Matos v. Saul

CourtDistrict Court, N.D. California
DecidedMarch 23, 2020
Docket3:19-cv-02505
StatusUnknown

This text of Matos v. Saul (Matos v. Saul) is published on Counsel Stack Legal Research, covering District Court, N.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Matos v. Saul, (N.D. Cal. 2020).

Opinion

1 2 3 4 UNITED STATES DISTRICT COURT 5 NORTHERN DISTRICT OF CALIFORNIA 6 7 HILDA M.,1 Case No. 19-cv-02505-TSH

8 Plaintiff, ORDER RE: CROSS-MOTIONS FOR 9 v. SUMMARY JUDGMENT

10 ANDREW M. SAUL, Re: Dkt. Nos. 13, 14 11 Defendant.

12 13 I. INTRODUCTION 14 Plaintiff Hilda M. brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial 15 review of a final decision of Defendant Andrew M. Saul, Commissioner of Social Security, 16 denying her claim for disability benefits. Pending before the Court are the parties’ cross-motions 17 for summary judgment. ECF Nos. 13 (Pl.’s Mot.), 14 (Def.’s Mot.). Pursuant to Civil Local Rule 18 16-5, the motions have been submitted on the papers without oral argument. Having reviewed the 19 parties’ positions, the Administrative Record (“AR”), and relevant legal authority, the Court 20 hereby GRANTS Plaintiff’s motion, DENIES Defendant’s cross-motion, and REMANDS for 21 further proceedings consistent with this Order. 22 II. BACKGROUND 23 A. Age, Education and Work Experience 24 Plaintiff is 56 years old. AR 160. She has worked as a receptionist, data entry clerk and as 25 an accounting clerk. AR 62-63. 26

27 1 Partially redacted in compliance with Federal Rule of Civil Procedure 5.2(c)(2)(B) and the 1 B. Medical Evidence 2 1. Medical Records 3 On April 22, 2015, Plaintiff saw Karen Khin Ouyang-Shwe, M.D., for leg pain and 4 dizziness. AR 315. An x-ray of her left knee showed mild osteoarthritis. AR 349. 5 On May 5, 2015, Iype Abraham, M.D., saw Plaintiff for ongoing pain in her left leg and 6 foot, aggravated by prolonged sitting or bending, and her symptoms were not improving with 7 physical therapy. AR 309. On examination, Plaintiff was 225lbs, had marked lordosis, tenderness 8 in her left knee, a positive straight leg raise test, and was using a cane to walk. AR 309-10. All 9 other findings were normal. Id. 10 On May 13, 2015, Dr. Abraham prepared a Work Status Report in which he found Plaintiff 11 could stand and walk only occasionally, lifting/carrying/pushing/pulling no more than ten pounds 12 and working no more than four hours a day. AR 231. At a visit with him on that date, Plaintiff 13 noted that her pain was aggravated by movement, with ongoing numbness and tingling, but that 14 her medications provided some relief and helped with sleep. AR 307. She also noted feeling 15 woozy and fatigued. Id. On examination, she had painful range of motion, a positive straight leg 16 raise test on the left, and a limping gait. AR 308. All other findings were within normal limits. 17 Id. Dr. Abraham opined that her fatigue could also be secondary to obesity. Id. 18 On June 9, 2015, James Nguyen, M.D., determined that Plaintiff was unable to perform 19 prolonged sitting or lifting, would have episodic, week-long flare ups approximately five times a 20 year, and would be unable to perform her work duties because of chronic pain. AR 232-35. 21 A C-Spine MRI from July 1, 2015 showed a moderate central and left disc spur or 22 protrusion at C4-5, a small protrusion at C5-6, without cord compression or neural impingement. 23 AR 249. A thoracic spine MRI from the same date showed a small central disc protrusion at T6-7. 24 Id. A lumbar spine MRI from the same date showed a right lateral disc protrusion at the right L5 25 nerve root. AR 250. 26 At a July 13, 2015 visit, Dr. Nguyen opined that Plaintiff’s pain was caused by myofascial 27 pain syndrome. AR 295-96. Plaintiff stated that climbing stairs, prolonged sitting and lifting 1 On September 8, 2015, Plaintiff saw psychologist Richard Beaver, Ph.D. AR 273-75. 2 Plaintiff reported that her daily activities included helping her parents for four hours a day, 3 performing housework and cooking but with a low sitting tolerance, and that her exercise was 4 limited. AR 274. She also reported that her current psychosocial stressor was “trying to complete 5 her daily duties due to limitations.” Id. Dr. Beaver noted a “flat affect, lethargic, [and] dysphoric” 6 mental status and diagnosed an adjustment disorder. Id. 7 Susan Casto, P.T., performed a physical therapy evaluation that same day and found 8 Plaintiff able to make position changes only very slowly and that she had more difficulty initiating 9 full strength with her left hand. AR 276. Plaintiff reported that her symptoms were activity 10 dependent, disrupted her sleep and that she experienced a worsening of symptoms after physical 11 therapy in June 2015. Id. 12 Plaintiff received acupuncture treatment in September 2015, reporting to the practitioner 13 that her activities were severely impacted by pain, which was currently at a level 7/10. AR 271- 14 72. At a September 8, 2015 visit with Joseph Robert Klein, M.D., she told him the acupuncture 15 was helpful for fatigue, but not pain. AR 277-78. 16 On September 15, 2015, Plaintiff saw Mohammad Hassan Moussavian, M.D., for a 17 neurology consult based on complaints of two years of “worsening left-sided body pain associated 18 with numbness/tingling that varies in both arms and left leg, also with dizziness and difficulties 19 with balance, blurred vision.” AR 268. Dr. Moussavian found Plaintiff’s neurologic examination 20 was unremarkable and diagnosed myofascial pain syndrome. AR 270. 21 At a phone appointment on September 25, 2015, Plaintiff complained of severe sedation 22 with Nortriptyline, as well as having personal difficulties because of her parents’ medical needs. 23 AR 266. She reported using a TENS unit that was “helpful.” Id. 24 On November 23, 2015, Plaintiff reported to Dr. Klein that some of her medications were 25 helpful, but she still had an 8/10 pain score for her lower back and was having poor sleep. AR 26 258. She also complained to a nurse of severe, significant interference with her daily activities. 27 AR 261. 1 physical therapy and a 90-minute group cognitive-behavioral therapy session conducted by 2 Psychologist Sarah Rabia Majid. AR 241, 260, 264-65. On January 13, 2016, Plaintiff reported to 3 Dr. Majid that her pain was more controlled, the relief was “moderate,” and she had increased 4 awareness of factors that increase or decrease pain perception. AR 252-53. However, she also 5 reported that she was “not able to cope with pain.” AR 253. Dr. Majid noted Plaintiff had a 6 depressed, anxious, stressed and frustrated mood with poor insight into her psychological 7 condition and its effect on pain symptoms. Id. 8 On February 2, 2016, Plaintiff saw Dr. Nguyen for her chronic left-sided pain, which she 9 continued to have even though she found the pain management program “helpful.” AR 248. Her 10 physical examination showed no abnormalities. AR 249. 11 On February 24, 2016, Plaintiff reported to Dr. Majid waxing and waning symptoms of 12 anxiety and depression influenced by “biopsychosocial stressors.” AR 242-43. On examination, 13 Dr. Majid found her to have a depressed and anxious mood with poor insight, diagnosing 14 Adjustment Disorder as well as Chronic Pain Syndrome. AR 243. Plaintiff declined a referral to 15 the Adult Psych Department at Kaiser, but she scheduled a one-on-one appointment with Dr. 16 Majid. AR 244. At the appointment on March 24, 2016, Plaintiff described her pain as a 7/10 but 17 that she had improved her coping skills, awareness of pain factors, and mood. AR 377. Plaintiff 18 also reported impaired memory and concentration. AR 378. Dr. Majid described her mood as 19 “concerned, down and anxious” with congruent affect and slowed speech. Id. 20 Plaintiff saw Dr. Klein again on March 23, 2016. AR 370. She reported that her pain was 21 “well controlled” but continued to be present despite medications, was aggravated by massage, 22 and was a 7/10. Id.

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Bluebook (online)
Matos v. Saul, Counsel Stack Legal Research, https://law.counselstack.com/opinion/matos-v-saul-cand-2020.