Opinion ID: 2982998
Heading Depth: 3
Heading Rank: 1

Heading: Treatment Records for Physical Impairments

Text: In August 2007, Reeves sought treatment for left neck and scapulothoracic pain and ear ringing with Nicholas Finley, M.D. Dr. Finley noted that Reeves had some signs of cervical disc disease, as well as tenderness along his left rotator cuff and trapezius muscle. Dr. Finley prescribed a muscle relaxant, recommended heat and massage treatment, and suggested a steroid injection, which Reeves refused. Two years later, Reeves saw Paula Sprow, MSN, CRNP, for high blood pressure and neck pain, as well as numbness in his left arm when his neck pain flared. Ms. Sprow found no abnormalities in Reeves’s neck and noted that he had a full range of motion. Ms. Sprow recommended a pain reliever for his neck pain, along with stretching exercises and alternating 1 Although the record contains extensive information relating to Reeves’s medical history, only those records relevant to the instant appeal are noted here. 2 No. 14-4140 Reeves v. Comm’r of Soc. Sec. heat/ice treatments. She increased Reeves’s blood pressure medication and advised him to follow up in three months. (R. 13 at 337, ID 383) On May 24, 2010, Reeves went to an emergency room complaining of neck pain that radiated down his left arm and numbness that affected his grip. He also reported a restricted range of motion in his left arm. The report noted that Reeves underwent neck surgery in 1990 for a fracture he sustained in a car accident. A CT scan of his cervical spine showed degenerative spondylosis with marginal spurs at multiple levels and disc degeneration with postsurgical changes at the site of the earlier fracture. However, the CT scan revealed no recent evidence of acute fracture, dislocation, disc herniation, or spinal stenosis. Reeves was diagnosed with cervical radiculopathy, prescribed a pain reliever and a soft cervical collar, and advised to follow up with his family doctor and to undergo physical therapy. (R. 13 at 338-45, ID 384-91) A year later, Reeves saw M. Stalter, M.D., complaining of weakness in his upper left arm and some pain and numbness in the lower extremity. Dr. Stalter observed that Reeves had tenderness along his cervical spine and slightly reduced strength (four out of five) in his left arm. Dr. Stalter noted that this was consistent with cervical radiculopathy and referred Reeves to an orthopedic surgeon, Ashok Biyani, M.D., for consultation and treatment of his neck pain. (R. 13 at 420, ID 466) At Reeves’s appointment with Dr. Biyani, he reviewed Reeves’s medical file, including the May 24, 2010, CT scan. Dr. Biyani noted that Reeves displayed tenderness with range of motion deficits in cervical extension, flexion, and rotation. Dr. Biyani determined that Reeves 3 No. 14-4140 Reeves v. Comm’r of Soc. Sec. had degenerative disc disease in his cervical spine and left arm radiculopathy, and recommended that Reeves start physical therapy. (R. 13 at 409-10, ID 455-56) Reeves did not return to see Dr. Biyani, nor has he sought physical therapy per Dr. Biyani’s recommendation. 2. Consultative Records for Physical Impairments Reeves met with consultative examiner Lamberto Diaz, M.D., for a disability examination. Dr. Diaz stated that Reeves presented with the “rather interesting syndrome” of numbness on the left side of the body, which extended periodically to the right hand. Dr. Diaz further noted that while Reeves claimed to have weakness in his left arm and loss of fine manipulation, his musculature was well preserved. Dr. Diaz concluded that based on Reeves’s history, he would not be suitable for sedentary work. However, Dr. Diaz also suggested that Reeves undergo neurological/neurosurgical and psychiatric evaluations to make a final determination as to whether his symptoms were attributable to malingering, neurological changes, or neuropathy cause by his alcoholism. (R. 13 at 405-07, ID 451-53) Reeves additionally underwent consultation by two state agency physicians. In August 2010, Willa Caldwell, M.D., opined that Reeves retained the ability to perform a reduced range of light work. Dr. Caldwell found that, despite Reeves’s impairments, he could lift twenty pounds occasionally, ten pounds frequently, and stand, sit, and/or walk six hours in an eight hour day. She also found that Reeves was limited to occasional pushing, pulling, overhead reaching with his left arm, and climbing ladders, ropes, and scaffolding. However, Dr. Caldwell stated that Reeves was unlimited in his ability to balance, stoop, kneel, crawl, crouch, climb ramps and 4 No. 14-4140 Reeves v. Comm’r of Soc. Sec. stairs, and did not have any manipulative, visual, communication, or environmental limitations. (R. 13 at 85-87, ID 131-33) In March 2011, state agency physician Lynne Torello, M.D., reached similar conclusions to those of Dr. Caldwell, with a few additional limitations. Dr. Torello opined that Reeves could not climb ladders, ropes, or scaffolds and could only occasionally balance and crawl. Dr. Torello additionally stated that Reeves was limited in his ability to perform fine and gross manipulation with his left hand, and that he should avoid heights, moderate exposure to dangerous machinery, and concentrated exposure to vibrations. (R. 13 at 114-16, ID 160-62) 3. Treatment Records for Mental Impairments Between December 2010 and November 2011, Reeves sought mental health treatment at Maumee Valley Guidance Center under the care of psychiatrist Enedina Berrones, M.D., and counselor David Brown, P.C.C. Reeves initially sought counseling to help with anger management and binge drinking. During this period, his mental health treatment consisted of counseling and a medication regimen. In January 2011, Mr. Brown diagnosed Reeves with adjustment disorder with mixed anxiety and depressed mood and alcohol abuse, and assessed his Global Assessment Functioning score (“GAF”) at 51, indicating “moderate symptoms.” Dr. Berrones later updated Reeves’s diagnosis to (1) depressive disorder; (2) pain disorder associated with psychological factors and a general medical condition chronic; and (3) alcohol dependence and nicotine dependence. His GAF score was assessed at 51-60, indicating “some 5 No. 14-4140 Reeves v. Comm’r of Soc. Sec. difficulty in functioning.” As of November 2011, Reeves’s diagnoses and GAF rating remained unchanged. (R. 13 at 431-44, ID 477-90) 4. Consultative Records for Mental Impairments In September 2010, Reeves met with consultative examiner Neil Shamberg, Ph.D., for a disability mental assessment. Dr. Shamberg opined that Reeves was of low-average intelligence and diagnosed him with major depressive disorder, bereavement, anxiety disorder, and nicotine and alcohol dependence. Dr. Shamberg gave Reeves a GAF score of 41, indicating that he has “serious symptoms.” Addressing Reeves’s work-related mental abilities, Dr. Shamberg opined that Reeves had marked limitations in his ability to relate to others and in his ability to withstand the stress and pressures associated with day-to-day work, as well as moderate limitations in his ability to understand, remember, and follow instructions and in his ability to maintain attention, concentration, persistence, or pace. (R. 13 at 388-93, ID 434-39) In October 2010, a state agency psychologist Melanie Bergsten, Ph.D., opined that Reeves was moderately limited in his ability to get along with co-workers and interact with the public; accept instructions; respond appropriately to changes in the work setting; and to complete a normal workday. Dr. Bergsten found that Reeves was capable of performing work-related tasks in situations where duties are relatively static and changes can be explained. Dr. Bergsten then considered the opinion of Dr. Shamberg and assigned it only partial weight, stating that it lacked substantial support from the record, which did not indicate more than a moderate degree 6 No. 14-4140 Reeves v. Comm’r of Soc. Sec. of impairment in Reeves’s ability to relate to others and tolerate stress. (R. 13 at 100-02, ID 14648) Similarly, in April 2011, state agency psychologist John Waddell, Ph.D., issued an assessment virtually identical to that of Dr. Bergsten. He opined that Reeves was moderately limited in his ability to maintain concentration; get along with co-workers and interact with the public; accept instructions; respond appropriately to changes in the work setting; and complete a normal workday. Like Dr. Bergsten, Dr. Waddell assigned Dr. Shamberg’s opinion partial weight because it lacked substantial support from the record. (R. 13 at 117-18, ID 163-64)