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Karen Factory v. Commissioner of Social Security

United States District Court, E.D. Texas, Sherman Division

March 29, 2017




         Plaintiff brings this appeal under 42 U.S.C. § 405(g) for judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying her claim for disability insurance benefits and supplemental security income [Dkt. 1]. After reviewing the Briefs submitted by the Parties, as well as the evidence contained in the Administrative Record, the Court finds that the Commissioner's decision should be AFFIRMED.



         On May 24, 2013, Karen Factory (“Plaintiff”) filed applications for disability income benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social Security Act (“Act”), alleging an onset of disability date of September 27, 2012 [TR at 208-14]. Plaintiff's application was initially denied by notice, and again upon reconsideration, after which Plaintiff requested a hearing before an administrative law judge (“ALJ”). Id. at 146-152, 161. The ALJ conducted a hearing on November 5, 2014 (“Hearing”), and heard testimony from Plaintiff, witness Quentin Salmond and Vocational Expert Donald Anderson (“Mr. Anderson” or “VE”). Id. at 63-92. Plaintiff was represented by counsel at Hearing. Id. On February 17, 2015, the ALJ issued his decision denying benefits, and found Plaintiff not disabled at step five of the prescribed sequential evaluation process (discussed infra). Id. at 45-62. On August 21, 2015, the Appeals Council denied Plaintiff's request for review, making the decision of the ALJ the final decision of the Commissioner. Id. at 1-5.

         On October 20, 2015, Plaintiff filed her Complaint with this Court [Dkt. 1]. On April 11, 2016, the Administrative Record was received from the Social Security Administration (“SSA”) [Dkt. 8]. On April 14, 2016, this case was assigned to the undersigned by consent of all Parties for further proceedings and entry of judgment [Dkt. 11]. Plaintiff filed her Brief on September 14, 2016 [Dkt. 26]. On November 14, 2016, the Commissioner filed her Brief in Support of the Commissioner's Decision [Dkt. 28].


         1. Age, Education, and Work Experience

         Plaintiff was born on July 12, 1954, making her fifty-eight years of age on the date of alleged onset, and sixty on the date of determination [TR at 208]. Plaintiff completed high school. Id. at 239-40. Her past relevant work experience is in medical sales. Id. Plaintiff was a “person of advanced age” on the date of decision. See 20 C.F.R. § 404.1563(e).

         2. Summary of Relevant Medical Treatment

         Plaintiff had dental implant surgery in September 2012. [TR at 308]. Thereafter, Plaintiff complained of “severely increased pain along the left side of jaw” and reported experiencing “dull, constant burning” pain and numbness. Id. On November 8, 2012, Plaintiff presented with these symptoms to neurologist Shari Rosen-Schmidt, M.D. Id. It was determined that Plaintiff was experiencing post-surgical infection requiring treatment with antibiotics, and one implant was removed after it was found to have been touching a nerve. Id. Plaintiff further reported to Dr. Rosen-Schmidt that she had a recent instance of blurred vision and had increased pain when talking or chewing. Id. On examination, Dr. Rosen-Schmidt noted decreased sensation in the fifth cranial nerve (the trigeminal) with loss of sensation in the V1, V2, and V3 distributions but no loss of strength or facial symmetry. Id. at 309. Dr. Rosen-Schmidt assessed trigeminal neuralgia, prescribed medications, and scheduled an MRI examination. Id. at 310. On November 13, 2012, Plaintiff continued to complain of pain and Dr. Rosen-Schmidt conducted a further examination. Id. at 304. On December 13, 2012, Plaintiff again saw Dr. Rosen-Schmidt, reporting that “[i]nstead of constant pain, she has occasional intermittent pain” and “hasn't had the stabbing headache in a very long time.” Id. at 301. On March 14, 2013, Plaintiff saw Dr. Rosen-Schmidt again and reported that she “had another implant taken out 3 weeks ago, which helped with her jaw pain tremendously.” Id. at 298. Plaintiff reported still being sensitive to contact on her jaw, and could not stand contact with cold items. Id. On examination, Dr. Rosen-Schmidt continued to observe decreased sensation in the V3 distribution. Id. at 299. Plaintiff also seemingly ceased using her prescribed pain medication in this timeframe. Id. at 300.

         Plaintiff underwent physical therapy from April to June 2013, with no significant changes in her condition. Id. at 315-325. During this time, Plaintiff saw Dr. David Garza for complaints of depression, crying spells and decreased concentration. Id. at 358. Plaintiff also complained of other symptoms such as loss of vision to Dr. Garza and other medical providers. Id. at 407, 431. Thereafter, Cary Conaway, Ph.D., performed a psychological evaluation of Plaintiff. Id. at 329-34. On August 30, 2013, Plaintiff reported to Dr. Conaway that she was in “constant pain” due to her trigeminal nerve being severed, and that the pain rendered her unable to focus or concentrate. Id. at 330. On examination, Dr. Conaway observed that Plaintiff demonstrated “average persistence and effort, ” that Plaintiff's “ability to maintain focus and concentration is not significantly limited.” Id. at 331-33. The records further reflect that Plaintiff displayed a “flatness of affect and limited display of emotion, ” but “no confusion or reduction in awareness.” Id. at 332-33. Dr. Conaway diagnosed Adjustment Disorder with Depressed Mood, noting depression and irritability relating to her current medical condition. Id. at 334. Plaintiff also saw psychiatrist Aaron Van Wright, M.D., during this same time frame, for medication management of her depressive problems. Id. at 401-03. After trying several different medications, Plaintiff reported discontinuing her medications and Dr. Wright recommended Plaintiff return as needed. Id. at 401-08. In this same vein, Plaintiff saw Stephanie Jones, M.D., on November 8, 2013, for pain management follow-up. Id. at 422-23. Plaintiff reported discontinuing all medications for her depressive conditions. Id. Then, on November 17, 2014, Plaintiff saw Padraig O'Suilleabhain, M.D., for pain complaints, reporting sharp jaw pains “maybe a couple of times a day, ” but she can also “go a couple of days without it.” Id. at 450. At this time, Plaintiff reported taking only Ibuprofen for her pain. Id. On examination, Dr. O'Suileabhain observed no facial paralysis or abnormal muscle movements, with reduced sensitivity in the mandible and increased sensitivity on her left temple. Id. at 451. Dr. O'Suileabhain opined that Plaintiff's sensation loss was unlikely to be corrected, but that Plaintiff might consider surgical intervention to try to manage her sudden recurrences of pain. Id.

         2. Hearing Testimony

         At Hearing, Plaintiff testified extensively regarding her symptoms and complaints of pain. Plaintiff testified that a dental accident had completely changed her life, that she experienced unpredictable, chronic pain in her mouth and that it felt like “a knife is stuck in [her] lip. [Her] teeth hurt. [Her] mouth hurts. [Her] neck hurts. [She has] stabbing, phantom pains that come uncontrollably.” Id. at 69. Plaintiff testified she also experiences blurred vision. Id. Plaintiff explained that her pain is unpredictable, and varies in intensity from day to day. Id. at 69, 71. Plaintiff stated that her pain is more intense with rainy or cold weather, and that she frequently develops headaches from the pain in her mouth. Id. at 70. Plaintiff went on to explain regarding the pain in her teeth, “if you have one toothache but when you have a whole row of teeth hurting you can't, I can't concentrate for long periods of time.” Id. at 71. Plaintiff reported that speaking causes more pain and that nothing can touch her face without severe pain. By way of example, she explained that her husband cannot kiss her due to the pain, that the wind touching her causes pain, and that she cannot sleep at night because even the bed covers touching her face cause significant pain. Id. at 70. Plaintiff also reported that her fingers, hand and neck are often numb. Id. Plaintiff was specifically asked how often she had pain, to which she responded “[n]ot every day but most days the pain is there. . . . On some days I feel ...

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