The opinion of the court was delivered by: McLAUGHLIN, Sean J., District Judge.
Julietta Molnar, ("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 August 5, 2008 alleging disability since May 31, 2007 due to severe asthma, esophagitis and fibromyalgia (AR 182-188; 214).*fn1 Her applications were denied (AR 97-104), and following a hearing held on December 11, 2009 (AR 33-78), the administrative law judge ("ALJ") issued her decision denying benefits to Plaintiff on April 13, 2010 (AR 10-22).
Plaintiff's request for review by the Appeals Council was subsequently denied (AR 1-6), 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, both motions will be denied and the matter will be remanded to the Commissioner for further proceedings.
Plaintiff was 38 years old on the date of the ALJ's decision (AR 32; 182). She has a high school education, completed two years of college, and has past work experience as an administrative assistant and loan officer (AR 215; 221).
Plaintiff has been treated by Andrew DeMarco, M.D., her primary care physician, since 2001 (AR 590-591). In 2001, Plaintiff complained of a persistent cough, fatigue and muscle weakness (AR 590-591). In 2002, Plaintiff was treated for her complaints of anxiety and shortness of breath on exertion (AR 585-587). In September 2002, Plaintiff reported intense muscle pain with activity, but her physical examination was unremarkable (AR 583). Dr. DeMarco assessed her with probable fibromyalgia related to her depression (AR 583). In 2003, Plaintiff was treated for gastroesophageal reflux disease ("GERD"), persistent coughing and migraine headaches (AR 576-580). In October 2003, Plaintiff complained of headaches occurring every two to three months (AR 576). She received injection therapy and her symptoms resolved (AR 576).
In 2004, Plaintiff was treated for GERD, anxiety, fatigue and generalized weakness (AR 570-573). In June 2005, Dr. DeMarco reported that Plaintiff was "doing fairly well" (AR 567). Plaintiff denied experiencing any weakness, and her physical examination was unremarkable (AR 567-568). In December 2005 Plaintiff was treated for complaints of depression and anxiety following a difficult break-up with her boyfriend (AR 560-563). On March 28, 2006, Plaintiff complained of left thigh pain and shortness of breath on exertion (AR 315). Her physical examination was unremarkable except for some tenderness of her thigh on palpation (AR 315). On March 30, 2006, Dr. DeMarco reported that Plaintiff's shortness of breath had responded "nicely" with Albuterol (AR 314).
On January 2, 2007, Plaintiff complained that she experienced headaches once per month (AR 310). She reported that her asthma had improved with medication, and that her depression and anxiety were "gone" (AR 310). Dr. DeMarco reported that Plaintiff was "actually doing fairly well and seem[ed] to be happy with her new position in life" (AR 310). Her physical examination was unremarkable, and she was prescribed medications for her headaches, asthma and GERD (AR 312). Dr. DeMarco diagnosed her with headaches; history of a pulmonary fungal infection; reactive airway disease; GERD; paresis in the upper extremity muscles; and anxiety and depression, well controlled (AR 312).
An MRI of Plaintiff's cervical spine dated January 5, 2007 revealed only minimal disc bulges in the mid cervical spine area, with no evidence of cervical nerve root or spinal cord compromise (AR 326). When seen by Dr. DeMarco on January 8, 2007, Plaintiff complained of diffuse muscle pain but denied any weakness or numbness (AR 308). She was assessed with fibromyalgia and prescribed Cymbalta (AR 308).
On January 30, 2007, Plaintiff was seen by Cheryl Bernstein, M.D., for complaints of generalized body pain (AR 300-301). Physical examination revealed findings "significant for tender points consistent with fibromyalgia" (AR 301). Dr. Bernstein diagnosed Plaintiff with fibromyalgia and recommended physical therapy, a trial of antidepressants, and an analgesic (AR 301).
Plaintiff returned to Dr. DeMarco on July 20, 2007 and reported that her fibromyalgia and depression had flared up (AR 303). He found she was in no acute distress and her physical examination was unremarkable (AR 303). Dr. DeMarco increased her GERD medication but found no specific treatment was indicated for her fibromyalgia or depression (AR 303).
Plaintiff was seen by Wesley Hilbert, M.D. on November 5, 2007 and complained of migraine headaches, asthma, GERD, fibromyalgia and intermittent left groin pain (AR 379). Her physical examination was normal, and she was assessed with, inter alia, acute cystitis and a urinary tract infection (AR 381). Plaintiff returned for follow-up on November 19, 2007, and Dr. Hilbert reported that Plaintiff's lungs were clear with "good" equal breath sounds (AR 376). She also had a full range of motion and no crepitus of the cervical spine (AR 376).
A pulmonary function test dated December 6, 2007 revealed normal lung volumes and flow rates with no evidence of obstructive or restrictive defects (AR 382). On December 19, 2007, Plaintiff reported to Dr. Hilbert that her headaches were less frequent with medication changes (AR 372). Her physical examination remained unchanged (AR 373).
On January 3, 2008, Plaintiff underwent a consultative examination performed by Leo Swantek, D.O. (AR 331-349). Plaintiff reported multiple impairments, including severe asthma, GERD, fibromyaligia and migraine headaches (AR 331-333). Dr. Swantek reported that her ear, nose and throat examination was essentially normal, although she experienced coughing and shortness of breath while talking (AR 335). He further reported that she had a good range of motion in her upper and lower extremities, and her straight leg raising test was negative (AR 336). Dr. Swantek opined that Plaintiff could lift and carry two to three pounds frequently and ten pounds occasionally; stand and walk for four hours a day; sit for eight hours a day with a sit/stand option; and occasionally engage in postural activities (AR 335-336). He also concluded that Plaintiff should avoid exposure to vibrations, extreme temperatures, wetness, humidity, fumes, odors, chemicals and poor ventilation (AR 336).
On February 14, 2008, Nghia Van Tran, M.D., a state agency reviewing physician, reviewed the medical evidence of record and concluded that Plaintiff could perform sedentary work, but could only occasionally climb, balance, stoop, kneel, crouch and crawl (AR 286-287). He further found that Plaintiff should avoid even moderate exposure to extreme temperatures, wetness, humidity, fumes, odors, gases and poor ventilation (AR 288). Dr. Tran concluded that Plaintiff's claimed restrictions were only partially credible in light of the medical evidence of record (AR 291). Dr. Tran found that his assessment partially reflected Dr. Swantek's opinion (AR 291).
Plaintiff was seen by Dr. Swantek on March 20, 2008 and complained that it was painful for her to move her hands overhead (AR 683). Her physical examination was unremarkable except for some mild epigastric tenderness (AR 683). Dr. Swantek diagnosed Plaintiff with, inter alia, chronic bronchial asthma and chronic cough, and prescribed medication (AR 683). On April 10, 2008, Dr. Swantek noted that Plaintiff's bronchial asthma was not severe based on her diagnostic studies, and she had decreased her medications without any negative impact (AR 682). On April 21, 2008, Dr. Swantek reported that Plantiff's lungs were clear on physical examination (AR 681).
On May 30, 2008, Plaintiff returned to Dr. Hilbert and complained of fatigue and achiness (AR 362). On physical examination, her lungs were clear and her respiration rhythm and depth were normal (AR 363). Dr. Hilbert found trigger points on Plaintiff's posterior neck and leg (AR 363). On July 23, 2008, Plaintiff reported she was doing well on her fibromyalgia medication (AR 360).
Plaintiff was evaluated by Joseph Rowaine, D.O., a pulmonologist, on July 28, 2008 (AR 350-355). Her physical examination revealed clear breath sounds and a pulmonary function test revealed no restrictive defect or obstructive disease (AR 352-353). A six-minute walk test was "completely normal" (AR 352-353). Dr. Rowaine recommended a cardiopulmonary exercise stress test (AR 352).
Plaintiff returned to Dr. Hilbert on July 30, 2008 and complained of left hip pain (AR 358). Physical examination was essentially normal except for a minimal positive straight leg raising on the left (AR 359). She was assessed with acute left sciatica (AR 359).
On July 31, 2008, Plaintiff was seen by Thaddeus Osial, Jr., M.D., a rheumatologist, for evaluation of her fibromyalgia (AR 357). Plaintiff complained of pain "everywhere" and claimed that daily activities were too painful to perform (AR 357). She stated that Ultram had helped her symptoms but she had stopped taking it due to pregnancy (AR 357). Dr. Osial reported that her physical examination was notable "only for diffuse tender points" (AR 357). There was no significant peripheral arthritis and no significant medical findings (AR 357). Dr. Osial found Plaintiff's history and physical were consistent with a diagnosis of chronic fibromyalgia, and he recommended she restart her medication following her pregnancy (AR 357).
Plaintiff began treatment with Gregory Zinni, M.D., on October 28, 2008 and complained of shortness of breath on minimal exertion (AR 420). Plaintiff's lungs were clear on physical examination, and she was diagnosed with asthma, fibromyalgia and GERD (AR 420). On December 8, 2008, Plaintiff reported that Albuterol helped alleviate her asthma symptoms (AR 420). Dr. Zinni reported that Plaintiff's lungs were clear on examination, and a pulmonary function test was normal (AR 420). She was diagnosed with asthma and referred to a pulmonologist (AR 420).
Plaintiff was evaluated by Digvijay Singh, M.D., a pulmonologist, on December 11, 2008 (AR 423-427). Plaintiff complained of shortness of breath and "coughing fits" (AR 423). She had no musculoskeletal complaints and denied any symptoms of anxiety or depression (AR 424).
On physical examination, Plaintiff's lungs were clear with no wheezes, rhonchi or crackles found, but frequent coughing was noted (AR 425). Plaintiff's musculoskeletal examination revealed no joint tenderness or stiffness, she had good muscle strength and tone, and her gait was normal (AR 425). Dr. Singh diagnosed her with a history of asthma, fibromyalgia, GERD, pulmonary candida infection and pulmonary fibrosis (AR 425). She was prescribed medication and advised to avoid extremely dry and cold temperatures (AR 426).
On January 26, 2009, Kathryn Drew, M.D., a state agency reviewing physician, reviewed the medical evidence of record and concluded that Plaintiff could perform medium work, but should avoid even moderate exposure to fumes, odors, gases and poor ventilation (AR 277-281). Dr. Drew noted that Plaintiff claimed she used a wheelchair, but the medical evidence did not support the need for an ambulatory aid of any type (AR 282). She further noted that Plaintiff's medications had been relatively effective in controlling her symptoms (AR 284). Dr. Drew concluded that Plaintiff's allegations relative to her functional restrictions were inconsistent with the objective findings and the medical evidence of record (AR 282).
Plaintiff was seen by Teresa Mellington, R.N. at Dr. Singh's office on February 24, 2009 and complained of shortness of breath, a racing heart, and dementia type symptoms (AR 620). She claimed she became confused and disoriented while driving, and had three auto accidents (AR 620). On physical examination, Ms. Mellington reported that Plaintiff was fully oriented and her lungs were completely clear with no wheezes, rhonci or crackles noted (AR 621). Her musculoskeletal examination revealed no joint tenderness or stiffness, she had good muscle strength and tone, and her gait was normal (AR 621). She was diagnosed with history of asthma, a history of fibromyalgia, GERD, pulmonary candida infection in 2000, and a history of pulmonary fibrosis (AR 621). Ms. Mellington advised her not to drive given her reported history of auto accidents (AR 621).
Plaintiff returned to Dr. Singh on March 6, 2009 and her physical examination remained unchanged (AR 421-422). Dr. Singh reported that her pulmonary function studies were "completely normal" and her laboratory studies were also normal (AR 421). She was ...