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Muller v. Saul

United States District Court, E.D. California

November 12, 2019

ANDREW SAUL,[1] Commissioner of Social Security, Defendant.



         I. Introduction

         Plaintiff Kimberly Andrea Muller (“Plaintiff”) seeks judicial review of a final decision of the Commissioner of Social Security (“Commissioner” or “Defendant”) denying her application for disability insurance benefits 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. 12, 15 and 16. Having reviewed the record as a whole, the Court finds that the ALJ's decision is supported by substantial evidence and applicable law. Accordingly, Plaintiff's appeal is denied.

         II. Procedural Background

         On April 11, 2014, Plaintiff filed an application for disability insurance benefits alleging disability beginning October 15, 2010. AR 17. The Commissioner denied the applications initially on May 28, 2014, and upon reconsideration on October 9, 2014. AR 17. On November 21, 2014, Plaintiff filed a request for a hearing before an Administrative Law Judge. AR 17.

         Administrative Law Judge G. Ross Wheatley presided over an administrative hearing on June 7, 2016. AR 32-74. Plaintiff appeared and was represented by an attorney. AR 32. Impartial vocational expert Lorian Ink Hyatt testified. AR 32.

         Administrative Law Judge Daniel G. Heeley presided over a second administrative hearing on September 19, 2017. AR 75-102. Plaintiff appeared and was represented by an attorney. AR 75. Impartial vocational expert Nina Salla testified. AR 75.

         On September 28, 2017, ALJ Healey denied Plaintiff's application. AR 17-26. The Appeals Council denied review on June 27, 2018. AR 1-4. On August 31, 2018, Plaintiff filed a complaint in this Court. Doc. 1.

         III. Factual Background

         A. Plaintiff's Testimony

         1. June 7, 2016

         Plaintiff (born October 23, 1965) lived in a house with her husband and their pet dog. AR 49. On a typical day, she was able to manage her own personal care. AR 49. Depending on her pain level on a particular day, she might be able to perform light housekeeping, do a little laundry or cook. AR 49. She enjoyed reading and television. AR 51. She sometime used a computer but was no longer able to type for very long. AR 52. On the days that her joints were swollen and painful, Plaintiff was less capable of working and needs to lie down and rest. AR 61.

         Plaintiff last worked in July 2009, when she was laid off from her job. AR 40. She had a driver's license and continued to drive. AR 52-53. Because her husband worked in a supermarket, he generally shopped for the family. AR 54.

         Despite other impairments such as high cholesterol, hypertension and cervical radiculopathy, Plaintiff's daily functioning was most affected by rheumatoid arthritis. AR 40. Although Plaintiff was taking medications daily and biweekly infusions of Humira, she still experienced daily arthritis pain with some days worse than others. AR 41-42. Her doctor encouraged exercise, and Plaintiff was able to walk around two blocks a few times weekly. AR 42.

         2. September 19, 2017

         Plaintiff's testimony was generally consistent with the first hearing. Her husband helped with any heavy task or lifting. AR 84.

         Plaintiff's rheumatoid arthritis affected her hands, wrists, knees and ankles on both sides. AR 79. Her left index finger “lock[ed] up” (trigger finger) but could not be surgically repaired because of her rheumatoid arthritis. AR 80. About three days a week, her joints swelled, particularly her knees, ankles and knuckles. AR 89-91. When her hands were swollen and painful, Plaintiff could only lift three or four pounds and had difficulty manipulating buttons or using a pen or pencil. AR 91-92. Pain also reduced her ability to concentrate. AR 95.

         Plaintiff was able to sit for 30 to 60 minutes before needing to get up and walk for five minutes or so. AR 87. She could lift about ten pounds. AR 87.

         B. Medical Records

         Kerry B. Evnin, M.D., a family physician, provided Plaintiff's primary care records from May 2011 through January 2017. AR 369-419, 558-625, 678-91, 757-65. Dr. Evnin's records indicate that Plaintiff had a history of hypercholesterolemia, hypertension, mild-to-moderate mitral regurgitation, mild tricuspid regurgitation, grade 1 diastolic dysfunction, hyperalphalipoproteinemia, fatty liver, elevated LFTS, C6-7 radiculopathy, alcohol abuse, metabolic syndrome, impaired fasting glucose and medication noncompliance. However, the doctor's notes indicated that Plaintiff was currently taking medication as directed. Plaintiff and Dr. Evnin agreed that Plaintiff could do a better job of watching her diet.

         X-rays taken May 18, 2011, revealed mild osteoarthritis of the knees, slightly worse on the right. AR 369. Foot x-rays taken that day were unremarkable. AR 370. Hand x-rays were unremarkable but for mild radiocarpal joint space narrowing. AR 371.

         Dr. Evnin referred Plaintiff to Kanwal Khanna, M.D., for treatment of joint pain, joint stiffness and fatigue. The record includes Dr. Khanna's treatment notes from June 2011 to June 2017. AR 426-92, 499-537, 544-52, 627-60, 696-714, 721-42, 745-56. The doctor's notes illustrate the variable nature of Plaintiff's disease which caused severe pain and swelling in various affected joints at various times.

         In June 2011, Dr. Khanna noted disproportionate pain in Plaintiff's left knee and wondered whether the pain, accompanied by popping and occasional locking, indicated internal derangement. AR 490-91. Magnetic resonance imaging of Plaintiff's left knee in July 2011 revealed small joint effusion and a tiny Baker cyst, but no meniscal tear or internal derangement. AR 427.

         In July 2011, Plaintiff had developed painful right third digit dactylitis. AR 487. She had chronic pain and swelling in her other joints. AR 487. Dr. Khanna discontinued Tramadol[3] and prescribed Vicodin[4] for Plaintiff's pain. AR 488. In September 2011, Plaintiff had increased pain in her neck and left ankle, and no improvement in other affected joints. AR 485. In November 2011, Plaintiff had decreased motion, synovitis, dactylitis and pain in various joints of her hands and fingers. AR 481. In May 2012, Plaintiff experienced a severe episode of pain and swelling in her left elbow for two days. AR 473. In May and October 2012, Dr. Khanna noted that Plaintiff had one-half to one-hour morning stiffness and daily pain. AR 467, 470. Plaintiff was limiting her activity to avoid provoking symptoms. AR 467, 470. Dr. Khanna noted that Plaintiff did not appear able to work full time, even in a sedentary job. AR 467, 470. In December 2012, the doctor noted increasing pain, particularly in the right hand, right wrist and right elbow, but also in elbows, shoulders, hips, knees, ankles and feet. AR 463. He also suspected right carpal tunnel syndrome. AR 463.

         In February 2013, Dr. Khanna noted triggering of Plaintiff's second digits bilaterally. AR 460. In April 2013, Plaintiff had pain in her second through fifth MCP joints as well as hands, wrists, elbows, knees, ankles and feet. AR 505. Plaintiff was getting minimal exercise by walking. AR 505. In June 2013, Plaintiff's knees and ankles were painful and stiff. AR 502. In September 2013, Dr. Khanna began considering whether to change Plaintiff's medication since the Humira did not give Plaintiff a full two weeks of relief. AR 522. The doctor discussed alternative medications and their side effects with Plaintiff and advised her to consider whether she wanted to change to another biologic. AR 522. In November 2013, Plaintiff was symptomatic in her hands, wrists, elbows, knees, ankles and feet. AR 519-20. She had increased pain in her left hand and decreased grip strength. AR 520. Current medications were not controlling Plaintiff's pain. AR 520.

         In January 2014, Plaintiff continued to exhibit disease activity with pain in her hands, wrist, elbows, shoulders, knees, ankles and feet and occasional triggering of several digits. AR 517-18. Because Plaintiff did not want to change Humira[5] for another biologic, Dr. Khanna increased the dosage of Azulfidine. AR 518. The doctor also prescribed zolpidem (Ambien) for insomnia. AR 518. In March 2014, Plaintiff reported mild to moderate joint pain and occasional triggering of her left hand second digit. AR 514. Dr. Khanna opined that the triggering was not yet serious enough to require an injection, but that increased triggering would require an injection to prevent a permanent flexion deformity. AR 515. Plaintiff was trying to walk regularly but walking occasionally caused ankle pain. AR 514. Dr. Khanna explained appropriate and inappropriate limits and regimens for exercise and suggested that soft ankle supports could decrease Plaintiff's ankle pain. AR 515.

         In May 2014, Plaintiff was tolerating Humira in combination with leflunomide and sulfasalazine, and elected not to make therapeutic changes. AR 545. Plaintiff's husband told Dr. Khanna that Plaintiff was not sleeping well and sometimes seemed more forgetful than usual. AR 545. Plaintiff reported that she did not find Ambien helpful and did not take it regularly. AR 545. She had difficulty staying asleep but did not think her pain was the problem. AR 546. Dr. Khanna prescribed a trial of off-label Elavil[6] to be taken at bedtime. AR 546. In December 2014, Plaintiff's trigger finger had begun to return after injected medication had alleviated it. AR 645, 647. Thinking that her dog's leash might be injuring Plaintiff's finger, Dr. Khanna suggested an accommodation using a vascular [clip?]. AR 647. The doctor encouraged walking and stretching to promote healthy muscle tone and range of motion. AR 647.

         In January 2015, Plaintiff accidentally injured her neck and shoulder while trying to control her dog. AR 566. She could lift her arm only with severe pain. AR 566. X-rays revealed no fracture or dislocation of Plaintiff's shoulder or neck. AR 564-65. In December 2015, Dr. Evnin expressed concern about Plaintiff's obesity, noting that Plaintiff was only walking about twenty minutes every other day and was not watching her diet carefully. AR 558. Dr. Evnin advised Plaintiff to stop drinking any alcohol, walk 45 to 60 minutes daily and reduce stress. AR 561.

         In August 2015, Plaintiff was experiencing pain and swelling of the right thumb metacarpal joint. AR 638. Plaintiff thought she was doing fairly well and because she was struggling with the large number of medications prescribed for her, had not yet tried Rayos.[7] In October 2015, Plaintiff was experiencing severe pain and triggering of her left second digit. AR 636.

         In January 2016, Dr. Khanna noted that Plaintiff was still experiencing inflammation but that her medication was sufficient to prevent progressive deformities. AR 635. Her fatigue appeared to be manifestation of her autoimmune disease. R 635. In March 2016, Dr. Khanna noted that Plaintiff took pain medications sparingly and showed no signs of narcotic impairment. AR 627. Her knees were more painful than other joints, including hands, wrists, elbows, shoulders, ankles and ...

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