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Christal Dawn Smith v. Michael J. Astrue

September 14, 2012

CHRISTAL DAWN SMITH, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Judge Nora Barry Fischer

MEMORANDUM OPINION

I. INTRODUCTION

Christal Dawn Smith ("Plaintiff") brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of the final determination of the Commissioner of Social Security ("Defendant" or "Commissioner") denying her application for supplemental security income ("SSI") benefits under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1383f ("Act"). The record has been developed at the administrative level, and the parties have brought cross-motions for summary judgment. For the following reasons, the Court finds that the decision of the Administrative Law Judge ("ALJ") is supported by substantial evidence. Accordingly, Plaintiff's Motion for Summary Judgment (Docket No. 8) is DENIED, and Defendant's Motion for Summary Judgment (Docket No. 10) is GRANTED.

II. PROCEDURAL HISTORY

Plaintiff applied for SSI on March 9, 2009, alleging both physical and mental impairments with a disability onset date of January 1, 2005. (R. at 161-167).*fn1 Following the initial denial of her application on August 4, 2009 (R. at 104-115), a hearing was held before an ALJ on November 17, 2010 at which Plaintiff and a vocational expert appeared and testified (R. at 41-80). The ALJ issued his unfavorable decision to Plaintiff on December 8, 2010. (R. at 21-40). Thereafter, Plaintiff filed a request for review by the Appeals Council. (R. at 14-20). The Appeals Council denied Plaintiff's request on February 10, 2012, thereby making the decision of the ALJ the final decision of the Commissioner. (R. at 1-6). Having exhausted all administrative remedies, Plaintiff filed her Complaint in this court on March 26, 2012, followed by Defendant's Answer on May 31, 2012. (Docket Nos. 4, 5). Subsequently, Plaintiff moved for summary judgment with a supporting brief on June 15, 2012. (Docket Nos. 8-9). Defendant filed his cross-motion and brief in support on July 19, 2012. (Docket Nos. 10-11).

III. FACTS

A. General Background

Plaintiff was born on October 1, 1978 and was thirty-two years of age at the time of her hearing.*fn2 (R. 48). She resided with her fiance in Jeannette, Pennsylvania, where Plaintiff also attended high school. (R. at 47-48). Plaintiff has a son from a previous marriage, who was ten years old at the time of the hearing. (R. at 48, 65, 73, 553). Prior to her March 9, 2009 filing, Plaintiff had applied for disability insurance benefits ("DIB") in 2006 and SSI in 2007, but was each time denied. (R. at 98-102, 218). She was not working at the time of the hearing. (R. at 53).

Plaintiff's highest level of education is a high school degree. (R. at 48-49). From kindergarten until completing the twelfth grade, she participated in special education, also taking vocational courses in food service. (Id.). Since graduating from high school in 1998, she has performed a number of unskilled, short-term and temporary jobs, including as a cashier in a grocery store and fast food restaurants. (R. at 52-53, 194, 554). Plaintiff's work history concluded in 2005 after a brief stint as a restaurant dishwasher. (Id.). Her daily activities primarily consisted of watching television, painting, and playing games. (R. at 67, 234, 586).

B.Medical History

Plaintiff's medical history includes ankle and knee injury, low back pain, obesity, asthma, migraine headaches, sleep apnea, hypothyroidism, a hiatal hernia, a learning disability, and depression. (R at 261, 359-364, 420-21). In her Disability Report, Plaintiff claimed that depression, thyroid problems, a sleep disorder, a hernia, and the fact that she is a "slow learner" limit her ability to work. (R. at 222). Her medications included Perphenazine,*fn3 Amitryptyline,*fn4 Verapamil,*fn5 Butalbital,*fn6 Levothyroxine,*fn7 and Sertraline.*fn8 (R. at 260). She does not abuse alcohol, nor does she use tobacco or illicit drugs. (R. at 586, 594).

1. Ankle, Knee, and Back

In October 2005, Plaintiff sustained injury to her left knee when she fell while taking out the garbage. (R. at 283, 294). However, an x-ray taken of her knee on October 21, 2005 at Mercy Jeannette Hospital did not reveal facture, dislocation, or degenerative change. (R. at 463). Thereafter, Plaintiff was treated for left knee and low back pain by Dr. Priya Prabhakar, M.D., who prescribed physical therapy and referred her to The PT Group in Jeannette, PA. (R. at 280, 285). Plaintiff appeared at The PT Group for an initial evaluation on November 23, 2005, complaining that walking, standing, and lifting were painful, yet she ambulated independently.

(R. at 283, 285). She also reported sleeping "fairly well" and that she was not using any medications. (R. at 283, 285). On November 28, 2005, Plaintiff visited Mercy Jeannette Hospital for an MRI of her left knee and lower back. (R. at 285, 294, 461-62). The MRI of her knee revealed intrameniscal degenerative changes in the posterior horns of the medial meniscus,*fn9 and the MRI of her back showed a "very slight disc bulge" posteriorly in her lumbar spine, but no other abnormalities were present. (R. at 294, 461-62).

As Plaintiff continued physical therapy through December 2005, she reported doing "very well" and was able to perform therapeutic exercises "without difficulty," noting improvements in her back and knee. (R. at 285-89). On December 21, 2005, although still complaining of knee pain to some degree, Plaintiff reported "no pain" in her lower back and was discharged by her physical therapist after completing all twelve prescribed sessions. (R. at 289-90). In a December 22, 2005 letter to Dr. Prabhakar, her physical therapist wrote that Plaintiff had "achieved all established goals" for her low back pain, in addition to all short-term goals and half of all long-term goals for her left knee pain. (R. at 290). However, due to Plaintiff's reported frustration with her left knee and "fairly persistent" pain, her physical therapist recommended she follow up with an orthopedic specialist. (Id.).

On January 9, 2006, Plaintiff was examined by Dr. George R. Hunter, a medical doctor specializing in orthopedics at Orthopedic Associates of Pittsburgh in Monroeville, PA. (R. at 294). Dr. Hunter's Office Notes referenced the history of Plaintiff's knee injury and her alleged difficulty walking because of pain. (Id.). He noted her left knee had a normal alignment and no effusion,*fn10 as well as full range of motion including full extension, but there was tenderness to the medial and lateral joint lines and palpation of the patellar tendon. (Id.). Dr. Hunter opined Plaintiff might have early arthritic changes in her knee and injected it with Lidocaine*fn11 and

Depomedrol,*fn12 instructing her to return for reassessment if her symptoms did not "settle down." (Id.).

In July 2006, Plaintiff injured her left ankle joint, of which an x-ray was taken on July 17, 2006 and was normal except for a small calcaneal spur.*fn13 (R. at 457-58). Treatment records indicate that Plaintiff saw her primary care physician, Dr. Edgar Derek Peske, M.D., that August for pain in her left knee and ankle. (R. at 359). On November 7, 2006, Plaintiff visited Mercy Jeannette Hospital for another x-ray of her ankle, which showed evidence of soft tissue swelling and presence of a plantar calcaneal spur. (R. at 359, 457). She saw Dr. Peske for ankle pain again on December 1, 2006, at which time he referred her to a physician named Dr. Kuorul, who diagnosed her with post-taylor tendonitis on December 6, 2006. (R. at 359). However, in his March 2007 medical source opinion to the Bureau of Disability, Dr. Peske wrote that Plaintiff experienced "occasional swelling" of her left ankle with pain strictly related to the joint and no other area in her leg. (R. at 363-64). Further, he stated that she had no problems getting up from a chair, the exam table, lying down, sitting up, or performing a range of motion examination, was able to ambulate without difficulty, and walked in an upright position. (Id.). On October 15, 2007, Plaintiff had an x-ray of her knee taken at Mercy Jeannette Hospital which did not show acute fracture, dislocation, or joint deformities, though there was evidence of minimal soft tissue swelling. (R. at 448). An x-ray of her ankle taken at Westmoreland Regional Hospital on December 3, 2007 showed no fracture, dislocation, or bony destructive change, but a plantar calcaneal spur was noted. (R. at 444).

On April 23, 2008, Plaintiff appeared at the Mercy Jeannette Hospital emergency room for pain in her lower back. (R. at 403). X-rays were taken and all results were normal. (R. at 409, 440, 441). Plaintiff's attending physician that day was Dr. Liza Chopra, who diagnosed Plaintiff with left hip strain. (R. at 404, 410). Dr. Chopra prescribed Plaintiff eight pills of Tylenol #3 (Tylenol plus codeine)*fn14 with instructions for Plaintiff to take one or two every six hours as needed for pain. (R. at 404, 411). Plaintiff was instructed to follow up with Dr. Peske. (R. at 412). Plaintiff visited Dr. Peske on December 22, 2008 after "throwing out" her knee a week earlier and requested a refill of Naproxyn.*fn15 (R. at 427). A month later, she returned to see Dr. Peske on January 23, 2009 after a trip to the emergency room when her knee "gave out." (R. at 426). However, an examination did not reveal abnormalities beyond some tenderness over both medial compartments. (Id.). The Court notes that at this visit, Plaintiff requested that Dr. Peske fill out a disability form on her behalf, but he declined because there was "no cause for disability." (Id.).

Plaintiff was evaluated for left knee pain by Dr. Gregory F. Habib, D.O. on January 12, 2010 after a referral by Dr. Kevin Wong, M.D., a primary care physician. (R. at 586). Plaintiff reported progressive pain and discomfort over the past six years, making it difficult for her to sit for any extended period of time. (Id.). She also reported stiffness upon standing. (Id.). After an xray, Dr. Habib diagnosed her with incidental right knee mild patellofemoral arthritis and mild varus deformity of the left knee and referred her for an MRI. (R. at 586-88). An MRI on January 18, 2010 revealed left knee patellar chondromalacia with infrapatellar synovitis. (R. at 585). Dr. Habib prescribed Plaintiff physical therapy, anti-inflammation medications, and a stabilizing brace, instructing her to follow up in six-week intervals. (Id.). On March 11, 2010, Plaintiff followed up with Dr. Habib and reported that physical therapy was helping her knee, that she had "less pain and discomfort," and felt "that she can live with the knee." (R. at 584). Dr. Habib noted that Plaintiff was wearing her knee brace and did not have any pain or discomfort and did have good range of motion. (Id.). He wrote she "has done well" and "told me that she could live with this at this point." (Id.).

2. Obesity, Hypothydroidism, Asthma, and Sleep Apnea

In his 2007 medical source opinion, Dr. Peske noted Plaintiff's obesity but that she "has no difficulty walking, sitting, [or] standing," and that it "does not give her any problem with shortness of breath or fatigue." (R. at 364). Here, he also acknowledged that Plaintiff had a history of asthma, but that she had not had an attack in approximately seven years. (R. at 360). Dr. Peske stated that upon examination, Plaintiff's chest and lungs were clear and she had no chest pain. (R. at 360, 363). He reported Plaintiff claimed to suffer shortness of breath going up hills or after about twenty steps; however, she reported no changes with seasonal allergies, temperature changes, and did not experience wheezing. (Id.). In his 2009 medical source opinion to the Bureau of Disability, again Dr. Peske reported that Plaintiff's asthma was well controlled, and that "she has actually required no medication for this problem." (R. at 545).Similarly, Plaintiff's thyroid condition has been consistently documented as well controlled; for example, on October 28, 2008 and again on December 22, 2008, Dr. Peske saw Plaintiff and noted that her hypothydroidism was stable. (R. at 427-28).

As for her sleep apnea, Plaintiff's relevant medical history begins on April 23, 2008, when she was evaluated at Westmoreland Sleep Medicine for "possible sleep apnea" by a pulmonologist, Dr. Bharat Jain, M.D. (R. at 431, 488). Plaintiff complained of difficulty initiating and maintaining sleep, often being awakened for "no apparent reason" or gasping for air and choking. (Id.). She described taking "anywhere from a few minutes to a few hours" to fall asleep, getting an estimated total of six and a half hours of sleep each night. (Id.). She denied quitting breathing, sleep walking, or teeth grinding, but did experience night sweats, early morning headaches, tiredness, memory lapses, difficulty concentrating, body aches, and joint pains during the day and asserted that she did not feel refreshed upon awakening. (Id.). Plaintiff subsequently underwent formal overnight polysomnography testing on June 3, 2008, which revealed mild obstructive sleep apnea syndrome.*fn16 (R. at 489, 500). When CPAP Titration*fn17 was added, Plaintiff reported that the sleep was better than usual and that she felt awake but not alert.

(R. at 501). Thereafter, Dr. Jain prescribed a CPAP machine to Plaintiff. (R. at 493, 501).

On August 14, 2008, Plaintiff followed up with Dr. Jain after using the CPAP machine for a few weeks and stated that she had noticed improvements in her sleep. (R. at 493). Dr. Jain concluded the appointment with instructions to continue using the same CPAP setup and follow up again in six months. (Id.). When Plaintiff returned to see Dr. Jain on February 12, 2009, she reported using the CPAP machine as prescribed, but that it had recently begun to cause her a cough and dry mouth. (R. at 495). Nevertheless, Dr. Jain decided against adjusting her current CPAP settings pending a repeat sleep study, noting Plaintiff had gained over twenty pounds since her last appointment six months ago. (Id.). When a second nocturnal polysomnography with CPAP Titration was performed later that month, Plaintiff reported sleeping worse than usual and that she felt awake but not alert. (R. at 502). However, Dr. Jain continued Plaintiff's CPAP treatment. (R. at 503).

Following Plaintiff's follow-up appointment with Dr. Jain on April 13, 2009, he wrote she "was exposed to significant hay and was experiencing significant rhinitis and difficulty breathing with cough." (R. at 497). Dr. Jain adjusted the settings on her CPAP machine and prescribed her Singulair to treat her rhinitis and asthma. (Id.). On January 25, 2010, Plaintiff saw Dr. Vilharika K. Bakshi, M.D. and stated she felt well other than "minor complaints," showing improvement in activity level and getting approximately four to eight hours of sleep daily. (R. at 604). On March 1, 2010, Dr. Wong noted that Plaintiff reported getting more than eight hours of sleep daily. (R. at 601).

3. Migraine Headaches

Plaintiff reports suffering from recurrent, severe headaches since high school. (R. at 519). Dr. Hunter ordered an MRI of Plaintiff's brain, which was performed on March 6, 2006 at Mercy Jeannette Hospital. (R. at 314, 459). Although the MRI revealed no abnormalities, it did show "minimal chronic sinusitis changes." (Id.). Months later, Plaintiff saw Dr. Peske in September 2006 complaining of rib pain, a cold, and tension headaches. (R. at 359). In his 2007 medical source opinion, Dr. Peske wrote that Plaintiff described a few frontal side and back headaches which seemed to be triggered by different odors. (R. at 362). He added that Plaintiff had no history of dizziness, fainting, blackouts, seizures, convulsions, eye trouble, hearing trouble, dental or mouth problems, nosebleeds, allergies, hay fever, or hoarseness. (Id.). In September 2008, Plaintiff saw Dr. Peske for a headache in her right temporal area and around her eyes that she claimed had ...


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