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Prochaska v. Berryhill

United States District Court, D. Nebraska

April 10, 2019

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


          Joseph F. Bataillon Senior United States District Judge

         This is an action for judicial review of a final decision of the Commissioner of the Social Security Administration (“the Commissioner”). The plaintiff, Dawn Prochaska, appeals the Commissioner's decision to deny her application for Social Security Disability (“Disability”) benefits under the Social Security Act and seeks review pursuant to 42 U.S.C. §405(g), see Filing No. 10 (Plaintiff's Motion for an Order Reversing the Commissioner's Decision) and Filing No. 11 (Defendant's Motion for an Order Affirming the Commissioner's Decision). A transcript of the hearing held on February 6, 2017, is found in the record at Filing No. 8. Administrative Record (“Admin. R.”) at 34-70.


         I. Procedural History

         Prochaska, at the age of fifty, applied for a period of disability and disability insurance benefits on October 20, 2014. She alleges disability due to brain aneurysm, right arm nerve damage, numbness on the right side of her body, memory loss, and left eye double vision. Prochaska claims a disability onset date of August 31, 2013. Initially, the Commissioner denied her claims on February 3, 2015, and again on May 7, 2015, upon reconsideration. On June 4, 2015, she filed a written request for a hearing with an Administrative Law Judge (“ALJ”). This hearing was held on February 6, 2017, in Lincoln, Nebraska. The Commissioner further denied benefits and held Prochaska not disabled on April 12, 2017. Prochaska seeks review of the ALJ's order denying disability benefits.

         II. Testimony

         Prochaska was born in 1964. She has a limited education, and a history of work experience as an injection molding machine operator, tractor assembler, and groundskeeper. At a hearing on February 6, 2017, Prochaska reported that since her aneurysm, there are times she must lay down because she is physically in too much pain to sit or stand. This occurs a couple of times per day for about ten minutes. Filing No. 8 Admin. R. at 53. Prochaska stated that she can only sit for approximately fifteen minutes before she needs to lay down or get up and walk around. Id. at 55. She testified that she can only stand for approximately five minutes without needing to sit or lay down. Id. at 53. Prochaska can reach overhead with her right hand, but reported it causes her pain. Id. at 53-54. Prochaska indicated that she has trouble sleeping and takes over-the-counter medication. Id. at 52. Prochaska also reported that she has had problems with constant double vision in her left eye since her surgery. Id. at 64.

         Prochaska testified that since her aneurysm, she has difficulty standing because it hurts her back and hip. This led her to quit her most recent job of sweeping the floors part-time at Duck Creek Farms. Id. at 39-40 and 51. Prior to sweeping floors, for about three hours per day, Prochaska worked at Duck Creek Farms mowing the grass during the 2013, 2014, and 2015 grass mowing seasons. She testified that she stopped mowing the grass in 2015 because of her pain. Id. at 43. Prochaska testified that she was a groundskeeper at Duck Creek Farms at the time of her aneurysm and that after the aneurysm she could not complete many of her duties, such as digging holes and assisting in the shop, because she did not have the strength to pick anything up anymore. Id. at 47. Prochaska specified in her testimony that the heaviest object she could lift was a gallon of milk. Id. at 49.

         Prochaska testified that since her aneurysm, she cannot drive alone further than five miles because she forgets where she is going. Id. at 48. She stated that she now has problems remembering things such as what movies she and her husband have watched, if people came over to their home in the evening, and if she has taken her medication. Id. at 56-57. Prochaska's husband reminds her to take her medication. She regularly takes Extra Strength Aleve for her pain and high blood pressure medicine. Id. at 52.

         Prochaska stated that she can provide some care for her four-year-old grandson whom she and her husband have custody of four days a week, but that she cannot lift him. Prochaska testified that she takes her grandson to daycare when she is in too much pain and does not think she can take care of him very well at home. Id. at 48-49. She stated that her grandson attends daycare at least one day per week and up to two or three days, depending on her pain level. Id. at 55.

         III. Medical Evidence

         Prochaska's medical record reflects that she presented to the emergency department at the Fremont Health Medical Center on August 31, 2013 with an altered level of consciousness and new onset seizure. Id. at 362. A computed tomography (CT) scan of her brain revealed a left intraparenchymal hematoma with associated left sided subarachnoid blood, which was noted to possibly be sequela of a ruptured MCA aneurysm. Id. at 362-363. Prochaska was subsequently transferred from the Fremont Health Medical Center to the University of Nebraska Medical Center where Dr. William Thorell, MD, performed a left frontotemporal craniotomy and clipping of ruptured left middle cerebral artery aneurysm and placed a right frontal external ventricular drain for the treatment of hydrocephalus on August 31, 2018. Id. at 506. Medical records show that Prochaska remained at the hospital until she was discharged on September 13, 2013. Upon discharge the medical record reflects she was stable neurologically and continued to show signs of improvement. Id. at 512.

         Prochaska presented to Brandon Reicks, PA, for a follow up on October 22, 2013. Id. at 514. On this date, the medical records reflect that Prochaska had done well in speech and physical therapy but had complaints about numbness and weakness in her right hand and left eye double vision when looking to the left. Id. Reicks noted that Prochaska's strength in her right upper and lower extremities was essentially full with some very mild breakaway weakness noted when compared to the left side and that she ambulated with a non-antalgic gait. Id. The records further state that although there was no observable evidence of word-finding difficulty at the appointment, Prochaska reported the issue on this date. Id. The follow up also notes that Prochaska had not contacted ophthalmology yet due to a lack of insurance. Id. at 515.

         Prochaska was seen by Dr. Antoinette Tribulato, a non-treating physician, for a consultative examination on January 27, 2015. Id. at 321. The medical report from this examination notes that Prochaska reported pain and numbness in her right arm and hand as well as headaches. Id. Dr. Tribulato observed that Prochaska presented with an antalgic gait and difficulty tandem walking. Id. at 322. The report documents that Prochaska had no apparent difficulty writing or hearing and that she followed directions, but that she did have difficulty recalling three items, spelling and counting backwards, and some obvious word-finding difficulty. Id. at 322 and 327. Dr. Tribulato concluded that Prochaska was limited in her ability to lift, carry, and grip on the right, but that she could handle sedentary duty. Id. at 326. Dr. Tribulato further concluded that Prochaska had no significant limitations to sitting or standing, mildly limited walking as tolerated, limited bending and twisting, and could not climb or crawl. Id.

         The ALJ afforded Dr. Tribulato's opinion “great weight.” Id. at 17. The ALJ found that Dr. Tribulato's opinions were “mostly consistent with the medical evidence of records in regards to the claimant's limitations.” Id. The ALJ found that Dr. Tribulato had no explanation for his opinion that the claimant could only perform sedentary work. Id.

         Prochaska was seen by Dr. Holly Filcheck, PhD, for a non-treating, consultative psychological interview and report on January 27, 2015. Id. at 331. Dr. Filcheck's records reflect that Prochaska did not use any assistive devices, but that Prochaska reported difficulty with her immediate and short-term memory, making it hard for her understand and remember short and simple instructions. Id. at 331 and 333-334. Dr. Filcheck's report noted that Prochaska appeared to have difficulty remembering complex instructions due to memory concerns, but that her concentration and attention appeared to be adequate. Id. at 333. Dr. Filcheck concluded that Prochaska would have no difficulty adapting to changes in life or structure but recommended a WMS-IV to determine the nature of her memory concerns. Id. The ALJ afforded Dr. Filcheck's opinion “some weight.” Id. at 17.

         Prochaska was also seen by her treating physician's assistant, James D. Witter, PA-C, between January 29, 2015 and August 16, 2016. Id. at 336-339, 499-503. Progress notes from a visit on August 21, 2015, reflects that Mr. Witter offered Prochaska other pain medications on this date for her chronic right pain and weakness, but that she was not interested mainly because of cost. Id. at 503. These progress notes also reflected that Prochaska reported that she worked about nine hours per week at this time, but that she felt like she had to take frequent breaks. Id. It also reflected her diplopia and memory recall issues. Id. A progress note from August 16, 2016, stated that Prochaska was in for a follow up regarding her hypertension and that things were going well for her on this date. Id. at 502. The progress note on this date does not reference Prochaska's pain or history of aneurysm. Id.

         On August 21, 2015, Mr. Witter, PA-C, prepared a medical source statement and opined that Prochaska could not reasonably be expected to work an 8-hour day, 40-hour work week, on a regular basis, without missing more than two days per month due to her disabilities. Id. at 342-343. Mr. Witter opined that Prochaska had the following limitations: sitting, standing, walking, stooping, and climbing. Id. Mr. Witter further concluded on the medical source statement that Prochaska would have a ...

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