was high, she could not focus, she remained distracted, and sleep was a chronic issue for her. Tr. 348. She reported that she had discontinued Seroquel on her own; although it helped her sleep, it made her congested. Tr. 348. She stated that the Nuvigil made her neck stiff. Tr. 348. Her exam findings were the same as her prior visit. Tr. 349. She stated that she needed to restart her ADHD medication. Tr. 350. Dr. McLaughlin gave her a trial of Ambien to help with sleep and, if that failed, Belsoma. Tr. 349.

         Rini saw Dr. McLaughlin on February 23, 2016, reporting that her anxiety exhausts her but that the Ambien was working. Tr. 371. She again complained that she could not focus, her anxiety was high, she remained distracted, and that sleep was a chronic issue for her. Tr. 371. She still had neck pain. Tr. 371. Her mood was “not bad today, ” her affect dysthymic, she was calm, cooperative and pleasant, and she had a tangential thought process. Tr. 372.

         On June 8, 2016, Rini reported that her mood was “really down.” Tr. 408. She had been “really depressed and stressed lately.” Tr. 410. In addition to her prior complaints, she admitted to having thoughts that life was not worth living. Tr. 408. She did not have a therapist and was not interested in therapy. Tr. 408-409. Upon exam, she had a mild memory impairment; her concentration was poor and she was easily distracted; she had intact associations and an appropriate fund of knowledge; her mood was anxious and distressed but she “maintains sense of humor and sarcasm;” and her affect was flat, sad and depressed. Tr. 409. The treatment note states that her speech was clear and distinct and her thought process was logical, coherent and rational; it also states that her speech was soft and slow and her thought content tangential “per her usual.” Tr. 409. Her behavior was calm, cooperative and pleasant. Tr. 410. Dr. McLaughlin added Abilify and her GAF remained 45. Tr. 409-410.

         Rini returned on June 27 and told Dr. McLaughlin, “I think I like that Abilify.” Tr. 415. Her sleep was erratic-only four hours a night-but, on the plus side, she was less depressed. Tr. 415. She was less anxious and more focused and reported that she had been able to read half of a book. Tr. 415. Her exam findings were the same as her prior visit except that she had a “better” mood, full affect, and no speech abnormalities noted. Tr. 415. Dr. McLaughlin discontinued her Ambien, started her on Sonata, and increased her Abilify. Tr. 416-417. Her GAF remained a 45. Tr. 417.

         Rini saw Dr. McLaughlin on August 3, 2016, reporting that she still has sleep problems. Tr. 418. The Sonata helped a bit but it was still not quite enough. Tr. 418. She reported that a close friend had died in her sleep. Tr. 418. She had been put on Topomax by her neurologist for headaches and stated that she likes this medication and that it helped stabilize her mood and “keep my brain even.” Tr. 419. Her exam findings were the same as her prior visit. 418-419. Dr. McLaughlin increased her Sonata. Tr. 419-420. Rini returned on August 31; she reported that she was tired all the time and stressed about finances. Tr. 421-422. She had not increased her Sonata. Tr. 422. Her exam findings were the same as her prior visit. Tr. 421-422. Dr. McLaughlin increased her Abilify. Tr. 422.

         On September 21, 2016, Rini saw Dr. McLaughlin and reported that she had no motivation or emotions lately. Tr. 424. She reported that her mood was “not bad” and “more even at work.” Tr. 425. Her exam findings were the same as her prior visit. Tr. 424-425. Dr. McLaughlin decreased her Abilify due to her blunted affect. Tr. 425.

         Rini did not show for her November 1, 2016, appointment. Tr. 428.

         On January 16, 2017, Rini again reported having no motivation or emotions lately. Tr. 436. Dr. McLaughlin commented that she was supposed to have decreased her Abilify but that “she has simply not been taking it at all.” Tr. 437. Dr. McLaughlin restarted it to treat her mood and increased her Topomax. Tr. 437, 439. She did not have a therapist and was not interested in therapy. Tr. 437.

         On February 16, 2017, Rini told Dr. McLaughlin that she was doing okay and that her sleep was better. Tr. 440. She felt like the Topamax gave her energy. Tr. 440. She had stopped taking her Abilify because she feared weight gain. Tr. 440. Upon exam, her mood was nervous and anxious although she maintained her sense of humor and sarcasm. Tr. 441. Her other exam findings were as they had been and her GAF score remained 45. Tr. 440-442. Dr. McLaughlin noted that she was “on Remeron???” and increased her Remeron for her mood, anxiety, and sleep. Tr. 440-441.

         C. Opinion Evidence

         1. ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.