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Shamp v. Colvin

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

June 30, 2015

JUNE M. SHAMP, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

MEMORANDUM OPINION

DAVID D. NOCE, Magistrate Judge.

This action is before the court for judicial review of the final decision of the defendant Acting Commissioner of Social Security denying the application of plaintiff June N. Shamp for a disability benefits under Titles II and XVI of the Social Security Act. The parties have consented to the exercise of plenary authority by the undersigned Magistrate Judge under 28 U.S.C. ยง 636(c). For the reasons set forth below, the decision of the Administrative Law Judge is affirmed.

I. BACKGROUND

Plaintiff June M. Shamp, born September 27, 1974, applied for disability benefits under Titles II and XVI of the Social Security Act on September 1, 2001. (Tr. 9.) Plaintiff alleged an onset date of disability of December 13, 2009, due to herniated disk, depression, panic attacks, nerve damage to the right and left hips, diabetes, degenerative disk disease, and carpal tunnel syndrome. (Tr. 220-34.) Plaintiff's claim was initially denied on January 30, 2012. (Tr. 104-11.) On February 10, 2012, plaintiff filed a Request for a Hearing. (Tr. 119-20.) Plaintiff appeared and testified at a hearing before an ALJ on March 4, 2013, and on March 25, 2013, the ALJ found that plaintiff was not disabled. (Tr. 6-25.) Plaintiff exhausted all of her administrative remedies when the Appeals Council denied her Request for Review on April 4, 2014. (Tr. 1-4.) Thus, the decision of the ALJ stands as the final decision of the defendant Commissioner.

II. MEDICAL HISTORY

A. Medical Records

On January 10, 2008, plaintiff a magnetic resonance imaging (MRI) of her back. Paula George, M.D., interpreted the results of the MRI and found small right paracentral disc herniation at L5-S1 with a mild impression on the right ventral thecal sac and right S1 nerve root; there was no neural stenosis. (Tr. 372-73.)

On January 28, 2008, plaintiff was examined by Joel T. Jeffries, M.D., at the Columbia Region Orthopaedic Clinic with a chief complaint of right side low back pain. Dr. Jeffries noted that plaintiff was pleasant and cooperative. Dr. Jeffries' impression of plaintiff's condition was lumbar radiculopathy.[1] (Tr. 276-79.)

On April 2, 2008, plaintiff again visited Dr. Jeffries for review the MRI findings. Dr. Jeffries diagnosed lumbar disk degeneration with small disk protrusion to the right at L5-S1. Dr. Jeffries' treatment included a right L5-S1 transforaminal epidural steroid injection. (Tr. 280-81.)

On July 9, 2008, plaintiff saw Dr. Jeffries with a chief complaint of low back pain. Plaintiff rated her pain at 2 out of 10. Dr. Jeffries' physical examination revealed no significant abnormality in the low back region. Dr. Jeffries recommended a lifting restriction of twenty pounds and physical therapy three times a week for eight weeks. (Tr. 282-83.)

On August 13, 2008, plaintiff saw Dr. Jeffries for a follow-up appointment. Dr. Jeffries noted that plaintiff had been in physical therapy and "has enjoyed substantial diminution in her symptoms" and that plaintiff rated the pain as a 1 out of 10. Plaintiff denied any lower extremity symptoms. Dr. Jeffries noted that plaintiff's low back pain was improving. Dr. Jeffries further noted that "[plaintiff] will be returned to work without restriction." (Tr. 284-85.)

On September 25, 2008, plaintiff visited Dr. Jeffries with a complaint of ongoing back discomfort. Dr. Jeffries noted that plaintiff missed the last two weeks of therapy due to "family conditions." Dr. Jeffries documented that plaintiff was pleasant and cooperative and that her lower extremity motor strength was normal. Dr. Jeffries noted that his impression was "mechanical low back pain, improved" and that he felt plaintiff was at maximum medical improvement. Dr. Jeffries recommended that plaintiff continue working without restriction. Additionally, Dr. Jeffries noted that he discussed the difference between impairment and disability with plaintiff and that in his opinion, plaintiff sustained a permanent partial impairment of three percent. (Tr. 286-87.)

On October 20, 2008, plaintiff saw Dr. Jeffries with a chief complaint of increased back pain. Dr. Jeffries noted that plaintiff was pain free at times and that she was able to find a position of comfort to address her pain. Dr. Jeffries' treatment plan included a home exercise program and for plaintiff to continue to work without restriction. (Tr. 288-90.)

On December 2, 2008, plaintiff returned to Dr. Jeffries for a follow-up appointment. Dr. Jeffries noted that plaintiff was doing reasonably well and should continue to work without restrictions. (Tr. 291.)

On January 7, 2009, plaintiff visited the Pike Medical Clinic, complaining of muscle cramping, excessive urination, and a possible tuberculosis exposure. The records do not state the locations of the muscle cramping. The records also do list the name or qualifications of the treating provider. (Tr. 347-48.)

On February 5, 2009, plaintiff again visited the Pike Medical Clinic with a complaint of low back pain. The provider prescribed Vicodin and Skelaxin for the pain. Plaintiff also received an injection of Depo-Medrol in the right hip to treat her pain. (Tr. 346.)

On June 8, 2009, plaintiff returned to Dr. Jeffries' office. Plaintiff complained of increased back pain and dysesthesias (impairment of sensitivity) radiating down her left lower extremity. Dr. Jeffries noted that plaintiff was pleasant and cooperative. Dr. Jeffries stated he did not want any additional treatment for plaintiff's back pain. Dr. Jeffries' treatment plan included a home exercise program and continuing working without restrictions. (Tr. 292-94.)

On July 15, 2009, plaintiff again returned to Dr. Jeffries' office. Plaintiff reported that her lower extremity pain was now more of a tingly sensation. Dr. Jeffries noted his impression of work-related back pain and lumbar disk degeneration and stated that plaintiff could continue to work without restriction. (Tr. 295-96.)

On August 19, 2009, plaintiff visited Dr. Jeffries, who noted that plaintiff experienced "spontaneous improvement in her condition" and that she had returned to work without restriction and was doing reasonably well. Dr. Jeffries also documented "I think that it is also reasonable to expect that [plaintiff] will have episodic back pain. She should continue her home exercise program. She is not desirous of injections or surgical intervention." (Tr. 297-98.)

On November 25, 2009, plaintiff went to the Arthur Center for an initial visit. The provider's impression was that plaintiff was depressed. The treatment plan included Prozac (an antidepressant) and hydroxyzine (an anti-anxiety drug). (Tr. 467-68.)

On May 8, 2010, plaintiff returned to the Arthur Center for medication management. Andrea Earlywine, APN, prescribed Prozac, Vistaril (hydroxyzine), and trazodone (an antidepressant). (Tr. 465-66.)

On June 24, 2010, plaintiff visited the Arthur Center for a follow-up appointment. Nurse Earlywine reported that plaintiff had recently filed for divorce and her nerves had been bad. She noted that plaintiff's mood appeared anxious and depressed. She stated that plaintiff's memory was intact and that she had no psychosis. Nurse Earlywine discontinued the trazodone and increased the Prozac dosage. (Tr. 464.)

On July 23, 2010, plaintiff returned to the Arthur Center and saw Nurse Earlywine. Nurse Earlywine noted that plaintiff rated her depression as 2 or 3 out of 10. She reported that plaintiff's mood was stable and that there was no psychosis. Nurse Earlywine's treatment plan included Prozac, hydroxyzine, and Rozerem (a sleep agent). (Tr. 463.)

On August 2, 2010, plaintiff returned to Wilbers Family Care Clinic with a chief complaint of back pain. Nurse Swoboda's treatment plan consisted of ibuprofen and Tylenol. (Tr. 388.)

On January 17, 2011, plaintiff returned to the Wilber Family Care Clinic for a follow-up appointment. Nurse Swoboda noted that plaintiff complained of anxiety. (Tr. 387.)

On May 5, 2011, plaintiff visited the Emergency Department at Hermann Area District Hospital complaining of back pain. Jaya Uppal, M.D., examined plaintiff and ordered an x-ray of the lower back and prescribed Toradol for pain. Dr. Uppal noted that the x-ray showed L5-S1 degenerative disc disease with facet hypertrophy and no acute fracture or subluxation. Dr. Uppal prescribed Vicodin for pain and discharged plaintiff noting that plaintiff's condition was improved. (Tr. 334-41.)

On June 20, 2011, plaintiff visited Thomas J. Spencer, Psy.D., at Associated Behavioral Consultants for a psychological evaluation to assist in determining Medicaid eligibility. Dr. Spencer noted that plaintiff complained of being depressed. Dr. Spencer opined that plaintiff had a mental illness with a duration that could exceed twelve months, "but with appropriate treatment and compliance, prognosis likely improves." Dr. Spencer further noted that plaintiff's daily functioning included fixing lunch, cleaning the house, watching movies, and fixing dinner. Additionally, ...


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