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Connie S. W. v. Berryhill

United States District Court, N.D. Oklahoma

May 15, 2019

CONNIE S. W., Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         This matter is before the undersigned United States Magistrate Judge for a report and recommendation. Plaintiff Connie S. W. seeks judicial review of the Commissioner of the Social Security Administration's decision finding that she is not disabled. For the reasons explained below, the undersigned RECOMMENDS that the Commissioner's decision denying benefits be AFFIRMED.

         I. General Legal Standards and Standard of Review

         A claimant for disability benefits bears the burden of proving a disability. 42 U.S.C. § 423(d)(5); 20 C.F.R. §§ 404.1512(a), 416.912(a). “Disabled” is defined under the Social Security Act as an “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). To meet this burden, a plaintiff must provide medical evidence demonstrating an impairment and the severity of that impairment during the time of his alleged disability. 20 C.F.R. §§ 404.1512(b), 416.912(b). A disability is a physical or mental impairment “that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques.” 42 U.S.C. § 423(d)(3). A medically determinable impairment must be established by “objective medical evidence, ” such as medical signs and laboratory findings, from an “acceptable medical source, ” such as a licensed and certified psychologist or licensed physician; the plaintiff's own “statement of symptoms, a diagnosis, or a medical opinion is not sufficient to establish the existence of an impairment(s).” 20 C.F.R. §§ 404.1521, 416.921. See 20 C.F.R. §§ 404.1502(a), 404.1513(a), 416.902(a), 416.913(a). A plaintiff is disabled under the Act only if his “physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy.” 42 U.S.C. § 423(d)(2)(A).

         Social Security regulations implement a five-step sequential process to evaluate a disability claim. 20 C.F.R. §§ 404.1520, 416.920; Williams v. Bowen, 844 F.2d 748, 750-51 (10th Cir. 1988) (setting forth five steps in detail). “If a determination can be made at any of the steps that a plaintiff is or is not disabled, evaluation under a subsequent step is not necessary.” Williams, 844 F.2d at 750. In reviewing a decision of the Commissioner, the Court is limited to determining whether the Commissioner has applied the correct legal standards and whether the decision is supported by substantial evidence. See Grogan v. Barnhart, 399 F.3d 1257, 1261 (10th Cir. 2005). Substantial evidence is more than a scintilla but less than a preponderance and is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion. See Id. The Court's review is based on the record, and the Court must “meticulously examine the record as a whole, including anything that may undercut or detract from the ALJ's findings in order to determine if the substantiality test has been met.” Id. The Court may neither re-weigh the evidence nor substitute its judgment for that of the Commissioner. See Hackett v. Barnhart, 395 F.3d 1168, 1172 (10th Cir. 2005). Even if the Court might have reached a different conclusion, the Commissioner's decision stands if it is supported by substantial evidence. See White v. Barnhart, 287 F.3d 903, 908 (10th Cir. 2002).

         II. Procedural History and the ALJ's Decision

         Plaintiff, then a 44-year-old female, applied for Title II disability insurance benefits on December 2, 2014, alleging a disability onset date of October 3, 2014. R. 14, 28. Plaintiff claimed that she was unable to work due to anxiety and lower back problems. R. 228. Plaintiff's claim for benefits was denied initially on May 4, 2015, and on reconsideration on June 29, 2015. R. 131-135, 139-141. Plaintiff then requested a hearing before an ALJ, and the ALJ conducted the hearing on February 23, 2017. R. 56. The ALJ issued a decision on May 17, 2017, denying benefits and finding Plaintiff not disabled because she was able to perform other work that exists in significant numbers in the national economy. R. 14-29. The Appeals Council denied review, and Plaintiff appealed. R. 1-4; ECF No. 2.

         The ALJ found that Plaintiff had not engaged in substantial gainful activity since her alleged onset date of October 3, 2014, and that Plaintiff had the following severe impairments: degenerative disc disease of the lumbar spine; degenerative joint disease of both knees; right wrist pain due to prior fracture; morbid obesity; generalized anxiety disorder; and depressive disorder. R. 16. The ALJ also found Plaintiff had non-severe impairments of high blood pressure; alleged seizure disorder and/or syncope; and kidney stones. R. 17. The ALJ identified a non-medically determinable impairment of rule out panic disorder. Id. At step three, the ALJ considered the severity of Plaintiff's disorders, singly and in combination, and concluded that none was of such severity to result in listing-level impairments. R. 18-20.

         A. Medical Evidence

         The ALJ summarized the objective and opinion evidence in the record.[1]

         1. Right Wrist Impairment

         The record revealed that Plaintiff has a history of right wrist pain due to prior fracture that did not heal correctly. At a consultative examination performed by Kenneth Trinidad, D.O., in April 2014, Dr. Trinidad noted weakness in wrist and grip strength and tenderness over the ulnar aspect and dorsum of the wrist to palpation. R. 317. Dr. Trinidad opined that she had a 20 percent impairment to the right hand as a result of a non-union styloid fracture in the wrist, associated stiffness and crepitance in the wrist, and weakness in right wrist and grip strength. R. 318. The ALJ gave little weight to Dr. Trinidad's opinions, because they covered disability issues germane only to worker's compensation matters. R. 24.

         At a consultative examination performed by Abrar Adil, D.O., in March 2015, Plaintiff stated her wrist pain was much improved after several steroid injections, and she reported only minimal 3/10 pain to the right dorsal wrist. R. 419. On examination, Dr. Adil noted Plaintiff had no tenderness to percussion over the right radial styloid, and her wrist and finger ranges of motion were full bilaterally with minimal signs of discomfort. R. 420, 424. Dr. Adil noted Plaintiff could manipulate small objects and grasp tools. R. 424. MRI of the right wrist in June 2015 showed a moderate amount of soft tissue edema adjacent to the ulnar styloid, with a small ununited ulnar styloid process fracture. R. 24, 537.

         Plaintiff underwent repair surgery on her right wrist in September 2016. R. 23, 545. In January 2017, her wrist surgeon noted she was slowly improving from surgery but still had swelling on the ulnar side of the wrist. R. 547. Her surgeon allowed her to work with a ten-pound weight restriction at that time. Id. At a visit with her physical therapist in January 2017, Plaintiff reported improvement in her right wrist range of motion, strength, and mobility but noted soreness along the ulnar wrist and into the ring and small finger, which increased with activity. R. 501. She reported she could make a fist but had difficulty gripping, and she denied any numbness or tingling. Id. At a later visit with the physical therapist in January 2017, Plaintiff reported continued improvements in her right wrist strength, range of motion, and mobility. R. 54. Plaintiff reported infrequent sharp pains with multidirectional movements, but she was able to perform more daily activities, such as light lifting, without difficulty. Id. She reported that gripping was improved, although she dropped things occasionally, and her pain was 4/10 at the visit and 10/10 at worst. Id. The therapist noted very mild swelling over the ulnar wrist with mild, vague soreness over the ulnar wrist and improved right wrist and elbow strength of 4 versus 3 at initial visit. R. 54-55.

         On February 8, 2017, Plaintiff's surgeon noted Plaintiff still had pain on the ulnar side of the wrist, with pain into the fourth and fifth metacarpals. R. 50. She could make a full fist with full extension of all digits and full radial and ulnar deviation and full pro/supination. Id. He recommended a permanent 20-pound lifting restriction. Id.

         On February 22, 2017, Plaintiff's primary care physician, Curt Coggins, M.D., completed a physical RFC assessment of Plaintiff. R. 318-535. Dr. Coggins opined that Plaintiff could lift and carry up to 20 pounds occasionally and up to five pounds frequently, and she had no limitations in use of her hands for repetitive movements, including grasping. R. 532-533. He further opined that Plaintiff could continuously handle and finger bilaterally. The ALJ gave little weight to Dr. Coggins' opinions, finding that Dr. Coggins' limitations appeared inconsistent and unsupported by the medical evidence. R. 26-27. At the hearing held in February 2017, Plaintiff testified she still experienced pain, weakness, and popping in her wrist. R. 77. However, Plaintiff testified she could still use both hands for short periods. R. 78.

         2. Back Impairments

         With regard to Plaintiff's complaints of pain, the ALJ noted that physical examinations and imaging results revealed modest findings. R. 22-26. In April 2014, Dr. Trinidad's consultative examination revealed lumbar spine tenderness and spasm, with negative straight-leg raising. R. 318. An MRI scan of the lumbar spine performed in 2013 revealed mild scoliosis of the thoracolumbar spine and mild to moderate facet joint degenerative changes, along with an incidental Tarlov cyst on the right at ¶ 1-S2.[2] R. 302. In August 2015, Plaintiff underwent another MRI of the lumbar spine, which revealed mild discogenic changes of the lumbar spine and a sacral cyst at ¶ 1-S2, with no focal disc abnormality, no significant central canal stenosis, and no neural foraminal narrowing. R. 452. In November 2016, Plaintiff obtained a third MRI of the lumbar spine, which showed no significant abnormality, moderate degenerative disc and facet joint changes, and a right S2 Tarlov cyst unchanged from the previous study. R. 447. In September 2016, a nerve conduction velocity study and EMG of the lower extremities revealed normal examination results, despite Plaintiff's complaints of back pain, numbness, and tingling of all extremities. R. 461.

         At Dr. Adil's consultative examination in March 2015, Dr. Adil observed Plaintiff moved about the exam room easily, had relatively well-preserved spinal range of motion, negative straight-leg raising bilaterally in seated and supine position, normal toe and heel walking, and normal gait. R. 420. Dr. Adil ...

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