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Martin v. Colvin

United States District Court, M.D. Pennsylvania

April 1, 2015

BETTY E. MARTIN, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of the Social Security Administration, Defendant.

MEMORANDUM

RICHARD P. CONABOY, District Judge.

Here we consider Plaintiff's appeal from the Commissioner's denial of Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act"). (Doc. 1.) Plaintiff claims disability since June 22, 2008 (R. 12), listing the conditions that limit her ability to work as heart valve replacement, arthritis in her knees and hips, and depression (R. 170). The Administrative Law Judge ("ALJ") who evaluated the claim concluded that Plaintiff did not have a medically determinable mental impairment. (R. 15.) He determined that Plaintiff's severe impairments of "status post heart valve replacement, and status post right knee replacement" (R. 14) did not meet or equal the listings (R. 16). The ALJ also found that Plaintiff had the residual function capacity ("RFC") to perform a full range of medium work with the nonexertional limitation that she needed to avoid hazards due to the risk of being cut while on her Coumadin regimen. (R. 16.) After finding that Plaintiff was capable of performing past relevant work, the ALJ denied Plaintiff's claim for benefits. (R. 22-23.)

With this action, Plaintiff argues that the decision of the Social Security Administration is error for the following reasons: 1) the ALJ found Plaintiff's mental health impairment to be non-severe; 2) the ALJ failed to properly evaluate Plaintiff's treating physicians; 3) the reasons the ALJ gave for finding Plaintiff not credible as to the severity of her limitations are not supported by substantial evidence; 4) the ALJ failed to adopt a clear and supported RFC; and 5) the ALJ did not make specific findings regarding the mental demands of Plaintiff's past work. (Doc. 9 at 2.) For the reasons discussed below, we conclude Plaintiff's appeal of the Acting Commissioner's decision is properly granted.

I. Background

A. Procedural Background

Plaintiff protectively filed a Title II application for DIB on July 19, 2011, alleging disability beginning June 22, 2008. (R. 12.) This claim was denied initially on September 6, 2011. ( Id. ) Plaintiff filed a written request for a hearing on September 12, 2011, and a video hearing was held before ALJ Theodore Brickell on October 2, 2012. ( Id. ) Plaintiff was represented by counsel at the ALJ hearing and a Vocational Expert also testified. ( Id. ) In his April 24, 2013, decision, the ALJ concluded that Plaintiff was not under a disability within the meaning of the Social Security Act from June 22, 2008, through December 11, 2011, the last insured date. (R. 23.) As noted above, this determination was made at step four where the ALJ concluded Plaintiff had the residual functional capacity to perform the requirements of her past relevant work. (R. 22.)

On June 4, 2013, Plaintiff requested review of the ALJ's hearing decision. (R. 7-8.) The Appeals Council denied his request for review on July 10, 2014. (R. 1-6.) In doing so, the ALJ's decision became the decision of the Acting Commissioner. (R. 1.)

On September 5, 2014, Plaintiff filed the above-captioned matter in this Court. (Doc. 1.) Plaintiff filed her supporting brief (Doc. 9) on December 31, 2014, and Defendant filed her responsive brief (Doc. 12) on March 12, 2015. With the filing of Plaintiff's reply brief (Doc. 13) on March 11, 2015, this case became ripe for disposition.

B. Factual Background

Plaintiff was born on June 2, 1958, and was fifty-four years old at the time of the ALJ hearing. (R. 33.) She did not engage in substantial gainful activity since the onset date. (R. 14.) Plaintiff left high school in the tenth grade and has a GED. (R. 33.) She has past relevant work experience as a cleaner and order picker. (R. 22.)

1. Summary of Evidence of Physical Impairments

a. Heart Impairment

Plaintiff underwent aortic valve replacement on January 4, 2008, after being followed for years by the Moffit Heart and Vascular Group because of a bicuspid aortic valve. (R. 560.) She had developed progressive symptoms as of November 2007. ( Id. ) At her February 12, 2008, follow-up visit, it was noted that Plaintiff was doing well and was asymptomatic. (R. 561.) In recording his "Assessments and Recommendations" based on the February 12th visit, Dr. Robert Martin opined that Plaintiff could return to work as a housekeeper and maintenance person, noting "[a]t this point, she has no real restrictions." (R. 562.) Dr. Martin added that Plaintiff would obviously need to be cautious because she was on Coumadin. ( Id. )

On June 16, 2008, Plaintiff was seen by Dr. Martin for a follow-up regarding her "aortic valve disease." (R. 565.) He noted that she continued to do well from a cardiovascular standpoint. ( Id. ) Dr. Martin also noted that Plaintiff reported "some shortness of breath occasionally at night when she first lies down in bed and needs to take a deep breath, but it resolves rather promptly, " but she did not have shortness of breath with exertion as she had prior to the valve surgery. ( Id. ) Dr. Martin recorded that Plaintiff wondered whether the shortness of breath could have something to do with the weight she had put on over the previous few months. ( Id. ) He added that "she has also been under a lot of stress due to her continued unemployment and financial difficulties at home." ( Id. )

On January 9, 2009, Dr. Martin evaluated Plaintiff for perioperative risk assessment prior to arthroscopic knee surgery. (R. 568-69.) He noted that she had improved clinically since the surgery and had little, if any, symptoms. ( Id. ) He also reported Plaintiff's social history to be "notable for the fact that she is disabled at this point and no longer working." ( Id. )

Plaintiff had an office visit on August 24, 2009, with her primary care physician, Baxter D. Wellmon, D.O., for the purpose, among other things, of discussing filing for disability. (R. 451.) Plaintiff reported she had difficulty completing home chores such as cleaning and basic homemaker duties due to fatigue and feeling "played out." ( Id. ) Dr. Wellmon opined that Plaintiff was "unable to work secondary to her cardiac condition with increased fatigue and poor exercise tolerance." ( Id. )

On December 17, 2009, Dr. Martin saw Plaintiff for cardiovascular follow-up. (R. 509.) In his correspondence about the visit to Dr. Wellmon, Dr. Martin noted that Plaintiff reported that she had been more short of breath with exertion over the previous month than she had been in the past. ( Id. ) Specifically she stated that she had to stop and rest frequently when vacuuming, and she could not walk long distances because of both shortness of breath and knee pain. (R. 509.) Dr. Martin assessed the following: "Based on her history and exam, I do not think she has significant heart failure. Given that her symptoms are more prominent over the last month or so, I think we should check a chest x-ray, BNP, and of course her yearly echo.... [S]hould there be no objective evidence of heart failure, other possible causes will need to be considered." ( Id. ) He planned to forward copies of testing to Dr. Wellmon, adjust Plaintiff's medical regimen if necessary, and see Plaintiff again in one year. (R. 510.)

A December 18, 2009, diagnostic study showed that the heart was mildly enlarged. (R. 391.) The Impression was: "Cardiomegaly, Status post median sternotomy. No CHF, pleural effusion, or acute process demonstrated." ( Id. )

On November 19, 2010, Dr. Martin again saw Plaintiff for a cardiovascular follow-up and corresponded with Dr. Wellmon about the visit. (R. 515.) He reported the following: "From a Cardiovascular standpoint she has been stable. She did complain of heaviness in her chest this past summer, this prompted an evaluation and period of observation in the emergency department at the Chambersburg Hospital. No acute cardiac issues were identified.... [H]er main complaint is that of fatigue." ( Id. ) Dr. Martin adjusted Plaintiff's medications and planned to see her in six months. (R. 516.)

At an office visit with Dr. Wellmon on January 28, 2011, Plaintiff complained of recently feeling dizzy and lightheaded, occasional chest pain, and right arm numbness. (R. 442.) A chest ECG showed no evidence of a current problem, but Plaintiff was directed to follow up with cardiology if her symptoms returned. ( Id. ) Dr. Wellmon noted that her chest complaints could have a possible peptic etiology or possibly "concaved" by stress Plaintiff stated she had been having recently. ( Id. )

On July 29, 2011, Plaintiff saw Dr. Wellmon with complaints of chest discomfort and tightness over one to two weeks while coughing or taking a deep breath. (R. 438.) Plaintiff also complained of right arm numbness and heaviness, occasional lightheadedness, and a marked increase in fatigue, but no shortness of breath. ( Id. ) Dr. Wellmon consulted with Dr. Iskander at the Moffit Heart & Vascular Group, and Dr. Iskander recommended that Plaintiff go to the Emergency Room for labs and further evaluation. ( Id. ) Plaintiff was offered options, including going to the ER via ambulance, but Plaintiff opted to go home and discuss the matter with her husband. ( Id. ) Plaintiff's current medication list included Ultram, 50 milligrams 4 times a day for pain. ( Id. )

On the same date, Plaintiff went to the Carlisle Regional Medical Center ("CRMC") and was admitted based on her symptoms. (R. 414.) Because of the numbness, Plaintiff had a consult with Mohammad K. Ismail, M.D., who assessed Plaintiff to have multiple factors for cerebrovascular disease. (R. 414.) His differential diagnosis included reversible ischemic neurological deficit and complex migraines. ( Id. ) He also noted that she was subtherapeutic on Coumadin. ( Id. )

While hospitalized, Plaintiff also had a consultation with Jeffrey S. Mandak, M.D., of the Moffit Heart & Vascular Group. (R. 583.) He opined that her symptoms seemed more gastrointestinal in nature. (R. 584.)

Upon discharge on August 1, 2011, the CRMC report noted that Plaintiff's cardiac enzymes were followed during her hospital stay and were negative. (R. 416.) She developed symptoms that were more in the midepigastric and right upper quadrant area, and worse after eating. ( Id. ) Ultrasound of her gallbladder was unremarkable and her symptoms improved with metoprolol. ( Id. )

On April 2, 2012, a report of Plaintiff's cardiovascular follow-up was sent to Daniel Hely, M.D., of Appalachian Orthopedic Center in anticipation of total knee surgery. (R. 683.) Dr. Martin noted that Plaintiff reported some chest discomfort when she lifts heavier objects, something which has occurred chronically since her surgery. ( Id. ) He assessed that Plaintiff did not exhibit any evidence for congestive heart flutter, she appeared to be in sinus rhythm, her 2011 echocardiogram suggested low-normal systolic function with EF of 50%, and she had normal function of her mechanical prosthetic aortic valve. ( Id. )

b. Knee Impairment

On September 26, 2008, Dr. Wellmon noted that he would make arrangements for an orthopedic consultation to address Plaintiff's knee pain, pain which Plaintiff described felt like a hot poker through her knee. (R. 453.)

On February 12, 2009, Daniel Hely, M.D., performed an arthroscopic medial meniscectomy of the right knee based on the diagnosis of a medial meniscal tear. (R. 614.) At her March 13, 2009, follow-up visit, Plaintiff showed steady improvement and no apparent complications. (R. 605.)

On August 7, 2009, Dr. Hely reported that Plaintiff had ongoing symptoms of pain. (R. 590.) On examination, he found swelling, an antalgic gait, full extension and pain with flexion greater than 120 degrees, and valgus stress produced pain. ( Id. ) His impression was "[r]efractory symptoms of pain secondary to degenerative arthritis post meniscectomy." ( Id. ) Dr. Hely's plan was activity based on symptoms, over-the-counter anti-inflammatory medication, gentle motion and strengthening exercises, and follow-up if things did not stay quiet. ( Id. )

On November 12, 2009, Dr. Wellmon reported that Plaintiff's pain appeared stable with regard to osteoarthritis of her knees. (R. 450.) At the time Plaintiff was taking Vicodin every six hours for pain. ( Id. )

Plaintiff was in an automobile accident on May 1, 2010, and injured her right knee. (R. 536.) She was seen at Orthopaedic Associates on May 17, 2010, ( id. ) and continued follow-up there for two months (R. 537-38). Physical therapy made her knee feel worse and a Neoprene brace, ice, elevation and anti-inflammatories were recommended. (R. 537.) By July 16, 2010, it was reported that her knee was doing reasonably well but Plaintiff still complained of discomfort with standing and walking. ( Id. ) The reporter opined that the accident probably aggravated the arthritic condition of the knee. ( Id. ) Plaintiff was instructed to do exercises and informed that she may sometime need knee replacement surgery. (R. 538.) Plaintiff declined a knee injection. ( Id. )

On July 29, 2011, notes from Plaintiff's office visit with Dr. Wellmon indicate her current medications included Ultram, 50 milligrams 4 times a day for pain. (R. 438.)

Plaintiff was seen by Tom Albert, M.D., at Summit Orthopaedics for her knee problem on October 7, 2011. (R. 718.) Dr. Albert assessed Plaintiff to have medial compartment bone on bone osteoarthritis. ( Id. ) He discussed with her that the next step for her surgically would be a knee replacement surgery, adding that "[o]ther options would be corticosteroid injection, anti-inflammatories as she has had many corticosteroid injections and Visco supplements in the past and has not had relief with that." ( Id. ) Plaintiff indicated she wanted to hold off on surgery, something Dr. Martin found reasonable. ( Id. )

On January 19, 2012, Plaintiff saw Dr. Wellmon for a variety of complaints and he noted that her exam was "unremarkable." (R. 739.) Her list of current medications included Ultram, 50 milligrams 4 times a day for pain. ( Id. )

April 2, 2012, correspondence from Plaintiff's cardiologist to Daniel P. Hely, M.D., of Appalachian Orthopedic Center, regarding Plaintiff's total knee surgery scheduled for April 24, 2012, indicates that Plaintiff had informed him she was quite limited by her knee pain, that she had to sit frequently because of knee discomfort, and had been more sedentary because of the knee pain. (R. 683.)

Plaintiff had partial knee replacement surgery on April 24, 2012. (R. 670.) The surgery was uneventful and Plaintiff was discharged on April 27, 2012. ( Id. ) At a follow-up office visit on May 7, 2012, Dr. Hely noted that Plaintiff was having "a remarkably smooth course with very little difficulty" and no apparent complications. ( Id. ) At her six-week post operative visit on June 4, 2012, Dr. Hely found no significant functional problem but Plaintiff was continuing to have hypersensitivity at the site of the surgical wound. (R. 713.) He found no sign of inflammation, full extension and flexion to well over 90 degrees, no tenderness medially or laterally, and some hyperesthesia over the surgical wound. ( Id. ) He assessed Plaintiff to have "slow improvement." ( Id. )

On August 10, 2012, Plaintiff had an office visit with Dr. Wellmon and wanted "to have forms completed from attorney." (R. 736.) Among other things, Dr. Wellmon noted that Plaintiff's pains were mainly in her knees requiring symptom management. ( Id. )

On September 7, 2012, Plaintiff again saw Dr. Hely. (R. 755.) He recorded that she was still having ongoing difficulty with the right knee and had been unable to advance to full work activity. ( Id. ) Examination showed a well-healed surgical scar, full extension and flexion to over 120 degrees, normal gait, and no tenderness on direct palpation. ( Id. ) Dr. Hely recommended that Plaintiff advance activity as pain allowed, continue motion and strengthening exercises, and follow up with him in three months. ( Id. )

2. Summary of Evidence of Mental Impairments

At Plaintiff's June 16, 2008, office visit with cardiologist Robert Martin, M.D., Plaintiff's occasional shortness of breath at night was discussed. As previously noted, in his report to Dr. Wellmon Dr. Martin stated that Plaintiff had been under a lot of stress due to her continued unemployment and financial difficulties at home. (R. 565.)

Plaintiff saw Dr. Wellmon on September 26, 2008, with complaints of shortness of breath, knee pain, lack of sleep, and feeling irritable and moody. (R. 453.) At the time ...


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