Feger v. Social Security Administration

Filing 20

MEMORANDUM AND ORDER IT IS HEREBY ORDERED that the decision of the Commissioner is AFFIRMED and plaintiff's Complaint is dismissed with prejudice. Judgment shall be entered accordingly. Signed by Magistrate Judge Frederick R. Buckles on 9/23/2009. (NCL)

UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI EASTERN DIVISION MAUREEN K. FEGER, Plaintiff, v. MICHAEL J. ASTRUE, Commissioner of Social Security, Defendant. ) ) ) ) ) ) ) ) ) )

No.

4:08CV1175 FRB

MEMORANDUM AND ORDER This cause is before the Court on plaintiff's appeal of an adverse ruling of the Social Security Administration. All

matters are pending before the undersigned United States Magistrate Judge, with consent of the parties, pursuant to 28 U.S.C. § 636(c). I. Procedural History

On March 11, 2005, plaintiff Maureen K. Feger filed an application for Disability Insurance Benefits pursuant to Title II, 42 U.S.C. §§ 401, et seq., and an application for Supplemental Security Income (SSI) pursuant to Title XVI of the Social Security Act, 42 U.S.C. §§ 1381, et seq., in which she alleged that she became disabled on July 20, 2004. consideration, the Social (Tr. 29-31, 77-79.) On initial denied

Security

Administration

plaintiff's claims for benefits.

(Tr. 39, 61-66.)

On October 12,

2006, upon plaintiff's request, a hearing was held before an Administrative Law Judge (ALJ). (Tr. 469-88.) Plaintiff testified and was represented by counsel. A vocational expert also testified

at the hearing.

On December 20, 2006, the ALJ issued a decision (Tr. 9-22.) On June 25,

denying plaintiff's claims for benefits.

2008, the Appeals Council denied plaintiff's request for review of the ALJ's decision. (Tr. 4-7.) The ALJ's determination thus 42 U.S.C. §

stands as the final decision of the Commissioner. 405(g). II. A. Evidence Before the ALJ

Plaintiff's Testimony At the hearing on October 12, 2006, plaintiff testified

in response to questions posed by the ALJ and counsel. of the hearing, plaintiff was forty-three years of age. is a high school graduate. child. (Tr. 471.)

At the time Plaintiff

Plaintiff has one adult

Plaintiff also has three minor children, one of whom lives

with her and two of whom she has joint custody with their father. (Tr. 477.) plaintiff. disability Plaintiff's fiancé and his daughter also live with (Tr. 483.) through her Plaintiff previously received short-term work, with the last of such payments

received in January 2005.

(Tr. 472-73.)

From 1989 to 1997, plaintiff was co-owner of Mike's Boat Repair, overseeing the tackle shop of the business and acting as office manager. From 1997 to July 2004, plaintiff worked as a tow For five weeks in 2003,

motor operator at Graham Packaging.

plaintiff worked for Anderson News as a laborer in the returns department. (Tr. 85.)

-2-

Plaintiff testified that she is unable to work full time because of problems with her legs, balance, and numbness in her head. (Tr. 473.) Plaintiff testified that she has had a constant

pins-and-needles sensation in her hands, feet, arms, legs, lips, and face during the previous six years. Plaintiff testified that Plaintiff testified,

she learned to get used to the sensation.

however, that she also experiences numbness in her head which results in an inability to function. (Tr. 477-78.) Plaintiff

testified that it feels as though her brain is asleep and she just stares off into space. (Tr. 478.) Plaintiff testified that the

numbness occurs every two weeks and lasts two or three days. Plaintiff testified that, during these episodes, her speech is slow and slurred and she sleeps a lot. (Tr. 473, 478.) Plaintiff

testified that her symptoms are triggered by heat, lack of sleep, and stress. (Tr. 479.) Plaintiff testified that she went to the

Mayo Clinic for her condition and was told that her symptoms were the result of electric shock. (Tr. 473-74.) Plaintiff testified

that the Mayo Clinic told her of a physician in Florida who specializes in such conditions, but that she is unable to go to Florida due to lack of income. Plaintiff testified that she

previously saw a psychiatrist for her condition but was told that she had no mental problems and that her condition was physical in nature. (Tr. 474.) Plaintiff testified that she experiences tremors which

-3-

cause difficulty with walking and balance.

Plaintiff testified

that she used to have such episodes on a daily basis and that they would last for hours. Plaintiff testified that she now takes

Neurontin which helps the condition in that the episodes now occur approximately once a month and last for fifteen minutes to half an hour. (Tr. 478.) Plaintiff testified that these symptoms as well (Tr. 479.)

are triggered by heat, lack of sleep, and stress.

Plaintiff testified that she previously believed that she had multiple sclerosis given her symptoms and her sister having been diagnosed with the condition. (Tr. 474.) Plaintiff testified that various diagnostic tests yielded negative results. Plaintiff

testified, however, that during such testing, it was discovered that she had a bulging disc at the T11-12 level. (Tr. 475.)

Plaintiff testified that she smoked marijuana in 2004 to help alleviate pain because none of her medications were working. Plaintiff testified that she used marijuana once a week and that it helped her pain. marijuana in March Plaintiff testified that she stopped using 2006 because her physician prescribed a

different medication, Trazodone, which alleviated approximately eighty percent of her pain. (Tr. 475-76.) Plaintiff testified

that she recently began experiencing muscle contraction in her hamstrings and calves and thus increased her dosage of Trazodone. (Tr. 476.) Plaintiff testified that her increased dosage of

Trazadone has resulted in a decrease of her pain from a level eight

-4-

to a level four or five on a scale of one to ten, but that she is also quite tired. (Tr. 476, 479.)

Plaintiff testified that she has trouble concentrating and remembering things, and experiences increased difficulty during episodes of numbness in her head. (Tr. 479-80.) Plaintiff

testified that she experiences fatigue and sometimes falls asleep without notice. Plaintiff testified that she usually takes naps (Tr. 480.)

approximately four days a week.

As to exertional abilities, plaintiff testified that she can walk around the block on a good day, but that she is limited in her ability to walk from room to room on a bad day due to pain. Plaintiff testified to her belief that she could stand without assistance for up to half an hour, but would experience problems with balance if she had to stand for longer periods. (Tr. 481.)

Plaintiff testified that she can sit for up to two hours before having to get up and use the restroom.1 Plaintiff testified that

she has difficulty climbing stairs, and with bending and stooping. Plaintiff testified that she was recently bending while working in her garden and fell because she became overheated and her legs knotted up. (Tr. 482.) Plaintiff testified that she also

experiences weakness and sometimes cannot lift a gallon of milk. (Tr. 480.) As to her daily activities, plaintiff testified that she Plaintiff testified that she currently takes medication for a bladder condition. (Tr. 482.) -51

wakes

in

the

morning

between

7:00

and

9:00

a.m.

Plaintiff

testified that she no longer has difficulty sleeping since taking Trazadone. (Tr. 483-84.) Plaintiff testified that upon waking,

she takes care of the dog, prepares herself some tea, turns on the television, and then plays games on the computer to keep her mind busy. Plaintiff testified that if her legs are not bad, she will

try to get up and do something, such as fix breakfast or clean the dishes. Plaintiff testified that she rests for approximately six

hours out of an eight-hour period during the day because of her fatigue. (Tr. 484.) Plaintiff testified that she does not drive (Tr. 481.) Plaintiff

often and drives only short distances.

testified that her sister and fiancé try to take her out for about an hour or two. Plaintiff testified that they go fishing several

times during the summer in an effort for plaintiff just to get out. Plaintiff testified that she sometimes has difficulty showering during her episodes of numbness and because of balance problems. (Tr. 482.) Plaintiff testified that her children help with the Plaintiff

housework, but that she always cleans the bathroom.

testified that she goes grocery shopping but has someone with her to assist her. B. (Tr. 483.)

Testimony of Vocational Expert Brenda Young, a vocational expert, testified at the

hearing in response to questions posed by the ALJ and counsel. The ALJ first asked Ms. Young to assume an individual

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forty-one years of age with a high school education and the same work history as plaintiff. The ALJ asked Ms. Young to further

assume the individual to be able to lift and carry up to 50 pounds occasionally, 25 pounds frequently; sit for six hours out of eight, stand or walk for six hours out of eight; can occasionally climb ropes, ladders and scaffolds; and should avoid moderate exposure to the hazards of moving and dangerous machinery, and unprotected heights. She is able to understand, remember and carry out at least simple instructions, and nondetailed tasks; and can perform some complex tasks as well. (Tr. 485.) Ms. Young testified past that such work a person than could her not perform work

plaintiff's

relevant

other

limited

involving magazine returns.

(Tr. 485.)

Ms. Young testified that

such a person could perform other medium, unskilled work, such as hand-packager, of which 9,000 such jobs exist in the St. Louis region; and machine operator, of which 3,500 such jobs exist in the St. Louis region. (Tr. 486.)

The ALJ then asked Ms. Young to assume the individual was limited to lifting and carrying up to twenty pounds occasionally and ten pounds frequently. Ms. Young testified that such a person

could perform light, unskilled work, such as retail sales, of which 40,000 such jobs exist in the St. Louis region; and counter attendant or dining room helper, of which 5,000 such jobs exist in

-7-

the St. Louis region.

(Tr. 486-87.)

The ALJ then asked Ms. Young to assume a person described by plaintiff in her testimony, that is, a person who "was unable to sit, stand or walk for a combination of eight hours a day[.]" Ms.

Young testified that no work was available on a full time basis for such a person. (Tr. 487.)

Counsel asked Ms. Young to consider a person who needed to rest three to four hours in an eight-hour workday. Ms. Young

testified that such a person could not work on a sustained, fulltime basis. (Tr. 487.) III. Medical Records

Plaintiff visited Dr. Mel E. Lucas on October 19, 2000, and reported that she began experiencing numbness the previous night at work, with such numbness beginning in her head and then spreading to her arms and legs. Plaintiff reported that she became very tired and weak. emergency room and Plaintiff reported that she went to the that tests performed there were normal.

Plaintiff also complained of headaches. performed by Dr. Lucas was normal. motion were noted to be normal.

Physical examination

Plaintiff's gait and range of

Dr. Lucas prescribed Cipro2 for

plaintiff and ordered various diagnostic tests to determine the etiology of plaintiff's symptoms. (Tr. 167.)

Cipro is indicated for the treatment Physicians' Desk Reference 848 (55th ed. 2001). -8-

2

of

infections.

On October 20, 2000, plaintiff underwent an MRI of the brain in response to her complaints of dizziness and numbness. The results of the MRI were normal. (Tr. 172.)

Plaintiff returned to Dr. Lucas on October 24, 2000, and reported that her numbness and lightheadedness had not improved. Plaintiff complained that she was really tired all of the time and that she experiences numbness all over, but especially in her arms and legs. Plaintiff reported that she has episodes during which (Tr. 167.) Upon plaintiff's

she feels she might pass out.

request, Dr. Lucas permitted her to return to work but restricted her from working at heights and from operating heavy machinery. (Tr. 166.) On November 6, 2000, plaintiff underwent an MRI of the cervical spine in response to her complaints of numbness and tingling in the arms and legs bilaterally. were normal. (Tr. 171.) The results of the MRI

Plaintiff returned to Dr. Lucas on November 9, 2000. Plaintiff reported that she experiences lightheadedness on a daily basis but that she does not pass out completely. Plaintiff

reported her episodes not to be associated with any one thing. Plaintiff reported having a rare headache and that she feels as though her equilibrium is off. Plaintiff reported experiencing

numbness and tingling at the base of her head and in her arms, legs, feet, and hands. Physical examination was unremarkable.

-9-

Reflexes were 2+ and strength was 5/5 bilaterally. testing was intact with no deficits. Dr.

Neurological noted all

Lucas

diagnostic testing thus far to be negative.

It was noted that Plaintiff was

plaintiff was scheduled for holter monitor testing. instructed to follow up in the office. (Tr. 166.)

An ECG performed on November 9, 2000, was normal. 170.)

(Tr.

Holter monitor testing performed on November 15 and 16, (Tr. 168-69.)

2000, showed no arrhythmia.

Plaintiff returned to Dr. Lucas on November 17, 2000, and complained of continued lightheadedness. Plaintiff reported that

she still continued to experience numbness all of the time all over her body. Plaintiff reported her family history of diabetes Plaintiff

mellitus, fibromyalgia, and multiple sclerosis (MS).

reported that she occasionally has problems with her left ankle due to a previous injury. her mid back. Plaintiff also complained of stiffness in

Physical examination showed tenderness at ten of Dr. Lucas diagnosed Addi-

fourteen trigger points for fibromyalgia.

plaintiff with lightheadedness, numbness, and fibromyalgia. tional testing was ordered and Zoloft3 was prescribed.

(Tr. 165.)

On November 22, 2000, plaintiff reported to Dr. Lucas that she continued to have episodes of lightheadedness without

Zoloft is indicated for the treatment of depression, Physicians' Desk Reference 2553-54 (55th ed. 2001), and is sometimes used to treat headaches, Medline Plus (last revised Mar. 1, 2009)<http://www.nlm.nih.gov/medlineplus/druginfo/meds/a697048 .html>. - 10 -

3

passing out. about one hour.

Plaintiff reported her episodes to improve after Plaintiff also complained of continued numbness. Plaintiff

Dr. Lucas noted that plaintiff drove a forklift at work.

reported that she experienced no real change with Zoloft. Physical examination was noted to be unchanged. Dr. Lucas diagnosed

plaintiff with lightheadedness and ordered more testing. Dr. Lucas also diagnosed plaintiff with fibromyalgia and instructed plaintiff to continue with Zoloft. On November (Tr. 165.) 28, 2000, plaintiff underwent an

echocardiogram for evaluation of history of presyncopal episode. Normal LV systolic function was noted. bicuspid aortic valve or aortic There was no evidence of Trivial mitral (Tr.

stenosis.

regurgitation and mild tricuspid regurgitation were noted. 159.)

Plaintiff reported to Dr. Lucas on November 29, 2000, that she felt worse. Plaintiff continued to complain of numbness, Dr. Lucas noted recent test results to be During an office visit on December 1, 2000,

tingling, and fatigue. negative. (Tr. 165.)

plaintiff continued to complain of worsening symptoms of numbness, weakness, and fatigue. Plaintiff reported that she wanted to sleep all of the time, and was depressed over not being diagnosed. Dr.

Lucas noted plaintiff to appear depressed, with a flat affect. Plaintiff also appeared fatigued. Physical examination was

unremarkable.

Strength was measured to be 5/5 in both upper and

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lower

extremities.

Reflexes

were

2+.

Dr.

Lucas

diagnosed

plaintiff with paresthesias and weakness.

Dr. Lucas also believed

plaintiff suffered from depression and recommended that she obtain a second opinion. Paxil4 was prescribed. Zoloft was discontinued. (Tr. 164.)

Plaintiff was told that she could return to work.

On December 15, 2000, plaintiff reported to Dr. Lucas that she continued to experience tingling all over, but that she had no episodes of lightheadedness for two days. Plaintiff

reported that she stopped taking Paxil because of its side effects, but that she felt good. return to work. Plaintiff requested a note to allow her to

(Tr. 164.)

Plaintiff visited Dr. Stephen G. Sanders on January 19, 2001, and complained of having experienced tingling all over her body for four months. except in her hands Plaintiff reported the sensation to be mild where she experiences weakness and the

sensation that the hands are asleep.

Plaintiff also reported

having episodes of lightheadedness occurring multiple times weekly and lasting up to twelve hours. Plaintiff identified no triggering events for these episodes. unremarkable. Physical examination was essentially

Dr. Sanders noted plaintiff to have a normal gait Phalen's test Dr. Sanders

and to be able to sit and stand without difficulty. and Tinel's test of the extremities were positive.

Paxil is used to treat depression, panic disorder, obsessive compulsive disorder, and social anxiety disorder. Physicians' Desk Reference 3114-16 (55th ed. 2001). - 12 -

4

determined the hand numbness/tingling to be consistent with carpal tunnel. the Dr. Sanders noted there to be no unifying diagnosis for body tingling" and opined that the episodes of

"whole

lightheadedness were likely vasovagal.

Dr. Sanders also opined Dr. nerve

that plaintiff may have experienced orthostatic hypotension. Sanders determined for plaintiff to undergo EMG and

conduction studies as well as laboratory testing. instructed to follow up in two months.

Plaintiff was

(Tr. 364-65.)

Plaintiff visited Dr. Carey Fredman of Midwest Heart Rhythm on January 29, 2001, with complaints of experiencing It was

numbness and tingling over her entire body for four months.

noted that diagnostic examinations, including MRI, echocardiogram, holter monitor, and blood tests, were normal. Plaintiff described

episodes of lightheadedness while either sitting or standing, and reported that lying down relieved this sensation. Plaintiff also

reported that taking Meclizine,5 which had been given to her in an emergency room, also seemed to help her lightheadedness. Plaintiff reported experiencing recent fatigue and some blurred vision. Plaintiff Review of reported the generalized weakness was be and cold intolerance. Physical otherwise

remaining

systems to

unremarkable. obese but was

examination

showed

plaintiff

unremarkable. Dr. Fredman expressed uncertainty as to the cause of

Meclizine is indicated for the management of nausea and vomiting, and dizziness associated with motion sickness. Physicians' Desk Reference 2469 (55th ed. 2001). - 13 -

5

plaintiff's

numbness

and

tingling,

and

he

recommended

that

plaintiff undergo a tilt table test. On February 2, 2001,

(Tr. 161-62.) underwent a nerve

plaintiff

conduction study (NCS) in response to her complaints of numbness and tingling in her hands and legs. Examination showed temperature and vibratory sensation to be intact in the upper and lower extremities. NCS Muscle bulk was noted to be intact. Results of the

showed no electrodiagnostic evidence of motor or sensory (Tr. 310.)

neuropathy.

Plaintiff underwent a tilt table test on February 6, 2001, the results of which were negative. Upon referral from Dr. (Tr. 160.) plaintiff visited

Sanders,

neurologist Dr. K. Philip Lee on February 22, 2001, for evaluation of her complaints of whole body paresthesias and lightheadedness. Plaintiff reported having experienced paresthesias involving both sides of her face, arms and legs since October 2000; and of having intermittent spells of lightheadedness while sitting or standing, having no association with movement. Plaintiff reported these Plaintiff reported her

spells to last twelve to fourteen hours. symptoms to worsen if she gets cold. symptoms. Dr. Lee noted plaintiff

Plaintiff reported no other to take Meclizine, which

plaintiff reported to help with dizziness. plaintiff took Florinef.6
6

It was also noted that

Examination showed plaintiff to be

Florinef is used to help control the amount of sodium and fluids in the body. Medline Plus (last reviewed Sept. 1, 2008) - 14 -

mildly obese, in no acute distress.

No nystagmus was noted.

Plaintiff had no facial weakness, but mild tingling bifacially was noted. Motor examination was unremarkable. Plaintiff's strength Plaintiff reported

was noted to be intact in all extremities.

having a mild pins-and-needles sensation in her arms and legs. Dr. Lee noted, however, that plaintiff had no diminution of sensation and had intact vibration and joint position sense. testing was performed without ataxia. a steady gait. Finger-to-nose

Plaintiff was noted to have

Plaintiff was able to walk on her toes and heels, Upon review of the examination and various

as well as tandem walk.

diagnostic tests all yielding negative results, Dr. Lee reported that a unifying diagnosis was not clear and that there were no specific features or evaluation to suggest the presence of a neurological disorder. Dr. Lee remarked on his inability to think

of other tests to perform and opined that plaintiff's symptoms may resolve on their own in time inasmuch as there was no anatomic or physical abnormality noted in her multiple tests. expressed frustration at the lack of diagnosis, and Plaintiff Dr. Lee

suggested that plaintiff get a second opinion from an entity such as Mayo Clinic, but opined that the "utility of that would not be high." 304.) Plaintiff returned to Dr. Sanders on February 23, 2001, (Tr. 303.) Dr. Lee had no further recommendations. (Tr.

<http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682549.html>. - 15 -

and reported that she experienced no improvement with her dizziness and continued to experience dizziness on a regular basis upon standing. Dr. Sanders noted there to be a component of vertigo

present but that such symptom was intermittent and independent of other symptoms. Plaintiff reported Florinef not to have helped. Physical

Dr. Sanders noted plaintiff to also take Meclizine. examination was unremarkable. plaintiff to be mildly ataxic.

Neurological examination showed Dr. Sanders noted plaintiff to have

a peculiar head bob and tremor in the right upper extremity while seated. Sensory, strength and reflex examinations were normal.

Dr. Sanders noted plaintiff to have positive Romberg's test and that she held on to the wall while ambulating. Dr. Sanders noted Dr. Sanders Florinef and

there to be no change in plaintiff's paresthesia. determined to increase plaintiff's dosage of

considered prescribing Prozac or beta-blockers.

Plaintiff was

instructed to remain off of work until further notice and was advised that she may have to change jobs. Plaintiff was instructed to return in one month for follow up. (Tr. 361.)

Plaintiff returned to Dr. Lee on March 1, 2001, with complaints of recent onset of head bobbing. Plaintiff reported

that the condition goes away if someone hugs her or if she squeezes the back of her head. No tremor was noted in the extremities.

Plaintiff also continued to complain of generalized paresthesias. Examination showed plaintiff to have a mild head-bobbing-type of

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tremor which was noted to come and go.

Dr. Lee questioned whether

the tremor became more pronounced when plaintiff was self-conscious of it. No limb or truncal ataxia was noted. Plaintiff had a

normal gait.

Dr. Lee questioned whether the head bobbing was the Dr. Lee determined for plaintiff to

onset of an essential tremor. undergo a repeat MRI.

Dr. Lee determined to treat plaintiff as

though she had an essential tremor, and he prescribed Mysoline.7 (Tr. 300-01.) Plaintiff visited Dr. Sanders on March 19, 2001, and reported some subtle improvement in her symptoms. Plaintiff

indicated that she wanted to return to work.

Plaintiff reported a

continued feeling of lack of equilibrium but reported her dizziness to have improved. Dr. Sanders questioned whether plaintiff's Neurological

improvement was due to the addition of Mysoline.

examination showed plaintiff to have mild ataxia with ambulation and to have positive Romberg's test. nerves was normal. ataxia or vertigo. Examination of the cranial

Dr. Sanders questioned whether plaintiff had Dr. Sanders continued in his observation of Dr. Sanders noted that plaintiff was to Plaintiff was instructed to stop

plaintiff's paresthesias.

be seen for a second opinion.

Florinef, to continue with Mysoline, and to return for follow up in three to four months. (Tr. 360.)

Mysoline is used to control certain types of seizures. Medline Plus (last revised June 1, 2009)<http://www.nlm.nih.gov/ medlineplus/druginfo/meds/a682023.html>. - 17 -

7

On March 29, 2001, plaintiff visited Dr.

G.

Robert

Kletzker of Ear Care & Skull Base Surgery, Inc., in relation to her five-month history of recurring bouts of imbalance and a constant sense of lightheadedness aggravated by head motion. Plaintiff also complained of near fainting spells and of developing dyskinesias, head bobbing, and poor control of muscle function. noted diagnostic testing to have been negative. Dr. Kletzker

It was noted that

plaintiff was scheduled for an upcoming cerebral spinal fluid test. Physical examination showed rhythmic head bobbing and cervical cranial torsion, but was otherwise unremarkable. finger testing was intact without tremors. Finger-nose-

Plaintiff's gait was

noted to be slow and cautious, but plaintiff performed tandem fairly well. Dr. Kletzker suspected that plaintiff's central

disequilibrium was related to her neuromuscular abnormalities. Dr. Kletzker recommended studies to rule out MS, lyme disease, or heavy metal poisoning. Dr. Kretzker advised that plaintiff need not

follow up with him unless the recommended studies were negative, which would thus indicate further testing. (Tr. 163.)

Dr. Stuart Weiss examined plaintiff on April 26, 2001, in relation to her complaints of paresthesias, lightheadedness, Plaintiff

intermittent head jerking and bobbing, and imbalance.

reported that she was frustrated with her increased fatigue and inability to function, and that she had been unable to work for the past six months. Plaintiff reported a remote history of

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depression. Physical examination as to muscle strength, sensation, coordination, and deep tendon reflexes was unremarkable. No

abnormality was initially noted with regard to plaintiff's gait; however, plaintiff began to jerk and twitch while undergoing testing for balance in the examination room. Plaintiff had normal

tandem gait, however, and was able to stand on one foot for ten to fifteen seconds with her eyes closed. Some tremors were also Dr. Weiss noted there

noted, but they disappeared with activity.

to be no objective neurological deficit other than nystagmus which, Dr. Weiss opined, may be related to plaintiff taking Mysoline to control her head tremor. Dr. Weiss opined that plaintiff may have Plaintiff was (Tr.

masked depression with multifocal somatic symptoms.

given Celexa8 and was instructed to follow up in six weeks. 311-12.)

Plaintiff returned to Dr. Sanders on May 8, 2001, for evaluation of persistent numbness, tingling, dizziness, and

occasional palpitations. Dr. Sanders noted the negative results of diagnostic testing. Dr. Sanders further noted Dr. Weiss's

suggestion that plaintiff take Prozac for somatoform disorder. Dr. Sanders noted plaintiff to vehemently deny being depressed and insisted that something was wrong. Physical examination was

unremarkable. Neurological examination was "entirely normal." Dr. Sanders opined that plaintiff had probable somatoform disorder. Celexa is indicated for the treatment Physicians' Desk Reference 1258 (55th ed. 2001). - 19 8

of

depression.

Dr. Sanders gave plaintiff samples of Effexor9 and suggested that she seek a psychiatric opinion. (Tr. 359.)

On August 21, 2001, plaintiff visited Dr. John E. Tessier of Mid County Orthopaedic Surgery and Sports Medicine for

evaluation of an injury which occurred on August 19, 2001.

It was

noted that plaintiff was in a go-cart accident in which the go-cart flipped and plaintiff landed on her left side, shoulder, and neck. Plaintiff currently reported pain in her left shoulder and cervical spine unrelieved by Vicodin.10 Plaintiff also reported that she had difficulty sleeping at night. no significant medical Dr. Tessier noted plaintiff to have Physical examination showed

history.

limited range of motion about the neck with tenderness to the cervical spine to palpation as well as along the medial scapular border. The left scapula was noted to be tender and an abrasion Other than showing a straightening of the cervical Dr. Tessier diagnosed plaintiff with

was noted.

spine, x-rays were negative.

strain to the cervical spine as well as contusion and crush injury to the left shoulder. Dr. Tessier recommended that plaintiff take

anti-inflammatory medication and muscle relaxants and apply ice and heat to the affected areas. Dr. Tessier instructed plaintiff to

remain off work for two weeks and to return to his office at that

Effexor is used to treat Reference 3361 (55th ed. 2001).
10

9

depression.

Physicians'

Desk

Vicodin is indicated for the relief of moderate to moderately severe pain. Physicians' Desk Reference 1629-30 (55th ed. 2001). - 20 -

time for follow up.

(Tr. 187.)

Plaintiff visited Dr. Sanders on December 12, 2002, and complained of a lump on her ankle. It was noted that plaintiff

worked as a forklift driver and sometimes worked a second job. Plaintiff also reported persistence in paresthesias of her hands, feet and face since January 2001. some fatigue. gained weight. Plaintiff also reported feeling

It was noted that plaintiff did not exercise and had Physical examination showed a tender inflammatory Otherwise, physical and

nodule in the left Achilles tendon.

neurological examination was unremarkable. Plaintiff was diagnosed with Achilles tendinitis, and paresthesias of unclear etiology. Laboratory testing was ordered and plaintiff was instructed as to diet, exercise, and sleep habits. Plaintiff was also instructed as to stretching of the Achilles and to take Aleve. Laboratory testing performed on (Tr. 358.) 18, 2002,

December

yielded normal results.

(Tr. 299.)

Plaintiff was admitted to St. John's Mercy Medical Center on February 3, 2003, after having experienced multiple spells of nonresponsiveness and head shaking during the previous two days. It was determined that plaintiff would undergo EEG, MRI and MRA testing. (Tr. 305.) Dr. Lee examined plaintiff on that same date

and noted plaintiff's complaints of multiple spells of altered level of consciousness and dizziness. paresthesias, head bobbing and head Plaintiff reported having shaking. Dr. Lee noted

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plaintiff not to be taking any medication. plaintiff's speech to be fluent. or numbness. normal tone

Examination showed

Plaintiff had no facial weakness

Plaintiff's strength was noted to be intact with and bulk. Sensory examination showed diffuse

paresthesias all over.

Deep tendon reflexes were 1+ bilaterally.

Plaintiff was able to perform finger-to-nose coordination testing without ataxia. (Tr. 309.) During EEG testing, plaintiff

experienced multiple spells of not responding as well as head bobbing or shaking; however, the EEG was unremarkable in that a normal background rhythm was maintained with no evidence of

electrographic seizures.

(Tr. 297.)

Dr. Sanders examined plaintiff on February 4, 2003, and noted that overnight EEG testing showed five or six spells,

sometimes severe, but that such spells were not consistent with epileptiform activity. Plaintiff reported head-to-toe paresthesias throughout the day, but Dr. Sanders noted that such condition did not prevent her from performing her nighttime work as a forklift driver. Plaintiff was noted to currently be taking Effexor.

Physical examination was normal. Dr. Sanders opined that plaintiff had spells "which are stereotyped" and which he considered "as vasovagal or psychologically based." (Tr. 306.) Dr. Sanders also plaintiff's

noted there to be no physiologic explanation for paresthesias.

Dr. Sanders determined for plaintiff to undergo MRI (Tr.

and MRA testing and to follow up with Dr. Lee and himself.

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307.) An MRI of the brain performed on February 4, 2003, showed no significant abnormality. (Tr. 319.) An MRI/angiogram of the

neck performed that same date showed mild plaque in both carotid arteries, but without significant flow limitation. Plaintiff was discharged from St. (Tr. 317.) Mercy on

John's

February 4, 2003, with instruction not to drive.

(Tr. 298.)

Plaintiff returned to Dr. Sanders on February 24, 2003, and reported that her episodes of syncope had nearly resolved. Plaintiff reported occasional dizziness. she would like to go back to work. have an appointment with a Plaintiff indicated that

Dr. Sanders noted plaintiff to to rule out any

psychiatrist

psychological input on her symptoms.

Physical and neurological and normal sensory,

examination was normal, with normal gait strength and reflex examinations.

It was noted that plaintiff

requested to see a vascular surgeon regarding her circulation. Dr. Sanders opined that, given the series of negative tests thus far, a sural nerve biopsy should be considered to rule out treatable causes of neuropathy. months. (Tr. 356.) On March 6, 2003, plaintiff visited Dr. Joseph J. Hurley at West County Surgical Specialists who noted plaintiff to have "a very bizarre" medical history, which included hands and legs going to sleep, legs hurting while walking, fainting spells, and Plaintiff was instructed to return in two

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hypotension.

It

was

noted

that

plaintiff

experienced

these

conditions for two and one-half years.

Dr. Hurley also noted

plaintiff to have a history of equilibrium problems as well as head bobbing. Physical examination was unremarkable. It was noted that plaintiff had normal speech and normal gait. grossly intact. Cranial nerves were

It was noted that plaintiff had been requested to

see a psychiatrist. Upon conclusion of the examination, Dr. Hurley suggested that plaintiff undergo treadmill testing to make certain that there is no occult underlying peripheral arterial disease. She has obviously been well worked up for the possibility of cerebrovascular disease. If there is no evidence of peripheral arterial disease, I do not have any other understanding of what is going on with her. (Tr. 190.) Plaintiff visited psychiatrist Dr. Scott J. Arbaugh on March 31, 2003. Upon examination, Dr. Arbaugh determined there to

be no evidence of any psychopathology, noting plaintiff not to "appear to have any type of a mood disorder, anxiety disorder or psychotic disorder." Dr. Arbaugh recommended that plaintiff Dr.

discontinue Effexor inasmuch as it had been ineffective.

Arbaugh noted plaintiff to have worked making lead weights in the past, and opined that such exposure to lead may be of some significance in determining the etiology of her complaints. 191, 294-96.) (Tr.

- 24 -

Plaintiff returned to Dr. Sanders on April 17, 2003, and reported that her symptoms had worsened. Plaintiff reported being

dizzy all day, every day, and that she must take off work because of it. toe. Plaintiff also reported numbness and tingling from head to Plaintiff reported being depressed and angry about her Plaintiff was convinced that she had MS. Physical and Dr. Sanders

illness.

neurological examination showed no evident symptoms.

concluded that plaintiff had somatic symptoms, not consistent with neurologic disease; and probable fibromyalgia. Additional

diagnostic testing was scheduled.

Dr. Sanders noted Dr. Lee to Dr. Sanders (Tr.

have given plaintiff Amitriptyline11 the previous day.

recommended that plaintiff titrate the dose for two weeks. 355.)

An MRI of the cervical spine performed on April 18, 2003, was unremarkable. (Tr. 315.)

In a letter to Dr. Sanders dated May 2, 2003, Dr. Lee reported that he provided an option to plaintiff that she undergo further evaluation or proceed with symptomatic treatment, of which she chose further evaluation. Dr. Lee reported that plaintiff

therefore underwent lumbar puncture and further laboratory testing, all of which yielded negative results. Dr. Lee reported that upon

Amitriptyline is used for the relief of symptoms of depression, Physicians' Desk Reference 626 (55th ed. 2001), but is also sometimes used to treat post-herpetic neuralgia, Medline Plus (last revised May 1, 2009)<http://www.nlm.nih.gov/medlineplus/ druginfo/medmaster/a682388.html>. - 25 -

11

advising plaintiff of these results, plaintiff indicated that her symptoms were improving. Dr. Lee reported that he instructed

plaintiff to call him if her symptoms worsened and if she wanted to proceed with symptomatic treatment. (Tr. 293.)

Plaintiff returned to Dr. Sanders on June 3, 2003, for symptoms including cough, fever and nasal congestion. noted plaintiff to still be working. Dr. Sanders

Plaintiff was diagnosed with

viral gastroenteritis and was instructed as to diet and fluid intake. (Tr. 354.) Plaintiff visited endocrinologist Dr. Irini Veronikis on June 22, 2003, in relation to her symptoms of paresthesias in her arms, legs, lips, and face; numbness; lightheadedness; fatigue; loss of balance; tremors; twitching; and myoclonus.12 It was noted

that plaintiff's symptoms had recently improved, but that "a viral infection brought everything back to the surface." that plaintiff took no medications. unremarkable. Examination of the It was noted

Physical examination was head and neck was normal.

Laboratory testing yielded normal results. Dr. Veronikis suggested that plaintiff be evaluated for sleep apnea given her tiredness and history of snoring. caffeine It was also due recommended to her that plaintiff and

discontinue

intake

irritability

Myoclonus refers to sudden, involuntary jerking of a muscle or group of muscles. Myoclonus generally is not a diagnosis of a disease but rather describes a symptom. Medline Plus, National Institute of Health (last updated Dec. 11, 2007)<http://www.ninds. nih.gov/disorders/myoclonus/detail_myoclonus.htm>. - 26 -

12

lightheadedness.

(Tr. 194.)

Plaintiff visited rheumatologist Dr. Robert J. Schneider on January 5, 2004. Plaintiff complained of face pain; tingling in her hands, arms, feet, and legs; leg spasticity; equilibrium

problems; numbness in the back of her head; tremors; and episodes of lightheadedness. Plaintiff reported that she currently worked (Tr. in

as a tow motor operator approximately fifty hours a week. 208.) Plaintiff reported that she was last

hospitalized

February 2003 for syncope and that she currently had diffuse musculoskeletal pain which caused difficulty with walking.

Plaintiff reported having poor sleep.

It was noted that plaintiff

worked at night and slept fitfully during the day, but that her sleep was okay on the weekends. past medications. (Tr. Dr. Schneider noted plaintiff's Physical examination was

207.)

unremarkable. tenderness.

Dr. Schneider noted there to be no trigger point Dr. Schneider noted plaintiff to speak with minimal

motion of the mouth until she was distracted whereupon her facial motion became more normal. (Tr. 205-06.) Dr. Schneider opined

that plaintiff had somatization disorder and did not have typical fibromyalgia. Dr. Schneider considered prescribing Neurontin for

symptom control and questioned whether plaintiff should be referred to a pain clinic for evaluation. In a letter to (Tr. 206.) dated March 1, 2004, Dr.

plaintiff

Schneider noted plaintiff's prior medical records and multiple

- 27 -

diagnostic tests to yield normal results.

Dr. Schneider stated

that he could not make a diagnosis of any primary rheumatologic disorder and that plaintiff's symptom complex did not fit the typical category of fibromyalgia syndrome. Dr. Schneider noted

that he had previously suggested a trial of Neurontin for symptom control, and recommended that plaintiff undergo repeat testing. (Tr. 218.) Plaintiff returned to Dr. Schneider on April 4, 2004, who noted plaintiff's present illness to be somatization disorder. Physical examination was normal. Additional testing was ordered Plaintiff was instructed

and plaintiff was prescribed Neurontin.13 to return in one month. (Tr. 203-04.)

An EMG and NCS performed April 14, 2004, showed no significant abnormalities. (Tr. 217.)

Plaintiff visited Dr. Schneider on May 6, 2004, and reported her tremors to be quiet. Dr. Schneider questioned whether this was the effect of Neurontin. Plaintiff also reported that her muscle cramps had decreased and that her facial pain was less intense. Dr. Schneider noted some fatigue and questioned whether

it was related to plaintiff's work schedule and/or medications. Physical examination was normal. Dr. Schneider continued in his

Neurontin is used as adjunctive therapy in the treatment of partial seizures, Physicians' Desk Reference 2458-59 (55th ed. 2001), as well as to relieve the pain of post-herpetic neuralgia. Medline Plus (last revised June 1, 2008)<http://www.nlm.nih. gov/medlineplus/druginfo/medmaster/a694007.html>. - 28 -

13

diagnosis of somatization disorder and instructed plaintiff to continue with Neurontin. (Tr. 200-01.)

Plaintiff visited Dr. Sanders on July 26, 2004, and complained of leg pain and tremors. It was noted that plaintiff

had an upcoming appointment with neurologist Dr. Christina Lenk. (Tr. 353.) In a note from Dr. Schneider's office dated July 30, 2004, it was noted that weekly messages had been left for plaintiff regarding her failure to appear for testing, and that no response had been received regarding these messages. (Tr. 202.)

Plaintiff returned to Dr. Schneider on August 6, 2004, and reported that she was on temporary disability. It was noted

that plaintiff's dosage of Neurontin had been increased and that plaintiff had not yet had an EMG study. Plaintiff reported

increased pain in her legs in the past months and expressed concern that she had MS. It was noted that plaintiff was scheduled to see Physical examination was normal. Dr.

Dr. Lenk in ten days.

Schneider continued in his diagnosis of somatization disorder and expressed doubt that plaintiff had MS. A repeat MRI was

considered.

Plaintiff was instructed to keep her appointment for (Tr. 198-99.)

neurological consultation.

Plaintiff visited neurologist Dr. Christina N. Lenk on August 17, 2004, for evaluation for possible MS. (Tr. 328-30.)

Dr. Lenk reviewed plaintiff's medical history and noted plaintiff's

- 29 -

current complaints of weakness in her left leg and arm with occasional difficulty with walking. leg to drag when she walks. Plaintiff reported her left

Plaintiff also reported intermittent It was noted that experienced no

head tremor which resolves if someone hugs her. plaintiff currently swam for exercise and

limitations in the activity.

(Tr. 328.)

Plaintiff's medications

were noted to be Neurontin, Vicodin, Robaxin,14 and Naproxen.15 Plaintiff's employment was noted to be as a tow motor operator. Physical examination was unremarkable. Neurological testing showed give-way weakness in both upper and lower extremities, but was otherwise unremarkable. Sensory examination was intact, strength

was noted to be 5/5, and plaintiff was able to ambulate without difficulty on heels, toes, and in tandem. (Tr. 329.) Upon review

of the physical examination and previous diagnostic tests, Dr. Lenk opined that plaintiff did not have MS. Dr. Lenk also opined that

plaintiff's symptoms were unrelated to an electrical shock received prior to their onset. Dr. Lenk noted plaintiff to be tearful and Dr. Lenk determined (Tr.

that she wanted to be given a diagnosis of MS.

to order additional tests and to review additional records.

Robaxin is indicated as an adjunct to rest, physical therapy and other measures for the relief of discomfort associated with acute, painful musculoskeletal conditions. Physicians' Desk Reference 2716 (55th ed. 2001). Naproxen is indicated for the treatment of rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, and for the management of pain. Physicians' Desk Reference 2744-45 (55th ed. 2001). - 30 15

14

330.) Plaintiff was admitted to the emergency room at St. Luke's Hospital on August 30, 2004, for tremors. It was noted that

although plaintiff's tremors were generalized, they were mostly confined to plaintiff's head and neck. noted to be slow. Flexeril.16 Plaintiff's speech was

Plaintiff was given Neurontin, Vicodin, and

During an EEG test, plaintiff experienced two episodes

of head tremors with intermittent episodes of head/body tremors. The occasional tremors were noted to be associated with muscular artefact not typical of cerebral activity. (Tr. 221-30.)

Plaintiff returned to Dr. Sanders on September 7, 2004, and complained of bilateral leg pain. It was noted that plaintiff (Tr.

was hospitalized the previous week and was taking Neurontin. 352.)

Plaintiff reported the Neurontin to help with her tremors,

but that she continued to experience tremors all over, as well as pain from head to toe, numbness, and tingling. Flexeril not to help her muscle spasms or Plaintiff reported pain. Physical

examination showed plaintiff's ambulation to be slow and limping. Calf muscles were slightly tender to palpation. Plaintiff had

normal strength, sensation, reflexes, and cerebellar exam and gait. No tremors were noted. Plaintiff was instructed to continue with

Flexeril is indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions. Physicians' Desk Reference 1929 (55th ed. 2001). - 31 -

16

Neurontin and to take Diazepam.17

(Tr. 351.) on

MRI's of the brain and cervical spine performed September 10, 2004, were negative. (Tr. 252, 253.)

On September 17, 2004, plaintiff visited Dr. Sanders for a spider bite. Robaxin. It was noted that plaintiff was taking Diazepam and (Tr. 350.)

Keflex, an antibiotic, was prescribed.

From October 27 through November 2, 2004, plaintiff visited the Mayo Clinic in Scottsdale, Arizona, for evaluation of her symptoms. Multiple tests and examinations failed to reveal any physiological cause of plaintiff's symptoms. Throughout her

examinations, plaintiff reported a history of fatigue with frequent falling asleep during the day, infrequent double vision, difficulty speaking, vertigo and loss of balance, lightheadedness, leg and hip pain, limb stiffness, leg and arm weakness, paresthesias and numbness, and head tremor. (Tr. 255-79.) Plaintiff reported the

intermittent and remitting nature of her condition since its onset in October 2000, but described the recurrence and persistence of her symptoms since July 2004. It was noted that plaintiff's

temporary disability ended on October 27, 2004, and that plaintiff was seeking total disability. yielded inconsistent results. (Tr. 265.) Physical examinations

Plaintiff's gait was noted to be

functional astasia, abasia with tearfulness due to the level of pain; however, it was noted that plaintiff could rise on her toes Diazepam is used to relieve anxiety and Physicians' Desk Reference 2814 (55th ed. 2001). - 32 17

muscle

spasm.

and heels.

It was noted that plaintiff appeared to have a

volitional tremor of the head and arms while walking; however, with distraction during the course of the examination, the tremor disappeared. Plaintiff was unable to lift her left leg to perform

a diagnostic maneuver, due to severe pain in her thigh; however, plaintiff was able to extend her knee fully, her quadriceps were examined without discomfort, and hip flexor movements were normal. It was noted that plaintiff throughout was the quite dramatic and tearful, 258.)

describing

pain

examination.

(Tr.

Neurologist Alan Yudell opined that plaintiff's examination and symptoms were compatible with somatoform disorder, to which

plaintiff appeared hostile in response. (Tr. 258-59.)

Dr. John A.

Freeman likewise opined that there was no specific musculoskeletal component to plaintiff's pain and disability. that myofascial pain was difficult to Dr. Freeman noted He prescribed

treat.

nortriptyline18 and instructed plaintiff to continue with Neurontin. Dr. Freeman further instructed plaintiff to discontinue Vicodin, Ultram and Robaxin, and to take Tylenol Arthritis. opined that plaintiff could benefit from a Dr. Freeman psychological

consultation for

coping mechanisms, as well as from physical (Tr. 268.) The final

therapies and a work hardening program.

report of plaintiff's evaluation at Mayo Clinic included a summary Nortriptyline is an antidepressant used to treat depression but may also be used to treat post-herpetic neuralgia. Medline Plus (last reviewed Sept. 1, 2008)<http://www.nlm.nih.gov/ medlineplus/druginfo/medmaster/ a682620.html>. - 33 18

of discussions with plaintiff regarding her

concern that the

presence of plastics at her last place of employment may be related to her symptomology, which Dr. Robert R. Orford was of the opinion that it was not. Plaintiff also questioned whether an electrical

shock sustained by her a few months prior to the onset of her symptoms in October 2000 could have caused these symptoms, in response to which Dr. Orford noted that a physician in Florida appeared to specialize in such occurrences and suggested that plaintiff contact him for consultation or referral. Plaintiff also requested that she see an MS specialist, but was informed that one was unavailable until the following week. It was noted that Dr. Orford

results from previous testing for MS were negative.

also noted that all tests for lupus were within the normal range, despite plaintiff's concern regarding the statistically significant number of women at her former workplace who had been diagnosed with the condition. (Tr. 256.)

Plaintiff returned to Dr. Sanders on November 16, 2004, and reported on her recent visit to Mayo Clinic. Dr. Sanders noted

that plaintiff and her sister refused to believe that plaintiff did not have something more significant than somatoform disorder and myofascial pain syndrome. Dr. Sanders noted plaintiff's current Physical

medications to be Nortriptyline, Neurontin, and Aleve.

examination showed plaintiff to have mild diffused pain in most of the muscle groups. Neurological examination was normal when

- 34 -

plaintiff did the exercises. Dr. Sanders opined that plaintiff had probable cystitis and myofascial pain syndrome versus somatoform disorder. Dr. Sanders noted plaintiff to do physical therapy and Dr. Sanders reassured plaintiff that there was

warm pool therapy.

no specific medical condition, but it was noted that plaintiff was "un-reassured." Plaintiff was given a trial of Nortriptyline and (Tr. 348.)

was instructed to return in three or four months.

Dr. Sanders examined plaintiff on December 22, 2004, for disability tremors. update in relation to plaintiff's body aches and

It was noted that plaintiff had been diagnosed with

somatoform disorder by the Mayo Clinic and was doing a little better on Nortriptyline. Plaintiff reported that she had normal

activity and energy levels, but that she walked with a wobbly and unsteady gait, and had tingling and tremors all over. examination was normal. Physical

Neurological examination showed sensation No tremor was

to be normal to touch, pinprick, and vibration. noted and no cerebellar signs were present. was within normal limits. symmetrical. (Tr. 345.)

Straight leg raising

Deep tendon reflexes were 2+/4 and

Psychiatric assessment showed plaintiff

to have impaired insight, but to have appropriate judgment, mood and affect. Plaintiff also had normal rate of speech with normal (Tr. 346.) Dr. Sanders diagnosed

articulation and spontaneity.

plaintiff with somatoform disorder and fibromyalgia. Plaintiff was continued on Nortriptyline and was given instruction as to diet and

- 35 -

exercise. (Tr. 346.)

Plaintiff was instructed to return in three months.

Plaintiff complained of

visited

SLUCare and

on of

January having

25,

2005,

and

having

tremor

pins-and-needles

sensations over her entire body.

Plaintiff reported that she

experienced an electrical shock in August 2000 after which she starting waking up in September 2000 with paresthesias in the occipital area. Plaintiff reported the sensation to spread to her

four limbs in October 2000 and that her thinking became clouded at work at that time. Plaintiff reported the symptoms to have

resolved in April 2001, and that they reoccurred on an intermittent basis in February 2003. Finally, plaintiff reported the symptoms

to have reoccurred in July 2004, and that she has experienced constant numbness, tingling, head and limb tremor, twitching, and decreased balance since that time. (Tr. 282.) Physical

examination showed muscle strength to be 5/5 in the upper and lower extremities. Muscle tone was normal. Plaintiff's gait was noted Sensation

to be normal in stance, heel, toe, tandem, and swing.

was noted to be decreased in her fingers versus her elbows, but was otherwise within normal limits. (Tr. 285.) Overall, plaintiff's It was noted that

examination was determined to be normal.

plaintiff was considering the University of Chicago's Electrical Trauma Program. (Tr. 286.)

Plaintiff returned to Dr. Sanders on March 31, 2005, for

- 36 -

follow up evaluation.

Plaintiff reported no significant change in

her pain but reported the pain to increase with walking. Plaintiff reported the pain to have been better the previous year with swimming. Plaintiff requested that Nortriptyline be discontinued.

As to plaintiff's fibromyalgia, it was noted that such condition had not changed. No complications were noted from her medication.

Plaintiff reported tingling sensations and that she experienced numbness. ability. Plaintiff reported no decrease in her concentration Plaintiff reported that she drags one foot when she walks Physical examination

and that she walks with shuffling steps.

showed mild diffuse tenderness in many muscle groups, but no swelling or warmth. was Neurologic examination Cymbalta19 was was normal.

Nortriptyline

discontinued.

prescribed.

Plaintiff was instructed as to diet and exercise, and was further instructed to return in four months. (Tr. 344.)

On May 19, 2005, A. Tayob, a medical consultant for disability determinations, completed a Physical Residual Functional Capacity Assessment. (Tr. 146-53.) In this assessment, it was

opined that plaintiff could occasionally lift and/or carry fifty pounds, and frequently lift and/or carry twenty-five pounds. It

was opined that plaintiff could stand and/or walk for a total of

Cymbalta is used to treat depression and generalized anxiety disorder, as well as pain and tingling caused by diabetic neuropathy and fibromyalgia. Medline Plus (last revised Mar. 1, 2009)<http://www.nlm.nih.gov/medlineplus/druginfo/meds/ a604030.html>. - 37 -

19

six hours in an eight-hour workday, and sit for a total of six hours in an eight-hour workday. It was further opined that

plaintiff had no limitations in her ability to push and/or pull. (Tr. 147.) As to plaintiff's postural limitations, it was opined

that plaintiff could frequently climb ramps and stairs, balance, stoop, kneel, crouch, and crawl. It was opined that plaintiff (Tr. 148.)

could occasionally climb ladders, ropes and scaffolds.

It was further opined that plaintiff should avoid moderate exposure to hazards, such as machines and heights, due to tremors. 150.) (Tr.

It was opined that plaintiff had no manipulative, visual or (Tr. 149-50.)

communicative limitations.

In a letter dated May 30, 2005, and addressed to "Whom It May Concern," Dr. Lenk wrote that none of plaintiff's evaluations revealed any evidence to support a diagnosis of MS and, further, that she did not believe plaintiff's symptoms to be related to previous electrical shock. (Tr. 327.)

On June 13, 2005, Psychologist Sherry Bassi completed a Mental Residual Functional wherein Capacity opined Assessment that for disability was not

determinations,

she

plaintiff

significantly limited in her ability to remember locations and work-like procedures, to understand and remember very short and simple instructions, to to carry an out very short and simple special

instructions,

sustain

ordinary

routine

without

supervision, to work in coordination with or proximity to others

- 38 -

without being distracted by them, to make simple work-related decisions, to interact appropriately with the general public, to ask simple questions or request assistance, to get along with coworkers or peers without distracting them or exhibiting

behavioral extremes, to maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness, to respond appropriately to changes in the work setting, and to be aware of normal hazards and take precautions. Dr. Bassi further

opined that plaintiff was moderately limited in her ability to carry out detailed instructions, to maintain attention and

concentration for extended periods, to complete a normal workday and workweek without interruptions from psychologically based

symptoms and to perform at a constant pace without an unreasonable number and length of rest periods, and to set realistic goals or make plans independently of others. (Tr. 128-29.) Dr. Bassi

concluded that, based on her diagnosed mental condition, plaintiff could understand, remember, carry out, and persist at simple tasks; make simple work-related judgments; relate adequately to coworkers and supervisors; and adjust adequately to ordinary changes in work routine and setting. On that (Tr. 130.) date, June 13, 2005, Dr. Bassi also

same

completed a Psychiatric Review Technique Form (PRTF) for disability determinations. (Tr. 132-45.) It was noted that Dr. Bassi was

reviewing plaintiff's medical records for evaluation of Listing

- 39 -

12.07, Somatoform Disorders.

(Tr. 132, 138, 142.)

Upon review of

the medical evidence of record, Dr. Bassi opined in the PRTF that plaintiff's somatoform disorder was a medically determinable

impairment, but that such disorder did not satisfy the diagnostic criteria of the Listing. limitations plaintiff (Tr. 138.) as With respect to functional a result of somatoform

experienced

disorder, Dr. Bassi opined that plaintiff was mildly limited in the domains of Activities of Daily Living and Maintaining Social Functioning; and moderately limited in the domain of Maintaining Concentration, Persistence or Pace. Dr. Bassi further opined that (Tr. 142.)

plaintiff had no extended episodes of decompensation.

Plaintiff visited Dr. Sanders on February 3, 2006, and complained of continued pain in her legs and numbness in her head. Plaintiff reported having difficulty walking, especially with the left leg. Plaintiff also reported the tingling in her scalp to Plaintiff reported experiencing memory

sometimes be very painful. loss.

Plaintiff's medications were noted to include Neurontin, Plaintiff reported feeling fatigued and of It was noted that plaintiff had Dr.

Vicodin, and Cymbalta.

having decreased energy level. gained weight.

Physical examination was essentially normal.

Sanders noted apparent weakness in the left knee with give-way weakness noted. Dr. Sanders continued in the diagnosis of

somatoform disorder and noted that plaintiff was to be referred for neuropsychological testing as recommended by the Mayo Clinic, but

- 40 -

had

not

followed

up.

Plaintiff

was

prescribed

Cymbalta

and

Restoril20 for fibromyalgia, and was referred to physical therapy for evaluation and treatment. With regard to plaintiff's numbness

and tingling sensation, Dr. Sanders noted this to be associated with plaintiff's somatoform disorder. Dr. Sanders noted that

plaintiff persisted in wanting to believe that electrical injuries contributed to this condition. Plaintiff was referred to a

psychologist for neuropsychological testing.

(Tr. 342.)

On March 16, 2006, plaintiff attended a physical therapy session at St. John's Mercy Medical Center and complained of a twoyear history of her left leg dragging with loss of control. Plaintiff reported the symptoms to have gradually worsened.

Plaintiff reported that her leg was "sore and achy" and complained that it was tight and had a burning sensation. Plaintiff rated her

pain at a level four to nine on a scale of one to ten, and described it as constant. Plaintiff's medications were noted to Plaintiff's gait was

include Neurontin, Cymbalta, and Trazodone.21 markedly antalgic. as decreased left

Decreased left hip flexion was noted, as well knee extension. Flexibility of the lower Faber

extremities was noted to be markedly decreased bilaterally.
20

Restoril is used on a short-term basis to treat insomnia. Medline Plus (last revised Oct. 1, 2008)<http://www.nlm.nih.gov/ medlineplus/druginfo/meds/a684003.html>. Trazodone is used to treat depression. It is also sometimes used to control abnormal, uncontrollable movements. Medline Plus (last revised Aug. 1, 2009)<http://www.nlm.nih.gov/medlineplus/ druginfo/meds/a681038.html>. - 41 21

test and Stork test were noted to be positive on the left.

It was

noted that plaintiff experienced marked difficulty in performing sit-stand exercises as well as going up a flight of stairs due to increased symptoms in the lower extremities. It was noted that

plaintiff's potential for rehabilitation was fairly good given plaintiff's motivation. Short and long term goals were set, and

plaintiff was scheduled to participate in physical therapy two to three times a week for four weeks. (Tr. 339.)

Between March 16 and March 30, 2006, plaintiff appeared for physical therapy on five occasions. (Tr. 378-81.) On March

30, 2006, it was noted that plaintiff had met all of her short-term and long-term therapy goals. Plaintiff reported that her pain had

decreased to a level zero with her home exercise program, but that she experienced some "achy" pain her back which ranged from zero to four. Plaintiff experienced no pain with palpation. Plaintiff's

range of motion had improved.

Plaintiff reported that she had no

difficulty performing sit/stand functions as well as with prolonged ambulating or standing, or with going up and down one flight of stairs. deviation. Plaintiff was noted to ambulate without any gait

It was noted that plaintiff had a slight instability in

the sacroiliac joint that referred symptoms into the hip area, but it was opined that continued trunk strengthening would result in further progress. Plaintiff was discharged from physical therapy

on March 30, 2006, with instruction to continue with the home

- 42 -

exercise program.

(Tr. 378.) Plaintiff

Plaintiff visited Dr. Sanders on May 2, 2006.

reported that she continued to experience numbness in her head but that it was better. Plaintiff reported that the condition was

severe for three days the previous week. Plaintiff stated that she wanted to return to work. Plaintiff's current medications were

noted to be Neurontin, Vicodin, Trazadone, and Cymbalta. Review of systems showed plaintiff to have a normal activity and energy level. Plaintiff had no heat or cold intolerance, or dyspnea. It

was noted that plaintiff exercised weekly. was unremarkable. Plaintiff was

Physical examination with peripheral

diagnosed

enthesopathies and allied syndromes. Cymbalta was refilled. months. (Tr. 452-53.)

Plaintiff's prescription for

Plaintiff was instructed to return in four

Plaintiff visited gynecologist Dr. Jay Padratzik on June 21, 2006, complaining of cramps and lower abdominal pain.

Plaintiff's past medical history was noted to include tremors. Plaintiff's medications were noted to be Neurontin, Trazadone, and Cymbalta. Plaintiff was prescribed Motrin and a urology evaluation was ordered. (Tr. 442.)

On June 30, 2006, Dr. Padratzik prescribed Darvocet22 for plaintiff. Later that same date, plaintiff reported to Dr.

Padratzik that Darvocet was not helping her pain.
22

Vicodin was then pain.

Darvocet is used to relieve mild to moderate Physicians' Desk Reference 1708-09 (55th. ed. 2001). - 43 -

prescribed.

Upon being notified that date that Vicodin did not

help plaintiff's pain, Dr. Padratzik advised plaintiff to go to an emergency room. (Tr. 446.)

On June 30, 2006, plaintiff was admitted to the emergency room at St. John's Mercy Medical Center complaining of lower abdominal pain and nausea. Plaintiff reported the pain to be sharp and constant and to be at a level six on a scale of one to ten. A

CT scan of the abdomen and pelvis showed no abnormality. Plaintiff was given morphine and Toradol for pain. that same date. Percocet for pain. Plaintiff was discharged

Discharge medications included ibuprofen and (Tr. 411-25.)

Plaintiff was admitted to St. John's Mercy Medical Center on July 20, 2006, and underwent transabdominal hysterectomy.

Plaintiff's medical and social history upon admission was noted to include a history of tremors and an electrical injury sustained at work