Opinion ID: 820993
Heading Depth: 3
Heading Rank: 1

Heading: History of Physical and Mental Impairments

Text: Selian began seeing Dr. Mark Corey on January 26, 2007, complaining of chronic pain in both shoulders, shortness of breath, and “severe” fatigue. Dr. Corey found that Selian had some tenderness in his shoulders and “weakly positive” impingement in both shoulders. Selian exhibited a good range of motion, and x-rays of his shoulders showed “no significant findings.” Dr. Corey diagnosed Selian with bilateral rotator cuff tendinitis and probable epicondylitis (i.e., tennis elbow), and initially treated Selian’s tendinitis by injecting both of his shoulders with Lidocaine (a pain reliever) and Depo-Medrol (a corticosteroid). Following this evaluation, Selian filed his initial application for disability insurance with the Social Security Administration (“SSA”) on February 8, 2007. In this application, he claimed -3- that he suffered from torn rotator cuffs in both shoulders, tendinitis in both elbows, and an underactive thyroid gland. On February 21, 2007, after Selian complained of continuing pain in his right shoulder, Dr. Corey prescribed Celebrex for Selian’s pain, assessed Selian as having persistent chronic rotator-cuff tendinitis, and recommended that he follow up with an orthopedist. Approximately one month later, on March 29, 2007, Dr. James Naughten gave Selian a consultative physical examination. Selian complained to Dr. Naughten about his rotator-cuff injuries and asthma. He reported that he experienced “sharp pain,” made worse by lifting, but that his medication helped manage the pain. During Dr. Naughten’s physical examination, he observed that Selian’s stance was normal and that Selian could perform a full squat, but also that Selian walked with a stiff gait and was “unbalanced” when walking on his heels and toes. Selian did not need any assistance to walk or to change his clothes, but he had “mild difficulty” getting on and off the examination table and rising from a chair. Dr. Naughten also administered several physical tests during this examination. The “straight-leg-raising” test was negative on both sides, and Selian displayed a full range of motion in his elbows, forearms, wrists, hips, knees, and ankles. Examining Selian’s shoulders, Dr. Naughten administered several tests and found that Selian’s range of motion in his shoulders was limited. Selian also had reduced sensitivity to touch and pain in both shoulders at the acromioclavicular (“AC”) joints. His hand dexterity and finger dexterity were intact, but his grip strength was reduced on both sides. An x-ray of his left shoulder suggested the “possibility of rotator cuff impingement syndrome.” Dr. Naughten acknowledged in his notes that Selian had a history of bilateral rotator-cuff injuries, asthma, and substance abuse. Dr. Naughten concluded that Selian would have no limitations in his ability to see, hear, talk, sit, or stand, but would have -4- moderate limitations in walking, climbing stairs, pushing, pulling, and reaching. He also opined that Selian could lift and carry “a mild degree of weight on an intermittent basis.” The same day that Selian saw Dr. Naughten, he also saw Dr. Dennis Noia, who performed a consultative psychological examination. Selian reported that he was experiencing difficulty sleeping, a decreased appetite, and multiple symptoms of depression, including dysphoric moods, crying spells, guilty feelings, hopelessness, and difficulties with memory and concentration. At the time of the examination, Selian was taking Cymbalta (an anti-depressant), which had improved his condition but had not eliminated his symptoms. Dr. Noia found that Selian’s intellectual functioning was in the average range, and that his judgment and insight were good, but also that his recent and remote memory skills were “mildly impaired.” Dr. Noia diagnosed Selian with a depressive disorder. In Dr. Noia’s opinion, Selian was able to understand and follow simple and some complex tasks, both with supervision and independently. He could learn new tasks, make appropriate decisions, appropriately relate to and interact with others, maintain attention and concentration on tasks, and follow a routine. By Selian’s next appointment with Dr. Corey on May 30, 2007, Selian had developed upper back spasms. He reported that another doctor “felt that he had fibromyalgia.” On physical examination, Selian displayed a reasonable range of motion in his shoulders but with “marked muscular tenderness posteriorly” and “tender points in various locations.” Dr. Corey assessed “[f]ibromyalgia-type pain,” which he determined was also associated with Selian’s sleeping and mood problems. He prescribed Selian Elavil (an antidepressant), and encouraged Selian to follow up with a psychiatrist. -5- A few weeks later, on April 17, 2007, a State-agency psychologist, Dr. E. Kamin, conducted a psychiatric assessment of Selian. Dr. Kamin indicated that Selian had mild limitations in his daily activities, that he had mild difficulties maintaining social functioning, and moderate difficulties maintaining concentration, persistence or pace. In terms of Selian’s mental functional capacity, Dr. Kamin concluded that Selian was moderately limited in his ability to understand and remember detailed instructions, but that he could remember short and simple instructions or work locations and procedures. Selian appeared moderately limited in his ability to respond appropriately to changes in his work setting. Dr. Kamin ultimately concluded that Selian’s allegations of psychiatric symptoms were “partially credible but not to the extent that he alleges,” and that he was able to perform simple tasks. On June 20, 2007, Selian saw Deena J. Schwartz, a nurse practitioner, for chronic pain and dysphoric mood. Selian told Nurse Schwartz that he had difficulty falling asleep at night and would wake up three hours later, and that he was napping during the daytime. He said that he thought he had fibromyalgia, and “possibly [c]hronic [f]atigue [s]yndrome.” Nurse Schwartz noted that her examination with respect to Selian’s mental status was “essentially unremarkable.” She also indicated that Selian’s mood was initially stable and cooperative but later degenerated; he became irritable and impatient, and his affect became arrogant and sarcastic. Schwartz indicated that she thought Selian had a “[r]eactive and irritable mood but no clear [b]ipolar symptoms or” other psychiatric diagnosis. She recommended that Selian continue therapy. Selian returned to Dr. Corey on June 25, 2007, for a follow up, and reported that he had seen a mental-health counselor. In his words, his sleep difficulties had improved “90%” and his -6- back pain was “pretty much resolved,” although he continued to feel pain in his shoulders. His affect was “reasonably appropriate.” He no longer had much posterior muscle tenderness. Dr. Corey assessed depression with some improvement and chronic pain syndrome with mild improvement, and increased Selian’s Elavil dosage. On September 4, 2007, Selian returned to Corey and reported improvement in his pain from a “10 out of 10” on the pain scale to a “5 out of 10.” He also stated, however, that he was having problems with his memory, as well as grogginess, trouble sleeping, and an increased appetite and weight gain. Dr. Corey determined that Selian was exhibiting fibromyalgia — which “apparently improved with Elavil” — excessive fatigue due to sleep disturbances and sleep apnea, cognitive difficulties related to depression, and hypothyroidism, the last of which was unlikely to cause his symptoms.1 Selian began mental therapy in September 2007, according to Nurse Schwartz’s treatment notes, and he spent “much of his time offering [reasons] why he needs disability” benefits. Selian complained of chronic daily pain and said that he could not “move, walk or sit,” and that the Elavil “sort of work[ed].” His mood was neutral and he had a full range of affect. Schwartz stated that she thought Selian suffered from an adjustment disorder due to chronic pain, and also noted that Selian was recovering from cocaine addiction. She found “inconsistencies in [Selian’s] reported history and behavior” and suspected he was malingering to obtain disability benefits. She prescribed him Prozac on a trial basis. 1 At this time, Selian also updated his application for disability benefits to include fibromyalgia. -7- Selian saw Schwartz again on December 3, 2007, and reported that he had run out of medication. Schwartz explained to Selian that this was inconsistent with his medical history; his last prescription had been refilled less than three weeks earlier, with three refills. Selian complained that he had been in “so much pain” recently, and he became agitated when Schwartz addressed his medication. Schwartz restarted him on Prozac and wrote another prescription for it. On July 23, 2008, Virginia Bronson, a licensed social worker, completed a questionnaire regarding Selian’s mental condition. She indicated that Selian had “moderate” limitations in the areas of maintaining attention and concentration for extended periods of time, performing activities within a schedule, maintaining regular attendance and punctuality, completing a normal work day and work week without interruptions from psychologically based symptoms, and performing at a consistent pace without an unreasonable number of rest periods. She indicated that Selian had “marked” limitations in his ability to carry out an ordinary routine without special supervision; interact appropriately with the public; accept instruction and respond to criticism appropriately; get along with coworkers; and appropriately respond to ordinary stressors and changes in the work setting. Bronson also indicated that Selian’s mental condition would cause him to have more than three absences from work per month. Dr. Corey completed a questionnaire for Selian on July 24, 2008. He indicated a diagnosis of fibromyalgia and possible rotator-cuff tendinitis, noting that Selian’s “condition is largely subjective in nature.” Corey opined that Selian would need to take rest breaks of more than one 10 minutes rest period per hour while working. He also stated that Selian could not sit for six or more hours a day and could stand for at least two hours in an eight-hour workday. He -8- explained that Selian’s medication would affect his concentration and ability to sustain a work pace “at least moderately.” Based on a referral from Dr. Corey, Dr. Paul Dura, a rheumatologist, undertook a consultative examination of Selian on May 18, 2009. Selian reported a history of fibromyalgia and depression to Dr. Dura and described a variety of pains in his body, as well as fatigue. Selian told Dr. Dura that he was unable to walk from his house to the mailbox and back and that he walked with a stiff gait. On physical examination, Dr. Dura found that Selian appeared healthy, and that he was able to get on and off the examination table and a stool without difficulty. Selian exhibited a good range of motion. Dr. Dura found no swelling in Selina’s shoulders, but also observed that moving Selian’s shoulders caused him some discomfort. Dura noted “numerous soft tissue tender points,” and reported to Dr. Corey that Selian “appear[ed] to have fibromyalgia syndrome” and “perhaps early degenerative arthritis.”