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Carmen De La Cruz v. Michael J. Astrue

August 10, 2011


The opinion of the court was delivered by: Hon. Faith S. Hochberg



HOCHBERG, District Judge:

This matter comes before the Court upon Plaintiff Carmen De La Cruz's motion to review a final determination of the Commissioner of the Social Security Administration (the "Commissioner") pursuant to the Social Security Act, as amended, 42 U.S.C. § 405(g). The motion has been decided upon the written submissions of the parties pursuant to Federal Rule of Civil Procedure 78.


I. PLAINTIFF'S MEDICAL AND VOCATIONAL HISTORY Plaintiff is a 48-year-old female with a high school education. (Tr. 41) She was born in the Dominican Republic and is a United States citizen. (Tr. 42, 52) She can understand spoken English, but her ability to communicate in English is limited. (Tr. 51) She is single and has a 23-year-old daughter who lives in Boston, Massachusetts. (Tr. 41) Plaintiff lives with her older sister in West New York, New Jersey. (Tr. 41) Plaintiff alleges that she suffers from chronic back and neck pain, depression and headaches. (Tr. 43-49)

Plaintiff worked as a soldering technician and assembly worker for an electronics business from May 1997 to March 2000. (Tr. 42) This work included lifting units of 10 lbs. frequently. (Tr. 150)From August 2002 to June 2007, Plaintiff worked as a home health aide for Care Finders, Inc., assisting elderly sick patients with day-to-day needs such as eating, bathing, walking, getting out of bed into a sitting position, light cooking, cleaning, and taking patients to doctor appointments, errands and grocery shopping. (Tr. 131, 148) Plaintiff frequently lifted 25 lbs. during the workday. (Tr. 149)

Plaintiff has been out of work since June 27, 2007. (Tr. 130) She claims that she was unable to continue working because of the severity of her pain. (Tr. 131)

In a typical day, Plaintiff gets up around 10:00 a.m. (Tr. 50) She bathes, brushes her teeth, eats breakfast, sits for a while, stands, and then sits or lies down until she goes to bed. (Tr. 50, 140) She is able to prepare her own meals, but she states that she mostly eats sandwiches and frozen dinners because she cannot stand for very long. (Tr. 142) Plaintiff claims that she is unable to do routine household chores without the assistance of pain medication. Id. Although she claims to only go outside approximately twice a year, Plaintiff is able to drive a car alone. (Tr. 142-43) Plaintiff can pay bills, handle a savings, count change, and use a checkbook and money order; however, her sister does the shopping. (Tr. 143)

Plaintiff's hobbies include watching TV a few times a week, but she is no longer able to sew. Id. She has a book, but she hardly ever reads it because she doesn't "feel like doing anything." (Tr. 50) She spends time with her family about once a week. (Tr. 144) Plaintiff can pay attention for a long time, finish what she starts and follow written and spoken instructions well. (Tr. 145)She gets along well with authority figures and handles stress and changes in routine "okay." (Tr. 146)

Plaintiff experiences pain in her neck, back and arms. (Tr. 43-44) These conditions cause her depression and headaches. (Tr. 40, 48) Plaintiff can walk only one block before needing to stop and rest, and she must rest for at least 20 to 30 minutes. Id. Plaintiff cannot be sitting, lying down or standing very long, which makes her feel "impotent." (Tr. 48) At most, she can sit in one place without a problem for 45 minutes. Id.

A. Plaintiff's Treatment for Back and Neck Pain Dr. Felix Roque, Director of the Pain Relief Center at St. Mary's Hospital, has treated Plaintiff since April 1, 2003, seeing her on a monthly basis. (Tr. 238) In 2000, Plaintiff claims that she fell and injured her back. (Tr. 198) Plaintiff has had physical therapy and epidural steroid injections for pain relief. Id. From February 1, 2006 to June 28, 2007, Plaintiff underwent five MRIs of her spine for back pain. (Tr. 250-52) Each MRI performed by Dr. Roque revealed degenerative disc changes and herniated discs. Id.

On July 26, 2007, Plaintiff was admitted to St. Mary's Hospital for back pain and left-sided leg, thigh and calf radiating pain. (Tr. 193) The admitting diagnosis was lumbar radiculopathy. (Tr. 193) Dr. Roque performed three procedures during surgery to determine the cause of Plaintiff's pain and to ease her pain. (Tr. 195-96) Plaintiff's pain was graded zero out of ten after the surgery, down from eight out of ten prior to the surgery. Id. She was also able to move the lower extremities without any muscular or neurological deficits after the surgery. (Tr. 196) Plaintiff was advised to resume taking her regular medications, including Percocet. Id.

On December 12, 2007, Dr. Roque performed another MRI on Plaintiff's spine, finding posterior herniations with mild to moderate canal stenosis. (Tr. 246) There was no evidence of fracture or ligamentous injury. Id.

Plaintiff's condition has been stable since January 2007. Dr. Roque concluded, based on his medical findings, that Plaintiff is functionally limited to the following: sitting less than 6 hours per day; standing or walking less than 2 hours per day; lifting or carrying only less than 5 lbs. occasionally; and limited push and pull. (Tr. 239)

B. Plaintiff's Treatment for Headaches

On March 24, 2008, Plaintiff was admitted to the Emergency Room at Palisades Medical Center for headache and neck pain. (Tr. 206) She complained that her headache had begun three days prior to her hospital visit. (Tr. 208) Plaintiff described the pain as throbbing and generalized, stating that her head felt too heavy for her neck and shoulders. Id. She denied fever, chills, photophobias, stiff neck, head trauma, nausea, vomiting, dizziness, ataxia, or weakness/paresthesias. Id. Plaintiff noted that she had had prior headaches, but this headache was not relieved by Percocet. Id. With additional medication, the headache was completely resolved, and Plaintiff was prescribed Motrin on an ongoing basis. Id.

Plaintiff returned to the Emergency Room with a headache on September 5, 2008. (Tr. 255, 257) Plaintiff denied nausea, vomiting, stiff neck, photophobia, and head trauma. Id. Plaintiff's headache responded to medication. Id. On the same day, Plaintiff underwent a CT head scan. (Tr. 264) The results were negative, showing no evidence of mass lesion, hemorrhage or territorial infarct. Id.

C. Plaintiff's Psychiatric Treatment

In 2008, Plaintiff commenced psychiatric treatment under the care of Dr. Zipproa Razin.

(Tr. 271) She presented with depressed mood and suicidal ideation, though she had no history of suicidal tendencies, nor had she made any plan or taken any steps toward taking her own life. (Tr. 278) Plaintiff complained of weight gain and trouble falling and staying asleep. Id. Plaintiff discussed her anxiety and worry about her ill daughter in Boston. (Tr. 275) She also reported feeling very depressed and agitated due to a conflict with a welfare worker and the loss of her benefits. Id. She learned relaxation techniques to help her better manage her chronic pain and stress, and Dr. Razin increased her medication. (Tr. 272) At Plaintiff's subsequent visit, she reported feeling better as a result of her medication and relaxation techniques. Id. Dr. Razin assessed Plaintiff's appearance, ...

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