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Fontes v. Saul

United States District Court, D. Massachusetts

December 6, 2019

ANA FONTES, Plaintiff,
ANDREW SAUL, Commissioner of the Social Security Administration, Defendant.




         Plaintiff Anna Fontes brings this action under 42 U.S.C. § 405(g) for judicial review of a final decision denying her application for Social Security Disability Insurance (“SSDI”) benefits.[1] Plaintiff suffers from various physical and mental impairments including major depressive disorder, anxiety disorder, panic disorder, cervical occipital neuralgia, [2] history of chronic left chronic otitis media, [3] and status post left tympanoplasty.[4] She argues that the Administrative Law Judge's (“ALJ”) residual functional capacity (“RFC”) findings were not supported by substantial evidence.

         For the reasons set forth below, the Court DENIES Plaintiff's motion to reverse the Commissioner's decision. (Docket No. 10) and ALLOWS Defendant's motion to affirm the Commissioner's decision (Docket No. 13).


         Plaintiff Ana Fontes (“Plaintiff”) was 52 years old when she filed her application for SSDI on March 19, 2018. R. 15, 50. She had previously worked as an industrial cleaner, cell coordinator, and material handler. R. 65. Plaintiff alleged disability due to major depressive disorder, anxiety disorder, panic disorder, cervical occipital neuralgia, history of chronic left chronic otitis media, and status post left tympanoplasty. Docket No. 1 at 2.

         I. Medical History

         Plaintiff's alleged onset date of disability was December 14, 2017, the date of her ear surgery. R. 15. Over the next year, Plaintiff would receive medical care from the Massachusetts Eye and Ear Infirmary, Hawthorn Medical Associates, and the Spaulding Rehabilitation facility.

         On December 22, 2017, Plaintiff had a post-surgery visit at the Massachusetts Eye and Ear Infirmary. Care providers noted that Plaintiff had a persistent earache, despite oral antibiotics. Plaintiff stated that her hearing had gradually worsened, and that she felt dizzy when bending over or turning her head quickly. R. 399. On February 2, 2018, Plaintiff attended a follow up visit at the same provider. Notes from the appointment indicate that Plaintiff's hearing had improved, but she was still bothered by dizziness. R. 407. She was given a referral to vestibular[5] physical therapy. R. 409.

         On February 21, 2018, Plaintiff had an appointment at Hawthorn Medical Associates. Documentation from Plaintiff's appointment noted that she was having abdominal pain of an unknown cause. R. 307.

         On March 22, 2018, Plaintiff went to Spaulding Rehabilitation for an initial physical therapy evaluation. Plaintiff reported a history of six surgeries related to her left tympanic membrane.[6]She described dizziness, headaches, tinnitus, and imbalance triggered by looking down and changing position. R. 606. She was enrolled in physical therapy for six weeks. R. 608.

         At a physical therapy session at Spaulding Rehabilitation on March 26, 2018, Plaintiff reported feeling unsafe on her feet due to dizziness. R. 604. She also stated that her pain was always at a five out of ten. Id. Finally, Plaintiff reported that she had little to no tolerance to noise or light. Id.

         On April 2, 2018, Plaintiff had a follow up appointment at Massachusetts Eye and Ear Infirmary, where she stated that she felt imbalanced when moving, could not dance, and experienced tunnel vision when driving down long and straight roads. R. 413. During her appointment, Plaintiff indicated that she had not experienced any improvement after several physical therapy sessions. Id. Upon examination, she was noted to have normal speech and language function, grossly normal memory and attention, and a very stiff neck with difficulty turning her head. Plaintiff's gait and balance were abnormal. R. 413-414. Plaintiff was referred for vestibular testing. R. 413.

         Upon follow up at Spaulding Rehabilitation facility in April 2018, Plaintiff noted no improvement to her symptoms. R. 602. She continued to attend her physical therapy treatment sessions over the following three months, but she reported continued headaches, dizziness, and balance impairments during this period. R. 582-602.

         One month later, on May 9, 2018, at her follow up appointment at Hawthorn Medical Facility, Plaintiff noted sharp pains on the right side of her head and requested a referral for a neurologist. R. 571, 574. She was given the requested referral, and was advised to quit smoking. R. 574-575.

         On June 19, 2018, Plaintiff had an ENT (ears, nose, and throat) appointment at Southcoast Health. Documentation from her appointment noted her left ear was “healing well, ” although she had continued trouble with balance. R. 621. Plaintiff's results were normal after table testing and vestibular testing. The cause of her ongoing symptoms was reportedly unknown. She reported difficulty in swallowing and was strongly encouraged to quit smoking. R. 622.

         Plaintiff attended physical therapy at Spaulding Rehabilitation on June 21, 2018. R. 585. Notes from the session indicate that the Plaintiff had been “gardening and doing light duty yard work for short periods.” R. 586.

         Based on Plaintiff's self-assessment on July 11, 2018, her physical therapist noted that she had not had any changes in symptoms since starting physical therapy, and had experienced ongoing headaches, dizziness, limited eye movement, balance impairment, and pain. Her physical therapist also noted that Plaintiff had little to no tolerance to noise and pressure changes, and that she limited any strenuous activity. Plaintiff was discharged with a home exercise program. R. 584.

         On July 19, 2018, Plaintiff was examined by an ophthalmologist for a routine eye exam. R. 613. She was noted to have 20/20 vision with corrective lenses. R. 616.

         On July 26, 2018, Plaintiff went to Hawthorn Medical Associates for a sick visit. Plaintiff was assessed with pharyngitis and constipation, and was advised to use a saline spray and zinc lozenges and to increase fluid intake. R. 541.

         Plaintiff's impacted ear wax was examined in a visit at Southcoast Health on August 2, 2018. R. 629.

         On August 13, 2018, Plaintiff had a neurology appointment at Hawthorn Medical Associates. R. 639. Plaintiff reported numbness and tingling in her neck. R. 641. Her provider noted that Plaintiff had significant occipital neuralgia, which can cause fleeting head pains and intermittent blurry vision. R. 642. She was advised to massage, stretch, and use heat on her neck. R. 642. The provider also referred Plaintiff for an MRI of a benign cerebral tumor, which the provider explained was not the cause of Plaintiff's head pains. R. 643. The physician declined to prescribe muscle relaxers for the Plaintiff's neck pain, because Plaintiff was drinking four glasses of wine per night. R. 642. Documentation from Plaintiff's August 13, 2018 appointment also noted that Plaintiff had been smoking one and a half packs of cigarettes per day. R. 642.

         On September 10, 2018, Plaintiff had a neurology appointment with Dr. Conroy, in the neurology department of Hawthorn Medical Associates. R. 634. Plaintiff complained of significant neck pain and tinnitus. Dr. Conroy noted that Plaintiff possibly had occipital neuralgia and “a lot of psychosocial stress.” R. 637. Plaintiff was advised that she would benefit from some therapy for her neck but was reportedly resistant to this treatment. Id. Dr. Conroy noted that Plaintiff had been prescribed a “modest dose of Lexapro 5mg and [a] small dose of Xanax” to take at bedtime. Plaintiff reported that she was taking the Xanax three to four times per day. R. 637. Dr. Conroy noted that the Xanax may have suppressed Plaintiff's vestibular input. Plaintiff was reassured that her benign cerebral tumor was stable and did not need to be addressed at that time. R. 637.

         On October 12, 2018, Plaintiff went to the Massachusetts Eye and Ear Infirmary. R. 645. She reported dizziness, headaches, blurred vision, ear pain, and anxiety. Id. Results from Plaintiff's ENG[7] and rotational chair testing were normal, and her MRI showed no interval growth. R. 646. She was advised to follow up in one year. Id.

         II. Psychiatric Treatment History

         Plaintiff has met with Nurse Practitioner Claire Olivier once a week to once every two months, depending on the severity of Plaintiff's needs, since October 21, 2009. R. 529. Nurse Practitioner Olivier offers individual psychotherapy and medication management. Id.

         On February 21, 2018, Plaintiff had an appointment with Nurse Practitioner Olivier. R. 449. She discussed her December 2017 ear surgery, which she felt was a “mess”. Id. She also discussed feeling sadness related to the recent loss of a friend. Id. Plaintiff expressed fear that she would not be able to return to her job, which required driving machinery. Id. Plaintiff also mentioned tension at her workplace, explaining that it was no longer a family-oriented place. Id. Nurse Practitioner Olivier recorded that Plaintiff had good eye contact, soft speech, goal-oriented thought processes, no abnormal thought content, intact memory, intact attention, and intact insight/judgement. R. ...

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