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Gonzalez v. Commissioner of Social Security

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

March 19, 2019

MARIA L. GONZALEZ, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          SOLOMON OLIVER, JR. JUDGE.

          REPORT & RECOMMENDATION

          THOMAS M. PARKER MAGISTRATE JUDGE.

         I. Introduction

         Plaintiff, 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.

         II. Procedural History

         On July 13, 2015, Gonzalez applied for DIB. (Tr. 423-29).[1] 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.

         III. Evidence

         A. Personal, Educational and Vocational Evidence

         Gonzalez 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).

         B. Relevant Medical Evidence

         Between 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).

         With 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).

         On 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).

         On 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).

         On June 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. 641).

         From 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. 561).

         On June 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).

         On 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).

         On 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).

         C. Relevant Opinion Evidence

         1. Treating Source-Samar El Sayegh, M.D.

         On July 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).

         2. Consultative ...


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