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Greasham v. Astrue

November 5, 2009

RONNIE L. GREASHAM PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Gary S. Austin United States Magistrate Judge

ORDER REGARDING PLAINTIFF'S SOCIAL SECURITY COMPLAINT

BACKGROUND

Plaintiff Ronnie L. Greasham ("Plaintiff") seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying his application for disability insurance benefits and supplemental security income pursuant to Titles II and XVI of the Social Security Act. The matter is currently before the Court on the parties' briefs, which were submitted, without oral argument, to the Honorable Gary S. Austin, United States Magistrate Judge.*fn1

FACTS AND PRIOR PROCEEDINGS*fn2

On September 15, 2005, Plaintiff filed applications for disability insurance benefits and supplemental security income, alleging disability since August 1, 1997, due to heart problems, arthritis, right knee and elbow problems, back pain, eye problems, muscle spasms, depression, chronic pain, rheumatoid arthritis, angina equivalent pain, shortness of breath, weakness and dizziness. AR 10, 30, 76-77. The applications were denied initially and upon reconsideration. AR 10. Plaintiff then requested a hearing before an Administrative Law Judge ("ALJ"). AR 10. ALJ Stephen W. Webster issued an order denying benefits on January 11, 2008. AR 7, 19. On March 19, 2008, the Appeals Council denied review. AR 3.

Hearing Testimony

The Plaintiff filed a timely written request for a hearing on May 10, 2007. However, on July 10, 2007, Plaintiff knowingly and voluntarily waived the right to personally appear and testify at the hearing. AR 10, 20.

Medical Record

The record consists of numerous reports from Truxton Radiology Medical Group, Sagebrush Family Practice, and the Kern Medical Center (KMC) covering Plaintiff's diagnoses and treatments beginning February 2, 1999, and ending March 3, 2007. AR 79, 106-349.

Plaintiff reported a history of hypertension and valvular heart disease. Reports from KMC dated April 8, 2003, evidenced mild mitral regurgitation and mild tricuspid regurgitation. AR 189-190. Plaintiff had been prescribed medication to control his hypertension. AR 194.

X-rays taken of the left hand in January, 2004, at KMC, showed some peri-articular erosion at the left third and fifth metacarpophalangeal joint, suggestive of inflammatory arthritis. AR 211.

In response to Plaintiff's allegations of back pain, Dr. Ghadiya R. Mansukh, M.D., ordered a radiological examination of the lumbosacral spine at KMC on March 18, 2005. AR 243. Dr. Parviz Massarat, M.D., reviewed the report but found no evidence of fracture or dislocation, and also found that both sacroiliac joints were well preserved. AR 243.

Plaintiff also has several orthopedic complaints. Although he reported back pain, lumbar x-rays taken March 21, 2005, at KMC were normal. AR 243.

On June 10, 2005, Plaintiff visited KMC complaining of chronic elbow pain and blurry vision. The vision problem was attributed to a refractive error. AR 244. On July 21, 2005, Plaintiff reported pain in his right elbow and right knee. AR 254. A subsequent radiological examination conducted on July 21, 2005, at KMC by Dr. Chester K. Lau, M.D., revealed that there was no recent fracture or osteolytic lesion of the right knee. Additionally, the right knee joint space was found to be normal, and no right knee effusion was observed. AR 250.

Laboratory tests run at KMC in August 2005, revealed a positive rheumatoid factor and anti-nuclear antibody. Plaintiff was subsequently diagnosed with rheumatoid arthritis. AR 267, 270.

Plaintiff also has a history of gastric problems. On September 6, 2005, Plaintiff underwent an esophagogastroduodenoscopy with biopsy at KMC. In a procedure note dated September 6, 2005, Dr. Ishaan Kalha, M.D., reported his findings as follows: distal esophagitis, grade 2, irregular squamocolumnar junction, moderate gastritis in the antrum, normal-appearing gastric cardia and gastric fundus, moderate duodenitis in the bulb of the duodenum, but normal-appearing second and third portions. AR 271.

On February 18, 2006, Dr. Emanuel Dozier, M.D., conducted a comprehensive internal medicine evaluation of Plaintiff in Bakersfield, California. AR 336. Dr. Dozier noted Plaintiff had a history of essential hypertension, controlled rheumatoid and gouty arthritis, peptic ulcer disease, valvular heart disease, and chronic mechanical low back pain. Dr. Dozier ruled out irritable bowel syndrome. AR 341. Dr. Dozier also performed a functional assessment. Based on this examination, he found that Plaintiff would have no postural or manipulation restrictions, and would not have any special sense or environmental restrictions. AR 341. Dr. Dozier also opined that Plaintiff would be able to lift and carry fifty pounds occasionally, and twenty-five pounds frequently, and that he would be able to stand, walk and/or sit for six hours in an eight-hour workday. AR 341.

On February 20, 2006, Dr. Ina Shalts, M.D., conducted a comprehensive psychiatric evaluation of Plaintiff in Bakersfield, California, pursuant to a referral from the Social Security Administration. AR 342. Plaintiff reported a history of depression and said he felt depressed due to his physical problems. Plaintiff said that he felt sad, slept poorly and did not want to be bothered by anybody. AR 16, 342. Plaintiff reported that he watched televison all night, and felt tired all the time. AR 16, 342. Plaintiff also reported multiple physical problems as being the reason for his inability to work. AR 16. Plaintiff stated that his daily activities were restricted because of his physical problems and that he had some difficulty with social functioning. Dr. Shalts diagnosed Plaintiff as suffering from a mood disorder secondary to general medical condition, and noted that he had a history of learning disability based on his own report, and that he had chronic back pain, rheumatoid arthritis, high blood pressure, heart disease, and chronic pain. She also assigned a Global Assessment of Functioning ("GAF") score of 55.*fn3 AR 344-345. Dr. Shalts determined that Plaintiff had some difficulty with concentration, persistence, and pace, but that he would be able to understand, remember, and carry out simple instructions and would be able to respond to co-workers, supervisors, the public, and to usual work situations. AR 17, 349.

On May 10, 2006, Dr. Harvey Biala, M.D., a nonexamining state agency psychiatrist, reviewed Plaintiff's medical record and recommended that further RFC assessments were necessary. Dr. Biala also reported coexisting non-mental impairments that required referral to another medical specialty. AR 92. He diagnosed Plaintiff with an affective disorder and also noted that Plaintiff had mild restrictions of activities of daily living. Plaintiff also had moderate difficulties in maintaining social functioning, concentration, persistence or pace, and yet he had no episodes of decompensation. AR 102. Dr. Biala concluded that Plaintiff retained sufficient ability to understand and remember simple instructions, and that he had sufficient ability to carry out short instructions, to perform activities without additional support and to maintain attention in two-hour increments. AR 102, 108.

A physical residual functional capacity ("RFC") report prepared by Dr. John T. Bonner, M.D., dated July 7, 2006, showed that Plaintiff could lift and carry fifty pounds occasionally, twenty-five pounds frequently, could stand and/or walk for a total of about six hours in an eight-hour workday, and could sit for a total of about six hours in an eight-hour workday. AR 85. According to the assessment, Plaintiff retained an unlimited ability to push and/or pull. AR 86. No postural limitations were established, and no manipulative, visual, communicative and environmental limitations were noted. AR 87. However, Dr. Bonner did note that Plaintiff's subjective complaints and limitations were not adequately supported by the medical evidence. AR 89.

On July 13, 2006, Plaintiff visited KMC and was prescribed Ultracet in order to alleviate pain in the left elbow. AR 289, 290. Treating notes from October 24, 2006, indicated that Plaintiff had been seen in the emergency department for hip pain. AR 318.

On March 3, 2007, Dr. Marina C. Vea, M.D., a nonexamining state agency psychiatrist, completed a functional capacity assessment of Plaintiff in which she noted that Plaintiff was moderately limited in the ability to understand and remember detailed instructions, and that he was moderately limited in the ability to carry out detailed instructions. AR 106. Based on her review of all the evidence on file, and based on her reading of the report compiled by Dr. Biala, Dr. Vea concluded that Plaintiff possessed sufficient ability to understand and remember simple instructions, and that he had sufficient ability to carry out short instructions. AR 106. She also determined that Plaintiff possessed sufficient ability to maintain socially appropriate behavior, accept instructions and respond appropriately to ...


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