Wallace v. Comm'r of Soc. Sec., Case No. 2:16-cv-316
| Decision Date | 03 March 2017 |
| Docket Number | Case No. 2:16-cv-316 |
| Parties | Rochelle L. Wallace, Plaintiff, v. Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Southern District of Ohio |
Plaintiff, Rochelle L. Wallace, filed this action seeking review of a decision of the Commissioner of Social Security denying her applications for disability insurance benefits and supplemental security income. Those applications were filed on December 20, 2012, and alleged that Plaintiff became disabled on February 1, 2012.
After initial administrative denials of her claim, Plaintiff was given a hearing before an Administrative Law Judge on January 26, 2015. In a decision dated March 11, 2015, the ALJ denied benefits. That became the Commissioner's final decision on February 22, 2016, when the Appeals Council denied review.
After Plaintiff filed this case, the Commissioner filed the administrative record on June 20, 2016. Plaintiff filed a statement of errors on August 8, 2016, to which the Commissioner responded on November 17, 2016. Plaintiff filed a reply brief on December 5, 2016, and the case is now ready to decide.
Plaintiff, who was 44 years old as of the date of the hearing and who has a twelfth grade education and also went to cosmetology school, testified as follows. Her testimony appears at pages 42-65 of the administrative record.
After describing her current living situation - Plaintiff lived with her father and her two teenaged children - Plaintiff was asked about her work history. She said she had last worked in 2012 as a self-employed hair stylist. Before that, she worked for a company that made circuit boards, but quit that job to go to school full-time. She had also been an engraver and had unloaded freight at a J.C. Penney store. Lastly, she had worked for a spark plug manufacturer as an inspector and as a cashier at a Family Dollar store.
When asked why she could no longer work, Plaintiff said that she had pain on a daily basis which affected her knees, hips, and hands. She was also short of breath and had become depressed due to being unable to work or care for her family. She took Prednisone every day and also got a Remicade infusion every five weeks, a procedure which took close to three hours and which left her exhausted for several days afterward. She recently had surgery on her hand and elbow.
On a typical day, Plaintiff got up at 9:00 or 10:00, put drops in her eyes, and got dressed. Sometimes she visited her mother, but mostly she watched television or went to medical appointments. She said, in response to questions from her counsel, that she was diagnosed with sarcoidosis in 2012 and that she took multiple medications for that condition. Also, as she got closer to the days on which she received her infusion, her joints would become very sore and her activities were limited. Plaintiff also suffered fatigue from the Methotrexate which she took every Monday. Her eyes were sensitive to light and she used drops to combat dryness. Finally, she described bad headaches which occurred on a monthly basis and which lasted two or threedays.
The pertinent medical records are found beginning at page 293 of the administrative record. They can be summarized as follows.
Chronologically, the first record of significance concerning Plaintiff's physical impairments is a questionnaire completed by Dr. Kaswinkel. He said that he had treated Plaintiff from May 11, 2012 to June 8, 2012 and that she had been diagnosed with sarcoidosis, Sjogrens syndrome (an immune system disorder), and ischemic retinopathy. Her symptoms included headaches, swollen eyes, light sensitivity, floaters, painful eyes, and crusting. She had been on Prednisone. She had also not returned for a December, 2012 appointment. He said he could re-evaluate her if she returned, and that she was functionally limited due to her sensitivity to light. (Tr. 344-45).
Continuing with the history of Plaintiff's physical health, the next group of records which she discusses in her statement of errors are treatment notes from Dr. Lake, who was a consulting rheumatologist. Dr. Lake saw Plaintiff on December 12, 2012 for various conditions including sarcoidosis. At that time, Plaintiff was being given Remicade infusions. She was tolerating the procedure but not noting any significant improvement. She reported some slight blurring of her vision as well. Also, she had acute right ankle pain and swelling. (Tr. 584-85). Prior treatment notes show the same diagnoses and treatment with prednisone before the Remicade infusions were approved, and symptoms such as headaches, shortness of breath, chest pain, and discomfort in the back, hips, knees and ankles. (Tr. 586-91). Dr. Lake continued to see Plaintiff in 2013, reporting on March 21 of that year that Plaintiff still had significant pain despitetaking both Remicade and methotrexate. Her areas of discomfort included her hands, wrists, ankles, knees, and hips. She demonstrated discomfort to slight touch throughout the hands and arms as well as in the lower extremities. Dr. Lake suggested that there might be a myofascial component to the pain, and started her on Cymbalta. The next report, dated May 29, 2013, stated that Plaintiff was getting day-long headaches several times per week and was still having significant pain in her hands and wrists, with somewhat lesser pain in her knees and hips. She also experienced some swelling in her legs as well as fatigue. Her Remicade infusions had been increased in frequency but Dr. Lake said that if she did not improve, the frequency could be increased again. (Tr. 727-30).
When Dr. Lake saw Plaintiff again in August, 2013 she was much the same, although she reported increasing shortness of breath. (Tr. 881-82). Dr. Lake saw Plaintiff again on March 26, 2014, at which point Plaintiff was put back on methotrexate (which had been discontinued) due to continued pain in her joints. She demonstrated diffuse pain but particularly in the hips, knees, and ankles. The frequency of her Remicade infusions was increased. Plaintiff returned to Dr. Lake in July, 2014, at which time she reported improvement in her joint pain, but still had significant problems in her hands. She had taken a trip to Florida and the Dominican Republic. Dr. Lake increased the amount of Neurontin she was prescribing. (Tr. 976-981).
Dr. Lake was subsequently asked to respond in writing to a question about whether Plaintiff's illness would cause her to miss two or more days of work per month. Dr. Lake said that such absences were likely due to flare-ups of Plaintiff's underlying disease (described in the question as "sarcoidosis and or rheumatoid arthritis") which could cause joint pain, vision changes, skin rash, shortness of breath, and chest pain, amongother side effects. (Tr. 1011).
Plaintiff also received treatment for her sarcoidosis from Dr. Baughman. He first saw her on June 8, 2012, noting that Plaintiff had been reporting breathing problems for many years. She was treated for asthma but got markedly worse in February of 2012. That exacerbation was treated with prednisone, and she told Dr. Baughman that her main problem was now headaches. He reviewed various diagnostic studies which showed some lung abnormalities and concluded that Plaintiff had sarcoidosis. He suggested Remicade infusions as one possible treatment option. On October 12, 2012, Dr. Baughman reported to Dr. Lake that Plaintiff was about the same as the last time he saw her. His next report, dated April 9, 2013, indicates that Plaintiff was still having a problem with aching joints "pretty much all the time." Dr. Baughman believed that this symptom was related to the sarcoidosis and he suggested increasing the frequency of her Remicade infusions. (Tr. 669-680). He saw Plaintiff again in July, 2014, noting that Plaintiff was doing fairly well with her medications but still had problems with her joints, including being able to retract her hands. (Tr. 1023-24).
Turning now to Plaintiff's mental health history, Plaintiff underwent a diagnostic assessment in 2012 at North Central Mental Health Services. In a report dated July 2, 2012, the counselor noted that Plaintiff was having trouble sleeping and had decreased appetite, experienced crying spells, and was depressed three or four days per week. She had lost interest in activities and had poor short-term memory. Her mood and affect were described as "clearly depressed" and Plaintiff said she had difficulty getting out of bed. She was diagnosed with a depressive disorder and her GAF was rated at 50. It was recommended that she continue to follow up with her regulardoctor and take all of her medications as prescribed. (Tr. 350-58).
There are also counseling notes from North Central. They appear to begin in October, 2013 and indicate diagnoses of anxiety and depression. The notes show generally that Plaintiff was upset about her physical impairments and that she also had some family stressors. Her chronic pain negatively impacted her mood. She was taking thirteen different medications and going to medical appointments several times per week. She was receiving medication from a psychiatric nurse practitioner. At one point, she reported improvement of her symptoms with Risperdal, and her mood had stabilized to the point where she was enjoying activities. In 2014, she began a relationship which turned out to be stressful, but in June of that year she said that her sleep and appetite were satisfactory although her energy level was slightly low. She also canceled a number of appointments between October, 2013 and August, 2014. (Tr. 900-44). At an appointment in September, 2014, she said she was feeling depressed but admitted to not taking all of her medications as prescribed. Plaintiff...
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