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Laura Jean Hill v. Michael J. Astrue

September 17, 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 her application for supplemental security income ("SSI") pursuant to Title XIV of the Social Security Act (the "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 1969, has a high school education, and has no past relevant work. (Administrative Record ("AR") 92, 197.) On May 20, 2007, Plaintiff filed an application for SSI, alleging disability beginning on August 3, 1993, due to diabetes, high blood pressure, high cholesterol, bi-polar disorder, neuropathy in both feet and legs, sleep apnea, and restless leg syndrome. (AR 166.)

A. Physical Health Medical History

Between November 2005 and February 2006, Plaintiff was examined by Eunice Baluyot, M.D., who diagnosed Plaintiff with urinary tract infections, uncontrolled diabetes, and high blood pressure. (AR 516-18.) In March 2006, Plaintiff presented at the Doctors Medical Center emergency room where she was diagnosed with eczema, hypertension, and hyperglycemia. (AR 219-32.) Plaintiff was treated by Dr. Baluyot between March 2006 and October 2007 for a variety of symptoms, including skin symptoms, pain on urination, and edema; Plaintiff was diagnosed with hyperlipidemia,*fn2 a heart murmur, uncontrolled hypertension, and diabetes mellitus. (AR 219-39, 278-90, 302-15, 318-22.)

On December 12, 2006, Plaintiff was seen for complaints of numbness on the left side of her face and body; she was diagnosed with hypertension, diabetes, and left-sided paresthesia. (AR 316.) Plaintiff was treated by Dr. Baluyot between November 2007 and April 2009, and was again diagnosed with diabetes mellitus under poor control, a urinary tract infection, hypertension, hyperlipidemia, and depression. (AR 299-301, 427-66, 545-52.)

On October 31, 2007, Plaintiff was examined by Tri Minh Pham, M.D. (AR 248-50.) Plaintiff presented with complaints of pain in her legs and feet, diabetes mellitus, and hypertension. (AR 248.) Upon examination, Dr. Pham noted that Plaintiff presented a history of leg pain radiating to her feet with no evidence of injury, no sensory deficit, and no limitation of range of motion. (AR 249.) Dr. Pham determined that Plaintiff could walk, stand, sit, carry, lift and handle objects with no restrictions. (AR 249.) Although Plaintiff had adult-onset diabetes mellitus, it was controlled with oral medications and there was no evidence of neuropathy or end organ damage. (AR 249.) Although Plaintiff was hypertensive, the problem was controlled with medication. (AR 249.)

In January 2008, Plaintiff reported numbness and tingling, worse on the right side of her body. (AR 299.) On May 16, 2008, Plaintiff was seen for complaints of stomach and abdominal pain, and she was diagnosed with hematuria.*fn3 (AR 449.) On October 10, 2008, Plaintiff underwent an abdominal hysterectomy, and was diagnosed with chronic menorrhagia,*fn4 chronic pelvic pain, uterine myomas,*fn5 type II diabetes mellitus, and chronic hypertension. (AR 421-26.)

On April 21, 2009, Dr. Baluyot wrote a request that Plaintiff's son be moved to a prison that was located closer to Plaintiff because of her medical conditions:

We'd like to request for Laura's son to be sent to a nearby prison if possible. Patient suffers from multiple health problems and can't tolerate traveling for several hours to visit her son in jail. (AR 431.) On April 23, 2009, Dr. Baluyot wrote a letter addressed "to whom it may concern," stating that Plaintiff was receiving medication for the following conditions/indications: peripheral neuropathy, diabetes, depression, anxiety, insomnia, GERD, back, feet and leg pain, and restless leg syndrome. (AR 430.)

On May 7, 2009, Plaintiff was examined by Dr. Levin who noted that Plaintiff was diabetic and had worsening paresthesias in her lower extremities. (AR 579.) Dr. Levine reported that Plaintiff was morbidly obese, that Plaintiff's cranial nerves II through XII were intact, and that Plaintiff "ha[d] a stocking glove distribution neuropathy to light touch, vibration, and pinprick." (AR 579.) Dr. Levin reported that Plaintiff had no pain with straight-leg raising in her lower extremities, and she was able to heel, toe, and tandem gait without difficulties. (AR 579.) Dr. Levine noted Plaintiff had color changes and coldness in her hands and feet; he administered an electromyogram ('EMG") test and determined that Plaintiff suffered from polyneuropathy,*fn6 most likely related to diabetes. (AR 579.)

On November 4, 2009, Dr. Levine wrote a letter to Dr. Baluyot relating to Plaintiff's condition:

Ms. Hill has been followed by myself prior to this on 05/07/09. She has been diagnosed with diabetic polyneuropathy. She appears to have a progression of her symptomatologies. She has severe pain, burning dysesthesias,*fn7 and dysautonomia.*fn8 She is treating with Dr. James Kraus and receiving numerous medications to treat her pain and dysesthesias Recently over the last few months she has also been treated for restless legs symptomatology, same as patients with progressive diabetic neuropathy. It appears that the treatment for neuropathy is somewhat disabling for her [as it] inhibits her from completing her activities of daily living on her own.

(AR 581.)

B. Mental Health Medical History

On October 6, 2007, Plaintiff was examined by James Scaramozzino, Ph.D. (AR 241-47.) At the examination, Plaintiff's chief complaints included episodes of not needing any sleep for two to three days at a time, and then becoming withdrawn, depressed, and isolated. (AR 241.) She reported becoming easily fatigued and being depressed most of the day. (AR 241.) Plaintiff reported that she first suffered depression in 1994 when her mother died. (AR 241-42.) Since 2002, Plaintiff had become more depressed and was unable to do things that she had done in the past, including involvement in multiple sports supervisory activities and driving her children to different activities. (AR 242.)

Dr. Scaramozzino described Plaintiff as being overweight, but noted that Plaintiff reported walking every night and had lost 20 pounds in the last year. (AR 243.) Dr. Scaramozzino described Plaintiff's attitude as "pleasant and frightened at the same time." (AR 243.) Plaintiff's mood was deemed depressed, and her affect was "consistent with the information provided." (AR 244.) Dr. Scaramozzino found that Plaintiff's stream of mental activity was within normal limits; her thought content was appropriate; her intellectual functioning was within the average range; and her concentration ability, abstracting thinking, and judgment and insight were within normal limits. (AR 245.)

Dr. Scaramozzino diagnosed Plaintiff with bipolar II disorder, and assigned her a Global Assessment of Functioning ("GAF") score of 50.*fn9 (AR 245.) Dr. Scaramozzino noted that Plaintiff appeared to respond to questions in an open and honest manner, there was no evidence that she was exaggerating her symptoms, and there were no apparent inconsistencies throughout the evaluation. (AR 245.) Dr. Scaramozzino opined that Plaintiff's ability to understand and remember very short and simple instructions or detailed instructions was fair to poor; Plaintiff's ability to accept instructions from a supervisor and respond appropriately was poor and primarily influenced by her depressive symptoms which were noted to be frequent; Plaintiff's ability to sustain an ordinary routine without special supervision was "fair"; Plaintiff's ability to complete a normal workday/workweek without interruptions at a constant pace was deemed "fair to poor due to the uncontrolled cycles that she continues to go through between depression and hypomania"; Plaintiff's ability to interact with co-workers and deal with various changes in a work setting was deemed to be "fair to poor"; and Plaintiff's likelihood of emotionally deteriorating in the work environment was considered "fair to high." (AR 246-47.)

On November 2, 2007, state-agency consulting psychiatrist Archimedes R. Garcia, M.D., completed a Mental Residual Functional Capacity Assessment and a Psychiatric Review Technique Form. (AR 251-64.) Other than finding Plaintiff moderately limited in her ability to understand and remember detailed instructions, Dr. Garcia reported that Plaintiff was "not significantly limited" in all other areas of sustained concentration and persistence, social interaction, or adaptation. (AR 251-52.) In rating Plaintiff's degree of functional limitation, Dr. Garcia concluded that Plaintiff had only mild restriction in activities of daily living, social functioning, and maintaining persistence, concentration, and pace. (AR 262.) He also noted that there was insufficient evidence of any episodes of decompensation of an extended duration. (AR 262.)

On May 14, 2008, state-agency consulting physician Evangeline A. Murillo, M.D., reviewed Plaintiff's medical records and affirmed Dr. Garcia's assessment finding that Plaintiff retained the mental residual functional capacity to perform simple, repetitive tasks. (AR 326-27.)

Plaintiff completed a depression questionnaire on May 21, 2008. (AR 440.) The questionnaire recorded how often, over the course of the two weeks prior to completing the form, the subject completing the form was bothered by certain symptoms. (AR 440.) Plaintiff indicated that on more than half of the days in the two weeks prior to May 21, 2008, she felt little interest or pleasure in doing things; she felt down, depressed or hopeless; she had trouble falling or staying asleep or slept too much; she felt tired or had little energy; she felt bad about herself or that she was a failure or let herself or her family down; and she had trouble concentrating on things such as reading the newspaper or watching television. (AR 440.) For at least several days over the course of the two weeks prior to May 21, 2008, Plaintiff checked the box indicating that she was either speaking so slowly that others noticed or she was so fidgety and restless that she was moving around more than usual, and she had thoughts that she would be better off dead or of hurting herself in some way. (AR 440.) The questionnaire also requested that the subject indicate how difficult these problems made it to perform work, take care of things at home, or get along with other people. (AR 440.) On a four point continuum from "not difficult at all" to "extremely difficult," Plaintiff indicated that her problems made it "very difficult" for her to complete her work. (AR 440.)

On June 2, 2009, Lawrence M. Ruiz, a Licensed Clinical Social Worker at Golden Valley Health Centers ("Golden Valley"), submitted a letter regarding Plaintiff, who has been a patient at Golden Valley since April 2007. (AR 580.) He listed his diagnostic impressions of Plaintiff as bipolar disorder II and post traumatic stress disorder ("PTSD"). (AR 580.) He indicated that Plaintiff's condition "is improving as of late but with this disorder it is too soon to know how she will do over the long run." (AR 580.) He noted that bipolar disorder is hereditary and requires treatment over the lifetime of the patient. (AR 580.) Mr. Ruiz reported that Plaintiff had attended five sessions as of the date of his letter, and had also attended several sessions with a different therapist at Golden Valley. (AR 580.)

B. Administrative Proceedings

The Commissioner denied Plaintiff's application initially and again on reconsideration; consequently, Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"). (AR 125-33.) On May 11, 2009, ALJ Sandra Rogers held a hearing where Plaintiff testified through the assistance of counsel. (AR 95-112.)

1. Plaintiff's Testimony

Plaintiff testified that her most significant difficulty was the pain she experiences in her feet and legs as well as her depression. (AR 98.) The pain in her legs is due to her diabetes, and she also experiences numbness and tingling "all the time." (AR 99.) Plaintiff experiences worsening pain when she walks, sits, or stands for long periods of time. (AR 99.) She needs to change positions frequently; she can stand for only 10 to 15 minutes before she must sit. (AR 99.) Her legs shake involuntarily, which causes pain and fatigue. (AR 100.)

Plaintiff reported that she is depressed and she cries all the time. (AR 101.) She sleeps a lot, and lies down about four times a day to sleep for approximately an hour each time. (AR 101.) She takes medication for her sleep issues as well as for her depression. (AR 101-02.) Plaintiff testified that she has difficulty thinking and remembering things, and she has to write everything down. She has carpal tunnel syndrome that causes her to drop things. (AR 102-03.) Her hands go numb frequently, and as a result, Plaintiff burns herself. Plaintiff was involved in a car accident many years ...

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