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Joseph W. Frantz v. Michael J. Astrue

April 7, 2011

JOSEPH W. FRANTZ, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: McLAUGHLIN, Sean J., District Judge.

MEMORANDUM OPINION

I.INTRODUCTION

Joseph W. Frantz ("Plaintiff"), commenced the instant action pursuant to 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner"), denying his claims for disability insurance benefits ("DIB") and supplemental security income ("SSI) under Titles II and XVI of the Social Security Act, 42 U.S.C. § 401, et seq. and § 1381 et seq. Plaintiff filed his applications on March 21, 2006 alleging disability since January 1, 2001 due to a history of heart attacks, herniated discs in his lower back and asthma (AR 127-138; 160).*fn1 His applications were denied and he requested and was granted an administrative hearing before an administrative law judge ("ALJ") (AR 93-98; 104-109; 115). Following a hearing held on October 14, 2008 (AR 21-43), the ALJ concluded, in a written decision dated October 31, 2008, that the Plaintiff was not entitled to a period of disability, DIB or SSI under the Act (AR 12-20). Plaintiff‟s request for review by the Appeals Council was denied (AR 1-4), rendering the Commissioner‟s decision final under 42 U.S.C. § 405(g). Plaintiff filed his complaint in this Court on May 6, 2010, challenging the ALJ‟s decision. Presently pending before the Court are the parties‟ cross-motions for summary judgment. For the reasons that follow, the Plaintiff‟s motion will be denied and the Commissioner‟s motion will be granted.

II.BACKGROUND

Plaintiff was 49 years old on the date of the ALJ‟s decision and has a limited education (AR 22). He has past work experience as security guard, laborer, janitor and cook (AR 161). The medical evidence reveals that the Plaintiff has a history of myocardial infarctions, coronary artery disease, hyperlipidemia, spondylosis of the lumbar spine with herniated discs, asthma and psoriasis. Although the Plaintiff has alleged disability since January 2001, the administrative record contains no treatment records before April 2004.

The relevant medical records reveal that the Plaintiff was treated at the Titusville Area Hospital on several occasions for his asthma complaints since April 2004. On August 13, 2004 he was seen in the emergency room for an asthma attack and was diagnosed with chronic obstructive pulmonary disease ("COPD") and prescribed an Albuterol inhaler and Prednisone (AR 251). His chest x-ray was reported as normal, and he was advised to quit smoking and return to the hospital if his symptoms worsened (AR 248; 251).

Plaintiff began treatment at the Conneaut Valley Health Center on September 10, 2004 under the direction of Frank McLaughlin, D.O. (AR 324).*fn2 Plaintiff was seen by Kelli Tautin, C.R.N.P. and reported that he had a heart attack at age 39, and relayed his previous emergency room treatments for his asthma (AR 324). He complained of trouble breathing, and stated that he had run out of his asthma medications three weeks prior (AR 324). He reported that he had stopped taking multiple heart medications, as well as the medication for his high cholesterol, due to a lack of insurance (AR 324). His physical examination was unremarkable and he was diagnosed with asthma, hyperlipidemia, fatigue and malaise (AR 323). Ms. Tautin ordered blood work and a chest x-ray (AR 323). Plaintiff was to return in one week for follow up (AR 323).

Plaintiff returned to Ms. Tautin on September 30, 2004 and reported that he felt well and that his asthma symptoms had improved with medication (AR 322). He complained of low back pain radiating down into his right leg exacerbated by extended walking (AR 322). Ms. Tautin reported that the Plaintiff was pleasant, alert, oriented and cooperative during the examination (AR 322). On physical examination, Ms. Tautin reported that the Plaintiff‟s muscle strength was  and equal in both his upper and lower extremities (AR 322). He exhibited full flexion of his back, but she found some mild tenderness to palpation in the low lumbosacral area (AR 322). He was assessed with asthma, hyperlipidemia and back pain (AR 322). Ms. Tautin prescribed Lipitor for his elevated cholesterol levels, and Daypro for his complaints of back pain, and ordered a lumbar x-ray (AR 322).

On February 9, 2005 the Plaintiff presented to the emergency room for treatment and was diagnosed with acute bronchitis and prescribed Prednisone and Robitussin AC (AR 231; 241). On June 5, 2005 he complained of difficulty breathing with symptoms of wheezing, and he was assessed with asthma and prescribed Prednisone (AR 221; 230).

Plaintiff returned to the Conneaut Valley Health Center on September 2, 2005, and it was noted that he had not been seen since September 2004 (AR 321). He complained of low back pain with increased intensity (AR 321). Ms. Tautin reported that the Plaintiff was very pleasant, alert, oriented and cooperative (AR 321). Plaintiff‟s physical examination was unremarkable, except some psoriatic lesions were noted on both arms and hands (AR 321). He was assessed with asthma, psoriasis and hyperlipidemia (AR 321). Ms. Tautin ordered diagnostic studies, refilled his medications, and stressed the importance of regular appointments (AR 321).

An x-ray of the Plaintiff‟s spine dated September 13, 2005 showed Grade I spondylolisthesis at the L4-5 level and mild degenerative disc disease at the L1-2, L4-5 and L5-S1 levels (AR 192).

Plaintiff returned to Ms. Tautin on October 11, 2005 and complained of increased back pain radiating down his right leg with some paresthesias (AR 320). Plaintiff reported that he wanted to work but was "truly miserable" while trying to work a full day (AR 320). He claimed back pain prevented him from working and presented disability forms to Ms. Tautin for completion (AR 320). On physical examination, Ms. Tautin found the Plaintiff‟s muscle strength was  and equal throughout (AR 320). She reported tenderness in the Plaintiff‟s lumbar spine that radiated down into his right hip (AR 320). Plaintiff also had increased pain with extension and flexion of his back with an inability to laterally bend due to pain (AR 320). Plaintiff was assessed with low back pain, prescribed Sulindac and Flexeril, and a lumbar MRI was ordered (AR 320).

An MRI of the Plaintiff‟s lumbar spine dated October 14, 2005 revealed a Grade I anterolisthesis at L4 with a broad based central disc herniation at the L5-S1 level (AR 190).

When seen by Ms. Tautin on November 11, 2005, the Plaintiff reported that his medications had been mildly effective, but he continued to have significant pain depending upon the weather and his activities (AR 317). Based upon the results of his MRI, the Plaintiff was scheduled for an appointment with Dr. Macielak, but could not be seen until February 2006 (AR 317). Ms. Tautin reported that the Plaintiff was very pleasant, alert, oriented and cooperative with the exam (AR 317). His muscle strength was  and equal throughout, but she reported that he had lumbar spine discomfort radiating down into his right leg with limited flexion and extension (AR 317). He was assessed with back pain and asthma and continued on medication (AR 317) On January 15, 2006, the Plaintiff presented to the emergency room complaining of chest pain and sought treatment for a possible acute myocardial infarction (AR 198; 219). He was diagnosed with a probable ongoing acute myocardial infarction and responded with conservative treatment (AR 218). It was recommended that he undergo a heart catheterization for a possible angioplasty, and he was transferred to St. Vincent Hospital to undergo further testing (AR 218).

Plaintiff was treated by Ross Peterson, M.D. at St. Vincent Hospital following his transfer (AR 280-282). An echocardiography report dated January 16, 2006 showed that his left ventricular ejection fraction was moderately reduced 30 to 35 percent (AR 270-271). He underwent a cardiac catheterization and was found to have blockages, but he was unable to undergo angioplasty (AR 318). Plaintiff was discharged on January 19, 2006 and instructed to take aspirin, Plavix, Vasotec and Lipitor, and was referred to a cardiac rehabilitation program (AR 262-263). He was instructed to stop smoking and follow a low cholesterol diet (AR 262). Plaintiff was restricted from lifting over ten pounds for one week and from driving for one week, and he was to follow up with his family physician in two weeks (AR 263).

Plaintiff returned to Ms. Tautin on March 3, 2006 and reported that he was doing well following his heart attack (AR 316). He indicated that he was following with a cardiologist, had not had any further chest pains, and was taking his medications as ordered (AR 316). Ms. Tautin noted she was "trying to get him off cigarettes" and had prescribed Wellbutrin, but the Plaintiff had not started taking it due to some questions (AR 316). Plaintiff voiced no complaints, his physical examination was unremarkable, and he was very pleasant, alert, oriented and cooperative (AR 316). Ms. Tautin diagnosed him with asthma, hyperlipidemia, and coronary artery disease (AR 316). Lab tests were ordered and following discussion, the Plaintiff indicated he would begin the Wellbutrin for smoking cessation (AR 316).

Plaintiff returned to Ms. Tautin on July 14, 2006 (AR 332). He indicated that he smoked less with the Wellbutrin and Ms. Tautin noted a "marked improvement" in his efforts (AR 332). He complained of weather related asthma symptoms (AR 332). His physical examination was unremarkable, although some faint scattered expiratory wheezes were noted that cleared when the Plaintiff coughed (AR 332). He was diagnosed with post MI, asthma, hyperlipidemia and tobacco dependence (AR 332). He was continued on medications (AR 332).

On September 19, 2006, Abu Ali, M.D., a non-examining state agency reviewing physician, reviewed the medical evidence of record and opined that the Plaintiff could perform sedentary work involving only occasional climbing, balancing, stooping, kneeling, crouching and crawling, and avoiding environmental hazards (AR 334-336).*fn3 Dr. Ali summarized the medical findings, noting that the medical evidence established that the Plaintiff had asthma, a prior myocardial infarction, low back pain and obesity (AR 338). Dr. Ali observed however, that medications had been successful in controlling the Plaintiff‟s symptoms, and that while he described limited daily activities, such limitations were not consistent with the other evidence in the record (AR 338).

An echocardiogram conducted on October 16, 2006 revealed that the Plaintiff‟s left ventricular ejection fraction was moderately reduced at 30 to 40 percent (AR 353). He reported to Ms. Tautin on October 27, 2006 that he was feeling well overall, had no specific complaints, and his physical examination ...


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