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Maki v. Commissioner of Social Security

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

July 15, 2019





         Plaintiff Joanne Marie Maki (“Plaintiff”) filed a Complaint against the Commissioner of Social Security (“Commissioner”) seeking judicial review of the Commissioner's decision to deny disability insurance benefits (“DIB”). (Doc. 1). The district court has jurisdiction under 42 U.S.C. §§ 1383(c) and 405(g). The parties consented to the undersigned's exercise of jurisdiction in accordance with 28 U.S.C. § 636(c) and Civil Rule 73. (Doc. 12). For the reasons stated below, the undersigned reverses the decision of the Commissioner and remands for further proceedings consistent with this opinion.

         Procedural Background

         Plaintiff filed for DIB in September 2015, alleging a disability onset date of April 23, 2015. (Tr. 267-68).[1] Her claims were denied initially and upon reconsideration. (Tr. 212-15, 219-21). Plaintiff then requested a hearing before an administrative law judge (“ALJ”). (Tr. 226-27). Plaintiff (represented by counsel), and a vocational expert (“VE”) testified at a hearing before the ALJ on June 16, 2017. (Tr. 139-81). On November 27, 2017, the ALJ found Plaintiff not disabled in a written decision. (Tr. 10-21). The Appeals Council denied Plaintiff's request for review, making the hearing decision the final decision of the Commissioner. (Tr. 1-6); see 20 C.F.R. §§ 404.955, 404.981. Plaintiff timely filed the instant action on April 9, 2018. (Doc. 1).

         Factual Background[2]

         Personal Background and Testimony

         Born in May 1957, Plaintiff was 58 years old on her amended alleged onset date, and 60 at the time of the ALJ hearing. See Tr. 149, 267. She had an associate's degree in accounting and business management (Tr. 149), and past work as a job costing clerk and cost estimator (Tr. 167-68).

         At the time of the hearing, Plaintiff lived with her husband. (Tr. 148-49). Plaintiff testified she was fired from her prior job “after months of coming in late” two to three times per week. (Tr. 151). She also took leave due to her irritable bowel syndrome (“IBS”) and asthma. Id. Plaintiff believed she was unable to work due to the fact that stress caused her IBS to flare up, as well as asthma and anxiety. (Tr. 152).

         Plaintiff testified to IBS flare-ups at least once or twice per week; she took dicyclomine. (Tr. 156). Her IBS was better since being off work “[b]ecause the stress level[] [is] gone”. Id.

         Plaintiff also testified to difficulty getting along with coworkers and authority figures, in part because she was nervous speaking to others. (Tr. 157). Plaintiff specifically had difficulty with two co-workers, and one supervisor at her last job. (Tr. 157-58). However, she “got along fine” with a previous supervisor. (Tr. 161). Plaintiff also cried at work, and got in trouble for not finishing tasks. (Tr. 161-62). Toward the end of her employment, Plaintiff was “constantly worried about whether [she] was going to lose [her] job under new management or [due to the] health issues [she] was experiencing.” (Tr. 162).

         She was able to interact with her family members, but had some difficulty with her twin sister. (Tr. 158-59). She also stayed in touch with friends, but did not belong to any clubs or organizations. (Tr. 159).

         Relevant Medical Evidence Physical

         Prior to her alleged onset date, in January 2013, Plaintiff went to North Shore Gastroenterology due to abdominal pain, gas, and diarrhea. (Tr. 386). Plaintiff reported an October 2012 emergency room visit for diarrhea and vomiting, and a negative CT scan. Id. Plaintiff ultimately underwent surgery and had her gallbladder and appendix removed. Id. Plaintiff was instructed to proceed with a colonoscopy with biopsy. (Tr. 386-87).

         In June 2014, Plaintiff went to University Hospitals Elyria Medical Center with right-sided “crampy” abdominal pain. See Tr. 484-500. Plaintiff was prescribed Percocet and Phenergan (Tr. 488), and diagnosed with diarrhea on discharge (Tr. 497). At an appointment later that month, Plaintiff reported severe diarrhea with over ten stools one morning. (Tr. 708).

         In March 2015, Plaintiff told a provider that she had been doing well until recently when her cramping abdominal pain recurred. (Tr. 705). She reported alternating diarrhea and constipation. Id. The provider prescribed a trial of Bentyl to treat possible bowel spasm. (Tr. 707). That same month Plaintiff underwent a CT enterography due to diverticulitis, generalized abdominal pain, diarrhea, and IBS. (Tr. 401). It revealed diffuse bowel wall thickening and diverticulosis of the sigmoid colon without evidence of acute diverticulitis. (Tr. 403).

         A May 2015 small bowel series showed rapid small bowel transit time, and an unremarkable appearance of the small bowel with no significant residual bowel wall thickening or edema corresponding to the region of abnormality detected on the CT. (Tr. 396-97). At a follow up visit later that month, Plaintiff was noted to have “occasional crampy pain in low abdomen followed by diarrhea”. (Tr. 571). Her medications were helpful, and the diarrhea resolved on its own. Id. The provider also noted Plaintiff “ha[d] many days of normal solid stool as well.” Id. On examination, Plaintiff had a normal abdominal examination. (Tr. 572). The provider noted Plaintiff was “[c]urrently doing well” and “currently stable on fiber and [B]entyl.” (Tr. 573).

         In November 2015, Plaintiff reported three to four “formed to loose stools” daily, and “some right lower quadrant crampy pain from time to time . . . but [it] is not severe and does not travel.” (Tr. 675). She noted the pain improved with Bentyl. Id. Plaintiff denied abdominal pain, constipation, diarrhea, indigestion, nausea and vomiting; on examination, she had normal bowel sounds and her abdomen was soft and not tender. (Tr. 676). The provider noted Plaintiff was “[c]urrently doing well and actually much better [since] she has been away from her job, which was quite stressful for her.” (Tr. 677).

         Plaintiff made similar statements and the provider noted similar findings in December. (Tr. 717). The provider noted Plaintiff's “crampy pain” was improved on dicyclomine, and he increased her dosage. (Tr. 719). Plaintiff reported increased stress after losing her job and having her house remodeled. Id.

         Also in December 2015, Plaintiff told a consultative psychologist that she had abdominal cramping and bowel urgency and went to the bathroom seven to eight times per day. (Tr. 680). She always used the bathroom before leaving the house and had to know where a bathroom was when she was out. Id. Plaintiff also reported cramping and diarrhea with anxiety. (Tr. 681).

         At a January 2016 mental health visit, Plaintiff reported she did not think she could work due to her IBS. (Tr. 562).

         At an appointment in August 2016, Plaintiff reported diarrhea, heartburn, and indigestion, but denied abdominal pain, constipation, nausea, or vomiting. (Tr. 891). Plaintiff reported symptoms “approximately once or twice weekly that last for a day” including crampy abdominal pain followed by urgent diarrhea. (Tr. 892). She described two to four “formed to loose” stools daily and noted her symptoms could be improved within the day with medication. Id. The provider noted Plaintiff had IBS which was “now stable with [approximately] 2 days a week where she may have episodes of crampy pain, diarrhea, improve[d] with Bentyl and dicyclomine”. (Tr. 894)

         Opinion Evidence

         In December 2015, State agency physician Steven McKee, M.D., reviewed Plaintiff's records and opined Plaintiff could: occasionally lift and/or carry twenty pounds; frequently lift and/or carry ten pounds; stand and/or walk a total of about six hours in an eight-hour workday; sit about six hours in an eight-hour workday; and occasionally climb ramps, stairs, ladders, ropes, or scaffolds. (Tr. 193-94).

         In March 2016, State agency physician Gerald Klyop, M.D., offered an identical opinion, with an added restriction to avoid concentrated exposure to pulmonary irritants. (Tr. 208-09).


         Records from the Far West Center in August 2015 show Plaintiff was diagnosed with an adjustment disorder with depressed mood, and assigned a Global Assessment of Functioning (“GAF”) score of 55[3]. (Tr. 515). She reported a recent job loss with subsequent feelings of anxiety and depression. (Tr. 516). Plaintiff reported anxiety triggered by problems, particularly financial ones. (Tr. 517). On examination, she had a frustrated mood, broad affect, normal speech, ruminating thought process, good memory, fair concentration, and excessively talkative behavior. (Tr. 516); see also Tr. 522. Plaintiff was angry about her previous employer and how her complaints were handled. (Tr. 517). She self-reported a depressed mood, loss of appetite, fatigue, and low motivation. Id. She stated she was “extremely nervous”, with mood ...

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