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Anna M. Ruiz v. Commissioner of Social Security

July 12, 2011


The opinion of the court was delivered by: Linares, District Judge.



Presently before the Court is an appeal by Anna M. Ruiz (hereinafter "Claimant") seeking review of the final decision by Administrative Law Judge ("ALJ") Richard L. De Steno denying her application for Supplemental Security Income Benefits ("SSI"). The Court has considered the submissions made in support of and in opposition to the instant appeal and, pursuant to Federal Rule of Civil Procedure 78, decides this matter without oral argument. For the reasons set forth below, the Court affirms ALJ De Steno's decision.


On January 23, 2007, Claimant filed an application for Social Security Income Benefits under Title XVI of the Social Security Act, alleging disability beginning September 1, 2006. This claim was denied initially and again upon reconsideration. On June 23, 2009, a hearing was held before ALJ De Steno, who determined that Claimant was not disabled under section 1614(a)(3)(A) of the Act. On June 4, 2010, the Appeals Council denied Claimant's request for review. Claimant has appealed this decision.

Claimant, Anna M. Ruiz, was born on February 21, 1959. (R. at 31.) She has a fifth-grade education and is unable to read, write, or speak English. (Id. at 32.) She lives with her son and husband and does not perform household chores. (Id. at 38-39.) She has not worked since becoming pregnant in December 1988 and claims she is unable to do so now because of heart and lower back problems. (Id. at 103.)

On August 23, 2006, Claimant visited her physician, Dr. Gregorio Guillen, M.D., complaining of heart palpitations. (R. at 186.) Dr. Guillen performed an electrocardiogram which showed normal tracings. (Id.) Two days later Claimant returned because of lower back pain. (Id. at 184.) Dr. Guillen performed a sacrum/lumbar spine examination which revealed moderate spinal curvature. (Id.) On September 27, 2006, x-rays confirmed Claimant's lumbago was due to scoliosis and showed that Claimant suffered from osteopenia with a moderate risk of fracture. (Id. at 179.) Claimant reported improvement in her palpitations. (Id.) Naproxen and Pyridium were prescribed. (Id.)

On December 21, 2006, Dr. Guillen wrote a letter stating that Claimant suffered from cardiac dysrhythmias and exacerbation of lower back pain. (R. at 178.) He continued that Claimant was permanently disabled and unable to obtain and maintain gainful employment. (Id.) Dr. Guillen provided no further explanation for his conclusion. (Id.)

On January 30, 2007, Claimant returned to Dr. Guillen claiming her lower back pain had worsened. (R. at 177.) Pain was radiating to her lower extremities, resulting in numbness and tingling. (Id.) Dr. Guillen noted that Claimant had a history of a heart murmur and that her heart palpitations had improved. (Id.) A physical exam revealed that Claimant had forward flexion of 50 degrees with pain; paralumbar muscle spasms; and positive straight leg raises at 45 degrees for both legs. (Id.) Claimant's lumbago was the same, and an MRI of the lumbar spine was recommended because of the signs of radiculopathy. (Id.) In addition, Claimant was referred to a psychologist. An echocardiogram performed on February 2, 2007, by Dr. Shaukat Chaudhery, M.D., F.A.C.C., showed normal results. (Id. at 176.)

In March 2007, Claimant returned to Dr. Guillen with lower back pain. (R. at 170). She had not yet taken the Naproxen prescribed in September or used the psychological referral. (Id.) An echocardiogram was completely normal, and Claimant's palpitations were listed as occasional. (Id.) Dr. Guillen indicated that the lumbago had not changed, and Claimant resisted medicine for it. (Id.) Dr. Guillen advised Claimant to avoid caffeine and over-the-counter decongestants to prevent a recurrence of her palpitations. (Id.)

Claimant returned to Dr. Guillen in May 2007 complaining of weight gain, hot flashes, nausea and occasional vomiting, periods of loose bowel movements, and colicky left abdominal pain. (R. at 168.) Dr. Guillen noted that Claimant's lumbago had improved and that she had occasional palpitations. (Id.) He prescribed Levsin and referred endocrinology and gastrointestinal visits to determine the cause of her weight and abdominal issues. (Id.)

In August 2007 Claimant visited Dr. Prem Nandiwada, M.D. because of intermittent epigastric pain. (R. at 199.) Claimant indicated that pain radiated to her periumbilical area but was improving with Antacid and H2 Blockers. (Id.) Dr. Nandiwada's notes show that Claimant did not suffer from nausea, vomiting, diarrhea, or constipation. (Id.) In addition, she had no neck or back pain, and the results from her physical examination were normal. (Id.) Dr. Nandiwada recommended an upper endoscopy if Claimant's abdominal symptoms did not improve. (Id. at 201.)

On September 19, 2007, per the request of the Commissioner of Social Security, Claimant underwent a physical examination by Dr. Francky Merlin, M.D.. (Def. br. at 4; R. at 158.) Claimant told Dr. Merlin that she had suffered from neck pain for 20 years and that it radiated to both her shoulders, though it was not associated with numbness or weakness of the upper extremities. (R. at 158.) Claimant explained that her pain was intermittent and was brought on by activities. (Id.) She also indicated that she could walk three blocks, take care of her personal hygiene, and that her husband helped with household chores. (Id.) Dr. Merlin noted that Claimant had abdominal pain and a history of osteoporosis. (Id.) His exam, including an echocardiogram, showed normal results. In addition, Claimant was able to flex her spine forward zero to 90 degrees; squat and walk on her heels and toes; and demonstrate a bilateral range of motion of zero to 150 degrees in her knees. (Id. at 159.) Dr. Merlin diagnosed Claimant with neck pain and said she needed to follow up with an orthopedist. (Id. at 159-160.)

On September 28, 2007, a state agency physician reviewed Claimant's medical records and determined her condition was only causing a slight impact on her work-related function. (R. at 165.) Consequently, her impairment was not considered severe, and her claim was denied. (Id. at 165-166.) This decision was later confirmed on February 14, 2008, when a second state agency physician evaluated Claimant's records. (Id. at 188.)

Claimant returned to Dr. Guillen in December 2007 because of slight weight gain. (R. at 166.) Claimant indicated that she still suffered from back pain and that it was aggravated by standing or walking. (Id.) She also said that she had difficulty with her household chores. (Id.)

A physical exam showed that Claimant had forward flexion of 60 degrees with pain; paralumbar muscle spasms; and positive straight leg raises of 45 degrees in both legs. (Id.). Dr. Guillen prescribed Ibuprofen ...

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