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Rodriguez v. Colvin

United States District Court, E.D. Pennsylvania

March 23, 2018

CAROLYN W. COLVIN, Acting Commissioner of Social Security Defendant.


          Jones, II J.

         I. Introduction

         Plaintiff commenced the within action after being denied Supplemental Social Security Income Benefits and Disability Insurance Benefits. Upon review by United States Magistrate Judge Jacob P. Hart, a Report and Recommendation (R&R) was issued affirming the Administrative Law Judge's (ALJ) denial of said benefits. Plaintiff has filed objections to the R&R, which are now before this Court for review. For the reasons set forth below, Plaintiffs objections shall be granted and the matter shall be remanded to the Commission of the Social Security Administration for further proceedings.

         II. Background

         A. Procedural History

         On September 9, 2013, Plaintiff submitted applications for Disability Insurance Benefits and for Supplemental Security Income, in which she alleged disability beginning July 4, 2013. (Admin. R. 220, 227.) Said applications were initially denied on February 19, 2014. (Admin. R. 104, 109.) Plaintiff filed a written request for a hearing on the decision on April 17, 2014, which was held via video on September 23, 2014 and presided over by ALJ Lawrence J. Neary. (Admin. R. 113.) On December 2, 2014, ALJ Neary issued an unfavorable decision regarding Plaintiffs claims. (Admin. R. 19.) On January 28, 2015, Plaintiff filed a Request for Review of the ALJ's determination, which was denied by the Appeals Council on June 21, 2016. (Admin. R. 17.) As such, Plaintiff commenced the above-captioned action on December 12, 2016. Upon completion of briefing, this matter was referred to United States Magistrate Judge Jacob P. Hart for preparation of a Report and Recommendation. Judge Hart ultimately determined that Plaintiffs request for relief should be denied. Plaintiff filed timely objections to Judge Hart's R&R, which are now before this Court for consideration.

         B. Factual History

         As of the date of her administrative hearing on September 23, 2014, Plaintiff was 50 years old. (Admin. R. 49.) According to Plaintiffs testimony, she had not engaged in any work for pay or profit since July 4, 2013. (Admin. R. 51.) Prior to that time, Plaintiff was employed as a part time taxi dispatcher, a fast food worker at McDonald's, and a pie line worker at Sweet Street. (Admin. R. 51.)

         On July 22, 2012, Plaintiff was admitted to Reading Hospital and Medical Center, and was diagnosed with dental abscess and dental pain. (Admin. R. 312.) Plaintiff was prescribed several medications for the pain and discharged the same day. (Admin. R. 312.) Prior to the discharge, Plaintiff indicated that she was not "under the influence of drugs/alcohol, " that she had "no history of substance abuse, " and that she had "no unresolved social issues." (Admin. R. 311.) Plaintiff was advised to "[f]ollow up with Primary Care Physician as needed, Follow up with Specialist within 1 week." (Admin. R. 313.)

         Approximately five months later-November 16, 2012- Plaintiff returned to the hospital complaining of chest pain. (Admin. R. 314.) Plaintiff was diagnosed with acute bronchitis, acute sinusitis, and asthma. (Admin. R. 320.) Prior to discharge, Plaintiff again indicated that she was not "under the influence of drugs/alcohol, " that she had "no history of substance abuse[, ]" and that she had "no unresolved social issues." (Admin. R. 317.) Upon discharge, Plaintiff was prescribed several medications, was given the number for the Berks Community Health Center with instructions to schedule an appointment, and was told to come back to the emergency room if her condition worsened. (Admin. R. 321.)

         From September 6, 2012 to August 1, 2013, Plaintiff received treatment at the Berks Community Health Center, where she was attended to by Dr. Ajay Jani and Nurse Practitioner Cindy Schmeltz. (Admin. R. 412, 414, 422.) On March 19, 2013, Plaintiff called the Berks Community Health Center sick line and talked to Veronica Diaz. (Admin. R. 414.) Plaintiff stated that she had "been experiencing left sided numbness to arm extended down towards leg, " that the pain had been going on for days, and that one side was weaker than the other. (Admin. R. 414.) On March 26, 2013, Plaintiff again met with Nurse Schmeltz (Admin. R. 415.) During this visit, Plaintiff complained of- among other things-sharp pain on her left side, which she rated as "seven" on a scale of one to ten, "one" being the least painful. (Admin. R. 415.) Nurse Schmeltz noted that the patient occasionally used marijuana-a potential risk factor. (Admin. R. 417.) On April 4, 2013, an x-ray report from St. Joseph's Medical Center[1] indicated that Plaintiff suffered from "cervical spine degenerative disease C5-C6" and that "there is encroachment upon neural foramina bilaterally." (Admin. R. 422.)

         During the course of her treatment at Berks, Nurse Schmeltz indicated that Plaintiff "suffered a TIA and has some difficulties in her speech, thinking, motor control and gait." (Admin. R. 395.) Nurse Schmeltz also stated that "it is recommended at this time, that she not be working to allow her to go to the necessary therapies for her to regain function." (Admin. R. 395.) On her Employability Assessment Form, Nurse Schmeltz indicated that Plaintiff was temporarily disabled and that the temporary disability began August 1, 2013 and was expected to last until December 1, 2014. (Admin. R. 404.)

         On July 5, 2013, Plaintiff was admitted to Reading Hospital and was diagnosed with a generalized seizure, as well as numbness and tingling. (Admin. R. 441.) On July 16, 2013, Plaintiff again met with Nurse Schmeltz. (Admin. R. 431.) Plaintiff informed Schmeltz that "she rubbed cocaine on her tooth times 2 for a toothache [but] was clean for 16 years prior to this use." (Admin. R. 431.) During the examination, Nurse Schmeltz noted that Plaintiff had "expressive aphasia" and "[generalized weakness." (Admin. R. 432, 440.)

         On October 3, 2013, Plaintiff went to Reading Hospital complaining of a possible stroke. (Admin. R. 451.) Upon examination, the following issues were noted: slurred speech; transient ischemic attack (TIA); cocaine abuse; generalized seizure; cerebral infraction without residual deficits; debility; and, marijuana use. (Admin. R. 451.) Dr. Ray A. Morganti noted in Plaintiffs record that she was "unable to raise left LE above stretcher more than a few inches due to pain in anterior right thigh that patient reports is sore from falling." (Admin. R. 458.)

         On January 11, 2014, Plaintiff met with Dr. Celestine Nnaeto. (Admin. R. 554.) The doctor reported that she had slurred speech and that her "short term memory seemed impaired." (Admin. R. 557.) On April 29, 2014, providers with the FamiliCare Counseling Center reported that Plaintiff was molested as a child. (Admin. R. 575.) They further reported that although she had past suicidal ideations, she has no current suicidal thoughts. (Admin. R. 575.) They also reported that Plaintiff had past legal charges for "possession of cocaine, conspiracy, marijuana, school fines, PV [and] simple assault." (Admin. R. 576.) At Plaintiffs July 12, 2014 visit to FamiliCare, Plaintiff was "stressed" and "appeared tearful, depressed, lack of motivation, fearful and passive thoughts of self-harm, self-defeat during the session. Thoughts negative, circumstantial. Sleep poor, disrupted, passive SI with no specific plan, visual/auditory hallucination, panic attacks." (Admin. R. 584.) The therapist further noted that Plaintiff had been "scratching her skin until it is raw, reports lack of motivation for self care, low self esteem, inability to leave house due to panic reaction when exposed to outside stimulus. Will have racing heartbeat and shortness of breath. Intensity is 10, happening through the day, most of the waking hours." (Admin. R. 585.) At that time, she was diagnosed (in part) with "major depression single ep[.]" (Admin. R. 586.)

         On July 28, 2014, Plaintiff met with Dr. James A. Coffey, a vascular specialist. (Admin. R. 797.) During that visit, Plaintiff admitted to "depression[, ] syncopal episodes[, ] and use of tobacco as well as THC." (Admin. R. 797.) The record also showed that Plaintiff last used marijuana in April 2014 and after being clean for 16 years, suffered a relapse of crack cocaine in March 2014. (Admin. R. 799.) Plaintiff was given prescription medications and discharged with instructions to follow up. (Admin. R. 803.)

         On August 11, 2014, Plaintiff met with Neurologist Lawrence A. Brzozowski. (Admin. R. 779.) Dr. Brzozowski noted that Plaintiff had a history of polysubstance abuse, prior cocaine use, and recent marijuana and tobacco abuse. (Admin. R. 780.) Dr. Brzozowski determined that Plaintiff had "a postural tremor bilaterally, " further noting that the only "muscles that have 5/5 power are her right knee extensor and right foot dorsiflexor. Right sided muscles are generally 4 left sided muscles are 4 to 4-/5 power." (Admin. R. 783.) Dr. Brzozowski also noted that that the "[p]atient stands well by herself. She walks with a quad cane in her right hand with her left leg abducted and a left leg limp and is unsteady." (Admin. R. 783.) Finally, on October 14, 2014, Plaintiff was admitted at Digestive Disease Associates, where she was treated for chronic constipation, generalized abdominal pain, bloating, and dysphagia. (Admin. R. 813.)

         III. Standards of Review

         Objections to an R&R issued by a magistrate judge are entitled to de novo review by the district court. 28 U.S.C. § 636(b)(1)(C). However, review of a final decision of the Commissioner of Social Security is deferential and is limited to determining whether the Commissioner's decision is supported by substantial evidence. 42 U.S.C. §§ 405(g), 1383(c)(3); Jenkins v. Comm 'r of Soc. Sec, 192 Fed.Appx. 113, 114 (3d Cir. 2006). Substantial evidence is difficult to precisely define; it '"does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'" Hartranft v. Apfel, 181 F.3d 358, 360 (3d Cir. 1999) (quoting Pierce v. Underwood, 487 U.S. 552 (1988)). In terms of the traditional burden of proof standards, substantial evidence is "more than a mere scintilla but may be somewhat less than a preponderance of the evidence." Ginsburg v. Richardson, 436 F.2d 1146, 1148 (3d Cir. 1971). However,

In making this determination ... the court must consider "the evidentiary record as a whole, not just the evidence that is consistent with the agency's finding." Monsour, 806 F.2d at 1190. "A single piece of evidence will not satisfy the substantiality test if the Secretary ignores, or fails to resolve, a conflict created by countervailing evidence. Nor is evidence substantial if it is overwhelmed by other evidence ... or if it really constitutes not evidence but mere conclusion." Kent v. Schweiker, 710 F.2d 110, 114 (3d Cir. 1983).

McClease v. Comm 'r of Soc. Sec, Civ. No. 08-1673, 2009 U.S. Dist. LEXIS 101190, at *8 (E.D. Pa. Oct. ...

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