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Bute v. Commissioner Social Security Administration

United States District Court, D. Oregon, Medford Division

March 28, 2018

HOLLY ANN MCDANIEL BUTE, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY,[1] Defendant.

          OPINION AND ORDER

          Youlee Yim You United States Magistrate Judge.

         INTRODUCTION

         Plaintiff, Holly A. McDaniel Bute (“Bute”), seeks judicial review of the final decision by the Social Security Commissioner (“Commissioner”) denying her application for Disability Insurance Benefits (“DIB”) and Supplementary Security Income (“SSI”) under Titles II and XVI of the Social Security Act (“SSA”), 42 U.S.C. §§ 401-433. This court has jurisdiction to review the Commissioner's decision pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3). For the reasons set forth below, that decision is AFFIRMED.

         PROCEDURAL HISTORY

         Bute protectively filed for DIB and SSI on March 5, 2013, alleging a disability onset date of August 1, 2012. Tr. 198, 205.[2] Her applications were denied initially and on reconsideration. Tr. 74-81, 106-16. On February 17, 2015, a hearing was held before Administrative Law Judge (“ALJ”) Robert F. Spaulding. Tr. 42-73. The ALJ issued a decision on May 11, 2015, finding Bute not disabled. Tr. 21-33. After the Appeals Council denied Bute's request for review on October 26, 2016, the ALJ's decision became the Commissioner's final decision subject to review by this court. Tr. 1-4; 20 C.F.R. §§ 404.1581, 416.981.

         BACKGROUND

         Born in September 1957, Bute was 58-years-old at the time of the ALJ hearing. Tr. 74. Bute is a high-school graduate and attended college for one year. Tr. 227. She worked as a mortgage banker from 1997 until August 1, 2012. Tr. 52, 103. Bute alleges she is unable to work due to a combination of: degenerative joint disease of the left hip; degenerative joint disease of the left shoulder; plantar fasciitis; sinus tarsi syndrome; obesity; anxiety; chronic fatigue, high blood pressure; edema; and hidradenitis suppurativa (“HS”).[3] Tr. 73, 83; Pl.'s Br. at 2.

         RELEVANT MEDICAL BACKGROUND

         On November 7, 2011, Bute was treated for an infected “bump” on her inner groin area[4] Tr. 357. She was diagnosed with HS and prescribed medication. Id. Bute did not have any skin lesions at treatment visits in December 2011. Tr. 373, 379. At that time, she also denied depression and anxiety, as well as muscle aches and joint pain. Id.

         On April 18, 2012, treatment records show her HS was “improved.” Tr. 359. Bute displayed no skin rashes at a medical visit on April 23, 2012. Tr. 355. In July 2012, records show that she had no skin lesions, no musculoskeletal pain, and no depression or anxiety. Tr. 362-64. She reported that she was moving to Oregon. Tr. 706.

         In May 2013, Bute was treated by Cheri M. Monteith, a nurse practitioner (“NP”) in Bly, Oregon. Tr. 393. Bute reported that she had recently moved to Oregon with her then fiancé (now husband) “for retirement.”[5] Id. Bute stated that she had a history of HS with “approximately 5-6 flare ups per month, ” and that she was using Ampicillin every six hours for flare-ups. Id. On examination, Bute's skin was negative for lesions. Tr. 393-94.

         On May 23, 2013, Mike Henderson, D.O., performed a consultative examination of Bute. Dr. Henderson diagnosed her primary impairment as “chronic fatigue, ” “due to severe depression associated with job loss, bankruptcy, home foreclosure, and divorce.” Tr. 401. Bute told Dr. Henderson that she “quit her job to move to Oregon and reduce stress.” Tr. 399. Dr. Henderson assessed left hip pain that “may be trochanteric bursitis versus mild posture arthritis.” Id. He also assessed left shoulder impingement caused by a bone protrusion of the acromion, which restricted her overhead reaching above shoulder height. Tr. 400-01. Dr. Henderson opined that Bute's HS was “intermittent and treatable, ” but “[i]f she does have a flare, [she] would have to avoid prolonged sitting for more than an hour at a time.” Tr. 401. Dr. Henderson concluded that there was no objective evidence to support a limitation in sitting, walking, or standing, and that Bute's “main limitations are secondary to obesity, deconditioning, [and] severe depression.” Id.

         In June 2013, Bute saw Dr. Edward Trobaugh. Her primary diagnosis was malaise and fatigue, likely caused by chronic fatigue syndrome “but may be OSA, depression, hypothyroidism.” Tr. 440. Dr. Trobaugh also noted foot pain consistent with plantar fasciitis, citing weight as a factor. Id. Bute had gained 50 pounds over the previous five to six years, and her body mass index was 47. Tr. 439-40.

         Bute began treatment with her primary care provider, Debra Hartley, M.D., in August 2013. Tr. 953. Bute expressed concern about her weight, fatigue, and general body pain, including leg pain when she walked. Id. She was 5'4” tall, weighed 278 pounds, and had a BMI of 47.72. Tr. 956.

         In September 2013, Bute complained of left shoulder pain. Tr. 948. In 2007, she had an injury, which resulted in an MRI and diagnosis of “supraspinatus tear vs tendinopathy.” She did pursue surgery, but had an injection in 2008, but still found the area was painful. Id. She received a steroid injection in her left shoulder. Tr. 949.

         In October 2013, Bute reported that her shoulder pain improved following a steroid injection but she was still able to raise her elbow over her head. Tr. 423. Her range of motion was within normal limits. Id. Dr. Hartley also noted that Bute had a history of HS: “[s]he has a lesion on her inner groin area that will get big and will break open and a [sic] decrease in the pressure. She will then have pus and blood that seeps for a couple of days but does not heal. Right now it is not inflamed . . . outbreaks tend to be worse in the summer. She rarely has outbreaks in her axilla [armpits].” Id. The doctor indicated that Bute “will call when she has a flare up.” Tr. 424.

         Bute saw Dr. Laneah Snyder on February 12, 2014, to follow up on an emergency room visit for chest pain. Tr. 747. She displayed no skin rash at that time. Id.

         On February 20, 2014, Bute was observed to have a skin rash on her face, neck, and upper chest, which was thought to be a “stress reaction.” Tr. 1008-09.

         On March 5, 2014, Bute's primary complaint was fatigue. Tr. 924. She was given a referral to a sleep medicine clinic. Id. Bute endorsed exercise-induced foot pain. Id. She was positive for skin rash, which was associated with anxiety. Tr. 922.

         On May 1, 2014, Bute was again negative for skin rash. Tr. 915.

         Bute was treated by NP Monteith again on May 12, 2014. Bute was advised to continue daily Hibiclens use and Ampicillin for HS outbreaks, but it was also noted that Bute's skin was negative for “concerning lesions.” Tr. 788. Bute was referred to dermatology for continuing management of HS, and because Bute's sister had melanoma. Tr. 789.

         On May 27, 2014, Bute received an injection in her left foot (specifically, the sinus tarsi). Tr. 774. Her doctor recommended she participate in walking exercises, but that she should avoid uneven surfaces. Id.

         At a visit in June 2014, Bute was negative for skin rash. Tr. 909.

         In July 2014, Bute asked for a referral to physical therapy for foot and hip pain. Tr. 994. It was noted Bute had never had an MRI of her back. Id. She was negative for skin rash. Tr. 995.

         A “medical source statement” form was completed by physical therapist G. Eric Mills (“Mills”) on July 23, 2014. Mills diagnosed left lower back pain with radiculopathy and left shoulder impingement syndrome, and indicated that the symptoms would “seldom” be severe enough to affect Bute's attention and concentration to work tasks. Tr. 834. He also indicated Bute could sit for four hours, stand for two hours, and walk for two hours of an eight-hour day. Id. He further noted that Bute would need to take short unscheduled breaks for positional changes four times per day. Tr. 836. Mills concluded Bute “would have a difficult time in most occupations due to her multiple medical conditions.” Tr. 837.

         Bute was negative for skin rash in July 2014. Tr. 991.

         Bute was negative for skin rash in August 2014. Tr. 988.

         Bute was negative for skin rash in December 2014 but requested an injection to ...


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