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Gladys M. Lewis v. Michael J. Astrue

April 15, 2011

GLADYS M. LEWIS, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Nanette K. Laughrey United States District Judge

ORDER

Before the Court is Plaintiff Gladys M. Lewis's Social Security Complaint [Doc. # 1] brought under 42 U.S.C. §§ 405(g) and 1383(c) to review a decision of the Commissioner of Social Security ("Commissioner") denying her applications for disability insurance benefits and supplemental security income. For the following reasons, the Court affirms the Commissioner's decision.

I. Background*fn1

In her Social Security application, Plaintiff alleged that she was born in 1957 and became disabled on July 1, 2000, at age 42. She alleged disability due to a heart attack, a stroke, an overactive thyroid, and high blood pressure. After the initial denial of her applications, Plaintiff alleged that she was slower and had more fatigue. Defendant Commissioner generally adopts the following facts as set out in Plaintiff's Statement of Facts. [Doc. # 10 at 3.]

A. Medical Evidence

On January 5, 2004, Plaintiff Lewis was admitted to St. Luke's Hospital after developing substernal chest pain. On admission, her labs demonstrated a positive troponin I, which went up as high as 12.6, consistent with non-Q wave myocardial infarction. She underwent left heart catheterization, during which she developed a significant hypertension with a blood pressure of 230/130 and was transferred to intensive care. She also underwent a renal angiography that did not demonstrate significant renal artery stenosis. Lewis was discharged on January 9, 2004, with diagnosis of non-ST segment elevation myocardial infarction. Her medications included Amiodipine, Lipitor, Carvedilol, Lasix, and Cozaar.

By letter dated February 10, 2004, Diane Cunningham, R.N., noted she saw Lewis that day for cardiovascular re-evaluation at Cardiovascular Consultants. Lewis reported she continued to experience shortness of breath with exertion, but it had improved since her hospitalization. She also stated she had a small stroke in 1999 with residual left-sided weakness. A physical exam revealed Lewis had bilateral 1 peripheral edema. Electrocardiogram results revealed sinus rhythm with occasional PAC, and inverted T waves in V5 and V6. The impression was coronary artery disease with non-Q-wave infarction in January 2004; hypertension, currently well controlled; dyslipidemia treated with Lipitor; tobaccoism; and obesity. Lewis was going to attempt to stop smoking with the help of nicotine gum.

On February 18, 2004, Plaintiff Lewis visited Truman Medical Center for endocrinology follow up. She had thyroid ablation in November 2003. Her doctor noted her recent myocardial infarction. He planned to check her thyroid levels.

By letter dated March 3, 2004, Diane Cunningham, the cardiac nurse at Cardiovascular Consultants, reported she evaluated Plaintiff Lewis that day. Lewis continued to have shortness of breath and also complained of left leg fatigue with some calf discomfort during ambulation. She attended cardiac rehabilitation for four sessions but was unable to return because she was helping to care for her niece's son. Her blood pressure remained moderately elevated and she continued to smoke about a half pack of cigarettes a day.

Lewis weighed 241 pounds. Physical exam revealed normal S1 and S2 with a 1/6 systolic murmur heard at the apex and a 2/6 systolic murmur heard at the right upper sternal border. She had trace edema bilaterally.

An echocardiogram on February 27, 2004, revealed mildly reduced left ventricular systolic function; mild left ventricular dilation with akinesis of the inferior posterior walls and basal lateral segments; and mild to moderate mitral regurgitation. Ms. Cunningham increased the dose of Norvasc, discontinued Lasix, and reinitiated hydrochlorothiazide.

On February 17, 2005, Plaintiff Lewis visited Gazala Parvin, M.D., for follow up of her chronic medical problems. Physical exam revealed she weighed 260 pounds. She had 2 pitting edema in both ankles and lower leg. Dr. Parvin's assessment was hypertension with mildly elevated blood pressure currently; hypothyroidism; and hypercholesterolemia.

Dr. Parvin advised her to restart hydrochlorothiazide and Lasix and to continue her three other anti-hypertensive medications. Her hypothyroidism was uncontrolled in January 2005 and Dr. Parvin instructed her to continue her higher dose of Levoxyl. He continued the same dose of Lipitor. Dr. Parvin noted Lewis reported she was going without cigarettes for three or four days in a week.

On March 21, 2005, Plaintiff Lewis visited Randall Thompson, M.D., at Cardiovascular Consultants for an annual evaluation. Lewis reported she was feeling fairly well and was walking about a mile a day. She experienced some mild chest tingling, but no other chest discomfort. She reported fatigue, daytime drowsiness, and swelling of ankles and legs. She said she woke up unrefreshed. She also reported numbness and weakness.

On physical exam, Plaintiff Lewis stood five feet six inches tall and weighed 253 pounds with a BMI of 40.80. Dr. Thompson noted Lewis had coronary artery disease based on prior cardiac catheterization; hypertension, currently controlled; dyslipidemia with fair control; obesity; and tobaccoism. Lewis was still smoking a few cigarettes a day. Dr. Thompson increased her dose of Lipitor and suggested she try stopping furosemide or take it only as needed for ankle edema. She was to follow up in one year.

On March 22, 2005, Plaintiff Lewis returned to Dr. Parvin for follow up. He noted a recent exam revealed enlarged uterus and ultrasound revealed the presence of multiple uterine fibroids and a small cyst in the left ovary. He referred her to a gynecologist.

On October 28, 2005, Plaintiff Lewis returned to Dr. Parvin for follow up on hypertension, hypercholesterolemia, and pain in her right knee. Physical exam revealed she weighed 256 pounds and had 2 pitting edema bilaterally in the ankles. Right knee joint revealed mild tenderness on palpation of right medial part of the knee around the patella. Dr. Parvin gave her Naprosyn for right knee bursitis. She advised her to continue Coreg, Cozaar, hydrochlorothiazide, Norvasc, aspirin, and furosemide at current doses.

On January 25, 2006, Plaintiff Lewis underwent uterine artery embolization procedure to treat uterine fibroids.

On April 3, 2006, Plaintiff Lewis returned to Dr. Parvin for follow up. She weighed 269 pounds and her blood pressure was 158/88. Lewis reported that she quit cigarettes completely in January 2006. Dr. Parvin noted her hypertension was uncontrolled and said he would add a new medication if it remained so.

On May 2, 2006, Plaintiff Lewis returned to Cardiovascular Consultants for an annual evaluation. Her chief complaint was dizziness. Lewis reported chest discomfort about every other week. She said she tried to exercise by walking two or three times a week, but said she had to walk slowly and had trouble keeping up with a walking companion. She reported fatigue, daytime drowsiness, waking up unrefreshed, shortness of breath, swelling of legs and ankles, lightheadedness, and weakness. A physical exam revealed she weighed 268 pounds with BMI of 43.30. No edema was noted. An EKG revealed normal sinus rhythm, left atrial enlargement, borderline first degree AV block, and borderline low voltage. The impression was coronary artery disease; hypertension, controlled; mild lightheadedness; dyslipidemia, fair control; and obesity. Her dose of Lipitor was doubled and she was instructed to go ahead with nuclear cardiac stress test scheduled that day. During the test, Lewis experienced symptoms of dizziness, lightheadedness, shortness of breath, leg fatigue, and chest discomfort.

On May 23, 2006, Dr. Thompson of Cardiovascular Consultants wrote a letter to Dr. Parvin in which he reported that Lewis underwent exercise myocardial perfusion imaging which revealed localized areas of ischemia, mixed with nontransmural scar, probably in the distribution of a diagonal vessel; mixture of ischemia, plus nontransmural scar, inferiorly and inferolaterally. He recommended continued medical treatment and PET scan. He added that his nurse noted Lewis was having dyspnea both at rest and with activity.

On May 25, 2006, Plaintiff Lewis visited Norman McCarthy, D.O., for a consultative evaluation at the request of Social Security. Lewis told Dr. McCarthy she was unable to work because she had a stroke, had an myocardial infarction, and her medications make her very sleepy. She stated she quit smoking in January 2006. On physical exam, Lewis weighed 271 pounds. Her blood pressure was 168/96. She had a great deal of dental decay. She exhibited normal range of motion and strength with the exception of hip adduction. Dr. McCarthy believed that this was due to her obesity. He noted hypothyroid, hypertension, shortness of breath, and chronic tobacco abuse. He concluded that he found no evidence of functional restrictions or physical impairments.

On May 31, 2006, Plaintiff Lewis returned to Cardiovascular Consultants and saw Kristina Calkins, a cardiac nurse. She noted that Lewis was unable to undergo PET scan for insurance reasons and because she could not pay out of pocket. Chest x-ray revealed no acute processes, but did reveal mild cardiomegaly. On physical exam, her BMI was 43.90, her blood pressure was 160/94, and her neck veins were not visible. Impressions were dyspnea; coronary artery disease with recent abnormal myocardial perfusion scan; recent discontinuation of tobacco abuse; ...


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