United States District Court, S.D. New York
OPINION & ORDER
ANDREW L. CARTER, Judge.
Plaintiff Luz Altagracia Geronimo ("Plaintiff") commenced 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 by the Defendant Commissioner of Social Security (the "Commissioner") which denied her application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). (ECF No. 2) Before the Court are motions for judgment on the pleadings from both parties. For the reasons set forth below, the Commissioner's motion (ECF No. 8.) is denied, and the Plaintiff's cross-motion (ECF No. 11) is granted.
I. FACTUAL BACKGROUND
A. Procedural Background
Plaintiff's complaint alleges that she became disabled on November 7, 2010 based on the impairments of low back pain, vertigo, hypertension and obesity. (Compl. ¶¶ 4, 5.) Plaintiff had previously worked as a cleaner and a home health aide, and was 60 years old and living with her daughter and granddaughter in an apartment on the date of alleged disability. (Soc. Sec. Admin. R. at 32-36 (hereinafter "R. at ___").) After Plaintiff's June 17 and July 5, 2011 applications for DIB and SSI, respectively, were denied, Plaintiff requested a hearing before an administrative law judge ("ALJ"). A hearing was held on June 18, 2012, and Plaintiff testified at the hearing with the assistance of a Spanish language interpreter. (R. at 32.)
Plaintiff testified that she was five feet and seven inches tall and weighed 185 pounds. (R. at 34.) She completed high school and home health aide training outside of the United States, (R. at 114, 118), and had indicated in a form that her back pain began in 2005, worsened over time, and is triggered by carrying heavy items, sweeping and mopping, and that pain medication only helped sporadically. (R. at 145-47.) Plaintiff testified that she could only stand for five minutes, walk three blocks and lift five pounds or less, and that she has to alternate between sitting and standing because she cannot sit for very long. (R. at 34.) Plaintiff testified that her daughter does the grocery shopping and that she only occasionally cooks. (R. at 35.) She stopped work as a cleaner in 2011 at the direction of her doctor. (R. at 33)
B. Medical Evidence
Plaintiff received primary care treatment at Centro Medico Dominicano ("CMD") from February 11, 2010, to August 19, 2010. (R. at 195-202, 208-10.) On February 11, 2010, Plaintiff was seen by primary care physician Dr. Rafael Barranco for complaints of lower back pain, left knee pain, and nasal congestion symptoms. (R. at 201-02.) A musculoskeletal examination revealed tenderness over the lumbar spine and left sacroiliac or SI joint. (R. at 201.) Dr. Barranco's assessment was hypertension, unspecified joint pain, osteopenia, allergic rhinitis due to unspecified cause, acid dyspepsia, and glaucoma. (R. at 201.) Dr. Barranco ordered lab work and prescribed Enalapril Maleate and Atenolol for hypertension, Celebrex for joint pain, Fosamax and calcium for osteopenia, Claritin for allergic rhinitis, and Nexium for acid dyspepsia. (R. at 201-02.)
On July 7, 2010, Plaintiff had a follow up with Dr. Barranco due to pain in her left buttock that radiated to her knee. (R. at 199-200.) Examination revealed tenderness over both SI joints and adjacent to the greater trochanter bilaterally, tenderness over the left ankle, mild pretibial and ankle edema bilaterally, and questionable positive straight leg raising bilaterally. (R. at 199.) Dr. Barranco diagnosed Plaintiff with radiculitis edema and referred plaintiff to a neurologist and podiatrist. (R. at 200.) He ordered lab work to further evaluate Plaintiff's joint pain, which came back negative for antinuclear antibody and rheumatoid factor, (R. at 197-98), while the results of additional arthritis tests were acceptable. (R. at 195.) He continued Plaintiff on the same medications (R. at 195-96.)
Plaintiff saw Dr. Barranco for another follow up on December 13, 2010. (R. at 192-94.) She was asymptomatic, except for sporadic arthralgia and dizziness, and Dr. Barranco noted a history of mild fatigue and lassitude and persistent discomfort in the left lower abdominal quadrant "for about two years." (R. at 192.) Examination showed extremities were normal, and musculoskeletal examination revealed no swelling or deformity (R. at 193.) Dr. Barranco assessed hypertension, radiculitis, osteopenia, dyspepsia, cervical dysplasia NOS, glaucoma NOS, dizziness, arthralgias, fatigue, and right lower quadrant abdominal pain. (R. at 193.) Dr. Barranco prescribed Enalapril Maleate and Atenolol for hypertension, Fosamax and calcium for osteopenia, Nexium for dyspepsia, Meclizine for dizziness, and Mobic for arthralgias. (R. at 193.) With regard to fatigue, he noted that thyroid lab results were within the normal range, and he referred Plaintiff to a gastroenterologist for evaluation of her abdominal pain. (R. at 193.)
On March 21, 2011, Plaintiff saw primary care physician Konstantino Zarkadas, M.D. at CMD, for an annual physical and for a follow up after visiting the emergency room for back pain. (R. at 190.) Examination of Plaintiff's back revealed scoliosis with convexity, multiple paired trigger points, and pain with lateral rotation. (R. at 190.) Dr. Zarkadas diagnosed back pain and noted that Plaintiff had a "complete work-up" during her emergency room visit, after which she was diagnosed with sciatica. (R. at 191.) Dr. Zarkadas referred Plaintiff to physiatrist and to an ophthalmologist. ( Id. )
On June 10, 2011, plaintiff returned to Dr. Zarkadas for a follow up and her referred her for physical therapy for her back pain and refilled her prescriptions for Nexium and Meclizine. (R. 186-87.) Plaintiff then returned to Dr. Zarkadas for a follow up and medication refills on June 17, 2011. (R. at 186-87.) Musculoskeletal examination revealed no swelling or deformity, and examination of extremities revealed two pulses bilaterally and no clubbing, cyanosis, or edema, and neurologic examination revealed that plaintiff was alert and oriented, and cranial nerves II-XII were grossly intact. (R. at 186.) Dr. Zarkadas diagnosed hypertension, low back pain, gastritis, osteoporosis and low risk vertigo, and refilled prescriptions for Atenolol and Enalapril Maleate for hypertension, and started Plaintiff on Mucinex. (R. at 186.)
On August 4, 2011, Dr. Aurelio Salon performed a consultative examination in connection with Plaintiff's SSI and DIB applications. (R. at 170-74.) Plaintiff advised Dr. Salon that she suffered from low back pain radiating to the left lower extremity and began approximately eight years prior, left shoulder and arm pain that began one year ago, dizziness that began five years ago, and generalized headaches that began two weeks ago. (R. at 170-74.) She stated that she experienced dizziness approximately twice per week, most recently five days ago, and that she was hospitalized in 2009 for dizziness. (R. at 170-74.) Plaintiff stated that she went to physical therapy for the first time last month but that she attended only one session because of back pain. (R. at 171.) As regards activities of daily living, Plaintiff stated that her daughter did the cleaning and laundry but that plaintiff was able to cook, shop, shower, and dress herself, and that she spent her time watching television, listening to the radio, and reading. (R. at 172.)
Dr. Salon weighed Plaintiff as 183 pounds, which he deemed "obese, " and her blood pressure was 150/88. (R. at 172.) Her gait and stance and hand and finger dexterity were normal, her grip strength was full bilaterally, but Plaintiff declined to walk on her heels and toes, and she squatted to only one-third of full. (R. at 172, 174.) Plaintiff did not need help changing or mounting and dismounting the exam table, and she was able to rise from a chair without difficulty. (R. at 172.) Salon's exam revealed full range of motion of the cervical spine and no scoliosis, kyphosis, or abnormality in the thoracic spine. (R. at 173.) Plaintiff declined to undergo an evaluation of the range of motion of her lumbar spine, but straight leg raising test was negative bilaterally, and her range of motion was full in her shoulders, elbows, forearms, wrists, hips, knees, and ankles bilaterally. (R. at 173.) There was no evidence of cyanosis, clubbing, or edema, and no muscle atrophy based on exam of Plaintiff's extremities. (R. at 174.) Dr. Salon diagnosed hypertension, history of lumbar radiculopathy, history of ...