United States District Court, N.D. Texas, Amarillo Division
REPORT AND RECOMMENDATION TO AFFIRM THE DECISION OF
CLINTON E. AVERITTE UNITED STATES MAGISTRATE JUDGE.
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.
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).
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).
medical records show the following:
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.
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.
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.).
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.).
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.).
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.).
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.).
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).
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
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
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.
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.
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.).
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 ...