United States District Court, N.D. Indiana, South Bend Division
OPINION AND ORDER
CHRISTOPHER A. NUECTHERLEIN, Magistrate Judge.
On January 3, 2014, Plaintiff, Tracy McLean ("McLean") filed her complaint in this Court. On May 29, 2014, McLean filed her opening brief requesting that this Court reverse and remand this matter to the Commissioner for further reconsideration, including a new hearing and decision, consistent with the principles outlined in her brief. On September 4, 2014, Defendant, Commissioner of Social Security, Carolyn W. Colvin ("Commissioner"), filed her response brief. McLean did not file a reply. The Court may enter a ruling in this matter based on the parties consent, 28 U.S.C. § 636(c) and 42 U.S.C. § 405(g).
On March 2, 2011, McLean filed an application for Supplemental Security Income ("SSI") and Disability Insurance Benefits ("DIB") alleging a disability due to back pain and diabetes mellitus with peripheral neuropathy beginning May 27, 2010. Her claims were denied initially on May 31, 2011, and also upon reconsideration on July 12, 2011. McLean appeared at a hearing before an Administrative Law Judge ("ALJ") on August 28, 2012.
On September 11, 2012, the ALJ issued a decision holding that McLean was not disabled under section 1614(a)(3)(A) of the Social Security Act. The ALJ also found that McLean met the insured status requirements of the Social Security Act through June 30, 2011. In addition, the ALJ found that McLean had not engaged in substantial gainful activity since May 27, 2010, and that her status post bilateral carpal tunnel release, degenerative disc disease of the cervical spine, degenerative joint disease of the left shoulder, diabetes mellitus with peripheral neuropathy, and obesity constituted severe impairments. However, the ALJ found that McLean did not have an impairment of combination of impairments that met or medically equaled one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. The ALJ found that McLean retained the residual functional capacity ("RFC") to perform less than the full range of light work as defined in 20 C.F.R. 404.1567(b) and 416.967(b). The ALJ found McLean could lift or carry and push or pull up to ten pounds frequently and twenty pounds occasionally; sit, stand, or walk for a total of about six hours in an eight-hour workday; never climb ladders, ropes, or scaffolds; crawl or kneel, and occasionally climb ramps, stairs, balance, stoop, and crouch. The ALJ further found that McLean could occasionally use foot controls with her lower extremities and she must avoid concentrated exposure to work hazards such as dangerous moving machinery and unprotected heights. The ALJ then found that McLean is capable of performing past relevant work in assembly and in packing.
On November 4, 2013, the Appeals Council denied review of the ALJ's decision making it the Commissioner's final decision. See Fast v. Barnhart, 397 F.3d 468, 470 (7th Cir. 2005); 20 C.F.R. § 404.981. On January 3, 2014, McLean filed a complaint in this Court seeking a review of the ALJ's decision.
McLean was a fifty-four year old female at the time the ALJ denied her claims. She has an eighth grade education and has obtained her GED. She reported past relevant work as a sewer, assembler, and packer.
1. Claimant's Hearing Testimony
At the hearing, McLean testified that she suffered from back pain and diabetes mellitus with peripheral neuropathy. McLean testified that she experiences constant numbness and tingling in her extremities. She testified that since her onset date May 27, 2010, she endured blurred vision as a result of cataracts surgery, difficulty remembering things, back pain due to degenerative disc disease, diabetes with neuropathy, thyroid issues, and gout, all of which prevented her from working. McLean also indicated she was able to take care of her personal needs and drive to the store on occasion where she would use an electric cart. She testified that she attended church three times weekly and would occasionally go to dinner with her husband or friends.
McLean also testified that her typical day included performing minor household chores, watching television, and reading. She explained that her light household work included cooking easy meals, dishes, putting laundry in the dryer, dusting, and straightening up the home. McLean testified that pain, tingling in her hands and feet, and neuropathy prevented her from completing tasks such as vacuuming, mowing, and caring for her disabled grandchild when she visited. McLean testified that she could sit for approximately an hour, but found it necessary to prop her feet up due to swelling. McLean testified she could walk for approximately a few feet and stand with the use of a cane for a short period. In addition, McLean believed she could lift a gallon of milk.
As to her treatment, McLean testified that she regularly experienced pain in her back and took prescription medication, including insulin shots, and muscle relaxers for her pain, diabetes, neuropathy, thyroid, cholesterol, and high blood pressure. She reported various side effects from her medications that included drowsiness, dizziness, lightheadedness, forgetfulness, dry mouth, diarrhea, and swelling in her legs and feet. McLean testified that even with her treatments and medications, her condition has worsened.
2. Relevant Medical Evidence
On January 20, 2010, McLean saw neurologist, Dr. Nasar Katariwala, who conducted an EMG/NCV for the evaluation of bilateral hand numbness and tingling. The results showed bilateral neuropathy in the upper extremities, more prevalent on her right side than her left. Dr. Katariwala noted that because McLean had more than a fifteen year history of insulin dependent diabetes mellitus, it was unclear whether the bilateral neuropathy was a result of the diabetes or whether it was related to carpal tunnel syndrome, indicated by prominent involvement of the median nerves. In February 2010, McLean underwent a right carpal tunnel release surgery by Dr. William Biehl, which provided complete relief in her right hand numbness. However, McLean's hand numbness returned one day prior to her follow up appointment with Dr. Katariwala on March 18, 2010. Dr. Katariwala reiterated the recurrence of McLean's hand numbness could be the result of either diabetes or carpal tunnel syndrome. In April 2010, Dr. Biehl performed a second carpal tunnel release surgery on McLean's left side. Dr. Biehl observed that McLean had a full range of motion the following month, but noted that McLean's sensation may not improve to normal despite the successful surgery because of her diabetes.
On October 14, 2010, McLean saw Dr. Thomas Ryan, D.O., for a new patient evaluation. During that visit, McLean presented complaints of upper back pain behind her left shoulder. McLean stated her pain level for that day was a zero out of ten, with ten being the worst level of pain. She stated that when she did experience pain, it was typically a ten out of ten. Dr. Ryan observed that McLean had tenderness, mild spasms, and a slightly reduced range of motion in her neck. Dr. Ryan noted that McLean had a decreased range of motion and pain with certain maneuvers in her left shoulder, but no specific weakness with rotator cuff testing. Dr. Ryan performed a left shoulder x-ray, which revealed some ...