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Smith v. Colvin

United States District Court, E.D. Virginia, Richmond Division

December 3, 2014

SHEILA SMITH, Plaintiff,
CAROLYN W. COLVIN Acting Commissioner of Social Security, Defendant.


DAVID J. NOVAK, Magistrate Judge.

Sheila Smith ("Plaintiff') is thirty-nine years old, and she previously worked as a an assembler, as a certified nursing assistant, at AmeriCare Plus providing in-home care and as a cook/cashier. On September 3, 2010, Plaintiff applied for disability insurance benefits ("DIB") and supplemental security income ("SSI"), claiming disability from sarcoidosis, irritable bowel syndrome ("IBS"), palpitations and diabetes, with an alleged onset date of March 15, 2011. The claims were denied both initially and upon reconsideration. On September 21, 2012, Plaintiff appeared before an Administrative Law Judge ("All"), who denied Plaintiff's claims in a written decision on November 29, 2012. On February 3, 2014, the Appeals Council denied Plaintiff's request for review, rendering the ALJ's decision the final decision of the Commissioner.

Plaintiff now appeals the Commissioner's decision in this Court pursuant to 42 U.S.C. § 405(g), arguing that the All erred in assessing Plaintiff's credibility. Defendant responds that the ALJ did not err and that substantial evidence supports the ALJ's decision. The parties have submitted cross-motions for summary judgment, which are now ripe for review.

Having reviewed the entire record in this case, the Court is now prepared to issue a Report and Recommendation pursuant to 28 U.S.C. § 636(b)(1)(B). For the reasons that follow, the Court recommends that Plaintiff's Motions for Summary Judgment or in the Alternative, Motions for Remand (ECF Nos. 13, 14) be DENIED, that Defendant's Motion for Summary Judgment (ECF No. 16) be GRANTED and that the final decision of the Commissioner be AFFIRMED.


Because Plaintiff challenges the All's decision in determining Plaintiff's credibility, Plaintiff's education and work history, medical records, state agency physicians' opinions, Plaintiff's function reports, Plaintiff's testimony and Vocational Expert ("VE") testimony are summarized below.

A. Education and Work History

Plaintiff finished school through the tenth grade. (R. at 230.) She additionally completed certified nursing assistant training. (R. at 230.) Plaintiff previously worked as an assembler, in a nursing home and as a cook/cashier at a restaurant. (R. at 230.)

B. Medical Records

On February 16, 2011, Plaintiff went to Halifax Regional Hospital, complaining of back pain, abdominal pain, headaches and dizziness. (R. at 335-36.) Plaintiff was diagnosed with abdominal pain and prescribed pain medications. (R. at 340.) She returned several days later, again complaining of abdominal pain. (R. at 317.) Plaintiff's respirations were not labored and a CT scan showed no acute intra-abdominal abnormalities. (R. at 318, 334.)

On February 18, 2011, Plaintiff saw Johnna S. Thomas, M.D., complaining of sarcoid, palpitations, migraines and asthma. (R. at 385.) Plaintiff admitted to not taking her medications as prescribed. (R. at 385.) Dr. Thomas restarted Plaintiff's medications and ordered an MRI of Plaintiff's abdomen. (R. at 385.) The MRI showed that Plaintiff had a right heptic lobe lesion and several splenic lesions, all of which were stable since August 2010. (R. at 316, 363, 401.)

On March 14, 2011, Plaintiff had a duodenal biopsy and gastric biopsy pathology report at Southern Gastroenterology Associates that showed only small bowel mucosa without significant histopathologic change, as well as mild chronic gastritis. (R. at 308, 486, 536.) She further underwent a colonoscopy that showed a polyp that was hyperelastic. (R. at 311-12, 398-400, 492-94, 538.) An esophangogastroduodemscopy revealed mild gastritis. (R. at 310, 403, 488-89, 540-41.) In April 2011, Plaintiff returned for treatment at Southern Gastroenterology Associates, and an x-ray of her abdomen came back negative. (R. at 483, 534.)

On March 18, 2011, Dr. Thomas performed a physical evaluation of Plaintiff that produced unremarkable results. (R. at 384.) Dr. Thomas advised Plaintiff to refrain from starting her anxiety medications until after her liver biopsy results. (R. at 384.) On April 21, 2011, Dr. Thomas diagnosed Plaintiff with Type II diabetes. (R. at 423.) An x-ray of Plaintiff's abdomen was negative. (R. at 427.) On May 25, 2011, Dr. Thomas advised Plaintiff to consult with her cardiologists regarding her complaints of heart palpitations. (R. at 422.) Dr. Thomas additionally indicated that Plaintiff could participate and work in classes and training for up to 20 hours each week. (R. at 422.)

On May 11, 2011, Plaintiff went to Halifax Heart Center and had a myocardial perfusion imaging with exercise stress. (R. at 409.) An echocardiogram report that day also showed a normal ejection fraction. (R. at 410-11.) In August 2011, Plaintiff's left heart catherterization produced normal results. (R. at 458-59, 502-03.)

In June 2011, Plaintiff returned to Halifax Regional Hospital, complaining of a migraine. (R. at 478.) A physical exam yielded normal results and a CT scan of her brain revealed no acute pathology. (R. at 478-80, 482.) Medication helped Plaintiff's migraine. (R. at 478-81.)

On July 1, 2011, Plaintiff saw Dr. Thomas for a check-up. (R. at 418-19.) Plaintiff complained of mood swings, difficulty sleeping and depression. (R. at 419.) Dr. Thomas indicated that Plaintiff was neither anxious nor depressed and that Plaintiff had normal cardiac, vascular, respiratory, neurological and gastrointestinal examinations. (R. at 419.) Additionally, Dr. Thomas noted that Plaintiff's diabetes was under control. (R. at 419.)

On July 25, 2011, Terrance Truitt, M.D. completed a polysomnography report that showed that Plaintiff had mild obstructive sleep apnea. (R. at 432-39, 476.) An August 2011 pulmonary function report showed minimal obstructive lung defect, as well as moderate restrictive lung defect and moderate decrease in diffusing capacity. (R. at 430-31.)

In July 2011, Plaintiff went to Clarkesville Counseling Center where she was diagnosed with non-specified depressive disorder. (R. at 443-51.) At that time, Plaintiff had not received mental health treatment for over fifteen years. (R. at 448-49.) The licensed counselor opined that Plaintiff was focused and oriented, and she had normal speech, appearance, and thought content and organization. (R. at 445-46, 450-51.) Plaintiff further only had a moderately depressed mood. (R. at 445-46, 450-51.) The counselor noted that Plaintiff had no deficits in memory, attention span, concentration, persistence or task completion. (R. at 445-46, 450-51.) Plaintiff had no psychosis. (R. at 445-46, 450-51.)

On August 23, 2011, Plaintiff weighed 199 pounds. (R. at 504.) On August 29, 2011, Plaintiff returned to Southern Gastroenterology Associates and an MRI of Plaintiff's abdomen showed a stable hepatic lesion, as well as multiple splenic lesions. (R. at 457, 533.) Arash Chehrazi, M.D. opined that this suggested nonmalignant lesions. (R. at 457, 533.) Returning in February 2012, Plaintiff's x-rays showed no obstruction or perforation. (R. at 532.)

In January 2012, Plaintiff returned to Dr. Thomas, complaining of headaches. (R. at 566.) Plaintiff stated that she needed corrective eyewear and had run out of her migraine medicine. (R. at 566.) Dr. Thomas noted that Plaintiff was not anxious, depressed or irritable and that Plaintiff had normal cardiac, vascular, respiratory neurological and gastrointestinal examinations. (R. at 567.) The next month, Plaintiff's same tests remained unremarkable. (R. at 554-55, 576-77.) Further, wearing prescription eyewear improved Plaintiff's headaches. (R. at 554, 576.)

In February 2012, Plaintiff reported to Dr. Truitt that Plaintiff had not filled her prescription for her rescue inhaler and that she slept well with a CPAP. (R. at 513, 561.) Dr. Truitt advised that Plaintiff consider pulmonary rehabilitation and that she should increase her activity for weight loss. (R. at 516, 564.)

In April 2012, Plaintiff returned to Dr. Thomas, again complaining of migraines. (R. at 571.) Plaintiff continued to smoke and she drank excessive amounts of caffeine. (R. at 571.) At ...

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