(SS) Smith v. Commissioner of Social Security

District Court, E.D. California·Decided October 28, 2020·No. 1:19-cv-01085·Unknown

Opinion

2 3 4 5 6 7 UNITED STATES DISTRICT COURT 8 EASTERN DISTRICT OF CALIFORNIA 9

10 ISAIAH III SMITH, Case No. 1:19-cv-01085-SKO 11 Plaintiff,

12 v. ORDER ON PLAINTIFF’S SOCIAL 13 SECURITY COMPLAINT ANDREW SAUL, 14 Commissioner of Social Security, 15 Defendant. (Doc. 1)

17 _____________________________________/ 18

19 I. INTRODUCTION 20 21 Plaintiff Isaiah Iii Smith (“Plaintiff”) seeks judicial review of a final decision of the 22 Commissioner of Social Security (the “Commissioner” or “Defendant”) denying his application 23 for Supplemental Security Income (SSI) under Title XVI of the Social Security Act (the “Act”), 24 42 U.S.C. § 1383(c). (Doc. 1.) The matter is currently before the Court on the parties’ briefs, 25 which were submitted, without oral argument, to the Honorable Sheila K. Oberto, United States 26 Magistrate Judge.1 27 /// 28 1 II. BACKGROUND 2 Having filed five previously-denied applications for SSI, Plaintiff protectively filed the 3 current SSI application on October 23, 2015, alleging disability as of August 27, 2015, due to 4 right wrist injury, right hip injury, head injury, bone issues, high blood pressure, neck issue, 5 arthritis, left knee issue, and cataracts. (Administrative Record (“AR”) 18, 209, 210, 223, 224, 6 227, 341, 342, 336, 337, 371, 377.) Plaintiff was born on October 9, 1965, completed high 7 school, and previously worked as a grocery store clerk and as a production worker at a 8 warehouse. (AR 28, 209, 223, 336, 342, 343, 356, 377) 9 A. Relevant Medical Evidence2 10 1. State Agency Physicians 11 On March 4, 2016, C. Bullard, M.D., a state agency physician, reviewed the record and 12 assessed Plaintiff’s residual functional capacity (RFC).3 (AR 215–18.) Dr. Bullard and found 13 that Plaintiff could (1) occasionally lift and/or carry 20 pounds and frequently 10 pounds; (2) 14 stand and/or walk for about six hours in an eight-hour workday; (3) sit for about six hours in an 15 eight-hour workday; (4) not push or pull with his right upper extremity; (5) occasionally climb 16 ramps and stairs, balance, stoop, kneel, crouch, and crawl; (6) not climb ladders, ropes, and 17 scaffolds; (7) not work above shoulder level with his right upper extremity; and (8) not be 18 exposed to working machinery and heights. (AR 215–17.) Upon reconsideration on June 15, 19 2016, another state agency physician, R. Fast, M.D., reviewed the record and affirmed Dr. 20 Bullard’s findings. (AR 231–33.) 21 State agency physician G. Ikawa, M.D., reviewed the record and assessed Plaintiff’s 22 mental RFC on March 3, 2016. (AR 218–19.) Dr. Ikawa opined that Plaintiff was capable of 23

24 2 Because the parties are familiar with the medical evidence, it is summarized here only to the extent relevant to the contested issues. 25 3 RFC is an assessment of an individual’s ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis of 8 hours a day, for 5 days a week, or an equivalent work schedule. 26 TITLES II & XVI: ASSESSING RESIDUAL FUNCTIONAL CAPACITY IN INITIAL CLAIMS, Social Security Ruling (“SSR”) 96-8p (S.S.A. July 2, 1996). The RFC assessment considers only functional limitations and restrictions that result 27 from an individual’s medically determinable impairment or combination of impairments. Id. “In determining a claimant’s RFC, an ALJ must consider all relevant evidence in the record including, inter alia, medical records, lay 28 evidence, and ‘the effects of symptoms, including pain, that are reasonably attributed to a medically determinable 1 performing simple, repetitive, tasks. (AR 218, 219.) Upon reconsideration on June 20, 2016, 2 another state agency physician, E. Murillo, M.D., reviewed the record and affirmed Dr. Ikawa’s 3 findings. (AR 233–34.) 4 2. Tulare Regional Medical Center 5 On June 16, 2016, Plaintiff presented for a physical therapy evaluation due to complaints 6 of neck pain. (AR 623–26.) A physical examination showed reduced range of motion in his 7 cervical spine, decreased strength in his right shoulder with abduction, and tenderness to the right 8 side of his C7 spine. (AR 624.) Plaintiff was recommended to attend physical therapy twice a 9 week for six weeks to decrease his neck pain and increase its range of motion. (AR 625.) After 10 missing several appointments (see AR 627), he was discharged for non-compliance in August 11 2016 (AR 622.) 12 3. Kaweah Delta Health Care District 13 On October 21, 2016, Plaintiff was transported to the emergency department after taking 14 medication in attempt to commit suicide following an argument with his wife. (AR 546–82.) He 15 admitted to wanting to kill himself due to an increase in the level of stress at home. (AR 546.) 16 On examination, Plaintiff appeared sad and his mood and affect were depressed, tearful, and 17 crying. (AR 547.) 18 On October 22, 2016, Vasileios Panagopoulous, M.D., performed a psychiatric 19 consultation and found Plaintiff “calm at times, irritable at other times,” yet cooperative, with 20 poor eye contact, slow speech, and poor grooming. (AR 556.) His flow and content of thought 21 was normal, with no hallucinations or delusions noted. (AR 556.) Plaintiff had a depressed 22 mood and dysthymic and dysphoric affect, with normal attention but poor insight and judgment. 23 (AR 556.) Dr. Panagopoulous found that Plaintiff’s presentation and history were “consistent 24 with the diagnosis of unspecified depressive disorder [and] alcohol use disorder.” (AR 556.) 25 Plaintiff was prescribed medication to address his agitation and was recommended for inpatient 26 admission with the mental health department. (AR 547–48, 556.) 27 Mandeep Bragga, M.D., performed a psychiatric evaluation on October 23, 2016. (AR 28 558–62.) On mental status examination, Dr. Bragga found Plaintiff cooperative, yet disheveled, 1 withdrawn, and guarded. (AR 559.) Plaintiff’s eye contact was limited but his speech within 2 normal limits. (AR 559.) His thought process was disorganized, but no overt psychosis was 3 noted. (AR 559.) Plaintiff’s mood was depressed and his affect sad, with poor insight and 4 judgment. (AR 5559.) Dr. Bragga noted Plaintiff continued to exhibit symptoms and behaviors 5 that represented a current danger to himself. (AR 559–60.) Plaintiff was diagnosed with severe 6 and recurrent major depressive disorder without psychotic features. (AR 559.) He was 7 prescribed medication for depression. (AR 560.) 8 Dr. Bragga again examined Plaintiff on October 24, 2016, and found him pleasant, 9 cooperative, and engaged, with good eye contact. (AR 569.) His mental status examination was 10 normal, with elevated, full, appropriate, and labile mood. (AR 569.) Plaintiff denied current 11 thoughts of harming himself and felt “hopeful.” (AR 569.) Dr. Bragga noted that Plaintiff 12 “achieved a fair level of improvement during this acute hospitalization” and his “long term 13 prognosis is good.” (AR 569.) Upon discharge to the care of his mother, Plaintiff was observed 14 to be “more energetic” and “significantly less guarded.” (AR 582.) He was advised to follow up 15 with a psychiatrist on an outpatient basis. (AR 581.) 16 4. Altura Centers for Health 17 On January 3, 2017, Plaintiff complained of anxious/fearful thoughts, depressed mood, 18 difficulty concentrating, difficulty falling asleep, diminished interest or pleasure, fatigue, loss of 19 appetite, and restlessness. (AR 702.) He denied thoughts of death or suicide. (AR 702.) 20 Plaintiff also complained of neck and back pain, which were “mild” and “stable,” respectively.

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