Searching over 5,500,000 cases.

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.

Christian v. Berryhill

United States District Court, S.D. Texas, Houston Division

March 27, 2017

NANCY A. BERRYHILL, [1] Acting Commissioner of the Social Security Administration, Defendant.



         Plaintiff seeks judicial review of the Acting Commissioner of the Social Security Administration's (“the Commissioner”) decision denying her application for Social Security disability insurance benefits. The parties consented to have this Court decide the matter pursuant to 28 U.S.C. § 636(c) and filed cross-motions for summary judgment. As explained below, the Court GRANTS Plaintiff's motion, DENIES the Commissioner's motion, and REMANDS the case to the Commissioner for further proceedings consistent with this opinion.

         I. BACKGROUND

         A. Procedural Background

         In August 2012, Plaintiff applied for disability insurance benefits under Title II of the Social Security Act (“the Act”). R. 216-24.[2] The Social Security Administration denied her application initially and upon reconsideration. R. 159-71. Pursuant to Plaintiff's request, a hearing was held on February 21, 2014 before Administrative Law Judge William B. Howard (“the ALJ”). R. 125-58. Plaintiff, who was represented by counsel, testified at the hearing, as did a vocational expert. On July 2, 2014, the ALJ issued an unfavorable decision, concluding that Plaintiff was not disabled within the meaning of the Act and therefore not entitled to the benefits for which she applied. R. 105-19. Plaintiff timely requested that the Appeals Council review the ALJ's decision. R. 89-91. The Appeals Council denied that request, R. 1-6, after which Plaintiff commenced this action, Pl.'s Compl., ECF No. 1. The Court heard argument on the parties' cross-motions for summary judgment on December 7, 2016.

         B. Factual Background 1. Plaintiff's Work History

         Plaintiff was born on December 12, 1967 and was 46 years old at the time of the hearing before the ALJ. R. 132. She earned a GED in February 2007. R. 133. From 1998 until early 2012, Plaintiff worked as a patient care provider, first in an assisted living facility and later in patients' homes. R. 134-36. Her job duties included bathing and grooming patients, preparing their meals, doing their laundry and shopping, making their beds, monitoring their vital signs, and ensuring that they took their medications. R. 134. Plaintiff has experienced chronic pain since 1986. R. 657. In November 2011, she was involved in a car accident, which she believes triggered many of her current physical impairments. R. 137, 313-20. She returned to work a week after the accident, but found herself unable to stoop, bend, or turn patients over. R. 137. These limitations impeded Plaintiff's work to such an extent that Plaintiff and the agency for which she worked mutually agreed to end her employment. R. 138. Plaintiff did not seek further employment thereafter. R. 138-39.

         2. Plaintiff's Medical History

         Between early 2012 and mid-2013, Plaintiff received medical treatment at hospitals and other health care locations. R. 139, 321-509, 541-612. In February 2012, Plaintiff presented at a community clinic with “muscle spasms/joint pain.” R. 333. Later that month, Plaintiff was hospitalized for chest pain, dizziness, neck/back pain with radiculopathy, [3] and anxiety. R. 336- 38. A physician's note from that visit states that Plaintiff might have been suffering from “cervical radiculopathy from shoulder/neck trauma at work where she helps move an elderly woman, ” but imaging tests were normal. R. 338. A neurological assessment concluded that Plaintiff had 5/5 strength in her upper extremities and feet, but a full examination of strength in her lower extremities could not be performed “due to pain.” R. 344. In March 2012, Plaintiff received treatment for cervical radiculopathy, chronic pain syndrome, and back pain, and was referred for pain management. R. 487-88. In May 2012, Plaintiff was assessed with joint pain in her shoulder region following an examination. R. 482. In August 2012, Plaintiff reported “having constant pain in her lower abdomen, ” experiencing “sharp sho[o]ting pains in her legs, ” and “suffering with back pain since her first car wreck in 1986.” R. 460. Plaintiff was reported positive for back pain, negative for joint swelling, and found to have a normal range of motion. R. 461. In October 2012, Plaintiff sought treatment for hypertension and pain in her back, joints, ankle, and feet; she was noted as “positive for back pain and arthralgias, ”[4] but was found to have a “[n]ormal range of motion.” R. 445-49. A December 2012 medical assessment stated that Plaintiff was suffering from “acute” “aching” pain in her “left knee/left side.” R. 444.

         In July 2013, Plaintiff began receiving regular medical treatment from Dr. Rhonda Barnes-Jordan, M.D. (“Dr. Barnes-Jordan”). R. 661. A medical report from Plaintiff's first visit to Dr. Barnes-Jordan on July 31, 2013 contains the following pertinent observations:

Patient complains of joint pain. The patient notes diffuse joint pain. This has been a problem for the past more than 5 years. She describes the discomfort as unbearable. Symptoms have been mild or transient punctuated by episodic flare-ups. Primary joints affected include the cervical and lumbar spine, shoulders, elbows, wrists, hands, fingers, hips, knees, ankles, feet, and toes. Muscle groups affected include both gastrocnemius and the hamstrings. Associated symptoms include fatigue, sleep problems, depression, joint stiffness, swollen joints, joint warmth and night sweats. . . . Pertinent medical history is remarkable for injury long ago from auto accident and joint trauma (Pt has been in 3 car accidents 1986, 1996, 2011).

R. 661. The report further described Plaintiff's gait as “affected by a limp and slowed” and noted tenderness in “both legs and arms and lower back.” R. 663. Dr. Barnes-Jordan assessed Plaintiff as having “diffuse arthralgia” and “dysmetabolic syndrome X” and prescribed her various medications. R. 663.

         Plaintiff visited Dr. Barnes-Jordan again on at least seven occasions: August 21, 2013, R. 657-60, 692-95; October 21, 2013, R. 652-56, 687-91; October 24, 2013, R. 686; November 6, 2013, R. 647-51, 682-85; January 13, 2014, R. 638-46, 673-81; January 21, 2014, R. 633-37, 668-72; and February 5, 2014, R. 712, 714-19. The “assessment” and/or “current problems” sections of the medical records from these visits show that Dr. Barnes-Jordan repeatedly noted Plaintiff as having the following conditions (among others): diffuse arthralgia, [5] fatigue, [6] dysmetabolic syndrome X, [7] muscle spasm, [8] and a body mass index consistent with obesity.[9] Between November 6, 2013 and February 5, 2014, Dr. Barnes-Jordan also repeatedly recorded Plaintiff as having hip pain, [10] knee pain, [11] low back pain, [12] and female pelvic pain.[13] The “review of systems” (“ROS”) portions of Dr. Barnes-Jordan's records show that: on August 21, 2013, Plaintiff was found “negative” for arthralgias, back pain, and myalgia, [14] R. 657; on October 21, she was found “positive” for arthralgias, back pain, shoulder pain, knee pain, and hip pain, but negative for joint stiffness, limp pain, and myalgia, R. 653; on November 6, she was found positive for left knee and hip pain, but negative for arthralgias, back pain, joint stiffness and myalgia, R. 647; on January 13, 2014, she was found positive for arthralgias, back pain, joint stiffness and “limb pain (knee pain), ” R. 638; on January 21, 2014, she was found positive for “limb pain (Bilateral knee pain)” and negative for arthralgias, back pain, joint stiffness and myalgia, R. 633; and on February 5, 2014, she was found positive for “limb pain (left knee)” and negative for arthralgias, back pain, joint stiffness and myalgia, R. 712, 714.

         Dr. Barnes-Jordan's notes from January 21, 2014 show that Plaintiff complained of chronic low back pain with episodes of acute exacerbation and bilateral knee pain. R. 633. The doctor noted that “[t]he pattern of joint symptoms has been progressive worsening.” Id. X-rays ordered by Dr. Barnes-Jordan on that date failed to indicate abnormalities in Plaintiff's lumbar spine but showed “minor degenerative changes” in her knees. R. 636, 720-21. On February 5, 2014, Dr. Barnes-Jordan injected lidocaine into Plaintiff's left knee joint to alleviate her pain. R. 716.

         3. Plaintiff's Testimony

         At the hearing, Plaintiff testified that Dr. Barnes-Jordan was then treating her for diabetes, arthritis, depression, and fibroid tumors. R. 139. Plaintiff stated that she had been undergoing treatment for diabetes and arthritis for three to six months prior to the hearing and had been suffering from depression due to her brother's murder six or seven years prior. R. 140- 41. Plaintiff also stated that she had been suffering from joint pain for “a long time, over 10 years.” R. 140. She described the pain as affecting her joints generally but noted particular discomfort in her “shoulder joints, hip joint, knee joint, toe joints, [and] knuckles.” R. 140. She detailed her pain as follows: “Pains are sharp; I have muscle spasms in my back; in my lower legs; I also catch them in my feet . . . it feels like my toes are curling upward.” R. 142. Plaintiff stated that she has trouble sleeping at night; she “wake[s] in discomfort from the muscle spasms, the pain” and also has trouble breathing. R. 142.

         Plaintiff testified that she uses a cane, which a doctor prescribed to her. R. 146. She described herself as walking “kind of slowly” and stated that, with her cane, she was able to walk from the parking lot to the building where the hearing was held, but then had to rest. R. 147. She cannot climb a flight of stairs. R. 147. Plaintiff said that she has problems sitting throughout the day due to severe back pain, which requires her to constantly shift position. R. 147. As she put it: “when I sit, I tend to hurt my back, my joints, especially this right side. And I don't know how long I could do that.” R. 148. Plaintiff testified that she has difficulty bathing and getting in and out of the bathtub and needs help getting dressed. R. 143. She stated that, on an average day, her daughter helps her get dressed and prepares her meals, R. 143. Plaintiff rests about four to eight hours per day, R. 146. She sometimes reads or watches television, but otherwise does not “do too much.” R. 144, 146. Plaintiff does not cook, do laundry, vacuum, mop, take out the garbage, go grocery shopping, or exercise. R. 144-45. Plaintiff stated that she has tried to wash dishes and cook but has difficulty standing or sitting for long periods of time, has to constantly adjust her body, and “wind[s] up dizzy” when she tries to stand. R. 144. She drives a vehicle twice a week, but “[o]nly when [she] ha[s] to because [she] fell asleep behind the wheel.” R. 145.

         At the hearing, Plaintiff stated she was taking metformin for diabetes, R. 140, and hydrocodone (a narcotic) every 12 hours for pain, R. 154. A list provided to the ALJ at the hearing shows that Plaintiff was also taking the following medications: losartan for high blood pressure; gabapentin and tramadol for pain; furosemide for fluid build-up; sertraline for depression; meloxicam for arthritis; potassium and iron supplements; and a laxative. R. 127, 309-11. Plaintiff stated that the medication helped with her pain but did not relieve it completely. R. 154.

         4. Assessments of Plaintiff's Physical Abilities/Impairments

         Plaintiff underwent a consultative physical examination on October 11, 2012. R. 511-18. The resulting report stated that Plaintiff had: no joint swelling but exhibited tenderness in her right paracervical muscles and right shoulder region; weakness in her right upper extremity; a normal range of motion in her left upper and lower extremity; “mild weakness” in her upper and lower extremity; and normal range of motion and strength in both knees. R. 513. The report further observed that Plaintiff was unable to squat or walk on her heels or toes, but able to rise from the sitting position and “get up and down from the exam table with some difficulty”; and that, while “able to maneuver about the exam room without the use of” her cane, Plaintiff needed the cane for “longer distances and uneven terrain.” Id. Plaintiff's muscle strength was assessed as 5/5 for “all muscle tested, ” except that her “right upper and lower was 4/5” and her grip strength was “reduced on the right.” R. 514. The “clinical impression” section included the following conditions: “chronic cervical and lumbar pain with radiculopathy secondary to multiple traumas”; “right-sided weakness/history of multiple trauma events with resultant radiculopathy with muscle weakness right upper and lower extremity”; and obesity. R. 514.

         The record also contains an eight-page form entitled “Physical Residual Functional Capacity Assessment.” R. 519-26. It is dated November 28, 2012 and signed by Dr. Shabnam Rehman, M.D., who is identified as a medical consultant. R. 526. The form states that Plaintiff can occasionally lift and/or carry a maximum of 20 pounds; frequently lift and/or carry a maximum of 10 pounds; stand and/or walk (with normal breaks) for a total of about 6 hours in an 8-hour workday; sit (with normal breaks) for a total of about 6 hours in an 8-hour workday; and that her ability to push and/or pull is “unlimited, ” subject to the “lift and/or carry” limitations. R 520.

         On January 30, 2014, Dr. Barnes-Jordan completed a form entitled “Medical Assessment of Ability To Do Work-Related Activities (Physical), ” in which she reported:

■ Plaintiffs lifting/carrying ability is limited to a maximum of 10-15 pounds, both occasionally and frequently, due to “upper extremity weakness, decrease [sic] ROM [i.e., range of motion], lower back pain, [and] chronic knee pain bilaterally.” R. 702.
■ Plaintiffs ability to stand and/or walk is limited to 3-4 hours in an 8-hour day, both in total and without interruption, due to “chronic lower back pain” and “bilateral knee pain.” R 702.
■ Plaintiffs ability to sit is limited to 3-4 hours in an 8-hour day, both in total and without interruption, due to “chronic lower back pain.” R. 702.
■ Plaintiff is “never” able to climb, kneel, crouch, stoop, or crawl, but she can “frequently” balance. R. 703.
■ Plaintiffs reaching, handling, and push/pulling abilities are impaired due to “decreased range of motion (ROM) of shoulders and antalgic gait” resulting from “chronic pain including lower back, shoulders, and knees.” Plaintiffs feeling, seeing, hearing, and speaking functions, however, are not affected by these impairments. R. 703.
■ Plaintiffs impairments cause “environmental restrictions” related to heights, moving machinery, temperature extremes, and vibration. Plaintiff “cannot climb to any height level or move machinery, ” and “extreme weather can worsen joint pain.” Dr. Barnes-Jordan noted that the medical findings supporting this assessment were “decreased ROM of knees, hips, back and shoulder.” R 703.

         Dr. Barnes-Jordan concluded the report by reiterating that Plaintiff “has difficulty with sitting/standing for long periods of time due to back and knee pain” and that she “cannot lift heavy objects due to upper extremity weakness.” R. 703.

         In a questionnaire dated February 3, 2014, Dr. Barnes-Jordan wrote that:

■ Plaintiff s physical therapy has aggravated her condition, not reversed it. R. 706.
■ Plaintiffs x-rays were “unremarkable” but that Plaintiff “complains of chronic pain.” R 706.
■ Plaintiff “shows moderate to severe pain and reports that pain has been chronic and consistent since prior accidents despite therapy.” R. 706.
■ Plaintiffs complaints of pain are credible, based on reasonable medical evidence. R. 706.
■ Plaintiff “has pain with range of motion flexion/extension of back and knees which are not consistent with x-ray.” R 707.
■ Plaintiff has a limited range of motion in moving from the vertical position; has weakness in her back and difficulty lifting more than 15 pounds; has no ability to squat due to knee pain; has a limited ability to walk on heels or toes due to back pain; experiences pain when rotating her right shoulder; experiences right hip pain and a decreased range of motion when raising or lowering legs in a standing position; has “significant motor loss” in her right shoulder, right hip, and back flexion; and has a “slowed gait assisted with cane.” R. 707-08.
■ Plaintiffs pain medications “would be expected to interfere” with her coordination, concentration, and ability to remain awake and alert. R. 709.

         Dr. Barnes-Jordan also stated that she did not believe Plaintiff “can perform in competitive gainful employment in a forty hour work week situation.” R. 709.

         C. The ALJ's Findings and Conclusions

         The ALJ's decision contains the following findings of fact and conclusions of law:

         1. Plaintiff met the Act's insured status requirements through December 31, 2016. R. 110.

         2. Plaintiff has not engaged in substantial gainful activity since March 2, 2012, the alleged onset date of her disability. Id.

         3. Plaintiff has the following severe impairments: morbid obesity and chronic pain syndrome with pain ...

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.