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Castleman v. Berryhill

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

August 14, 2019

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



         Plaintiff 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.

         I. Proceedings Below

         Plaintiff 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).

         II. Facts

         Plaintiff 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).

         On May 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).

         On 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.” (R. 478).

         On 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).

         On 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 therapy. (Id.).

         On 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[1] and paronychia[2] of her toe and prescribed Lamisil. (Id.).

         On 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).

         On 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).

         On May 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).

         On June 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).

         On 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).

         On 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.).

         On 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).

         On 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).

         On July 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.).

         On 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. ...

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