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Donna M. Redfield v. Michael J. Astrue

June 4, 2012

DONNA M. REDFIELD, 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

Donna M. Redfield ("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 September 25, 2008, alleging disability since June 1, 2008 due to fibromyalgia (AR 125-132; 151).*fn1 Her applications were denied (AR 76-85), and following a hearing held on October 14, 2009 (AR 1-37), the administrative law judge ("ALJ") issued his decision denying benefits to Plaintiff on December 8, 2009 (AR 61-72).

Plaintiff's request for review by the Appeals Council was subsequently denied (AR 38-42), rendering the Commissioner's decision final under 42 U.S.C. § 405(g). The instant action challenges 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 46 years old on the date of the ALJ's decision and has a high school education (AR 70; 156). She has past work experience as daycare provider and telemarketer (AR 152).

The relevant medical records reveal that the Plaintiff was seen in the emergency room at UPMC Northwest in Seneca, Pennsylvania on April 15, 2008 for complaints of difficulty breathing (AR 205-222). She was diagnosed with chronic obstructive pulmonary disease ("COPD"), Albuterol therapy was administered, and she was advised to stop smoking (AR 205-206). On April 21, 2008, Plaintiff was seen for follow up at Seneca Medical Center (AR 292-294). Plaintiff reported that her lungs felt "heavy" at the end of the day (AR 292). She indicated that she had been a cigarette smoker since she was twelve, and had tried unsuccessfully to quit in the past (AR 293). Her physical examination was unremarkable, except some diminished sound was noted over her lungs bilaterally (AR 293). She was prescribed Advair and a Bronchodilator (AR 293).

On April 28, 2008, Veronica Santee, M.D., noted that Plaintiff appeared to have myofascial pains associated with stress or yard work (AR 291). She assessed Plaintiff with myalgia and myositis unspecified, recommended conservative treatment, and added Flexeril to her medication regimen (AR 291). Plaintiff was seen by Bradley Fell, M.D. for follow up on May 28, 2008 (AR 288-289). Her physical examination was unremarkable and her medications were continued (AR 289).

On June 23, 2008, Plaintiff complained of low back pain when seen by Dr. Santee but denied any other associated symptoms (AR 285). Plaintiff reported that she hurt herself hauling wood approximately three years prior (AR 285). On physical examination, Dr. Santee noted that Plaintiff walked with a normal gait, had decreased flexion, normal extension, tenderness to palpation of her sacroiliac joint bilaterally, and normal deep tendon reflexes (AR 286). She was assessed with lumbago, Prednisone was prescribed, and x-rays were ordered (AR 286). While Dr. Santee preferred that Plaintiff attend physical therapy, he noted that she was "reluctant" to do so "due to time constraints" (AR 286). On June 29, 2008, x-rays of the Plaintiff's lumbar spine revealed minimal disc and facet degenerative disease (AR 251).

When seen by Kim Davis, CRNP on July 7, 2008, Plaintiff continued to complain of back pain radiating into her hips (AR 282). Plaintiff rated her pain levels as a 5 on a 10-point scale (AR 282). Physical examination revealed no tenderness, normal strength and muscle tone, negative straight leg raise testing, no sensation loss and good mobility in all extremities (AR 283). Range of motion testing revealed some limited movement and pain on left rotation and extension (AR 283). Medications were prescribed and Plaintiff was instructed on proper lifting and body mechanics, and back exercises (AR 283). An MRI of the Plaintiff's lumbar spine dated July 18, 2008 showed multilevel degenerative disc disease (AR 249).

When seen by Michael Mewes, CRNP on July 21, 2008, Plaintiff complained of moderate pain and intermittent achiness that had worsened since the death of her mother in July 2007 (AR 279). Plaintiff reported that the pain radiated to her legs and was aggravated by bending, driving, lifting and postural changes (AR 279). On physical examination, Mr. Mewes found Plaintiff's range of motion was mildly limited with some lumbar tenderness (AR 280). Her straight leg raise testing was negative bilaterally (AR 280). She was assessed with lumbago and intervertebral lumbar disc degeneration (AR 280). Mr. Mewes completed a form for the Pennsylvania Department of Public Welfare ("DPW") stating that Plaintiff was temporarily disabled from July 21, 2008 to October 21, 2008 due to a primary diagnosis of lumbago and a secondary diagnosis of degenerative disc disease (AR 193).

Plaintiff continued to complain of low back pain when seen by Frederick Krueger, D.O. on July 30, 2008 (AR 276). On physical examination, Dr. Krueger found that Plaintiff walked with a "markedly antalgic gait," had tenderness of the spine bilaterally, and had some decreased range of motion on flexion and extension (AR 277). She exhibited full spine extension and normal muscle tone bilaterally (AR 277). Her motor strength and sensation were intact, and she had good mobility in all extremities (AR 277).

Plaintiff underwent physical therapy for her complaints of back pain on three occasions from July 30, 2008 through August 7, 2008 (AR 233-243). At her final treatment session, Plaintiff reported her pain level as a 3 to 4 out of 10 (AR 233). Plaintiff met some of her treatment goals, but failed to continue treatment and was discharged from physical therapy (AR 233).

Plaintiff returned to Seneca Medical Center on August 11, 2008 and reported to Ms. Davis that she continued to suffer from aching back pain radiating to her thighs and associated fatigue (AR 272). Plaintiff rated her pain as a 5 out of 10 when inactive, and a 10 with activity (AR 272). On physical examination, Ms. Davis found Plaintiff walked with a normal gait, had a limited range of motion, and limited flexion with pain (AR 273). Her straight leg raise testing was negative bilaterally and she was able to normally heel and toe walk (AR 273). It was noted that she needed DPW forms completed in order to obtain her COPD medications (AR 272). Ms. Davis completed the DPW form stating that Plaintiff was temporarily disabled from July 21, 2008 to October 21, 2008 due to back pain, COPD and a "heart murmur" (AR 194-196). An echocardiogram conducted on August 15, 2008 was essentially normal (AR 246-248).

Plaintiff was evaluated by John Karian, M.D., a neurosurgeon, on August 12, 2008 for her complaints of back pain (AR 232). On physical examination, she exhibited a physiologic gait and stance, had full strength, and her reflexes were 2 at all sites with no pathologic signs noted (AR 232). Dr. Karian reviewed Plaintiff's MRI of her lumbar spine, and noted that it showed decreased stature at the L5-S1 level and mild degenerative changes at several sites (AR 232). Dr. Karian concluded that no surgical intervention was warranted, and recommended that she continue with conservative treatment (AR 232).

Plaintiff returned to Dr. Krueger on August 28, 2008 and complained of back and neck pain (AR 269). Plaintiff walked with a normal gait, but Dr. Krueger found multiple tender points on her back and legs (AR 270). He assessed her with myalgia and myositis unspecified, with fibromyalgia as a "working diagnosis" (AR 270).

When seen by Dr. Fell on September 18, 2008, he noted that Plaintiff's recent lab work had been negative for any rheumatic disease, and that her "clinical picture" and history were suggestive of fibromyalgia (AR 266). Although Plaintiff reported that she exercised regularly, her ...


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