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Love v. Berryhill

United States District Court, S.D. Alabama, Southern Division

May 19, 2017

LATASHIA M. LOVE, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION AND ORDER

          P. BRADLEY MURRAY UNITED STATES MAGISTRATE JUDGE.

         Plaintiff brings this action, pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of Social Security denying her claim for a period of disability and disability insurance benefits. The parties have consented to the exercise of jurisdiction by the Magistrate Judge, pursuant to 28 U.S.C. § 636(c), for all proceedings in this Court. (Doc. 15 (“In accordance with the provisions of 28 U.S.C. 636(c) and Fed.R.Civ.P. 73, the parties in this case consent to have a United States Magistrate Judge conduct any and all proceedings in this case, . . . order the entry of a final judgment, and conduct all post-judgment proceedings.”); see also Doc. 17 (order of reference)). Upon consideration of the administrative record, plaintiff's brief, the Commissioner's brief, and the arguments of counsel at the April 26, 2017 hearing before the Court, it is determined that the Commissioner's decision denying benefits should be affirmed.[1]

         I. Procedural Background

         Plaintiff protectively filed an application for disability insurance benefits on April 6, 2015, alleging disability beginning on March 31, 2015. (See Tr. 133-34.) Her claim was initially denied on May 7, 2015 (Tr. 91-95) and, following Plaintiff's request for a hearing before an Administrative Law Judge (“ALJ”) (see Tr. 98-100), a hearing was conducted before an ALJ on January 8, 2016 (Tr. 43-76). On March 24, 2016, the ALJ issued a decision finding that the claimant was not disabled and, therefore, not entitled to disability insurance benefits. (Tr. 24-38.) More specifically, the ALJ went to the fifth step of the five-step sequential evaluation process and determined that Love retains the residual functional capacity to perform those sedentary jobs identified by the vocational expert (“VE”) during the administrative hearing (compare Id. at 37 with Tr. 73-74). On April 26, 2016, the Plaintiff appealed the ALJ's unfavorable decision to the Appeals Council (Tr. 17-18) and, the Appeals Council denied Love's request for review on June 30, 2016 (Tr. 1-3). Thus, the hearing decision became the final decision of the Commissioner of Social Security.

         Plaintiff alleges disability due to degenerative disc disease of the lumbar spine with sciatica and partial sacralization at ¶ 5, migraine headaches, obstructive sleep apnea, tinnitus, obesity, peripheral vestibular disorder, fibromyalgia, depression, and post-traumatic stress disorder (“PTSD”). In light of the issues raised by Plaintiff in her brief (see Doc. 9, at 2 & 7), the Court simply replicates most of the residual functional capacity portion of the ALJ's decision (Tr. 30-36), as follows:

5. After careful consideration of the entire record, I find that the claimant has the residual functional capacity to perform a wide range of sedentary work as defined in 20 CFR 404.1567(a). She can lift and carry 10 pounds occasionally. She can stand or walk 2 hours per eight-hour workday and sit for 6 hours per eight-hour workday, with customary breaks. She can occasionally stoop, but is precluded from climbing, kneeling, crouching, and crawling. She is precluded from working at unprotected heights; operating hazardous, moving equipment, or driv[ing]. She is precluded from exposure to loud noises or noxious chemical fumes or gases. She is precluded from pushing and pulling leg and foot controls. She requires a hand-held assistive device for prolonged ambulation (more than three minutes) on uneven terrain. She cannot work around light above the office level, and cannot operate vibratory equipment. She can perform short, simple, routine tasks. She can work in customary proximity to coworkers but is precluded from coordinating with them in order to complete her own tasks. She can occasionally interact with the public. She can attend and concentrate for two hours, after which she is expected to be off task for approximately three minutes before resuming work tasks.
. . .
June 2013 to April 2015 records from VA Gulf Coast Veteran's Health note complaints of Meniere's [d]isease, vertigo, lightheadedness, migraine headaches, and pain that the claimant rated as 7 to 10 out of 10. Examination findings revealed positive straight leg raise tests, tenderness to palpitation at ¶ 4-5, reduced range of motion of the lumbar spine, and obesity, which led to diagnoses of degenerative disc disease of the lumbar spine, obstructive sleep apnea, migraine headaches, tinnitus, and obesity. Additionally, multiple x-rays note congenital sacralization at ¶ 5.
The record also includes, however, otherwise normal examination findings, including normal reflexes and strength in the upper and lower extremities, negative straight leg raise tests, normal range of motion of the claimant's hip and ankles, and indications that the claimant ambulated without the assistance of devices. Additionally, a May 2014 audiogram noted normal hearing in her bilateral ears and notes indicate that the claimant did not suffer from vertigo or Meniere's disease. These records note that the claimant's spinal problems were not service related, she was prescribed traction therapy, and she indicated on at least one occasion[] that she was “doing good[.]”
July 2015 records note that the claimant was prescribed orthopedic inserts for her shoes to help her back. August 2015 records from Gulf Coast Pain Institute note that the claimant received multiple facet joint injections for management of her pain. August to September 2015 records note diagnoses of lumbar spondylosis, facet syndrome, and sciatica, which were based on spinal pain, spasms, and weakness. Examination findings revealed tenderness to palpitation, some distress because of pain, decreased sensation and range of motion, and obesity, and the claimant received facet joint injections. Otherwise, however, examination findings were essentially normal, including a normal heart and other symptoms, including her hearing and breathing.
Finally, April to September 2015 records from VA Biloxi noted complaints of pain that [s]he rated 7 to 10 out of 10, migraine headaches that last 4 to 5 hours, problems falling, and low back pain with radiculopathy, which led to diagnoses of degenerative disc disease of the lumbar spine, paravertebral muscle spasms, obstructive sleep apnea, migraine headaches, tinnitus, and obesity. Examination findings from this period note elevated blood pressure readings, obesity, tenderness to palpitation in her lumbar spine and hip, and pain on range of motion in her lumbar spine. Records also note, however, on other occasions that the claimant noted her pain levels were 0 out of 10 and she denied dizziness. Other examination findings revealed that the claimant was not in acute distress, she had full range of motion in her back, normal upper and lower extremities, negative straight leg raise tests, and ambulated with a normal gait and station, while a July 2015 electromyography (EMG) revealed no evidence of neuropathy. These records also note that she quit her job to “invest in her health and wellness” and wanted to open a counseling center, and she indicated that she was performing gardening.
The aforementioned objective findings and the claimant's admissions and activities reduce the overall credibility of her allegations and undermine any alleged disabling limitation resulting from her degenerative disc disease of the lumbar spine, migraine headaches, obstructive sleep apnea, tinnitus, obesity, and peripheral vestibular disorder. Although the evidence of record documents the claimant's diagnoses and treatment for these impairments, a review of the overall evidence of record includes a wealth of relatively normal examination findings on multiple occasions, including normal audiology testing, no vertigo, negative straight leg raise tests, and a normal gait.
Additionally, the claimant's admitted and indicated activities and abilities undermine the alleged severity of her allegations. She indicated that she stopped working to invest in her health and wellness and noted that while she was okay not working at the time, she wanted to open a counseling center in the future. She also indicates that she performs activities that are inconsistent with the level of symptomology that she alleges, including caring for her 2-year-old child, preparing meals, performing some household chores, driving, and gardening.
Based on the overall evidence of record, including the aforementioned examples, I find the claimant's allegations regarding the intensity, duration, and persistence of her symptomology to be less than fully credible.
Accordingly, the aforementioned objective findings, including the relatively normal examination findings from throughout the VA records, as well as the claimant's admitted activities and abilities, including caring for her children, driving, and gardening, all indicate that the claimant's symptomology resulting from her degenerative disc disease of the lumbar spine, migraine headaches, obstructive sleep apnea, tinnitus, obesity, and peripheral vestibular disorder are not completely disabling. However, I note that the claimant's occasional symptomology can reasonably be expected to cause some limitations to the claimant's ability to function, and has limited the claimant to a wide range of work at the sedentary exertional level. The limitation to lifting and carrying 10 pounds occasionally; standing or walking 2 hours per eight-hour workday; occasionally stooping; and the preclusion from climbing, kneeling, crouching, and crawling all accommodate her degenerative disc disease of the lumbar spine, migraine headaches, obstructive sleep apnea, tinnitus, obesity, and peripheral vestibular disorder. The preclusion from exposure to loud noises, noxious chemical fumes or gases, the preclusion from exposure to light above the office level, and the preclusion from exposure to vibrations, including vibratory equipment[, ] further accommodates the claimant's migraine headaches. The preclusion from pushing and pulling leg and foot controls further accommodates the claimant's degenerative disc disease of the lumbar spine. The requirement for a hand-held assistive device for prolonged ambulation further accommodates her vertigo and problems with falling. The preclusions from working at unprotected heights; operating hazardous, moving machinery; and the driving accommodate the claimant's vertigo, concentration deficits secondary to pain, and potential medication side effects.
As for opinion evidence, I have considered and give[n] great weight to the May 2015 opinion of James Sims, M.D., who reviewed the evidence of record and indicates that the claimant can perform a range of light work. This opinion is generally consistent with the overall evidence of record, including the relatively normal examination findings from throughout the record, as well as the claimant's admitted and indicated activities and abilities, which include gardening, driving, and performing some household chores.
I give no weight to the September 2015 opinion of Chris Zandt, Physician Assistant, as he is not a medically acceptable source, any opinion regarding the claimant's ability to work full-time in a competitive environment is an opinion reserved to the Commissioner, and this opinion is inconsistent with the relatively normal examination findings from throughout the record, as well as the claimant's admitted and indicated activities and abilities.
Turning to the claimant's mental impairments, the objective medical findings and admitted activities and abilities support the limitation in 5, above, that the claimant can perform simple, routine tasks consistent with unskilled work with additional limitations related to social interactions and attention and concentration.
The record includes physical treatment records that document the claimant's complaints of anxiety and depression, but also not[e] relatively normal mental examination findings, including alertness and orientation.
June 2013 to April 2015 records from VA Gulf Coast include complaints of sleep problems and nightmares, which led to diagnoses of a depressive disorder and anxiety-related disorders, including post-traumatic stress disorder (PTSD). Although the claimant received a global assessment of functioning (GAF) score of only 50, mental examination findings were essentially normal including proper alertness and orientation, intact memory, intact attention and concentration, a euthymic mood, a pleasant affect, good eye contact, cooperation, and good grooming with casual dress.
Likewise, April to September 2015 records from VA Biloxi include diagnoses for depression and PTSD, which were based on complaints of no social life, marital problems, relationship problems, and problems dealing with others, as well as examination findings that included abnormal mood and dysthymic affect. These records also note, however, that the claimant denied homicidal and suicidal ideations, and she indicated that she was “doing okay.” Other examination findings also revealed that she was in no acute distress, was alert and oriented, had proper dress and grooming, had intact attention and concentration, demonstrated appropriate eye contact, had a normal mood, and had intact memory.
The aforementioned objective findings do not support a determination that the claimant is disabled by her mental impairments. Although the aforementioned records document the claimant's diagnoses and treatment for her mental impairments, a review of the overall evidence of record includes a wealth of relatively normal mental examination findings, including proper dress and ...

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