United States District Court, N.D. California
ORDER REMANDING CASE FOR CLARIFICATION RE: DKT. NOS. 20, 21
MARIA-ELENA JAMES, Magistrate Judge.
Plaintiff Eulalie Francis White Martinez ("Plaintiff") brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final decision of Defendant Carolyn W. Colvin, the Acting Commissioner of Social Security, denying Plaintiff's claim for disability benefits. Pending before the Court are the parties' cross-motions for summary judgment. Dkt. Nos. 20, 21. Pursuant to Civil Local Rule 16-5, the motions have been submitted on the papers without oral argument. Having carefully reviewed the parties' papers, the Administrative Record ("AR") in this case, and relevant legal authority, the Court hereby REMANDS this case for clarification as discussed below.
In April 1999, Plaintiff sustained a head and shoulder injury when "a bunch of stuff" fell on her head at work. AR 91, 446, 450. Neurological tests at the time of the injury indicated a mildly reduced range of motion in her neck, tenderness over her neck and arm muscles, and no nerve damage. AR 461-62. A shoulder x-ray and head scan were both normal. AR 471, 474. Plaintiff has not worked since her April 1999 workplace injury. In 2004, when Plaintiff last saw her treating orthopedist, Richard Nolan, M.D., he opined that Plaintiff could return to modified work. AR 976-82.
John D. Warbritton III, M.D.A., a consultative orthopedic surgeon, examined Plaintiff on December 14, 2004, in connection with her workers compensation claim. AR 746-53. He diagnosed her with occasional slight to moderate headaches and opined that she was precluded from heavy lifting or repetitive, twisting neck motion. AR 750.
In connection with a previous 2006 disability application,  Calvin Pon, M.D., completed an orthopedic consultative examination on August 8, 2006. AR 759-61. Based on his evaluation and review of the records, Dr. Pon diagnosed chronic neck pain with a diagnosis of cervical spondylosis per the medical record review and chronic mild low back pain. AR 761. Dr. Pon found no restriction in standing, walking, or sitting, but limited stooping, crouching, kneeling, and squatting to occasionally. AR 761. He opined that Plaintiff could lift and carry 20 pounds occasionally and 10 pounds frequently, and occasionally stoop, crouch, kneel, squat, crawl, and climb ladders. AR 761.
On September 25, 2006, State agency physician L. L. VanCompernolle, M.D., completed a Physical Residual Functional Capacity Assessment. AR 763-67. Dr. VanCompernolle opined that Plaintiff could: (1) occasionally lift and/or carry 20 pounds and frequently lift and/or carry 10 pounds; (2) stand, sit, and/or walk about 6 hours in an 8-hour workday; (3) push and/or pull in an unlimited capacity; (4) frequently balance and kneel; (5) occasionally climb, stoop, crouch, and crawl; and (6) never balance. AR 764-65. Dr. VanCompernolle found no manipulative, visual, or environmental limitations. AR 765-66.
In connection with Plaintiff's 2008 disability application, Kamyar Madani, M.D., completed a comprehensive internal medicine evaluation on August 19, 2008. AR 789-92. Dr. Madani noted that Plaintiff lived by herself and does her own housework, and the only medication she took was white willow as an herbal supplement. AR 789-90. He diagnosed chronic neck and shoulder pain, as well as lower back pain, likely degenerative disc disease, myofascial pain syndrome, and traumatic brain injury. AR 791. Dr. Madani determined that Plaintiff could stand, sit, and walk at least six hours, with no need for an assistive device. AR 791-92. She could lift and carry 10-20 pounds, but could not continuously bend, stoop, crawl, pull, or reach. AR 792. He determined that she did not have complete language skills, but could carry on a "fairly normal" conversation in terms of expression and did not have any major word finding difficulties. AR 792.
On August 26, 2008, Plaintiff underwent a consultative psychological evaluation with Maria Kerosky, Ph.D. AR 794-800. Dr. Kerosky administered a mental status examination, Bender Gestalt II Test; WAIS-III, and WMS-III. AR 794. She found that Plaintiff functions in the low average range of intelligence. AR 798. Dr. Kerosky determined that Plaintiff would have no significant difficulty following complex/detailed instructions at work, but would have mild difficulty maintaining adequate pace and persistence to perform tasks consistently, and would have mild difficulty maintaining adequate attention/concentration. AR 799. Dr. Kerosky also determined that Plaintiff would have mild difficulty adapting to change in job routine, moderate to marked difficulty withstanding the stress of a routine work day, and mild to moderate difficulty maintaining emotional stability/predictability. AR 799. She found no significant difficulty in her ability to communicate and interact appropriately with co-workers, supervisors, and the public. AR 799.
Dr. VanCompernolle completed a second Physical Residual Functional Capacity Assessment on September 8, 2008. AR 802-07. Dr. VanCompernolle opined that Plaintiff could: (1) occasionally lift and/or carry 20 pounds and frequently lift and/or carry 10 pounds; (2) stand, sit, and/or walk about 6 hours in an 8-hour workday; (3) push and/or pull in a limited capacity in the upper extremities; (4) frequently balance, kneel, climb ramps and stairs, stoop, crouch, and crawl; and (5) occasionally climb ladders, ropes, and scaffolds. AR 803, 805. Dr. VanCompernolle found no visual or environmental limitations. AR 805-06. While Plaintiff was unlimited in handling, fingering, and feeling, Dr. VanCompernolle found that Plaintiff was limited in reaching in all directions. AR 805.
On September 19, 2008, R. Lee, M.D., completed a Mental Residual Functional Capacity Assessment. AR 811-13. Dr. Lee found that Plaintiff was "moderately limited" in her ability to: (1) understand, remember, and carry out detailed instructions; (2) maintain attention and concentration for extended periods; (3) work in coordination with or proximity to others without being distracted by them; (4) complete a normal workday without interruptions from psychologically based symptoms; (5) interact appropriately with the general public; and (6) respond appropriately to changes in the work setting. AR 811-12. He found no significant limitations for any other categories.
In July 2009, Board-certified physican Todd Nguyen, D.O., interviewed and examined Plaintiff at the request of the agency. AR 37-38, 57, 861-65. Dr. Nguyen diagnosed chronic neck and low back pain, and shoulder pain from an impingement in primarily the right shoulder. AR 863. On examination, Plaintiff's neck and low back were tender to touch, she had a negative straight leg raise test,  and positive Waddell's signs which could indicate a non-organic cause of pain or symptom exaggeration. AR 863. Plaintiff had a reduced range of motion in the low back and right shoulder, and a normal neck range of motion. AR 863-64. She also had normal muscle strength (5/5) in her arms and legs. AR 864. Given these findings, Dr. Nguyen opined that Plaintiff could lift and carry 50 pounds frequently (consistent with heavy exertional level work), stand, sit and walk for 6 hours in an 8-hour workday, and should limit herself to occasional activities above the shoulder. AR 864.
Clinical psychologist Ahmed El-Sokkary, Psy.D., interviewed, examined, and tested Plaintiff in July 2009 at the request of the agency. AR 34, 857-59. Plaintiff reported head, back, shoulder, and knee injuries and complained of poor sleep. AR 857. On examination, Plaintiff was polite, cooperative, alert and oriented, made good eye contact, and had logical and goal-directed thought processes. AR 857. Testing revealed an average I.Q., below average psychomotor speed, and low average memory. AR 858-59. Based on the results of the examination and testing, Dr. El-Sokkary opined that Plaintiff had the cognitive and emotional ability to understand, remember and perform simple to moderately difficult tasks. She could maintain concentration, persistence, and pace for basic to moderately complex work, and would be able to interact appropriately with supervisors and co-workers. AR 859.
In August 2009, State agency physician Sadda V. Reddy, M.D., reviewed the longitudinal physical medical evidence and opined that, given Plaintiff's history of neck and shoulder pain, she could lift and carry 25 pounds frequently and 50 pounds occasionally, and stoop and reach overhead occasionally. AR 37, 867-69. Also in August 2009, a State agency psychologist, A. Middleton, Ph.D., reviewed the mental health evidence and opined that Plaintiff had a medically determinable impairment (adjustment disorder) that did not significantly limit her ability to perform basic work activities (i.e., a non-severe impairment, 20 C.F.R. § 416.930(c)). AR 874-84. The psychologist opined that Plaintiff's mental ...