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Carol Vaughn v. Michael J. Astrue

April 28, 2011


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



Carol Vaughn ("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 her 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 her applications on October 19, 2006, alleging disability since September 4, 2006 due to "hand problems and numbness in body" (AR 113-117; 141).*fn1 Her applications were denied and she requested and was granted an administrative hearing before an administrative law judge ("ALJ") (AR 69-79). Following a hearing held on April 15, 2008 (AR 31-64), the ALJ concluded, in a written decision dated June 3, 2008, that the Plaintiff was not entitled to a period of disability, DIB or SSI under the Act (AR 11-22). Plaintiff‟s request for review by the Appeals Council was denied (AR 1-5), rendering the Commissioner‟s decision final under 42 U.S.C. § 405(g). Plaintiff filed her complaint in this Court on June 24, 2010 challenging the ALJ‟s decision. Presently pending before the Court are the parties‟ cross-motions for summary judgment. For the following reasons, the Commissioner‟s motion will be denied and the Plaintiff‟s motion will be granted only to the extent she seeks a remand for further consideration.


Plaintiff was 54 years old on the date of the ALJ‟s decision and has a high school education (AR 20). Plaintiff has past relevant work experience as a bus driver and stopped working on September 1, 2006 (AR 141). Plaintiff stated that that hand problems and body numbness limited her ability to work (AR 141). Plaintiff claimed that severe hand pain made it hard for her to "do anything" and that she could not "feel [her] feet" (AR 141).

The relevant medical records reveal that the Plaintiff has been evaluated and treated by a number of health care providers, including several neurologists, rheumatologists and neuromuscular specialists for her complaints of pain (AR 176-229; 237-317).*fn2 On September 22, 2006, the Plaintiff was seen by Lawrence Adams, M.D. and complained of pain and a burning sensation in her hands and pain in her left knee (AR 212). An MRI of the Plaintiff‟s brain dated October 6, 2006 showed no acute ischemic event, but changes in the white matter tract were moderately suspicious for a demyelinating disease (AR 206).

Plaintiff was evaluated on October 18, 2006 by Alan Kivitz, M.D., a rheumatologist, for her complaints of hand and foot pain/numbness (AR 181-183). Her physical examination was unremarkable and lab studies were ordered (AR 183). On November 9, 2006, Dr. Kivitz‟s physical examination of the Plaintiff remained unchanged and he was of the opinion that her complaints were probably not the result of a "true rheumatologic process" (AR 178).

On November 13, 2006, the Plaintiff was evaluated by Kathleen Schaefer, M.D., a neurologist (AR 189-191). Dr. Schaefer noted that the Plaintiff‟s MRI showed no acute abnormalities, but that she had some chronic changes which were likely ischemic, given her history of severe hyperlipidemia and cigarette smoking, but noted these abnormalities were not atypical in a patient with a demyelinating disease (AR 190). Her physical examination of the Plaintiff revealed no deficits, except some decreased sensation was noted below the Plaintiff‟s left wrist, below the right mid-palm and the dorsum of the hand, and her sensation was "somewhat" decreased in her calves bilaterally (AR 190). Dr. Schaefer diagnosed the Plaintiff with paresthesia, numbness and joint swelling (AR 190). On November 28, 2006, Dr. Schaefer reported that nerve conduction studies revealed mild bilateral sensory median neuropathy consistent with mild carpal tunnel syndrome (AR 189).

Plaintiff was seen by Robert Gotoff, M.D., an infectious disease specialist on December 6, 2006, who reported that an examination of her extremities revealed no joint deformities, effusion or inflammation, and her neurological examination revealed no abnormalities and no focal motor deficits (AR 198). Dr. Gotoff assessed her with an abnormal MRI of the brain consistent with a demyelinating disease and considered either MS and Lyme disease as a possible diagnosis (AR 198). A subsequent CT scan of the Plaintiff‟s head dated December 16, 2006 revealed minimal cortical cerebral atrophy and right ethmoid sinusitis, but no evidence of intracranial hemorrhage or mass effect (AR 215; 221).

On March 1, 2007, Juan B. Mari-Mayans, M.D., a non-examining state agency reviewing physician, reviewed the medical evidence of record and opined that the Plaintiff could perform light work involving only occasional climbing, balancing, stooping, kneeling, crouching and crawling (AR 230-234). *fn3

Plaintiff was seen by Dr. Schaefer in January 2007, and continued to complain of diffuse pain in her limbs, joints and back, as well as headaches (AR 238). Dr. Schaefer noted she was on a "variety of narcotics" for her pain and that a lumbar puncture performed that month was unremarkable (AR 238). Plaintiff‟s neurological examination showed mild to moderate spinal tenderness without any deformity (AR 238). Her strength was symmetric, she had reduced sensation of the index and middle fingers bilaterally, mildly diffuse brisk reflexes and no pathologic reflexes (AR 238). Dr. Schaefer felt the Plaintiff‟s symptoms were suggestive of a systems disorder (AR 238).

Plaintiff was evaluated by Milind Kothari, D.O., at a neuromuscular clinic in February 2007 (AR 290-293). Physical examination was unremarkable except for some mildly diminished pin prick sensation in the finger tips and of the ankles, left greater than right (AR 291-292). An MRI conducted on March 27, 2007 showed scattered periventricular changes but no change from her previous MRI (AR 294; 298-299).

Plaintiff was evaluated by Larry Moreland, M.D., a rheumatologist on September 12, 2007 (AR 262-264). Her physical examination was unremarkable except for some "positive trigger points" in her back and shoulder area, and she was diagnosed with an undefined connective tissue disease based on her neurological history (AR 263-264).

Plaintiff returned to Dr. Moreland on September 19, 2007 who reported that all of her laboratory studies and radiographic studies were normal except for some minor changes of osteoarthritis in her hands (AR 258). Plaintiff reported that she was still suffering from severe pain and her medications were not effective (AR 258). Her physical examination remained unchanged (AR 258). Plaintiff was diagnosed with fibromyalgia syndrome and osteoarthritis (AR 258). Her Vicodin dosage was increased and she was referred for pain management (AR 258). A November 14, 2007 musculoskeletal examination performed by Dr. Moreland revealed osteoarthritic changes of her DIP and PIP joints but no other abnormalities were noted (AR 254). She had a good range of motion of all joints and exhibited normal strength (AR 254).

Plaintiff was seen by Renu Pokharna, M.D. on November 29, 2007 who noted that all of her studies had been negative (AR 301). Her physical examination remained unchanged (AR 302). Dr. Pokharna ruled out multiple sclerosis and concluded that ...

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