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.

Ortiz v. Berryhill

United States District Court, N.D. Texas, Dallas Division

March 3, 2017

ERMA S. ORTIZ, Plaintiff,
v.
NANCY A. BERRYHILL, ACTING, COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, Defendant.

          FINDINGS, CONCLUSIONS, AND RECOMMENDATION

          IRMA CARRILLO RAMIREZ UNITED STATES MAGISTRATE JUDGE.

         Pursuant to Special Order No. 3-251, this social security appeal was automatically referred for full case management. Before the Court are Plaintiff's Appeal from the Decision of the Commissioner of Social Security, filed April 16, 2016 (doc. 16), Defendant's Brief in Support of the Commissioner's Decision, filed June 15, 2016 (doc. 19), and Plaintiff's Reply to Brief of Defendant filed July 1, 2016 (doc. 20). Based on the relevant filings, evidence, and applicable law, the Commissioner's decision should be AFFIRMED.

         I. BACKGROUND[1]

         A. Procedural History

         Erma S. Ortiz (Plaintiff) seeks judicial review of a final decision by the Commissioner of Social Security (Commissioner)[2] denying her claims for disability insurance benefits (DIB) under Title II of the Social Security Act (Act) and for supplemental security income (SSI) under Title XVI of the Act.[3] (R. at 1, 7.) On April 18, 2013, Plaintiff filed her applications for DIB and SSI, alleging disability beginning on May 9, 2012. (R. at 197, 201.) Her claims were denied initially and upon reconsideration. (R. at 135-42, 148-54.) Plaintiff requested a hearing before an Administrative Law Judge (ALJ), and personally appeared and testified at a hearing on October 9, 2014. (R. at 28-59.) On October 23, 2014, the ALJ issued a decision finding that Plaintiff was not disabled and denying her claims for benefits. (R. at 7-27.)

         Plaintiff timely appealed the ALJ's decision to the Appeals Council. (R. at 6.) The Appeals Council denied her request for review on December 18, 2015, making the ALJ's decision the final decision of the Commissioner. (R. at 1-5.) Plaintiff timely appealed the Commissioner's decision under 42 U.S.C. § 405(g). (See doc. 1.)

         B. Factual History

         1. Age, Education, and Work Experience

         Plaintiff was born on August 29, 1965, and was 49 years old at the time of the hearing before the ALJ. (R. at 21.) She graduated from high school and earned a diploma. (R. at 21.) She had past relevant work experience as a washer and washer/driver. (R. at 21.)

         2. Medical Evidence

         On March 22, 2012, Plaintiff was admitted to Parkland Memorial Hospital (Parkland) for recurrent back pain. (R. at 391-92.) She received X-rays that showed “mild-moderate” degenerative changes of the lower thoracic and lumbar spine. (R. at 391.) She was diagnosed with lumbar spine degenerative changes with no acute abnormalities and prescribed pain medication. (R. at 391, 413-14.)

         Between April 12, 2012, and January 6, 2013, Plaintiff returned to Parkland on four separate occasions for pain in her legs, shoulders, back, and ears. (R. at 415-17, 418-19, 420-21, 421-23.) During each visit, she received a musculoskeletal exam that showed tenderness and discomfort in her lumbar spine area. (R. at 417, 419, 420, 422.) During her visit on September 22, 2012, Plaintiff had a “slightly restricted” and painful range of motion in her shoulder. (R. at 420.) During her visits on April 12, 2012, and January 6, 2013, however, she had a “normal range of motion” and appeared “negative for back pain.” (R. at 416-17, 422.)

         On July 15, 2013, Plaintiff met with Dr. Paul Patrick, D.O., for an internal medicine examination. (R. at 332-44.) He noted that she reported “10/10” stabbing back pain and extreme physical limitations due to the pain. (R. at 333-34.) Dr. Patrick reported tenderness in her lumbar spine, left shoulder, both knees, and both ankles. (R. at 336.) He further noted that she was “unable to perform heel and toe walking, squatting, and hopping.” (R. at 336.) Dr. Patrick examined and tested the range of motion of both her upper and lower extremities, which showed significant limitations on Plaintiff's left shoulder, left hip, and lumbar spine. (R. at 341-42.) She exhibited pain but had a normal range of motion in her right shoulder and right hip. (R. at 341-42.) There were also minor limitations in the range of motion of her wrists, elbow, knees, ankles, and cervical spine. (R. at 341-42.) Her upper extremity grip and strength was assessed at “5/5” for both the right and left sides, while her lower extremity strength was assessed at “3/5” for both the right and left sides. (R. at 341-42.) Dr. Patrick opined that Plaintiff was limited to sitting for 30 minutes or less, standing for 20 minutes or less, walking half a block at most, able to lift 10 pounds in her right hand and only 1-2 pounds in her left hand, and had a limited ability to perform fine finger control in her left hand. (R. at 337.)

         On August 15, 2013, Dr. Betty Santiago, M.D., a state agency medical consultant (SAMC), completed a medically determinable impairment and residual functional capacity (RFC) assessment of Plaintiff based upon the evidence on record. (R. at 92-95.) She diagnosed her impairments as dysfunction of her major joints and diabetes mellitus, but she determined that the “overall impact of [Plaintiff's] symptoms [did] not wholly compromise [her] ability to function independently, appropriately, and effectively.” (R. at 93.) She opined that Plaintiff had the following limitations: could occasionally lift or carry 50 pounds and frequently lift or carry 25 pounds; could stand, walk, or sit about 6 hours in an 8-hour workday; could frequently climb ramps and stairs, stoop, kneel, crouch, and crawl; could occasionally climb ladders, ropes, and scaffolds; and had unlimited pushing, pulling, and balancing ability. (R. at 94.)

         On October 28, 2013, and January 3, 2014, Plaintiff returned to Parkland for leg and neck pain. (R. at 430-32, 434-36.) Her musculoskeletal exams showed tenderness in her hips, knees, left ankle, and lumbar back, but she was “negative for myalgias and back pain” and “exhibit[ed] normal range of motion” in her back. (R. at 432, 434-36.) She was diagnosed with degenerative joint disease and prescribed pain medication. (R. at 367, 436.)

         On January 6, 2014, Plaintiff met with Dr. Patrick for a second internal medicine evaluation. (R. at 366-78.) She reported that her pain was at a “7/10” in her ankles and knees, a “8/10” in her left shoulder, a “9/10” in her left hip, and a “10/10” in her back. (R. at 369.) Dr. Patrick again noted tenderness in her lumbar spine, left shoulder, both knees, and both ankles. (R. at 372.) He further reported that she was “unable to perform heel and toe walking, squatting, and hopping.” (R. at 372.) He again examined and tested Plaintiff's range of motion in her upper and lower extremities; she had minor but painful restrictions in her left shoulder and lumbar spine but no longer had any bilateral pain in her knees or ankles. (R. at 374-75.) Her upper extremity grip and strength was assessed at “5/5” for both the right and left sides, and her lower extremity strength was increased to “4/5” for both the right and left sides. (R. at 374-75.) Dr. Patrick opined that Plaintiff was limited to sitting for 30 minutes or less, standing for 10 minutes or less, walking half a block at most, able to lift 5 pounds or less in both hands, and could use fine finger control without limitation. (R. at 373.)

         On January 23, 2014, Dr. Shabnam Rehman, M.D., a SAMC, completed a medically determinable impairment and RFC assessment of Plaintiff based upon the evidence on record. (R. at 116-19.) She agreed with Dr. Santiago's diagnosis that her impairments were dysfunction of her major joints and diabetes mellitus. (R. at 116.) She opined that Plaintiff had the following limitations: could occasionally lift or carry 20 pounds and frequently lift or carry 10 pounds; could stand, walk, or sit about 6 hours in an 8-hour workday; could frequently stoop, kneel, and crouch; could occasionally crawl, balance, and climb ramps, stairs, ladders, ropes, and scaffolds; and had unlimited pushing and pulling ability. (R. at 117-18.)

         On February 7, 2014, and April 8, 2014, Plaintiff returned to Parkland for hip, shoulder, and back pain. (R. at 436-38, 443-45.) Her musculoskeletal exams showed that she exhibited tenderness on her lower lumbar spine and restricted joint movements in her left hip and shoulder due to pain. (R. at 437, 441.) She received X-rays that showed “slightly worse” lumbar disc degeneration than she had two years prior and “mild bilateral osteoarthritis” of her hips. (R. at 393-94.) She was diagnosed with degenerative joint disease and prescribed pain medication. (R. at 437-38, 441.)

         On April 14, 2014, Plaintiff began physical therapy at Parkland. (R. at 443-45.) Her symptoms were noted as being “consistent with degenerative changes of bilateral shoulders and possible rotator cuff pathology.” (R. at 444.) It was assessed that she was capable of “carrying, moving, and handling objects, ” but was “at least 60 percent but less than 80 percent impaired, limited, or restricted.” (R. at 444.)

         On May 29, 2014, Plaintiff was discharged from her physical therapy program. (R. at 446-47.) It was noted that she had “demonstrated slow but steady progress, ” had decreases in her pain ratings, and had met all of her goals except to increase the range of motion in her shoulders. (R. at 446.) She was found capable of “carrying, moving, and handling objects, ” and “at least 40 percent but less than 60 percent impaired, limited, or restricted.” (R. at 447.)

         3. Hearing Testimony

         On October 9, 2014, Plaintiff and a vocational expert (VE) testified at a hearing before the ALJ. (R. at 28-59.) Plaintiff was represented by an attorney. (R. at 30.)

         a. Plaintiff's Testimony

         Plaintiff testified that she was born on August 29, 1965, and was 49 years old. (R. at 34.) She had never been married and lived with her mother and brother. (R. at 35.) She could drive and was able to complete routine errands such as buying groceries. (R. at 36.) She graduated from high school, but she had been placed in special education classes for reading and writing. (R. at 36.)

         Plaintiff had not worked in over two years and had not applied for any jobs since May 2012. (R. at 37.) She most recently worked for a car rental company where she would check-in, drive, wash, and detail the cars that were returned. (R. at 38.) When Plaintiff was first hired at the rental company, she primarily cleaned and detailed the rental cars, but she was later “moved up” to driving and checking-in the cars because she could no longer “bend over very much . . . to vacuum the cars and clean them.” (R. at 40-41.) After she stopped working at the car rental company in early 2012, she collected unemployment benefits during the first, second, and third quarter of 2012. (R. at 39.) Plaintiff testified that she had suffered from osteoarthritis that prevented her from working. (R. at 39.) She could not perform any of her previous work due to the pain or work at any job where she had to stand on her feet most of the time. (R. at 41-42.) It hurt when she lifted her shoulders, reached forward, and reached overhead. (R. at 44-45.) She had been prescribed pain medication for pain in her knees, back, and shoulders; the medication “help[ed] at the time, but it . . . still hurt.” (R. at 43, 45.) She took hot showers and applied a heating pad “almost every day” to help alleviate the pain. (R. at 45.) Her lower back pain became worse when she “sat too long or walk[ed] too much” and the pain frequently “traveled down” her legs. (R. at 46-47.) She had to lie down “at least twice a day” for 30 minutes to an hour at a time to help her back pain. (R. at 46.) She also testified that she had suffered from diabetes and experienced “burning sensations” in her feet and hands when her blood sugar was high. (R. at 52-53.) She stated that she could walk only half a block, stand for 15 minutes, sit for 30 minutes to an hour, and could not lift a gallon of liquid. (R. at 49-50.)

         b. ...


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.