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Hollins v. Berryhill

United States District Court, N.D. California

June 7, 2017



          MARIA-ELENA JAMES United States Magistrate Judge.


         Plaintiff Sterling James Hollins (“Plaintiff) brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final decision of Defendant Nancy A. Berryhill (“Defendant”), the Acting Commissioner of Social Security, denying Plaintiffs claim for disability benefits. Compl., Dkt. No. 1. Pending before the Court are the parties' cross-motions for summary judgment. Pl.'s Mot., Dkt. No. 16; Def.'s Mot., Dkt. No. 17. Pursuant to Civil Local Rule 16-5, the motions have been submitted on the papers without oral argument. Having carefully reviewed the parties' positions, the Administrative Record (“AR”), and the relevant legal authority, the Court hereby GRANTS IN PART Plaintiffs motion and DENIES Defendant's cross-motion for the reasons set forth below.


         Plaintiff complained of migraines and right knee pain starting in 2011. AR 264. In May 2012, he contracted Ludwig's angina, a mouth infection that spread systemically through his brain, heart, and other vital organs; he spent 15 days as an inpatient in the Intensive Care Unit of the Alameda County Medical Center. AR 254, 281, 286, 328, 340, 351, 404. Plaintiff needs a cane to stand and to walk. AR 17. He has consistently tested negative for rheumatoid factor and antinuclear antibodies; he has not exhibited joint deformities. AR 380, 423, 430, 442-43, 448. He suffers from cognitive and affective disorders. AR 13.


         On July 18, 2012, Plaintiff filed a claim for Disability Insurance Benefits, alleging disability beginning on May 14, 2012. AR 184. The Social Security Administration (“SSA”) denied Plaintiffs claim, finding that Plaintiff did not qualify for disability benefits. AR 59. Plaintiff subsequently filed a request for reconsideration, which was denied. AR 69. On March 11, 2014, Plaintiff requested a hearing before an Administrative Law Judge (“ALJ'). AR 102. Plaintiff also filed a request for good cause for filing his appeal twenty-two days late, which the SSA granted. AR 109-11. ALJ Mary Parnow conducted a hearing on October 11, 2014. AR 30-57. Plaintiff testified in person at the hearing and was represented by counsel, Katherine Siegried. AR 11, 30-32. The ALJ also heard testimony from Vocational Expert (“VE”) Robert Raschke and medical expert Dr. Gilberto Munoz. Id.

         A. Medical Evidence of Record

         Plaintiff was examined by four SSA consultants: Dr. Rana, Dr. Tang, Dr. Van Gaasbeek, and Dr. Snyder. AR 374-376, 396-99, 400-03, 404-08. His records were reviewed by four SSA Reviewing Physicians: Dr. Williams, Dr. Blanco, Dr. Fair, and Dr. Schumacher. AR 64, 66, 69, 77.

         1. Dr. Farah M. Rana, M.D.

         Dr. Rana performed an internal medicine evaluation of Plaintiff on behalf of the SSA on January 16, 2013. AR 374-76. Dr. Rana observed Plaintiff walked with a mild limp and used a cane to support himself while walking, but all the tests and examinations she performed were normal. Id. Dr. Rana noted Plaintiffs history of Ludwig's angina in May 2012, migraines, and right knee pain with probable strain/tendinitis. AR 376. In relevant part, Dr. Rana opined Plaintiff could stand and walk up to six hours with breaks in an eight-hour work day; had no sitting limitations; could carry 25 pounds frequently and 50 pounds occasionally; and did not need any assistive devices. Id.

         2. Dr. Robert Tang, M.D.

         Internist Dr. Tang performed a comprehensive internal medicine evaluation of Plaintiff on September 18, 2013 on behalf of the SSA. AR 396-99. Dr. Tang observed that Plaintiff walked with a cane; appeared to have not more than 75 percent weight-bearing on the right step due to hip discomfort; 3/5 strength in the right hip; and decreased pinprick sensation on the right forearm, right hand, and lower legs. Id. He diagnosed Plaintiff with severe gum infection resulting in sepsis and lower extremity swelling; residual neuropathy in the right forearm and both lower legs; right step decreased weight-bearing due to hip pain; and neuropathy due to main-end organ. AR 398-99. His findings were otherwise normal. AR 396-99. In relevant part, Dr. Tang opined that Plaintiff could walk up to six hours with a cane, had no limitation in sitting, had medical necessity for a cane, could carry 20 pounds occasionally and 10 pounds frequently, and had no postural, manipulative, or height limitations. AR 399.

         3. Dr. Kyle Van Gaasbeek, Psy. D.

         Dr. Van Gaasbeek, conducted a comprehensive psychiatric evaluation of Plaintiff on September 21, 2013 at the request of the SSA. AR 400-403. In relevant part, Dr. Van Gaasbeek found Plaintiff had “quite slow” movements, “concentration, persistence and pace” were “a bit slow, ” his thoughts were “a bit slow to organize, ” his speech “a bit pedantic”; blunted affect and self-described bad mood; average intellectual functioning; was able to recall three out of three objects for immediate memory; could recall one out of three words after several minutes, but could remember a second one on cue; had adequate past memory. Id. He further found Plaintiff had a fair fund of knowledge, reduced calculation ability, fair concentration, adequate abstract thinking, could distinguish similarities and differences, and had adequate judgment and insight. Id. He described Plaintiff as “open and cooperative.” AR 401.

         Dr. Van Gaasbeek diagnosed Plaintiff with cognitive and depressive disorders, and assessed Plaintiff as having a GAF[1] score of 45. AR 402-03. While Dr. Van Gaasbeek opined Plaintiffs depression was treatable and was “a reaction to his health decline, ” he believed Plaintiffs cognitive problems “may potentially be chronic” and found “indications that they developed after his infection and emergency surgery.” AR 403. Dr. Van Gaasbeek opined Plaintiff was “moderately impaired” in his ability to perform detailed and complex tasks, interact with coworkers and the public, perform work activities on a consistent basis without special or additional instruction, ability to maintain regular attendance, and dealing with the usual stress encountered in a competitive work environment. AR 403. He also found Plaintiff was substantially impaired in completing a normal workday and workweek without interruptions from his psychiatric condition. Id.

         4. Dr. Jodi Snyder, Psy. D.

         Dr. Snyder, performed a psychological evaluation of Plaintiff on December 3, 2013 at the SSA's request. AR 404-408. Dr. Snyder observed Plaintiff put forth “good effort during testing” but that his gross motor skills appeared abnormal, he walked with a cane and moved “very slowly, ” he had difficulty with cognitive sequencing and shifting sets of information; psychomotor retardation was noted. AR 404. The mental status exam Dr. Snyder administered was mostly normal, except for speech (spoke slowly and had difficulty with annunciation), attention (“poor”), memory (recalled 0/3 words after brief delay), mood (depressed/anxious), and affect (sad). AR 406. Plaintiff tested borderline in verbal comprehension, perceptual reasoning, working memory and full scale IQ (“FSIQ”); he tested “extremely low” in processing speed. AR 406. He tested “low average” in auditory memory index and borderline in visual working memory index. AR 407. He took 1:37 to complete a Trail A test, and 4:38 to complete a Trail B test; these results placed him below the first percentile of the population and exhibited a “severe deficit” in both trails. Id[2] Dr. Snyder opined Plaintiff s borderline to extremely low range performance was “most likely secondary to his residual cognitive deficits from Ludwig's angina.” AR 407.

         Dr. Snyder's prognosis was guarded: Plaintiff “continues to have significant residual cognitive difficulties secondary to his medical issue of Ludwig's angina.” AR 407. She suggested he “may benefit from an acquired brain injury support group to address the cognitive changes as well as support and mental health treatment to address his mood symptoms.” AR 407-08. Based on the results of her tests, a clinical interview, and Plaintiffs personal history and documentation, she opined that from a psychological standpoint alone, Plaintiff was “moderately impaired” in his ability to follow complex/detailed instructions; maintain adequate pace or persistence to perform complex tasks; maintain adequate attention/concentration; adapt to changes in job routine; withstand stress of a routine workday; ...

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