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Wilcox v. Astrue

July 31, 2008

EUGENIA E. WILCOX, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, DEFENDANT.



The opinion of the court was delivered by: Simandle, District Judge

HONORABLE JEROME B. SIMANDLE

OPINION

This matter comes before the Court pursuant to Section 205(g) of the Social Security Act, as amended, 42 U.S.C. § 405(g) (2006), to review the final decision of the Commissioner of the Social Security Administration ("Defendant") denying the application of Claimant Eugenia E. Wilcox ("Claimant") for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("the Act"), 42 U.S.C. §§ 401-434. This Court must determine whether the decision of Administrative Law Judge ("the ALJ"), Joseph A. Pachnowski, that Claimant was not disabled within the meaning of the Act between January 3, 1994 and September 30, 1997, is supported by substantial evidence.

Claimant brings four challenges, arguing that the ALJ: (1) failed to support his determination of her residual functional capacity ("RFC") with substantial evidence; (2) failed to use a medical expert to infer Claimant's disability onset date as required by the Social Security regulations; (3) failed to follow the Social Security regulations regarding vocational evidence; and (4) failed to assess the credibility of Claimant's subjective complaints in a manner consistent with the requirements of the Social Security Administration. Because the Court finds that the ALJ failed to explain his observation that Claimant had "significant additional limitations" beyond those that might enable performance of light work, and the ALJ failed to consider relevant medical evidence of obesity in assessing Claimant's RFC, the Court will vacate the decision of the Commissioner denying Claimant's application for DIB and remand for further proceedings consistent with this Opinion.

I. BACKGROUND

A. Procedural History

Claimant filed applications for DIB and Supplemental Security Income ("SSI") payments on August 24, 1989, and was denied on both requests on March 15, 1991. (R. at 12.) Claimant did not request an appeal regarding the former applications. (Id.) On April 21, 2004, Claimant filed her current applications for both benefits alleging a disability onset date of January 3, 1994, due to the effects of congestive heart failure, asthma, sleep apnea, hypertension, an enlarged thyroid, and obesity. (R. at 87.) Nachelle Broach ("Ms. Broach"), of the Division of Disability Determination Services ("DDS"), assessed Claimant's applications. (R. at 77.) Ms. Broach found that ". . . there [was] insufficient information to rate the claim for the [DIB application], [though] there [was] sufficient [information] for the [SSI application]." (Id.) Ms. Broach found that Claimant met the disability requirement for the SSI application and was approved with an onset date of April 1, 2004.*fn1 (R. at 12, 77.)

However, the DIB application was denied and Claimant filed a request for reconsideration on November 30, 2004, and this too was denied on March 3, 2005. (R. at 39-43.) Claimant filed a request for a hearing on March 22, 2005. (R. at 44.) After the hearing on January 20, 2006, the ALJ issued his decision denying the DIB application on March 15, 2006. (R. at 12, 44.)

The ALJ found that Claimant did not suffer from a disability on or before September 30, 1997, which was the date she was last insured for such benefits. (R. at 12, 80.) On March 27, 2006, Claimant filed a request for review of the ALJ's decision, which was denied by the Appeals Council on May 14, 2007. (R. 296-301, 5-7.) Thus, the decision of the ALJ became the final decision of the Commissioner. Claimant timely filed this action before the Court.

B. Evidence in the Record

1. Plaintiff's Testimony on January 20, 2006

Claimant, Eugenia E. Wilcox, was born on February 16, 1945. (R. at 65.) Claimant received her GED in 1969, completed college, and has a master's degree in education. (R. at 305.) Claimant worked as a full-time teacher and as an on-call substitute teacher from 1976 - 1992. (R. at 96, 305-07.) Her most recent job was at Haddon Heights High School as an on-call substitute teacher in 2002. (R. at 305.)

According to Claimant, her job requirements as a teacher included: standing at and writing on the chalkboard, maintaining discipline while teaching, and carrying 50 pounds of paper (including lesson plan book) occasionally and 25 pounds of paper frequently.*fn2 (R. at 97.) Claimant alleged that her position required her to walk, stand, climb, kneel, handle objects, and write for seven hours. (Id.) In addition, Claimant alleged that she was required to sit for an hour. (Id.)

Claimant testified that her pain became progressively worse over time beginning in January of 1994. (R. at 307-08.) At that time she stopped working because of the unbearable pain in her knees and arms, and drowsiness caused by her hypertension medication. (Id.) During the hearing with the ALJ, Claimant testified that she could not walk more than fifty feet. (R. at 308.) When the ALJ questioned Claimant about a recommended knee surgery, she stated that one of her doctors made the recommendation in 1994 and that the doctor continued to recommend this type of surgery. (R. at 308.) However, Claimant feared the surgery due to negative feedback she received from acquaintances who underwent the surgery. (Id.) Claimant testified that it was hard for her to stand or sit and write on the blackboard due to the pain in her knees and arms. (R. at 309.) During the hearing, Claimant complained that her asthma caused her to have shortness of breath while walking up and down flights of steps at work. (R. at 309.) Claimant stated that she was embarrassed because she fell asleep in class. (Id.)

Although Claimant's Work History Report*fn3 shows that she stopped working in 1992, she testified that she worked for a short while in 1996, 1998, 1999, and 2002 (she earned $130 in 1996, $480 in 1998, $180 in 1999, and $520 in 2002). (R. at 309.) She testified that she went back to work because she loved teaching but could not continue to work because it was hard for her to walk around the school. (R. at 310.) Besides this source of income, the only disability benefit that she received was SSI.

(R. at 310-11.)

Claimant testified that three of her adopted children are her dependents. (R. at 67.) Two of the three dependent children live with Claimant and she testified that since 1993 they have assisted her with bathing, dressing, and shopping. (R. at 312.) Claimant stated she was seen by various doctors including Dr. Goldstein, Dr. Colopinto, and Dr. Siddiqi. (R. at 313.) Claimant testified that both Dr. Goldstein and Dr. Colopinto diagnosed her with fibromyalgia.*fn4 (Id.) Claimant also discussed her weight gain and stated that it could be caused by the steroids given to her to assist her in moving her arms. (R. at 314.) Claimant continued to explain that she suffers from sleep apnea, and that she uses a Continuous Positive Air Pressure ("CPAP")*fn5 machine to help her sleep at night. (R. at 315.) Claimant also spoke about her trouble with sitting and stated that it was hard for her to sit with her back erect due to the pain it caused her. (R. at 316.) She reiterated that these were the reasons why she gave up teaching. (Id.) When asked by her attorney, Mr. Polonsky, if she thought she could do any other work that would require her to be on her feet for more than two hours she stated that she could not because of this pain. (R. at 317.) Even though Claimant had a cane with her at the hearing, she refused to use one ten years prior to the hearing because she was too embarrassed and wanted to give off the image that she was a healthy teacher. (Id.) During the ALJ's examination of Claimant, she stated that there was another health condition that plagued her after 1994 -- incontinence, which she claimed began between 1993 or 1994. (R. at 320.)

2. Medical Reports Prior to September 30, 1997 (Date Last Insured)

a. Treatment History by Dr. Jack Goldstein-Treating Physician

A prescription note dated June 19, 1990, is the only documentation in the record that shows Claimant was seen by Dr. Jack Goldstein ("Dr. Goldstein"), a doctor of osteopathic medicine. (R. at 145.) During this appointment Dr. Goldstein diagnosed Claimant with fibromyalgia and arthritis in the spine and knee. (Id.) Dr. Goldstein opined that she was totally disabled. (Id.)

b. Treatment History by Primary Physician

Claimant's primary care physician, Dr. Christopher Colopinto ("Dr. Colopinto"), a doctor of osteopathic medicine, treated her from May 9, 1982 to October 9, 2005. (R. at 246, 277-294.) During the relevant time period, Dr. Colopinto treated Claimant's degenerative joint disease and hypertension. (Id.) On February 22, 1990, Dr. Colopinto wrote that Claimant weighed 219 pounds and her blood pressure was 120/70. (R. at 293.) On March 20, 1990, Dr. Colopinto noted that Claimant weighed 221 pounds and her blood pressure was 110/70. (R. at 290.) During this visit Claimant complained of neck pains she experienced at night. (Id.) In addition, Dr. Colopinto diagnosed Claimant with degenerative joint disease, and placed her on Voltaren.*fn6 (Id.) On April 18, 1990, Dr. Colopinto recorded Claimant's back and shoulder pain and her weight at 227 pounds. (R. at 289.) Claimant was seen again by Dr. Colopinto on May 22, May 31, and October 8 of 1990. During these visits Claimant alleged she experienced the same back, neck, and shoulder pains; and her weight and blood pressure fluctuated, with her highest weight being 226 pounds and her highest blood pressure 100/70 -- though this is considered "low normal" blood pressure. (R. at 287-88.) Specifically on October 8, 1990, Dr. Colopinto noted swelling in Claimant's hands, inflammation in her uvula*fn7 , hoarseness in her voice, and she complained that her coughs got worse at night.

(R. at 287.) Dr. Colopinto prescribed her Codeine*fn8 to relieve her pain and Amoxil*fn9 to treat her infections. (Id.)

Claimant saw Dr. Colopinto a year later on September 28, 1991. The doctor noted that Claimant weighed 239 pounds and her blood pressure was 120/80. (R. at 287.) Dr. Colopinto also made note that Claimant needed all of her medications and added Vicodin*fn10 and Procardia*fn11 to her list of medications. (Id.) Another year passed before Claimant went to see Dr. Colopinto again, on September 10, 1992. (R. at 286.) At that time he only noted her weight -- 242.5 pounds. (Id.) On June 19, June 21, October 8, and October 21 of 1993, Claimant's blood pressure and weight were monitored and she was prescribed all of the medication she previously received. (R. at 284.)

On October 22 to October 25 of 1993, Antinuclear Antibody*fn12 and Rheumatoid Fact*fn13 tests were performed on Claimant and her results were in normal range, thus Claimant did not suffer from rheumatoid arthritis. (R. at 281-82.) On February 18, 1994, Dr. Colopinto refilled Claimant's prescription for Procardia. (Id.) On April 28, 1994, Dr. Colopinto noted her hypertension and degenerative joint disease. (R. at 280.)

On October 3, 1995, Dr. Colopinto noted Claimant's physical progress in relation to her impairments. (R. at 279.) Dr. Colopinto stated that her heart had a regular rhythm with no murmurs, her abdomen had no masses, her weight was 242 pounds, and her blood pressure was 134/90. (Id.) On June 25, 1996, Dr. Colopinto's notes were similar besides her increase in weight and blood pressure (252.75 pounds and 160/90, respectively). (Id.)

c. Treatment History at Osborn Family Health Center--Treating Physicians

Claimant sought treatment at the Osborn Family Health Center ("OFHC") from July 19, 1996 to December 30, 2002. (R. at 165-96.) During the relevant time period, the doctors at OFHC only treated Claimant's hypertension, obesity, fibromyalgia, degenerative joint disease, and asthma. (Id.) On her initial visit, Claimant stated that she suffered from chest pains and dizziness. (R. at 194.) Claimant also stated that she was interested in losing weight. (Id.) At that point in time she weighed 257.5 pounds and her blood pressure was 164/88. (Id.) Dr. Thomas Sexton ("Dr. Sexton"), the primary physician who cared for Claimant, noted that Claimant had no neck vein distension*fn14 , no masses or enlargement of her thyroid, and her heart was at a regular rhythm (no murmur or gallop). (R. at 194.) Dr. Sexton also noted that Claimant did not suffer from any sensory motor cerebellar*fn15 abnormalities; her CN II-XII*fn16 were intact; her Babinski's reflex*fn17 was normal; she had no edema*fn18 , cyanosis*fn19 or clubbing in her extremities; and none of her lymph nodes were palpable. (R. at 195.) Dr. Sexton noted that Claimant suffered from hypertension and obesity. (Id.) On July 22, 1996, the examination chart showed that Claimant may need a stress test, her weight was 260 pounds, and her blood pressure improved to 140/70. (R. at 193.) During Claimant's examination on July 26, 1996, Dr. Sexton advised her of her high cholesterol. (R. at 192.) On September 17, 1996, Claimant's examination chart showed that she weighed 260 pounds, her blood pressure was 130/90, and she was still interested in losing weight. (R. at 191.) Dr. Sexton also treated Claimant's hypertension with Procardia, as did Dr. Colopinto. (Id.) In addition, Dr. Sexton placed Claimant on a new drug called Redux*fn20 (15mg), and advised her to exercise, which included walking, due to the Claimant's interest in losing weight. (Id.)

Claimant returned to the OFHC for a follow-up appointment and to refill her prescription of Procardia on October 1, 1996.

(R. at 190.) Her weight at that time was 258 pounds and her blood pressure was 150/96. (Id.) Dr. Sexton informed her about her hypertension and obesity again, and continued to prescribe her Procardia (3mg) and Redux (15mg). (Id.) On October 1, 7, and 21 of 1996 Dr. Sexton noted the fluctuation in Claimant's weight and blood pressure, and again noted her hypertension and obesity. (R. at 188, 189.)

On December 19, 1996, Claimant's blood pressure was listed as 156/88 and Dr. Sexton stopped her prescription of Redux, yet noted that Claimant was noncompliant in taking her medication to treat her hypertension. (R. at 186.) In addition, Dr. Sexton prescribed Adalat*fn21 to treat her hypertension instead of Procardia. (Id.) On January 10, 1997, Claimant refused to be weighed and Dr. Sexton recorded her blood pressure as 150/92.

(R. at 185.) Claimant told Dr. Sexton that she wanted him to examine her arthritis because she complained that it was getting worse. (Id.) During this visit, OFHC first diagnosed her with fibromyalgia and degenerative joint disease. (Id.) On February 18, 1997, the Claimant complained of having an asthma attack and Dr. Sexton noted that Claimant had a cough and wheezed. (R. at 184.) Dr. Sexton prescribed her Cedax*fn22 , Proventil*fn23 , and Robitussin. (Id.) From April 9, 1997 to July 21, 1997, OFHC noted that Claimant weighed 260 pounds and her blood pressure was 150/90. (R. at 183.) Dr. Sexton refilled her medication and noted that Claimant was feeling well. (Id.)

d. Dr. Siddiqi - Treating Physician

Claimant was referred by both Dr. Ira Stark, a physician for DDS, and Dr. Colopinto to receive an examination by Dr. Tariq Siddiqi, a neurosurgeon, in order to get a more thorough evaluation of Claimant's conditions. (R. at 270.) On March 5, 1990, Dr. Siddiqi noted the same pain that Claimant complained of to Dr. Stark. (Id.) He observed that her medical history included hypertension and a heart murmur and that at the time of the visit she was taking Lozol with Motrin, Tylenol #3, and Volteran. (Id.) Dr. Siddiqi stated that Claimant was 5'7" tall and weighed 212 pounds. (Id.) Claimant's nerve examination produced results within the "normal limits," and there was mild tenderness in the paracervical area on the right side. (Id.)

Dr. Siddiqi noted that she had some difficulty moving both shoulders above the horizontal. (Id.) Similar to Dr. Stark's examination, Dr. Siddiqi found no focal motor deficit. (Id.)

Dr. Siddiqi wrote "I think Eugenia Wilcox may have: degenerative cervical arthritis and possible involvement of both shoulder joint areas." (Id.) Dr. Siddiqi scheduled a CT scan of her cervical spine and stated that she was a candidate for an orthopedic opinion regarding her shoulder. (Id.)

On April 5, 1990, Dr. Siddiqi wrote to Dr. Stark and Dr. Colopinto, informing the doctors of his follow-up appointment with Claimant. (R. at 144.) He noted that Claimant had "some spondylitic changes"*fn24 in her cervical spine, and he added that there was no evidence of a herniated disc. (R. at 144.) Dr. Siddiqi discussed these changes with Claimant and said they were predominantly due to arthritis, and for this he gave her a prescription for Vicodin. (R. at 122.)

e. Dr. Ira Stark - Consultative Physician

Documentation of Claimant's impairments dates back to her initial visit with Dr. Stark, on May 9, 1983. (R. at 140.) Claimant's most recent visit with Dr. Stark took place on March 20, 1990; he diagnosed her with cervical degenerative joint disease due to the results of her CT scan of her cervical spine. (Id.) On February 14, 1990, Dr. M. Goldenberg, the physician who administered the CT scan, noted that the scan revealed ventral spondylitic and degenerative changes in her cervical spine. (R. at 140-42.) Dr. Stark noted in Claimant's range of motion evaluation that her muscles "were equal bilaterally with no decreased range of motion." (Id.) He also noted Claimant's pain, and stated the pain in ...


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