United States District Court, D. Connecticut
RULING ON THE PLAINTIFF'S MOTION TO REVERSE AND
THE DEFENDANT'S MOTION TO AFFIRM THE DECISION OF THE
Vanessa L. Bryant United States District Judge.
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.
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.
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.
Plaintiff's Medical History
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].
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].
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 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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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,
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].
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].