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Fleet v. Commissioner of Social Security

United States District Court, W.D. Pennsylvania

June 3, 2015



Terrence F. McVerry, Senior United States District Judge.

I. Introduction

Patricia Fleet (“Plaintiff”) brings this action for judicial review of the decision of the Acting Commissioner of Social Security, which denied her application for disability insurance benefits (“DIB”) under Title II of the Social Security Act (“Act”), 42 U.S.C. §§ 401-403. Pending before the Court are the parties’ cross-motions for summary judgment (ECF Nos. 6, 9). The motions have been fully briefed and are ripe for disposition (ECF Nos. 7, 10).

II. Background

A. Facts

Plaintiff was born on June 11, 1946, and graduated from high school in 1964. (R. 143-162). She has prior work experience as a hostess and retail sales attendant, but she stopped working in August 2002 “because of [her] condition(s).”[1] (R. 162-63). She alleges disability as of December 31, 2007, due to fibromyalgia, asthma, and several other alleged impairments. (R. 162). She last met the insured-status requirement for DIB on December 31, 2007. (R. 14). Thus, the period under consideration is August 30, 2002, through December 31, 2007.

The medical evidence from that period is rather sparse. Plaintiff underwent a neurosurgical consultation with J. William Bookwalter, III, M.D., on January 21, 2002, upon referral from her primary care physician, Mary Jo Houston, M.D. (R. 238-39). Dr. Bookwalter noted that Plaintiff had been diagnosed with fibromyalgia, though it is not clear from the record when this diagnosis was first made. (R. 238). She complained of bilateral shoulder pain and upper extremity discomfort, particularly numbness and tingling in her left arm. (R. 238). She also complained of headaches. (R. 238). On examination, Plaintiff displayed “pretty good range of motion of her neck and no real spasm.” (R. 238). Likewise, “[h]er motor exam was normal in her upper extremities” and she had “no sensory loss.” (R. 238). Furthermore, Dr. Bookwalter reviewed a recent MRI and noted that it “doesn’t look bad.” (R. 239). Though he did observe “some degenerative changes, ” Dr. Bookwalter disagreed with the assessment of one of Plaintiff’s other doctors that there were “tiny focal midline herniation at C5-6.” (R. 239).

Following this consultation with Dr. Bookwalter, there is a four-year gap in the record. Plaintiff finally returned to Dr. Bookwalter’s office in June 2006, after a sinus CT scan showed a lesion on her left frontal lobe. (R. 235). Dr. Bookwalter reviewed the results of the CT scan and found that the lesion was “basically a very small questionable meningioma, ” which was “in no way causing her right-sided body pain symptoms.” (R. 235). On examination, Plaintiff had full range of motion, normal muscle strength, symmetric reflexes, and no sensory changes. (R. 235). She was prescribed Medrol (a steroid) and Motrin for her neck pain and advised to follow-up in a few weeks. (R. 235).

Plaintiff next saw Dr. Bookwalter on July 10, 2006, at which time he noted that she was “better on the steroids and nonsteroidals suggesting that her symptoms regarding her neck are really related to degenerative disc disease.” (R. 228). He suggested that she attempt to lose weight and also suggested sending her to a physiatrist (a rehab physician) to manage her degenerative disc disease. (R. 228).

To that end, Plaintiff was referred to Gin-Ming Hsu, M.D., at East Suburban Rehabilitation Associates, Inc. (“East Suburban”). (R. 492). During her initial appointment on August 17, 2006, Plaintiff complained of right-sided chronic neck pain, which she rated 5/10 on average, along with intermittent numbness in her hands and arms. (R. 492). She had trouble sleeping because of the pain. (R. 492). Nevertheless, she reported that she worked part-time as a bridal consultant. (R. 493). According to Dr. Hsu, Plaintiff received some pain relief with the application of heat. (R. 492). Motrin also gave her some relief, and Medrol produced “good results” – though the latter drug had been discontinued. (R. 492). Upon exam, Plaintiff’s range of motion of was limited, but she displayed full strength in her upper extremities. (R. 493). Dr. Hsu recommended that Plaintiff continue taking Motrin and also that she undergo trigger-point injections followed by physical therapy (“PT”). (R. 493).

Plaintiff underwent her first trigger-point injections at East Suburban on August 28, 2006. (R. 242-43). Her symptoms were unchanged from her last visit. (R. 242). Following this appointment, she was ordered to begin PT. (R. 423). The next month, she returned to East Suburban for a follow-up, reporting that her first PT session had been “very helpful.” (R. 240). Ambien also reportedly helped. (R. 240). Plaintiff received another round of trigger-point injections, and was instructed to continue undergoing PT two to three times per week and to obtain a Transcutaneous Electrical Nerve Stimulation (“TENS”) unit. (R. 241).

Plaintiff returned to East Suburban in November 2006, at which time she reported experiencing pain relief from her PT and TENS unit. (R. 486). She also reported that her trigger-point injections and Lunesta were both “wonderful.” (R. 486). She described experiencing side effects from Lunesta, but she said that she could “deal with it.” (R. 486). And although she said that she was “really tired all the time, ” she was still working part-time in bridal sales. (R. 486).

Plaintiff returned to Dr. Hsu’s office for additional trigger-point injections in January 2007. (R. 484). She still complained of neck and shoulder pain radiating into her right hand and right side. (R. 484). Her range of motion was limited, but her stability and muscle strength were both normal, as was the rest of her physical examination. (R. 484). She reported that her trigger-point injections were providing “fairly good” relief. (R. 484). Likewise, she considered her TENS unit “effective” and said she got temporary relief from PT. (R. 484).

In April 2007, Plaintiff reported that her latest round of trigger-point injections had not been as effective as previous rounds, though she still received “some relief.” (R. 482). She complained that she felt very exhausted, as her fibromyalgia and the neck pain related thereto had worsened. (R. 482). However, her physical examination was largely the same as it had been in prior months (i.e., unremarkable). (R. ...

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