Opinion ID: 2978289
Heading Depth: 3
Heading Rank: 1

Heading: Physical

Text: Simpson’s past medical history includes a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Treatment notes prepared by Dr. Thomas W. Wehmann reveal that Simpson had two incisional hernia repairs in her inguinal region in 2000 and 2001 as a result of her hysterectomy. Beginning in January 2003, Simpson sought treatment for pain in her right hip, pelvic and inguinal areas, after doing some heavy lifting, along with facial pain, shoulder pain and depression, which she had been previously experiencing. She saw a series of doctors throughout 2003 and 2005, who treated her with medication but were unable to cure her of the pain she was experiencing on the right side of her body, particularly in her hip, pelvic and inguinal areas. Notably, on January 5, 2004, Simpson agreed to proceed with surgery to repair what appeared to be a right inguinal hernia. The surgery took place on January 20, 2004, and Dr. Wehmann noted that the surgery revealed “a lot of reaction and scar tissue.” On February 6, 2004, Simpson was admitted to the Cuyahoga Falls General Hospital, with a chief complaint of right inguinal abdominal pain and swelling. She also complained of rectal pain and bleeding. “A CT scan of her abdomen and pelvis revealed a supra rectus muscle abscess,” and she underwent a “percutaneous drainage of the abdominal seroma” by general surgery the day she was admitted. Simpson was discharged on February 11, in stable condition, with a series of No. 08-3651 Simpson v. Comm’r of Soc. Sec. Page 5 medications and an assessment of noninfectious seroma and proctitis. On February 24, 2004, Simpson was again admitted to the Cuyahoga Falls General Hospital still complaining of right lower quadrant pain. She underwent a procedure the next day in which Dr. David Dellinger explored her abdominal wound, drained a hematoma, and excised the entire hematoma pocket found. On March 19, 2004, Simpson reported to Dr. Garimah Jones that she continued to have pain following her surgery on February 25, 2004. Dr. Jones noted that Simpson was wincing during the interview, sitting very still while holding her side, and clenching her fist during the exam. Dr. Jones prescribed some medication and informed the patient that she was “most likely unable to make her pain free,” and so encouraged her to manage and to control her pain. On April 28, 2004, Dr. Elizabeth Das, a physician for the state agency, reviewed Simpson’s file and determined that she was not disabled. On May 25, 2004, Simpson was again seen by Dr. Jones. Simpson reported that she had been to the pain management clinic at the Cleveland Clinic Foundation six times, was told that she had “nerve entrapment,” and stated that “they’ve done nothing for me.” Simpson returned for a followup appointment with Dr. Jones on June 18, 2004, and reported that she went to the pain management clinic again and received an intraarticular shot that only lasted for a short time. Based upon this appointment, and the previous ones with Simpson, Dr. Jones filled out a questionnaire from the Social Security Administration (“SSA”) describing Simpson’s “longstanding history of endometriosis,” noting that Simpson is barely able to sit, appears in moderate distress and has diffuse pain to minimal palpitations in her right lower quadrant area. Dr. Jones also noted that Simpson “would be unable to perform any employment that requires prolonged sitting.” “She is also unable No. 08-3651 Simpson v. Comm’r of Soc. Sec. Page 6 to perform changes in position (i.e., bending, lifting)” and her “chronic pain limits her ability to communicate with others.” On August 18, 2004, Dr. David A. Rath, a physician for the state agency, reviewed Simpson’s file and determined that she was not disabled. On September 22, 2004, Dr. Scott Bedwell of St. Vincent Health Center performed the following procedure on Simpson: “excision of mesh versus tumor with repair of resultant hernia using alloderm mesh.” During the procedure, Dr. Bedwell found “a wadded mass along the medial aspect of the inguinal canal,” and “a very densely adherent loop of small bowel to the undersurface of th[e] mesh which was dissected free.” His post-operative diagnosis was a foreign body reaction to implanted mesh or a tumor. On January 25, 2005, Simpson underwent a diagnostic laparoscopy at Barberton Citizens Hospital, performed by Dr. Stephen D’Abreau, and was diagnosed with chronic pelvic pain and multiple pelvic adhesions, some of which “were intimately associated with bowel and could not be dissected off safely using the laparoscope.” Dr. D’Abreau referred Simpson to Dr. Robert Geiger, whom she saw on March 28, 2005. Dr. Geiger assessed that Simpson’s right inguinal pain is “probably secondary to neuralgia/neuritis of local nerves trapped within surgical scar tissue,” and that her right anterior thigh pain “could be anterior cutaneous nerve of the thigh, but in combination with back pain could be a manifestation of L4 sciatica.” Dr. Geiger took charge of ordering Simpson’s medication, ordering an MRI of the lumbosacral spine, and recommended that she go to physical therapy. The results of the MRI indicated three mild disc bulges, with mild spinal canal stenosis and an absence of foraminal stenosis. No. 08-3651 Simpson v. Comm’r of Soc. Sec. Page 7 From April through June 2005, Simpson attended seven physical therapy sessions and “ was very pleased with her progress,” reporting “it was the most she has ever improved” in physical therapy. On June 2, 2005, Simpson underwent colon surgery performed by Dr. Bedwell, who “found a fairly large defect in [Simpson’s] right inguinal area with adhesions going up into the sac . . . and found that the colon was tightly adhesed into the sac right into the femoral canal.” As a result of her surgery, Simpson was unable to return to physical therapy for re-evaluation. Simpson saw Dr. Benson Bonyo from June 2004 through October 2005. On October 5, 2005, Dr. Bonyo completed a “Residual Functional Capacity Questionnaire” for Simpson, in which he opined that Simpson has a severe medical impairment that should limit her ability to do work-related activities and that she should not be “lifting, [carrying,] pushing or bending over 5 [pounds].” In an 8-hour day, Dr. Bonyo stated that Simpson should not sit, stand, walk, or work at all. He stated that Simpson can use her hands for simple grasping and fine manipulation but not for pushing or pulling. He also opined that she cannot use her feet for repetitive movements such as operating foot controls. Dr. Bonyo stated that Simpson could occasionally crawl, reach or kneel but could never bend, squat, climb, stoop, or crouch.