Albert v. Commissioner of Social Security

District Court, S.D. Ohio·Decided November 3, 2023·No. 2:23-cv-01238·Unknown

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO EASTERN DIVISION

KRISNEY A.,

Plaintiff, v. Civil Action 2:23-cv-1238 Judge Sarah D. Morrison Magistrate Judge Kimberly A. Jolson

COMMISSIONER OF SOCIAL SECURITY,

Defendant.

REPORT AND RECOMMENDATION Plaintiff, Krisney A., brings this action under 42 U.S.C. § 405(g) seeking review of a final decision of the Commissioner of Social Security (“Commissioner”) denying her applications for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”). For the following reasons, it is RECOMMENDED that the Court OVERRULE Plaintiff’s Statement of Errors and AFFIRM the Commissioner’s decision. I. BACKGROUND In December 2020, Plaintiff protectively applied for DIB and SSI, alleging that she was disabled beginning April 25, 2020, due to ADHD (attention deficit hyperactivity disorder), fibromyalgia, fatty liver, chronic liver, PCOS (polycystic ovary syndrome), GERD (gastroesophageal reflux disease), sleep apnea, asthma, plantar fasciitis, and “lympoma” on her brain. (R. at 302–15, 370). After her applications were denied initially and on reconsideration, the Administrative Law Judge (the “ALJ”) held a hearing. (R. at 36–78). Ultimately, the ALJ denied Plaintiff’s applications in a written decision on April 27, 2022. (R. at 13–35). When the Appeals Council denied review, that denial became the Commissioner’s final decision. (R. at 1– 7). Next, Plaintiff brought this action. (Doc. 1). As required, the Commissioner filed the administrative record, and the matter has been fully briefed and is ripe for review. (Docs. 7, 10, 11, 12). A. Relevant Hearing Testimony The ALJ summarized Plaintiff’s hearing testimony as follows:

[Plaintiff] testified that she is unable to work due to problems with the right wrist, including constant pain, swelling, and numbness, with dropping of items she is trying to hold. [Plaintiff] also endorsed daily nausea and vomiting, albeit with some days better than others, in addition to migraine headaches which cause light and sound sensitivity, dizziness, and nausea. During migraines, [Plaintiff] will sleep in a dark room, noting that headaches can last for between four hours to a whole day. She stated she takes as needed medications for her migraines, using them about three times per week. She also reported asthma symptoms with use of an inhaler, with exacerbations related to cold, heat, and walk for 20 minutes. She also noted nausea and shaking due to her diabetes. [Plaintiff] reported diarrhea and dizziness from her medications, specifically Metformin.

[Plaintiff] endorsed experiencing anger and mood issues often, as well as depression and crying spells, with sleep disturbance due to stress and her medical problems. She stated she used oxygen during her sleep for four years but that she stopped using it as it was making her sick. She stated she has no concentration ability and that she has someone constantly telling her to focus. She indicated she does not like interacting with others and gets anxious or angry in those situations.

During a typical day, [Plaintiff] reported poor energy, but is still able to work part time at Kroger, between 9-12 hours per week. [Plaintiff] indicated she is able to read a newspaper or job application with help, can complete a job application with help, is able to read a magazine with help with some words, and has help from her mother in managing her bank account. [Plaintiff] stated she lives with her parents because his is unable to live alone as she forgets to shower, eat, take medications, attend doctors’ appointments, and required help for rides.

(R. at 23).

B. Relevant Medical History The ALJ summarized Plaintiff’s medical records as to her relevant physical impairments as follows: Emergency department notes on April 26, 2020, showed complaints of left lower leg pain in the context of a morbidly obese body habitus (Exhibit 2F, pages 94-95). Physical examination as notable for a BMI of 49.7, elevated blood pressure, a steady gait, 5/5 lower extremity strength, with pain with light palpation and stroking of the left lower leg (Exhibit 2F, pages 96-97). [Plaintiff] was treated symptomatically, with nerve irritation suspected, and crutches provided to help with ambulation (Exhibit 2F, page 95).

Neurology notes in January 2021, showed [Plaintiff] with a history of lipoma of the brain, with headaches and nausea and vomiting (Exhibit 11F, pages 10). Physical examination was notable for a BMI of 50.5, 5/5 muscle strength with the exception of an untested right arm due to a recent fall, normal motor bulk and tone, and a normal gait (Exhibit 11F, pages 14-15). Prior brain images were discussed with [Plaintiff]’s lipoma assessed as tiny and likely of no clinical significance (Exhibit 11F, page 16). [Plaintiff] was ordered to undergo evaluative tilt table testing as well as endocrinology assessment for further work up (Exhibit 11F, page 16).

Endocrinology notes in January 2021, showed [Plaintiff] was evaluated for weight gain, with physical examination notable for a BMI of 50.05, unremarkable breath sounds, and was otherwise unremarkable (Exhibit 12F, pages 81-82). [Plaintiff] was advised to restart Phentermine (Exhibit 12F, pages 77). In a physical therapy note in the same month, [Plaintiff] was noted has having left knee pain, waiting on a new brace, and having not attended physical therapy in over a month due to work and an alleged fall (Exhibit 12F, page 84). Records showed [Plaintiff] had only attended two visits since November 2020, but despite her inconsistent attended indicated she had approximately 40% improvement in knee pain (Exhibit 12F, page 85). Improved attendance and compliance was counseled (Exhibit 12F, page 85). Unfortunately, [Plaintiff] was discharged after only four total visits and last being seen on January 12, 2021, due to inactivity (Exhibit 12F, page 89).

On March 8, 2021, [Plaintiff] underwent a medical consultative evaluation with Mark Weaver, M.D., alleging disability due to fibromyalgia, asthma, left knee and right wrist problems, obstructive sleep apnea, foot problems, abdominal problems, and mental difficulties (Exhibit 5F, page 2). [Plaintiff] was noted as a poor medical historian, noting no treatment for fibromyalgia symptoms, no use of any assistive devices for ambulation but intermittent use of a left knee brace, use of an Albuterol inhaler, and a history of orthotic use (Exhibit 5F, page 3). Physical examination was notable for a calculated BMI of 48.3 based on a height of 6 feet 2 inches and weight of 376 pounds; ambulation with a stiffened gait and left limp with complaints of low back and left knee pain; slight shortness of breath and some fatigue after walking 40 feet up and down the hallway; a few scattered wheezes on lung auscultation; ½ inch atrophy of the left lower extremity; give way weakness in the right wrist and hand with wrist pain inhibition; left knee joint pain inhibition; restricted motion in both shoulders, in the right wrist, and left knee; some swelling and tenderness over the dorsal right wrist joint; and tenderness to palpation over the medial left knee and patella with mild anterior-posterior laxity in drawer testing noted and the sub-patella crepitus to palpation on active motions (Exhibit 5F, pages 4-6, 9-13). Dr. Weaver also noted several tender trigger points greater than 11 out of 18 in total; bilateral plantar foot tenderness to palpation; and constant mild involuntary spasm to inspection and palpation of the lower cervical, upper thoracic trapezius muscle area and lumbar paravertebral muscle region (Exhibit 5F, page 6). Dr.

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Albert v. Commissioner of Social Security, (S.D. Ohio 2023).

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