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LISA JEAN CASTLE v. MICHAEL J. ASTRUE

November 29, 2010

LISA JEAN CASTLE, PLAINTIFF,
v.
MICHAEL J. ASTRUE, ) JUDGE SHEILA FINNEGAN COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Sheila FINNEGANUnited States Magistrate Judge

MEMORANDUM OPINION AND ORDER

Plaintiff Lisa Jean Castle seeks to overturn the final decision of the Commissioner of Social Security ("Commissioner") denying her application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act. 42 U.S.C. §§ 416, 423(d). The parties consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c), and Plaintiff filed a motion for summary judgment. On April 26, 2010, the case was reassigned to this Court for all further proceedings. After careful review of the record, the Court now denies Plaintiff's motion and affirms the Commissioner's decision.

PROCEDURAL HISTORY

Plaintiff applied for DIB on October 19, 2005, alleging that she became disabled on April 15, 2005 from depression, a heart attack, hardened arteries and a heart stent. (R. 95-99, 119.) The Social Security Administration ("SSA") denied the application initially on June 21, 2006, and again on reconsideration on November 1, 2006. (R. 51-57, 53-60, 61-64.) Pursuant to Plaintiff's timely request, Administrative Law Judge ("ALJ") John K. Kraybill held an administrative hearing on November 4, 2008. The ALJ heard testimony from Plaintiff, who appeared with counsel, and from vocational expert ("VE") Edward F. Pagello, and medical expert ("ME") Sheldon J. Slodki, M.D. A little more than two weeks later, on November 21, 2008, the ALJ found that Plaintiff is capable of performing the full range of sedentary work and, thus, is not disabled under Rule 201.25 of the Medical-Vocational Guidelines (the "Grid"). (R. 8-14.) The Appeals Council denied Plaintiff's request for review on April 20, 2009, and Plaintiff now seeks judicial review of the ALJ's decision, which stands as the final decision of the Commissioner. (R. 1-3.)

In support of her request for a remand, Plaintiff argues that the ALJ erred by failing to order a consultative examination. For reasons discussed below, the Court rejects this argument.

FACTUAL BACKGROUND

Plaintiff was born on August 14, 1964, and was 44 years old at the time of the ALJ's decision. (R. 117.) She has a tenth grade education, and worked for approximately 20 years as an apheresis technician drawing blood from people (i.e., phlebotomist). (R. 120, 124.) She stopped working in April 2005.

A. Medical History

1. 2002 through 2004

Plaintiff suffered a heart attack in 2002 and underwent angioplasty and stenting on April 2 of that year. (R. 186, 199.) She reported feeling better on May 8, 2002, and a June 4 stress echocardiogram ("stress test") was unremarkable. (R. 186, 197, 206.) On October 3, 2002, Plaintiff saw Dr. Abbas A. Khawaja for chest pain lasting three to five minutes per episode. Dr. Khawaja conducted a physical examination, which was unremarkable, and noted that Plaintiff continued to smoke despite "significant risk factors." He diagnosed coronary artery disease ("CAD"), hypertension and hyperlipidemia, and recommended that she have a repeat stress test with echocardiogram. (R. 196-97.) The October 8, 2002 stress test was normal. (R. 205.)

Plaintiff continued to complain of chest pain, palpitations and shortness of breath in May 2003, and on September 12, 2003, Dr. Khawaja ordered another stress test. (R. 194-95.) The September 19, 2003 test was normal, with only "[m]ildly reduced functional aerobic capacity for patient's age." (R. 204.) Despite these normal findings, Plaintiff returned to Dr. Khawaja in February 2004 complaining of high blood pressure. (R. 193.) Shortly thereafter on March 29, 2004, Plaintiff had a left heart catheterization, LV (left ventricular) angiography and coronary angiography. The test showed 50% stenosis in the middle part of the right coronary, but was otherwise unremarkable. (R. 207-08.) At an April 7, 2004 follow-up visit with Dr. Khawaja, Plaintiff reported always experiencing some shortness of breath, but denied having chest pains or swelling. Dr. Khawaja told Plaintiff to see him again in six months. (R. 192.)

Plaintiff next received medical treatment on September 13, 2004, when she reported to the Rush-Copley Family Practice Residency ("Rush-Copley") with nausea and heartburn lasting two months, and high blood pressure. The doctor advised her to quit smoking and to follow up with her cardiologist. At the time, Plaintiff's medications included Prevacid (for heartburn), Toprol (a beta-blocker), Plavix (to prevent blood clots), and Zocor (for cholesterol). (R. 171.) The following month, on October 6, 2004, Plaintiff saw Dr. K.G. Chua at Fox Valley Cardiovascular Consultants ("Fox Valley"), because of chest discomfort and hypertension. Plaintiff said that she had been experiencing central chest discomfort "on and off" for the previous month, each episode lasting approximately 5 minutes and improving with nitroglycerin. (R. 199.) Dr. Chua noted Plaintiff's March 29, 2004 angiogram results, which showed a "50% mid right stenosis which was non-critical," but no "LAD [left anterior descending] in-stent restenosis" and "normal LV function." (Id.) He increased Plaintiff's dosage of Hyzaar (for hypertension), and indicated that she would need another stress test with Dr. Khawaja once her blood pressure returned to a normal level. (Id.)

2. 2005 through 2006

On January 6, 2005, Plaintiff had another stress test at Fox Valley. The results were entirely normal. (R. 238-48.) Approximately four months later, on April 6, 2005, Plaintiff presented to Rush-Copley with shortness of breath. An EKG showed no acute changes and a chest x-ray was unremarkable with "[n]o acute process." (R. 169, 175-76.) The doctor diagnosed shortness of breath, history of CAD, hypertension, hyperlipidemia, and gastroenteritis, and referred Plaintiff to Dr. Khawaja for further treatment. (R. 169.) Plaintiff saw Dr. Khawaja on April 15, 2005. She denied having any chest pain at that time and admitted that she still smoked a pack of cigarettes per day. Dr. Khawaja conducted a physical examination, which he described as "totally unremarkable," refilled Plaintiff's prescriptions, and made no further recommendations. (R. 180, 198).

On April 20, 2005, a doctor at Rush-Copley diagnosed Plaintiff with an adjustment disorder with depressed mood. Plaintiff complained of feeling sad, tearful and anxious, and said that she wanted "time off to recover." The doctor prescribed Effexor and counseling at the "Mercy Center." (R. 168.) At a follow-up examination on May 6, 2005, the doctor advised Plaintiff to maintain a safe environment for herself and her daughter. (R. 167.) Shortly thereafter, on May 13, 2005, Plaintiff started seeing Dr. Kishwar Ali on a monthly basis for psychiatric treatment. (R. 161.) The record does not contain Dr. Ali's treatment notes.

Plaintiff last reported to Rush-Copley on July 11, 2005, complaining of high blood pressure and a throbbing headache. The doctor increased her dosage of Toprol, put her on Norvasc (for high blood pressure), and gave her Tylenol. (R. 166.) In August 2005, Plaintiff obtained notes from Dr. Khawaja and Dr. Ali stating that she "needs to be on disability." Neither doctor provided any explanation for this assessment. (R. 160.)

On February 8, 2006, Dr. Ali completed a Psychiatric Report on Plaintiff for the Bureau of Disability Determination Services ("DDS"). (R. 161-64.) Dr. Ali noted Plaintiff's history of depression, anxiety, insomnia, stress eating and crying spells, but stated that she was able to care for herself. Dr. Ali found Plaintiff to have a depressed mood and ...


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