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Gora v. Commissioner of Social Security

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

December 17, 2019

TERRIE GORA, Plaintiff,



         I. Introduction

         Plaintiff, 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.[1] 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 consideration.

         II. Procedural History

         On 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.

         III. Evidence

         A. Personal, Educational and Vocational Evidence

         Gora 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).

         B. Relevant Medical Evidence

         1. Physical Limitations

         On July 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).

         On 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).

         EMG 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).

         On 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).

         In 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).

         In 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. 1008).

         On 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).

         Gora 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).

         2. Mental Limitations

         Gora 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. (Tr. 561).

         In 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).

         On July 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).

         On 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).

         On 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. 584-585).

         On May 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).

         On 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).

         Treatment 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). ...

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