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Singleton v. Berryhill

United States District Court, N.D. Alabama, Southern Division

November 16, 2018

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



         Plaintiff Sherry Singleton brings this action pursuant to Section 205(g) of the Social Security Act (the “Act”), seeking review of the decision of the Commissioner of Social Security (“Commissioner”) denying her claims for a period of disability and disability insurance benefits (“DIB”). See 42 U.S.C. § 405(g). Based on the court's review of the record and the documents submitted by the parties, the court finds that the decision of the Commissioner is due to be affirmed.

         I. Proceedings Below

         On August 6, 2014, Plaintiff protectively filed an application for disability and disability insurance benefits (“DIB”) under Title II of the Social Security Act and for supplemental security income (“SSI”) under Title XVI of the Act alleging disability as of June 29, 2014. (R. 16, 56, 58, 73, 153-68). The Social Security Administration (“SSA”) initially denied Plaintiff's application on November 12, 2015. (R. 16, 36, 92-100). On January 14, 2015, Plaintiff filed a request for a hearing before an Administrative Law Judge (“ALJ”). (R. 16, 90-91). That request was granted (R. 103-05), and Plaintiff received a hearing before ALJ Emilie Kraft on December 7, 2016. (R. 16, 34-55, 117-22). On January 31, 2017, the ALJ issued a partially favorable decision, finding that Plaintiff was not disabled prior to March 28, 2016, but became disabled on that date and continued to be disabled through the date of the decision. (R. 12-33). After the Appeals Council (“AC”) denied Plaintiff's request for review of the ALJ's decision[1] (R. 1-11, 151-52), the ALJ's decision became the final decision of the Commissioner, and, therefore, a proper subject for this court's review.

         II. Statement of Facts

         Plaintiff's application alleges disability due to a brain aneurysm. (R. 57, 204). She completed two years of college and has past relevant work as a licensed practical nurse. (R. 52, 205, 371, 376-77). She was 44 years old at the time of the ALJ decision. (R. 12, 38).

         On June 29, 2014, Plaintiff suffered a brain aneurysm while driving. (R. 269). She presented to the emergency department at UAB Hospital and was diagnosed with encephalopathy secondary to subarachnoid hemorrhage, intraparenchymal hemorrhagic stroke, concussion, and electrolyte imbalance. (R. 270, 272, 307). Plaintiff was treated with endovascular coil embolization on June 30, 2014, followed by placement of a ventriculoperitoneal shunt to treat hydrocephalus on July 7, 2014. (R. 280, 291, 309-11, 313-18, 517). She was discharged on July 10, 2014. (R. 332-46).

         On July 22, 2014, Plaintiff had a follow-up visit with UAB neurologist Dr. Mark Harrigan. (R. 348). Dr. Harrigan removed Plaintiff's staples and noted that she was doing “quite well.” (R. 348). Plaintiff was told to return to Dr. Harrigan in six months and was encouraged to follow-up with her primary care physician for blood pressure control. (R. 348).

         Two months after the aneurysm, in August 2014, Plaintiff and her daughter completed function reports. (R. 210-28). Both reports indicated that Plaintiff had significant limitations in performing activities of daily living and stated that Plaintiff could not drive, cook, or go out alone. (R. 19-20, 211-15, 217-21, 223-24).

         Plaintiff followed-up with Dr. Harrigan as instructed on October 14, 2014. (R. 517). Plaintiff reported having “several spells of staring associated with some headaches, no loss of bladder control, no evidence of generalized tonic-clonic seizures.” (R. 517). Dr. Harrigan prescribed Plaintiff Keppra as “empiric therapy” to “see if the spells resolve.” (R. 517). Dr. Harrigan also ordered a head CT scan which was “unremarkable” with “no sign of subdural hematoma, ventriculomegaly or other concerning findings.” (R. 518-19).

         On October 18, 2014, Plaintiff underwent a consultative examination by Dr. Danielle Powell at MDSI Physician Services. (R. 370-74). Plaintiff reported being able to attend to her personal needs but stated that she was able to perform very little housework or yard work due to headaches and fatigue. (R. 370). She reported experiencing headaches, memory loss, and fatigue since her surgery, but stated that her treating physician advised her that it could take more time for headaches to resolve following surgery. (R. 371). After examination, Dr. Powell concluded that Plaintiff was able to do the following: stand for up to four hours secondary to fatigue; walk up to five hours secondary to fatigue; reach overhead and forward, handling, fingering, and feeling occasionally; climb steps and stairs occasionally; stoop, crouch, kneel, and crawl occasionally secondary to fatigue. (R. 374). Dr. Powell concluded that Plaintiff was unable to lift due to recent surgery, and climb ladders, scaffolds, or ropes. (R. 374). Plaintiff was also advised to limit travel. (Id.).

         On October 24, 2014, Plaintiff underwent a consultative psychological evaluation by Dr. Sharon Waltz. (R. 376-79). Plaintiff reported symptoms of anxiety since the aneurysm and short-term and long-term problems with memory. (R. 377). Dr. Waltz found that Plaintiff “has a mental impairment present to a moderate degree. … [with] constriction of interests and difficulties relating to others due to mental health symptoms.” (R. 378). As to her ability to work, Dr. Waltz concluded that Plaintiff's “ability to understand, to carry out and to remember instructions and to respond appropriately to supervision, co-workers and work pressures in a work setting, despite her impairments, is Moderately Impaired.” (R. 378). Around the same time, state agency psychiatrist Dr. Robert Estock completed a mental health assessment of Plaintiff, and found Plaintiff had moderate limitations but remained capable of carrying out short and simple instructions. (Tr. 20, 67-69).

         On November 2, 2014, Plaintiff was brought to the UAB emergency department by ambulance for possible seizures. (R. 432). Notes from the visit indicate that Plaintiff had “a staring spell” with associated “uncontrollable upper and lower extremity shaking” and “a right sided throbbing headache today which she says she has had frequently since discharge from [aneurysm] admission.” (R. 432, 438). Medical testing revealed no acute intracranial abnormality, stable conditioning of the shunt catheter, and unchanged size of the ventricles. (R. 435). The seizure was “not believed to be related to shunt” and Plaintiff was directed to restart Keppra, the anti-seizure drug she had been prescribed in October 2014, which she had stopped taking due to side effects. (R. 436-37).

         On January 27, 2015, Plaintiff returned to Dr. Harrigan for a routine follow-up. (R. 520). Plaintiff reported “occasional” headaches and that she had once again stopped taking Keppra because of dizziness as a side effect. (R. 520). Despite discontinuing use of Keppra, Plaintiff reported that she had not had any more spells “concerning for possible seizure.” (R. 520). Dr. Harrigan ordered an MRI of Plaintiff's head which revealed “mild residual filling of the coiled ACOM aneurysm along the base and medial margins of the aneurysm sac. No. new intracranial aneurysm identified.” (R. 523).

         On February 11, 2015, Plaintiff again went to the emergency room at UAB due to a throbbing headache with intermittent sharp pain lasting 3 days. (R. 448). A CT scan revealed no acute or significant intracranial abnormality, no intracranial hemorrhage, and a stable right front shunt catheter. (R. 453, 456-57).

         Four months later, on June 23, 2015, Plaintiff presented to Dr. Mark Harrigan at TKC Neurosurgery due to “some trouble with headaches and a single brief spell of blurry vision while she was driving, no trouble with seizures.” (R. 459). Dr. Harrigan noted that “overall she is doing quite well.” (R. 459). Dr. Harrigan noted that Plaintiff tried Keppra but discontinued using it due to side effects. (R. 459). A CT scan was unremarkable with no sign of hydrocephalus and Dr. Harrigan informed Plaintiff that he did not believe she was having shunt ...

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