United States District Court, E.D. Virginia, Richmond Division
REPORT AND RECOMMENDATION
DAVID J. NOVAK, Magistrate Judge.
Kimberly Ahnen ("Plaintiff") is forty-nine years old and previously worked as a pharmacy technician. On August 6, 2010, Plaintiff filed for Disability Insurance Benefits ("DIB"), claiming disability from spinal stenosis, lupus anticoagulant, osteoarthritis, carpal tunnel syndrome, asthma, hypertension, renal disease and limited mobility, with an alleged onset date of March 11, 2008. Her claims were denied initially and upon reconsideration. On October 25, 2012, Plaintiff (represented by counsel), Plaintiff's husband and a vocational expert ("VE") testified at a hearing before an Administrative Law Judge ("ALJ"). On November 5, 2012, the ALJ denied Plaintiff's request for benefits, finding that she was not disabled under the Social Security Act ("Act"). On December 18, 2013, the Appeals Council denied her request for review, rendering the ALJ's decision the final decision of the Commissioner.
Plaintiff now appeals the ALJ's decision in this Court pursuant to 42 U.S.C. § 405(g), arguing that the ALJ erred in assessing Plaintiffs credibility and in affording limited weight to Plaintiff's physical therapist's opinion. Defendant responds that the ALJ did not err and that substantial evidence supports the ALJ's decision. The parties have submitted cross-motions for summary judgment, which are now ripe for review.
Having reviewed the entire record in this case,  the Court is now prepared to issue a Report and Recommendation pursuant to 28 U.S.C. § 636(b)(1)(B). For the reasons that follow, the Court recommends that Plaintiff's Motion for Summary Judgment (ECF No. 13) be DENIED, that Defendant's Motion for Summary Judgment (ECF No. 14) be GRANTED and that the final decision of the Commissioner be AFFIRMED.
Because Plaintiff challenges the ALJ's decision, Plaintiff's education and work history, medical history, state agency physicians' opinions, Plaintiff's testimony, Plaintiff's husband's testimony and VE testimony are summarized below.
A. Education and Work History
Plaintiff was forty-three years old on her alleged onset date. (R. at 218.) Plaintiff graduated from high school and completed some phlebotomy school, but did not become certified to draw blood. (R. at 38, 223.) She previously worked as a pharmacy technician, administrative assistant, call center account specialist and agent/supervisor. (R. at 223, 243.) Plaintiff last worked on March 11, 2008. (R. at 40.)
B. Medical History
On March 29, 2007, Plaintiff visited Jeffrey R. Rehm, M.D. at Pulmonary Associates of Fredericksburg for a pulmonary function test. (R. at 300.) A physical examination and pulmonary function test revealed that Plaintiff had moderate obstructive lung disease, likely a result of smoking. (R. at 300.) Dr. Rehm described Plaintiff as "well-nourished" and in "no apparent distress." (R. at 300.) Plaintiff's extremities did not exhibit signs of edema. (R. at 300.) Dr. Rehm instructed Plaintiff to stop smoking and to continue taking her medication as prescribed. (R. at 300.)
On March 11, 2008, Plaintiff underwent surgery to correct mandibular hypoplasia - a congenital malformation of the mandible - at Walter Reed Army Medical Center. (R. at 376-79.) No complications occurred during the procedure. (R. at 376-79.) On April 4, 2008, during a follow-up appointment, Plaintiff complained of a swollen right mandible, fevers, pain and difficulty swallowing. (R. at 332.) Plaintiff underwent further procedures and was hospitalized because of a mandibular infection. (R. at 332-33.) On April 17, 2008, Plaintiff was discharged from the hospital and returned home to recuperate after she showed stable vital signs and no fever. (R. at 333.) Further, Plaintiff acknowledged that medication controlled her pain. (R. at 333.)
On October 15, 2008, Plaintiff returned to Dr. Rehm at Pulmonary Associates of Fredericksburg. (R. at 297.) Plaintiff had resumed smoking and was caring for an invalid living in her home. (R. at 297.) Dr. Rehm found that Plaintiff's mild obstructive lung disease had developed into moderate obstructive lung disease and strongly recommended that Plaintiff stop smoking. (R. at 297.) He prescribed an albuterol inhaler for the condition. (R. at 297.) Plaintiff again showed no signs of edema. (R. at 297.) In February 2009, Plaintiff returned to Dr. Rehm with an upper respiratory tract infection. (R. at 299.) Dr. Rehm advised Plaintiff to continue with a course of antibiotics and prescribed additional steroids. (R. at 299.)
On March 22, 2009, Plaintiff went to Stafford Hospital, complaining of abdominal pain, nausea and vomiting. (R. at 722-23.) CAT scans depicted a gall bladder abnormality and Plaintiff was diagnosed with acute cholecystitis. (R. at 723.) Plaintiff underwent laparoscopic surgery to remove her gall bladder. (R. at 723.)
On June 9, 2009, Plaintiff underwent a laparotomy, a bilateral salpingo-oophorectomy and a resection of cystic mass. (R. at 445.) Plaintiff experienced chronic pelvic pain and had previously undergone a total abdominal hysterectomy for reported endometriosis. (R. at 447.) There were no complications from the surgery and Plaintiff was discharged three days later. (R. at 446-47.) On June 15, 2009, Plaintiff returned to Stafford Hospital, complaining of abdominal pain and low grade fevers. (R. at 675-76.) Madhuri V. Vallabhaneni, M.D. noted that Plaintiff "ha[d] been asking for pain medicines and nausea medicines" and "ha[d] been seeking more pain medicines and nausea medicines and also Atrivan very frequently in the hospital." (R. at 676.) Plaintiff was discharged on June 21, 2009. (R. at 675.)
On June 24, 2009, Plaintiff returned to Stafford Hospital, complaining of nausea, vomiting and abdominal pain. (R. at 807.) Plaintiff underwent an endoscopy that showed an ulcer in the antrum and the second portion of the duodenum. (R. at 807-08.) Plaintiff also underwent a colonoscopy, which revealed no evidence of colitis, polyps or diverticulosis. (R. at 673-74.) Between July 2009 and July 2010, Plaintiff received treatment from the Associates in Gastroenterology in Stafford, Virginia, for abdominal pain and nausea/vomiting. (R. at 456-61, 467-71.) Doctors gave Plaintiff medications for her nausea and gastrointestinal pain. (R. at 456-61, 467-71.) Plaintiff indicated that she was smoking throughout this period. (R. at 456, 458, 469, 471.)
On August 19, 2009, Plaintiff underwent a follow-up endoscopy at Stafford Hospital that revealed a normal esophagus, a healing antral ulcer and a normal duodenal bulb with only mild redness near the second portion of the duodenal bulb. (R. at 805-06.) The doctor's overall impression was that Plaintiff experienced a healing peptic ulcer disease. (R. at 806.)
On November 24, 2009, Plaintiff met with Christopher N. Vaughn, M.D. regarding her history of low blood platelet count. (R. at 504-06.) Plaintiff tested positive for antinuclear antibodies, indicating possible lupus. (R. at 505-06.) Plaintiff had a platelet count of 140, 000, up from her low of 96, 000. (R. at 504.)
In December 2009, Mark Doughty, M.D. became Plaintiff's primary care physician. (R. at 606.) Dr. Doughty diagnosed Plaintiff with chronic kidney defect that limited functionality. (R. at 625.) Dr. Doughty referred Plaintiff to a rheumatologist to determine whether she had lupus and needed ongoing treatment or management. (R. at 606-7.) Plaintiff sought prescriptions for her pain, but Dr. Doughty was unwilling to prescribe pain medication without a proper work-up and diagnosis. (R. at 606.)
During December 2009, Plaintiff received treatment at Arthritis Care Center and was diagnosed with osteoarthritis in both knees. (R. at 1086.) Plaintiff was referred to a neurologist and prescribed medication for her pain. (R. at 627.) On December 15, 2009, Plaintiff returned to Dr. Vaughn to undergo further tests for possible antiphospholipid syndrome. (R. at 503.) Dr. Vaughn indicated that he needed to repeat the test over the course of several weeks for a positive diagnosis. (R. at 503.) Although the results of the tests were inconclusive, Dr. Vaughn was concerned by Plaintiff's symptoms and prescribed her anticoagulants to prevent blood clots. (R. at 499.) Plaintiff underwent cervical spine surgery in August 2010 and knee surgery in the fall of 2011. (R. at 1091, 1094.) Dr. Vaughn altered the medications for Plaintiff to resume taking after both surgeries. (R. at 1091, 1094.)
On April 13, 2010, Plaintiff returned to Stafford Hospital and received a esophagogastroduodenoscopy that revealed a normal duodenal bulb, mild gastritis in the antrum and a small hiatus hernia in the esophagus. (R. at 472.) During a follow-up appointment, Plaintiff underwent a gastric-emptying study that revealed no evidence of gastroparesis. (R. at 554.)
On April 19, 2010, Plaintiff saw Naurang S. Gill, M.D., complaining of generalized myalgias, athralgias and difficulty with balance and tremors. (R. at 565.) Plaintiff complained of difficulty holding things, dropping objects, and numbness and tingling in her hands. (R. at 565.) Plaintiff claimed that she had been walking with a limp since childhood. (R. at 565.) She further stated that she had no history of mental confusion or disorientation. (R. at 565.) Tinel and Phalen tests for carpal tunnel syndrome were positive and a motor examination revealed tremors in Plaintiff's hands. (R. at 566.) Dr. Gill found no evidence of mono- or hemi-paresis or arm drift. (R. at 566.) Dr. Gill determined that Plaintiff's hand tremors were predominantly postural without any kinetic tremor. (R. at 566.) On May 7, 2010, Plaintiff returned to Dr. Gill, and he performed an EMG/Nerve conduction study that revealed evidence of right carpal and cubital canal syndrome with no electromyographic evidence of cervical radiculopathy. (R. at 577.)
In June 2010, Plaintiff returned to Dr. Gill. (R. at 573.) Plaintiff experienced swelling in her hands and feet as a result of her medication. (R. at 573.) Although Plaintiff continued to have hand tremors, Plaintiff reported that they did not interfere with her activities of daily living. (R. at 573.) Dr. Gill noted that Plaintiff maintained good strength of the APB muscle and good handgrips. (R. at 573.) On June 26, 2010, Plaintiff underwent an MRI for her cervical spine that revealed degeneration of three of her discs and stenosis of the central canal. (R. at 570.)
On July 13, 2010, Plaintiff returned to Dr. Gill, complaining of worsening foot and back pain. (R. at 572.) Dr. Gill found that Plaintiff had evidence of a Babinsky sign, weakness of the right extensor hallicis longus muscle and tenderness along the lumbar spine. (R. at 572.) Plaintiff complained of pain when she extended her cervical spine. (R. at 572.) Dr. Gill refilled Plaintiff's prescription for Percocet and ordered further testing. (R. at 572.) Dr. Gill put Plaintiff under a nerve conduction study, which revealed only mildly increased sensory latencies of peroneal and sutral nerves. (R. at 576.) Otherwise, the study revealed no abnormalities, no electromyographic evidence of radiculopathy or myopathy. (R. at 576.)
During a follow-up appointment, Dr. Gill conducted a neurological evaluation supplement that indicated that Plaintiff had moderate to normal strength in the upper and lower extremities. (R. at 637.) The study also revealed that Plaintiff had mostly abnormal coordination, gait and station. (R. at 637.) Dr. Gill noted that Plaintiff had limited range of motion in her cervical spine and suggested that Plaintiff proceed with surgery. (R. at 639.) Dr. Gill recommended that Plaintiff take off work until further notice. (R. at 639.)
On July 30, 2010, Archimedes Ramirez, M.D. ordered x-rays of Plaintiff's cervical and lumbar spine. (R. at 1142.) The x-rays revealed "[m]ultilevel degenerative changes within the cervical spine with disc space narrowing and posterior osteophyte formation." (R. at 1142.) On August 2, 2010, Plaintiff complained to Dr. Ramirez of pain that radiated up and down her spine, neck, shoulders, arms and legs. (R. at 556.) Dr. Ramirez noted that Plaintiff had good strength in both her upper and lower extremities and retained good handgrips. (R. at 558.) Dr. Ramirez also observed that Plaintiff had normal cognitive function. (R. at 558.) Plaintiff had a positive Tinel sign for carpal tunnel syndrome over the median nerve of both wrists and the ulnar nerve at the elbows. (R. at 558.) Dr. Ramirez further noted that Plaintiff had difficulty walking, because she was pigeon-toed. (R. at 558.) Dr. Ramirez ordered an MRI of Plaintiff's cervical spine to determine whether she had cervical spondylostenosis. (R. at 559.) Plaintiff's MRI revealed multilevel degenerative changes in the cervical spine with no evidence of a cord syrinx. (R. at 551.) The MRI revealed no abnormalities of her thoracic spine. (R. at 578.)
On August 9, 2010, Plaintiff visited Michael W. Hasz, M.D. of the Virginia Spine Institute, complaining of increased neck pain and diminished quality of life. (R. at 582.) Dr. Hasz observed that Plaintiff had severe symptoms in the neck and upper extremities. (R. at 582.) Dr. Hasz reviewed Plaintiff's medical history, conducted a physical examination of Plaintiff's cervical spine and determined that Plaintiff was a candidate for surgery on the cervical spine. (R. at 584.) After examination, Dr. Hasz recommended anterior surgery to decompress the spinal cord and stabilize the spine. (R. at 595.) Significantly, Dr. Hasz noted that Plaintiff's work status was "employed without restrictions." (R. at 582.)
On August 12, 2010, Plaintiff returned to Dr. Doughty for a pre-operative consult for her cervical discectomy and fusion. (R. at 597.) Dr. Doughty observed that Plaintiff had a supple neck with a restricted range of motion, but had no tremor and full range of motion in her extremities. (R at 597-98.) Dr. Doughty medically cleared Plaintiff for surgery. (R. at 598.) Dr. Doughty noted that Plaintiff had no blood in her urine, no difficulty urinating and no increased urinary frequency. (R. at 598.)
On September 2, 2010, Plaintiff underwent cervical partial veterbrectomies with decompression of the spinal canal, cervical interbody fusions and the placement of intervertebral prosthetic devices. (R. at 663-64.) On September 5, 2010, Plaintiff was discharged from the hospital. (R. at 653-59.) On September 6, 2010, following her cervical spine surgery, Plaintiff went to Stafford Hospital, complaining of wheezing, low-grade fever, chest pain and severe neck pain. (R. at 832.) Barbara Newberg, M.D. ordered an EKG that returned unremarkable results and advised that Plaintiff's platelets be monitored. (R. at 833.) Dr. Newberg also prescribed an Advair inhaler to relieve Plaintiff's wheezing. (R. at 833.) Plaintiff admitted that she continued to smoke a half pack of cigarettes each day, and a CAT scan revealed extensive upper lung airspace opacities. (R. at 827-28.) On September 6, 2010, Plaintiff visited Paul Fiore, M.D., seeking treatment for symptoms of an infectious disease. (R. at 826-29.) Dr. Fiore suggested that Plaintiff would require a pulmonary consultation. (R. at 828.) On September 10, 2010, a bronchoscopy revealed that Plaintiff had normal airways with no endobronchial lesions. (R. at 830.) An echocardiogram revealed no abnormalities and no pulmonary hypertension. (R. at 885.)
On September 21, 2010, Plaintiff underwent a resection of the upper and lower lobes of her lung, as well as an ultrasound of the abdomen and a CT scan of the chest. (R. at 925.) The resections revealed "focal organizing pneumonia in a background of respiratory bronchiolitis with mild centriacinar emphysema." (R. at 969.) On September 27, 2010, Plaintiff was discharged from Stafford Hospital. (R. at 976.) In a post-operative evaluation, Timothy Sherwood, M.D., the doctor who performed the diagnostic wedge resection, noted that Plaintiff's exam was "unremarkable" and that her incisions had healed. (R. at 1010.) Dr. Sherwood further advised Plaintiff to cease smoking. (R. at 1010.)
On October 18, 2010, Plaintiff returned to Dr. Hasz for a follow-up appointment after her surgery. (R. at 1000-02.) Plaintiff was happy with the results, noting decreased pain and improved balance. (R. at 1000.) Plaintiff also noted that her back and leg pain had improved since the surgery. (R. at 1000.) Dr. Hasz prescribed Percoset for pain and Robaxin for spasms. (R. at 1001.) Dr. Hasz strongly advised Plaintiff to cease smoking to help with recovery. (R. at 1001.)
Plaintiff returned to Dr. Hasz in December 2010, complaining of pain in the cervical spine. (R. at 1074.) Plaintiff admitted that she had only attended one session of physical therapy for her cervical spine and "was unimpressed with the home exercises they gave her." (R. at 1074.) Thus, Plaintiff stated that she did not return for physical therapy and took care of her husband as he recovered from surgeries. (R. at 1074.) Plaintiff described stiffness in her neck when she drove and stated that she recently slipped and fell when she walked on ice. (R. at 1074.) Dr. Hasz prescribed Percocet for pain and recommended that Plaintiff resume physical therapy, quit smoking and continue using a bone stimulator. (R. at 1075.) Plaintiff subsequently underwent an MRI of the cervical spine that ...