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Catalina Leon v. Michael J. Astrue

March 18, 2011


The opinion of the court was delivered by: Sheila K. Oberto United States Magistrate Judge

(Doc. 1)



Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security (the "Commissioner" or "Defendant") denying her application for Supplemental Security Income ("SSI") pursuant to Title XVI of the Social Security Act. 42 U.S.C. §§ 405(g), 1383(c)(3). The matter is currently before the Court on the parties' briefs, which were submitted, without oral argument, to the Honorable Sheila K. Oberto, United States Magistrate Judge.*fn1


Plaintiff was born in 1966, has a high-school education, and previously worked as a produce sorter. (Administrative Record ("AR") 32, 76, 91, 159.) On September 27, 2006, Plaintiff filed an application for SSI, alleging disability beginning on July 1, 1997, due to a back injury.*fn2 (AR 24, 159-62, 167.)

A. Medical Evidence

1. Fresno County Human Services Department of Behavioral Health

Between September 28, 2005, and July 25, 2007, Plaintiff attended group and individual mental health therapy sessions provided by Fresno County Human Services. (AR 375-448.) The sessions lasted at most from 50 to 120 minutes. (AR 376-77, 379, 386, 393, 407, 412, 414.)

2. State Agency Physicians

On January 8, 2007, Glenn Ikawa, M.D., a state agency psychiatrist, assessed Plaintiff's mental residual functional capacity ("RFC")*fn3 and opined that, although Plaintiff was moderately limited in her ability to understand, remember, and carry out detailed instructions, she was not otherwise significantly limited. (AR 275-78.)

On that same date, Dr. Ikawa also completed a psychiatric review technique form in which he opined that Plaintiff's major depressive disorder and borderline personality disorder caused Plaintiff (1) mild to moderate restriction in activities of daily living; (2) mild difficulties in maintaining social functioning; and (3) mild to moderate difficulties in maintaining concentration, persistence, or pace. (AR 292-305.) Plaintiff experienced no episodes of decompensation. (AR 302.)

On January 8, 2007, Charles Fracchia, M.D., a state agency physician, assessed Plaintiff's physical RFC and found that Plaintiff (1) could occasionally lift and/or carry up to 10 pounds and frequently up to 10 pounds; (2) stand for about six hours in an eight-hour workday; (3) sit for about six hours in an eight-hour workday; and (4) perform unlimited pushing/pulling with the upper and lower extremities. (AR 280.) Plaintiff could occasionally climb, balance, and stoop, and frequently kneel, crouch, and crawl. (AR 281.) Plaintiff had no manipulative, visual, communicative, or environmental limitations. (AR 282-83.) Another state agency physician, Ian Ocrant, M.D., affirmed Dr. Fracchia's findings on September 21, 2007. (AR 286.)

3. Chinyere Amadi, M.D.

On May 30, 2007, Dr. Amadi, Plaintiff's treating physician, completed a physical RFC questionnaire. (AR 458-61.) Plaintiff was diagnosed with low back pain with radiculopathy,*fn4 and her prognosis was "fair to good with adequate pain control." (AR 458.) Dr. Amadi noted Plaintiff's symptoms included back and right knee pain, which Plaintiff rated at times "8" out of "10." (AR 458.) Plaintiff's pain was aggravated by prolonged walking and bending at the knee. (AR 458.) When asked to identify all clinical findings and objective signs supporting the doctor's diagnosis, prognosis, and description of symptoms and limitations, Dr. Amadi indicated that there were "[n]o physical objective findings on exam"; X-rays revealed bilateral facet arthropathy*fn5 and slight disc bulge at L4-S1. (AR 458.) Dr. Amadi stated that Plaintiff tolerated Tylenol, which could cause drowsiness. (AR 458.) Dr. Amadi further opined that Plaintiff's impairments had lasted, or were expected to last, over twelve months. (AR 458.) Dr. Amadi did not know whether Plaintiff was a malingerer. (AR 459.)

According to Dr. Amadi, Plaintiff's depression contributed to the severity of Plaintiff's symptoms and functional limitations. (AR 459.) The doctor opined, however, that Plaintiff's pain and other symptoms were rarely severe enough to interfere with the attention and concentration necessary to sustain simple, repetitive work tasks. (AR 459.) According to Plaintiff's own report, Plaintiff was capable of performing only "low stress" work. (AR 459.)

Dr. Amadi ultimately opined that Plaintiff could neither sit for more than two hours nor stand for more than thirty minutes at a time. (AR 459-60.) In an eight-hour workday, Plaintiff could only stand/walk for a total of less than two hours and sit for a total of about four hours. (AR 460.) Plaintiff did not require unscheduled breaks during an eight-hour workday as long as she was not standing for prolonged periods of time. (AR 460.) Plaintiff could frequently lift and/or carry up to ten pounds and occasionally up to twenty pounds. (AR 460.) Plaintiff could occasionally twist, stoop/bend, and climb stairs. (AR 460.) Plaintiff could rarely crouch or climb ladders. (AR 460.) Plaintiff did not have limitations in performing repetitive reaching, handling, or fingering. (AR 460.) Dr. Amadi estimated that Plaintiff would be absent from work for about four days per month as a result of her impairments. (AR 461.)

4. Ekram Michiel, M.D.

On September 8, 2007, Dr. Michiel performed a consultative psychiatric evaluation of Plaintiff. (AR 449-51.) Dr. Michiel diagnosed Plaintiff with depressive disorder not otherwise specified. (AR 451.) Dr. Michiel ultimately opined that Plaintiff "is able to maintain attention and concentration and to carry out simple job instructions." (AR 451.) Further, Plaintiff "is able to relate and interact with co-workers, supervisors and the general public." (AR 451.) Dr. Michiel found, however, that Plaintiff "is unable to carry out an extensive variety of technical and/or complex instructions." (AR 451.)

5. Abbas Mehdi, M.D.

On September 8, 2007, Dr. Mehdi performed a consultative orthopedic evaluation of Plaintiff. (AR 452-55.) Dr. Mehdi found that Plaintiff's "symptoms are consistent with a possible right L4-5 radiculopathy secondary to lumbar disk disease and degenerative spine disease." (AR 455.)

Dr. Mehdi's orthopedic examination revealed "[s]traight leg raising positive on the right but negative on the left." (AR 453.) Plaintiff's motor strength was "Normal = 5/5." (AR 454.) Motor examination of Plaintiff "was consistent with the presence of mild right calf atrophy compared to the left side." (AR 454.) However, "[o]n manual motor muscle testing there was no weakness of the right lower extremity compared to the left." (AR 454.) Further, Dr. Mehdi found that, while Plaintiff "had decreased sensation in the right L4-5 dermatome," "right leg sensory [sic] involving the others [sic] areas, the back of the leg and the upper thigh was [sic] normal. Left lower extremity sensation was normal." (AR 454.)

In assessing Plaintiff's functional capacity, Dr. Mehdi opined as follows: [Plaintiff] can lift and carry 20 pounds occasionally and 10 pounds frequently. [Plaintiff] can stand and walk six hours out of an eight hour day with normal breaks. [Plaintiff] can sit six hours out of an eight hour day with normal breaks. Exertional limitations include ...

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