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Castlel v. Colvin

United States District Court, S.D. Indiana, Indianapolis Division

January 25, 2017

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.


          Denise K. LaRue United States Magistrate Judge

         Entry on Judicial Review

         Francesca N. Castlel applied for social security disability benefits and supplemental income security benefits. An Administrative Law Judge (ALJ) denied her claims, the Appeals Council denied review, and Castlel brought this action for judicial review. The parties have consented to the Magistrate Judge's jurisdiction. For the reasons that follow, the ALJ's decision will be affirmed.


         Castlel alleges disability since February 2012 due to chronic fatigue resulting from chemotherapy and radiation treatments for breast cancer. [R. 199.] In October 2014, the ALJ held a hearing at which Castlel testified. She was 32 years old at that time and lived with her parents. [R. 32.]

         Castlel was diagnosed with cancer in her right breast in November 2011. She had a lumpectomy at which time 11 to 12 lymph nodes were removed. After surgery to remove the tumor, she underwent chemotherapy and radiation. [R. 38.] She was on medical leave during her treatment and returned to work in June 2012. [R. 39.] However, she did not work between December 2012 and February 2013 because of lymphedema (swelling accompanied by pain or discomfort) of her right arm and hand. [Id.] She is right-handed. [R. 33.] The lymphedema improved with physical therapy, and she has a compression glove that she uses one or two hours a day and a compression sleeve to wear at night. [R. 39, 42.]

         At the time of the hearing, Castlel had been working part-time, 20 hours or less per week, at JC Penney as a clerk. This work required her to stand or walk 4-6 hours each day. [R. 33, 39.] Castlel has a 20-pound weight restriction on lifting with her right arm. [R. 34.]

         Castlel claims that she cannot work due to chronic fatigue. She had a complete workup for fatigue, which was negative except for depression. [R. 20, 748-49.] The fatigue has not improved since her chemotherapy. [R. 41.] Castlel works out at a gym two or three times each week, but she said this does not help with her fatigue. She testified that she also has problems with her memory and concentration. [R. 44.] She has been treated for an adjustment disorder and depression.

         Medical records reflect that Castlel began chemotherapy in February 2012, reporting minimal fatigue at her second round. [R. 390.] At her fourth round of chemotherapy, her oncologist noted that she was tolerating the treatment well. [R. 392.] In May it was noted that she had “done well” and her only complaint was of back pain. [R. 397.] In August 2012, while she was receiving radiation therapy, Castlel reported to Dr. Lida Mina that she was recovering well and her energy level was good. [R. 403.] An oncologist noted that Castlel's fatigue was mild and not severe enough to require any break in treatment. [R. 676, 679.] In October that year, Castlel reported to her oncologist that she was doing well and her fatigue had largely returned to baseline, though she had some slight fatigue requiring occasional naps after work. [R. 669.] Dr. Mina noted in May 2013 that Castlel had begun working 6 hours at a time in a job which required her to be on her feet for 6 hours and rquired lifting. [R. 657.]

         In June 2013, Castlel was seen in an oncology clinic and reported “significant fatigue.” [R. 655.] She was working 6 hours a day; her fatigue was getting worse, and she was not feeling better. She had been feeling depressed. Dr. Mina believed that her fatigue could be related to her depression and mood and advised that she might have to restart medication for depression. [R. 656.]

         That same month, Dr. Mauro Agnelneri conducted a consultative physical exam of Castlel at the request of the state agency. He noted that she was “overcome by fatigue” but she was nonetheless working part-time. [R. 642.] At a consultative mental status examination also in June, Castlel stated that she was disabled due to fatigue, lymphedema, and “chemo-brain.” She reported that she had not regained her normal energy level and had to rest after working because it made her tired. [R. 647-53.] The psychologist thought that Castlel's low energy level could be due in part to her depression. [R. 653.] He diagnosed Major Depressive Disorder, Moderate. [Id.]

         In July 2013, Castlel was seen by her primary care clinic for depression. She was tired and fatigued. The physician thought her fatigue was likely due to depression rather than her cancer treatment. [R. 745.]

         In August 2013, at her oncology clinic, Castlel reported fatigue, which was “getting significantly worse” and was “not improving.” [R. 748-49.] She said that she was fatigued after work. [R. 748.] In contrast, Castlel reported to another physician that same month that she was doing well and she had no complaints other than she was not recovering her strength to her satisfaction. [R. 772.] In October 2013, Castlel again reported fatigue to the oncology clinic. [R. 774-75.] On examination, Dr. Kathy Miller noted that Castlel “appears quite well” [R. 774] and “clinically is without evidence of disease recurrence.” [R. 775.] Dr. Miller noted that it was “well-documented [that] approximately 5% to 10% of patients who have ongoing difficulty with much more severe fatigue after completing chemotherapy and radiation” and that “[p]revious studies to try to identify an underlying physiologic explanation for the fatigue have been largely unremarkable.” [Id.] Dr. Miller suggested a trial of Ritalin for the fatigue.

         The next month (November 2013), Castlel reported no improvement in her fatigue while taking Ritalin. [R. 776-77.] Dr. Miller's notes reflect that Castlel “does continue to work full time” but was “really quite exhausted at the end of the day.” [R. 777.] Dr. Miller advised Castlel that she thought cutting back her work schedule would aggravate her fatigue. [Id.] In December, Dr. Ernest Carrasco evaluated Castlel at a primary care clinic. He noted that her stamina had been ...

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