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Angela Shankles v. Michael J. Astrue

December 13, 2010


The opinion of the court was delivered by: Kendall J. Newman United States Magistrate Judge


Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying plaintiff's request for Supplemental Security Income under Title XVI of the Social Security Act.*fn1 Plaintiff contends that the Administrative Law Judge ("ALJ") erred by: (1) determining that there are jobs in significant numbers in the national economy that plaintiff can perform despite plaintiff's mental impairments; (2) determining that plaintiff was able to perform jobs in the national economy without first consulting a Vocational Expert ("VE"); (3) failing to properly assess plaintiff's non-mental impairments at step two of the required five-step analysis; and (4) failing to properly document his findings regarding plaintiff's mental impairments in accordance with 20 C.F.R. § 416.920a and the Commissioner's Hearings, Appeals, and Litigation Manual ("HALLEX") I-2-8-25C(2). (Pl.'s Mot. for Summ. J. ("Pl.'s Mot."), Dkt. No. 17.) The Commissioner filed a cross-motion for summary judgment. (Def.'s Opp'n & Cross-Motion for Summ. J., Dkt. No. 19.) Plaintiff filed a reply to defendant's motion. (Pl.'s Reply to Def.'s Opp'n & Cross-Motion for Summ. J. ("Pl.'s Reply"), Dkt.No. 21.)

For the reasons that follow, the court denies plaintiff's motion for summary judgment in part, grants the Commissioner's cross-motion for summary judgment in part, and remands this case to the agency for further proceedings consistent with this order.


A. Procedural Background

On January 3, 2006, plaintiff filed an application for Supplemental Security Income ("SSI"). (Administrative Transcript ("AT") 31.) Plaintiff alleged a disability onset date of December 1, 2000. (AT 44, 46.) Following an initial denial of her claims, plaintiff filed a Request for Reconsideration that was subsequently denied on February 7, 2006. (AT 12, 36, 37.) Plaintiff timely filed a request for a hearing, and the ALJ conducted a hearing on October 29, 2008. (AT 35, 135.) At the hearing, the ALJ heard testimony only from plaintiff. (AT 40, 135.) The ALJ also considered written statements submitted by plaintiff's sister, Teddi Hamilton, and plaintiff's husband, William Shankles. (AT 17, 166-69.)

In a decision dated February 2, 2009, the ALJ denied plaintiff's application, finding that there were a significant number of jobs in the national economy that plaintiff could perform despite some limitations in her residual functional capacity.*fn2 (AT 20.) The ALJ's decision became the final decision of the Commissioner when the Appeals Council denied plaintiff's request for review on April 17, 2009. (AT 2-5.) Plaintiff seeks judicial review of the denial of her application.

B. Summary of Relevant Medical History and Evidence At the time of her hearing before the ALJ, plaintiff was 39-years-old and had not worked since approximately 2003. (AT 31, 62.) Plaintiff completed the ninth grade of high school and received her diploma through home schooling in approximately 2002. (AT 139-40.) Plaintiff had worked doing yard-duty and bus-duty for her daughter's school, but quit amidst an incident involving her daughter's classmate. (AT 143-46.) Prior to that time, plaintiff worked as a dietary aide and for a Burger King restaurant. (AT 146.)

Plaintiff first sought medical treatment relative to her condition herein on August 17, 2004, at Midtown Medical Center ("MMC"). (AT 130.) Plaintiff complained of a right knee fracture after an auto accident. (Id.) An x-ray revealed that there was no fracture. (AT 122.) From August 24, 2004, through December 29, 2004, plaintiff was prescribed Vicodin,*fn3 Ultram,*fn4 and Soma.*fn5 (AT 121, 126, 127, 128, 196-98, 270.)

Plaintiff returned to MMC on June 1, 2005, and was prescribed Lexapro*fn6 and Seroquel.*fn7 (AT 125.) In January 2006, plaintiff presented to MMC for a physical examination and complained of depression. (AT 124.) Plaintiff was prescribed Zoloft*fn8 as a replacement for Lexapro. (Id.)

Plaintiff presented to Timothy Canty, M.D., for a psychiatric evaluation on February 2, 2006. (AT 109.) Plaintiff's primary complaint was that she was "not so good with people," and she indicated that her mood had improved with medications. (Id.) Plaintiff reported that she was taking Seroquel and Zoloft. (Id.) Plaintiff reported that she had not sought mental-health treatment "but was placed on a 72-hour hold after she complained of suicidal ideation while in jail." (Id.)

Dr. Canty diagnosed plaintiff's DSM-IV characteristics as follows:

Axis I: Methamphetamine dependence in remission per claimant, Anxiety disorder NOS. Axis II: None. Axis III: Deferred. Axis IV: Mild. Axis V: 65/70.*fn9 (AT 111.)

Dr. Canty determined that plaintiff had the cognitive ability to manage money, but that she "would not do well in a public or overly stressful job." (AT 112.) Dr. Canty stated that plaintiff would not have difficulty in "most nonpublic, simple jobs." (Id.) Lastly, Dr. Canty reported that plaintiff's anxiety would not interfere with attending work that she was highly motivated to perform, but that she would probably do best with a limited number of co-workers and supervisors. (Id.)

On February 24, 2006, plaintiff returned to MMC complaining of left arm pain and headaches. (AT 239.) The chart note indicated that plaintiff's depression was "controlled on Zoloft." (Id.)

During March and April of 2006, plaintiff continued to be seen at MMC for headaches and depression. (AT 281, 283.) Plaintiff was prescribed Imitrex,*fn10 but on May 17, 2006, she complained that the medication was not helping with her headaches. (AT 279, 283.)

Plaintiff also complained that she had low back pain since 2004 when she underwent a procedure to treat kidney stones. (AT 279.) On July 25, 2006, plaintiff was prescribed Topomax*fn11 for her headaches, and on August 25, 2006, plaintiff reported that Topomax helped. (AT 233, 234.)

During the remainder of 2006 and early 2007, plaintiff continued to visit MMC and was prescribed medication for migraines, anxiety, and depression. (See AT 228-32.) On February 23, 2009, plaintiff complained of chest pain and was diagnosed with gastroesophageal reflux disease ("GERD"). (AT 227.) Plaintiff's GERD symptoms were treated with Prevacid,*fn12 and she was prescribed Xanax.*fn13 (Id.)

On May 17, 2007, plaintiff presented to Mercy San Juan Hospital and was diagnosed with acute lumbar strain. (AT 192.) On May 29, 2007, plaintiff returned to MMC complaining of back pain and was prescribed Flexeril.*fn14 (AT 224.)

Between June 28, 2007, and July 3, 2008, plaintiff continued to be treated at MMC on an approximately monthly basis for a number of health reasons including anxiety, depression, headaches, low back pain, and cough. (AT 210-13, 217-23.) During this time period, plaintiff was treated with the following medications: Zoloft, Xanax, Seroquel, Ultram, Flexeril, and Topomax. (Id.)

On July 12, 2008, plaintiff presented to Mercy San Juan Hospital where she was diagnosed with colitis. (AT 195.) Plaintiff followed up regarding her colitis symptoms at MMC on July 16, 2008, and July 24, 2008. (AT 208, 209.) On August 4, 2008, plaintiff presented to MMC complaining of right side back pain and left side "belly pain." (AT 206.) Plaintiff's corresponding chart note reported colitis, abdominal pain which required a colonoscopy, GERD which was treated with Prilosec,*fn15 constipation, anxiety which was treated with Xanax, depression which was treated with Zoloft, headaches which were treated with Topomax, and low back pain which was treated with Flexeril and Ultram. (Id.)

On August 28, 2008, an ultrasound of plaintiff's abdominal region identified a calculus*fn16 measuring 5.0 x 2.3 mm in plaintiff's left kidney. (AT 252.) The ultrasound also revealed that plaintiff's "pancreas is echogenic consistent with atrophy." (Id.)

A radiological report dated September 2, 2008, revealed that plaintiff had "two adjacent calcifications projecting over the inferior pole left kidney measuring 3 and 4 mm." (Id.) From September 2, 2008, to October 1, 2008, plaintiff continued treatment at MMC and complained of left side stomach pain, nausea, vomiting, sharp pain in her lower back, and anxiety. (AT 202-04.)

On October 7, 2008, plaintiff presented to Mercy San Juan Hospital. (AT 194.)

A CT scan of her abdomen and pelvis revealed calcified granuloma at plaintiff's right lateral lung base and multiple old calyceal stones in her left kidney. (Id.) The report indicated that plaintiff was at risk for episodes of left sided renal colic and that the colitis that had been present on a scan from the previous July had been resolved. (Id.)

On October 8, 2008, plaintiff presented to MMC complaining of blood in her urine, and kidney pain. (AT 201.) During her October 28, 2008 visit to MMC, plaintiff also complained of lower back pain and left side stomach pain. (AT 200.) The diagnosis and treatment plan taken from the chart notes of these two visits are as follows: renal stones for which plaintiff was to be referred to urology; obesity which listed "lifestyle" as a treatment plan; GERD, which was treated with Prilosec; depression, which was treated with Zoloft; anxiety, which was treated with Xanax; headaches, which were treated with Topomax; chronic low back pain, which was treated with Vicodin and Flexeril; shingles, which was treated with Acyclovir;*fn17 bipolar disorder, which was treated with Seroquel; and colitis. (AT 200-01.)

Meanwhile, on October 15, 2008, plaintiff presented to John T. Hata, M.D., complaining of abdominal pain, blood in her stool, and GERD. (AT 250.) Dr. Hata reported that plaintiff suffered from chronic anxiety and that plaintiff's prescribed medications included: Prilosec, Seroquel, Zoloft, Vicodin, Xanax, Topomax, and Flexeril. (Id.) Plaintiff further complained of episodic lower back pain and shingles. (Id.) Plaintiff also stated that the onset of her heartburn was four years ago and that the problem had not resolved. (Id.) Dr. Hata reported that plaintiff was stable on Prilosec and should continue treatment with medication. (AT 251.)

On October 23, 2008, plaintiff was referred by her attorney to Michelina Regazzi, Ph.D., for a psychological evaluation. (AT 272.) With regard to her medical history, plaintiff reported that was recently told she had colitis and that she was being treated for kidney stones. (Id.) Plaintiff reported that her medications included Xanax, Prochlorperazine,*fn18 ...

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