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Stacy Matthews v. Michael J. Astrue

January 22, 2013

STACY MATTHEWS,
PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY,
DEFENDANT.



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

ORDER REGARDING PLAINTIFF'S SOCIAL SECURITY COMPLAINT (Docket No. 1)

I. BACKGROUND

Plaintiff Stacy Matthews ("Plaintiff"), representing herself pro se, seeks judicial review of a final decision of the Commissioner of Social Security (the "Commissioner" or "Defendant") denying her application for Disability Insurance Benefits ("DIB") pursuant to Title II of the Social Security Act. 42 U.S.C. § 405(g).

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

II. FACTUAL BACKGROUND

Plaintiff was born in 1966, has one year of college, and worked as an office clerk typist and a packer. (Administrative Record ("AR") 35, 49, 90, 119, 125.) On September 28, 2006, Plaintiff filed an application for DIB, alleging disability beginning on September 15, 2001, due to muscular dystrophies, other myopathies, hypothroidism, and myasthenia gravis. (AR 52-53, 90-92, 118.)

A. Medical Evidence

Plaintiff was treated at Central Valley Medical Group from January 21, 2005, through August 2, 2005, for thyroid abnormalities. (AR 229-32.)

On July 28, 2005, Plaintiff was seen at Kern Medical Center by Victor Ettinger, M.D., who noted that Plaintiff has a history of hypothroidism dating back to 2001 and that a radio iodine ablation had been performed in 2002. (AR 182; see also AR 160, 169.) Plaintiff did not remember the names of the medication she had been taking previously. (AR 182.) Plaintiff complained of anxiety and fatigue. (AR 182.) Laboratory work was ordered and Plaintiff was placed on medication. (AR 182.)

On September 20, 2005, Dr. Ettinger again noted that a radio iodine ablation on Plaintiff's thyroid had been performed in 2002. (AR 167.) Dr. Ettinger reported that Plaintiff currently had hair loss and a hand tremor, and that the tremor was not improved by medication. (AR 167.) Plaintiff's medication was adjusted. (AR 167.) Dr. Ettinger also noted that Plaintiff's anxiety was "better." (AR 167.) Plaintiff was scheduled to repeat the radio iodine therapy. (AR 167.)

On January 17, 2006, Dr. Ettinger noted that Plaintiff had not undergone the radio iodine ablation "due to 'personal problems.'" (AR 169.) Plaintiff complained of anxiety and palpitations. (AR 169.) The radio ablation was planned for February 2006. (AR 169.)

On March 28, 2006, Dr. Ettinger indicated that Plaintiff had undergone the radioactive iodine ablation on her thyroid in February 2006, which had been scheduled "due to persistent symptoms of anxiety, palpitation, [and] tremors." (AR 160.) Plaintiff reported her symptoms "improved" since the treatment. (AR 160.) Dr. Ettinger noted that Plaintiff had "[n]o muscle weakness, mental slowing, [or] confusion." (AR 160.) Plaintiff, however, reported "persistent blurred vision" and was referred to the ophthalmology department. (AR 160.)

On April 10, 2006, Plaintiff was seen at Central Valley Medical Group for left eye problems. (AR 228.)

On April 28, 2006, magnetic resonance imaging ("MRI") of Plaintiff's orbits and brain was performed at Kern Radiology Medical Group, Inc. (AR 156-57.) The MRI of the orbits indicated "[n]on-specific asymmetric outward gaxe of the right globe" but "[o]therwise no gross structural abnormality or mass identified about either orbit or glove. No parasellar or para-cavernous mass [was] identified." (AR 156.) The MRI of Plaintiff's brain indicated "[c]erebellar tonsillar ectopia resulting in mild crowding, but no obvious compression." (AR 157.) This was found to be "of uncertain, but doubtful clinical significance." (AR 157.) The report also noted "[i]ncidental partially empty sella" but that "[n]o actue intracranial process [was] identified." (AR 157.)

On May 8, 2006, Dr. Ettinger noted that Plaintiff reported that she had been experiencing extreme fatigue for approximately a month and muscle cramps for one to two months. (AR 162.) Plaintiff also had blurry vision and ptosis (drooping) of the left eye. (AR 162.) Plaintiff's medication was changed. (AR 162.)

On May 19, 2006, Plaintiff was seen by Vinutha N. Ravi, M.D., of Kern County Neurological Medical Group, Inc. (AR 158-59.) Plaintiff reported that "the droopiness started in the left eye and she now has droopiness in the right as well. She has difficulty keeping her left eye open." (AR 158.) Plaintiff stated that she developed "some diplopia" (double vision) in December 2005 when she was diagnosed with hyperactive thyroid; Plaintiff "received radioactive iodine" and was "now hypothyroid." (AR 158.) Dr. Ravi noted that Plaintiff had an eye patch on her left eye. (AR 159.) Upon examination, Plaintiff had "lateral erectus palsy on the left side" with "bilateral ptosis; worse on the left side and mild ptosis on the right side." (AR 159.) Dr. Ravi also found that Plaintiff had "bilateral diplopia on downward gaze," "weakness of the orbicularis oculi muscles," and "[n]ormal facial sensation [with] no facial asymmetry." (AR 159.) Plaintiff was diagnosed with probable ocular myasthenia gravis.*fn2 (AR 159.) Follow-up testing was planned and Dr. Ravi noted that the ptosis improved when an ice pack was placed on Plaintiff's left eye. (AR 159.) Plaintiff was seen on May 22, 2006, by Dr. Ravi for a follow-up visit and testing. (AR 154.) Plaintiff was given an injection for the ptosis, and Dr. Ravi noted that there was "improvement." (AR 154.) Plaintiff was prescribed medication. (AR 154.)

Plaintiff was seen by Dr. Ettinger on September 5, 2006, for a follow-up visit, who noted that Plaintiff had peri-orbital edema, a patch on the left her, and eyelid droop. (AR 165.)

On February 5, 2007, John Bonner, M.D., reviewed Plaintiff's medical records and completed a physical residual functional capacity ("RFC") assessment.*fn3 (AR 189-95.) Dr. Bonner determined that Plaintiff could lift and carry 20 pounds occasionally and 10 pounds frequently; could sit, stand, and/or walk six hours in an eight-hour day, and was unlimited in her capacity to push and/or pull. (AR 190.) Dr. Bonner stated that Plaintiff had limited depth perception and should avoid heights due to Myathenia. (AR 191.) Plaintiff had no other limitations. (AR 190-93.) Dr. Bonner opined that Plaintiff "should be capable of light RFC with some limitations, including for depth perception when eye patched." (AR 195.)

On March 12, 2007, H.R. Waranch, Ph.D., performed a case analysis on Plaintiff's psychiatric state, finding that "[t]here is no evidence of psych treatment" and thus there was "insufficient info to determine if she has a severe mental impairment." (AR 196.)

Plaintiff was seen at Central Valley Medical Group in April 2007, complaining of redness, soreness, and sensitivity to light. (AR 225-26.)

On September 14, 2007, K. J. Loomis, M.D., performed a case analysis of Plaintiff's records. (AR 241-42.) Dr. Loomis noted that he spoke with Plaintiff on September 6, 2007, and she asserted that her physical problems had worsened and that she had not seen any mental health doctors. (AR 242.) Dr. Loomis noted that all of Plaintiff's problems with concentration, attention, and memory were directly related to her thyroid problems. (AR 242.) Plaintiff informed Dr. Loomis that, "since her initial application, her thyroid has been stabilized, which has basically rid her of the problems with concentration, attention and memory. Her current complaints are physical." (AR 242.) Dr. Loomis affirmed the prior psychiatric analysis. (AR 242.)

On October 26, 2007, Dr. De La Rosa reviewed the case analysis and affirmed Dr. Bonner's RFC assessment. (AR 242.) Dr. De La Rosa noted that Plaintiff stated "her hypothyroid condition has improved and while she has been alleging muscle weakness more proximal than distal[,] neuro exams did not support limitations except for pstosis [left greater than right]." (AR 242.) Dr. ...


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