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Delois Gallien v. Michael J. Astrue

October 1, 2012

DELOIS GALLIEN,
PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Charles F. Eick United States Magistrate Judge

MEMORANDUM OPINION AND ORDER OF REMAND

Pursuant to sentence four of 42 U.S.C. section 405(g), IT IS HEREBY ORDERED that Plaintiff's and Defendant's motions for summary judgment are denied and this matter is remanded for further administrative action consistent with this Opinion.

PROCEEDINGS

Plaintiff filed a complaint on February 17, 2012, seeking review of the Commissioner's denial of disability benefits. The parties filed a consent to proceed before a United States Magistrate Judge on March 26, 2012. Plaintiff filed a motion for summary judgment on August 8, 2012. Defendant filed a cross-motion for summary judgment on September 10, 2012. The Court has taken the motions under submission without oral argument. See L.R. 7-15; "Order," filed February 22, 2012.

BACKGROUND AND SUMMARY OF ADMINISTRATIVE DECISION

Plaintiff, a former home health aide, asserts disability since September 30, 2008, based on alleged heart problems (Administrative record ("A.R.") 100-06, 120, 124, 143-44). Plaintiff alleges "severe mr [mitral regurgitation,] tr [tricuspid regurgitation,] mitral valve prolapse[,] s and p [status post] mv [mitral valve] replacement," which assertedly causes her to have shortness of breath and problems breathing (A.R. 143-44; see also A.R. 379 (medical record containing diagnoses)).*fn1

The ALJ found the following severe impairments: "history of congestive heart failure, status post mitral valve replacement, and low back pain" (A.R. 13). The ALJ found that, despite these impairments, Plaintiff retains the residual functional capacity to perform medium work with some postural and environmental limitations, and can perform her past relevant work (A.R. 14-16 (adopting consultative examiner's opinion at A.R. 187-88, and vocational expert testimony at A.R. 39, 41-42)). The Appeals Council denied review (A.R. 1-3).

STANDARD OF REVIEW

Under 42 U.S.C. section 405(g), this Court reviews the Administration's decision to determine if: (1) the Administration's findings are supported by substantial evidence; and (2) the Administration used proper legal standards. See Carmickle v. Commissioner, 533 F.3d 1155, 1159 (9th Cir. 2008); Hoopai v. Astrue, 499 F.3d 1071, 1074 (9th Cir. 2007). Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971) (citation and quotations omitted); Widmark v. Barnhart, 454 F.3d 1063, 1067 (9th Cir. 2006).

DISCUSSION

I. Summary of the Medical Record Concerning Plaintiff's Heart Condition.

Plaintiff was treated at Harbor UCLA Medical Center Cardiology Clinic and the Hubert H. Humphrey Comprehensive Health Center. See A.R. 161, 178-82, 214-424, 427-49, 451-52, 455-57, 459-71 (medical records); see also A.R. 29 (testimony). In or about January 2008, doctors diagnosed, inter alia, congestive heart failure and atrial fibrillation (A.R. 235-36, 375-79). Plaintiff underwent mitral valve replacement for mitral regurgitation on January 22, 2008 (A.R. 379).

Consulting examiner Dr. Sohelia Benrazavi provided a Complete Internal Medicine Evaluation for Plaintiff dated June 9, 2009 (A.R. 183-88). In the course of making this evaluation, Dr. Benrazavi did not review any medical records from other physicians (A.R. 187). Plaintiff complained to Dr. Benrazavi of congestive heart failure, diabetes, and back pain, and said she tires easily and has shortness of breath (A.R. 183-84). On examination, Plaintiff had "metallic" heart sounds but no evidence of cardiomegaly [enlarged heart] (A.R. 185, 187). An EKG showed sinus bradycardia at a rate of 59 beats per minute but no signs of ischemia [restriction in blood supply] (A.R. 187). Dr. Benrazavi opined that Plaintiff would be capable of medium work with climbing and stooping limitations (A.R. 187-88). State agency physician Dr. J. Akers reviewed Dr. Benrazavi's evaluation and completed a Physical Residual Functional Capacity Assessment form, also opining that Plaintiff is capable of medium work (A.R. 190-98).

When Plaintiff presented to the Cardiology Clinic for a follow up visit on August 28, 2009, she reported "doe" [Dyspnea on Exertion, or shortness of breath] with two blocks of walking, and "steady 2 pillow orthopnea" [discomfort in breathing from lying flat].*fn2 Plaintiff's treating physician, Dr. Arsen Hovanesyan, noted "Class II" (A.R. 429). Dr. Hovanesyan's impression was "s/p MVR" [status post mitral valve replacement] and "a-fib" [atrial fibrillation], and his plan was to have Plaintiff continue her current medications (A.R. 429). Plaintiff returned on March 9, 2010, reporting increased "doe" over the past month (A.R. 428). Dr. Hovanesyan noted "Class II-III symptoms (was Class II before)" (id.). Dr. Hovanesyan planned for Plaintiff to undergo further testing to evaluate Plaintiff's mitral valve in one to two months (A.R. 428). Plaintiff returned on July 2, 2010, reporting that she "feels well" with no complaints, is able to do "ADL's" [activities of daily living], but ...

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