Opinion ID: 2819117
Heading Depth: 2
Heading Rank: 1

Heading: Baker's Medical History

Text: Baker is a 58-year-old male suffering primarily from back pain. Baker served in the military during the 1970s and has worked consistently over the years in sedentary, light, and heavy work. Baker injured his back on the job on October 30, 2008, lifting heavy flooring panels. Baker visited a medical center on October 31, 2008, to address the back pain. An examination showed that Baker performed negatively on his straight-leg raising test but otherwise had normal gait, normal reflexes, and a full range of motion in his back. The examining physician put Baker on moderate activity restrictions, and Baker underwent a course of physical therapy at the Veterans Administration Medical Center (VAMC). When Baker completed physical therapy several months later, the discharge notes stated that Baker continues with some pain but that it was manageable with pain medication and traction stretches. On November 14, 2008, Baker underwent an x-ray on his back. The x-ray revealed that Baker had mild degenerative disc disease at L2-L3 and L3-L4 with no evidence of acute injury. 1 The Honorable Thomas D. Thalken, United States Magistrate Judge for the District of Nebraska, to whom the case was referred for final disposition by consent of the parties pursuant to 28 U.S.C. § 636(c). -2- On December 16, 2008, Dale Davis, a Physician's Assistant, examined Baker and noted several uncontrolled conditions. Among other things, Davis recorded that Baker had uncontrolled obesity, uncontrolled degenerative disc disease, and controlled [h]earing [l]oss w/ intermittent tinnitus. In a follow-up exam on March 11, 2009, Davis noted that Baker's [s]pine shows no vertebral tenderness. On April 29, 2009, Dr. Glen Knosp, M.D., a state physician, examined Baker and completed a physical residual functional capacity (RFC) assessment. Baker reported that he had pain all the time [and] cannot twist, bend or stand without pain. Baker also stated that he can only walk for 10 minutes, stand for 10 minutes and sit for 15–30 minutes because of the pain in his lower back. After reviewing Baker's medical history and conducting a physical examination, Dr. Knosp considered Baker to be only partially credible and concluded that the examination did not support the degree of limitations that [Baker] alleges in terms of walking, standing, [and] sitting. Dr. Knosp instead concluded that Baker could stand or walk for six hours each day and could sit for six hours each day. Dr. Knosp also opined that Baker could occasionally lift 20 lbs. and could frequently lift 10 lbs. Finally, he opined that Baker could frequently climb ramps and stairs, balance, kneel, and crawl and could occasionally stoop and crouch. On July 10, 2009, Dr. Jerry Reed, M.D., also a state physician, reviewed Dr. Knosp's medical opinion and agreed with its conclusions. On July 9, 2009, Baker underwent an MRI on his spine. The MRI revealed a mild diffuse disc bulge at L5-S1 and moderate facet degenerative changes at L4L5 and L5-S1. While the radiologist concluded that Baker had [m]ild multilevel [degenerative disc disease], he also found that Baker's [v]ertebral body height and alignment are normal without subluxation, that there were [n]o destructive lesions, and that [p]araspinal soft tissues [were] normal. On September 9, 2009, Davis completed a RFC questionnaire. Davis stated that Baker's diagnoses included, among other things, degenerative disc disease [in the] -3- LS spine, myofascial pain [in the] mid back, meralgia parasthetela [in the] right thigh . . . obesity, [and] hearing loss w/ intermittent tinnitus. Davis reported that Baker could only sit for 30 minutes, stand for 20 minutes, would have to get up and walk every 15 minutes, and could only sit and stand for a total of six hours each day. Davis also reported that Baker could occasionally twist, stoop, crouch, and climb stairs; that he could rarely climb ladders; and that he could occasionally lift 20 lbs. On November 12, 2010, Baker underwent an audiology exam to test his hearing loss. The exam revealed that Baker had high-frequency hearing loss and required hearing aids. This hearing loss was confirmed in further testing on December 9, 2010. On January 26, 2011, Dr. Isaac Witkowski, M.D., examined Baker. Dr. Witkowski noted Baker's hearing loss and complaints of tinnitus. Regarding Baker's back, Dr. Witkowski found that Baker's gait was abnormal and that Baker appeared to have moderate back pains. Dr. Witkowski's report specifically states that there was [n]o testing today. Testing was gathered throughout a review of CPRS.2 Dr. Witkowski's report also stated that in regard to Baker's disabilities, [a]ll disabilities are listed as above. No testing was performed. Dr. Witkowski ultimately diagnosed Baker with, among other things, [m]yofascial [p]ain [s]yndromes, [d]egeneration of intervertebral discs, and [s]ensorineural [h]earing [l]oss. According to Dr. Witkowski, this affected Baker's mobility, his ability to lift and carry, and his ability to reach. He further opined that Baker can sit for 30 minutes and stand for 15 minutes and walk about one block. Dr. Witkowski concluded that Baker's back condition was disabling because of frequent pain episodes. On March 2, 2011, the Department for Veterans Affairs (VA) issued a decision that Baker was partially disabled on account of his mild tinnitus, bilateral hearing 2 CPRS stands for a computerized patient record system. See Bd. Vet. App. 0822815 (2008). -4- loss, and various other medical conditions. This decision relied on medical evidence from Omaha VAMC Records from February 16, 2005 through January 27, 2011, as well as Dr. Witkowski's VA examination dated January 26, 2011. First, the decision assigned Baker a ten percent disability rating for his tinnitus because it is at least as likely as not that the tinnitus is related to the claimed military noise exposure. This finding corroborated Baker's later testimony before the ALJ that he developed tinnitus because of all the noise that he experienced as an airplane mechanic for the marines. Next, Baker's claim related to bilateral hearing loss was also granted. In regard to his other medical conditions, the decision found that Baker was disabled due to the following disability(ies): right foot condition, chronic mechanical low back strain with multilevel degenerative disc disease, diabetes mellitus type II, myofascial pain syndromes, hypertension NOS, [e]rectile dysfunction, myocardial infarction with dyspnea on exertion, dermatitis, meralgia paresthetica. These disabilities combine to 70% disabling. On March 28, 2011, Dr. Meryl Severson, II, M.D., a state physician, examined Baker. Dr. Severson diagnosed Baker with degenerative disc disease at L5-S1, mild degenerative facets changes in the lumbar spine, and chronic back pain. Dr. Severson also noted that Baker could perform most daily activities with little to no difficulty. Dr. Severson also opined that Baker could sit and stand for 25 minutes at a time and could walk for 15 minute intervals. In total, Dr. Severson concluded that Baker could sit for 175 minutes, stand for 175 minutes, and walk for 60 minutes during a workday. According to Dr. Severson, Baker could lift up to 10 lbs. frequently and could lift up to 20 lbs. occasionally. Finally, Baker could balance, stoop, kneel, crouch, and crawl occasionally; climb stairs and ramps frequently; but could not climb ladders or scaffolds. On July 14, 2011, Dr. James Bane, M.D., another state physician, examined Baker and completed a physical RFC assessment. Along with the physical examination, Dr. Bane also based his opinion upon a review of Baker's medical -5- records from 2010–11. Dr. Bane opined that Baker could occasionally lift 20 lbs. and could frequently lift 10 lbs. Dr. Bane also found that Baker could stand or walk for about six hours a day and could also sit for about six hours a day. Dr. Bane further found that Baker could occasionally climb ramps and ladders, balance, stoop, kneel, crouch, and crawl. In 2012, Baker continued to take pain medication and see physicians. On March 9, 2012, Dr. Christine Mitchell, M.D., examined Baker. Baker told her that his chronic pain was stable but that he continued to use pain medication and muscle relaxers. Later in the year, on September 19, 2012, Baker again enrolled in physical therapy for his back pain. On September 27, 2012, Baker commented that his back pain was temporarily relieved after heat therapy and back traction, but that it soon returned to a high pain level.