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Huss v. Colvin

United States District Court, N.D. California, San Francisco Division

April 14, 2015

MARY HUSS, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

ORDER GRANTING IN PART AND DENYING IN PART PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT, DENYING DEFENDANT'S MOTION FOR SUMMARY JUDGMENT, AND REMANDING FOR FURTHER PROCEEDINGS. [Re: ECF Nos. 13 and 14]

LAUREL BEELER, Magistrate Judge.

INTRODUCTION

On May 19, 2014, Mary Huss filed a complaint against the acting Commissioner of Social Security, Carolyn Colvin, seeking judicial review of the Commissioner's final decision denying her claim for disability benefits for her claimed disabilities caused by a combination of physical and psychological maladies. (Complaint, ECF No. 1.[1]) The Administrative Law Judge ("ALJ") found that Ms. Huss had the residual functional capacity to perform her past relevant work as a caseworker. (Administrative Record ("AR") 18-22.) Now, Ms. Huss and the Commissioner both move for summary judgment. (Motion, ECF No. 13; Cross-Motion and Opposition, ECF No. 14.) All parties have consented to the court's jurisdiction. (ECF Nos. 8, 9.) Pursuant to Civil Local Rule 16-5, the matter is deemed submitted for decision by this court without oral argument. For the reasons stated below, the court grants in part and denies in part Ms. Huss's motion, denies the Commissioner's motion, and remands this case to the Social Security Administration for further proceedings.

STATEMENT

I. PROCEDURAL HISTORY

Ms. Huss, who was born on February 7, 1951, applied for disability insurance benefits and supplemental security income on December 30, 2009. (AR 107-08.) In both applications, she alleged that her disability began on August 15, 2008. The Commissioner denied Ms. Huss's claims initially on June 24, 2010, and upon reconsideration on July 6, 2011. (AR 114, 121.) On August 3, 2011, Ms. Huss requested a hearing before an ALJ. (AR 126.)

ALJ Philip Lyman conducted a hearing on May 29, 2012 in San Jose, California. (AR 29-80.) Ms. Huss was represented by attorney Angelina Valle. (AR 29.) Ms. Huss, vocational expert Ronald Morrell, and psychological expert Tracy Gordy testified. (AR 29.) On June 14, 2012, the ALJ issued his decision that Ms. Huss was not disabled under the Social Security Act. (AR 11-23.) On April 15, 2014, the Appeals Council denied Ms. Huss's request for review, rendering the ALJ's decision the final decision of the Commissioner. (AR 1-3.)

On April 19, 2014, Ms. Huss filed the complaint in this action. (Complaint, ECF No. 1.) Ms. Huss filed a motion for Leave to Proceed in forma pauperis, which the court granted on April 29, 2014. (Motion, ECF No. 3; Order, ECF No. 5.) The Commissioner answered the complaint on September 8, 2014. (Answer, ECF No. 11.) Ms. Huss moved for summary judgement on October 6. 2014. (Motion, ECF No. 13.) The Commissioner responded with a cross-motion for summary judgement and opposition to Ms. Huss's motion on November 4, 2014. (Cross-Motion and Opposition, ECF No. 14.) Ms. Huss filed her reply on November 17, 2014. (Reply, ECF No. 15.)

II. SUMMARY OF RECORD AND ADMINISTRATIVE FINDINGS

This section summarizes the medical evidence in the administrative record from (A) Ms. Huss's treating physicians, (B) her non-treating physicians, (C) the hearing testimony, and (D) the ALJ's findings.

A. Medical Evidence: Treating Physicians

1. Dr. Robert Wlodarczyk, D.O. (March 12 and June 10, 2008)

Notes from Ms. Huss's two physical exams with Dr. Robert Wlodarczyk on March 12 and June 10, 2008 were generally unremarkable indicating morbid obesity, diabetes, sleep apnea, fibromyalgia, and allergies. (AR 290-93.) The only legible symptom mentioned in the notes is congestion. (AR 291.) Dr. Wlodarczyk recommended diet and weight loss, use of a CPAP, and Zyrtec. (AR 291.)

2. Dr. B. Elene Brandt, M.D. (March 3, 2008-March 16, 2010)

The record includes Dr. Elene Brandt's notes from 22 routine physical exams over two years between March 2008 and March 2010. (AR 335-56.) During exams conducted in early and mid-2008 Ms. Huss reported shoulder pain, vomiting, sore throat, and fever, and Dr. Brandt noted the possible need for hand surgery. (AR 351-53.) Ms. Huss was briefly hospitalized in early July 2008, as discussed below, but this visit is not mentioned in Dr. Brandt's notes from the same time period. (AR 342-50.) Dr. Brandt noted that Ms. Huss's diabetes and hypertension were well controlled. (AR 340, 342, 350.) During the period from late 2008 until the notes end in March 2010, Ms. Huss had a number of spells of bronchitis (AR 336, 339, 341, 349), an asthma attack brought on by stress at home (AR 348), and bruising from falling at the grocery store (AR 345). In an exam on August 2, 2008 Ms. Huss reported working only two days a week because funding had been cut for her position. (AR 348.) Her boss recommended that she apply for disability. (AR 348.) During exams in late 2009 Ms. Huss began reporting severe abdominal pain and Dr. Brandt told her to go to the hospital and ask for MediCal. (AR 337.) Dr. Brandt noted on Ms. Huss's last three visits in early 2010 that Ms. Huss needed a colonoscopy. (AR 335 and 336.)

3. Salinas Valley Memorial Hospital. (July 6-8, 2008)

On July 7, 2008, Ms. Huss went to Salinas Valley Memorial Hospital complaining of slurred speech, facial drooping, and slight frontal headache. (AR 306.) Her son took her to the hospital after she had been shopping at Target in the morning. (AR 300.) At the hospital, numerous physicians, including Dr. Brandt, treated and examined Ms. Huss. (AR 294-333.) Dr. Rakesh Singh did not notice any slurred speech and noticed only a slight facial droop, which resolved itself. (AR 307.) A chest x-ray showed no acute disease, and a CT scan of Ms. Huss's head showed probable small chronic ischemic change with no clear evidence of acute ischemia. (AR 302.) Consulting neurologist Dr. Wayne Shen reported that her EKG was normal and her CT scan was unremarkable. (AR 299.) Dr. Shen further stated that Ms. Huss's very minimal symptoms were cerebrovascular in nature and recommended a MRI and further testing. (AR 299.) Dr. Robert Wlodarczyk reviewed the MRI results and found "cerebral white matter changes most compatible with chronic deep white matter ischemia, " but did not identify any "acute intra cranial pathology." (AR 295-96.) He recommended Ms. Huss start taking aspirin, begin dieting to lose weight, and consider using a BiPAP or CPAP mask for her sleep apnea. (AR 296.) Dr. Brandt diagnosed Ms. Huss with left lower lung scarring, diabetes, metabolic syndrome, hypertension, sleep apnea, asthma, and a trigger finger. (AR 300.) Dr. Brandt treated her for hypercholesterolemia but believed her diabetes and blood pressure were under control. (AR 302.)

4. Letter from Dr. B. Elene Brandt, M.D. (March 19, 2010)

In a letter addressed "To Whom It May Concern, " Dr. Brandt stated that Ms. Huss ended treatment because she "can not afford medical care or evaluation." (AR 359.) Dr. Brandt declared Ms. Huss to be "disabled because I have serious concerns about her health." (AR 359.) Nonetheless, this evaluation was "not about orthopedic concerns or how long she can stand or sit." (AR 359.) Rather, Dr. Brandt opined that Ms. Huss might have "colon cancer or MS." (AR 359.) Dr. Brandt stated later that she has not performed a colonoscopy or brain MRI. (AR 359.) She also stated that Ms. Huss has diabetes, hypertension, and COPD[2] with asthma. (AR 359.)

5. Natividad Medical Center. (November 14 and December 28, 2010)

On November 14, 2010, Ms. Huss went to Natividad Medical Center for treatment of a laceration on her right index finger. (AR 448.) On December 28, 2010, Ms. Huss went to Natividad Medical Center a second time for treatment of a head injury. (AR 434.) Dr. Craig Walls described the injury as not serious but cautioned that Ms. Huss should watch for warning signs of more serious injury. (AR 434.) Dr. Walls was concerned that the injury was the result of domestic abuse. (433.)

6. Dr. Laura M Solorio, M.D., Laurel Family Practice (December 6, 2010)

Ms. Huss visited Dr. Laura Solorio at the Laurel Internal Medicine Clinic for the first time on December 6, 2010. (AR 475.) Dr. Solorio conducted a new patient physical exam which revealed mostly normal results with mild tenderness of the abdomen and soft nodules on her left hand. (AR 476.) Dr. Solorio determined that Ms. Huss's ailments included diabetes without complication type II, COPD, unspecified essential hypertension, unspecified vitamin D deficiency, and abdominal pain. (AR 476-77.)

7. Dr. Laura M Solorio, M.D., Laurel Family Practice (January 11, 2011)

On January 11, 2011, Dr. Solorio noted that Ms. Huss went to the ER in December after an assault by her daughter and she was told everything was ok. (AR 473.) Ms. Huss also mentioned a bad root canal she had on an upper left tooth that was starting to become sore and possibly infected. (AR 473.) Dr. Solorio did not note any tooth swelling or pus, but did observe tenderness over the area over the left cheek. (AR 473.) Additional physical examination revealed nothing abnormal. (AR 473-74.)

8. Dr. Laura M Solorio, M.D., Laurel Family Practice (February 8, 2011)

On February 8, 2011, Dr. Solorio noted that Ms. Huss had visited a dentist since her last exam and had a decayed root pulled from her right side. (AR 471.) Ms. Huss reported no pain. (AR 472.) Dr. Solorio conducted a physical exam that did not reveal any abnormal results. (AR 472.) Ms. Huss's diabetes, COPD, and hypertension were still under control. (AR 472.)

9. Dr. Laura M Solorio, M.D., Laurel Family Practice (March 10, 2011)

In an exam on March 10, 2011, Ms. Huss reported to Dr. Solorio significant pain in her shoulder. (AR 469.) The results of a "basic metabolic panel calcium total" revealed results all within the normal range. (AR 470.) Dr. Solorio added arthritis to her list of diagnoses. (AR 470.)

10. Dr. Laura M Solorio, M.D., Laurel Family Practice (April 26, 2011)

On April 26, 2011, Ms. Huss reported that her blood pressure medication makes her cough so she had started taking it in the morning instead of at night. (AR 466.) Ms. Huss also complained of minor shoulder pain. (AR. 466.) Dr. Solorio's physical exam revealed nothing abnormal. (AR 466-67.) Lab results were all within normal ranges. (AR 467.) Dr. Solorio added degenerative joint disease and joint pain to Ms. Huss's ailments. (AR 468.)

11. Dr. Laura M Solorio, M.D., Laurel Family Practice (June 3, 2011)

On June 3, 2011, Ms. Huss reported to Dr. Solorio that she had completed her dental work with an oral surgeon and all her dental ailments had been resolved. (AR 464.) Ms. Huss complained of level 3 back pain. (AR 464.) Dr. Solorio's physical exam and pelvic exam of Ms. Huss revealed nothing abnormal. (AR 464-65.) Ms. Huss's mammogram and cervical cancer screening both came back negative, but Dr. Solorio did diagnosed Ms. Huss with Dysuria. (AR 465.)

Additionally, Dr. James Kowalski, MD, consulted on films taken of Ms. Huss's right hand finding that she had some "subchondral cystic change of the waist of the carponavicular bone best result of old trauma. Minor osteoarthritic spurring noted of the interphalangeal joint of the thumb. Less prominent spur formation noted of the DIP joint of the 2nd and 5th digits. No evidence for any erosive change, sclerosis, fracture, or dislocation." (AR 462.) Dr. Kowalski concluded "[m]inimal osteoarthritic change is noted of the right hand. No evidence for recent osseous injury." (AR 462.)

12. Dr. Laura M Solorio, M.D., Laurel Family Practice (July 1, 2011)

On July 1, 2011, Ms. Huss visited Dr. Solorio stating that she had kicked the vacuum cleaner the previous day. (AR 614.) Ms. Huss did not experience any pain until it woke her at 3 am. (AR 614.) Dr. Solorio noted "very mild swelling" on her right foot and "tenderness to palpation." (AR 614.) An x-ray revealed no fracture to be present. (AR 614.)

13. Dr. Laura M Solorio, M.D., Laurel Family Practice (August 3, 2011)

On August 3, 2011, Ms. Huss visited Dr. Solorio complaining of "chest pain when she feels very nervous." (AR 612.) She described it as "like I'm having a panic attack." (AR 612.) Ms. Huss also reported failing to use her CPAP as advised in order to treat her sleep apnea. (AR 612.) Dr. Solorio diagnosed her with obstructive sleep apnea and referred her for a cardiac stress test. (AR 613.)

14. Alma C. Ritsema, Laurel Family Practice (August 17, 2011)

On August 17, 2011, Ms. Huss visited Ms. Alma Ritsema complaining of stress and depression. (AR 603.) Ms. Ritsema diagnosed Ms. Huss as having "major depressive disorder, recurrent episode, moderate." (AR 603.) Ms. Ritsema also assigned Ms. Huss a GAF score of 55. (AR 606.) Additionally, Ms. Ritsema switched Ms. Huss from Effexor to Wellbutrin in order to treat her depression. (AR 607.) Finally, Ms. Ritsema referred Ms. Huss "to Luz for counseling." (AR 606.)

15. Dr. Laura M. Solorio MD, Laurel Family Practice (September 8, 2011)

On September 8, 2011, Ms. Huss reported improved chest pain, "but still has panic' attack associated with it." (AR 601.) Dr. Solorio noted that Ms. Huss visited Ms. Ritsema to try "to deal with stressors in her life." (AR 601.) Ms. Huss reported not being able to tolerate the change from Effexor to Welbutrin. (AR 601.) Blood test results were all within the normal range. (AR 601-02.) Dr. Solorio wanted to conduct a stress test to further investigate Ms. Huss's chest pain. (AR 602.)

16. Luz Venegas LCSW, Laurel Family Practice (September 13, 2011)

On September 13, 2011, Ms. Venegas, a Licensed Clinical Social Worker, conducted and Initial Referral Assessment Mental Status Exam with Ms. Huss to help develop "coping strategies around family boundaries." (AR 600.) Ms. Venegas introduced Ms. Huss to "the concept of self-care...." (AR 600.) Ms. Venegas noted state that she "could not focus and wanted to share some of her own self-care techniques." (AR 600.)

17. Alma C. Ritsema, Laurel Family Practice (September 15, 2011)

On September 15, 2011, Ms. Huss reported to Ms. Ritsema not being able to tolerate the Welbutrin and that she switched back to taking Effexor. (AR 596.) She said it gave her nausea, her head felt "big, " and she started hearing voices. (AR ...


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