United States District Court, D. Arizona
J. Markovich, United States Magistrate Judge.
Charissa Dawn Wilson brought this action pursuant to 42
U.S.C. § 405(g) and 42 U.S.C. § 1383(c)(3) seeking
judicial review of a final decision by the Commissioner of
Social Security (“Commissioner”). Plaintiff
raises four issues on appeal: 1) the Administrative
Law Judge (“ALJ”) erred by failing to include
substantial evidence of Plaintiff's impairments at Step
Two; 2) the Vocational Expert (“VE”) stated that
Plaintiff could not maintain competitive employment; 3) the
ALJ failed to adequately develop the record by not obtaining
or properly submitting materially relevant evidence from
Plaintiff's treating physicians that Plaintiff produced,
therefore Plaintiff was prejudiced by an incomplete medical
record; and 4) the ALJ failed to give adequate weight to the
diagnostic findings of Plaintiff's treating physicians.
the Court are Plaintiff's Opening Brief, Defendant's
Response, and Plaintiff's Reply. (Docs. 26, 28, &
29). 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
filed an application for social security disability benefits
on September 3, 2014. (Administrative Record
(“AR”) 129). Plaintiff alleged disability
beginning on November 1, 2013 based on musculoskeletal
disorder, depression, anxiety, PTSD, kidney disease,
osteoarthritis, polyneuropathy, and Reynaud's. (AR 57).
Plaintiff's application was denied upon initial review
(AR 71) and on reconsideration (AR 91). A hearing was held on
January 4, 2017 (AR 28), after which ALJ MaryAnn Lunderman
found, at Step Five, that Plaintiff was not disabled because
there were jobs existing in significant numbers in the
national economy that Plaintiff could perform. (AR 22-23). On
January 18, 2018 the Appeals Council denied Plaintiff's
request to review the ALJ's decision. (AR 1).
Factual History 
was born on June 24, 1984, making her 29 years old at the
alleged onset date of her disability. (AR 57). She received a
GED and has worked a number of jobs including receptionist,
busser, hostess, call center, cocktail waitress, front desk,
and housekeeping. (AR 33-38, 148).
2, 2009 Plaintiff was treated for pyelonephritis (a kidney
infection). (AR 390).
September 10, 2013 Plaintiff reported urinary problems, mild
to moderate and occurring rarely, and lower back pain,
moderate to severe. (AR 209). She had a normal exam of the
lumbar spine with no compression fracture or
spondylolisthesis. (AR 208).
September 25, 2013 Plaintiff reported a history of kidney
infection, bilateral hip pain from a short leg, popping
joints, right wrist and knee swelling, chronic severe joint
pain especially in neck and back, history of fainting and
frequent migraines, and history of depression. (AR 238).
Exercise helps but she had not exercised in a year. On exam
she had normal movement of all extremities, no abnormalities,
and no swelling, but complained of pain everywhere with
palpation. (AR 240-41). The assessment was urethritis,
arthritis, and depression, and Plaintiff was referred for lab
work and x-rays. (AR 238-39).
September 26, 2013 an x-ray of the hips showed right femoral
herniation pit raising concern for femoral acetabular
impingement. (AR 236).
October 11, 2013 Plaintiff reported she was doing fantastic
on Cymbalta and physically her pain improved substantially.
(AR 234). The assessment was chronic pain and depression and
exercise or yoga was recommended.
6, 2014 Plaintiff presented to SAMHC for a crisis consult for
severe depression and anxiety attacks. (AR 214). Plaintiff
reported struggling with depression, going home from work and
crying, and not being able to keep a job. (AR 215). The
impression was depressive disorder NOS and Plaintiff was
referred to La Frontera. (AR 217).
August 6, 2014 Plaintiff had an assessment at La Frontera.
(AR 275). Plaintiff reported leaving her last four jobs
because of mental health issues and described uncontrollable
crying, feeling down, hopeless, and sad, anxiety, and
nightmares and flashbacks about past trauma. The diagnosis
was major depressive disorder, recurrent moderate, and
posttraumatic stress disorder, with a GAF score of 51. (AR
August 19, 2014 an x-ray of the spine showed minimal degree
scoliosis and bilateral transverse mega-apophysis at a
transitional lumbosacral vertebral body. (AR 231). A
scanogram of the legs showed age appropriate bone
mineralization, synovial herniation pit in the right femoral
neck, and the left leg length was longer. (AR 230).
August 21, 2014 Plaintiff reported flares of aches and pains
in her joints and muscles. (AR 227). Imaging showed minimal
scoliosis and right leg was 1.1 cm longer than the left. The
assessment was lumbago; there was no clear indicator of what
was causing Plaintiff's pain and she was referred to
September 30, 2014 Plaintiff had a new client medication
evaluation appointment at La Frontera. (AR 295). On exam she
was pleasant and cooperative, tearful at times, normal gait
and station, normal muscle strength and tone, good attention
span and concentration, and appropriate affect. (AR 296).
Plaintiff was prescribed Hydroxyzine for anxiety.
October 21, 2014 Plaintiff saw Dr. Yekta to establish a PCP
and reported a history of recurrent pyelonephritis,
Raynaud's, depression/anxiety, chronic back pain, and
muscle pain. (AR 245). Plaintiff also reported left calf pain
radiating to her hip and right wrist and shoulder pain. (AR
246). On exam she was tearful and anxious appearing,
extremities nontender and full ROM without swelling of the
joints, slight crepitus in right shoulder and knees, and full
ROM and nontender spine. (AR 247).
ultrasound on November 10, 2014 showed no hydronephrosis. (AR
November 10, 2014 Plaintiff saw Dr. Yekta for a follow-up.
(AR 250). All lab work for kidneys and possible autoimmune
issues was normal. (AR 250-251, 253). Plaintiff reported
muscle and bone pain, pain causing her to wake up at night
for 1-3 hours, low energy, tiredness, and unable to exercise
due to pain. (AR 251). On exam she was tearful, anxious, and
depressed, extremities full ROM without swelling of the
joints, and slight crepitus in right shoulder. (AR 252).
Plaintiff was referred to PT and sports medicine for her
joint and muscle pain, and Dr. Yekta noted that her
autoimmune workup was completely negative, but per the
diagnostic criteria of fibromyalgia, there was a high
possibility of diagnosis. (AR 253). Plaintiff was prescribed
of the hands on November 20, 2014 were normal. (AR 256).
December 1, 2014 Plaintiff told La Frontera that everything
was pretty good, that she stopped the healthy living group,
was attending PT, and was prescribed Amitriptyline for nerve
pain and it helped her depression. (AR 341).
January 22, 2015 Plaintiff saw Dr. Buchsbaum for leg
problems, myalgia, and anxiety. (AR 369). The diagnosis was
muscle pain, joint pain, depression, history of
pyelonephritis, and Raynaud's. On exam she had normal
muscle strength in all extremities with mild diffuse atrophy
and weakness in the right leg. (AR 370). The impression was
congenital hemiatrophy and anxiety.
February 26, 2015 Plaintiff saw Dr. Buchsbaum and had normal
muscle strength in all extremities with mild diffuse atrophy
and weakness in the right leg. (AR 368). The impression was
hemiatrophy, anxiety, and multiple presyncopal episodes, and
the plan was a scan of the spine to make sure the findings
were static cord findings from early childhood.
23, 2015 MRI of the cervical spine showed mild degenerative
disc disease at ¶ 6-C7 but was otherwise normal. (AR
383). A MRI of the thoracic spine was normal. (AR 385).
April 2, 2015 Dr. Buchsbaum noted there was no answer image
wise for Plaintiff's hemiatrophy so they discussed it as
congenital and would order electrical studies to prove it was
not active or progressive. (AR 382).
22, 2015 nerve conduction study was normal with no evidence
of mononeuropathy, LS radiculopathy, peripheral neuropathy,
or myopathy. (AR 430).
11, 2015 MRI of the head showed: “Tiny curvilinear
focus of signal hyperintensity in the left periventricular
white matter. This may be related to small vessel ischemic
change but is nonspecific. Appearance is not typical for
demyelinating disease.” (AR 415). The remainder of the
brain was unremarkable.
August 13, 2015 MRI of the lumbar spine showed sacralization
of the L5 vertebral body and mild degenerative changes of the
lumbar spine. (AR 411).
October 2, 2015 Plaintiff was referred to physical therapy
and the pain clinic for her lower back pain. (AR 443-444).
October 2, 2015 Plaintiff's problem list included: muscle
pain, joint pain, depression, history of pyelonephritis,
Raynaud's phenomenon, muscle atrophy, weakness, muscle
wasting and atrophy lower right leg, muscle spasticity,
hyperreflexia, congenital hemihypertrophy, other congenital
abnormality of the spine, and Bertolotti's syndrome. (AR
November 5, 2015 Plaintiff saw Dr. Bamford and he noted the
Plaintiff has numerous exaggerated complaints. I had to speak
to her and tell her that her complaints were unreasonable and
unrealistic. She responded that she had to exaggerate to get
the point across said that people were taken seriously
The patient claimed the following complaints: She has to call
[sic] to swallow. She used to choke. She says that
it takes 1 minute for her to hear what someone is saying. She
says that both of her arms are symmetrically weak. She says
that her legs are weak and the right leg is weaker . . . her
legs go numb if she crosses her legs . . . She has constant
low back pain [and] constant severe neck pain.
(AR 501). Dr. Bamford stated that Plaintiff had
“[n]umerous subjective symptoms with relatively few
objective signs, ” and that the severity of her
problems was “unclear” with “probable
exaggeration.” On exam she had normal strength of all
extremities; tone slightly increased in right lower extremity
and normal in the remaining three; normal sensation and
coordination; and mild right hemiparetic gait. (AR 502). The
impression was probable mild cerebral palsy; hypochondriasis,
exaggeration, unreliable historian, and tangential; she wants
to be believed but ...