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Smith v. Berryhill

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

March 29, 2018

CHARLES RONALD SMITH, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION

          HON. GLEN E. CONRAD, SENIOR UNITED STATES DISTRICT JUDGE

         Plaintiff has filed this action challenging the final decision of the Commissioner of Social Security denying plaintiffs claims for disability insurance benefits and supplemental security income benefits under the Social Security Act, as amended, 42 U.S.C. §§ 416(i) and 423, and 42 U.S.C. § 1381 et seq, respectively. Jurisdiction of this court is pursuant to 42 U.S.C. § 405(g) and 42 U.S.C. § 1383(c)(3). This court's review is limited to a determination as to whether there is substantial evidence to support the Commissioner's conclusion that plaintiff failed to meet the requirements for entitlement to benefits under the Act. If such substantial evidence exists, the final decision of the Commissioner must be affirmed. Laws v. Celebrezze, 368 F.2d 640 (4th Cir. 1966). Stated briefly, substantial evidence has been defined as such relevant evidence, considering the record as a whole, as might be found adequate to support a conclusion by a reasonable mind. Richardson v. Perales. 402 U.S. 389, 401 (1971).

         The plaintiff, Charles Ronald Smith, was born on October 13, 1957, and eventually completed his high school education. Mr. Smith has been employed as a janitor/cleaner, delivery driver, material handler, and cemetery laborer. He last worked on a regular and sustained basis in April of 2011. (Tr. 47, 115). On July 5, 2013, Mr. Smith filed applications for disability insurance benefits and supplemental security income benefits. In filing his current claims, Mr. Smith alleged that he became disabled for all forms of substantial gainful employment on April 8, 2011, due to pain in his lower back and left side. (Tr. 236, 250). Mr. Smith now maintains that he has remained disabled to the present time. With respect to his application for disability insurance benefits, the record reveals that Mr. Smith met the insured status requirements of the Act at all relevant times covered by the final decision of the Commissioner. See generally, 42 U.S.C. §§416(i) and 423(a).

         Mr. Smith's applications were denied upon initial consideration and reconsideration. He then requested and received a de novo hearing and review before an Administrative Law Judge. In an opinion dated February 29, 2016, the Law Judge also determined that Mr. Smith is not disabled. The Law Judge found that Mr. Smith suffers from several severe impairments, including degenerative disc disease in the lumbar spine, hypertension, obesity, and lumbar strain. (Tr. 22). Nevertheless, the Law Judge determined that Mr. Smith retains the residual functional capacity to perform a limited range of medium exertional activity. More specifically, the Law Judge found that plaintiff is capable of performing medium work, as defined in 20 C.F.R. §§ 404.1567(c) and 416.927(c), except that he can only "occasionally push or pull, or climb ladders, ropes and scaffolds, " but can "frequently climb ramps and stairs, and frequently stoop, kneel, crouch, and crawl."[1] (Tr. 24). Given such a residual functional capacity, and after considering testimony from a vocational expert, the Law Judge determined that Mr. Smith remains capable of performing his past relevant work as a janitor/cleaner. In the alternative, the Law Judge found that if even if Mr. Smith is disabled for past relevant work, he retains the capacity to perform other work roles existing in significant number in the national economy. Accordingly, the Law Judge concluded that Mr. Smith is not disabled, and that he is not entitled to benefits under either federal program. See generally 20 C.F.R. §§ 404.1520(f)-(g) and 416.920(f)-(g). The Law Judge's opinion was adopted as the final decision of the Commissioner by the Social Security Administration's Appeals Council. Having exhausted all available administrative remedies, Mr. Smith has now appealed to this court.

         While plaintiff may be disabled for certain forms of employment, the crucial factual determination is whether plaintiff is disabled for all forms of substantial gainful employment. See 42 U.S.C. §§ 423(d)(2) and 1382c(a). There are four elements of proof which must be considered in making such an analysis. These elements are summarized as follows: (1) objective medical facts and clinical findings; (2) the opinions and conclusions of treating physicians; (3) subjective evidence of physical manifestations of impairments, as described through a claimant's testimony; and (4) the claimant's education, vocational history, residual skills, and age. Vitek v. Finch. 438 F.2d 1157, 1159-60 (4th Cir. 1971); Underwood v. Ribicoff 298 F.2d 850, 851 (4th Cir. 1962).

         After a review of the record in this case, the court is constrained to conclude that the Commissioner's final decision is supported by substantial evidence. The Law Judge's opinion reflects a thorough evaluation of Mr. Smith's medical problems and the extent to which they affect his ability to work. Although Mr. Smith suffers from several physical impairments, substantial evidence supports the Law Judge's determination that he retains the residual functional capacity to perform a limited range of medium work.

         The record reveals that Mr. Smith has received intermittent treatment for pain in his lower back and extremities. On February 24, 2010, plaintiff presented to the emergency department of Carilion Roanoke Memorial Hospital with complaints of pain in his lower back and left leg. (Tr. 300). He was discharged home and encouraged to follow up with his primary care physician. (Tr. 303). A spinal x-ray performed the following year revealed degenerative disc disease at ¶ 3-L4, L4-L5, and L5-S1, facet arthropathy of the mid and lower lumbar spine, Grade 1 spondylolisthesis, and diffuse idiopathic skeletal hyperostosis. (Tr. 328). Mr. Smith returned to the hospital with complaints of back pain on October 23, 2012. The attending physician prescribed Lortab, Valium, and Prednisone, and advised him to follow up with his primary care physician.

         Mr. Smith was established as a new patient at Carilion Clinic Family Medicine -Roanoke/Salem on April 25, 2013, at which time he denied having any back or joint pain. (Tr. 348). He was diagnosed with hypertension and obesity, and counseled about losing weight. (Tr. 349-351). Mr. Smith returned with elevated blood pressure on February 12, 2014, and once again denied having any pain. (Tr. 365) ("Pt reports pain is 0 out of 10."). During follow-up evaluations on March 17, 2014, July 7, 2014, August 8, 2014, and September 26, 2014, Mr. Smith's range of motion was normal, and he was encouraged to exercise five days a week to aid in losing weight and controlling his hypertension. (Tr. 371, 385, 401, 407, 414).

         Mr. Smith returned to Carilion Clinic Family Medicine on November 21, 2014, and was examined by Dr. Andrew Walters. At that time, plaintiff reported experiencing soreness in his shoulders, feet, and sides. (Tr. 421). During a follow-up appointment on January 16, 2015, Mr. Smith continued to complain of generalized soreness. Dr. Walters noted that plaintiff was a "poor historian" and that it was "hard to get a good grasp on why he is applying for disability and what his [symptoms] actually are." (Tr. 429).

         Five months later, Mr. Smith returned to Dr. Walters with complaints of pain on his left side. Dr. Walters placed him on a trial of Flexeril and ordered an x-ray of his left hip to "rule out worsening of his [left] hip arthritis." (Tr. 439). The x-ray revealed "[m]oderate left hip joint degenerative changes with little if any significant change from [the] last exam" on February 25, 2010. (Tr.451).

         Mr. Smith was referred to Carilion Clinic Rheumatology, where he was examined by Dr. Carl Henderson on June 24, 2015. At that time, plaintiffs range of motion and peripheral pulses were normal, and the examination revealed no active synovitis or deformities other than bilateral knee crepitus. Dr. Henderson diagnosed plaintiff with osteoarthritis and diffuse idiopathic skeletal hyperostosis. He recommended that Mr. Smith take Tylenol and nonsteroidal anti-inflammatory drugs as needed for discomfort. (Tr. 474).

         Mr. Smith returned to Carilion Clinic Family Medicine on December 17, 2015, when he was seen by Dr. Benjamin Morgan for complaints of pain in his left shoulder. (Tr. 482). Dr. Morgan opined that plaintiff was likely experiencing "muscle strain" and recommended that he take Ibuprofen. (Tr. 484). During a follow-up appointment on January 14, 2016, Mr. Smith continued to complain of soreness in his left shoulder. Dr. Morgan advised him to take Tylenol every eight hours as needed for pain. (Tr. 496).

         At the administrative hearing, Mr. Smith testified that he experiences "constant pain, " primarily in his shoulders and lower back. (Tr. 48-49, 51). Plaintiff also claimed that his feet swell and hurt, and that he has to elevate them two or three times every day for approximately 30 minutes. (Tr. 49-52). Mr. Smith further testified that he experiences a "pinching pain" in his hands, which leads to numbness and affects his ability to use them. (Tr. 52-53). When questioned by his attorney regarding his ability to sit or stand, Mr. Smith testified that he can only sit for about an hour before needing to stand and move, and that he can only stand for about 20 or 25 minutes before needing to walk. (Tr. 55). Plaintiff further testified that he needs to lie down approximately twice a day for 45 minutes. (Tr. 57).

         After considering all of the evidence of record, the Law Judge determined that Mr. Smith retains the residual functional capacity to perform medium work activity that does not involve more than occasional pushing, pulling, or climbing ladders, ropes, or scaffolds. In reaching this decision, the Law Judge reviewed the existing medical records, noting that the clinical evaluations discussed above include relatively benign objective findings. The Law Judge also observed that Mr. Smith's treating physicians have consistently recommended conservative treatment measures for his complaints of pain, and that none of them have placed restrictions on his ability to work. Accordingly, the Law Judge determined that plaintiff suffers from certain medical ...


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