United States District Court, N.D. Alabama, Northwestern Division
ANNA L. SIMPLER, Claimant,
v.
NANCY A. BERRYHILL, Acting Commissioner, Social Security Administration, Defendant.
MEMORANDUM OPINION
Claimant,
Anna Simpler, commenced this action on September 19, 2018,
pursuant to 42 U.S.C. § 405(g), seeking judicial review
of a final adverse decision of the Commissioner affirming the
decision of the Administrative Law Judge denying her claim
for a period of disability, disability insurance, and
supplemental security income benefits.
The
court's role in reviewing claims brought under the Social
Security Act is a narrow one. The scope of review is limited
to determining whether there is substantial evidence in the
record as a whole to support the findings of the
Commissioner, and whether correct legal standards were
applied. See Lamb v. Bowen, 847 F.2d 698, 701 (11th
Cir. 1988); Tieniber v. Heckler, 720 F.2d 1251, 1253
(11th Cir. 1983).
Claimant
argues that the Commissioner's decision was neither
supported by substantial evidence nor in accordance with
legal standards. Specifically, claimant asserts that the ALJ
improperly considered the consultative examiner's
assessment, improperly substituted her opinion for that of
the medical experts, and failed to consider the side effects
of claimant's medications upon her ability to work. Upon
consideration of the record and the parties' briefs, the
court finds merit in claimant's first and third
arguments.
A.
Consultative Physician's Opinion
Social
Security regulations provide that, in considering what weight
to give any medical opinion, the Commissioner should
evaluate: the extent of the examining or treating
relationship between the doctor and patient; whether the
doctor's opinion can be supported by medical signs and
laboratory findings; whether the opinion is consistent with
the record as a whole; the doctor's specialization; and
other factors. See 20 C.F.R. §§
404.1527(c), 416.927(c). See also Wheeler v.
Heckler, 784 F.2d 1073, 1075 (11th Cir. 1986)
(“The weight afforded a physician's conclusory
statements depends upon the extent to which they are
supported by clinical or laboratory findings and are
consistent with other evidence as to claimant's
impairments.”).
Dr.
Ernest Lee Mollohan conducted a consultative physical
examination on July 19, 2016.[1] Claimant reported experiencing
lumbar radiculopathy since 2015, which caused weakness,
numbness, tingling, and dull, sharp, and stabbing pain at a
level six on a good day and level ten on a bad day. The pain
could be relieved by changing positions, medication,
stretching, propping up her legs, and rest. It was aggravated
by standing and walking more than five minutes, bending, and
stooping. She also reported right knee pain at level 4-10
since 2012. The pain manifested as sharp and stabbing, and
she also experienced weakness and numbness in the knee. The
pain was relieved by propping up her knee, resting, lying
down, and taking medications. It was aggravated by standing
and walking more than five minutes, bending, and stooping.
Although she experienced intermittent weakness, numbness, and
tingling in her lower back into both feet, she did not suffer
from those symptoms on the date of the examination. During
the musculoskeletal examination, claimant did not use an
ambulatory device but did demonstrate antalgic gait secondary
to level ten pain in her thoracic vertebrae. She also
experienced level ten pain in her hip and right knee while
walking sixty feet, causing her to be unable to complete the
other sixty feet that were planned for the gait analysis. She
was able to sit for thirty minutes and stand for only five to
ten minutes before having to sit down for comfort. She moved
slowly when standing from a seated position, and she was able
to move on and off the examination table without difficulty
or complaint. She was able to heel-toe walk, and her straight
leg raise tests were normal. She demonstrated
level-six-to-seven tenderness upon palpitation to her
vertebrae and paraspinal musculature and level-ten tenderness
upon palpitation to her sacroiliac joint. She had good
cervical range of motion, but the testing elicited level-nine
pain. Her hip and lumbar range of motion was limited, and the
testing elicited level-eight to level-nine pain. Femoral
rotation was normal, but testing elicited level-five pain.
She could only minimally squat due to level-nine knee pain,
and her knee range of motion was limited. Range of motion in
her ankles, feet, shoulders, arms, elbows, wrists, hands, and
fingers was normal, but she did experience level-six pain in
her shoulder. She had full bilateral grip strength. Claimant
did not complain of any radicular pain or other neurological
symptoms during the examination, and she “displayed a
genuine, honest and motivated effort to perform all of the
examination maneuvers.”[2]
Dr.
Mollohan also completed a “Medical Source Statement Of
Ability To Do Work Related Activities (Physical)” form.
He indicated that claimant could occasionally lift up to ten
pounds, but she could never carry any weight. She could sit
for forty-five minutes at a time, and for seven total hours,
during an eight-hour work day. She could stand for ten
minutes at a time, and for a total of thirty minutes. She
could walk for five minutes at a time, and for a total of
thirty minutes. She did not require an assistive device to
ambulate. She could continuously use both hands to handle,
finger, and feel, frequently use both hands to reach
overhead, and occasionally use both hands to push, pull, and
perform other reaching movements. She could frequently use
both feet to operate foot controls. She could occasionally
balance, but could never climb, stoop, kneel, crouch, or
crawl. She had no visual or hearing impairments. She could
not walk a block at a reasonable pace on rough or uneven
surfaces, or climb a few steps at a reasonable pace with the
use of a single hand rail. She could shop, travel without a
companion, ambulate without an assistive device, use standard
public transportation, prepare a simple meal, feed herself,
care for her personal hygiene, and sort, handle, and use
paper files. All of the limitations Dr. Mollohan imposed had
lasted or would last for twelve consecutive
months.[3]
Dr.
Mollohan's assessment is consistent with the ability to
perform sedentary work, [4] but not any higher level of work. That
is important because if claimant were limited to only
sedentary work, the grids would dictate a finding of
disability.[5] The ALJ, however, found claimant to be
capable of performing a limited range of light work
activity, which did not require a finding of disability under
the grids.[6] In so finding, the ALJ assigned Dr.
Mollohan's assessment only little weight because, in the
ALJ's words,
the limitations are excessive in comparison to the medical
evidence and Dr. [Mollohan's] own examination findings.
Although the claimant has demonstrated some limitation in
range of motion, particularly with regard to lumbar flexion
and extension, hip flexion, and right knee. . ., Dr.
[Mollohan's] examination and various other examinations
have generally shown intact cranial nerves, full strength,
normal sensation, negative straight leg raises, symmetrical
reflexes, ambulation without an assistive device, and no
difficulties with toe walking and heel walking . . . . This
combined with the claimant['s] testimony that she is able
to lift and carry 10 pounds comfortably and her statement
that she has changed her 28 pound grandson's diapers,
support the conclusion that she is able to lift and carry 20
pounds occasionally and 10 pounds frequently, stand/walk for
a total of six hours, and sit for a total of six hours in an
eight hour work day with normal breaks. The undersigned
further concludes that the claimant is able to push and pull
as much as she can lift and carry, frequently climb ramps and
stairs but should never climb ladders, ropes, and scaffolds,
frequently balance, and occasionally stoop, kneel, crouch,
and crawl. Given her history of cervical degenerative disc
disease, the claimant should avoid more than occasional
overhead reaching with the bilateral upper extremities. She
should too avoid work [at] unprotected heights, work around
moving mechanical parts, and more than occasional exposure to
vibrations.
Tr. 19
(alterations supplied).
As a
general matter, the ALJ adequately articulated her reasons
for not fully crediting Dr. Mollohan's findings, but
there were some conclusions she failed to explain. For
example, the ALJ concluded that Dr. Mollohan's findings
of “intact cranial nerves, full strength, normal
sensation, negative straight leg raises, symmetrical
reflexes, ambulation without an assistive device, and no
difficulties with toe walking and heel walking”
outweighed the findings of limited range of motion, antalgic
gait, inability to walk more than sixty feet, slow movement
when arising from a seated position, and tenderness to
palpitation in her vertebrae and paraspinal muscles, but she
failed to explain why. The latter group of findings would
support more significant limitations than those imposed by
the ALJ.
Looking
beyond Dr. Mollohan's assessment, some other portions of
the record contain findings like normal gait, [7] good knee
strength, [8] and negative straight leg raise
tests.[9] Even so, the record also contains
objective findings that would be inconsistent with Dr.
Mollohan's findings. A March 24, 2015 MRI revealed
“dessication of the L4-5 disc with diffuse bulge of
this same disc. This results in compression of the anterior
thecal sac to a moderate degree.”[10] An August 8,
2014 MRI revealed “right paramedian disc protrusion at
the C5-6 level, of moderate degree.”[11] Examination
records from other treatment providers also revealed
asymmetrical gait, positive straight leg raise tests, and
tenderness to palpitation in the knee and lumbar
regions.[12]Finally, the ALJ appears to have given
significant weight to the fact that claimant changes her
28-pound-grandson's diapers, but claimant testified that
her grandchild removes the diapers for her, and she does not
have to lift him because he can climb into a carseat or onto
a changing table.[13] As a whole, the record contains
some evidence to support the ALJ's conclusion
about Dr. Mollohan's report, but it was not supported by
substantial evidence. Remand is warranted for
further consideration of Dr. Mollohan's report, and for
further development of the record regarding the effects of
claimant's functional impairments, if necessary.
B.
Medication Side Effects
Claimant
testified during the first administrative hearing that she
experienced dizziness, lightheadedness, and tiredness as side
effects of her medications, including Lyrica and
Ultram.[14] She testified during the second hearing
that her medications in general made her feel drowsy and
sleepy.[15] Claimant argues that the ALJ erred by
failing to mention that testimony in her administrative
decision, or to give any other indication that she considered
the effects of claimant's medications on her ability to
work. This court agrees. Social Security regulations provide
that medication side effects are a permissible consideration
in evaluating a claimant's complaints of pain.
See 20 C.F.R. ยงยง 404.1529(c)(3)(iv),
416.929(c)(3)(iv). Without any mention of claimant's side
effects, there is no way to know whether the ALJ merely
overlooked them, discredited them, or acknowledged them but
determined they did not have a material effect on
claimant's ability to work. ...