Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Prather v. Commissioner of Social Security

United States District Court, M.D. Florida, Tampa Division

March 31, 2017

Marie Prather, on behalf of M.C., Plaintiff,
v.
Commissioner of Social Security, Defendant.

          ORDER AFFIRMING COMMISSIONER'S DECISION

          Patricia D. Barksdale United States Magistrate Judge

         This is a case under 42 U.S.C. § 1383(c)(3) to review a final decision of the Commissioner of the Social Security Administration (“SSA”) denying Marie Prather's claim on behalf of her minor son, M.C., for supplemental security income.[1] She seeks reversal, Doc. 24; the Commissioner, affirmance, Doc. 25. This order adopts the summaries of facts and law in the Administrative Law Judge's (“ALJ's”) decision, Tr. 10-23, and in the parties' briefs, Docs. 24, 25.

         I. Issues

         Prather presents three issues: (1) whether substantial evidence supports the ALJ's finding M.C. has no impairment or combination of impairments that functionally equals an impairment in the Listing of Impairments, 20 C.F.R. Part 404, Subpart P, Appendix 1; (2) whether the ALJ properly evaluated Prather's testimony; and (3) whether the ALJ properly evaluated M.C.'s subjective complaints. Doc. 24 at 3, 10-16.

         II. Background

         M.C. was born in 1997 and was an adolescent at all relevant times. Tr. 127; see 20 C.F.R. § 416.926a(g)(1)(v)[2] (defining adolescent as “age 12 to attainment of age 18”). In April 2012, Prather applied for supplemental security income on M.C.'s behalf, alleging M.C. has been disabled since October 2011[3] due to juvenile rheumatoid arthritis, Sjögren's syndrome, [4] and asthma. Tr. 127, 159. She proceeded through the administrative process, failing at each level. Tr. 1-6, 10-23, 41-59, 61- 67, 73-79. This case followed. Doc. 1.

         III. Evidence

         A. Medical Evidence

         In April 2011, M.C. reported to his primary care physician, Dr. Amanda Puentes, that his knees had been giving out during physical-education classes and he had been experiencing pain in his wrists, ankles, and knees for more than a year. Tr. 303. She advised him to take ibuprofen as needed and apply heat. Tr. 304.

         In August 2011, M.C. returned to Dr. Puentes complaining of right-shoulder pain. Tr. 301. She ordered an MRI of the shoulder and recommended ibuprofen and alternating heat and ice after school and after using the shoulder. Tr. 301-02.

         In October 2011, M.C. saw Dr. Drew Warnick for evaluation of a right-shoulder injury he had sustained a few months earlier when trying to open a cattle gate. Tr. 314-16. Dr. Warnick observed he had “full pain-free range of motion of the” shoulder, full rotation strength, nearly full abduction strength, and “slight discomfort with the empty drawer test.” Tr. 315. Dr. Warnick observed no swelling of other joints and slight tenderness of the left ankle. Tr. 315. He opined M.C. had synovitis in the right shoulder with no tear and “stressed the importance of him seeing a rheumatologist to be placed on appropriate medication” for arthritis. Tr. 315.

         In October 2011, M.C. saw Dr. Robert Nickeson for evaluation for possible arthritis. Tr. 434-35. Dr. Nickeson observed he had mild swelling in the knees, joint hypermobility, [5] and his small hand joints were unremarkable. Tr. 435. He started him on piroxicam. Tr. 435.

         In December 2011, M.C. returned to Dr. Nickeson complaining of occasional dry eyes and joint pain about two days a week. Tr. 433. Dr. Nickeson observed his shoulder seemed to be a particular problem and his hand and leg joints did not show significant swelling. Tr. 433. A few days later, Dr. Nickeson contacted another doctor about performing a lip biopsy to test for Sjögren's syndrome. Tr. 286.

         In February 2012, M.C. returned to Dr. Puentes complaining of ongoing joint pain “due to baseball and FHA activities.” Tr. 295. Dr. Puentes noted Prather reported M.C.'s arthritis causes him to be tardy on days when he needs to take longer showers to relieve pain. Tr. 295. Dr. Puentes provided a note indicating M.C. should be allowed to be tardy “at most 2 times a week due to flare up of joint pain.” Tr. 296. She encouraged Prather to call any time M.C. would be tardy so they could keep a record of the frequency. Tr. 296.

         In February 2012, M.C. returned to Dr. Warnick and stated “his shoulder has completely resolved, [but] he has developed right knee, right hip, and right ankle pain.” Tr. 311. Dr. Warnick observed M.C. had started baseball within the previous two weeks, “which seemed to exacerbate this pain.” Tr. 311. He observed mild tenderness to palpation but normal gait. Tr. 311. He stated, “The treatment for [M.C.'s] knee, hip, and ankle are stretching and strengthening exercises” and advised M.C. to continue taking medication as prescribed. Tr. 312.

         About twice a week from February to April 2012 and again a few times in May 2012, M.C. participated in physical therapy. Tr. 320-69.

         In October 2012, M.C. returned to Dr. Nickeson complaining of continuing joint pain. Tr. 423-24. Dr. Nickeson observed no problems in M.C.'s arms and “2-plus” swelling in his ankles, and he advised him to continue taking prednisone at the current dose for another three to four weeks and reduce the dose after that. Tr. 423.

         In January 2013, M.C. returned to Dr. Nickeson. Tr. 421. Dr. Nickeson observed he continued to experience ankle, knee, and wrist swelling, had been playing “a number of instruments, including piano, guitar, sax[ophone], and ukulele, ” was teaching computer skills to other people, wanted to play more baseball, and was intermittently participating in homebound education. Tr. 421. He observed M.C.'s arthritis was not responding well to current medication, so he introduced weekly methotrexate injections. Tr. 421.

         In September 2013, M.C. returned to Dr. Nickeson and reported “feeling better with methotrexate” and having more pep. Tr. 419. Dr. Nickeson observed he had been playing baseball with friends, enjoyed being in the outfield, and intended to practice pitching. Tr. 419. He observed swelling in the elbows, small hand joints, ankles, and right knee. Tr. 419. He concluded, “[M.C.] is doing well with methotrexate. I think we could push the dose higher, due to his size.” Tr. 419.

         In December 2013, M.C. returned to Dr. Nickeson. Tr. 415. Dr. Nickeson observed, “Energy is good and is increased with slight raising of his methotrexate dose. He is playing baseball and is more active. He is down 15 pounds from last year with increase in activity. He is not complaining of nausea.” Tr. 415. He concluded, “Assessment is good arthritis control.” Tr. 415. He reduced the prednisone dose and left the methotrexate dose unchanged. Tr. 415.

         In April 2014, M.C. returned to Dr. Nickeson reporting his right shoulder (his “biggest problem” since October 2013) had improved over the previous month. Tr. 417. Dr. Nickeson observed M.C. had been off methotrexate around that time because Prather had had difficulty keeping up with refills due to a combination of transportation and insurance problems. Tr. 417. At the time of examination, he was taking prednisone daily, methotrexate weekly, and Tylenol as needed. Tr. 417. Dr. Nickeson observed he had limited range of motion of the right shoulder but could “extend both arms over his head pretty well.” Tr. 417. A joint exam showed “no particular problems except for [mild] swelling in the right wrist” and swelling in the knees and ankles. Tr. 417. He maintained M.C. on the same methotrexate dose and reduced the prednisone dose. Tr. 418.

         B. Opinion Evidence

         In June 2012, Pauline Correia, M.C.'s eighth-grade exceptional student education (“ESE”) teacher for math and language arts, completed a questionnaire. Tr. 165-67. She stated she sees him twice each school day, and he is on grade level for reading, math, and written language. Tr. 165. She stated he has an unusual absenteeism “[d]ue to his illness-Sjogrens' [sic]; migraine headaches[;] arthritis.” Tr. 165.

         For the domain of acquiring and using information, Ms. Correia opined M.C. has an obvious problem expressing ideas in written form, stating, “Due to stiffness in joints, difficulty holding writing instruments.” Tr. 166.

         For the domain of attending and completing tasks, Ms. Correia opined M.C. has obvious problems weekly with completing class or homework assignments and working at a reasonable pace and finishing on time. Tr. 167. She stated, “The student is independent, however, due to physical difficulties, [he] cannot write at an excellerated [sic] pace and in a large amount for his grade level. For ex: can barely write 3 full sentences during written assignments.” Tr. 167.

         For the domain of moving about and manipulating objects, Ms. Correia opined M.C. has obvious problems moving his body from one place to another and managing the pace of physical activities or tasks. Tr. 169. She stated, “Dexterity is minimal when grasping a pencil to write. Due to arthritis, kneeling, sitting for long periods, standing, and crouching are painful activities.” Tr. 169.

         Ms. Correia opined M.C. has no observed problems in the domains of interacting and relating with others and caring for himself. Tr. 168, 170.

         For the domain of health and physical well-being, in response to the question asking her to describe “any chronic or episodic condition” and whether its physical effects interfere with his functioning, she responded, “none seen at school.” Tr. 171. She stated M.C. “has morning stiffness causing severe difficulties in moving with pain. There may be some mornings when he arrives tardy as a result. Very unpredictable and unavoidable physical state.” Tr. 171.

         Later in June 2012, state-agency medical consultant Dr. Edith Davis opined M.C. has severe impairments of inflammatory arthritis, Sjögren's syndrome, and asthma. Tr. 44. She opined he has less-than-marked limitations in the domains of moving about and manipulating objects and health and physical well-being, and no limitations in the domains of acquiring and using information, attending and completing tasks, interacting and relating with others, and caring for himself. Tr. 44- 45. Regarding moving about and manipulating objects, she stated, “There may be limitations due to painful joints. Teacher Questionnaire: difficulty writing at a fast pace.” Tr. 45. On health and physical well-being, she stated:

14 yr old boy with dx of JRA, Sj[ö]gren's Syndrome. Sinding-larsen-johnson syndrome of rt knee. Bursitis of rt hip & rt ankle stain [sic]. Responding to present treatment. OrthoPedic OV: 2/24/12: Rt shoulder pain resolved[.] Has rt knee, rt hip, & rt [ankle] pain. PE: Tenderness over inferior pole of patell [sic] & tendon. Mildly tenderness [sic] on rt trochanter. Tenderness of anterior talofibular lig[a]ment. Nl gait. No joint effusion. X-Ray of pelvis: WNL. Plan: Strengthening exercises. f/u PRN.
12/9/11 Rhe[u]matology OV: Has dry eyes, not daily. Has tear production. Joint pains about 2 days a week. Wt 111kg@>97%. Ht 175cm @ 50%. PE: Joint[s] are not showing a lot of swelling in hand or lower extremities. Less than marked.

Tr. 45.

         In October 2012, state-agency medical consultant Dr. Shakra Junejo found the same severe impairments and limitations in the functional domains. Tr. 54-55. For the domain of health and physical well-being, besides the evidence Dr. Davis cited, she cited new ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.