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M.B.M.G. v. Commissioner, Social Security Administration

United States District Court, N.D. Georgia, Atlanta Division

September 3, 2019

M.B.M.G., Plaintiff,



         Plaintiff in the above-styled case brings this action pursuant to § 205(g) of the Social Security Act, 42 U.S.C. § 405(g), to obtain judicial review of the final decision of the Commissioner of the Social Security Administration which denied her disability application. For the reasons set forth below, the court ORDERS that the Commissioner's decision be AFFIRMED.

         I. Procedural History

         Plaintiff filed an application for a period of disability and disability insurance benefits on February 5, 2015, alleging that she became disabled on September 15, 2014. [Record (“R.”) at 16, 215-19]. After Plaintiff's application was denied initially and upon reconsideration, a hearing was held by an Administrative Law Judge (“ALJ”) on June 19, 2017. [R. at 16, 33-62, 78-104]. The ALJ issued a decision denying Plaintiff's claim on November 7, 2017, and the Appeals Council denied Plaintiff's request for review on May 25, 2018. [R. at 1-6, 16-27]. Plaintiff filed a complaint in this court on July 23, 2018, seeking judicial review of the final decision of the Commissioner. [Doc. 3]. The parties have consented to proceed before the undersigned Magistrate Judge.

         II. Facts

         The ALJ found that, through the date last insured, Plaintiff had the following impairments which are “severe” within the meaning of the Social Security regulations: cervical radiculopathy and ischemic heart disease. [R. at 18]. The ALJ also found that Plaintiff had the following non-severe impairments: obesity, osteoarthritis, migraine headaches, essential hypertension, and depression. [R. at 19]. Despite the presence of these impairments, the ALJ found that, through the date last insured, Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. [R. at 19-20]. The ALJ found that, through the date last insured, Plaintiff was unable to perform any of her past relevant work, however, that there were jobs that existed in significant numbers in the national economy that she could have performed. [R. at 25-26]. As a result, the ALJ concluded that Plaintiff was not under a disability from September 15, 2014, the alleged onset date, through June 30, 2017, the date last insured. [R. at 27].

         The decision of the ALJ [R. at 16-27] states the relevant facts of this case as modified herein as follows:

         The claimant is alleging disability as of September 15, 2014, due to stroke, cyst on the brain, neck problems, heart condition, hypertension, pinched nerves in the hands, thyroid, and depression. She testified that she began having headaches, described as migraines, in September 2014. She was seen at Emory Hospital and reported being told that she had a benign cyst and was prescribed medication for headaches. She denied significant relief with the medications. The claimant estimated that she had intermittent headaches approximately three days per week, lasting up to six hours at a time. The claimant related having a history of stroke, with some left-sided weakness in the left leg from the knees to the ankles and with constant swelling. She stated that she experienced shortness of breath and heart palpitations.

         The claimant estimated that she was able to walk and stand for 12 to 15 minutes due to knee problems. She stated that she had been diagnosed with arthritis. She reported that she was able to sit “ok.” The claimant stated that she had been diagnosed with carpal tunnel and estimated that she was able to lift 12 pounds occasionally due to numbness in her hands. She reported feeling easily tired when climbing stairs. As to mental health, the claimant stated that she suffered from frequent anxiety and crying due to stress. She denied receiving any mental health treatment. She reported taking medications in the past but remarked that she ran out.

         A consultative evaluation was completed on August 10, 2010, by Dianne Bennett-Johnson, M.D. The claimant complained of problems with a disc in neck and arthritis in the knees. She related that she was originally injured in 2008, undergoing right knee surgery, and that symptoms worsened after surgery. She denied arthritis in the right knee but related recently being advised of having arthritis in the left knee. She reported being rear-ended in December 2010 and subsequently experiencing radiating pain down the right side of all of the fingers on the right, with diminished grip. The claimant complained of experiencing neck pain, with difficulty sitting, but no difficulty standing. She added that she suffered from lower extremity swelling. She reported that she required assistance with brushing and combing her hair due to upper extremity issues. She also reported that she received help when taking a shower due to loss of balance. The claimant related having a low mood and added that she was recently widowed and had suffered the loss of other relatives as well. She reported having some incontinence issues with her bowels and bladder.

         On examination, the claimant was observed to be obese and fatigued; however, she did not appear to be in acute distress while sitting. She was in obvious distress on arising, complaining of neck pain, and she was unable to lie on the examination table. Blood pressure was 140/90. She weighed 260 pounds and was five feet, seven inches tall. The report reflects spasm of the neck muscles, especially on the right, tender to palpation. Cardiac examination revealed regular rate and rhythm, great 2/6 systolic murmur, absent S3 and S4, with no elevation of jugular venous pulsation or carotid bruit. There was no edema or varicosities. Musculoskeletal evaluation revealed markedly diminished extension with pain, diminished flexion of the cervical spine, lumbar flexion to 80 degrees, and complaints of neck pain. There was crepitance on palpation of the right knee, with no joint line tenderness or effusion. The claimant exhibited a normal gait and tandem walk. Sensation was noted as diminished at the fingertips on the right, with reduced grip strength on the right. There was no cyanosis, clubbing, or edema of the extremities. The claimant exhibited a depressed mood, alert and fully oriented, with otherwise normal mentation. X-ray of the right knee revealed mild degenerative medial joint space narrowing, without evidence of acute abnormality. Dr. Bennett-Johnson diagnosed the claimant with cervical radiculopathy, status/post motor vehicle accident, depression, and knee arthritis. (Exh. 5F).

         Donald Kent, Ph.D., completed a consultative psychological evaluation of the claimant on July 7, 2011. The claimant alleged problems with a disc in the neck, arthritis in the knees, and headaches. She attributed depression to difficulty coping with the deaths of her husband and her sister. She stated that she cannot sleep well. She reported being forgetful and having difficulty focusing. She denied seeking mental health treatment. Mental status examination reflects that the claimant was alert and oriented. Adequate rapport was established. Dr. Kent noted that the claimant appeared to be moderately to severely depressed. She was diagnosed with major depressive disorder, single episode, severe without psychotic features and Axis II diagnosis of estimate borderline intellectual functioning, without intelligence testing, along with Axis III diagnoses of neck injury, headaches, and arthritis by history.

         Dr. Kent opined that the claimant's ability to maintain concentration and attention to tasks was impacted by her depressed mood and that she was generally not able to follow through and complete tasks. The doctor concluded that the claimant was only capable of following simple directions and completing well-learned tasks and that she was likely a slow learner on a new job. Dr. Kent indicated that the claimant would have no particular problems regarding interaction with co-workers, supervisors, and/or the public. The doctor opined that the claimant's depressed mood would likely make it difficult to adhere to a work schedule and meet production norms. (Exh. 4F).

         An emergency room report from Emory University Hospital dated September 4, 2014, shows that the claimant presented with a headache, a history of coronary artery disease, hypertension, and anemia. She related that the headache radiated to the back of her neck and prevented sleep. She described it as an “ice cream freeze” headache. The claimant complained of neck pain but denied changes in vision, nausea, vomiting, or recent trauma. She denied chest pain, shortness of breath, numbness, or tingling. Blood pressure was 192/92, and oxygen saturation was 100 percent. The claimant was alert, in no acute distress, smiling, and laughing intermittently throughout the evaluation. There was normal range of motion of the back with normal alignment and full range of motion of the neck without pain. Cardiovascular examination was essentially normal. The musculoskeletal evaluation revealed no edema. Gait was normal, and there was no difficulty with tandem gait. Neurologically, the claimant was alert and oriented, with no focal neurological deficits.

         According to the report, the claimant complained of difficulty with balance. However, both a cerebellar test and ambulation were normal. A computerized tomography (“CT”) scan of the head showed no evidence of acute ischemic or hemorrhagic insult. There was a pineal lesion, likely representing a pineal cyst, with a referral for a magnetic resonance imaging (“MRI”). According to progress notes, it was not believed that the mass was related to headaches. Treatment notes show that the claimant ambulated to the bathroom with no difficulty and in no distress. The report shows that she felt better after medications. The claimant was diagnosed with headache and pineal mass. The report shows that the claimant remained stable with no vomiting and no complaints of headache, dizziness, or nausea. She underwent an MRI of the brain, which revealed no CT evidence of acute ischemic or hemorrhagic insult, along with a 1.0 centimeter pineal gland cyst, a normal variant, and an otherwise normal MRI of the brain. No. follow-up was necessary. (Exh. 8F).

         A discharge summary from Emory University Hospital shows that the claimant was admitted from January 3 to January 6, 2015, for complaints of leg weakness and numbness. It was noted that the claimant had a history of coronary artery disease, hypertension, congestive heart failure, anemia, and fibroids. According to the report, symptoms resolved within 15 minutes of arrival to the emergency room. A CT scan of the head showed no acute intracranial abnormality and stable pineal gland cyst. Neurological examination revealed some slight leg weakness and facial droop. An MRI revealed bilateral shattered infarcts in the occipital and temporal areas with a left vertebral occlusion and atherosclerosis in the right vertebral artery. The claimant was diagnosed with cerebrovascular accident, having posterior circulation infarcts, likely thromboembolic from atherosclerosis in the vertebral arteries, improving in lower left extremity weakness since admission. According to an echocardiogram, there was mild diastolic dysfunction and ejection fraction of 55 percent. The claimant was further diagnosed with coronary artery disease, heart failure, anemia, and hypertension. It was noted that she was non-compliant with medications at home. She was discharged in stable condition and was prescribed Aspirin, Atorvastatin, Ferrous Sulfate, Lisinopril, and Nicotine patches. Home exercises, physical therapy, occupational therapy, and rehab medicine were recommended. (Exh. 9F, pp. 8 to 10).

         A progress note from Aaron Anderson, M.D., with Emory Health, shows that the claimant was evaluated in January 2015 for follow-up of a stroke. The claimant denied any new focal neurological deficits since discharge. Her blood pressure was 154/82, and she weighed 270 pounds. Cranial nerves and motor and sensory examinations were essentially normal. Strength was full in all four extremities and her gait was stable. Deep tendon reflexes were reduced in the bilateral biceps, triceps, patellar, and ankles. Cerebellar evaluation revealed normal finger to nose to finger with rapid alternating movements and normal heel to shin testing. The claimant ...

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