United States District Court, N.D. Ohio, Eastern Division
MARIA L. GONZALEZ, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, Defendant.
SOLOMON OLIVER, JR. JUDGE.
REPORT & RECOMMENDATION
M. PARKER MAGISTRATE JUDGE.
Maria Gonzalez, seeks judicial review of the final decision
of the Commissioner of Social Security, denying her
application for disability insurance benefits
(“DIB”) under Title II of the Social Security
Act. This matter is before me pursuant to 42 U.S.C.
§ 405(g) and Local Rule 72.2(b). Because
the ALJ applied proper legal standards and reached a decision
supported by substantial evidence, I recommend that the
Commissioner's final decision denying Gonzalez's
application for DIB be affirmed.
13, 2015, Gonzalez applied for DIB. (Tr.
423-29). Gonzalez alleged that she became disabled
on June 26, 2015, due to fibromyalgia, anxiety, and migraine
headaches. (Tr. 328, 423). The Social Security Administration
denied Gonzalez's application initially and upon
reconsideration (Tr. 327-60). Gonzalez requested an
administrative hearing. (Tr. 375-76). Administrative Law
Judge (“ALJ”) Joseph Hajjar heard Gonzalez's
case on February 15, 2017, and denied the claim in a May 30,
2017, decision. (Tr. 254-71, 284-326). On February 16, 2018,
the Appeals Council denied further review, rendering the
ALJ's decision the final decision of the Commissioner.
(Tr. 1-7). On April 18, 2018, Gonzalez filed a complaint to
seek judicial review of the Commissioner's decision.
ECF Doc. 1.
Personal, Educational and Vocational Evidence
was born on August 20, 1967, and she was 47 years old on the
alleged onset date. (Tr. 423). She was a high school
graduate, and she had a technical school certificate in
“medical office.” (Tr. 290). She had past
relevant work experience as a front desk receptionist,
billing specialist, and office manager. (Tr. 269, 290-93).
Relevant Medical Evidence
August 10, 2010, and March 28, 2017, Gonzalez regularly saw
Laxman Cingireddi, MD, for general treatment of all her
conditions. (Tr. 635-38, 685-709, 714-17, 728-31, 745-94,
800-78, 1111-14, 1243-47, 1367-1404, 1676-1748, 1854-89).
With regard to Gonzalez's physical condition, Dr.
Cingireddi regularly noted that Gonzalez had a normal gait,
full strength in her upper and lower extremities, normal
muscular development, and a normal range of motion. (Tr.
745-74, 787, 794, 864-77, 1114, 1246, 1372, 1403, 1699, 1747,
1876, 1859). On November 11, 2013, Gonzalez complained that
she had numbness, tingling, and joint pain in her legs;
however, her neurological exams were normal and Dr.
Cingireddi advised her to diet and exercise. (Tr. 695, 699).
On April 2, 2014, Gonzalez complained that she had body aches
and pains, but she denied any weakness, numbness, or
tingling. (Tr. 685, 690). Dr. Cingireddi found that her
shoulders, hips, and knees were tender. (Tr. 690). On April
15 and April 18, 2014, Gonzalez told Dr. Cingireddi that her
medications controlled her fibromyalgia, but she had numbness
and tingling in her hands. (Tr. 845, 860). Gonzalez's
hands were normal on neurological examination. (Tr. 850). At
eleven appointments from July 28, 2014, through February 1,
2016, Gonzalez denied having any weakness, numbness, or pain
in her muscles, back, and joints. (Tr. 635, 791, 801, 810,
820, 828, 837, 1111, 1243, 1400). Nonetheless, Gonzalez
complained that she could not work due to her fibromyalgia
and other conditions on June 18, 2015, and she had pain and
swelling in her ankle on August 17, 2015. (Tr. 784, 791). On
September 23, 2015, December 3, 2015, February 1, 2016, May
17, 2016, October 31, 2016, January 10, 2017, February 24,
2017, and March 24, 2017, Dr. Cingireddi found that Gonzalez
had an adequately aligned spine, intact range of motion in
her spine and extremities, normal muscular development, and a
normal gait. (Tr. 787, 794, 1114, 1246, 1372, 1403, 1699,
1747, 1859, 1876). Gonzalez complained that she had some
tenderness in her knee on May 3, 2016; neck pain and
scoliosis on November 29, 2016; muscle, back, and joint pain
on December 27, 2016; and pain, tenderness, and decreased
range of motion in her left shoulder on January 24, 2017.
(Tr. 1383, 1681, 1716, 1725). Nevertheless, Gonzalez said
that she did not want to go to physical therapy or see a
surgeon for her shoulder pain. (Tr. 1682). On November 29,
2016, and March 24, 2017, Gonzalez told Dr. Cingireddi that
she exercised to help control her weight; however, she
decreased her exercise “a little” due to pain.
(Tr. 1709, 1854).
regard to mental symptoms, Dr. Cingireddi regularly noted
that Gonzalez was pleasant, and had normal mood, memory,
affect, and judgment. (Tr. 637, 708, 716, 730, 751, 757, 765,
769-73, 787, 794, 803, 813, 822, 831, 839, 849, 860, 864-73,
1114, 1246, 1403, 1682, 1731, 1747, 1876, 1859). In July
2011, Gonzalez told Dr. Cingireddi that she had depression
and anxiety, but she refused antidepressants and psychiatric
consultation. (Tr. 767). On October 12, 2011, Gonzalez said
that her medication helped her anxiety, but she continued to
refuse counseling or psychiatric consultation. (Tr. 761,
763). On April 4, 2014, and April 15, 2014, Gonzalez denied
having any anxiety. (Tr. 783, 861). On June 18, 2015,
Gonzalez said that her anxiety and other conditions prevented
her from working, but she again refused counseling and
psychology referrals. (Tr. 791, 794). On May 17, 2016,
Gonzalez told Dr. Cingireddi that she saw a psychiatrist, and
that her medication helped with her depression and anxiety.
(Tr. 1368). On January 24, 2017, and March 24, 2017, Gonzalez
denied having any anxiety. (Tr. 1683, 1860).
August 24, 2010, Gonzalez saw Preetha Muthusamy, MD, for her
dizziness and headaches. (Tr. 971). On examination, Dr.
Muthusamy noted that Gonzalez had normal tone and full
strength in all her extremities and neck, and she had a
normal gait. (Tr. 972). On April 22, 2014, Gonzalez told Dr.
Muthusamy that she had progressively worse body pain and
numbness/tingling in her extremities. (Tr. 956). She rated
her pain as a 9/10. (Tr. 956Dr. Muthusamy diagnosed Gonzalez
with fibromyalgia, and prescribed medication and physical
therapy. (Tr. 959-60). On June 9, 2014, Dr. Muthusamy
conducted a nerve conduction study, which did not reveal any
evidence of generalized sensorimotor peripheral neuropathy.
(Tr. 913- 16). At a follow-up on August 13, 2014, Dr.
Muthusamy noted that Gonzalez stopped taking her neuropathic
medication, had swelling in her legs, and had pain in her
back, wrist, and ankle. (Tr. 632). Upon physical examination
on April 22, 2014, August 13, 2014, September 1, 2015,
September 1, 2016, Dr. Muthusamy noted that Gonzalez had
normal range of motion, no muscle or joint tenderness, and a
normal gait. (Tr. 634, 945, 958, 1362-63). Dr. Muthusamy
advised Gonzalez to exercise and stay physically active. (Tr.
634, 945). On January 5, 2017, Dr. Muthusamy noted that
Gonzalez had normal range of motion and no muscle or joint
tenderness; however, her gait was wide based and ataxic. (Tr.
1654). On March 1, 2017, Gonzalez told Dr. Muthusamy that she
had constant pain in her feet, legs, hands, left shoulder,
back, buttocks, and hips. (Tr. 1814). On examination, Dr.
Muthusamy noted that Gonzalez had normal range of motion,
tenderness in her neck and arms, full strength in her upper
and lower extremities, and normal muscle tone. (Tr. 1818).
March 19, 2012, Gonzalez told Patel Bhupendra, MD, that she
had pain in her right index finger. (Tr. 882). Dr. Bhupendra
found mild narrowing in her finger joints, but did not find
any evidence of soft tissue swelling, erosive changes, or
arthritis. (Tr. 882).
13, 2014, Gonzalez saw Apostolos Kontzias, MD, for treatment
of pain and fatigue. (Tr. 638-39). Gonzalez told Dr. Kontzias
that she had muscle aches, and worsening pain in her left
wrist and left ankle. (Tr. 639). On examination, Dr. Kontzias
found that Gonzalez had full muscle strength, normal muscle
tone, and good range of motion in her shoulders, wrists,
knees, ankles, and hips. (Tr. 640-41). Dr. Kontzias
prescribed aerobic exercise, sleep, and medication. (Tr.
June 17, 2014, through November 12, 2014, Gonzalez went to 13
physical therapy sessions for treatment related to her
fibromyalgia diagnosis. (Tr. 561-70). During her physical
therapy sessions, Gonzalez reported pain ranging from 4/10 to
10/10, with her most common pain ratings in the 5-6/10 range.
(Tr. 561-70). On July 2, 2014, July 14, 2014, and August
2014, Gonzalez reported that her physical therapy helped her
feel better and she felt less sore after therapy sessions.
(Tr. 565-66). On July 21, 2014, she reported that she was
able to go dancing. (Tr. 564). At discharge from physical
therapy, Charlene Jackson, PT, noted that Gonzalez had 5/10
pain in her ankles/knees, and that her wrists bothered her.
(Tr. 561). Gonzalez also had 4/5 left hip flexion, 5/5 right
hip flexion, 3 left hip abduction, 4 right hip
abduction, 3 left extension, and 5/5 right extension. (Tr.
29, 2015, Gonzalez told Kaitlyn Ferguson, PA-C, that she quit
her job due to “overwhelming” pain in her
buttocks, legs, feet, and hands. (Tr. 590). Gonzalez said
that her pain was worse in the morning. (Tr. 590). On
examination, Ferguson noted that Gonzalez did not have any
weakness or balance issues, but her hands and feet were
intermittently numb. (Tr. 591-93). Gonzalez's gait was
normal, and she had full strength in her upper and lower
extremities. (Tr. 593). At a follow-up on April 19, 2016,
Ferguson noted that Gonzalez's leg pain got worse in the
previous month, and that she ached “after exercising a
long time.” (Tr. 1392). On examination, Ferguson noted
that Gonzalez had normal range of motion, no muscle or joint
tenderness, full strength in her upper and lower extremities,
and a normal gait. (Tr. 1395).
August 6, 2015, Gonzalez saw Samar El Sayegh, MD, for
assessment and management of her mood and anxiety. (Tr. 667).
Dr. El Sayegh noted that Gonzalez had anxiety and depression
since 2013, but that she got worse after quitting work due to
pain. (Tr. 667). On examination, Dr. El Sayegh noted that
Gonzalez was nervous, organized, cooperative, and anxious.
(Tr. 669). She had an intact orientation, memory, attention,
and fund of knowledge. (Tr. 669). She also had adequate
judgment and insight. (Tr. 669). Dr. El Sayegh diagnosed
Gonzalez with major depressive disorder and generalized
anxiety disorder. (Tr. 670). He referred Gonzalez to therapy,
but she declined. (Tr. 670). At follow-ups on November 17,
2015, and September 21, 2016, Dr. El Sayegh did not note any
changes in Gonzalez's mental condition on examination or
her receptiveness to therapy. (Tr. 1044-45, 1050). On
February 4, 2016, Gonzalez told Dr. El Sayegh that she had
panic attacks and that her anxiety was not controlled due to
her fibromyalgia pain. (Tr. 1642). Dr. El Sayegh again did
not note any significant changes on examination, and Gonzalez
declined therapy. (Tr. 1643-44). On July 29, 2016, Gonzalez
told Dr. El Sayegh that she had difficulty concentrating, was
not ‘very nice, ” did not want to be around
people, had anxiety, and felt overwhelmed. (Tr. 1635). On
examination on July 29, 2016, and December 30, 2016, Dr. El
Sayegh again did not note any significant changes in
Gonzalez's mental health condition. (Tr. 1637-38,
1794-95). However, on July 29, 2016, Dr. El Sayegh gave
Gonzalez a list of therapists. (Tr. 1638).
January 24, 2017, Dr. Bhupendra found mild degenerative
changes in Gonzalez's shoulder. (Tr. 1667). On January
27, 2017, Priya Sundaram, MD, took an MRI of Gonzalez's
back, which revealed degenerative changes in her cervical
spine. (Tr. 1893).
Relevant Opinion Evidence
Treating Source-Samar El Sayegh, M.D.
29, 2015, Dr. El Sayegh completed an “assessment of
ability to do work-related activities (mental).” (Tr.
1325-27). Dr. El Sayegh opined that Gonzalez had mild
limitations in relating to other people, sustaining a routine
without special supervision, responding appropriately to
supervision, using good judgment, and performing simple
tasks. (Tr. 1325-26). She had moderate limitations in
performing activities within a schedule maintaining regular
attendance, and being punctual; understanding, carrying out,
and remembering instructions; responding appropriately to
coworkers; responding to customary work pressures; responding
appropriately to changes in the work setting; performing
complex, repetitive, or varied tasks; behaving in an
emotionally stable manner; and performing daily activities.
(Tr. 1325-26). He also indicated that Gonzalez had marked
limitations in maintaining concentration and attention for
extended periods. (Tr. 1325).