DeCaro v. Commissioner of Social Security

CourtDistrict Court, N.D. Ohio
DecidedMarch 29, 2022
Docket1:20-cv-01516
StatusUnknown

This text of DeCaro v. Commissioner of Social Security (DeCaro v. Commissioner of Social Security) is published on Counsel Stack Legal Research, covering District Court, N.D. Ohio primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
DeCaro v. Commissioner of Social Security, (N.D. Ohio 2022).

Opinion

UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF OHIO EASTERN DIVISION

DONNA J. DeCARO, ) CASE NO. 1:20-cv-01516 Plaintiff, V. JUDGE DAVID A. RUIZ KILOLO KIJAKAZI, Acting Comm’ of Soc. Sec., ) MEMORANDUM OPINION AND ORDER Defendant.

Plaintiff, Donna J. DeCaro (Plaintiff), challenges the final decision of Defendant Kilolo Kijakazi, Acting Commissioner of Social Security (Commissioner),! denying her application for Disability Insurance Benefits (DIB) under Title II of the Social Security Act, 42 U.S.C. §§ 416(1), 423, 1381 et seg. (Act). This court has jurisdiction pursuant to 42 U.S.C. § 405(g). For the reasons set forth below, the Commissioner’s final decision is AFFIRMED. I. Procedural History On August 8, 2017, Plaintiff filed her application for DIB, alleging a disability onset date of October 7, 2016. (R. 16, Transcript (Tr.) 178-188). The application was denied initially and upon

! Pursuant to Rule 25(d), the previous “officer’s successor is automatically substituted as a party.” Fed.R.Civ-P. 25(d).

re consideration, and Plaintiff requested a hearing before an Administrative Law Judge (ALJ). (Tr. 107-123). Plaintiff participated in the hearing on June 11, 2019, was represented by counsel, and testified. (Tr. 29-73). A vocational expert (VE) also participated and testified. Id. On July 11, 2019, the ALJ found Plaintiff not disabled. (Tr. 24). The Appeals Council denied Plaintiff’s request to review the ALJ’s decision on May 15, 2020, and the ALJ’s decision became the Commissioner’s final decision. (Tr. 1-6). Plaintiff’s complaint challenges the Commissioner’s final decision. (R. 1). The parties have completed briefing in this case. (R. 17, 18 & 19). Plaintiff asserts the following assignments of error: (1) the ALJ failed to properly evaluate the evidence documenting the limited use of her upper extremities; (2) the ALJ erred by finding Plaintiff’s testimony was not fully credible; and, (3) the Step Four finding was not supported by substantial evidence. (R. 17). II. Evidence A. Relevant Medical Evidence2 1. Treatment Records

On September 9, 2016, a nerve conduction study of the right median motor response was “abnormal with normal distal latency.” (Tr. 306). EMG studies yielded an impression of active and chronic denervation and reinnervation in both upper extremities. (Tr. 307). On January 9, 2017, Plaintiff saw neurologist Christopher Uchiyama, M.D., about five weeks after neck surgery. (Tr. 334). Plaintiff stated that she was “not having much in the way of neck symptoms,” but she reported continued pain and weakness in her upper extremities, worse

2 The recitation of the evidence is not intended to be exhaustive. It includes only those portions of the record cited by the parties in their briefs and also deemed relevant by the court to the assignments of error raised. on the right. Id. She was not taking any pain medication. Id. Dr. Uchiyama reviewed x-rays indicating stable placement of surgical hardware, and he indicated that her lack of relief may be the result of permanent damage to her nerves prior to surgery. (Tr. 334). On March 29, 2017, Dr. Uchiyama noted that Plaintiff continued to report hand weakness and pain of uncertain etiology. (Tr. 337). On August 30, 2017, Plaintiff was seen for her annual exam by Isabel Kuo Cheon, M.D. (Tr. 340). Plaintiff reported she began exercising one month earlier six times a week for a duration of one hour each. Id. She had an elliptical, treadmill, and stationary bike at home. Id. Plaintiff was taking Tramadol, a pain medication, and Diazepam for spasms. Id. Physical examination was unremarkable. (Tr. 341-42). On September 22, 2017, Plaintiff saw Dr. Uchiyama and reported ongoing cervical thoracic pain and “transient lightheadedness exacerbated by neck flexion or extension.” (Tr. 374). She complained of low back pain “but not much radicular symptoms.” Id. He reviewed new x-rays of Plaintiff’s spine and noted interval worsening since her x-rays from 2012. (Tr. 376).

On October 16, 2017, Plaintiff’s chief complaint was pain in her cervical spine and lower back. (Tr. 384). She had a history of complaints regarding right arm pain and right hand cramping. Id. Treatment notes indicate Plaintiff previously had multiple cervical spine surgeries. Id. Plaintiff reported she can sit for thirty minutes, stand ten minutes, and walk fifty yards before he feet hurt. (Tr. 385). On August 24, 2018, Plaintiff visited the emergency room (ER) for a head injury and, on physical examination she had normal range of motion in her neck, normal musculoskeletal range of motion, and no edema. She had tenderness in her cervical back. (Tr. 490, 493-94). On October 29, 2018, Plaintiff established care with Paul Shin, M.D., a pain management sp ecialist, and complained of long-standing lower back pain and lower extremity pain that was worsening. (Tr. 517). She reported pain was exacerbated by standing, walking, and flexion, and relieved by sitting. Id. She complained that this pain interfered with getting out of bed or a chair and performance of household chores. Id. On examination, Plaintiff had limited range of motion in her neck and back, abnormal posture and spinal curves, moderate pain to palpation, negative straight leg raise test bilaterally, 5/5 motor strength and tone, and an antalgic gait. (Tr. 520). Plaintiff was prescribed Lorazepam and counseled on the importance of exercise. (Tr. 521). On December 10, 2018, Plaintiff saw Dawn Boyle, CNP, at Dr. Shin’s office for a follow- up and reported persistent pain at a present level of four on a ten-point scale. (Tr. 535). She reported the pain radiates down her leg, arm, abdomen, and back, causing weakness, numbness, and tingling. Id. She reported that pain interfered with shopping and household cleaning, and that nothing mitigated her pain. Id. On physical examination, Plaintiff had no neck tenderness or pain on range of motion, intact range of motion of the back with pain, tenderness on palpation of the lumbar spine and global tenderness throughout the thoracic lumbar region, an antalgic gait, no

loss of sensation, and full strength in all four extremities. (Tr. 536). Transforaminal epidural steroid injection (ESI) for the lumbar spine was ordered and nurse Boyle recommended regular exercise at home, including walking 20 minutes daily. (Tr. 537). On March 20, 2019, Plaintiff saw Andrea Vastola, NP, who noted Plaintiff was “well- known to our clinic, having last seen Dr. Christopher Uchiyama in September 2017.” (Tr. 442). Plaintiff reported intermittent, diffuse, and poorly differentiated neck pain and cramping in her fingers that was several years in duration. Id. Plaintiff reported her main concern was back pain, which radiated down to her knee. Plaintiff rated the severity of her pain as moderate and tolerable, but as interfering with her usual recreational activities and some restrictions in daily ac tivities. (Tr. 442). On physical exam, Plaintiff had a slowed gait that was balanced and non- antalgic; in her back there was no atrophy or pain on palpation; pain with flexion and extension of the lumbar spine; and tandem walk was impaired due to balance issues. (Tr. 445). Examination of the hands was not expressly noted. (Tr. 442-447). Nurse Vastola attributed Plaintiff’s reported finger cramps to chronic cervical myelopathy. (Tr. 446). 2. Opinions Concerning Plaintiff’s Functional Limitations On October 16, 2017, Mark Vogelgesang, M.D., performed a consultative examination. (Tr. 384-92). Plaintiff complained of right arm pain, right hand cramping, difficulty moving her right hand, difficulty lifting with the right arm, and occasional numbness. (Tr. 384-85).

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DeCaro v. Commissioner of Social Security, Counsel Stack Legal Research, https://law.counselstack.com/opinion/decaro-v-commissioner-of-social-security-ohnd-2022.