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Norma S. Delgado v. Michael J. Astrue

March 7, 2012


The opinion of the court was delivered by: Jeffrey T. Gilbert Magistrate Judge


Claimant Norma S. Delgado ("Claimant") brings this action seeking review of the decision by Respondent Michael J. Astrue, Commissioner of Social Security ("Commissioner"), in which the Commissioner denied Claimant's application for Supplemental Security Income ("SSI") under Section 1614(a)(3)(A) of the Social Security Act. 42 U.S.C. § 1382c(a)(3)A). This matter is before the Court on Claimant's motion for summary reversal or remand [Dkt.#19]. Claimant argues that the Commissioner's decision is not supported by substantial evidence and is contrary to the legal standard for determining disability set forth in the federal regulations. Claimant raises the following issues in support of her motion: (1) whether the ALJ failed to address evidence regarding Claimant's mental impairments from her treating psychiatrist Dr. Cruz and (2) whether the ALJ erred in finding Claimant less than credible. For the reasons explained in this Memorandum Opinion and Order, Claimant's motion is granted in part and denied in part, and the case is remanded to the Social Security Administration for further proceedings pursuant to this opinion.


A.Procedural History

Claimant initially filed for SSI on March 31, 2008, alleging a disability onset date of April 13, 2006 due to depression and injury to her feet and ankles. R.10, 90, 108. The Social Security Administration ("SSA") initially denied her application on May 20, 2008, and again upon reconsideration on August 8, 2008. R.38-39. On November 18, 2009, Claimant appeared before Administrative Law Judge ("ALJ") John L. Mondi. R.7-16. Only Claimant, who was unrepresented, and her sister-in-law testified at the hearing.

R.10. No medical or vocational experts were heard. On January 14, 2010, the ALJ rendered a decision finding that Claimant was not disabled under the Social Security Act.

R.16. The ALJ determined that Claimant had not engaged in substantial gainful activity ("SGA") since March 31, 2008; that she had severe physical impairments, but could ambulate effectively; that she did not have a severe mental impairment; that she had the residual functional capacity ("RFC")*fn1 to perform the full range of sedentary work; and that she was unable to perform any past relevant work, but could perform a significant number of jobs in the economy. R.13-16. On March 2, 2011, the Appeals Council denied Claimant's request for review, making the ALJ's decision the final decision of the Commissioner. R.1. On September 19, 2011, Claimant filed this action for review pursuant to 42 U.S.C. § 405(g).

B.Hearing Testimony -- November 18, 2009

1.Claimant Norma S. Delgado

At the time of the hearing, Claimant was 34 years old and single with three children, ages 4, 10, and 12. R.29. Claimant completed school through the 8th grade and was working on her GED at the time of the hearing. Id. She had past work experience as a babysitter and a host at IHOP. R.30. She also had been a cashier, waitress, and press operator. R.31. Claimant testified that her job at IHOP ended after a month because it was hard to be on her feet for long periods of time. Id.

On April 13, 2006, when Claimant alleged her disability began, she went to the hospital because of pain that spread from her foot to her knee. R.31. Claimant testified that she can walk half a block before she starts to experience pain. R.32. Due to her difficulty climbing stairs, she moved to a first floor residence. R.32-33. Claimant wears braces on both feet when she drives or is in severe pain. R.33. She also had to wear a boot for three weeks. Id. Claimant testified that she has fallen twice because of her ankles. Id.*fn2

In addition to pain in her feet, Claimant suffers from anxiety and depression. R.32, 33. She takes Lexapro for depression, Metadate for anxiety, and Lunestra to help her sleep. R.33. Side effects from the medications include drowsiness. Id. For pain, she takes ibuprofen and Tylenol, and the doctor gives her shots in her ankles. Id.

Claimant testified that she needs help with groceries and maintaining the house.

R.34. Rather than walk, she drives three minutes to the closest stores. Id. Claimant's sister-in-law assists Claimant with her grocery shopping. Id. 34-35. Claimant stated that her condition has been the same for a year-and-a-half; she is in pain every day from the time she awakes. R.35. According to her doctor, there is a 50 percent chance that she would get better from surgery, which Claimant has not chosen to undergo. Id.

2.Claimant's sister-in-law Irma Munoz

Mrs. Munoz testified that she assists Claimant two or three times a week by helping her around the house and with the children. R.36. She stated that she believes Claimant's pain and depression are getting worse. Id.

C.Medical Evidence

1.MacNeal Hospital and Mercado Foot & Ankle Clinics South

On November 19, 2007, Dr. Patricia Gavin saw Claimant at the MacNeal Hospital for her bilateral foot pain and noted that Claimant had flattening of both feet. R.160. Dr. Gavin found that no hallux valgus deformity was demonstrated and bones and joint spaces otherwise appeared "unremarkable". Id.

Dr. Shaffer of Mercado Foot & Ankle Clinics South saw Claimant on November 27, 2007. R.162. Dr. Shaffer diagnosed Claimant with shin splints, right ankle pain tendinitis and plantar fasciitis. Id. He ordered physical therapy three times a week for three weeks. Id.

Claimant returned to MacNeal Hospital on December 12, 2007 for a physical therapy evaluation. R.163. Fan Chin Tsai noted that Claimant had extreme pronated feet and decreased stability. Id. While she had been experiencing pain, she had no weakness in her ankle muscles. Id. Claimant was prescribed physical therapy three times a week for six weeks. Id. On December 27, 2007, Claimant's records show that she had received relief from ultrasound, and it was recommended that this modality be continued.

R.171. Claimant's physical therapy records from January 7 and 15, 2008 read that Claimant had not been doing her exercises because she had to care for her children and study for the GED. R.175. She also needed re-instruction to do certain stretches correctly. Id. On January 15, 2007, the records note that Claimant had missed several appointments due to childcare. R.170.

On January 29, 2008, Claimant returned to Mercado Foot and Ankle Clinics South. R.182. Voltaren was prescribed, and a MRI was scheduled. Id. On February 12, 2008, a MRI was taken of Claimant's right ankle, which revealed findings compatible with sinus tarsitis syndrome. R.177. The report indicates that the remainder of the examination was unremarkable. Id. On February 14, 2008, a MRI of her left ankle was taken and showed findings suggestive of tibialis posterior tendon dysfunction, although there was no tibialis posterior tendon tear. R.178. Claimant also had low-grade tibiotalar capsulosynovitis, but no osteochondral erosion, stress fracture or substantive arthropathy. Id. On February 28, 2008, Claimant reported having decreased pain in her right foot, although she had not been going to physical therapy. R.181. She did stretching at home and only took Voltaren when it "hurts bad". Id.

2.Dr. Cruz-Access Community Health Network

On January 10, 2008, Claimant had an initial intake at Access Community Health Network for her depression. R.232-34. She had a Global Assessment of Functioning ("GAF") score of 65, which indicates only mild symptoms or limitations.*fn3 R.233. On March 13, 2008, Claimant was seen by Dr. Cruz. R.188, 230. Claimant reported a longstanding history of depression, and rated her current level of depression as a nine out of ten, ten being the worst. Id. Claimant listed a history of physical and sexual abuse, gang involvement, prostitution, and use of crack cocaine and marijuana. Id. Claimant had been seen by a psychiatrist when she was pregnant with her daughter and was prescribed Zoloft, although she never took the medication. Id. She reported no past psychiatric hospitalizations and no suicide attempts. Id.

Dr. Cruz diagnosed Claimant with major depression, both recurrent and severe; an anxiety disorder; and a history of cocaine dependence. R.189. Dr. Cruz prescribed Lexapro, Lunestra, and individual therapy. Id. When Claimant returned on April 17, 2008, Dr. Cruz reported major depression-moderately severe-and anxiety. R.190, 229. Dr. Cruz increased the Lexapro dose and decreased Lunestra. Id. On June 19, 2008, Dr. Cruz reported few improvements in Claimant's symptoms and added a diagnosis of PTSD and a prescription for Wellbutrin. R.218.

On July 24, 2008, Claimant had a follow-up appointment. R.214. Dr. Cruz again noted that Claimant had not experienced any improvements in symptoms. Id. Claimant reported being unable to focus well, easily distracted, and extremely forgetful. Id. She was struggling in school. Dr. Cruz discontinued Claimant's Wellbutrin and added a diagnosis of ADHD and a prescription for Ritalin. Id. Dr. Cruz noted that Claimant's disability had been denied and that she planned to appeal the decision. Id. Partially dated progress notes from Dr. Cruz, beginning on December 12, 2008 and ending shortly ...

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