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Angelina Gomez v. Michael J. Astrue

March 19, 2012


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



Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security (the "Commissioner" or "Defendant") denying his application for disability insurance benefits ("DIB") and supplemental security income ("SSI") pursuant to Title II and XVI of the Social Security Act (the "Act"), respectively. 42 U.S.C. §§ 405(g); 1383(c). 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 on January 23, 1965, has completed a high school equivalency certificate, attended some vocational business college classes, and has formerly worked as an administrative assistant. (Administrative Record ("AR") 16, 23.) On December 12, 2006, Plaintiff protectively filed an application for DIB, and on December 29, 2006, protectively filed an application for SSI. In both applications, Plaintiff alleged her disability arose on January 13, 2006, due to fibromyalgia, tendinitis, arthritis, and inflamation. (AR 9, 129.)

A. Relevant Medical Evidence

On November 15, 2006, rheumatologist Kenneth Hsu, M.D., examined Plaintiff and referred her for x-rays of her hands. (AR 241-42.) The radiological reports showed findings consistent with rheumatoid arthritis in both hands, but showed "no appreciable erosive or productive changes" in either hand. (AR 241-42.) Dr. Hsu diagnosed Plaintiff with fibromyalgia and arthritis.

On February 12, 2007, Dr. Hsu completed a medical source statement for social security as Plaintiff's treating physician since November 2006. (AR 225-27.) He opined that Plaintiff could lift or carry less than ten pounds occasionally; carry no weight frequently; stand or walk less than two hours in an eight-hour workday; sit for less than one hour in a workday; and had some non-exertional limitations resulting from her fibromyalgia. (AR 225-27.)

On May 26, 2007, Plaintiff underwent a comprehensive orthopedic evaluation by Doojin Kim, M.D. (AR 250.) Plaintiff reported that she began experiencing joint pain at the end of 2005 in her wrists, elbows, and knees. (AR 250.) She described the pain as aching that was worse in the morning and during the cold weather. (AR 250.) Dr. Kim made general findings, including that Plaintiff had "enlargement of the first metacarpophalangeal joint on the right, but there was no effusion and no pain with palpation." (AR 252-53.) Plaintiff's motor strength was noted to be "5/5 and equal throughout." (AR 253.) Dr. Kim diagnosed Plaintiff with "probable rheumatoid arthritis." (AR 253.) Dr. Kim explained that the diagnosis of rheumatoid arthritis is based on a blood test, but that such a test was not available to Dr. Kim "at this time." (AR 253.) Dr. Kim determined that Plaintiff could be expected to sit for six hours in an eight-hour workday; lift or carry ten pounds frequently and ten pounds occasionally given the probable rheumatoid arthritis; and Plaintiff should "avoid frequent fine fingering and feeling given the probability of rheumatoid arthritis." (AR 253.) He also reported that Plaintiff had no postural, visual, communicative, or workplace environmental limitations. (AR 253.)

On July 6, 2007, state agency medical consultant L. N. Yates, M.D., completed a physical residual functional capacity assessment ("RFC") form.*fn2 (AR 255-59.) Dr. Yates opined that Plaintiff could occasionally lift or carry 20 pounds; frequently lift or carry ten pounds; stand and walk at least two hours in an eight-hour workday; sit approximately six hours in an eight-hour workday; frequently stoop; occasionally climb, kneel, and crawl; but could never balance or crouch. (AR 256-57.)

On September 8, 2007, Plaintiff underwent a comprehensive psychiatric evaluation administered by psychiatrist Ina Shalts, M.D. (AR 260-63.) Plaintiff reported that her chief complaint was her fibromyalgia, arthritis, and depression. (AR 260.) Dr. Shalts reported that Plaintiff's speech was coherent and goal directed, but fast; there was no loosening of association or flight of ideas; she had no suicidal or homicidal ideation; her mood was depressed, anxious, and tearful; she was oriented to time, day, month, city, and person; she was unable to recall 3/3 objects in three and five minutes, but she was able to recite the names of recent Presidents; she was able to answer simple geography questions and perform serial 7's; and she was able to interpret proverbs and knew the differences and similarities between two objects. (AR 262.) Dr. Shalts assigned a Global Assessment of Functioning score of 50. (AR 262.) Dr. Shalts indicated that Plaintiff's depression could improve with treatment, but she was "suffering from chronic pain." (AR 263.) Dr. Shalts explained that Plaintiff's prognosis was dependent on her medical condition, and noted that Plaintiff had involuntary movements in her extremities, and she made facial grimaces. (AR 263.) Dr. Shalts recommended a neurological evaluation. (AR 263.)

In terms of functional limitations, Dr. Shalts indicated that Plaintiff had the ability to understand, carry out, and remember simple instructions; she would have difficulty with supervisors and co-workers, as well as the public; she would have some difficulty with the usual work situation and dealing with a routine work setting due to her chronic pain and depression; and she was able to manage her own funds. (AR 263.)

On October 1, 2007, Craig A. Smith, M.D., completed a mental RFC assessment form. (AR 264-66.) In areas of understanding and memory, Dr. Smith determined that Plaintiff had no more than moderate limitations; in the area of sustained concentration and pace, Plaintiff was no more than moderately limited; in all areas of social interaction, Plaintiff was found not significantly limited; and in all areas of adaptation, Plaintiff was at most moderately limited. (AR 264-65.) Dr. Smith concluded that Plaintiff is able to understand, remember, and carry out one- and two-step simple commands on an extended basis and relate appropriately. (AR 266.)

On June 27, 2008, state agency consultative examiner, Lavanya Bobba, M.D., reviewed Plaintiff's medical records and confirmed the findings of Dr. Yates. (AR 293.)

B. Administrative Proceedings

The Commissioner denied Plaintiff's applications initially and again on reconsideration; consequently, Plaintiff requested a hearing before an Administrative ...

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