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Vidal v. Colvin

United States District Court, N.D. Indiana, Hammond Division

March 24, 2015

LAURA VIDAL, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.


JON E. DeGUILIO, District Judge.

Plaintiff Laura Vidal applied for but was denied social security disability benefits by the Social Security Administration. She then filed a complaint in this Court, seeking review of that decision, and the matter has been fully briefed. [DE 15, 18, 23]. For the following reasons, the Court AFFIRMS the decision of the Commissioner.


Laura Vidal was fifty-one years old at the time of the ALJ's decision, and had worked at a grocery store as a floral manager for about five years prior to her alleged disability. On October 8, 2010, Vidal applied for Social Security Disability Insurance Benefits, alleging an onset date of April 1, 2008. (R.165). Her claim was denied upon initial consideration, and then again upon reconsideration, so she filed a written request for a hearing before an Administrative Law Judge. Vidal appeared and testified at the hearing, as did her husband and an independent vocational expert. ALJ Edward P. Studzinski issued his decision on July 25, 2012, denying Vidal benefits and finding that she was not disabled within the meaning of the Social Security Act. (R. 36). Vidal requested that the Appeals Council review the ALJ's decision, but the Appeals Council denied the request, making the ALJ's decision the final decision of the Commissioner. Vidal then filed her complaint, and this Court has jurisdiction to review the decision of the Commissioner pursuant to 42 U.S.C. ยง 405(g).

A. Medical History

Vidal's relevant medical history begins in 2007. Vidal saw her primary care physician twelve times in 2007, many of which were for routine checkups and refills of her medications. (R. 354-65). At her November 19, 2007 appointment, Vidal complained of headaches, so her doctor ordered an MRA and an MRI of her brain. Those were performed as outpatient procedures on December 1, 2007. The doctor's impression of the MRA was "Normal MRA of the brain, " and the impressions of the MRI were "1. No acute infarct. 2. No enhancing lesions.

3. Tiny high signal areas within the periventricular white matter regions bilaterally, may be due to small vessel disease." (R. 218-19). Vidal continued to visit her doctor about monthly in 2008, and complained of headaches during four of her appointments. (R. 341-52). During many of the visits, Vidal either reported no complaints, or complained of issues such as a cough or a lump on her breast that were successfully resolved. ( Id. ). In April 2008, after the alleged onset of Vidal's disability, Vidal's physician completed a Certificate to Return to Work. He indicated that Vidal had been under treatment for anxiety, otalgia, and acute sinusitis, and that she was cleared to return to work. (R. 400). He also wrote "No" in the blanks next to "Restrictions" and next to "Light Work." ( Id. ).

In May 2009, Vidal was admitted to the hospital due to severe abdominal pain with nausea and vomiting. She was diagnosed with acute cholecystitis, and underwent a laparoscopic cholecystectomy, or removal of her gallbladder. Vidal tolerated the procedure well, and was released after spending a week in the hospital. (R. 221-23). These records also indicate that Vidal's past medical history included anxiety, among several other conditions. (R. 221). Vidal was again hospitalized in October 2009 for intractable stomach pain with nausea, vomiting, and diarrhea. A treatment note on October 12, 2009 stated that Vidal's "symptoms may be irritable bowel related or infectious gastroenteritis, " (R. 263), and she was subsequently diagnosed with gastritis, esophagitis, and stomach function disorder. (R. 258). Vidal's next medical record of note was nearly a year later, in September 2010, when she was hospitalized for complaints of severe chest congestion, coughing, difficulty breathing, headache, and a low grade fever. (R. 288). Her admitting diagnosis was an exacerbation of her asthma. ( Id. ). However, imaging studies of her lungs and sinuses were normal, and other tests only revealed a fatty liver. In a visit with her primary care physician the following week, Vidal noted that she had been experiencing extreme emotional highs and lows since her discharge from the hospital. (R. 321). Two weeks later, she reported that her mood swings were slightly better, and an office visit note from December 4, 2010 indicated that Vidal was feeling better but still experiencing some depression. (R. 320).

Having submitted her claim for social security benefits in October 2010, Vidal underwent a psychological consultative examination by Dr. Irena Walters on December 8, 2010. Dr. Walters observed that Vidal was alert, oriented, and cooperative, but that she was "intermittently tearful." (R. 417). Vidal stated that she "is not able to do any heavy lifting and that there is left hand weakness, " but that she is able to groom, bathe, and dress herself, and to do various chores around the house. Vidal also noted that she had recently stopped drinking, but had been drinking two 12-packs of beer in a weekend, and that she had begun using marijuana about four years ago, and was using it every other day to calm her down. Vidal stated that she had hopeless/helpless feelings each week, with tearfulness every other day. She also described her anxiety symptoms as follows: "It feels like something is sitting on my chest; I can't breathe; I have shakiness, especially when I'm upset." (R. 419). Dr. Fisher's diagnoses were depressive disorder and panic disorder without agoraphobia, with alcohol and marijuana abuse. She gave Vidal a Global Assessment Functioning score of 60 to 65. A state agency reviewing psychiatrist then prepared an assessment in which he found that Vidal's mental impairments were not severe. He also analyzed Vidal's functional limitations, and found that Vidal was at most mildly limited in her activities of daily living, social functioning, and concentration, persistence, or pace, and that she had experienced no episodes of decompensation. (R. 438).

Vidal also underwent a medical consultative examination on December 17, 2010, with Dr. Geoffrey Onyeukwu, a state agency medical examiner. (R. 422-24). Vidal reported a history of asthma and irritable bowel syndrome, and reported occasional vomiting and diarrhea. The examination of Vidal's arms showed no swelling, stiffness, or effusion, with a full range of motion in each joint and full strength in all major muscle groups. Dr. Onyeukwu further found "normal grip strength at 4/5 in both hands" and normal fine finger manipulative ability. Vidal was also "able to open jar, zip/unzip and button/unbutton without difficulty, " (R. 424), though she reported to Dr. Onyeukwu that she had difficulty gripping and holding objects. The rest of the examination was unremarkable. Under his findings, Dr. Onyeukwu stated that Vidal had "multiple medical conditions that compromise functional capabilities, " and that she "has a history of GERD, hypothyroidism, Cholecystectomy, depression, anxiety, asthma, and irritable bowel syndrome" and "has difficulty gripping objects and complains of loss of feeling in both hands attributed to polyarthritis." (R. 424).

A state agency reviewing physician then prepared a physical residual functional capacity assessment. (R. 442). He opined that Vidal could lift 50 pounds occasionally and 25 pounds frequently, but that she had no other exertional limitations, meaning she was able to sit, stand, or walk for six hours in an eight-hour work day, and was unlimited in her ability to push or pull. (R. 443). The reviewer also found that Vidal had no postural or manipulative limitations, but recommended that she avoid concentrated exposure to extreme heat or cold, or to fumes, odors, dusts, gases, or poor ventilation, due to her history of asthma. (R. 444-46).

Vidal was briefly hospitalized in February 2011 for complaints of chest discomfort, with a cough and episodes of vomiting and diarrhea. In March 2011, tests confirmed that Vidal had an overactive thyroid, so in May 2011, she underwent a radioactive thyroid ablation. (R. 523, 539). Vidal continued to visit her primary care physician on about a monthly basis, and in August 2011 began complaining of pain in her left thumb. Vidal was referred to a specialist, who prescribed a brace for her thumb, and an x-ray on her right wrist in November 2011 indicated "moderate arthropathy at the first carpometacarpal joint" in her left hand. (R. 633). On February 14, 2012, Vidal underwent a trapeziectomy on her left wrist, which removed a bone from her wrist, and she also received an injection to the same area on her right wrist. (R. 650-51). In a visit with her primary care physician on February 27, 2012, Vidal's doctor noted that she was "doing well" following the surgery on her wrist, that her "asthma has been well controlled since her last visit, " and she was "stable on meds." (R. 565). A follow-up x-ray on May 15, 2012 on Vidal's left wrist showed "no obvious postsurgical complication" and showed that the bone was stable. (R. 624). At another visit with her primary care physician on May 29, 2012, Vidal's doctor again noted that Vidal was "doing well" following her surgery. A notation at the end of that office visit note stated: "s/p wrist surgery. [Patient] has forms to be filled for disability. [S]he is unable to use her left hand and going through PT for this now. Follows up with Dr[.] Kung." (R. 557). During Vidal's other office visits in this timeframe, she did not raise any specific complaints, except for one appointment at which she complained of cold symptoms. (R. 552, 560, 565, 570).

B. Hearing Testimony

Three witnesses testified at the administrative hearing on June 26, 2012: Vidal, her husband, and a vocational expert. Vidal testified that she last worked in April 2008 as a floral manager in a grocery store, but that she quit because she was constantly getting sick and could not handle the physical demands of the job. She initially testified that she could barely do any daily activities, but acknowledged upon further questioning that she completed tasks such as getting dressed, making the bed, doing light cooking and laundry, and driving.

Vidal testified that she could barely lift 5 pounds with her left hand, and would drop things several times a day. Her pain in her right hand was typically around 2 out of 10, but was at 6 at the time of the hearing because a door that she was opening a few days prior got caught in the wind and pulled her hand. As to her right hand, Vidal testified that she could not lift 10 pounds. Vidal also testified that she suffered pain in her left shoulder and elbow, and that these limitations prevented her from activities such as cutting the grass, raking, shoveling, and mopping. She testified that this pain had been constant since a fall she experienced in 2003.

Vidal also testified that she experienced migraines three times each month, and that they last two days. When her migraines occur, Vidal takes Aleve and lies down in a dark room for a couple of hours, and she is unable to do anything else. As to her inflammatory bowel syndrome, Vidal said that she would have diarrhea two or three days a week, and that on those days she would have to use the bathroom 10 to 12 times. Upon questioning from the ALJ, however, her attorney acknowledged that there was no support in the record for IBS symptoms of that severity.[1] Vidal also testified as to her asthma symptoms that she uses her inhaler three times a day, and that about every three months, she would have to use a nebulizer, which she would use for fifteen minutes at a time, every four to six hours, for about a two-week period.

As to her mental conditions, Vidal testified that she cries often, and that she experiences panic attacks at least twice a month. The panic attacks would typically occur when Vidal was in public in busy places or when she would receive phone calls from bill collectors. For example, two weeks prior, Vidal had been in Walmart filling a prescription, but it was very crowded, so she left and asked her husband to do it for her. She claimed that she had seen a psychiatrist a couple of times about a year and a half prior to the hearing, but did not pursue further treatment because she was unable to afford the copayments, which were $30 for each regular office visit and $50 for each visit to a specialist. The psychiatrist had also recommended that Vidal see a therapist, but she was unable to do that for the same reason.

Next, Vidal's husband briefly testified. He stated that Vidal's testimony was accurate, and he offered a few brief details consistent with her testimony. Finally, Dr. Leonard Fisher, an independent vocational expert, testified. The ALJ first asked Dr. Fisher a hypothetical about an individual with Vidal's age, education, and experience who was limited to medium-level work, with some other limitations on her postures, environment, and activities. Dr. Fisher responded that such an individual could perform Vidal's past work. When limited to light work, however, the individual would not be able to perform Vidal's past work. The ALJ finally added some mental or emotional limitations and some further limitations on the individual's use of her left hand. Dr. Fisher testified that such an individual would be able to perform several other jobs, including inspector of electronics worker positions.

C. ALJ's Decision

The ALJ issued his decision on July 25, 2012. He found that Vidal met the insured status requirements through December 31, 2013, and that she had not engaged in substantial gainful activity since April 1, 2008, the alleged onset date. At step two, he found that Vidal's severe impairments included asthma, arthritis to both upper extremities, carpel tunnel syndrome, cholecystitis, residuals from a gallbladder removal, gastritis, esophagitis, irritable bowel syndrome, anxiety and depression. At step three, the ALJ found that Vidal did not meet or equal any listed impairment. Before proceeding to step four, the ALJ formulated Vidal's residual functional capacity as follows:

[T]he claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) with exceptions. Specifically, the claimant is able to lift up to 20 pounds occasionally and 10 pounds frequently, stand and/or walk up to 6 hours in an 8-hour workday and sit up to 6 hours in an 8-hour workday, but is to be allowed to alternate positions every hour for five minutes at a time. She is never to climb ladders, ropes or scaffolds, but may perform other postural frequently. The claimant is to avoid concentrated exposure to extreme cold and hot temperatures, humidity, and pulmonary irritants such as fumes, odors, dusts, gases and poorly ventilated areas. She is also to avoid exposure to hazardous work environments, including work that involves driving or operating moving machinery, working at unprotected heights or being exposed to flames, unprotected large bodies of water and concentrated exposure to hazardous unguarded machinery such as operating a punch press or working in proximity of moving blades. The claimant is capable of performing frequent, but not constant fine manipulation, but is unable to use her left hand for forceful working movements. Mentally, the claimant is limited to simple, routine and repetitive tasks in a low stress job that involves simple decision-making, which is defined as being able to choose within a limited number of anticipated options; however she is unable to come up with created solutions to novel situations. Additionally, the claimant would be limited to occasional and minor changes to the work setting and workplace and is limited to work that requires simple judgment, which includes dealing with the concrete rather than the abstract and things rather than people. She is limited to no direct public service positions, such as dealing with significant direct interaction with the public or with the public over the telephone. Lastly, the claimant is limited from performing jobs that are in extremely crowded or hectic environments, such as street fairs or carnivals, but is capable of tolerating brief and occasional interaction with her supervisors and co-workers as required in unskilled work.

(R. 28). Based on this RFC and the vocational expert's testimony, the ALJ found at step four that Vidal was unable to perform any past relevant work. However, he found at step five that Vidal could perform jobs that exist in significant numbers in the national economy. Accordingly, he found that Vidal was not under a disability, as ...

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