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Barraza v. Berryhill

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

September 18, 2017

HERMAN BARRAZA Plaintiff,
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION Defendant.

          MEMORANDUM AND ORDER ON MOTIONS FOR SUMMARY JUDGMENT

          MARY MILLOY, UNITED STATES MAGISTRATE JUDGE

         On July 14, 2016, the parties consented to proceed before a United States magistrate judge for all purposes, including the entry of a final judgment, under 28 U.S.C. § 636(c). (Docket Entry #9). The case was then transferred to this court. (Docket Entry #10). Cross-motions for summary judgment have been filed by Plaintiff Hermann Barraza (“Plaintiff, ” “Barraza”) and Nancy Berryhill (“Defendant, ” “Commissioner”), in her capacity as Acting Commissioner of the Social Security Administration (“SSA”). (Plaintiff's Motion for Summary Judgment [“Plaintiff's Motion”], Docket Entry #13; Defendant's Cross Motion for Summary Judgment [“Defendant's Motion”], Docket Entry #12). Defendant has also filed a reply. (Defendant's Response to Plaintiff's Motion for Summary Judgment [“Defendant's Response”], Docket Entry #14). After considering the pleadings, the evidence submitted, and the applicable law, the court ORDERS that Defendant's Motion be GRANTED, and that Plaintiff's Motion be DENIED.

         Background

         On March 19, 2012, Plaintiff Herman Barraza filed an application for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (“the Act”), and under Part A of Title XVIII of Act. (Transcript [“Tr.”] at 144). In his application for benefits, Barraza claimed that he has been unable to work since February 16, 2007, because he has arthritis, nerve damage in his arms, legs, back and neck, high blood pressure, depression, anxiety, and joint pain. (See Tr. at 144, 175). On June 14, 2012, the SSA found that Barraza was not disabled under the Act, and so his application was denied. (Tr. at 57-58). Plaintiff petitioned for a reconsideration of that decision, but his claim was again denied on September 4, 2012. (Tr. at 85). He then successfully requested a hearing before an administrative law judge (“ALJ”). (Tr. at 99-100). That hearing took place on September 5, 2013, before ALJ William B. Howard. (Tr. at 27-35). Plaintiff testified at the hearing and was assisted by his attorney, Donald Dewberry. (Tr. at 52-83). Dr. Robert H. Smiley, a medical expert witness, testified at the hearing, as did Kay Squires Gilreath, a vocational rehabilitation consultant. (Tr. at 71-83).

         On October 25, 2013, the ALJ engaged in the following five-step, sequential analysis to determine whether Plaintiff was capable of performing substantial gainful activity or was, in fact, disabled:

1. An individual who is working or engaging in substantial gainful activity will not be found disabled regardless of the medical findings. 20 C.F.R. §§ 404.1520(b) and 416.920(b).
2. An individual who does not have a “severe impairment” will not be found to be disabled. 20 C.F.R. §§ 404.1520(c) and 416.920(c).
3. An individual who “meets or equals a listed impairment in Appendix 1” of the regulations will be considered disabled without consideration of vocational factors. 20 C.F.R. §§ 404.1520(d) and 416.920(d).
4. If an individual is capable of performing the work he has done in the past, a finding of “not disabled” must be made. 20 C.F.R. §§ 404.1520(f) and 416.920(f).
5. If an individual's impairment precludes performance of his past work, then other factors, including age, education, past work experience, and residual functional capacity must be considered to determine if any work can be performed. 20 C.F.R. §§ 404.1520(g) and 416.920(g).

Newton v. Apfel, 209 F.3d 448, 453 (5th Cir. 2000); Martinez v. Chater, 64 F.3d 172, 173-74 (5th Cir. 1995). It is well-settled that, under this analysis, Barraza has the burden to prove any disability that is relevant to the first four steps. Wren v. Sullivan, 925 F.2d 123, 125 (5th Cir. 1991). If he is successful, the burden then shifts to the Commissioner, at step five, to show that he is able to perform other work that exists in the national economy. Myers v. Apfel, 238 F.3d 617, 619 (5th Cir. 2001); Wren, 925 F.2d at 125. “A finding that a claimant is disabled or is not disabled at any point in the five-step review is conclusive and terminates the analysis.” Lovelace v. Bowen, 813 F.2d 55, 58 (5th Cir. 1987).

         It must be emphasized that the mere presence of an impairment does not necessarily establish a disability. Anthony v. Sullivan, 954 F.2d 289, 293 (5th Cir. 1992) (quoting Milam v. Bowen, 782 F.2d 1284, 1286 (5th Cir. 1986)). Under the Act, a claimant is deemed disabled only if he demonstrates an “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death, or which has lasted or can be expected to last for a continuous period of not less than twelve months.” Selders v. Sullivan, 914 F.2d 614, 618 (5th Cir. 1990) (citing 42 U.S.C. § 423(d)(1)(A)). Substantial gainful activity is defined as “work activity involving significant physical or mental abilities for pay or profit.” Newton, 209 F.3d at 452. A physical or mental impairment is “an impairment that results from anatomical, physiological or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques.” Hames v. Heckler, 707 F.2d 162, 165 (5th Cir. 1983) (citing 42 U.S.C. § 423(d)(3)). Further, the impairment must be so severe as to limit the claimant so that “[he] is not only unable to do [his] previous work but cannot, considering [his] age, education, and work experience, engage in any kind of substantial gainful work which exists in the national economy.” Greenspan v. Shalala, 38 F.3d 232, 236 (5th Cir. 1994) (citing 42 U.S.C. § 423(d)(2)(A)).

         Based on these principles, as well as his review of the evidence presented at the hearing, the ALJ found that Barraza has not engaged in substantial gainful activity since February 16, 2007, when he last worked. (Tr. at 29). The ALJ further concluded that Plaintiff suffers from degenerative disc disease of the cervical and lumbar spine, hypertension, and obesity, and that these impairments are severe. (Id.). The ALJ also considered Plaintiff's testimony that he continues to have pain in both hands following surgery for carpal tunnel syndrome. (Id.). The ALJ determined this condition to be a non-severe impairment, because there was no objective medical evidence that Plaintiff's hands were limited in any way. (Id.). The ALJ further found that Barraza's impairments did not meet, or equal in severity, the medical criteria for any disabling impairment in the applicable SSA regulations.[1] (Id.). He then assessed Plaintiff's residual functional capacity (“RFC”), and concluded that he is capable of performing light work, [2] although he can stand and/or walk for only about four hours in an eight hour workday, and he can sit for only six hours. (Tr. at 32). The ALJ also determined that Barraza should not work at unprotected heights or around dangerous machinery, and he can only occasionally climb one flight of stairs. (Tr. at 32). With these limitations, the ALJ decided that Barraza is capable of performing his past relevant work as a security guard. (Tr. at 34). For that reason, he concluded that Barraza is “not under a disability, as defined in the Social Security Act, ” and he denied the application for benefits on October 25, 2013. (Tr. at 35).

         On November 21, 2013, Plaintiff requested an Appeals Council review of the ALJ's decision. (Tr. at 23). SSA regulations provide that the Appeals Council will grant a request for a review if any of the following circumstances is present: “(1) there is an apparent abuse of discretion by the ALJ; (2) an error of law has been made; (3) the ALJ's actions, findings, or conclusions are not supported by substantial evidence; or (4) there is a broad policy issue which may affect the public interest.” 20 C.F.R. §§ 404.970 and 416.1470. On October 7, 2014, the Appeals Council denied Plaintiff's request, finding that no applicable reason for review existed. (Tr. at 1-3). With this ruling, the ALJ's decision became final. See 20 C.F.R. §§ 404.984(b)(2) and 416.1484(b)(2).

         On April 15, 2016, Plaintiff filed this lawsuit, pursuant to section 205(g) of the Act (codified as amended at 42 U.S.C. § 405(g)), to challenge that decision. (Plaintiff's Original Complaint, Docket Entry #1). The parties have filed cross-motions for summary judgment. (Docket Entries 12, 13). Having considered the pleadings, the evidence submitted, and the applicable law, Defendant's motion for summary judgment is GRANTED, and Plaintiff's motion for summary judgment is DENIED.

         Standard of Review

         Federal courts review the Commissioner's denial of disability benefits only to ascertain whether the final decision is supported by substantial evidence and whether the proper legal standards were applied. Newton, 209 F.3d at 452 (citing Brown v. Apfel, 192 F.3d 492, 496 (5thCir. 1999)). “If the Commissioner's findings are supported by substantial evidence, they must be affirmed.” Id. (citing Martinez, 64 F.3d at 173). “Substantial evidence is such relevant evidence as a reasonable mind might accept to support a conclusion. It is more than a mere scintilla and less than a preponderance.” Ripley v. Chater, 67 F.3d 552, 555 (5th Cir. 1995); see Martinez, 64 F.3d at 173 (quoting Villa v. Sullivan, 895 F.2d 1019, 1021-22 (5th Cir. 1990)). On review, the court does not “reweigh the evidence, but . . . only scrutinize[s] the record to determine whether it contains substantial evidence to support the Commissioner's decision.” Leggett v. Chater, 67 F.3d 558, 564 (5th Cir. 1995); see Fraga v. Bowen, 810 F.2d 1296, 1302 (5th Cir. 1987). If no credible evidentiary choices or medical findings exist that support the Commissioner's decision, then a finding of no substantial evidence is proper. Johnson v. Bowen, 864 F.2d 340, 343 (5th Cir. 1988).

         Discussion

         Before this court, Barraza argues that the ALJ erred, because he did not consider Plaintiff's carpal tunnel syndrome when determining his residual functional capacity. (Plaintiff's Motion at 6, 7-11). Plaintiff also contends that the ALJ ignored the testimony from the medical expert witness when he concluded that Barraza was capable of doing light work, rather than only sedentary work. (Plaintiff's Motion at 6, 11-14). Finally, Plaintiff complains that the ALJ incorrectly concluded that he could perform his past work as a security guard even though his physical limitations, as described by the ALJ, prevent him from meeting all of the job requirements for that position. (Plaintiff's Motion at 6, 14-16). Defendant insists, however, that the ALJ properly considered all of the available evidence, and followed the applicable law, in determining that Barraza is not disabled. (Defendant's Motion at 4).

         Medical Facts, Opinions, and Diagnoses

         The earliest medical records show that Plaintiff was treated at the Veterans Administration Medical Center in October, 2001. (Tr. at 577-580). An x-ray of his right shoulder was normal. (Tr. at 565). X-rays of both knees revealed bone spurring on both kneecaps.[3] He complained of back pain, and x-rays showed that his lumbar spine was normal, but he had degenerative changes in the lower thoracic spine. (Tr. at 561, 564). Barraza was seen at the VA clinic's eye care center on November 1, 2001, as part of a new patient evaluation. (Tr. at 546). He complained of hypertension, as well as arthritis in his right shoulder, hips, and knees. (Tr. at 546-547).

         An MRI of the left knee was completed on January 9, 2002, at the request of Dr. John Vanderpool. (Tr. at 558, 560-561). That examination showed that Barraza had tendonitis, which was caused by calcium deposits in the muscles surrounding the knee, but no structural defect or damage to the knee was apparent. (Id.). X-rays of the lower back were repeated. (Tr. at 557-558). This time, the x-rays were interpreted to show spondylosis throughout the lumbar spine with small anterior osteophytes.[4]

         The following year, in May of 2003, Barraza went to the Bay Area Neurology for an EMG because of pain and tingling in his left arm and hand. (Tr. at 501-505). Dr. Edward Good (“Dr. Good”) believed the test showed mild carpal tunnel syndrome in the left hand and wrist. (Tr. at 500). Dr. Good did posit that it was possible that the left hand complaints were caused by pressure on the spinal nerve root at the junction of the cervical spine and the thoracic spine. (Tr. at 500). One week after the EMG was completed, Barraza returned to Dr. Good's office. (Tr. at 506). While at work that day, Barraza developed a sharp, severe pain in his back, which was accompanied by numbness and tingling in his face. (Id.). He also complained of pain under his left arm when turning his head to the left and raising his arm. (Id.). Dr. Good's neurological examination of Plaintiff was unremarkable. Plaintiff's strength, reflexes, and sensations were intact and normal. (Tr. at 506). Dr. Good recommended an MRI of the cervical spine, but the results of that test are not included in the administrative record. (Id.).

         Plaintiff next went to see Dr. Michael Brown (“Dr. Brown”), at The Hand Center, to have surgery on his left hand and arm. (Tr. at 509). He told Dr. Brown that for several months, he had experienced numbness and tingling in the fingers and fingertips of his left hand. (Id.). Dr. Brown's examination of Barraza revealed symptoms consistent with carpal tunnel syndrome. (Tr. at 509). A nerve conduction study confirmed that diagnosis, and also ruled out a nerve injury in the neck as a cause of the numbness in his hands. (Tr. at 510-511). Barraza was also diagnosed with tennis elbow in his left arm. (Tr. at 508). Dr. Brown operated on Plaintiff's left hand and elbow on July 15, 2003, to correct the tennis elbow and carpal tunnel syndrome. (Tr. at 496-498).

         On June 10, 2004, Barraza told Dr. Benny Sanchez (“Dr. Sanchez”), of Doctor's Hospital - Tidwell, that he had experienced pain in his neck and upper left arm for more than six months. (Tr. at 367). Dr. Sanchez diagnosed a pinched nerve in his neck, and, because conservative treatment had not been successful, he recommended a cervical epidural steroid injection. (Tr. at 62, 367). That procedure did succeed in reducing Plaintiff's pain, and a second injection took place on July 26, 2004. (Tr. at 365).

         Dr. Terry Newman (“Dr. Newman”) treated Plaintiff on March 8, 2005, for high blood pressure. (Tr. at 328). Dr. Newman's records show that Barraza had been taking medication to control his blood pressure, but he wanted to discontinue the medication. (Id.). Because his blood pressure was still borderline high, the doctor decided to continue the medication. (Id.). Plaintiff then had surgery for carpal tunnel syndrome on his right hand in March of 2006. (Tr. at 518, 330). Plaintiff testified that this surgery was necessary because he injured his hand while assembling air conditioning units at work. (Tr. at 61). The next record of treatment is dated October 27, 2006, when Plaintiff saw Dr. Benjamin Guillermo (“Dr. Guillermo”) at Gulf Coast Medical Group to review and refill his prescriptions for Tricor and Caduet.[5] (Tr. at 285).

         On December 18, 2006, Barraza went to the emergency room at Clear Lake Regional Medical Center, complaining of left arm and left leg pain, as well as facial numbness. (Tr. at 255). He was worried because the pain originated in his chest and radiated to his extremities. (Id.). Several cardiac tests were completed, but they did not explain his complaints of chest or arm pain. (Tr. at 257-258). An MRI of the cervical spine showed mild degenerative changes in Barraza's neck, but no herniations or narrowing of the spinal canal. (Tr. at 259-260). An x-ray confirmed degenerative changes at the level of C2-3. (Tr. at 264). An MRI of the lumbar spine showed a herniated disc at the L5-S1 level in his lower back. (Tr. at 262-263).

         Barraza then saw Dr. Guillermo on December 20, 2006, complaining of headaches, neck pain, left arm pain and pain down his left side. (Tr. at 283). X-rays of the lumbar spine revealed minimal bone spurring in the upper lumbar spine and lower thoracic spine. (Tr. at 312). Cervical spine x-rays showed arthritis in his neck at the C2-C3 level, and mild narrowing of the disc spaces at the C5-C6 level. (Tr. at 313). Dr. Guillermo prescribed Flexeril, a muscle relaxant, and methylprednisolone, a steroid used to treat inflammation from arthritis. (Tr. at 283). He also referred Plaintiff to Dr. Ali Javanshir (“Dr. Javanshir”) for a neurological evaluation. (Tr. at 283). Dr. Janvashir, at Omega Neurology, treated him on December 28, 2006. (Tr. at 314). Plaintiff explained to Dr. Janvashir that his neck and back pain had occurred suddenly about two weeks earlier while he was driving. (Tr. at 314). Although he had pain in his neck radiating to his left arm, and pain in his lower back extending into his left leg, he did not have any weakness or difficulty in walking. (Tr. at 314). When Dr. Janvashir examined him, Barraza did not have any spinal pain, was able to walk normally, and had a normal sensation in his fingers and toes. (Tr. at 315-316). Dr. Javanshir considered several possible causes of Plaintiff's pain, including spinal stenosis, entrapped nerves, nerve damage, either at the spine or in the extremities (polyradiculopathy and polyneuropathy), and multiple sclerosis. (Tr. at 316). He recommended an MRI of Plaintiff's brain and spine, and an emg/nerve conduction study of his left arm and leg. There is no evidence these tests were ever completed. (Tr. at 317).

         Plaintiff again complained of back pain to Dr. Rajeswari Rajan (“Dr. Rajan”), at Gulf Coast Medical Group, on April 4, 2007, when he sought treatment for a rash. (Tr. at 281). Dr. Rajan reported that Barraza had a reduced range of motion, but a normal heel/toe walk. (Tr. at 281). Dr. Rajan prescribed an antifungal cream for the rash, and refilled Plaintiff's prescriptions for Caduet, Tricor, Flexeril, and Vicodin, a painkiller. (Tr. at 281). Barraza saw Dr. Rajan again for an annual physical on April 18, 2007. (Tr. at 279-280). Dr. Rajan listed obesity, spondylosis, high cholesterol, and high blood pressure, when describing Barraza's health conditions. (Tr. at 279). Dr. Rajan's physical examination showed no abnormalities in Plaintiff's upper or lower extremities, and normal coordination without sensory or motor deficits during the neurological examination. Dr. Rajan did report that Plaintiff had a reduced range of motion during the examination. (Tr. at 279). Dr. Rajan counseled Plaintiff to diet and to exercise, and to return in one month. (Tr. at 279). Barraza went back to Dr. Rajan on April 30, 2007, complaining of pain in the right side of his abdomen, reporting that the pain had begun a month earlier. (Tr. at 277). Dr. Rajan ordered an ultrasound of the abdomen that showed a slightly enlarged liver, but no other abnormalities. (Tr. at 309). Plaintiff returned to Gulf Coast Medical Group on August 22, 2007, to have his prescriptions refilled. (Tr. at 274). He complained that his medications were not strong enough, and he was prescribed Soma in place of Flexeril, and given Norco, a stronger version of Vicodin. (Tr. at 274). During the examination, Dr. Rajan reported that Plaintiff had a reduced range of motion in his spine. (Tr. at 274). He again instructed Barraza to diet and exercise, and return in one month. (Tr. at 274).

         Barraza continued to complain of neck pain when he returned to Dr. Guillermo on November 1, 2007. (Tr. at 271). Although he did not have low back pain at that time, he complained of neck pain radiating to both shoulders and arms. (Tr. at 271). He also complained that the pain was worse on the left side. (Id.). Dr. Guillermo found Plaintiff to have a normal range of motion in his shoulders and neck, but he did complain of discomfort when bending his neck. (Id.). He walked with a normal gait, had no muscle weakness, tingling or numbness, and no joint stiffness. (Tr. at 271). Dr. Guillermo replaced the Norco prescription with Darvocet and Flexeril, and ordered an MRI and x-rays of his neck. (Tr. at 272). The x-ray showed arthritis at ¶ 2-C3 and C5-C6 with some narrowing of the opening where the nerve exits the spine at ¶ 5-C6. (Tr. at 308). An MRI showed bone spurring at the C5-C6 level that pressed into the spinal canal and caused narrowing of the opening for the nerves. (Tr. at 300). There was also a small disc bulge at ¶ 3-C4. (Id.). An x-ray of the low back showed bone spurring at several levels, but, did not show any significant structural problems with the lumbar spine. (Tr. at 297). Dr. Guillermo discussed the results of these studies with Plaintiff on November 19, 2007. (Tr. at 269). At that time, Barraza still complained of neck pain radiating into both arms, but he now also complained of low back pain radiating into his legs. (Tr. at 269). A straight leg test was positive, and Plaintiff complained of tenderness in his lower back.[6] (Tr. at 269). However, he had a normal gait when Dr. Guillermo examined him, and the doctor saw no evidence of spinal tenderness, muscle spasms, or abnormal motor, sensory or reflex responses. (Tr. at 269). Dr. Guillermo prescribed Ultram, and told Plaintiff to see a spine specialist. (Tr. at 269-270).

         Dr. Newman saw Plaintiff on February 25, 2008, to treat his hypertension and high cholesterol. (Tr. at 267). Barraza did not describe any significant neck or back complaints at that time, and he had no edema or abnormal pulses in his extremities. (Id.). Dr. Newman refilled Plaintiff's blood pressure medication. The next medical record available is from August 19, 2008, when Plaintiff returned to the VA clinic. (Tr. at 536). At that time, he complained of pain in his neck and shoulders, lower back, and left knee. (Tr. at 539). Plaintiff told Dr. Ronald Marek (“Dr. Marek”) that he had received a series of three injections in his neck and back between November 2007, and January 2008, because of pain radiating into his arms and legs.[7](Tr. at 536). He also told Dr. Marek that the injections relieved his pain for only a month, at most, and that the only medications he was taking were Caduet for hypertension, and ibuprofen. (Tr. at 536). During the examination, Plaintiff had a full range of motion in his neck, without any significant limitations. (Tr. at 539). Although Plaintiff complained of back pain, Dr. Marek saw no evidence of a neurological deficit in his spine. (Tr. at 535). Dr. Marek prescribed naproxen and gabapentin for the back pain.[8] (Tr. at 535).

         On December 1, 2008, Plaintiff returned to the VA clinic for treatment. (Tr. at 531). During this visit, Dr. Marek reported that Barraza did not have any weakness, numbness, or tingling in his extremities, and he saw no sign of any motor or sensory deficits. (Tr. at 532, 533). The doctor also noted that Plaintiff's “walking distance [was] not limited.” (Tr. at 532). Plaintiff was prescribed naproxen and gabapentin for pain and inflammation, and continued on medication for high cholesterol and high blood pressure. (Tr. at 532). He was referred to the nutrition clinic for help with his diet and weight loss, but he did not attend that appointment. (Tr. at 530).

         On April 1, 2009, Plaintiff was seen again at the VA clinic. (Tr. at 524). He complained of pain on the left side of his body. (Tr. at 523). Dr. Marek found no neurological deficits and no motor or sensory deficits during his examination of Plaintiff. (Tr. at 525-526). Plaintiff told the doctor that he was not taking his pain medication, but instead occasionally used his wife's Vicodin. (Tr. at 526). Dr. Marek prescribed gabapentin and started Plaintiff again on Piroxicam in place of naproxen. (Tr.at 523, 526).

         Dr. John Samuel ordered an echocardiogram on July 7, 2009. (Tr. at 432). The right ventricle of Plaintiff's heart was found to be enlarged, and he had mild mitral valve regurgitation, but there were no other abnormalities found. (Tr. at 432). A treadmill exercise stress test did not show any problems with the function of his heart during exercise. (Tr. at 433). An x-ray of the cervical spine was interpreted to show degenerative disc disease throughout the spine, as well as narrowing of the neural foramen on the right side at ¶ 3-C4, C4-C5, and both sides at ¶ 5-C6. (Tr. at 428). A lumber spine x-ray showed degenerative changes throughout the lower back, with disc space narrowing and osteophytes. (Tr. at 427). Later that month, Plaintiff described a history of back pain and numbness/tingling in his arms to Dr. Asha Samuel (“Dr. Samuel”). (Tr. at 415). He also complained of pain in both of his arms and shoulders, his left hip, and his left leg. (Tr. at 410). On September 14, 2009, he again complained of left hip pain. Dr. Samuel treated these complaints with Celebrex. (Tr. at 407). On October 19, 2009, Barraza complained that his “whole body hurt.” (Tr. at 406). Plaintiff went back to the VA clinic nine days later, on October 28, 2009. (Tr. at 520). At that time, he complained of pain in his left arm and hand. (Tr. at 515). He did not complain of any acute episodes of back pain during this visit. (Tr. at 516). His medications were changed to Tramadol, cyclobenzaprine, and Celebrex.[9] (Tr. at 516).

         On November 11, 2009, Plaintiff saw Dr. Samuel after two days of severe back pain that radiated to his left leg. (Tr. at 405). He told Dr. Samuel that he did not have numbness or weakness in his leg, but he described his pain to be at a level of “8 to 9 out of 10.” (Tr. at 405). X-rays of the lumbar spine were similar to the previous films and showed degenerative disc disease throughout the lower back, but worsening at the L1-L2 and L2-L3 levels. Dr. Samuel prescribed Flexeril and Ultram and referred him to a pain management doctor. (Tr. at 405). Two weeks later he returned to Dr. Samuel for a follow up examination. (Tr. at 404). He told Dr. Samuel that his back was better, but there is no indication that he had seen a pain management doctor. (Id.). The records from this treatment show that Plaintiff told Dr. Samuel the “spine surgeon wants [him] to lose weight.”[10] (Tr. at 404).

         On April 5, 2010, Plaintiff complained to Dr. Samuel that he had low back pain and intermittent shoulder pain. (Tr. at 403). Barraza wanted Dr. Samuel to refill the prescriptions for Celebrex, Flexeril, and Tramadol. (Tr. at 403). Dr. Samuel diagnosed “degenerative disc disease” of the spine, told Plaintiff to exercise, and refilled his prescriptions. (Tr. at 403). On September 10, 2010, Plaintiff bent over to lift a basket of laundry when he felt a shooting pain in his lower back and right leg. (Tr. at 402). He saw Dr. Samuel four days later, and the doctor continued the prescriptions for Flexeril and Celebrex. (Id.). Plaintiff was then seen at the VA clinic on August 31, 2010. (Tr. at 514). During this visit, he complained of pain in his left arm and hand. (Id.). Although his history of chronic back pain was included in a list of “active problems, ” Plaintiff listed only medications for depression, high blood pressure, and high cholesterol, and did not list Flexeril or Celebrex, when identifying his current medications. (Tr. at 514). Dr. Utpal Ghosh told Plaintiff to take ibuprofen for the hand pain, and also prescribed Celebrex, Tramadol, and Flexeril for his back pain. (Tr. at 515).

         Barraza returned to Dr. Samuel on October 14, 2010, to review the results of blood tests to monitor his high cholesterol and hypertension. (Tr. at 401). He complained of low back pain at this visit. (Tr. at 401). The following month, on November 23, 2010, Plaintiff told Dr. Samuel that his lower back hurt, and the pain radiated into both legs. (Tr. at 399). Dr. Samuel reported that Plaintiff was not in any distress and did not want to see an orthopedic doctor, but instead wanted to return to pain management. (Tr. at 399). Plaintiff was continued on Tramadol and Flexeril, as well as the medications for high cholesterol and hypertension. (Tr. at 399). Dr. Samuel then sent Plaintiff to see Soraya Hoover, M.D. (“Dr. Hoover”), because he was having difficulty in sleeping. (Tr. at 370). Dr. Hoover diagnosed a deviated septum, and Plaintiff had surgery to correct that problem on November 4, 2010. (Tr. at 370). Plaintiff saw Dr. Samuel on March 7, 2012, for ongoing pain in his back, shoulder, hip and knee. (Tr. at 392). Plaintiff was “not in any distress, ” and Dr. Samuel did not find any neurological deficits. (Tr. at 392). The doctor told Plaintiff to exercise, and continued his pain medications. (Tr. at 392).

         On May 14, 2012, Barraza was examined by Dr. Manoj Vakil (“Dr. Vakil”), a doctor of internal medicine acting on behalf of the state. (Tr. at 455-457). Plaintiff told Dr. Vakil that his neck and back pain began five years earlier. (Tr. at 455). He claimed that his low back pain was getting worse, and he described it as a constant dull pain that radiates into his legs. (Tr. at 455). He also said that his neck and upper back pain radiates into his shoulders and arms. (Id.). Plaintiff explained that his back pain worsens if he sits in one position for more than 20 minutes, or if he lifts objects weighing more than 30 pounds. (Tr. at 455). Plaintiff was able to walk on his toes and heels, and could get on and off the examination table without help. (Tr. at 456). Dr. Vakil examined Plaintiff's spine and said that Barraza had a normal range of motion in both his neck and lower back, with no indications of any muscle spasms. (Tr. at 456-457). Plaintiff also had the full range of motion in his hips, knees, ankles, elbows, shoulders and wrists. (Tr. at 457). A straight leg raising test was negative, and there was no muscle atrophy, loss of sensation, or loss of reflex. (Tr. at 456-457). Barraza could squat, but he could not hop, because of his back pain. (Tr. at 457). He told Dr. Vakil that he is able to drive, and that he helps his wife cook and clean the house. (Tr. at 455). An x-ray of the lumbar spine was interpreted by Dr. Ali Salehi, a radiologist, to show mild degenerative changes and bony spondylosis in the lumbar spine. (Tr. at 459). An EKG showed non-specific ST-T wave changes, a finding that ruled out a past heart attack, but not other primary or secondary heart problems. (Tr. at 457). From this examination, Dr. Vakil concluded that Plaintiff is able to sit, stand, move around, and lift and carry objects weighing up to thirty pounds without any problem. (Tr. at 457).

         Using Dr. Vakil's report from this examination, Dr. Hajra Madani (“Dr. Madani”), an internal medicine doctor acting on behalf of the state, prepared an evaluation of Barraza's physical residual functional capacity. (Tr. at 461-468). Dr. Madani listed “mild lumbar degenerative disc disease” and high cholesterol as the diagnoses for Plaintiff. (Tr. at 461). She found that Plaintiff could occasionally lift or carry items weighing up to fifty pounds, and could frequently lift or carry items weighing up to twenty-five pounds. (Tr. at 462). She also found that he could stand and/or walk for about six hours in an eight hour work day; he could sit for the same amount of time; and that he could perform an unlimited amount of pushing and pulling, within the weight limitations previously stated. (Tr. at 462). Dr. Madani found that Barraza had no postural limitations, no manipulative limitations, no visual limitations, no communication limitations, and no environmental limitations. (Tr. at 463-465). Dr. Madani determined that the alleged severity and limiting effects of Plaintiff's impairments were not fully supported by the medical evidence. (Tr. at 545). Dr. Madani also said that it was reasonable to assume that Plaintiff had the same level of function for the six month period before Dr. Vakil's examination. (Tr. at 468).

         Dr. Roberta Herman, an internist retained by the state, reviewed the conclusions by Dr. Vakil and Dr. Madani, on September 4, 2012, during the reconsideration of Plaintiff's claim for disability benefits. (Tr. at 474). Dr. Herman agreed with their findings, and pointed out that Plaintiff had not followed up with a doctor for his back pain since the examination by Dr. Vakil. (Tr. at 474).

         Educational Background, Work History, and Present Age

         At the time of the hearing, Barraza was 54 years old. (Tr. at 54, 484). He had dropped out of high school in the eighth grade, had joined the job corps, and had earned his GED. He then joined the United States Navy as a machinist in 1981. (Tr. at 56, 144, 58, 538). He served in the Navy for twenty years, during which he was stationed overseas in the Persian Gulf War. (Id.). He was honorably discharged from the Navy on April 30, 2001. (Id.). He received a 10% service connected disability rating for tinnitus caused by his service in the military. (Tr. at 515). After leaving the Navy, he worked as a machinist for Baker Oil from 2001 until 2005. (Tr. at 182). He then worked as a security guard for five months before going to work at Lennox, where he assembled air conditioning units. (Tr. at 182). He returned to work as a security guard in May, 2006, and continued in that position until March, 2007, when he stopped working altogether. (Tr. at 182).

         Subjective Complaints

         Barraza claims that he has been unable to work since February 16, 2007, because of arthritis in his neck, back, shoulders and knees. (Tr. at 144, 190). He explained that his neck stiffens up, begins to hurt, and the pain then spreads through both shoulders and down his arms, and he cannot grasp or hold his gun. (Tr. at 62-63). He does not have any trouble raising his arms above shoulder level, but his hand cramps if he writes more than a few lines, or types for more than five minutes. (Tr. at 66-67).

         He also has daily pain in his lower back that is only partially relieved by the medications that he takes. (Tr. at 65). Because of his lower back pain, he is not able to bend over to pick up objects off the floor or walk long distances. He said that his back pain is the primary reason he is not able to work, because he is not able to walk around the property and the parking lot. (Tr. at 64, 68). Plaintiff tries to use Vicodin only at night to help him sleep, because he is worried about becoming addicted. (Tr. at 65-66). To cope with back pain during the day, he adjusts his sitting position, and will also lie down once or twice for an hour or more. (Tr. at 66). He sleeps in a loveseat, and has to change his position every couple of hours, because of his back pain. (Tr. at ...


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