The opinion of the court was delivered by: David Stewart Cercone United States District Judge
April M. Baker ("Plaintiff") brings this action pursuant to 42 U.S.C. § 405(g), seeking review of the final determination of the Commissioner of Social Security ("Defendant" or "Commissioner") denying her application for disability insurance benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-433, 1381 - 1383f ("Act"). This matter comes before the court on cross motions for summary judgment. (ECF Nos. 9, 11). The record has been developed at the administrative level. For the following reasons, Plaintiff's Motion for Summary Judgment is DENIED, and Defendant's Motion for Summary Judgment is GRANTED.
Plaintiff filed for DIB and SSI with the Social Security Administration July 25, 2007, claiming an inability to work due to disability beginning June 2, 2007. (R. at 125 -- 33)*fn1 . Plaintiff was initially denied benefits on October 5, 2007. (R. at 75 -- 92). A hearing was scheduled for September 30, 2008, and Plaintiff appeared to testify represented by counsel. (R. at 7). A vocational expert also testified. (R. at 7). The Administrative Law Judge ("ALJ") issued a decision denying benefits to Plaintiff on November 13, 2008. (R. at 59 -- 73). Plaintiff filed a request for review of the ALJ's decision by the Appeals Council, which request was denied on December 3, 2010, thereby making the decision of the ALJ the final decision of the Commissioner. (R. at 1 -- 5).
Plaintiff filed her Complaint in this Court on January 10, 2011. (ECF No. 3). Defendant filed his Answer on March 21, 2011. (ECF No. 6). Cross motions for summary judgment followed.
III.STATEMENT OF THE CASE
The facts relevant to the present case are limited to those records that were available to the ALJ when rendering her decision. All other records newly submitted*fn2 to the Appeals Council or this court will not be considered, here, and will not inform the decision of this Court. See Matthews v. Apfel, 239 F.3d 589, 592, 594 -- 95 (3d Cir. 2001).*fn3
Plaintiff was born February 18, 1960, and was forty eight years of age at the time of her administrative hearing. (R. at 125, 129). Following graduation from high school, Plaintiff never received any post-secondary education or training. (R. at 13). Her last two jobs were as a kitchen cook, which position she held for approximately nine years, and as a deli clerk, which position she held approximately one year. (R. at 13 -- 14). Plaintiff had been living in a trailer home for the past two years with her fiance. (R. at 11). Plaintiff had a number of children, and eleven grandchildren. (R. at 12). Her grandchildren visited her occasionally, and one of her daughters visited her every day. (R. at 11 -- 12). Plaintiff's fiance received social security disability benefits as a result of back-related ailments. (R. at 12). Plaintiff helped to provide care for him on a daily basis. (R. at 12).
In April of 2006, Joel E. Nystrom, M.D. -- Plaintiff's primary care physician -- examined Plaintiff for a regular check-up. (R. at 244). He indicated that Plaintiff's mood was "pretty good." (R. at 244). He noted her complaints of achy, localized, fibromyalgia-type pain. (R. at 244). She complained about her hip in particular, but Dr. Nystrom found Plaintiff's hip had a full range of motion. (R. at 244). She did exhibit mild discomfort in her lower back and shoulders. (R. at 244). However, no other trigger points were found, and Plaintiff's knees were non-tender. (R. at 244). Dr. Nystrom recommended home exercise and walking. (R. at 244). He also increased her prescription Zoloft dosage for her anxiety and depression. (R. at 244). At a check-up in March of 2007, Dr. Nystrom found Plaintiff had not been taking her prescribed Zoloft for two months due to insufficient funds. (R. at 243). As a result, he noted an uptick in her anxiety and panic attacks. (R. at 243).
In May of 2007, Plaintiff visited Dr. Nystrom complaining of a fear of large crowds and big stores. (R. at 240, 253). She stated that she would go to Wal-Mart, but only at night when it was quieter. (R. at 240, 253). Plaintiff reported that she was still capable of working as a deli clerk. (R. at 240, 253). She also informed the doctor that she experienced low back and hip pain, with occasional pain in the upper back and chest. (R. at 240, 253). Minimal muscular tenderness was noted upon examination. (R. at 240, 253). Straight leg raising was negative. (R. at 240, 253). Her arms and legs were non-tender. (R. at 240, 253). Dr. Nystrom believed Plaintiff had strained her low back by working on her feet all day. (R. at 240, 253). He noted some pain and stiffness in her hands, and attributed this to mild carpal tunnel syndrome. (R. at 240, 253). He diagnosed mild degenerative arthritis, as well. (R. at 240, 253). He noted that prescription Zoloft had been providing Plaintiff was some benefit for her anxiety. (R. at 240, 253). Yet, in July of 2007, Plaintiff complained to Dr. Nystrom of feeling panicky and not wishing to leave her house. (R. at 239). He noted that she had not sought any counseling. (R. at 239). He diagnosed generalized anxiety disorder with panic attacks. (R. at 239).
Plaintiff was seen in the emergency department of UPMC Horizon Hospital in Greenville, Pennsylvania on August 9, 2007, for complaints of moderate, sharp upper back pain between her shoulder blades. (R. at 212 -- 35). Plaintiff claimed that breathing, coughing, and moving were painful. (R. at 212 -- 35). An EKG and chest x-ray returned normal results. (R. at 212 -- 35). Plaintiff was diagnosed with acute myofascial strain, and was discharged following improvement in her condition. (R. at 212 -- 35). Her extremities were noted to be non-tender, with a full range of motion. (R. at 212 -- 35). Her grip was normal and symmetrical, and her reflexes were normal, as well. (R. at 212 -- 35). Plaintiff was provided a prescription for Tylenol with codeine. (R. at 212 -- 35).
While at the hospital, Plaintiff was asked if she was feeling sad or lonely, or if she was confined to her home with limited contact with others. (R. at 212 -- 35). She replied that she was not. (R. at 212 -- 35). She did not wish to talk to anyone about her feelings, either. (R. at 212 -- 35). She was noted to have a history of anxiety. (R. at 212 -- 35).
Plaintiff followed up with Dr. Nystrom subsequent to her emergency room admission.
(R. at 238, 252). Dr. Nystrom noted the normal EKG and x-ray results. (R. at 238, 252). He also noted Plaintiff's complaints of intermittent pain in the upper and lower back, occasionally moving up the right side of her neck and into her jaw. (R. at 238, 252). Sometimes the pain moved into her right anterior chest. (R. at 238, 252). Upon examination, Dr. Nystrom found only slight muscle tenderness, full range of motion in the neck, and regular heart rhythm. (R. at 238, 252).
On September 17, 2007, Plaintiff was examined by Dr. Nystrom, and reported that the Zoloft prescribed for her anxiety was helping, and that she was feeling better. (R. at 237, 251). She still preferred not to go out in public places with crowds. (R. at 237, 251). Plaintiff continued to complain of lower back and buttock pain; however, Dr. Nystrom noted past x-rays of her back and hips were normal. (R. at 237, 251). He also found that she had good range of motion in her lower back, with some tenderness along the sacroiliac area of her spine, but nowhere else. (R. at 237, 251). Dr. Nystrom diagnosed Plaintiff with generalized anxiety disorder, depression with anxiety, and occasional panic attacks. (R. at 237, 251).
At an appointment with Dr. Nystrom in October of 2007, Plaintiff reported that prescription Klonopin had been helping with her leg pain. (R. at 236, 250). Dr. Nystrom was considering increasing the dosage. (R. at 236). Plaintiff was able to go into public more, and had only had one "panicky spell" since her last visit. (R. at 250). Plaintiff reported no side effects from her Zoloft. (R. at 250). Dr. Nystrom increased her dosage on Zoloft, as well. (R. at 250). In November and December of 2007, Plaintiff experienced no anxiety or panic attacks when at home, but would reportedly still have difficulty with crowds in public places. (R. at 249). It was noted that she had an appointment for an evaluation by a counselor. (R. at 249). Medication management for Plaintiff's fibromyalgia symptoms was to be continued. (R. at 249).
Several months passed before Plaintiff's last appointment with Dr. Nystrom on the record, in July of 2008, and it was noted that Plaintiff complained of back pain, and difficulty with both sitting and standing. (R. at 186). However, Dr. Nystrom described this as a "new problem." (R. at 186). Upon examination, Plaintiff's straight leg raising was negative, she exhibited minimal tenderness in her calves, and reflexes in her knees and ankles were intact. (R. at 186). Dr. Nystrom considered Plaintiff's discomfort to be fibromyalgia-type pain. (R. at 186). He indicated that he would order x-rays if her lower back continued to be a problem. (R. at 186). Plaintiff informed Dr. Nystrom that she was planning to go away for the summer to visit a friend for a while. (R. at 186). No other physical issues were discussed in the notes. (R. at 186). Plaintiff was noted to be taking Klonopin and Gabapentin for her fibromyalgia. (R. at 186).
C. Functional Assessments
On September 17, 2007, Dr. Nystrom completed a Medical Source Statement of Ability to do Work-Related Activities (Mental) on behalf of Plaintiff. (R. at 267 -- 74). In it, he indicated that Plaintiff's appearance, behavior, speech, affective expression, appropriateness, stream of thought, thought content, intelligence, concentration, orientation, memory, impulse control, judgment, and insight were all normal. (R. at 267 -- 74). He further indicated that Plaintiff had no difficulties performing daily activities on a sustained basis. (R. at 267 -- 74). She did have difficulty getting along with/interacting with family, friends, neighbors, co-workers, employers, and the ...