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Giacomelli v. Berryhill

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

June 14, 2019

DANYEL GIACOMELLI, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OF OPINION AND ORDER

          JONATHAN D. GREENBERG UNITED STATES MAGISTRATE JUDGE.

         Plaintiff, Danyel Giacomelli (“Plaintiff” or “Giacomelli”), challenges the final decision of Defendant, Nancy A. Berryhill, [1] Acting Commissioner of Social Security (“Commissioner”), denying her applications for a Period of Disability (“POD”) and Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 416(i), 423, and 1381 et seq. (“Act”). This Court has jurisdiction pursuant to 42 U.S.C. § 405(g) and the consent of the parties, pursuant to 28 U.S.C. § 636(c)(2). For the reasons set forth below, the Commissioner's final decision is AFFIRMED.

         I. PROCEDURAL HISTORY

         In November 2015, Giacomelli filed an application for POD and DIB alleging a disability onset date of December 1, 2014 and claiming she was disabled due to arthritis and carpal tunnel syndrome. (Transcript (“Tr.”) at 134, 149.) The applications were denied initially and upon reconsideration, and Giacomelli requested a hearing before an administrative law judge (“ALJ”). (Tr. 75, 82, 89.)

         On December 13, 2017, an ALJ held a hearing, during which Giacomelli, represented by counsel, and an impartial vocational expert (“VE”) testified. (Tr. 25.) On January 31, 2018, the ALJ issued a written decision finding Giacomelli was not disabled. (Tr. 8.) The ALJ's decision became final on July 23, 2018, when the Appeals Council declined further review. (Tr. 1.)

         On August 23, 2018, Giacomelli filed her Complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 13, 15.) Giacomelli asserts the following assignment of error:

(1) Whether substantial evidence supports the ALJ's finding that Ms. Giacomelli can perform frequent handling, fingering and feeling.

(Doc. No. 13.)

         II. EVIDENCE

         A. Personal and Vocational Evidence

         Giacomelli was born in August 1970 and was forty seven years-old at the time of her administrative hearing, making her a “younger” person under social security regulations. (Tr. 19.) See 20 C.F.R. §§ 404.1563. She has a high school education and is able to communicate in English. (Id.) She has past relevant work as a data entry clerk. (Tr. 18.)

         B. Relevant Medical Evidence[2]

         On June 19, 2013, Giacomelli visited orthopedist Alan L. Panteck, M.D. for a right foot injury. (Tr. 203.) She reported injuring her foot eight months prior on a set of stairs. (Id.) Giacomelli denied any treatment for this injury but indicated she was waking up at night with pain. (Id.) On examination, she displayed no obvious swelling, but had tenderness and a minimally antalgic gait. (Id.) X-rays of the right foot revealed a possible old fracture at the base of the third metatarsal. (Id.) Dr. Panteck ordered an MRI to evaluate Giacomelli for a Lisfranc sprain. (Id.) A June 25, 2013 right foot MRI indicated Lisfranc joint arthrosis, but no discrete stress fracture or definite sprain. (Tr. 209.)

         Giacomelli returned to Dr. Panteck on January 19, 2016, reporting a three-month history of right upper extremity pain. (Tr. 204.) She described pain along the medial aspect of the right elbow and right thumb. (Id.) Giacomelli denied treating this pain with anti-inflammatory medication, but indicated she modified her activities without much relief. (Id.) On examination, she had a full range of motion in her right elbow, wrist, and fingers. (Id.) She was “exquisitely tender over the medial epicondyle, ” but had no tenderness over the lateral epicondyle or radial tunnel. (Id.) Giacomelli displayed significant pain with resisted wrist and finger flexion and tenderness at her first CMC joint. (Id.) However, x-rays of her right thumb revealed essentially no arthritic changes at her first CMC joint or any evidence of STT arthritis. (Id.) Dr. Panteck diagnosed Giacomelli with right medial epicondylitis and administered a Kenolog and Lidocaine injection on the right side. (Id.)

         On January 20, 2016, Giacomelli visited primary care physician Jason Sustersic, D.O., for bilateral hand eczema and ear pain. (Tr. 213.) Dr. Sustersic observed redness in both ears and diagnosed bilateral ear infections. (Tr. 214.) He prescribed a course of antibiotics for this issue. (Id.) Dr. Susteric also prescribed steroids for the severely dry skin on Giacomelli's hands. (Id.)

         On February 16, 2016, Giacomelli visited neurologist Augusto C. Juguilon, M.D., for neck, shoulder, hand, and wrist pain. (Tr. 226.) She described “generalized aches and pains” on a constant and daily basis. (Id.) She reported constant hand pain, despite undergoing bilateral carpal tunnel release procedures over a decade prior. (Id.) On examination, Giacomelli was tender in her cervical spine and shoulders, with minimal discomfort to palpation in the lumbar region. (Id.) Her motor strength was good in both her upper and lower extremities and she displayed no tremor. (Id.) She had decreased pinprick sensation in both hands. (Id.) An EMG/nerve conduction study of her arms and neck revealed (1) bilateral mild recurrent carpal tunnel syndrome; (2) bilateral mild ulnar compression neuropathy at the elbow; (3) bilateral multi-level cervical radiculopathy; (4) no evidence of ulnar compression neuropathy at the canal of the guyon; (5) no peripheral neuropathy; and (6) no myopathy. (Tr. 221.)

         Giacomelli returned to Dr. Juguilon on April 19, 2016. (Tr. 225.) Dr. Juguilon reviewed Giacomelli's recent labwork, which revealed an elevated sedimentation rate of 30, satisfactory C-reactive protein levels, severe anemia, and low B12 levels. (Id.) Her CCP antibodies were highly elevated and the remainder of the testing was negative. (Id.) Dr. Juguilon noted Giacomelli “claims that she is unable to do any daytime job because [she] is constantly fatigued plus having generalized aches and pains.” (Id.) He referred her to rheumatology for a connective tissue disease and hematology for anemia and B12 deficiency. (Id.)

         An April 25, 2016 cervical MRI revealed the following: (1) degeneration of the left paramedian protrusion of the C5-6 disc causing mild flattening of the left side of the spinal cord; (2) a diminished T1 signal in the marrow, possibly due to marrow replacement disease; and (3) prominent adenoidal tissue, which was unusual for Giacomelli's age. (Tr. 242.)

         Giacomelli saw Dr. Sustersic on May 24, 2016, for left shoulder, hip, and groin pain. (Tr. 310.) She indicated her left shoulder pain began after dropping a bag of groceries two weeks prior. (Id.) Dr. Sustersic noted Giacomelli needed to start B12 shots due to her recent labwork results. (Id.) On examination, Giacomelli had tenderness in her left AC joint, with a normal range of motion and muscle strength. (Tr. 311.) Dr. Sustersic prescribed a course of steroids for her symptoms. (Tr. 312.)

         On October 25, 2016, Giacomelli visited Dr. Panteck for left hip pain. (Tr. 292.) She described this pain as radiating distally, but not going into her knee. (Id.) She denied any numbness or back pain. (Id.) On examination, Giacomelli tended to “lurch towards her left side” and was tender along her left greater trochanter. (Id.) She had no tenderness along her IT band. (Id.) Giacomelli voiced no complaints of groin pain with hip range of motion testing or heel tap. (Id.) X-rays of her left hip confirmed no arthritic changes, acute dislocation, or fracture. (Id.) Dr. Panteck concluded Giacomelli's hip pain was likely due to greater trochanteric bursitis and administered a Kenalog and Lidocaine injection. (Id.)

         Giacomelli visited Dr. Sustersic several days later, on October 28, 2016. (Tr. 307.) She described myalgias and pain in her back and neck. (Id.) On examination, she had tenderness and skin sensitivity in multiple joints, but her range of motion and strength testing was normal. (Tr. 308.) Dr. Sustersic diagnosed fibromyalgia, recommended regular exercise, and prescribed Cymbalta. (Tr. 309.)

         Giacomelli followed up with Dr. Sustersic on December 23, 2016. (Tr. 304.) She felt “much better” on Cymbalta and her chronic pain levels had dropped from an 8/10 to a 4/10. (Id.) She reported continued bilateral hip and lower back pain, but it was improved. (Id.) She requested an increased dosage of Cymbalta, which Dr. Sustersic provided. (Tr. 304, 306.) On examination, she had no joint swelling and a normal range of motion and movement in her extremities. (Tr. 305.)

         On May 9, 2017, Giacomelli visited Dr. Panteck for bilateral hand and elbow pain, the right side worse than the left. (Tr. 316.) On examination, her right arm was tender to palpation over the lateral epicondyle and she had significant pain with resisted wrist and finger extension. (Id.) There was no tenderness over the medial epicondyle. (Id.) On the left side, Giacomelli again had tenderness over the lateral epicondyle, but not to the same degree as the right side. (Id.) She had mild pain with resisted wrist and finger extension. (Id.) Dr. Panteck administered Kenalog and Lidocaine injections in Giacomelli's lateral epicondyles. (Id.)

         Giacomelli continued to report bilateral wrist and elbow pain on May 18, 2017. (Tr. 336.) She indicated the recent injections provided minimal relief. (Id.) On examination, Giacomelli had no joint swelling, a normal range of motion, and normal movements in all of her extremities. (Tr. 337.) Dr. Sustersic advised her to wear wrist braces at bedtime and ice her hands for 20-30 minutes, 2-3 times a day. (Tr. 338.) Giacomelli returned to Dr. Sustersic for right elbow pain on July 21, 2017. (Tr. 333.) On examination, her lateral epicondyle was tender. (Tr. 335.) Dr. Sustersic prescribed a course of steroids. (Id.)

         C. State Agency Reports

         On April 30, 2016, Giacomelli underwent a consultative examination with physician Kyle E. Walker, M.D. (Tr. 259-266.) She reported arm and hip pain. (Tr. 259.) She indicated her bilateral carpal tunnel release procedures only alleviated her hand pain for about 2-3 years. (Id.) On examination, Giacomelli had 4/5 strength in her left shoulder and 3/5 strength in her left hip flexor. (Tr. 260.) Otherwise, she had full strength in her upper and lower extremities. (Id.) She reported numbness and paresthesia in her 1st, 2nd, 4th, and 5th digits, but her light touch sensation was otherwise intact in her arms and legs. (Id.) Her gait favored the left side. (Id.)

         X-rays of the left hip indicated “mild joint space narrowing but no other signs of chronic inflammation or degeneration.” (Tr. 261.) Her right shoulder x-ray was normal. (Id.) Her grasp was slightly weak bilaterally, but she had normal manipulation, pinch, and fine motor coordination. (Tr. 263.) Her cervical spine, shoulder, elbow, hand, and finger ranges of motion were all normal. (Tr. 264-265.) Her hip, knee, and ankle ranges of motion were also normal. (Tr. 266.)

         Based upon this examination, Dr. Walker provided the following statement:

Ms. Giacomelli's history and physical, except for the 1st and second digit parethesias, is typical for ulnar neuropathy that can be the result of [carpal tunnel syndrome] or cubital tunnel syndrome. The numbness/parenthesis of the 1st and 2nd digits might be attributed to polyneuropathy. An EMG could better support this. Despite this minor inconsistency, I believe Ms. Giacomelli's exam to be reliable and would expect she would have mild to moderate limitations with lifting and carrying. This is especially true when performing these activities with heavier objects or for long periods of time. She may also have mild limitations with handling objects.
The claimant does not have any limitations with sitting, standing, walking, hearing, speaking, traveling or with memory.

(Tr. 261.)

         On May 12, 2016, state agency physician Stephen Sutherland, M.D., reviewed Giacomelli's medical records and completed a Physical Residual Functional Capacity (“RFC”) Assessment. (Tr. 68-70.) Dr. Sutherland determined Giacomelli could lift and carry 20 pounds occasionally and 10 pounds frequently; stand and/or walk for 6 hours in an 8-hour workday; and sit for about 6 hours in an 8-hour workday. (Tr. 68-69.) He further found Giacomelli was limited to occasional climbing of ramps and stairs, never climbing ladders, ropes, or scaffolds, frequent stooping, kneeling, and crouching, and could occasionally crawl. (Tr. 69.) Dr. Sutherland opined Giacomelli was limited to frequent handling, fingering, and feeling with the bilateral upper extremities. (Tr. 70.) He concluded Giacomelli would need to avoid concentrated exposure to extreme cold, vibration, and hazards and could not work at unprotected heights or perform commercial driving. (Id.)

         On August 26, 2016, state agency physician Dimitri Teague, M.D., reviewed Giacomelli's medical records and completed a Physical RFC Assessment. (Tr. 56-58.) He adopted Dr. Sutherland's findings. (Id.)

         D. ...


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