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West v. Berryhill

United States District Court, S.D. Mississippi, Eastern Division

March 27, 2017

ADDIE RUTH WEST PLAINTIFF
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY DEFENDANT

          ORDER

          F. Keith Ball United States Magistrate Judge

         I. Introduction

         Addie Ruth West filed for a period of disability, disability insurance benefits, and supplemental security income on February 29, 2012. Her application was denied both initially and upon reconsideration. She requested and was granted a hearing before an ALJ, which was held on January 22, 2014. On June 24, 2014, the ALJ issued a decision finding that West is not disabled. The appeals council denied review. West now brings this appeal pursuant to § 205(g) of the Social Security Act, 42 U.S.C. § 405(g). Having considered the memoranda of the parties and the administrative record, the Court concludes that the decision of the Commissioner should be affirmed.

         II. Facts and Evidence before the ALJ

         West was born on November 18, 1956, and was 57 years of age at the time of the decision of the ALJ. She has a high school education and completed one year of college. She alleges disability beginning April 29, 2011, due to back pain, osteoarthritis, and hypertension.

         The medical treatment record is sparse. In a letter dated March 20, 2012, Denton Spiers, D.C., stated that he treated West from October 2006 until January 2007. R. 259-60, [4] at 262-63. West's presenting complaints were severe neck pain, lower back pain, and numbness and tingling radiating into the right arm. R. 259, [4] at 262. Physical examination revealed spasms and tenderness of the paraspinal muscles in the cervical, thoracic and lumbar spine and pain in all regions. Id. Range of motion was normal in the cervical spine and moderately restricted in the lumbar spine. Id. Maneuvers were positive for pinched nerves in the cervical and lumbar spine. Id. Diagnosis was degenerative disc disease of the cervical and lumbar spine, midback pain, and severe muscle spasm. R. 260, [4] at 263. Dr. Spiers stated in his letter that West's prognosis in October of 2006 was poor and that while she was under his care, she was unable to lift or do any repetitive work for any amount of time. Id.

         On January 9, 2007, West underwent a series of x-rays after being involved in a motor vehicle accident. The x-rays indicated mild bilateral hip osteoarthritis, degenerative disc disease at ¶ 5-C6, neuroforaminal stenosis that was moderate at ¶ 4-C5 and mild at ¶ 5-C6, and degenerative disc disease of the lumbar spine. R. 227-31, [4] at 330-34.

         Dr. Spiers completed a medical source statement on June 11, 2013. There is no indication that he had treated or evaluated West since January of 2007. In the statement, he rated as moderately severe West's limitations in maintaining attention and concentration for extended periods, performing activities within a schedule, and maintaining regular attendance and being punctual. R. 306, [4] at 309. He rated as severe her limitations in the ability to complete a normal workday and workweek without interruptions from medically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods. Id. Dr. Spiers opined that West was not capable of performing light or sedentary work, even if she were allowed a sit/stand option. R. 307, [4] at 310.

         On February 26, 2013, West was seen by Dr. Bridget Tah-Clayton at the Hattiesburg Clinic. Dr. Tah-Clayton's diagnoses were hypertension, osteoarthritis, degenerative joint disease at multiple sites, vitamin D deficiency, and decreased range of motion in the right shoulder. R. 303, [4] at 306. On January 21, 2014, Dr. Tah-Clayton completed a medical source statement. In the statement, she rated as moderately severe West's limitations in maintaining attention and concentration for extended periods. R. 314, [4] at 317. In the areas of the ability to perform activities within a schedule, maintain regular attendance, and be punctual; to complete a normal workday and workweek without interruptions from medically based symptoms, and to perform at a consistent pace without an unreasonable number and length of rest periods, Dr. Tah-Clayton rated her as severely limited. Id. Dr. Tah-Clayton opined that West suffers from cervical and lumbar degenerative joint disease with radiculopathy, diabetes, and dysphagia. R. 316, [4] at 319. She recommended an EGD to evaluate West's numbness and tingling in the arms, hands, and feet. Id. According to Dr. Tah-Clayton, West is incapable of performing light or sedentary work, even with a sit/stand option. R. 315, [4] at 318. Dr. Tah-Clayton stated that West suffers from headaches as a result of pinched nerves and that her headaches cause problems with her concentration. R. 316, [4] at 319. She identified West's medications as Benicar HCT and Claritin. R. 318, [4] at 321.

         Dr. Stephen Massey performed a consultative physician examination of West on June 8, 2012. West's recorded height at the exam was 5'6”, and her weight was 226 pounds. R. 263, [4] at 266. West relayed to Dr. Massey a history of neck pain, low back pain, and intermittent numbness in her legs at night. R. 262, [4] at 265. Dr. Massey observed that she experienced minor difficulty in getting on and off the examination table. R. 263, [4] at 266. Physical examination revealed a full range of motion in her upper extremities and in her lower extremities except for her left hip, where she experienced pain with flexion and rotation. R. 264, [4] at 267. There was no back tenderness or spasm. Id. Range of motion in the lumbar spine was 45 degrees with flexion, 10 degrees with extension, and 20 degrees with rotation. Id. Her gait was slightly antalgic, but she used no assistive device. Id. She was able to squat halfway, at which point she stopped with complaints of knee and leg pain. Id. West was unable to walk heel-to-toe because of unsteadiness. Id. Straight leg raising was negative. Id. Deep tendon reflexes were 2/4 in the arms and legs, and strength was 5/5. Id. Hand grip was 4/5 bilaterally. Id. Fine and gross manipulation were within normal limits. Id. Dr. Massey's diagnoses were chronic low back pain, chronic neck pain, polyarthralgia, hypertension, obesity, diabetes, and dyspnea on exertion. R. 264-65, [4] at 267-68. As to her exertional abilities, Dr. Massey opined that Plaintiff could lift only light objects, would need to avoid climbing, kneeling, and squatting, and would need periodic position changes when sitting. R. 265, [4] at 268. He stated that she should avoid repetitive and prolonged manipulation of small objects, squeezing, and grasping. Id. Dr. Massey also warned that West was at risk for injury due to knee instability. Id.

         Dr. Alvin Brent conducted a consultative review of West's medical records on July 20, 2012. Dr. Brent identified West's diagnoses as hypertension and degenerative joint disease. R. 274, [4] at 277. He opined that West was capable of lifting ten pounds frequently and 20 pounds occasionally, that she could stand and walk six hours in an eight-hour workday, that she could occasionally climb, that she could frequently balance, stoop, kneel, crouch, and crawl, and that she had no manipulative limitations. R. 276-78, [4] at 279-81. X-rays of the lumbar spine performed in connection with the examination revealed mild multilevel degenerative changes. R. 268, [4] at 271.

         At the hearing, West testified and gave the following account of her living circumstances, work history, medical problems, and symptoms. She lives alone in an RV. R. 41, [4] at 44. West's only source of income is the help she receives from her children. R. 42, [4] at 45. West also depends on her children and grandchildren to perform housekeeping and laundry tasks. R. 55, [4] at 58. She owns a truck and drives it approximately once per week. R. 41, [4] at 44.

         West previously worked in a photo processing lab but had to quit because of back pain. R. 43, [4] at 47. At Kohler Company, she worked as a machine operator, but she left that job because of problems with her hands. R. 44, [4] at 47. West tried to work as a janitor but had to quit because she developed overuse syndrome from operating a buffer. R. 45, [4] at 48. West also worked as a childcare worker at the University of Southern Mississippi and as an activities director for the Boy Scouts. R. 46, [4] at 49. According to West, the main problems that prevent her from working are pain in her lower back, hips, neck, and arms; arthritis in her hands; and carpal tunnel syndrome. R. 47, [4] at 50. She takes Aleve for her pain but no other pain medication because of side effects, difficulty swallowing pills, and the inability to afford payment for drugs. R. 50-51, [4] at 53-54.

         West described significant difficulties with her morning routine. To help with getting out of bed, she sleeps on a board with a mattress that is tilted sideways so that she can slide out. R. 51, [4] at 54. Once her feet are on the floor, she has to place her feet apart to keep from falling and has to hold onto the wall to get to the bathroom. R. 52, [4] at 55. She has difficulties getting up from the toilet. Id. West is unable to lift her arms and for that reason has been unable to brush her teeth for the past year. Id. When she finishes in the bathroom, she usually goes back to the bed and rests. Id. Before taking a shower, West checks her blood pressure to make sure it is not too high for her to get up. R. 53, [4] at 56. Once in the shower, she is unable to wash certain parts of her body, such as her legs, because she cannot bend down. R. 52, [4] at 55. She wears bath gloves for scrubbing because she is unable to hold a washcloth. Id. Taking a shower usually causes her blood pressure to go up, so she rests again before getting dressed. R. 53, [4] at 56. She has to lie down in order to put her clothes on and does not wear undergarments because she is unable to put them on. R. 53, 54, [4] at 56, 57. Once she is dressed, she eats cold cereal for breakfast. R. 54, [4] at 57. She is unable ...


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