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Thomason v. Colvin

United States District Court, W.D. Virginia, Lynchburg Division

August 23, 2016

Ann Juanita Thomason, Plaintiff,
Carolyn W. Colvin, Acting Commissioner of Social Security, Defendant.



         This matter is before the Court on the parties’ cross Motions for Summary Judgment (dkts. 14 and 16), the Report & Recommendation of United States Magistrate Judge Robert S. Ballou (dkt. 21, hereinafter “R&R”), and Plaintiff’s Objections to the R&R (dkt. 22, hereinafter “Objections to R&R”). Pursuant to Standing Order 2011-17 and 28 U.S.C. § 636(b)(1)(B), the Court referred this matter to U.S. Magistrate Judge Ballou for proposed findings of fact and a recommended disposition. Judge Ballou filed his R&R, advising this Court to deny Plaintiff’s Motion for Summary Judgment and grant the Commissioner’s Motion for Summary Judgment. Plaintiff timely filed his Objections, obligating the Court to undertake a de novo review of those portions of the R&R to which objections were made. See 28 U.S.C. § 636(b)(1)(B); Farmer v. McBride, 177 F. App’x 327, 330 (4th Cir. 2006). For the following reasons, I will overrule Plaintiff’s Objections and adopt Judge Ballou’s R&R in full.

         I. Background

         In October 2010, Thomason visited the Village Family Physicians complaining of hypertension, headache, and depression. R. 217. At this appointment, Thomason indicated that she had not had any medication for approximately four days and had been experiencing increased depression and crying. R. 217. To help with these problems, the doctor prescribed her four different types of medication. R. 220.

         In November and December 2011, Thomason returned to Village Family Physicians. R. 213. She continued to complain of hypertension, depression and headaches, along with new complaints of back and joint pain. R. 213. This examination revealed that she had pain and spasms in her lower back and swelling of her knee. R. 211.

         In August 2012 and January 2013, Thomason once again returned to Village Family Physicians for medication refills. R. 225, 254. At these appointments, she complained of headaches, back and joint pain, and an inability to fall asleep. R. 225, 254. The examination revealed that Thomason was obese, but had normal posture, muscle tone, and strength in her arms and legs. R. 227. The mental status exam indicated that she had appropriate mood and affect, normal judgment and insight, and could perform basic computations and apply abstract reasoning. R. 227.

         On May 23, 2012, Thomason protectively filed for SSI, claiming that her disability began on that same day due to back problems, knee pain, high blood pressure, depression, and migraines. R. 12, 161, 180. The state agency denied Thomason’s application at the initial and reconsideration levels of review. R. 60-67, 69-79.

         In September 2012, Richard J. Milan, Jr., Ph.D., state agency psychologist, indicated that Thomason’s mental status examinations were within normal limits and her depression was controlled with medication. R. 63. Dr. Milan determined that Thomason “retain[ed] the ability to handle all levels of work tasks.” R. 63. Similarly, in June 2013, Hillery Lake, M.D., state agency physician, determined that Thomason’s mental impairment was non-severe, noting that Thomason’s mental status exams were normal and she attended regular education classes in school. R. 74. Two other state physicians, Dr. Michael Hartman and Dr. Robert McGuffin, also reviewed the record. Dr. Hartman determined that Thomason had the ability to perform work at the medium extertional level, while Dr. McGuffin found that Thomason could perform a limited range of light work, with postural limitations due to her knee and back pain. R. 66, 76-77.

         On June 15, 2013, Sung-Joon Cho, M.D., performed a medical consultative evaluation on Thomason. R. 268-71. At this evaluation, Dr. Cho noted that Thomason had complained of chronic knee and back pain for approximately ten years, due to a vehicle accident. Dr. Cho, however, noted that Thomason walked with “otherwise unremarkable” gait and without assistance. Dr. Cho also indicated that Thomason had “some problems with reading.” R. 269.

         The physical exam revealed that Thomason was 5’3” tall and weighed 209 pounds. Dr. Cho noted that Thomason was “limited by her obesity” making it difficult for her to walk on her tip-toes and squat. R. 269-70. However, her motor function was a full five out of five in the upper and lower extremities, with no joint effusion or significant crepitus in her knee, and no evidence of major inflammation or instability, and her straight leg test was negative. R. 270. Dr. Cho noted that Thomason had full range of motion except for lumbar flexion, lumbar extension, and lateral flexion. R. 270.

         Dr. Cho found that Thomason’s affect, thought content, and memory were adequate; however, her general fund of information was limited and she had difficulty counting in intervals of three. R. 270. This limitation was consistent with Thomason dropping out at school at age fourteen due to pregnancy. R. 46, 270.

         At the end of the examination, Dr. Cho diagnosed Thomason with obesity, chronic low back pain, degenerative joint disease of the knee exacerbated by obesity, and illiteracy. R. 270. Dr. Cho imposed the functional limitations of maximum standing and walking of two to four hours and maximum lifting of ten pounds frequently and twenty pounds occasionally. R. 270- 71. Dr. Cho also noted that Thomason should only occasionally balance, stop, kneel, crouch, and crawl and should avoid climbing. R. 271.

         A. The ALJ’s Decision

         On January 22, 2014, Administrative Law Judge (“ALJ”) Ann V. Sprague held a hearing to consider Thomason’s claims for SSI. R. 25-52. Counsel represented Thomason at the hearing, which included testimony from vocational expert Robert Jackson. On April 8, 2014, the ALJ entered her decision analyzing Thomason’s claim.

         The ALJ analyzed Thomason’s claim under the required five-step inquiry. Walls v. Barnhart, 296 F.3d 287, 290 (4th Cir. 2002). In this process, the ALJ determines whether: (1) the claimant is engaged in substantial gainful activity; (2) the claimant has a medical impairment (or combination of impairments) that is severe; (3) the claimant’s medical impairment meets or exceeds the severity of one of the impairments listed in Appendix I of 20 C.F.R. Part 404, Subpart P, Appendix 1, and the impairment meets the duration requirement in 20 C.F.R. §§ 404.1509 and 416.909; (4) the claimant is able to perform her past relevant work; and (5) the claimant can perform other specific types of work. Johnson v. Barnhart, 434 F.3d 650, 653 n.1 (4th Cir. 2005) (citing 20 C.F.R. § 404.1520).

         The claimant has the burden of production and proof in Steps 1-4. See Hunter v. Sullivan,993 F.2d 31, 35 (4th Cir. 1992) (per curiam). If the claimant meets that burden, at Step 5 the burden shifts to the Commissioner “to produce evidence that other jobs exist in the national economy that the claimant can perform considering his age, education, and work experience.” Id. If a determination of disability can be made at ...

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