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Dorothy V. v. Saul

United States District Court, D. Minnesota

August 15, 2019

Dorothy V., Plaintiff,
Andrew Saul, Commissioner of Social Security Defendant.



         This matter is before the Court on Plaintiff Dorothy V.'s (“Plaintiff”) Motion for Summary Judgment (Dkt. 14) (“Motion”) and Defendant Commissioner of Social Security Andrew Saul's (“Defendant”) Cross Motion for Summary Judgment (Dkt. 17) (“Cross Motion”). Plaintiff filed this case seeking judicial review of a final decision by Defendant denying his application for disability insurance benefits. For the reasons stated below, Plaintiff's Motion is denied, and Defendant's Cross Motion is granted.

         I. BACKGROUND

         Plaintiff filed an application for Disability Insurance Benefits on June 24, 2015, alleging disability beginning September 19, 2012. (R. 158.)[1] Her application was denied initially (R. 82) and on reconsideration (R. 94). Plaintiff requested a hearing before an ALJ, which was held on September 20, 2017 before ALJ Peter Kimball. (R. 10.) The ALJ issued an unfavorable decision on October 17, 2017. (R. 7.) Following the five-step sequential evaluation process under 20 C.F.R. § 404.1520(a), the ALJ first determined that Plaintiff had not engaged in substantial gainful activity since September 19, 2012, the alleged onset date. (R. 12.)

         At step two, the ALJ determined that Plaintiff had the following severe impairments: chronic fatigue syndrome, fibromyalgia, vertigo, and Raynaud's syndrome. (R. 12.) The ALJ determined that Plaintiff's other physical impairments were not severe, including headaches, restless leg syndrome, hypertension, history of rheumatoid arthritis, tremors, insomnia, chronic right knee pain, and cervical degenerative disc disease. (R. 12.) The ALJ noted that each of these impairments were not severe, as the evidence and testimony establish that they result in at most mild work-related limitations. (R. 12-13.)

         At the third step, the ALJ determined that Plaintiff does not have an impairment that meets or medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 13-14.)

         At step four, after reviewing the entire record, the ALJ concluded that Plaintiff had the following residual functional capacity (“RFC”):

[T]o perform light work as defined in 20 CFR 404.1567(b) with lifting, carrying, pushing and pulling twenty pounds occasionally and ten pounds frequently, standing six hours, walking six hours and sitting six hours in an eight hour work day, except no more than occasional climbing of ramps and stairs, no more than occasional balance, stoop, kneel, crouch and crawl, never climb ladders, ropes or scaffolds, no work with exposure to unprotected heights or moving mechanical parts, no work in humidity and wetness, and no work in extreme cold or heat.

(R. 14.) Based on this RFC, the ALJ determined that Plaintiff is capable of past relevant work as a child care worker, which the vocational expert (“VE”) testified a hypothetical individual with the determined RFC could perform. (R. 18-19.)

         Alternatively, at step five, the ALJ asked the VE what other jobs a hypothetical person with Plaintiff's RFC, age, education, and work experience could perform in the national economy. (R. 28.) Given all the factors, the VE testified that such an individual could perform jobs such as mail clerk and assembler, plastic hospital products, which exist in significant numbers in the national economy. (R. 19.) Accordingly, the ALJ found Plaintiff not disabled. (R. 19.)

         Plaintiff requested review of the decision. (R. 1.) The Appeals Council denied Plaintiff's request for review, which made the ALJ's decision the final decision of the Commissioner. (R. 1.) Plaintiff then commenced this action for judicial review. The Court has reviewed the entire administrative record, giving particular attention to the facts and records cited by the parties. The Court will recount the facts of record only to the extent they are helpful for context or necessary for resolution of the specific issues presented in the parties' motions.

         II. RECORD

         On October 9, 2012, Plaintiff saw Shaun Dekutoski, M.D. regarding a “flutter sensation” in her chest that occurred 1-2 times a month. (R. 329.) At the time, Plaintiff was taking Dexedrine and Xyrem to help her sleep, and tramadol[2] for restless leg syndrome. (R. 329-30.) At the visit, Plaintiff stated that her pain was 9 out of 10 for restless leg syndrome, but she was asymptomatic at the visit. (R. 330.) Dr. Dekutoski did not make any medication changes and recommended a 30-day heart monitor if her palpitations continued. (R. 330.)

         Plaintiff saw Dr. Dekutoski again on November 1, 2012 due to spells of lightheadedness. (R. 324.) Dr. Dekutoski recounted the following issues from Plaintiff:

Now, she returns and brings in an extensive diary of symptoms. On 10/13/2012, she states she was under a lot of stress and suddenly felt a headache and a flushed feeling and then a few palpitations. She states she did get some right shoulder pain at that time but mainly noticed her headache and a sparkling sensation in her eye and felt that her vision was blurred bilaterally. She thinks she may have blacked out.
Then, on 10/28 /2012, she was up on a chair reaching to get a vase when she suddenly felt a cold rush in her face. She also felt extremely nauseous and lightheaded and had a headache that was 8 out of 10 and fuzzy vision in her left eye. This time, the symptoms lasted for 1-1/2 to 2 hours before resolving. She did not have any associated palpitations with this episode. It has not recurred since that time, and she currently is asymptomatic.
She does continue to have nocturnal leg pain which she describes as 7 out of 10, but this has been longstanding and has not changed.
She denies any chest pain, shortness of breath, easy fatigability, orthopnea or leg swelling.
She also recently was lifting a picture frame and the glass broke, and a shard of glass fell and punctured the top of her right foot on approximately 10/18/2012 while at home. She washed the wounds with soap and water, but has noticed it is increasingly painful since that time. She did pull out the shard of glass and has not felt that there is any foreign body still remaining. She had a tetanus vaccine that is currently up to date.

(R. 324.) Dr. Dekutoski gave Plaintiff medication for the foot injury and ordered an MRI of her head because of the reported black out. (R. 325-26.)

         On December 5, 2012, Plaintiff saw Angela Borders-Robinson, D.O. for a consultation regarding the headaches she described to Dr. Dekutoski. (R. 320.) Dr. Borders-Robinson noted that Plaintiff had an MRI of her brain with and without contrast, and that they “both are essentially normal.” (R. 320.) Dr. Borders-Robinson reported that the headaches may be recurrent due to perimenopause and that if the headaches become more persistent or recur, she should return. (R. 322.) Otherwise, Dr. Borders-Robinson did not alter Plaintiff's care. (R. 322.)

         Plaintiff saw Dr. Dekutoski again on January 9, 2013 on a follow-up for hypertension and for the right foot injury. (R. 318.) Regarding hypertension, Dr. Dekutoski restarted medication that had worked previously (R. 319), and regarding the right foot pain, Dr. Dekutoski ordered an MRI because Plaintiff reported she “has exquisite sensitivity to touch if anything touches the distal tips of her toes and also has pain with weightbearing.” (R. 318-19.) Plaintiff did not report other symptoms or distress at the visit. (R. 319.)

         Plaintiff saw a podiatrist on January 29, 2013 for the right foot pain, at which time she received injection therapy with a plan for follow up. (R. 315-16.) At the follow up on February 20, 2013, Plaintiff reported improvement in the right foot pain “down to a 0 on a 1-10 scale.” (R. 312.) Plaintiff also noted right ankle pain, which was treated with a support brace and stretching and strengthening. (R. 312.)

         On April 15, 2013, Plaintiff saw Dr. Dekutoski for preoperative clearance for elective surgery. (R. 308.) Plaintiff had “no recent illness or complaints or concerns” and was medically cleared for surgery. (R. 308-10.)

         Plaintiff saw Dr. Dekutoski next on May 29, 2013 regarding restless leg syndrome. (R. 304.) Plaintiff stated her restless leg syndrome “is getting more severe and 9 out of 10 where it really interferes with her day-to-day life.” (R. 304.) “She feels that she has pain all the way from her hips down to her ankles, ” but it “is not worse with weightbearing.” (R. 304.) Dr. Dekutoski noted in his exam that her “[b]ilateral hips, knees and ankles show full nontender range of motion” and her “[m]uscle strength [was] symmetrical and intact to resistance in bilateral lower extremities.” (R. 305.) “Reflexes symmetrical in the bilateral lower extremities.” (R. 305.) Dr. Dekutoski prescribed a trial of 10 mg oxycodone for nighttime use. (R. 305.)

         Plaintiff returned on July 25, 2013 to Dr. Dekutoski because “she has for the past 3 weeks had extreme pain in the bilateral shins and bilateral knees and hips and arms, including forearms.” (R. 302.) Plaintiff reported that “that those seem to be pain in her joints as well as in the muscles.” (R. 302.) Plaintiff also reported that within the previous three weeks she began having a prickly skin feeling all over. (R. 302.) Dr. Dekutoski ordered various tests and continued her course of treatment until results from the tests were received. (R. 303.)

         On August 28, 2013, Plaintiff saw Kathryn Khouri, D.O. about “ongoing body pain for several years.” (R. 299.) Plaintiff described debilitating pain and feeling like bugs are crawling on her skin when nothing is there. (R. 299.) Plaintiff told Dr. Khouri that her symptoms were worsening and that the body pains were worse with weather changes. (R. 299.) Plaintiff also told Dr. Khouri that she has taken Oxycontin, which worked well overnight so she could sleep, but then the pain returns in the morning and lasts all day. (R. 299.) In addition, Plaintiff was taking tramadol, 2 tablets every 4 to 6 hours as needed for pain, with a maximum of 8 tabs per 24 hours. (R. 299.) Plaintiff was negative in all her lab work “for connective tissue disease, and other immunologic causes.” (R. 299.) Dr. Khouri reported she thought ...

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