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Brock v. Berryhill

United States District Court, E.D. Kentucky, Southern Division, London

April 6, 2018

NANCY A. BERRYHILL, Deputy Commissioner of Operations of the Social Security Administration, [*] Defendant.


          Danny C. Reeves United States District Judge

         This matter is pending for consideration of cross-motions for summary judgment filed by Plaintiff Candace Le Shel Brock (hereafter, “Brock” or “the Claimant”) and Defendant Nancy A. Berryhill, Deputy Commissioner of Operations of the Social Security Administration (hereafter, “the Commissioner.”) [Record Nos. 13, 15] Brock argues that the Administrative Law Judge (“ALJ”) erred in concluding that she was not disabled within the meaning of the Social Security Act (“Act”). Specifically, she asserts that the ALJ failed to properly evaluate the opinion evidence and her subjective complaints of pain. She also argues that the ALJ's decision was not supported by substantial evidence. Brock asks this Court to direct the Commissioner to award her benefits or, alternatively, to remand the matter for further consideration before a new ALJ. The Commissioner contends that the ALJ properly evaluated the evidence and that the ALJ's decision should be affirmed because it is supported by substantial evidence. For the reasons that follow, The Commissioner's motion will be granted the relief sought by Brock will be denied.

         I. Procedural History

         Brock filed an application for Supplemental Security Income (“SSI”) under Title XVI of the Act on September 23, 2013. [See Administrative Transcript, hereinafter “Tr., ” 458.] She alleged an onset of disability of August 14, 2013. Id. After the application was denied initially and upon reconsideration, Brock requested a hearing before an ALJ. [Tr. 362, 366, 376] She appeared before ALJ Michael A. Lehr for video hearings on December 10, 2015, and March 31, 2016. [Tr. 265-89, 251-64] ALJ Lehr denied benefits in a written decision on May 2, 2016, which the Appeals Council later affirmed. [Tr. 219-37, 1-4] Accordingly, the Claimant has exhausted her administrative remedies and this matter is ripe for review under 42 U.S.C. § 405(g).

         II. Background

         Brock was thirty-one-years-old and was married with two young children at the time of the ALJ's decision. [Tr. 270, 237, 271] She had obtained her GED and had completed some online college courses, but had never worked anywhere “for more than a day or two.” [Tr. 270] She claimed that she was unable to work due to inflammatory bowel disease, bipolar disorder, anxiety, depression, fibromyalgia, osteomyelitis, and chronic fatigue syndrome. [Tr. 269]

         Brock alleged that her most limiting condition was fibromyalgia, which caused difficulty with sitting, standing, and walking. [Tr. 272] She described the pain as a constant ache and burning throughout her body. [Tr. 554] She estimated that she could sit and stand for ten to fifteen minutes and stated that she had to lie down eight to ten times per day. [Tr. 274] Brock reported that some days, she stayed in bed because she could not move. [Tr. 275] She also testified that she had difficulty picking up items and that she would have trouble holding a pen or typing on a keyboard. [Tr. 276]

         Brock advised the ALJ that she had experienced stomach problems since she was a teenager. [Tr. 276] She reported frequent cramping and nausea and stated that she spent “a big part of the day” in the bathroom. [Tr. 277] She also reported severe mood swings and depression. [Tr. 280-81] Brock described going shopping as a “horrible experience” and reported that she had panic attacks and problems concentrating. [Tr. 281] She reported that she rarely left the house due to these problems. [Tr. 3437]

         Brock first received inpatient mental health treatment at the age of 14 after expressing suicidal thoughts. [Tr. 593] She was diagnosed with major depression with psychotic features and began taking medication to manage the symptoms. Id. She also began outpatient counseling, which she continued sporadically throughout the years, and was given a good prognosis. Id. Pam Wenger, a psychiatric-mental health nurse practitioner (“PMHNP”) managed Brock's medications and Brock attended individual counseling sessions at Cumberland River Comprehensive Care Center (“CRCC”) from 2008 through 2011. [Tr. 814-927] Later, she returned to CRCC and received psychiatric treatment in 2013. [Tr. 2094-2123]

         Brock was treated by numerous doctors from 2012 through 2016, including several primary care physicians and specialists in gynecology, rheumatology, and gastroenterology. Brock visited the emergency department frequently over the years, often complaining of abdominal pain. [Tr. 708, 711, 713, 1307] Gastroenterologist Rehana Begum, M.D., evaluated Brock in 2008. [Tr. 736] A gastric biopsy indicated that Brock had moderate chronic gastritis, but there was no evidence of acute inflammation or intestinal metaplasia. [Tr. 744] An upper endoscopy with biopsy and a colonoscopy with biopsy also were performed. [Tr. 760] This examination and testing revealed minimal gastritis, grade I reflux esophagitis, and mild hemorrhoidal irritation. [Tr. 761] A follow-up colonoscopy in 2010 was essentially unremarkable. [Tr. 800] Serologic testing performed in 2012 was not consistent with inflammatory bowel disease. [Tr. 937]

         Brock also treated with Ashok Kanthawar, M.D., a digestive and liver specialist, in 2012. [Tr. 1242] Kanthawar diagnosed irritable bowel disease, morbid obesity, and elevated liver enzymes. [Tr. 1243] In addition to ordering further studies, he advised Brock to lose weight and to “consider antidepressants.” [Tr. 1245-46] Brock saw another gastroenterologist, Morris Beebe, M.D., in 2014. [Tr. 2445] Beebe started medications to address Brock's complaints of nausea, diarrhea, and abnormal liver function. [Tr. 2448] A subsequent colonoscopy with biopsies of the duodenum, antrum, and colon appear to have been within normal limits. [Tr. 2457]

         Brock presented for a rheumatology evaluation with Scott Lewis, M.D., in September 2013. [Tr. 2275] She advised Lewis that she had pain in her neck, back, hips, chest, arms, fingers, legs, shoulders, hands, and feet. Id. She had 18 out of 18 tender points, but her upper extremity strength was five out of five and lower extremity strength was four out of five. [Tr. 2277] Lewis diagnosed her with myalgia and myositis, unspecified, and polyarthralgias/fibromyalgia. [Tr. 2277-78] He discussed with her the need for non-pharmacologic management such as stress reduction, sleep hygiene, and exercise. Id.

         Louie Williams, M.D., a rehabilitation specialist, treated Brock in 2015. [Tr. 3080-3140] Brock complained at that time of insomnia, numbness and tingling, chronic pain, fatigue, and IBS symptoms. [Tr. 3080] She alleged that, at times, she had trouble rolling over in bed. [Tr. 3135] Williams commented that Brock had either a severe case of fibromyalgia or “something else [was] going on as well.” [Tr. 3138] She had fourteen out of eighteen trigger points and an MRI scan of her brain was unremarkable. [Tr. 3124, 3127] Williams administered Toradol injections and prescribed pain medication. [Tr. 3128] Brock advised Williams that she had to terminate physical therapy because she “went numb from the waist down.” [Tr. 3113] Williams recommended water therapy, but Brock stated that it was not available near her home. Id.

         None of Brock's treating sources provided an opinion regarding her functional abilities. The ALJ sought the opinion of Subramaniam Krishnamurthi, M.D., regarding Brock's physical impairments. [Tr. 3281] After reviewing Brock's file, Krishnamurthi reported that Brock could frequently lift or carry up to 10 pounds, could occasionally lift or carry 11 to 20 pounds, but could never lift or carry over 20 pounds. [Tr. 3285] He also believed that she could sit for two hours without interruption and stand or walk for one hour without interruption. Krishnamurthi opined that Brock could sit for a total of six hours in an eight-hour workday, but could stand or walk for a total of only three hours in an eight-hour workday. [Tr. 3286] He reported that Brock could frequently perform activities with her upper extremities and feet and that she could occasionally climb, balance, stoop, kneel, crouch, and crawl. [Tr. 3287-88] Finally, he concluded that she could frequently tolerate exposure to environmental hazards and that she could sort, handle, and use paper and files. [Tr. 3289-90].

         Leigh A. Ford, Ph.D. examined Brock in March 2016 and provided a mental health assessment. [Tr. 3436] Brock maintained eye contact with Ford during the examination, although Brock's affect appeared flat and her mood appeared anxious and pessimistic. [Tr. 3437] No. preoccupation of thought was apparent, and organization of thought was logical and goal-oriented. Id. Brock appeared to have some gaps in insight, but recognized that she had some difficulty making decisions. Ford administered the Wechsler Adult Intelligence Scale-Fourth Edition. Brock's full-scale IQ was 75, falling within the borderline range of cognitive abilities. [Tr. 3438] Her verbal comprehension index scale, a measure of acquired knowledge, verbal reasoning, and attention to verbal materials, was 85, falling within the low-average range. Id. Likewise, her perceptual reasoning index score was within the low-average range, while her working memory index was within the average range. Id. Brock's processing speed index, which measures an individual's ability to process visual information quickly, fell within the extremely low range. Id.

         Ford also administered the WRAT-4 to assess Brock's academic functioning in the areas of reading and math. Brock displayed average reading skills and low-average math skills. [Tr. 3439] Ford concluded that Brock's ability to understand, remember, and carry out simple instructions was mildly limited. [Tr. 3441] Her ability to make judgments on simple work-related decisions was also mildly limited. Id. Ford opined that Brock's ability to perform these tasks with respect to complex instructions was moderately limited. Id. She also believed that Brock's ability to interact appropriately with the public, supervisors, and co-workers was moderately limited. [Tr. 3442] ...

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