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Juanita D.Perez v. Michael J.Astrue

July 3, 2012


The opinion of the court was delivered by: Magistrate Judge Cole


The plaintiff, Juanita Perez, seeks judicial review of the final decision of the Commissioner ("Commissioner") of the Social Security Administration denying her applications for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Title II and Title XVI of the Social Security Act ("Act"). 42 U.S.C. §§ 423(d)(2); 1382c. Ms. Perez asks the court to reverse and remand the Commissioner's decision, while the Commissioner seeks an order affirming the decision.


PROCEDURAL HISTORY On December 10, 2007, Ms. Perez applied for DIB and SSI alleging that she had been disabled since March 9, 2007. (Administrative Record ("R.") 143)*fn1 . Her application was denied initially on March 6, 2008, and upon reconsideration on August 18, 2008. An Administrative Law Judge ("ALJ") convened a hearing on November 12, 2009, at which Ms. Perez, represented by counsel, appeared and testified. In addition, Grace Gianforte, an impartial vocational expert ("VE"), also testified. On December 4, 2009, the ALJ issued a decision finding that Ms. Perez was not disabled.

This became the final decision of the Commissioner when the Appeals Council denied Ms. Perez's request for review on March 8, 2011 (R. 3). On May 11, 2011, Ms. Perez appealed that decision to the federal district court under 42 U.S.C. § 405(g), and the parties have consented to the jurisdiction of a magistrate judge pursuant to 28 U.S.C. § 636(c).



Ms. Perez was born on November 14, 1956, making her fifty-years old on her alleged onset date and fifty-three years old at the time of the ALJ's decision (R. 143). At the time of her administrative hearing, she was approximately 5'1" and 236 pounds (R. 34). Ms. Perez is married with an adult son (R. 143, 33). She also has a daughter, who, according to multiple treatment notes, is one of the primary sources of her unhappiness. (See R. 273-74, 953-977). At the time of her application for SSI, her husband was gainfully employed with METRA making approximately six thousand dollars a month. (R. 145).


Vocational Evidence Ms. Perez has an eleventh-grade education, and acquired her GED in June 2006. (R. 35, 227). From 1994 to 1995 Ms. Perez worked for 3HP Investments, Inc., in an unknown capacity (R. 157-158). From 1996 until 2004 she worked for Parko Foods, LLC., in various capacities primarily as a lead label maker. (R. 68-69, 155-157, 211). Starting in late 2004, she worked as patient services representative for Pronger-Smith, Id., until she was fired from that position in March, 2007 because, "[t]he team leader and I didn't get along, so she filled out a bad report on me." (R. 36). She has not worked since although she has been looking for work. (R.36).


Medical Evidence


Mental Health

On January 2, 2007, Ms. Perez saw psychiatrist Dr. Jody Reed. Dr. Reed noted: sadness, tearfulness, crying, helplessness, hoplessness, eight-pound weight loss, no precipitants, no previous episodes, anxiety and worrying -- constantly worries about everything, is "SOB", no panics, and difficulty with memory and attention. (R. 265). Her "current" medications were amitriptyline, Paxil, and Xanax. Ms. Perez denied taking other medication in the past. Dr. Reed diagnoses her with Major Depression, severe, recurrent. He differed an Axis II diagnosis and for Axis IV he listed interpersonal. He determined a Global Assessment of Functioning ("GAF") score of 45-50. Dr. Reed proposed the following treatment plan: discontinue amitriptyline and Paxil, prescribe Cymbalta, psychological and neurological testing, therapy with "Anna", and a follow up in two weeks.

Three days later, on January 5, 2007, Ms. Perez met with therapist Anna Schiff. (R. 977). She denied any history of depression, but admitted seeing a psychologist "a long time ago." She reported some problems at work related to a difficult co-worker. The resulting treatment plan called for weekly therapy sessions with Dr. Reed providing medication management. There are no other treatment/progress notes from Dr. Reed's practice until over a year later in November 2008.

Dr. Reed completed a Psychiatric Report for DDS on July 23, 2008. (R. 272-75). Under General Observations, he noted: "Normal posture and gait. Normal hygiene and at times can have decreased psychomotor activity. Normal clothing." (R. 273). He noted, "Over the past few years, she has been having mood difficulties more related to interpersonal conflicts within her family. She has been in treatment and shown improvement." (R. 273). He wrote, "She is able to function without assistance," (R. 273), and she has a "[n]ormal level of interest in various activities", but she has a "[s]trained relationship with her husband and child, which seems to serve as a significant stressor, which worsens her mood." (R. 274).

Dr. Reed described her mood and affect as within normal limits, although , "at times she can become restricted and tearful." (R. 274). Her speech was normal, her thought process logical and sequential with no hallucinations of delusion, and her orientation was normal and intact. (R. 274). Her abstract thinking was normal with no concrete thinking, her ability to note similarities and differences was normal, and her judgment was good. (R. 275).

Less than a month after the above Psychiatric Report, on August 11, Dr. Reed submitted another report to DDS.( R. 673). It reiterates a diagnosis of major depression and indicates treatment with medication and individual psychotherapy with a "Marginal Response." Id. Also noted is "Significant impairment in mood energy, interest, hopelessness." Id. Nonetheless, Dr. Reed indicated Ms. Perez, should have the ability to understand, carry out, and remember instructions as well as respond appropriately to supervision, co-workers and customary work pressures. Id.

Just seven days layer, on August 18, 2008, Dr. Reed submitted a completed Mental Impairment Questionnaire. (R. 696-699). For the first time, in addition to depression, he diagnosed her as Dependent Personality Disorder and Avoidant Personality Disorder and assessed a GAF score of 50-55. Id. On the form Dr. Reed checked off a multitude of symptoms. He listed her medications (Seroquel, Lexapro, Cymbalta), and indicated they did not cause any side-effects that might impact her ability to work. Id. Despite characterizing her prognosis as "Guarded," he indicated her impairment has neither lasted nor could be expected to last at least twelve months. Id. He checked that her mental impairment would result in her absence from work more than three times a month. Id.

Dr. Reed opined Ms. Perez had no useful ability to do work related activities on a day-today basis in a competitive work setting, (R. 697), explaining, "Her diagnosis of Depression and Personality Disorder make her unable to function. Severe impairment in Mood, Cognition, Affect, and Sleep." (R. 699). He went on to indicate extreme difficulties in maintaining social functioning, constant deficiencies of concentration, persistence, and pace resulting in a failure to complete tasks in a timely manner, and repeated -- three or more -- episodes of deterioration or decompensation in work or work-like settings. (R. 699). However, despite these assessments of crippling and pervasive dysfunction, Dr. Reed indicated that she had no restriction of activities of daily living. Id.

Meanwhile, at the Agency's request, two Psychiatric Review Techniques were completed by consultative psychologists. (R. 513-525, 674- 686). Both psychologists concluded Ms. Perez suffered from an Affective Disorder, but that her impairment was not severe. (R. 513, 674). Both found she had only mild restrictions of activities of daily living and mild difficulties in maintaining concentration, persistence, and pace. (R. 523, 684). Neither found any evidence of any episodes of decompensation. Both also indicated there was no evidence that Ms. Perez's depression caused more than a minimal limitation of ability to do any basic work activity. (R. 524, 685).

Dr. Reed's treatment notes begin again on November 21, 2008, when Dr. Reed noted Ms. Perez continued to have conflicts with her daughter. (R. 965). A mental status exam/assessment ("MSE") was entirely normal. On February 2, 2009, Ms. Perez indicated trouble sleeping and low energy levels. She said her overall mood was bad. Her MSE, however, was within normal limits.

On March 16, 2009, Ms. Perez reported she was still having conflicts with her daughter. She was still having trouble sleeping and her energy level was low. Her MSE was unremarkable noting normal mood and attention. On March 30, 2009, Ms. Perez reported she was doing better and sleeping well. (R. 959.) Dr. Reed noted an improvement in appetite, attention and concentration. Her MSE was again within normal limits. On April 13, 2009, improvements in appetite, attention, and concentration were noted. Her MSE was still within normal limits.

On June, 15, 2009, Ms. Perez's appetite, attention, and concentration continued to improve. (R. 955). Her therapist note her condition was stable and that she reported having fewer conflicts with her daughter. Her MSE was normal. On July 11, 2009, Ms. Perez although still frustrated with her daughter, indicated she was doing well on meds, she was sleeping well -- without nightmares, and was taking care of herself including, going to the gym. Her mood was noted as sad, but her MSE was otherwise unremarkable. On July 17, 2009 Ms. Perez was still upset with her daughter. (R. 973). She also reported having nightmares. Her mood was depressed, but the rest of her MSE was normal. On July 30, 2009, her MSE was normal but for her depressed mood (R. 974).

On August 13, 2009, Ms. Perez reported she and her daughter were speaking again. (R. 975). Although tired, she was feeling better physically and her diabetes was under control. She still felt sad occasionally. She indicated she no longer needed Lunesta to help her sleep. A MSE was completely unremarkable. On August 20, 2009, Dr. Reed noted she was doing well. (R. 976). She was still sleeping well and not taking Lunesta, despite occasional nightmares surrounding her past abuse. Her mood was depressed, but her MSE otherwise normal. On August 25, 2009, Ms. Perez reported she was continuing to have difficulties with her daughter.

(R. 971). She stated she was feeling "good" and denied health problems and reported doing well on her meds and sleeping well. She described the previous week with her husband as a good week overall. Her MSE indicated a sad mood, but all other assessments were normal.

On September 1, 2009, Ms. Perez's MSE was normal and it was noted she was doing well. (R. 969) She indicated she felt she was making progress in therapy and "starting to heal." She also reported her relationship with her daughter was improving. She said she felt fine physically although her blood sugar was high. On September 8, 2009, although sad, her MSE was normal. (R. 967). Again, it was noted she was doing well. She reported she was sleeping well and denied any issues. Her relationship with her daughter was still improving and she related she was content with the way things currently were. She was given homework to continue to identify her strengths and the positives in her life, and to start affirming that she is worthy and strong. 2.

Physical Health The bulk of medical documents come from Pronger-Smith Medical Care, where Ms. Perez used to work. Most of these records omit the list of Ms. Perez's medications, vitamins and supplements, referring the reader to an unattached "med list" or chart. Her list of medications, when listed, is extensive. (See, e.g., R. 978). Overall, these records consistently note Ms. Perez's longstanding diagnoses of diabetes, anemia, and hypertension. They frequently note a history of diabetic complications of kidney disease, retinopathy, autonomic neuropathy, and albuminuria and occasionally indicate reports of depression.

On August 8, 2006, Ms. Perez was complaining of pain in both her knees. (R. 590). She reported her pain in the left a 9/10 and in her right a 4/10. Dr. Dolitsky's physical examination revealed minimal synovitas of the left knee but with full range of motion in both. He noted both knees showed tenderness, which was worse on the left. X-rays taken showed a "possible minimal joint space narrowing medially on both sides, but as stated only minimal." Id. Dr. Dolitsky, indicated he explained to Ms. Perez the possibility of mild degenerative joint disease versus a medial meniscus tear, but that he would have to either do a arthroscopy or MRI to confirm a diagnosis. He offered her the option of an injection of Depo-Medrol, which she opted for left knee only as she did not mind the pain in her right. Id. A subsequent treatment note from August 29 indicates her left knee pain was a 0/10, her right a 6/10. (R. 587).

On August 14, 2006, Ms. Perez was seen by Dr. Mayer following a syncope/presyncope episode in April of uncertain etiology --notes from St. Francis suggested low blood sugar. (R. 594). A physical exam was unremarkable, noting her muscle strength and tone were normal in all extremities as was her reflexes, and gait. Id.

On January 2007, Ms. Perez had no new complaints and reported an improved energy level and feeling good in general. (R. 457). During a follow-up at Southwest Nephrology, for her kidney disease in February 2007, Ms. Perez indicated she felt well and had no complaints. (R. 403, 449).

On May 1, 2007, at the Hematology Clinic, a review of systems was normal, except under psych, where depression was noted. (R 455). However, it was noted her depression was improving on meds and that she was seeing a psychologist. Id. On May 4, 2007, Ms. Perez was asymptomatic, and a physical exam was unremarkable (R. 445). On May 14, 2007 Ms. Perez stated she was doing "very, very well" and a review of systems was otherwise unremarkable noting, no complaints of chest pain, shortness of breath, or palpitations (R. 437). Dr. Manglano found her to be "completely asymptomatic." Id. On May, 15, 2007, her diabetes was noted as being still uncontrolled, but better. (R. 451).

On July 27, 2007, Ms. Perez was hospitalized at St. Francis following a near syncope event, secondary to anemia, while on a treadmill at cardiac rehab. An ECG revealed a normal sinus rhythm. (R. 367). She was given IV fluids for dehydration and discharged in stable condition the following day and advised to follow a diabetic diet and perform activity as tolerated. (R. 367). A follow-up at Pronger-Smith a few days later was unremarkable. (R. 443-44).

On August 7, 2007, during another follow-up at Southwest Nephrology for stage 3 kidney disease, Ms. Perez presented essentially asymptomatic and stated she had been feeling well, (R. 399). Her kidney disease was stable and she was recommended a low potassium diet.

(R. 400). Later that month it was noted that her diabetes, although still uncontrolled, was better; she was exercising 4 to 5 times a week and following a good diet. (R. 432). An October 2007 examination was unremarkable. (R. 430).

On November 5, 2007, Ms. Perez was admitted to St. Francis Hospital complaining of severe -- 10 out of 10 -- chest pain. (R. 322-365). A venous duplex study showed no evidence of deep venous thrombosis. (R. 344). Several ECGs, a chest CT and chest X-ray yielded unremarkable results. (R. 345-354). A physical examination indicated her hand strength and leg strength were normal. (R. 323). She was preliminarily diagnosed with atypical chest pain. (R. 359, 362-363).

On November 21, 2007, Ms. Perez was admitted to St. Francis Hospital for acute renal insufficiency with chronic renal disease secondary to diabetes, hypertension, and anemia. (R. 282-321). Once again, a venous duplex study showed no evidence of deep venous thrombosis or insufficiency. (R. 316). An X-Ray Bone Survey showed some unspecified degenerative changes in her spine and joints, (R. 317). A physical examination noted no pedal edema and a normal gait. (R. 291). An ultrasound of her kidneys revealed no significant abnormalities. (R. 319). Ms. Perez was given IV fluids and antibiotics for her leukocytosis, and kept for observation until her kidney function returned to baseline levels. She was then discharged as stable on November 24, 2007 with instructions to follow a low fat, low cholesterol diet and was permitted activity as tolerated. (R. 283).

During Ms. Perez's December 7, 2007 visit, her uncontrolled diabetes, hypertension, and anemia were noted, however, a physical examination was unremarkable. (R. 421, 422). She reported she felt much better. (R. 421).

On February 7, 2008, at the Agency's request, Dr. Patil conducted a consultative examination of Ms. Perez. (R. 500- 504). His diagnostic impressions were diabetes mellitus, chronic renal disease -- stage 3, mild diabetic retinopathy, extreme obesity, and hypertension, with a history of dyslipidemia, anemia, depression and anxiety. (R. 503). Ms. Perez was on time for the evaluation and had driven herself. (R. 500). She claimed she was compliant with a 1500 calorie diet and regularly exercised at the gym. Id. But she also reported that she gets short-winded walking more than two blocks or going up and down the stairs. Ms. Perez complained of polyuria, fatigue, and polydipsia. Id. She had no complaints of blurry vision, dysuria, chronic infection, diarrhea, or vomiting. She denied having any chest pain, dyspnea at rest, headaches, gait imbalances, or dizziness. Id. Ms. Perez also denied any other medical ailments. Id.

Dr. Patil noted she was hospitalized in November 2006 for chest pain and uncontrolled hyperglycemia, but that the cardiac work up was negative and there is not history of heart attack or stroke. Dr. Patil noted past surgeries, involving her cervical spine in 2000, and bilateral trigger fingers in 2002/2003. (R. 501). He noted she was obese. Her speech and gait were normal. An examination of her skin, head, ears, nose, mouth, and throat, neck, chest and lungs, heart, and abdomen were all unremarkable. (R. 501). An examination of her eyes indicated mild bilateral non-proliferative diabetic retinopathy with no external evidence of recent trauma. (R. 501). Her far vision with correction, in both eyes, was 20/25.

A mental status examination was unremarkable; her attention and concentration were fair, she was alert and her mood relaxed. (R. 502). With respect to her history of depression, Dr. Patil noted her mentation was normal, she was seeing a psychiatrist for medication and a psychologist for therapy, and that she reported her medications help to some extent. (R. 504). He also noted that Ms. Perez had no history of past inpatient psychiatric care. Id.

A visual inspection of her spine and back showed no obvious deformities of the spine. (R. 502). Nor was there any paravertebral tenderness or spasm and her neck and shoulders were normal. Dr. Patil observed minor limitations in her lumbar spine range of motion. Id. Ms. Perez was neurologically intact, as her reflexes were brisk and equal bilaterally, cerebral function tests were normal, superficial and deep sensations were unimpaired, and all cranial nerve functions were preserved. Id. Furthermore, she had a motor strength of 5/5 in both upper and lower extremities and there was no sign of muscle wasting or paralysis. Id. With respect to her extremities and musculoskeletal system, a full range of motion in her joints was noted. Ms. Perez had no difficulty performing all fine and gross manipulative movements with her hands and fingers, with a grip strength in both hands of 5/5. (R. 503). Her gait was normal, she walked without an aiding device, and no abnormalities were observed in her ability to squat and arise, stand up, or heel to toe walk. Id. He concluded his examination asking her if he had addressed all of her medical complaints, to which she responded affirmatively. Id.

Also at the request of the Agency, Dr. Wabner completed a Physical Residual Functional Capacity Assessment on February 26, 2008. Dr. Wabner assessed that Ms. Perez was capable of performing a full range of light work with no additional limitations. (R. 506-09). Dr. Wabner noted Ms. Perez's allegations of diabetes, kidney problems, heart palpitations, depression, HPB, anxiety, high cholesterol, and anemia. (R. 512). He relied on Dr. Patil's observations including minor limitations in range of motion in her lumbar spine, her full range of motion in her joints, her motor strength of 5/5, her bilateral ability to perform fine and gross manipulation, and her normal gait. (R. 512).

On March 10, 2008, Ms. Perez visited Pronger-Smith with a bruised right shin. (R. 537-538, 583). There is a notation relating to her left leg, but it is indecipherable. Other than her bruise, a physical examination was unremarkable. A follow-up for her diabetes on March 31, 2008, was alsounremarkable. (R. 539-540, 575).

On March 18, 2008, Ms. Perez was seen by Dr. Fahey at Pronger-Smith, he noted her poorly controlled diabetes and her primary complaint of several recent falls. She reported two recent falls, one in February, the other on March 12, 2008, when she fell face first, chipping two front teeth. (R. 546). She claimed in both instances, she was walking when her left leg "suddenly buckled". Id. She also reported that her left leg has been getting weaker over the course of the previous 3 months and that she has developed neck pain and numbness and tingling over most of her left leg. Id. She denied any symptoms on her right side or any shooting or proximal pain in her left leg. Id. She claimed she had falls resulting from left leg weakness in 2000 before her operation for a herniated cervical disk and that her symptoms then where qualitatively identical to what she was currently experiencing. Id. She related that she had syncopal spells in the past related to autonomic insufficiency from her diabetes, but that these falls were different as she never felt dizzy or lost consciousness. Id. Dr. Fahey indicated that other than her claimed leg weakness, her review of systems was unremarkable. (R. 547). Despite her allegations, Dr. Fahey physical examination revealed very mild limitations in her left leg motor abilities and minor deficits in sensation. Id. He noted she was currently using a cane, and recommended she continue using it. He indicated she had no pain that would suggest diabetic amyotrophy and no obvious wasting on her left side. Id. He ordered a nerve conduction study of her lower left extremity and an MRI of her cervical spine. Id.

On March 31, 2008, there is a record from Pronger-Smith that indicates someone reviewed Ms. Perez's MRI with her. (R. 585). On April 9, 2008, Ms. Perez reported multiple falls, and back and neck pain. (R. 535). It was noted her blood sugar was better and a physical examination was unremarkable. Id.

On April 10, 2008, an EMG was performed on Ms. Perez's lower left extremity. (R. 545). Dr. Mayer's clinical impression was "[e]ssentially normal electromyography/nerve conduction study of the left lower extremity. There was no electro physiological evidence for a polyneuropathy or myopathy affecting this extremity."

On May 9, 2008, Ms. Perez reported episodic gate instability associated with falling, but Dr. Mayer noted she exhibited no clear neurological abnormalities during her physical examination and her gait was normal. (R. 568). Dr. Mayer noted her recent EMG/NCV of her left leg was completely normal. Similarly, an MRI of her cervical spine showed a post cervical spine fusion at C6/C7 and a herniated disk at C7/T1, but did not show any clear cord abnormalities. Id. Because both the EMG and MRI were "normal" Dr. Mayer did not feel any further neurological workup was needed. (R. 568). He noted that Ms. Perez "seems to imply her left knee gives out periodically" so he recommended she wear a knee brace and starting in June begin exercising with it. (R. 568-69). Dr. Mayer did comment that she was on a "very long list of medications."O (R. 568).

During a May 14, 2008 follow-up for her anemia, Ms. Perez reported no complaints, and denied fatigue or shortness of breath. (R. 541). A physical exam was unremarkable: under neck, it was noted, "no masses, pain, stiffness, or LAD;" with respect to musculoskeletal, "no pain, weakness, or functional disability;" under neurological, "no numbness, tingling, dizziness, or dyscoordination;" and for psychiatric, "no depression, anxiety, insomnia, dementia, or SI/HI."

(R. 542). Similarly, in a second report from the same visit, the doctor noted, "[n]ormal gait and balance, symmetrical muscle strength, mass or tone. Full active range of motion or extremities, no instability or joint swelling." (R. 543). The treating physician did note that Ms. Perez reported 2 falls in the past, but none recently, and that she should continue following up with Neurology. Id.

On May 20, 2008, Ms. Perez returned to Pronger-Smith, after a fall. (R. 534, 579). She reported her left leg gave out, and she complained of injury, to her left shoulder and ribs. (R. 534). On May 21, she was referred to Dr. Markus who diagnosed her with a low-grade acromioclavicular separation of her left shoulder and left rib contusions. (R. 589). He noted a CT scan of her brain and cervical spine showed no acute pathology and a chest and lumbar spine x- rays were normal. Id. He took X-rays of her shoulder, which were unremarkable, and prescribed her Vicodin for pain. Id.

Ms. Perez returned on June 12, 2008, reporting her pain had subsided considerably, but that she still had some discomfort in her left anterior chest and difficulty raising her left shoulder. (R. 588). Dr. Markus noted limited range of motion in her left shoulder, but that she had no tenderness in her neck or midback. Id. She indicated she was still sore in her rib region. Id. Dr. Markus ordered an MRI of her shoulder to make sure her injury was not anything more serious than a simple low grade separation as he original suspected. Id. A record from follow-up for MRI/labs on June 25, 2008, although largely indecipherable, contains notations of left knee buckling, no pain, high blood sugar, and increased creatinine. (R. 577-578). Although the review of symptoms has check marks indicating negative findings, the concurrent physical examination is entirely normal. (R. 578).

Referred by Dr. Markus, on June 30, 2008, Ms. Perez began physical therapy for her injured shoulder. (R. 931). At Physical Therapy and Sports Injury Rehabilitation ("PTSIR") she related that in April, she was on a step-stool at her hope when she slipped and fell, landing on her left shoulder and hitting her head. Her main complaint was pain. The therapist noted she displayed shoulder biomechanical faults consistent with shoulder anterior glide syndrome, and opined that she was "an excellent candidate for physical therapy." Id. A treatment plan lasting four weeks was indicated.

A general follow-up on July 7, 2008, yielded no remarkable findings. (R. 570). During a follow-up for anemia on July 14, 2008, Ms. Perez reported no complaints other than mild fatigue associated with anemia, and intermittent nausea. (R. 563). Her current medication list was extensive covering approximately a page. She reported no pain or stiffness in her neck, no pain, weakness, or functional disability in in her musculoskeletal system, and no numbness, tingling, dizziness, or dyscoordination. (R. 565). The treating physician noted normal gait and balance, symmetrical muscle strength, mass and tone. She also noted full active range of motion in Ms. Perez's extremities with no instability or joint swelling. Id. The treating physician indicated Ms. Perez reported a fall in the past month but denied any dizziness. Id.

On July 31, 2008, Ms. Perez reported having increasing pain and stiffness in her left shoulder. (R. 829). Dr. Markus diagnosed a frozen shoulder and recommended manipulation under general anesthesia with a cortisone injection. Id. On August 5, 2008, after falling out of her bed and hitting her nightstand, Ms. Perez complained of pain in her upper chest and right shoulder. (R, 804). An X-ray revealed no signs of acute trauma and minimal degenerative changes at the aromioclavicular joint; the radiologist noted there were no significant changes compared to an X-ray from January 31, 2006. Id.

On August 14, 2008, at the Agency's request, Dr. Pilapil completed a second Physical Residual Functional Capacity Assessment with updated records from Pronger-Smith. Like the February 2008 assessment, see supra, Dr. Pilapil, assessed that Ms. Perez was capable of performing a full range of light work. (R. 688-695). Due to her obesity, hypertension, and some decrease in lumbar range of motion, he limited her to occasionally lifting/carrying nor more than 20 pounds, frequently lifting/carrying no more than 10 pounds, standing/walking for a total of about 6 hours in an 8-hour workday, sitting for a total of six hours in an 8-hour workday, with no limits in her ability to push/pull. (R. 689). He found no postural, manipulative, or communicative limitations. (R. 690-92). Noting Ms. Perez's history of non-proliferative diabetic retinopathy, and that a recent vision test revealed her pupils were equal and reactive to light, her visual acuity was 20/25, and that she had no complaints of blurry vision he concluded she did not have any visual limitations. (R. 691, 693). Given her history of shortness of breath he indicated she should avoid concentrated exposure to fumes, odors, gases, poor ventilation, etc. (R. 692).

Following her left shoulder manipulation by Dr. Markus on August 27, 2008, Ms. Perez was again referred to physical therapy. On September 4, 2008, at PTSIR she reported that she felt significantly better since the manipulation, but still had some tenderness and discomfort in that area. (R. 938). On October 1, 2008, the physical therapist indicated she had met all goals -- including an increase in range of motion and strength as well as a reduction in pain and tenderness -- and was recommending her discharge from therapy. (R. 937).

Also on October 1, 2008, Dr. Dholakia noted that since her shoulder manipulation, Ms. Perez had been doing great with "that." (R. 801). Her range of motion was better and he noted she could "do a lot of things she could not do before." Id. With respect to her diabetes, he indicated her pre-lunch and pre-supper sugars were high and he would adjust her medication. ...

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