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Wells v. Colvin

United States District Court, E.D. Missouri, Eastern Division

July 18, 2014

PATRICIA WELLS, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

MEMORANDUM AND ORDER

TERRY I. ADELMAN, Magistrate Judge.

This is an action under 42 U.S.C. § 405(g) for judicial review of the Commissioner's final decision denying Patricia Wells's application for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401, et seq. All matters are pending before the undersigned United States Magistrate Judge, with consent of the parties, pursuant to 28 U.S.C. § 636(c). Because the Commissioner's final decision is supported by substantial evidence on the record as a whole, it is affirmed.

I. Procedural History

On January 27, 2010, the Social Security Administration denied plaintiff Patricia Wells's October 7, 2009, application for disability insurance benefits (DIB) in which she claimed she became disabled on July 1, 2003, because of bulging discs in the back and neck, fibromyalgia, chronic obstructive pulmonary disease, depression, and right upper extremity numbness. (Tr. 61, 65-69, 112-15, 140.) Upon plaintiff's request, a hearing was held before an administrative law judge (ALJ) on December 15, 2011, at which plaintiff testified. (Tr. 43-60.) On January 3, 2012, the ALJ denied plaintiff's claim for benefits, finding plaintiff not to be disabled prior to the expiration of her insured status on December 31, 2005. The ALJ found plaintiff's disorders of the back to be her only severe impairment during the relevant period and that, prior to the expiration of her insured status on December 31, 2005, plaintiff could perform the full range of light work, which resulted in a finding of "not disabled" as directed by the Medical-Vocational Guidelines. (Tr. 27-38.) On May 15, 2013, the Appeals Council denied plaintiff's request for review of the ALJ's decision. (Tr. 1-5.) The ALJ's determination thus stands as the final decision of the Commissioner. 42 U.S.C. § 405(g).

In the instant action for judicial review, plaintiff claims that the ALJ's decision is not supported by substantial evidence on the record as a whole. Plaintiff specifically argues that the ALJ failed to undergo the proper analysis in formulating her residual functional capacity (RFC). Plaintiff also claims that the ALJ improperly discounted the medical opinion evidence of record and should have obtained the opinion of a medical advisor to determine whether the date of onset occurred prior to the date last insured. Finally, plaintiff claims that the ALJ erred in determining her credibility and by failing to consider third party observations when evaluating her subjective complaints. Plaintiff requests that the final decision be reversed and that the matter be remanded for an award of benefits or for further consideration. For the reasons that follow, the ALJ did not err in his determination.[1]

II. Testimonial Evidence Before the ALJ

At the hearing on December 15, 2011, plaintiff testified in response to questions posed by the ALJ and counsel.

At the time of the hearing, plaintiff was fifty-five years of age. Plaintiff stands five feet, two inches tall and weighs 156 pounds. Plaintiff testified that she weighed about 142 pounds in December 2005. Plaintiff is married. Plaintiff attended college for two years. (Tr. 47, 49.)

Plaintiff's Work History Report shows that plaintiff worked for Kanes Keeping, Inc., in 1996 and 1997. From 1998 to 2002, plaintiff worked for Jeannette G. Murray, a dog groomer. In 2002 and 2003, plaintiff worked at Value City Department Stores. (Tr. 53, 122-23.) Plaintiff testified that she and her husband considered purchasing a dog grooming business in 2006 or 2007, but that her impairments prevented her from doing the grooming work more than a day or two. (Tr. 49-50.)

Plaintiff testified that during her period of insured status, she was limited by impairments of her neck, back, and right shoulder from which she had suffered since she was twenty-eight years of age. Plaintiff testified that her condition worsened with her work as a dog groomer because of her arms constantly being elevated. (Tr. 50-51, 56-57.) Plaintiff testified that she could not work full time grooming dogs because of the pain associated with her impairment. (Tr. 53.) Plaintiff testified that her lifting ability was also limited, and she had to quit her retail job because of her inability to lift ten pounds. (Tr. 56.) Plaintiff testified that her impairments have since worsened. (Tr. 50-51.)

Plaintiff testified that, prior to 2005, her physician believed she had a tear in the shoulder blade, and she underwent traction for the condition. Plaintiff testified that surgery performed in 2006 initially helped. Plaintiff testified that her medications during the relevant period were Trazodone, Prozac, and a nerve pill. Plaintiff testified that she was currently receiving cortisone injections in the spine. (Tr. 51-52, 55.)

Plaintiff testified that she has a driver's license but limits her driving because of difficulty with her arms. Plaintiff testified that she drove herself forty-five minutes to the hearing. (Tr. 47-48.)

III. Relevant Medical Records Before the ALJ

Plaintiff visited Dr. Thomas R. Forget, a neurologist, on March 31, 2003, with complaints of decreased vision in her left eye. It was noted that plaintiff was taking Prozac, hormone replacement therapy, and Fiorinal and codeine for headaches. Plaintiff reported to be in good general health, and she had no musculoskeletal complaints. Motor and sensory examination was normal. Plaintiff underwent testing for possible aneurysm. (Tr. 174-90.)

Plaintiff visited Dr. Leonard Lucas on December 9, 2004, with complaints of pain in the left ankle aggravated with walking. A venous examination of the left leg performed that same date yielded normal results. Indocin was prescribed, and plaintiff was instructed to elevate the leg. (Tr. 363, 409.)

Between August 27, 2004, and March 29, 2005, Dr. Lucas prescribed Levaquin, Prednisone for allergies, Trazodone, Alprazolam (Xanax), Prozac, and Zoloft for plaintiff. (Tr. 364, 367.)

Plaintiff visited Dr. Lucas on June 22, 2005, and was diagnosed with right shoulder tendinitis. Plaintiff was referred to physical therapy. (Tr. 360.)

Plaintiff visited Farmington Sports and Rehabilitation Center on June 28, 2005, upon referral from Dr. Lucas for evaluation relating to tendinitis of the right shoulder. Plaintiff reported having pain for about ten years with such pain increasing with use of the right arm. Plaintiff reported that she had to return to work as a dog groomer in a couple of weeks after being semi-retired for some time and that she wanted to prepare her shoulder for such work. Plaintiff reported no other significant medical history. Plaintiff's medications were noted to include hormone replacement therapy, Prozac, and a muscle relaxer taken as needed. Plaintiff reported her shoulder pain to currently be at a level seven out of ten. Physical examination showed limited active range of motion about the right shoulder. A plan for strengthening and treatment was put in place. (Tr. 402-04.)

Plaintiff visited Dr. Lucas on August 10, 2005, with complaints of bilateral shoulder pain. Plaintiff reported that therapy helped, but that the pain returns once therapy ends. Decreased range of motion about the right shoulder was noted with increased pain. Physical therapy was continued for both shoulders. (Tr. 356, 396-98.)

MRIs of the right and left shoulders dated August 16, 2005, yielded negative results. (Tr. 399, 400.)

Between March and September 2005, Dr. Lucas prescribed Singulair, Trazodone, ibuprofen, and hormone replacement therapy for plaintiff. (Tr. 362.)

On December 15, 2005, plaintiff reported to Dr. Lucas that she was having trouble with her neck and shoulder blades. Plaintiff was referred for an orthopedic consultation. (Tr. 351.)

On December 21, 2005, and January 13, 2006, Dr. Lucas prescribed Darvocet for plaintiff to take as needed for headaches. (Tr. 393, 394.) Between October 2005 and February 2006, Dr. Lucas also prescribed Prozac, Xanax, Singulair, Fiorinal, Trazodone, and Prednisone for plaintiff. (Tr. 352-54.)

On February 23, 2006, plaintiff visited Dr. Duane Turpin, a neurologist, with complaints of a twenty-year history of shoulder pain and discomfort. Plaintiff's medications were noted to be hormone replacement therapy and Prozac. Dr. Turpin noted MRI results to show disc and osteophyte abnormality at C5-6 and C6-7, with mild flattening of the cervical spinal cord noted at that level. Dr. Turpin also noted EMG studies to show bilateral C6 radiculopathy of an acute and chronic nature. Physical examination showed full strength in the upper extremities, bilaterally, but with absent biceps and brachioradialis reflex on the right. Dr. Turpin opined that plaintiff had cervical radiculopathy/myelopathy and recommended that plaintiff participate in physical therapy. Upon being advised that plaintiff had already done so, Dr. Turpin recommended a neurosurgical consultation. (Tr. 391, 392.)

On March 7, 2006, plaintiff visited Dr. Kevin D. Rutz, an orthopedic specialist, upon referral by Dr. Lucas for spinal consultation in response to plaintiff's complaints of chronic persistent back and bilateral upper extremity pain, paresthesias, and weakness. Plaintiff reported having experienced the symptoms for twenty years but that they had worsened. Plaintiff reported the symptoms to worsen with bending, lifting, and exercise and to be relieved with rest. Plaintiff reported having no hand weakness and no gait or balance abnormalities. Plaintiff's medications were noted to include codeine and ibuprofen, and plaintiff reported her treatment to date to only be physical therapy. Physical examination showed plaintiff's gait to be smooth. Plaintiff was able to heel and toe walk. Plaintiff had decreased range of motion with flexion and extension secondary to neck pain and right-sided upper trapezius pain. Observation of the spine was unremarkable. Tenderness to palpation was noted across the midline cervical spine and bilateral paraspinal musculature in the cervical spine with pain in the bilateral parascapular region. Plaintiff was noted to have full strength in the upper extremities, bilaterally. Positive impingement signs were noted in the right shoulder. Dr. Rutz noted an MRI dated February 3, 2006, to show moderate disc degeneration at C5-6 with a small right-sided disc herniation and degenerative changes at C6-7. It was also noted that an EMG study showed evidence of C6 radiculopathy. Plaintiff was diagnosed with cervical spondylosis, cervical disc herniation, and cervical radiculopathy. A nerve root block was scheduled. (Tr. 233-35.)

On March 17, 2006, plaintiff underwent a nerve root injection at the C6 level of the spine. (Tr. 238.) On March 23, Dr. Rutz reported to Dr. Lucas that the nerve root block significantly improved plaintiff's right arm and shoulder pain but that plaintiff continued to complain of neck pain with radiation to the right shoulder. Dr. Rutz informed Dr. Lucas that, because of plaintiff's long history of symptoms that were slowly getting worse, a cervical discectomy and fusion would be performed. (Tr. 232.)

On March 29, 2006, plaintiff underwent a C5-6 and C6-7 anterior cervical discectomy and fusion with a prosthetic implant. It was noted that plaintiff had a longstanding history of neck pain and bilateral arm pain (right greater than left) and that diagnostic testing showed cervical radiculopathy and cervical spinal stenosis. Plaintiff was otherwise healthy, with her only medications noted to be Prozac and hormone replacement therapy. Plaintiff was discharged on March 30, 2006, with adequate pain control on oral pain medications. (Tr. 217-22.)

Plaintiff returned to Dr. Rutz for follow up on April 11, 2006, who noted plaintiff to continue to show mild to moderate impingement symptoms in the right shoulder. A Depo-Medrol injection to the shoulders relieved plaintiff's discomfort. Plaintiff's prescription for Vicodin was refilled, and Dr. Rutz instructed plaintiff to slowly increase her activity level. (Tr. 231.) On May 9, plaintiff reported to Dr. Rutz that injections to her shoulders provided significant improvement and she was able to decrease her pain medication. Plaintiff was noted to have no restrictions. (Tr. 230.) On June 29, Dr. Rutz noted plaintiff to continue to have no restrictions but that she had some residual shoulder bursitis and trapezial tightness. Dr. Rutz instructed plaintiff to resume exercises for the condition. (Tr. 229.)

Plaintiff visited Farmington Sports and Rehabilitation Center on September 14, 2006, with complaints of pain in her upper back since undergoing surgery in March 2006. Plaintiff reported that she could not work a full day as a dog groomer because of her pain. Plaintiff reported that she currently took no pain medication. Physical examination showed limited range of motion about the cervical spine with flexion, extension, and bilateral rotation. Plaintiff had full range of motion about the upper extremities, bilaterally. Diminished reflexes were noted about the right upper extremity. Tenderness to palpation was noted about the upper trapezius and levator scapulae musculature. It was determined that plaintiff's signs and symptoms were consistent with muscular strain and that plaintiff would benefit from an overall strengthening program and modality treatments to control muscle spasms and pain. (Tr. 255-57.) Plaintiff participated in physical therapy on four additional occasions through October 4. Plaintiff reported no significant change in her symptoms with therapy. (Tr. 252-54.)

Plaintiff returned to Dr. Rutz on October 19, 2006, with complaints of persistent aching between her shoulder blades, primarily aggravated with lifting. Plaintiff reported being frustrated with her attempts to return to work because of the condition. Dr. Rutz questioned whether there was non-union or delayed union at the C6-7 level. (Tr. 228.) A CT scan of the cervical spine showed solid fusion at C5-6 and C6-7; mild bilateral C3-4, C4-5, C5-6 and minimal left C6-7 uncovertebral spurring, but with no significant foraminal stenosis at any level; and no central canal stenosis at any level. (Tr. 237.) Noting the CT scan to show solid fusion, Dr. Rutz recommended that plaintiff take non-narcotic pain medication and over-the-counter medication. (Tr. 227.)

Between April 2006 and January 2007, Dr. Lucas prescribed Prozac, ibuprofen, Trazodone, Alprazolam, Albuterol, Paxil, Prednisone, and hormone replacement therapy for plaintiff. (Tr. 350.)

A CT scan of the cervical spine dated May 10, 2007, showed anterior plating from C5 through C7 with a defect through the C6-7 disk space suggesting lack of fusion and possible fracture through the implant with intact plate. The fusion between C5-6 was noted to be solid. (Tr. 276.)

On May 10, 2007, Dr. Rutz administered an injection of Depo-Medrol for plaintiff's bilateral shoulder bursitis with marked improvement in symptoms. Dr. Rutz noted a CT scan of the cervical spine to show the fusion from C5 to C7 to be solid. Plaintiff was referred ...


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