Ford v. SSA

2005 DNH 105
District Court, D. New Hampshire·Decided July 7, 2005·No. CV-04-194-PB·Published·Cited by 2 cases

Opinion

Ford v. SSA CV-04-194-PB 07/07/05

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW HAMPSHIRE

Alichia M. Ford

v. Case No. 04-CV-194-PB Opinion No. 2005 DNH 105

Jo Anne B. Barnhart, Commissioner Social Security Administration

MEMORANDUM AND ORDER

Alichia Ford applied for Disability Insurance Benefits ("DIB") on May 6, 2002.1 Ford alleged that she became disabled on May 11, 2000 due to nerve changes and spinal cord damage resulting from encephalomyelitis.2 Her application was denied on July 30, 2002. At Ford's reguest, an administrative hearing to review the denial was held on May 1, 2003 in front of Administrative Law Judge ("ALJ") Edward G. Hoban. In a September 26, 2003 order, ALJ Hoban once again denied Ford benefits. Ford

1 Ford also applied for Supplemental Security Income ("SSI") payments on May 6, 2002, with a protective filing date of March 21, 2 002.

2 Encephalomyelitis is an acute inflammation of the brain and spinal cord. Stedman's Medical Dictionary 507 (25th ed. 1990) ("Stedman's")

requested review of that decision, and on April 1, 2004, the Appeals Council denied her request for further review, makinq the ALJ's determination the final decision of the Commissioner. See 20 C.F.R. § 404.981. Ford now seeks reversal of the Commissioner's decision.

I. BACKGROUND3

A. Education and Work History Alichia Ford was born on March 13, 1976, and was twenty-

seven years old when ALJ Hoban issued his decision. She is a hiqh school qraduate, and her past relevant work include jobs as a jewelry assembly worker, a sales clerk for a florist and a qreetinq card store, and an assistant manaqer of a shoe store. Ford reportedly left her last job because of pain and stress. B. Medical History Ford was admitted to Dartmouth Hitchcock Memorial Hospital on Auqust 4, 1999 in an altered mental state with diffuse body pain. She was larqely unresponsive to auditory and tactile

3 Unless otherwise noted, the Backqround facts are drawn from the Joint Statement of Material Facts (Doc. No. 7) submitted by the parties pursuant to Local Rule 9.

stimulus. A magnetic resonance imaging ("MRI") of her brain taken the same day was essentially unremarkable, though an August 8 MRI that included images of her spinal cord showed high signals in the cervical spine. Further, an August 5 electroencephalogram ("EEC") produced results consistent with encephalopathy.4 Based on these findings. Ford was diagnosed with meningoencephalitis5 and was treated with intravenous antibiotic and antiviral medications, as well as steroid therapy. Even after her mental state ultimately returned to normal, however, she continued to suffer from bilateral lower extremity weakness and diminished strength, which at times left her unable to walk. Despite these infirmities. Ford made dramatic improvements in muscle strength while hospitalized, largely due to physical therapy and occupational conditioning. Hence, she was "much improved" and walking independently on the parallel bars as well as transferring in and out of a wheelchair by the time she was discharged on August 13, 1999.

4 Encephalopathy is any degenerative disease of the brain.

See Stedman's 508.

5 Meningoencephalitis is an inflammation of the brain and its membranes. Stedman's 943.

Ford was examined by Dr. Alida Griffith at the Hitchcock Clinic on September 1, 1999. Dr. Griffith's treatment notes refer to an MRI revealing increased signal in the thoracic spine. Ford told Dr. Griffith that she was doing well at home and could walk without much difficulty, but that her left leg was still weak. Her physical examination was largely normal, except for 4/5 strength in the right lower extremity, a slight decrease in vibration sensitivity in the distal lower extremities, and a slightly unsteady tandem gait. Ford also reported urinary incontinence, and Dr. Griffith referred her for a urology consultation. Dr. Griffith instructed Ford to return for a follow-up in six months.

Instead, Ford returned to Dr. Griffith on October 10, 2000.

Ford explained that she had been doing "pretty well" since being discharged from the hospital, but complained of an odd feeling in her legs, with sensitivity and dysethesia6 to hot and cold temperatures. Ford also reported a jerking sensation and motion in her legs. A physical examination revealed 4/5 strength in her right hip flexor and knee extensor, and she complained of pain

6 Dysethesia is a condition in which a disagreeable sensation is produced by ordinary stimuli. Stedman's 476.

with cold sensation below the knee, while warm stimulus felt like pressure. Dr. Griffith opined that Ford's symptoms were the lingering effect of acute disseminated encephalomyelitis, although they could have been an unusual presentation of multiple sclerosis. Ford reported ongoing urinary freguency, though she admitted that she had not followed up with Dr. Griffith's prior referral to a urologist. Dr. Griffith gave her a trial dose of Neurontin for her dysesthesias and leg jerking and again referred her to a urologist.

Ford next saw Dr. Griffith on December 12, 2000. She complained of urinary freguency, painful leg spasms, and difficulty sleeping. The Neurontin had caused intolerable side effects, including drowsiness and dizziness. A physical examination revealed that Ford's lower extremity strength was 5/5 and her sensation was intact, except for a small area of hypesthesia7 on her left thigh. Dr. Griffith believed Ford's symptoms were secondary to a static lesion of the thoracic spinal cord. Although she again failed to keep Dr. Griffith's urology referral. Ford assured Dr. Griffith that she would see a

7 Hypesthesia is diminished sensitivity to stimulation.

Stedman's 747.

urologist closer to her home. Dr. Griffith prescribed Ditropan for spastic bladder and Baclofan as a muscle relaxant and antispastic agent.

Ford next sought medical care on July 17, 2002, after filing her application for disability benefits, when she was examined by Dr. Lawrence Jenkyn. Dr. Jenkyn observed that Ford was not taking any medication for pain. Upon examination. Ford had 5/5 strength in all four extremities, with increased tone in the lower extremities. Although her sensation was intact, cold stimulus to her feet resulted in withdrawal responses due to burning pain that she experienced subjectively. A mental status exam revealed normal mental status, speech and language functions, visual fields, and cranial nerves. Her gait and station were normal. Dr. Jenkyn believed that Ford was suffering from the chronic after-effects of encephalomyelitis. He opined that her burning dysesthesias might respond to Baclofen, which "probably should be offered to her at some point."

Ford returned to Dr. Jenkyn for a follow-up neurological consultation on April 21, 2003. She reported increasing difficulty with her right hand, which had caused her to drop things unpredictably. She also reported that her lower extremity

pain and spasticity were "as bad as ever." Ford stated that she had tried several over-the-counter medications, but had never taken the Baclofen that Dr. Jenkyn had prescribed.

Dr. Jenkyn referred Ford to psychologist Lewis Sussman on March 26, 2003 for a clinical interview with psychometric testing, in connection with her Social Security disability appeal. Ford told Dr. Sussman that physical activities such as lifting and bending, staying in one position for an extended period of time, and stress worsened her pain, but that she got temporary relief from a hot bath or shower. Ford estimated that she got about four hours of non-restorative sleep each night and awakened several times per night. She noted that she was not taking any prescription medications and complained of low energy level and motivation, decreased appetite with weight loss, and difficulty with her memory and concentration. Ford attributed this in part to a motor vehicle accident she was involved in when she was 17 years old. Ford described her mood as edgy, irritable, and depressed, but denied that she was suicidal.

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