United States District Court, S.D. Alabama, Southern Division
APRIL M. LUCAS, Plaintiff,
CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION
BERT W. MILLING, Jr., Magistrate Judge.
In this action under 42 U.S.C. § 405(g), Plaintiff seeks judicial review of an adverse social security ruling which denied a claim for disability insurance benefits. The action was referred for report and recommendation pursuant to 28 U.S.C. § 636(b)(1)(B). Oral argument was waived in this action (Doc. 17). Upon consideration of the administrative record and the memoranda of the parties, it is recommended that the decision of the Commissioner be affirmed, that this action be dismissed, and that judgment be entered in favor of Defendant Michael J. Astrue and against April M. Lucas.
This Court is not free to reweigh the evidence or substitute its judgment for that of the Secretary of Health and Human Services, Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983), which must be supported by substantial evidence. Richardson v. Perales, 402 U.S. 389, 401 (1971). The substantial evidence test requires "that the decision under review be supported by evidence sufficient to justify a reasoning mind in accepting it; it is more than a scintilla, but less than a preponderance." Brady v. Heckler, 724 F.2d 914, 918 (11th Cir. 1984), quoting Jones v. Schweiker, 551 F.Supp. 205 (D. Md. 1982).
At the time of the administrative hearing, Plaintiff was thirty-five years old, had completed a college education (Tr. 39), and had previous work experience as an ultrasound technologist, data entry clerk, office manager, and secretary ( see Tr. 51). In claiming benefits, Lucas alleges disability due to fibromyalgia, migraine headaches, and major depressive disorder (Doc. 13 Fact Sheet).
The Plaintiff filed a protective application for disability benefits on April 23, 2012 (Tr. 140-46; see Tr. 19). Benefits were denied following a hearing by an Administrative Law Judge (ALJ) who determined that although she could not return to her past relevant work, there were light work jobs that she could perform (Tr. 19-29). Plaintiff requested review of the hearing decision (Tr. 14) by the Appeals Council, but it was denied (Tr. 1-5).
Plaintiff claims that the opinion of the ALJ is not supported by substantial evidence. Specifically, Lucas alleges that: (1) The ALJ did not properly consider the opinions and conclusions of her treating physician; (2) the ALJ improperly discounted her testimony of pain and limitation; and (3) the ALJ failed to re-contact the consultative examiner for questions about the opinion rendered (Doc. 13). Defendant has responded to-and denies-these claims (Doc. 14). The Court's review of the relevant evidence follows.
On August 10, 2011, Dr. Mark Robinson saw Lucas for a migraine headache and nausea; he prescribed Stadol,  Phenergan,  and Topomax (Tr. 304). On September 9, Robinson again saw Plaintiff for a three-day headache; Lucas indicated that although she got no relief from her home medications, the Topomax helped with the frequency of the headaches (Tr. 303). On September 26, 2011, Dr. Elizabeth J. Low, a General Practitioner, examined Plaintiff for a dull, throbbing, continuing headache with photophobia, nausea, and vomiting; Low noted that Lucas was in no distress, continued her former medications, and prescribed Savella,  Amitriptyline,  Maxalt,  and Ultram (Tr. 298-301, 513). On October 10, Plaintiff's migraine resulted in injections of Phenergan and Demerol as well as a prescription for Demerol (Tr. 296-97). The next day, Lucas was seen for a three-day headache; the doctor noted no acute distress, diagnosed a migraine, and continued the Demerol prescription (Tr. 292-94). On November 7, Dr. Low examined Plaintiff for a three-day headache (Tr. 282-85). On December 15, Lucas complained of a headache, nausea, and blurred vision for which Dr. Low continued the Stadol prescription (Tr. 274-76). A throbbing two-day headache on December 26 led to re-prescribing of Stadol and Phenergan (Tr. 270-73).
On October 3, 2011, Dr. Ellen W. McKnight, Rheumatologist, examined Lucas for an inability to stay asleep, fatigue, weakness, muscular pain, stiffness, headaches, and poor memory; Plaintiff rated her pain as five on a ten-point scale (Tr. 323-27; see also Tr. 25; Doc. 13, p. 3). The Doctor noted that she was in no acute distress and the physical exam was normal; McKnight's impression was fibromyalgia, fatigue, chronic debilitating migraine headaches, severe depression, restless legs syndrome, osteoarthritis, possible inflammatory polyarthritis, and vitamin D deficiency for which she prescribed Mobic and Vitamin D and continued her Prozac,  Topamax, and Maxalt. On March 13, 2012, McKnight's examination reported everything to be within normal limits; she prescribed Cymbalta and decreased the Prozac daily dose (Tr. 319-22).
On February 14, 2012, Dr. Badr Sultan examined Plaintiff for her headaches (Tr. 315-17). His neurological exam was as follows:
The patient was alert and oriented x 3. Her speech and language were intact. Cranial nerve examination showed full visual field and intact extraocular muscles. Facial sensations were intact. Facial muscles were symmetric. Motor examination showed 5/5 muscle strength throughout. Coordination examination showed finger-to-nose without dysemetria. Deep tendon reflexes showed symmetric response throughout. Plantar was downgoing bilaterally.
(Tr. 316). Dr. Sultan discontinued one drug and prescribed Lyrica and Fioricet; he also discussed some treatment options that could be used in the future.
Records from Dr. Low indicate that she examined Lucas five times between February 28 and April 2, 2012 for complaints of headache (Tr. 332-53). Though four exams noted that Plaintiff was in no acute distress, the March 19 record indicates that she was in obvious distress (Tr. 343).
On March 30, Dr. Mark E. Larkins, of the West Florida Medical Center, examined Lucas for neck pain and headaches (Tr. 361-63). On exam, the Doctor noted discomfort on extension of the cervical spine indicating possible cervical facet loading with some tenderness to palpation over the paracervical musculature at the splenius cervicis and capilis regions, into the facets and trapezius bilaterally. X-rays showed a normal cervical spine (Tr. 364). Indocin was prescribed (Tr. 362). On April 6, 2012, Dr. Kristin L. Davis examined Lucas and noted that she had "significant analgesic overuse with overuse of stadol, maxalt, fioricet, Excedrin migraine and Indocin" before prescribing Depakote and Verapamil (Tr. 360; see generally Tr. 359-61). Dr. Davis saw Plaintiff again four days later and noted that she had quit taking most of the drugs the Doctor had indicated were being overused; Lucas presented with a headache and reported having been fired from her job because she had missed too much work (Tr. 356-57). The examination was normal though Plaintiff was reported to be in mild distress; Davis indicated a desire to try Botox injections for the headaches. On April 16, Dr. Larkins determined that Botox injections were inappropriate at that time (Tr. 355).
On June 4, Plaintiff went to the D. W. McMillan Memorial Hospital Emergency Room for a migraine headache for which she was given Phenergan, Toradol, and Morphine; she was ...