United States District Court, D. New Hampshire
Kary R. Estabrook
Carolyn Colvin, Acting Commissioner, Social Security Administration.
ORDER OPINION NO. 2014 DNH 222.
PAUL BARBADORO, District Judge.
Kary Estabrook seeks judicial review of a ruling by the Social Security Administration denying her application for disability insurance benefits ("DIB") and supplemental security income ("SSI"). For the reasons set forth below, I deny Estabrook's request and affirm the decision of the Commissioner.
On August 5, 2010, Estabrook applied for DIB and SSI. At that time, she was 38 years old and working part time as a technician for a pest control company. Estabrook alleges that beginning around May 1, 2010, she became disabled. She states that her impairments stem from lupus, neuropathy in her legs, and degenerative disc disease, as well as other mental and physical impairments.
A. Medical Evidence
1. Physical Impairment
a. Dr. Guiry
Plaintiff treated with primary care physician Colleen Guiry, M.D. Dr. Guiry's records indicate that she treated plaintiff for: (1) systemic lupus erythematosus (lupus),  starting July 2, 2010; (2) back pain, starting June 28, 2010; (3) chest pain, starting May 18, 2010; (4) a tick bite, on May 11, 2010; (5) nausea, starting May 10, 2010; (6) joint pain, starting May 10, 2010; and (7) asthma and pleurisy,  starting on March 14, 2009. After a tick bite, plaintiff went to the emergency room on May 7, 2010, complaining of lower back pain, abdominal cramping, tingling and burning in the legs, a general feeling of fatigue, and difficulty focusing. She had blood work to evaluate for Lyme disease and was prescribed antibiotics as a precaution. Plaintiff saw Dr. Guiry on May 10, 2010, after her evaluation for Lyme disease in the emergency room, as she was still experiencing nausea and body aches. Plaintiff was advised to return to the hospital for additional blood work for other tick-borne diseases and rheumatologic conditions that could cause the sudden onset of joint pain.
Plaintiff saw Dr. Guiry on May 18, 2010 for chest pain and joint pain, which she reported at a pain level of two out of ten when she took Aleve and six out of ten at its worst. Dr. Guiry prescribed diclofenac sodium and ordered a chest x-ray. The chest x-ray was negative for acute cardiac or pulmonary pathology. Plaintiff contacted her primary care office on May 28, 2010 to ask for a note for her employer so she could begin an every-other-day work schedule, as she was not getting relief from her joint pain. Dr. Guiry's office prescribed Tramadol for her pain on June 14, 2010, until she was able to see John Gorman, M.D., the rheumatologist.
Plaintiff went to the emergency room on June 27, 2010, for a possible lupus flare-up. She was experiencing increased pains in her back, joints, legs, and arms. The emergency room physician, Brian Miller, D.O., prescribed Percocet for the pain and recommended that plaintiff follow-up with her rheumatologist, Dr. Gorman, or with Dr. Guiry to discuss steroids as a course of treatment. Plaintiff was seen at Dr. Guiry's office on June 28, 2010, complaining of pain in her back and feet. She informed Jennifer Thebodeau, M.A., of her possible lupus diagnosis. Plaintiff stated the medication Dr. Gorman prescribed, Plaquenil,  could take months to work. Plaintiff reported she was in too much pain to work and requested a note saying she could not work at all so that she could "get disability or [asked the doctor to give her] something to take away the pain so that she c[ould] work." Thebodeau suggested x-rays of the back, to see if plaintiff's pain had another origin. The x-ray of the lumbar spine was negative, showing a normal alignment and no degenerative changes.
Plaintiff saw Dr. Guiry on July 2, 2010, for follow-up after her possible lupus diagnosis. Plaintiff reported that her pain was not better and she had pain in her upper back, chest, legs, hips, ankles, and on her left side with radiation to the left arm; the record notes plaintiff had the left side pain for years. No new recommendations were given and plaintiff was told to follow-up with Dr. Gorman. Plaintiff saw Dr. Guiry on July 20, 2010 for an acute visit, due to the pain on the left side of her chest and numbness of the left arm. Plaintiff reported that she had not taken anything for the pain, including the Diclofenac, which Dr. Guiry previously prescribed to her. Dr. Guiry scheduled an echocardiogram and urged Plaintiff to quit smoking. Plaintiff's echocardiogram on July 23, 2010 demonstrated normal heart function and structure.
b. Dr. Gorman
Plaintiff began seeing Dr. Gorman on June 24, 2010. Plaintiff reported pain in the lower back, hips, and knees, swelling of the knees and ankles, frequent nasal ulcers, dry mouth, pleurisy, facial rash with sun exposure, and discomfort in her fingers when exposed to cold. Dr. Gorman reported that plaintiff's blood work was positive for antinuclear antibodies and a number of her symptoms were consistent with lupus. Dr. Gorman recommended plaintiff have further studies done to detect antibodies and prescribed Hydroxychloroquine ("HCQ").
Plaintiff saw Dr. Gorman for follow-up on August 5, 2010. The doctor stated that plaintiff was tolerating HCQ well but still had considerable generalized pain, her pleurisy was not improved, and her energy was a little diminished. Dr. Gorman opined that plaintiff's lab data was not completely supportive of a lupus diagnosis, but he was still concerned given her other symptoms. The doctor questioned whether plaintiff's chronic pain could be from a different musculoskeletal pain condition. He prescribed Prednisone,  to taper over a 12-day period.
Plaintiff saw Dr. Gorman on August 17, 2010, the day after completing her Prednisone taper. Plaintiff reported that the medication helped her pain significantly the first three days, but her pain returned as the dose decreased. The Prednisone did eliminate her rash, mouth ulcers, and pleurisy, which had not returned. Dr. Gorman noted that plaintiff was "[s]till very achy, " but concluded that her suspected lupus was "a little improved."
On September 28, 2010, plaintiff reported to Dr. Gorman that she still had pain in her lower lumbar area radiating into her buttocks and legs. Plaintiff believed the HCQ was controlling her rash, mouth ulcers, and pleurisy. On examination, plaintiff had no fibromyalgia tender points or joint swelling or tenderness, but did have mild lower lumbar tenderness. Dr. Gorman opined that plaintiff had a lumbar strain and recommended physical therapy.
c. Dr. Couture
On March 21, 2011, plaintiff was referred to Christopher Couture, M.D., a sports medicine specialist, by Gary Fleischer, M.D., to treat her lower back pain and a bulging disk. Plaintiff's MRI showed a "slightly desiccated disc and annular tear at L4-5, " but Dr. Fleischer did not think this was the cause of her symptoms. Plaintiff also had an electromyogram,  which showed polyneuropathy,  with no evidence of lumbar radiculopathy,  which was being treated with Gabapentin. Dr. Couture opined that plaintiff had an iliolumbar ligament sprain and gave her an injection of an anti-inflammatory steroid. Physical therapy was recommended to treat plaintiff's iliolumbar ligament and neuropathy pain.
Plaintiff returned to Dr. Couture on May 2, 2011, as her back pain had started to return in the previous two weeks. Plaintiff reported that her back pain was relieved for about four weeks after her last visit and the steroid injection. Plaintiff stated that her physical therapy was going well overall; she saw the physical therapist about once a week and supplemented with at home exercises. Plaintiff received an autologous blood injection in the left iliolumbar ligament and experienced immediate relief of her pain. Plaintiff followed up with Dr. Couture on June 8, 2011, and reported she was going "quite a bit better[, ]... still getting episodes of pain about once or twice a week but [not] nearly the frequency or intensity as before starting physical therapy." Plaintiff received a second autologous blood injection at the left iliolumbar ligament and again experienced immediate improvement in her pain. Plaintiff received a third and fourth injection with similar results on July 13, 2011 and August 17, 2011.
On September 15, 2011, Plaintiff returned to Dr. Couture because the pain in her lower back had returned, after being out of physical therapy and relatively inactive. Plaintiff's sacroiliac joints on both sides were tender to touch. Plaintiff was advised to resume physical therapy and she received cortisone injections in each of her sacroiliac joints, experiencing immediate relief of fifty percent of her pain. Plaintiff saw Dr. Couture on October 11, 2011 to follow-up after her sacroiliac joint injections. Plaintiff reported that her pain had improved but she still had "good days and bad days." The doctor opined that plaintiff was symptomatically improved and should transition from physical therapy to an independent home exercise program.
d. Dr. Fairley
Hugh Fairley, M.D., a state Disability Determination Services ("DDS") consultant and family medicine specialist, evaluated plaintiff's physical residual functional capacity ("RFC") on November 23, 2010. As to exertional limitations, he opined that plaintiff could occasionally lift/carry 20 pounds, frequently lift/carry 10 pounds, stand or walk for 6 hours in an 8-hour workday, sit for 6 hours in an 8-hour workday, and push and/or pull without limitation, except those described for lifting and carrying. Dr. Fairley stated that Plaintiff could never climb ladders, ropes, or scaffolds, but could occasionally climb stairs, balance, stoop, kneel, crouch, and crawl. He also stated that plaintiff had no manipulative, visual, or communicative limitations, but should avoid hazards.
e. Application to City of Nashua Welfare Department
Plaintiff applied to the City of Nashua Welfare Department for financial assistance on April 21, 2011. Dr. Guiry completed a statement of plaintiff's capabilities on November 10, 2010, which was submitted with her application. Dr. Guiry reported plaintiff's diagnosis of lupus, with a prognosis of "fair, " and stated that plaintiff had been in pain for seven months and it was not clear when she would respond to medication. Dr. Guiry opined that plaintiff could perform sedentary activities, including frequent sitting or occasional standing or walking, such as classroom situations, desk work, counseling sessions, or other appointments. Dr. Guiry also noted that, depending on the day, plaintiff could perform light work activities. The doctor reported that plaintiff could sit, stand, or walk for one hour per day, but that she needs to change position every 20 to 30 minutes. Dr. Guiry stated that plaintiff could occasionally: lift and carry up to 20 pounds, kneel, bend from the waist, crouch, climb stairs, climb ladders or scaffolds, crawl, reach above shoulder level, twist at the waist, use both hands for simple grasping, fine manipulation, and pushing and pulling, and use both feet. She stated that plaintiff should also avoid fumes or dust, hard floors, extreme cold and heat, hazardous areas, and outside terrain. Dr. Guiry's ultimate opinion was that plaintiff was not capable of participating in work-related activities at that time.
Dr. Guiry completed a second evaluation of plaintiff's physical capabilities on April 21, 2011, which was also submitted with her welfare application. This evaluation was substantially the same as the November 2010 evaluation, except that in addition to plaintiff's lupus, Dr. Guiry listed degenerative disc disease and neuropathy as diagnoses. Plaintiff's prognosis was again reported as "fair" and Dr. Guiry again noted that Plaintiff could perform sedentary work or light work, depending on the day. Her exertional and non-exertional ...