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Wood v. Berryhill

United States District Court, N.D. Alabama, Middle Division

July 29, 2019

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Melissa Gay Wood (“Plaintiff”) brings this action pursuant to Section 205(g) of the Social Security Act (“the Act”) seeking review of the decision by the Commissioner of the Social Security Administration (the “Commissioner”) denying her application for disability insurance benefits (“DIB”). See 42 U.S.C. § 405(g). Based on the court's review of the record and the briefs submitted by the parties, the court finds that the decision of the Commissioner is due to be affirmed.

         I. Proceedings Below

         Plaintiff filed an application for DIB on June 11, 2015, alleging a disability onset date of November 10, 2014 due to heart attacks, mitral valve prolapse, underactive thyroid, depression, acid reflux, high blood pressure, and arthritis in her hands and wrists. (R. 111, 175-76, 192). Plaintiff's application was initially denied on August 20, 2015. (R. 113-15). Plaintiff requested and received a hearing before Administrative Law Judge (“ALJ”) Paul W. Johnson. (R. 120-21, 138-43, 163). On December 13, 2016, the claimant appeared in Anniston, Alabama while the ALJ presided over the video hearing from Montgomery, Alabama. (R. 11). In his decision dated March 30, 2017, the ALJ determined that Plaintiff was not disabled under the Act from the alleged onset date through the date of decision. (R. 18). On February 6, 2018, the Appeals Council denied Plaintiff's request for review. (R. 1-6). Because the denial of review by the Appeals Council constitutes the final act of the Commissioner, the case is now ripe for this court's review.

         II. Facts

         Plaintiff was born on August 11, 1959 and was 55 years old on the date of alleged disability onset. (R. 98, 188). She is a high school graduate and studied clerical key punch at a business college. (R. 85, 102, 110, 193). On November 10, 2014, Plaintiff left her most recent work at Honda due to her alleged disability. (R. 192).

         On January 23, 2009, Plaintiff complained to her primary care physician, Dr. William Perry, that she was experiencing numbness in the left hand, which Dr. Perry identified as “[m]ost likely carpal tunnel. If it does not get better in a month wearing a split will do nerve conduction.” (R. 324). On September 29, 2009, Plaintiff complained to Dr. Perry about numbness in her hands, toes, and leg, as well as overall fatigue. (R. 328). At that visit, Dr. Perry gave her a vitamin B12 shot and suctioned a ganglion cyst on her ankle. (R. 328). Plaintiff received vitamin B12 shots for fatigue on eight other occasions between her September 2009 visit and February 12, 2015. (R. 350). At a September 27, 2010 visit, Dr. Perry wrote, “Still having the fatigue. She does mention snoring, probably need to test her for sleep apnea…Still on the Effexor and the Nexium, refills given.” (R. 323). Plaintiff again complained to Dr. Perry about fatigue at a March 28, 2011 visit. (R. 323). At a check-up on September 19, 2011, Dr. Perry recorded that Plaintiff was having “sharp left upper chest pains, strong family history. Usually not exertional. She lifts a lot at work.” (R. 323).

         On October 1, 2012, Dr. Perry performed arthrocentesis[1] on the Plaintiff's shoulder, hip, and knee. (R. 350). He also gave Plaintiff an injection at the base of that joint, in response to her complaints of thumb pain. (R. 322). At a visit on October 12, 2012, Dr. Perry recorded that Plaintiff had a “[l]ong history of carpal tunnel left wrist with numbness in fingers” and treated her with another shot at the base of the thumb. (Id.). On June 17, 2013, Dr. Perry noted that Plaintiff “still has some fatigue ever[y] morning when she wakes up. There is a questionable history [of] sleep apnea but never had the test. I would recommend getting that[.]” (Id.).

         Plaintiff alleges a disability onset date of November 10, 2014 (the date she stopped working at Honda), but the record does not indicate any particular medical incident that occurred on that date. (R. 111, 175-76, 192).

         On January 30, 2015, Dr. Glenn L. Wilson of Gadsden Orthopaedics Associates, PC x-rayed Plaintiff's wrist in response to her complaints of wrist pain. (R. 278). The x-ray showed “mild [degenerative joint disease] of the cmc joint. No. other deformity.” (Id.)

         On February 28, 2015, Plaintiff reported excruciating chest pain that was radiating to her back and left arm. (R. 301, 303). She went to the emergency room at Gadsden Regional Medical Center and was referred to the cardiology department, where she was diagnosed as having a myocardial infarction (heart attack). (R. 301). A stent was inserted into her heart on March 2, 2015. (R. 285, 292-97, 301). Plaintiff was released from the hospital on March 3, 2015. (R. 301-02). On April 6, 2015, at the Plaintiff's post-stent follow-up appointment, Dr. G. Bruce Head III at Southern Cardiovascular Associates reported: “The patient's cardiovascular status is quite stable without recurrent angina or evidence of left ventricle dysfunction.” (R. 315). Dr. Head noted that since discharge she had done “extremely well” and that there has been “no recurrence of any type of chest pain.” (R. 314).

         At the request of the Social Security Administration, on July 24, 2015, Dr. Celtin Robertson of MDSI Physician Group, Inc. provided a functional assessment of Plaintiff's condition. The assessment found that Plaintiff had “[n]o limitations on maximum standing/walking or sitting. No. assistive device. No. limitations on maximum lifting/carrying, postural activities, or manipulative activities. No. limitation on workplace environmental activities.” (R. 99, 358-63). Dr. Robertson also reported that Plaintiff's motor strength was “5/5 in both upper and lower extremity muscle groups including bilateral grip strength.” (R. 362). He reported that Plaintiff is able to “grip and hold objects securely to the palm by the last three digits…and to grasp and manipulate both large and small objects with the first three digits.” (R. 362).

         On September 1, 2015, Plaintiff visited Gadsden Orthopaedics Associates, PC, complaining of worsening pain in the joint of her left hand. (R. 369). Dr. Glenn L. Wilson treated Plaintiff's hand with arthrocentesis and an injection, after identifying carpal tunnel syndrome and degenerative joint disease. (R. 369-70). Follow-up testing and imaging was performed on September 4, 2015 and confirmed the diagnosis of mild bilateral carpal tunnel syndrome. (R. 371-76). On September 15, 2015, Dr. Wilson performed electromyogram and nerve conduction velocity (EMG/NCV) tests on Plaintiff, again confirming mild bilateral carpal tunnel syndrome. (R. 368). Dr. Wilson noted on this date that Plaintiff's thumb is “better after injection.” (Id.) On September 15, 2015 and again on February 16, 2016, Dr. Wilson treated Plaintiff's left hand with arthrocentesis and an injection to treat her arthritis and carpal tunnel syndrome. (R. 365-68).

         Plaintiff visited Southern Cardiovascular Associates, PC on January 29, 2016, complaining of blood pressure issues, dull chest pain, shortness of breath, numbness of left leg, and headaches. (R. 386). The attending provider, Jennifer J. Crowder, CRNP, performed a Holter Monitor test on Plaintiff to measure her heart activity over 48 hours. (R. 389). On February 18, 2016, Plaintiff again saw Dr. Head at Southern Cardiovascular Associates, PC to review her Holter monitor test results. (R. 378-83). Dr. Head explained that her Holter test results suggested a benign non-sustained arrhythmia, with no treatment necessary. (R. 382).

         In addition to her regular check-ups (R. 392-406), Plaintiff saw Dr. William B. Perry, her primary care provider, on February 12, 2016 to inquire about having carpal tunnel surgery because of pain in her left wrist. (R. 394). She also had a wrist joint aspirated again. (R. 394).

         Plaintiff was admitted to Gadsden Regional Medical Center again on August 26, 2016 for nausea, heart palpitations, weakness, and intermittent chest pain. (R. 408-27). The attending physician, Dr. Sunil J. Jaiswal, referred her to Dr. Head. (R. 412), who referred her for an outpatient cardiovascular stress test with nuclear imaging, stating that he did not see evidence of ischemic syndrome and that her bradycardia was related to her blocker therapy. (R. 410). She was discharged from the hospital on August 27, 2016. (R. 412-13). A cardiovascular stress test performed on September 12, 2016 revealed normal left ventricular function and no evidence of recurrent myocardial ischemia. (R. 429). Left ventricular ejection fraction was 60%. (Id.). Reviewing this stress test on October 6, 2016, Dr. Head explained to Plaintiff that the test did not indicate any recurrent obstruction in the coronary arteries and discussed management of her low heart rate. (R. 433).

         In documents submitted to the Social Security Administration, Plaintiff described her daily activities as cooking, cleaning, shopping, sewing, and caring for pets. (R. 209-16, 221-23). Plaintiff's mother-in-law reported that Plaintiff shops, cleans house, ...

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