United States District Court, S.D. Alabama, Southern Division
THERESA D. LOYD, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER
WILLIAM E. CASSADY, Magistrate Judge.
Plaintiff brings this action, pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking judicial review of a final decision of the Commissioner of Social Security denying her claims for disability insurance benefits and supplemental security income. The parties have consented to the exercise of jurisdiction by the Magistrate Judge, pursuant to 28 U.S.C. § 636(c), for all proceedings in this Court. (Docs. 22 & 23 ("In accordance with the provisions of 28 U.S.C. 636(c) and Fed.R.Civ.P. 73, the parties in this case consent to have a United States Magistrate Judge conduct any and all proceedings in this case, ... order the entry of a final judgment, and conduct all post-judgment proceedings.").) Upon consideration of the administrative record, plaintiff's brief, the Commissioner's brief, and the arguments of plaintiff's counsel at the April 30, 2014 hearing before the Court, it is determined that the Commissioner's decision denying benefits should be affirmed.
Plaintiff alleges disability due to a history of a cerebrovascular accident, migraine headaches, backache, and a history of substance abuse. The Administrative Law Judge (ALJ) made the following relevant findings:
1. The claimant last met the insured status requirements of the Social Security Act through June 30, 2011.
2. The claimant has not engaged in substantial gainful activity since October 16, 2010, the alleged onset date (20 CFR 404.1571 et seq. , and 416.971 et seq. ).
3. The claimant has the following severe impairments: history of cerebrovascular accident, migraine headaches, backache, and history of substance abuse (20 CFR 404.1520(c) and 416.920(c)).
A review of the record discloses the claimant's hospitalization in October 2010, with the discharge summary citing the claimant's assessed sensory motor lacunar stroke affecting the left side of her body, as well as additional assessments of hypertension, tobacco abuse, history of asthma, history of migraine[s] in the past, and history of anxiety. Notations indicated that the claimant had experienced a three-day history of left-sided weakness and mild dysarthria prior to hospitalization, but that, during hospitalization, her dysarthria resolved and she made significant progress in muscle strength. An MRI of the brain illustrated two adjacent recent lacunar infarcts, and carotid duplex studies showed mild to moderate plaquing at the level of the common carotid arteries bilaterally. Further, there was Doppler evidence suggesting 50-69% diameter stenosis of both proximal internal carotid arties, with both vertebral arteries having normal antegrade flow.
Notations from Mobile County Health Department from October 26, 2010, disclosed that the claimant had experienced back pain for the previous three days and needed a refill of Soma. She was assessed with anxiety, backache, and lacunar stroke. During examination, while tenderness to palpation was noted, no sensory exam abnormalities were detected; no dysfunction in motor examination was observed; no coordination/cerebellum abnormalities were noted; and normal reflexes were detected. The claimant returned to the health department on November 15, 2010, with notations indicating that her stroke symptoms were resolving and that she had equal grip bilaterally. Notations further indicated that the claimant was not taking medication. At a visit to the Mobile County Health Department on February 14, 2011, examination illustrated sound distortions in the claimant's speech, reduced motor strength on the left side, incoordination of the left side during coordination/cerebellum examination, and limited balance. She was assessed with observed combined systolic and diastolic elevation, backache, and right hemispheric stroke. Medication refills were given. The claimant returned for treatment on March 1, 2011, with assessments of headache syndrome and left hemisphere stroke being made.
At a visit to the Mobile County Health Department on April 13, 2011, the claimant received assessments of anxiety, observed combined systolic and diastolic elevation, asthma, backache, and continuous nicotine dependence. Medications were administered and refills of prescription medications obtained. The claimant was assessed with backache and stroke syndrome at a visit on June 13, 2011, with it also being noted that she presented for a repeat prescription for medication. Treatment notations dated October 3, 2011, disclosed that... examination of [the claimant's] musculoskeletal system was normal; her motor examination demonstrated no dysfunction; and no coordination/cerebellum abnormalities were noted. She was diagnosed with classic migraine, anxiety, and backache, and she obtained medication refills. The claimant was evaluated on February 2, 2012, at the Mobile County Health Department and was observed to have pain with palpation of the lower lumbar spine. However, motor examination demonstrated no dysfunction and no coordination/cerebellum abnormalities were noted. Assessments included classic migraine, backache, headache syndromes, and primary insomnia, and medication refills were obtained. On February 28, 2012, the claimant underwent imaging of the cervical spine that reflected well preserved disc spaces, no anterior soft tissue swelling, and normal alignment and contour of the vertebrae with minimal spurring anteriorly at the C5 level. Additionally, no acute fracture or dislocation was appreciated. Imaging of the claimant's lumbar spine illustrated minimal spurring; no compression fracture or subluxation; and either a small intervertebral disc herniation or Schmorl's node at the superior endplate of the L2 level.
At a consultative neurological evaluation with Ilyas A. Shaikh, M.D., in April 2011, the claimant complained of neck and back pain, as well as left-sided weakness. Examination of the spine disclosed no tenderness to palpation and a fairly normal range of motion. During neurological examination, the claimant did not demonstrate any dysarthria, dysphasia, or dysphonia; her face was bilaterally symmetrical. The claimant's motor strength was bilaterally symmetrical and 5/5 to abduction, adduction, flexion, and extension of the upper and lower extremities, despite her demonstration of poor effort on the left side. Physical examination disclosed no rigidity or spasticity. Additionally, the claimant's fine motor skills were normal; she was able to make a fist and oppose her thumb to her fingers; and she was able to turn the doorknob and tie her shoelaces. Dr. Shaikh also noted that the claimant's grip strength was 5/5 and bilaterally symmetrical; her sensations were intact; her Romberg was negative; her cerebellar functions were intact by finger-nose-finger, finger tapping, and rapid alternate movements; her deep tendon reflexes were 2 bilaterally at the biceps, triceps, brachioradialis, knees, and ankles; and her toes were down going and there was no clonus. Regarding gait/station, the claimant was able to stand on her heels and toes and her tandem gait was mildly compromised. According to Dr. Shaikh, the claimant showed poor effort in touching the fingers to the toes and she limped and favored her left leg. However, the claimant did not use any hand held assistive device and had a normal association of arm swings. Dr. Shaikh's diagnostic impression consisted of history of back pain, history of left-sided weakness, and history of headaches (probably migraine in nature). In comments, Dr. Shaikh noted that the claimant had been treated for mild left-sided weakness related to her lacunar sensory motor infarct and that, despite neurological examination being fairly normal, she continued to demonstrate left-sided weakness and to experience migraine headache, as well.
In June 2011, Kenneth Sherman, M.D., [the] treating source associated with Mobile County Health Department, completed a physical capacities evaluation in which he referenced the claimant's multiple TIA's and stroke. Dr. Sherman opined that the claimant could sit for four hours total during an entire eight hour day, could stand for three hours total during an eight hour day, and could walk for two hours total during an eight hour day. He further concluded that the claimant could continuously lift up to five pounds, could frequently lift six to ten pounds, could occasionally lift eleven to twenty pounds, and could never lift twenty-one pounds or more. According to Dr. Sherman, the claimant could frequently carry up to five pounds, could occasionally carry six to ten pounds, and could never carry eleven or more pounds. While Dr. Sherman indicated that the claimant could use her right hand for simple grasping, he reported that she could not use her left hand for simple grasping. Dr. Sherman opined that the claimant could use both hands for pushing and pulling of arm controls, but could not use either hand for fine manipulation. He additionally concluded that the claimant could use both feet for pushing and pulling of leg controls; could frequently bend; could occasionally crawl; and could never squat, climb, or reach. Finally, Dr. Sherman assigned the claimant a total restriction on exposure to dust, fumes, and gases; moderate restriction of activities involving being around unprotected heights and driving automotive equipment; and mild restriction of activities involving being around moving machinery and exposure to marked changes in temperature and humidity. In his clinical assessment of pain evaluation, Dr. Sherman concluded that the claimant's pain was present to such an extent as to be distracting to the adequate performance of daily activities or work and that physical activity, such as walking, standing, bending, stooping, and moving of extremities, would greatly increase the claimant's pain to such a degree as to cause distraction from a task or total abandonment of the task. Further, Dr. Sherman indicated that medication side effects could be expected to be severe and to limit the claimant's effectiveness due to distraction, inattention, and drowsiness.
4. The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), ...