Citations
- 679 F. Supp. 2d 664
Full opinion text
ORDER ADOPTING MAGISTRATE JUDGE’S REPORT AND RECOMMENDATION
IRENE M. KEELEY, District Judge.
Pursuant to 28 U.S.C. § 636(b)(1)(B), Rule 72(b), Federal Rules of Civil Procedure and Local Court Rule 4.01(d), on June 22, 2009, the Court referred this Social Security action to United States Magistrate Judge James E. Seibert with directions to submit proposed findings of fact and a recommendation for disposition.
On November 22, 1009, Magistrate Judge Seibert filed his Report and Recommendation (“R & R”), and directed the parties, in accordance with 28 U.S.C. § 636(b)(1) and Fed.R.Civ.P. 6(e), to file with the Clerk of Court any written objections within ten (10) days after being served with a copy of the R & R. He further advised the parties that failure to file objections would result in a waiver of their right to appeal from the judgment of this Court. The parties did not file any objections.
Upon consideration of the Magistrate Judge’s recommendation, and having received no written objections, the Court accepts and approves the R & R and ORDERS that Magistrate Judge Seibert’s R & R is accepted in whole and that this civil action be disposed of in accordance with the recommendation of the Magistrate. Accordingly,
1. the Commissioner’s motion for Summary Judgment (dkt. no. 11) is GRANTED;
2. the plaintiffs motion for Summary Judgment (dkt. no. 10) is DENIED; and
3. this civil action is DISMISSED WITH PREJUDICE and RETIRED from the docket of this Court.
Pursuant to Fed.R.Civ.P. 58, the Court directs the Clerk of Court to enter a separate judgment order and to transmit copies of this Order to counsel of- record.
REPORT AND RECOMMENDATION SOCIAL SECURITY
JAMES E. SEIBERT, United States Magistrate Judge.
I. Introduction
A. Background
Plaintiff, Desiree Williams (Claimant), filed a Complaint on June 22, 2009, seeking Judicial review pursuant to 42 U.S.C. §§ 405(g) of an adverse decision by Defendant, Commissioner of Social Security, (Commissioner). Commissioner filed his Answer on August 24, 2009. Claimant filed his Motion for Summary Judgment on September 23, 2009. Commissioner filed his Motion for Summary Judgment on October 21, 2009.
B. The Pleadings
1. Plaintiffs Brief in Support of Motion for Summary Judgment.
2. Defendant’s Brief in Support of Motion for Summary Judgment.
C. Recommendation
I recommend that:
1. Claimant’s Motion for Summary Judgment be DENIED because substantial evidence supports the ALJ’s decision to discredit Claimant and to accord little weight to the opinion of Claimant’s treating source.
2. Commissioner’s Motion for Summary Judgment be GRANTED for the same reason set forth above.
II. Facts
Procedural History
Claimant filed an application for Supplemental Security Income (SSI) on June 26, 2006, alleging disability due to tendonitis and bursitis in left arm and shoulder; inflammation in neck, shoulder and back; diabetes; high cholesterol; GERD; gout; and glaucoma with an onset date of June 1, 2006. (Tr. 100). The claim was denied initially on August 23, 2006, and upon reconsideration on April 13, 2007. (Tr. 70, 75). Claimant filed a written request for a hearing on June 12, 2007. (Tr. 78). Claimant’s request was granted and a hearing was held on July 15, 2008. (Tr. 33-67).
The ALJ issued an unfavorable decision on September 26, 2008. (Tr. 12-32). The ALJ determined Claimant was not disabled under the Act because she had no impairment or combination of impairments that met or medically equaled one of the listed impairments in 20 C.F.R. Part 404 Subpart P, Appendix 1 (20 C.F.R. 416.920(d), 416.925 and 416.926), and there are jobs that exist in significant numbers in' the national economy that the Claimant can perform (20 CFR 404.1560(c) and 404.1566). (Tr. 18-30). On November 5, 2008, Claimant filed a request for review of that determination. (Tr. 5-7). The request for review was denied by the Appeals Council on April 25, 2009. (Tr. 1). Therefore, on April 25, 2009, the ALJ’s decision became the final decision of the Commissioner.
Having exhausted her administrative remedies, Claimant filed a Complaint with this Court seeking judicial review of the Commissioner’s final decision.
A. Personal History
Claimant was born on January 29, 1958, and was forty-eight (48) years old as of the onset date of her alleged disability and fifty (50) as of the date of the ALJ’s decision. (Tr. 37, 100). Claimant was therefore considered a “younger person,” under the age of 50 and, generally, whose age will not seriously affect the ability to adjust to other work, under the Commissioner’s regulations at the time of her onset date. 20 C.F.R. §§ 404.1563(c), 416.963(c) (2009). Claimant was considered a “person closely approaching advanced age,” age 50-54, at the time of the ALJ’s decision. 20 C.F.R. §§ 404.1563(d). Claimant completed the seventh grade, received her GED in 1991, and received a nursing certificate. (Tr. 38-39). Claimant has previous work experience as a cashier at Convenient Food Mart and CNA for an in-home nursing agency. (Tr. 40-45).
B. Medical History
The following medical history is relevant to the issue of whether substantial evidence supports the ALJ’s determination that Claimant’s subjective complaints were not entirely credible:
Psychiatric Review Technique, Frank Roman, Ed.D., 11/18/05 (Tr. 218-24)
• medical dispositions: impairment(s) not severe
• categories upon which medical disposition is based:
• 12.03 schizophrenic, paranoid and other psychotic disorders
• delusions or hallucinations
• 12.04 affective disorders
• rating of functional limitations
• restriction of daily activities: mild
• difficulties in maintaining social functioning: mild
• difficulties in maintaining concentration, persistence, or pace: mild
• episodes of decompensation, each of extended duration: none
• notes:
• mental status exam: adequately oriented; depressed with sad demeanor and flat affect; at times showed some mild confusion; no paranoid ideations; at times showed an indifferent attitude; no perceptual deficits; fair insight; severely impaired judgment; mildly deficient concentration
• memory: moderately deficient immediate memory; severely impaired recent memory
• Dx: Axis I 295.30 schizophrenia, paranoid type; 296.5 bipolar disorder, most recent episode depressed
Physical Residual Functional Capacity Assessment, Cindy Osborne, DO, 8/8/06 (Tr. 298-305)
• primary diagnosis: tendonitis left shoulder
• secondary diagnosis: vision impairment
• exertional limitations
• occasionally lift: 50 pounds
• frequently lift: 25 pounds
• stand and/or walk (with normal breaks) for a total of: about 6 hours in 8-hour workday
• sit (with normal breaks) for a total of: about 6 hours in an 8-hour workday
• push and/or pull (including operation of hand and/or foot controls): unlimited
• postural limitations: none
• manipulative limitations: none
• visual limitations: none
• communicative limitations: none
• environmental limitations: none
• symptoms: complaints are out of proportion to expected and therefore partially credible; decrease RFC to medium
Physical Residual Functional Capacity Assessment, Fulvio Franyutti, M.D., 4/3/07 (Tr. 422-29)
• primary diagnosis: tendonitis of left shoulder
• secondary diagnosis: vision impairment
• external limitations:
• occasionally lift: 50 pounds
• frequently lift: 25 pounds
• stand and/or walk (with normal breaks) for a total of about 6 hours in an 8-hour workday
• sit (with normal breaks) for a total of about 6 hours in an 8-hour workday
• push and/or pull (including operation of hand and/or foot controls): unlimited
• postural limitations: none
• manipulative limitations: none
• visual limitations: none
• communicative limitations: none
® environmental limitations: none
• symptoms: claimant appears to be partially credible
Vocational Analysis, Laurel Klein, 4/3/07 (Tr. 166)
reviewed vocational analysis in file dated 8/16/07 and agrees with it
Progress Notes, Goodwin Foot and Ankle Center, OVMC, 9/24/04-10/13/05 (Tr. 208-17)
• EMG Report 9/24/04
• results: nerve conduction velocities of peroneal and posterior tibial nerves bilaterally were unremarkable; amplitudes were normal. Distal motor latencies of peroneal and posterior tibial nerves bilaterally were unremarkable; amplitudes were normal. Distal sensory latencies for sural nerves bilaterally were normal; amplitudes were normal. F waves bilaterally of peroneal and posterior tibial nerves were normal. H reflexes for posterior tibial nerves bilaterally were normal.
• impression: abnormal nerve conduction velocities suggestive of neuropathy effecting both right and left lateral plantars. No radiculopathy detected.
• 11/4/04
• exam: mild to moderate incurvation of medial and lateral margins of left hallux nail. Extreme pain with palpation of these areas. Large amount of subungual debris and callus in medial and lateral nail margins, increased on medial side. Mild erythema, mild soft tissue swelling, negative drainage and negative break in skin. Nails are thick and irregular discolored and mycotic.
• assessment: DM non-insulin dependent. Ingrown nail medial and lateral margins of left hallux nail; painful ambulation left foot. Paronychia of medial and lateral margins of left hallux nail with increase on medial side
• 5/26/05
• exam: pain in left hallux; mild soft tissue swelling and mild erythema; negative drainage.
• assessment: diabetes mellitus non-insulin dependent; gout of the 1st IPJ left foot; painful ambulation
• 6/9/05
• exam: left MPJ has improved; small possible ganglion of extensor tendon. Mild pain of the dorsal right hallux.
• assessment: diabetes mellitus non-insulin dependent. Gout of 1st IPJ left foot. Onychomycosis bilateral. Painful ambulation
• 7/14/05
• exam: left MPJ is improved
• assessment: diabetes mellitus non-insulin dependent. Gout of 1st IPJ left foot. Painful ambulation
• 8/11/05
• exam: mild onycholysis
• assessment: diabetes mellitus non-insulin dependent. Onycholysis left hallux. Onychomycosis bilateral. Onychogryphosis bilateral. Painful ambulation.
• 9/16/05
• plan: begin insulin therapy
• 10/13/05
• exam: mild spicule formation in left hallux nail
• assessment: diabetes mellitus non-insulin dependent. Onychomycosis bi-
lateral; onychogryphosis bilateral. Painful ambulation.
Internal Medicine Examination, Kathleen Monderewicz, M.D., 9/5/05 (Tr. 192-97)
• chief complaint: neck and back pain
• physical exam:
• neck: no evidence of thyromegaly, palpable masses or lymphadenopathy. Carotid arteries are normal and symmetrical bilaterally without bruits
• hands: no tenderness, redness, warmth, or swelling; no atrophy; claimant can make a fist; no Heberden or Bouchard nodes; grip strength measures 27 kg of force on right and 20 kg on left; able to write and pick up coins without difficulty; normal range of motion
• cervical spine: tenderness over muscle inserts of occiput and cervical spinous process at C7; no evidence of paravertebral muscle tenderness or spasm; flexion is normal; extension is slightly decreased; lateral flexion is normal; rotation is normal to right and limited to left
• dorsolumbar spine: normal curvature; no tenderness over thoracic or lumbar spinous processes or over facette joint lines; tenderness over medial areas of upper trapezius muscles; straight leg raise test in sitting and supine position is normal; forward flexion is normal; no hip joint tenderness, erythema, warmth, swelling, or crepitus; normal extension, abduction, and adduction of hips
• impression: chronic neck and back pain
• summary: neck tender around occiput and C7 with only slight decrease in extension and decrease in rotation to the left. Deep tendon reflexes and sensation were normal and symmetric; Tinel and Phalen testing negative; fine manipulation was intact. Only areas of tenderness in back were over trapezius muscles; straight leg test negative for radiculopathy; deep tendon reflexes and sensation were normal and symmetric; only evidence of possible nerve root impingement was weakness with left ankle plantar flextion. Only slight decrease with lateral flexion bilaterally.
Emergency Room Records, Ohio Valley Medical Center, 7/16/05-2/10/06 (Tr. 225-43)
• 12/5/05
• chief complaint: gout
• clinical impression: pain, left first toe, suspect gout
• disposition: prescription for Indocin and Darvocet
• 12/29/05
• chief complaint: left great toe distally
• hospital course: do not feel this is gout. See podiatrist since she is diabetic. Given prescription for Tramadol
• final diagnosis: left great toe pain; probably ingrown nail; diabetes, on insulin
• 2/10/06
• chief complaint: chest pain
• diagnosis: chest pain and MVA
• disposition: AMA
• condition: satisfactory
Radiology and Lab Reports, Ohio Valley Medical Center 7/16/05-5/17/06 (Tr. 261-76)
• M/06 Mammography Unilateral Right
• no pathological calcifications, skin thickening or spiculated masses
• impression: stable moderate fibrocystic changes; Bi-rads 3 probably benign findings
X-ray Report, Eli Rubenstein, M.D., 8117105 (Tr. 198)
• lumbar spine
• impression: normal lumbar spine
Emergency Department Records, Wheeling Hospital, 2/10/06 (Tr. 244-60)
• chief complaint: back, neck, and chest pain
• seem at OVMC for same complaint— discomfort started 2/9/06 at night. Unable to sleep due to pain in left shoulder and arm.
• impression: thoracic vertebrae are of normal height and alignment; some mild scoliosis present; no fracture or malalignment
• impression: cervical vertebrae are of normal height and alignment; well corticated bony density adjacent to anterior aspect of inferior endplate of C6, which appears to be a chronic osteophyte. No fracture or malalignment seen
• overall assessment: normal
• findings/change: heart size is normal; lungs are clear
• discharge instructions: continue current medications
Medical Reports, Roland Chalifoux, Jr., DO, Valley Neurosurgery, 2/23/06-11/7/06 (Tr. 306-39)
• 2/23/06
• physical exam:
• neck: soft and supple with decreased range of motion, particularly with rotation. Multiple paracervical spasm
• musculoskeletal:
• cervical: left and right rotation 60 degrees bilaterally; lateral bending 40 degrees bilaterally; flexion 60 degrees; extension 50 degrees
• shoulder: normal range of motion in both left and right arms
• thoracic: rotation 20 degrees bilaterally; kyphosis 20 degrees
• lumbar: intact; left and right lateral flexion 20 degrees; flexion 40 degrees; extension 20 degrees
• impression: progressive neck discomfort due to cervical sprain/strain with need for further evaluation and treatment
• recommendations: medication; trigger point injections; occipital blocks
• 3/2/06
• impression: progressive occipital pain with occipital cephalgia and trigger point pain with need for further evaluation
• recommendations: trigger point injections; occipital blocks bilaterally
• 3/8/06
• impression: progressive occipital pain with occipital cephalgia and trigger point pain bilaterally, left worse than right
• recommendations: continue current medications; continue chiropractic treatments
• 3/15/06 Procedure Report
• preoperative and postoperative diagnosis: flexion injury to cervical region with secondary multiple trigger points in and around cervieothoracic junction
• procedure: trigger point injections x6, 2 to 3 muscles in and around trapezial regions bilaterally involving the levator scapulae, trapezius, and rhomboid major.
• U/5/06
• preoperative and postoperative diagnosis: secondary injury to cervical spine with cervical sprain/strain as well as pain to left upper shoulder region
• procedures: trigger point injection x3 involving 2 to 3 muscles in cervical spine, trapexius, levator scapulae, and rhomboid muscles; injection of shoulder bursa in and around suprascapular muscle
• 5/3/06
• neck: carotids are intact; trigger point pain in suprascapular and trapezial area
• impressions: secondary pain to cervical, lumbar, and shoulder with cervical and shoulder giving her most problems; progressive neck discomfort with decreased range of motion; trigger points in suprascapular and trapezial area
• 7/U/06
• impressions: secondary pain to cervical and shoulder areas; progressive neck pain; decreased range of motion secondary to herniated disk at C4-C5, C5-C6 per MRI; left shoulder pain secondary to tendinitis; multiple trigger points in left area
• procedure: insert ESI cervical spine
• preoperative/postoperative diagnosis: left arm pain secondary to supraspinatus tendinitis
• 8/3/06
• preoperative/postoperative diagnosis: progressive neck pain secondary to herniated disk at C4-C5, C5-C6
• procedures: use of C-arm for identification of proper location for epidural injection; interlaminar epidural steroid injection at C4-C5
• 8/9/06
• assessment: status post MVA with secondary pain in cervical and shoulder area on the left; decreased range of motion secondary to centralized disk at C4-C5, C5-C6
• recommendations: needs physical therapy, has no followed up with this; trigger point of cervical area
• procedure: injection of Kenalog to multiple triggers involving 2-3 muscles in Cervical spine
• 8/23/06
• impressions: status post MVA with secondary pain in cervical and shoulder area; decreased range of motion secondary to centralized disk at C4-C5, C5-C6 which has been only marginally responsive to ESIs
• recommendations: facet injections; multiple trigger point and spasm due to postural issues in cervical spine and shoulder area; supraspinatus tendinitis in left shoulder
• 10/16/06
• impression: status post MVA with secondary pain in cervical and shoulder area on left; decreased range of motion secondary to centralized disk at C4-C5, C5-C6 as well as continued neck pain with range of motion
• marginal improvement with ESIs with recommendation for mechanical treatment since she has no focal or lateralizing issues
• recommendations: facet injections needed without corticosteroids; orthopedic evaluation for left arm shoulder area
• 10/31/06
• preoperative/postoperative diagnosis: status post motor vehicle accident with secondary neck pain, secondary to facet pain and dysfunction
• procedure: left sided facet injections of C4-C5, C5-C6, C6-C7 using C-arm fluroscopic guidance; injection of Kenalog
• 11/7/06
• impression: status post MVA with secondary pain in cervical and shoulder area on left; decreased range of motion secondary to combination of centralized disk at C4-C5, C5-C6 as well as facet discomfort
• MRI Report 5/25/06
• findings: straightening of cervical lordotic cervature; cervical vertebrae and cervical spinal cord are normal
• impression: disc herniation centrally at C4-5 and C5-6
• MRI Report 5/25106
• findings: supraspinatus tendon is intact with mild tendinopathy; remaining tendons of rotator cuff are normal in signal and morphology
• impression: supraspinatus tendinopathy
Progress Notes, William Grubbs, D.C., 3/22/06-1/3/07 (Tr. 345-73)
• 3/22/06
• primary symptoms: neck pain; left arm pain, numbness, and tingling; upper back pain that comes and goes
• recommend continued therapy to consist of moist heat, EMS, US, MM, and manipulation
• 3/24/06
• subjective: therapy was of some benefit; felt a little looser
• objective: posterior cervical muscles were taut; tender at base of occiput; trigger points in upper trap
• 3/27/06
• subjective: improving; heat helps
• objective: tautness and tenderness in posterior cervical area; latent trigger points in upper trap and levator scapulaa
• 3/29/06
• subjective: doing better, little less neck and back pain
• objective: base of occiput is tender; latent trigger points in upper trap, levator scapula bilaterally
• 3/31/06
• subjective: improving but still sore in neck and upper back
• objective: posterior cervical muscles are taut; base of occiput is tender; latent trigger points in levator scapula and upper trap bilaterally
• 4/3/06
• significant neck and upper back pain; quit job on the 24th. Posterior cervical muscles are taut; latent trigger points in upper trap and levator scapula bilaterally
• 4/7/06
• posterior cervical muscles are taut; latent trigger in upper trapezius and levator scapula
• 4/10/06
• neck and upper back pain, but doing better overall. Posterior cervical muscles are taut; latent trigger points in upper trap and levator scapula bilaterally
• 4/12/06
• feeling better not as much neck and upper back pain. Less tautness and tenderness
• 4/19/06
• more neck and upper back pain; notices difference without treatment. Posterior cervical muscles and base of occiput are very taut. Trigger points in upper trapezius bilaterally
• 4/21/06
• improving; not as much neck pain. Posterior cervical muscles are taut; no active trigger points
• 4/24/06
• feels staffer; active trigger points in upper traps and levator scapula
• 4/26/06
• neck and upper back pain; is improving. No active trigger points just tenderness
• 4/28/06
• improving. Latent trigger points in upper trap. Nothing active; base of occiput is tender
• 5/8/06
• neck and upper back pain; posterior cervical muscles are taut. Base of occiput is tender. Active trigger points in upper trap and levator scapula bilaterally.
• 5/10/06
• overall feeling better; less tenderness and tautness; latent trigger points in upper trapezius and levator scapula
• 5/26/05
• more neck and upper back pain. Posterior cervical muscles are taut; base of occiput is tender; active trigger points in upper trapezius and levator scapula bilaterally.
• 6/2/06
• doing better; not as much pain; spasm in lower thoracic area on left with latent trigger points in upper trapezius
• 6/7/06
• feeling better; posterior cervical muscles remain taut; latent trigger points in upper trap
• 6/9/06
• doing better; doesn’t have as much tautness or tenderness
• 6/12/06
• not as much tautness or tenderness; tenderness at base of occiput; latent trigger points in upper trap
• 6/19/06
• neck feels tight and tense; base of occiput is tender; latent trigger points in upper trap
• 6/21/06
• doing better; less neck pain and stiffness; palpates better
• 6/23/06
• showing improvement; trigger points in upper traps bilaterally
• 7/5/06
• active trigger points in upper trapezius bilaterally; cervical range of motion restricted; shoulder depressor test positive on left
• 8/23/06
• cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in upper trapezius bilaterally; cervical spine mobilized in prone position with good movement
• 8/25/06
• showing improvement; posterior cervical muscles not as taut and tender. Latent trigger points in upper trapezius bilaterally
• 8/30/06
• showing improvement; latent trigger points in upper trapezius bilaterally; palpation revealed posterior cervical muscles taut and tender
• 9/6/06
• cervical range of motion restricted; shoulder depressor test positive bilaterally; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in upper trapezius bilaterally
• 9/11/06
• cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in upper trapezius
• 9/13/06
• condition showing improvement; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in left upper trapezius
• 9/15/06
• pain and stiffness in neck and upper back; palpation revealed posterior cervical muscles taut and tender; no active or latent TP’s
• 9/20/06
• neck and upper back pain; cervical range of motion was restricted; palpation revealed posterior cervical muscles were taut and tender; trigger points were found in upper trapezius bilaterally
• 9/22/06
• showing improvement; best felt in some time; palpation revealed posterior cervical muscles were taut and tender. Shoulder depressor test positive on left
• 9/25/06
• best weekend had in months; palpation revealed posterior cervical muscles taut and tender; no TP’s
• 9/27/06
• continued improvement; cervical range of motion restricted; palpation revealed posterior cervical muscles were taut and tender
• 10/2/06
• neck and upper back pain; pain getting less with regular tx; palpation revealed posterior cervical muscles were taut and tender; latent trigger points found in upper trapezius bilaterally
• lO/k/06
• showing improvement; less pain; palpation revealed posterior cervical muscles taut and tender; cervical distraction test negative; foramina compression test negative; shoulder depressor test positive on left; no TP’s
• 10/9/06
• neck and upper back pain; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in upper trapezius bilaterally
• 10/18/06
• showing improvement; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in left upper trapezius
• 10/16/06
• neck and upper back pain; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in upper trapezius bilaterally
• 10/20/06
• neck and upper back pain; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in upper trapezius bilaterally and left levator scapula; C3 to T-4 spinouses are tender
• 10/27/06
• neck and upper back pain; palpation revealed posterior cervical muscles taut and tender; shoulder depressor test positive on left; trigger points found in upper trapezius bilaterally, left levator scapula, and left rhomboid major
• 11/8/06
• neck and upper back pain; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in upper trapezius bilaterally, left levator scapula, and left rhomboid major; shoulder depressor test positive on left
• 11/8/06
• showing improvement; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in left upper trapezius
• 11/10/06
• feeling better; less neck pain and stiffness; palpation revealed posterior cervical muscles were not as taut and tender; trigger points found in upper trapezius; shoulder depressor test was negative
• 11/18/06
• feeling better; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in left upper trapezius
• 11/17/06
• improving; cervical range of motion restricted; palpation revealed posteri- or cervical muscles taut and tender; latent trigger points found in left upper trapezius
• 11/22/06
• neck and upper back pain and headaches; tautness and tenderness of posterior cervical area with an active trigger point in left upper trapezius and left levator scapula
• 11/29/06
• neck and upper back pain; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left leator scapula; shoulder depressor test was positive on left
• 12/4./06
• neck and upper back pain; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius bilaterally and left levator scapula. Shoulder depressor test positive bilaterally
• 12/6/06
• showing improvement; less tenderness and better motion; cervical range of motion full with pain at extremes; cervical distraction test was negative; shoulder depressor test positive on left
• 12/11/06
• feels better; not as much pain or stiffness; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; shoulder depressor test positive on left
• 12/13/06
• showing improvement; less tenderness and better mobility; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in left upper trapezius
• 12/20/06
• neck and upper back pain; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius; shoulder depressor test positive bilaterally
• 12/22/06
• showing improvement; palpation revealed posterior cervical muscles taut and tender; no trigger points found
• 12/27/06
• neck and upper back pain; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in left upper trapezius; shoulder depressor test positive on left
• 12/29/06
• showing improvement; ROM better; less tautness and tenderness
• 1/3/07
• neck and upper back pain; pain worse on left; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in left upper trapezius and left scapula; shoulder depressor test positive on left
Physical Therapy Treatment Notes, OVMC, 6/22/06-6/29/06 (Tr. 283-89)
• 6/22/06
• referred for s/p MVA left shoulder pain, left biceps tendonitis, and neck pain.
• problem list: decreased ROM, pain, decreased strength
• goals: ROM WNL’s; pain less than or equal to 2/10; 4+/5 Rue strength
• prognosis: fair prognosis for improved functional abilities provided she is compliant with treatment.
• 6/26/06
• subjective: decreased pain since last Rx
• objective: aquatics; Rx completed with Ionto/Ice to left LH biceps tendon and MH/IFES to bilateral Cpsm’s and UT
• assessment: Pt tol TX well
• 6/27/06
• subjective: no new complaints
• objective: continue with MH/IFES to bilateral C-psm’s and Ionto/Ice to left LH biceps tendon
• assessment: Pt tol Rx well
Emergency Treatment Records, Wheeling Hospital, 7/5/06 (Tr. 290-97)
• chief complaint: left great toe
• diagnosis: contusion left great toe
Medical Records, Marilyn Horacek, D.O., 8/21/06-1/3/07 (Tr. 374-84)
• 8/21/06
• chief complaint: numbness on right side; illegible
• exam: head/neck — illegible; mood/affect: angry and fearful at times
• assessment/plan: chronic severe neck pain; illegible
• 10/2/06
• chief complaint: neck pain
• assessment/plan: illegible; chronic neck pain
• 1/3/07
® no specific complaints today
• neck exam: supple without organomegaly, mass or lymphadenopathy
• musculoskeletal: spine without tenderness, curvature or back spasm
® neurologic: patient is A & 0 and in no acute distress; answers questions appropriately
• assessment: diabetes mellitus; early abscess to right hand; rhinitis
• plan: given Keflex
Treatment Records, Mark Rodosky, M.D., UPMC Center for Sports Medicine, 11/20/06 (Tr. 341-43)
• chief complaint: left shoulder pain
• assessment: impingement left shoulder
• plan: left shoulder arthroscopy with arthroscopic subacrominal decompression with possible repair
Medical Records, Marilyn Horacek, D.O., 1/16/07-7/7/08 (Tr. 540-615)
• 1/16/07 stress test report
• conclusions: non-diagnostic EKG portion of the stress test because of preexisting changes; no chest pain; mildly hypertensive blood pressure response with mild hypertension at baseline; no complex ventricular ectopy
• 1/16/07 myocardial perfusion imaging report
• conclusions: normal myocardial perfusion study with no evidence of ischemia or prior infarction; normal left ventricular volumes, wall motion and wall thickening and ejection fraction; LV volume curve consistent with normal systolic and diastolic function
• 3/10/07 radiology report
• chest impression: no acute or active process
• cervical spine impression: negative cervical spine
• left shoulder impression: negative left shoulder
® dorsal spine impression: no definite evidence of an acute fracture
• 8/30/07 radiology report
® chest impression: no acute pulmonary process; normal heart size
• 5/16/07 MRI of cervical spine
• impression: small posterior central disc herniations at C4/C5 and C5/C6 without interval change since study of 5/25/06
7/9/07 EMG report
• clinical impression: could have bilateral carpal tunnel syndrome vs. diabetic polyneuropathy effecting both median and ulnar nerves in upper extremities. Chronic process most likely in C5 nerve root distribution
8/30/07 Operative Report
• preoperative and postoperative diagnosis: left shoulder chronic full-thickness rotator cuff tear; left shoulder subacromial impingement; left shoulder frozen shoulder
3/25/08 radiology report
• impression: significant decrease in size of joint space and edema within the rotator cuff; small partial tear involving the articular surface of supraspinatus; labrum is intact
5/2/08 radiology consultation
• impression: no evidence of nephrolithiasis or hydronephrosis; multiple pelvic calcifications; no other abnormalities
1/22/07
• assessment/plan: left rotator cuff injury; diabetes mellitus; hypertension; chronic pain
3/12/07
• extremities: left shoulder — no deformity appreciated
• neck: some posterior cervical spasm
• assessment: chronic left shoulder and left neck pain; diabetes mellitus
3/28/07
• extremities: no edema
5/U/07
• chief complaint: left shoulder pain; illegible
• exam: left shoulder — no deformity appreciated
• assessment: left shoulder pain; prescribed vicodin; MRI; illegible
8/6/07
• chief complaint: elevated blood sugar
• assessment: left shoulder pain; rota-tor cuff; completed pre-op at UPMC; illegible
• 11/5/07
• chief complaint: illegible
• assessment: left shoulder pain; illegible
• l/i/08
• chief complaint: spasms in shoulders and arms
• assessment: left shoulder pain — refill Vicodin
• 3/10/08
• chief complaint: still having shoulder pain
• assessment: DM Type II, chronic left shoulder pain — vicodin
• Ip/7/08
• chief complaint: still having shoulder pain; constant pain
• assessment: left shoulder adhesive illegible; depression — stable; DM Type II insulin dependent
• lp/29/08
• chief complaint: left shoulder pain
• assessment: left shoulder adhesive capsulitis; small supraspinatus tear; possible infection left shoulder area; DM Type II
• 5/13/08
• chief complaint: left shoulder pain feels better
• assessment: left shoulder adhesive capsulitis; small supraspinatus tear; DM Type II; illegible
• 6/19/08
• chief complaint: clearance for surgery; rotator cuff repair
• assessment: left shoulder adhesive capsulitis; left shoulder supraspinatus tear; DM; illegible
• 7/7/08
• assessment: left shoulder pain illegible; DM type II illegible; illegible
Progress Notes, William Grubbs, D.C., 1/24/07-8129107 (Tr. 515-24)
• l/2tí07: neck, upper back, left shoulder pain and stiffness; cervical range of motion and shoulder motion restricted; trigger points in left upper trapezius, left levator scapula, and left rhomboid major; shoulder depressor test positive bilaterally
• 1/29/07: neck and upper back pain; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula; shoulder depressor test positive on the left
• 1/81/07: patient reported feeling better; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in left upper trapezius and left levator scapula; shoulder depressor test positive on left
• 2/28/07: better movement in left shoulder; neck and upper back pain; cervical range of motion restricted; shoulder motion full with pain on left; weakness on left bicep, triceps and deltoid; tinel’s sign negative; Cozen’s test negative; palpation revealed posterior cervical muscles taut and tender; trigger points found in upper trapezius bilaterally; foramina compression test positive; cervical distraction test negative
• 2/26/07: feeling better; cervical range of motion restricted; shoulder depressor test positive on left; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius
• 3/9/07: showing improvement; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in left upper trapezius and left levator scapula
• 3/H./07: foramina compression test positive for increased neck pain; shoulder depressor test positive bilaterally; palpation revealed posterior cervical muscles taut and tender; trigger points found in upper trapezius bilaterally, left levator scapula, and left rhomboid major; left shoulder motion restricted; left drop arm test negative; left deltoid quite tender; lumbar range of motion full and uneventful; gait normal
• 3/21/07: limited movement in left shoulder; restricted cervical range of motion; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in left upper trapezius and left levator scapula
• 3/23/07: little improvement; not quite as tender; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in upper trapezius bilaterally and left levator scapula
• 3/26/07: showing improvement; less pain and tightness
• tí‘2/07: neck, upper back, and left shoulder pain; cervical range of motion and shoulder motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• títí07: showing improvement; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in left levator scapula
• tí 11/07: neck, left shoulder and upper back pain; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula; left shoulder ROM is restricted
• tí 18/07: showing improvement; palpation revealed posterior cervical muscles taut and tender; latent trigger points found in left upper trapezius and left levator scapula
• 4/25/07: cervical range of motion and shoulder motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 4/80/07: cervical range of motion and shoulder motion restricted; trigger points found in left upper trapezius and left levator scapula
• 5/4/07: showing improvement; cervical range of motion and shoulder motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius
• 5/9/07: condition regressed; cervical bilateral shoulder range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula; shoulder depressor test positive on left; foramina compression test positive for increased neck pain
• 5/14/07: tenderness in upper trapezius area
• 5/21/07: cervical range of motion and shoulder motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 5/25/07: cervical range of motion and shoulder motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius; shoulder depressor test positive on left
• 5/30/07: palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 6/1/07: cervical range of motion and shoulder motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 6/4/07: cervical and shoulder ROM restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 6/13/07: cervical range of motion and shoulder motion restricted; trigger points found in left upper trapezius and left levator scapula
• 6/18/07: cervical range of motion and shoulder motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius
• 6/22/07: palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 6/25/07: cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 6/29/07: condition regressed; cervical range of motion and shoulder motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 7/6/07: palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 7/9/07: not doing well; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 7/13/07: showing some improvement; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius
• 7/18/07: cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 7/20/07: latent trigger points in left upper trapezius and levator scapula; posterior cervical muscles are taut and tender
• 7/25/07: cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 7/30/07: condition regressed; cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius
• 8/1/07: cervical range of motion and shoulder motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius
• 8/3/07: cervical range of motion and shoulder motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 8/8/07: not as much pain or tautness or tenderness
• 8/13/07: cervical range of motion and shoulder motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula; shoulder depressor test positive on left; foramina compression test positive for increased neck pain; cervical distraction test negative
• 8/17/07: cervical range of motion and shoulder motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula; shoulder depressor test positive on left
• 8/20/07: cervical range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 8/24/07: cervical and shoulder range of motion restricted; palpation revealed posterior cervical muscles taut and tender; trigger points found in left upper trapezius and left levator scapula
• 8/29/07: palpation was a little looser; not as taut or tender
Outpatient Medical Records, Wheeling Hospital 2/6/07-2/9/07 (Tr. 385-93)
• 2/6/07
• diagnosis: L shoulder manipulation and injection/ DOS 2/9/07
® 2/6/07
• procedure: left shoulder manipulation and injection
• 2/9/07 Outpatient Surgery/Procedure
• pre-op diagnosis: frozen left shoulder
• proposed surgery/procedure: man/ illegible left frozen shoulder
• 2/9/07 Operative Report
• preoperative and postoperative diagnosis: adhesive capsulitis left shoulder
• operation: manipulation, lysis of adhesions and injections left frozen shoulder
Office Notes, Zaleski Orthopedics, Inc., Wheeling Hospital, 2/9/07-3/20/07 (Tr. 421)
• 2/20/07
• internal/external rotation views of left shoulder reveal no bony disruption or other displacement. Normal glenohumeral relationship. Motion is markedly improved.
• 3/20/07
• motion is fairly well maintained subsequent to a manipulation; some limitation in internal rotation; reproducible tenderness in subacromial space; x-ray internal external rotation views reveal glenohumeral joint to be well preserved; no evidence of fracture; no significant tenderness over AC joint. Presumptive working diagnosis of left subacromial bursitis
Emergency Department Records, Wheeling Hospital, 2/10107 (Tr. 394-408)
• reason for visit: elevated blood sugar
• diagnosis: hyperglycemia
• medications & treatments: regular insulin
• discharge instructions: watch sugars; continue with usual amount of insulin
• impression: no acute infiltrates or change except for possible increase in heart size
Emergency Department Records, Wheeling Hospital, 2/27/07 (Tr. 409-15)
• reason for visit: muscle spasm in neck
• diagnosis: neck spasms
• discharge instructions: flexeril; hydrocodone bitartrate and acetaminophen
Emergency Department Records, OVMC, 3/10/07 (Tr. 417-19)
• chief complaint: motor vehicle accident
• assessment: multiple contusions, cervical strain, left shoulder contusion, status post motor vehicle collusion
• disposition: discharged home, given a prescription for Motrin, contusion instructions. Return for worsening symptoms or concerns
• condition at discharge: good
Office treatment Records, Roland Chalifouz, DO, 3/19/07-5/2/07 (Tr. 530-38)
• 3/19/07
• neck exam: soft with paracervical spasm on left primarily; able to shrug shoulder but with complaints of pain primarily in supraspinatus area
• neurologic: motor strength is 5/5; no drift; palpation of left shoulder reveals pain in suprascapular region and infrascapular region; biceps pain; decreased strength on left primarily secondary to pain
• impressions: acute rotational injury to left shoulder area; history of diabetes mellitus and need for good control; history of left shoulder pain with need for reevaluation
• recommendations: MRI
• k/9/07
• impression: secondary rotational injury to left shoulder area; history of diabetes with need for good control and significant sensitization to corticosteroids; history of left shoulder pain with need for follow up MRI study
• recommendations: continue with Vicodin and chiropractic manipulative treatment
• 5/2/07
• discharged from service; indicates patient doing well
• recommendations: one month’s supply of medication; follow up with primary physician
Office Treatment Records, Mary Haus, M.D., 5/21/07-7/2107 (Tr. 525-28)
• 5/21/07
• assessment: shoulder impingement; R/O adhesive capsulitis; R/O cuff tear
• plan: follow up after MRI
• 6/20/07
• assessment: rotator cuff tear
• plan: check EMG
• 7/2/07
• assessment: rotator cuff tear
• plan: EMG; injection
Radiology Report, Mary Haus, OVMC, 6/6/07 (Tr. 430-31)
• MRI left shoulder
• impression: full thickness supraspinatus tendon tear near attachment with no tendon retraction; edema within anteri- or rotator cuff interval as well as a small amount of fluid in subacromial-subdeltoid space. Lateral downsloping of acromion process; intact biceps-labral anchor complex; normal marrow signal
Medical Records, Mark Rodosky, M.D., 6/6/07-10/22/08 (Tr. 625-56)
• 6/6/07 MRI left shoulder
• impression: full thickness supraspinatus tendon tear near attachment with no tendon retraction; edema within anterior rotator cuff interval; small amount of fluid in subacromial-subdeltoid space; lateral downsloping of acromion process
• 7/23/07
• chief complaint: left shoulder pain
• assessment: left shoulder subacromial impingement, full-thickness rotator cuff tear, and adhesive capsulitis
• plan: recommend left shoulder arthroscopy with arthroscopic subacromial decompression, arthroscopic rotator cuff repair, capsular release, manipulation, and possible other repair
• 8/30/07 operative record
• preoperative and postoperative diagnosis: left shoulder chronic full-thickness rotator cuff tear; left shoulder subacromial impingement; left shoulder frozen shoulder
• 9/7/07 post op
• objective: left shoulder is supple and neurovascularly intact
• assessment: doing well; begin passive range of motion
• 11/12/07 follow up
• objective: external rotation is to neutral, forward flexion is to 80 degrees, internal rotation is to just past greater trochanter of hip; no bruising or ecchymosis; no significant tenderness; pain with range of motion
• assessment: physical therapy
• 1/11/08 office note
• chief complaint: doing well in terms of pain, but is still stiff
• approximately 100 degrees of elevation and 20 degrees of external rotation
• 3/17/08 office note
• objective: still stiff
• assessment: MRI arthrogram to look at rotator cuff
• 6/16/08 diagnostic report text
• MRI upper extremity arthrogram
• impression: significant decrease in size of joint space and edema within rotator cuff interval are findings suggestive of adhesive capsulitis; small partial tear involving articular surface of supraspinatus; bursal surface of rotator cuff is intact; supraspinatus is decreased in muscle bulk; labrum is intact
• 6/16/08 office note
• objective: recurrent rotator cuff tear; full thickness or at least 50%
• assessment: recommend right shoulder revision arthroscopic rotator cuff repair, capsular release, manipulation, possible repair of other tissue
• 10/11/08 operative report
• preoperative diagnoses: recurrent chronic full-thickness rotator cuff tear, left shoulder; recurrent subacromial impingement, left shoulder; recurrent frozen shoulder left shoulder; left shoulder type I slap lesion
• 10/22/08 office note
• objective: wounds are healing without sign of infection
• assessment: back to therapy
Office Notes, Zaleski Orthopedics, Inc., Wheeling Hospital, 6/21/07 (Tr. 617)
• continued pain, weakness, dysfunction, and disruption in night sleep
• full thickness rotator cuff tear exists as well as a downward sloping acromium that probably predisposes to such pathology
• recommendation: repair left rotator cuff
Medical Evidence of Record, Northwood Health Systems 7125/07-5/21/08 (Tr. 472-513)
• 7/25/07
• presenting problems: stress; suspicious; appears angry; crying
• presenting problem codes: 17 mental illness; 25 relationship problems; 21 physical health problems
• current mental status: oriented x4; speech within normal limits; disheveled appearance; thought content within normal limits; withdrawn; memory mildly impaired
• diagnostic impressions:
• primary axis I: major depression, recurrent, with psychosis
• secondary axis I: cocaine dependence
• axis IV: social environment
• treatment domains: psychiatric symptoms; psychological distress; physical health
• 7/26/07
• problems: anxiety, medical problems
• assessment:
• appearance: unremarkable
• grooming: unremarkable
• speech: normal
• suicidal ideation: denied
• violent ideation: denied
• mood: normal
• affect: unknown
• outcome: attend therapy
• 8/13/07
• mental status: grooming and attire is organized and casual; defensive and withdrawn; speech is normal; eye contact is fleeting; alert x4 with some indications of cognitive slowing at times; no suicidal or homicidal thoughts; no evidence of any psychotic thinking
• assessment:
• axis I: major depressive disorder, severe, recurrent with psychosis; cocaine abuse in remission; consider alcohol abuse
• axis III: left shoulder pain, diabetes, hypertension, hypercholesterolemia
• axis IV: difficulties with medical concerns
• plan: antidepressants
• 9/18/07
• problems: depressed mood
• assessment:
• appearance: unremarkable
• grooming: unremarkable
• speech: slow
• suicidal ideation: denied
• violent ideation: denied
• mood: depressed
• affect: normal
• outcomes: therapeutic interventions
• 10/1/07
• assessment: depressive disorder with exacerbating symptoms
• plan: start Zoloft
• 10/30/07
• problem: anxiety
• assessment:
• appearance: unremarkable
• grooming: unremarkable
• speech: normal
• suicidal ideation: denied
• violent ideation: denied
• mood: anxious
• affect: normal
• outcome: coping strategies
• 11/1/07
• assessment: symptoms improving with medication
• plan: continue current medications
• 12/11/07
• assessment: symptomatic with depression and insomnia
• plan: increase Zoloft and Restoril
• assessment:
• appearance: unremarkable
• grooming: unremarkable
• speech: normal
• suicidal ideation: denied
• violent ideation: denied
• mood: depressed
• affect: normal
• 1/16/08
• content: depressed; anxious; irritable; not sleeping
• objective: cooperative; appearance is unremarkable; motor activity is slowed; speech soft; affect is blunted; oriented to person, place, and time
• assessment: non-compliant with medication; depression
• 1/30/08
• content: no difficulties today; no reported problems with sleep or appetite; denies irritability or agitation; normal mood; client notices improvement in mood, irritability and agitation
• objective: cooperative; unremarkable appearance; activity level is normal; speech is normal; appears in good spirits; oriented to person, place and time
• assessment: making progress
• plan: no change; continue current medications
• 2/27/08
• content: no difficulties; no reported problems with sleep or appetite; energy level normal; normal mood; no problems with medications
• objective: cooperative; appears well groomed; activity level is normal; speech is normal; normal affect; oriented to person, place and time
• assessment: no acute symptoms today
• plan: continue current medications
• 3/26/08
• content: physical problems; feeling depressed because of health and inability to work; trouble sleeping
• objective: cooperative; appears well groomed; activity level is normal; speech is normal; affect is blunted; oriented to person, place and time
• assessment: having situational difficulties
• plan: continue medications; increase Restoril
• Ut'8/08
• problem: relationship problem
• assessment:
• appearance: unremarkable
• grooming: unremarkable
• speech: rapid
• suicidal ideation: denied
• violent ideation: denied
• mood: depressed
• affect: irritable
• outcome: therapeutic intervention-conflict resolution
• lp/22/08
• problems: anxiety
• assessment:
• appearance: unremarkable
• grooming: unremarkable
• speech: rapid
• suicidal ideation: denied
• violent ideation: denied
• mood: angry
• affect: irritable
• outcome: strategic therapeutic intervention: conflict resolution; therapeutic assignments: continue and follow through NHS services and treatment
Í/23/08
• content: no difficulties; sleeping well; energy level is normal; mood is normal; denies problems with medications
• objective: cooperative; unremarkable appearance; normal activity level; normal speech; normal affect; oriented to person, place and time; no psychosis
• assessment: making progress
• plan: continue current medications
b/29/08
• diagnosis:
• primary axis I: major depression, recurrent, with psychosis
• primary axis IV: social environment
• secondary axis I: cocaine dependence
• secondary axis V: current GAP
• assessments needed: periodic evaluation
• discharge plan/level of care change: reduction in symptoms to a level that doesn’t interfere with daily functioning
• summary/recommendations: history of substance abuse but denies any use or urges to use; recommend individual therapy to assist with development and utilization of coping mechanisms
5/21/08
• content: no difficulties; sleeping well; energy level is normal; normal mood; no problems with medications
• objective: cooperative; unremarkable appearance; normal activity level; normal speech; normal affect; oriented to person, place and time; no psychosis
• assessment: situational difficulties
• plan: no change; return in 4 weeks
Physical Therapy Proyress Notes, Jill Prezzia, PT, Mason Rehab 12/3/07-3/19/08 (Tr. 436-71)
• 12/3/07: patient is stiff today; continue with IFES to shoulder, therapeutic exercises for ROM
• 12/10/07: continue with IFES to shoulder and PROM in all planes of her shoulder
• 12/lk/07: continue with IFES and therapeutic strengthening per her flow sheet
• 12/19/07: continue with IFES to shoulder, PROM in all directions and therapeutic strengthening
• 12/2Jp/07: continue with IFES and therapeutic exercises for strengthening
• l/lp/08: continue with PROM for shoulder, all directions. Continue with strengthening and IFES to shoulder
• 1/7/08: continue with PROM for shoulder. Patient notes some increase in discomfort. Continue with IFES and therapeutic strengthening.
• 1/9/08: clicking in shoulder today. Completes therapeutic exercises and IFES to shoulder.
• 1/11/08: continue with PROM of shoulder in all directions and therapeutic strengthening along with IFES, patient is to see her physician in next several days.
• 1/18/08: patient is without new complaints today. Continued with IFES to left shoulder. Continued with PROM in supine in all directions for shoulder. Continued with strengthening to increase motion and active use of left shoulder along with increasing strength
• 1/23/08: continue with PROM of shoulder, IFES and therapeutic exercises in gym
• 1/28/08: patient doing fairly well. Continue with PROM for all directions of shoulder, IFES and therapeutic strengthening
• 1/30/08: continue with PROM for shoulder in all directions. Still very tight, wants to get up to approximately 120 degrees of flexion and approximately 110 degrees of abduction. ER has increased; still very tight along with her IR. Continue with strengthening and IFES to shoulder
• 2/4./08: patient states she’s doing fairly well. Continue with PROM in all directions of shoulder, continue with IFES and therapeutic strengthening
• 2/15/08: completed PROM today for all ranges of shoulder; continue IFES and therapeutic strengthening
• 2/18/08: continue with IFES to shoulder, PROM for all directions of shoulder and therapeutic strengthening
• 2/20/08: continue with IFES to shoulder, PROM and strengthening for left shoulder
• 2/25/08: continue with IFES to left shoulder along with PROM in all planes
• 3/5/08: continue with IFES to shoulder, PROM for flexion, abduction and rotations, and therapeutic strengthening
• 3/10/08: continue with PROM for shoulder, IFES to shoulder and therapeutic strengthening
• 3/12/08: continue with IFES to shoulder, PROM for flexion, abduction and rotation along with therapeutic exercises for strengthening
• 3/U/08: continue with IFES to shoulder, PROM and therapeutic exercises for strengthening
• 3/19/08: saw physician — therapy not helping. Discharged claimant from PT
Questionnaire, Marilyn Horacek, D.O., 7/7/08 (Tr. 619-23)
• psychological conditions: depression, anxiety, personality disorder
• incapable of performing low stress jobs
• can walk 1 block without resting
• can sit continuously for 30 minutes
• can stand continuously for 15 minutes
• can sit about 2 hours in 8-hour workday
• can stand/walk less than 2 hours in 8-hour workday
• can occasionally carry less than 10 pounds; can never carry more than 10 pounds
• patient has significant limitations in doing repetitive reaching, handling, fingering
C. Testimonial Evidence
Testimony was taken at the hearing held on March 21, 2007. The following portions of the testimony are relevant to the disposition of the case:
Q Okay, and your date of birth, according to the record, is January 29, 1958. Is that correct?
A Um-hum.
Q How old are you today?
A How old am I? Fifty.
Q Okay. How far did you go in school? A Eighth grade.
Q Did you complete the eighth grade? A No.
Q Okay, so you completed the seventh grade?
A Yeah.
Q And went to the eighth?
A Um-hum.
Q Have you, at any point, obtained a GED subsequent to your schooling?
A Yeah.
Q And when did you do that?
A In 19 — I think' — I believe 91.
Q Have you had any kind of vocational training, such as refrigeration, drafting, welding, anything like that, since getting your GED?
A Since getting my GED?
Q Or at any point.
A Well, I went to nursing for a Certified Nursing Assistant — ■
Q Okay.
A At Drat (Phonetic) School, which I didn’t — I wasn’t able to complete because of my health reasons.
Q Okay, when did you do that?
A That was back in, I believe in '86, I believe.
Q Okay, so you never got a certificate.
A Well, not from Drat School; then I went to Park High not long after that and got a- — my nursing certificate.
Q Okay, so you — do you still have a CNA then?
A No.
Q The work