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Mercado v. Berryhill

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

June 14, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security Defendant.



         Plaintiff brings this action, pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking judicial review of a final decision of the Commissioner of Social Security denying her claims for a period of disability, disability insurance benefits, and supplemental security income. 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. (Docs. 18 & 20 (“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.”)). 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 applications for disability insurance benefits and supplemental security income on March 4, 2013 and April 1, 2013, respectively, alleging disability beginning on March 29, 2012. (See Tr. 244-51.) Her claims were initially denied on August 30, 2013 (Tr. 174-78) and, following Plaintiff's request for a hearing before an Administrative Law Judge (see Tr. 181-82), a hearing was conducted before an ALJ on December 4, 2014 (Tr. 61-109). On March 13, 2015, the ALJ issued a decision finding that the claimant was not disabled and, therefore, not entitled to social security benefits. (Tr. 35-57.) More specifically, the ALJ went to the fourth step of the five-step sequential evaluation process and determined that Mercado is capable of performing past relevant work as an administrative clerk and a human resources clerk as she actually performed those jobs (see Tr. 55-56). On April 21, 2015, the Plaintiff appealed the ALJ's unfavorable decision to the Appeals Council (Tr. 28) and, the Appeals Council denied Mercado's request for review on June 3, 2016 (Tr. 1-3). Thus, the hearing decision became the final decision of the Commissioner of Social Security.

         Plaintiff alleges disability due to hypothyroidism, depression, obesity, and degenerative disc disease. In light of the issues raised by Plaintiff in her brief (see Doc. 12, at 2), the Court replicates the essential residual functional capacity portions of the ALJ's decision, as well as the past relevant work determination, as follows:

5. After careful consideration of the entire record, I find that the claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b), which involves lifting and carrying no more than 20 pounds occasionally and 10 pounds frequently, sitting at least 6 hours in an 8 hour day, and standing and walking at least 6 hours in an 8 hour day, except she can perform only frequent handling bilaterally, occasionally climb stairs, perform no kneeling or crawling, and have only occasional contact with the public.
. . .
The claimant's hypothyroidism, obesity and degenerative disc disease result in the limitation to perform light work with the additional limitations as described above. Light work[, ] as defined in 20 CFR 404.1567(b) and 416.967(b)[, ] involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm and leg controls. To be considered capable of performing a full or wide range of light work, the claimant must have the ability to do substantially all of these activities. If the claimant can do light work, the regulations also reflect that she can also do sedentary work, unless there are additional limiting factors such as loss of fine dexterity or inability to sit for long periods of time.
The medical evidence of record documents that the claimant was seen at LSU Medical Center Clinics between January 12, 2011 and January 19, 2012. On January 12, 2011, she was noted to have a low TSH of 0.46 (reference range 0.50-5.00), a low free T4 of 0.57 (reference range 0.60-1.15) and a low vitamin D level of 10.3 (reference range 32.0-100.0). On February 4, 2011, she told her provider that she recently moved here from Puerto Rico. She had a thyroid sonogram on February 9, 2011, which showed no abnormality. Repeat labs in February 2011 and September 2011 also showed a low TSH and free T4, but a normal free T3. She underwent an MRI of the pituitary, which was negative for any pituitary microadenoma. Likewise, the MRI of the brain on September 21, 2011 was within normal limits. The claimant was started on Levothyroxine 50 mcg daily in September 2011. The claimant initially stated that she had not noticed any change in her symptoms of fatigue and weight gain since starting the Levothyroxine. However, in November 2011, it was noted that she was taking her medication with food. She was told to take it on an empty stomach 1 hour prior to any meals or medications. Her free T4 was within normal limits at 0.70 on November 29, 2011. Her vitamin B12 level was normal at 342, but her vitamin D was low at 10.5.
The claimant's Levothyroxine was discontinued on December 1, 2011. However, on January 19, 2012, the claimant said her symptoms were now worse and she felt more fatigued [and] had gained weight since discontinuing the Levothyroxine. Her doctor noted, however, that her weight change was only two-tenths of a pound since her last visit. The physical exam on January 19, 2012 showed her neck was supple with no thyromegaly, no thyroid nodules, and no thyroid bruits. . . . Her doctor decided to recheck her TSH and free T4, as well as a total T4 and a free T3. She was started on Vitamin D supplementation twice a week for 6 weeks. The January 19, 2012 thyroid tests showed a low free T4 of 0.51 and a low TSH. Her vitamin D was also low at 15.3.
The claimant was treated by Dr. Salgado in Louisiana on June 1, 2012 for back pain and pain to her left shoulder and lower left leg. The claimant said Mobic and Flexeril had helped some, but had not completely relieved her pain. Dr. Salgado noted the claimant brought copies of her lumbar spine MRI that showed no abnormality. On physical exam, the claimant had no tenderness to palpation over the spine, normal range of motion of the lumbar spine and a negative SLR bilaterally. She had normal range of motion of all joints in the upper and lower extremities. Dr. Salgado assessed the claimant with backache and gave her Tramadol to take as needed for pain.
The claimant saw Dr. Kakazu on July 10, 2012 for prescription refills. She reported back symptoms and muscle aches, but no arthralgia, soft tissue swelling, muscle cramps, restless legs, muscle spasms, localized joint swelling or localized joint stiffness. She was not feeling tired. The physical exam was normal except tenderness to palpation was present in the back. She was assessed with hypertension, menopause, and midback pain and was given Naproxen, Metoprolol, Levothyroxine and Amlodipine.
She saw Dr. Salgado on September 7, 2012 for head and back pain. The claimant also said she had been feeling very fatigued and had difficulty sleeping and she needed refills of her thyroid medication. She said she had been taking Tylenol for headaches without relief. The claimant said she stopped taking Tramadol for pain because it caused dizziness. The physical exam showed tenderness to palpation over the lower spine and a positive SLR bilaterally. She was assessed with hypothyroidism, spinal ankylosis and hypertension. She was given a prescription of Levothyroid 60 mcg, with 3 refills. The labs showed her TSH was low at 0.106. Her T3 uptake was within normal limits at 29% and T4 was within normal limits at 7.0. She saw Dr. Kakazu on January 4, 2013 for lower back pain and said she did not need refills of her medications. She also told Dr. Kakazu that she was walking 1-2 times per week for exercise. She was assessed with lower back pain, but no physical exam findings were noted. She was given Mobic to take as needed for pain.
The claimant was seen by Ms. Harris at the health department in Alabama on April 16, 2013, and reported she has high blood pressure, joint pain in the left leg, back symptoms and muscle spasms. She said she was taking Amlodipine, Lisinopril and Levothyroxine daily. She also said she was taking Mobic and Flexeril as needed, as well as Vistaril as needed for anxiety. The physical exam showed tenderness to palpation and muscle spasm in the back, but no costovertebral angle (CVA) tenderness. Ms. Harris assessed her with hypertension, hyperthyroidism and backache. She returned to the health department on April 30, 2013 for lab results. The labs showed a low TSH of 0.102 and a free T4 that was within normal limits at 1.08. She denied palpations, shortness of breath, chest pain, abdominal pain or dizziness. She complained of recurrent low back pain that is worse in the morning. She was not feeling tired or poorly and reported no headaches. She rated her pain a 2/10 on the pain scale (0=no pain, 10=worst possible pain), but no abnormalities were noted on exam. She was assessed with hypertension, obesity and depression with anxiety. Ms. Harris decreased her Synthroid from 50 mcg to 25 mcg and started her on Zoloft. She also decreased her Norvasc from 10 mg to 5 mg because her blood pressure was 100/88.
During the consultative exam with Dr. Ozment on July 27, 2013, he noted the claimant was identified by her Louisiana driver's license, but she was driven to the clinic by a relative. The claimant's chief complaint related to her low back. The claimant reported that she has sharp pain that she rated a 10/10. She said there is no radiation of the pain. She said heat helps the pain and pain medications help a little bit. . . . She said she goes for a short walk when she gets up in the morning for about 15 minutes. The claimant reported that her current medications include Naproxen, Flexeril, Vistaril, Metoprolol, Norvasc and Levothyroxine.
Dr. Ozment noted the claimant walked to the exam room and appeared to sit comfortably. She could get on the exam table and sit down but she could not lie down on the table “because her back was hurting so bad.” The claimant was 5'4” tall and weighed 199 pounds. He blood pressure was 110/70. . . . Her neck was supple without adenopathy, thyromegaly or masses. [Th]e claimant's lungs were clear to auscultation throughout. Her abdomen was soft, nontender and nondistended. Peripheral pulses were 2 and equal bilaterally.
Dr. Ozment noted her station and gait were normal. She was poorly coordinated due to left back pain. She was unable to tandem walk, walk on toes or heels, hop or squat. However, there was no assistive device. She was only able to forward flex her back with fingers extended to the level of about the knees. The Romberg was negative. The claimant had decreased range of motion in the lumbar spine, but range of motion was generally normal in the cervical region, knee joints, ankle joints and elbows/forearms. Dr. Ozment noted he was unable to adequately evaluate her hips because she could not lie down. She had decreased range of motion in the left shoulder with abduction to about 90 degrees, but she said that this was because her back was hurting. The seated SLR was positive in the back at about 15 degrees of lift in the left side of the back. She could not lie down, so the test was not performed in the supine position.
Dr. Ozment said the claimant could not abduct her shoulder above 90 degrees, but she said this was due to low back pain. Motor strength in the lower extremities was 5/5 on the right and 4/5 on the left. There was no evidence of localized tenderness, erythema or effusion. There was no evidence of diminution of function with repetition, spasticity or ataxia. Joint position and vibration sense were normal. Sensation to light touch and pinprick were grossly intact throughout the upper and lower extremities. Dr. Ozment diagnosed the claimant with low back pain on the left side with decreased range of motion of the lumbar spine probably secondary to degenerative disc disease, decreased range of motion of the left shoulder of uncertain cause, and positive SLR on the left.
The claimant saw Dr. Bond at the health department on November 22, 2013 for complaints of intermittent lower back pain. She rated her pain a 6/10. She also had been out of Synthroid for weeks and needed refills; but she did not report feeling tired or poorly. The physical exam showed a normal musculoskeletal system. No sensory exam abnormalities were noted and the motor exam demonstrated no dysfunction. No coordination/cerebellum abnormalities were noted and reflexes were normal. Dr. Bond assessed the claimant with hypothyroidism, backache and “no migraine headache.” She was prescribed Levothyroxine, Tramadol to take as needed for pain and Robaxin to take as needed for muscle spasms.
On April 2, 2014, Dr. Teplick noted the claimant was seen primarily for stronger medication for her low back pain. The claimant said Tramadol was ineffective. Dr. Teplick noted the only drug stronger would be an opiate, which “would be inappropriate for chronic pain, although a pain clinic may prescribe one.” She also reported having weakness of her left ankle for the last year with pain down the lateral side of the left leg to the ankle. She said she can walk for 15 minutes before having pain. She also reported having a frontal headache daily for 2 months lasting 2 hours if not treated, but resolved with Ibuprofen. The claimant reported that she had lost 11 pounds over the last year. Her weight was 187 pounds at this visit. Dr. Teplick noted sternum tenderness on physical exam; but her back had no tenderness to palpation, no muscle spasms, and no CVA tenderness. The SLR was negative and the musculoskeletal exam was normal. A motor exam demonstrated no dysfunction and no lower extremity weakness. Dr. Teplick assessed the claimant with depression; hypertension, well controlled on low dose Amlodipine; hypothyroidism, thyroid function tests within normal limits on Synthroid with no symptoms; and backache with leg pain unlikely to be sciatica. He recommended a trial of 800 mg Ibuprofen and Amitriptyline.
The claimant saw Dr. Teplick on July 7, 2014, with continued low back pain. Dr. Teplick noted the pain was unchanged except instead of radiating down the leg to the ankle, it now radiates only to the top of her thigh. Dr. Teplick noted the x-rays were within normal limits. She had gained 12 pounds in the last 4 months. She reported occasional swelling in both feet for the last 2 months that is present in the morning, resolves during the day, and returns in the evening. She said her headaches were resolved. On physical exam, there was no sternum tenderness and no edema was present in the extremities. The back had tenderness to palpation mostly midline with no muscle spasms and no CVA tenderness. The SLR was negative. The motor exam demonstrated no dysfunction, and lower extremity strength was normal and equal. Dr. Teplick assessed the claimant with hypertension, apparently no need for even low dose Amlodipine; obesity; hypothyroidism, free T4 within normal limits with slightly low TSH on 50 mcg Levothyroxine; and backache, no radiculopathy, and lumbar spine x-ray within normal limits. He gave her a trial of Carisoprodol and Ibuprofen, and discussed the importance of weight loss and exercise.
The claimant was seen at the health department most recently of record by Robin Normand, CRNP, on August 29, 2014. She complained of weakness, dizziness and feeling very tired. The claimant was concerned about having some daytime drowsiness from her Amitriptyline that she was taking for back pain and sleep. The claimant rated her pain at this visit a 1/10. Her weight was 196, with a BMI of 34.7. She appeared to be in no acute distress. She was assessed with fatigue and depression with anxiety, as she told Ms. Normand that she was being treated for same at Altapointe. Ms. Normand restarted the claimant on Amlodipine for blood pressure, which was 122/87 when checked and planned to check her vitamin D level.
In terms of the claimant's hypothyroidism, treatment has been essentially routine and/or conservative in nature. The claimant's representative said this is the claimant's most prevalent condition, as it affects her energy level. Despite the fact that the claimant's TSH has remained slightly low during the period at issue, the record does not document significant complications related to the thyroid condition. The claimant's weight has generally remained around 200 pounds during the period at issue, with the exception of an 11-pound weight loss over the last year as reported in April 2014. Additionally, her skin has generally been normal on exams and her speech has been normal. The physical exam on January 19, 2011 noted a goiter with the right side being larger than the left. However, no subsequent exams noted any thyroid-related abnormalities of the neck.
The claimant testified that she feels weak, tired and fatigued every day. However, many of her treatment notes reflect that she did not report these symptoms. Indeed, she often reported that she was not feeling tired or poorly. She also testified that she sleeps at night by taking medication to fall asleep, but her medication takes many hours to take affect and she only gets about 3 hours of deep sleep per night. However, Dr. Starkey's consultative exam report and the treatment notes from Altapointe reflect that the claimant improved sleep with the medications prescribed.
The claimant also testified that she has been having headaches for a long time, which started when she was placed on thyroid medication. The claimant said she talked to her doctor about the new onset of headaches, and he gave her other medications for headaches and back pain. The records in Exhibit B1F mention a diagnosis of migraine headaches, but Dr. Bond later specifically provided a diagnosis of “no migraine headaches” in November 2013. In addition, the record includes multiple office visits in which the claimant did not complain of headaches. She has not complained of ongoing shortness of breath, heart palpitations, and her blood pressure has remained within normal limits on medication. I have accounted for the claimant's hypothyroidism, as well as her documented complaints related to fatigue/weakness, dizziness, headaches, difficulty sleeping, etc. with the limitation to performing light work that includes only occasionally climbing stairs and performing no kneeling or crawling.
In terms of the claimant's degenerative disc disease, the record includes x-rays from September 23, 2011, which showed degenerative changes with disc space narrowing and moderate posterior and anterior vertebral spondylosis from C4 to C7 level and minor degenerative changes in the mid thoracic vertebrae. However, the claimant's complaints have generally involved only the lower back. The x-rays of the lumbosacral spine were normal in September 2011. Dr. Salgado also noted the claimant brought copies of her lumbar MRI to her June 2012 visit, and it showed no abnormalities. The x-rays of the lumbar spine on August 27, 2013, which showed minimal degenerative change at L 5-S1. However, x-rays of the lumbar spine on November 22, 2013 were normal.
The physical exams have shown tenderness to palpation in the back and decreased range of lumbar spine at times. The claimant also had a positive SLR bilaterally in September 2012 and a positive SLR on the left in July 2013. I have taken the x-rays of the cervical, thoracic and lumbar spine into consideration, along with the physical exams as noted above into account in the residual functional capacity with the limitation to performing light work including lifting and carrying no more than 20 pounds occasionally and 10 pounds frequently, sitting at least 6 hours in an 8 hour day, standing and walking at least 6 hours in an 8 hour day, occasionally climbing stairs, and performing no kneeling or crawling. However, no greater limitation is warranted, as the other physical exams have shown no tenderness along the spine, no CVA tenderness, normal range of motion of the lumbar spine, no muscle spasms and a negative SLR bilaterally. Furthermore, the neurologic exams have shown no focal deficits, no sensory abnormalities and no motor dysfunction.
The claimant has also complained of left shoulder and left leg pain, as noted in June 2012, April 2013 and April 2014. The only physical exam finding that showed abnormality in the left shoulder was when Dr. Ozment said she had decreased range of motion and 4/5 motor strength in the left upper extremity. However, Dr. Ozment noted the claimant said this was because her back was hurting. Dr. Ozment also noted she had 4/5 motor strength in the left lower extremity; however, her treating providers have noted no lower extremity weakness. Dr. Ozment also said she was poorly coordinated due to left back pain. However, she has generally had normal range of motion of all joints and no weakness in the lower extremities, normal gait and station and no coordination/cerebellum abnormalities. However, I have accommodated the claimant's left shoulder complaints and her complaints of CTS symptoms in the right hand and wrist as noted above with the ...

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