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Gipson v. Commissioner of Social Security

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

August 30, 2017

JUNE GIPSON Plaintiff,


          James R. Knepp, II United States Magistrate Judge.


         Plaintiff June Gipson (“Plaintiff”) filed a complaint against the Commissioner of Social Security (“Commissioner”) seeking judicial review of the Commissioner's decision to deny disability insurance benefits (“DIB”). (Doc. 1). The district court has jurisdiction under 42 U.S.C. § 405(g). The parties consent to the exercise of jurisdiction by the undersigned in accordance with 28 U.S.C. § 636(c) and Civil Rule 73. (Doc. 13). For the reasons stated below, the Court affirms the Commissioner's decision denying benefits.

         Procedural Background

         Plaintiff filed for DIB on August 6, 2013, alleging a disability onset date of July 16, 2007. (Tr. 173). Plaintiff's date last insured for DIB was December 31, 2011. (Tr. 192). Plaintiff's DIB claim was denied initially (Tr. 113) and upon reconsideration (Tr. 125). On January 2, 2014, Plaintiff filed a Request for Hearing. (Tr. 130-31). Thereafter, on May 12, 2015, Plaintiff (represented by counsel) appeared before an Administrative Law Judge (“ALJ”). (Tr. 36-87). The ALJ denied Plaintiff's application for DIB, finding that from the alleged onset date to the date last insured, Plaintiff was capable of performing a reduced range of light work. (Tr. 23). The Appeals Council denied Plaintiff's request for a review of the ALJ's decision, making it the final decision of the Commissioner. (Tr. 1). On May 10, 2016, Plaintiff filed the instant action for judicial review pursuant to 42 U.S.C. § 405(g). (Doc. 1).

         Factual Background

         Plaintiff was born on August 6, 1957, and was fifty-seven years old at the time of the administrative hearing. (Tr. 88). Plaintiff was married, had two adult children, a high school degree, and a driver's license. (Tr. 41, 43, 56). For eighteen years, Plaintiff worked for Coltene-Whaledent, employed as a machine and hand packager, general inspector, compounder, and store laborer. (Tr. 45-49, 72-73).

         Medical Evidence

         Treatment Records Prior to Date Last Insured

         Physical Impairments

         Dr. Atul Goswami had been Plaintiff's treating physician since 2001. (Tr. 277). Dr. Goswami noted that, in May 2006, Plaintiff reported pain in both upper extremities, as well as numbness and tingling in both upper extremities, her hands, and fingers. Id. In December 2006, Dr. Goswami ordered an MRI of Plaintiff's cervical spine that revealed mild relative congenital central canal stenosis throughout the cervical spine due to congenitally short pedicles. (Tr. 285). In addition, the MRI revealed mild multilevel cervical degenerative disc disease with multilevel central canal stenosis that was moderate at the C5-C6 and C6-C7 levels. Id. There was focal endplate osteophyte formation versus a small broad based left paracentral disc protrusion at the C6-C7 level. Id. Furthermore, Dr. Goswami noted a probable small disc protrusion at ¶ 7-T1, causing only mild central canal stenosis but no cord deformity, and a possible, but very mild neural foraminal narrowing at the C6-C7 level. Id. Thereafter, Plaintiff saw Dr. Georges Markarian, a neurosurgeon, who diagnosed Plaintiff with herniated discs at ¶ 5-C6 and C6-C7. (Tr. 286). As a result, Dr. Markarian performed partial C5, C6, and C7 corpectomies, arthrodesis at ¶ 5-C6 and C6-C7, inserted biomedically threaded bone dowels at ¶ 5-C6 and C6-C7, and plating from C5 through C7. Id.

         Plaintiff began physical therapy on April 26, 2007. (Tr. 324). The treatment goals were to: 1) return Plaintiff to a 10/10 activity level and to be able to hold her grandchild; 2) return her range of motion to normal; and 3) be able to walk for exercise. Id. Plaintiff completed physical therapy on July 3, 2007, attaining her treatment goals. (Tr. 331).

         In June 2007, Dr. Goswami completed a form regarding Plaintiff's symptoms and treatment after her neck surgery. (Tr. 277-78). He noted that Plaintiff had a “good response” to surgery, but she still had some pain. (Tr. 278). Dr. Goswami said Plaintiff could sit okay, and stand and walk better. Id. However, he said she was unable to bend, stoop, lift, or grasp. Id.

         On July 12, 2007, Plaintiff returned to Dr. Markarian for post-surgical evaluation. (Tr. 281). She said she was doing very well, and Dr. Markarian noted no obvious neurological deficits. Id. Thereafter, on July 20, 2007, Dr. Markarian reexamined Plaintiff who again stated she was doing well and had no specific complaints. (Tr. 280). Dr. Markarian noted Plaintiff's back looked good and the bone graft was starting to fuse. Id. He also remarked that there was a gap that would have to be closely followed. Id. However, Dr. Markarian did not identify any complications. (Tr. 282).

         Plaintiff went to the emergency room on February 17, 2011, for a urinary tract infection. (Tr. 301). She did not have any pain on palpitation in the cervical, thoracic, or lumbar spine. (Tr. 303). The hospital discharged Plaintiff approximately 12 hours later. Id.

         Mental Impairments

         Plaintiff received mental health care at the Center for Akron Psychiatry in 2006 and 2007 with Dr. Todd Ivan. (Tr. 259-74). Dr. Ivan diagnosed Plaintiff with major depression and panic disorder and prescribed Pamelor and Xanax. (Tr. 273-74). However, by June 2007, Dr. Ivan said Plaintiff's condition had improved, indicating: no depression; only mild anxiety; cooperative demeanor; good eye contact; normal activity; logical and goal-directed thought processes and content; good judgment and insight; intact memory; good attention and concentration; and full and appropriate affect. (Tr. 259).

         On the evening of October 14, 2009, Plaintiff went to the emergency room with reports of hallucinations starting the day before. (Tr. 314). Plaintiff's husband had left her five days prior to the start of her hallucinations. Id. The examining physician observed Plaintiff was alert, oriented, pleasant, conversational, with normal speech, range of motion, and affect. (Tr. 315). The diagnostic impression was acute psychosis versus acute stress reaction versus depression. Id. The hospital discharged Plaintiff four hours later on October 15, 2009. Id.

         Medical Records After Date Last Insured

         Physical Impairments

         Plaintiff visited Dr. Goswami on March 14, 2013, complaining of a painful cough with greenish mucus. (Tr. 373). She did not complain of any back or neck pain. Id.

         Plaintiff went to the emergency room on April 12, 2013, complaining of back and left shoulder pain starting a couple of days prior. (Tr. 293). Plaintiff reported some numbness and difficulty moving her left arm. Id. Plaintiff received pain medication and instructions to follow up with her primary care physician and neurosurgeon. (Tr. 294).

         On April 22, 2013, Dr. Goswami diagnosed Plaintiff with cervical and lumbar radiculopathy; however, he noted her musculoskeletal, neurologic, and psychiatric examinations were normal. (Tr. 369-72). On April 25, 2013, Dr. Goswami ordered an MRI of Plaintiff's cervical spine that revealed postsurgical changes of the C5-C6 and C6-C7 levels as well as C4-C5 mild canal stenosis with mild diffuse disk bulging. (Tr. 289). Dr. Goswami also ordered an MRI of her lumbar spine that showed only minimal disk bulging at the L1-L2 level without central canal stenosis. (Tr. 290).

         On referral from Dr. Goswami, Plaintiff saw Shelly Krampf, a physical therapist, on May 15, 2013, to reduce her neck and lower back pain. (Tr. 375). Plaintiff reported her neck pain had increased five weeks prior, and her lower back pain had increased over the past year. Id. Plaintiff had a reduced range of motion in her trunk and cervical spine. Id. Ms. Krampf noted Plaintiff was able to walk with no acute distress; however, she had a lateral shift to the right. Id. Ms. Krampf observed Plaintiff's “upper extremity range of motion [was] within normal limits.” Id. She also observed Plaintiff's “foot and ankle motions are within normal limits.” Id. Plaintiff's “side bending and rotation right and left [were] within functional limits” and her “lower extremity range of motion [was] within functional limits.” Id.

         Dr. Goswami supplied a medical source opinion on September 21, 2013. (Tr. 384). He opined Plaintiff could occasionally carry five pounds and frequently carry two pounds; could stand and walk for 30 minutes at a time, for a total of two hours; and could sit for ten hours without interruption and for three hours total during an eight-hour workday.[1] (Tr. 383). He also opined that Plaintiff could rarely climb, balance, stoop, crouch, kneel, crawl, reach, push, pull, or use fine or gross manipulation. Id. Dr. Goswami opined that Plaintiff's pain would interfere with her concentration, cause her to be off task, and cause absenteeism. (Tr. 384). Lastly, he opined that Plaintiff would need six unscheduled breaks during the workday. Id.

         On October 1, 2013, Dr. Goswami indicated Plaintiff continued to have pain in the lumbar and cervical regions, but the pain did not cause any motor loss. (Tr. 368). Dr. Goswami observed Plaintiff's range of motion was limited in the lumbar region. Id. In contrast to his September 21, 2013 opinion, he opined that Plaintiff could perform fine and gross manipulation. Id. He also noted Plaintiff's gait was slow, but an ambulatory aid was not medically necessary. Id.

         In a February 2014 emergency room visit, Plaintiff reported increased neck pain after lifting a heavy bag of dog food. (Tr. 398, 423). She returned to physical therapy on March 26, 2014, reporting increased neck pain over the last month or two. (Tr. 397). At that visit, Plaintiff also stated her lower back pain had been occurring for the last “2 years this time.” (Tr. 414). On July 30, 2014, Plaintiff's physical therapist discharged her from physical therapy with no improvement in her neck or back pain. (Tr. 493).

         On August 8, 2014, Plaintiff saw an orthopedist who observed a limited range of motion in her neck and recommended Plaintiff continue physical therapy and see Dr. Markarian. (Tr. 423-24). On November 26, 2014, Plaintiff received a lumbar epidural injection, which lowered her pain. (Tr. 465). X-Rays of Plaintiff's spine, taken on December 29, 2014, showed no fractures or subluxations, well-preserved disc spaces, minimal anterior osteophyte formation at ¶ 3 and L4, and only minimal degenerative changes at the L4-5 and L5-S1 facet joints. (Tr. 464).

         On April 16, 2015, Dr. Goswami opined Plaintiff could lift five pounds frequently, was limited to standing for ten minutes at a time and for a total of one hour during the workday, and limited to sitting for 30 minutes[2] at a time and two hours total during the workday. (Tr. 543). Furthermore, he opined that Plaintiff could rarely climb, balance, stoop, crouch, kneel, crawl, reach, or push. (Tr. 543-44). However, he was of the opinion that Plaintiff could occasionally perform fine manipulation. (Tr. 544). He characterized Plaintiff's pain as moderate, and submitted her pain would interfere with her concentration, take her off task, and cause absenteeism. Id. Dr. Goswami opined that Plaintiff's limitations were caused by cervical and lumbar spinal stenosis. (Tr. 543-44).

         Mental Impairments

         On May 21, 2013, Dr. Ivan reported Plaintiff had a cooperative demeanor, normal activity, and good eye contact. (Tr. 361). She had a normal speech rate, was coherent, and spontaneous. Id. She exhibited good judgment, insight, concentration, full and appropriate affect, intact memory, and no anxiety or hallucinations. Id. However, Dr. Ivan noted Plaintiff still ...

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