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Collins v. Astrue

July 27, 2009


The opinion of the court was delivered by: Rosalyn M. Chapman United States Magistrate Judge


Plaintiff Terri L. Collins filed a complaint on December 28, 2007, seeking review of the decision denying her application for disability benefits. On July 16, 2008, the Commissioner answered the complaint, and the parties filed a joint stipulation on September 16, 2008.



On April 17, 2003 (protective filing date), plaintiff filed a claim for disability benefits under the Supplemental Security Income program of Title XVI of the Social Security Act ("the Act"), 42 U.S.C. § 1382(a), claiming an inability to work since April 11, 2003, due to fibromyalgia. Certified Administrative Record ("A.R.") 99-101, 103, 109. The plaintiff's application was initially denied on November 6, 2003, and was denied again on March 4, 2004, following reconsideration. A.R. 51-62. The plaintiff then requested an administrative hearing, which was held on April 4, 2005, before Administrative Law Judge Joseph Schloss ("ALJ Schloss"). A.R. 19-48, 65. On April 29, 2005, ALJ Schloss issued a decision finding plaintiff is not disabled. A.R. 11-17. The plaintiff appealed that decision to the Appeals Council, which denied review on July 28, 2005. A.R. 4-10.

On August 22, 2005, plaintiff filed her first complaint seeking review of the Commissioner's decision denying her application for disability benefits, Collins v. Astrue, EDCV 05-0751-RC ("Collins I"),*fn1 and on December 7, 2006, this Court granted plaintiff's request for relief and remanded the matter to the Social Security Administration under 42 U.S.C. § 405(g), sentence four. A.R. 349-66. The Appeals Council, in turn, remanded the matter for further administrative proceedings,*fn2 A.R. 367-70, and on June 19, 2007, Administrative Law Judge Jay E. Levine ("the ALJ") held a new administrative hearing. A.R. 954-76. On October 11, 2007, the ALJ issued a decision finding plaintiff is not disabled, A.R. 325-35, and that decision is now before this Court for review.


The plaintiff, who was born on May 9, 1967, is currently 42 years old. A.R. 22, 99, 395. She has attended two or three years of college, and has previously worked as a bus driver, secretary and hair braider. A.R. 23-26, 110, 115, 118-24, 401-08.

This Court, in its Collins I decision, summarized the relevant medical evidence as follows:

On September 25, 2002, R. Prakash, M.D., a cardiologist, examined plaintiff and diagnosed her with hypertension, tiredness, sleep problems, and anemia, and prescribed medication and recommended a low fat diet and exercise. Dr. Prakash also obtained a doppler echocardiogram, which was consistent with possible mitral valve prolapse, but unremarkable for ischemic heart disease. [¶] On April 9, 2003, Rana A. Bahl, M.D., examined plaintiff and diagnosed her as having coronary artery disease, angina, hypertension, early congestive heart failure, and arrhythmia. A stress test revealed equivocal changes for ischemia with no evidence of angina or arrhythmia, and an ECG was abnormal. An echocardiogram performed April 18, 2003, revealed a left ventricular ejection fraction of 68% and trace pulmonic regurgitation. On December 23, 2003, and January 16, 2004, plaintiff had additional ECGs, both of which were abnormal.

[¶] On April 11, 2003, plaintiff was admitted to Doctor's Hospital Medical Center of Montclair with complaints of recurrent atypical chest pain. Chest x-rays taken April 11, 2003, showed no active cardiopulmonary disease, and an ECG obtained April 13, 2003, also was normal. Plaintiff was discharged from the hospital on April 15, 2003, with diagnoses of atypical chest pain, hypertension, which was controlled with medication, and stable degenerative joint disease. [¶] On April 16, 2003, Dee Beng Lim, M.D., examined plaintiff and diagnosed her with fibromyalgia, noting plaintiff has multiple tender points. Dr. Lim treated plaintiff for fibromyalgia and also diagnosed her with chronic fatigue syndrome, depression, insomnia, tension headaches, trapezius and lumbosacral myofascitis, costochondritis, hypertension, obesity, and angina, among other conditions. On May 6, 2003, Dr. Lim opined plaintiff had been permanently disabled since 2002 due to fibromyalgia and chronic fatigue syndrome. On June 19, 2003, Dr. Lim prescribed multiple trigger point injections to plaintiff. On July 24, 2003, Dr. Lim opined plaintiff had fibromyalgia since 1994. Dr. Lim found plaintiff has constant tenderness in her ankles and fingers, paravertebral muscle spasms, paresthesia of her fingers and toes, is limited in her ability to reach, handle, and finger, has trouble walking, and needs an assistive device to walk longer than 10 minutes. [¶] On August 17, 2003, plaintiff was admitted to Pomona Valley Hospital Medical Center, where Dr. Lim examined plaintiff and diagnosed her with atypical chest pain, fibromyalgia, hypertension, and possible myocardial ischemia (not shown on the electrocardiogram). ECGs performed August 17 and August 18, 2003, were abnormal; however, a chest CT scan and chest x-ray done on August 17, 2003, were normal. On August 18, 2003, Dr. Bahl examined plaintiff and diagnosed her with coronary artery disease and unstable angina with hypertension. On the same date, Dr. Bahl performed a cardiac catheterization and angiogram procedure on plaintiff, which was normal, and plaintiff was discharged from the hospital. [¶] . . . [¶] On April 24, 2004, Dr. Lim opined plaintiff has fibromyalgia that meets the American Rheumatological criteria for the disease,*fn3 hypertension, gastroesophageal reflux disease, and anxiety, and her symptoms include chronic pain from head to toe, multiple tender points, nonrestorative sleep, morning stiffness, muscle weakness, subjective swelling, irritable bowel syndrome, frequent severe headaches, temporomandibular joint dysfunction, numbness and tingling, dysmenorrhea, anxiety, panic attacks, depression, mitral valve prolapse, and chronic fatigue syndrome. Dr. Lim found plaintiff's pain is precipitated by changing weather, fatigue, movement/overuse, stress, cold, hormonal changes and being in a static position; her pain is frequently sufficiently severe to interfere with her attention and concentration; and she has a severe limitation in her ability to deal with work-related stress. Dr. Lim opined plaintiff can occasionally lift up to 10 pounds and bend and twist at the waist; can sit for 20 minutes at a time and for less than 2 hours in an 8-hour workday; can stand for 30 minutes at a time, walk for less than one block without resting or experiencing severe pain, can stand and/or walk for less than 2 hours in an 8-hour day, and must use a cane or other assistive device; and can use her arms to perform such activities as reaching, grasping, and fine manipulations for only 5% of the workday. Dr. Lim also opined plaintiff needs to shift positions at will and must walk for 5 minutes every 20 minutes. Furthermore, Dr. Lim opined plaintiff must lie down at unpredictable intervals during the work day and must elevate her legs at least 90 degrees with prolonged sitting 3-4 times a day. Finally, Dr. Lim opined plaintiff's condition is likely to produce good and bad days, and she is likely to miss more than 3 days of work a month due to her condition. [¶] On June 17, 2005, Dr. Lim noted he has treated plaintiff's fibromyalgia with "various trigger points at sub-occipital, cervical paraspinals, trapezius, levator scapulae, ilio-lumbars and sacro-iliacs, lateral epicondyles, sternal borders, iliac crests, [and] both knees[,]" and plaintiff also has hypertension, chronic fatigue syndrome, irritable bowel syndrome, and severe anxiety and depression. Dr. Lim further noted plaintiff has been treated with multiple trigger point injections and a course of physical therapy. Further, Dr. Lim noted that plaintiff's pain level is always "10/10" and she requires morphine for a few hours of pain relief, and plaintiff also takes numerous other medications, including Zelnorm, Avinza, Aciphex, Baclofen, Motrin, Zestril, Verapamil, Ativan, Klonopin, Cymbalta, and Vicodin ES. Dr. Lim opined plaintiff "is unable to do any kind of work because of her pain and fatigue. She can not lift more than 10 [pounds], [she is] unable to sit for more than 15 minutes, [she] can not concentrate because of severe anxiety-depression [and s]he could definitely not perform her old profession of being a secretary or a hairdresser." Finally, Dr. Lim stated he is trying to refer plaintiff to a rheumatologist and pain management specialist. [¶] Medical expert Joseph C. King, M.D., an internist, testified at the administrative hearing that plaintiff has hypertension, which is controlled, costochondritis, a history of fibromyalgia, and a history of mild anemia, and that none of her conditions meets or equals any listed impairment. Dr. King opined plaintiff has "too much medication in her system at one time and . . . apparently is dependent on this medicine now. . . ." With regard to plaintiff's fibromyalgia, Dr. King opined plaintiff has "only 10 trigger points that I could find [though a]t one time she had 14 trigger points." Dr. King also opined fibromyalgia usually involves certain tender points and "doesn't involve the whole body from the feet to the head[,]" and plaintiff has "too [many] symptoms to go with the diagnosis of fibromyalgia."

Collins I at 3:4-11:13 (footnotes and citations omitted; footnote added).

Between July 8, 2005, and January 13, 2006, plaintiff received treatment at the Hi-Desert Family Health Clinic, where she was diagnosed with degenerative disc disease, lupus, fibromyalgia and hypertension, among other problems.*fn4 A.R. 683-725. Thoracic spine x-rays taken January 6, 2006, showed modest degenerative changes with spurring at the lower levels anteriorly, and lumbosacral spine x-rays taken the same day showed modest levoscoliosis, narrowing of the L3-L4 disc space, and moderate tiny anterior spurs suggestive of degenerative changes. A.R. 685-86.

The plaintiff was hospitalized at St. Bernardine Medical Center between September 21 and 23, 2006, and diagnosed with chest pain, hypertension, mitral valve prolapse, irritable bowel syndrome, and fibromyalgia. A.R. 775-864. During this hospitalization, plaintiff was examined by several physicians, including Shuang Bai, M.D. A.R. 791-92, 912-13. Diagnostic testing included a normal chest x-ray, abnormal ECGs, and an exercise stress test, which revealed no exercise-induced chest pain or arrhythmias and normal hemodynamic response to exercise. A.R. 831-32, 834, 850, 855-56. Additionally, a lumbar spine CT scan demonstrated circumferential disc bulging and facet arthropathy with mild spinal stenosis at L3-L4, circumferential disc bulging and bilateral facet arthropathy with moderate spinal stenosis at L4-L5, and mild circumferential disc bulging at L5-S1. A.R. 829-30, 907-08.

Dr. Bai continued to treat plaintiff through June 6, 2007, diagnosing her with fibromyalgia, obesity and hypertension, among other conditions. A.R. 883-95. On March 16, 2007, Dr. Bai opined plaintiff has been unable to work since April 15, 2003. A.R. 923-26. Dr. Bai further opined: plaintiff can sit for 0-2 hours at a time and 0-2 hours in an 8-hour day because her legs lock up, she stiffens up, and its painful for her to move; plaintiff can walk for 0-2 hours at a time and 0-2 hours in an 8-hour day, and she uses a cane to get around; plaintiff is restricted in using her hands/fingers and feet for repetitive movements due to her fibromyalgia; cold, damp and heat make plaintiff's body hurt; plaintiff can occasionally lift and/or carry up to 10 pounds, balance, stoop, kneel, crouch, crawl, and reach; and plaintiff can never climb. A.R. 924-25. Finally, Dr. Bai found plaintiff is depressed and is taking depression medication, which affects her daily activities. A.R. 926.

Between March 30 and April 2, 2007, plaintiff was hospitalized at Community Hospital of San Bernardino, where she was diagnosed with chest pain, new onset Type II diabetes mellitus, chronic back pain, fibromyalgia and ...

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