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Sams v. Berryhill

United States District Court, N.D. Oklahoma

May 22, 2018

PAULA J. SAMS, Plaintiff,
v.
NANCY A. BERRYHILL, [1] Deputy Commissioner for Operations, performing the duties and functions not reserved to the Commissioner of Social Security, Defendant.

          OPINION AND ORDER TO DENY PLAINTIFF'S APPEAL

          COHN MAGISTRATE JUDGE.

         This matter is before the undersigned United States Magistrate Judge for decision. Paula J. Sams (“Plaintiff”) seeks judicial review of the Commissioner of the Social Security Administration's decision finding of not disabled. As set forth below, the Court DENIES Plaintiff's appeal and AFFIRMS the Commissioner's decision in this case.

         I. Procedural Background

         On December 30, 2013, and January 7, 2014, Plaintiff respectively filed applications for Disability Insurance Benefits (“DIB”) under Title II and disability benefits under XVI of the Social Security Act, 42 U.S.C. §§ 401-433, 1382-1383 (“Act”), with a last insured date of December 31, 2014, [2] and a disability onset date August 9, 2011. (Tr. 30). On November 19, 2015, the Administrative Law Judge (“ALJ”) found Plaintiff was not disabled within the meaning of the Act. (Tr. 27-50). Plaintiff sought review of the unfavorable decision, which the Appeals Council denied on December 9, 2016, thereby affirming the decision of the ALJ as the “final decision” of the Commissioner of the Social Security Administration. (Tr. 1-6).

         On February 13, 2017, Plaintiff filed the above-captioned action pursuant to 42 U.S.C. § 405(g) to appeal a decision of Defendant denying social security benefits. (Doc. 1). On June 26, 2017, Defendant filed an administrative transcript of proceedings. (Doc. 14). On August 29, 2017, Plaintiff filed a brief in support of the appeal. (Doc. 147(“Pl. Br.”)). On October 27, 2017, Defendant filed a brief in response. (Doc. 20 (“Def. Br.”)). On November 14, 2017, Plaintiff filed a reply. (Doc. 22 (Reply)).

         II. Issues on Appeal

         On appeal, Plaintiff argues “[t]he ALJ erred as a matter of law in failing to properly consider the opinion of the treating physician.” (Pl. Br. at 4).[3]

         III. Facts in the Record[4]

         A. Background

         Plaintiff was born in June 1972 and thus is classified by the regulations as a younger individual through the date of the ALJ decision. (Tr. 230); 20 C.F.R. §§ 404.1563(c), 416.963(c). Plaintiff alleged disability due to: (1) Degenerative Disc Disease, issues with lumbar and cervical spine; (2) bone spurs; (3) anxiety; (4) shoulder pain; (5) migraine headaches; (6) left arm and elbow pain; (7) knee pain and swelling; (8) ankle swelling, and; (9) numbness in her hands and fingers. (Tr. 70-84, 106). Plaintiff graduated with an associate degree in nursing and an associate degree in liberal arts. (Tr. 68).

         B. Summary of Relevant Treatment for Physical Impairments

         1. Tulsa Pain Consultants: Andrew F. Revelis, M.D.; Martin L. Martucci, M.D.; Brad Helton, PA-C

         On June 30, 2014, Plaintiff sought follow-up treatment for lower back pain. (Tr. 710). Dr. Revelis noted that Plaintiff maintained on Norco at 7.5 mg t.i.d. p.r.n. to alleviate the pain. (Tr. 710). Plaintiff reported not getting adequate relief, had no significant relief from injection therapy, and still experienced low back pain of a level six out of ten. (Tr. 710). Upon examination, Dr. Revelis observed that Plaintiff did not use an assistive device to walk, was able to stand from a seated position without any significant difficulties or limitations, and was able to move all four extremities. (Tr. 710). Dr. Revelis noted that there were no new signs of gross motor or sensory deficits. (Tr. 710). Dr. Revelis assessed Plaintiff with post lumbar fusion pain and lower extremity radiculopathy. (Tr. 710). Dr. Revelis started Plaintiff on Xartemis, continued Norco, and recommended follow-up assessment in three months, or sooner if problems arise. (Tr. 710).

         In the subsequent visits from August 28, 2014, through June 15, 2015, the notes indicated continued report of experiencing a pain level between five and seven on a scale where ten is the highest, and subsequent adjustments to medications and dosages. (Tr. 695-708). In all of the records within that time period the notes indicated that Plaintiff: (1) did not use an assistive device to walk; (2) was able to stand from a seated position without any significant difficulties or limitations; (3) was able to move all four extremities, and; (4) there were no new signs of gross motor or sensory deficits. (Tr. 695-708).

         2. Saint John Clinic: Brent Laughlin, M.D.

         On July 17, 2014, Plaintiff reported experiencing left knee pain for over two years and was treating the pain with ibuprofen. (Tr. 761). Plaintiff reported that the left knee never “locked, ” however it had been painful and swollen at times which limited ambulation. (Tr. 761). There was previous arthroscopy of the left knee and treatment for torn medial meniscus. (Tr. 761). Dr. Laughlin assessed Plaintiff chondromalacia of the left knee. (Tr. 762).

         On February 2, 2015, Plaintiff reported experiencing back pain and left leg radiculopathy. (Tr. 766-67). Dr. Laughlin noted no motor or sensory losses, and a positive SLR bilaterally and assessed with “backache.” (Tr. 767).

         On October 8, 2015, Plaintiff reported that she was experiencing back pain. (Tr. 829). It was noted that she had an artificial disc in 2011 and more surgery was not recommended. (Tr. 829). Plaintiff reported that ever since surgery, she had experienced continued back pain, pain radiating to both legs, and a significant limitation in activities. (Tr. 829). Upon examination, Dr. Laughlin observed no motor or sensory losses, positive Phalen's and Tinel's signs, decreased sensation in the hands, and a tender left knee and shoulder in response to firm palpation. (Tr. 829). Dr. Laughlin assessed Plaintiff with radiculopathy of the lumbar region and tendonitis of the left knee. (Tr. 829).

         3. Progress Notes: James Griffin, M.D., Antoine Jabbour, M.D.; Colby Coulson, M.D.

         In a treatment record dated September 8, 2014, Plaintiff reported moderate left knee pain that is exacerbated by climbing stairs and denied any additional symptoms. (Tr. 787). Dr. Griffin noted that Plaintiff remained “ABLE to perform their present job duties at this time.” (Tr. 787). Upon examination, Dr. Griffin noted no knee effusion, the MRI scan revealed mild chondromalacia and mild malalignment of the patella and that day's x-rays of the left knee were normal. (Tr. 787). Plaintiff did not get relief from physical therapy and Dr. Griffin administered injections to the patella which provided good immediate relief. (Tr. 787). Dr. Griffin noted “exquisite tenderness” in the patellar tendon region, range of motion was full and painless with active flexion and extension, and there was no crepitance, no instability upon manual testing, and strength was 5/5 with flexion and extension. (Tr. 788). Dr. Griffin observed that Plaintiff's gait was normal and the radiology results did not demonstrate any fractures or osteoarthritis. (Tr. 788). Dr. Griffin assessed Plaintiff with left patellar tendonitis and left popliteal tendinitis. (Tr. 788).

         On September 30, 2014, Plaintiff sought follow-up treatment for left knee pain. (Tr. 789). It was noted that her knee pain was moderate, had an aching quality, and that she has partially responded to treatment of NSAIDs and steroid injections. (Tr. 789). The notes where substantively identical to those in the September 8 record, including that Plaintiff's gait was normal and that she remained “ABLE to perform their present job duties at this time. (Tr. 789-90). Dr. Griffin noted the previous injections provided relief for approximately two weeks and administered more injections. (Tr. 789-90).

         On October 30, 2014, Plaintiff sought follow-up treatment for left knee pain and right hip pain. (Tr. 791). The notes where substantively identical to those in the September 8 and September 30 records, including that Plaintiff's gait was normal and that she remained “ABLE to perform their present job duties at this time. (Tr. 791-92). It was noted that she started to complain of pain over the right iliac crest (hip). (Tr. 791). In addition to left patellar tendonitis and left popliteal tendinitis, Dr. Griffin assessed Plaintiff with low back pain. (Tr. 792). Dr. Griffin noted the previous injections provided relief for approximately four weeks and administered more injections to the left knee and right iliac crest. (Tr. 791-92).

         On November 25, 2014, Plaintiff sought follow-up treatment for left knee pain and right hip pain. (Tr. 793). The notes where substantively identical to those in the October 30 record, including that Plaintiff's gait was normal and that she remained “ABLE to perform their present job duties at this time. (Tr. 793-94). Dr. Griffin noted the previous injections provided relief for approximately four weeks, however, noted that her patellar tendinitis had “been ...


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