United States District Court, N.D. Ohio, Eastern Division
JENNIFER L. JOHNSON, Plaintiff,
NANCY A. BERRYHILL, Acting Comm'r of Soc. Sec., Defendant.
REPORT AND RECOMMENDATION
A. RUIZ, UNITED STATES MAGISTRATE JUDGE
Jennifer L. Johnson (hereinafter “Plaintiff”),
challenges the final decision of Defendant Nancy A.
Berryhill, Acting Commissioner of Social Security
(hereinafter “Commissioner”), denying her
applications for a 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.
1, 2015, Plaintiff filed her applications for POD, DIB, and
SSI, alleging a disability onset date of September 10,
2013. (Transcript (“Tr.”) 247-254).
The application was denied initially and upon
reconsideration, and Plaintiff requested a hearing before an
Administrative Law Judge (“ALJ”). (Tr. 171-202).
Plaintiff participated in the hearing on March 6, 2017, was
represented by counsel, and testified. (Tr. 36-73). A
vocational expert (“VE”) also participated and
testified. Id. On May 15, 2017, the ALJ found
Plaintiff not disabled. (Tr. 29). On April 17, 2018, the
Appeals Council denied Plaintiff's request to review the
ALJ's decision, and the ALJ's decision became the
Commissioner's final decision. (Tr. 1-6). On June 14,
2018, Plaintiff filed a complaint challenging the
Commissioner's final decision. (R. 1). The parties have
completed briefing in this case. (R. 11, 13 & 14).
asserts the following assignment of error: (1) the RFC
determination was not supported by substantial evidence. (R.
Evidence A. Relevant Medical Evidence 
8, 2014, Peter Bambakidis, M.D., saw Plaintiff for a follow
up for multiple sclerosis, and noted Plaintiff was clinically
stable. (Tr. 366). Plaintiff reported a few falls in the last
two months. Id. Her gait was ataxic, but there was
only borderline rombergism. Id. She had rapid,
alternating movements of the fingers performed in an
irregular manner suggesting a volitional element.
August 11, 2014, Dr. Bambakidis noted that Plaintiff had been
approved for Tecfidera. (Tr. 364). Plaintiff was doing
“relatively well” and had a fairly ataxic gait.
August 18, 2014, Plaintiff was seen by Andrew Z. Filiatraut,
D.O., for a “recheck of joint pain.” (Tr. 400).
Plaintiff complained of joint pain, joint stiffness,
decreased range of motion (ROM) and morning stiffness.
Id. Plaintiff characterized her pain as throbbing,
severe, and occurring daily. Id. On examination,
Plaintiff had full ROM in the spine, as well as the upper and
lower extremities without pain or weakness. (Tr. 401).
September 17, 2014, Mohammed A. Ali, M.D., treated Plaintiff
for complaints of joint pain and tenderness in her lower
back, hands, fingers, and hips. (Tr. 393). Plaintiff reported
moderate but worsening pain. Id. Dr. Ali noted that
Plaintiff had skin psoriasis since the 1990s, and observed
Plaintiff had gained fifty pounds in the last two years since
she stopped working. Id. He assessed psoriatic
arthritis. (Tr. 394).
November 19, 2014, Plaintiff reported feeling well to Dr. Ali
with minor complaints. (Tr. 388). She measured 5'7”
tall and weighed 316 pounds with a BMI of 49.57. Id.
On examination, her upper and lower extremities were noted as
abnormal, but she had normal cervical spine movements.
November 23, 2014, Plaintiff reported to Dr. Bambakidis that
she was “doing relatively well as of late and is
tolerating the Tecfidera without much in the way of
difficulty.” (Tr. 363).
January 20, 2015, Plaintiff reported that she felt well with
minor complaints. (Tr. 386). Dr. Ali noted that
Plaintiff's rash is 90 percent better, and her joint
symptoms were improving. Id. On examination,
Plaintiff's upper and lower extremities “show
normal ROM without pain or weakness.” Id.
April 20, 2015, Plaintiff told Dr. Ali that she does not feel
well due to pain in her back, hands, and wrists. (Tr. 381).
On examination, Plaintiff's upper and lower extremities
“show normal ROM without pain or weakness.”
13, 2015, Dr. Bambakidis noted Plaintiff was doing very well
on her Tecfidera medication with no adverse side effects.
(Tr. 361). Plaintiff had not had the blood work drawn that he
ordered. Id. Her gait had a spastic-ataxic quality.
Id. He stated overall she was relatively stable and
did not alter her medication (Tr. 362).
October 5, 2015, Dr. Ali saw Plaintiff for complaints of
lower back pain of acute onset occurring for four weeks. (Tr.
525). On examination, Plaintiff's upper and lower
extremities “show normal ROM without pain or
weakness.” Id. Dr. Ali assessed psoriatic
arthritis that was “stable and doing well” with
no synovitis and improved rash, as well as chronic sprain or
strain of lumbar region for which he recommended exercise
weight reduction. Id.
November 30, 2015, Plaintiff saw Dr. Bambakidis, who again
noted Plaintiff tolerated her medication without difficulty.
(Tr. 613). Her gait was “mild to moderately wide-based
and … similarly ataxic.” Id. She
performed rapid alternating movements of the fingers well.
January 4, 2016, Plaintiff indicated that she felt well with
no complaints. (Tr. 637). On examination, Plaintiff's
upper and lower extremities “show normal ROM without
pain or weakness.” Id.
31, 2016 visit, Dr. Bambakidis noted that Plaintiff's
symptoms were largely unchanged save for some numbness she
reported in her right hand. (Tr. 618). He gait was mildly
wide-based and mildly ataxic. Id. In summary, he
noted Plaintiff was doing well and did not alter her
21, 2016, Dr. Ali noted Plaintiff felt well with minor
complaints, specifically pain in her lower back and hips.
(Tr. 631). Her upper extremities “show[ed] normal ROM
without pain or weakness and Lower extremities show full ROM
without pain or weakness….” Id.
October 12, 2016, Plaintiff was seen by Bassam Alhaddad,
M.D., as a new patient. (Tr. 655). In his summary of
Plaintiff's “History of Present Illness, ”
Dr. Alhaddad notes Plaintiff had a history of multiple
sclerosis, was diagnosed with psoriatic arthritis and was
“[d]iagnosed with fibromyalgia.” (Tr. 655). On
rheumatological examination, Plaintiff had normal flexion and
extension of the cervical spines, unremarkable straight leg
raise test, normal bending of the lumbar spine, normal ROM in
the shoulders, normal extension of the elbows, normal ROM of
the wrists with mild tenderness on flexion/extension,
tenderness of the metacarpals despite no swelling or
synovitis, normal ROM of the hips and normal ROM of the
knees, no pain or swelling in the ankles, and no tenderness
in the feet. (Tr. 656).
November 18, 2016, Plaintiff was seen in an expedited
follow-up visit complaining of worsening symptoms of multiple
sclerosis. (Tr. 623). Dr. Bambakidis noted that Plaintiff had
mild to moderately wide-based stance, mildly ataxic gait, and
borderline rombergism. Id. In summary, he believed
Plaintiff was doing well overall, but thought it prudent to
assume that Plaintiff was experiencing a mild exacerbation,
which he treated with a short course of steroids.
November 3, 2014, Plaintiff was prescribed Xanax for anxiety
by Dr. Filiatraut, who recommended Plaintiff see a
psychiatrist due to the fact that he did not believe any
progress was being made. (Tr. 391).
February 6, 2015, Plaintiff was seen by a social worker, Joan
Meister, LISW, for complaints of helplessness, frustration,
and anxiety. (Tr. 334). She was diagnosed with agoraphobia
without a history of panic disorder. Id.
February 24, 2015, Plaintiff was seen by Amanda Davis, MSN.
(Tr. 509-517). Plaintiff reported “feeling a little bit
depressed the past month, ” being in a down mood most
of the time, frequent mood swings, feelings of worthlessness,
and irritable mood. (Tr. 509). Her last panic attack was six
months ago, but she continued to avoid public spaces and does
not like to leave home. Id.
March 17, 2015, Plaintiff reported that she noticed no change
in her anxiety symptoms, and reported a panic attack the day
before because she had to see a new family doctor. (Tr. 499).
The symptom review noted that Plaintiff had mild depressive
symptoms, mood swings, and irritability, but moderate anxiety
with weekly panic attacks as well as moderate racing
thoughts. Id. She was prescribed Xanax and Abilify,
continued on Buspar, and Klonopin was discontinued as
ineffective. (Tr. 502).
April 14, 2015, Plaintiff reported that medication helped
alleviate her symptoms and she suffered only one panic attack
the previous month. (Tr. 494). Nevertheless, she continued to
feel anxious throughout the day and did not want to leave her
house. Id. On mental status examination, she had
depressed/anxious mood and constricted affect, logical
thought process, impaired attention/concentration, average
insight, and fair judgment. (Tr. 496). Her Xanax was
increased and Abilify was discontinued due to side effects.
August 31, 2016, Plaintiff was seen by Vidya Pandit, M.D.,
who noted Plaintiff did not want to be seen by a nurse
practitioner and insisted on a psychiatrist. (Tr. 629-630).
Plaintiff reported her symptoms had not changed since her
last visit three months earlier; those symptoms include
depressed mood, crying spells, fatigue, poor concentration,
irritability, loss of interest, weight gain, poor sleep,
sense of failure, headaches, and anxiety. (Tr. 629). Dr.
Pandit assessed depression and altered her medications,
psoriatic arthritis for which she restarted Plaintiff on 800
mg of Ibuprofen three times daily, and morbid obesity for
which she recommended a healthy diet and exercise. (Tr. 630).
Medical Opinions Concerning Plaintiff's Functional
25, 2015, Doug Waltman, Ph.D., completed a Mental Status
Questionnaire. (Tr. 460-462). He indicated Plaintiff was
first seen on February 24, 2015 and last seen on July 8,
2015. (Tr. 460). Dr. Waltman indicated that Plaintiff had a
depressed and irritable mood, with constricted affect, as
well as mild depression with mood swings, moderate anxiety
and racing thoughts. Id. Dr. Waltman noted that
Plaintiff was impaired in attention and concentration, had
fair judgment, and average insight. Id. Plaintiff
had a positive response to medications but not fully
effective. (Tr. 461). He further indicated that Plaintiff was
capable of remembering, understanding, and following
instructions; her ability to maintain attention and sustain
concentration were impaired; her ability to engage in social
interaction was impaired due to anxiety; and her ability to
cope with stress was greatly impaired by her anxiety.
30, 2015, state agency physician Edmond Gardner, M.D.,
completed a physical RFC assessment finding that Plaintiff
could frequently lift/carry ten pounds, stand for two hours,
and sit for six hours in an eight-hour workday. (Tr. 113,
Exh. B3A). Further, Plaintiff could never climb
ladders/ropes/scaffolds or crawl, but could perform other
postural activities occasionally. (Tr. 114). Dr. Gardner
opined Plaintiff was limited to frequent handling and
fingering bilaterally. Id. Plaintiff also had to
avoid concentrated exposure to extreme heat and all exposure
to hazards. (Tr. 115).
August 25, 2015, state agency psychologist Karla Voyten,
Ph.D., determined that Plaintiff had mild restriction of
activities of daily living; moderate difficulties maintaining
social functioning; moderate difficulties maintaining
concentration, persistence, or pace; and no repeated episodes
of decompensation of an extended duration. (Tr. 111, Exh.
B3A). She completed a mental RFC assessment finding that
Plaintiff had no understanding and memory limitations but did
have sustained concentration and persistence limitations.
(Tr. 116). She assessed moderate limitations in the following
categories: ability to carry out detailed instructions;
ability to maintain attention and concentration for extended
periods; ability to sustain an ordinary routine without
special supervision; ability to work in coordination with or
in proximity to others without being distracted by them; and,
ability to complete a normal workday and workweek without
interruptions from psychologically based symptoms ...