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Zina Steagall v. Michael J. Astrue

July 18, 2012


The opinion of the court was delivered by: Suzanne H. Segal United States Magistrate Judge



Plaintiff Zina Steagall ("Plaintiff") seeks review of the decision by the Commissioner of Social Security Administration ("the Commissioner") to deny her disability benefits. She filed a Complaint on September 9, 2011. The parties consented to the jurisdiction of the undersigned United States Magistrate Judge, pursuant to 28 U.S.C. § 636(c). For the reasons stated below, the Commissioner's decision is AFFIRMED.


Plaintiff filed a previous application for disability insurance benefits under Title XVI of the Social Security Act, which was denied on October 16, 1997. (Administrative Record "AR" 134). Plaintiff filed the current application for supplemental security income on March 27, 2007, alleging a disability onset date of March 27, 2007. (AR 601). Plaintiff based her claim on back pain. (AR 138). The Social Security Administration (the "Agency") denied Plaintiff's claim on June 15, 2007. (AR 59). The denial was upheld upon reconsideration on August 10, 2007. (AR 64).

Plaintiff then requested a hearing, (AR 70), which was held before an Administrative Law Judge ("ALJ"). (AR 28-56). Plaintiff appeared and was represented by counsel. (AR 28). A vocational expert ("VE"), Joseph Mooney, testified at a separate hearing on March 5, 2009. (AR 23-27).

On May 19, 2009, the ALJ issued a decision denying benefits. (AR 8-20). Plaintiff sought review of the ALJ's decision before the Appeals Council, (AR 21), which denied her request on July 31, 2009. (AR 1-3). In 2009, Plaintiff sought review by this Court by filing Steagall v. Astrue, Case No. EDCV 09-1601 SS. (AR 566-67). On April 4, 2010, this Court remanded for further administrative proceedings, to obtain supplemental testimony from the VE. (AR 566-69). The Appeals Council expanded on the grounds for remand and ordered that a subsequent claim be associated and consolidated with this case on June 10, 2010. (AR 572-73).

ALJ Sharilyn Hopson held a third hearing in this case on April 13, 2011. (AR 496-549). The ALJ heard testimony from Plaintiff; a medical expert, Dr. Jeremy Landau; a lay witness, Cynthia Quinn, Plaintiff's aunt; and a vocational expert, David Rinehart. (Id.). Plaintiff was represented by counsel. (AR 496). On June 17, 2011, the ALJ denied Plaintiff's claim, finding Plaintiff able to perform a limited range of light work. (AR 457-468). Plaintiff did not seek review from the Appeals Council. The ALJ's decision therefore became the final decision of the Agency. Plaintiff commenced this action on August 31, 2011. (Compl. 1).


Plaintiff was born on July 13, 1967 and was forty-three years old at the time of the last hearing. (AR 133). Her highest level of education is eleventh grade. (AR 32). Plaintiff speaks, reads and writes English. (AR 137).

A. Plaintiff's Medical History

On August 20, 2006, Plaintiff was admitted to Hemet Valley Medical Center for complaints of chest pain, headaches and hypertension. (AR 229). Plaintiff injured her neck and lower back in a car accident on December 7, 2006. (AR 197-98). Plaintiff was treated for non-bleeding hemorrhoids, and there was evidence of a past rectal bleeding on December 21, 2006. (AR 219). On May 19, 2007, Plaintiff went to the emergency room for headaches, but a CT scan was normal. (AR 278). Plaintiff went to the emergency room on November 29, 2007 for right shoulder pain following a car accident on November 17, 2007, but the Xray was normal. (AR 276).

On May 22, 2007, Dr. Mohammad Khayali conducted a neurological consultative examination of Plaintiff after she was admitted to the hospital complaining of headaches and a sore throat. (AR 284-85). Dr. Khayali diagnosed nonspecific headaches and recommended that Plaintiff cease taking antibiotics. (Id.).

On December 6, 2007, Dr. Milind Panse, an orthopedist, examined Plaintiff for right shoulder pain. (AR 357). Dr. Panse's physician's assistant, Amber Hollenbeck, diagnosed bursitis and tendinitis. (AR 358). Plaintiff declined a cortisone injection. (AR 358). Plaintiff followed up with Amber Hollenbeck, who prescribed eight sessions of physical therapy, as well as ice and heat therapy. (AR 356).

Plaintiff was admitted to Hemet Valley Medical Center for headaches and hypertension on August 29, 2008. (AR 298). The doctors suspected that "rebound," or withdrawal, and "possible opioid dependency" caused her headaches because Plaintiff "continued to ask for Dilaudid frequently." (Id.). Plaintiff complained of back and neck pain, but X-rays were normal. (AR 310-11).

On September 1, 2008, Dr. Khayali conducted a neurological examination after Plaintiff was admitted to the hospital for headaches. (AR 303-04). He determined the cause to be rebound from narcotic dependency and hypertension. (Id.). He recommended pain management and continued analgesics. (Id.).

Plaintiff saw Dr. Kurt Frauenpreis, her primary care physician, for complaints of hypertension and headaches on September 17, 2008. (AR 322). He diagnosed poorly controlled high blood pressure and opioid withdrawal. (Id.). On October 24, 2008, Plaintiff followed up with Dr. Humayun Qureshi, a cardiologist, who diagnosed improvement with her blood pressure. (AR 365-67). Dr. Qureshi also determined that Plaintiff had suffered tachycardia in the hospital, but it passed quickly. (Id.). She saw a nephrologist, Dr. Ishak, on January 13, 2009, who determined that her blood pressure was under control. (AR 653).

Plaintiff had carpal tunnel release surgery on her left hand on September 25, 2009. (AR 735-742). Further examination showed increased function in her left hand. (AR 735). Plaintiff was hospitalized for abdominal pain on March 2, 2009. (AR 439). She was diagnosed as having diverticulitis. (AR 440).

On February 8, 2011, Dr. Khayali conducted a neurological consultative examination. (AR 854-56). Plaintiff's strength and gait were both normal. (Id.). Plaintiff still had mild to borderline carpal tunnel on the left and mild carpal tunnel syndrome on the right. (Id.). Both sides had improved. (Id.). He recommended that Plaintiff decrease pain medication and use more non-steroidal anti-inflammatory medications. (Id.).

B. Consultative Examinations

On May 25, 2007, Dr. Sabourin conducted an orthopedic consultation that revealed no nerve damage, but Plaintiff was "not completely cooperative." (AR 260-63). Dr. Sabourin observed that Plaintiff "refuses to move the back stating it will hurt. She is noted to be able to sit on the examination with her legs straight out in front of her." (AR 261). She also refused to move her neck or shoulders. (AR 261-62). Dr. Sabourin noted that there "is no deformity, scar, tenderness, spasm, swelling or warmth in the neck" and "no tenderness, warmth, crepitus, instability, or swelling" in the shoulders. (Id.). Dr. Sabourin also wrote that "[e]xamination reveals giving way with every muscle tested in the upper and lower extremities." (AR 262). He found that Plaintiff could lift or carry 20 pounds occasionally and 10 pounds frequently. (AR 263). She could stand and walk for six hours of an eight hour workday and sit for six hours. She has no manipulative limitations. (Id.).

On December 3, 2008, Plaintiff received a complete internal medicine evaluation from Dr. Gabriel T. Fabella, which showed hypertension, limited range of motion for the right shoulder and atypical sharp pain. (AR 389-94). She had no tenderness in the back, and she had a normal range of motion in the neck. (Id.). Dr. Fabella noted that Plaintiff drove herself to the office. (AR 389).

On October 15, 2009, Plaintiff received a complete internal medicine evaluation from Dr. Nizar Salek, who determined that Plaintiff had normal range of motion in both shoulders and her neck. (AR 716-23). Plaintiff walked normally, had no trouble getting in or out of her chair and did not complain of headaches. (Id.). Plaintiff's hands had scars from her recent carpal tunnel surgery, but there was no evidence of tenderness, and range of motion was normal. (Id.).

A blood test in September 2010 came back positive for Phencyclidine but negative for Plaintiff's prescribed painkillers. (AR 752). The laboratory also noted that "Phencyclidine is a DEA Schedule II controlled substance with no known licit pharmaceutical applications."*fn1 (Id.). The laboratory noted that the lack of analgesics "is inconsistent with the reported prescription." (Id.). A January 2011 blood test was again negative for Plaintiff's prescribed painkillers. (AR 747).

C. Non-Consultative Examinations

On June 12, 2007, Dr. M. H. Yee reviewed Plaintiff's records and found that she suffered from a cervical strain, a lumbar strain and hypertension. (AR 266-71). She also complained of having headaches about once a month when she did not take her hypertension medicine. (AR 268). Dr. Yee's residual functional capacity ("RFC") assessment recommended that Plaintiff could lift ten pounds frequently and twenty pounds occasionally; she could stand and/or walk about six hours in an eight-hour workday; she could sit about six hours in an eight-hour workday; she had no limitations on pushing or pulling; she should never climb; and she should avoid concentrated exposure to hazards like machinery and heights. (Id.). Otherwise, she was capable of a light level of exertion. (AR 273). On August 6, 2007, Dr. J. Hartman confirmed Dr. Yee's analysis and Defendant's first denial of benefits. (AR 274).

On October 26, 2009, Dr. A. Lizarraras reviewed Plaintiff's record. (AR 727-34). His RFC assessment was identical to Dr. Yee's, except that he removed the restriction on exposure to hazards. (Id.). Dr. Lizarraras found Plaintiff's allegations credible except as to the persistence, intensity and functional limitations. (AR 732, 734).

D. Plaintiff's Testimony

Plaintiff testified on October 31, 2008. (AR 30). She was 41 years old at the time of the hearing, weighed 224 pounds and was 5'8". (AR 32). Her highest education level was eleventh grade. (Id.). She testified that she last worked in 2000 as a full-time childcare provider. (AR 33). She noted that she was in car accidents in December 2006 and November 2007. (AR 33, 47). As ...

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