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Otis v. Colvin

United States District Court, M.D. Tennessee, Nashville Division

April 17, 2015

JANICE MARIE OTIS,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security[1]

REPORT AND RECOMMENDATION

JULIET GRIFFIN, Magistrate Judge.

The plaintiff filed this action pursuant to 42 U.S.C. § 405(g) to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying the plaintiff's claim for Disability Insurance Benefits ("DIB"), as provided by the Social Security Act.

Upon review of the Administrative Record as a whole, the Court finds that the Commissioner's determination that the plaintiff is not disabled under the Act is supported by substantial evidence in the record as required by 42 U.S.C. § 405(g), and that the plaintiff's motion for judgment on the administrative record (Docket Entry No. 9) should be DENIED.

I. INTRODUCTION

In May 2008, the plaintiff protectively filed an application for DIB, alleging a disability onset date of August 1, 2007, due to, inter alia, fibromyalgia, irritable bowel syndrome ("IBS"), gastroesophageal reflux disease ("GERD"), Sjogren's syndrome, poor vision, mouth sores, burns, hip pain, neck pain, headaches, fatigue, sleep disorder, forgetfulness, and irritability. (Tr. 23, 70, 127-33, 142, 147.) Her application was denied initially and upon reconsideration. (Tr. 69-78.) The plaintiff appeared and testified at a hearing before Administrative Law Judge Daniel Whitney ("ALJ") on June 3, 2010. (Tr. 36-64.) On June 25, 2010, the ALJ entered an unfavorable decision. (Tr. 23-31.) On November 17, 2011, the Appeals Council denied the plaintiff's request for review of the ALJ's decision, thereby making the ALJ's decision the final decision of the Commissioner. (Tr. 1-6.)

II. BACKGROUND

The plaintiff was born on July 24, 1952 (tr. 45), and she was 55 years old as of her alleged disability onset date. She graduated high school and has worked as a receptionist and crew chief at a fast-food restaurant. (Tr. 41, 44, 46, 157.)

A. Chronological Background: Procedural Developments and Medical Records

1. Medical Evidence

From approximately April 2005 until December 2008, the plaintiff presented to Dr. Michael Helton for treatment of a variety of maladies including, inter alia, sinusitis, allergic rhinitis, dizziness, ear pain, hyperlipidemia, dermatitis, rash, gastroenteritis, diarrhea, urinary tract infection, history of Lyme disease, neck pain and spasm, polyarthralgia/myalgias, sleep apnea, anxiety, and weakness. (Tr. 307-37, 584-88, 649.) Dr. Helton prescribed Zoloft and BuSpar for the plaintiff's anxiety. (Tr. 314, 317-18, 618.)

In August 2006, the plaintiff presented to Dr. Carolyn Parrish with right eye conjunctival dysplasia. (Tr. 229, 232-33.) Dr. Parrish surgically removed the lesion, which was positive for dysplasia. (Tr. 229, 231.) The plaintiff returned to Dr. Parrish in March 2008 and an exam "revealed some ocular surface drying with decreased tear production but was otherwise unremarkable." (Tr. 229-30.) Dr. Parrish recommended that she begin using Restasis eye drops for dry eyes. Id. The plaintiff continued to report problems with "itchy" and "sticky" eyes in 2008, and she told Dr. Parrish that she had difficulty driving at night. (Tr. 592-93.) In February 2009, Dr. Parrish noted that the plaintiff's vision and tear production were "much improved" and recommended that she continue her prescribed regimen. (Tr. 590.) The plaintiff returned to Dr. Parrish in August 2009 for a follow-up visit and reported that she was "doing well" with no recurrence of dysplasia but with decreased tear film. (Tr. 639.)

The plaintiff also sought treatment at the Murfreesboro Medical Clinic primarily under the care of Dr. Asim Razzaq, a rheumatologist, from approximately May 2006 until April 2010. (Tr. 390-557, 613-37, 640-62.) During this time, the plaintiff received treatment for, inter alia, anxiety, IBS, GERD, cervicalgia, hip pain, foot pain, fibromyalgia, sicca symptoms, questionable Sjogren's syndrome, hyperlipidemia, vertigo, and dizziness. Id. Dr. Razzaq treated the plaintiff with a number of different medications for fibromyalgia and sicca symptoms with negative serologies.[2] (Tr. 391-94, 421-37, 444-47, 453-93, 497-511, 614-32, 642-51, 655-62.) After she was suspected of having Sjogren's syndrome, a biopsy was taken in April 2009 of her lower lip minor salivary gland, which revealed mild chronic inflammation but no evidence of Sjogren's syndrome.[3] (Tr. 511, 622, 624-25, 630-32.)

The plaintiff also complained of symptoms related to IBS. (Tr. 525-28.) A March 2007 biopsy revealed a hyperplastic polyp on her colon. (Tr. 518-21.) Following complaints of cervicalgia, an August 2007 cervical spine x-ray showed marked degenerative changes at C4-C5, C5-C6, and C6-C7 with mild narrowing of the right neural foramen at C2-C3. (Tr. 512.) After the plaintiff complained of hip pain, Dr. Razzaq also ordered a hip x-ray in August 2007, which returned normal. (Tr. 509-12.) During an examination on August 3, 2007, Dr. Razzaq found "no evidence of overt synovitis" and observed that the plaintiff "move[d] upper and lower extremity joints well, " although she had tenderness along her femoral trochanters. (Tr. 510.) In September 2007, Dr. Razzaq diagnosed her with likely right trochanteric bursitis and administered a steroidal injection in the right hip. (Tr. 484.) In March 2008, he administered trigger point injections into both hips. (Tr. 456-58.)

Dr. Razzaq referred the plaintiff to Dr. William Jekot, an orthopedist, who examined the plaintiff on May 5, 2008. (Tr. 451, 453-55.) Dr. Jekot diagnosed her with tendonitis in her right hip, administered an injection of Depo-Medrol, Marcaine, and Lidocaine, and recommended physical therapy. (Tr. 451.) The plaintiff attended physical therapy from May to July 2008 (tr. 260-304), at the conclusion of which she reported "no improvement in symptoms" and "no significant change in functional abilities." (Tr. 260.) The physical therapist observed that the plaintiff had "responded well to therapy" but had "not met treatment goals." Id. Upon discharge, the plaintiff demonstrated normal range of motion in her cervical and lumbar spine as well as normal range of motion and strength in her upper and lower extremities. Id. Her general flexibility was mildly decreased, and she had mild tenderness in her shoulder girdle and cervical region as well as moderate tenderness in her periscapular region. Id. The plaintiff returned to Dr. Jekot in June 2008, reporting that her hip pain was "much improved" after the steroid injection and physical therapy and that the pain was "more of a nuisance" and did not "disturb her sleep or limit her activity." (Tr. 448.) On examination, she had "very slight tenderness" and good range of motion, strength, and stability with a positive Ober's test. Id. Dr. Razzaq noted in August and October 2008 that physical therapy had improved the plaintiff's right hip bursitis/tendonitis. (Tr. 432, 437.)

In December 2008, the plaintiff complained of vertigo and dizziness. (Tr. 411.) Objective testing was negative, and she was treated for mild Meniere's disease and prescribed Dyazide.[4] (Tr. 400-01.) At a follow-up visit in February 2009, she was doing well, although she complained of "some occasional mild high pitched tinnitus, " and was taken off of Dyazide. (Tr. 630, 633.)

2. Opinion Evidence

On June 25, 2008, Dr. Rebecca Joslin, Ed.D., a nonexamining Tennessee Disability Determination Services ("DDS") psychological consultant, completed a Psychiatric Review Technique ("PRT"), opining that the plaintiff's anxiety disorder caused mild restrictions of the activities of daily living and mild difficulties in maintaining concentration, persistence, or pace. (Tr. 234-47.) On September 2, 2008, Dr. Brad Williams, a nonexamining DDS psychological consultant, completed a PRT with identical conclusions. (Tr. 338-65.)

On July 2, 2008, Dr. Lina Caldwell, a nonexamining DDS consultative physician, completed a physical Residual Functional Capacity ("RFC") assessment. (Tr. 248-55.) Dr. Caldwell opined that the plaintiff could lift and/or carry twenty pounds occasionally and ten pounds frequently, stand and/or walk two hours in an eight-hour workday, sit about six hours in an eight-hour workday, and push and/or pull in unlimited capacities. (Tr. 249.) Dr. Caldwell also opined that the plaintiff could frequently balance, stoop, kneel, and crawl; occasionally crouch and climb ramps and stairs; and never climb ladders, rope, or scaffolds. (Tr. 250.)

On July 8, 2008, Dr. Nathaniel Robinson, a nonexamiming DDS consultative physician, evaluated the plaintiff's visual impairment and opined that it was not severe. (Tr. 256-59.)

On September 10, 2008, Dr. Joe Allison, a nonexamining DDS consultative physician, completed a physical RFC assessment. (Tr. 366-73.) Dr. Allison opined that the plaintiff could lift and/or carry twenty pounds occasionally and ten pounds frequently, stand and/or walk about six hours in an eight-hour workday, sit about six hours in an eight-hour workday, and push and/or pull in unlimited amounts. (Tr. 367.) He opined that the plaintiff could occasionally climb ladders, ropes, or scaffolds and frequently climb ramps and stairs as well as balance, stoop, kneel, crouch, and crawl. (Tr. 368.)

On February 10, 2010, Dr. Woodrow Wilson, a DDS consultative physician, physically examined the plaintiff. (Tr. 558-61.) The plaintiff reported having a history of fibromyalgia, IBS, GERD, hypertension, high cholesterol, and eye problems including dry eyes and blurred vision. (Tr. 558.) Upon examination, Dr. Wilson observed that the plaintiff had full range of motion in her neck, elbows, wrists, hands, hips, knees, ankles, and shoulders except for external rotation to 40 degrees bilaterally. (Tr. 560.) She could tandem walk "six steps without too much difficulty, " balance her weight on each foot, and get out of a chair without difficulty. (Tr. 559-60.) She had a normal gait and a negative straight leg raise bilaterally. (Tr. 560.) Her motor strength was 5/5, and she had intact sensation and 2 deep tendon reflexes bilaterally in her upper and lower extremities. Id.

Dr. Wilson diagnosed the plaintiff with obesity as well as a history of fibromyalgia, IBS, GERD controlled on medication, dry eyes, hypertension, hypercholesterolemia, and sleep apnea. Id. Dr. Wilson completed a Medical Source Statement assessing the plaintiff's ability to perform work-related activities (tr. 562-67) and opined that, due to fibromyalgia, the plaintiff could continuously lift up to 10 pounds, frequently lift 11 to 20 pounds, and never lift 21 pounds or more and that she could frequently carry up to 10 pounds and never carry 11 pounds or more. (Tr. 562.) Dr. Wilson also opined that, in an eight-hour workday, the plaintiff could sit one hour at a time for four hours total, stand ten minutes at a time for two hours total, and walk three minutes at a time for three hours total. (Tr. 563.) He opined that, due to bilateral shoulder pain and fibromyalgia, the plaintiff could frequently reach overhead with either hand and continuously reach all other directions, handle, finger, feel, push, and pull. (Tr. 563-64.) He opined that she could continuously operate foot controls, frequently balance, and occasionally climb, stoop, kneel, crouch, and crawl. (Tr. 564.) Finally, Dr. Wilson opined that the plaintiff should never be exposed to unprotected heights but could continuously be exposed to moving mechanical parts and extreme heat and frequently be exposed to humidity, wetness, operating a motor vehicle, extreme cold, vibrations, dust, odors, fumes, and pulmonary irritants. (Tr. 565.)

On February 13, 2010, Dr. LaShonda Hughes, Psy.D., a DDS consultative psychologist, completed a psychological evaluation of the plaintiff. (Tr. 568-74.) The plaintiff reported that she had "difficulty staying in a deep sleep because of her sleep apnea, " "that her predominant mood is cranky, " and that she had "anxiety attacks'... about 4-8 times per month." (Tr. 569.) She said that her anxiety attacks were "not as severe because [her] medication ha[d] [the attacks] fairly under control." Id. She described the anxiety attacks as "getting a pins and needly feeling, ' lightheaded, and sweaty." Id. The plaintiff reported that she was able to manage her ...


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