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Rondan v. Colvin

United States District Court, D. Arizona

September 17, 2015

Lucy Rondan, Plaintiff,
v.
Carolyn W. Colvin, Defendant.

ORDER

Bridget S. Bade United States Magistrate Judge

Plaintiff Lucy Rondan seeks judicial review of the final decision of the Commissioner of Social Security (the Commissioner) denying her application for 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. As set forth below, the Court affirms the Commissioner’s decision.

I. Procedural Background

On August 27, 2010, Plaintiff applied for a period of disability and disability insurance benefits under Title II the Act. (Tr. 25.)[1] Plaintiff alleged that she had been disabled since September 15, 2008. (Id.) 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. 15-36.) 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 alleged impairments. The record also includes opinions from state agency physicians who examined Plaintiff or reviewed the records related to her impairments, but who did not provide treatment.

A. Medical Treatment Evidence

1. Treatment for Physical Impairments

In June 2010, Plaintiff’s primary care physician referred her to Gabriel Colceriu, M.D., at the rheumatology clinic at St. Joseph’s Hospital and Medical Center. (Tr. 351.) Plaintiff complained of pain in her knees, hands, wrists, neck, left shoulder, and hip. (Id.) On examination, Dr. Colceriu noted bilateral crepitation of the first CMC joints, bilateral patellofemoral crepitation with “exquisite tenderness to palpation over the media meniscal area bilaterally, ” and bilateral valgus deformities. (Tr. 352.) He also noted that Plaintiff was in no acute distress, she had normal rotation in her hips, full range of motion in her lower extremities, and her “hand grip was intact.” (Id.) Dr. Colceriu noted that an x-ray of Plaintiff’s knee from 2009 showed minimal degenerative changes. (Tr. 353.) An x-ray of Plaintiff’s right hand from 2009 showed degenerative arthritis at the first CMC and second and third distal interphalangeal (DIP) joints. (Tr. 353.) Dr. Colceriu diagnosed polyarthritis in the absence of rheumatoid arthritis and prescribed oxycodone. (Id.)

Dr. Colceriu’s treatments records from July 12, 2010, note continued joint pain in Plaintiff’s knees, hands, and lower back, which was mildly alleviated with oxycodone taken several times a day. (Tr. 348.) On examination, Plaintiff had mild crepitation in her “first CMC bilaterally, ” normal rotation in her hips, crepitation in her knees, and her left knee was tender to palpation over the medial and lateral meniscus. (Tr. 349.) Dr. Colceriu prescribed fentanyl. (Id.)

On August 23, 2010, Plaintiff sought treatment from orthopedic surgeon Dr. Robert Kasa. (Tr. 403.) On examination, Plaintiff was in no acute distress and was alert and oriented with a normal mood and affect. (Id.) Dr. Kasa noted bilateral antalgic gait (limping) and valgus deformities of both knees, with “crepitation at the patellofemoral joint with a range of motion.” (Id.) Dr. Kasa also ordered x-rays that showed “no real patellofemoral arthritic changes or mild ones if any.” (Tr. 403.) He noted some “mild arthritic changes of the medial and lateral compartment of the knee and a valgus alignment with mild narrowing laterally.” (Id.) He stated that “[a]ll of the changes [were] quite mild.” (Id.) Dr. Kasa administered steroid injections in both knees. (Tr. 404.)

Plaintiff retuned to Dr. Colceriu in September 2010. During a September 29, 2010 examination, Dr. Colceriu noted that Plaintiff was in no acute distress. (Tr. 345.) He noted “significant crepitations” in both first carpometacarpal joints and crepitation in both knees, but no active synovitis. (Tr. 346.) He noted full range of motion in Plaintiff’s elbows, and mild tenderness in Plaintiff’s back on palpation. (Id.) Dr. Colceriu concluded that degenerative arthritis was “the most likely etiology of [Plaintiff’s] polyarthralgias, ” or joint pains. (Tr. 346.) He noted that “MS Contin 15” had “helped the pain but not significantly.” (Tr. 345.) Dr. Colceriu ordered an x-ray of Plaintiff’s cervical spine, which revealed multilevel degenerative disc disease, mild at C-3-C-4 and C7-T1, and “moderate to moderately severe at the C4-C5 through C6-C7 levels, ” with reversal of the normal lordotic curvature of the spine related to muscle spasm, and “moderate to moderately severe bilateral neural foraminal narrowing at the C3-C4 through C6-C7 levels.” (Tr. 356.)

At a November 2010 appointment, Dr. Colceriu noted that Plaintiff did not have “radicular symptoms in terms of neuropathic changes in her arms or decreased strength.” (Tr. 388.) Plaintiff reported that fentanyl had helped her pain “tremendously, ” but she was not pain free. (Id.) On examination, Plaintiff was in no acute distress, she had no palpable synovitis, her left shoulder had an improved range of motion, her neck had normal flexion, extension, and rotation, she had mild to moderate tenderness in her back on palpation, crepitation in her lower extremities, and no synovitis. (Tr. 389.) Dr. Colceriu increased Plaintiff’s dosage of fentanyl. (Id.)

Dr. Colceriu ordered a cervical MRI in December 2010. (Tr. 390-91.) The MRI showed mild narrowing of the spinal cord neuroforaminal throughout C2 through C7, “mild narrowing of the central spinal canal and flattening of the anterior [spinal] cord” at C4-5, and a disc osteophyte complex (bone spur) and bilateral facet arthrosis that caused “mild narrowing of the central spinal canal and flattening of the anterior [spinal] cord . . . [at C6-7].” (Tr. 390-91.) The MRI also revealed “severe narrowing of the left neuroforamen.” (Id.)

During a February 28, 2011 appointment, Dr. Colceriu noted that Plaintiff had an episode of sciatica and heel pain several weeks before the appointment when she moved to a new place. (Tr. 386.) Plaintiff reported that she was “quite happy” with pain control from fentanyl, and she did not have any episodes of joint swelling. (Id.) On examination, Plaintiff ambulated without assistance and she had no synovitis in her hands or wrists. (Tr. 386.) Plaintiff had tenderness to palpation and “mild crepitation in fourth metacarphophalangeals bilaterally.” (Tr. 386-87.) She had an average range of motion in her shoulder, mild tenderness in her lumbar spine on palpation, lower extremity crepitation, and tenderness in her right heel on palpation. (Tr. 387.) Dr. Colceriu noted “that Plaintiff’s “cervical spondylitic symptoms [had] gone away.” (Id.) Dr. Colceriu diagnosed diffuse osteoarthritis and degenerative joint disease in multiple locations in Plaintiff’s lower back, cervical spine, and hands “with no evidence of inflammatory arthropathy.” (Id.) Dr. Colceriu increased Plaintiff’s dosage of fentanyl and continued her prescription for morphine. (Tr. 387.)

On April 28, 2011, Dr. Colceriu noted that Plaintiff’s pain was “better controlled” with the increased dosage of fentanyl, but that Plaintiff had stopped using it due to side effects and had increased her use of morphine. (Tr. 384.) Plaintiff reported falling on her left knee and sustaining some bruising, but she could walk without assistance. (Id.) On examination, Dr. Colceriu noted that Plaintiff walked without assistance, had no synovitis in her upper extremities, her lower extremities had some crepitation and bruising, but no instability. (Id.) He also observed that Plaintiff’s back was tender to palpation throughout. (Id.) Dr. Colceriu diagnosed diffuse degenerative joint disease and recommended that Plaintiff restart fentanyl at the lower dose she had previously tolerated, and that she reduce morphine. (Id.)

On June 6, 2011, Dr. Colceriu noted that Plaintiff was doing much better on her new doses of fentanyl and morphine. (Tr. 382.) Plaintiff did not report any side effects from the new combination of medications and her “pain [was] better controlled overall.” (Id.) Plaintiff had moved into a two-story house and reported difficulty climbing stairs. (Id.) On examination, Plaintiff walked unassisted with a slow gait. (Id.) She had no synovitis in her upper extremities, a full range of motion in her upper extremities, moderate tenderness in her back on palpation, “severe crepitation in both knees, ” but no lateral instability, no warmth, and no redness. (Tr. 382.) Dr. Colceriu administered a corticosteroid injection to Plaintiff’s left knee. (Tr. 383.) He assessed diffuse degenerative joint disease and noted that Plaintiff was “doing much better clinically on a combination of fentanyl 37 mcg and morphine sulfate 15 mg ER.” (Id.)

In August 2011, Dr. Colceriu noted that Plaintiff had reported that the corticosteroid injection in the left knee helped for a week and then her pain returned “to normal.” (Tr. 562.) Plaintiff also reported that her left knee buckled more frequently, she had problems climbing stairs and walking in a straight line, she limped all the time, and had unbearable pain daily. (Id.) Plaintiff stated that morphine and fentanyl helped “minimally.” (Id.) On examination, Dr. Colceriu noted that Plaintiff limped, she had “severe grinding and more than 25 degrees of valgus on the left but 10 degrees of valgus on the right with crepitation on the right . . . .” (Id.) He also noted that she had no warmth over her joints. (Id.) Dr. Colceriu assessed “diffuse osteoarthritis/degenerative joint disease including the lower spine, cervical spine, and knees.” (Id.) He noted that Plaintiff’s pain was “uncontrolled, ” and stated that because pain medication, steroids, and range of motion exercises did not help, he would increase her dose of fentanyl and refer her for possible total knee replacement surgery. (Id.) Dr. Colceriu also stated that he would “take into consideration the fact that the left knee ha[d] an exaggerated valgus angle, which ma[de] the mechanics of her mobility even worse.” (Tr. 562.)

During a November 2, 2011 examination, Plaintiff reported joint pain and stiffness, but no swelling. (Tr. 559.) Plaintiff was in no acute distress and ambulated independently. (Tr. 560.) She had joint tenderness in her upper extremities with no active synovitis, tender paraspinal muscles, and crepitation in both knees. (Id.) Plaintiff walked with a limp and had a normal hand grip. (Id.) Dr. Colceriu noted that Plaintiff “failed” range of motion exercises and “steroid trial.” (Id.) He continued Plaintiff’s prescriptions for fentanyl and morphine. (Id.)

At a February 24, 2012 appointment with Dr. Colceriu, Plaintiff complained of pain her in knees and back that was worse with activity and cold. (Tr. 556.) Plaintiff reported joint pain and stiffness, but no swelling or muscle pain. (Id.) She stated that physical therapy had helped in 2010. (Id.) On examination, Dr. Colceriu noted that Plaintiff was in no acute distress and ambulated independently with a mild limp. (Tr. 557.) She had joint tenderness in her upper extremities with no synovitis. (Id.) She had non-focal tenderness in her spine, crepitation in both knees, and a normal hand grip. (Id.) Dr. Colceriu continued Plaintiff’s prescriptions for medications and stated that he would refer her to physical therapy when she returned from Sierra Vista.[2] (Id.)

During a July 19, 2012 appointment, Plaintiff reported that she had been “run over by a car” and contracted an infection that required hospitalization. (Tr. 552.) She reported continued pain that was worse in her back. (Id.) She had stopped using morphine and was using “short acting pain pills” and fentanyl. (Id.) She reported that her pain was better with medication. (Id.) On examination, Plaintiff was in no acute distress and ambulated independently. (Tr. 554.) She had mild joint tenderness in her upper extremities, no synovitis or atrophy, a full range of motion in both of her elbows, a normal hand grip, crepitation in both knees, no active synovitis in her lower extremities, and walked with a limp. (Id.) Dr. Colceriu assessed osteoarthritis and cellulitis in her Plaintiff’s left leg. (Id.)

Plaintiff returned to Dr. Colceriu for a follow up on September 20, 2012. (Tr. 548.) She reported that she had surgery for her left leg infection. (Id.) She reported that she mainly had pain in her lower left extremity, but also had pain in her back and hands. (Id.) Her pain was better with medication and worse with ambulation and activity. (Id.) She did not report any joint swelling or redness. (Id.) On examination, Plaintiff was in no acute distress and ambulated independently. (Tr. 549.) She had tenderness in the joints of her upper extremities, but no active synovitis or atrophy. (Id.) She had a full range of motion in both elbows and a normal grip. (Id.) Plaintiff had tenderness in her paraspinal muscles, crepitation in both knees, no active synovitis in her lower extremities, and walked with a limp. (Id.) Dr. Colceriu noted that Plaintiff had osteoarthritis at several sites and prescribed fentanyl and ibuprofen. (Tr. 550.)

2. Treatment for Mental Impairments

In December 2009, Plaintiff had an initial psychiatric examination at the Pinal Hispanic Council in Coolidge, Arizona. (Tr. 317-21.) Plaintiff reported experiencing depression for the previous seven years. (Tr. 317.) On examination, Plaintiff was oriented, she had good hygiene, appropriate affect, a depressed mood, normal speech, logical associations, unremarkable stream of thought, non-psychotic thought content, no thoughts of harm, normal perception, good concentration, intact memory, and good fund of knowledge, insight, and judgment. (Tr. 319-20.) Plaintiff was diagnosed with major depressive disorder, moderate, recurring (Tr. 320), and prescribed Lexapro and Ambien. (Tr. 321.)

On September 14, 2010, a psychiatric nurse practitioner (NP), Judy Yurgel, noted that Plaintiff’s mental status examination was unremarkable. (Tr. 402.) She found that Plaintiff was alert and oriented. (Id.) She had good concentration, unremarkable speech and thought process, no destructive thoughts, intact memory, and good insight and judgment. (Id.) NP Yurgel diagnosed major depressive disorder, discontinued Ambien due to side effects, and prescribed Vistaril. (Id.) On April 2, 2011, NP Yurgel again described Plaintiff’s mental status examination as unremarkable. (Tr. 397.) She noted that Plaintiff was alert and oriented. (Id.) She had good concentration, no psychosis, unremarkable speech and thought process, no thoughts of harm, intact memory, and good insight and judgment. (Id.) NP Yurgel diagnosed major depressive disorder and prescribed Lexapro and Trazadone. (Id.) A July 8, 2011 progress note indicates that Plaintiff was alert and oriented. (Tr. 462.) She had good hygiene, good eye contact, normal motor activity, appropriate affect, a euthymic mood, normal speech, logical associations, an unremarkable stream of thought, non-psychotic thought without depressive content, no thoughts of harm, normal perception, good concentration, intact memory, good fund of knowledge, and good insight and judgment. (Tr. 464-65.)

After Plaintiff moved to Phoenix, she received treatment at Terros from December 2011 through September 2012. (Tr. 434, 569-632.) On December 6, 2011, Plaintiff reported that she had sadness daily and that she sometimes felt like she could cry all day. (Tr. 631.) She reported that she lived with her adult daughter and that she provided for her, cooked for her, and cared for “the animals.” (Id.) Plaintiff reported that she got along well with others, loved to cook, and that family values were important to her. (Tr. 614.) The progress note indicates that Plaintiff was calm, had good interaction, and a depressed mood. (Tr. 625) She was not a danger to herself or others. (Tr. 624.) Plaintiff had an appropriate affect, articulate speech, relevant thought process, depressive thought content, good recall of events, average intelligence, limited judgment, and fair insight. (Tr. 618.)

In December 2011, a progress note from Terros indicates that Plaintiff had “slight progress.” (Tr. 606.) Plaintiff was encouraged to attend a women’s counseling group. (Tr. 605.) Her diagnosis remained major depressive disorder. (Tr. 602-04.) On December 16, 2011, Plaintiff reported that she slept too much, did not go out in public, cried a lot, wanted to be by herself, had “horrible” concentration, and mood swings. (Tr. 594.) The progress note indicates that Plaintiff was alert and oriented. (Tr. 596-97.) She had good eye contact, normal motor activity, a tearful affect, an anxious and depressed mood, normal speech, logical thought process, unremarkable stream of thought, non-psychotic thoughts, depressive thought content, no thoughts of harm, normal perception, poor concentration, intact memory, and good intellect, insight, and judgment. (Tr. 596-98.) Plaintiff was diagnosed with major depressive disorder in partial remission. (Tr. 598.)

On January 2, 2012, Plaintiff left a voice mail message for her healthcare provider at Terros stating that she need to reschedule her January 13, 2012 appointment because she was going to be out of town for three months caring for a terminally ill family member. (Tr. 592.) Plaintiff’s appointment was reset to January 6, 2012. During that appointment, Plaintiff reported that her brother who lived in Sierra Vista was sick and wanted her to help manage his tax preparation business. (Tr. 588.) Plaintiff did not report any side effects from her medication. (Id.) The progress note indicates that Plaintiff was alert and oriented. (Tr. 588-89.) She had good appearance, good eye contact, normal motor activity, appropriate affect, euthymic mood, normal speech, logical thought process, no psychotic or depressive thought content, no thoughts of harm, normal perception, good concentration, intact memory, and good intelligence, insight, and judgment. (Tr. 589.) She was diagnosed with major depressive disorder in partial remission. (Tr. 590.)

On March 22, 2012, a Terros provider telephoned Plaintiff for a wellness check. (Tr. 587.) Plaintiff reported that she planned to attend the women’s counseling group when she “moved back” after helping her brother. (Id.) The progress note indicates that Plaintiff had been “going back and forth to help her brother.” (Id.)

On March 23, 2012, Plaintiff had an appointment with Beatrice Yang, M.D. (Tr. 584-86.) Plaintiff reported no side effects from her medication. (Tr. 584.) Plaintiff was alert and oriented. (Tr. 584-85.) She had good appearance, good eye contact, normal motor activity, tearful affect, euthymic mood, normal speech, logical thought process, non-psychotic and non-depressive thought content, no thoughts of harm, normal perception, good concentration, intact memory, and good intelligence, insight, and judgment. (Tr. 585.) Dr. Yang diagnosed major depressive order in partial remission. (Tr. 586.)

During a June 11, 2012 telephonic wellness check, Plaintiff reported no side effects from her medication. (Tr. 580.) During a June 13, 2012 appointment with Dr. Yang, Plaintiff was alert and oriented. (Tr. 578.) She had good eye contact, normal motor activity, appropriate affect, euthymic mood, normal speech, logical thought process, non-psychotic and non-depressive thought content, no thoughts of harm, normal perception, good concentration, intact memory, and good intelligence, insight, and judgment. (Id.) Dr. Yang diagnosed major depressive disorder in partial remission. (Tr. 579.)

Plaintiff next saw Dr. Yang on September 10, 2012. (Tr. 570.) She was alert and oriented. (Tr. 571.) She had good eye contact, normal motor activity, appropriate affect, euthymic mood, normal speech, logical thought process, unremarkable stream of thought, non-psychotic and non-depressive thought content, no thoughts of harm, normal perception, good concentration, intact memory, and good intelligence, insight, and judgment. (Id.) Plaintiff was diagnosed with major depressive disorder in partial remission. (Tr. 572.)

B. Opinion Evidence

1. William Chaffee, M.D.

On August 31, 2011, Plaintiff saw William Chaffee, M.D., for a physical examination related to her application for disability benefits. (Tr. 444-48.) Dr. Chaffee noted that he reviewed Dr. Colceriu’s progress notes from June 2011, the report of a December 2010 cervical MRI scan, 2011 x-rays of Plaintiff’s knees, and a July 14, 2011 function report that Plaintiff completed. (Tr. 444, 447.) Plaintiff complained of chronic joint pain, leg pain, and poor sleep. (Tr. 444-45.) On examination, Plaintiff had normal range of motion in her cervical, thoracic, and lumbar spine. (Tr. 446.) Her hip, knee, ankle, shoulder, elbow, wrist, and elbow joints were “within normal limits bilaterally.” (Id.) She had a normal gait and station and could squat and heel-toe walk normally. (Id.) She had “straight leg raising 60 degrees right and left without pain supine.” (Tr. 447.) Dr. Chaffee found that Plaintiff had a genu valgus bilaterally, no swelling or crepitation in either knee, and slight tenderness in both wrists without swelling. (Id.) Plaintiff had normal muscle tone and bulk, and full strength in her upper and lower extremities, including “grip strength and pinch strength.” (Id.) Dr. Chaffee diagnosed chronic polyarthralgias and opined that Plaintiff did not have a condition that would impose limitations for twelve continuous months. (Id.)

2. Sharon Steingard, D.O.

On August 4, 2011, Plaintiff was examined by Sharon Steingard, D.O., for her disability benefits application. (Tr. 433-39.) Dr. Steingard noted that she reviewed an adult function report that Plaintiff completed and progress notes from the Pinal Hispanic Council. (Tr. 433.) Plaintiff reported that she was stressed and depressed. (Tr. 434.) She described herself as forgetful and distracted. (Id.) She stated that she got along “fairly well” with her adult children. (Id.) Plaintiff had no suicidal attempts or psychiatric hospitalization. (Id.) She reported that she lived with her adult daughter. (Tr. 435.) During a typical day, Plaintiff spent forty-five minutes on the computer, read the bible, listened to music, cared for household pets, and did light cooking. (Tr. 436.) She stated that she sometimes needed reminders to maintain her personal hygiene. (Id.)

On examination, Plaintiff was clean, appropriately dressed, and alert. (Tr. 436.) She had normal posture and a normal gait and station. (Id.) After sitting during the interview, she was stiff on standing. (Id.) Plaintiff had good eye contact, satisfactory attention, unremarkable speech, logical associations, and unremarkable stream of thought. (Tr. 436.) She was tearful and cried the entire interview, she seemed depressed, and had a sad facial expression and a labile affect. (Id.) Plaintiff was not helpless or hopeless and was goal-directed to continue treatment. (Id.) She had some suicidal ideation without any intention or plan to hurt herself. (Id.) She had limited insight and judgment, a poor general fund of knowledge, and trouble with memory. (Id.) Dr. Steingard diagnosed Plaintiff with major depressive disorder, recurrent. (Tr. 437.)

Dr. Steingard completed a Psychological/Psychiatric Medical Source Statement. (Tr. 438-39.) In areas of understanding and memory, Dr. Steingard found that Plaintiff would need to have some instructions repeated, and that she would have more problems with detailed instructions or complicated procedures. (Tr. 438.) She also found that Plaintiff had a limited ability to multitask, “displayed some trouble with frustration tolerance, ” “got a little agitated ...


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