Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Rich v. Commissioner of Social Security Administration

United States District Court, D. Arizona

September 27, 2017

Roberta Rich, Plaintiff,
v.
Commissioner of Social Security Administration, Defendant.

          ORDER

          ERIC J. MARKOVICH UNITED STATES MAGISTRATE JUDGE

         Plaintiff Roberta Rich (“Rich”)[1] brought this action pursuant to 42 U.S.C. § 405(g) seeking judicial review of a final decision by the Commissioner of Social Security (“Commissioner”). Rich raises three issues on appeal: 1) whether substantial evidence establishes that Rich's major depression is a severe impairment; 2) whether substantial evidence supports the Administrative Law Judge's (“ALJ”) light Residual Functional Capacity (“RFC”) assessment; and 3) whether the ALJ committed harmful error by adopting a light RFC with no mental limitations. (Doc. 25).

         Before the Court are Rich's Opening Brief, Defendant's Response, and Rich's Reply. (Docs. 25, 26, & 27). The United States Magistrate Judge has received the written consent of both parties and presides over this case pursuant to 28 U.S.C. § 636(c) and Rule 73, Federal Rules of Civil Procedure. For the reasons stated below, the Court finds that the Commissioner's decision should be affirmed.

         I. Procedural History

         Rich filed an application for Disability Insurance Benefits (“DIB”) on July 27, 2012. (Administrative Record (“AR”) 19, 50). Rich alleged disability beginning January 5, 2008[2] based on diabetes, neuropathy, kidney disease, heart disease, and depression. (AR 50, 170). Rich's application was denied upon initial review (AR 49, 63) and on reconsideration (AR 64, 79). A hearing was held on October 24, 2014 (AR 34), after which ALJ Peter J. Baum found, at Step Four, that Rich was not disabled because she was able to perform her PRW as an information clerk (AR 19). On June 14, 2016 the Appeals Council denied Rich's request to review the ALJ's decision. (AR 1).

         Rich's date last insured (“DLI”) for DIB purposes is December 31, 2012. (AR 19, 155). Thus, in order to be eligible for benefits, Rich must prove that she was disabled during the time period of her amended alleged onset date (“AOD”) of November 1, 2012 and her DLI of December 31, 2012.

         II. Factual History

         Rich was born on May 1, 1963 (AR 50), making her 49 at the amended AOD of her disability (AR 239). Rich earned a G.E.D. and attended some college but did not complete a degree. (AR 39, 171). She worked primarily as a customer service representative and also did home sales for Avon and Tupperware and internet sales on eBay. (AR 155, 172, 183).

         A. Treating Physicians[3]

         On December 10, 2007 Rich saw Dr. Rothe for abdominal pain and he noted no unusual anxiety or evidence of depression. (AR 882-83).

         On January 7, 2008 Dr. Rothe noted Rich was having problems with her hips and a heel bruise. (AR 261).

         On February 11, 2008 Dr. Rothe noted Rich's mood was normal. (AR 259).

         On March 3, 2008 Dr. Rothe noted that other than her toe bothering her, Rich was not ill, and her mood was normal. (AR 257).

         On March 5, 2008 Rich was seen for a follow-up to discuss CAT scan results and a toe infection. (AR 254). Dr. Rothe noted she was in moderate distress and her mood was normal.

         On March 6, 2008 Rich had a follow-up for her aortic stenosis. (AR 272). Dr. Mendoza noted that symptomatically she was not any worse off than she was a year before, and recommended a revascularization procedure. Because her demeanor was “somewhat aggressive and not very pleasant, ” Dr. Mendoza suggested Rich find a vascular surgeon more suitable to her.

         A March 7, 2008 addendum to the February 29, 2008 CTA abdomen report notes that a comparison to the prior CT scan from March 2007 shows worsening atherosclerotic stenosis of the distal abdominal aorta. (AR 297-98).

         A March 17, 2008 letter from Pima Heart notes that Rich was positive for fatigue, claudication, post-prandial abdominal discomfort and nausea, anxiety and stress related to her medical problems, and muscle aches. (AR 269). Dr. Tuli noted she was mildly anxious but appropriate in her answers. (AR 270). He assessed heart disease and recommended a stress test and an echocardiogram.

         On March 19, 2008 Rich reported nausea, indigestion/heartburn, stress, and anxiety. (AR 266-67). The doctor documented no unusual anxiety or evidence of depression, and assessed generalized abdominal pain and hiatal hernia. (AR 268).

         A March 25, 2008 stress test had normal results. (AR 303).

         On March 27, 2008 an echocardiogram showed normal left ventricular size and ejection fraction, and no valvular pathology. (AR 301).

         On April 3, 2008 Dr. Rothe noted Rich was doing well for the most part, her mood was normal, and her feet were much improved since quitting smoking and starting Plavix. (AR 252).

         An April 7, 2008 letter from Arizona EndoVascular Center notes that Rich's CT scan showed worsening of severe atherosclerotic stenosis of the distal abdominal aorta. (AR 350). Dr. Berens recommended an aortoiliac bifurcated graft. He also noted that she had moderate left renal artery stenosis that was not severe enough to warrant intervention.

         On April 17, 2008 Rich had an aortoiliac bifurcated graft procedure. (AR 274).

         A May 5, 2008 letter from Arizona EndoVascular Center states that Rich was two weeks post aortoiliac bypass and was doing well overall and able to walk without restriction or pain. (AR 265).

         On May 27, 2008 Rich was seen for a follow-up after her aortic bypass. (AR 329). The nurse documented abdominal pain, probably related to increased activity, and nausea and dizziness due to a medication change.

         On June 2, 2008 Rich was seen for a follow-up for hypertension, diabetes, and hypothyroidism. (AR 249). She reported mild abdominal pain/discomfort but said her hips did not hurt and her legs were perfect. (AR 249-50). Dr. Rothe noted she was doing well for the most part and that her mood was normal. (AR 250).

         A June 17, 2008 letter from Arizona EndoVascular Center notes that Rich was two months postoperative and still experiencing nausea and postprandial discomfort. (AR 264).

         An August 19, 2008 letter from Arizona EndoVascular Center notes that Rich had no specific postoperative problems from the aortobifemoral bypass. (AR 358). She was smoking again and reported right upper quadrant pain, left thigh and neck spasms, light headedness, and dizziness. Dr. Berens stated that he could not isolate a particular problem related to her vascular disease, and that her symptoms were musculoskeletal.

         On April 30, 2009 Rich was seen at Arizona Kidney Disease & Hypertension Center. (AR 315). Dr. Cohen described her as “a very angry woman” and “was just complaining as soon as she walked into the room.” He also noted that she was “very unpleasant” but did calm down, and that she “was obviously in a very bad mood.” (AR 316). Rich said she had no problems with diabetes, denied numbness in her legs, had no pain, but reported she always felt terrible. (AR 315). She had no neuropathy symptoms, no claudication, and no psychiatric problems. (AR 316). Dr. Cohen noted her kidney diseases was not very bad and that she did not need dialysis, but Rich kept talking about getting a transplant. He recommended that she better control her blood pressure and blood sugars.

         On August 1, 2009 Rich went to the ER with a complaint of left jaw pain radiating to the left arm and chest pain. (AR 527). The report notes that while her pain was not necessarily typical for cardiac pain, she had multiple risk factors and her symptoms were relieved with nitroglycerin. She left against medical advice due to lack of insurance/money.

         On August 4, 2009 Rich was seen for a complaint of chest pain. (AR 395). She reported that the pain began 1 week ago, occurred every 1 to 2 days, lasted 1 hour, and was moderate. Review of systems was positive for chest pain, nausea, diaphoresis, anxiety, and increased stress. The impression was chest pain, unspecified, non-cardiac, likely secondary to stress. (AR 396).

         On September 16, 2009 Rich had no claudication symptoms, was in no acute distress, her gait and stance were normal, and her cardiovascular and abdomen findings were normal. (AR 312-14). A segmental blood pressure examination showed mild arterial diseases for the right ABI and no significant arterial disease for the left ABI. (AR 318). A lower arterial Doppler showed no significant abnormalities. (AR 320).

         On October 28, 2009 Rich saw Dr. Los for a new patient appointment. (AR 678). Rich stated she hadn't checked her sugars for more than 2 years and that she saw Dr. Tuli and Dr. Berens for peripheral artery disease. Physical findings included joints with full range of motion, no edema, tenderness, or crepitus, positive Hawkins and Neer test on right, normal gait, and mood unhappy with congruent affect. (AR 679). Dr. Los assessed diabetes uncertain control, hypertension stable, hypothyroidism labs ordered, hyperlipidemia tolerating meds, and peripheral artery disease.

         On November 5, 2009 Rich saw Dr. Los with a complaint of heel pain, present for 5 days, and also reported pain in her right shoulder. (AR 676). Exam of the feet revealed no obvious bony deformities; Dr. Los assessed plantar fasciitis and prescribed Ultram for heel and shoulder pain. (AR 677).

         On November 30, 2009 Rich saw Dr. Los and reported her pain was much improved. (AR 673). Findings on exam included joints with full range of motion, no edema, tenderness, or crepitus, normal gait, and mood unhappy with congruent affect. (AR 674). Dr. Los assessed diabetes poor control, hypertension stable, and hyperlipidemia tolerating meds.

         On December 30, 2009 Rich saw Dr. Los for a diabetes check. (AR 670). Physical findings included joints with full range of motion, no edema, tenderness, or crepitus, normal gait, and mood unhappy with congruent affect. (AR 672). Dr. Los assessed diabetes improved control, hypertension stable, kidney disease stable, and hyperlipidemia tolerating meds.

         On February 27, 2010 Rich went to the ER with a complaint of feeling bad, run down, palpitations, and chest pains. (AR 507). She reported symptoms started three weeks ago when her brother committed suicide. The impression was palpitations and chest pain secondary to emotional anxiety with a recommendation that Rich be admitted for further treatment, but she left against medical advice. Rich went back to the ER later that day with a complaint of chest discomfort; she actually came in because she could hear her heartbeat in her ear and because she had some epigastric discomfort, and then denied any actual chest pain or discomfort. (AR 497). Her affect was appropriate, though she was initially somewhat agitated. (AR 498). The doctor assessed atypical chest pain, actually epigastric discomfort with negative cardiac enzymes, likely a GI issue because it did respond to Mylanta.

         On March 2, 2010 Rich saw Dr. Los for a follow-up after she was hospitalized for anemia. (AR 667). Rich was calm with a normal affect. (AR 669). Dr. Los assessed anemia likely due to a GI bleed and referred Rich for a GI evaluation.

         On March 3, 2010 Rich had a GI consultation. (AR 686). Rich was described as pleasant with appropriate mood and affect. (AR 686-87).

         On March 4, 2010 Rich was seen at Tucson Endocrine Associates. (AR 683). Rich reported a 26 year history of diabetes and a lot of grief after her brother recently committed suicide. The impression was diabetes uncontrolled, clinical significant neuropathy absent, increased coronary risk (smoking, diabetes, peripheral vascular disease, and weight), and kidney disease stage unknown. (AR 683-84).

         On March 23, 2010 Rich saw Dr. Los for a follow-up. (AR 663). Physical findings included joints with full range of motion, no edema, tenderness, or crepitus, normal gait, and mood unhappy with congruent affect. (AR 665).

         On March 26, 2010 Rich went to the ER for a cough and fever. (AR 474). She was described as pleasant and cooperative and admitted for treatment of pneumonia. (AR 476).

         On June 29, 2010 Rich reported right shoulder pain after sleeping on it wrong. (AR 652). Physical findings included full range of motion, no edema or crepitus, right shoulder positive for impingement, normal gait, and mood unhappy with congruent affect. (AR 654). Dr. Los assessed severe anemia likely from B12 deficiency, PT referral for right rotator cuff syndrome, diabetes improved control, kidney disease stable, and hyperlipidemia tolerating meds.

         A July 26, 2010 letter from Ideal Rehabilitation recommends that Rich have PT for her right shoulder pain, to consist of home exercises and stretching. (AR 691). A discharge note dated September 3, 2010 states that Rich reported she was doing really well and had full range of motion (other than being able to reach behind to fasten her bra) and no pain. (AR 699).

         On August 23, 2010 Rich saw Dr. Los for a follow-up. (AR 649). Findings on exam included joints with full range of motion, no edema or crepitus, right shoulder positive for impingement, normal gait, and depressed mood with full affect. (AR 651). Dr. Los assessed anemia resolved, right rotator cuff syndrome improved, diabetes improved control, kidney disease stable, hyperlipidemia tolerating meds, and self-referral to behavioral health for depression.

         On September 15, 2010 Rich saw Dr. Los for sciatica and reported pain radiating down her right leg to her foot, and pain in right wrist. (AR 646). Physical findings included no back or hip tenderness, deep tendon reflexes diminished bilaterally, moderately positive straight leg raise (“SLR”) on right, and right arm positive Tinel sign. (AR 647). Dr. Los assessed lumbosacral strain with sciatica and carpal tunnel syndrome, right wrist, and recommended heat for the back and a wrist brace.

         On October 14, 2010 Rich reported having only intermittent shoulder pain after going to PT, right low back pain that comes and goes, and she did not go to behavioral health because she denied depression. (AR 642). Findings on exam included joints with full range of motion, no edema or crepitus, negative SLR bilaterally, right shoulder positive for impingement, right trochanter tender to palpation (“TTP”), normal gait, and depressed mood with full affect. (AR 644). Dr. Los assessed right rotator cuff syndrome improved, hypertension high, right trochanteric bursitis and possible sciatica, diabetes improved control, kidney disease stable, hyperlipidemia stable, and depression self-referral to behavioral health.

         On October 18, 2010 Rich was seen for concerns about her right big toe turning purple at times. (AR 393). Review of systems findings were all negative except for anxiety. (AR 393-94). Rich had not followed up with Dr. Berens for her peripheral vascular disease due to insurance reasons and was not taking her cholesterol medication due to cost. (AR 394).

         On October 19, 2010 Rich had an ABI with exercise test. (AR 392). The impression was normal left lower extremity ABI; normal left lower extremity exercise ABI; abnormal right lower extremity ABI consistent with moderate obstructive peripheral vascular disease; and abnormal right lower extremity exercise ABI consistent with mild to moderate obstructive peripheral vascular disease.

         On November 11, 2010 a bilateral arterial duplex showed no focal stenosis. (AR 391).

         On November 17, 2010 a CTA of the abdomen, pelvis, and lower extremity showed occlusion of the right limb of the aortobiiliac bypass graft. (AR 704).

         On January 16, 2011 Rich went to the ER for chest and neck discomfort and was described as a “hostile and angry female in no obvious physical distress.” (AR 442, 444). She went to the ER 5 days earlier when her symptoms started but left against medical advice. (AR 442, 444). Her cardiac markers were mildly positive, there were no obvious changes in her EKG, and x-rays and CT scan of the chest were normal. (AR 442, 444, 456, 458). She was discharged home in stable and improved condition, with a recommendation to quit smoking and follow-up with her doctors. (AR 442-43).

         On January 25, 2011 Rich was seen for coronary artery disease and reported chest pain, claudication, and apprehension. (AR 388-39). Other systems and physical exam findings were normal. (AR 389).

         On March 28, 2011, Rich was seen for a complaint of intermittent claudication and reported waking almost every night with burning leg pain. (AR 334). Rich reported fatigue and sleep disturbances secondary to pain, and no anxiety or depression. (AR 335). The nurse noted normal mood and affect, and assessed atherosclerosis of the extremities with rest pain. (AR 336). Rich was referred for further testing and told that smoking cessation was mandatory. (AR 337).

         On April 4, 2011 Rich went to the ER complaining of right leg pain and stated she had a femoral artery occlusion. (AR 637). She ran out of Oxycodone at home and was unable to bear the pain. Findings on exam were largely normal, with some TTP of the calf without swelling, and palpable but diminished pulses in the entire right lower extremity. (AR 638-39). A CT of the abdomen and pelvis showed occlusion of the right common iliac segment of the aorta bilateral iliac graft. (AR 639). Rich's leg pain improved significantly after her blood sugar was replenished in the ER and she was normal glycemic. (AR 640).

         On April 5, 2011 Rich reported she could not get her lab work done due to lack of insurance. (AR 386). She had no symptoms attributable to valvular heart disease. Review of systems and physical exam findings were largely normal. (AR 387).

         An April 12, 2011 letter from Arizona EndoVascular Center states that Rich was evaluated for severe right leg claudication. (AR 363). Dr. Berens opined that the “right aortoiliac graft limb is occluded and probably shut down over six months ago, ” and recommended a left-to-right femoral-femoral bypass.

         On May 6, 2011 Rich had a left-to-right femoral-femoral bypass. (AR 364).

         A May 23, 2011 letter from Arizona EndoVascular Center notes that Rich's right leg pain had improved since the surgery, that she was experiencing dysesthesias along her thighs probably related to the ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.