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Trolinger v. Commissioner of Social Security

United States District Court, M.D. Pennsylvania

July 27, 2015




This is an action brought under Section 205(g) of the Social Security Act, 42 U.S.C. §405(g), seeking judicial review of a partially favorable decision of the Commissioner of Social Security ("Commissioner") awarding Plaintiff Galen Trolinger Disability Insurance Benefits ("DIB") under Title II of the Social Security Act beginning July 27, 2011 - rather than on Plaintiff's alleged onset date of November 21, 2008. This matter has been referred to the undersigned United States Magistrate Judge on consent of the parties, pursuant to the provisions of 28 U.S.C. § 636(c) and Rule 73 of the Federal Rules of Civil Procedure. (Doc. 26; Doc. 27).

For the reasons stated herein, we conclude that the final decision of the Commissioner was made in accordance with the law and applicable regulations, and is supported by substantial evidence. As such, we will AFFIRM the final decision of the Commissioner, and DENY Plaintiff's request for the award of benefits or remand for a new administrative hearing.


On January 26, 2009, Plaintiff protectively filed a Title II application for DIB alleging that he became unable to engage in his past work, or any other work, on November 21, 2008, due to diabetes, sciatica, neuropathy, and a heart condition. (Admin. Tr. 223; Doc. 11-6 p. 6). In addition to the impairments alleged, the ALJ also evaluated the medically determinable impairments of hypothyroidism, hypertension, hyperlipidemia, arthritis, depression, and gastrointestinal reflux disease ("GERD"). (Admin. Tr. 22; Doc. 11-2 p. 23).

Plaintiff was fifty-four years old on the date of his first administrative hearing. He has a high school education, and is a certified electrician. (Admin. Tr. 500; Doc. 29 p. 8). Plaintiff last worked as a tire loader. He was laid off in November 2008 when his employer closed the plant where he worked. (Admin. Tr. 518; Doc. 29 p. 26). His position as a tire loader required him to be on his feet all day. (Admin. Tr. 44; Doc. 11-2 p. 45). He was required to constantly lift and carry objects weighing between thirty and a couple hundred pounds. (Admin. Tr. 47; Doc. 11-2 p. 48); (Admin. Tr. 520; Doc. 29 p. 28).

Plaintiff testified that he has severe neuropathy in both of his feet, which radiates up both of his legs. (Admin. Tr. 503; Doc. 29 p. 11). He reported that he cannot stand or walk for longer than ten minutes. (Admin. Tr. 512; Doc. 29 p. 20). His pain is alleviated with he sits with both feet elevated, (Admin. Tr. 503; Doc. 29 p. 11), but during a typical day he is constantly changing positions to alleviate pain. (Admin. Tr. 514; Doc. 29 p. 22). He also takes Lyrica twice per day. He testified that his medication does help with his pain, but does not significantly improve his ability to walk or stand. (Admin. Tr. 503; Doc. 29 p. 11). Despite his difficulty walking and standing, Plaintiff does not use an assistive device, motorized vehicle, or wheelchair to ambulate. Id.

Plaintiff testified that he lives in an efficiency apartment attached to his brother's home. He has to walk up ten steps to reach his apartment, but testified that walking up stairs does not bother him any more than walking on a flat surface. (Admin. Tr. 504, 513; Doc. 29 p. 12, 21). Cold temperatures cause his legs to stiffen up, and his pain disturbs his sleep. (Admin. Tr. 509; Doc. 29 p. 17). On the date of his hearing, Plaintiff was able to drive thirty minutes without stopping. (Admin. Tr. 508-09; Doc. 29 p. 16-17).

He testified that his neuropathy has intensified since he completed his adult function report in March 2009, and that he is no longer able to do certain activities. For example, in 2009 he was able to drive his girlfriend to work, care for a small dog, shop for groceries, and mow the lawn using a riding mower. (Admin. Tr. 242-51; Doc. 11-6 pp. 25-34.). As of August 2010, he reported that he no longer had a girlfriend or dog, no longer shopped for his own groceries, and no longer mowed the lawn. (Admin. Tr. 504, 506-07; Doc. 29 p. 12, 14-15). Although medical records reflect that he injured himself moving furniture, Plaintiff reported that he actually injured his shin by walking into a piece of furniture. (Admin. Tr. 515; Doc. 29 p. 23). He also reported that he attempted to exercise by walking on his brother's treadmill in April 2010, but could not do it because of the pain. Id.

Plaintiff reported that he was first diagnosed with peripheral neuropathy in 2005. (Admin. Tr. 334; Doc. 11-7 p. 45). During examinations in November 2007, June 2008, and December 2008, Dr. Carey noted that Plaintiff exhibited symptoms of peripheral neuropathy. (Admin. Tr. 295-98; Doc. 11-7 pp. 6-9). Treatment records from the Sadler Health Center, where Plaintiff was treated by Dr. Hieb reflect a diagnosis of severe peripheral neuropathy dating back to December 2008, when he first established care at that facility. (Admin. Tr. 330-31; Doc. 11-7 p. 41-42). Treatment records also reflect that Plaintiff's diabetes was poorly controlled. He was informed that he may need basal insulin in February 2009. In September 2009, Plaintiff reported that he could not sleep due to pain in his legs.

With respect to Plaintiff's heart impairment, the record reflects that treating source Dr. Philip Carey recommended that Plaintiff undergo a dual isotope stress test in 2007. On June 18, 2007, the electrocardiographic portion of a dual isotope stress test was negative for ischemia, and revealed no definite angina. (Admin. Tr. 292; Doc. 11-7 p. 3). Plaintiff's left ventricular function was normal. Id. There was, however, evidence of reversibility on the nuclear scans, consistent with ischemia. Id. In November 2007, Dr. Carey noted that Plaintiff was negative for chest pain and shortness of breath, but referred him to cardiologist Dr. Emad Iskandar based on the results of the stress test. (Admin. Tr. 297; Doc. 11-7 p. 9). During examinations in November 2007, June 2008, Dr. Carey noted that Plaintiff denied chest pain, syncope, and shortness of breath. (Admin. Tr. 295-98; Doc. 11-7 pp. 6-9).

On December 31, 2007, Plaintiff presented to Dr. Iskandar for evaluation of mild sternal chest pain in light of his abnormal stress test. (Admin. Tr. 299; Doc. 11-7 p. 10). Dr. Iskandar recommended that Plaintiff undergo cardiac catheterization as the next step in Plaintiff's cardiac workup and asked Plaintiff to begin an aspirin regimen. (Admin. Tr. 301; Doc. 11-7 p. 12). Dr. Iskandar also noted that Plaintiff's hypertension was adequately controlled with medication, and that his hyperlipidemia was maintained by medication. Id. Treatment notes also reflect that Plaintiff wanted to wait to have the recommended cardiac catheterization due to financial constraints. Id. Plaintiff never had the cardiac catheterization procedure, (Admin. Tr. 295; Doc. 11-7 p. 6), and did not return to Dr. Iskandar for further treatment until February 2010, when Plaintiff presented with complaints of twice weekly episodes of sharp midsternal chest pain. (Admin. Tr. 384-85; Doc. 11-7 pp. 95-96). Dr. Iskandar recommended a non-exercise nuclear stress test to assess ischemia, and noted that Plaintiff's hypertension and hyperlipidemia were adequately controlled by medication. Id.

Treatment records from the Sadler Health Center, where Plaintiff was treated by Dr. Hieb, reflect that Plaintiff was positive for chest pain in December 2008, and was diagnosed with coronary artery disease in February 2009. (Admin. Tr. 323; Doc. 11-7 p. 34). In August 2010, a pharmacologic stress test was negative for ischemia, but was considered mildly abnormal due to small fixed apical and basal inferior defects - which appeared to be reversible on the prior study. Plaintiff's left ventricular ejection fraction was considered normal. (Admin. Tr. 435; Doc. 11-8 p. 50); (Admin. Tr. 50; Doc. 11-2 p. 51).

Plaintiff was diagnosed with hypothyroidism in May 2012. (Admin. Tr. 456; Doc. 11-8 p. 71). He refused to begin treatment with Synthroid in April 2012 despite elevated levels of TSH in his blood work. (Admin. Tr. 458; Doc. 11-8 p. 73).

With respect to his alleged impairment due to depression, treatment record reflect that Plaintiff reported feeling depressed in December 2008, and again in April 2009. (Admin. Tr. 295, 376; Doc. 11-7 p. 6, 88). Plaintiff was prescribed Zoloft. (Admin. Tr. 375; Doc. 11-7 p. 86). Plaintiff continued to report feelings of depression and anxiety throughout the relevant period, but was reported to be doing well psychiatrically.

In addition to treatment notes, the record in this case also includes medical opinions by treating, nontreating, and nonexamining medical sources.

On May 5, 2009, Plaintiff was examined by nontreating source, Dr. Ronald Vandegriff for a disability evaluation. (Admin. Tr. 334-42; Doc. 11-7 pp. 45-53). Plaintiff reported that he was diagnosed with peripheral neuropathy secondary to diabetes mellitus in 2003. Id. Dr. Vandegriff reported the impression of diabetes mellitus (type 1), hypothyroidism, hyperlipidemia, and neuropathy (bilateral, feet). Id. On examination, Dr. Vandegriff noted that Plaintiff's range of motion was within normal limits in all joints. Id. He opined that Plaintiff retained the physical capacity to: frequently lift up to twenty pounds; frequently carry up to ten pounds, and occasionally carry up to twenty pounds; stand or walk up to two hours per eight-hour day; sit without restriction; push or pull without limitation; frequently bend and kneel; occasionally stoop and crouch; never balance or climb; and reach, handle, finger, feel, see, hear, speak, taste, and smell without restriction. Id. Dr. Vandegriff also assessed that Plaintiff should avoid exposure to heights and moving machinery. Id.

On June 18, 2009, nonexamining psychologist Dr. Karen Weitzner completed a psychiatric review technique form. (Admin. Tr. 343-55; Doc. 11-7 pp. 54-66). Dr. Weitzner assessed that Plaintiff had no medically determinable mental impairment. Id. In so doing, she explained that although Plaintiff reported treatment for depressive symptoms in the past, there is was no medical evidence in the record at that time indicating that Plaintiff was receiving any current mental health treatment. Id.

On June 25, 2009, nonexamining general practitioner Dr. Vrajlal Popat completed a physical RFC assessment of Plaintiff's abilities. (Admin. Tr. 356-63; Doc. 11-7 pp. 67-74). Dr. Popat noted the diagnoses of diabetes, thyroid disease, arthritis, and bilateral neuropathy in the lower extremities. Id. He assessed that Plaintiff could: occasionally lift or carry up to fifty pounds and frequently lift or carry up to twenty-five pounds; stand or walk up to six hours per eight-hour workday; sit up to six hours per eight-hour workday; push or pull with his upper and lower extremities without restriction; frequently climb, balance, and stoop; and occasionally kneel, crouch, and crawl. Id. Dr. Popat also noted that Plaintiff had no established manipulative, visual, communicative or environmental limitations. Id. In support of his assessment, Dr. Popat explained that the totality of the evidence did not support the lifting, carrying, standing, or walking limitations noted by Dr. Vandegriff or Plaintiff's claims, and does not contain the type of significant clinical or laboratory abnormalities to support a finding of disability. Id.

On July 17, 2010, treating source Dr. Hieb completed a medical source statement about Plaintiff's ability to do physical work-related activities. (Admin. Tr. 430-33; Doc. 11-8 pp. 45-48). In his check-box assessment, Dr. Hieb opined that Plaintiff could: lift or carry objects weighing less than ten pounds on an occasional or frequent basis; stand or walk less than two hours per eight-hour workday; sit without restriction; push or pull objects without restriction; never climb, balance, kneel, or crouch; occasionally crawl, stoop, and engage in handling or fingering. Id. Dr. Hieb also noted that Plaintiff had visual disturbances that affected his ability to see, and should avoid work environments where he would be exposed to vibration, humidity, and hazards due to occasional vertigo. Id. On August 26, 2010, Dr. Hieb authored ...

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