Janice S. v. Berryhill

          REPORT AND RECOMMENDATION

          Robert S. Ballou United States Magistrate Judge.

         Plaintiff Janice S. (“Janice”) filed this action challenging the final decision of the Commissioner of Social Security (“Commissioner”) determining that she was not disabled and therefore not eligible for disability insurance benefits (“DIB”) under the Social Security Act (“Act”). 42 U.S.C. §§ 401-433. Specifically, Janice alleges that the ALJ improperly discounted her credibility and failed to properly evaluate her tremors. I conclude that substantial evidence supports the Commissioner's decision on all grounds. Accordingly, I RECOMMEND DENYING Janice's Motion for Summary Judgment (Dkt. 13), and GRANTING the Commissioner's Motion for Summary Judgment (Dkt. 15).

         STANDARD OF REVIEW

         This Court limits its review to a determination of whether substantial evidence supports the Commissioner's conclusion that Janice failed to demonstrate that she was disabled under the Act.^[2] Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001). “Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance.” Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996) (internal citations omitted). The final decision of the Commissioner will be affirmed where substantial evidence supports the decision. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990).

         CLAIM HISTORY

         Janice filed for DIB on June 6, 2013, claiming that her disability began on February 13, 2013. R. 160-62. The Commissioner denied Janice's application at the initial and reconsideration levels of administrative review. R. 80, 91. On December 2, 2015, ALJ H. Munday held a hearing to consider Janice's disability claim. R. 30-69. Janice was represented by an attorney at the hearing, which included testimony from Janice and vocational expert Andrew V. Beale. Id.

         On January 11, 2016, the ALJ entered his decision analyzing Janice's claim under the familiar five-step process, ^[3] and denying her claim for benefits. R. 14-24. The ALJ found that Janice suffered from the severe impairments of tendonitis of the right shoulder, degenerative disc disease of the cervical spine, cervical radiculopathy, fibromyalgia, and chronic obstructive pulmonary disease. R. 16. The ALJ found that these impairments did not meet or medically equal a listed impairment. R. 18. The ALJ further found that Janice had the residual functional capacity (“RFC”) to perform light work, except that she: (1) can never climb ladders, ropes, and scaffolds, but can occasionally climb ramps and stairs; (2) can occasionally balance, stoop, kneel, crouch, and crawl; (3) can frequently reach overhead and handle with the right upper extremity; and (4) can occasionally be exposed to vibration, fumes, odors, dusts, gases, poor ventilation, and hazards such as unprotected heights and moving machinery. R. 18-19.

         The ALJ determined that Janice is capable of performing her past relevant work as a bartender and a waitress. R. 22. The ALJ also found that Janice could perform competitive work that exists in significant numbers in the national economy, such as sorter, recreation aide, and cashier. R. 23. Therefore, the ALJ concluded that Janice is not disabled. R. 24.

         Janice requested that the Appeals Council review the ALJ's decision, but the Appeals Council denied her request for review. R. 1-3. This appeal followed.

         ANALYSIS

         Janice argues that the ALJ improperly discounted her credibility and failed to properly evaluate her tremors.

         Medical Evidence

          Janice has a history of cervical spine degenerative disc disease, and had an anterior cervical discectomy and fusion at ¶ 5-7 in 1999.

         Janice saw Craig L. Bookout, M.D., on February 16, 2013, reporting pain in her lower neck and shoulder blades. R. 251. Janice explained that for the last two days, she experienced numbness in her hands and right arm and throbbing in her upper arm. Id. Janice had excellent grip strength and sensation in both hands. R. 252. Dr. Bookout's final impression was neck pain. R. 253. On February 21, 2013, Janice saw Henry R. Ivey, Jr., M.D., for pain in her right arm without tingling or numbness. R. 267. Dr. Ivey diagnosed tendinitis, and prescribed steroid medication. R. 266. Dr. Ivey recommended moist heat and application of arthritis cream three times a day. Id. Dr. Ivey noted that Janice's degenerative disc disease was stable. Id.

         Janice saw Lauren E. Goater-Mathis, P.A., on March 6, 2013 for neck pain radiating into her right shoulder, right arm, and right elbow. R. 279. On examination, Janice was neurologically intact with normal reflexes, gait, and strength in all major muscle groups. Id. Ms. Goater-Mathis counseled Janice to return to physical therapy and to stop smoking, and prescribed Voltaren, Tylenol, and Flexeril. Id. Ms. Goater-Mathis gave Janice a work excuse until April 8, 2013. R. 281. Janice had a cervical MRI which revealed “[m]oderately severe degenerative disc disease at ¶ 4-C5 with a broad disc osteophyte complex which causes slight effacement of the ventral spinal cord as it crosses this level.” R. 272.

         On March 18, 2013, Janice saw Virginia Capps, P.T., and Lauren Goada, PA-C, at Professional Therapies of Roanoke for a physical therapy consultation. R. 285. Janice was diagnosed with cervical radiculopathy with a fair rehabilitation potential. Id. Janice performed physical therapy and was started on a home exercise program. Id. Janice tolerated physical therapy well without ...