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Sanchez v. Colvin

United States District Court, D. South Dakota, Southern Division

June 26, 2015

ROSE E. SANCHEZ, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner, Social Security Administration, Defendant.

MEMORANDUM OPINION AND ORDER AFFIRMING THE DECISION OF COMMISSIONER

KAREN E. SCHREIER, District Judge.

Plaintiff, Rose E. Sanchez, seeks review of the decision of the Commissioner of the Social Security Administration denying her claim for disability insurance benefits. The Commissioner opposes the motion and moves the court to affirm the denial. For the following reasons, the court affirms the decision of the Commissioner.

PROCEDURAL HISTORY

Sanchez applied for benefits on June 14, 2011, alleging disability since August 15, 2010. AR 156-62.[1] The Social Security Administration (SSA) denied Sanchez's application initially on August 18, 2011, and again upon reconsideration on January 25, 2012. AR 23, 78-83. Sanchez then requested an administrative hearing and appeared with counsel before Administrative Law Judge James Olson (ALJ) on January 30, 2012. See AR 38-54. Thereafter, the ALJ issued an unfavorable decision finding that Sanchez retained the residual functional capacity (RFC) to perform past relevant work. AR 20-32. Accordingly, the ALJ determined Sanchez was not disabled. AR 32. Sanchez timely appealed the ALJ's decision and requested review by the Appeals Council. Her request was denied on April 8, 2013.[2] AR 1-7, 18. On May 8, 2014, Sanchez commenced this action seeking judicial review of the Commissioner's denial of her claim. Docket 1.

FACTUAL BACKGROUND

Sanchez was born on September 25, 1957. AR 156. Sanchez obtained her GED in June 1991. AR 203. She completed CNA job training in June 2000. Id. Sanchez reported working three jobs from 1995 until the time of her application. She worked at a factory, a nursing home, and most recently at a convenience store as a deli cook. Id. Sanchez testified that her responsibilities from her most recent job included using ovens and fryers, cooking, and cleaning. AR 42. Sanchez stated she had not worked since August 15, 2010, due to anxiety. Id. Sanchez also testified that she suffered from a heart attack in November 2010. Id. According to Sanchez, after the heart attack she was unable to perform daily functions and was limited by the side effects of her medications. AR 42-51. Sanchez testified she still had constant pain and fatigue despite changes in her diet and exercise, along with assistance from her husband. AR 51.

I. Coronary Artery Disease and Peripheral Vascular Disease

On November 22, 2010, Sanchez experienced symptoms of a heart attack and was airlifted to Wyoming Medical Center. AR 272-73, 283.[3] Sanchez underwent a left ventriculogram, coronary angiography, and left heart catheterization on November 23, 2010. AR 291-93. On November 26, 2010, Sanchez underwent a coronary bypass graft times four. AR 294-95. Sanchez was discharged on December 1, 2010, with diagnoses of angina, left main and triple vessel coronary artery disease, diabetes mellitus, myocardial infarction, hypertension, hypercholesterolemia, tobacco abuse, peripheral vascular disease, depression, and anxiety. AR 272.

On December 16, 2010, Sanchez began treating with James Walder, M.D., a cardiologist at Regional Heart Doctors in Rapid City, South Dakota. AR 266. Sanchez was doing well after her surgeries, with no reports of chest discomfort or panic attacks since being discharged, and seemed to "be on the right medications." Id. Dr. Walder recommended, however, that Sanchez return to the Wyoming Medical Center to follow up with her surgeon. Id. The next day, Sanchez was seen by Eric Webb, PA-C, at the Wyoming Medical Center for treatment of her surgical wound which had opened due to Sanchez "moving, doing a lot of walking and carrying items." AR 280.

On March 22, 2011, Sanchez presented to Douglas Everson, M.D., a Family Medicine/General Practitioner, with a left ear complaint. AR 362. Sanchez had been hospitalized with an infection and was receiving intravenous antibiotics. Id. At her appointment, Sanchez claimed her symptoms from her heart condition were improving, and that she was not experiencing dyspnea[4] or chest discomfort with daily activities. Id.

Sanchez was again seen by Dr. Everson on April 18, 2011, for a bilateral ear complaint. AR 360. Sanchez did not report any changes in symptoms related to her heart condition. Id. On May 27, 2011, Sanchez saw Dr. Everson for a physical and medication refills, and reported dyspnea on exertion, but all other symptoms remained unchanged. AR 358. Dr. Everson ordered an electrocardiogram (EKG) and chest x-ray. The chest x-ray showed no acute cardiopulmonary abnormalities. AR 367. He indicated Sanchez needed to see a cardiologist and have a stress test performed. AR 359.

On July 1, 2011, Sanchez met with Dr. Everson for diabetic control and medication refills. AR 412. Sanchez reported chest discomfort and dyspnea with household activities and yard work. Id. Upon a lung examination, Dr. Everson concluded there was no dyspnea. AR 414. Dr. Everson once again indicated Sanchez needed an appointment with a cardiologist and to have a stress test completed. Id. Dr. Everson did not note any changes on July 15, 2011, but ordered an echocardiogram (Echo) for July 21, 2011, and a stress test with Dr. Vanmarel on August 4, 2011. AR 409, 411.

At a follow-up appointment for her stress test on August 5, 2011, Sanchez reported her symptoms were worsening. She continued to experience chest discomfort and dyspnea with household activities and yard work. AR 406. Dr. Everson noted the nuclear medicine stress test was abnormal. Id. Sanchez was scheduled to see Dr. Walder for a consultation. AR 408.

On August 10, 2011, Sanchez reported to Dr. Walder that she was still having problems with chest discomfort and shortness of breath. AR 383. Dr. Walder confirmed the findings of the stress test, and determined Sanchez needed cardiac catheterization with coronary and graft angiography. AR 385. Dr. Walder placed two cardiac stents on August 18, 2011. AR 376-79.

On August 25, 2011, Sanchez met with Dr. Everson and continued to report chest discomfort and dyspnea with household activities and yard work, despite the two cardiac stents placed on August 18. AR 403. Dr. Everson ordered a same-day chest x-ray, which came back as stable and unremarkable. AR 415. On September 1, 2011, Sanchez met with Dr. Everson for a medication review and to continue diabetic treatment, and again reported chest discomfort and dyspnea despite attending cardiac rehab. AR 399.

Sanchez met with Dr. Walder on September 14, 2011, for a one-month post-hospital visit. AR 421. Sanchez reported she was unable to take deep breaths when walking and had taken nitroglycerin three times for chest tightness, which was separate from her inability to take deep breaths. Id. Sanchez reported the chest tightness sensation occurred when she exercised or did housework like cleaning, laundry, or dishes. Id. Sanchez continued to attend cardiac rehab and could walk for about twelve minutes on a treadmill before experiencing the inability to take a deep breath. Id. Dr. Walder's report concluded with:

After talking with [Sanchez] at some length, I am not as concerned that she is having a lot of angina as I was when I heard about her situation from cardiac rehab and from telephone conversations with our nurses. The discomfort she gets on deep inspiration and on bending over probably is less related to her surgery and may not have changed a lot since then. The chest tightness on the other hand may well represent angina, but it is pretty infrequent.

AR 424.

Sanchez returned to Dr. Walder on October 5, 2011, for a stress test. AR 426. The scans returned normal and were "reassuring" as the results did not indicate ischemia. AR 427. Despite the normal scans and continued attendance at cardiac rehab, Sanchez still reported chest discomfort and dyspnea to Dr. Everson at an October 20, 2011, appointment for treatment of depression. AR 395.

On October 24, 2011, Sanchez had a follow-up visit with Julie Smyser, a Family Nurse Practitioner, on behalf of Dr. Walder. AR 429. Sanchez reported doing very well and denied any symptoms of dizziness, dyspnea, edema, palpitations, syncope, or near syncope. Id. Sanchez did experience occasional chest tightness while cleaning her house. Id. The episodes occurred only one or two times per month and were rarely comparable to the pain she experienced during her heart attack. Id. Smyser advised Sanchez to monitor these episodes and report if there was any increase in frequency or severity, and to schedule a follow-up appointment in six months. AR 432.

On November 4, 2011, Sanchez met with Dr. Everson. She continued to report episodes of chest discomfort and dyspnea with household activities and yard work despite attending cardiac rehab. AR 465. Dr. Everson noted Sanchez had an appointment with her cardiologist in three weeks. AR 461. Ten days later, on November 14, 2011, Sanchez reported to Dr. Everson that her symptoms were improving, and she denied any chest pain, dyspnea, fatigue, or use of her nitroglycerin. AR 470. Sanchez continued with her cardiac rehab. Id.

On December 9, 2011, Sanchez saw Dr. Everson and reported she had recently been seen in an emergency room in Spearfish, South Dakota, for symptoms similar to a heart attack. AR 475. Sanchez complained of chest pain, but not with daily activities, and she reported use of her ...


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