Brocklesby v. Kijakazi
| Decision Date | 25 October 2021 |
| Docket Number | Civil Action 20-10113-IT |
| Parties | JOHN W. BROCKLESBY, Plaintiff, v. KILOLO KIJAKAZI, Acting Commissioner of the Social Security Administration, Defendant.[1] |
| Court | U.S. District Court — District of Massachusetts |
REPORT AND RECOMMENDATION RE: PLAINTIFF'S MOTION TO REVERSE AND REMAND TO THE SOCIAL SECURITY ADMINISTRATION (DOCKET ENTRY # 15); DEFENDANT'S MOTION TO AFFIRM THE COMMISSIONER'S DECISION (DOCKET ENTRY # 17)
Pending before this court are cross motions by the parties, plaintiff John W. Brocklesby (“plaintiff”) and defendant Kilolo Kijakazi (“Commissioner”), acting commissioner of the Social Security Administration. Plaintiff seeks to reverse and remand the decision of the Commissioner (Docket Entry # 15) whereas the Commissioner moves for an order to affirm the decision (Docket Entry # 17).
On February 2, 2018, plaintiff completed an application for disability insurance benefits (“SSDI”) (Tr 212-13).[2] Plaintiff also applied for supplemental security income (“SSI”). (Tr. 214-22). Both applications allege a disability rendering plaintiff unable to work as of June 26, 2017. (Tr. 212, 214). The Social Security Administration (“SSA”) denied both claims initially and on reconsideration. (Tr. 149, 152, 160 163).
Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”), who conducted a hearing on August 6 2019. (Tr. 63-89, 166-67). Plaintiff and a vocational expert (“VE”) testified at the hearing. (Tr. 63-89). In a decision on September 3, 2019, the ALJ concluded plaintiff was not disabled. (Tr. 33-56).
After an unsuccessful appeal, plaintiff filed this action seeking a reversal of the Commissioner's final decision or, alternatively, a remand pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). (Docket Entry # 1). After conducting a hearing on the motion to affirm and the motion to reverse or remand, this court took the motions (Docket Entry ## 15, 17) under advisement.
Plaintiff, born on February 9, 1973, was 45 years old on the date of his application for SSDI, and 46 years old on the date of his application for SSI. (Tr. 72-73, 212, 214). He has a high school diploma and completed two years of community college without obtaining a degree. (Tr. 73). He was homeless at the time of the ALJ hearing and has relevant work experience in the hardware sales department of Home Depot, operations management at Jiffy Lube, maintenance at Seasons Market, loss prevention at Best Buy, and assembly at Toys “R” Us. (Tr. 72-74). Plaintiff alleged an inability to work because of various physical and psychological conditions. (Tr. 74-84, 214).
A. Physical Conditions
1. Sjögren's Syndrome and Related Conditions
In November 2016, plaintiff underwent testing for Sjögren's syndrome, rheumatoid arthritis, and other conditions. (Tr. 408, 629-35). On May 8, 2017, plaintiff had an initial rheumatology consult with Rachel L. Gross, M.D. (“Dr. Gross”) at PMG Physicians Associates (“PMG Associates”) in Plymouth, Massachusetts due to positive antibody tests. (Tr. 464-68).
Dr. Gross took note of plaintiff's: chronic joint pain in his knees and shoulders; difficulty getting up from sitting; worsening of the pain in the cold; lack of swelling in his knees; dry mouth; dry eyes; past diagnosis of chronic obstructive pulmonary disease (“COPD”); fingers turning white and blue in the cold; and eczema. (Tr. 465). Plaintiff informed Dr. Gross that taking ibuprofen alleviates his pain. (Tr. 44, 465). She explained the issues associated with Sjögren's syndrome and manifestations of the condition. (Tr. 464). She also noted plaintiff's history of celiac disease and recommended a gluten-free diet. (Tr. 464-65). On examination, Dr. Gross documented a “normal range of motion and strength in all joints” and a normal gait. (Tr. 44, 467). Her office notes reflect a body mass index (“BMI”) of 17.61 and a weight of 133 pounds.[3] (Tr. 466).
After being hospitalized at Beth Israel Deaconess in Plymouth, Massachusetts on June 24, 2017, for fever, rash, nausea, vomiting, acute renal failure, lethargy, “tea colored urine, ” and sneezing, plaintiff was diagnosed with and treated for: right lower lobe pneumonia; hand, foot, and mouth disease; nephrotic syndrome; acute renal failure; and membranous glomerulonephritis. (Tr. 403, 405, 408-09, 429). Testing showed abnormalities in kidney and liver function, including a kidney biopsy with the diagnosis of membranous glomerulonephritis in a pathology report. (Tr. 396, 401-406). A June 24, 2017 chest X-ray revealed a “small pleural effusion” at the base of the right lung associated with “basilar airspace disease, ” as noted by the ALJ. (Tr. 50, 402, 981). A discharge summary reflects plaintiff's diagnosis of mononucleosis two days prior to his admission. (Tr. 408). It also recites that plaintiff “understands the plan of care to follow up closely with . . . Dr. [Panagiotis] Vlagopoulous of nephrology” and call his office for an appointment. (Tr. 410, 416). The symptoms of fever and acute renal failure resolved prior to plaintiff's discharge, and the rash was in the process of resolving at the time of discharge on or about July 3, 2017. (Tr. 409-416).
On September 18, 2017, plaintiff had a follow-up appointment with Peter M. McIver, M.D. (“Dr. McIver”), during which plaintiff reported joint pain but was otherwise feeling better. (Tr. 549). Despite being thin and weighing 126 pounds, the examination of plaintiff's mouth, eyes, pulmonary function, abdomen, and range of motion were normal, and plaintiff was in no acute distress. (Tr. 549, 551).
On September 28, 2017, Dr. Gross examined plaintiff and took note of his hospitalization in June 2017. (Tr. 458).
Plaintiff denied fever and shortness of breath but did report dry mouth, dry eyes, fatigue (as noted by the ALJ), arthralgia, and left leg pain. (Tr. 45, 458-59). On examination, plaintiff appeared to be in no acute distress, had normal eyes, a dry mouth, normal pulmonary function, no swelling in the joints, a normal range of motion, and normal coordination. (Tr. 460). Dr. Gross noted that plaintiff continued to be underweight at 127 pounds, had a normal pulse oximeter reading of 98%, and was purchasing Ensure to supplement his meals and gain weight but had stopped because he could no longer afford it. (Tr. 458-60). During this same visit, Dr. Gross noted that “Sjogrens is possible” and prescribed Plaquenil and low dose prednisone “[f]or his Sjogrens.” (Tr. 458, 461). Her office notes for the visit as well as subsequent visits reflect that plaintiff did not follow up with nephrology, as instructed, which the ALJ also noted. (Tr. 45, 46, 50, 442, 458, 973).
On December 22, 2017, plaintiff saw Dr. McIver complaining of fever, chills, vomiting, and a runny nose. (Tr. 537-38). On examination, plaintiff exhibited normal pulmonary effort and normal breath sounds with “no wheezes” or rales. (Tr. 541). Dr. McIver diagnosed plaintiff with a viral upper respiratory infection and recommended plaintiff use cough medicine and “drink plenty of fluids.” (Tr. 541).
On February 21, 2018, plaintiff reported to Dr. Gross that his joint pain had resolved, and he had no fever, no chest pain, and no shortness of breath. (Tr. 452, 454). Dr. Gross' office notes do not indicate that plaintiff reported experiencing fatigue. On examination, Dr. Gross documented: a normal pulse oximeter of 98%; a dry mouth; normal eyes; normal pulmonary effort and breath sounds; a normal range of motion in plaintiff's joints; and normal strength in plaintiff's joints. (Tr. 454). She continued plaintiff's prescription for Plaquenil, restarted plaintiff on low dose prednisone, and noted his kidney function could “be followed with observation” if urine studies remained stable. (Tr. 454-55).
On June 14, 2018, plaintiff had another appointment with Dr. Gross. (Tr. 445). Plaintiff reported knee pain “[m]ostly in his left knee, ” “riding his bike a lot” (as noted by the ALJ), and experiencing more shortness of breath with exercise. (Tr. 46, 446). On examination, Dr. Gross noted a weight of 131 pounds, a BMI of 17.28, a dry mouth, normal eyes, normal pulmonary effort, normal breath sounds, no swelling, no fever, normal range of motion, normal coordination, dyspnea on exertion, keratoconjunctivitis sicca, membranous glomerulonephritis, and acute pain of the left knee. (Tr. 445-48, 454).
On June 18, 2018, X-rays of plaintiff's knees showed a “[s]light narrowing . . . at the medial compartments of both knee joints suggesting mild degenerative change.” (Tr. 395). On June 27, 2018, plaintiff complained of dry and itchy eyes at an eye examination with ophthalmologist Kimberly Hsu, M.D. (“Dr. Hsu”). (Tr. 1340). During the same appointment, Dr. Hsu inserted plugs into plaintiff's eyelids to address the dry eye issue. (Tr. 1340). Plaintiff reported some improvement to his dry and itchy eyes six weeks later on August 8, 2018. (Tr. 1339).
On July 30, 2018, plaintiff underwent pulmonary function testing ordered by Dr. Gross. (Tr. 1107-08). The pulmonary function report suggested “primary restrictive pathophysiology” and stated that clinical correlation would be required. (Tr. 1107).
On August 13, 2018, plaintiff had an annual exam with his primary care provider, William G. Griever, M.D. (“Dr Griever”), who found plaintiff negative for chest tightness, shortness of breath, gastrointestinal problems, genitourinary symptoms, numbness, and decreased concentration. (Tr. 510-12). However, plaintiff did present with mild effusion in his left knee, pain in both knees, and arthralgia in the left knee, “shoulder[, ] and left elbow.” (Tr. 511-12,...
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