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Dethlefs v. Colvin

United States District Court, D. Nebraska

May 19, 2015

CAROLYN W. COLVIN, Acting Commissioner of the Social Security Administration, Defendant.


LYLE E. STROM, Senior District Judge.

This matter is before the Court on the appeal of plaintiff, Julee Dethlefs ("Dethlefs"), of a final decision by the Acting Commissioner of the Social Security Administration ("SSA") denying Dethlefs' application for disability benefits. The Court finds that the decision of the Administrative Law Judge ("ALJ") should be affirmed.


On July 6, 2011, Dethlefs filed an application for disability insurance benefits (Tr. 11). On October 5, 2011, the application was initially denied ( Id. ). On January 10, 2012, the application was then denied on reconsideration ( Id. ). On March 20, 2013, the ALJ held a video hearing with Dethlefs (Tr. 23). On April 26, 2013, the ALJ found that Dethlefs was not under a "disability" as defined in the Social Security Act (the "Act") (Tr. 13-18). On March 21, 2014, the Appeals Council of the SSA denied Dethlefs' request for review (Tr. 1). On May 19, 2014, Dethlefs timely filed this appeal(Filing No. 1; see 42 U.S.C. § 405(g)). The Court now reviews the ALJ's decision, which stands as the Commissioner's final decision.


Dethlefs was a forty-seven-year-old woman on her alleged onset date, November 1, 2010, and held a general educational development certificate (Tr. 52). Dethlefs alleges disability due to "facial pain, headache, neuralgia, fatigue, " and neck pain (Filing No. 1, at 3, ¶6).

Prior to November 1, 2010

Dethlefs' pain stems from a car collision on June 7, 1999. In the collision, Dethlefs sustained injuries to the mid-third of her face (Tr. 218). In September 2002, Dethlefs received a frontal cranioplasty as treatment for ongoing discomfort in the region (Tr. 272).

In March 2004, Dethlefs complained to Louise E. Kleager, M.D. ("Dr. Kleager"), that her nose felt swollen (Tr. 322). Dr. Kleager noted Dethlefs had difficulty breathing through the right side, but the doctor observed no visible swelling and patent airways on both sides ( Id. ). Dr. Kleager indicated Dethlefs complained of some pain around her right eye despite normal and "virtually unremarkable" examinations (Tr. 322). The following month of April, Dr. Kleager noted, after reviewing scans of Dethlefs' sinuses, the scans were excellent and showed no evidence of sinusitis ( Id. ). No evidence showed air around the cranioplasty ( Id. ). Dr. Kleager noted that the source of Dethlefs' chronic frontal headaches was not secondary to infection, but presumably post-traumatic in origin ( Id. ).

On May 7, 2007, Roger Simpson, M.D. ("Dr. Simpson"), performed sinus surgery on Dethlefs (Tr. 334-38). Approximately two weeks later, Dr. Simpson noted Dethlefs was doing well (Tr. 333). On May 23, 2005, Advanced Practice Registered Nurse Cynthia Gilmet, D.N.P. ("Dr. Gilmet"), noted Dethlefs complained of experiencing headaches once a week to once a fortnight (Tr. 275). Dethlefs reported fatigue and denied any visual changes ( Id. ). Dethlefs reported some difficulties breathing at night but denied shortness of breath during the day ( Id. ). Dethlefs denied any increase in symptoms ( Id. ).

In July 2007, Dethlefs reported to Dr. Simpson that she felt great, was having no headaches, and was breathing better (Tr. 330). Dethlefs expressed no other complaints (Tr. 330). Dr. Simpson noted that Dethlefs' deviated nasal septum and sinusitis had resolved (Tr. 330-31).

On December 15, 2009, Dethlefs told Dr. Gilmet that she had been taking her husband's Meloxicam, which had significantly helped her headaches (Tr. 280). Dr. Gilmet provided Dethlefs with her own prescription for Meloxicam (Tr. 280).

On June 10, 2010, Dethlefs complained to James Plate, M.D. ("Dr. Plate"), about pain in the frontal area of the plastic plate in her forehead (Tr. 280). Dr. Plate posited that Dethlefs had a "little bit of frontal sinus" due to barometric pressure changes aggravated by plaintiff's smoking ( Id. ). This was the last examination prior to Dethlefs' alleged onset date: November 1, 2010.

Following November 1, 2010

On August 4, 2011, Dethlefs sought chiropractic treatment from Dale Wee, D.C., ("Dr. Wee") with complaints of headaches and neck pain (Tr. 325-26). Dr. Wee performed manual chiropractic adjustments (Tr. 325). On November 3, 2011, Dr. Wee wrote a To-Whom-It-May-Concern letter, stating that he had been performing chiropractic adjustments on Dethlefs and he recommended future treatment on an "as needed" basis (Tr. 323). On February 28, 2012, Dr. Wee noted that Dethlefs was in a relief phase of care (Tr. 348).

On August 22, 2011, David Lindley, M.D. ("Dr. Lindley"), performed a consultative examination on Dethlefs (Tr. 289-93). Dr. Lindley noted that Dethlefs' nose was unremarkable (Tr. 291). He observed that Dethlefs was unable to raise her eyebrows properly and Dethlefs reported double vision while following Dr. Lindley's finger to the extremities on the right (Tr. 292). Dethlefs had bilateral, reduced sensation on her forehead and upper face ( Id. ). The remainder of Dethlefs' cranial nerves were unremarkable ( Id. ). Dethlefs had normal range of motion in her extremities ( Id. ). Dethlefs had a normal peripheral nerve system ( Id. ). Dr. Lindley diagnosed Dethlefs with olfactory nerve damage, smell and taste issues, and migraines ( Id. ). Dr. Lindley opined that Dethlefs had significant disabilities since the motor vehicle accident where she is unable to get around other than avoidance, which resulted in an inability to leave the house to go shopping, or to family gatherings, or to take part in any significant work place activity ( Id. ).

On October 5, 2011, Arthur Weaver, D.O. ("Dr. Weaver") and State agency physician, completed a physical RFC assessment on Dethlefs (Tr. 296-304). Dr. Weaver opined that Dethlefs had no exertional, postural, manipulative, or visual limitations (Tr. 297-99). He also opined that Dethlefs should avoid concentrated exposure to extreme heat and moderate exposure to fumes, odors, dusts, gases, and poor ventilation (Tr. 300). On January 5, 2012, another State agency physician, Glen Knosp, M.D., affirmed Dr. Weaver's assessment (Tr. 311-12).


On March 20, 2013, the ALJ held a hearing (Tr. 23-50). Dethlefs testified she was last employed in November 2010 (Tr. 28-29). The ALJ then focused on Dethlefs' alleged physical impairments (Tr. 29). Dethlefs attributed her disability to being unable to work with people wearing perfume, damage to her face and sinus, lack of olfactory glands, headaches, and sinusitis (Tr. 29-30, 34). Dethlefs took Meloxicam and Tylenol Codeine for ...

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