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Maldonado v. Berryhill

United States District Court, E.D. California

June 8, 2017

TARA L. MALDONADO, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1]Defendant.

          ORDER DIRECTING ENTRY OF JUDGMENT IN FAVOR OF DEFENDANT NANCY BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY, AND AGAINST PLAINTIFF TARA L. MALDONADO

          GARY S. AUSTIN UNITED STATES MAGISTRATE JUDGE

         I. INTRODUCTION

         Plaintiff,, Tara Maldonado (“Plaintiff”), seeks judicial review of a final decision of the Commissioner of Social Security (“Commissioner” or “Defendant”) denying her application for Disability Insurance Benefits (“DIB”) pursuant to Title II of the Social Security Act. The matter is currently before the Court on the parties' briefs which were submitted without oral argument to the Honorable Gary S. Austin, United States Magistrate Judge.[2] (See, Docs. 16, 19, and 20). Upon a review of the entire record, the Court finds that the ALJ applied the proper standards and the decision is supported by substantial evidence. Accordingly, the Court affirms the agency's disability determination and denies Plaintiff's appeal.

         II. FACTS AND PRIOR PROCEEDINGS[3]

         A. Background

         Plaintiff filed an application for DIB under Title II of the Act on March 22, 2012, alleging an onset of disability due to congestive heart failure beginning April 11, 2011. AR 28; 191-194; 206. The agency denied Plaintiff's application initially and on reconsideration. AR 28; 134-137; 140-144. On June 10, 2014, after holding an administrative hearing on May 5, 2014 (AR 58-111), Administrative Law Judge (“ALJ”) Gail Reich issued a decision denying the application. AR 28-38. The Appeals Council upheld that decision on December 16, 2015 (AR 1-6), making that decision the final decision of the Commissioner. Plaintiff sought judicial review by commencing the instant action pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3).

         B. Summary of the Medical Record The Court has reviewed the entire medical record and will be referenced where appropriate. AR 307-1199.

1. Treatment Records

         In 2007, Plaintiff was diagnosed with cardiomyopathy and received an implantable cardioverter defibrillator (ICD). AR 32; 332. She also underwent a mitral valve repair in 2009 AR 32, 329. In 2010, while Plaintiff was pregnant with twins, clinicians noted her cardiac function had improved and her ejection fraction (EF) was 52%. AR 32; 329.[4] She sought treatment for palpitations during her pregnancy and for shortness of breath after giving birth at the end of 2010. AR 32; 358-360; 418-421; 438-446.

         On examination in January 2011, she denied shortness of breath or chest pains and stated she was feeling better. AR 32; 582-583. She presented to the emergency room with chest pain in February 2011, but one week later she indicated that she felt good, had more energy, and had returned to her job at the credit union. AR 582-583.

         In March and April 2011, Plaintiff complained of chest pain and palpitations and clinicians modified her medications for better blood pressure control. AR 33; 583. In May 2011, Plaintiff reported feeling fairly well and it was noted that she had labored breathing when she carried the twins, who weighed around forty pounds, but she denied shortness of breath when performing activities of daily living or walking, including walks with a stroller. AR 33; 583.

         In July 2011, when Plaintiff was hospitalized for repair of an ICD lead, clinicians noted she was clinically stable and denied chest pain, shortness of breath, or palpitations, and she was “otherwise asymptomatic.” AR 33; 514. In September 2011, Plaintiff presented with an irregular heartbeat but had no chest pain, dizziness, weakness, or shortness of breath. AR 33; 857. An echocardiogram showed mild left ventricular enlargement with adequate systolic function and normal right ventricular size and function; Plaintiff's EF was 45% and her BNP[5] was normal, consistent with a compensated state.[6] AR 33; 863; 873; 1090.

         In December 2011, Plaintiff presented to the emergency room complaining of palpitations; she denied chest pain or shortness of breath and her physical examination yielded unremarkable results, including normal respiration and cardiovascular findings. AR 34; 887-889.

         In January 2012, Plaintiff presented to the emergency room complaining of chest pain. Her EKG showed no acute findings, her cardiac function was stable, and her echocardiogram showed no ischemia (insufficient blood supply). AR 1147. A few days later, clinicians modified Plaintiff's medication, which reduced her palpitations, and she was reportedly asymptomatic and hemodynamically stable. AR 34; 955-956. A January 2012 chest x-ray showed stable mild cardiomegaly (enlargement) and no evidence of congestive heart failure. AR 33, 1153.

         In March 2012, her doctor adjusted Plaintiff's medication to address difficulties sleeping due to skipped heartbeats and a tendency for bradycardia (slow heartbeats), but she was again noted to be hemodynamically stable with “very well controlled” blood pressure. AR 33; 962. She also reported feeling better with fewer palpitations. AR 33; 963.

         In May 2012, an echocardiogram showed mildly depressed left ventricular systolic function with an EF of 45%, and normal right ventricular size and function. A mitral annuloplasty ring was present with mild mitral valve regurgitation. AR 33; 1155. In June 2012, Plaintiff stated she felt palpitations at times and “mild” shortness of breath but was doing “pretty well;” a clinician noted moderate mitral valve stenosis on Plaintiff's echocardiogram but her cardiovascular examination and all other systems were normal. AR 34; 1142-1143.

         In October 2012, Plaintiff presented to the emergency room with chest pain complaints. On examination, clinicians reported unremarkable findings including, among other things, no shortness of breath, no respiratory distress, and normal cardiovascular findings. AR 1003-1004. Imaging studies revealed no evidence of deep venous thrombosis, pulmonary embolism, or active cardiopulmonary disease. AR 33; 1005-1006; 1014-1017. February 2013 lab results showed Plaintiff's BNP was 101. AR 77;1139.[7] In a May 2013 examination, clinicians reported Plaintiff was in no distress and documented normal findings for all systems, including her heart AR 35; 1138.

2. Medical Opinions

         a. State Agency Medical Physicians

         Dr. Leah Holly, D.O., completed a Physical Residual Functional Capacity Assessment on July 10, 2011. AR 34; 645-650. Dr. Holly opined Plaintiff could lift or carry twenty pounds occasionally and ten pounds frequently; she could stand or walk for two hours and sit for six hours in an eight-hour workday; she had no limits on pushing or pulling; she could never climb ladders, ropes or scaffolds but could occasionally climb ramps or stairs; she could frequently stoop and occasionally balance, kneel, crouch, or crawl; she had no manipulative limitations; and she should avoid exposure to fumes, odors, dusts, gases, and poor ventilation as well as hazards such as machinery or heights. AR 646-648.

         In a Physical Residual Functional Capacity Assessment dated August 8, 2012, Dr. B. Vaghaiwalla, M.D., opined Plaintiff could lift or carry ten pounds occasionally and less than ten pounds frequently; she could stand or walk for three hours and sit for six hours in an eight-hour workday; she had no limits on pushing or pulling; she could never climb ladders, ropes or scaffolds but could occasionally climb ramps or stairs; she could occasionally balance, stoop, kneel, crouch, or crawl; and she had no manipulative or environmental limitations. AR 119-120.

         In a January 29, 2013 Physical Residual Functional Capacity Assessment, Dr. M. Sohn, M.D., opined Plaintiff could lift or carry twenty pounds occasionally and ten pounds frequently; she could stand or walk for two hours and sit for six hours in an eight-hour workday; she had no limits on pushing or pulling; she could occasionally climb ladders, ropes, scaffolds, ramps or stairs; she could occasionally balance, stoop, kneel, crouch, or crawl; and she had no manipulative or environmental limitations. AR 129-131.

         b. Dr. Venkat Warren, M.D., Consultative Examiner

         Dr. Venkat Warren, M.D., performed a consultative cardiology evaluation on July 26, 2012. AR 33, 1120-25. Dr. Warren noted Plaintiff's medical history included pulmonary hypertension, chest pains, EF in the 40-48% range, and an ICD implant in 2007, which was working normally aside from a problem with a lead in 2011. AR 1122. Dr. Warren documented Plaintiff's self-reported complaints of palpitations, dizziness, and shortness of breath when walking. AR 1120. On examination, however, the doctor observed Plaintiff was in no acute distress; she had no shortness of breath when walking; and there was no cyanosis or edema in her extremities. AR 1123.

         Dr. Warren found Plaintiff was “compensated with no signs of acute cardiac arrhythmias or congestive heart failure.” AR 33, 1124. Based on her history, however, the doctor asserted Plaintiff was disabled. AR 34, 1124. He also opined that Plaintiff could not lift or carry heavy objects; she could sit, stand, and walk at a mild pace; she had no problems with her hands, feet, hearing, or vision; she could not balance, stoop, kneel, crawl, crouch, or climb stairs or ladders; and she would have significant difficulty with unprotected heights, moving machinery, and humid and dusty environments. AR 34, 1124.

         c. Dr. Ernest Schwarz, M.D., Treating Physician

         Plaintiff's treating physician, Ernest Schwarz, M.D., completed a Physical Residual Functional Capacity Questionnaire on March 28, 2014. AR 35, 1195-99. Dr. Schwarz opined Plaintiff could sit for forty-five minutes and stand for fifteen minutes at one time; she could sit for less than two hours and stand or walk for less than 2 hours in an eight-hour workday; her symptoms would frequently interfere with her attention and concentration; she would need unscheduled breaks; she would need to elevate her legs; she could lift or carry less than ten pounds occasionally; she could use her hands for grasping, fine manipulations, and reaching for only 5% of the time; she could not bend or twist at the waist; and she would be absent from work more than three times per month. AR 1196-1199.

         d. Dr. Hugh Savage, ...


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