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Patricia James v. Michael J. Astrue

August 6, 2012


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



Patricia James ("Plaintiff") brings this action seeking to overturn the decision of the Commissioner of the Social Security Administration (hereinafter the "Commissioner" or the "Agency") denying her application for Supplemental Security Income ("SSI"). The parties consented, pursuant to 28 U.S.C. § 636(c), to the jurisdiction of the undersigned United States Magistrate Judge. For the reasons stated below, the decision of the Commissioner is AFFIRMED.


Plaintiff filed an application for SSI on April 30, 2007. (Administrative Record ("AR") 14, 56-57). She alleged a disability onset date of April 24, 2007 (AR 14, 107), for arthritis, a left arm injury, and depression. (AR 106-07).

The Agency denied Plaintiff's application initially on October 9, 2007, and on reconsideration on December 20, 2007. (AR 58-62, 66-70). Plaintiff then requested a hearing, which was held before Administrative Law Judge ("ALJ") Lowell Fortune on March 20, 2009. (AR 22). Plaintiff appeared with counsel and testified at the hearing. (AR 22-55).

On September 9, 2009, the ALJ issued a decision denying benefits. (AR 14-21). Plaintiff sought review of the ALJ's decision before the Appeals Council (AR 9-10), which denied her request on July 19, 2011. (AR 1-4). Plaintiff commenced the instant action on September 19, 2011.


Plaintiff was born on August 21, 1961, and was forty-seven years old at the time of the hearing. (AR 26). She has a twelfth-grade education, and speaks, reads, and writes English. (AR 48, 106, 110). Plaintiff's past work experience has been as a janitor. (AR 107-08).

A. Plaintiff's Medical History

Plaintiff arrived at the emergency room of Arrowhead Regional Medical Center ("ARMC") on June 11, 2007, complaining of back and hip pain. (See AR 134-36). X-rays of her lumbar spine and right hip were normal. (AR 207). She was diagnosed with sciatica, a condition that usually "improves greatly with conservative treatment." (AR 135).

On January 8, 2008, Plaintiff was assessed by Drs. Miulli and Panchal in the Neurosurgery Clinic at ARMC. (AR 202-03). They noted Plaintiff's "chief complaint of lower back pain" and performed a physical and neurological examination. They also noted that an MRI showed "degenerative disk disease with mild central canal stenosis [at] L3 through 4" and "[d]egenerative disk disease and facet joint disease with moderate central canal and neural foraminal stenosis at L4 through 5." (AR 202; see AR 204-06). They diagnosed Plaintiff with "[r]ight L3 radiculitis with possible radiculopathy versus pain" and a "[p]soas spur." (AR 203). They recommended that Plaintiff see her primary care physician to begin treatment with Naprosyn and Robaxin, that Plaintiff receive nerve stimulation treatment, and that she receive physical therapy three times per week. (Id.).

Plaintiff underwent an outpatient physical therapy evaluation at ARMC that day (January 8, 2008). (AR 197-98). Plaintiff complained of pain in her back and was found to have "limited and painful" rotation of her hips and limited range of motion in her lumbar spine. (AR 197). The physical therapist believed Plaintiff's "rehab potential" was fair and that a limiting factor was her compliance. (AR 198).

A medical report completed by N. Pham at the San Bernardino Transitional Assistance Department on September 30, 2008, relayed that Plaintiff was temporarily incapacitated due to low back pain from September 30, 2008, through January 30, 2009. (AR 224). More tests were necessary "before the degree and permanence of the incapacity [could] be determined." (Id.). There do not appear to be any treatment notes accompanying this report.

Plaintiff was evaluated by Dr. Jothen on November 25, 2008. She was diagnosed with degenerative disk disease and herniated nucleus pulposus at L3-L4 and L4-L5. (AR 221). It was recommended that she receive an epidural facet joint block and follow up with her primary care physician for pain control. (Id.). Dr. Miulli recommended facet joint injections on January 6, 2009. (AR 220).

On February 5, 2009, Plaintiff was seen at ARMC for an "initial consultation for chronic pain." (AR 216-17). She was diagnosed with an "L4-L5 disk bulge with mild to moderate facet hypertrophy," "mild to moderate canal stenosis," "[b]ilateral neuroforaminal stenosis," and "[m]ultiple degenerative disk disease canal foraminal stenosis." (AR 217). Plaintiff was scheduled for epidural steroid injections, which she received on February 18, 2009 (AR 215), "[c]autioned on overuse of narcotics," and prescribed ibuprofen and Neurontin. (AR 217).

On February 24, 2009, a nurse practitioner at ARMC Rehabilitation Services evaluated Plaintiff for use of a front wheel walker. Plaintiff was noted to have an unsteady gait and bilateral lower extremity weakness. Plaintiff's goals were to increase strength and become capable of independent ambulation. (AR 225). Plaintiff was prescribed a front wheel walker on April 9, 2009. (AR 227).

On January 21, 2011, Plaintiff underwent surgery at ARMC to excise an intervertebral disc (laminectomy). Her principal diagnosis was *fn1 "[d]isplacement of lumbar intervertebral disc without myelopathy." (AR 236, see 535-37). She also had L3-L4 and L4-L5 stenosis, and left L4-L5 radiculitis and radiculopathy with "failed non-operative treatment in the past." (AR 535). The surgeons found that Plaintiff had "severe central canal and lateral foraminal stenosis at L3, L4 and L5," "severe degenerative disk disease," and that the "disk space was so small [they] could barely get [their] instruments into the disk space." (Id.). Plaintiff "did well" after her operation and ...

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