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Holt v. Colvin

United States District Court, D. Connecticut

March 13, 2018



          Hon. Vanessa L. Bryant United States District Judge.

         Before this Court is an administrative appeal following the denial of the application for disability insurance (“DI”) benefits and supplemental security income (“SSI”) benefits filed by Plaintiff Bridgett Catena Holt (“Holt” or “Plaintiff”). Plaintiff requests the decision issued by the Commissioner of Social Security (“the Commissioner” or “Defendant”) be reversed and remanded pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) on the basis that ALJ Ronald Thomas (“ALJ Thomas”) failed to develop the administrative record, misconstrued the evidence, failed to assess Plaintiff's impairments as a whole, and did not properly present hypothetical scenarios to the vocational expert during the hearing. The Commissioner moves to affirm. For the following reasons, the Court GRANTS Plaintiff's motion and DENIES Defendant's motion.


         The parties have stipulated to the facts set forth in Plaintiff's Statement of Facts. See [Dkt. 21-1 (Pl. Stmt of Facts); Dkt. 22-1 (Mot. Affirm) at 2]. The Court has reviewed the evidence and adopts the stipulated facts, hereby incorporating them into this opinion. The following facts derive from the stipulated facts and the record.

         Plaintiff was born in March of 1969 and alleges her disability began on or about May 1, 2005. See [R. 115]. Plaintiff applied for DI and SSI benefits on June 7, 2013, when she was 44 years old. [R. 114]. At the time of the administrative hearing on January 23, 2015, Plaintiff was living with her mother, stepfather, sister, and her sister's son. [R. 205].

         I. Plaintiff's Medical History

         Prior to Plaintiff's onset date, Thomas Rago, M.D. (“Dr. Rago”), diagnosed Plaintiff with carpal tunnel syndrome in both hands on June 23, 2000. [R. 460]. She received carpal tunnel release surgery for her left hand on August 22, 2000, but did not have surgery on her right hand due to slow healing and her request to hold off on surgery. [R. 460-61].

         On September 22, 2005, Plaintiff returned to Dr. Rago on September 22, 2005, with complaints of pain and swelling in and around her right thumb. [R. 464]. Dr. Rago observed the plaintiff still had “very mild carpal tunnel disease” and that symptoms were minimal so no treatment was recommended. [R. 464]. Her file was directed to remain open in case she needed surgery in the future. [R. 464]. Dr. Rago identified her complaints relating to trigger thumb, “some capsulitis, ” and “early arthritis at the base of her thumb.” [R. 464].

         On February 3, 2006, Plaintiff visited Orthopedic Specialty Group P.C. (“OSG”) with complaints of severe pain in her neck and arm. [R. 628]. Plaintiff underwent x-ray testing of her cervical spine, wherein osteophytes (i.e. bone spurs) were discovered in her lower vertebrae. Dr. Malin[1] concluded Plaintiff's “presentation is that of a cervical disk disease with a combination of C-6 symptoms on the right and C-7 symptoms on the left.” [R. 628]. At that time, Dr. Malin recommended physical therapy and over-the-counter anti-inflammatories. [R. 628]. On February 27, 2006, Plaintiff had a follow up appointment at OSG and was noted to have “markedly improved” as a result of physical therapy and the use of traction. [R. 627]. It was also noted that the Plaintiff had a “good range of motion of the shoulders elbows and wrist” with “mild pain” in her left trapezius paracervical region when she extended. [R. 627].

         Plaintiff returned to OSG on January 18, 2008 and was seen by Henry A. Backe, Jr., M.D. (“Dr. Backe”). [R. 469]. She complained of wrist and hand pain, “numbness and tingling that radiates up her forearm, ” and “mild discomfort” in her elbow. [R. 469]. Dr. Backe's notes indicate Plaintiff's carpal tunnel symptoms returned when she resumed repetitive work, so she stopped working with her initial employer in 2001 and again with a second employer within a year “due to the progressive pain her hands and wrist.” [R. 469]. At that time she had no complaints of neck pain and had full motion in her cervical spine, elbow, forearm, and wrist. [R. 469]. She went to OSG for follow-up treatment regarding pain in her arms and hands on February 4, February 26, and March 26 of 2008. [R. 471-73].

         Plaintiff returned to OSG approximately one year later on May 14, 2009, complaining of numbness in both hands, pain in her left elbow and forearm, and swelling in her forearm. [R. 470]. Dr. Backe conducted a physical examination and determined she had full range of motion in her cervical spine and shoulder. [R. 470]. Dr. Backe concluded Plaintiff would benefit from a right carpal tunnel release and a repeat left carpal tunnel release. [R. 470]. Dr. Backe stated that if Plaintiff did not respond to treatments and injection therapy, she may require surgical intervention. [R. 470]. He also stated, “I do not think this patient has a good chance of returning to a former type of work. This would only cause recurrence of her symptoms.” [R. 470].

         On December 7, 2011, Plaintiff visited the St. Vincent Medical Center's Emergency Department with complaints of chest pain and shortness of breath. [R. 723-32]. She was prescribed an albuterol inhaler and 600 mg Motrin, and then was discharged. [R. 728]. On February 29, 2012, Holt visited St. Vincent Medical Center's Family Health Center for neck, upper back, and shoulder pain. [R. 707]. At that time, Holt underwent a cervical spine and left shoulder x-ray as well as a thyroid sonography. [R. 483]. She received her results on April 18, 2012: her thyroid was negative for nodules, and she was noted to have large osteophytes in the C-4 through C-7 region of the spine and mild degenerative joint disease of the spine and left shoulder. [R. 485].

         On May 21, 2012, Holt visited Advanced Radiology consultants for an MRI as follow-up to her visit to the Family Health Center. [R. 465, 467]. The MRI showed numerous osteophyte complexes and several disc herniations. [R. 465, 467]. Gerard J. Muro, M.D. (“Dr. Muro”), evaluated the results as “multilevel degenerative changes resulting in central canal stenosis at ¶ 4-5 through C7-T1 levels.” [R. 467]. An MRI of the thoracic spine showed a herniated disc at the T1-2 resulting “moderate right lateral recess and mild right sided foraminal stenosis.” [R. 466].

         Plaintiff returned to OSG on June 13, 2012, for “daily left sided neck, posterior thigh and thoracic complaints.” [R. 477-78]. Plaintiff informed John N. Awad, M.D. (“Dr. Awad”), that her “symptoms were constant” and ranged between “severe and extremely severe.” [R. 477]. Dr. Awad discussed physical therapy with the Plaintiff and decided to hold off considering any possible injections until after seeing the outcome of physical therapy. [R. 478].

         Plaintiff attended physical therapy at Ahlbin Centers for Rehabilitation Medicine Bridgeport hospital for 3 months from June 23, 2012, to September 29, 2012. [R. 641-45]. The therapy discharge notes stated “goals not met” and “patient has had max benefit from therapy.” [R. 629]. At her follow up appointment on July 25, 2012, Dr. Awad diagnosed Plaintiff with “C4-C5, C5-C6 and C6-C7 central canal stenosis without myelopathy and mechanical leg pain.” [R. 476]. Dr. Awad did not believe surgical intervention was necessary at that time, he would continue monitoring the patient and reassess if she presented myelopathy or significant radiculopathy. [R. 476]. At Plaintiff's next follow up October 24, 2012, her condition was unchanged. [R. 475].

         On November 15, 2012, Plaintiff received a chest CT scan at St. Vincent's Health Services, which showed an enlarged thyroid. [R. 651-52]. She received a pulmonary function test the next day and her results were within the normal range for most of the tests; Robert B. Brown, M.D. (“Dr. Brown”), opined her reduced “ERV” could be attributed to her obesity. [R. 519]. Plaintiff made several medical visits in regards to her persistent shortness of breath. [R. 480-506]. On May 24, 2013, Plaintiff was seen at St. Vincent's Chest Clinic, where Plaintiff complained three to four times a week she needed to take deep breaths and these episodes lasted for ten minutes at a time before subsiding; albuterol sometimes gave mild relief. [R. 510].

         On July 8, 2013, Plaintiff returned to St. Vincent's Family Health Center with complaints of tightness in both of her legs. [R. 551]. Shortly thereafter on July 19, 2013, Plaintiff went to St. Vincent's Emergency Room with complaints of “swelling and tightness in both legs” and swelling in her neck. [R. 529]. She also visited St. Vincent's Family Health Center on August 12, 2013, with the same complaints. [R. 555].

         On September 10, 2013, Patrick J. Carolan, M.D. (“Dr. Carolan”), an orthopedist, performed a physical examination and determined her range of motion in the cervical spine was about 50% of what would be normally expected. [R. 549]. Dr. Carolan's impressions were that Plaintiff had cervical disk disease with disk herniation, ankylosing spondylitis of the thoracic spine, and probable degenerative disk disease of the lumbar spine. [R. 549]. He recommended physical therapy and prescribed motrin. [R. 550]. Plaintiff attended nine 30-45 min physical therapy sessions between September 20, 2013 and October 31, 2013. [R. 665-69]. On October 29, 2013, Plaintiff told Dr. Carolan that she had not noticed any benefit from physical therapy. [R. 545]. Dr. Carolan observed the following: “Examination of cervical spine revealed marked loss of motion throughout the cervical spine with complaints of pain going into her upper extremity. Her neurological examination revealed some weakness of volar flexion of her left wrist. Her deep tendon reflexes were hypoactive in both upper extremities.” [R. 545]. Dr. Carolan ordered an MRI and her remaining therapy sessions were cancelled “per MD order.” [R. 545, 671].

         Pl an MRI onaintiff obtained November 14, 2013, which indicated “[e]xuberant osteophyte formation throughout the cervical spine, mild cord compression at ¶ 4/5 and left foraminal narrowing at ¶ 5/6.” [R. 543-44]. The notations indicated the vertebrae appearance and any abnormalities are “unchanged” from the prior MRI taken May 21, 2012. [R. 543]. Plaintiff thereafter made additional visits to Family Health Center and the St. Vincent's Emergency Room with complaints about pain in her spine and legs. [R. 854 (April 11, 2014), 922 (Feb. 3, 2014)].

         Plaintiff was referred by her primary physician to an ENT for a consultation on a “thyroid mass.” [R. 673]. On March 21, 2014, Sara Richer, M.D., F.A.C.S. (“Dr. Richer”), discussed with the Plaintiff “the need for a total thyroidectomy to eliminate compression of her airway” and the “need to obtain a TSH level for further evaluation of enlarged thyroid.” [R. 674]. Plaintiff was “started on a PPI for reflux symptoms and was given an antireflux diet.” [R. 674].

         Plaintiff visited Fairfield Medicine, St. Vincent's MultiSpecialty Group, on April 25, 2014, for nighttime leg pain, headaches and dizziness. [R. 690]. In relevant part, Anna Pankratov, M.D. (“Dr. Pankratov”), prescribed Gabapentin for her leg pain, and she recommended regular exercise and caloric restrictions to address her obesity. [R. 693]. Three days later, Plaintiff received treatment from Dr. Sara Richer (“Dr. Richer”) and appeared “hesitant to undergo surgery.” [R. 677]. Plaintiff returned to Dr. Prankatov for headaches and leg pain on August 26, 2014. [R. 686]. Dr. Pankratov ordered x-rays, which revealed calcaneal spurs and ankle swelling. [R. 689, 966]. During a follow up visit on December 22, 2014, Plaintiff complained of pain in her neck, left arm, and lower back. [R. 678]. She also stated her grip was weak, requiring her to wear wrist braces daily and that she was still experiencing headaches. [R. 678]. On January 30, 2015, Dr. Pankratov noted Plaintiff was “unable to walk four blocks without symptoms and unable to walk two flights of stairs without symptoms” and that “she has poor tolerance to exertion due to her weight.” [R. 926].

         II. Proce ...

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