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Garcia v. Berryhill

United States District Court, W.D. Arkansas, Fayetteville Division

March 29, 2018

MOISES ALBARRAN GARCIA PLAINTIFF
v.
NANCY A. BERRYHILL, Commissioner Social Security Administration DEFENDANT

          MAGISTRATE JUDGE'S REPORT AND RECOMMENDATION

          HON. ERIN L. WIEDEMANN UNITED STATES MAGISTRATE JUDGE.

         Plaintiff, Moises Albarran Garcia, brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a decision of the Commissioner of the Social Security Administration (Commissioner) denying his claims for a period of disability and disability insurance benefits (DIB) and supplemental security income (SSI) benefits under the provisions of Titles II and XVI of the Social Security Act (Act). In this judicial review, the Court must determine whether there is substantial evidence in the administrative record to support the Commissioner's decision. See 42 U.S.C. § 405(g).

         I. Procedural Background:

         Plaintiff protectively filed his current applications for DIB and SSI on September 30, 2014, alleging an inability to work since September 1, 2014, due to diabetes, ADHD (attention deficit hyperactivity disorder), neuropathy, tendonitis, high blood pressure and high cholesterol. (Tr. 65, 177, 184). An administrative video hearing was held on September 21, 2015, at which Plaintiff appeared with counsel and testified. (Tr. 38-62).

         By written decision dated January 27, 2016, the ALJ found that during the relevant time period, Plaintiff had an impairment or combination of impairments that were severe. (Tr. 13). Specifically, the ALJ found Plaintiff had the following severe impairments: diabetes mellitus with peripheral neuropathy; degenerative joint disease (knee); and obesity. However, after reviewing all of the evidence presented, the ALJ determined that Plaintiff's impairments did not meet or equal the level of severity of any impairment listed in the Listing of Impairments found in Appendix I, Subpart P, Regulation No. 4. (Tr. 15). The ALJ found Plaintiff retained the residual functional capacity (RFC) to:

perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except that the claimant that the claimant (sic) can occasionally lift and carry 20 pounds and frequently lift and carry 10 pounds; the claimant can stand and/or walk about 6 hours in an 8-hour workday; and the claimant can sit about 6 hours in an 8-hour workday; the claimant can occasionally climb, balance, crawl, kneel, stoop, and crouch; the claimant can frequently finger and handle; and the claimant must avoid hazards, including unprotected heights and moving machinery.

(Tr. 15). With the help of a vocational expert, the ALJ determined Plaintiff could perform work as a cleaner/housekeeper, a cashier II, and a sales attendant. (Tr. 23).

         Plaintiff then requested a review of the hearing decision by the Appeals Council, which denied that request on January 31, 2017. (Tr. 1-4). Subsequently, Plaintiff filed this action. (Doc. 1). Both parties have filed appeal briefs, and the case is before the undersigned for report and recommendation. (Docs. 11, 12).

         The Court has reviewed the entire transcript. The complete set of facts and arguments are presented in the parties' briefs, and are repeated here only to the extent necessary.

         II. Evidence Presented:

         At the administrative video hearing held before the ALJ on September 21, 2015, Plaintiff testified that he was thirty-eight years of age and had obtained a high school education. (Tr. 41, 43). Plaintiff's past relevant work consists of work as floor cleaner and a forklift operator. (Tr. 59). Prior to the relevant time period, Plaintiff sought treatment for various impairments to include, but not limited to diabetes mellitus, a depressive disorder, gastroesophageal reflux disorder (GERD), and back pain.

         The pertinent medical evidence during the relevant time period reflects the following. On September 15, 2014, Plaintiff was seen at the Community Clinic by Mitchell Atkins, APRN. (Tr. 302). Plaintiff complained of stomach pain for the past two weeks, mainly with meals. Plaintiff described the pain as burning in the pit of his stomach. Upon examination, Nurse Atkins noted Plaintiff's abdomen was normal without tenderness to palpation. Plaintiff was assessed with generalized abdominal pain.

         On September 23, 2014, Plaintiff entered the Mercy Hospital Northwest Arkansas emergency room complaining of abdominal pain. (Tr. 373-392). Plaintiff reported that he had experienced right-sided abdominal and epigastric pain for a couple of weeks, and the pain was progressing. Plaintiff indicated that his pain increased with oral intake. Plaintiff also complained of intermittent nausea and vomiting. The review of symptoms was negative for myalgias, back pain, dizziness, lightheadedness, headache, confusion or decreased concentration. Upon examination, Dr. Bradley Shane Holland noted Plaintiff was oriented to person, place and time and in no distress. Plaintiff's neck had a normal range of motion. Tenderness was noted in the right upper abdominal quadrant and epigastric region. Plaintiff had no CVA (costovertebral angle) tenderness. A musculoskeletal exam revealed normal range of motion with no edema or tenderness. Plaintiff was found to have a normal mood and affect. Plaintiff was diagnosed with acute abdominal pain and epigastric abdominal pain. Plaintiff was prescribed medication and discharged.

         On October 18, 2014, Plaintiff entered the Mercy Hospital Northwest Arkansas emergency room complaining of abdominal pain following a motor vehicle accident. (Tr. 445- 455). Plaintiff was driving at the time of the accident. Plaintiff denied experiencing fatigue, arthralgias, myalgias, dizziness, tingling, loss of consciousness, light headedness, numbness or headaches. Plaintiff denied experiencing confusion or decreased concentration. After an examination of Plaintiff, lab work and studies, Dr. Holland assessed Plaintiff with acute abdominal pain.

         On October 20, 2014, Plaintiff was seen by Dr. Marianela Lavena for a follow-up after his motor vehicle accident the previous Friday. (Tr. 439-440). Plaintiff reported he did not have pain at the time of the accident, but developed pain early on Saturday and went to the emergency room. Plaintiff reported a worsening of his pain. Plaintiff reported he was given hydrocodone in the emergency room, but was not taking it because it caused him to vomit. Plaintiff reported he had not been bothered by feeling down, depressed or hopeless over the previous two weeks. Plaintiff reported he had not had a bowel movement since the accident. After examining Plaintiff, Dr. Lavena diagnosed him with generalized abdominal pain and Ilues, NOS.

         Later on October 20, 2014, Plaintiff entered the Mercy Hospital Northwest Arkansas emergency room complaining of abdominal pain and nausea. (Tr. 456-477). Plaintiff denied back pain or fatigue. Plaintiff was ...


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