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Parker v. Berryhill

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

March 30, 2017




         Pursuant to the consent of the parties and the order of reassignment dated April 8, 2016 (doc. 15), this case has been transferred for the conduct of all further proceedings and the entry of judgment. Before the Court are Plaintiff's Brief on Review of the Social Security Administration's Denial of Benefits, filed May 11, 2016 (doc. 17), Defendant's Brief, filed June 10, 2016 (doc. 19), and Plaintiff's Reply to the Commissioner's Brief, filed June 29, 2016 (doc. 20). Based on the relevant filings, evidence, and applicable law, the Commissioner's decision is REVERSED, and the case is REMANDED for further administrative proceedings.

         I. BACKGROUND[1]

         A. Procedural History

         Shelia Fay Parker (Plaintiff) seeks judicial review of a final decision by the Acting Commissioner of Social Security (Commissioner)[2] denying her claim for supplemental security income (SSI) under Title XVI of the Social Security Act. (R. at 1, 132.) On November 17, 2011, Plaintiff filed her application for SSI, alleging disability beginning February 1, 2011.[3] (R. at 439.) Her claim was denied initially and upon reconsideration. (R. at 360-62, 372-80.) Plaintiff requested a hearing before an administrative law judge (ALJ), and she personally appeared and testified at a hearing on April 17, 2013. (R. at 147-81.) On May 20, 2013, the ALJ issued a decision finding that she was not disabled and denying her claim for benefits. (R. at 132-46.)

         Plaintiff timely appealed the ALJ's decision to the Appeals Council and included new medical evidence. (R. at 12-28, 35-116.) The Appeals Council determined that the new evidence did not provide a basis for changing the decision and denied her request for review on December 15, 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 November 17, 1959, and was 53 years old at the time of the hearing. (R. at 473.) She left school in the 11th grade and never received a GED. (R. at 467-68.) She had past relevant work experience as a home health attendant and a cook helper. (R. at 175.)

         2. Medical Evidence[4]

         On July 14, 2009, Plaintiff visited the urgent care clinic of Parkland Health and Hospital System (Parkland) for pain in her right shoulder and arm. (R. at 658-60.) No weakness or numbness was reported, but she did exhibit a decreased range of motion in her right shoulder. (R. at 659.) X-rays showed degenerative changes in her shoulder, and she was prescribed pain medication. (R. at 659, 680.) She returned for a follow-up appointment on July 30, 2009, and complained of pain in her chest and left shoulder, but her physical exam was negative for tenderness and showed a normal range of motion. (R. at 655-56.)

         On September 21, 2009, [5] Dr. Kavitha Reddy, M.D., a state agency medical consultant (SAMC), completed a physical residual functional capacity (RFC) assessment of Plaintiff.[6] (doc. 17-2 at 1-8.) Dr. Reddy opined that Plaintiff had the following exertional limitations: could occasionally lift 20 pounds and frequently lift 10 pounds; could stand, walk, or sit with normal breaks for a total of about 6 hours in a normal 8-hour workday; and an unlimited ability to push or pull. (doc. 17-2 at 2.) She had no postural or manipulative limitations except for a limited ability to only occasionally reach with her bilateral upper extremities due to degenerative changes. (doc. 17-2 at 3-4.)

         On August 13, 2010, Plaintiff met with Dr. Nasrin Safari, M.D., of Parkland's Bluitt Flowers Adult Clinic for pain in her left shoulder and arm. (R. at 900-09.) Plaintiff reported that she was unable to raise her left arm without pain, but her physical exam showed a normal range of motion in her neck and musculoskeletal system. (R. at 905.) X-rays of her left shoulder were taken a week later and revealed osteroarthritis with spur formation. (R. at 744.) Plaintiff returned for a follow-up on September 27, 2010, and complained of hand swelling. (R. at 913-14.) Her musculoskeletal exam was positive for myalgias and joint pain, and she exhibited a decreased range of motion and tenderness in both hands. (R. at 914.) She was diagnosed with osteoarthritis and prescribed pain medication. (R. at 914-15.)

         On November 19, 2010, Plaintiff returned to Dr. Safari and complained of increased pain in her left shoulder. (R. at 918-19.) She also reported left ankle pain and use of a cane for ambulation. (R. at 919.) Dr. Safari ordered an MRI and diagnosed her with shoulder pain and ankle pain. (R. at 919.) The MRI of her left shoulder revealed no abnormalities, but the results were suggestive of moderate rotator cuff tendinopathy and moderate degeneration and osteoarthritis. (R. at 670, 739.)

         On March 9, 2011, Plaintiff visited Parkland's orthopedic clinic for left shoulder pain. (R. at 611-14.) Her physical exam revealed a tenderness in her shoulder, “5/5” upper extremity strength, and a forward flexion range of motion limited to 110 degrees with a maximum range of 160 degrees with pain. (R. at 614.) Subacromial injections were suggested as treatment for her shoulder pain, and they were administered later that month. (R. at 611-12, 614.)

         On August 23, 2011, Plaintiff visited Parkland's rheumatology clinic due to pain in her knees and hands. (R. at 592-98.) She met with Dr. Laura Tarter, M.D., who reported bilateral knee pain and swelling in Plaintiff's hands. (R. at 592.) Although a physical examination revealed “4/5” strength in Plaintiff's upper extremities with no tenderness, there was a limited range of motion with the abduction and internal rotation of her left shoulder. (R. at 593, 598.) X-rays of her hands revealed small erosion and minimal narrowing near the medial base of the middle finger of her right hand and no abnormalities in her left hand. (R. at 668-69, 737-38.)

         On January 24, 2012, Plaintiff returned to Dr. Tarter for pain and swelling in her hands. (R. at 1383-86.) She exhibited “4/5” upper extremity strength with no inflammation or swelling in her joints, but she again had a decreased range of motion in her left shoulder. (R. at 1401-02.) X-rays showed no abnormalities in either of Plaintiff's hands, and Dr. Tarter found no evidence of inflammatory arthritis during the exam. (R. at 1385.) Dr. Tarter “suspect[ed]” her pain came from mild osteoarthritis or a “component of chronic pain syndrome.” (R. at 1385.)

         On January 28, 2012, Plaintiff met with Dr. Harar Yusuf, M.D., for a consultative physical examination. (R. at 565-70.) She reported “9/10” pain in her left shoulder and “7/10” pain in her right knee. (R. at 565.) Dr. Yusuf reported that she was alert, oriented, able to walk without assistive devices, and had a normal station and gait. (R. at 566.) He further reported that she had “5/5” upper and lower extremity strength with no swelling. (R. at 567.) Plaintiff could make a fist bilaterally and could fully extend both hands and all fingers, however she did show a decreased range of motion in her left shoulder and had an inability to squat. (R. at 567-68.) Dr. Yusuf opined that Plaintiff should be able to sit, stand, push, pull, kneel, crawl, and crouch. (R. at 568.) He further opined that she could reach, grasp, handle, and finger objects. (R. at 568.) X-rays of her left shoulder showed mild degenerative joint disease with no evidence of dislocation, fracture, or soft tissue injury. (R. at 570.) Overall, there were no significant radiographic abnormalities. (R. at 570.)

         On March 5, 2012, Dr. James Wright, M.D., a SAMC, completed a physical RFC assessment based upon the record. (R. at 572-78.) He opined that Plaintiff had the following exertional and postural limitations: able to occasionally lift or carry 50 pounds and frequently lift or carry 25 pounds; able to stand, walk, or sit with normal breaks for a total of about 6 hours in an 8-hour workday; an unlimited ability to push and pull; occasionally able to balance, stoop, kneel, crouch, crawl, and climb ramps/stairs; and never able to climb ladders/ropes/scaffolds. (R. at 572-73.) She also had an unlimited ability to handle, finger, feel, and reach, but was only frequently able to reach overhead with her left shoulder. (R. at 574.)

         On March 7, 2012, Plaintiff returned to Parkland's orthopedic clinic for left shoulder pain. (R. at 1370-71.) She reported that the subacromial injections did not decrease her shoulder pain and requested additional therapy. (R. at 1370.) Her left shoulder had a range of motion of 90 degrees forward flexion, 90 degrees abduction, 45 degrees external rotation, and “great difficulty getting her hand behind her back.” (R. at 1370.) She had “5/5” strength in her upper extremities and an intact sensation. (R. at 1371.) She was prescribed physical therapy to help with the pain. (R. at 1371.)

         On April 25, 2012, Plaintiff began a physical therapy program at Parkland for her left shoulder. (R. at 1362-63.) She had a “moderate loss of range of motion” which caused an “impact in ability to reach overhead with dominant arm [and to] lift/carry with left arm.” (R. at 1363.) Her goals were to improve the functional reach of her left shoulder and to improve her active range of motion in her arms. (R. at 1363.)

         On June 19, 2012, Plaintiff was “self-discharged” from her physical therapy program at Parkland because she had missed several appointments and had “not followed up per recommendation.” (R. at 1298-99.) She reported an increased range of motion in her left shoulder but had failed to achieve her goals fully. (R. at 1298.)

         On August 28, 2012, Dr. Maureen A. Finnegan, M.D., of Parkland performed a subacromial decompression surgery with distal clavicle excision on Plaintiff's left shoulder. (R. at 1238-40, 1250-53, 1282-85.) The next day, Plaintiff continued to complain about pain in her left shoulder, but it was “well controlled” by her current pain medication. (R. at 1226.) She had a full range of motion in her wrist and a “5/5” wrist flexion and extension. (R. at 1226-27.) Two weeks after the surgery, Plaintiff returned for a follow-up appointment and continued to complain of pain in her left shoulder. (R. at 1210-11.) She was provided a “pain sling for comfort” and enrolled in a different physical therapy program. (R. at 1210-11.)

         On October 17, 2012, Plaintiff began physical therapy at Parkland for arm and shoulder pain. (R. at 1186-89.) She wore a sling but was “doing well with some pain.” (R. at 1186.) Her elbows were “a little stiff, ” ...

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