Ciraulo v. Colvin

          MEMORANDUM AND ORDER REGARDING PLAINTIFF'S MOTION FOR JUDGMENT ON THE PLEADINGS AND DEFENDANT'S MOTION FOR ORDER AFFIRMING DECISION OF COMMISSIONER (DKT. NOS. 17 AND 22)

          MICHAEL A. PONSOR U.S. DISTRICT JUDGE

         I. INTRODUCTION

         Plaintiff Cynara Ciraulo has applied for Social Security Disability Insurance benefits (DIB) and Supplemental Security Income benefits, alleging disability due to various physical impairments dating from August 6, 2012. Her initial application and petition for reconsideration were denied. A hearing before Administrative Law Judge (ALJ) Kim Griswold took place on January 6, 2015. After considering all the evidence, a second ALJ, Addison Massengill, issued a decision dated June 26, 2015, concluding that Plaintiff was not disabled.^[1]Plaintiff seeks to have the unfavorable finding reversed and moves for judgment on the pleadings. In response, Defendant has moved to affirm the final decision of the Commissioner. For the reasons laid out below, Plaintiff's motion will be allowed and Defendant's denied.

         II. FACTUAL BACKGROUND

         At the time of her initial application, Plaintiff was a 27-year old female claiming disability due to chronic pain, hydronephrosis of the left kidney, an undiagnosed muscle condition, muscle spasm, and severe muscle tension. She has a high school education and a Bachelor of Science degree.

         Plaintiff has worked as a parking lot attendant, medical records clerk, and a camp counselor. Plaintiff lives mainly with her parents, but visits her husband in Kentucky every several months, where she stays for a month. All citations are to the Social Security Administration's Administrative Record of Social Security Proceedings (“A.R.”) (Dkt. No. 16).

         A. Medical Background

         Plaintiff has a complex medical history, including asthma, chronic pain, chronic laryngitis, bilateral kidney issues, and frequent visits to emergency rooms for primary care. (A.R. 418-525, 606-07.)

         In August 2011, Plaintiff underwent ureteropelvic junction surgery with pyeloplasty to remove a blockage in her left kidney. (A.R. 555, 584.) She subsequently had a right pyeloplasty in February 2012 and cystoscopy and bilateral retrograde pyelogram with stent placement in August 2012. (A.R. 555-56, 916-17.) In October and November 2012, Plaintiff underwent a thoracic epidural steroid injection in her left flank. (A.R. 557-59, 562-63.)

         In December 2012, Plaintiff presented to the Albany Medical Center Hospital emergency room complaining of flank pain for which she had had multiple interventions, including ureteral stent placement and nephrostomy tubes placed on the left side, without any significant reduction in pain. (A.R. 584.) An ultrasound revealed left mild-to-moderate hydronephrosis. (A.R. 584, 603.)

         In January 2013, Plaintiff visited Brian Banker, M.D., complaining of a sinus infection, difficulty breathing, and nausea. (A.R. 608.) Dr. Banker treated Plaintiff for acute bacterial sinusitis and refilled her Albuterol. (A.R. 609.) That same month, Plaintiff visited Spencer L. Haller, M.D., reporting urological concerns and back pain; Dr. Haller renewed her prescription for oxydocone. (A.R. 682-84.)

         In February 2013, Plaintiff continued to report back pain to Dr. Haller as well ongoing flank pain, swelling and pain in her fingers and neck, trouble sleeping, heartburn, and mild ankle swelling. (A.R. 680.) Dr. Haller ordered MRI testing of the spine and a bilateral renal ultrasound. (A.R. 682.) The MRI of the thoracic spine showed minimal discogenic degenerative changes with no focal signal abnormalities in the spinal cord or focal disc herniation or spinal cord compression at any level. (A.R. 611.) The MRI of the lumbar spine showed minimal bulging of the L5-S1 disc. (A.R. 612.) The renal ultrasound revealed “bilateral pelvocaliectasis left greater than right.” (A.R. 613.)

         In March 2013, Plaintiff visited the Mercy Medical Center emergency room complaining of flank pain occurring every few months. (A.R. 615.) Her physical examination was normal except for paraspinal muscle tenderness. (A.R. 616-17.) An x-ray was unremarkable. (A.R. 618.) The physician recommended Plaintiff take Dilaudid if her pain worsened. (Id.) The same month, Plaintiff presented to Jeffrey G. Mulhern, M.D. for further evaluation of her left flank pain and urological concerns. (A.R. 606-07.) Dr. Mulhern noted that Plaintiff reported constant pain, mainly on her left flank. (A.R. 607.) He noted that the physical examination was remarkable for blood pressure, which he reported as 128/75. He told Plaintiff he did not believe there was an active issue regarding kidney function and recommended Plaintiff speak to her urologist. (Id.)

         In May 2013, Plaintiff presented to the emergency room with complaints of left leg pain, numbness, hoarseness, muscle pain, and sleep problems. (A.R. 626.) On examination, Plaintiff had normal range of motion in her back and “sock like numbness and delayed hyperesthesia of [the] left lower leg and foot in a sock-like distribution.” (A.R. 628.) The differential diagnosis included chronic pain, conversion, fibromyalgia, and multiple sclerosis; she was discharged in stable condition. (Id.)

         That same month, Plaintiff reported to Dr. Haller that she was having “ascending pain that went up to her shoulder and now into her neck, and also started to go down her legs.” (A.R. 672.) Plaintiff's physical examination was normal except for diffuse tenderness to palpation in her back and extremities. (A.R. 673.) Dr. Haller said that Plaintiff's diffuse pain was of unclear etiology and recommended a neurological evaluation and brain and cervical spine MRIs. (A.R. 674.)

         At the end of August 2013, Plaintiff met with Dr. Haller. She was assessed with chronic back pain, dysuria, and central pain syndrome. (A.R. 666.)

         The next month, Plaintiff presented to Dr. Haller with complaints of chronic pain in her back, calves, thighs, head, neck, shoulders, and legs. She reported tingling, numbness, and muscle spasms in her legs, and tics in her legs and hands as well as elbow pain and pain in her left knee, hip, and ankle. (A.R. 660.) Her physical examination was normal except for mild back pain to palpation on the left straight-leg raise. Plaintiff's diagnoses included mild, intermittent asthma; chronic back pain; and ureteropelvic junction obstruction. Dr. Haller noted that “fibromyalgia has been questioned but I'm not certain given some of her neurologic symptoms.” (A.R. 663.)

         In October 2013, Plaintiff presented to Lahey Clinic Medical Center for a preoperative visit ahead of vocal cord surgery. She reported suffering from urological concerns, chronic pain, asthma, hay fever, gastroesophageal reflux, muscle pain and weakness, and swelling in her legs, more on the left than right. (A.R. 689.) Treatment notes stated that Plaintiff was being treated by “neurology who continue to follow her, considering fibromyalgia at this time.” (A.R. 689.) Plaintiff denied musculoskeletal concerns and said her asthma, hay fever, and gastrointestinal reflux were controlled with medication. (A.R. 691.) Plaintiff said she was able to climb two flights of stairs without symptoms. (A.R. 692.)

         That same month, Plaintiff was examined by neurologist Kinan Hreib, M.D. The exam was normal as to motor and sensory function. (A.R. 745.) He assessed “[p]ain without a neurological explanation . . . with a possible diagnosis of fibromyalgia.” (A.R. 730).

         In December 2013, Plaintiff told Dr. Haller that she had continued back pain and toe problems. (A.R. 1046.) Plaintiff's examination was essentially normal except for mild erythema (reddening of the skin) and swelling in her right toe. (A.R. 1048.)

         The same month, Plaintiff visited rheumatologist Matthew Axelrod, M.D. of the Lahey Clinic with complaints of a hoarse voice, sore throat, and radiating left flank pain. Dr. Axelrod noted that Plaintiff's “initial flank pain improved but she has been left with long standing flank and muscle pain on the left side.” He also noted that Plaintiff had been told she had fibromyalgia. (A.R. 1128.) On physical examination, Plaintiff had tenderness at the left greater trochanter (hip joint) with palpation as well as diffusely tender muscles but no weakness and full range of motion and motor strength. (A.R. 1129.) Dr. Axelrod assessed chronic pain and administered a Depo-Medrol and lidocaine injection in her left hip. (A.R. 1130.)

         Later that month, Plaintiff visited Dr. Hreib with reports of chronic pain and involuntary movements in her hands. Plaintiff said Gabapentin had “reduced the pain by 75%.” (A.R. 1122.) On examination, Dr. Hreib noted that Plaintiff had no tremors, myoclonus (muscle contractions), or focal weakness; her gait was normal. The doctor did not observe any involuntary movements. (A.R. 1124.)

         In February 2014, Plaintiff visited Priya Shastri, M.D., a Lahey Clinic neurologist, with complaints of involuntary motor movements for the past eight to nine months. Plaintiff said although Gabapentin helped with the pain, it did not with the movements. (A.R. 1102.) Plaintiff's musculoskeletal and neurological examinations were normal. (A.R. 1103.) Dr. Shastri made similar findings in May 2014 and July 2014. (A.R. 1079, 1088-89.)

         A physical examination conducted by Dr. Axelrod on March 7, 2014, showed muscle tenderness but no weakness or limitations in range of motion. (A.R. 1100.) Dr. Axelrod assessed swelling in the larynx, diffuse pain, and “symptoms that sound like inflammatory back pain.” (A.R. 1101.) Dr. Axelrod administered an injection of Depo-Medrol and lidocaine. (Id.)

         Plaintiff underwent an x-ray and an MRI of the pelvic joints in March 2014. The x-ray revealed no acute bone or joint abnormality, while the MRI demonstrated mild bilateral sacroiliitis. (A.R. 1097, 1098.) That same month, Plaintiff reported continued problems with hoarse voice and back pain. (A.R. 1099.) On April 15, 2014, Dr. Axelrod noted that the MRI had shown bilateral sacroiliitis and spondyloarthropathy, and stated that he felt this was “likely anky[l]osing spondylitis.”^[2] (A.R. 1094.) Follow-up visits on July 8, and October 15, 2014, showed the same symptoms. (A.R. 1076, 1082, 1093.) During an April 2014 visit, Dr. Haller also assessed ankylosing spondylitis. (A.R. 1043, 1094.)

         In May 2014, Plaintiff underwent a routine gynecological examination. (A.R. 1032.) Plaintiff reported no gynecological concerns and denied chest pain, leg swelling, palpitations, back pain, joint pain or swelling, muscle pain, headaches, ...