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Jenkins v. Berryhill

United States District Court, M.D. Pennsylvania

September 11, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Pending before the Court is Plaintiff's appeal from the Commissioner's denial of Supplemental Security Income (“SSI”) under Title XVI. (Doc. 1.) Plaintiff filed her application for benefits on November 11, 2013, alleging a disability onset date of January 1, 2008. (R. 17.) After she appealed the initial denial of the claim, a hearing was held on May 14, 2015, and Administrative Law Judge (“ALJ”) Randy Riley issued his Decision on June 11, 2015, concluding that Plaintiff had not been under a disability from November 11, 2013, to the date of the decision. (R. 24.) Plaintiff requested review of the ALJ's decision which the Appeals Council denied on December 2, 2016. (R. 1-6, 12-13.) In doing so, the ALJ's decision became the decision of the Acting Commissioner. (R. 1.)

         Plaintiff filed this action on February 3, 2017. (Doc. 1.) She asserts in her supporting brief that the Acting Commissioner's determination should be remanded for the following reasons: 1) the step two determination was not supported by substantial evidence; and 2) the residual functional capacity (“RFC”) determination was not supported by substantial evidnece. (Doc. 16 at 1.) After careful review of the record and the parties' filings, the Court concludes this appeal is properly denied.

         I. Background

         Plaintiff was born on February 7, 1970, and was forty-three years old on the alleged disability onset date. (R. 23.) She has a tenth-grade education and no past relevant work. (Id.)

         A. Medical Evidence

         Plaintiff received primary care at Biglerville Family Medicine. (R. 181-249.) In January 2013 CRNP Danielle Gourley saw Plaintiff for the chief complaints of bilateral lower leg pain, and constant fatigue with headaches. (R. 214.) Plaintiff did not have a physical examination “due to the nature of the visit, ” and she was assessed to have hypertension, type 2 diabetes mellitus and depression with anxiety. (R. 214, 216.)

         In February 2013, Ms. Gourley saw Plaintiff for a routine follow-up of multiple chronic illnesses including coronary artery disease, hypertension, type 2 diabetes mellitus, and depression with anxiety. (R. 204.) Plaintiff reported that she felt her depression was controlled and she was tolerating her medications without side effects, she denied specific problems related to diabetes, hypertension, hyperlipidemia, and coronary artery disease. (R. 205-06.) Physical examination showed that Plaintiff had age appropriate range of motion and strength, normal vascular examination, and neurological examination indicated normal judgment, orientation and mentation, and deep tendon reflexes were normal and symmetric. (R. 208.)

         In April 2013, Plaintiff saw Ms. Gourley with complaints of bilateral leg swelling, particularly after she was on her feet a lot. (R. 200.) Plaintiff also complained of hand pain which Ms. Gourley suspected could be related to cervicalgia in that Plaintiff had “a history of discs in her neck.” (Id.) Musculoskeletal examination showed left foot tenderness near the great toe, peripheral vascular pulses were normal, and neurological exam was normal. (R. 203.) Office notes indicate Plaintiff said she felt strongly that her glucose was under control and she did not need insulin. (R. 200.) Plaintiff was to have follow-up labs in May and get an x-ray of the left foot. (Id.)

         On May 22, 2013, Plaintiff presented to the Emergency Department at Gettysburg Hospital for evaluation of elevated blood sugar levels. (R. 265.) Her only complaints were nausea, generalized malaise, and fatigue. (Id.) Other than weakness, fatigue, and back pain, the Review of Systems was negative. (Id.) Plaintiff's recorded medical history included coronary artery disease, hypertension, and diabetes. (R. 266.) No specific problems other than low temperature (98.2 degrees) were noted on Physical examination. (R. 266-67.) Notes indicate that Plaintiff presented with generalized malaise and some fatigue with hyperglycemia, her blood sugar improved with fluids and insulin, she had a prescription from her primary care provider for a new oral hypoglycemic drug, and she would follow up outpatient. (R. 269.)

         On May 24, 2013, Plaintiff had a follow-up visit with Ms. Gourley at Biglerville Family Medicine, particularly to check up on her diabetes. (R. 196.) Plaintiff said she did not want to restart metformin despite that fact that she knew her glucoses were going up but she agreed to start a long-acting insulin (Levemir). (R. 195.) Ms. Gourley commented she suspected Plaintiff's nausea was stress related. (Id.) Plaintiff reported that she felt her depression was controlled and she was tolerating the medications without side effects. (R. 196.) Physical exam showed no problems and Plaintiff was assessed to have age appropriate range of motion and strength, normal judgment, mentation and orientation, and normal and symmetric deep tendon reflexes. (R. 199.) Both feet were determined to be normal and a monofilament wire test was normal. (Id.) Later in May the Levamir dosage was increased due to her diabetes not being at goal. (R. 191.)

         At a routine check up in August 2013, Plaintiff reported heart palpitation and sweating but denied other problems related to hypertension; she felt her depression was controlled; and she said was taking her diabetes medication as prescribed and denied episodes of feeling excessively weak/shaky/sweaty but reported low blood sugars. (R. 186-87.) Musculoskeletal and neurological examination findings were the same as noted at previous visits. (R. 190.) Foot examination and monofilament tests were also normal. (Id.)

         On November 5, 2013, Plaintiff reported to Ms. Gourley that her legs were getting worse with pain that started in her upper thighs and went all the way to her feet and nothing helped it. (R. 181.) Plaintiff also reported that she was tired of her legs hurting, tired of waking up crying, she could not stand for any length of time, and she could only sit for twenty minutes at a time. (Id.) Lumbar spine MRI was ordered, it was noted that Plaintiff needed counseling and should be given related information, and effexor and xanax dosages were increased. (Id.) Physical exam showed that Plaintiff was in mild distress, forward flexion and extension were decreased but she had no tenderness. (R. 183.)

         On November 29, 2013, Plaintiff had MRI of the lumbar spine. (R. 243-44, 261-62.) The following impression was recorded: 1) multilevel disc bulges; disc protrusions at ¶ 4-5 and L5-S1; 3) discogenic disease pronounced at ¶ 5-S1; 4) multilevel spondyloarthropathy; 5) artifact or right neural low signal focus at ¶ 5 (“can be further evaluated with followup enhanced study”); and 6) small right renal cyst. (R. 243, 261.)

         Plaintiff again saw Ms. Gourley on December 16, 2013, for follow-up of her leg pain. (R. 217.) Office notes indicated that neuropathy was suspected and a bulging disc may have been contributing to the problem--Plaintiff had been seen by podiatry and a neurosurgery referral was arranged. (Id.) Notes also indicate that Plaintiff was not self-monitoring blood glucose levels due to cost but she was urged to do so to be certain her levels were ok. (Id.) Plaintiff reported that she “always” had foot pain and leg pain bilaterally. (R. 220.) Physical exam showed foot with decreased sensation, palpable pulses, feet were cool (not cold), and pain was reproducable with pressure on the arches. (Id.)

         Plaintiff had a neurosurgical consultation with Troy J. Hamilton, PA-C, at Wellspan Neurosurgery on January 16, 2014. (R. 252.) Physical exam showed moderate tenderness to palpation throughout the paravertebral musculature of the lumbar spine, strength and deep tendon reflexes grossly preserved through the lower extremities, and negative straight leg raise bilaterally. (R. 256.) Mr. Hamilton assessed disc degeneration, lumbar canal stenosis, and lumbar radiculopathy. (Id.) He reported that Plaintiff's discomfort was likely the result of the stenosis at ¶ 4-5, and he recommended consideration for epidural steroid injections. (Id.) He noted that he would make the referral to pain management and Plaintiff should have a followup for surgical consultation if the steroid injections were ineffective. (Id.)

         On January 19, 2014, Plaintiff was seen at the Emergency Department of Gettysburg Hospital for sudden onset of severe back pain in the lumbar region which was worse than her chronic back pain. (R. 257.) The “Impression” was sciatica and Plaintiff was given pain medication, a Medrol dose pack, and instructions to follow up with her regular doctor within a day or two.[1] (R. 260.)

         On January 30, 2014, Mark Christopher, M.D., (identified as a specialist in pathology (R. 282)) conducted an internal medicine examination of Plaintiff on the referral of the Bureau of Disability Determination. (R. 279-82.) He recorded that her chief complaint was low back pain with shooting pain down her legs which had progressed over the preceding two years which she rated at a level of eight or nine out of ten. (R. 279.) Plaintiff also reported that she could not walk because of severe pain, she could not sit or stand for long periods of time, the pain induced nausea at times, and it was relieved by laying down and taking pressure off her lower back. (Id.) Plaintiff reported symptoms related to her heart problems (legs swell after standing for a long period of time and shortness of breath) and her diabetes (feet extremely painful and associated numbness). (Id.) Physical examination showed that Plaintiff was in apparent pain, her gait was extremely guarded and she was tilted forward, she declined to walk on heels and toes, her squat was 25%, her stance was guarded, she used no assistive device and needed no help changing for exam or getting on and off exam table, and she was able to rise from a chair without difficulty. (Id.) Musculoskeletal examination showed leg raise positive bilaterally to five degrees, joints stable and nontender, and no redness, heat, swelling or effusion. (R. 281.) Neurologic examination showed deep tendon reflexes physiologic and equal in upper and lower extremities, no sensory deficit noted, and strength 4/5 in the lower extremities and 5/5 in upper extremities. (Id.) Examination of the extremities showed no muscle atrophy. (Id.) The Mental Status Screen showed no evidence of impaired judgment or significant memory impairment and normal affect. (R. 281-82.)

         Medical Records from Biglerville Family Medicine indicate that Plaintiff was seen on March 11, 2014, when she complained of tingling in her feet. (R. 299.) No examination or medical findings are contained in the record of the visit. (See id.)

         A Discharge Summary from Gettysburg Hospital Emergency Department dated May 13, 2015, indicates that Plaintiff was seen for the chief complaint of back pain, she was given pain medication and information about back care and sacroiliitis and she was to follow up with her primary care provider within one to two weeks.

(R. 306-07.)

         B. Opinion Evidence

         Dr. Christopher completed a Medical Source Statement of Ability To Do Work-Related Activities (Physical) on January 30, 2014. (R. 283-88.) He opined that Plaintiff could lift and carry up to ten pounds occasionally and never more than that due to back pain; she could sit for one hour at a time and for a total of two hours in an eight-hour work day due to back pain; she could use her hands and feet frequently; and she could never climb, balance, stoop, kneel, crouch, or crawl due to back pain. (R. 283-86.) Dr. Christopher also opined that Plaintiff had numerous environmental limitations due to her back pain--of all listed, the only thing she was able to do was drive a motor vehicle occasionally. (R. 287.) He further concluded that Plaintiff was not able to walk a block at a reasonable pace on an uneven surface or climb a few steps at a reasonable pace with the use of a single ...

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