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Dolores M. Reid v. Michael J. Astrue

April 19, 2011

DOLORES M. REID, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Judge Edmond E. Chang

MEMORANDUM OPINION AND ORDER

Plaintiff Dolores Reid seeks judicial review of the Social Security Administration's (SSA) denial of disability insurance benefits under the Social Security Act, 42 U.S.C. §§ 416(i) and 423. Before the Court is Reid's motion for summary judgment seeking an award of benefits, or in the alternative, a remand for further proceedings. R. 14.*fn1 For the reasons stated below, Reid's motion is granted insofar as the denial is vacated and the case is remanded for further proceedings.

I.

A.

Reid filed for disability insurance benefits in September 2005, alleging that she became disabled on February 8, 1999. Tr. 65.*fn2 Reid's claim was denied initially in January 2006, and again denied upon reconsideration in April 2006. Tr. 60-61, 80, 88. In May 2006, Reid filed a timely written request for a hearing before an administrative law judge (ALJ). Tr. 93. On April 22, 2008, Reid, represented by counsel, appeared and testified before an ALJ. Tr. 17. A vocational expert (VE) was the only other witness who testified at the hearing. Tr. 49-58. In September 2008, the ALJ issued a written decision denying Reid's claim for benefits. Tr. 73. The SSA's Appeals Council denied Reid's request for review of the ALJ's decision on September 1, 2009, making the ALJ's decision the final decision of the Commissioner under 42 U.S.C. § 405(g). Tr. 2-4; 20 C.F.R. § 404.981. Thereafter, Reid requested an extension to respond to the Appeals Council's denial of review and timely filed her complaint with this Court on November 3, 2009. R. 1.

B.

1. Education and Work History Reid was born in 1960, and was 38 years old at the time of her alleged disability onset date. Tr. 24-25, 184. She is five feet and five inches tall and weighs approximately 180 pounds. Tr. 24. Academically, she did not progress beyond ninth or tenth grade and did not earn a GED. Tr. 24. From 1991 to 1992, Reid worked as a telemarketer. Tr. 190. From April 1996 to November 1998, Reid worked as a bartender and cashier at Land Oak Liquors. Tr. 25, 199. In 2000, she worked for a short period at McCormick Food Services. Tr. 25. March 30, 2004 is the last date Reid was insured and eligible for disability insurance benefits. Tr. 22, 85.

2. Medical Evidence

Reid was diagnosed with diabetes mellitus at the age of twenty-three and, as a result, suffers from peripheral neuropathy and chronic open-angle glaucoma. Tr. 67-68. Reid's other physical ailments include arthropathy and tendonitis in her right shoulder and osteopenia of the right hip. Tr. 68. Reid also suffers from depression. Tr. 484. She takes various prescription medications to treat her physical and mental illnesses. R.194-95. To support her claim for benefits, Reid submitted numerous medical reports from her treating physicians dating September 2003 to April 2008.

a. Evidence of physical impairments Reid has insulin-dependent diabetes mellitus. Tr. 297, 371. She has been hospitalized and treated several times for low blood sugar. Tr. 265-72. Reid also suffers from diabetic peripheral neuropathy. Tr. 122, 371. In October 2003, Reid underwent testing due to complaints of numbness and tingling in her legs and feet. Tr. 275. The electromyogram (EMG) nerve conduction study over Reid's bilateral lower extremity was "suggestive of moderately severe peripheral neuropathy without evidence of denervation." Tr. 273. The test results were sent to Reid's primary care physician, Dr. Nitin Sardesai, who has been treating Reid since 2003. Tr. 273-75, 371. Subsequent examinations have revealed decreased sensation in her legs. Tr. 121, 124. Reid also has a medical history of glaucoma and diabetic retinopathy, which has caused her vision to deteriorate. Tr. 133, 139, 366, 371.

In addition to her regular visits to Dr. Sardesai, Reid's medical record shows several visits to other doctors for treatment related to pain in her lower extremities, shoulders, and hips. For instance, Reid saw rheumatologist Dr. Keith Reich for the first time on September 9, 2003. Tr. 311. At that consultation, Reid reported that her left leg went numb after sitting for an hour and a half. Tr. 311. According to Dr. Reich, Reid stated that she felt better when walking, but standing was much more difficult. Tr. 311. Dr. Reich's examination of Reid's left shoulder revealed restriction in internal rotation with evidence of impingement and subacromial bursal tenderness. Tr. 312. An x-ray of Reid's right shoulder taken on September 13, 2003 showed "mild degenerative arthritic changes in the AC joint and glenohumeral joint." Tr. 279. Dr. Reich examined Reid again on December 2, 2003 and noted that her chief complaint was pain in her right shoulder and left hip. Tr. 309. According to Dr. Reich, Reid reported that the pain in her hip ran down her leg, and became worse when sitting and lying on it at night. Tr. 309. Dr. Reich's notes reflect that Reid told him that she had been experiencing this pain for a couple of months and it was getting worse. Tr. 309.

On October 8, 2004, Dr. Reich examined Reid's right shoulder and found restriction in internal rotation to about 80 degrees and external rotation to about 85 degrees, with significant restriction in movement away from her mid-line. Tr. 307. The doctor recommended formal physical therapy on her right shoulder. Tr. 307. In March 2005, Reid's complaints of severe pain in her right shoulder prompted an MRI. Tr. 295. The MRI showed some problems with the tendon and Reid was recommended for further evaluation. Tr. 295. An MRI of Reid's left hip was also done in March 2005. Tr. 294. This MRI showed no evidence of fractures or dislocations and her bone density was normal. Tr. 294.

On August 24, 2005, Dr. Reich saw Reid for a rheumatologic follow-up. Tr. 296. In reporting the results of his exam to Dr. Sardesai, Dr. Reich stated that Reid's "hip problem has been going on now for probably almost two years." Tr. 296. He reported that Reid "appeared uncomfortable" on exam and "[h]er gait was slow." Tr. 296. Dr. Reich referred Reid for an MRI of her hips, which was taken on August 25, 2005. Tr. 288. The MRI showed that the osseous structures were all intact and no periarticular fluid collections were detected. Tr. 288. It also indicated that the supporting soft tissue structures were unremarkable in appearance. Tr. 288. The MRI of Reid's right hip found no significant radiographic abnormalities. Tr. 289. However, one month later, Reid was diagnosed with osteopenia (the abnormal reduction of bone) in her right hip. Tr. 252.

Reid's medical record also contains several reports from Dr. William Dodson, a board certified physician in physical medicine and rehabilitation. Tr. 120-29, 148-150. Dr. Sardesai referred Reid to Dr. Dodson for pain evaluation. Tr. 120. In 2007, Dr. Dodson observed decreased sensation in Reid's lower extremities. Tr. 149. He also noted that "[p]ulses are difficult to palpate in the lower extremities." Tr. 149. Throughout Reid's course of treatment, Dr. Dodson tracked her pain medication and occasionally increased it for better relief. Tr. 125, 423-37.

b. Evidence of mental impairments

According to the documents in the record, Reid's treating physicians began observing her mental distress in 2003. In December 2003, Dr. Reich reported to Dr. Sardesai that he saw Reid in September 2003, shortly before her mother died. Tr. 309.

He noted that, as of December 2003, Reid was "still underneath a fair amount of stress, as her mom has passed away and her mother-in-law is quite ill and is apparently close to death as well." Tr. 309. In October 2004, Dr. Reich reported that Reid was "under a lot of stress in the last year with having the anniversary of her mother's passing away and a sister who was murdered earlier this year." Tr. 306. Dr. Reich observed that "[t]his has really overall been a bad year for her and she seems to be just getting by." Tr. 306.

In May 2007, Dr. Sanker Jayachandran, an adult psychiatrist, evaluated Reid, noting her diagnoses of generalized anxiety disorder, bipolar disorder, and peripheral neuropathy. Tr. 488-91. In October 2007, Dr. Jayachandran completed another psychiatric assessment and treatment plan for Reid. Tr. 480-85. Noting that Reid had been depressed for one year, Dr. Jayachandran diagnosed her with major depressive disorder and prescribed Lexapro. Tr. 484-84. In November 2007, Dr. Jayachandran completed a medical assessment of Reid's ability to do mental work-related activities. Tr. 100-02. He explained that Reid has mood swings, poor concentration, and major depressive disorder. Tr. 101. He stated that Reid "avoids social situations . . . and does not attend consistently to personal grooming." Tr. 101. Overall, Dr. Jayachandran ranked Reid's ability to adjust to a job as very poor. Tr. 100-01.

c. State agency physicians

Non-examining state agency medical consultants evaluated Reid's file in 2005 and 2006. With respect to Reid's condition, the state agency physicians acknowledged the following allegations: diabetes, rheumatoid arthritis, osteoporosis, neuropathy in both legs and feet, joint replacement in the second toe of the right foot, cyst on left hip, depression, and glaucoma. Tr. 327. However, the state agency physicians opined that there was not enough medical evidence to establish a disabling condition before March 31, 2004. Tr. 327-28, 357. Similarly, the state agency physicians found insufficient medical evidence to document a severe mental condition before March 31, 2004. Tr. 325, 359.

3. Hearing Testimony

a. Reid

At the administrative hearing, Reid testified that between February 1999 and March 2004 she "could hardly move" and experienced severe pain in her feet for years. Tr. 25, 30-31. She explained that her neuropathy was very bad and there were days when she couldn't even stand because "her legs and feet would swell so bad." Tr. 26. She would have to sit down after 30 to 45 minutes of standing. Tr. 28. Reid described the pain as feeling "like somebody has taken a knife and literally is stabbing me in my feet." Tr. 30. She estimated that the pain in her feet started approximately nine to ten years before the hearing. Tr. 41. Reid stated that around 2004 her rheumatologist, Dr. Reich, recommended that she use a cane to help with the pain in her legs and feet, as well as the severe arthritis in her hip. Tr. 36. While using the cane in her right hand, Reid is unable to carry anything with her left. Tr. 36. Reid testified that she uses the cane "most of the time," including around her house. Tr. 36. She stated that she can only spend one to two hours total on her feet each day. Tr. 43-44. Reid testified that she is often in bed by 7:00 p.m. because her pain worsens in the evening and "there's no reason to stay up." Tr. 44.

Reid testified that she was diagnosed with glaucoma in 2003. Tr. 32. She stated that she has cloudy vision, which gets worse when her sugar is low. Tr. 32. Reid's low sugar episodes have also caused her to pass out, sometimes behind the wheel of a car. Tr. 33. Reid testified that, before March 31, 2004, the paramedics visited her home several times to treat incidents of very low sugar. Tr. 45-46.

Regarding her mental health, Reid testified that she first experienced depression at 22 years old, after her infant son was killed in a car accident. Tr. 41-42. She also recalled being depressed in the late-1990s when she discovered her first husband dead in bed. Tr. 41. Reid testified that her depression worsened after her mother and sister died approximately four years before the hearing. Tr. 40. At the time of the hearing, Reid stated that she was depressed three to four times per week. Tr. 39. She testified that her bipolar disorder causes her to experience manic states where she feels overly elated. Tr. 39.

Reid also testified that she began seeing Drs. Sardesai, Legaspi, Dodson and Reich about five years prior to the hearing. Tr. 44-45. She had only been seeing her psychiatrist, Dr. Jayachandran, for around one year before the hearing. Tr. 45. Reid takes a long list of prescription drugs to treat her physical pain and mental illnesses, including Vicodin, Neurontin, Lexapro, and Xanax. Tr. 30-32. Her medication has caused her to gain weight over the years. Tr. 28.

Reid testified that she was not able to take care of herself before March 31, 2004. Tr. 26. Rather, she needed her husband and his children to help her clean and "get around places." Tr. 26. Reid stated that she could not lift anything heavy around the house, but she could dust. Tr. 27. Reid testified that she could do some grocery ...


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