United States District Court, N.D. Alabama, Middle Division
DAVID PROCTOR UNITED STATES DISTRICT JUDGE.
Tammy Faye Castleman (“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 and 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.
applied for a period of disability and DIB on December 17,
2014, alleging disability commencing September 3, 2013 due to
type II diabetes, neuropathy, rheumatoid arthritis, kidney
dysfunction, back surgery, neck surgery, mental confusion,
memory loss, lack of sleep, and anemia. (R. 61, 74, 80, 203).
Plaintiff's application was initially denied on January
30, 2015. (R. 72-73). On April 3, 2015, she requested a
hearing before an Administrative Law Judge
(“ALJ”). (R. 100). The hearing was held on
January 31, 2017; thereafter, an unfavorable decision was
issued on March 22, 2017. (R. 11-32, 37-59). The Appeals
Council denied Plaintiff's request for review of the
ALJ's decision on January 26, 2018. (R. 1-4). 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 pursuant to 42 U.S.C. § 405(g).
was born on August 2, 1960 and was 56 years old at the time
of the ALJ's decision. (R. 11, 41). Plaintiff has some
college education and previously worked as an apartment
assistant manager, bookkeeper, and accounting technician. (R.
41, 56). She alleges disability due to type II diabetes,
neuropathy, rheumatoid arthritis, kidney dysfunction, back
surgery, neck surgery, mental confusion, memory loss, lack of
sleep, and anemia, commencing September 3, 2013. (R. 203).
The date she was last insured for disability benefits, or her
date last insured (“DLI”), was December 31, 2014.
(R. 16, 174).
17, 2012, Plaintiff saw her primary care physician, Dr. Rupen
Joshi, for a physical exam. (R. 429-35). He diagnosed her
with the following conditions: degeneration of the
intervertebral disc; essential hypertension; diabetes
mellitus without mention of complication; abnormal weight
gain; heartburn; pain in joint; and allergic rhinitis, cause
unspecified. (Id.). On May 31, 2012, Dr. Joseph
Christian Scales, a radiologist, performed a radiologic
examination of Plaintiff's thoracic spine, finding her
disc spaces to be degenerated at several levels with anterior
osteophytes (bone spurs) present; Dr. Scales's overall
impression was “[n]o acute findings in the thoracic
spine. Multilevel degenerative disc disease.” (R. 480).
Dr. Scales also conducted a radiologic examination of
Plaintiff's cervical spine, finding anterior cervical
fusion from C3 to C5, degenerative disc disease at ¶ 5
to C6, moderate left foraminal encroachment at ¶ 5 to
C6, and right foraminal narrowing at ¶ 6 to C7. (R.
481). Overall, Dr. Scales noted “[n]o acute findings in
the cervical spine. Degenerative change at ¶ 5-C6 and
C6-C7.” (Id.) The radiological examination of
Plaintiff's lumbosacral spine was unremarkable. (R. 482).
September 27, 2012, Plaintiff saw Dr. Joshi with severe pain
in the mid to lower back, neck, and left shoulder. (R. 420).
Plaintiff reported being in a car wreck the previous week,
where she was hit from behind by another car. (R. 420).
Plaintiff's extremities exhibited no edema. (R. 420). Dr.
Joshi also noted mild tenderness in the spine. (R. 420). On
that same date, Dr. Thomas Charles Bell, a radiologist,
recorded the results of a radiologic examination of the spine
as “[m]odest degenerative disease, ” noting
“moderate degenerative facet changes” and
“modest osteophytosis of the vertebral bodies.”
October 11, 2012, Plaintiff saw Dr. Joshi with back pain. (R.
416). Dr. Joshi diagnosed a sprain and strain of her sacrum,
degeneration of intervertebral disc, diabetes mellitus
without mention of complication, and hypertension. (R. 417).
November 6, 2012, Plaintiff checked into the emergency room
complaining of back pain. (R. 259-60). Dr. Russell Simpson
diagnosed her with acute lumbar myofascial strain and chronic
low back pain, then prescribed her methocarbamol and Medrol
upon discharge. (Id.). The next day, November 7, she
called Dr. Joshi's office, reporting that she was not
able to walk without severe pain and that the pain pills and
muscle relaxers were not helping her. (R. 452). Dr. Joshi
agreed to refill her muscle relaxers and recommended physical
December 12, 2012, Plaintiff saw Dr. Joshi with pain in her
toes and lower back. (R. 413). Dr. Joshi treated an ingrown
toenail on Plaintiff's left toe. (R. 415). He also
diagnosed onychia and paronychia of her toe and prescribed
March 13, 2013, Plaintiff saw Dr. Joshi, describing pain in
her neck and back, as well as numbness in her hands from
sleeping on her side. (R. 410). Dr. Joshi prescribed Robaxin
for the degeneration of her intervertebral disc. (R. 412).
April 26, 2013, Dr. Larry Parker, an orthopedist, reported
Plaintiff had intractable lower back pain and radiculitis.
(R. 254-55). On April 29, 2013, Dr. Parker performed a
microlumbar discectomy on Plaintiff's left L5-S1
vertebral segment, citing her history of back pain with
radiation to the left lower extremity. (R. 252). Plaintiff
saw Dr. Parker again on May 7, 2013 for a post-surgery visit;
Dr. Parker noted that Plaintiff had “not been very
active and I have informed her of the importance of her
activity and getting back to a normal daily activity
level.” (R. 269).
26, 2013, Plaintiff was admitted to the hospital, reporting
persistent nausea, vomiting, and diarrhea, as well as
abdominal pain. (R. 243, 245). Although flat view imaging
initially showed a possible small-bowel obstruction (R. 250),
the follow-up helical CT images of Plaintiff's abdomen
presented normal results. (R. 248). On May 27, an abdominal
ultrasound revealed suspected fatty infiltration of the
liver; there was no indication of hydroureter or
hydronephrosis in her kidneys. (R. 247). Upon her discharge
on May 28, attending physician Dr. Devi P. Misra diagnosed
Plaintiff with acute gastroenteritis (most likely viral
type), hypokalemia (corrected), hypomagnesemia (corrected),
and fever. (R. 243).
18, 2013, Plaintiff saw Dr. Joshi in follow up to her
hospital visit. (R. 407). Plaintiff reported swelling in her
right leg since being discharged from the hospital. (R. 407).
Dr. Joshi conducted ultrasound imaging on Plaintiff's
right leg; he ruled out deep vein thrombosis and advised
exercise and a low-salt diet. (R. 408, 477).
December 4, 2013, Plaintiff followed up with Dr. Joshi. (R.
401). He reported that Plaintiff had lost weight after
exercising and changing her diet. (R. 402). Her extremities
exhibited no edema. (R. 403).
February 4, 2014, Plaintiff saw Dr. Larry M. Parker to review
her progress following her April 2013 microdiscectomy
surgery. (R. 266). Dr. Parker reported that she had no leg
pain and her back pain was moderate. (Id.). He also
noted that physical therapy had helped. (Id.). She
had lost weight and was doing well overall. (Id.).
She exhibited 5 motor strength and no sensory deficits in
the lower extremities, and a good range of motion in the
hips, knees, and ankles. (Id.).
March 3, 2014, Plaintiff visited Dr. Dale Culpepper at
SportsMed Orthopaedic Surgery and Spine Center. (R. 299). Dr.
Culpepper recommended surgery for a recurrent ganglion cyst
in her left wrist. (R. 299-300). On March 21, 2014, Plaintiff
had the ganglion cyst excised. (R. 309-10). On April 1, 2014
and May 21, 2014, Dr. Culpepper reported that Plaintiff was
doing well and had good movement of the wrist and fingers
following the surgery. (R. 297, 303).
March 11, 2014, Plaintiff visited Dr. Joshi for left foot
pain. A diabetic foot exam revealed a normal inspection,
normal circulation, and normal monofilament. (R. 400).
Plaintiff exhibited no edema in her extremities. (R. 400). In
his treatment plan, Dr. Joshi continued Plaintiff on
Metformin HCl tablets for her diabetes mellitus and
encouraged her to exercise and have a diabetic eye exam
performed annually. (R. 400). In addition to prescribing
Robaxin, Ultram, and Mobic for the degeneration of her
intervertebral disc, Dr. Joshi notes that Plaintiff was
receiving physical therapy for this issue. (R. 400-01).
15, 2014, Dr. Scott C. Hitchcock, a neurologist, conducted a
nerve conduction study and limited electromyography on
Plaintiff. (R. 495, 516). Dr. Hitchcock found that the
“electrodiagnostic study reveals no evidence of
peripheral neuropathy. A small fiber neuropathy can cause
paresthesias and lack of temperature discrimination as she is
experiencing. She may have a diabetic small fiber neuropathy,
which can happen even with borderline diabetes. Autonomic
dysfunction may occur as well.” (R. 487). An evaluation
of the left sural anti-sensory nerve showed prolonged distal
peak latency and decreased conduction velocity. (R. 487). The
evaluation indicated that all remaining nerves were within
the normal limits. (Id.).
September 2, 2014, Plaintiff saw Dr. Michael Quadrini, a
nephrologist, for evaluation of her renal insufficiency. (R.
312). She had trace edema in her lower extremities, primarily
in the feet and toes, but her sensation was intact, muscle
tone was intact, and her gait appeared steady. (R. 314). Her
creatinine level was 1.4, but Dr. Quadrini did not know her
baseline creatinine level. (R. ...