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Donna Vance v. Michael J. Astrue

January 28, 2013

DONNA VANCE,
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

FINDINGS AND RECOMMENDATIONS REGARDING PLAINTIFF'S SOCIAL SECURITY COMPLAINT (Doc. 1) OBJECTIONS DUE: 14 DAYS

I. BACKGROUND

Plaintiff Donna Vance ("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 XVI of the Social Security Act (the "Act"). 42 U.S.C. § 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.

II. FACTUAL BACKGROUND

Plaintiff was born in 1959, has a high school diploma, and previously worked as a home health attendant. (Administrative Record ("AR") 497, 1121, 1146.) On April 18, 2005, Plaintiff filed an application for SSI, alleging disability beginning on September 6, 2003, due to osteoarthrosis and allied disorders and affective mood disorders. (AR 395-96, 417-21, 490.) Plaintiff has filed five prior applications for SSI. (See AR 18, 54, 397-98, 406-16, 422-32.)

A. Relevant Medical Evidence

Plaintiff was seen May 19, 2004, by John Payne, M.D., of Stanislaus County Health Services Agency. (AR 1023.) Plaintiff indicated that her knees hurt when walking. (AR 1023.)

On July 15, 2004, Plaintiff was seen at the emergency room of Doctors Medical Center for pain in the extremities. (AR 6459) She was diagnosed with degenerative joint disease of the knees with increasing pain and was prescribed Vicodin. (AR 660.)

On July 15, 2004, Plaintiff was seen at Golden Valley Health Centers ("Golden Valley") by Nurse Practitioner Linda Tripp for knee pain and medications. Plaintiff indicated that she had been without medication for ten days. (AR 1071.) Plaintiff reported that the pain in her knee had increased. (AR 1071.) The medical notes indicate that Plaintiff's knee needed surgery, but there were complications due to age and morbid obesity. (AR 1071.) Plaintiff was diagnosed with bilateral knee deterioration, severe hypertension, and depression. (AR 1071.)

On August 16, 2004, Plaintiff was seen at Golden Valley by Nurse Tripp for knee pain, carpal tunnel syndrome, and to refill her medications. (AR 675.) Plaintiff complained that her leg hurt and felt like it would "collapse." (AR 675.) Plaintiff was assessed with morbid obesity, knee pain in need of surgery, and carpal tunnel pain; it was noted that her hypertension had "improved." (AR 675.)

On September 8, 2004, Plaintiff was seen at the emergency room of Doctors Medical Center for pain and swelling in the left leg. (AR 648.) She was assessed with left leg cellulitis and was treated with antibiotics. (AR 648-49.)

On September 20, 2004, Plaintiff was seen at Golden Valley by Nurse Tripp for a medication refill and to follow up on her cellulitis. (AR 673.) Her left lower leg had been infected, but it was "better" although there was still "some tenderness." (AR 673.)

On October 19, 2004, Plaintiff was seen by Necholas Aboughannam, M.D., for a comprehensive internal medicine evaluation. (AR 606-10.) Dr. Aboughannam reviewed Plaintiff's records and noted that bilateral knee x-rays had been performed in November 2003 that showed "severe narrowing of the medial joint space involving the left knee." (AR 606.) There were also x-rays performed on the pelvis and hips that "demonstrated mild sclerosis involving the right sacroiliac joints" and bilateral ankle x-rays that showed "no gross abnormalities." (AR 606.) Dr. Aboughannam reported that Plaintiff's present illnesses were carpal tunnel syndrome and bilateral knee pain. (AR 606-07.) Plaintiff complained of "numbness in her fingers and burning pain in her right wrist and hands that interferes with her manual activities" and "pain and swelling in both knees in the left more than the right." (AR 606-07.) Plaintiff reported difficulties cause by carpal tunnel that interfered with "manual activities such as buttoning, writing, cooking, holding, and even holding food to eat," and an inability to stand or walk for long periods because of bilateral knee pain. (AR 607.)

Dr. Aboughannam examined Plaintiff and noted the following general findings:

1. Phalen's sign. The claimant was not able to hold her wrists flexed for one minute because of pain in the right forearm.

2. Tinel's sign did not cause numbness in the right hand.

3. Bilateral knee tenderness and mild effusion.

4. Bilateral lower extremity pedal edema . (AR 609.) Plaintiff was diagnosed with right carpal tunnel syndrome, severe by history; left knee severe osteoarthritis; morbid obesity; hypertension; gastroesophageal reflux disease; and depression. (AR 609-10.) Regarding the carpal tunnel diagnosis, Dr. Aboughannam noted that "[t]here is no decrease in grip strength on today's physical examination but it would be helpful for [Plaintiff] to have diagnostic studies to assess her disability of her right carpal tunnel which is interfering with her activities of daily living as she described . . ." (AR 609.)

On October 20, 2004, Plaintiff was seen for a medication refill visit at Golden Valley by Nurse Tripp. (AR 672.) Plaintiff reported that her knees and legs felt stiff and painful upon standing. (AR 672.)

On October 25, 2004, Plaintiff underwent a comprehensive psychiatric evaluation by Sudha Manjunath, M.D. (AR 611-15.) Dr. Manjunath noted that Plaintiff reported that "as long as she is taking her medication, which is Zoloft 100mg[,] she is fine." (AR 611.) She was being prescribed Zoloft by a nurse practitioner. (AR 612.) Plaintiff stated that she was in a "different psychologic condition than she was three years ago" before taking Zoloft, when she was "very depressed, very sad, [and] think[ing] of dying all the time." (AR 611.) However, Plaintiff reported that "[e]ver since taking Zoloft, . . . she is less distressed, more motivated, and has good energy. She looks at the bright side of life." (AR 611.) Plaintiff stated that her relationship with her current husband, who she had met three years prior, "plays a role in her feeling better psychologically." (AR 611.) Plaintiff also reported having been in an abusive prior marriage. (AR 611.) Plaintiff further reported that "she has four children, but two of her children were taken away by Children Services because she could not handle them." (AR 612.) Plaintiff reported that she had "depression for several years," and had tried several medications.

Dr. Manjunath noted that Plaintiff reported that Plaintiff had not worked "in a long time" due to complaints of carpal tunnel and knee pain, and that she had provided in-home care at her prior job, which "lasted for three months" before "she had to quit because she did not like the job." (AR 613.) Dr. Manjunath found Plaintiff to be "pretty functional" in her activities of daily living, and she would socialize with a few friends and mostly spend time with her husband. She would, "at times," see her children who were in foster care, and reported that her children "can call her anytime." (AR 613.) Plaintiff reported that she drinks "very, very occasionally," and that she "experimented with marijuana, but does not do this anymore." (AR 613.)

Dr. Manjunath performed a mental status examination. (AR 614.) Plaintiff was diagnosed with dysthymic disorder and dependent personality disorder. (AR 614.) Plaintiff was assessed with a Global Assessment of Functioning score ("GAF") of 65.*fn1 Dr. Manjunath opined that Plaintiff's "problem is treatable. Right now, her symptoms are under control. . . . As long as she is compliant with her medications, her problems seem pretty good." (AR 615.) Dr. Manjunath provided a functional assessment and stated that Plaintiff was "able to perform simple and repetitive tasks" and could "probably handle more complex tasks." (AR 615.) Plaintiff "should not have any difficulties accepting instructions from supervisors and interacting with co-workers," and "should be able to maintain regular attendance." (AR 615.)

On November 16, 2004, both mental and physical capacity assessments were completed. (AR 616-26.) Plaintiff's mental assessment showed that she was "not significantly limited" in any area. (AR 616-18.) Plaintiff's physical assessment indicated that she could lift 20 pounds occasionally and 10 pounds frequently; could sit, stand and/or walk six hours in an eight-hour day; was limited in her upper extremities in her ability to push and/or pull; and was occasionally limited to climbing ramps and stairs, as well as stooping, kneeling, crouching, and crawling. (AR 620-21.) Plaintiff was also limited in her ability to perform fingering (fine manipulation). (AR 622.)

On November 19, 2004, Plaintiff was seen for a follow up visit for her hypertension at Golden Valley. (AR 671.) Plaintiff reported pain in both knees. (AR 671.)

On December 3, 2004, a psychiatric review was completed by Charlotte Bible, M.D., which indicated that Plaintiff suffered from affective and personality disorders, but she had no limitations in activities of daily living, maintaining social functioning, or in maintaining concentration, persistence, or pace. (AR 627-30.) There was insufficient evidence to show that Plaintiff had any episodes of decompensation of an extended duration. (AR 630.)

On December 9, 2004, Plaintiff was seen at the emergency room of Doctors Medical Center for bilateral lower-leg swelling, with the left-leg swelling being greater than the right. (AR 632.) She was assessed with left lower cellulitis and was treated with antibiotics. (AR 633.)

On December 10, 2004, Plaintiff was seen at Golden Valley for a follow-up visit to her emergency room visit the previous day. (AR 670.)

On December 17, 2004, Plaintiff had a medication refill visit at Golden Valley by Nurse Tripp. (AR 668.) The edema had decreased in her legs, and her knee pain was being treated with Celebrex. (AR 668.) Her laboratory work showed improvement. (AR 668.) Plaintiff was also diagnosed with major depressive disorder and post-traumatic stress disorder ("PTSD"). (AR 669.) Plaintiff reported being depressed and feeling grief and guilt over losing her children to foster care. (AR 669.) While Plaintiff admitted to suicidal ideations, she also reported "feeling better" and denied any current suicidal or homicidal thoughts. (AR 669.) The treatment notes indicate that the clinician offered Plaintiff "support and encouragement." (AR 669.)

On January 25, 2005, Plaintiff was seen at Golden Valley by Nurse Tripp for pain in both knees. (AR 667.) On April 5, 2005, Plaintiff was seen at Golden Valley by Locum Coh Locum, M.D., for wheezing and to obtain medications. (AR 1062.)

On July 11, 2005, Larry R. Sutter, M.D., performed a comprehensive psychiatric evaluation of Plaintiff. (AR 755-60.) Plaintiff was asked why she was applying for Social Security benefits and responded that she applied due to her "mental health . . . [her] carpal tunnel syndrome . . . [her] knees . . . and [her] hips," indicating that she has a "hard time getting up and moving around" if she sits too long and that her "knees start to buckle" when she stands. (AR 755.) Plaintiff indicated that her "mental health is pretty good -- there's no distress" and that there were days she was "mostly up," although she had "down days too." (AR 755.) Plaintiff indicated that she has a history of past abuse as a child. (AR 756.) She stated that she "last drank alcohol two weeks ago when she had some malt liquor." (AR 756.) Plaintiff denied any history of DUIs, blackouts or tremors and denied any use of illicit drugs. (AR 756.) Plaintiff indicated that she did "[c]ooking, cleaning and laundry," at her home. (AR 756.) Dr. Sutter performed a mental health examination and diagnosed Plaintiff with depressive disorder, not otherwise specified, mild. (AR 758-59.) Dr. Sutter opined that "[f]rom the psychiatric point of view this claimant would have no impairment or mild impairment interacting with co-workers, supervisors and the public in a work or work-like situation. The claimant had good-normal facial expression. The anti-depressant medication Zoloft has helped a lot. The theme of the interview was physical problems -- especially knee pain, back pain and carpal tunnel syndrome." (AR 760.) Dr. Sutter further stated that, from a psychiatric point of view, Plaintiff would have "no impairment" or only "mild impairment" in the workplace performing detailed and complex tasks and maintaining regular attendance. (AR 760.)

On July 22, 2005, Plaintiff was examined by Tri Minh Pham, M.D., who noted that Plaintiff had not taken her medication for over a month "due to no money to buy medications." (AR 761.) Dr. Pham reported that Plaintiff had "no tenderness" in her back and that the range of motion was normal except for bending down about two inches before touching her toes. (AR 762.) There was no edema, clubbing, or cyanosis in Plaintiff's extremities. (AR 762.) Dr. Pham examined Plaintiff and tested her range of motion. (AR 762.) Dr. Pham's impression was that Plaintiff presented with hypertension controlled by medication, knee pain with history of old operation for the knee and normal range of motion for both knees, excessive obesity, and history of depression treated with medication. (AR 762.)

Plaintiff was seen at Golden Valley by Dr. Locum on August 19, 2005, for carpal tunnel in the right hand, possible menopause, and to obtain medications. (AR 1061.) Plaintiff reported that her right hand was "tingly." (AR 1061.) There were positive "tingle on tapping [right] medial nerve." (AR 1061.) Plaintiff was diagnosed with hypertension, carpal tunnel, obesity, and cellulitis, and was prescribed medication. (AR 1061.)

On August 29, 2005, David Pong, M.D., reviewed Plaintiff's records and assessed her physical residual functional capacity ("RFC").*fn2 Dr. Pong opined that Plaintiff could occasionally lift 20 pounds and frequently lift 10 pounds; could stand, walk and/or sit six hours in an eight-hour day; was unlimited in her ability to push and/or pull; had occasional limitations on her ability to climb, balance, stoop, kneel, crouch, and crawl; and had no other limitations. (AR 765-70.)

On September 9, 2005, Plaintiff was seen for a follow-up visit for hypertension at Golden Valley by Vikram Khanna, M.D. (AR 1060.)

On September 14, 2005, Mario Morando, M.D., performed a review of Plaintiff's psychiatric records and opined that she had a mild depressive impairment with mild limitations regarding restrictions of activities of daily living, maintaining social functioning, and maintaining concentration, persistence, and pace with insufficient evidence to determine any episodes of decompensation of an extended duration. (AR 772-74.)

Plaintiff was seen in October, November, and December 2005, by Dr. Khanna at Golden Valley for follow-up visits. (AR 1055-59.) Plaintiff indicated that medication made her feel "drowsy" but "better," although she was "stressed" because she had to move suddenly. (AR 1059.) By November 22, 2005, Plaintiff had become homeless. (AR 1057.) The notes indicate that Plaintiff had abnormal Tinels. (AR 1057.) In December 2005, Plaintiff reported that methadone was making her "very tired." (AR 1056.)

In January 2006, Plaintiff reported to Dr. Khanna that she had ongoing pain in both knees and that she no longer had insurance. (AR 1054.)

On February 19, 2006, Steve McIntire, M.D., performed a comprehensive medical evaluation on Plaintiff. (AR 776-79.) Plaintiff described "persistent pain of both knees" and indicated that the "pains occur diffusely involving all aspects of both knees." (AR 776.) Plaintiff reported "swelling and giveaway at times" and that her "knee pain increases with walking or bending activities." (AR 776.) Dr. McIntire performed a neurological/orthopedic examination. (AR 777-78.) For his general findings as to Plaintiff's knees, Dr. McIntire noted bony deformity or effusions, but found "diminished flexion bilaterally," with "medial and lateral joint line tenderness" and "crepitus" bilaterally. (AR 778.) Plaintiff was diagnosed with probable mild osteoarthritis of both knees. (AR 778.) Plaintiff had diminished flexion of both knees without ligamentous instability and that she walked with a mildly antalgic gait. (AR 778.) Dr. McIntire opined that Plaintiff would be limited to six hours of walking or standing in an eight-hour day with no more than two to three hours of continuous walking or standing, she should not engage in activities requiring frequent squatting, crawling, kneeling and climbing, and she should not lift or carry more than 15 pounds frequently and 30 pounds occasionally. (AR 778-79.) Plaintiff had no limitations as to sitting and no manipulative limitations. (AR 779.)

On February 23, 2006, Dr. Bible performed another psychiatric review and opined that Plaintiff was capable of simple unskilled tasks with no other limitations. (AR 780-85.)

On March 9, 2006, Sandra Clancey, M.D., conducted a physical RFC assessment. (AR 786-93.) Reviewing additional medical evidence, Dr. Clancey opined that Plaintiff could occasionally lift 20 pounds and frequently lift 10 pounds; could stand or walk at least two hours in an eight-hour day; could sit six hours in an eight-hour day; was unlimited in her ability to push and/or pull; had occasional limitations on her ability to climb, balance, and stoop; should avoid concentrated exposure to fumes, odors, dusts, gases, and poor ventilation; and had no other limitations. (AR 786-93.)

Plaintiff was seen several times from March 2006 to August 2006 at the emergency department of Doctors Medical Center for leg pain. (AR 849-78.)

On April 25 and 26, 2006, Plaintiff was seen by Dr. Khanna at Golden Valley for a follow-up visit. (AR 1051-52.) Plaintiff continued to have knee pain. (AR 1051.) Plaintiff was out of many of her medications. (AR 1052.) Dr. Khanna noted that Plaintiff could not afford the copayments on her medication. (AR 1051.)

`Plaintiff was seen at Golden Valley by Dr. Locum on July 7, 2006, for a check-up. (AR 1049.) The notes indicate that Plaintiff had "multiple problems," and she was diagnosed with cough and upper respiratory infection; stable hypertension; osteoarthritis of her knees; and high cholesterol. (AR 1049.) Plaintiff was "doing well" with her depression and there was "no need for meds." (AR 1049.)

On August 1, 2006, Plaintiff was seen by Dr. Khanna at Golden Valley to refill her medication. (AR 1048.) She reported that she was living at a Christian women's home and that "clean [and] sober is the rule of the house." (AR 1048.) Plaintiff tested positive for Phalen and Tinel signs. (AR 1048.)

On August 2, 2006, Dr. Khanna completed a questionnaire concerning Plaintiff's treatment. (AR 845-46.) Dr. Khanna opined that Plaintiff was capable of working but could perform no more than sedentary work and that Plaintiff could sit eight hours and stand/walk two hours in an eight-hour day. (AR 845.) Plaintiff's primary impairments were identified as severe knee osteoarthritis, carpal tunnel syndrome, depression, and obesity. (AR 845.). Dr. Khanna noted that his opinions were based on the objective findings of positive Tinel's and Phalen's sign and that "EMGs [electromyography]*fn3 have not been possible due to lack of insurance." (AR 845.) Dr. Khanna stated that Plaintiff "cannot use her hand more than 1 hour[] per day" and "cannot cope with added stress of phone calls [and] multiple demands." (AR 845.) Dr. Khanna diagnosed Plaintiff with carpal tunnel syndrome in both hands and stated that she can carry less than eight ounces frequently. (AR 846.) Dr. Khanna did not indicate on what date he believed Plaintiff had become disabled to the degree indicated. (AR 846.)

Plaintiff was seen from August through October 2006 at Golden Valley by Dr. Khanna and Daniel Diep, M.D., for follow-up visits. (AR 1042-47, 1053.)

On December 5, 2006, Plaintiff was seen by Karin Forno, M.D., of Stanislaus County Health Services Agency. (AR 1022.) Plaintiff had a cold and indicated that she wanted a sleep study. (AR 1022.) Plaintiff stated that she wanted pain medication and requested "narcotic pain meds [and] sleeping pills." (AR 1022.) Plaintiff had a tender lumbar and reduced range of motion in both knees. (AR 1022.) Plaintiff was diagnosed with sinusitis, hypertension, allergies, asthma, knee problems, back pain, and gastroesophageal reflux disease ("GERD"). (AR 1022.) Plaintiff was seen by Dr. Forno in March, April, and June 2007 for follow-up visits due to hypertension. (AR 1020.)

On June 18, 2007, Plaintiff was seen at the emergency department of Doctors Medical Center for a headache that had lasted two days. (AR 920-26.) Plaintiff was diagnosed with a tension headache and prescribed Percocet and Valium. (AR 922.)

Plaintiff was seen in January and February 2008 at Golden Valley for follow-up visits by Dr. Diep. (AR 1040-41.) Plaintiff complained of pain in her knees and a lump on her ...


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