Opinion ID: 4582882
Heading Depth: 3
Heading Rank: 1

Heading: Medical-record evidence

Text: Coleman was born in 1982. He alleges the onset of disability as of November 5, 2013 due to spine, shoulder, and elbow problems. In May 2014, Coleman’s treating physician, Steven Foster, D.O., diagnosed Coleman with lumbago and cervicalgia and opined that Coleman was limited to sedentary work. Two and a half months later, Dr. Foster diagnosed Coleman with lumbar stenosis and completed another opinion form that reflected severe limitations. Dr. Foster cited Coleman’s complaints of pain, limited range of motion, and MRI results in support of his findings. The doctor continued to treat Coleman until April 6, 2015. On that date, Coleman terminated his relationship with Dr. Foster after the doctor declined to prescribe additional pain medication. In November 2014, Coleman visited Christopher Benner, ARNP. Nurse Practitioner Benner noted that the X- ray images of Coleman’s spine were “normal” and that Coleman exhibited the basic range of motion. The nurse practitioner also noted Coleman’s complaints of severe pain and observed Coleman’s pain behavior with minimal palpation. A psychological evaluation was then recommended. Accordingly, Coleman met with Leslie Schneider, Ph.D., in January 2015. Dr. Schneider diagnosed Coleman with “pain disorder associated with psychological and physical factors,” but expressed uncertainty, commenting that “[t]his seems to be a rather unusual case, COLEMAN V. SAUL 5 with a lot of factors here where I do not think that I have a really good grasp on.” The psychologist also noted that Coleman “may very well qualify for Disability. This is quite a strange and unusual case that just does not fit into any neat category.” Coleman began treatment with Michael Chang, M.D., in early 2015. Dr. Chang diagnosed Coleman with spinal stenosis in the cervical region and recommended surgery. In May 2015, Dr. Chang performed an anterior C5-C6 discectomy. Coleman was evaluated six days later by Nancy Schwarzkopf, ARNP. Nurse Practitioner Schwarzkopf opined that Coleman’s functional capacity was severely limited, that he could not meet the demands of sedentary work, and that this limitation would persist for at least 12 months. In September 2015, Joanna Kass, ARNP, also opined that Coleman was severely limited. The following month, Charles Linsenmeyer, M.D., reviewed the medical record current at that time and concluded that Coleman’s impairments medically equaled Listing 1.04A (“Disorders of the spine”). By early 2016, other treating and reviewing physicians began to reach different conclusions. In January 2016, Coleman met with Dave Atteberry, M.D. Dr. Atteberry reviewed the MRI scans of Coleman’s lumbar spine and found nothing requiring intervention. Examination showed normal motor strength, tone, and gait. Zornitza Stoilova, M.D., examined Coleman in March 2016 and noted similar findings. Dr. Stoilova observed that Coleman’s repeat cervical and lumbar spine MRIs did not show any abnormalities that would explain his pain. Coleman’s reports of pain, however, persisted. And in March 2016, Caryn Jackson, M.D.—who had treated Coleman since October 2015—assessed severe limitations. 6 COLEMAN V. SAUL The medical evidence also includes treatment notes from several emergency room visits. Between the end of May and early June 2015, the record shows that Coleman visited the emergency room on three separate occasions with reports of severe neck pain. When he arrived at the ER on June 5, the ER doctor declined his request for pain medication, noting that an Emergency Department Information Exchange alert showed multiple prescriptions for pain medication being filled by multiple providers, with approximately 380 pills in the last 30 days and 800 pills in the last five months. When Coleman returned the next day with reports of even more severe pain, he was again denied pain medication. During the administrative hearings, held on September 30, 2015 and April 20, 2016, Coleman testified to the severity, persistence, and limiting effects of his pain. He testified that he could not return to his work as a desktopsupport technician because “all [he] could think about was how much pain [he was] in.” Coleman further testified that he has the same levels of pain that he experienced before surgery and that he is unable to sit down for more than a short period of time. Allan Levine, M.D., also testified during the April 20, 2016 hearing. Dr. Levine had reviewed the medical record and testified that the various imaging studies and physical examinations showed no evidence of nerve root or spinalcord compromise, findings required for an impairment to meet Listing 1.04A. He nonetheless opined that Coleman retained less than sedentary functional ability during the year following his May 2015 neck surgery, an opinion that was inconsistent with Dr. Atteberry’s January 2016 examination of Coleman. In addition, Dr. Levine opined that Coleman would be much less limited after May 2016 and could, for example, sit for six out of eight hours in a day. COLEMAN V. SAUL 7