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Dodge v. Berryhill

United States District Court, E.D. Arkansas, Northern Division

March 15, 2017

NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration DEFENDANT


         Plaintiff Bonna L. Dodge (“Dodge”) commenced this case by filing a complaint pursuant to 42 U.S.C. 405(g). In the complaint, she challenged the final decision of the Acting Commissioner of the Social Security Administration (“Commissioner”), a decision based upon findings made by an Administrative Law Judge (“ALJ”).

         Dodge maintains that the ALJ's findings are not supported by substantial evidence on the record as a whole and offers two reasons why.[1] Dodge first maintains that her chronic back pain/degenerative disc disease is a severe impairment, and the ALJ erred when she failed to so find at step two of the sequential evaluation process. Dodge also maintains that her residual functional capacity was erroneously assessed because the pain caused by her degenerative disc disease and fibromyalgia was not properly considered.

         At step two, the ALJ is required to identify the claimant's impairments and determine whether they are severe. An impairment is severe if it has “more than a minimal effect on the claimant's ability to work.” See Henderson v. Sullivan, 930 F.2d 19, 21 (8th Cir. 1992) [internal quotations omitted].

         Between steps three and four, the ALJ is required to assess the claimant's residual functional capacity, which is a determination of “the most a person can do despite that person's limitations.” See Brown v. Barnhart, 390 F.3d 535, 538-39 (8th Cir. 2004). The assessment is made using all of the relevant evidence in the record, and the assessment must be supported by some medical evidence. See Wildman v. Astrue, 596 F.3d 959 (8thCir. 2010). As a part of making the assessment, the ALJ is required to evaluate the claimant's subjective complaints. See Pearsall v. Massanari, 274 F.3d 1211 (8th Cir. 2001). The ALJ makes that evaluation by considering the medical evidence and evidence of the claimant's “daily activities; duration, frequency, and intensity of pain; dosage and effectiveness of medication; precipitating and aggravating factors; and functional restrictions.” See Id. at 1218 [citing Polaski v. Heckler, 739 F.2d 1320 (8th Cir. 1984)].

         Dodge alleges that she became disabled beginning on April 25, 2013. See Transcript at 144. The ALJ denied Dodge's application for disability insurance benefits on May 10, 2015. See Transcript at 25. Consequently, the relevant time period in this case is from April 25, 2013, through May 10, 2015. Although the evidence prior to April 25, 2013, is outside the relevant period, it will nevertheless be noted in order to place Dodge's medical condition in a proper context.

         The evidence relevant to Dodge's physical impairments reflects that she sought treatment for, inter alia, degenerative disc disease, back pain, and fibromyalgia on several occasions between May 15, 2012, and November 26, 2012. See Transcript at 309-320, 375-376.[2] The progress notes contain no findings as to the limitations caused by her impairments. CT scans of her lumbar spine were performed on September 10, 2010, and August 13, 2012, and the results revealed minimal degenerative disc bulges from L3-4 through L5-S1 with facet arthropathy appearing moderate at ¶ 4-5. See Transcript at 277, 376. The notes reflect that she was prescribed medication for her pain.

         On April 24, 2013, Dodge saw Richard Van Grouw, M.D., (“Van Grouw”) for complaints of chest pain. See Transcript at 298-299.[3] He noted her diagnoses of fibromyalgia and heart irregularities but observed, inter alia, that she is “normally able to be active physically without developing chest discomfort or shortness of breath.” See Transcript at 299. Upon physical examination, Van Grouw found Dodge to have a regular heart rate and rhythm with no “murmurs, rubs, or gallops.” See Transcript at 299. He assessed chest pain, atypical for cardiac, and hypertension and adjusted her medication.

         Six days later, on April 30, 2013, Dodge presented to the White River Medical Center Emergency Room complaining that she just did not feel right. See Transcript at 331-345. She reported that her hands felt “clammy, ” see Transcript at 331, and she was having dull chest pains in the middle part of her chest. She reported having had the symptoms previously but reported that Van Grouw had told her the symptoms were related to hypertension. Upon physical examination, Dodge had a regular heart rate and rhythm and exhibited no murmurs. It is also worth noting that an examination of her back revealed normal results. Testing in the form of an EKG and x-rays was performed, and the results were unremarkable. Borderline hypertension was diagnosed, and she was discharged with instructions to see Van Grouw and continue “home antihypertensives.” See Transcript at 334.

         Beginning on May 7, 2013, and continuing through June 18, 2013, Dodge was seen at the Ozark Medical Center on three occasions for pain associated with fibromyalgia. See Transcript at 306-308 (05/07/2013), 304-305 (05/21/2013), 301-303 (06/18/2013). She reported that she was experiencing a widespread, sharp, aching pain that occurred constantly and caused nausea. She reported that her pain was exacerbated by daily activities, and she was having difficulty standing and sitting. Dodge was examined each time, and the findings were unremarkable. She was repeatedly observed to have normal strength and tone in the lumbar portion of her spine. She was also observed to have normal posture, gait, coordination, and reflexes, although some tenderness was noted.

         Her medication was adjusted, and she was referred to a pain specialist.

         Beginning on June 26, 2013, and continuing through October 23, 2013, Dodge saw Miraj Siddiqui, M.D., (“Siddiqui”) on four occasions for pain management. See Transcript at 355-358 (06/26/2013), 347-351 (07/23/2013), 408-409 (09/25/2013), 403-405 (10/23/2013). At the June 26, 2013, initial consultation, Siddiqui recorded Dodge's history of present illness to be as follows:

... Refer[r]ing physician has asked my opinion in regards to [Dodge's] pain condition. She has been experiencing this pain for last several years. She reports onset of pain gradual. Stated that the pain has progressively gotten worse, not being controlled with rest, activity modification and medication(s). [She] describes the pattern of pain as constant with intermittent flare ups. She described the quality of pain as aching, stabbing, sharp, deep, cramping and pressure. The pain radiates to back side of both thighs. [Dodge] says, at its worse, her pain is 9/10, at its least it is 2/10, on an average about 5/10, and right now it is 4/10. Worsening factor(s) include: standing, walking, getting up from sitting or lying position, cold weather, pressure changes and increased activity. Relieving factor(s): stopping activities that aggravates pain, rest and taking pain medicine. Other associated symptoms/problems: restrictions on the activities, difficulty sleeping due to pain and frustration because of pain.

See Transcript at 355. Upon physical examination, he observed that her gait and station were antalgic, but she was able to heel-to-toe, heel walk, and toe walk and had normal motor strength and tone in her extremities. He additionally observed the following:

... Palpation of lumbar facet joints at ΒΆ 3-4, L4-5, and L5-S1 levels reproduced lower back pain. Hyperextension at lumbar spine reproduced lower back pain. Stooping 20-30 degree relief pain. Bilateral facets loading maneuver by lateral flexion/bending reproduced pain. Bilateral lateral rotation also causes pain. Palpable taut bands/trigger points in bilateral Latissimus dorsi muscles. Palpable taut ...

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