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Colter v. Colvin

United States District Court, D. Arizona

February 12, 2015

Alexia Colter, Plaintiff,
v.
Carolyn W. Colvin, Acting Commissioner of Social Security, Defendant.

ORDER

BRIDGET S. BADE, Magistrate Judge.

Plaintiff Alexia Colter seeks judicial review of the final decision of the Commissioner of Social Security (the Commissioner) denying her application for disability insurance benefits under the Social Security Act (the Act). The parties have consented to proceed before a United States Magistrate Judge pursuant to 28 U.S.C. § 636(b), and have filed briefs in accordance with Local Rule of Civil Procedure 16.1. For the following reasons, the Court affirms the Commissioner's decision.

I. Procedural Background

On September 29, 2010, Plaintiff applied for disability insurance benefits under Titles II and XVI of the Act. (Tr. 13.)[1] Plaintiff originally alleged disability beginning August 2008, but later amended the disability onset date to January 2010. (Tr. 167-82, 46-47.) After the Social Security Administration (SSA) denied Plaintiff's initial application and her request for reconsideration, she requested a hearing before an administrative law judge (ALJ). After conducting a hearing, the ALJ issued a decision finding Plaintiff not disabled under the Act. (Tr. 10-29.) This decision became the final decision of the Commissioner when the Social Security Administration Appeals Council denied Plaintiff's request for review. (Tr. 1-6); see 20 C.F.R. § 404.981 (explaining the effect of a disposition by the Appeals Council.) Plaintiff now seeks judicial review of this decision pursuant to 42 U.S.C. § 405(g).

II. Administrative Record

The record before the Court establishes the following history of diagnosis and treatment related to Plaintiff's health. The record also includes opinions of state agency physicians who examined Plaintiff and reviewed the records related to Plaintiff's impairments, but who did not provide treatment.

A. Treatment Records

1. Treatment Related to Headaches

After receiving some treatment for migraine headaches (Tr. 373, 648-50), on referral from Dr. Veena Gulaya, Plaintiff started seeing neurologist Dr. Nirmal Aryal in November 2009. (Tr. 427-29.) Plaintiff reported having headaches "for years" and complained of recent tingling in her hands. (Tr. 427.) Plaintiff complained that she had a "daily headache" with "photophobia, phonophobia, .. nausea, [and] dizz[ness]." (Tr. 427.) On examination, Dr. Aryal found irritated nerves in Plaintiff's hands and arms (Tinel's and Phalen's positive). (Tr. 428-29.) She also noted that all of Plaintiff's sensory modalities were within normal limits, she had full motor strength and a normal gait. (Id. ) Dr. Aryal diagnosed migraine headache, chronic daily headaches, and carpal tunnel syndrome, she prescribed Topamax and Relpax and continued use of a wrist splint, and she ordered diagnostic tests. (Tr. 427-29.)

In January 2010, after Plaintiff's alleged disability onset date, Plaintiff reported to Dr. Aryal that her headache was "much better" and she denied having daily headaches. (Tr. 425-26.) Dr. Aryal's treatment notes contain no indication that Plaintiff had ancillary symptoms (such as nausea or dizziness) related to her headaches. (Tr. 425-26.) Plaintiff also reported that her hands were doing better. (Tr. 425.) Dr. Aryal made no significant findings on examination of Plaintiff. (Id. ) Plaintiff's gait was normal, her "modalities" were within normal limits, and she was alert and oriented. (Id. ) Dr. Aryal described a recent MRI of Plaintiff's brain (Tr. 436) as "normal, " recent nerve conduction and EMG testing as "normal, " and opined that Plaintiff was "doing very well." (Tr. 425-26.)

Electro-diagnostic testing of Plaintiff's arms and hands conducted in March 2010 was also normal. (Tr. 474.) There was no evidence of peripheral neuropathy or distal nerve impairment. (Id. ) In May 2010, Dr. Aryal noted that Plaintiff had a "chronic daily headache, " which Plaintiff described as "mild" and said that her headache would "come[] and go[], " but it was "not completely resolved." (Tr. 423.) The treatment notes do not indicate that Plaintiff suffered ancillary symptoms related to her headaches. (Tr. 423-24.) Plaintiff also reported continued tingling and numbness in her hand. (Id. ) On examination, Dr. Aryal found that Plaintiff's sensory modalities were within normal limits, she had full strength, her gait was normal, and she was alert and oriented. (Id. )

In August 2010, Dr. Aryal again described Plaintiff as having a history of a "chronic daily headache." (Tr. 421.) Plaintiff reported that her headache was "much better" and she had one headache per month. (Tr. 421.) The treatment notes do not identify any ancillary symptoms related to Plaintiff's headaches. (Tr. 421-22.) Plaintiff reported that her hands were still numb and tingly, but Dr. Aryal noted that a nerve conduction study had ruled out carpal tunnel syndrome. (Id. ) On examination, Plaintiff was alert and oriented, had full strength, her sensory modalities were within normal limits, and she had a normal gait. (Tr. 421.) In October 2010, Dr. Aryal noted that Plaintiff's "chronic daily headache seem[ed] to be doing very well on Neurontin, " and that her hand symptoms had improved. (Tr. 563-65.) The treatment notes do not describe any ancillary symptoms related to Plaintiff's headaches. (Id. ) In December 2010, Plaintiff's primary care physician Dr. Olu Orinsile noted that Plaintiff's headaches had returned, but did not state the frequency of Plaintiff's headaches or describe any ancillary symptoms. (Tr. 588.)

In March 2011, Plaintiff reported to Dr. Aryal that her headache was "much better" and that her hands had also "improved significantly but [were] still tingly at times." (Tr. 510.) The treatment note does not describe the frequency of Plaintiff's headaches or identify any ancillary symptoms. (Id. ) Dr. Aryal described Plaintiff's neurological examination as "stable, " noting that her sensory modalities were within normal limits, she had a normal gait, and full strength in her extremities. (Tr. 510-11.) In April 2011, Plaintiff reported to Dr. Olinsile that her headaches were worse, but the treatment note does not state the frequency of the headaches. (Tr. 580.)

In August 2011, Plaintiff reported to Dr. Aryal that her headaches were "much better, " and reported ongoing tingling and numbness in her hands. (Tr. 679.) The treatment note does not indicate the frequency of Plaintiff' headaches and does not indicate that Plaintiff had any ancillary symptoms when she had a headache. (Id. ) Plaintiff's neurological examination was unremarkable. (Tr. 679-80.) On examination, Plaintiff was alert and oriented, had full strength, her sensory modalities were within normal limits, and she had a normal gait. (Tr. 680.) Dr. Aryal did not make a specific diagnosis related to Plaintiff's reported tingling and numbness in her hands. (Tr. 679-680.) In October 2011, Plaintiff reported to Dr. Aryal that her headaches "were much better, " but she continued to experience tingling and numbness in her hands. (Tr. 676.) The treatment note does not state the frequency of Plaintiff's headaches or identify any ancillary symptoms. (Tr. 676-77.) On examination, Plaintiff was alert and oriented, her sensory modalities were within normal limits, she had full strength, and a normal gait. (Tr. 676.)

On January 17, 2012, Plaintiff reported to Dr. Aryal that her headaches were worse and she was having daily headaches. (Tr. 673.) Plaintiff said she was under a lot of stress following her breast cancer diagnosis. (Id. ) She was scheduled for surgery the next day. (Id. ) The treatment note does not describe any ancillary symptoms related to Plaintiff's headaches. (Tr. 673-74.) Plaintiff reported bilateral tingling and numbness in her lower extremities. (Tr. 673.) On examination, Plaintiff was alert and oriented, her sensory modalities were within normal limits, she had full strength in her extremities, and a normal gait. (Tr. 674.)

2. Treatment Related to Plaintiff's Knee, Back, and Joint Pain

On referral from Dr. Gulaya, in November 2009, Plaintiff saw physician assistant (PA) Brian Nelson for knee, back, and hip pain and stiffness. (Tr. 468-70.) PA Nelson assessed osteoarthritis of the hip, collagen vascular disease, and patellofemoral syndrome. (Tr. 469.) In November 2009, X-rays of Plaintiff's hips showed "mild degenerative changes" (Tr. 478), and X-rays of Plaintiff's knees showed evidence of degenerative osteoarthritis more severe on the right than the left. (Tr. 477.) A November 2009 X-ray of Plaintiff's lumbar spine showed "mild degenerative disc disease at L2-3." (Tr. 476.)

After the January 2010 alleged onset of disability, Plaintiff saw PA Nelson every few months for joint pain, and he diagnosed osteoarthritis. At these visits PA Nelson made findings on examination, including tenderness of the spine and cracking and swelling of the knee, and he prescribed pain medication. (Tr. 465-67 (January 2010), 461-64 (March 2010), 458-60 (June 2010), 455-57 (September 2010), 451-54 (October 2010), 568-70 (December 2010).) At several subsequent visits in the fall of 2010, PA Nelson recommended that Plaintiff consult a physical therapist, but the record does not include any physical therapy records. (Tr. 451-54, 568-70.)

X-rays of Plaintiff's knees in October 2010 showed moderate osteoarthritis in her right knee and mild to moderate osteoarthritis in her left knee. (Tr. 472.) In October 2010, An X-ray and MRI of Plaintiff's spine showed "mild degenerative disc disease" in the lumbar spine (Tr. 471), and "mild spondylitic disease at L4-L5 and L5-S1." (Tr. 602.) In October 2010, X-rays of Plaintiff's sacroiliac joints were "normal." (Tr. 473.)

Plaintiff continued seeing PA Nelson in 2011. PA Nelson continued to make the same findings on examination - including pain, swelling, and crepitus in the knees, pain on motion of the hip, and tenderness on palpation to the lumbrosacral spine - and prescribed pain medication for osteoarthritis of the hip and knee. (Tr. 565-67 (March 2011), 726-28 (June 2011), 721-25 (August 2011), 716-20 (November 2011).) At these appointments, PA Nelson recommended a consultation to consider epidural injections for Plaintiff's back pain. (Tr. 567, 719, 723, 728.) There are no medical records documenting that Plaintiff received these injections. However, the record reflects that Plaintiff had Supartz knee injections. (Tr. 451-53.)

During 2010, Plaintiff also saw her primary care provider Dr. Onisile for joint pain. (Tr. 590.) Dr. Onisile noted that Plaintiff reported neck, shoulder, back, and hip pain. (Id. ) He also noted right hand weakness with occasional loss of grip. (Id. ) On examination, Dr. Onisile found tenderness in Plaintiff's cervical and lumbar spine and sacroiliac joint. (Id. ) He also noted pain with lumbar flexion, right hip rotation, and right shoulder adduction. Plaintiff had a positive straight-leg test and mild tenderness of her right forearm and wrist. (Tr. 590.) In November 2010, Dr. Onisile's examination was essentially the same, but he also found 11/18 trigger points and noted radiating pain into Plaintiff's upper and lower extremities. (Tr. 589.) During 2011, Plaintiff continued seeing Dr. Onisile who noted that Plaintiff reported back and joint pain at some visits. (Tr. 578, 579, 584, 585, 586, 587.)

On July 19, 2011, Plaintiff saw rheumatologist Dr. Michael Fairfax for low back pain and general musculoskeletal pain. (Tr. 662.) On examination, Dr. Fairfax found no musculoskeletal tenderness or deformity, no muscle weakness or gross neurologic deficit, and no synovitis on joint examination. (Id. ) However, he noted a positive ANA.[2] (Id. ) In September 2011, Dr. Fairfax diagnosed low back pain (lumbago) and abnormal blood chemistry; he prescribed medication (Plaquenil) to treat a possible autoimmune illness or connective tissue disorder. (Tr. 661.) Plaintiff followed up with a nurse practitioner in December 2011. (Tr. 659.) In November 2011, X-rays of Plaintiff's hands showed a small foreign body on her right thumb but otherwise no significant osteoarthritis. (Tr. 740.) In November 2011 X-rays of Plaintiff's feet and knees showed degenerative changes consistent with osteoarthritis (Tr. 741), and moderate osteoarthritis in Plaintiff's "medial right knee." (Tr. 742.)

3. Treatment Related to Plaintiff's Breast Cancer

In November 2011, a biopsy taken from a lump in Plaintiff's breast was positive for breast cancer. (Tr. 697.) Plaintiff had a mastectomy and chemotherapy in late 2011 and early 2012. (Tr. 690-92, 755-75, 785-96.) Plaintiff also had follow-up surgery related to the mastectomy. (Tr. 745, 749.) Plaintiff had follow-up visits through March 2012. (Tr. 755-75, 785-96.)

B. Medical Opinion Evidence

1. Kathleen Handal

In December 2010, as part of the administrative proceeding, state agency physician Dr. Kathleen Handal reviewed Plaintiff's medical records and completed a Physical Residual Functional Capacity (RFC) Assessment. (Tr. 267-69.) Dr. Handal opined that Plaintiff could occasionally lift twenty pounds and frequently lift ten pounds, that she could stand or walk four hours in an eight-hour workday, and that she could sit for six hours in an eight-hour workday. (Tr. 267.) She also found that Plaintiff could frequently balance and stoop, occasionally kneel, crouch, and climb ramps or stairs, but that she could never crawl or climb ladders, ropes, and scaffolds. (Tr. 267-68.) She further found that Plaintiff should avoid hazards (heights and machinery), and concentrated ...


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