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Wheeler v. Commissioner of Social Security

United States District Court, Second Circuit

May 14, 2013

JOHN P. WHEELER, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, [1] Defendant.

REPORT AND RECOMMENDATION

HUGH B. SCOTT, Magistrate Judge.

Before the Court are the parties' respective motions for judgment on the pleadings (Docket Nos. 13 and 15).

INTRODUCTION

This is an action brought pursuant to 42 U.S.C. ยง 405(g) to review the final determination of the Commissioner of Social Security that plaintiff is not disabled and, therefore, is not entitled to disability insurance benefits and/or Supplemental Security Income benefits.

PROCEDURAL BACKGROUND

The plaintiff, John P. Wheeler ("Wheeler" or "plaintiff"), filed an application for disability insurance benefits on October 5, 2004 claiming that he had become disabled on January 1, 2000. (R. 336A). That application was denied. The plaintiff appeared before an Administrative Law Judge ("ALJ"), who considered the case de novo and concluded, in a written decision dated March 26, 2007, that the plaintiff was not disabled within the meaning of the Social Security Act. The plaintiff filed a request for review by the Appeals Council, which denied the appeal. The plaintiff subsequently commenced a federal court action challenging the denial of benefits. On April 23, 2008, the determination to deny benefits was remanded by stipulation. See Wheeler v. Astrue, Civ. No. 01CV749S at Docket No. 4. Upon remand, a supplemental hearing was conducted before the ALJ on January 13, 2009. (R. 474). The plaintiff amended his alleged disability onset date to October 5, 2004. (R. 476). The ALJ determined that the plaintiff became disabled as of May 8, 2007 - the date of his 55th birthday. (R. 388). The plaintiff appealed that determination to the Appeals Council, which denied the request for review, making the ALJ's decision the final decision of the Commissioner on September 16, 2011.

Plaintiff subsequently commenced this action (Docket No. 1). He alleges that he became disabled on October 5, 2004[2] and seeks benefits for the period from October 5, 2004 through May 7, 2007. (Docket No. 15-1 at 2-3). The parties have moved for judgment on the pleadings.

FACTUAL BACKGROUND[3]

Wheeler was born in 1952 and has a high school education. (R. 477). He claims he was disabled for the period in question due to pain in his back due to a herniation; pain in his neck, knees, and chest; an enlarged heart muscle; feeling lightheaded; depression; hypertension; and bilateral carpal tunnel syndrome. (R. 477-78, 481). His past relevant work was as an auto mechanic which required him to lift an average of 100 pounds at a time. (R. 479).

The record reflects that the plaintiff has had problems with his back going back to 2002. An x-ray dated April 25, 2002 revealed degenerative disc space narrowing at L5/S1, as well as mild C4/5, C5/6 and C6/7 spondylosis including disc space narrowing, and bilateral C6/7 intervertabral foramen narrowing secondary to uncovertebral joint spurring. (R. 236-37). A CT of his cervical spine on February 4, 2003, showed left paracentral and left lateral recess bony spur formation at C3-4, right paracentral and lateral recess disc herniation into the central region, with mild to moderate spinal stenosis. (R. 232).[4]

Wheeler was involved in a motor vehicle accident on July 19, 2003. (R. 194). Upon examination on August 15, 2003, he was experiencing neck pain, low back pain, left shoulder pain, knee pain and chest discomfort. The neck pain radiated to his left shoulder. He declined physical therapy and asked for a note allowing him to return to work. (R. 194). An x-ray taken on August 15, 2003 revealed peritendinitis calcaria in his right shoulder with calcifications in the area of the supraspinatus tendon; mild osteoarthritis of the left acromioclavicular joint; and changes in the left shoulder suggestive of degeneration of the rotator cuff tendon. (R. 229). An x-ray of the plaintiff's cervical spine taken on July 22, 2003 again revealed spondylosis predominantly at C6/7 with mild bilateral foraminal stenosis. (R. 231).

On December 31, 2003, Wheeler was seen by Dr. Ronald Boersma with respect to chest pains. A resting cardiogram showed a sinus rhythm "with perhaps a small Delta wave in the frontal plane and V5-V6." (R. 126). A stress test was terminated after 7 minutes because Wheller "developed a significant ST depression in the inferior and lateral precordial leads which at peak effort was in the 5mm range inferiorly and 2-3 mm in the lateral precordial leads." Dr. Boersma stated that the test "provokes an ischemic ST/T vector change in the inferior and lateral precordial leads with no clinical angina pectoris symptomatlolgy." (R. 126). The test was not conclusive as to whether the result was ischemic mediated or a false positive. Dr. Boersma stated that a nuclear scan was pending and concluded that Wheeler should be limited to "sedentary work for age." (R. 126).

On January 29, 2004, Wheeler was taken to Mercy Hospital by ambulance at the direction of Dr. Michael Kane, his treating physician, after complaining of chest pains during an office vist with Dr. Kane. (R. 132). Upon examination by Dr. Deolindo Ocampos, Wheeler was found to be suffering from atypical chest pain, hypertension, gastroesophageal reflux disease and anxiety. An EKG performed on Wheeler at that time was suggestive of ischemia and his work performance was "rather low." A coronary angiogram was scheduled (R. 133). On January 30, 2004, a cardiac catheterization performed by Dr. Nadeem Haq. revealed normal coronary anatomy and an ejection fraction of 60 percent. (R. 138).

The plaintiff was seen by Dr. Michael Landi on February 18, 2004, for a neurological consultation due to continued neck and back pain exacerbated by the 2003 car accident. (R. 155-56). Dr. Landi stated that x-rays reflected cervical spondylosis predomniantly at C6/7 and C7/T1, and a suggestion of cervical disc herniations at C3-4 and C5-6. (R. 158). Dr. Landi also reviewd an EMG nerve conduction study conducted in 2002 and stated that the results demonstrate that Wheeler suffers from carpel tunnel syndrom "more evolved on the left than on the right." (R. 158).

The plaintiff was also examined by Dr. John A. Moscato, an orthopedic surgeon, on February 19, 2004, based upon complaints of left knee pain. (R. 152-53). On examination, Dr. Moscato observed that the plaintiff's knees were normal except that the left knee demonstrated mild point tenderness over the medial collateral ligament without instability. Dr. Moscato concluded that Plaintiff was functioning well and instructed him to do knee exercises and use heat and massage. (R. 153). From an orthopaedic standpoint, Dr. Moscato opined that Plaintiff may return to work as a maintenance man. (R. 153).

Plaintiff was examined by Dr. Ocampos, again on February 24, 2004 (R. 242-43). Plaintiff complained of an aching pain in the lower sternal region. (R. 242). Dr. Ocampos reviewed Plaintiff's past test results and concluded that the plaintiff was "somewhat reassured" and that his symptoms were atypical but that cardiological studies failed to demonstrate significant coronary artery disease. (R. 242-43). The plaintiff was seen by Dr. Kane on July 22, 2004, again complaining of chest pain and neck pain. (R. 176). Dr. Kane advised him that his past tests relating to his cardiac function were within normal limits. (R. 177).

On December 9, 2004, the plaintiff was psychiatrically evaluated by Thomas Ryan, Ph.D., a consultative examiner for the State agency. (R. 250-53). At the examination, Wheeler complained of feeling depressed, but reported no past psychiatric hospitalizations or treatment. (R. 250-51). Dr. Ryan observed that the plaintiff was able to follow and understand simple directions and instructions, perform simple tasks independently, and maintain concentration and attention as well as a regular schedule, but may have some difficulty with complex tasks. Wheeler's insight was found to be "poor" and his judgement to be only "fair." (R. 252). Dr. Ryan concluded that the results of his evaluation "were consistent with psychiatric problems which may somewhat interfere with his ability to function on a daily basis." Dr. Ryan diagnosed the plaintiff as suffering from a "depressive disorder, NOS, mild". (R. 252).

On December 9, 2004, Wheeler was also evaluated by Fenwei Meng, M.D., a consultative physician for the State agency. (R. 254-58). The plaintiff complained of pain in his neck, lower back, leg, and chest. He also complained of carpal tunnel syndrome. (R. 254). On examination, Dr. Meng found that the plaintiff's gait and stance were normal; he was able to squat and walk on heels and toes without difficulty; he was able to rise from a chair without difficulty; his cervical spine flexion was full; the lumbar spine showed full flexion, extension, lateral flexion, and full rotary movement bilaterally; straight leg raising was negative bilaterally; he had a full range of motion of the upper extremities, hips, and ankles; near full range of motion of the knees with mild pain. (R. 256-257). According to Dr. Meng, a lumbosacral spine x-ray showed slight narrowing of the disc space at L5-S1 and a left knee x-ray was normal. (R. 258). Dr. Meng diagnosed (1) status post motor vehicle accident with pain in the neck, back, and knees, (2) carpal tunnel syndrome, (3) left elbow tendonitis, and (4) chest pain (noncardiac). (R. 257). Dr. Meng concluded that the plaintiff's upper extremity had minimal limitation with dexterity due to carpal tunnel syndrome; and that the plaintiff had minimal limitation with heavy lifting, pushing, and reaching, bending, extension, and turning his head to the side. (R. 257).

In a letter dated March 21, 2005, the plaintiff's treating physician, Dr. Kane, opined that Wheeler "has difficulty doing any job that requires repetitive lifting, bending, twisting, standing or repetitive hand motions, secondary to carpal tunnel syndrome and degenerative disc disease of the neck." (R. 305). Dr. Kane further opined that the plaintiff was not helped by traditional pain medications or physical therapy. Dr. Kane concluded that Wheeler "likely has a permanent disability of a marked degree" and recommended he follow up with Dr. Landi, a neurosurgeon. (R. 305).

An April 2005 x-ray of the lumbar spine revealed mild spondylitic spurring and mild degenerative joint disease in the sacroiliac joint. (R. 327). Wheeler was again examined by Dr. Kane on September 8, 2005. (R. 318). Dr. Kane stated that the plaintiff's asthma was mild and persistent and recommended Albuterol. He also advised Wheeler to continue taking Mobic for osteoarthritis and neck pain. (R. 318). Wheeler next saw Dr. Kane on December 15, 2005. (R. 316-17). At that time, Wheeler did not complain of chest pain, palpitations, anxiety, or ...


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