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Encarnacion v. Astrue

September 1, 2009

ESTEBAN ENCARNACION, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Pitman, United States Magistrate Judge

OPINION AND ORDER

I. Introduction

Plaintiff, Esteban Encarnacion, brings this action pursuant to section 205(g) of the Social Security Act, 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of Social Security (the "Commissioner") denying his application for disability insurance benefits. The parties have consented to my exercising plenary jurisdiction pursuant to 28 U.S.C. § 636(c). Both plaintiff and the Commissioner have moved for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. For the reasons set forth below, the Commissioner's motion is granted and plaintiff's motion is denied.

II. Facts

A. Procedural Background

Plaintiff filed an application for disability benefits, pursuant to 42 U.S.C. § 423(b), on May 15, 2003 (Tr.*fn1 93-96). Plaintiff claimed in his application that he had been unable to work since April 12, 2003, because of chest pain and frequent dizziness (Tr. 106). On July 28, 2003, the Social Security Administration denied plaintiff's application for benefits (Tr. 57-61).

Plaintiff timely requested and was granted a hearing before an Administrative Law Judge ("ALJ") (Tr. 62-67). The ALJ, Paul A. Heyman, conducted a hearing on January 31, 2006 at which both plaintiff and a medical expert testified (Tr. 34-56).*fn2 In a decision issued on February 27, 2006, the ALJ found that plaintiff had the residual functional capacity ("RFC") to perform "sedentary work with no work in proximity to dangerous machinery or heights or involving driving a motor vehicle," and, therefore, was not disabled through the date of the ALJ's decision (Tr. 11, 19-20). The ALJ's decision became the final decision of the Commissioner on June 3, 2006, when the Appeals Council denied plaintiff's request for review (Tr. 4-6).

Plaintiff commenced this action on August 21, 2006. On February 5, 2007, the Commissioner moved for judgment on the pleadings under Rule 12(c) of the Federal Rules of Civil Procedure (Memorandum of Law in Support of Defendant's Motion for Judgment on the Pleadings, dated Feb. 5, 2007 ("Def.'s Br.")). Plaintiff opposed the Commissioner's motion, and cross-moved for judgment on the pleadings under Rule 12(c) on or about May 4, 2007 (Undated Memorandum of Law in Support of Plaintiff's Motion for Judgment on the Pleadings ("Pl.'s Br.")). The Commissioner filed a memorandum in opposition to plaintiff's cross-motion and in further support of his motion on June 8, 2007 (Memorandum of Law in Opposition to Plaintiff's Cross-Motion for Judgment on the Pleadings and in Further Support of Defendant's Motion for Judgment on the Pleadings, dated June 8, 2007 ("Def.'s Opp.")).

B. Relevant Evidence

1. Plaintiff's Age, Education and Experience

Plaintiff was born on May 1, 1959 in the Dominican Republic, completed the tenth grade of high school there, and learned to read and write in Spanish and to read in English (Tr. 14, 36, 93, 111 (plaintiff stated on his disability benefits application that he had completed 10th grade in 1976), 331 (plaintiff's treating physician, Dr. Sujatha Baskar, noted that plaintiff had high school education). But see Tr. 37 (plaintiff testified that he did not advance past first grade in elementary school and taught himself to read)). From March 20, 1990 until April 12, 2003, he was self-employed as a taxicab driver (Tr. 37-38). On the evening of April 12, 2003, he was admitted to Bronx-Lebanon Hospital Center ("Bronx-Lebanon") suffering from a myocardial infarction, commonly known as a heart attack (Tr. 125, 128). As a result, plaintiff ceased driving altogether (Tr. 37, 42). He has not worked again since that time (Tr. 107).

2. Medical Evidence

a. Treatment for Heart Attack

Dr. Oronde Smith and Dr. Latha Menon treated plaintiff in the Bronx-Lebanon Hospital emergency room on April 12 and 13, 2003. Plaintiff told Dr. Smith that, beginning approximately one week prior to his visit, he had been experiencing intermittent episodes of pain and pressure in the center of his chest, which radiated out to his right arm (Tr. 125). In addition, plaintiff reported that he had diabetes mellitus,*fn3 high blood pressure and high blood cholesterol and that he smoked one pack of cigarettes per day (Tr. 125, 127). Dr. Menon diagnosed plaintiff with unstable angina and a non-Q-wave myocardial infarction*fn4 and placed him on a number of medications (Tr. 127, 128).

On April 16, 2003, plaintiff was no longer experiencing chest pain, and he was transferred from Bronx-Lebanon to Montefiore Medical Center ("Montefiore") (Tr. 131, 141-42). There, Dr. Adam Goldman performed a percutaneous coronary angioplasty*fn5 and inserted a stent in his artery (Tr. 139, 141-43, 219). Plaintiff was discharged to his home the following day (Tr. 146).

b. Treatment for Dizziness

On May 5, 2003, plaintiff returned to Bronx-Lebanon, complaining of dizziness and nausea (Tr. 186, 191, 207). Dr. Chantal Simpson admitted plaintiff for inpatient treatment (Tr. 180). Dr. Simpson noted that plaintiff was primarily diagnosed with syncope*fn6 and collapse, and secondarily diagnosed with uncontrolled Type II diabetes,*fn7 high blood pressure, high blood cholesterol, tobacco use disorder, and coronary artery disease (Tr. 180). According to Dr. Simpson, plaintiff reported that he was experiencing chest pain in the form of pressure and tenderness in his upper left chest area (Tr. 188). However, another attending physician subsequently noted that plaintiff was not experiencing chest pain and that his condition was stable (Tr. 185).

From May 6, 2003 until May 11, 2003, Dr. Shivaji Kadam treated plaintiff. Dr. Kadam noted that plaintiff was apparently well after his angioplasty until May 3, 2003, when he experienced a sudden onset of dizziness that was accompanied by nausea but not vomiting, diarrhea or abdominal pain, and that plaintiff did not faint or lose consciousness and had no complaints of chest pain (Tr. 191). In addition, Dr. Kadam noted that, according to plaintiff, the dizziness was not related to his posture and he had had previous episodes of similar dizziness beginning in 1993, when he was first diagnosed with diabetes (Tr. 191). Dr. Kadam also noted that plaintiff was taking the following medications: Enalapril (to lower blood pressure), Atenolol (to lower blood pressure), Lipitor (to lower blood cholestorol), Plavix (to inhibit blood clots), Glipizide (to increase insulin release), and Acetosalicylic Acid (aspirin) (Tr. 192). Dr. Kadam's impression was that plaintiff had uncontrolled diabetes, and that his fluctuating blood sugar should be monitored (Tr. 202, 214). Dr. Kadam stated that plaintiff "does not take med[ication]s," but did not explain this statement (Tr. 214).

On May 8, 9 and 10, 2003, Dr. Kadam reported that plaintiff was no longer experiencing dizziness or chest pain (Tr. 218-20, 224, 227). Plaintiff's glucose level ranged from 108 to 240 mg/dL, but he was asymptomatic.*fn8 Dr. Kadam subsequently counseled plaintiff about the risks of continuing to smoke cigarettes and of the importance of stopping smoking (Tr. 221-22). He discharged plaintiff on May 11, 2003, and instructed plaintiff to follow a diet restricted in sugar, fat and salt (Tr. 274).

c. Follow-up Treatment

Plaintiff returned for follow-up appointments at Bronx-Lebanon approximately every four to six weeks for the next two years. Doctors Tricia Chan, Sujatha Baskar and Yogendra Prasad treated plaintiff during this period.*fn9 Dr. Chan treated plaintiff only through November 2003, Dr. Prasad treated plaintiff through April 2004, and Dr. Baskar treated plaintiff through at least February 2005. Dr. Baskar appears to have been plaintiff's primary treating physician (see Tr. 323 (Dr. Chan's notes refer to Dr. Baskar as plaintiff's primary medical doctor); Tr. 344, 356, 379 (Dr. Prasad stated on several occasions that he advised plaintiff to follow up with his primary medical doctor). But see Tr. 321, 354 (Dr. Prasad stated that plaintiff would be seen by his primary medical doctor on September 10, 2003, and plaintiff was seen on that date by Dr. Chan).

At plaintiff's first follow-up appointment in May 2003, Dr. Baskar noted that plaintiff complained of occasional squeezing chest pain (Tr. 328). However, plaintiff's physicians did not note that such complaints on any subsequent occasion.

Moreover, plaintiff's physicians specifically stated that plaintiff did not experience any further chest pain on numerous follow-up visits (Tr. 184-85 (May 6, 2003), 221-22 (May 9, 2003), 354 (September 8, 2003), 378-79 (November 10, 2003), 316-17 (December 1, 2003), 361 (January 26, 2004), 343-44 (April 26, 2004)), and did not note any further heart attacks.*fn10

Plaintiff's diabetes remained uncontrolled throughout 2003 and 2004, even after he agreed to try taking insulin (Tr. 289, 294-95, 305-06, 308, 313, 314-15, 343-44, 354, 361, 378-79 (July 18, November 10, and December 12, 2003, as well as January 26, January 29, April 2, April 26, September 9 and October 8, 2004)). In November 2003, Dr. Chan advised plaintiff to begin taking insulin because, given his history of coronary artery disease, he required strict blood-sugar control (Tr. 319). Dr. Prasad agreed (Tr. 379). Plaintiff refused (Tr. 319). Subsequently, in January 2004, plaintiff agreed to try insulin, after Dr. Baskar advised him to do so (Tr. 313). However, even after plaintiff began to be prescribed insulin, Dr. Baskar repeatedly expressed or implied that plaintiff was noncompliant with his prescribed diet and medication regimens (see Tr. 294-95 (September 2004), 290 (October 2004), 283-84 (February 2005)).

In addition to his uncontrolled diabetes, plaintiff reported localized pain in certain extremities on several occasions in 2003 and 2004. In August and September 2003, both Dr. Chan and Dr. Prasad noted that plaintiff reported experiencing pain in the median nerve distribution of his right (dominant) hand, arm and wrist for two to three months, which worsened at night (Tr. 321, 354, 355-56). Dr. Chan noted that his symptoms were consistent with carpal tunnel syndrome and advised plaintiff to use a hand brace (Tr. 321). On November 5, 2003, Dr. Chan noted that plaintiff reported that he had been experiencing lower extremity pain for the past six to seven months which would occur after he had walked for three blocks (Tr. 319). Dr. Prasad noted in November 2003 that plaintiff could walk ten blocks (Tr. 378-79). In January 2004, Dr. Prasad stated that plaintiff reported steady pain unrelated to exertion, but no chest pain, and that he could walk either five to six blocks without any increase in pain (Tr. 354). Likewise, Dr. Baskar noted in January 2004 that plaintiff reported pain in both lower extremities but did not specify how far plaintiff could walk without pain (Tr. 313).

Plaintiff also reported dizziness and blurred vision on several occasions in 2003 and 2004. On three occasions in 2003 and 2004, Drs. Baskar and Prasad noted that plaintiff reported experiencing dizziness when standing up (Tr. 303-04 (June 2004: plaintiff "c[omplained] o[f] dizziness"), 328 (May 2003: plain- tiff "c[omplained] o[f] dizziness . . . upon getting up"), 355-56 (August 2003: plaintiff "occasionally fe[lt] dizziness on standing [up]")). Dr. Chan did not note whether plaintiff experienced dizziness. In January and March 2004, Dr. Baskar also stated that plaintiff complained of blurred vision (Tr. 311-12, 313).

d. RFC Assessments

i. Dr. Chan

Dr. Chan completed a questionnaire concerning plain-tiff's RFC on November 12, 2003, apparently at the request of the Commissioner (Tr. 165-68). Dr. Chan stated that plaintiff was capable of lifting no more than ten pounds frequently, which the questionnaire defined as "occurring one-third to two-thirds of an 8-hour workday (cumulative, not continuous)" due to his history of coronary artery disease (Tr. 165). Dr. Chan further noted that plaintiff's abilities to sit, stand, walk, push, pull, reach, handle, manipulate objects with his fingers, feel, see, hear and speak were not affected by his impairment, and that plaintiff could climb, balance, kneel, crouch, crawl and stoop frequently (Tr. 166-67). Although the questionnaire instructed that it was "very important [for Dr. Chan] to describe the factors that support[ed] [her] assessment [because the Commissioner was] required to consider the extent to which [her] assessment [was] supported" (Tr. 165), Dr. Chan did not give any further information concerning the medical findings supporting her assessments (Tr. 165-66).

ii. Dr. Baskar

Dr. Baskar, who had been treating plaintiff every one to two months since May 16, 2003, also completed a questionnaire concerning plaintiff's RFC on January 29, 2004, apparently at plaintiff's request (Tr. 370-75). Dr. Baskar diagnosed plaintiff with Type II diabetes mellitus,*fn11 coronary artery disease, high blood pressure and high blood cholesterol, and noted that his prognosis was fair (Tr. 370). Dr. Baskar stated that plaintiff experienced the following symptoms associated with his diabetes: fatigue, general malaise, pain and numbness in his extremities, episodic blurriness in his vision, excessive thirst, rapid heart beat or chest pain, dizziness or loss of balance, hyperglycemic and hypoglycemic ...


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