United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OF OPINION AND ORDER
M. PARKER MAGISTRATE JUDGE.
Terrie Gora, seeks judicial review of the final decision of
the Commissioner of Social Security, denying her application
for supplemental security income (“SSI”) under
Title XVI of the Social Security Act. This matter is before me
pursuant to 42 U.S.C. §§ 405(g) and the parties
consented to my jurisdiction under 28 U.S.C. § 636(c)
and Fed.R.Civ.P. 73. ECF Doc. 11. Because the Administrative
Law Judge (“ALJ”) failed to apply proper legal
standards and failed to build a logical bridge between the
evidence and his decision, the Commissioner's final
decision denying Gora's application for SSI must be
VACATED and Gora's case must be REMANDED for further
September 29, 2016, Gora protectively applied for SSI. (Tr.
494). Gora alleged that she became disabled on March 13, 2015
due to depression, back pain, “carpal tunnel in both
arms, ” “hernia disc, ” arthritis in back,
heart aorta valve problem, long QT syndrome, pinched nerve in
neck, asthma, bronchitis, “cist and tumor” on
right foot, spinal meningitis, narrowing of the spine, right
thumb pain, anxiety and she couldn't be around a lot of
people. (Tr. 494, 512). The Social Security Administration
denied Gora's application initially and upon
reconsideration. (Tr. 431-443). Gora requested an
administrative hearing. (Tr. 447). ALJ William Leland heard
Gora's case on March 16, 2018 and denied the claim in a
July 31, 2018, decision. (Tr. 292-377). On October 26, 2018,
the Appeals Council denied further review, rendering the
ALJ's decision the final decision of the Commissioner.
(Tr. 1-6). On December 30, 2018, Gora filed a complaint
challenging the Commissioner's decision. ECF Doc. 1.
Personal, Educational and Vocational Evidence
was born on April 15, 1968 and was 49 years old at the time
of the administrative hearing. (Tr. 494). She quit school in
seventh grade and did not obtain her GED. (Tr. 349). She had
never obtained her driver's license and had never had a
job. (Tr. 348-349).
Relevant Medical Evidence
1, 2016, Gora saw Shauna Pagel, CNP, at MetroHealth for right
elbow and arm pain that had lasted for three weeks. (Tr.
647). She saw Dr. Arjun Dhoopar on July 27, 2016 with similar
complaints. (Tr. 640-641). Dr. Dhoopar noted that an x-ray
was unremarkable. Gora reported living and caring for her
parents including lifting them because of their age. She was
not exercising. (Tr. 640). Examination showed swelling in her
right hand and forearm, more than her left, with positive
Phalen's maneuver on the right and tenderness to
palpation of her right lateral epicondyle. Dr. Dhoopar
diagnosed carpal tunnel syndrome and epicondylitis (tennis
elbow) on the right. (Tr. 642).
August 30, 2016, Gora went to urgent care complaining of
numbness and tingling in both hands and her right elbow. (Tr.
627). The doctors were concerned that the numbness and
tingling could have been caused by nerve impingement instead
of carpal tunnel/tennis elbow, so they recommended that she
undergo nerve conduction studies. They also ordered bilateral
DME splints. (Tr. 628).
testing on October 3, 2016, showed findings consistent with
carpal tunnel syndrome, “moderate on the left and mild
on the right.” There was no evidence of ulnar
neuropathy (pinched nerve in the hand and near the elbow.)
(Tr. 717). Gora continued to complain of numbness, weakness
and dropping things. (Tr. 747). Physical examination in
October 2016 was positive for Phalen's and Tinel's
signs in both hands. (Tr. 750).
November 11, 2016, Gora met with Dr. Stephen Cheng. Physical
examination showed decreased range of motion in the hands,
musculoskeletal tenderness diffusely in both hands, positive
Tinel's signs, positive Durkan's signs, as well as
mild thenar atrophy. Gora was not in “acute
distress.” Her sensory examination was grossly normal.
Dr. Cheng diagnosed bilateral carpal tunnel syndrome and
discussed treatment options. Gora declined injections because
she “does not like shots.” Dr. Cheng recommended
night splinting and an exploration of surgical remedies, for
which Gora would need “cardiac clearance before any
surgery.” (Tr. 738). On November 15, 2016, Gora met
with Dr. Dhoopar for surgical clearance. (Tr. 732). She was
given an immunization injection and treatment notes indicate
that she tolerated it well. (Tr. 735).
December 2016, x-rays of Gora's hands showed mild
degenerative disease at the base of the distal phalanxes of
both thumbs. (Tr. 754, 756). Gora reported she was taking
care of her sick mother. (Tr. 758). Examination continued to
show positive Tinel's and Durkan's signs with mild
thenar atrophy in December 2016. (Tr. 759).
September 2017, clinical nurse specialist, Ann Harrington,
conducted a “disability examination.” (Tr.
977-983). Gora reported severe neck, back, leg and hand pain
and that she had been experiencing symptoms for three years.
Ms. Harrington noted that Gora had not had any
“significant treatment” for her conditions. Gora
refused injections. (Tr. 977-978). Physical examination
showed tenderness to palpation in both the lumbar and
cervical spines, with positive sacroiliac joint, ischial and
greater tuberosity tenderness, severely reduced trunk and hip
range of motion, decreased range of motion in the neck and
mild degenerative disease in the cervical and lumbar spine
and both hands. Ms. Harrington noted normal motor strength in
Gora's upper and lower extremities. Her fine motor
coordination was also normal. (Tr. 983). Ms. Harrington
discussed with Gora that carpal tunnel surgery would
potentially help with radial four digit numbness, but was
unlikely to help with her little finger. (Tr. 978). Gora
agreed to try to attend occupational therapy and to follow-up
when she was ready for surgery. (Tr. 978-979). Gora met with
Ms. Harrington on October 26, 2017. Ms. Harrington noted that
Gora was positive for 14/18 tender points for pain. (Tr.
November 20, 2017, Gora reported to nurse practitioner,
Margaret Onyeukwu, that her carpal tunnel in both hands was
causing a lot of discomfort. She also stated that she wanted
to have surgery but did not have anyone to take care of her
mother. (Tr. 1020).
was evaluated again by Ms. Harrington on December 13, 2017.
She reported that she could not tolerate physical therapy
because it made her pain worse. (Tr. 1026). Ms. Harrington
reviewed x-rays of Gora's cervical and lumbar spine and
of her hands from August 2017. An x-ray of her lumbar spine
showed multilevel degenerative disc disease with narrowing at
¶ 3-4, facet hypertrophy L3-S1 and some sclerosis at
¶ 5-S1. An x-ray of her cervical spine showed
degenerative disc disease from C4 to C7 with foraminal
encroachment of her spinal cord at ¶ 5, C6 and C7, with
straightening of her cervical lordosis. X-rays of her hands
showed mild degenerative disease of the base of the distal
phalanxes. (Tr. 1030-1031). She was diagnosed with chronic
low back pain and wide spread neuropathic pain. Ms.
Harrington continued her prescriptions of Cymbalta and
increased her nerve pain medication, Gabapentin. (Tr. 1031).
started receiving mental health treatment in 2015. She
received regular mental health treatment throughout 2015 and
2016. (Tr. 560, 567, 573, 579, 584, 590, 595, 601, 606, 611,
616, 741). Mental status examinations during that time period
consistently documented anxiety, depression and vague
perceptual disturbances. She was prescribed multiple
medications, including: Zoloft, Clonidine, Remeron and
Klonopin. (Tr. 560). She was diagnosed with panic disorder,
major depressive disorder and post-traumatic stress disorder.
March 2015, Gora saw certified nurse specialist, Carol
Cardello. Gora reported that she had been coping well but was
still having panic attacks when around a lot of people.
Examination showed that Gora was cooperative, logical and
coherent. Though anxious, Gora's attention and
concentration were sustained. (Tr. 610-611).
10, 2015, Gora reported to Ms. Cardello that she was
“active in helping both parents” along with her
sister. (Tr. 595). She said that she had a lot on her mind
but was “stable overall.” (Tr. 595-596).
November 19, 2015, Gora reported that she was more depressed
during that appointment because she had lost her brother and
sister and was concerned about a “lack of
finances.” She stated she had run out of antidepressant
medication “a few weeks ago and is now affected by the
absence of medication.” (Tr. 590). Ms. Cardello noted
that Gora had sustained attention and concentration and a
logical and coherent thought process. Gora planned to restart
medication. (Tr. 589-590).
December 28, 2015, Ms. Cardello noted that Gora was not
consistently compliant with her medications. She reported
that she still felt depressed and anxious. She spent much of
her time with her mother and did not have much time for
herself. Ms. Cardello noted that Gora's thought process
was logical and coherent, her attention and concentration
were sustained, and her judgment and insight were fair. (Tr.
16, 2016, Gora reported that she spent “most her time
caring” for her sick mother. She was mildly anxious,
but had a logical and coherent thought process with sustained
attention and concentration. She said she heard voices, but
they were “vague and longstanding.” She reported
“going daily” to methadone meetings and
counseling. Ms. Cardello's impression was that Gora was
“still stressed but coping.” (Tr. 573).
October 21, 2016, Gora was more depressed and anxious because
her father had died. She had been very close to him and
reported difficulty coping with the loss. However, her
thought process was logical and coherent, and she had
sustained attention/concentration. (Tr. 741).
notes on January 13, 2017 state that Gora's sister had
died unexpectedly of septic shock on December 2, 2017, two
months after their father died. (Tr. 945). Mental status
examinations for January and April 2017 were the same. Gora
was noted to be anxious, depressed and continued to have
vague perceptual disturbances. (Tr. 945, 959). ...