United States District Court, W.D. Virginia, Roanoke Division
GLEN E. CONRAD, SENIOR UNITED STATES DISTRICT JUDGE
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, 368F.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).
plaintiff, Kay Frances Reynolds, was born on March 20, 1961.
She eventually graduated from high school and also completed
two years of college. (Tr. 315). Ms. Reynolds has been
employed as a twister, hooker, sales attendant, cashier,
sandwich maker, and fast food worker. She was still working
at Taco Bell on a part-time basis at the time of the
administrative hearing on April 27, 2016. (Tr. 51). On
October 3, 2013, Ms. Reynolds filed applications for
disability insurance benefits and supplemental security
income benefits. In filing her current claims, Ms. Reynolds
alleged that she became disabled for all forms of substantial
gainful employment on August 15, 2008, due to bipolar
disorder, post-traumatic stress disorder, attention-deficit
hyperactivity disorder, obsessive-compulsive disorder,
degenerative arthritis in her shoulders and lower back, bone
spurs, left knee pain, and kidney stones. (Tr. 281, 314).
Ms. Reynolds now maintains that she has remained disabled to
the present time. With respect to her application for
disability insurance benefits, the record reveals that Ms.
Reynolds met the insured status requirements of the Act
through the third quarter of 2015, but not thereafter.
See generally, 42 U.S.C. §§ 416(i) and
423(a). Consequently, plaintiff is entitled to a period of
disability and disability insurance benefits only if she has
established that she became disabled for all forms of
substantial gainful employment on or before September 30,
Reynolds' applications were denied upon initial
consideration and reconsideration. She then requested and
received a de novo hearing and review before an
Administrative Law Judge. In an opinion dated August 19,
2016, the Law Judge also determined, after applying the
five-step sequential evaluation process, that Ms. Reynolds is
not disabled. See 20 C.F.R. §§ 404.1520 and
416.920. Based on the earnings records from her job
at Taco Bell, the Law Judge first ruled that Ms. Reynolds
engaged in substantial gainful activity during the third and
fourth quarters of 2015, and that the disability inquiry
therefore ended at the first step of the sequential
evaluation process with respect to that period. (Tr. 17).
However, the Law Judge found that there had been continuous
12-month periods during which the claimant did not engage in
substantial gainful activity. (Tr. 18). Accordingly, the Law
Judge focused the remainder of her decision on such periods.
The Law Judge found that Ms. Reynolds suffers from several
severe impairments, including "cervical and lumbar
degenerative disc disease, compression fracture at LI,
obesity, bipolar affective disorder, post-traumatic stress
disorder (PTSD), anxiety disorder, and a personality
disorder, ", but that these impairments do not, either
individually or in combination, meet or medically equal the
requirements of a listed impairment. (Tr. 18-19). The Law
Judge then assessed Ms. Reynolds' residual functional
capacity as follows:
After careful consideration of the entire record, I find that
the claimant has the residual functional capacity to perform
less than a full range of light work as defined in
20'C.F.R. 404.1567(b) and 416.967(b) except: occasional
stairs and ramps; no ladders, ropes or scaffolds; occasional
balancing, stooping, kneeling, crouching and no crawling;
moderate noise environment; and occasional exposure to
extreme cold, vibrations and workplace hazards such as
dangerous moving machinery but no exposure to unprotected
heights. She can perform unskilled work at an SVP 1
or 2 where the pace of productivity is not dictated external
outside her control, such as conveyor belts.
(Tr. 20). Given such a residual functional capacity, and
after considering testimony from a vocational expert, the Law
Judge determined that Ms. Reynolds remains capable of
performing her past relevant work as a fast food worker. In
the alternative, the Law Judge found that if even if Ms.
Reynolds is disabled for past relevant work, she retains the
capacity to perform other work roles existing in significant
number in the national economy. Accordingly, the Law Judge
concluded that Ms. Reynolds is not disabled, and that she 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, Ms. Reynolds
has now appealed to this court.
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).
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 Ms. Reynolds'
medical problems and the extent to which they affect her
ability to work. Although Ms. Reynolds suffers from a
combination of physical and emotional impairments,
substantial evidence supports the Law Judge's
determination that she, retains the residual functional
capacity to perform a limited range of light, unskilled work.
record reveals that Ms. Reynolds was incarcerated from
November 2011 through August 2013, after being convicted of
statutory burglary and grand larceny. (Tr. 321, 441). Records
from the Virginia Department of Corrections contain
references to an abnormal affect, an impaired mood, and
musculoskeletal pain for which plaintiff received
medications. (Tr. 484-663). In May of 2011, correctional
officers found twenty-five carbamazapine tablets, which
plaintiff was supposed to be taking twice a day, in
plaintiffs cell. (Tr. 663). Ms. Reynolds was also found to be
hoarding Ibuprofen and Benadryl. (Tr. 663). The prison
physician recommended that plaintiff stop receiving
medications at that time. (Tr. 662).
September of 2013, following her release from incarceration,
Ms. Reynolds reestablished treatment at Bassett Family
Practice. (Tr. 437-38). She complained of feeling depressed
and asked to be tested for obsessive-compulsive disorder
(OCD) and attention-deficit hyperactivity disorder (ADHD).
(Tr. 437). Dr. Kwamba Nkembe noted that Ms. Reynolds was
hyperactive during the examination and had trouble staying on
track, but that she was alert and oriented with normal speech
form and content. He diagnosed plaintiff with bipolar
affective disorder and OCD. (Tr. 437). Dr. Nkembe advised her
to continue taking Tegretol (carbamazapine) and referred her
to a counselor. (Tr. 438). He also wrote a "to whom it
may concern letter" indicating that Ms. Reynolds was
incapable of working. (Tr. 434).
September 17, 2013, Ms. Reynolds met with Erin Jenkins, LPC
for an initial behavioral health evaluation. Ms. Reynolds
reported that she had been forced to stop taking college
classes as a result of being incarcerated, but that she had
since re-enrolled to work on another degree. (Tr. 441).
During the evaluation, plaintiffs thought process appeared to
be scattered and her speech was pressured. (Tr. 442).
However, Ms. Jenkins noted that she was well-groomed with
normal eye contact, a reactive affect, an engaged and
cooperative attitude, normal thought content, and fair
insight and judgment. (Tr. 442).
Reynolds returned to Dr. Nkembe on October 2, 2013 with
complaints of neck pain and muscle spasms in her back. (Tr.
443). On examination, plaintiff exhibited normal range of
motion in her spine and her straight leg raise test was
normal. Dr. Nkembe prescribed a 15-day • supply of
Lortab for pain and a muscle relaxant for spasms. (Tr. 443).
a follow-up appointment with Ms. Jenkins on October 22, 2013,
Ms. Reynolds reported ongoing conflicts with her father and
brother, but noted that she had been going to church and
speaking with her pastor and his wife. (Tr. 452). Although
plaintiff continued to have pressured speech, she was well
groomed, exhibited a logical, goal-directed thought process,
was oriented in all four spheres, and demonstrated fair
insight and judgment. (Tr. 452).
symptoms remained relatively unchanged through November and
December of 2013. (Tr. 454, 456). On December 12, 2013, Ms.
Jenkins met with Megan Ellis, LPC at Bassett Family Practice.
(Tr. 456). Although she complained of ongoing issues with her
father, Ms. Reynolds reported that she had developed a good
relationship with her pastor, that she was attending ...