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Navarette v. Berryhill

United States District Court, N.D. Texas, Amarillo Division

March 13, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Sasha Navarette brings this cause of action pursuant to 42 U.S.C. § 405(g), seeking review of a final decision of defendant NANCY A. BERRYHILL, Acting Commissioner of Social Security (Commissioner), denying plaintiffs application for disability insurance benefits (DIB) and Social Security Income benefits (SSI). For the reasons hereinafter expressed, the undersigned United States Magistrate Judge recommends the Commissioner's decision finding plaintiff not disabled and not entitled to benefits be AFFIRMED.


         THE RECORD

         Plaintiff filed an application for DIB and SSI on November 2, 2011, alleging a disability onset date of October 1, 2011. (Tr. 13, 115-24, 135, 139). Plaintiffs claim was denied initially and on rehearing. Plaintiff requested an administrative hearing, which was held January 3, 2014. (Tr. 31-56, 65-70, 74-77). The ALJ issued an unfavorable decision on March 19, 2014, finding plaintiff not disabled. (Tr. 13-25). The ALJ found plaintiff had the following severe impairments: lupus nephritis, systemic lupus erythematosus, obesity, and rheumatoid arthritis. (Tr. 15-16). He determined none of plaintiff s impairments met or equaled the severity of a listed impairment. (Tr. 16). The ALJ next evaluated plaintiff s RFC, reaching the conclusion plaintiff was able to "lift or carry, push or pull ten pounds occasionally and less than ten pounds frequently. She can sit for six hours out of an eight-hour day, and stand or walk a combined total of two hours out of an eight-hour day. The claimant is occasionally able to climb ramps or stairs, but is unable to climb ladders, ropes, or scaffolds. The claimant is unable to tolerate exposure to hazards." (Id.). The ALJ found plaintiff was able to perform her past relevant work as medical clerk. (Tr. 23).

         Upon the Appeals Council's denial of plaintiff s request for review on June 19, 2015, the ALJ's determination that plaintiff was not under a disability during the relevant time period became the final decision of the Commissioner. (Tr. 1-5, 10-25). Plaintiff now seeks judicial review of the denial of benefits pursuant to 42 U.S.C. § 405(g).

         The medical records show the following:

         Plaintiff received primary care from Perryton Health Center, where she was seen by Jennifer McGaughy, M.D., and occasionally was seen by a Physician's Assistant. (Tr. 227-48). On February 21, 2011, plaintiff reported her big toe was numb and she had bruising on her left breast after an incident involving someone throwing a stool. (Tr. 227). In April 2011, plaintiff was seen for a sore throat and diagnosed with strep pharyngitis. (Tr. 248). On August 18, 2011, plaintiff presented with blisters on the roof of her mouth, which resolved with treatment. (Tr. 246). Dr. McGaughy contacted Constantine Saadeh, MD, plaintiffs rheumatologist to determine if her medication should be adjusted. (Id.). A chest x-ray was ordered on October 4, 2011, when plaintiff presented with shortness of breath and a history of lupus. (Tr. 41). No acute cardiopulmonary abnormalities were noted. (Id.). On March 9, 2012, plaintiff was seen for a follow up from increased abdominal pain over two weeks. (Tr. 244). Plaintiff had cut out spicy food and taken Nexium, and the gastritis pain was improving. (Id.). On March 16, 2012, plaintiff was seen for eye pain and redness, and was referred to J.A. Rush, M.D., P.A. (Tr. 243).

         Plaintiff had extensive treatment by Constantine Saadeh, M.D., F.A.C.P., who was her rheumatologist. On February 20, 2010, Plaintiff was initially seen by Dr. Saadeh and reported being diagnosed with lupus in August 2009. (Tr. 251-54). Plaintiff reported developing a rash on her face and being concerned about her kidneys as she was experiencing pain. (Id.). She was taking prednisone for the rash. (Id.). She reported experiencing pain in the joints of her fingers, hands, wrists, elbows, knees, ankles, feet, and toes. (Id.). Dr. Saadeh's plan was for plaintiff to continue plaquenil, wean off the prednisone, and obtain x-rays and an ultrasound. An x-ray of her hands and feet was ordered and showed juxtarticular osteopenia across the metacarpalphalangeals (MCPs) and the carpal bones showed soft tissue swelling and cystic changes were noted over the capitate on the right. (Tr. 255-57). Dr. Saadeh noted this was consistent with inflammatory arthritis. (Id.). X-rays of the ankles and feet showed no evidence of calcaneal spurs, but there was juxtarticular osteopenia and soft tissue swelling across the metatarsophalangeals (MTPs) with cystic changes noted over the first MTP bilaterally. (Id.). Dr. Saadeh again noted these findings were consistent with inflammatory arthropathy. (Id.). X-rays of the hips were taken on March 31, 2010, with normal results indicated. (Tr. 273).

         On June 15, 2010, plaintiff was seen by Dr. Saadeh and reported doing great. (Tr. 283). Plaintiff had run out of the methotrexate protocol (MTX) that she had started in the past, and plaintiff noted an improvement in fatigue and pain after stopping the medication. (Id.).

         On October 11, 2010, plaintiff returned to Dr. Saadeh complaining of recurrence of lesions and mild right arm and hand pain. (Tr. 287-88). Dr. Saadeh had plaintiff restart the MTX, folic acid, and plaquenil. (Id.).

         On March 7, 2011, plaintiff presented with complaints of her right big toe being numb, left hip/groin pain, and headaches. (Tr. 292-95). The history of present illness section states that plaintiff has not tolerated MTX or plaquenil well, stating "Plaquenil caused dizziness and MTX caused severe depression per pt." (Id.). Plaintiff requested to start medications again due to increased joint pain and psoriasis lesions. (Id.). Plaintiff was to start Humira injections. (Id.).

         Ten days later, plaintiff was seen again for a follow-up and reported no improvement on Humira. (Tr. 302-04). Plaintiff reported pain in all joints bilaterally, except her shoulders. (Id.). She also stated she may need to be on disability. (Id.). Patient still had psoriasis lesions, but they were only on her ears at that point and no other area. (Id.). She was to continue the Humira for 12 weeks and add Cutivate and Bactroban to treat the lesions. (Id.). She also received a prescription for Tramadol as needed for pain. (Id.). On June 27, plaintiff returned for a follow up. (Tr. 308-12). Plaintiff did not feel the Humira was working and still had unbearable headaches, pain in bilateral hands, hips, and thighs, and in the right wrist and first two fingers. (Id.). An ultrasound was done and did show active disease, mostly along the MCPs and wrists. (Id.). Plaintiff was started on MTX again. (Id.).

         On August 31, 2011, plaintiff presented with continued complaints of pain in the back of her head and joints. (Tr. 332-36). The impression upon examination and review of a bilateral hip x-ray that was ordered was: a history of lupus, lupus induced tenosynovitis, knee pain, abnormal liver test, mouth herpes, and a history of inflammatory arthropathy. (Id.). Plaintiff was restarted on Plaquenil and started on Imuran. (Id.).

         On September 12, 2011, plaintiff returned and reported having no joint pain and feeling better after the IV Solu-Medrol. (Tr. 341-43). Plaintiff was to continue treatment. (Id.). On October 11, 2011, a right renal biopsy was performed and showed lupas nephritis, predominantly stage II. (Tr. 354-66).

         On November 1, 2011, plaintiff returned complaining of running a low grade temp for the last week, fatigue, "all over joint pain, " and that pain pills were making her sick and she wanted something that would make her "feel good ... like 5 Tylenols do." (Tr. 378-81). She also reported swelling in her hands, pain in her right hip and left knee, and her left arm was hurting and felt like she was having a heart attack. (Id.). The chest pain was determined to be consistent with osteoarthritis, while plaintiffs other increased symptoms were attributed to a flare up of her lupus. (Id.). Plaintiff had worsening protein excretion. (Id.). Plaintiff was to continue Solu-Medrol, Lasix, and start CellCept to control her kidney process. (Id.).

         Dr. Saadeh started plaintiff on Cytoxan and she received infusions on November 10, 2011, November 29, 2011, December 13, 2011, December 27, 2011, January 17, 2012, February 16, 2012, March 20, 2012, April 10, 2012, and May 3, 2012. (Tr. 412, 421, 427431-32, 447-48, 465-66, 484-85, 488-89, 493-94). Plaintiff showed general improvement, reporting on November 14, 2011, her joint pain was better and there was no tenderness or swelling. (Tr. 414-16). She was experiencing nausea, so Phenergan was ordered. (Id.). Another follow-up exam was conducted December 1, 2011, and plaintiff reported her joint pain was good. (Tr. 425-26). She was having some knee pain, but she used Volteran gel and it helped. (Id.).

         On February 8, 2012, plaintiff was seen and stated she had no complaints at that time. (Tr. 459-61). She reported that she had not been feeling bad and was frustrated with her lab results, which had been showing her white blood cell counts were not at a therapeutic level. (Id.). She denied any complaints of joint pain or morning stiffness. (Id.).

         On February 29, 2012, plaintiff was seen presenting with diarrhea, nausea, congestion, and stomach ache. (Tr. 471-72). Plaintiff stated she didn't want to see her PCP for it, so she waited for this appointment. (Id.). She needed to obtain lab work to see if she needed Neupogen, as another injection of Cytoxan was scheduled. (Id.). Plaintiff had a full range of motion of the spine, shoulders, elbows, and wrists, but did have sinus tenderness on exam. (Id.). Her white blood cell count was very low at 1.6. (Id.). She was diagnosed with lupus nephritis, sinusitis, and chronic neutropenia secondary to Cytoxan. (Id.).

         Plaintiff had to discontinue Cytoxan due to a urinary tract infection. (Tr. 616-18, 628-30). She received a shot of Rocephin and a urology consult was ordered. (Id.).

         On May 30, 2012, plaintiff reported feeling much better, not having difficulties, and medications were working well. (Tr. 632-35). She reported increased energy level and overall feeling much improved. (Id.). The plan was to repeat lupus labs in one month and ...

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