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Cousins v. Berryhill

United States District Court, M.D. Pennsylvania

November 2, 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 of the Social Security Act. (Doc. 1.) Plaintiff protectively filed an application for benefits on July 5, 2013. (R. 19.) After she appealed the initial denial of the claim, hearings were held on August 25, 2015, and January 12, 2016. (Id.) Plaintiff requested to amend the alleged disability onset date to January 27, 2014. (Id.) Administrative Law Judge (“ALJ”) Sharon Zanotto issued her Decision on August 12, 2016, concluding that Plaintiff had not been under a disability from the alleged onset date of of January 27, 2014, through the date of the decision. (R. 33.) Plaintiff requested review of the ALJ's decision which the Appeals Council denied on February 6, 2017. (R. 1-6, 14-15.) In doing so, the ALJ's decision became the decision of the Acting Commissioner. (R. 1.)

         Plaintiff filed this action on May 10, 2017. (Doc. 1.) She asserts in her supporting brief that the ALJ erred on two grounds: 1) the ALJ based the Plaintiff's residual functional capacity (“RFC”) on her own lay opinion; and 2) the ALJ did not properly evaluate Plaintiff's symptoms. (Doc. 9 at 1-2.) After careful review of the record and the parties' filings, the Court concludes this appeal is properly denied.

         I. Background

         Plaintiff was born on January 17, 1964, and was fifty years old on the amended alleged onset date. (R. 31.) She has a limited education and past relevant work as a certified nurse assistant and a home health aide. (Id.)

         A. Medical Evidence [1]

         An August 29, 2013, Disability Report indicates that Plaintiff identified the following conditions as limiting her ability to work: diabetes, thyroid, depression, bipolar, heart, and high blood pressure. (R. 329.)

         Plaintiff visited the Kline Health Center on June 4, 2013, complaining of right thumb pain which had started a week before. (R. 491.) Office notes indicate that Plaintiff's diabetes was poorly controlled and she was encouraged to return to her primary care provider for diabetes management. (R. 491, 493.) On June 28, 2013, Plaintiff saw Joan Weaver, CRNP, at Kline Health Center to go over lab tests. (R. 499.) Ms. Weaver noted that Plaintiff's A1c was better but still too high and Plaintiff may need to adjust her insulin. (R. 499-500.)

         On August 27, 2013, Plaintiff presented at Harrisburg Hospital with chest discomfort. (R. 459.) Her past medical history included hypertension, diabetes, and dyslipidemia. (Id.) Plaintiff was found to have an elevated troponin and was admitted with a non-ST segment elevation myocardial infarction. (Id.) Plaintiff had cardiac catheterization, angioplasty, and stent placement and was discharged on August 29, 2013. (R. 463.) At a September 6, 2013, follow up visit with Angel Cirilo, M.D., he noted that Plaintiff had no acute complaints and was feeling better. (R. 530.)

         Plaintiff saw her cardiologist Aarti Campo, M.D., on September 13, 2013. (R. 594-97.) He reported that Plaintiff continued to have chest discomfort and shortness of breath, noting that Plaintiff was “a poor historian and it is difficult to illicit details about these episodes from her.” (R. 596.) Dr. Campo sent Plaintiff for further testing and advised her to keep a log of her symptoms to assist with gaining a better understanding of them. (Id.)

         On September 25, 2013, Plaintiff presented at Pinnacle Health Internal Medicine Associates with pain on her right side from her back to her front which had started two days earlier. (R. 702.) Review of Systems was negative for chills, fatigue, fever, chest pain, anxiety, depression, insomnia, dizziness, extremity weakness, gait disturbance, headache, memory impairments, numbness in extremities, back pain, joint swelling muscle weakness, and neck pain. (R. 702-03.) It was positive for abdominal pain. (R. 702.) Jessica Stefanic, CRNP, assessed a possible urinary tract infection, started an antibiotic, and planned additional tests. (R. 703.)

         Plaintiff was seen by Michael Vanscoy, M.D., at Pinnacle Health on November 13, 2013, for pain in both hands and pain in her shoulders when she flexed her arms. (R.705.) She reported that her sugars were better controlled, but Dr. Vanscoy noted that she had symptoms which he believed were related to uncontrolled diabetes. (R. 705, 707.) A November 13, 2013, report from the Pinnacle Health Polyclinic Diagnostic Department indicated that hand studies showed very minimal scattered degenerative changes, more pronounced within the left fifth DIP joint and no acute right or left hand abnormality. (R. 681.)

         At a December 16, 2013, consultation, Linda Sobkowksi, CRNP, of Pinnacle Health's Kline Health Center made the following physical examination findings: normal respiratory effort; normal vascular findings; musculoskeletal normal range of motion, muscle strength, and stability in all extremities with no pain on inspection; normal examination of the extremities; neurologically memory intact, no sensory loss, normal fine motor skills, and preserved and symmetric deep tendon reflexes; and psychiatrically oriented to time, place, person, and situation with appropriate mood and affect. (R. 712.) A dietition referral was made for Plaintiff's uncontrolled diabetes, her hypertension was noted to be controlled, lipitor was increased for the hyperlipidemia, a nephrology referral was made of chronic kidney diseases, stage II, and neuropathy was noted to be controlled with Gabapentin. (R. 713.)

         On January 16, 2014, Plaintiff saw Dr. Campo for follow up of coronary artery disease and hypertension. (R. 618-20.) She had a blood pressure monitor which indicated lower readings over the preceding few days. (R. 618.) Plaintiff said she had adjusted her diet but she did not exercise. (Id.) Dr. Campo noted that Plaintiff continued to have left breast pain, mostly at night, and she was going to talk to her primary care doctor at her January 21, 2014, appointment. (Id.) In addition to the breast pain, the Review of Systems indicates that Plaintiff reported fatigue, arthritis (denied cramping and joint pain), and occasional headaches and numbness/tingling (denied lightheadedness and loss of consciousness). (R. 619.) Physical exam showed that Plaintiff was overweight but otherwise normal findings were recorded. (Id.) Dr. Campo assessed Plaintiff with atypical non-cardiac chest pain for which she would see her primary care provider. (R. 620.) He noted that Plaintiff's blood pressure was well controlled on her current regimen, he encouraged Plaintiff to exercise daily and continue a low fat diet in connection with her hyperlipidemia, and he wanted to see her again in one year. (Id.)

         On January 27, 2014, Plaintiff had another office visit with Ms. Sobkrowski at which time she reported regarding diabetes that she was experiencing “dyesthesias - numbness, frequent urination and polydipsia.” (R. 715.) She denied chest pain, diarrhea, dyapnea, heartburn, weight gain, and weight loss. (Id.) Plaintiff reported no symptoms associated with her hypertension or hyperlipidemia. (Id.) Physical examination was much the same as the previous month except that monofilament exam was abnormal although the assessment noted that neuropathy was controlled with Gabapentin. (R. 717-18.) Diabetic foot screening was also performed at this visit and showed there had been no change since the previous evaluation and her Risk Category was 1 “Loss of protective sensation - with no weakness, deformity, callus, pre-ulcer or history of ulceration.” (Id.)

         On February 21, 2014, Plaintiff saw Sunita G. Ray, M.D. at the Milton S. Hershey Medical Center Nephrology Clinic. (R. 834-36.) Dr. Ray noted that Plaintiff complained of frequent urination and intermittent chest pains but she reported that she felt well overall with no complaints of shortness of breath, leg edema, fever, chills, nausea, vomiting, diarrhea, abdominal pain, dizziness, or headaches. (R. 834.) Dr. Ray planned to do more testing related to kidney problems and increase Plaintiff's hypertension medication. (R. 835.)

         Between March 2014 and August 2014, Plaintiff treated at PA Retina Specialists for ocular complications related to diabetes. (R. 723-43.) Provider Thomas R. Pheasant, stressed the importance of blood sugar control in the prevention of such complications. (See, e.g., R. 725.) He reported a diagnosis of Severe Nonproliferative Diabetic Retinopathy OU and administered a laser treatment on July 1, 2014. (R. 727.)

         On July 7, 2014, Plaintiff presented to the hospital with complaints of intermittent chest pain. (R. 627.) Plaintiff was admitted and, though EKG and cardiac enzymes were normal, she was scheduled for a cardiac catheterization and possible PCI. (R. 630.) Following left heart catheterization, left ventriculography, and left posterolateral drug-eluting stent implantation, William Bachinsky, M.D., recorded the following impression: normal LC systolic function; patent third obtuse marginal stent with new severe stenosis involving left posterolateral; and successful left posterolateral drug-eluting stent implantation. (R. 636.)

         At a February 26, 2015, Kline Health Center office visit, the provider noted that Plaintiff's diabetes was “[u]ncontrolled due to noncompliance, states that she gets tired sometimes injecting insulin.” (R. 720.)

         Plaintiff was admitted to the hospital on March 15, 2015, with the “Highest Priority Diagnosis on Admission” recorded to be hypertension urgency. (R. 777.) Plaintiff presented with headache, nausea, blurry vision, and left arm heaviness. (R. 779.) Plaintiff's blood pressure was elevated but physical exam was normal except for mild decreased sensation in the right upper extremity. (R. 781-82.) Her coronary artery disease, diabetes, hyperlipidemia, and depression were noted to be stable. (R. 782.) Plaintiff was discharged on March 17, 2015, at which time the physical examination revealed no problems. (R. 777-78.)

         At her March 24, 2015, hospital discharge follow-up at Kline Health Center, Plaintiff reported that her blood pressure had been high and she had not been compliant with taking all of her prescribed medications but since her discharge she had been feeling well and was medication-compliant. (R. 876.) Notes indicated that Plaintiff denied chest pain and shortness of breath but complained of right lower quadrant abdominal pain which started the previous month, was intermittent, and occurred after meals. (Id.) Review of systems was otherwise normal. (R. 876-77.) Physical exam findings were also normal. (R. 877; see also R. 873.) Plaintiff agreed to an endocrinology referral for her diabetes. (Id.)

         On April 24, 2015, Plaintiff was seen by Michael Link, M.D., at the Pinnacle Health CardioVascular Institute for a pre- colonoscopy screening. (R. 819.) Dr. Link noted that Plaitnff reported she had not had any further episodes of chest pain since her last stent in July 2014. (Id.)

         At a CardioVascular Institute follow-up visit on July 14, 2015, Aarti Campo, M.D., noted that Plaintiff had modified her diet, she had occasional chest pain, and she had a normal nuclear stress test in April. (R. 816.) In addition to presenting problems, Review of Systems indicates that Plaintiff reported fatigue, arthritis (denied cramping and joint pain), and occasional headaches and numbness/tingling (denied lightheadedness and loss of consciousness). (R. 817.) Dr. Campo determined that Plaintiff should remain on Plavix lifelong and continue her other heart medications. (R. 818.)

         On July 24, 2015, Plaintiff presented at Pinnacle Health Harrisburg Campus Emergency Department with chest pain. (R. 797.) Plaintiff was not admitted but was discharged to home in stable condition with instructions to follow up with her primary care provider in seven days and her cardiologist as scheduled. (R. 798, 804.)

         At a November 20, 2015, routine visit to Kline Health Center, Plaintiff complained of left shoulder pain of two-month duration, and right should pain of one-month duration which were not due to injury and had gotten progressively worse. (R. 868.) She reported that the pain was achy and intense when she lifted her arms over ninety degrees. (Id.) Plaintiff also complained of abdominal pain that she described as sharp and worse about one hour after eating, especially after eating fatty foods. (Id.) She added that it subsides about an hour or two after eating. (Id.) Plaintiff also reported that she got frequent heartburn. (Id.) Physical exam was normal except for neck goiter. (R. 869.) Provider Sayed Kazi, M.D., referred Plaintiff to ...

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