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Jirousek v. Commissioner of Social Security

United States District Court, N.D. Ohio, Eastern Division

May 12, 2017

TRACY L. JIROUSEK, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          MEMORANDUM OPINION & ORDER

          KATHLEEN B. BURKE, United States Magistrate Judge

         Plaintiff Tracy L. Jirousek (“Plaintiff” or “Jirousek”) seeks judicial review of the final decision of Defendant Commissioner of Social Security (“Defendant” or “Commissioner”) denying her application for social security disability benefits. Doc. 1. This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned Magistrate Judge pursuant to the consent of the parties. Doc. 18. As explained more fully below, the Court AFFIRMS the Commissioner's decision.

         I. Procedural History

         Jirousek protectively filed an application for Disability Insurance Benefits (“DIB”) on November 30, 2012.[1] Tr. 18, 69, 151, 169. Jirousek alleged a disability onset date of February 1, 2006 (Tr. 18, 151, 169), which she later amended to November 1, 2012 (Tr. 18, 38-39, 168). Jirousek alleged disability due to neck pain and stiffness, low back pain, shoulder pain, arm numbness and tendency to drop things, headaches, depression (low energy, irritable), insomnia due to pain, impaired concentration, very slow pace due to pain and stiffness, side effects from medication, needs sit/stand/walk/recline, and limited reaching. Tr. 69-70, 95, 103, 180. Jirousek's application was denied initially (Tr. 95-101) and upon reconsideration by the state agency (Tr. 103-109). Thereafter, she requested an administrative hearing. Tr. 110.

         On February 26, 2015, an administrative hearing was conducted by Administrative Law Judge Susan Giuffre (“ALJ”). Tr. 35-68. On April 6, 2015, the ALJ issued her decision. Tr. 15-34. In her decision, the ALJ determined that Jirousek had not been under a disability within the meaning of the Social Security Act from November 1, 2012, through March 31, 2013, her date last insured. Tr. 18, 30. Jirousek requested review of the ALJ's decision by the Appeals Council. Tr. 14. On March 22, 2016, the Appeals Council denied Jirousek's request for review, making the ALJ's decision the final decision of the Commissioner. Tr. 1-6.

         II. Evidence

         A. Personal, vocational and educational evidence

         Jirousek was born in 1969. Tr. 151. She completed high school and obtained a certificate from a medical massage school. Tr. 41-42. However, she never used her medical massage certificate. Tr. 42. Jirousek last worked full time in 2006 as a bartender/waitress at Henry's Bar. Tr. 42. From 2006 until 2009, Jirousek filled in at Henry's Bar. Tr. 42. Jirousek lives in a house with her husband and her two minor children. Tr. 45, 46. At the time of the hearing, her children were ages nine and five. Tr. 46.

         B. Medical evidence[2]

         1.Treatment history[3]

         Medical evidence pre-dating amended alleged onset date

         Starting in 2005, Jirousek received chiropractic treatment from Gregory R. Poyle, D.C. Tr. 231-243. Jirousek's complaints included neck and back pain and tingling in her hands/wrists. Tr. 234, 237, 238, 241, 242. She continued treatments with Dr. Poyle through 2007. Tr. 232-243.

         On October 25, 2007, upon referral of Douglas Potoczak, M.D., Jirousek's primary care physician since 2006 (Tr. 592), Jirousek saw Sanjay Kumar, D.O., of Neurosurgical Services, Inc., for a consultation regarding her pain (Tr. 392-393). Jirousek was reporting some neck pain and pain going down the arm with numbness and tingling into the thumbs since May or June of 2007. Tr. 392. Jirousek's pain was present with turning and twisting and sometimes her pain level was a 7/10. Tr. 392. Jirousek had been taking Vicodin, which helped minimally. Tr. 392. Jirousek was recently pregnant so she had stopped taking her medicines except for Tylenol as needed. Tr. 392. She had tried a prednisone taper but it did not help. Tr. 392. On physical examination, Dr. Kumar noted that extension and flexion caused some pain in the neck area; there was mild pain to palpation over the right mid lower cervical paraspinal muscles; and spurling maneuver caused some mild radiating pain down the right arm. Tr. 392. Dr. Kumar noted that Jirousek described “some paresthesias in the C6 distribution.” Tr. 392. Dr. Kumar observed that Jirousek's reflexes were 2 and symmetric; there were no upper motor neuron signs or symptoms seen; strength was at least 5/5 in the upper extremities; gait was normal; and there were no obvious spinal deformities noted. Tr. 392. Dr. Kumar indicated that a September 27, 2007, MRI showed generalized disk bulging at ¶ 4-C5, C5-C6 and C6-C7, greatest at ¶ 6-C7, with no stenosis. Tr. 392. Dr. Kumar's impression was right-sided neck pain with pain going down the arm likely secondary to C6 radiculitis with mild disk bulging. Tr. 393. Because of Jirousek's pregnancy, treatment options were limited. Tr. 393. Jirousek indicated she had tried chiropractic manipulations and traction which had been helping. Tr. 393.

         In November 2007, approval was obtained from Jirousek's OB/GYN to proceed with injections. Tr. 391. On December 11, 2007, Jirousek reported that the right C5-C6, C6-C7 facet injection helped for about a week. Tr. 389. She was still having some numbness and tingling in her thumb and index finger and sometimes pain in the parascapular region and shoulder blade and neck. Tr. 389. Jirousek had experienced a miscarriage and was taking Vicodin at night. Tr. 389. Nerve conduction studies were performed and Dr. Kumar concluded that there appeared to be electrodiagnostic evidence of mild right-sided carpal tunnel syndrome characterized by sensory fiber demyelination. Tr. 389. Dr. Kumar recommended carpal tunnel wrist splints and a cervical epidural injections. Tr. 389.

         Several weeks after receiving the cervical epidural injections, on December 31, 2007, Jirousek saw Dr. Kumar for follow up reporting that the injections had helped significantly. Tr. 387. Most of her pain was now in the low back right side. Tr. 387. Her pain was worse with bending and standing and sometimes it was hard to get out of bed. Tr. 387. She was taking Vicodin and Tylenol rarely. Tr. 387. On examination, Dr. Kumar observed some tenderness over the right lumbosacral junction and SI region. Tr. 387. Flexion bothered Jirousek more than extension. Tr. 387. Otherwise, she was neurologically stable. Tr. 387. Dr. Kumar recommended x-rays of the lumbar spine and SI joints. Tr. 387. Jirousek was going to continue her home exercise program and see Dr. Kumar in two weeks for follow up. Tr. 387.

         During a January 11, 2008, follow up visit with Dr. Kumar, Jirousek reported that her neck was still feeling pretty good but she was having low back pain, with her pain worse with lying down. Tr. 385. The x-rays showed some posterior element sclerosis in mid distal lumbar spine and arthritic changes at the bilateral SI joints, right greater than left. Tr. 385. Jirousek was taking Vicodin and Tylenol only as needed and she reported that her pain interfered with her activities of daily living and quality of life. Tr. 385. Dr. Kumar recommended an MRI since lying down made her symptoms worse. Tr. 385.

         During a January 25, 2008, Dr. Kumar indicated that the MRI showed a broad base disk bulge at ¶ 4-L5, a small central disk protrusion at ¶ 5-S1, and bilateral mild facet arthropathy. Tr. 383. Jirousek's back hurt with extension but her neck pain was stable. Tr. 383. Jirousek was taking medicine only as needed. Tr. 383. She was walking “twice a day 3 miles” which Jirousek felt helped her. Tr. 383. The plan was for Jirousek to continue her home exercise program with some flexion oriented exercises. Tr. 383. It was decided that Jirousek would hold off on injections and Dr. Kumar directed Jirousek to call if she had any flare ups. Tr. 383.

         On May 2, 2008, Jirousek saw Dr. Kumar reporting that her pain was worse and she could not take it anymore. Tr. 381. She wanted injections. Tr. 381. Dr. Kumar agreed to schedule L4-L5, L5-S1 facet joint injections first. Tr. 381. Dr. Kumar prescribed both Vicodin and Naprosyn. Tr. 381. On May 21, 2008, Jirousek saw Dr. Kumar and reported that her pain was significantly better following the facet joint injections performed two weeks prior. Tr. 379. Jirousek indicated that she felt “awesome[.]” Tr. 379. She did indicate that sometimes she still had issues with her neck. Tr. 379. Dr. Kumar was happy with Jirousek's results and indicated that he would see Jirousek back if she had any flare ups. Tr. 379.

         On July 7, 2008, Jirousek returned to see Dr. Kumar reporting that the pain in her neck had returned with numbness in her arms, limited range of motion and some spasms. Tr. 377. Dr. Kumar recommended epidural injections and physical therapy thereafter. Tr. 377. On July 30, 2008, Jirousek reported 80% relief from her cervical epidural injections. Tr. 375. Jirousek inquired about cervical traction. Tr. 375. On examination, Dr. Kumar observed minimal pain to palpation over the neck and lower back paraspinal muscles. Tr. 375. Jirousek's range of motion and strength were functional, her sensation was intact to light touch, and neurologically she was stable. Tr. 375. Dr. Kumar recommended comprehensive outpatient therapy and a cervical traction unit that she could use at home. Tr. 375.

         Jirousek next saw her primary care physician Dr. Potoczak on February 8, 2010, for follow up of her chronic neck and shoulder pain, which Jirousek described as slightly worse. Tr. 293. Jirousek indicated that her shoulder pain had started last summer and was continuing to bother her but it was not interfering with daily activities. Tr. 293. Jirousek indicated that she “[f]elt a pop and some clicking last summer in the pool with [her] daughter. She threw her up into the air playing with her.” Tr. 293. On examination, Dr. Potoczak observed pain and tenderness over the biceps; “decreased range of motion, flexion, extension, rotational movement[;]” some pain over supraspinatus; trapezius muscle and paracervical muscular spasm and pain with palpation; mild decreased range of motion; flexion and extension, lateral bending secondary to pain; no parasthesias in arms; good grip strength; some lumbar discomfort, worse when on her feet a lot; and negative straight leg raises. Tr. 293. Dr. Potoczak's diagnoses included chronic lumbar pain; sciatica with intermittent exacerbation; and chronic shoulder pain, cannot rule out rotator cuff tear. Tr. 293. An x-ray of Jirousek's right shoulder taken on February 8, 2010, showed mild degenerative changes. Tr. 324. Dr. Potoczak indicated that the x-ray was negative but noted that an MRI might be required. Tr. 293. Dr. Potoczak prescribed steroids for 11 days; recommended heat in the morning and ice at night; and Vicodin every 6 hours as needed. Tr. 293. An MRI of the right shoulder taken on March 1, 2010, showed “No rotator cuff abnormality identified. Acromioclavicular degenerative changes.” Tr. 322.

         The following month, on March 31, 2010, Jirousek returned to see Dr. Kumar almost two years since her last visit with him. Tr. 320, 372. Jirousek complained of right sided low back pain. Tr. 320. Jirousek indicated that her back pain had flared up on the right side. Tr. 320. She described her pain as a dull ache and reported that bending and lifting bothered her. Tr. 320. Jirousek rated her pain as a 4/10. Tr. 320. She had minimal numbness down her right leg. Tr. 320. She was taking Vicodin as needed, three or four time per week, and Skelaxin, Motrin and Tylenol as needed. Tr. 320. Jirousek had started to jog. Tr. 320. She indicated that her pain affected her quality of life and her sleep was decreased. Tr. 320. Jirousek had another child about a year prior. Tr. 320. Dr. Kumar assessed low back pain with degenerative disk and joint disease of the lower lumbar spine with facet arthropathy, symptomatic on the right. Tr. 320. Dr. Kumar noted that Jirousek had done well with facet joint injections in the past and recommended L4-L5, L5-S1 facet joint injections. Tr. 320. On April 19, 2010, Jirousek reported to Dr. Kumar's office that she felt 75% better following her injections. Tr. 371.

         On September 21, 2010, Jirousek saw Dr. Potoczak with complaints of intermittent problems with her back and neck. Tr. 287. She was interested in trying more muscle relaxant and needed a refill on Vicodin. Tr. 287. Dr. Potoczak observed pain and tenderness in the paracervical musculature and into the trapezius but she was improved since before. Tr. 287. Dr. Potoczak refilled Jirousek's medications with instructions to follow up in a month or sooner if her symptoms worsened. Tr. 287.

         Jirousek saw Dr. Potoczak on July 27, 2011, complaining of muscle pain in her chest, shoulders and arms that had been going on for about a month. Tr. 284. Dr. Potoczak indicated that the muscle pain was possibly related to her use of Zocor, which she had been on for almost a year. Tr. 284. Dr. Potoczak diagnosed history of hyperlipidemia and chronic neck/back pain, now with myalgias. Tr. 284. Dr. Potoczak discontinued the Zocor and recommended follow up in two weeks. Tr. 284. During an August 12, 2011, follow-up visit with Dr. Potoczak Jirousek's myalgias had improved slightly. Tr. 283. On examination, Jirousek's bicep area was not as tender but she had continued pain in the paracervical musculature and trapezius bilateral with muscle spasm, achiness in her upper deltoid and tricep, and some chronic low back pain and paresthesias in the right buttock area. Tr. 283. Dr. Potoczak recommended keeping Jirousek off the Zocor and noted that she was scheduled to see Dr. Kumar for an evaluation of lumbar cortisone injections. Tr. 283. Dr. Potoczak planned to follow up with Jirousek in a month and would see if Dr. Kumar felt that physical therapy was appropriate. Tr. 283.

         On August 17, 2011, Jirousek saw Dr. Kumar with complaints of right-sided low back pain and neck pain. Tr. 303, 369. Jirousek had not seen Dr. Kumar for about 16 months. Tr. 303. Jirousek reported that her pain had returned over the prior three months on the right side of her low back. Tr. 303. Her pain was worse with bending and twisting and the numbness, tingling, and neck pain had returned on both sides but it was not as bad as her low back pain. Tr. 303. On examination, Dr. Kumar observed tenderness on the right mid lower lumbar paraspinal muscles with positive facet joint provocative maneuvers; straight leg raising was negative; Jirousek could heel and toe walk; gait, coordination and balance were normal; mild tightness in her hamstrings; no pain with hip rotation; and neck range of motion was functional. Tr. 303. Dr. Kumar assessed low back pain right sided with facet arthropathy and history of neck pain. Tr. 303. Dr. Kumar advised that Jirousek should proceed with right L4-5 and L5-S1 facet joint injections. Tr. 303. If Jirousek's neck continued to bother her, Dr. Kumar indicated that Jirousek may need interventional pain management. Tr. 303. Jirousek was continuing to do exercises at home and they discussed the possibility of an inversion table and DRX machine, which would be more for diskogenic pain. Tr. 303. Jirousek was going to continue to take Motrin and had enough Vicodin. Tr. 303. On September 6, 2011, Jirousek reported to Dr. Kumar's office that the injections she had on August 22, 2011, provided 75% relief but she still had some pain and wanted to know whether she should have another injection. Tr. 368. Dr. Kumar recommended holding off. Tr. 368.

         Jirousek saw Dr. Potoczak on November 8, 2011, for follow up after having discontinued the Zocor. Tr. 420-421. Jirousek had no chest pain, focal weakness or shortness of breath. Tr. 420. Jirousek was interested in restarting Zocor. Tr. 420. Dr. Potoczak provided a refill for the Zocor. Tr. 422. On examination, Dr. Potoczak observed multiple trigger points with deep muscle spasm. Tr. 421. Dr. Potoczak provided samples of Savella. Tr. 422. During a follow-up visit with Dr. Potoczak on November 22, 2011, Jirousek reported that pain was present in her neck, left clavicle, left elbow, left shoulder, right clavicle, upper right arm, upper left arm, upper back and right shoulder and she described her pain as “medium.” Tr. 422. Jirousek reported that physical therapy was helping with her pain. Tr. 423. Jirousek was interested in a different muscle relaxer. Tr. 423. She had no improvement with Savella so Dr. Potoczak discontinued the medication. Tr. 423. Dr. Potoczak's physical examination revealed an unremarkable neurologic exam; upper and lower extremities within normal limits; and full strength. Tr. 423. Dr. Potoczak diagnosed fibromyalgia and he prescribed Flexeril to be taken 2 times daily as needed for muscle spasms. Tr. 423.

         On November 30, 2011, Jirousek saw a new chiropractor, Dr. Ross C. Lubrani, DC, for evaluation and treatment of her neck and lower back pain. Tr. 245-247. Jirousek complained of “very severe constant sharp neck pain, severe constant aching low back pain and moderate numbness in both arms.” Tr. 245. Dr. Lubrani's objective findings included evidence of muscle spasms, active myofascial trigger points, and range of motion loss. Tr. 247. Dr. Lubrani treated Jirousek through at least March 2012. Tr. 245-272.

         During an April 11, 2012, visit with Dr. Potoczak regarding her anxiety, Dr. Potoczak noted in his physical examination findings that Jirousek had a normal range of motion and her back and neck pain were much better with therapy. Tr. 424. On May 8, 2012, Jirousek returned to see Dr. Kumar with complaints of bilateral shoulder pain that had been bothering her for the prior 6 months. Tr. 366. She also reported neck pain but her shoulders were really bad. Tr. 366. Both sides bothered her with lifting her arms and sleeping at night. Tr. 366. She had a hard time reaching behind her back. Tr. 366. Jirousek was using Vicodin sparingly and tried Motrin. Tr. 366. Dr. Kumar diagnosed bilateral shoulder pain with rotator cuff tendonitis and bursitis. Tr. 366. Dr. Kumar started Jirousek on Mobic; ordered x-rays of both shoulders; and scheduled bilateral shoulder subacromial injections. Tr. 366. During a visit at Dr. Kumar's office on May 30, 2012, Jirousek reported significant relief following bilateral shoulder subacromial injections earlier that month. Tr. 363. She had more relief while awake but was still having bad pain at night. Tr. 363. She was using Mobic and Tylenol, which seemed to help her perform her daily activities. Tr. 363. Because Jirousek was continuing to have significant discomfort in the evening, the nurse indicated that an MRI of the left shoulder would be taken to rule out any rotator cuff involvement. Tr. 363.

         Following her left shoulder MRI (Tr. 354, 415-416), on June 27, 2012, Jirousek saw David Zanotti, M.D., of the Center for Orthopedics, for an evaluation of her shoulder pain (Tr. 337-338, 347). Jirousek reported that her right shoulder was worse than her left. Tr. 337. On examination, Dr. Zanotti observed that Jirousek had full overhead motion of both shoulders; very limited neck flexion and extension with pain radiating down both paracervical regions; significant pain in the biceps groove on both sides; 5/5 abduction and supraspinatus strength with mild pain during stressing; pain with impingement maneuvers on both sides; and subscapularis stretching caused significant discomfort on both sides. Tr. 337. Jirousek denied any numbness or tingling during the visit but reported having radiating pain down her arms at times. Tr. 337. Dr. Zanotti indicated that x-rays of both shoulders showed minimal degenerative changes of the glenohumeral joint with the alignment maintained and an MRI of the left shoulder showed subluxated biceps tendon with some cuff tendinitis. Tr. 337, 354, 415-416. Dr. Zanotti assessed right greater than left shoulder biceps tendinitis with left sided bicipital subluxation and bilateral impingement and a history of cervical radiculopathy. Tr. 338. An MRI of the right shoulder was ordered and Dr. Zanotti administered an injection of Celestone and Lidocaine in the left bicipital groove. Tr. 338.

         A July 2, 2012, MRI of the right shoulder showed distal supraspinatus and infraspinatus with partial undersurface tearing of the distal anterior fibers of the supraspinatus without full-thickness tear; moderate AC joint osteoarthrosis with inferior projecting osteophyte from the distal clavicle causing mass effect on the myotendinous junction of the supraspinatus; and mild subacromial and subcoracoid bursitis. Tr. 351, 417.

         Jirousek saw a physician assistant at Dr. Zanotti's office on July 23, 2012.[4] Tr. 345. The assessment was right shoulder impingement, right shoulder bicipital tendinitis, and improved left shoulder bicipital tendinitis. Tr. 345. Jirousek received an injection of Celestone and Lidocaine into the right subacromial space and was referred her to physical therapy for her neck and shoulder. Tr. 345. On August 1, 2012, Jirousek received an initial physical therapy evaluation at Total Joint Rehab. Tr. 339-340.

         In September 2012, Jirousek saw a physician assistant at Dr. Zanotti's office for two different visits. Tr. 342, 344. Jirousek continued to report pain in both shoulders as well as in her neck with stiffness in her neck. Tr. 342, 344. Jirousek reported some relief from an earlier injection in her left bicipital groove and past cortisone injections. Tr. 342, 344. Dr. Zanotti ordered a cervical MRI, which was taken on September 19, 2012, and showed degenerative and arthritic changes in the cervical spine; multilevel discogenic degenerative disease and a few bulging disks in the cervical spine but no evidence of a frank herniated nucleus pulposus; a few narrowed neural foramina but no spinal canal stenosis in the cervical spine; and unremarkable cervical cord with no cord compression at the c-spine. Tr. 348-349, 418-419.

         A September 26, 2012, examination at Dr. Zanotti's office showed that Jirousek had “full overhead motion with the ability to get her hand behind her back lacking two-levels bilaterally.” Tr. 342. She exhibited pain on impingement maneuvers and significant bicipital groove pain on the right with less on the right. Tr. 342. She had a positive Spurling's maneuver. Tr. 342. She reported no numbness or tingling in her hands. Tr. 342. Jirousek received an injection in her left shoulder, both subacromially and bicipitally, and a cortisone injection in the right bicipital groove. Tr. 342. Jirousek was provided a prescription for Mobic, since it had provided some relief in the past. Tr. 342. It was recommended that Jirousek be seen on an as needed basis if she had further concerns or questions regarding her shoulder or neck. Tr. 342.

         On October 24, 2012, Jirousek was seen again at Dr. Zanotti's office. Tr. 329-330. Jirousek reported increasing pain in her left shoulder along the outside of her arm. Tr. 329. The physical examination showed full overhead motion with ability to get her hand behind her head and behind her back. Tr. 329. There was pain with internal rotation and pain on stressing in abduction as well as cross body stressing. Tr. 329. Jirousek exhibited 5/5 abduction and supraspinatus strength. Tr. 329. Upon Jirousek's request, an injection of Celestone and Lidocaine was administered into the left subacromial space. Tr. 330. Jirousek would follow up with Dr. Zanotti on an as needed basis. Tr. 330. She planned to schedule an appointment with Dr. Kumar regarding her neck pain. Tr. 330.

         Medical evidence post-dating amended alleged onset date

         Jirousek saw Dr. Kumar on November 13, 2012. Tr. 361. She reported that the left side of her neck had flared up quite a bit from last seeing Dr. Kumar six months prior. Tr. 361. Jirousek indicated she sometimes had pain down the arm and numbness in her hands and arms when using them. Tr. 361. She was also having right-sided low back pain. Tr. 361. On examination, Dr. Kumar's observations included tenderness in the left mid-lower cervical paraspinal muscles with positive facet joint provocative maneuvers; strength was functional in the upper extremities; some pain with shoulder strength testing on the left; tenderness in the right lower lumbar paraspinal muscles with positive facet joint provocative maneuvers; some tenderness in the lumbrosacral junction; strength was functional for ambulation; and gait, coordination and balance were normal. Tr. 361. Dr. Kumar diagnosed left-sided back pain with cervical spondylosis, degenerative disk disease; numbness and tingling in the hands and arms; right-sided low back pain with facet arthropathy; chronic pain; and left shoulder pain with rotator cuff syndrome. Tr. 361. Dr. Kumar ordered physical therapy for the low back; x-rays of the lumbar and cervical spine; and facet joint injections in the cervical and lumbar regions. Tr. 361. Dr. Kumar also ordered EMG testing of the upper extremities. Tr. 361.

         On November 28, 2012, Jirousek underwent EMG testing of the upper extremities to evaluate for carpal tunnel syndrome. Tr. 449. The testing showed “electrodiagnostic evidence of mild bilateral median mononeuropathies at the wrist or carpal tunnel syndrome characterized primarily by sensory fiber demyelination, left worse than right.” Tr. 449. Jirousek was wearing wrist splints. Tr. 449.

         On December 6, 2012, Jirousek received facet joint lumbar injections. Tr. 451-453. On December 12, 2012, Jirousek reported to Dr. Kumar's office that the injections had taken the edge off and she was doing about 70-80% better at the time. Tr. 364. There is a handwritten note on the December 12, 2012, office note that states, “When pain comes back we will do RF [radiofrequency].” Tr. 364.

         In February 2013, Jirousek saw Dr. Potoczak with complaints of back pain. Tr. 430-434. Jirousek reported a gradual worsening of her back pain, which she described as burning with a severity level of 7/10. Tr. 431. On examination, Dr. Potoczak observed decreased range of motion, tenderness and spasm in the cervical back. Tr. 433. There was normal range of motion in the neck but pain and spasm in the neck and trapezius muscle. Tr. 433. Dr. Potoczak prescribed some medication but no other orders were placed. Tr. 434.

         Medical evidence post-dating date last insured

         On April 24, 2013, Jirousek called Dr. Kumar's office to report that she was having pain again and her injections for right side lumbar had worn off. Tr. 454. Per Dr. Kumar's prior instructions, she was calling about right side lumbar radiofrequency. Tr. 454. On May 2, 2013, radiofrequency ablation was performed at the right L3, L4, and L5 area. Tr. 455-457. Also, on May 2, 2013, knee x-rays were taken, which were normal. Tr. 443-444. Also, in May 2013, Dr. Kumar administered a right shoulder subacromial injection due to right shoulder pain. Tr. 458. Dr. Kumar held off on administering an injection in the left knee. Tr. 458.

         Jirousek returned to see Dr. Potoczak on June 25, 2013, with reports of new pains - - bilateral shoulder pain, bilateral knee pain, and bilateral hip pain for about two months. Tr. 434-438. She was receiving moderate relief through the use of Flexeril, Mobic, Vicodin, Tylenol and Motrin. Tr. 434. On examination, Dr. Potoczak observed normal range of motion in the neck but decreased range of motion and tenderness in the right shoulder; decreased range of motion, pain and spasm in the lumbar back; and tenderness in the left forearm. Tr. 437. Dr. Potoczak recommended that Jirousek try physical therapy and Lyrica. Tr. 437. Also, Dr. Potoczak indicated that Jirousek needed to have an MRI performed and a rheumatologist consult. Tr. 437.

         Upon Dr. Potoczak's referral, on July 2, 2013, Jirousek saw Vagesh M. Hampole, M.D., for possible fibromyalgia. Tr. 572-574. Dr. Hampole's examination findings included no swelling of any of the joints of upper and lower extremities; tender areas present over back, across shoulders and upper and lower extremities; no weakness; pain with range of motion in neck rotation, bilateral shoulder abduction, bilateral elbow flexion and extension, bilateral hip internal rotation and external rotation; motor and sensory function, reflexes, gait and coordination all intact. Tr. 573. Dr. Hampole assessed fibromyalgia and prescribed Flexeril and directed Jirousek to continue taking Lyrica as she had been. Tr. 574. Dr. Hampole ordered lab work, including an arthritis panel. Tr. 574. Jirousek's lab work showed a positive anti-nuclear antibodies (ANA) test at 1:80 titers.[5] Tr. 577. Dr. Hampole reviewed the lab work with Jirousek on July 23, 2013, and continued the diagnosis of fibromyalgia but added cervical radiculitis. Tr. 579. Dr. Hampole started Jirousek on Trazadone and stopped the Flexeril. Tr. 579. Lyrica, Mobic, and Vicodin were continued. Tr. 579. Jirousek was going to follow up with Dr. Kumar regarding the cervical radiculitis. Tr. 579. Jirousek continued to see Dr. Hampole from September 2013 through April 2014. Tr. 582-587. Dr. Hampole's examination results were generally the same throughout with some changes to medications made during Dr. Hampole's treatment of Jirousek. Tr. 585.

         On July 24, 2013, Jirousek saw Dr. Kumar with complaints of shoulder and neck pain. Tr. 461. She was having numbness down her right arm. Tr. 461. Jirousek indicated that the numbness was driving her crazy at times and affecting her quality of life. Tr. 461. She was frustrated with the pain. Tr. 461. On examination, Spurling's maneuver was mildly positive and there was positive impingement signs in the right shoulder. Tr. 461. Strength was 5/5 in the upper extremities. Tr. 461. Extension and rotation were limited in the neck and forward flexion past 100 degrees caused some shoulder pain. Tr. 461. Gait, coordination and balance were normal. Tr. 461. Dr. Kumar assessed right sided cervical spondylosis with radiculitis, most likely at ¶ 6; rotator cuff dysfunction right shoulder; chronic pain; and history of lumbar pathology. Tr. 461. Dr. Kumar recommended an MRI of the right shoulder and a cervical epidural. Tr. 461. An August 3, 2013, MRI of the right shoulder showed no significant change since the July 2, 2012, MRI. Tr. 439-440. Jirousek received a cervical epidural injection at the C7-T1 level on July 25, 2013. Tr. 463-465. During an August 8, 2013, appointment for medial branch blocks at the C4, C5, and C6 levels for right-sided neck pain radiating down the shoulder, Jirousek reported no improvement from the cervical epidural injections she had received two week earlier. Tr. 466-468. She also reported that when she saw a surgeon there was no indication for surgical intervention. Tr. 466. On August 15, 2013, Jirousek reported about 30% relief of her right shoulder and arm pain from the C4, C5, and C6 medial branch blocks but she was continuing to have pain from the neck down to her index finger along the C6 dermatome. Tr. 469. Thus, a C6 right nerve block was administered. Tr. 469-471.

         On September 6, 2013, Jirousek saw Dr. Kumar reporting continued pain and only minimal relief from the C6 nerve block. Tr. 472. The medial branch blocks and epidural were not helpful. Tr. 472. Jirousek relayed to Dr. Kumar that she was seeing Dr. Hampole who was prescribing Lyrica for possible fibromyalgia. Tr. 472. Dr. Kumar recommended an EMG of the upper extremities, noting that a cervical spine MRI might be required depending on the results of the EMG. Tr. 472. He also recommended a “small work LSO brace to help reduce pain in the lumbar spine and restrict[] mobility of the trunk and to help support the spinal muscles.” Tr. 472.

         EMG testing was performed on September 13, 2013. Tr. 474. The results of the testing showed “electrodiagnostic evidence of mild to moderate bilateral median mononeuropathies at the wrist or carpal tunnel syndrome characterized primarily by demyelination with some chronic changes. There is also a hint of axonal irritation on the right at ¶ 6 but no active denervation.” Tr. 474. Dr. Kumar recommended a right-sided carpal tunnel injection. Tr. 474. If that did not work, Dr. Kumar indicated that an MRI of the cervical spine may be needed. Tr. 474. On September 18, 2013, Jirousek received a right carpal tunnel injection. Tr. 476-477.

         During an October 18, 2013, follow-up visit with Dr. Kumar, Jirousek reported that the carpal tunnel injection did not help much. Tr. 478. She was still having pain in the neck going down the right arm. Tr. 478. Also, Jirousek indicated she was favoring her right leg but her low back was hurting more on the right side. Tr. 478. Physical examination findings, included a positive Spurling maneuver on the right; numbness in the C6 distribution on the Right; tenderness in the right lower lumbar paraspinal muscles with positive facet joint provocative maneuvers; gait was antalgic favoring the right lower extremity; balance was fair; coordination was normal; and there was a decreased range of motion with right sided rotation and side bending of the cervical spine. Tr. 478. Dr. Kumar recommended radiofrequency ablation on the right at ¶ 3-4-5 and a cervical spine MRI. Tr. 478.

         Radiofrequency ablation was performed on November 4, 2013, on the right at ¶ 3, L4, and L5. Tr. 480-482. A November 8, 2013, cervical spine MRI showed “Mild cervical spondylosis, with canal narrowing with mild canal narrowing at ¶ 5-6 and C6-7. Right foraminal narrowing at ¶ 3-4. No significant change from MRI scans dated September 19, 2012.” Tr. 441.

         In early January 2014, Jirousek called seeking an appointment with Dr. Kumar, indicating she was having severe pain in her right shoulder and she was interested in an injection. Tr. 485. She saw Dr. Kumar on January 14, 2014. Tr. 486. Dr. Kumar noted that Jirousek was at the visit for right sided neck pain and posterior shoulder pain and she wanted a shoulder injection. Tr. 486. However, on examination, Jirousek did not have any pain with the shoulder with internal or external rotation or abduction and flexion so no shoulder injection was administered. Tr. 486. She did have significant spasms in the right parascapular region and trapezius region; her neck range of motion was impaired significantly and there was tenderness in the right mid lower cervical paraspinal muscles. Tr. 486. Turning and twisting bothered her. Tr. 486. She was taking two Norco at a time at 5 mg strength, which helped a little, and she was taking Flexeril and Motrin. Tr. 486. Dr. Kumar increased the Norco strength to 10 mg, twice a day, as needed, and recommended C4-5, C5-6, and C6-7 cervical facet joint injections to calm down her pain. Tr. 486. The facet joint injections were performed on January 15, 2014. Tr. 488-490.

         Jirousek saw Caryn DeLisio, CNP, with Dr. Kumar's office on May 21, 2014, for follow up. Tr. 491. Nurse DeLisio noted that Jirousek had done very well with radiofrequency ablation in the past, as well as with cervical facet joint injections. Tr. 491. Accordingly, radiofrequency ablation on the right at levels L3-4 and 5 was set up and, after that, cervical facet joint injections would be performed on the right at ¶ 4-5, C5-6 and C6-7. Tr. 491, 493-495, 496-498. Also, a TENS unit was ordered. Tr. 491. Jirousek reported point tenderness on the right elbow so an x-ray of the right elbow was ordered to rule out other issues. Tr. 491.

         Upon Dr. Kumar's referral, on June 25, 2014, Jirousek saw Robert Perhala, M.D., for a consultation for possible lupus. Tr. 515-519. Jirousek reported neck stiffness and pain for about 6-7 years and low back and hip pain for about 4-5 years. Tr. 515. She reported 2-3 hours of morning stiffness, mostly in the spinal area. Tr. 515. Jirousek reported that she walked regularly for exercise. Tr. 516. On examination, Dr. Perhala observed that Jirousek walked with a slightly antalgic gait; there was moderate tenderness of the cervical paraspinal area bilaterally, right lumbar paraspinal area down into the right SI joint area; tenderness in the shoulders bilaterally; synovial thickening and tenderness of the right elbow; tenderness in right finger joints; tenderness in the knees; and full range of motion in shoulders, elbows, wrists, hips, knees, ankles. Tr. 517. Dr. Perhala found no tenderpoints of fibromyalgia present but noted 8 tender joints and 1 swollen joint. Tr. 517. Jirousek's upper and lower extremity strength was 5/5 bilaterally and her reflexes in her upper and lower extremities were normal bilaterally. Tr. 518. Dr. Perhala reviewed radiology reports, noting that Jirousek's left knee x-ray was normal; an x-ray of her knees bilaterally was normal; a cervical spine MRI showed “DDD with mild stenosis, ” and a right shoulder MRI showed “AC arthrosis and RC tendonosis.” Tr. 518. Dr. Perhala assessed unspecified polyarthropathy inflammatory; unspecified backache; cervicalgia; and “shoulder region affections other not elsewhere class.” Tr. 518. Dr. Perhala indicated that he felt strongly that Jirousek's arthritis was “inflammatory in basis, that she should be on DMARD therapy” and he was “going to initiate sulfasalazine . . . a high risk medication requiring lab monitoring consistently.” Tr. 519. Lab work showed an ANA titer of 1:160. Tr. 522.

         In July 2014, Jirousek saw Dr. Kumar. Tr. 499. She had some relief from the radiofrequency ablation and facet joint injections. Tr. 499. She was continuing to use Norco 10 mg at night. Tr. 499. Jirousek was seeing Dr. Perhala for more rheumatologic workup. Tr. 499. She was having pain in her knees, back and neck with spasms. Tr. 499. Activity bothered Jirousek. Tr. 499. She had no new numbness or weakness. Tr. 499. Dr. Kumar continued Jirousek on Norco 10 mg and directed Jirousek to call if she needed a right SI joint injection. Tr. 499. On August 11, 2014, Jirousek called Dr. Kumar requesting the SI injection and, on August 18, 2014, Dr. Kumar administered the injection. Tr. 502-504.

         Jirousek saw Dr. Perhala on August 18, 2014, for follow up of her inflammatory arthritis. Tr. 523-526. Jirousek reported being more fatigued but her inflammatory arthritis was under “fair control.” Tr. 523. She reported a “degree of stiffness and pain in the hands, wrists, shoulders, knees and feet more on the right side. Most other joints [were] stable.” Tr. 523. Norco, prescribed through her other doctors, was providing her relief for breakthrough pain. Tr. 523. On examination, Dr. Perhala observed 13 tender joints and 1 swollen joint but no tenderpoints of fibromyalgia and full range of motion. Tr. 525. Because of the possibility that Jirousek's medication was causing her fatigue, Dr. Perhala changed Jirousek from Sulfasalazine to Plaquenil. Tr. 526, 529.

         Jirousek saw Dr. Perhala on October 20, 2014, for follow up. Tr. 529-532. Jirousek's inflammatory arthritis had been under “fair control” since the last visit. Tr. 529. Plaquenil therapy was providing minimal control of Jirousek's arthritis. Tr. 529. As he had in the prior visit, Dr. Perhala observed 13 tender joints and 1 swollen joint. Tr. 531. There was full range of motion. Tr. 530-531. Dr. Perhala stopped Plaquenil since the effects were minimal and started Jirousek on Methotrexate. Tr. 532.

         On October 23, 2014, Jirousek saw Dr. Kumar for follow up. Tr. 506. She indicated that she had been diagnosed with rheumatoid arthritis and was taking Methotroxate. Tr. 506. She reported being in miserable pain and understood she could not have another radiofrequency procedure until December. Tr. 506. Norco helped some but she sometimes needed to take two in a day. Tr. 506. Dr. Kumar's physical examination revealed that Jirousek ambulated in a flexed spine position favoring the left leg; she was very tender in the right mid-low back with positive facet joint provocative maneuvers; straight leg raising was negative for radicular pain; there was quite a bit of muscle hypertonicity appreciated; balance was fair; coordination was normal; neck pain was worse on extremes; there was mild tightness in hamstrings; there was generalized stiffness. Tr. 506. Dr. Kumar's diagnoses were right sided mid-low back pain with facet arthropathy; SI joint dysfunction; cervical spondylosis; degenerative disk disease; rheumatoid arthritis; and chronic pain. Tr. 506. Until the radiofrequency ablation procedure could be performed, Dr. Kumar recommended right L3-4, L4-5, L5-S1 facet joint injections. Tr. 506. Also, Dr. Kumar planned to get lumbar flexion/extension x-rays. Tr. 506. Dr. Kumar also increased Jirousek's Norco. Tr. 506. X-rays of the lumbar spine were taken on October 23, 2014, which showed “[m]ild mid and distal lumbar posterior element arthritis, no change with flexion and extension.” Tr. 445. Facet joint injections were performed on October 27, 2014. Tr. 508-509.

         On November 21, 2014, Jirousek saw Dr. Kumar and reported that the facet joint injections had helped her a lot and were continuing to help her but they were wearing off. Tr. 510. She indicated that the Methotrexate and Motrin helped. Tr. 510. She did not need to take as much Norco because of the facet joint injections. Tr. 510. Activity bothered her and her pain was affecting her quality of life. Tr. 510. Dr. Kumar recommended radiofrequency ablation after December 2, 2014. Tr. 510. There was some tenderness in the right mid low back with positive facet joint provocative maneuvers but her straight leg raising was negative and she could heal walk ...


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