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Ahmad v. Berryhill

United States District Court, E.D. Virginia, Alexandria Division

March 15, 2019

NOHA H. AHMAD, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         This matter is before the Court on the parties' cross-motions for summary judgment. Plf. Mot. for Summ. J., ECF. No. 17 [hereinafter Plf. Summ. J.]; Def. Mot. for Summ. J., ECF No. 22 [hereinafter Del'. Summ. J.]. Pursuant to 42 U.S.C. § 405(g), Noha Hussien Ahmad ("Plaintiff) seeks judicial review of the final decision of the Commissioner of the Social Security Administration ("Defendant") denying her claim for disability insurance benefits ("DIB") under Title II of the Social Security Act ("the Act"), 42 U.S.C. § 423. For the reasons stated below, the undersigned finds that Plaintiffs Motion for Summary Judgment is DENIED and Defendant's Motion for Summary Judgment is GRANTED.


         Plaintiff filed her application for DIB on June 8, 2013, alleging disability commencing on September 9, 2010, based on the following severe impairments: pituitary disorder, vertiginous syndrome, right maxillary sinus nodules/sinusitis, total thyroidectomy with hypothyroidism/hypoparathyroidism. vestibular disorder, cholecystectomy, appendectomy, degenerative disc disease. Heberden nodes of the hands, C7 vertebral body hemangioma, osteoporosis/osteopenia, osteoarthritis of the right ankle, fibromyalgia, hypomenorrhea, continued arterial hypertension, diabetes mellitus type II depression, and anxiety disorder. Administrative Record ("R.") 18, 216, 234.

         After the state agency denied Plaintiffs claim twice, Plaintiff requested an administrative hearing. R. 152, 165. The Administrative Law Judge ("ALJ") held a hearing on November 30, 2016. R. 15, 36-90. On February 21, 2017, the ALJ issued a decision finding that Plaintiff was not disabled within the meaning of the Act. R. 15-35.

         On October 3, 2017, the Appeals Council for the Office of Disability and Adjudication denied Plaintiffs request for review of the ALJ's decision, rendering the ALJ's decision the final decision of the Commissioner for purposes of review under 42 U.S.C. § 405(g). R. 1-6. Having exhausted her administrative remedies, Plaintiff filed the instant suit challenging the ALJ's decision on December 7, 2017. Compl., ECF No. 1. This matter is ripe for disposition because the parties filed cross-motions for summary judgment and oral arguments were heard on November 2, 2018.


         Plaintiff was born on November 16, 1966, and was forty seven (47) years old at the time of her alleged onset Dated: June 30, 2014. R. 15, 28. Plaintiff is a college graduate and worked as a school bus attendant, retail cashier, and veterinarian at a poultry farm. R. 41. Plaintiff is married and has a minor daughter. R. 40-41.

         A. Medical Evidence

         On September 16, 2010, Plaintiff visited the emergency room at Inova Fair Oaks Hospital complaining of facial pain. R. 554. Plaintiff was diagnosed with acute sinusitis, but there was no finding of sinus opacification or acute intracranial abnormality. R. 554. There was mild mucosal thickening within the ethmoid sinuses and a possible mucosal retention cyst. R. 554. Plaintiffs mastoid air cells were well aerated. R. 554. Plaintiff was prescribed Antivert, Phenergan, and Ativan. R. 556. Plaintiff was discharged on the same day in stable condition. R. 556.

         Between October 2010 and January 2011, Plaintiff visited the Neurology Center of Fairfax, Ltd. ("Neurology Center") multiple times. R. 433-36, 524, 531. During her October 2010 visit, Plaintiff developed episodic vertigo (triggered by head movement) with associated right-side pulsatile tinnitus. R. 433, 530. Upon examination, Plaintiff was described as pleasant and cooperative with a normal tone. R. 434, 531. Doctor Marco D. Castro, M.D., also noted that she had a normal cardiovascular system, grossly normal mental status, speech, and language, full strength in both arms and legs, intact coordination, and normal light touching. R. 434, 531. A visit to the Neurology Center in November 2010, revealed no electrophysiologic evidence of a generalized peripheral neuropathy, bilateral carpal tunnel syndrome, right ulnar neuropathy, or right cervical or lumbosacral radiculopathy in response to Plaintiffs complaint of tingling sensation around her mouth, hands, and feet. R. 436, 524. In January 2011, Plaintiff reported an improvement in her dizziness and that her paresthesia was less frequent. R. 435. Plaintiffs neurological evaluation and gait were normal and she had full strength in both arms and legs. R. 435.

         In May 2011, Plaintiff reported that she has a history of motion illness since childhood and has had transient episodes of vertigo for years. R. 658. In June 2011, Plaintiff reported that she had improvements in her overall function, can engage in routine domestic tasks, and can walk her daughter to school if she feels well enough. R. 656. Plaintiff also indicated that she can bathe and dress herself. R. 656. An examination on December 28, 2011, revealed that Plaintiff had a full range of motion in her neck, no cervical adenopathy, normal cardiovascular exam, clear lungs, normal neurological exam, good eye contact, and depressed mood. R. 723. In April 2012, Plaintiff reported that she had been walking every day. R. 712.

         On May 1, 2012, Plaintiff was evaluated at the National Institute of Health ("NIH") for management of her endocrine disorder R. 1067. Plaintiff complained of weight gain after being diagnosed with type II diabetes, easy bruising, insomnia, and proximal muscle weakness. R. 1066. Plaintiff was instructed to discontinue Prednisone and start hydrocortisone, and return in one (1) week for an ACTH (adrenocorticotropic hormone) stimulation test. R. 1068.

         On June 5, 2012, Plaintiff went to a follow up visit at NIH for management of diabetes, hypoparathyroidism, and adrenal insufficiency. R. 1206. There were no clinical signs of adrenal insufficiency and Plaintiff was advised to continue her dosage of calcium and calcitriol to treat hypoparathyroidism. R. 1208-09.

         From November 29, 2012, to December 2, 2012, Plaintiff was hospitalized at NIH for partial central adrenal insufficiency. R. 1001-03, 1055. After administering a low dose of a cosyntropin stimulation test and metyrapone test, it was "confidently" concluded that Plaintiff did not have any degree of adrenal insufficiency. R. 1056. Plaintiff was discharged in stable condition. R. 1057.

         On January 10, 2013, Plaintiff visited Healthworks for Northern Virginia ("Healthworks") complaining of sinusitis, abdominal pain, finger joint pain, right shoulder pain, and diffuse muscle aches. R. 681. Plaintiff was diagnosed with fibromyalgia, chronic sinusitis, osteoarthritis, a mild tear/strain in her rotator cuff disc, diabetes, and an upper respiratory infection. R. 683. Plaintiff was prescribed Trazodone to treat her fibromyalgia and Omnaris spray for her chronic sinusitis. R. 683. She was also shown isometric strengthening exercises to treat the tear in her rotator disc cuff. R. 684.

         On January 10, 2013, Dr. Glenn Tomkins, M.D., Plaintiffs primary care physician, examined Plaintiff. R. 681. She reported pain in her fingers for six (6) months, myalgia in her back, chest, and shoulder, fatigue, and low energy. R. 681-82. On examination, Plaintiff had slightly tender finger joints, but no limitation in range of motion, pain in her right shoulder when elevated to ninety (90) degrees, pain with hyperextension of the right knee, and tender points in her upper back. R. 681-83. Doctor Tomkins assessed fibromyalgia, diabetes in good condition, osteoarthritis not generalized or localized, and a mild rotator cuff tear. R. 683-84. Plaintiff was prescribed new medications and some medications were refilled. R. 683-84.

         Plaintiff followed up with Dr. Tomkins in four (4) weeks. R. 675. Plaintiff had not taken any of the prescribed medications and was not following isometric strengthening recommendations for her rotator cuff disc. R. 678. Plaintiff was given prescription to treat her chronic sinusitis, fibromyalgia, rotator cuff disc, and osteoarthritis. R. 679.

         On May 2, 2013, Plaintiff returned to Dr. Tomkins and complained of a headache, swishing sounds in her right ear, arm pain and swelling, and thigh pain. R. 778. Doctor Tomkins noted that April 2013 x-rays did not reveal any vertebral body issues or any other contributory findings. R. 778. Plaintiff appeared alert, oriented, and in no distress. R. 778. She had full strength bilaterally, 2/4 reflexes and symmetric in upper extremities, no tremors, clear speech, and normal gait. R. 778. Doctor Tomkins continued her medications and ordered labs for her diabetes, headache, cholesterol, and hypoparathyroidism. R. 779. A few weeks later, Plaintiff reported that her sinusitis was under control and most of her headaches resolved with medications. R. 764. Plaintiff was sleeping six (6) to eight (8) hours a night and her vertigo improved with a vestibular program and medications. R. 765. Doctor Tomkins assessed Plaintiffs fibromyalgia, but noted that the labs refuted any inflammatory process. T. 768.

         In a June 2013 examination with Dr. Tomkins, Plaintiff reported headaches and mild tenderness to her left neck and thyroid. R. 756. Doctor Tomkins noted fibromyalgia without inflammatory markers and that Trazadone normalized Plaintiffs sleep. R. 757. Later that month, Plaintiff complained that her right-hand pain was worse, but there was no tenderness or swelling in her finger joints. R. 739.

         In July 2013, Dr. Tomkins noted that Plaintiffs myalgia decreased after stopping certain medications and that her fibromyalgia was partially attributable to the use of a statin. R. 732. In August 2013, Plaintiff reported that she received "near total relief from the chronic headaches with use of Maxalt. R. 931. Doctor Tomkins opined that Plaintiffs metabolic abnormalities might explain her fibromyalgia syndrome. R. 935.

         In September 2013, Plaintiff visited both Dr. Tomkins and Dr. Andrew Demidowich, M.D. R. 923, 1327-38. Plaintiff reported that Lyrica helped with her body aches, Nortriptyline was helping her sleep better, and there were no specific tasks that were impossible or difficult. R. 923-24. Plaintiff denied anxiety, lethargy, and difficulty sleeping. R. 1327-38. Doctor Tomkins reported that Plaintiff had normal strength. R. 926.

         Doctor Tomkins wrote a letter on October 11, 2013, describing Plaintiffs medical conditions. R. 943. Doctor Tomkins noted that Plaintiff suffers from fibromyalgia, which limits her to "sedentary work that does not require ambulation beyond five minutes at a time, or lifting more than five pounds, or lesser exertion prolonged past 10 minutes." R. 943. Also stated was that Plaintiff suffers from inflammatory bowel disease, which can be treated within weeks, but requires frequent bathroom breaks. R. 944. Doctor Tomkins opined that Plaintiff has uncontrolled headaches and vertigo with nausea, which are severe enough to keep her from work on an "average of 10% of days, though this is variable from month to month, and can reach up to 25% of days some months." R. 944.

         On December 28, 2013, Plaintiff had an infectious disease consult. R. 1220. Plaintiff complained that she was experiencing intermittent fevers and myalgia about two (2) to three (3) times a month. R. 1220. Plaintiff stated that she had a complete resolution of her symptoms while she was taking Prednisone. R. 1220. She also noted improvement in her symptoms when she discontinued Simvastatin. R. 1220. The physician found that her basic lab results appeared within normal limits, except with a mildly elevated ALT (a type of liver enzyme). R. 1221. The physician also opined that her symptoms were intermittent, which made the infectious process less likely, and had a resolution with her symptoms while she was on steroids. R. 1221.

         On April 3, 2014, Plaintiff visited Dr. Liaw Winston, M.D., complaining of neck, right arm, and finger pain. R. 1161. Plaintiff was assessed with acute neck pain and prescribed Cyclobenzaprine and Imitrex. R. 1163. A few days later, on April 8th, Plaintiff visited Healthworks complaining of neck, head, back, and arm pain, and a swollen middle finger. R. 1155. Plaintiff was advised to continue Pregabalin to treat her fibromyalgia and Naproxen and Cyclobenzaprine to treat her muscle strain. R. 1158. Also, during this month, Plaintiff told Dr. Tomkins that Lyrica was providing her with relief for her diffuse muscle pain. R. 1155. Doctor Tomkins noted that Plaintiffs fibromyalgia was responding fairly well to Pamelor. R. 1157.

         In May 2014, Plaintiff had a neuromuscular consult with the University of Virginia Hospital. R. 1135. Plaintiff reported a history of generalized weakness for more than six (6) months and weakness over the last seven (7) years. R. 1135. Doctor Sarah Jones, M.D., indicated that Plaintiff had normal strength in her neck, giveaway weakness in her limbs with normal bursts of strength, and decreased sensation to light touch in the right face and leg. R. 1136. Plaintiff could stand with arms crossed, had a normal gait, and could walk on her heels and toes. R. 1136. Doctor Jones reported that there were no clear neuromuscular abnormalities to explain her symptoms. R. 1137.

         Doctor Tomkins wrote another letter on May 5, 2015, stating that Plaintiffs abilities are limited by her fibromyalgia. R. 1260. The fibromyalgia pain limits Plaintiff to "sedentary work that does not require ambulation beyond ten minutes at a time, or lifting more than ten pounds, or lesser exertion prolonged past 10 minutes." R. 1260. Doctor Tomkins also reported that Plaintiffs arthritis is active and treatment was going to start in a few weeks, Plaintiff started seeing a psychiatrist for possible depression and anxiety, but her symptoms overlap with chronic sleep deprivation. R. 1260-61. In an addendum written on May 31, 2016, a year later, Dr. Tomkins stated that Plaintiffs fibromyalgia is unchanged and her hand arthritis is present. R. 1395.

         i. Diagnostic Images

         In September 2010, a Magnetic Resonance Imaging ("MRI") of both of Plaintiffs temporomandibular joints revealed no evidence of disc displacement or focal bone abnormality, and had normal range of motion. R. 558. An MRI angiography of Plaintiff s brain, pituitary, and neck taken on October 22, 2010, revealed no abnormal findings. R. 426-428. An MRI of Plaintiffs head and pituitary gland taken on April 18, 2013, found a few nonspecific small FLAIR hyperintense foci, but no restricted diffusion abnormality of the brain. There was no definite mass in the sella turcica and the paranasal sinuses were unremarkable. R. 1032-33, 1045-46. An MRI of Plaintiff s brain and pituitary was taken on February 7, 2014. R. 1107, 1169. The results revealed stable postoperative changes within the nasal fossa and sella turcica without evidence of residual or recurrent pituitary adenoma. R. 1107.

         In response to Plaintiffs complaint of neck pain and osteoporosis, x-rays of Plaintiffs cervical, thoracic, and lumbar spine were taken on April 3, 2013. R. 1040. The x-rays were unremarkable. R. 1040. X-rays of Plaintiff s chest taken on May 17, 2013, revealed clear lungs, a normal cardiac silhouette, and no pneumothorax or pleural effusion. R. 1031. In response to Plaintiffs complaint of lower back pain, x-rays of her lumbar spine and thoracic spine were taken again on June 18, 2013. R. 1028-29. Stable tiny anterior osteophytes at ¶ 4 and L5 were found, but there were no acute fractures or subluxation and the SI joins were unremarkable. R. 1028. Plaintiff had a ...

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