Opinion ID: 76431
Heading Depth: 2
Heading Rank: 3

Heading: Medical History From Treating Physicians

Text: 9 In 1993, Phillips began treatment with Dr. Sam Schatten, a rheumatologist. Phillips complained of: eye, mouth, and nail dryness; memory loss; itching; muscle pain; low energy; fatigue; trouble sleeping; easy bruising; and mitral valve prolapse. Dr. Schatten remained Phillips's primary treating physician through the time of her administrative hearing in this case. 10 Dr. William Whaley, a specialist in oncology and hematology, examined Phillips on July 13, 1995, and indicated that he thought Phillips had Sjögren's syndrome, mitral valve prolapse syndrome, multiple urinary tract infections, fibrocystic disease of the breast, and allergies. Dr. Whaley reported that [t]he problem list looks a little long, but [Phillips] is basically a 40 year old completely and fundamentally healthy state employee. 11 On February 26, 1996, Phillips saw Dr. Olivia Mulligan, an endocrinologist, complaining of night sweats, muscle pain, irritability, and brief depression. However, all test results were normal. 12 On October 14, 1996, Phillips saw Dr. Amy Lang, a specialist in physical medicine and rehabilitation, complaining of constant neck and back pain that averaged 5 on a scale of 1 to 10 in intensity. Dr. Lang reported that the pain was beginning to interfere with Phillips's participation in social and recreational activities and completion of household chores and projects. Dr. Lang noted that Phillips demonstrated multiple symmetric tender points above and below the diaphragm meeting the criteria for fibromyalgia syndrome. An October 26, 1996, radiology report indicated small to moderately sized disc herniation in two places on Phillips's cervical spine. The remainder of Phillips's spine appeared normal. 13 On December 30, 1996, Phillips's psychologist, Mary Melton, Ph.D., terminated treatment after six months, noting major depression resolved. On an employer's form for disability retirement verification, Dr. Melton noted that Phillips's depression was not disabling, and that Phillips had been successful in treatment for depression and in altering lifestyle to adjust for her chronic illness. 14 On December 31, 1996, Dr. Lang noted that Phillips's left-sided neck pain is `almost well.' Dr. Lang's examination notes indicated that Phillips's cervical active range of motion was within normal limits with no pain reported. Dr. Lang diagnosed cervical facet syndrome (characterized by neck pain and a decrease in range of motion of the neck); regional myofascial pain syndrome of the neck and upper back; bilateral sacroiliitis (inflammation of the sacroiliac joint (located between the lumbar spine and the pelvis)); one centimeter right leg length discrepancy; depression, with noted intolerance of Paxil side effects; and Sjögren's syndrome, noted as stable. Dr. Lang provided Phillips with heel inserts to correct the leg discrepancy and to help Phillips's sacroiliitis. That same day, Dr. Lang wrote a separate report to an insurance provider, diagnosing fibromyalgia and cervical degenerative disease. 1 15 On February 26, 1997, Dr. Lang noted that Phillips's stabilization exercises and stretching program had helped to decrease fibromyalgia symptoms and that her pain had been reduced to soreness. On May 28, 1997, Dr. Lang documented Phillips's problems as Sjögren's syndrome; fibromyalgia; cervical spondylosis (lesion of the spine of a degenerative nature); cervical facet syndrome; bilateral sacroiliitis; pes planus (flatfoot); one centimeter leg length discrepancy; and depression, noted as treated. 16 Dr. Lang noted that Phillips did not pursue cervical facet rhizotomy (surgical severance of spinal nerve roots to relieve pain), nor did Phillips fill the prescription for orthotics to correct the leg length discrepancy. Dr. Lang indicated that Phillips was planning to file for long-term disability due to inability to keep up with the pace at work. Dr. Lang wrote that virtually all activities of daily living aggravated Phillips's pain problems, and that she felt overwhelmed by chronic pain and depression. 17 On June 25, 1997, Dr. Whaley evaluated Phillips and performed comprehensive laboratory and physical testing. Dr. Whaley described the issue as: is she disabled by virtue of a medical condition such as hypothyroidism, lupus, collagen vascular disease, or is the disability psychiatric? On July 16, 1997, Dr. Whaley documented normal test results and reported that [w]e still don't know if she really is disabled or not but if she is disabled, it is certainly not from anemia, hypothyroidism, biochemical abnormality or lupus. Dr. Whaley noted that Phillips was to be seen by Dr. Gene Abel, a psychiatrist, for evaluation and consultation. 2 Dr. Whaley also noted that Phillips had discontinued using Plaquenil, a drug used to manage the symptoms of Sjögren's syndrome. 18 On July 22, 1997, Dr. Susan Dreyer, a specialist in physical medicine, diagnosed chronic back and neck pain, secondary to fibromyalgia; remote history of disk herniation (stable); and history of depression. Dr. Dreyer emphasized the importance of aerobic exercise and stretching in treating fibromyalgia. Radiology reports from that day revealed that Phillips's lumbar spine was normally aligned and the interspaces were well maintained, with mild degenerative disc disease at one of Phillips's vertebrae. 19 On November 5, 1998, Dr. Schatten indicated that Phillips's exercise routine consisted of water aerobics 2-3 times weekly and walking one and a half miles four to five times per week. On December 21, 1998, Dr. Whaley wrote, Phillips is much better now in exercise than she has been in prior years going 5 days a week, 2 sessions of water aerobics, 3 on a stationary bike, and some light weights for osteoporosis prevention. 20 A February 24, 1999, assessment of Phillips's psychological condition by Gary Bible, Ph.D., indicated that typical activities for Phillips included reading, stretching and bending exercises, watching television, doing a small amount of chores, preparing dinner without difficulty, preparing sandwiches for lunch, eating out two or three times per week, visiting with a friend twice per week, talking on the phone, shopping for groceries twice a week, trips outside the home to do errands or visit friends two to three times per week, and occasional movies or trips to Florida. Dr. Bible's impression was that Phillips was capable of functioning within any number of simple and minimally demanding work settings that would make allowances for her medical problems. He noted that Phillips appeared quite capable of understanding and carrying out simple instructions and handling social interactions, but that Phillips had mild impairments with regard to sustaining focused attention and task persistence. 21 On March 9, 1999, Phillips saw Dr. John Horney, a specialist in gastroenterology, for an assessment of her bowel condition that she indicated was a problem for approximately five years. Phillips described her symptoms as constipation alternating with diarrhea with some associated left lower quadrant pain. Dr. Horney diagnosed [c]hange in bowel habits consistent with irritable bowel syndrome. A flexible sigmoidoscopy (a procedure in which a scope is used to view the colon) was normal. 22 Phillips saw Dr. Robert Cowles III in January of 1999 for recurrent urinary tract infections. On April 19, 1999, Dr. Cowles reported that Phillips's symptoms have completely resolved on the Macrobid suppression and she is not only asymptomatic but says she has not felt this well in many years. 23 On May 3, 1999, Dr. Schatten noted that Phillips had a runny nose and runny eyes, but that prior to the date of the exam, she overall felt good with intermittent fatigue, depression, LBP [lower back pain], pain in hips, thighs, and knees. He noted further that Phillips had neck and trapezii pain with activity, but that the pain was less severe overall than before. Dr. Schatten assessed Phillips as having primary Sjögren's syndrome, stable; cervical myofascial pain syndrome, stable; urinary tract symptoms, treated well with drugs; osteoporosis; intermittent myalgias (pain in the muscles) of the lower back and lower extremities, exact etiology unclear; and allergic sinusitis. 24 In a functional capacities evaluation completed on January 24, 2000, Dr. Schatten reported that Phillips: (1) could work three hours in an eight-hour day; (2) could sit intermittently for up to 30 minutes; (3) could stand and walk up to 30 minutes; (4) had to lie down three to four times per day for 30 minutes to an hour at a time; (5) could never lift or carry more than ten pounds, and occasionally could lift or carry up to 10 pounds; (6) could use her hands and feet for repetitive actions; (7) could never crawl or climb; (8) could occasionally bend, squat, or reach; and (9) had mild restrictions for activities involving unprotected heights and exposure to changes in climate, moderate restrictions for activities involving exposure to dust, fumes and gases, and no restrictions for activities involving moving machinery or driving automotive equipment. Dr. Schatten's medical rationale for the assessment was listed as: Sjögren's syndrome; fibromyalgia; myofascial pain; sleep disorder; cervical facet syndrome, including several surgeries; and frequent urinary tract infections.