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Beilman v. Colvin

United States District Court, M.D. Pennsylvania

January 6, 2017

AMANDA BEILMAN, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM

          RICHARD P. CONABOY, United States District Judge

         Pending before the Court is Plaintiff's appeal from the Commissioner's denial of Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (“Act”). (Doc. 1.) She alleged disability beginning on September 26, 2011. (R. 15.) The Administrative Law Judge (“ALJ”) who evaluated the claim, Michelle Wolfe, concluded in her August 28, 2014, decision that Plaintiff had the severe impairments of cervicalgia, lumbar facet syndrome, cervical and lumbar sprain, sacroliliitis, obesity, asthma traumatic brain injury with post-concussive syndrome, and cervicogenic headaches, as well as non-severe impairments including GERD, anxiety disorder, depressive disorder and carpal tunnel syndrome. (R. 17.) ALJ Wolfe found that these impairments did not meet or equal a listing when considered alone or in combination. (R. 19.) She also found that Plaintiff had the residual functional capacity (“RFC”) to perform sedentary work with certain nonexertional limitations and that she was capable of performing jobs that existed in significant numbers in the national economy. (R. 19-30.) ALJ Wolfe therefore found Plaintiff was not disabled from September 26, 2011, through the date of the decision. (R. 31.)

         In the “Statement of Errors Alleged, ” Plaintiff identifies two errors: 1) “the ALJ erred by concluding the Plaintiff did not have a severe medically determinable impairment or combination of impairments”; and 2) “the ALJ erred by concluding the Plaintiff's impairments did not meet or equal a listed impairment.” (Doc. 11 at 7.) After careful review of the record and the parties' filings, the Court concludes this appeal is properly denied.

         I. Background

         A. Procedural Background

         Plaintiff protectively filed for DIB July 7, 2012. (R. 15.) The claim was initially denied on February 6, 2013, and Plaintiff filed a request for a hearing before an ALJ on April 5, 2013. (Id.)

         ALJ Wolfe held a hearing on May 20, 2014, in Harrisburg, Pennsylvania. (Id.) Plaintiff, who was represented by an attorney, appeared at the hearing as did Vocational Expert (“VE”) Michelle Georgio. (Id.) As noted above, the ALJ issued her unfavorable decision on August 28, 2014, finding that Plaintiff was not disabled under the Social Security Act during the relevant time period. (R. 32.)

         Plaintiff's request for review of the ALJ's decision was dated October 30, 2014. (R. 7-11.) The Appeals Council denied Plaintiff's request for review of the ALJ's decision on April 19, 2016. (R. 1-6.) In doing so, the ALJ's decision became the decision of the Acting Commissioner. (R. 1.)

         On June 15, 2016, Plaintiff filed her action in this Court appealing the Acting Commissioner's decision. (Doc. 1.) Defendant filed her answer and the Social Security Administration transcript on August 24, 2016. (Docs. 9, 10.) Plaintiff filed her supporting brief on October 11, 2016. (Doc. 12.) Defendant filed her brief on November 10, 2016. (Doc. 13.) Plaintiff did not file a reply brief and the time for doing so has passed. Therefore, this matter is ripe for disposition.

         B. Factual Background

         Plaintiff was born on March 8, 1986, and was twenty-five years old on the alleged disability onset date. (R. 30.) She has a high school education and past relevant work as a diet clerk, a dispatcher, a resident aide, and a security guard. (Id.)

         1. Impairment Evidence[1]

         Plaintiff alleged disability beginning on September 26, 2011, due to cervical whiplash, lumbago, pinched nerves in her back, neck injury, back injury, anxiety, erosive lichen planus, and depression. (R. 134.)

         Moses Taylor Hospital records from September 26, 2011, show that Plaintiff had a CT scan of the brain due to head and neck pain following a motor vehicle accident. (R. 186.) Clinical History indicates that Plaintiff was in a neck brace. (Id.) The Impression was “[n]o acute intracranial abnormality [and] [n]o skull fracture identified.” (Id.) X-rays on the same date showed “straightening of the normal lordosis which may represent muscle spasm” and no evidence of fracture or subluxation. (R. 187.) Plaintiff was advised to follow up if symptoms persisted. (Id.) Cervical spine CT showed no acute bone abnormality and loss of normal cervical lordosis which could be secondary to muscle spasm. (R. 189.)

         At the time, Plaintiff received primary care treatment at The Wright Center Medical Group. (R. 240-48.) At her September 23, 2011, appointment Plaintiff was seen by Alycia Coar, PA-C, and reported a two-day history of pain in her left calf, stating that it hurt when she walked and elevation had not provided relief. (R. 240.) Her medical problems included back pain from a 2005 work injury. (R. 241.) Other than the presenting problem, Plaintiff denied any other difficulties. (Id.) Examination showed full range of motion bilaterally in her upper and lower extremities and Plaintiff was sent to the ER and advised to call if the symptoms worsened, persisted, or changed. (R. 242.)

         On September 28, 2011, Plaintiff was seen at the Wright Center by Jignesh Sheth, M.D., for complaints of neck and back pain related to the September 26, 2011, accident. (R. 244.) Plaintiff had full range of motion bilaterally in her upper and lower extremities, she was alert and oriented x3 and her affect was normal. (R. 247.) Dr. Sheth diagnosed asthma, tobacco use disorder, generalized anxiety disorder, Lichen Planus, cellulitis, and sleep disorder. (R. 247.) Office notes from the same date relate more specifically to Plaintiff's complaints related to the September 26, 2011, accident and dizziness is noted to be an additional presenting problem. (R. 249-52.) Plaintiff reported that she was in the passenger seat not wearing a seat belt when she was rear-ended by a pickup truck while in stopped traffic. (R. 250-51.) She remembers the impact and then being in the ambulance on her way to Moses Taylor Hospital where neck, chest and CT scan of her head were negative. (Id.) She was discharged without medications for pain. (Id.) Examination showed tenderness of the thoracic and lumbar parvertebral region bilaterally. (R. 251.) Neurological examination was normal. (Id.) Plaintiff was prescribed pain medication and referred to a chiropractor. (Id.) Other than presenting problems, the Review of Systems was negative. (R. 246, 251.)

         On October 19, 2011, Plaintiff was again seen by Dr. Sheth for complaints related to her motor vehicle accident: neck, back and shoulder pain, headaches, and nausea and vomiting. (R. 253.) Plaintiff reported that she was seeing a chiropractor and improved initially but was getting worse. (R. 254.) Other than presenting problems, the Review of Systems was negative. (R. 258.) Examination showed tenderness of the thoracic and lumbar parvertebral region bilaterally and normal neurological findings. (R. 255.) Dr. Sheth noted that he was awaiting approval for a MRI to assess Plaintiff's severe neck pain and made a neurology referral. (R. 256.)

         At Plaintiff's November 14, 2011, visit to the Wright Center, Plaintiff reported to Nancy Greer, CRNP, that she was still in pain. (R. 257.) Examination showed that Plaintiff had neck stiffness and full range of motion of her upper extremities bilaterally. (R. 258.) Ms. Greer noted that Plaintiff had a CT scan which showed muscle spasm but it was difficult to ascertain on evaluation because Plaintiff was very obese. (Id.) Neurological examination was normal. (Id.) Ms. Greer noted that Plaintiff did not appear to be in any pain and she had noticeable full range of motion but palpable muscle tenderness. (R. 259.) The Review of Systems indicates that Plaintiff denied any problems. (R. 260.) Ms. Greer recorded that Skelaxin would be tried for pain “for this visit only” and that Plaintiff was advised that she should continue with the chiropractor for non-medicine pain relief and she would not be given a long-term narcotic--she “would need to have another plan.” (R. 259.) Regarding generalized anxiety disorder, office records indicate that Plaintiff was doing well on her current medications. (R. 262.)

         Plaintiff followed up at the Wright Center on December 6, 2011, reporting that she was seeing a chiropractor (Dr. Yusavage) three times a week and she did not feel it was helping. (R. 264.) Plaintiff also reported that she now had pain starting between her shoulder blades and shooting to her left hip and “her legs go numb and she falls to the floor, ” and she has left leg tingling and numbness, especially if she is sitting for a while. (Id.) In the Review of Systems, Plaintiff denied any problems other than the specific presenting complaints. (R. 265.) Examination showed that Plaintiff had bilateral muscle spasm and tightness in her neck, and stiffness with palpation of lower paraspinal muscles, no spinal tenderness, pain with single leg raise on the left but not on the right, and equal strength in all extremities. (R. 265-66.) Mr. Greer planned to check EMG/NCV of upper extremities and order an MRI of the lumbar spine. (R. 266.) Plaintiff was advised that pain medications would be refilled until all testing was done. (R. 267.)

         Plaintiff was seen at Regional Hospital of Scranton on December 12, 2011, with the chief complaint of thoracic back pain radiating down the left leg resulting from the motor vehicle collision. (R. 191.) Vicodin, Skelaxin, Prednisone, and Klonopin were recorded to be her medications. (Id.) Though the Nurses Note is difficult to read it appears that Plaintiff refused Percocet and Toradol, she “threw objects in room, ” and she said she expected an MRI that night. (R. 192.) Physical examination showed tenderness in the left back thoracic and lumbar region. (R. 194.)

         Electrodiagnostic examination/consultation was performed on December 14, 2011, due to complaints of low back pain extending to the left hip along with left leg weakness and loss of grip strength in both hands. (R. 196-97.) The following history was provided:

Approximately one and a half weeks ago, she developed electric pains extending from her left low back into her left hips and from her left inguinal region to her left knee. She has had numbness in the dorsum of her left foot and the left leg occasionally gave way. She has also ad occasional numbness in her right hip. On December 6, 2011, while eating she lost grip strength in both hands. She has longstanding difficulty opening tight bottles. She has had no numbness or tingling in her hands and no neck pain. She has a 10 year history of an autoimmune disorder. She also was involved in an automobile accideent in which she was rear-end[ed] in September of 2011.

(R. 197.) Examination showed the following:

She was obese. Deep tendon reflexes were absent in the biceps, triceps, quadriceps and Achilles tendons. She had decreased sensation to pinprick in the dorsum of the left great toe and the left medial arch. There was also decreased sensation to pinprick in the left medial calf. There was moderate weakness in the left anterior tibialis, quadriceps femoris, iliiopsoas and hamstrings. Toe tapping was moderately decreased in the left and normal in the right. She had no loss of sensation to pinprick in either upper extremity and there was no loss of strength in either upper extremity.

(Id.) Clinical Interpretation showed “[a]n old or chronic mild left L3 radiculopathy was presented based upon mild motor unit loss and chronic motor unit changes of the left L3 distribution. There was suspected involvement of the left L4 distribution. Lumbar paraspinal involvement contained increased insertional irritability.” (R. 198.)

         MRI of the lumbar spine on January 5, 2012, showed “normal lumbar spine” and a “2.8 X 3.7 centimeter left ovarian cyst” with a similar finding described on a 2005 study. (R. 199.)

         At her visit to the Wright Center on January 6, 2012, Plaintiff had the same complaints related to the accident as at her December 6, 2011, visit. (R. 264, 268.) Ms. Greer noted that the MRI of the lumbar spine was a normal study and the EMG study of the upper extremities showed mild nerve root irritation. (R. 268.) In the Review of Systems, Plaintiff denied problems other than those indicated above. (R. 269.) Physical examination was the same as in December. (R. 265-66, 270.) Plaintiff was advised that she had to try physical therapy as the Wright Center would not continue to provide narcotic pain medications. (R. 270.) Regarding generalized anxiety disorder, office records indicate that Plaintiff continued to do well on her current medications. (R. 262.)

         On February 16, 2012, Plaintiff presented to the Wright Center for a recheck for her return to work. (R. 276.) Plaintiff reported that she had been seeing the chiropractor and it had been helping but she fell on the stairs at home and said that “everything the therapy was helping is now injured again.” (R. 276.) Plaintiff did not feel she could go back to work due to the recent fall. (Id.) Review of Systems indicated that Plaintiff denied problems other than left arm pain, back pain, limitations of movement, muscle pain and neck pain. (R. 277.) Examination showed mild neck soreness with palpation, left upper arm sore to palpation, and lower back muscles sore to palpation. (Id.) Ms. Greer noted that Plaintiff would need to be x-rayed again because of the fall and she should hold off on physical therapy until the x-rays were done. (Id.) She also noted that Plaintiff had a follow up appointment on March 9th and she would need to be off work until then. (R. 278.)

         On February 23, 2012, Plaintiff presented for facial swelling with blistering on her lips. (R. 279.) Review of Systems shows that Plaintiff denied back pain, stiffness, or trouble walking, and denied anxiety, depression, or paranoia. (R. 280-81.) Examination showed problems with Plaintiff's lips, her neck was supple on inspection, and she had full range of motion bilaterally of upper and lower extremities. (R. 281.)

         On March 13, 2012, Plaintiff presented for heartburn, anxiety, depression, and asthma and was seen by Dr. Sheth. (R. 283.) She reported that her anxiety was of sudden onset following the motor vehicle accident, she was unaware of any aggravating factors, and it was not alleviated by anything. (Id.) Regarding accident related problems, Plaintiff said she felt better compared to her previous visit, she was “improving and mostly well controlled, ” she was taking prescribed medications with no side effects, and she reported moderate upper and lower back aching pain that did not radiate. (R. 283.) In the Review of Systems, Plaintiff reported ambulatory dysfunction, back pain, stiffness and spasms, and anxiety. (R. 285.) Examination showed that the neck was symmetric and supple on inspection, facet pain of the thoracic and lumbar vertebra, moderate spasm on the paravertebral muscles, limited range of motion with discomfort but full range of motion bilaterally of upper and lower extremities, cooperative attitude, normal mood and affect, logical and coherent thought processes, and no thoughts of delusions, hallucinations, obsessions, preoccupations or somatic thoughts were elicited. (Id.) Dr. Sheth noted that Plaintiff had worsening anxiety disorder symptoms and started her on Celexa. (R. 286.) Regarding her accident symptoms, Dr. Sheth noted that Plaintiff was continuing PT/OT at Allied Services which she had been in for five weeks, she reported good progress, her pain was tolerable and worse at night, it was relieved with Advil, and she still complained of headaches. (R. 286.) He recommended that she get a letter from Allied for release to work. (Id.)

         On April 13, 2012, Dr. Sheth noted that Plaintiff continued to do well with physical therapy, she was feeling much better, and wanted to go back to work. (R. 291.) He noted “Correspondence: Return to Work, ” and commented that Plaintiff was in good general health and he would follow her annually. (Id.)

         On April 25, 2012, Plaintiff said she felt worse since her last visit, she was taking medication as prescribed and she had no side effects. (R. 292.) She reported that she went back to work and did sedentary work on the first day but, when she did full duty on the second day (involving bed changes and laundry) she started having neck and back pain after four hours, was vomiting from the pain, and has been worse since then. (Id.) Examination showed the neck was symmetric and supple on inspection, facet pain of the lumbar vertebra, moderate spasm on the paravertebral muscles, limited ranges of motion with discomfort, full range of motion of the upper and lower extremities bilaterally, and normal mood, affect and thought processes. (R. 293-94.) Dr. Sheth noted a referral to Advanced Pain Management Specialists and the chiropractor, Dr. Yusavage. (Id.) Dr. Sheth also advised aqua therapy and he noted that Plaintiff would consider these options. (Id.)

         On May 5, 2012, Pravin Patel, M.D., of Advanced Pain Management Specialists, conducted an initial evaluation of Plaintiff. (R. 202.) Plaintiff's chief complaints were pain in the neck with muscle spasms and headaches, and low back pain, more on the left side radiating down the left leg, with numbness in the left leg. (R. 202.) At the time, Plaintiff was taking only Albuterol as needed for asthma. (Id.) Physical examination showed that Plaintiff was alert, awake and oriented times three, excruciating tenderness with muscle spasms of both paracervical muscles, right more than left, bilateral trapezoids and rhomboids. (R. 204.) Active and passive range of motion was complete but painful with slight restrictions in extension and flexion. (Id.) Motor function of the upper extremities was 5/5, there was no paresthesia, and no pain in the upper extremities. (Id.) There was also tenderness along the lumbar facet joints, L4-L5 and L5-S1 with excruciating tenderenss of both sacroiliac joins and Patrick's and Gillette's signs positive bilaterally. (Id.) Active and passive range of motion was restricted especially in extension, flexion and lateral flexion. (Id.) Straight leg raising test was positive on the left side at forty-five degrees and negative on the right side. (Id.) Plaintiff's gait was normal. (Id.) Dr. Patel diagnosed cervicalgia, neck pain with muscle spasms, low back pain, bilateral lumbar facet syndrome, and bilateral sacroiliac joint pain and sacroilitis. (R. 205.) He opined that the pain was related to injuries she sustained in the September 2011 accident and he planned to give her a series of injections, trigger point release, moist heat compresses, stretching exercises, and over-the-counter NSAID pain relievers. (Id.)

         On May 11, 2012, Dr. Sheth noted that Plaintiff said she was following up with pain management and her pain was 10/10 which was hindering her from sleeping and was associated with vomiting. (R. 296.) He also recorded that Plaintiff presented with anxiety and new onset of not remembering ordinary and familiar things. (Id.) In the Review of Systems, Plaintiff reported back pain, neck pain and stiffness, she denied trouble walking, and she reported some anxiety and frustration. (R. 297.) Examination showed that her neck was supple on inspection, and she had a full range of motion bilaterally of her upper and lower extremities. (R. 298.)

         Plaintiff had a lumbar back brace and continued to express that she was going to think about Dr. Sheth's referrals for physical therapy, aqua therapy, and chiropractor services. (R. 298.) Dr. Sheth noted that Plaintiff's anxiety was mostly controlled and he advised her to exercise to control stress. (Id.) He also noted that he would start Remeron. (Id.) Regarding memory ...


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