Salisbury v. Commissioner of Social Security

CourtDistrict Court, S.D. Ohio
DecidedSeptember 4, 2020
Docket2:19-cv-05277
StatusUnknown

This text of Salisbury v. Commissioner of Social Security (Salisbury v. Commissioner of Social Security) is published on Counsel Stack Legal Research, covering District Court, S.D. Ohio primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Salisbury v. Commissioner of Social Security, (S.D. Ohio 2020).

Opinion

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

MELISHA A. SALISBURY,

Plaintiff, v. Civil Action 2:19-cv-5277 Chief Judge Algenon L. Marbley Magistrate Judge Kimberly A. Jolson

COMMISSIONER OF SOCIAL SECURITY,

Defendant.

REPORT AND RECOMMENDATION Plaintiff Melisha A. Salisbury 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”). For the reasons set forth below, it is RECOMMENDED that the Court REVERSE the Commissioner’s non-disability determination and REMAND this case for rehearing to the Commissioner and the Administrative Law Judge (“ALJ”) pursuant to Sentence Four of § 405(g). I. BACKGROUND

Plaintiff filed her applications for DIB on February 18, 2016, alleging that she became disabled on October 20, 2015, due to multiple sclerosis (MS), atrial fibrillation, and optic neuritis. (Tr. 312, 347). After her application was denied initially and on reconsideration, the ALJ held a video hearing on October 11, 2018, at which Plaintiff, represented by counsel, testified. (Tr. 199– 227, 32–67). The ALJ denied Plaintiff’s application for benefits on December 4, 2018. (Tr. 11– 24). The Appeals Council denied Plaintiff’s request for review, making the ALJ’s decision the final decision of the Commissioner. (Tr. 1–7). Plaintiff initiated this action seeking review of the Commissioner’s decision on December 2, 2019 (Doc. 3), and the Commissioner filed the administrative record on March 2, 2020 (Doc. 9). This matter is now ripe for consideration. (See Docs. 10, 11). A. Relevant Hearing Testimony

The ALJ summarized Plaintiff’s hearing testimony: The claimant was diagnosed with multiple sclerosis on the alleged onset date. She testified that the primary reason she is unable to work is “extreme fatigue.” The claimant explained that she needs to sleep after being up for two hours. She said that her daughter prepares meals and washes the dishes and her son attempts to assist with outside work. The claimant explained that her husband works so much that she still tries to mow the yard and keep up with the lawn.

The claimant testified that her children do most household chores prior to visiting friends or going out. She said she “pretty much” stayed in bed. The claimant noted that her tendency to stay in bed was due to both mental and physical challenges. She said that she enjoyed crocheting but could not do it for prolonged periods. The claimant explained that her hands cramp up.

The claimant testified that she used to enjoy fishing and hunting. She reported negative impacts on these hobbies as well. The claimant estimated that she last went hunting two years ago. Now when it gets cold, she cannot go. The claimant said that she only hunted for deer because that was the only thing she was able to eat. She was not able to recall the weight of the deer but noted that her brother-in- law assisted her in dragging it. The claimant said it was a 12-point. She last went fishing about two weeks ago. She said she either sits in the car, plays on her phone, or sits on the bank. The claimant noted that they liked to catch fish to eat them.

The claimant testified that she had been trying to remodel her home. She explained that she was doing minor things, such as painting and hole patching. Although the claimant reported that she has been working on it since last fall, she noted that they have yet to complete one room. The claimant states that she is unable to progress on the room due to fatigue.

The claimant testified that her pain and numbness had progressed to all four extremities. She estimated that it began in July 2018. The claimant noted that her physician prescribed her a handicapped placard and a cane. She noted that she was not able to walk for any distance and she had a history of falls. The claimant stated that she injured her left knee after falling. The claimant reported that she started using the cane five to six months ago.

The claimant testified that her arms get so tired that she was not even able to fix her hair. She estimated that she could not use her arms more than 30 minutes before feeling fatigued. The claimant added that she continued to have visual disturbances. She explained that she has difficulty focusing because of blurry vision. The claimant reported continued respiratory problems. Although she will be tobacco free for one year in November, the claimant said she was on 2 different inhalers. She noted that if she gets active, she becomes short of breath.

(Tr. 17–18).

B. Relevant Medical Records

The ALJ also summarized Plaintiff’s treatment history: The claimant was diagnosed with multiple sclerosis after presenting with symptoms consistent with that neurological finding, such as visual disturbance, vertigo, optic neuritis, headaches, poor balance, and intermittent pain with numbness. The claimant has also been troubled with a history of asthma and tobacco use, chronic back pain, orthostatic hypotension, left knee bursitis/partial tear and paroxysmal atrial fibrillation.

The claimant was enrolled in a clinical trial for a therapeutic drug for multiple sclerosis at OSU Eye Physicians and Surgeons in January 2016. Initially, the claimant reported constant left eye pain, intermittent vision loss in the left eye and intermittent right-sided headaches . . . .

The claimant demonstrated improvement with compliance to the clinical trial. The claimant presented to Dr. Katz in August 2016. She denied headaches, loss of vision, eye pain/irritation, redness and discharge. Dr. Katz observed no evidence of macular edema. His assessment was multiple sclerosis, examination of participant in clinical trial, encounter for therapeutic drug monitoring, subjective vision disturbance bilateral and optic neuritis of the left . . . .

The claimant is followed by Amjad Rass, MD, for primary care. Dr. Rass observed that the claimant generally appeared well. He consistently described the claimant’s motor function as “normal” and symmetrical. Dr. Rass described the claimant’s gait and station as “normal” and her sensation as “intact.” In July 2016, the claimant told Dr. Rass that she had generalized joint pain and continued to sleep a lot. The claimant complained of intermittent visual problems on the right. Dr. Rass noted that the claimant was followed for a trail [sic] study for MS patients[.] . . .

The claimant’s multiple sclerosis symptoms continued to be stable and caused at most only moderate limitations with compliance with recommended medical treatment . . . . She underwent pulmonary function testing in August 2016. Michael Rache, MD concluded that the pulmonary function study was “normal[.]”

Linda Swallie, CRNP, observed lower extremity edema on examination in March 2017. The claimant told Ms. Swallie that she had stopped smoking since November 2016. She advised the claimant to wear knee highs . . .

Dr. Racke’s treatment records consistently documents the claimant’s symptoms and impairments as no more that “mild” in severity. Often his examinations and studies showed the claimant as being “within normal limits.” The claimant’s mental status exam was within normal limits in October 2015 and April 2016. Dr. Racke observed in October 2015 that the claimant’s symptoms were currently “mild” in severity. In December 2015, Dr. Racke described the claimant’s physical exam as “within normal limits” . . .

In July 2017, Ms. Swallie reported that the claimant’s motor function was “normal” and symmetric. Her sensation was “intact.” The claimant ambulated with a “normal” gait and station. Ms. Swallie observed no drift.

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Salisbury v. Commissioner of Social Security, Counsel Stack Legal Research, https://law.counselstack.com/opinion/salisbury-v-commissioner-of-social-security-ohsd-2020.