United States District Court, W.D. Pennsylvania
MAURICE B. COHILL, Senior District Judge.
Pending before this Court is an appeal from the final decision of the Commissioner of Social Security ("Commissioner" or "Defendant") denying the claims of Martha Ruthann Hartsock ("Plaintiff" or "Claimant") for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("SSA"), 42 U.S.c. §§ 1381 et. seq. (2012). Plaintiff argues that the decision of the administrative law judge ("ALl") should be reversed or remanded because the ALl's residual functional capacity ("RFC") determination failed to include all of the Claimant's limitations and was not supported by substantial evidence as required by 42 U.S.c. § 405(g).
To the contrary, Defendant argues that the evidence of record established functional limitations and identified representative occupations which showed Claimant could perform in a gainful occupation despite her limitations and, therefore, the ALl's decision should be affirmed. The parties have filed cross motions for summary judgment pursuant to Rule 56(c) of the Federal Rules of Civil Procedure.
For the reasons stated below, the Court will deny the Defendant's Motion for Summary Judgment in part and grant the Defendant's Motion for Summary Judgment in part affirming the decision of the ALJ with regard to Plaintiffs claim for physical disability. In turn, the Court will deny the Plaintiffs Motion for Summary Judgment in part and grant Plaintiffs Summary Judgment in part with regard to Plaintiff's claim of mental disability.
II. Procedural History
On September 19, 2010, Plaintiff protectively filed an application for SSI alleging disability beginning September 16, 2010 (R. at 18). The claim was initially denied on March 2, 2011 (R. at 18). On April 22, 2011., Claimant filed a written request for a hearing (R. at 18). A hearing was held before an Administrative Law Judge ("ALJ") on May 1., 2012 (R. at 18). Eugene A. Czuezman, an impartial vocational expert ("VE"), also appeared during the hearing (R. at 18). On May 9, 2012, the ALJ, Karen B. Kostal, determined that Plaintiff was not disabled under Section 1614(a)(3)(A) of the Social Security Act (R. at 27). The ALJ stated that, "Based on the testimony of the vocational expert, the undersigned concludes that, considering the claimant's age, education, work experience, and residual functional capacity, the claimant is capable of making a successful adjustment to other work that exists in significant numbers in the national economy." (R. at 27). On May 9, 2012 Plaintiff submitted a timely written request for review by the Appeals Council which was denied on September 11, - (R. at 1-3), thus making the Commissioner's decision final under 42 U.S.c. § 405(g).
III. Medical History
Plaintiffs is 5'3" tall and weighs 230 pounds (R. at 22). The ALJ found the Claimant to have the following severe impairments: (1) Major depressive disorder; (2) panic disorder with features of agoraphobia; (3) post-traumatic stress disorder ("PTSD"); (4) degenerative disc disease of the lumbar spine with mild radiculopathy; (5) obesity; (6) hypertension; and (7) headaches (R. at 20). Dr. Walter Bobak is Plaintiff's primary care physician who prescribes the following medications for Plaintiff's conditions: 50 mg of atenolol for high blood pressure, vitamin B for a deficiency, Zolofl for depression CR. at 133), cyclobenzaprine and gabapentin for dry mouth, mirtazapine for sleep, orne prazole for stomach problems, sertraline for dizziness and nausea, and topiramate for headaches (R. at 151). Plaintiff reported taking 800 mg of Motrin every 8 hours and 500 mg of Naproxen as needed for pain (R. at 145). Plaintiff reported being under the care of Dr. Sally of Fayette Podiatry where she receives cortisone shots (R. at 134), Lee Goddich, DC for physical therapy, and psychiatrist Dr. Shahoud Geith, MD.
On May 5, 2010 Dr. Bobak performed a Thyroid exam. Impressions were a diffusely enlarged heterogeneous thyroid gland with nodules in each lobe of the thyroid but there were no significant changes from previous exam. Further, we saw no information connecting a thyroid condition with Plaintiffs claims of disability.
On October 13, 2010 Plaintiff went to National Pike Chiropractic and reported severe low back pain and neck pain as well as swelling. She rated the pain a 9110 and said she has the pain all of the time (R. at 160). She also reported headaches that start at the back of her neck and travel up the back of her head (R. at 161). There were no further chiropractic reports.
On December 16, 2010 Dr. Raymond Nino completed a consultative examination report and found that Plaintiff could occasionally lift and/or carry 2-3 pounds due to low back pain (R. at 163). His further findings were that Plaintiff could only ambulate for less than 200 feet without stopping and reported she only had the capacity to stand or walk for an hour or less in an 8-hour day (R. at 163). His report stated she could sit less than 6 hours a day or she could sit for 8 hours a day alternating sit and stand positions (R. at 163). She is limited in lower extremity to push and pull 30 pounds (R. at 163). He reported she can frequently bend, kneel and balance, occasionally stoop, crouch, and climb (R. at 164). Dr. Nino also restricted Plaintiff from heights, moving machinery, vibration, and temperature extremes (R. at 164).
On December 20, 2010 Dr. Nino performed a general medical exam as requested by the Bureau of Disability. Dr. Nino reported Plaintiff to have a generally normal exam. Even though Plaintiff reported stiffness and chronic pain in her lower back he found no swelling or atrophy referable to her spine (R. at 168). Her neck and neurological exam were normal (R. at 169). Plaintiffs reflexes were intact and she was able to get on and off the exam table without difficulty, could rise from a chair without difficulty, and could stoop and rise with pain (R. at 169). Plaintiff s stance and gait were normal (R. at 169).
On January 13, 2011 John Carosso, Psy.D reviewed records provided by the Disability Bureau, conducted a clinical interview of the Plaintiff and administered a mini mental state exam and a Sheehan work disability work scale. Dr. Carosso made the following observations regarding Plaintiffs mental capabilities: She had moderate restrictions in understanding and remembering short simple instructions, she had marked restrictions in carrying out short simple instructions and making judgments on work-related decisions, she had extreme restrictions in understanding, remembering, and carrying out detailed instructions (R. at 171). Dr. Carosso also reported Plaintiff to have moderate limitations in her ability to interact appropriately with co-workers, marked limitations in her ability to interact appropriately with supervisors, and extreme limitations in her ability to interact appropriately with the public as well as her ability to respond to work pressures in a work setting (R. at 171). He attributed these restrictions to her depression (R.at 171). In summary he stated,
There is evidence of lack of attention to-task and poor concentration as per the Mini-Mental State Exam-2 results. Ms. Hartsock, however, presents as relatively intelligent and capable of understanding, retaining, and following instructions but her ability to do so on a consistent and reliable basis is likely limited. In that regard, she has difficulty with attention to-task and becomes easily overwhelmed with subsequent avoidant behaviors. She has problems relating to others without panic episodes and, for example, she needs her daughter to take her to the store.
Dr. Carosso gave Plaintiff a prognosis of guarded (R. at 177). He provided a diagnosis of Major Depressive Disorder, Moderate to Severe, Panic Disorder with Agoraphobia, Generalized Anxiety Disorder, PTSD, Foot Pain, Back Pain, Headaches (R. at 177). He gave her a Global Assessment Functioning Score of 50 (R. at 177)
On January 18, 2011 Plaintiff attended an appointment with Neurologist, Shobha Asthana, M.D. complaining of headaches. Plaintiff reported chills, headache, dizziness, eye pain, and blurred vision (R. at 178). Dr. Asthana prescribed Topiramate and ordered blood work and an MRI (R. at 179).
On January 19, 2011 a U.S. Venous Doppler Lower Right Extremity was performed by Dr. Sunjeev Katyal due to Plaintiffs lower extremity edema and pain. Dr. Katyal found the right common femoral and popliteal veins demonstrated normal compressibility, normal phasic venous flow, and normal response to augmentation. There was no evidence for echogenic thrombi. Furthermore, there was no evidence for deep venous thrombus from the right common femoral to the popliteal vein (R. at 226).
On February 2, 2011 an MRI of Plaintiffs brain was performed due to headaches and history of hypertension. No abnormalities were detected (R. at 240). On this same date an MRI of the lumbar spine was performed. The study showed a moderate degeneration of the L4-LS and LS-S1 discs with mild central spinal stenosis noted at ...