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Bethanie Hallam v. Social Security Administration

March 29, 2011

BETHANIE HALLAM, PLAINTIFF,
v.
SOCIAL SECURITY ADMINISTRATION, DEFENDANT.



The opinion of the court was delivered by: Donald G. Wilkerson United States Magistrate Judge

ORDER

Plaintiff Bethanie Hallam ("Claimant") applied for disability insurance benefits and supplemental security income on January 16, 2007 (Tr. 94). The Social Security Administration denied the application initially on March 13, 2007, and again upon reconsideration on June 5, 2007 (Tr. 51, 59). Claimant filed a timely written request for a hearing before an administrative law judge ("ALJ"), and the hearing was held on June 23, 2008 (Tr. 18-37, 61). By decision dated August 28, 2008, the ALJ found that Claimant was not entitled to disability insurance benefits as she was not disabled under The Social Security Act at any time from June 1, 2006 through the date of the decision (Tr. 16). Claimant's request for review by the Appeals Council was denied on June 25, 2009 (Tr. 1). Thus, the ALJ's decision became the final decision of the Commissioner. 20 C.F.R. § 416.1481; Skarbeck v. Barnhart, 390 F.3d 500, 503 (7th Cir. 2004). Claimant now seeks judicial review of the Agency's final decision pursuant to 42 U.S.C. § 405(g). For the reasons set forth below, the Claimant's petition is DENIED.

BACKGROUND

Claimant's Application for Benefits

Claimant was born on December 16, 1962 (Tr. 94). She was 44 years-old at the alleged onset-of-disability date of June 1, 2006. Id. Claimant has a high school education and worked from 2001 to 2008 as a baby sitter, dental assistant, receptionist, secretary and substitute aid (Tr. 25, 126). Claimant alleged that her multiple sclerosis affected her ability to work as her right arm and leg were very weak and shaky, and prevented her from holding or lifting items on her right side (Tr. 125). She also alleged that she had a slight limp in her right leg and weakness in her right hand that caused numbness and tingling. Id. Claimant indicated that she stopped working full-time on June 1, 2006, but continued to work part-time from June 1, 2006 to April 28, 2008 (Tr. 24, 25). Claimant's date last insured is June 30, 2011 (Tr. 9).

Summary of Medical Records

On August 8, 2006, Claimant visited Dr. Christopher Ballard for complaints of arthralgia in the left wrist, right shoulder and right elbow, and parethesias below the right knee to her foot. Claimant reported that her right leg felt "heavy" and complained that she "can't always use it appropriately." She did not have complaints of a sore throat, fever, chills, night sweats, headaches, diplopia, loss of vision, other parathesias, weakness or back pain. Dr. Ballard noted that Claimant's strength in her lower extremities was rated "5/5" and had some mild sensory deficit on the right knee to the ankle area (Tr. 279).

On August 11, 2006, Claimant underwent an MRI of the brain. The MRI revealed an active plaque formation in the left parietal region secondary to multiple sclerosis or a focal metastatic deposit. Dr. Ballard reviewed the MRI and noted "her ANA, sed rate and RF factors were all normal with a sed rate only noted as 1. Her CBC, TSH and CMP were completely normal." He reported that Claimant had experienced arthralgia, but noted that she had not been taking Celebrex as prescribed. Dr. Ballard's impression was that Claimant had parethesias in her right lower extremity over the shin with enhancing focus in the left parietal region and stated, "this is concerning for the underlying multiple sclerosis. I don't know of any obvious primary so I think that metastatic disease is unlikely" (Tr. 271, 286).

On August 23, 2006, Claimant saw Dr. Barry Singer with complaints of right-sided weakness and numbness. Dr. Singer noted that in June 2006, Claimant noticed a gradual onset of numbness in her right hand extending up to her forearm, and within two weeks she had a gradual onset of numbness extending from her right hand to her right foot. He reviewed an MRI scan of the brain on August 11, 2006 and discovered a ring enhancing lesion in her left posterior frontal portion of her brain which suggested "possible dymyelination (sic), abscess, or tumor such as metastasis or glioblastoma." Dr. Singer recommended that Claimant go directly to the hospital for a diagnostic evaluation (Tr. 190-91).

Later that day, Claimant was admitted to the hospital. Upon admission, Claimant denied any focal weakness, but stated that she felt extremely weak for past two weeks. She indicated that she continued to have numbness in her right hand and lower arm for the past two weeks, but admitted that she did not limit the activity of her right hand and continued to write and do daily tasks with that hand. Claimant complained that her right leg felt weak and her balance was off, but denied dropping objects. She denied any facial numbness or facial droop, and she had not experienced any electric shock sensations down her spine. She also denied vision loss, double vision, hearing loss, ringing in her ears, and vertigo (Tr. 201-207, 224).

On August 24, 2006, an MRI of the cervical and thoracic spine revealed mild degenerative disease of the cervical spine and possibly mild myelitis at the C2-C4 and T-3 levels (Tr. 234).

On August 30, 2006, she returned to Dr. Ballard. An examination revealed that Claimant did not have edema or calf tenderness, but she did have sensory deficit in the right lower extremity below the knee and the right upper extremity below the hand. Dr. Ballard noted that Claimant had "multiple sclerosis of new onset" and continued Claimant on 1 gram of SoluMedrol IV daily for three days on an outpatient basis. Claimant was to follow-up with Dr. Singer to start Interferon injections on an outpatient basis (Tr. 280).

On September 6, 2006, Claimant returned to Dr. Singer. He noted that Claimant's right leg was stronger and the numbness in her right arm had improved (Tr. 219).

On October 19, 2006, Claimant had a visit with Dr. Elizabeth Sweet-Friend, a gynecologist. Dr. Sweet-Friend noted that Claimant had been diagnosed with relapsing remitting multiple sclerosis in September 2006. She reported that Claimant's right-sided symptoms had subsided since she had been taking Interferon injections (Tr. 277).

On November 17, 2006, Dr. Singer indicated that Claimant's right leg was strong, but became weak toward the end of the day due to fatigue. The record also states that Claimant's right hand and lower leg had good balance (Tr. 217).

On March 12, 2007, an agency physician, C.A. Gotway, evaluated Claimant's medical records and completed a Physical Residual Functional Capacity Assessment. The agency evaluator found, based upon the medical records, that Claimant could occasionally lift 50 pounds; frequently lift 25 pounds; stand or walk for a total of about six hours in an eight-hour work day; sit for a total of about six hours in an eight-hour workday; and perform unlimited pushing and/or pulling. Regarding postural limitations, Claimant could occasionally climb ramps, stairs, ladders, ropes, or scaffolds; and frequently balance, stoop, kneel, crouch and crawl. No manipulative, visual or communicative limitations were established. Regarding environmental limitations, Claimant should avoid concentrated exposure to hazards such as machinery and heights. The evaluator noted that there were no treating or examining source statements regarding the Claimant's physical capabilities in her file (Tr. 299-308).

On March 29, 2007, Claimant saw Dr. Ballard for complaints of increased weakness in her right upper hand with some mild parethesias. With respect to her physical limitations, Dr. Ballard noted that Claimant: 1) was still having weakness and her right leg and is unable to keep with her job at school as a personal assistant to a student; 2) was unable to lift any of the children and has not been able to work as much as she would like to; 3) was having difficulty typing, especially with her right hand, so she had been unable to perform her typing duties; 4) could not walk for prolonged periods of time or far distances due to weakness in the right leg which has been persistent; and 5) misses one day of work per week, and was taking Rebif injections every other day which causes her to have nausea, vomiting and headaches -- which in turn, interferes with her ability to work. Dr. Ballard noted that Claimant's symptoms were exacerbated when she was playing golf, "they played three holes and was unable to go any further and had to be carried off." Claimant was about to take a weekend trip to Springfield, so Dr. Ballard instructed her to continue the Provigil- if that did not work he would set her up for outpatient IVSoluMedrol 1 gram daily for three days (Tr. 276).

On June 4, 2007, Richard Bilinsky, an agency physician, reviewed the medical file and affirmed the March 12, 2007 Residual Functional Capacity Assessment (Tr. 308).

On August 7, 2007, Claimant saw Dr. Ballard for aching and weakness in her right arm and leg, and numbness in her tongue that had begun a week earlier. Dr. Ballard noted that Claimant's symptoms had already improved and diagnosed her as having experienced a multiple sclerosis flare with "right sided weakness typical with her usual flares." An exam revealed 3-4/5 strength in her right upper and lower extremities and 5/5 strength in her left upper and lower extremities. Dr. Ballard noted that it had been one year since Claimant had IV Solu-Medrol, and prescribed a course of Solu-Medrol IV for three days (Tr. 330).

On August 17, 2007, Claimant returned to Dr. Ballard for a follow-up. Claimant had experienced a multiple sclerosis flare-up a couple of days prior to her appointment. Claimant still had weakness in her right lateral forearm and some paresthesias, but overall her hand had improved. She denied suffering from headaches, diplopia, chest pain, local parathesias, weakness and abdominal pain. Dr. Ballard reported that had a "moderately good response" to the prednisone despite the fact that she experienced significant side effects with it. He then commented, "[u]nfortunately she is still unable to work as this mainly involves her right upper extremity which is her dominant extremity. Affects her ability to concentrate causing significant fatigue, even on Provigil" (Tr. 328).

On August 24, 2007 Dr. Singer noted that Claimant was experiencing pain in her right forearm, right arm and right leg. Claimant had vision loss in her right eye, fatigue, bladder urgency, constipation and depression and balance off. Dr. Singer diagnosed her with multiple sclerosis exacerbation and noted that Claimant had "no face droop, sensory intact, mild difficulty with gait" (Tr. 320-321).

On September 4, 2007, plaintiff had a follow-up visit with Dr. Ballard. Claimant had previously experienced hypertensive side effects from the Solu-Medrol, but Dr. Ballard noted that the symptoms of her multiple sclerosis had improved, as had the side effects from the Solu-Medrol. Claimant's condition was stable and she was feeling "fine with no new complaints." Dr. Ballard noted that Claimant continued to have weakness in her right upper extremity, ...


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