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Adrianne Williams v. Michael Astrue

December 9, 2010

ADRIANNE WILLIAMS, PLAINTIFF,
v.
MICHAEL ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Matsumoto, United States District Judge:

NOT FOR PUBLICATION

MEMORANDUM & ORDER

Pursuant to 42 U.S.C. § 405(g),*fn1 plaintiff Adrianne Williams ("plaintiff"), appeals the final decision of defendant Michael J. Astrue, Commissioner of Social Security ("defendant" or "Commissioner"), who denied plaintiff's application for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("the Act"). Proceeding pro se, plaintiff contends that she is entitled to receive SSI benefits due to severe medically determinable impairments, which she alleges render her disabled and prevent her from performing any work. Presently before the court is defendant's motion for judgment on the pleadings. For the reasons stated below, defendant's motion is denied and the case is remanded for furthering proceedings consistent with this opinion.

BACKGROUND

A.Procedural History

Plaintiff filed for SSI benefits on January 26, 2007, alleging disability due to arthritis, high blood pressure, asthma, heart problems, tendonitis in the left arm, and leg pain and swelling in both legs. (Tr. 88.)*fn2 Plaintiff stated that her disabilities made her forgetful, unable to lift or pull heavy objects, and caused her to tire easily. (Id.) Plaintiff claimed she had not been able to work since September 1, 2003 due to pain in her legs.*fn3 (Id.) The Social Security Administration ("SSA") denied her application on July 12, 2007. (Tr. 34-37.) On August 21, 2007, plaintiff requested a hearing on her SSI application before an administrative law judge. (Tr. 39-42.) The request was received (Tr. 43-49), and a hearing was scheduled for May 2, 2008. (Tr. 56-62.) The hearing was subsequently rescheduled, and held on July 21, 2008 before Administrative Law Judge Lucian A. Vecchio (the "ALJ"). (Tr. (Tr. 19-32, 66-72.) Although the Commissioner informed plaintiff she had the right to have counsel represent her at the administrative hearing, she chose to proceed without counsel. (Tr. 21-22, 43-44.)

On August 22, 2008, the ALJ issued a decision denying plaintiff's application for SSI. (Tr. 9-18.) After reviewing the entire record, including plaintiff's medical files, the ALJ determined that plaintiff had severe impairments due to arthritis in the knees, asthma, hypertension, obesity, and residual effects of thyroid cancer.*fn4 (Tr. 14.) However, the ALJ found that the impairments did not individually or in combination meet or equal one of the impairments listed in the regulations.*fn5 (Id.) The ALJ concluded that plaintiff was not significantly limited in her ability to perform the full range of light work.*fn6 (Id.)

On September 15, 2008, plaintiff requested review of the ALJ's decision by the Appeals Council. (Tr. 6-8.) On July 30, 2009, the Appeals Council denied plaintiff's request for review, making the ALJ's decision the final decision on plaintiff's claim for benefits. (Tr. 1-5.) This pro se action followed.

B.Non-Medical Facts in the Administrative Record

1. Background

Plaintiff was born on January 20, 1961 and is a United States citizen. (Tr. 77.) The record indicates that plaintiff completed either the 10th or the 11th grade.*fn7 (Tr. 24, 93.) She is able to speak, understand, read, and write in English. (Tr. 87.) During the time period relevant to the SSI application, plaintiff lived in Brooklyn with three of her children, ages 16, 12, and 8. (Tr. 106.)

2. Employment History

Plaintiff's Disability Report (Form SSA-3368) shows that she worked intermittently in the following jobs from 1977 through 2002, with multi-year gaps in employment. (See Tr. 87-94.) During the summers of 1977 and 1978, plaintiff did office work for a summer youth program. (Tr. 89.) In 1979, plaintiff worked as a cashier in a card store and in a fast food restaurant, as an office worker, and at a supermarket. (Id.)

In 1983 and 1984, plaintiff worked as a bag screener for a security company. (Id.) As a bag screener, she was on her feet for approximately seven and a half hours a day, during which she walked, stood, stooped, crouched, and handled bags weighing less than ten pounds. (Tr. 89-90.) She cleaned hotel rooms in 1987. (Tr. 89.) In 1989, plaintiff performed customer service work for a bus company. (Id.) Plaintiff did office work in 1991. (Id.) She also worked in a school lunchroom from May to August 1991. (Tr. 89, 117.) Plaintiff reported that she did not work from 1992 to 1997 because she was raising her children. (Tr. 94.) Plaintiff worked in customer service in 1998. (Tr. 89.) Her last reported job on the Disability Report was as a babysitter from 2001 to 2002.*fn8 (Tr. 89.) She indicated that she worked from home in 2002 and 2003 because it was "much easier" considering her health problems.*fn9 (Tr. 88.) Plaintiff stated that she did not work at all in 1981, 1982, 1985, 1986, or from 1992 to 1997. (Tr. 94.)

C.Medical Evidence in the Administrative Record

1. Medical Evidence Prior to the SSI Claim*fn10

Plaintiff was examined at Kings County Hospital Center ("KCHC") on June 5, 1997 because of right knee pain lasting one week that was both diffuse and also present in the patella.*fn11

(Tr. 146). An evaluation of the right knee found that it was normal. (Id.)

Plaintiff was examined at KCHC for pelvic inflammatory disease,*fn12 asthma, a urinary tract infection, edema,*fn13 and urticaria*fn14 on May 19, 1998. (Tr. 123, repeated at Tr. 141.) The examining physician described the plaintiff as a "high complexity" patient. (Id.)

On May 9, 2003, plaintiff was treated for bronchitis at the KCHC emergency room. (Tr. 125.) The attending radiologist reported subsegmental platelike atelectasis*fn15 at the base of the left lung. (Id.)
X-rays of both of plaintiff's knees taken on March 23, 2005 revealed a mild loss of joint space in the medial*fn16 compartment. (Tr. 169, repeated at Tr. 207, 226.) Plaintiff's knees showed normal mineralization.*fn17 (Id.) On June 15, 2005, a magnetic resonance image ("MRI") of plaintiff's knees revealed a small synovial effusion,*fn18 a possible tear of the posterior horn of the medial meniscus*fn19 and a possible tear of the medial collateral ligament*fn20 in the right knee. (Tr. 167, repeated at Tr. 205, 224.) The left knee had a tear of the posterior horn of the medial meniscus, and synovial fluid. (Id.) An x-ray of the plaintiff's lumbar spine*fn21 and sacroiliac joints*fn22 showed mild scoliosis*fn23 and mild degenerative changes. (Tr. 168, repeated at Tr. 206, 225.)
Plaintiff was examined at the KCHC orthopedic clinic on August 2, 2006, on a referral from her primary care physician. (Tr. 122, 124, repeated at Tr. 140, 145.) Plaintiff complained of knee pain that began after she fell ten years ago. (Tr. 122, repeated at Tr. 140.) The knee pain had neither worsened nor improved since the fall. (Id.) The examining physician noted the plaintiff had crepitus*fn24 in the right knee, but was fully functioning and had a range of motion in the both knees from zero to 130 degrees.*fn25 (Id.) A Lachman test*fn26 and a McMurray test*fn27 were both negative. (Id.) X-rays showed narrowing*fn28 and osteophyte*fn29 formation of the medial compartments of both knees. (Tr. 124, repeated at Tr. 145.) Irregularity of the dorsal patella cortices in both knees was also present.*fn30

(Id.) The attending radiologist noted that the examination was otherwise unremarkable. (Id.)

On October 3, 2006, plaintiff was seen at the KCHC physical medicine and rehabilitation unit, on referral from the orthopedic clinic due to her persistent knee pain. (Tr. 121, repeated at Tr. 139.) The plaintiff reported four to five falls during her pregnancies, and stated that she could only walk two blocks before experiencing pain and that she had difficulty climbing stairs. (Id.) A report from the visit states that plaintiff had a partial hysterectomy in February 2006 and surgery on her thyroid in April 2006. (Id.) The examining physician noted that plaintiff's knees were swollen, with the right knee more swollen than the left knee. (Id.) Plaintiff described her knee pain as having an aching quality. (Id.) Plaintiff showed full range of motion and had a manual muscle test rating of five out of five, representing full muscle strength. (Id.) The physician recommended that plaintiff complete four to six physical therapy sessions to strengthen her quadriceps, and that she continue taking Motrin when necessary. (Tr. 121, repeated at Tr. 139.)

2. Medical Evidence From the Relevant Period

a. KCHC Cardiology Clinic

On January 31, 2007, plaintiff was examined at the KCHC cardiology clinic following an abnormal echocardiogram.*fn31

(Tr. 119-20, repeated at Tr. 137-38.) The examining physician diagnosed moderate concentric left ventricular hypertrophy.*fn32

Plaintiff denied having chest pains or shortness of breath. (Tr. 119, repeated at 137.) She reported her exercise tolerance to be two to three blocks walking. (Id.) No orthopnea*fn33 or paroxysmal nocturnal dyspnea*fn34 was found. (Id.) A recent stress test had normal results.*fn35 (Id.) A urine analysis was positive for protein.*fn36 (Id.) Plaintiff's blood pressure was 160/80 (systolic/diastolic).*fn37 (Id.) Plaintiff's heart rate was 80 beats per minute. (Tr. 119, repeated at Tr. 137.) The physician diagnosed plaintiff with benign essential hypertension,*fn38 and increased plaintiff's dosage of Diovan to 320mg.*fn39 (Tr. 119-20, repeated at Tr. 137-38.)

b. Dr. Salon's Consultative Examination Plaintiff underwent a consultative examination by Dr. Aurelio Salon on April 6, 2007. (Tr. 126-30.) Dr. Salon noted that plaintiff had been diagnosed with goiter in 2005,*fn40 and underwent a subtotal thyroidectomy in 2006.*fn41 (Tr. 126.) Dr. Salon also remarked that plaintiff was diagnosed with asthma in 1987, and visited an emergency room on a few occasions. (Id.) Plaintiff's last reported asthma attack was in October 2006, and she reported averaging about three or four a year. (Id.) Plaintiff told Dr. Salon she had been suffering from knee pain and swelling for "a couple of years," and as a result, had undergone six to eight weeks of physiotherapy beginning in October 2006. (Id.) She informed Dr. Salon that she still suffered from "off and on" pain in her knees. (Id.) Dr. Salon noted that plaintiff was diagnosed with a heart murmur and an enlarged heart in 1980,*fn42 but noted that plaintiff showed no symptoms and had never been prescribed medication for her heart murmur. (Tr. 126.) Dr. Salon also noted that plaintiff complained of left elbow pain in 2006 and was diagnosed with tendinitis and given pain medications. (Tr. 127.) She told Dr. Salon that she continued to suffer from "off and on pain" in the elbow. (Id.) Dr. Salon indicated that plaintiff had a partial hysterectomy in 2005 due to abnormal uterine bleeding.*fn43 (Id.)

At the time of the examination, plaintiff was taking the following medications: Diovan, Hydralazine,*fn44 Advair,*fn45 Lodine,*fn46 Tylenol, and Albuterol.*fn47 (Id.) Plaintiff told Dr. Salon she has smoked since she was a teenager and still smoked five or six cigarettes a day.*fn48 (Id.).

Dr. Salon's report stated that plaintiff was able to cook, clean, do laundry, and shop, but that she needed the help of her children occasionally.*fn49 (Id.) Dr. Salon's report further stated that plaintiff was able to shower and dress herself, but that she sometimes needs her children to put on her shoes. (Id.) Dr. Salon described plaintiff as obese; at the time of the examination, she was five feet two inches tall and weighed 203 pounds. (Id.) She appeared to be in no acute distress. (Id.) Her gait and stance were normal, she could walk on her heels and toes without difficulty, and she was able to squat one-third of the way. (Tr. 127-28.) She did not require help changing into or out of her clothing for the exam, getting on and off the exam table, or rising from her chair. (Tr. 128.) Dr. Salon detected a one-sixth apical heart murmur.*fn50

He did not observe any problems with plaintiff's musculoskeletal system, extremities, or hand function. (Tr. 128-29.) An x-ray of the right knee showed moderate osteoarthritic changes. (Tr. 129, 131.) Dr. Salon diagnosed hypertension, bronchial asthma, arthralgias*fn51 of the knees and left elbow, an asymptomatic heart murmur, and obesity. (Tr. 129.) Dr. Salon stated that he made "no objective findings to support the fact that the claimant would be restricted in her ability to sit or stand or in her capacity to climb, push, pull, or carry heavy objects." *fn52 (Id.)

Dr. Salon advised the plaintiff to avoid "smoke, dust, and other known respiratory irritants because of [her] history of bronchial asthma." (Id.)

c. Disability Examiner's Physical Residual Functional Capacity Assessment

On July 12, 2007, a disability examiner filed a Physical Residual Functional Capacity ("RFC") Assessment of plaintiff. (Tr. 147-52.) The examiner believed that plaintiff could occasionally lift items weighing up to twenty pounds, frequently lift items weighing up to ten pounds, stand or walk for up to six hours a day if provided breaks, sit for six hours, and push or pull items, such as hand or foot controls, without limits. (Tr. 148.) The examiner thought plaintiff could never climb ramps, stairs, ladders, ropes, or scaffolds, but could occasionally balance, stoop, kneel, crouch, or crawl. (Tr. 149.) The examiner found no limits on the plaintiff's ability to see, communicate, or manipulate objects with her hands. (Tr. 149-50.) The assessment noted that plaintiff was not able to work in enclosed areas with dust or fumes because of asthma, but placed no other environmental limits on her potential employment. (Tr. 150.)

d. Plaintiff's Thyroid Cancer

On March 6, 2008, plaintiff had the remaining piece of her thyroid removed. (Tr. 162, repeated at Tr. 170.) No evidence of malignancy was found. (Tr. 163, repeated at Tr. 171.) On March 28, 2008, Dr. Agnieszka Gliwa, an endocrinologist, wrote a letter stating that she was treating plaintiff for thyroid cancer and asked that plaintiff be excused from work until April 28, 2008. (Tr. 174.) On April 11, 2008, Dr. Subhendu Kundu, plaintiff's primary care physician, wrote a similar letter stating that he was treating plaintiff for hypertension, arthritis, mild to moderate asthma, and thyroid cancer. (Tr. 176.) Dr. Kundu recommended that plaintiff delay any new work program at that time due to her cancer treatment and arthritis. (Id.)

On May 15, 2008, plaintiff underwent radioiodine ablation treatment.*fn53 (Tr. 234.) Plaintiff was discharged the following day and advised to maintain a low salt diet and to perform activities she could tolerate. (Tr. 233.) On June 2, 2008, plaintiff underwent a whole body scan that showed no evidence that the cancer had spread from the thyroid. (Tr. 196, repeated at 217, 234.)

e. Dr. Kundu's Assessment

On April 25, 2008, plaintiff's treating physician, Dr. Kundu, filled out a Medical Source Statement of Ability to Do Work-Related Activities (Physical).*fn54 (Tr. 155-61.) In Dr. Kundu's opinion, plaintiff could occasionally lift or carry items weighing up to twenty pounds. (Tr. 155.) Dr. Kundu wrote that, as a result of plaintiff's hypertension, asthma, arthritis, and obesity, she "might be able to lift object[s] up to twenty [pounds] but carrying for [a] period of time will be difficult because of her condition." (Id.) Dr. Kundu estimated that plaintiff could sit for five hours, stand for two hours, and walk for one hour, without interruption. (Tr. 156.) He estimated that those were also her limits in total during an eight-hour work day. (Id.) Dr. Kundu wrote that plaintiff's arthritis would cause pain in her knees if she had to stand or walk "for long hours." (Id.) He noted that she "suffer[s] from arthritis with frequent swelling of her knee joints, [right knee greater than left knee,] with overuse." (Id.) Dr. Kundu indicated that plaintiff was able to continuously use her hands. (Tr. 157.) She was able to frequently use her right foot and continuously use her left foot to operate foot controls. (Id.) Due to her obesity and arthritis, Dr. Kundu opined that plaintiff could never climb ladders or scaffolds, balance, kneel, crouch, or crawl. (Tr. 158.) He stated that she could occasionally stoop and climb stairs or ramps, but that she would have difficulty doing so. (Id.) However, Dr. Kundu indicated that plaintiff should avoid unprotected heights, moving mechanical parts, operating a motor vehicle, humidity and wetness, dust, odors, fumes, and other pulmonary irritants, extreme cold or heat, and vibrations. (Id.) He stated that plaintiff could withstand moderate noise. (Id.) She was able to shop, travel alone, walk without ...


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