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Machael Marie Castro v. Carolyn W. Colvin

February 28, 2013


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



Plaintiff Machael Marie Castro ("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.*fn1


Plaintiff was born in 1964, completed a certified nursing assistant program, and worked as caregiver. (Administrative Record ("AR") 30-31, 69, 81, 147, 174.) On August 14, 2007, Plaintiff filed an application for SSI, alleging disability beginning on August 1, 2007, due to severe back problems, anxiety, scoliosis of the spine, bipolar disorder, diabetes mellitus, and fracture of lower limb. (AR 69-88, 147-53, 161, 173.)

A. Medical Evidence

Plaintiff's medical records pre-date Plaintiff's alleged onset date of August 1, 2007. (See AR 69-88.) On March 29, 2006, Plaintiff saw Kenneth Bernstein, M.D., at Darin M. Carmarena Health Center for hypertension, diabetes, asthma, and bipolar disorder. (AR 284.) Dr. Bernstein continued Plaintiff's medication regime and indicated that her thyroid would be reassessed. (AR 284.)

On April 28, 2006, a computed tomography ("CT") scan was performed at Fresno Imaging Center on Plaintiff's cervical and lumbar spine, which revealed right posterolateral disc protrusion, moderate narrowing of the left neural foramen, moderate anterior compression fracture, marked left neural forminal stenosis with bulging disc, and moderate left posterocentral marginal hypertropic spur with mild effacement. (AR 330-34.)

Plaintiff was seen by Dr. Bernstein between April and November 2006 for diabetes and hypertension re-checks. (AR 224, 229, 288-94.) On April 28, 2006, Dr. Bernstein discussed bariatric surgery and adjusted Plaintiff's medication. (AR 288.) On June 23, 2006, Dr. Bernstein noted that Plaintiff was "doing okay and stable." (AR 292.) On October 18, 2006, Dr. Bernstein reported that Plaintiff had "questionable anxiety and psychogenic component" and a "history of bipolar disorder, diabetes mellitus, history of osteoarthritis, reflux esophagitis, and asthma." (AR 229.) Plaintiff had "noticed clicking on lower extremities, which is DVT [deep vein thrombosis] in nature." (AR 229.) On November 3, 2006, Dr. Bernstein indicated that Plaintiff has a history of migraine headaches and needed her medication adjusted. (AR 223.)

On January 18, 2007, Dr. Bernstein saw Plaintiff for a diabetic re-check. (AR 224, 295.) On March 19, 2007, Dr. Bernstein stated that Plaintiff has a "history of auto accident" but that she was "doing much better." (AR 225, 296-97.) Plaintiff was treated for diabetes and morbid obesity, and she was referred for a gastric bypass. (AR 225, 296-97.)

On April 13, 2007, Plaintiff was seen by a licensed nurse practitioner at Madera Community Hospital for a referral for gastric bypass surgery. (AR 274.) Plaintiff was assessed with an eating disorder and morbid obesity, but informed that there was no gastric bypass available for MediCal patients at that facility. (AR 274.) Plaintiff was referred to a different facility that accepted MediCal patients but required $3,000 for the procedure. (AR 274.)

On May 7, 2007, Plaintiff was seen by Dr. Bernstein for leg pain and a rash. (AR 227, 298-99.) Plaintiff reported to that she had been in "pain on and off for a month . . . . The left upper calf cramps up." (AR 227, 298.) Dr. Bernstein noted "some tenderness" but that "flexion and extension are okay" and that Plaintiff's "[j]oints seemed okay." (AR 227. 298.)

On July 17, 2007, Plaintiff underwent a sleep study at Madera Community Hospital, and was referred for a pulmonary evaluation. (AR 273.)

On June 18, 2007, Dr. Bernstein saw Plaintiff for a re-check, and on September 11, 2007, Dr. Bernstein saw Plaintiff for a medication re-fill. (AR 300, 302.)

On October 5, 2007, Plaintiff was seen by Orlando T. Collado, M.D., at Madera County Behavioral Health Services. (AR 384.) Plaintiff was diagnosed with bipolar disorder depressed. (AR 386.) Plaintiff reported some problem with her medication, which was adjusted. (AR 384.) Plaintiff had made "minimal improvement." (AR 384.) Plaintiff returned on October 29, 2007, and indicated that she was "doing fine" on her medication, although she had experienced weight gain. (AR 386.)

On October 17, 2007, J. Martin, M.D., conducted a physical examination of Plaintiff. (AR 230-32.) Dr. Martin noted Plaintiff's medical complaints as being "high blood pressure, asthma, diabetes and 'arthritis.'" (AR 230.) Plaintiff reported that she had been treated for high blood pressure and diabetes for seven years and had been medication compliant. (AR 230.) Plaintiff reported that she had a heart murmur and had been diagnosed with osteoarthritis and rheumatoid arthritis "for many years." (AR 230.) Plaintiff also reported a "lifelong history of asthma." (AR 230.) Dr. Martin reviewed "some clinic notes" and noted that there "was no mention of any arthritic diagnosis in the provided records." (AR 230.) Upon examination, Dr. Martin found that Plaintiff had "[s]ome difficulty . . . transferring on/off the examination table and moving about the site." (AR 231.) In evaluating Plaintiff's musculoskeletal system, her "[c]ooperation was unclear with some grimacing and pain vocalization as well as cogwheeling[,] none of which were noted casually." (AR 231.) Dr. Martin assessed Plaintiff with the medical/physical issues of obesity/deconditioned state, hypertension, asthma, non-insulin dependent diabetes, and "'arthritis,' not otherwise specified." (AR 232.) Dr. Martin opined that Plaintiff "could lift no more than 10 pounds at a time and carry 5 pounds," and that there was "no specific indication for restriction from standing, sitting, gross or fine motor manipulations. The claimant should be provided work space devoid of non-bronchospastic agents. The claimant would likely benefit from weight loss." (AR 232.)

On November 9, 2007, Elpidio A. Fonte, M.D., reviewed Plaintiff's records and provided a physical residual functional capacity ("RFC")*fn2 assessment. (AR 233-37.) Dr. Fonte noted that Plaintiff was primarily diagnosed with diabetes, hypertension, and heart murmur, and secondarily diagnosed with lumbar strain, asthma, and obesity. (AR 233.) Dr. Fonte opined that Plaintiff was able to lift and/or carry 20 pounds occasionally and 10 pounds frequently, could sit, stand, and walk 6 hours in an 8-hour day, and was unlimited in her ability to push and/or pull. (AR 234.) Dr. Fonte indicated that Plaintiff had no other limitations other than the need to avoid concentrated exposure to fumes, odors, dusts, gases, poor ventilation, etc. (AR 235-36.) Dr. Fonte provided a case analysis, and noted that Plaintiff's alleged back problems were not support by x-rays of the lumbar spine and that she did not have significant medical records to support her allegations concerning her mental condition. (AR 240.)

On November 12, 2007, Aimee V. Riffel, Ph.D., performed a psychological evaluation of Plaintiff. (AR 242-47.) Plaintiff indicated that her chief complaints were "[b]ipolar disorder, sleep apnea, obesity, high blood pressure, diabetes, asthma, osteo [and] rheumatoid arthritis, scoliosis and gout." (AR 243.) Plaintiff reported that she was limited in her ability to work because she was "dealing with feeling suicidal now (this phase of illness, but not at this moment)," would "sleep all day," was "depressed," and "constantly ha[d] to have people around [her] because [she] can't be alone." (AR 243.) Plaintiff stated that she attempted to work in 2007 doing in-home care, earning minimum wage, but quit after approximately one month because she "couldn't do it" and couldn't "stand people." (AR 243.) Plaintiff's history included "psychiatric hospitalization, suicidal or aggressive behavior, 5150, individual counseling services, and medication management for psychiatric condition." (AR 243.) Dr. Riffel provided a diagnostic impression of bipolar disorder, not otherwise specified, and limited coping skills and social interests. (AR 246.)

Based on the mental status examination, clinical interview including personal history, and review of the medical records, Dr. Riffel opined that Plaintiff had a "fair" ability to understand, remember and follow very short and simple instructions, and a "fair" level of concentration, pace, and persistence to perform one- or two-step simple instructions and repetitive tasks. (AR 246.) Plaintiff's ability to relate to others, including co-workers, supervisory personnel, and the general public, was poor. (AR 246.) Plaintiff needed a "considerable level of support for her emotional, medical and mental health needs." (AR 246.) Dr. Riffel further opined that Plaintiff "may also have a tendency to incorporate outside individuals into her delusions that may influence or exacerbate her symptoms of paranoia." (AR 246.) Plaintiff's ability to handle the stresses and pressures of work activities was "poor," and her ability to manage changes in a routine work situation was "moderately impaired." (AR 246.) Plaintiff was assessed with a Global Assessment of Functioning score ("GAF") of 55.*fn3 Dr. Riffel noted that, although Plaintiff received psychopharmacological medications and mental health services, her overall functioning had not significantly improved. (AR 246.)

On November 21, 2007, Plaintiff was seen by Dr. Bernstein and complained of lower back pain. (AR 306.) Dr. Bernstein noted tenderness in the lumbosacral region and the lower thoracic region, and stated that Plaintiff's "back sprain/strain is chronic." (AR 306.)

On December 4, 2007, Plaintiff was seen at Madera Community Hospital for a leg fracture. (AR 271.) Plaintiff was prescribed Tylenol with codeine and provided an orthopedic referral. (AR 271.) A cast was placed on Plaintiff's leg. (AR 270.)

On December 5, 2007, Marina C. Vea, M.D., reviewed Plaintiff's records and completed a psychiatric review technique form. (AR 248-61.) Dr. Vea noted that Plaintiff had mild limitations related to restrictions of activities of daily living and maintaining concentration, persistence, or pace, and moderate limitations maintaining social functioning. (AR 256.) Plaintiff had no episodes of decompensation of an extended duration. (AR 256.) Dr. Vea indicated that Plaintiff had a history of incarceration and of drug and alcohol abuse. (AR 258.) Plaintiff was moderately limited in her ability to understand, remember, and carry out detailed instructions, sustain an ordinary routine without special supervision, and complete a normal workday and workweek without interruptions from psychologically based symptoms; Plaintiff had no other limitations. (AR 259-60.) Dr. Vea opined that Plaintiff was able to understand and remember simple tasks; able to sustain concentration and attention for 8-hours a day, 40-hours a week; able to interact in a socially appropriate manner and request assistance from others; and able to adapt to routine changes in a work setting, set realistic goals, and make plans independent of others. (AR 261.)

On December 21, 2007, Plaintiff returned to Dr. Collado. (AR 388.) Plaintiff indicated that she was medication compliant and that her mood was "fairly stable." (AR 388.) The notes indicate that Plaintiff had made "marked improvement." (AR 388.)

In January and February 2008, Plaintiff was seen for follow-up care at Madera Community Hospital for her leg fracture. (AR 263-64.)

On February 12, 2008, Plaintiff was seen by Dr. Bernstein for a positive strep throat. (AR 308-09.) Plaintiff was seen by Dr. Bernstein for a diabetic re-check on March 10, 2008. (AR 311-12.)

On February 15, 2008, Plaintiff was seen by Dr. Collado for a medication adjustment. (AR 390.) Plaintiff indicated that she "still has depression and anxiety," but the notes indicated "marked improvement" to Plaintiff's progress. (AR 390.)

On March 28, 2008, John T. Bonner, M.D., evaluated Plaintiff's medical records and affirmed Dr. Fonte's physical RFC assessment "overall," but noted Plaintiff's recent fracture. (AR 276-83.) Dr. Bonner noted that Plaintiff's fracture was expected to "heal and resolve" by August 2008, and that the rest of Dr. Fonte's opinion "was affirmed as written." (AR 283.)

On March 28, 2008, Plaintiff returned to Dr. Collado for a medication adjustment. (AR 392.)

Plaintiff indicated that she was depressed and irritable. (AR 392.) On April 25, 2008, Dr. Collado was informed by Plaintiff that she was "feeling good" and had no side effects to her medication. (AR 394.)

In June 2008, Central Valley Sleep Disorders Center, Inc., prepared a report indicating that Plaintiff suffered from obstructive sleep apnea. (AR 413-31.)

On June 27, 2008, Dr. Collado noted that Plaintiff continued to take her medication and that she was sleeping better. (AR 396.) Plaintiff, reported that she was "still having mood swings," but Dr. Collado noted "marked improvement" to Plaintiff's progress. (AR 396.)

On July 17, 2008, Plaintiff was seen by Dr. Bernstein and indicated that she was "[f]eeling fine." (AR 313.)

On October 8, 2008, Plaintiff returned to Dr. Collado and reported that the medication was making her drowsy but she did "not sleep good." (AR 398.) Plaintiff had been diagnosed with sleep apnea. (AR 398.) Plaintiff's medication was adjusted. (AR 398.)

On December 31, 2008, Plaintiff was seen by Dr. Collado, who noted that Plaintiff's "[a]ffect is blunted" and she exhibited ...

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