Opinion ID: 3165140
Heading Depth: 2
Heading Rank: 2

Heading: facts/record

Text: In 1999, a malignant melanoma was removed from Stephenson’s left calf and a lymphadenectomy was performed. There was no recurrence of the disease in 2 Case No. 14-4154, Stephenson v. Comm’r of Soc. Sec. the following ten years. On June 17, 2009, Stephenson visited her primary care physician, James Byatt, M.D., complaining of a painful swollen left leg. Dr. Byatt ordered a venous scan of the left lower extremity, which revealed no evidence of deep vein thrombosis. Stephenson was referred by Dr. Byatt to Andrew J. Seiwert, M.D., a vascular surgeon at Fostoria Vascular Clinic, for further evaluation and treatment. Stephenson saw Dr. Seiwert on July 6, 2009, who diagnosed her with lymphedema on her left leg, “likely due to lymphatic obstruction secondary to melanoma excision and lymphadenectomy.” (R. 12 at PgID 345). Dr. Seiwert noted that Stephenson’s legs were normal, except for a trace of edema in her left calf, ankle and foot regions. Dr. Seiwert also noted that Stephenson’s weight gain and increased skin perfusion associated with the warm summer months exacerbated the condition. Dr. Seiwert referred Stephenson to the Lymphedema Clinic for further evaluation. On October 19, 2009, Todd Russell, M.D. of the Lymphedema Clinic noted that the swelling in Stephenson’s left leg was under control since it was half the size it had been prior to the Clinic’s treatment, but Stephenson continued to complain of pain in her left leg. Dr. Russell noted that this was unusual since in most people affected by lymphedema, the swelling was relatively painless. Dr. Russell encouraged Stephenson to continue with compression therapy and 3 Case No. 14-4154, Stephenson v. Comm’r of Soc. Sec. recommended further testing to determine the source of the pain. On November 23, 2009, Stephenson underwent a venous duplex bilateral examination. The result of the venous Doppler study was unremarkable, with no evidence of deep vein thrombosis, superficial venous thrombosis or venous valvular insufficiency in either leg. A State of Ohio agency consultant, Leigh Thomas, M.D., assessed Stephenson’s residual functional capacity on November 25, 2009. Dr. Thomas found that Stephenson could lift twenty pounds occasionally and ten pounds frequently. Dr. Thomas noted that Stephenson could sit six hours in an eight-hour work day and that standing/walking was limited to two hours. Dr. Thomas indicated that Stephenson’s symptoms are not disproportionate to her medically determinable impairment, and Dr. Thomas found Stephenson credible. Edmond Gardner, M.D., a state agency consultant, agreed with Dr. Thomas’ assessment after reviewing Stephenson’s file on April 22, 2010. On December 7, 2009, Dr. Seiwert reported that Stephenson had a somewhat favorable response to treatment at the Lymphedema Clinic, including use of compression stockings. Dr. Seiwert noted, however, that her lower left leg was considerably more swollen than the right leg. Dr. Seiwert found no signs of ulceration at the calf or prominent varices over the groin and that Stephenson’s thigh had nearly normal tissue turgor. Dr. Seiwert encouraged Stephenson to be 4 Case No. 14-4154, Stephenson v. Comm’r of Soc. Sec. more active and to use chaps to keep her stockings from slipping down her leg. Dr. Seiwert indicated that May-Thurner syndrome remained possible. On January 7, 2010, Stephenson complained to Dr. Byatt of bilateral neuropathic symptoms, but denied back pain. Dr. Byatt noted this as classic parasthesias with tingling and shooting vague numbness associated with bilateral pain. Dr. Byatt found clinical evidence for an entrapment neuropathy. Dr. Byatt prescribed Sinernet for symptoms of restless leg syndrome and Darvocet-N for pain and to reduce Stephenson’s upset stomach caused by taking ibuprofen. Dr. Byatt noted that Stephenson’s weight had steadily increased, which Stephenson claimed was because of drinking regular soda and being laid off from her job. Dr. Byatt ordered an MRI of the lumbar spine and lab work performed on January 13, 2010. On February 8, 2010, Dr. Byatt noted negative results from the MRI and lab work, noting that Stephenson was still experiencing chronic lymphedema of her left leg and bilateral parasthesias. Dr. Byatt prescribed Lyrica to Stephenson. On April 22, 2010, Dr. Byatt filled out a Basic Medical Form for the Ohio Department of Job and Family Services where he indicated that Stephenson suffered from persistent severe lymphedema of her left leg with chronic swelling. Dr. Byatt checked the boxes regarding Stephenson’s functional limitations 5 Case No. 14-4154, Stephenson v. Comm’r of Soc. Sec. indicating Stephenson could not work for twelve months or more because she visited the Lymphedema Clinic three times a week. On June 7, 2010, Stephenson reported to Dr. Seiwert that her compression wraps were keeping her symptoms from becoming too prominent and that she had drainage from the scars located near her melanoma excision on her left calf. Dr. Seiwert found that Stephenson continued to have prominent venous structures, with a possibility of central venous hypertension. He ordered a venography to determine if Stephenson had obstructive venous pathology due to May-Thurner physiology. The venography on June 16, 2010 revealed a trace deep femoral reflux on the left side, with no signs of iliocaval venous obstruction. Stephenson saw Dr. Byatt on September 24, 2010 reporting that she used Darvocet for her lymphedema pain and that she hoped to work again. Dr. Byatt refilled the Darvocet prescription. On March 2, 2011, Stephenson reported to Dr. Byatt that Lyrica was helping with her leg neuropathy. Stephenson indicated she was taking fifteen online classes to pursue a Bachelor’s degree. Dr. Byatt noted that Stephenson looked wonderful. Dr. Byatt filled out disability forms for Stephenson on April 4, 2011. He indicated that Stephenson had lymphedema on her left leg with secondary neuropathy since her survey to remove the melanoma in 1999. Dr. Byatt reported that Stephenson has symptoms of chronic painful swelling in her left leg with 6 Case No. 14-4154, Stephenson v. Comm’r of Soc. Sec. burning parasthesias on the left leg with hyperparasthesias. Dr. Byatt stated that Stephenson was unable to work, because she could not stand for more than a few minutes. Dr. Byatt indicated that Stephenson could sit for a half hour at a time, could stand for a half hour total in an eight-hour day, could occasionally lift fifteen pounds, would require unscheduled breaks every half hour, and would be absent five days of the month. At the hearing before the ALJ, a vocational expert (“VE”) testified. The VE testified that Stephenson’s past work experience ranged from light to medium exertional levels and unskilled to skilled positions. The ALJ posed a hypothetical question to the ALJ where the individual with the same experience as Stephenson, who is able to lift no more than fifteen pounds, standing and walking at no greater than the sedentary exertional level, but not required to stand or walk for more than a few minutes at a time, with the option of alternating between sitting and standing, would be precluded from using her left lower extremity for pushing, pulling or operation of foot controls, and also precluded from climbing, kneeling, crouching or crawling, with occasional stooping, avoiding exposure to extreme heat. The VE responded that the individual would not be able to perform Stephenson’s past jobs, but identified sedentary jobs which such an individual could perform. The ALJ added a limitation that the individual would be required to elevate her left lower extremity on a regular basis. The VE responded that there would be no 7 Case No. 14-4154, Stephenson v. Comm’r of Soc. Sec. occupations available for such an individual. The VE testified that for semi-skilled jobs, no more than three absences per month would be tolerated, and for unskilled jobs, no more than one or two absences per month would be tolerated. The ALJ found that Stephenson suffered from severe lymphedema of her left leg. The ALJ indicated that this impairment did not meet or medically equal a listed impairment. The ALJ found Stephenson was not credible because of Stephenson’s contradictory statements regarding medication side effects, and her daily living activities, and because the medical evidence did not support Stephenson’s claims of pain. The ALJ noted the lack of objective evidence regarding Stephenson’s claim of headaches and the need to elevate her leg throughout the day.