(SS) Rodriguez v. Commissioner of Social Security

District Court, E.D. California·Decided February 3, 2020·No. 1:19-cv-00016·Unknown

Opinion

1 2 3 4 5 6 7 UNITED STATES DISTRICT COURT 8 EASTERN DISTRICT OF CALIFORNIA 9 JAIME PLACENSIA RODRIGUEZ, 10 Case No. 1:19-cv-00016-SKO Plaintiff, 11 v. ORDER ON PLAINTIFF’S SOCIAL 12 SECURITY COMPLAINT

13 ANDREW SAUL, Commissioner of Social Security,1 14 (Doc. 1) Defendant. 15 _____________________________________/ 16

17 18 I. INTRODUCTION 19 On January 3, 2019, Plaintiff Jaime Placensia Rodriguez (“Plaintiff”) filed a complaint under 20 42 U.S.C. § 405(g) seeking judicial review of a final decision of the Commissioner of Social 21 Security (the “Commissioner” or “Defendant”) denying his application for disability insurance 22 benefits (“DIB”) under Title II of the Social Security Act (the “Act”). The matter is currently before 23 the Court on the parties’ briefs, which were submitted, without oral argument, to the Honorable 24 Sheila K. Oberto, United States Magistrate Judge.2 25

1 On June 17, 2019, Andrew Saul became the Commissioner of the Social Security Administration. See 26 https://www.ssa.gov/agency/commissioner.html (last visited by the court on September 12, 2019). He is therefore substituted as the defendant in this action. See 42 U.S.C. § 405(g) (referring to the “Commissioner’s Answer”); 20 27 C.F.R. § 422.210(d) (“the person holding the Office of the Commissioner shall, in his official capacity, be the proper defendant”). 28 2 The parties consented to the jurisdiction of a U.S. Magistrate Judge. (Docs. 6, 8.) 1 2 On August 8, 2015, Plaintiff protectively filed an application for DIB payments, alleging he 3 became disabled on March 28, 2012, due to the following impairments: lumbar herniated disc, major 4 depression, acute neck pain, constant pain in knees, stress, anxiety, insomnia, no energy, no hunger, 5 constipation and frequent urination. (Administrative Record (“AR”) 14, 15–16, 71–72, 116.) 6 Plaintiff was born on January 17, 1972 and was 46 years old as of the hearing date. (See AR 35.) 7 He completed high school, can speak English and Spanish, and has past work experience as an 8 electronics supervisor, field worker, sales consultant and property manager. (AR 35–40, 223.) 9 A. Summary of Relevant Medical Evidence3 10 1. Community Medical Centers 11 On March 8, 2012, Plaintiff presented at Community Medical Centers with symptoms of 12 right knee pain. (AR 357.) Plaintiff reported that he “twisted his knee in 2011” and had been having 13 pain with “locking, popping and clicking.” (AR 357.) Plaintiff reported that he had an MRI in June 14 2011 that “showed Lateral meniscal tear.” (AR 357.) The examining physician recommended to 15 Plaintiff that arthroscopy could help his knee pain and Plaintiff decided to proceed with right knee 16 arthroscopy and meniscectomy. (AR 358.) On March 28, 2012, Plaintiff underwent a “lateral 17 meniscectomy of right knee.” (AR 359.) 18 2. Turning Point of Central California 19 On September 21, 2015, Plaintiff went to Turning Point of Central California for an initial 20 intake assessment to address his mental impairments. (See AR 549.) Plaintiff reported that to live 21 a happy life he would need to “feel better in public, have more motivation, work, and be with [his] 22 sons.” (AR 549.) Plaintiff reported he has “abused” alcohol since age 17 and has used drugs. (AR 23 550.) The therapist assessed the severity of Plaintiff’s anxiety as a 3 out of 8 and his depression as 24 a 5 out of 8. (AR 551.) The therapist also noted that Plaintiff was “cooperative and respectful,” 25 “calm,” and “alert and oriented.” (AR 553.) On October 8, 2015, Plaintiff returned for a second 26 appointment to begin cognitive behavioral therapy. (See AR 556.) The therapist recommended 27

28 3 The parties also submitted summaries of the relevant medical evidence with their respective briefs. (See Doc. 16 at 3– 1 Plaintiff attend therapy sessions three times per month.4 (See AR 556.) 2 3. Emergency Room Visits 3 On October 3, 2014, Plaintiff saw emergency department physician Douglas Kerr, M.D. and 4 reported he “was moving around yesterday” and experienced an “onset of left back pain radiat[ing] 5 down to leg.” (AR 387.) Plaintiff was released later that day in stable condition. (See AR 389.) 6 On August 5, 2015, Plaintiff was seen by emergency department physician John David 7 McNaughton, M.D. for “chronic back pain.” (AR 405.) Dr. McNaughton noted Plaintiff’s back 8 pain was “controlled” and directed Plaintiff to rest. (AR 406.) 9 4. Erin Dueker, P.T. 10 Plaintiff intermittently underwent physical therapy for his back problems and on September 11 22, 2015, presented to Dueker Fee Physical Therapy for an initial evaluation. (See AR 439.) 12 Physical therapist Erin Dueker evaluated Plaintiff and noted that the pain in his lumbar area was an 13 average of 7 out of 10 and the pain in his cervical area was an average of 4 out of 10. (AR 439.) 14 Dr. Dueker assessed that Plaintiff would “benefit from therapeutic intervention of stretching, 15 strengthening, pain management, postural corrections, and teaching him a home exercise program 16 appropriate for his condition.” (AR 440.) Dr. Dueker recommended Plaintiff return 1-2 times per 17 week for a total of 12 visits in 3 months. (AR 441.) A treatment note from May 2, 2016, states that 18 Dr. Dueker saw Plaintiff for “13 visits,” although the record does not appear to contain treatment 19 notes from most of these visits. (See AR 618.) 20 5. Robert Fernandez, M.D. 21 On October 8, 2014, Plaintiff established care with family practice physician Robert 22 Fernandez. (See AR 521.) At his initial visit, Plaintiff reported “severe back pain which started on 23 10/3/14 after lifting heavy objects.” (AR 521.) Dr. Fernandez noted that Plaintiff took diazepam 24 and ibuprofen for his pain. (AR 521.) As to Plaintiff’s mental symptoms, Dr. Fernandez stated that 25 Plaintiff had no manic/depressed moods, excessive anxiety, or problems with memory, 26 concentration, or thinking. (AR 521.) Dr. Fernandez further noted that Plaintiff was “oriented to 27 person, place, and time . . . able to demonstrate good judgment and reason,” and “without . . . 28 1 abnormal affect or abnormal behaviors.” (AR 522.) On November 6, 2014, Dr. Fernandez wrote a 2 note excusing Plaintiff from work for 12 weeks and referred Plaintiff to start physical therapy. (AR 3 498–99.) Dr. Fernandez also noted that Plaintiff was “well nourished, alert and cooperative, and 4 appears to be in mild acute distress secondary to pain.” (AR 499.) On January 8, 2015, Dr. 5 Fernandez noted that Plaintiff reported his “pain is going away and he is able to tolerate better” and 6 Plaintiff “only had one flare up since his last visit.” (AR 450.) Dr. Fernandez also noted that 7 Plaintiff declined to go to physical therapy because he did not want to travel to Fresno. (AR 450.) 8 That same day, Dr. Fernandez cleared Plaintiff to return to work. (AR 449.) 9 On August 6, 2015, Dr. Fernandez saw Plaintiff after he had been in the emergency room 10 the night before for “left arm numbness.” (AR 466.) Dr. Fernandez noted that Plaintiff had 11 “attempted to go back to work doing construction which worsened his back” and he was “having 12 severe radicular neck pain which radiates down his left arm to his hand.” (AR 466.) As to his 13 mental condition, Dr. Fernandez noted Plaintiff “[d]emonstrated good judgment and reason and 14 normal affect” but was also taking Cymbalta. (AR 466.) Plaintiff returned to Dr. Fernandez on 15 September 17, 2015 and reported that he continued to have chronic pain. (AR 422.) Dr.

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