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Shead v. Colvin

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

November 24, 2014

ANNETTE SHEAD, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

MEMORANDUM

DAVID D. NOCE, Magistrate Judge.

This action is before the court for judicial review of the final decision of the defendant Commissioner of Social Security denying the application of plaintiff Annette Shead for a period of disability and disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401-434. The parties have consented to the exercise of plenary authority by the undersigned Magistrate Judge under 28 U.S.C. § 636(c). For the reasons set forth below, plaintiff's claim is denied.

I. BACKGROUND

Plaintiff Annette Shead, born November 7, 1962, applied for a period of disability and disability insurance benefits under Title II of the Social Security Act on June 29, 2011. (Tr. 85-93.) She alleged an onset date of disability of July 1, 2008, due to carpal tunnel syndrome (CTS) in her right and left hands. (Tr. 135-39.) Plaintiff's claim was initially denied on November 28, 2011, and she filed a Request for Hearing on December 12, 2011. (Tr. 40-41.) The hearing was held before an ALJ on January 9, 2013, and at the hearing plaintiff amended her alleged onset date to September 1, 2010. (Tr. 123.) On January 24, 2013, the ALJ found that plaintiff was not disabled. (Tr. 7-20.) Plaintiff exhausted all of her administrative remedies after the Appeals Council denied her Request for Review on February 12, 2014. (Tr. 1-5.) Therefore, the decision of the ALJ became the final decision of the defendant Commissioner.

II. MEDICAL HISTORY

A. Medical Records

On June 15, 2008, plaintiff sought treatment at the St. Alexius Hospital Emergency Department for pain in her right bicep and forearm. Plaintiff told the medical staff the pain had started two weeks prior, and she also reported numbness in her right arm. The medical staff's impression was a right arm sprain, and plaintiff was discharged with a work release form. (Tr. 278-79.)

On July 1, 2008, plaintiff was seen at the Barnes-Jewish Hospital Emergency Department. She complained of a "stinging and funny feeling in [her] right hand and arm" which worsened at night. (Tr. 220.) She said the symptoms were getting worse, but denied having weakness in any of her extremities. She was given a wrist cock-up splint, and was prescribed acetaminophen and codeine for her pain. (Tr. 218-27.)

On July 2, 2008, plaintiff sought treatment at St. Alexius Hospital Emergency Department for pain in her right hand. Plaintiff complained that the pain she experienced was 10 out of 10 on a pain scale. She told the staff she had been diagnosed with CTS. The medical staff determined she had joint pain, but found no signs of swelling, deformity, bruising, or limited range of motion. The medical staff's impression was right arm CTS. Plaintiff was given a dose of Toradol for her pain, and a prescription for Xanax to help her sleep. (Tr. 288-94.)

On February 11, 2009, plaintiff went to St. Alexius Hospital Emergency Room for pain and swelling in her right hand. She described having occasional numbness in her thumb and first two fingers. The physician documentation from her visit states she appeared to be in obvious pain, had soft tissue swelling and tenderness, and had a positive Tinnel's sign, or a sensation of tingling in the distribution of the median nerve over her hand. The medical staff evaluated plaintiff as having CTS, and she was prescribed naprosyn and Ultram for her pain. The staff recommended she wear her splint as much as possible and follow up with her doctor for a possible referral to a neurologist or neurosurgeon. (Tr. 300-06.)

On August 29, 2010, plaintiff went to St. Alexius Hospital Emergency Department for pain and swelling in her right hand. She described the pain as intermittent and aching, and she reported having some numbness in her fingertips. The medical staff opined that plaintiff was suffering from chronic hand pain. She was prescribed Motrin and Ultram for her pain. (Tr. 318-24.)

On June 16, 2011, plaintiff sought treatment at St. Alexius Hospital Emergency Department due to numbness in her right hand. She also reported having chronic pain and numbness in both hands. During her examination, medical staff determined she had 3/5 grip strength in both hands and was suffering from CTS in both hands. Plaintiff was instructed to take ibuprofen and wear splints as much as possible. She was given a work release which stated she would be able to return to work the next day. (Tr. 230-40.)

On November 9, 2011, at the request of the State, plaintiff was examined by Patrick A. Hogan, M.D., a neurologist. Dr. Hogan opined that plaintiff "may have CTS but has a number of functional findings which lead one to question whether she actually has true CTS." (Tr. 334-35.) Dr. Hogan advised that plaintiff be thoroughly examined for CTS. (Tr. 334.)

On November 25, 2011, Donna Muckerman-McCall, D.O., a non-examining medical consultant for the State, completed a Physical Residual Functional Capacity regarding plaintiff. After examining all the evidence in plaintiff's file, Dr. Muckerman-McCall opined that, in an eight-hour workday, plaintiff could occasionally lift 20 pounds, frequently lift 10 pounds, and stand or walk 6 hours. She also found that plaintiff had no pushing or pulling limitations aside from her lifting restrictions, but did have some limitations as to fingering and feeling due to her possible CTS. Dr. Muckerman-McCall found plaintiff to be mostly credible, but stated that plaintiff's CTS could not be completely diagnosed without a nerve conduction study. (Tr. 341-46.)

On January 3, 2012, plaintiff went to Grace Hill Murphy-O'Fallon Health Center for bilateral arm pain, and was examined by Miranda Coole, M.D. During the examination, plaintiff stated she took six Aleve pills per day, and used a rigid brace daily. Plaintiff also stated she had recently obtained insurance, and explained she had been unable to properly address her pain in the past due to her lack of insurance. Dr. Coole noted that plaintiff had reduced grip strength and mild pain in both wrists. Dr. Coole assessed plaintiff as having CTS, and she requested plaintiff undergo nerve conduction studies for further evaluation. (Tr. 397-99.)

On July 21, 2012, plaintiff sought treatment at St. Alexius Hospital Emergency Department for pain in her left shoulder. Plaintiff indicated that she was unable to raise her left arm. An X-ray was taken of plaintiff's left shoulder, which revealed minimal degenerative changes in the shoulder and no fractures or dislocation. Plaintiff was informed that if her symptoms persisted, an MRI should be taken of her shoulder for further evaluation. (Tr. 359-68.)

On August 29, 2012, plaintiff again sought treatment at the St. Alexius Hospital Emergency Department due to pain in her left shoulder. She was given a dose of Toradol for her pain, and her left arm was placed in a soft splint. (Tr. 318-20.)

On October 10, 2012, plaintiff was seen by Dr. Coole at the Grace Hill Health Center for pain in both of her wrists. Plaintiff described the pain as radiating from her wrists to her hands, and reported waking up at night due to the pain. She reported to the medical staff that she had tried using braces but had been unable to work with them on. Plaintiff tested positive for Phalen's, or a tingling sensation in the distribution of the median nerve over the hand, in both of her hands, and she was assessed as likely having CTS. She was restarted on gabapentin and NSAIDs for pain and inflammation, was given a referral for further diagnostic testing, and was prescribed Tramadol for her pain. (Tr. 380-82.)

On November 15, 2012, plaintiff sought treatment at the St. Alexius Emergency Department due to pain in both of her hands. Plaintiff reported that ibuprofen was not helping her pain, she had trouble sleeping, and she was out of oxycodone. She was discharged with a refill on her narcotics medication. (Tr. 349-52.)

On November 27, 2012, plaintiff was seen by Dr. Coole at the Grace Hill Murphy Clinic for her CTS and a medication refill. Plaintiff reported she had stopped taking gabapentin because it did not work. Plaintiff rated her pain 10 out of 10 on a pain scale. She said her symptoms were aggravated by repetitive work and hand intensive activity. Plaintiff was assessed as having CTS and was given a referral to a neurologist. ...


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