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Joann Ruiz v. Michael J. Astrue

March 8, 2011


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



Plaintiff Joann Ruiz ("Plaintiff") seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner" or "Defendant") denying her application for disability insurance benefits pursuant to Title 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


Plaintiff filed her application on or about April 25, 2006, alleging disability beginning April 1, 2003. AR 91. Her application was denied initially (AR 71-76) and on reconsideration (AR 80-85). Thereafter, Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"). AR 86. ALJ Bert C. Hoffman, Jr., held a hearing on December 9, 2008 (36-70), and issued an order denying benefits on February 12, 2009. AR 7-17. Plaintiff requested a review of the decision (AR 5) and on April 10, 2009, the Appeals Council denied review. AR 1-4.

Hearing Testimony

ALJ Hoffman held a hearing on December 9, 2008, in Fresno, California. Plaintiff appeared and testified. He was represented by attorney Geoffrey L. Hayden. AR 36-70.

Plaintiff is forty-eight years old. She completed the tenth grade and can read and write. She is five feet tall and weighs 120 pounds. AR 42. She has hepatitis B and C and suffers from high blood pressure. AR 45, 49. She also has a history of heroin addiction, however, she has not taken the drug in five years. AR 48. She was taking methadone, but has not used it in almost a year. AR 48. Plaintiff has a criminal history, however, she has not been in trouble with the law since 1999.*fn3 AR 49.

Plaintiff last worked in 2003 as a dishwasher and cook. AR 44, 64. She has also worked as a waitress in the past. AR 45. She is currently unable to work because she had two minor stokes in 1996 and 1997, and suffers from pain in her arms and legs. AR 45, 53. As a result, Plaintiff has difficulty walking because her legs become numb and she falls. AR 51. She is able to walk only one block, she can lift a gallon of milk, and she can stand and sit for fifteen minutes to one-half hour. AR 55-56.

In addition to the pain in her arms and legs, Plaintiff also suffers from pain in her side from her liver. AR 54. She is hard of hearing because she has two plastic ear drums.*fn4 AR 50-51. Plaintiff's current medications include Nexium, Zoloft, Elavil and Aspirin. AR 49-50.

For fun, Plaintiff watches television. AR 63. She does not have any friends. Plaintiff is able to go grocery shopping with family and occasionally goes to church. AR 57-58. She also does some housework including dusting and cooking. AR 57. She is able to bath herself, although she sometimes needs assistance getting out of the bathtub. AR 58.

Plaintiff has had a boyfriend "on and off for four years." AR 52. She is currently living with her boyfriend and they have been together most recently for two years. AR 57. She supports herself through food stamps. AR 57. Plaintiff's boyfriend suffers from bipolar disorder. AR 52. Plaintiff also suffers from psychological impairments. AR 65-66. She has received mental health treatment in the past, however, she only had two appointments because she was unable to afford treatment. AR 55-56. She has recently lost interest in everything and only likes to sit and do nothing. AR 59. She frequently has crying spells and she suffers from hallucinations and hears voices. AR 65-67. She has attempted suicide three times in the past. AR 66.

Medical Record

The entire medical record was reviewed by the Court. Summaries of the relevant reports and treatment notes are provided below.

Plaintiff received treatment from Clinica Sierra Vista from September 2005 through March 2006. AR 154-162. Treatment notes indicate Plaintiff suffered from depression, anxiety and insomnia. AR 161. Plaintiff was prescribed Zoloft which was controlling her depression. AR 158-159. Plaintiff stopped attending her counseling appointments beginning March 2006. AR 157-158.

On June 3, 2006, Ina Shalts, M.D., conducted a consultative psychiatric examination in Bakersfield, California, at the request of the Social Security Administration. AR 163-167. Dr. Shalts noted that Plaintiff had been molested by her uncle beginning at the age of three. Plaintiff suffered severe molestation over several years which stopped when she was ten years old after Plaintiff set her room on fire and threw hot water on her uncle. AR 164. Plaintiff reported suffering from depression and using heroin as a teenager to self medicate. AR 164.

During the evaluation, Dr. Shalts found that Plaintiff's mood was very depressed, however, she could understand, carry out, and remember simple instructions. AR 166. She was able to do digit spans forward and backwards and interpret proverbs. AR 166. Further, Plaintiff was oriented to person, place, and time, was able to maintain eye contact, and could answer simple geographic questions. In addition, Dr. Shalts found that Plaintiff was cooperative, that she could tell similarities and differences, and that her intellect was in the average range. AR 166-167.

Dr. Shalts diagnosed Plaintiff with posttraumatic stress disorder, major depressive disorder recurrent and severe, heroin dependence in remission with methadone, and a history of alcohol abuse. AR 166. Dr. Shalts also opined Plaintiff is able to understand, carry out and remember simple instructions, but that she would have difficulty responding to the ususal work situations or dealing with the routine work settings due to her mental illness. Although Dr. Shalts found that Plaintiff's condition could improve with treatment, she nonetheless determined Plaintiff was not able to maintain gainful employment. AR 167.

On August 12, 2006, Sarupinder Bhangoo, M.D., conducted a consultative internal medicine evaluation. AR 168-172. Dr. Bhangoo's examination did not reveal any musculoskeletal or neurological deficits pertaining to the left arm or leg. AR 171. Although Plaintiff reported a history of hepatitis C, there was no evidence of spastic decomposition in the form of ascites, or jaundice. AR 171. Dr. Bhangoo did note Plaintiff was hard of hearing. AR 171-172.

Dr. Bhangoo opined that: 1) Plaintiff could sit eight hours in an eight-hour work day, 2) she needs no assistive devices, 3) she does not have any postural limitations with bending, stooping, or crouching, 4) she does not have any manipulative limitations with reaching, handling, feeling, grasping, or fingering, 5) she has no relevant visual or ...

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