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Malena v. Berryhill

United States District Court, W.D. Arkansas, Fort Smith Division

June 1, 2018

NANCY A. BERRYHILL, [1] Acting Commissioner, Social Security Administration DEFENDANT



         Plaintiff, Glenda Malena, 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 her claim for a period of disability and disability insurance benefits (DIB) under the provisions of Title II 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 her current application for DIB on March 16, 2015, alleging an inability to work since November 22, 2014, due to Regional Sympathetic Dystrophy (RSD). (Tr. 59, 76). For DIB purposes, Plaintiff maintained insured status through September 30, 2016. (Tr. 59, 76). An administrative hearing was held on June 6, 2016, at which Plaintiff appeared with counsel and testified. (Tr. 38-52). Debra Steele, Vocational Expert (VE), also testified. (Tr. 52-57).

         In a written opinion dated July 8, 2016, the ALJ found that the Plaintiff had the following severe impairments: complex regional pain syndrome, regional sympathetic dystrophy, obesity, migraines, anxiety, post-traumatic stress disorder, and depressive disorder. (Tr. 15). However, after reviewing the evidence in its entirety, the ALJ determined that the Plaintiff's impairments did not meet or equal the level of severity of any listed impairments described in Appendix 1 of the Regulations (20 CFR, Subpart P, Appendix 1). (Tr. 15-17). The ALJ found Plaintiff retained the residual functional capacity (RFC) to perform light work as defined in 20 CFR 404.1567(b), with the following exceptions:

[Claimant can] occasionally grasp, lift, push, or pull with the left non-dominant upper extremity; no exposure to extremes of cold; occasional exposure to dust, fumes, smoke, or chemicals; can understand, remember, and carry out simple instructions and tasks, and can concentrate on those tasks for extended periods of two or more hours at a time.

(Tr. 17). With the help of VE testimony, the ALJ determined that Plaintiff was unable to perform her past relevant work as a machine operator. (Tr. 22). However, based on the Plaintiff's age, education, work experience, and RFC, the ALJ determined that Plaintiff was capable of work as a public area attendant or a photo finishing clerk. (Tr. 23). Ultimately, the ALJ concluded that the Plaintiff had not been under a disability within the meaning of the Social Security Act during the relevant time period of November 22, 2014, the alleged onset date, and July 8, 2016, the date of the ALJ's opinion. (Tr. 23).

         Subsequently, Plaintiff requested a review of the hearing decision by the Appeals Council, and that request was denied on July 15, 2017. (Tr. 1-4). Plaintiff filed a Petition for Judicial Review of the matter on September 13, 2017. (Doc. 1). Both parties have submitted briefs, and this case is before the undersigned for report and recommendation. (Docs. 15, 16).

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

         II. Evidence Submitted:

         At the hearing before the ALJ on June 6, 2016, Plaintiff testified that she was forty-six years of age. She testified that she finished the tenth grade and later obtained her GED and her CNA license. (Tr. 41). Plaintiff's past relevant work consisted of work as a machine operator. (Tr. 52-53).

         Before the relevant time period, Plaintiff was seen by various healthcare providers for the following health issues: left hand and arm pain due to Complex Regional Pain Syndrome, a persistent cough, anxiety, common migraine headaches, and a possible allergic reaction. During that time, Plaintiff had the following tests that yielded normal results: an x-ray of her chest, a CT scan of the soft tissue of the neck, an x-ray of her left wrist, mammograms, an EMG evaluation for carpal tunnel syndrome, an x-ray of the left hand, and a MRI of the cervical spine, which showed only minor chronic degenerative changes. Prior to the relevant time period, Plaintiff was treated conservatively with medication and multiple ganglion blocks.

         Medical evidence during the relevant time period reflects that Plaintiff was seen at FS&V Physical Therapy for an evaluation of the symptoms in her left arm, where therapist Mary McKinley recommended therapy twice a week for eight weeks. (Tr. 360).

         On February 10, 2015, Plaintiff was seen by Dr. Kelly Hubbard at Arkansas Pain Specialists for complaints of pain in her left hand, wrist, thumb, index, and middle finger. (Tr. 298). A physical exam of Plaintiff's left upper extremity strength, left shoulder, and left elbow was normal. However, Plaintiff's left wrist was tender with decreased range of motion, and Phalen's test was positive for carpal tunnel syndrome. (Tr. 301). Plaintiff was assessed with severe allodynia of the left hand and wrist and a note was made about a previous diagnosis of RDS. (Tr. 303). Dr. Hubbard also noted moderate depression. (Tr. 303).

         On May 4, 2015, Plaintiff was seen by Dr. John Jacobs, her primary care physician, at River Valley Primary Care for abdomen pain and swelling, nausea and vomiting, lack of appetite. (Tr. 330). Dr. Jacobs prescribed medication and ordered additional tests. (Tr. 332). An abdominal ultrasound performed on May 5, 2015, showed fatty infiltration of the liver and a mildly prominent common bile duct. The remainder of the exam was unremarkable. (Tr. 340).

         On May 18, 2015, Plaintiff presented to Mercy Hospital with complaints of abdominal pain. Hospital records indicate Plaintiff had recently received normal results from a CT scan of her abdomen. (Tr. 312). Records also indicate that an endoscopy report showed the possibility of little inflammatory change in the upper stomach, very minimal change in the distal stomach, no ulcerations, no other lesions, and good motility. (Tr. 316). Dr. John Smith's notes indicate that Plaintiff's endoscopy results were not in line with Plaintiff's symptoms. (Tr. 316). Plaintiff was ...

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