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Rodriguez v. Commissioner of Social Security

United States District Court, D. New Jersey

February 26, 2018


          Agnes S. Wladyka, Esq. AGNES S. WLADYKA, LLC Attorney for Plaintiff.

          Andrew Charles Lynch Social Security Administration Office of the General Counsel Attorney for Defendant Commissioner of Social Security.




         This matter comes before the Court pursuant to 42 U.S.C § 405(g) to review the final decision of the Commissioner of the Social Security Administration (“SSA”) denying Plaintiff Alixa Rodriguez's (“Plaintiff”) application for supplemental security income under Title XVI of the Social Security Act, 42 U.S.C. § 401 et. seq. Plaintiff, who suffers from degenerative disc disease, degenerative joint disease, a major depressive disorder, a schizoaffective disorder, and anxiety disorder, was denied benefits for the period beginning June 1, 2009, the date of alleged disability, to October 14, 2014, the date on which the Administrative Law Judge (“ALJ”) issued a written decision.

         In the pending appeal, Plaintiff argues that the ALJ's decision should be reversed and remanded on two grounds. First, Plaintiff contends that the ALJ erred in determining the Plaintiff's Residual Functional Capacity (“RFC”). Second, Plaintiff argues that the ALJ erred in interpreting and applying the vocational expert's (“VE”) testimony.


         A. Procedural History

         Plaintiff filed an initial application for supplemental social security income on July 20, 2011, alleging disability beginning June 1, 2009 due to herniated discs in the back, osteoporosis of the right hip, depression, and anxiety. (R. at 19, 81.) The SSA denied the claim on November 17, 2011 (R. at 107), and upon reconsideration on December 14, 2012. (R. at 115.) Hearings were held on March 21, 2014 before ALJ Nicholas Cerulli, at which Plaintiff appeared with counsel and testified, and at which a vocational expert also testified. (R. at 19.) On October 14, 2014, the ALJ issued an opinion denying Plaintiff benefits. (R. at 32-33.) The Appeals Council denied Plaintiff's request for review (R. at 1.), and Plaintiff timely filed the instant action.

         B. Personal and Medical History

         The following are the facts relevant to the present motion. Plaintiff was 55 years old as of the date of the ALJ decision. (R. at 31). Plaintiff completed a high school education in Puerto Rico. (R. at 49.) She has no past relevant work experience. (R. at 31.)

         1. Physical Impairments

         Plaintiff was regularly seen as a patient of CAMcare Internal Medicine (“CAMcare”) and treated by its doctors and staff. Plaintiff had a history of hyperlipidemia and was seeing a dietician and walking one-and-a-half hours weekly. (R. at 487.) In November 2009, Deborah Horowitz, a resident nurse, and nurse practitioner, treated Plaintiff for a rash. (R. at 501.) Nurse Horowitz diagnosed Plaintiff with bronchitis, but Plaintiff denied discomfort or shortness of breath and wheezing. (R. at 501-502.) Accordingly, Nurse Horowitz prescribed medication and directed that Plaintiff use a nebulizer every four to six hours, as needed. (R. at 502.) The next year, Plaintiff exhibited shortness of breath, wheezing, cough, fever, abdominal pain, sore throat, and earache. (R. at 449.) Nurse Horowitz again diagnosed Plaintiff with acute bronchitis. (R. at 450.)

         On February 26, 2010, Plaintiff returned to see Nurse Horowitz, where a scan revealed osteopenia of the right hip. (R. at 478.) Plaintiff, also reporting congestion, had clear lungs. (R. at 478.) Nurse Horowitz prescribed Actonel and Caltrate for Plaintiff's osteopenia. (R. at 480.)

         On April 4, 2010, Plaintiff fell and admitted herself to the Cooper University Hospital emergency room. (R. at 438-439.) Cooper University reported a small contusion and superficial hematoma of left flank and hip. (R. at 438-439.) There was no dislocation or fracture of the left shoulder or elbow, nor were the joints affected. (R. at 438-498.)

         Two days later, Plaintiff went to Nurse Horowitz exhibiting shoulder pain and swelling of the left hand. (R. at 473.) Nurse Horowitz's physical examination of Plaintiff revealed a decrease in range of motion of the left shoulder, and small nodules on her lung. (R. at 473.) Plaintiff returned for another office visit with Nurse Horowitz on April 23, 2010 for lightheadedness. (R. at 469.) Following a physical exam, Nurse Horowitz noted that Plaintiff had normal sensation, reflexes, coordination, and muscle strength and tone. (R. 469-471.)

         Plaintiff's test results in July 2010 showed liver with diffuse steatosis and elevated FTS. (R. at 461, 463.) Consequently, Plaintiff's doctor ordered a GI consult. (R. at 463.) On December 13, 2010, Plaintiff saw Dr. Joshua DeSipio on referral for abnormal liver tests and fatty liver. (R. at 413.) Dr. DeSipio's impression was elevated liver tests, possibly secondary to nonalcoholic steatohepatitis, which could be implicated by several medications Plaintiff was taking, specifically Seroquel. (R. at 413.) Seven days after, Plaintiff showed normal LFTs, no changes to her liver, and improved hepatic stenosis. (R. at 417.)

         On September 7, 2011, Plaintiff saw her treating internist, Dr. Jimmie Young, complaining of ongoing joint, left shoulder, and back pains. (R. at 400.) Plaintiff stated these pains were a problem since her fall in April 2010. (R. at 400.) Dr. Young completed a physical exam noting tenderness of the left shoulder and spine but normal full range of motion in all joints. (R. at 401, 403.) Dr. Young prescribed pain medications for both Plaintiff's lower back and left shoulder, and recommended she apply heat and exercise. (R. at 403.) He also ordered an MRI for the upper extremities and an x-ray for her back. (R. at 404.)

         On September 22, 2011, Dr. Young made the following findings based on Plaintiff's left shoulder MRI: severe tendinopathy and degeneration, consistent with mild degenerative joint disease. (R. at 398.) The next day, Plaintiff went to Dr. Young for a follow up visit at which she was referred to see an orthopedics doctor and directed to begin physical therapy and schedule a follow up in three months. (R. at 407.) Comparing the examination of Plaintiff's shoulder with her previous exam from April, 4, 2010, Dr. Young noted there was some interval widening of the A.C. joint, but no abnormality or significant arthropathy was apparent. (R. at 397.)

         On January 12, 2012, Plaintiff returned to CAMcare for a follow-up visit with Dr. Young, still complaining about back and shoulder pain. (R. at 409.) Plaintiff's physical exam showed mild tenderness in the back and shoulder with full range of motion in all joints. (R. at 410.) Plaintiff was discharged with instructions to apply heat and take her pain medications as prescribed (Flexeril110mg, Naprosyn 500mg), and advised to exercise. (R. at 411.) She was also directed to make an appointment with an orthopedist and schedule a follow up in three months. (R. at 411.)

         An exam of Plaintiff's right hip in November 2012 revealed that her hip joint was preserved and the bones were normally mineralized with most likely vascular calcifications of the right lower pelvis. (R. at 610, 613.)

         On March 11, 2013, Plaintiff's lumbar spine MRI was examined, finding that the lumbar vertebral bodies demonstrated satisfactory alignment and were of adequate stature. (R. at 666.) The MRI exhibited minimal annular bulging with mild anterior endplate spur formation and no indication of central or neural canal stenosis of the L2-3 level. (R. at 666.) At the L3- 4 level, there was a small left posterolateral disc protrusion causing mild left lateral recess and stenosis. (R. at 666.) The remaining discs were intact. (R. at 666.)

         Plaintiff continued seeing Dr. Young and Nurse Horowitz regularly through at least December of 2013, reporting various levels of pain, and sometimes none. (R. at 615-665.) Plaintiff also exhibited spine and right hip tenderness and chronic low back pain. (R. at 627-631, 637-638.) Dr. Young kept Plaintiff on medications for her pain and regularly recommended that she apply heat and home exercise. (R. at 655-691.) When Plaintiff complained of chest pains and asthma attack, Dr. Young noted there was no true “hx” of asthma, but instead severe congestion with cold or illness. (R. at 620.) Plaintiff showed decreased BS of lungs on left and right. (R. at 622.) Plaintiff's medical records showed no evidence of hepatosplenomegaly. (R. at 401-431, 447-498.)

         On June 27, 2013, Plaintiff complained of pain all over her body. (R. at 655.) Dr. Young completed an examination report indicating that Plaintiff was unable to work with a disability for 12 months or more. (R. at 653.) He marked her limitations as standing, walking, climbing, stooping, bending, and lifting. (R. at 653.) Dr. Young did not think Plaintiff was a likely candidate for Social Security Income. (R. at 653.)

         2. Mental Impairments

         Plaintiff's medical records regarding her depression and anxiety begin on December 4, 2009, from South Jersey Behavioral Health Resources (“SJBH”). (R. at 511.) There, Plaintiff reported having mood swings, insomnia, and depression. (R. at 350.) She stated she was diagnosed with depression following the death of her mother. (R. at 346.) Plaintiff took medications for both anxiety and depression, including Xanax, Vistaril, and Elavil, with no side effects. (R. at 513.) She also reported to have previously seen a physiatrist. (R. at 513.) Plaintiff wanted to get back on medication to feel better. (R. at 351.)

         Plaintiff's Mental Status Evaluation indicated that she was cooperative and oriented. (R. at 350.) She experienced decreased appetite and insomnia. (R. at 350.) The evaluation reported Plaintiff felt sad and depressed, with thoughts of suicide and feelings of hopelessness and helplessness. (R. at 350.) She reported auditory hallucinations, obsessions, compulsions, phobias, derealization, and paranoia. (R. at 350.) Plaintiff showed moderately-impaired judgment, but fair insight and alert consciousness. (R. at 351.) Plaintiff's problem areas included mood disorder, anxiety, SI, and homelessness. (R. at 351.) Plaintiff's prognosis was fair and she was recommended for individual psychotherapy, psych evaluation, and medication monitoring. (R. at 351.) Outpatient records from December 2009 through April 2011 provide Plaintiff's diagnoses of major depressive disorder, single episode; major depressive disorder, recurrent, unspecified; and schizoaffective disorder. (R. at 345.)

         On December 15, 2009 and January 4, 2010 Plaintiff visited Nurse Horowitz, her primary medical provider at the time, who described Plaintiff's mental condition as alert and cooperative with normal mood, attention span, and concentration. (R. at 492, 487.) Plaintiff's next office visit was on January 15, 2010, at which she complained of anxiety, depression, and mental problems. (R. at 484.) Plaintiff was seeing SJBH for therapy and was trying to see a psychiatrist. (R. at 484.) After a physical exam, Nurse Horowitz recorded Plaintiff's mental condition as depressed and tearful and instructed her to come in for a follow up in one month. (R. at 484.)

         On January 20, 2010, Dr. Pedro Garcia conducted a psychiatric evaluation. (R. at 386.) Plaintiff exhibited depressed mood and restricted affect. (R. at 390.) Her insight and judgement were fair and intelligence was within average range. (R. at 390.) Plaintiff's Global Assessment of Functioning (“GAF”) score was estimated to be 50. (R. at 390.) Therapy was recommended every two to four weeks. (R. at 390.) SJBH's subsequent Medical Management Progress Notes from February 2010 through December of 2011 show Plaintiff's mental status exam was within normal limits. (R. at 531-556.)

         On February 26, 2010, Plaintiff returned to Nurse Horowitz with complaints of depression, but noted the “depression is much better.” (R. at 478.) Plaintiff denied anxiety and thoughts of violence and suicide, and Nurse Horowitz observed Plaintiff to be alert and cooperative with normal mood. (R. at 478.) Plaintiff remained on medication for her depression, which had “improved, ” and was instructed to schedule a follow-up appointment in three months. (R. at 479.) On July 9, 2010, Plaintiff was “alert and cooperative; normal mood and affect; normal attention span and concentration.” (R. at 462.)

         On December 13, 2010, Dr. Joshua DeSipio treated Plaintiff for abnormal liver tests. (R. at 573.) Plaintiff stated she was “doing well” and Dr. DeSipio reported that she was pleasant, alert, and oriented. (R. at 573.) Records from CAMcare Health four days later indicate Plaintiff was “alert and cooperative; normal mood and affect; normal attention span and concentration.” (R. at 285.)

         When Plaintiff returned on December 20, 2010, Nurse Horowitz noted Plaintiff was “feeling quite depressed today, ” is having issues sleeping, and that is had been a “very hard year.” (R. at 415.) On September 7, 2011, Dr. ...

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