PASTUCH v. COMMISSIONER OF SOCIAL SECURITY, No. 3:2017cv00989 - Document 21 (D.N.J. 2018)

Court Description: OPINION filed. Signed by Judge Anne E. Thompson on 5/1/2018. (mps)

Download PDF

PASTUCH v. COMMISSIONER OF SOCIAL SECURITY Doc. 21 NOT FOR PUBLICATION UNITED STATES DISTRICT COURT DISTRICT OF NEW JERSEY KATHLEEN J. PASTUCH, Plaintiff, I I I Civ. No. 17-989 j OPINION ! I v. COMMISSIONER OF SOCIAL SECURITY, Defendant. 1 R e c EI VE D I I I 0 1 2018 AT 8j30 M . WILLIAM T. WALSH CLERK ! I THOMPSON. U.S.D.J. INTRODUCTION i This matter comes before the Court upon the appeal by Plaintiff Kathleen J. Pastuch ("Plaintiff') of the final administrative decision of Defendant Commissioner lof the Social Security Administratfon (''Defendant") regarding Plaintiffs claim for Social lsecurity disability I insurance benefits and supplemental security income ("SSI"). (ECF No. 1.) 1fhe Court has I decided this appeal based on the submissions of the parties without oral argu'1ent pursuant to Federal Rule of Civil Procedure 78(b). For the reasons set forth herein, the C9urt will remand for I further consideration consistent with this Opinion. BACKGROUND This case concerns Plaintiffs application for disability benefits. 1 At Je time of alleged I disability onset, Plaintiff was a 47-year-old woman reportedly unable to due to symptoms I from physical and psychological impairments. (R. at 17, 24, 39, 93.) Her I included degenerative disc disease of the cervical spine at C3-C4 and C4-C5 and of the lumbar spine at I I 1 All citations formatted as "R. at_·"refer to the Administrative Record (E€F No. 14), provided by Defendant pursuant to Local Civil Rule 9.l(c)(2). 1 I 1 Dockets.Justia.com . I L5-S 1; bilateral shoulder tendonitis; asthma; hypothyroidism; and mental health issues including I anxiety disorder, panic attacks, and majo;r depression. (R. at 14, 18, 96, 202.) I I Plaintiff has a high degree, with some online college courses. (R. at 39, 203, 292.) I She has worked in office positions. (R. at 23, 39-43, 204, 218-25.) Between 2007 and February I 2013, she worked as an administrative assistant for a production manager at Qistek Inc. (R. at 39, 187-89, 204.) She spent the prior ten years as a receptionist, in systems admirlistration, and in accounts payable for United Natural Foods. (R. at 39-41, 186-89, 204). In March 2012, Plaintiff I had a car accident which kept her out of work until July 2012. (R. at 18, 44.) Her anxiety and ! physical limitations increased from the accident. (R. at 44-45, 53, 294, 306, 3p9.) Between her return to work in July 2012 and February 2013, Plaintiff had trouble meeting I following directions, and maintaining focus. (R. at 44-46; see also R. at 203, e25.) She was let I, go on February 28,-2013 (R. at 44, 46-47, 63-64) and has not worked at 39). In April 2013 and December 2014, respectively, Plaintiff filed applications for disability insurance benefits and SSI, alleging a disability onset date of February 28, 20113. (R. at 11, 93, . . I 106-07, 183-84.)2 On August 21, 2013, Plaintiffs disability application was penied. (R. at 12529.) Reconsideration was likewise denied. (R. at 134-39.) Plaintiff requested !a hearing before an I Administrative Law Judge ("AU"). (R. at 141-47). On April 28, 2015, ALJ ShiHin ! conducted a comprehensive hearing with Plaintiff, represented by counsel, where Plaintiff I explained the timeline of her disability, work history, limitations, and abilities. (See R. at 31-92.) I. Plaintiff's Testimony, Submissions, and Claimed Disabilities 1 Plaintiff claims physical and psychological impairments that render hbr disabled. I Plaintiffs undated Disability Report listed the following medical conditions: severe anxiety 1 I Plaintiffs application for SSI does not appear in the record but is Administrative Law Judge Beth Shillin. (Def.'s Br. at 2 n.1, ECF No. 19.) 2 2 I in the decision by 1 ,. I I I I I disorder, panic attacks, major depression, hypothyroidism, and asthma. (R. at 202.) At the time, . I she was taking Advair and ProAir for asthma, Klonopin for anxiety, Levothroid for hypothyroidism, and Lexapro for anxiety and depression. (R. at 205.) She re4rted receiving I treatment from Dr. Ranjit Mitra for anxiety disorder, panic attacks, and major 'depression from May 2007 until 2009. (R. at 206.) She reported receiving treatment for anxietJ, depression, hypothyroidism, asthma, and borderline diabetes from Dr. John Joseph Smith beginning at an unknown time (indicated with a question mark), with her last visit in FebruJ 2013. (R. at 206.) At the hearing, Plaintiff testified to shoulder pain, exacerbated by the iarch 2012 car I accident. (R. at 44-46.) Thanks to injections she received, her accident-related back pain 'improved by December 2012, and her back was pain-free until shortly before hearing, although it gets stiff when she sits for too long. (R. at 18, 48, 294.) Plaintiff nJeds to stand up I and stretch for 10 to 15 minutes for every 45 minutes she is seated or her legs ]become numb. (R. at 49.) She experiences pain when reaching with her left, non-dominant hand that radiates from her shoulder down to her elbow. (R. at 49-50.) Plaintiff testified that she first experienced anxiety and panic attacks at age five, has I I experienced anxiety and depression throughout her adult life, and occasionally the attacks cause I her to pass out. (R. at 58, 62-63.) In her last job, she passed out during meetings (R. at 58), and ! she credits losing all prior jobs to issues with managing stress and anxiety (R.j at 59). Plaintiffs anxiety makes social interaction difficult; when coworkers approached her un:announced, she would "lash out, jump out of [her] chair." (R. at 52; see also R. at 203 ("Due L the anxiety I I disorder [she] began to make simple mistakes repeatedly due to being in an open area where I people could walk up on [her] without [her] knowing."); R. at 225.) The car accident increased her anxiety. (R. at 44-46.) She stopped driving in 2014 due to stress. (R. at 53-54, 229, 290.) i 3 At the time of the hearing in 2015, Plaintiff lived in an apartment with her boyfriend, I Douglas, and his mother. (R. at 54-55.) She and Douglas were roommates ,d friends before becoming involved. (R. at 55.) Soon after the hearing, Plaintiff, Douglas, anQ his mother all . I . moved into a house together. (R. 55-56, 182). Plaintiff testified that she and goes grocery shopping if someone accompanies her, provided she can go off hours and getl out of the store quickly. (R. at 65-66; see also R. at 233.) I l After losing her job, Plaintiff volunteered as the caretaker of a friend' autistic, homeschooled 13-year-old child. (R. at 68.) She ensured he took his medication in ithe morning and I made him lunch; when he re-entered the school system, she drove him to (R. at 69-70.) She was only able to drive him to school for a two-month period at the end became too stressful. (R. at 70.) Plaintiff testified that she does not leave the . 2013 before it for meetings I or activities, like church, going to a movie, or eating at a restaurant. (R. at 66]67.) In her April 2013 Adult Function Report, Plaintiff attested to taking care of her cats, I watching television, reading, and using a computer. (R. at 226-27, 229.) She cooks but no longer . I enjoys it, does laundry, and washes dishes. (R. at 228). She rarely goes outside because of her panic attacks and anxiety. (R. at 228-30.) She is able to handle her own finanles. (R. at 229.) Her impairments cause difficulties with memory, concentration, following instructions, and I getting along with others. (R. at 231.) She has difficulty being around peopleJmostly strangers and crowds, and is unable to concentrate. (R. at 227, 230.) She is good at written instructions, but struggles with verbal instructions-both understanding and lmembering them. I (R. at 231.) She gets along well with authority figures provided they are not Yf lling or threatening. (R. at 232). She handles stress very poorly, handles changes in her routine very I poorly, and has unusual behaviors of shaking and scratching or clawing her skin. (R. at 232.) ! ! 4 Plaintiffs boyfriend (then-friend and roommate) completed a third party function report in May 2013, confirming that Plaintiff cares for her cats and regularly uses a Lmputer. (R. at 210). He wrote that Plaintiff drives him to medical appointments and the ph+acy, although she remains in the car, and shares household chores. (R. at 211, 214). She cannot be in crowded places, has restless and disrupted sleep, sometimes needs encouragement to et because of depression, sometimes needs reminders to take medication on days when she ok, and has difficulties with memory, concentration, understanding, and completing tasks! (R. at 211-16.) II. Medical Evidence Considered by the ALJ: Treating Medical A. Dr. Ranjit Mitra, M.D., Treating Psychititrist (2007-2009) Plaintiff regularly visited Dr. Ranjit Mitra, M.D., from May 2007 to February 2009. (R. I at 274--82.) Dr. Mitra's records are largely illegible handwritten notes. AU Shillin extrapolated "these records reflect only changes to the claimant's medications and do not ,lggest any impairment in her functioning or exacerbation of her anxiety. Mostly, these treatment records reflect a history of medication refills and do not report any substantive findinls." (R. at 20.) The Court notes that Dr. Mitra fitst diagnosed Plaintiff's mental healJ conditions. At the first visit in May 2007, Plaintiff's chief complaints related to her mood and pLic attacks (R. at 274), and Dr. Mitra diagnosed Plaintiff with general anxiety disorder and depLssion, found her Global Assessment of Functioning ("GAF') score was 50, and prescribed Kllopin (a sedative) and another medication (R. at 275). Plaintiff never demonstrated suicidal or hbmicidal ideation and at each visit Dr. Mitra continued her medicine regimen. (R. at 276-82.) B. Dr. Serge Menkin, M.D., Post-Accident Treating Specitilist (2012) After her March 2012 car accident, Plaintiff sought treatment from Drl Serge Menkin, M.D., at the Center for Joint and Spine Relief. (R. at 286-87.) She reported hladaches, neck and 5 lower back stiffness, and numbness and tingling in her upper extremities on 10, 2012. 3 (R. at 286.) She also reported anxiety, worsening depression, and difficulty with $1eep. (R. at 286.) I Plaintiff said she had been undergoing physical therapy, acupuncture, and therapy post-accident. (R. at 286.) She reported difficulty with daily activity due to p1n. (R. at 286.) She had been taking Skelaxin (a muscle relaxant) and Diclofenac (a non-steroidal anti-inflammatory drug ("NSAID")) without significant relief of symptoms as well as undergoing therapy with modest, temporary relief of symptoms. (R. at 286.) She rated her pain 8/10 on the Visual Analog I Scale and reported limitations in range of motion of the left shoulder, lower back pain with radiation, and paresthesias in bilateral upper extremities, worse on the left. (J. at 286.) On physical examination, Dr. Menkin observed antalgic gait; limited Lge of motion in her cervical spine, shoulders, and lower back; positive signs on cervical and I facet loading maneuvers; severely decreased range of motion on the left side; and that Plaintiff required ! I assistance to and from the exam table. (R. at 287.) Dr. Menkin diagnosed bilateral shoulder tendonitis, left shoulder adhesive capsulitis, left cervical radiculopathy, and lLbar sprain. (R. at 287.) He recommended ongoing physical therapy; Mobic (an NSAID), Robl (a muscle relaxant), and Percocet (an opioid) for pain; and a left shoulder MRI to rule oli a rotator cuff I i tear. (R. at 287.) The records were forwarded to Plaintiff's Primary Care Physician ("PCP"), Dr. I John Joseph Smith, M.D., on May 24, 2012. (R. at 288.) C. Dr. John Joseph Smith, M.D., Primary Care Physician (through 2013) The records provided from Plaintiff's PCP are sparse. Plaintiff undeJent routine testing on March 17, 2011, including a metabolic panel, thyroid function panel, and Lnalysis. (R. at . I 283-85.) Plaintiff had another appointment with Dr. Smith on August 22, (R. at 289.) I I I 3 The notes describe it as a "Follow-Up Patient Visit." (R. at 286 ("The patierlt returns for reevaluation of symptoms related to a motor vehicle accident on March 23, 201:2.").) 6 I I D. Dr. Kathleen Waldron, Ph.D., APN-C, Psychologist (Jan. Dr. Kathleen Waldron, Ph.D., APN-C, performed an intake evaluation on January 10, 2014. (R. at 306--09). Plaintiff reported that she 2015) ! psychiatric bk alcoholic from age 18 until in 2007 she went to the Trinitas emergency been a severe I they determined I she was self-medicating anxiety with alcohol, and they referred her to Dr. Mitra for treatment. . I (R. at 306, 309.) She reported that she left Dr. Mitra in 2009 because he was: discontinuing her I medication and telling her she no longer needed it. She then received psychiatric treatment from I her PCP, who prescribed Lexapro (a Selective Serotonin Reuptak:e Inhibitor !("SSRf')) and I increased her Klonopin dosage. (R. at 306, 309.) She stopped receiving psychiatric treatment in I 2013 when she lost her job and could not afford her PCP appointments. (R. Jt 306, 309.) ! Plaintiff reported lifelong anxiety beginning in childhood; that she her job in March i 2013 because she was unable to focus or get things done; and that she had sttess at home due to a difficult relationship with the friend's mother she lives with. (R. at 306.) "Sobe of her early I history is contributing to her symptoms since she did not have a good relatiotship with her mother." (R. at 306.) Dr. Waldron noted that Plaintiff lacked suicidal or homicidal ideation or I paranoia, but reported hearing "phantom noises" such as bells and knocking at night. (R. at 306.) I On mental status exam, Dr. Waldron noted Plaintiff was alert and interactiveJ had excessively I loud speech, restricted affect, partially intact insight, and depressed and anxiJus mood; and had I intact cognition, judgment, and thought processes. (R. at 306-08.) She diagnosed recurrent and I I chronic major depressive disorder and anxiety disorder. (R. at 308.) She assigned a GAF score of I 55 and prescribed Lexapro and Buspirone (an anxiolytic). (R. at 309.) Although not mentioned in the AU' s decision, Plaintiff returned to Dr. Waldron in I January 2015. (R. at 310-14.) Dr. Waldron noted that Plaintiff was "less dep*ssed and anxious I 7 since we switched to Paxil CR." (R. at 310.) Dr. Waldron also noted that . I "continued to I sleep well with Seroquel." (R. at 310.) Plaintiffs January 2015 mental. reflected normal, intact, or unremarkable markers across' all categories. (R. at 311-131) Dr. Waldron I continued prescribing Paxil and Seroquel. (R. at 313.) Plaintiff again retumd,d to Dr. Waldron in I April 2015. (R. at 315-18.) Plaintiff reported stress related to moving and boyfriend's mother's surgery. (R. at 315.) Dr. Waldron wrote "the medicine has helped Jer to not get too anxious or depressed." (R. at 315.) The mental status exam was again normal!. (R. at 316-18.) Dr. Waldron continued Plaintiffs existing prescriptions. (R. at 318.) Dr. Waldron provided a medical source statement dated April 1, i (R. at 303-05.) I Using the form check boxes, she opined that Plaintiff had marked to severe lfmitations in her ability to interact with co-workers, supervisors, and the public, to use to function independently, to maintain attention and concentration, and to deal with workplace stress. (R. at I 303.) In narrative, Dr. Waldron explained that Plaintiff "has extreme anxietylin public places. . I Mood can be depressed and unstable. Stress exacerbates all symptoms." (R. *t 304.) Again using the check boxes, Dr. Waldron opined that Plaintiff has a fair ability to underJtand, remember, I and carry out simple instructions, but poor ability to understand, remember, fid carry out ! detailed or complex instructions. (R. at 304.) In narrative, she noted Plaintiff'is "poor coping skills." (R. at 304.) Using the check boxes in a final section, Dr. Waldron marked limitations in Plaintiffs ability to make personal social adjustments, moderate to I in I narrative "Client has difficulty with social interactions." (R. at 304-05.) E. Dr. Juhee Gupta, M.D., Primary Care Physician (May 2014Apr. 2015) Dr. Juhee Gupta, M.D., treated Plaintiff regularly between May 2014 April 2015, and I the Record includes partly legible handwritten notes memorializing those visits. (R. at 320-55). I 8 In a patient history taken on May 5, 2014,4 Dr. Gupta noted that Plaintiff reported receiving i I steroid injections in her left shoulder after her 2012 accident as well as to a herniated disc in I her neck and lumbar spine. (R. at 340.) She complained of migraines, diabetes II, asthma, and chronic bronchitis; she reported smoking a half-pack of per day. (R. at 340.) After conducting bloodwork, he prescribed Synthroid for hypothyroiJsm. (R. at 340-42.) Plaintiff returned to the office on May 30, 2014 to discuss her blood Lork results, and reported difficulty with sleeping, anxiety, constipation, dry skin, and migraile headaches once per month. (R. at 342.) An APN-C in Dr. Gupta's office noted Plaintiff deniL taking any medication "except her bipolar and anxiety medications prescribed by her pslychiatrist Dr. Waldron." (R. at 342.)5 Plaintiff was described as not in acute distress after Jer physical exam. A treatment plan, including medications, was prepared for hypothyroidism, hJerlipidemia, migraines, and Vitamin D deficiency. (R. at 343.) Handwritten notes dated June 2014 to April 2015 confirm Plaintiffs continuing visits to Dr. Gupta's office and medication regimen. 6 (R. at 320-55.) Plaintiff had a 1attery of tests regarding pulmonary function on June 6, 2014. (R. at 334--39.) On June 20, t014, Plaintiff returned for blood work, not in any acute distress, and reported two migrain¢ attacks since her last visit. (R. at 344.) Dr. Gupta's office prescribed Fioricet for migraines in addition to her continuing prescriptions. (R. at 344.) Plaintiff complained of fatigue in Augqst 2014 (R. at 331), I and Dr. Gupta recommended a sleep study and a sleep machine, pending authorization. (R. at I 4 This visit is called a "check up" and appears to be the oldest visit with Dr. $upta in the Record. Dr. Gupta's notes, there are many references to "bipolar" (see, :e.g., R. at 320, 321, 323, 325, 326, 342, 348, 351, 352), but it appears this may be an inference (and not a diagnosis) based on Plaintiffs psychiatric medications of Seroquel and Pax.ii. 6 The ALJ decision did not cite or discuss any of Dr. Gupta's records or notes. 5 Throughout ! 9 345-46; see also R. at 333 (results of the August 2014 sleep apnea study).) oh October 29, 2014, Plaintiff remained pending approval for a CPAP machine. (R. at 350.) On November 7, 2014, Plaintiff complained of left neck and left arm pain. (R. at 350.) I Dr. Gupta noted Aleve was not effective in reducing her pain and prescribed 500 mg Naproxen (an NSAID). (R. at 325.) Eleven days later, Dr. Gupta noted that she had chronic left shoulder pain and takes Naproxen for relief, and that x-rays and MRI were benign. (R.lat 351.) She had I normal range of motion in all extremities. (R. at 351.) In December 2014, again reported left shoulder pain, noted as stable with Naproxen. (R. at 352.) Dr. Gupta refeJred her for an ultrasound of her neck. (R. at 324, 352.) The December 2014 thyroid ultrasold revealed three I ! solid nodules in the vicinity of her upper right thyroid gland lobe. (R. at 332. Plaintiff reported a March 2015 fall resulting in lacerations, a spraineq left wrist, and i bruised left ribs; she went to the emergency room and received seven staples bn her scalp. (R. at_ 320, 355). Plaintiff reported rib pain when taking deep breaths. (R. at 320.) Dt. Gupta x-rayed I I her ribs, prescribed Motrin, gave her a tetanus shot, and wrapped her wrist. (It at 320, 355.) m. Medical Evidence Considered by the ALJ: State Agency DocJrs A. Dr. Joseph Dilallo, M.D., Physical Consultative Examiner qune 2013) Dr. Joseph DiLallo, M.D., performed a physical consultative examination in June 2013. (R. at 294--300.) Plaintiff complained of depression, anxiety, panic attacks, I diabetes (controlled with diet), back pain secondary to her March 2012 car accident, aJd a history of mild I asthma. (R. at 294.) She reported inconsistent medications due to a lack of fuJds and difficulty I getting to doctors. (R. at 294.) She had gained 30 pounds in the last year. (R. at 294.) I I During the review of symptoms, Plaintiff reported fairly good range of motion, occasional cervical spine and back pain, occasional stiffness and tenderness 10 her neck and i back, no joint deformities, good grip strength, intact fine and gross no generalized I muscle weakness, intact sensation, some (not excessive) fatigue, a chronic b4t not extreme sleep i problem, and no coordination or balance difficulties. (R. at 295.) Dr. DiLalloffound mild, very I localized tenderness in the lumbosacral muscles and spine. (R. at 295-96.) Plaintiff reported that I her asthma attacks were generally very mild (R. at 296), but the worst one was recent, in I October 2012, and required a visit to the emergency room (R. at 294). Dr. DiLallo noted that Plaintiff was not extremely anxious or depressed at the time of the examinatiln (R. at 295-96), but also emphasized her history of lifelong major depression, chronic anxie, attacks and panic attacks, and that she believed her disability was "psychiatric" (R. at 294, 296+-97). 7 Dr. DiLallo opined that Plaintiff can sit for 30 minutes and stand for ]5-20 minutes 1 before developing a pinching sensation in her nerves, and that she claimed shl could lift and carry 10 pounds. (R. at 297.) While he described her bending as "good," he nfted that crouching, squatting, and stooping were "fair." (R. at 297.) Dr. DiLallo determined that Plaintiffs "history I I of chronic depression and anxiety attacks ... seem to interfere with her activities of daily living I I and would interfere with her work situation. She needs a sedentary clerical low-stress type of job. There is no absolute contraindication to gainful employment at this time.'' (R. at 297.) B. Dr. Vasudev N. Makhija, M.D., Psychiatric Consultative Examiner (July 2013) Dr. Vasudev Makhija, M.D., performed a psychiatric consultative exa;mination in July I I 2013. (R. at 290-93.) Plaintiff reported recurrent panic attacks since the age Jf five sometimes causing her to pass out; constant anxiety (debilitating in crowded places); recLnt, chronic depression which made her lose interest in everything; and difficulty sleepinJ. (R. at 290-91.) Dr. DiLallo's handwritten notes suggest Plaintiff commented ''don't care myself' and "don't want to interact with people," as well as "Isolates, gets meltdown - self." (R. at 298.) He noted one instance of suicidal ideation, providing an illegible specific date. (R. at 298.) 7 11 She reported one psychiatric hospitalization at age 18 at Trinitas Hospital by stress after I her grandmother's death (R. at 291) and outpatient psychiatric treatment fromj 2007-2009 with I Dr. Mitra, who prescribed Klonopin (R. at 291). She left Dr. Mitra's practice because she was I not comfortable with him. (R. at 291.) She was taking Lexapro from leftover prescriptions, but could not access Klonopin because she could not afford to see her PCP. (R. 291-92.) On mental status examination, Dr. Makhija found Plaintiff to be coopdrative and I pleasant; posture and gait were unremarkable; speech was rapid but appropriate and coherent; I affect was appropriate to thought content; moCld was anxious, cheerful, tense.land at times slightly depressed; and thoughts were goal directed. (R. at 293.) Dr. Makhija further found ability to comprehend and follow instructions; intact remote and short-term Jemory; orientation I to time, place, and person; ability to recall three out of three objects after five[ minutes; and limited fund of knowledge. (R. at 293.) He diagnosed Plaintiff with panic disbrder with . I I agoraphobia, generalized anxiety disorder, and dysthymic disorder. (R. at 293.) He opined that Plaintiff was capable of handling benefit funds in her own best interest. (R. aJ 293.) i C. Dr. Seung Park, M.D., State Agency Doctor, Physical RFC (Sept. 2013) On September 18, 2013, state agency doctor Seung Park, M.D., prepared a physical I residual functional capacity ("RFC") assessment after reviewing Plaintiff's niedical records. (R. I at 112-14, 301 ). He reported that Plaintiff "has depression and back pain duej to MVA in I 3/2012." (R. at 114, 301.) He noted that her lumbar spine had very mild localized tenderness but I she had normal gait. (R. at 301.) He affirmed that she was credible and her was supported i I by the medical evidence. (R. at 114, 301.) He agreed with the initial decisionl(see R. at 98-101 (signed by Deogracias Bustos, specialty code 19 indicating internal specialty))-that I she was impaired and had a decreased RFC and affirmed it as written. (R. at 114, 301.) The 1 I I 12 I initial RFC reflected that Plaintiff could lift or carry 20 pounds occasionally Jid 10 pounds I frequently; could stand, sit, or walk for six hours in an eight-hour workday, with unlimited I pushing and pulling in her extremities (R. at 99; R. at 112 (affirming)), postudii limitations, no I manipulative limitations, and environmental limitations (R. at 99-101; R. at 1jl3-14 (affirming)). i D. Dr. Robert Campion, M.D., State Agency Psychiatrist, Mental RFC (Oct. 2013) . ! ' In October 2013, state agency psychiatrist Robert Campion, M.D., prepared a mental RFC assessment after reviewing Plaintiffs medical records. (R. at 110--11, 1 He did not ! alter the analysis provided by Jane Shapiro at the initial level of determination (see R. at 97-98, I 101-02); he wrote "I have reviewed all the evidence in file - there is no new J?sychiatric evidence I I on recon [sic] - and I affirm the DDS assessment of July 22, 2013, as written-j' (R. at 111, 116.) I At the initial level, Jane Shapiro-who appears to be a clinical psychologist according to I public records-assessed moderate limitations to Plaintiffs ability to carry detailed i instructions and maintain attention and concentration for extended periods, otherwise no significant limitations to concentration, persistence, or pace; marked limitatidns to Plaintiff's I ability to interact appropriately with the general public; moderate limitations :to Plaintiffs ability I to accept instructions and respond appropriately to criticism from supervisor* and moderate limitations to Plaintiff's ability to respond to changes in the work setting. I R. at 101-02.) She I found Plaintiff could attend and concentrate and complete routine tasks (R. al 101; see also R. at I I 115); interact appropriately with supervisors in low contact work (R. at 102; also R. at 115); i and adapt to modest changes in the workplace (R. at 102; see also R. at 1l6)J I IV. Mary D. Anderson, Vocational Expert Testimony by the ALJ I AU Shillin requested the testimony of Mary D. Anderson, Vocationf Expert ("VE"). (R. at 174.) ALJ Shillin asked the VE to assume an individual of Plaintiffs age,1education, and work 13 I experience who could lift and carry up to 20 pounds occasionally and 10 frequently; could stand, sit, or walk for six of eight hours; could occasionally reach overhbad; could not use I ladders, ropes, scaffolds, or heavy machinery; could occasionally use ramps ahd stairs; could occasionally kneel, crouch, crawl, or balance; could have occasional exposurJ to extreme heat, I cold, environmental pollutants, high ambient noise, or high vibration; and codld have no I exposure to unprotected heights. (R. at 72.) She then added limitations to soci!al interaction: no I contact with the general public and only occasional contact with co-workers a:nd supervisors. (R. I at 72.) In response, the VE testified that Plaintiff could not perform any of hef past relevant work I (R. at 72), but could perform other jobs in the national economy, such as a srtj.all parts assembler or bander (R. at 73). The ALT added the restriction of no reaching in any dirJtion and • I occasional fingering and feeling with the non-dominant hand, and the VE initally testified there were no jobs, but at the ALJ' s prompting, agreed that a surveillance system dtonitor was the only I I job at the sedentary level that met all the limitations. (R. at 76-77.) After Plairtifrs counsel emphasized the need for a condition of low stress, the VE affirmed that the previously identified I jobs were low stress, especially the bander. (R. at 88-89.) V. I I Procedural History ALT Shillin issued a decision on July 15, 2015, denying disability on Plaintiffs RFC to perform work available in sufficient numbers in the national economy. (R. at 8-29.) Plaintiff sought review with the Appeals Council of the Social Security Administration, which I denied Plaintiffs request on December 13, 2016, finding no reason to revie.J or reconsider the I ALJ' s decision. (R. at 1-6.) Plaintiff filed the present appeal of the final ageqcy decision on February 14, 2017. (ECF No. I.) After Defendant submitted the administratite record in lieu of an answer (ECF No. 14), Plaintiff filed her brief on October 17, 2017 (ECF No. 18). Defendant 14 replied with its brief pursuant to Local Civil Rule 9.1 on December 1, 2017. (ECFNo. 19.) I Plaintiff did not submit a reply. The Court now considers the appeal. STANDARD OF REVIEW Social Security appeals are reviewed under 42 U.S.C. § 405(g), whichl empowers this Court to enter "a judgment affirming, modifying or reversing the decision of the Commissioner I ·... with or without remanding the cause for a rehearing." 42 U.S.C. § 405(g).j This Court has plenary review over legal issues and applies a "substantial evidence" standard of review to the ALJ's factual determinations. Id.; Richardson v. Perales, 402 U.S. 389, 401 "Despite the deference to administrative decisions implied by this standard, appellate coutjs retain a responsibility to scrutinize the entire record and to reverse or remand if the Secretary's decision I is not supported by substantial evidence." Smith v. Califano, 637 F.2d 968, 910 (3d Cir. 1981). Substantial evidence requires "more than a mere scintilla" of support, Richarilson, 402 U.S. at I I 401, or "such relevant evidence as a reasonable mind might accept as adequate," Thomas v. Comm' r of Soc. Sec. Admin., 625 F.3d 798, 800 (3d Cir. 2010), but "it need of a preponderance," McCrea v. Comm'r of Soc. Sec., 370 F.3d 357, 360 (3d rise to the level I Fir. 2004). Where the Commissioner's factual findings are supported by substantial evidence in the I record, the Court may not set aside such determinations even if the court might have decided the I inquiry differently. 42 U.S.C. § 405(g); see, e.g., Hagans v. Comm 'r of Soc. Sec., 694 F.3d 287, . I 292 (3d Cir. 2012); see also Holley v. Colvin, 975 F. Supp. 2d 467, 475 2013) ("The presence of evidence in the record that supports a contrary conclusion does ntt undermine the I Commissioner's decision so long as the record provides substantial support for that decision." I (quoting Sassone v. Comm 'r of Soc. Sec., 165 F. App'x 954, 955 (3d Cir. 2006))), aff'd sub nom. Holley v. Comm 'r of Soc. Sec., 590 F. App'x 167 (3d Cir. 2014). 15 DISCUSSION I. Legal Standard for Disability Benefits In order to receive benefits, an applicant must establish disability withln the meaning of I the Social Security Act and its implementing regulations. Disability is defined as "inability to engage in any substantial gainful activity by reason of any medical! y determfable physical or .1505(a). An AU mental impairment." 8 42 U.S.C. § 423(d)(l)(A); id. § 416(i); 20 C.F.R. § 4041 employs a five-step evaluation for claims under the Act. See 20 C.F.R. § 404j1520(a). The threshold inquiry looks to (1) whether the claimant has engaged in any "substantial gainful activity" since her alleged disability onset date. Id. § 404.1520(a)(4 )(i ). Next,Ithe ALI considers I i (2) whether the claimant has any impairment or combination of impairments rsevere" enough to limit the claimant's ability to work. Id.§§ 404.1520(a)(4)(ii), (b)-(c), .1521. If the claimant has a severe impairment, the AU examines the objective medical evidence to I (3) whether I i the impairment matches or equals one of the impairments listed in 20 C.F.R. Part 404, Subpart P, i App'x 1. Id.§§ 404.1520(a)(4)(iii), (d), .1525, .1526. If so, the claimant is automatically eligible for benefits; if not, the ALI determines (4) whether the claimant is unable to tturn to her past relevant work. Id.§ 404.1520(a)(4)(iv), (f), 404.1560(b); Poulos v. Comm'r df Soc. Sec., 474 F.3d 88, 92 (3d Cir. 2007) (internal citations omitted). At step five, the burden shifts to the AU I to consider and show (5) whether the claimant can perform other work based rn her RFC, age, education, and work experience. 20 C.F.R. § 404.1520(a)(4)(v), (g); Poulos, 474 F.3d at 92. I II. The ALJ's Findings and Final Determination Following the five-step procedure, ALI Shillin concluded as follows: , Plaintiff had not I engaged in substantial gainful activity from her alleged onset date of February 28, 2013 (R. at . 8 "Substantial gainful activity" refers to jobs that exist in large numbers in the: region where the claimant lives ornationwide. 42 U.S.C. § 423(d)(2)(A); see also 20 C.F.R. § r.1520(a)(4)(i). 16 14); (2) Plaintiff had severe medically determinable impairments of . I disc disease of I the cervical and lumbar spine, bilateral shoulder tendonitis, asthma, an disorder, and an I affective disorder, as well as the non-severe impairment of hypothyroidism (R. at 14); (3) I . Plaintiff did not have an impairment or combination of impairments that or equaled listings 1.00 (musculoskeletal system), 3.03 (asthma), 12.04 (affective disorders), orl 12.06 (anxiety disorders) (R. at 14-17); (4) Plaintiff could not perfonn any of her past relevbt work (R. at 23 ); I I and (5) Plaintiff had the RFC to perform light work, but was limited to jobs that are lower stress I (consistency at a production rate, but with a lower rate of required output thar other jobs) which permit no contact with the general public (and only occasional contact with and coworkers) (R. at 17-23), such as a "bander" or "small parts assembler" (R. at 24-25). The AU I found Plaintiff was not disabled from February 28, 2013 through the date of decision. (R. at 25.) III. Analysis of the ALJ's Determination I I Plaintiff presents two umbrella arguments on appeal: (i) the AU imptoperly evaluated I the medical evidence at step three and beyond, failing to incorporate all of Plaintiffs physical I and mental impairments in the decisional RFC, and (ii) the AU committed error in questioning the VE at step five. Plaintiff asks this Court to reverse the AU' s !decision or remand I for further consideration. (Pl.'s Br. at 1, ECF No. 18.) A. Evaluation of the Medical Evidence for Plaintiff's RFC i I I In evaluating medical evidence, a treating physician's opinion must bb given "controlling I weight" if it is well supported by medical techniques and not inconsistent I substantial evidence in the case record. Fadly v. Colvin, 2014 WL 2889641, at *6 (D.N.Ji. June 25, 2014) I I (quoting Johnson v. Comm'r Soc. Sec., 529 F.3d 198, 202 (3d Cir.2008)), affld sub nom. Elfadly v. Comm'r Soc. Sec., 588 F. App'x 93 (3d Cir. 2014). "[A] longtime treating physician's opinion I 17 carries greater weight than that of a non-examining consultant ...." Brownawell v. Comm' r of I Soc. Sec., 554 F.3d 352, 357 (3d Cir. 2008) (citing Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. I 2000); Dorfv. Bowen, 794 F.2d 896, 901 (3d Cir. 1986)). An AU may "reject a treating I physician's opinion outright only on the basis of contradictory medical evidtnce and not due to his or her own credibility judgments, speculation or lay opinion." Morales, 425 F.3d at 317-18 I (internal citations and quotations omitted). The AU must not ignore the of treating I professionals or cherry pick evaluations, diagnostics, or opinions that support a particular i conclusion. See, e.g., Holley, 590 F. App'x at 169 (affirming that substantiallevidence supported I the AU's finding of residual functional capacity where "[t]he AU did not niisinterpret or ignore I the reports of any physician" or "put words in their mouths"); Brownawell, 5;54 F.3d at 356--57 I (reversing and remanding where the ALJ "ignored" opinions of treating * and rejected I one opinion "in large part on evidence that does not exist"); Dorf, 794 F.2d 902 (reversing and I remanding where the ALJ "improperly ignored" clinical findings of the treating physician). I 1. Assessment of Physical Impairments & Treating Sources j Plaintiff argues that the decisional RFC is not supported by substanticµ evidence because I "the combination of disc disease at two cervical levels and one lumbar level cbombined with I chronic tendonitis in both shoulders do not translate into any restriction whatsoever in plaintiff's I ability to stand, walk, bend, use both arms to reach, feel or handle." (Pl.'s Br.1at11; see also id. at 19-20.) In determining the extent of Plaintiff's musculoskeletal limitationsl AU Shillin I I considered Plaintiffs treatment with Dr. Menkin post-accident, examination by state agency I doctor Joseph DiLallo in 2013, her own observations of Plaintiff during the and I I I 9 Plaintiff argues that the AU engaged in improper "sit and squirm" analysis (Pl.'s Br. at 12 n.3); Defendant responds that an AU' s lay observations are permissible as an eleo1ent of a credibility determination (Def.'s Br. at 16--18). The Court concurs with Defendant. See Holley, 975 F. Supp. 2d at 480-81 (declining to reverse where AU's observations were a part of ctedibility analysis). I 18 I Plaintiffs self-reports of activities of daily living in testimony and functional reports. (R. at 181 20.) However, ALJ Shillin's decision seemed to reject objective medical evidence from treating physicians regarding the severity of Plaintiffs pain and limitations to her range of motion. I AU Shillin wrote that "[a] careful review of the claimant's medical records indicates she has received no treatment for her shoulders or back impairments since her date of disability." (R. at 18.) She further explained, "[c]onsidering ... the lack of Jidence of consistent I treatment for her chronic pain, I find the claimant's symptoms were not as lin;tlting as she alleged." (R. at 19.) These conclusions did not seem to be supported by substktial evidence. For example, in Dr. DiLallo's 2013 examination of Plaintiff, he filled out a Range of Motion Chart. (R. at 299-300.) His findings reflected that Plaintiff did not have probiems with range of motion of the cervical spine (R. at 299), but did have significantly reduced rlge of motion for I flexion-extension and lateral flexion of her left lumbar spine (scoring 20 out Of 90), as well as I I mid-ranging straight leg raising tests in both the supine and sitting positions (R. at 300). This reflects only some improvement from May 2012, when Dr. 70 out of 90) reported, among other negative musculoskeletal findings, "[s]everely decreased range Of motion on the left , I i side. 0 to 90 degrees abduction and forward flexion on right side. Range of mbtion is functional 0 to 150 degrees, abduction and forward flexion." (R. at 287.) Furthennore, documented that Plaintiff reported back pain on July 31, 2013, and determined that Plaintiff was "credible" . I and that her pain and allegation were "grossly supported" by the medical (R. at 114, I 301.) ALJ Shillin did not cite the longitudinal treatment notes of Plaintiffs from 20141 2015, Dr. Gupta. His notes reflect that in November and December 2014, Plaintiff complained of left shoulder and neck pain and was prescribed Naproxen when Aleve was "nlt effective." (R. at 325, 350-51.) Dr. Gupta described Plaintiff's pain as "chronic." (R. at 351.) 19 I I I AU Shillin gave Dr. DiLallo's opinion limiting Plaintiff to a job little weight because "nothing in Dr. Dilallo's [sic] objective findings and observations of the claimant I supports a limitation to a sedentary residual functional capacity." (R. at 21.) 'Fhe AU focused on I Dr. DiLallo's positive findings regarding Plaintiffs muscle strength, grip manipulations, and normal gait, balance, and stability. (R. at 19.) However, fine and gross J this portion of the decision, the AU described Dr. DiLallo's findings regarding range of motion as "mild" without I reporting the objective results, did not mention his finding of localized tende$ess in the I . lumbosacral area in the muscles and very mildly over the spine, and did not ahdress his review of Dr. Menkin' s treatment history regarding Plaintiffs musculoskeletal imparrJents post-accident. I ! She also did not mention his comment that "[Plaintiff] can sit for Y2 hour and stand for 15-20 I minutes beyond which she develops nerves that feel like they are pinching." (R. at 297.) The I AU noted that Plaintiff reported a treatment history that included epidural injbctions and radiofrequency ablation, but did not provide documentation substantiating thj treatment. (R. at 18.) However, since 2012 Plaintiff consistently reported to her doctors havinJ undergone I physical therapy and receiving those injections. (See, e.g., R. at 48, 286-87, 294, 296, 340.) I All told, the ALJ's conclusions that Plaintiffs physical limitations and pain were not as i I marked as her subjective reports, and that her treatment history failed to docuµient her pain, are belied by medical evidence that supports Plaintiffs reports from the period of 2012-2015. The i Court concludes that it must remand for further consideration of Plaintiff's RFC at step three. 2. Assessment of Mental Impairments & Treating Sources Plaintiff likewise argues that the ALJ failed to translate Plaintiffs mwked psychiatric . I impairments into the decisional RFC, substituting her own judgment for that of treating medical I I professionals. (Pl.'s Br. at 12-13, 16-17.) After conducting its own review of the Record, the 20 Court finds that ALJ Shillin did not sufficiently consider the evidence regarding Plaintiffs mental health impairments. In particular, AU Shillin did not give sufficient leight to the evaluations and opinion evidence of Plaintiff's treating psychologist, and theJeby reached a I I conclusion that Plaintiff had never experienced exacerbation of her symptom$. I I In evaluating Plaintiffs mental health impairments, ALJ Shillin noted "a onetime mental status examination from January 2014." (R. at 20.) She then cited findings frjm the January 2014 visit describing Plaintiff as alert, with normal affect and intact insight and jjgment. (R. at 21.) I These findings came from notes from three separate visits to Dr. Waldron. 10 I R. at 306--09 I (January 2014); R. at 310-14 (January 2015); R. at 315-18 (April 2015); see also Defs. Br. at . ! 7-8.) Contrary to the ALJ's conclusion, each visit included its own mental stJtus exam. (See R. at 311-13, 316-18.) Moreover, the January 2014 visit reflects a findings, I including speech described as evidencing "excessive volume," affect not desGribed as "normal" (R. at 21) but rather "restricted," mood described as "depressed and anxious,': and insight described as "partially intact." (R. at 307--08; see also Def.'s Br. at 8.) The laJer two mental status exams, conducted after Plaintiff resumed a psychiatric medication regiien, showed improvement and largely unremarkable or normal findings. (R. at 311-13, 31l18.) I I I 10 The Court infers a continuing clinical relationship beyond these three visitsl In January 2014, Dr. Waldron prescribed Plaintiff Buspirone and Lexapro. (R. at 309.) In her "history of present illness" note in January 2015, Dr. Waldron noted that Plaintiff "is less and anxious since we switched to Paxil." (R. at 310.) This strongly suggests that Dr. Walill-on reviewed and Medications" changed Plaintiffs medication in the intervening year. Plaintiffs questionnaire from summer 2014 said her medications had already been switdhed to Paxil and Seroquel. (R. at 258.) Additionally, Dr. Gupta noted on May 30, 2014 "[Patiept] denies any medication ... at this time except her bipolar and anxiety medications prescriped by her psychiatrist Dr. Waldron." (R. at 342.) Plaintiff listed Dr. Waldron as her on the "Claimant's Recent Medical Treatment" questionnaire in summer 2014, describing the treating period as "January 2014 ongoing." (R. at 259.) I I 21 Dr. Waldron also provided a mental medical functional assessment dhted April 1, 2015. I (R. at 303-05.) AU Shillin misread her signature as "Kathy Walbem, Ph.D.i' (R. at 21), but it I appears she signed Kathleen Waldron, Ph.D., APN-C (R. at 305). 11 (See Defl's Br. at 8 n.3.) ALJ Shillin discounted Dr. Waldron's medical opinion evidence, writing ''There no description of Dr. Walbem's relationship with the claimant, and a review of the available medical records does I not indicate Dr. Walbem examined the claimant on any regular or consistent[basis." (R. at 21.) However, the Record indicates that Dr. Waldron had a continuing clinical relationship with I Plaintiff as her mental health provider, and that ALJ Shillin's decision to give her medical I . opinion little weight would not be supported by substantial evidence. Notably, ALJ Shillin gave I "some weight" to the opinions of state agency medical consultants at the recJnsideration level I (R. at 22 (describing opinions ofDrs. Park and Campion)), neither of whom airectly examined I I Plaintiff and both of whom affirmed the initial determinations as written. ALJ Shillin reasoned that their opinions deserved deference because they were based on a review of the I I available medical records, reflected comprehensive understanding of agency tules and regulations, and were internally consistent. (R. at 22.) The Court concludes ttlat because she was I Plaintiffs treating mental health provider, Dr. Waldron's opinion should been given greater weight--especially the portions that reflected her own narrative assessments above I I noting that Plaintiff had severe anxiety, poor coping skills, and inability to hahdle stress. (See R. I at 303-05.) I 11 Defendant takes issue with the ALJ's consideration of Dr. Waldron as an aJceptable medical Nurse source because she is an advanced practice nurse (APN). (See Def.'s Br. at 7 practitioners are categorized as "other sources" under a 2006 Social Security Ruling, but according to the Record and available public records, Dr. Waldron also holds \a Ph.D. in clinical psychology and is licensed to practice. The Court thus refers to her as Dr. Waldron, and she is an "acceptable medical source" within the meaning of the applicable regulations land Social Security Ruling 06-03P. See, e.g., 20 C.F.R. § 404.1502(a)(2) ("Acceptable medical source means a • medical source who is a ... Licensed psychologist ...."). 1 1 22 ALJ Shillin wrote that "[d]espite reporting an onset date of Februaryl2013, the claimant's medical records do not suggest she experienced any cognitive decline or of her I symptoms." (R. at 20.) However, she cited only the 2007-2009 medical recdrds of Dr. Mitra. I I This conclusion would not be supported by substantial evidence. The Record reflects both I subjective reports and objective medieal evidence that Plaintiff did experiende periods of I exacerbated symptoms after the 2012 car accident, especially when un-medi¢ated. I For example, in May 2012 Dr. Menkin noted that Plaintiff reported abxiety, worsening I depression, as well as difficulty with sleep. (R. at 286.) She also reported headaches since her car . I accident. Plaintiffs own functional report, Douglas Smith's functional and Plaintiffs I testimony about the post-accident period reflect that her anxiety and depressipn had both i increased after her car accident, becoming so debilitating that she could not f at work, lost I her job, and stopped driving. Though AU Shillin reported that Dr. Makhija qescribed Plaintiffs mood during the 2013 mental status exam as "anxious" and "cheerful" (R. at !1s), she omitted the I part of the sentence which described her as "tense and at times slightly (R. at 293). In 2014, Dr. Waldron's mental status exam noted Plaintiffs restricted affect, depressed and anxious I mood, partially intact insight, and that Plaintiff reported hearing phantom in the middle of I the night (R. at 306-08)-all at a time when Plaintiff was not receiving psycbliatric treatment. In I the context of Plaintiffs medical history, this reflects a period of exacerbatiotl of symptoms; i once she resumed a medication regimen, her symptoms improved. (R. at 31Q...f18 (noting I improvement on Paxil, medicine helping her to not get too anxious or depressfd).) Plaintiff also I reported migraines to Dr. Gupta in 2014, and he prescribed Fioricet. I I 23 Overall, the limitations from Plaintiffs general anxiety disorder, panic attacks, and major 1 I . depression were not sufficiently evaluated at step three and thereafter. The concludes that it I must remand this case for further consideration. I I B. ALJ Questioning of the Vocational Expert I Having determined that the decisional RFC was not supported at sigqificant points by I substantial evidence, the Court need not consider Plaintiffs additional argutjient that the AU I committed legal error in questioning the VE at step five of the analysis. Of course, any questioning of a VE must account for all relevant limitations in the decisioJ RFC in order to have benefit to the AU in determining the availability of viable jobs for sombone with the I I plaintiffs limitations. I I CONCLUSION I For the reasons stated above, Defendant's decision is to be vacated add remanded. The Commissioner is requested to conduct a new hearing. An accompanying will follow. I ANNE E.1'Jiill1PSON: ::0}. I Date: }L.... £ r' 'J-0 ({ I I 24

Some case metadata and case summaries were written with the help of AI, which can produce inaccuracies. You should read the full case before relying on it for legal research purposes.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.