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Stadtfeld v. Commissioner of Social Security

April 16, 2009


The opinion of the court was delivered by: Terrence F. McVerry United States District Court Judge


I. Introduction

Pending before the court are cross-motions for summary judgment based on the administrative record: DEFENDANT'S MOTION FOR SUMMARY JUDGMENT (Document No. 14) and PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT (Document No. 11). The motions have been fully briefed and are ripe for resolution.

Plaintiff, Beth A. Stadtfeld, brought this action pursuant to 42 U.S.C. § 405(g) and §1383(c)(3) for judicial review of the final determination of the Commissioner of Social Security ("Commissioner") which denied her application for disability insurance benefits ("DIB") and supplemental security income ("SSI") under titles II and XVI of the Social Security Act ("Act"), 42 U.S.C. §§ 401-403; 1381-1383f.

II. Background

A. Facts

Plaintiff was born on September 2, 1965, and was 41 years old at the time of the hearing, and therefore was defined as a "younger individual," age 18-44, pursuant to 20 C.F.R. § 404.1563 and §416.963. R. 23. Plaintiff has at least a high school education and is able to communicate in English. R. 23. Plaintiff's relevant work history was as a lottery ticket cashier and as a healthcare aide. R. 478, 482. She was working as a hostess three or four days a week at the time of the hearing. R. 460. Her earnings record reveals that she has acquired sufficient coverage to remain insured through September 30, 2009. R. 17.

Plaintiff alleges disability since August 26, 2004 due to diabetes, high blood pressure, tachycardia, and emotional problems. R. 44-47, 68, 71, 421-22. Plaintiff was diagnosed with diabetes and hypertension in January 2000. R. 166. On January 7, 2001, Plaintiff was hospitalized for three days due to elevated blood sugars. R. 197-200. Plaintiff was provided with insulin and given Buspar for reported anxiety and depression problems. R. 197-200. In September 2003, Plaintiff hurt her shoulder and neck lifting a patient at her home health aide job. R. 269. X-rays of the shoulder showed no gross osseous abnormalities and x-rays of the cervical spine showed a loss of cervical lordosis. R. 271. Plaintiff attended physical therapy sessions from September 2003 through December 2003 for left shoulder rotator cuff tendonitis. R. 238-253.

On May 12, 2004, Plaintiff was admitted to the hospital and upon arrival was anxious, confused, agitated, and screaming. R. 356. Plaintiff reported that she was short of breath, that her heart was racing, and that she felt like she was in a dream. R. 362. She further reported that she felt like she was leaving her body and also that she was dying. R. 377. Plaintiff told doctors that she was working a lot of hours at her job, which was producing anxiety. R. 362, 377, 382. Plaintiff reported that she was working two jobs trying to support her child and the child's father. R. 362, 377, 382. Plaintiff reportedly stopped taking her blood pressure medications prior to her hospitalization because she could not afford them. R. 362. Plaintiff's spouse was disabled. R. 377. Plaintiff denied a history of sexual, verbal, or physical abuse. R. 385.

Dr. Steven Riggall diagnosed Plaintiff with generalized anxiety disorder while she was hospitalized. R. 363. Plaintiff had a global assessment of functioning (GAF) score of 21.*fn1 R. 363. During Plaintiff's mental status examination, Dr. Riggall reported that Plaintiff had fair concentration, good memory, did not report irritability, reported that she was always tired, and denied hopelessness. R. 362. Riggall further reported that Plaintiff was alert and oriented times three, her speech was normal with regard to rate and flow, her eye contact was fair, she denied homicidal or suicidal ideation, she denied hallucinations or delusions, she was positive for flight of ideas, had good hygiene, and was dressed appropriately. R. 362. On May 14, 2003, Plaintiff reported feeling much better since restarting her blood pressure medications and reported that she would decrease her workload to reduce her stress, and would spend more quality time with her daughter. R. 369, 399.

On August 31, 2004, Plaintiff was seen by her cardiologist, Dr. Ronnie Mignella, M.D., for a follow-up appointment. R. 254-55. Dr. Mignella reported a history of sinus tachycardia, valvular heart disease, mild hypertension, and morbid obesity. R. 254. Plaintiff reported palpitations which Mignella felt were the result of anxiety from emotional stress. R. 254. He noted that she had been monitored at the emergency room and found to have a normal rhythm. R. 254. He further noted that Plaintiff's hypertension was well controlled and that the remainder of the examination was unremarkable. R. 254-55. He reported that the patient was doing "quite well." R. 254.

On September 3, 2004, Plaintiff was evaluated by Dr. Mark Stabile, D.O., at Parkside Orthopedic Associates following the re-injury of shoulder and her neck at work on August 26, 2004. R. 269-71. Plaintiff had x-rays which revealed no gross osseous abnormalities in the left shoulder, but also revealed a loss of the cervical lordosis. R. 271. An MRI indicated mild broad-based disc bulging "of the disc indenting the anterior thecal sac, but not causing any significant impression on the foramina or exiting nerve roots." R. 272. Dr. Stabile prescribed Naprosyn and physical therapy, which Plaintiff attended from September 2004-November 2004. R. 265, 273-85. At her first physical therapy appointment, the therapist noted that "this lady with significant limitations in cervical spine causing local reproduction of her symptoms. I am unable to reproduce her left shoulder pain with cervical spine exam." R. 277. On October 18, 2004, Plaintiff returned to Dr. Stabile who indicated that Plaintiff's neck was fine, but that Plaintiff was still experiencing pain in her left shoulder. R. 259. However, she also reported that the physical therapy was providing relief. R. 259. Upon discharge from physical therapy, the therapist reported that Plaintiff had mild discomfort in her left shoulder and could lift and carry thirty pounds. R. 273.

On September 9, 2005, Dr. Roy Sartori, D.O., performed a consultative exam at the state agency's request. Examination of Plaintiff's heart indicated no murmurs, gallops, rubs, or honks and no arrhythmia. R. 289. She further had normal grip strength in her right hand, but a 25% reduction in her left hand. She was able to bend and crouch normally and get on and off the examination table normally. R. 289. Dr. Sartori further indicated that there were no problems with lifting and grasping. R. 289. Dr. Sartori's impressions included that Plaintiff suffered from palpitations secondary to anxiety, morbid obesity, cervical radiculitis with chronic cervical strain and sprain, degenerative disc disease of the cervical spine, anxiety disorder, type II diabetes mellitus, and hypertension well controlled. R. 289. Dr. Sartori opined that Plaintiff could lift 25 pounds frequently and carry 10 pounds frequently. R. 291. He further opined that Plaintiff could stand for 1 to 2 hours; could sit for less than 6 hours; had no limitations on pushing or pulling; could frequently bend, kneel, stoop, crouch, balance, and climb; and that she had restriction in reaching with her left arm but not her right. R. 291.

On September 14, 2005, Dr. Joseph Kalik, plaintiff's family practitioner, filled out a form regarding Plaintiff's diagnoses. R. 298-99. Dr. Kalik indicated that Plaintiff suffered from anxiety with occasional panic attacks, but that Plaintiff was having a good response to Lorazepam. R. 298. Dr. Kalik further indicated that Plaintiff kept her scheduled appointments, interacted appropriately with office staff, and dressed appropriately. R. 298. Finally, he noted no difficulties with Plaintiff's activities of daily living, ability to function socially, and maintain concentration, persistence, and pace. R. 298-99. In a treatment note dated September 9, 2005, Dr. Kalik indicated that Plaintiff could walk steady and fast, bend and crouch, and get on an off the examination table easily. R. 300. On January 24, 2006, Plaintiff was seen by Dr. Iftikhar Chatha, M.D. and reported no new complaints. R. 344-45. Her physical examination was completely normal. R. 344-45. No changes were reported at two follow-up appointments in April and August of 2006. R. 334-35, 337-38.

On September 19, 2006, Jule Uran, Ph.D. and Martin Meyer, Ph.D., prepared a psychological report for the Office of Vocational Rehabilitation. (OVR). R. 347-81. Plaintiff was given cognitive testing and was found to have borderline cognitive ability. R. 350. Plaintiff reported that she had been mentally, sexually, and physically abused by her daughter's father who was currently living in her home. R. 348. Based on their assessment, Uran and Meyer diagnosed Plaintiff with major depressive disorder, recurrent (without psychotic ...

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