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Lyons v. Commissioner of Social

July 22, 2009


The opinion of the court was delivered by: Conti, District Judge


This is an appeal from the final decision of the Commissioner of Social Security ("Commissioner" or "defendant") denying the claims of Debra Lyons ("plaintiff") for disability insurance benefits ("DIB") under Title II of the Social Security Act ("SSA"), 42 U.S.C. §§ 401-33 and supplemental security income ("SSI") benefits under Title XVI of the SSA, 42 U.S.C. §§ 1382-83. Plaintiff contends that the decision of the administrative law judge ("ALJ") that she is not disabled, and therefore not entitled to benefits, should be reversed or remanded because the decision is not supported by substantial evidence. Defendants assert that the decision of the ALJ is supported by substantial evidence. The parties filed cross-motions for summary judgment pursuant to Rule 56 (c) of the Federal Rules of Civil Procedure. The court will not grant summary judgment in favor of plaintiff or defendant. The ALJ's decision will be reversed because it is not supported by substantial evidence and this case will be remanded for proceedings consistent with this opinion. Procedural History

On February 22, 2005, plaintiff protectively filed applications for DIB and SSI alleging disability since September 23, 2004, due to a cardiac condition, panic disorder, right arm and shoulder pain, right ear hearing loss, chronic obstructive pulmonary disease ("COPD")*fn1 , spinal stenosis*fn2 , carpal tunnel*fn3 , degenerative joint disease*fn4 ("DJD") in the knees and back, cataracts, and depression. (R. at 63-66, 446-49.) Plaintiff's claims were denied on June 2, 2005. (R. at 31-32, 450-51.) Plaintiff's case was randomly selected to test modifications to the disability determination process, and the reconsideration step of the administrative review process was eliminated and the case went directly to the hearing level. (R. at 37, 454.) Plaintiff requested a hearing, which was held before the ALJ on April 25, 2006. (R. at 40, 473-500.) Plaintiff, who was represented by counsel, testified at the hearing. (R. at 473-500.) A vocational expert ("VE") and plaintiff's daughter also testified. (R. at 501-11.) On June 13, 2006, the ALJ issued an unfavorable decision (R. at 12-23) and plaintiff filed a timely request for review with the appeals council. (R. at 462-63.) After a denial of that request on April 30, 2008, and having exhausted all administrative remedies, plaintiff filed this appeal.

Plaintiff's Background and Medical History

At the time of the hearing, Plaintiff was fifty-two years old. (R. at 63). She had a high school education. (R. at 82.) In the past, plaintiff had worked as a nurse's assistant. (R. at 77.) Plaintiff stopped working on August 23, 2004, due to her "illness, injuries or conditions", which she reported as being "constantly tired", "short of breath", and experiencing "chest pains." (R. at 76.)

Medical Evidence

In November 2002, plaintiff suffered a myocardial infarction. (R. at 122.) On February 19, 2004, plaintiff was seen by Dr. Gopalan Vasudevan for a follow-up cardiac appointment.

(R. at 154.) Plaintiff indicated occasional episodes of chest discomfort and pain in the arms and legs. (Id.) She had been asked to stop her Lipitor to determine if that was the cause of her arm and leg pain, but she noted no difference after discontinuing that medication. (Id.) After a review of plaintiff's cardiac catheterization films, Dr. Vasudevan saw no indications of significant disease to warrant additional intervention. (Id.) Dr. Vasudevan noted his impression as coronary artery disease with symptoms suggestive of stable angina, bronchial asthma, depression, obesity, hyperlipidemia,*fn5 and DJD. (Id.)

On May 27, 2004, plaintiff presented to Dr. Bernard Scherer, her family practitioner, for a follow-up appointment. (R. at 249.) On examination, Dr. Scherer noted no issues and indicated that plaintiff's asthma was doing well, as was her coronary disease, which was stable.

(R. at 249.) Dr. Scherer noted that plaintiff was still having problems with short term memory and had to write things down fairly often, but noted that her memory seemed good while in his office. (R. at 249.)

On August 16, 2004, plaintiff was admitted to the hospital with chest pains. (R. at 120.) Dr. Bernard Scherer noted in his assessment plan that plaintiff had dyspnea*fn6 and ordered a stress test. (R. at 121.) He also noted a history of panic disorder and depression, which was well controlled and asthma/COPD. (Id.) An x-ray of the chest was normal. (R. at 124). A dual isotope adenosine myocardial scan stress test was also normal. (Id.) Dr. Richard Seccof noted that plaintiff's ECG was negative for ischemia. (R. at 125.) On August 19, 2004, plaintiff was seen for a follow-up by Dr. Gopalan Vasudevan. (R. at 151.) Plaintiff reported infrequent sharp jabbing pains in her chest and continued pain in her legs, which was attributed to spinal stenosis. (Id.) Dr. Vasudevan noted his impression as minor coronary artery disease, bronchial asthma, depression, obesity, hyperlipidemia, spinal stenosis, and neuropathy of lower extremities. (R. at 151.

On October 14, 2004, plaintiff was seen by Dr. Bruck Hershock for a follow-up appointment for her left knee arthritis. (R. at 233). Plaintiff indicated a bit more discomfort than she had been experiencing at previous visits. (Id.) Upon examination, Dr. Hershock found no effusion to the knee. (Id.) He further indicated that plaintiff's range of movement ("ROM") remained unrestricted, but that, as he previously noted, she had patella femoral crepitance.*fn7 (Id.)

On October 22, 2004, plaintiff was admitted for a second time to Latrobe Area Hospital for chest pain. (R. at 165.) Plaintiff's examination was normal except for mild wheezing in the lungs. (R. at 170.) An x-ray of plaintiff's chest was normal. (R. at 173.) An x-ray of plaintiff's lumbosacral vertebra indicated L4-5 and L5-S1 degenerative disc disease*fn8 with some, mild degenerative facet arthropathy.*fn9 (R. at 174.) On October 26, 2004, plaintiff was transferred to Allegheny General Hospital for a cardiac catheterization. (R. at 156.) Plaintiff underwent a coronary arteriography and left ventriculography. (R. at 156-57.) The angiography indicated mild coronary irregularities, particularly a small caliber diagonal branch that contained approximately a 40-60% stenosis. (R. at 156.) Left ventricular function was normal and Dr. Howard Grill noted that plaintiff's symptoms were likely noncardiac in nature as the partially blocked vessel was small and the lesion noncritical. (Id.)

On November 9, 2004, plaintiff was seen for a cardiac follow-up by Dr. Seecof. (R. at 254.) Dr. Seecof noted that plaintiff reported occasional shortness of breath, which he presumed was related to her asthma. He further reported that plaintiff did not have classic angina, but had some nausea and lightheadedness. (Id.) Upon examination, Dr. Seecof noted that plaintiff's heart had regular rate and rhythm without audible murmur, rub, gallop or click. He further noted no peripheral edema and no jugular venous distension. (Id.) He concluded that plaintiff's mild coronary disease was stable and made no changes to her regime. (Id.)

On January 8, 2005, plaintiff was seen in the emergency room at Latrobe Area Hospital.

(R. at 186.) Plaintiff reported that when she bent down to pick up a towel off the floor, she had right lower back pain that radiated down both legs to her feet. (R. at 187.) Plaintiff underwent an x-ray of the lumbar spine which indicated degenerative change to the lower lumbar spine at L3/4, L4/5, and L5/S1 without spondylolisthesis or spondylolysis.*fn10 (R. at 192.)

On January 21, 2005, plaintiff underwent right eye cataract extraction and implant. (R. at 194.) On March 8, 2005, plaintiff saw her eye surgeon, Dr. Patrick Lally, for a follow-up examination for her cataract extraction. (R. at 260.) He noted that plaintiff's surgery resulted in a nice outcome. (R. at 260.) On May 3, 2005, plaintiff underwent left eye cataract extraction and implant. (R. at 332, 383.) Following the surgery, plaintiff had blurry vision only during reading and was given prescription glasses. (R. at 330.)

On February 11, 2005, plaintiff returned to Dr. Seecof for a cardiac follow-up and he noted that her status was stable and made no changes to her regime. (R. at 253.)

On April 12, 2005, plaintiff presented to Dr. Scherer with complaints of leg pain, right arm and shoulder pain, and bilateral hand numbness. (R. at 419.) On April 28, 2005, plaintiff underwent an MRI of the cervical spine, which indicated mild right foraminal stenosis at C4/5, minimal disc bulging without central or foraminal stenosis at C5/6, and some potential foraminal stenosis at C6/7. (R. at 266.) Plaintiff was referred to Dr. Louis Catalano, a neurologist. (R. at 420.)

In May 2005 plaintiff underwent a consultative examination by Dr. Duree Ahmed. (R. at 269-72.) Plaintiff complained of shortness of breath since 2002, chest pain on and off, trouble going up and down the steps, panic attacks since 2001, and constant knee pain. (R. at 269.) Dr. Ahmed indicated plaintiff's past medical history as heart problems, hyperlipidemia, depression, panic attacks, hearing problems, spinal stenosis, and degenerative joint disease. (R. at 269.) Upon examination, Dr. Ahmed noted that plaintiff had no murmurs or gallop in her heart; no enlargement of the spleen, liver, or kidney; negative edema in the extremities; normal range of motion in the shoulder, elbow, wrist, hip, knee, and ankle; normal gait; normal reflexes; and good behavior, memory, and orientation. (R. at 271.) Plaintiff could also rise from a chair, but would not squat due to eye surgery two days prior and instructions from her eye surgeon. (Id.)

Dr. Ahmed completed a functional capacity evaluation for plaintiff. (R. at 273-76.) Dr. Ahmed indicated that plaintiff could occasionally lift and carry two to three pounds. (R. at 273.) He further indicated that plaintiff could stand and walk one hour or less per day; could sit for thirty minutes per day; and could push and pull small objects. (Id.) Dr. Ahmed also reported that plaintiff had hearing ...

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