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Colville v. Berryhill

United States District Court, W.D. Arkansas, Fayetteville Division

February 2, 2018

NANCY A. BERRYHILL,[1] Commissioner Social Security Administration DEFENDANT



         Plaintiff, Alicia Ann Colville, brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a decision of the Commissioner of the Social Security Administration (Commissioner) denying her claims for a period of disability and disability insurance benefits (DIB) under the provisions of Title II of the Social Security Act (Act). In this judicial review, the Court must determine whether there is substantial evidence in the administrative record to support the Commissioner's decision. See 42 U.S.C. § 405(g).

         I. Procedural Background:

         Plaintiff protectively filed her current application for DIB on May 21, 2014, alleging an inability to work since May 31, 2013, due to congestive heart failure (CHF) or cardiac problems, memory problems, sleep problems, headaches, knee problems, back pain, dyslexia, and depression. (Tr. 220, 253). For DIB purposes, Plaintiff maintained insured status through December 31, 2018. (Tr. 18). An administrative hearing was held on July 30, 2015, at which Plaintiff appeared with counsel and testified. (Tr. 49-98).

         By written decision dated January 27, 2016, the ALJ found that during the relevant time period, Plaintiff had an impairment or combination of impairments that were severe. (Tr. 18). Specifically, the ALJ found Plaintiff had the following severe impairments: congestive heart failure and chronic diastolic heart failure with a history of aortic valve replacement, recurrent right patellofemoral instability, right patellofemoral joint osteoarthritis and right lateral meniscus tear status post-surgery, obesity, headaches, insomnia, obstructive sleep apnea, and depression. (Tr. 18). However, after reviewing all of the evidence presented, the ALJ determined that Plaintiff's impairments did not meet or equal the level of severity of any impairment listed in the Listing of Impairments found in Appendix I, Subpart P, Regulation No. 4. (Tr. 18). The ALJ found Plaintiff retained the residual functional capacity (RFC) to:

perform the full range of sedentary work as defined in 20 CFR 404.1567(a) except the claimant cannot climb, can occasionally balance and stoop, and cannot kneel, crouch or crawl. She must avoid concentrated exposure to temperature extremes, noise, fumes, odors, dusts, gases, poor ventilation and hazards. She is able to perform work where interpersonal contact is incidental to the work performed; tasks are no more complex than those learned and performed by rote, with few variables and little use of judgment; and the supervision required is simple, direct and concrete.

(Tr. 20). With the help of a vocational expert, the ALJ determined Plaintiff could perform work as a toy stuffer, tile table worker, and eyeglass frame polisher. (Tr. 26).

         Plaintiff then requested a review of the hearing decision by the Appeals Council, which denied that request on December 19, 2016. (Tr. 1-3). Subsequently, Plaintiff filed this action. (Doc. 1). Both parties have filed appeal briefs, and the case is before the undersigned for report and recommendation. (Docs. 11, 12).

         The Court has reviewed the entire transcript. The complete set of facts and arguments are presented in the parties' briefs, and are repeated here only to the extent necessary.

         II. Evidence Presented:

         At the time of the administrative hearing held on July 30, 2015, Plaintiff was forty years of age and had a limited education. (Tr. 53-54). Plaintiff obtained a certified nursing assistant certificate. (Tr. 55). Plaintiff's past relevant work consisted of working as a purchasing agent, inventory clerk, receptionist, and file clerk. (Tr. 57-63, 93, 230-232).

         A review of the pertinent medical evidence reflects the following. On February 21, 2012, Plaintiff underwent an echocardiogram (EKG) and moderate to severe aortic regurgitation was noted. (Tr. 562-565).

         On March 23, 2012, Plaintiff underwent a left heart catheterization, and the results yielded a referral for aortic valve replacement surgery. (Tr. 376-379, 546-549). Normal coronary arteries were observed. (Tr. 377).

         On April 9, 2012, Plaintiff presented herself to Northwest Medical Center and complained of heart palpitations and worsening chest pain, shortness of breath, and a 30-pound weight gain over the past three to four months. (Tr. 306-307, 540-541). An EKG revealed moderate to severe aortic regurgitation and an ejection fraction of 50-55 percent. Plaintiff was diagnosed with palpitations and congestive heart failure. (Tr. 307). On the same day, Plaintiff underwent an aortic valve replacement with a mechanical valve. (Tr. 309-310, 312-313, 538-539). Plaintiff was discharged after four days. (Tr. 309-310, 536).

         On April 24, 2012, Plaintiff returned to Northwest Medical Center complaining of dizziness and shortness of breath. (Tr. 304-305, 530-531). An EKG showed cardiac tamponade and pericarditis. (Tr. 304-305, 558-561). Plaintiff underwent an immediate pericardial drain placement to relieve the symptoms. (Tr. 311, 535). It was reported that she experienced immediate relief. Plaintiff remained in the hospital for five days. (Tr. 311). On April 29, 2012, Dr. Robert Jaggers, M.D. and Dr. James Counce, M.D. removed the drain, and they noted she returned to sinus rhythm. (Tr. 308, 534).

         On May 5, 2012, Plaintiff presented herself to the emergency department of Northwest Medical Center and was admitted to the hospital. (Tr. 373-374, 384-387, 532-533, 554-557). She complained of chest and neck pain, orthopnea, and headache. (Tr. 373). An EKG showed mild pericardial effusion and no tamponade. (Tr. 374). A head computed tomography (CT) scan showed no acute intracranial abnormality. (Tr. 374). On May 8, 2012, Plaintiff was discharged after she reported feeling better without chest tightness or dyspnea. (Tr. 374).

         On May 30, 2012, Plaintiff presented herself to Dr. Jose Loyo-Molina, M.D., a cardiologist, for a three-week follow up visit after her most recent hospital stay. (Tr. 368-371). Plaintiff reported that she felt better, but continued experiencing palpitations and left-sided pain with shallow breathing. (Tr. 368, 371). Dr. Loyo-Molina diagnosed her with aortic valve replacement, congestive heart failure, and she remained at functional class II. (Tr. 371).

         On June 15, 2012, Dr. Mandu Kalyan, M.D. conducted a sleep study and diagnosed Plaintiff with mild obstructive sleep apnea syndrome with an overall index of 7.2. (Tr. 478-479). Dr. Kalyan recommended a continuous positive airway pressure (CPAP) titration study, supervised weight loss, treatment of restless legs syndrome or periodic limb movements, and evaluation of insomnia etiologies. (Tr. 479).

         On August 27, 2012, Plaintiff presented herself to Dr. Kalyan for a CPAP device follow up visit. (Tr. 471-476). Plaintiff was diagnosed with obstructive sleep apnea, mild obesity, rapid eye movement (REM) behavior disorder, history of aortic valve disorder, and nicotine dependence. (Tr. 475). Dr. Kalyan encouraged compliance with CPAP device use. (Tr. 475).

         On November 27, 2012, Plaintiff presented herself to Dr. Loyo-Molina for a six-month follow up visit. (Tr. 364-367). Plaintiff reported that she felt much better and had recovered strength. (Tr. 364). She complained of chest pain that relieves on its own, shortness of breath, palpitations, and dizziness. (Tr. 364). Dr. Loyo-Molina found her chest pain was atypical. (Tr. 366). Plaintiff was ordered to undergo an EKG and pulmonary function test (PFT). (Tr. 366).

         On December 4, 2012, an EKG was conducted. (Tr. 360-363, 380-383, 550-553). The EKG revealed mild (stage 1) left ventricular diastolic dysfunction. (Tr. 362). The remainder of the results showed normal global and regional left ventricular systolic function; trace mitral regurgitation; and a normally functioning mechanical prosthetic valve in the aorta. (Tr. 362). Dr. Loyo-Molina noted Plaintiff's congestive heart failure remained at functional class II. (Tr. 362).

         On April 23, 2013, Dr. Loyo-Molina noted that Plaintiff underwent a hysterectomy on March 14, 2013, and she returned for a follow up visit to check her prothrombin time with international normalized ration (PT/INR) after Coumadin was discontinued for surgery. (Tr. 356-359). Plaintiff's INR during the visit was 3.5. (Tr. 356). Plaintiff admitted to smoking one pack of cigarettes daily since she was 20 years old. (Tr. 357). Dr. Loyo-Molina diagnosed her with status post aortic valve replacement, congestive heart failure, status post hysterectomy, aortic valve disorder, mild mitral regurgitation, and status post emergent pericardiocentesis due to tamponade and cardiogenic shock. (Tr. 358). No medication changes were suggested. (Tr. 358).

         The medical evidence continues after the alleged onset date of May 31, 2013. On June 30, 2013, Dr. Kalyan found Plaintiff's obstructive sleep apnea was improving. (Tr. 511). Dr. ...

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