Nelms v. Colvin

Filing 20

Order entered that the decision of the Commissioner of Social Security denying Plaintiff's claim for a period of disability, disability insurance benefits, and supplemental security income be AFFIRMED. Signed by Magistrate Judge Sonja F. Bivins on 3/26/2015. (mjn)

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
SOUTHERN DIVISION
MONEKE LATASHA NELMS,

*
*
Plaintiff,
*
*
vs.
*
*
CAROLYN W. COLVIN,
*
Commissioner of Social Security,*
*
Defendant.
*

CIVIL ACTION NO. 14-00018-B

ORDER
Plaintiff

Moneke

Latasha

Nelms

(hereinafter

“Plaintiff”)

brings this action seeking judicial review of a final decision
of the Commissioner of Social Security denying her claim for a
period

of

disability,

disability

insurance

benefits,

and

supplemental security income under Titles II and XVI of the
Social Security Act, 42 U.S.C. §§ 401, et seq., and 1381, et
seq.

On October 15, 2014, the parties waived oral argument, and

on October 21, 2014, they

consented to have the undersigned

conduct any and all proceedings in this case.

(Docs. 16, 18).

Thus, the action was referred to the undersigned to conduct all
proceedings and order the entry of judgment in accordance with
28 U.S.C. § 636(c) and Federal Rule of Civil Procedure 73.
careful

consideration

of

the

administrative

record

and

Upon
the

memoranda of the parties, it is hereby ORDERED that the decision
of the Commissioner be AFFIRMED.

I.

Procedural History
Plaintiff filed an application for a period of disability,

disability insurance benefits and supplemental security income
on March 3, 2011. 1

(Tr. 173).

Plaintiff alleged that she had

been disabled since November 10, 2010, due to a “slipped disc in
back[;] right leg is numb[;] [and] diabetic.” (Id. at 172, 175).
Plaintiff’s applications were denied, and upon timely request,
she was granted an administrative hearing before Administrative
Law Judge Kim McClain-Leazure (hereinafter “ALJ”) on May 11,
2012.

(Id. at 30).

Plaintiff attended the hearing with her

counsel and provided testimony related to her claims.
33).

(Id. at

A vocational expert (“VE”) also appeared at the hearing

and provided testimony.

(Id. at 45).

On July 16, 2012, the ALJ

issued an unfavorable decision finding that Plaintiff is not
disabled.

(Id. at 23).

The Appeals Council denied Plaintiff’s

request for review on November 20, 2013.

(Id. at 1).

Thus, the

ALJ’s decision dated July 16, 2012, became the final decision of
the Commissioner.
Having

exhausted

her

administrative

timely filed the present civil action.

remedies,

(Doc. 1).

Plaintiff

The parties

agree that this case is now ripe for judicial review and is

1

Plaintiff filed a prior claim on April 3, 2009, which was
denied and was pending at the Appeals Council level at the time
that she filed the instant claim. (Tr. 174).

2

properly before this Court pursuant to 42 U.S.C. §§ 405(g) and
1383(c)(3).
II.

Issue on Appeal
Whether the ALJ erred in giving “little
weight” to the opinions of Plaintiff’s
treating physician?

III. Factual Background
Plaintiff was born on March 4, 1980, and was thirty-two
years of age at the time of her administrative hearing on May
11, 2012.

(Tr.

in

and

school

hospital.

30, 33, 172).
last

worked

She completed the twelfth grade

in

2008

as

a

housekeeper

at

a

(Id. at 33, 176).

Plaintiff testified that she suffers from diabetes, 2 high
blood pressure, 3 back pain, and right leg numbness.
36).

(Id. at 35-

She described her pain as constant, and she rated it as a

seven on a ten-point pain scale.

(Id. at 36-37).

She stated

that

which

drowsy

she

takes

pain

medication,

makes

her

and

2

Plaintiff testified that her blood sugar, on average, tends to
run “around 280,” but it has shot up as high as 498 and dropped
as low as 40. (Tr. 39). A normal fasting blood glucose target
range for an individual without diabetes is 70-100 mg/dL (3.95.6 mmol/L).
The American Diabetes Association recommends a
fasting plasma glucose level of 70–130 mg/dL (3.9-7.2 mmol/L)
and after meals less than 180 mg/dL (10 mmol/L). See
http://www.mayoclinic.org/diseases-conditions/diabetes/expertblog/blood-glucose-target-range/bgp-20056575.

3

Plaintiff testified that her high blood pressure is fairly well
controlled with medication. (Tr. 40).

3

dizzy. 4

(Id. at 36, 42).

She has also had repeated epidurals

for pain, but they only made her condition worse.

(Id. at 42).

Plaintiff testified that she cannot work because of her
medical

conditions

and

(Id. at 35-36, 42).

the

side

effects

of

her

medications.

According to Plaintiff, she spends the

majority of her day lying down.

(Id. at 37).

She takes care of

her four-year old daughter alone, except that her mother comes
over and helps approximately three days a week.

(Id. at 37-38).

She can shop, but she has to do it quickly.

(Id. at 41).

Plaintiff testified that she cannot clean, sweep, mop, bathe her
child, or put on her child’s clothes.
IV.

(Id. at 38).

Analysis
A.

Standard of Review

In reviewing claims brought under the Act, this Court’s
role

is

a

determining

limited
1)

one.

whether

The
the

Court’s
decision

review
of

the

is

limited

to

Secretary

is

supported by substantial evidence and 2) whether the correct
legal standards were applied.
1520, 1529 (11th Cir. 1990).

5

Martin v. Sullivan, 894 F.2d

A court may not decide the facts

anew, reweigh the evidence, or substitute its judgment for that
4

Plaintiff listed her medications as Glipizide (for diabetes),
Integra Plus (for low iron), Percocet (for pain), and Xanax (for
panic attacks). (Tr. 199).

5

This Court’s review of the Commissioner’s application of legal
principles is plenary. Walker v. Bowen, 826 F.2d 996, 999 (11th
Cir. 1987).
4

of the Commissioner.
Cir.

1986).

The

Sewell v. Bowen, 792 F.2d 1065, 1067 (11th
Commissioner’s

findings

of

fact

affirmed if they are based upon substantial evidence.

must

be

Brown v.

Sullivan, 921 F.2d 1233, 1235 (11th Cir. 1991); Bloodsworth v.
Heckler,

703

F.2d

1233,

1239

(11th

Cir.

1983)

(holding

substantial evidence is defined as “more than a scintilla, but
less

than

a

preponderance”

and

consists

of

“such

relevant

evidence as a reasonable person would accept as adequate to
support

a

conclusion.”).

In

determining

whether

substantial

evidence exists, a court must view the record as a whole, taking
into account evidence favorable, as well as unfavorable, to the
Commissioner’s decision.

Chester v. Bowen, 792 F. 2d 129, 131

(11th Cir. 1986); Short v. Apfel, 1999 U.S. Dist. LEXIS 10163, *4
(S.D. Ala. June 14, 1999).
B.

Discussion

An individual who applies for Social Security disability
benefits

must

prove

404.1512, 416.912.

his

or

her

disability.

20

C.F.R.

§§

Disability is defined as the “inability to

engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can
be expected to result in death or which has lasted or can be
expected to last for a continuous period of not less than 12
months.”

42

404.1505(a),

U.S.C.

§§

416.905(a).

423(d)(1)(A);
The

5

see

Social

also

20

Security

C.F.R.

§§

regulations

provide

a

five-step

sequential

evaluation

process

determining if a claimant has proven his disability. 6

for

20 C.F.R.

§§ 404.1520, 416.920.
In the case sub judice, the ALJ determined that Plaintiff
has not engaged in substantial gainful activity since November
10, 2010, the alleged onset date, and that she has the severe
impairments of disorders of the back, diabetes, hypertension,

6

The claimant must first prove that he or she has not engaged in
substantial gainful activity.
The second step requires the
claimant to prove that he or she has a severe impairment or
combination of impairments. If, at the third step, the claimant
proves that the impairment or combination of impairments meets
or
equals
a
listed
impairment,
then
the
claimant
is
automatically found disabled regardless of age, education, or
work experience.
If the claimant cannot prevail at the third
step, he or she must proceed to the fourth step where the
claimant must prove an inability to perform their past relevant
work. Jones v. Bowen, 810 F.2d 1001, 1005 (11th Cir. 1986). In
evaluating whether the claimant has met this burden, the
examiner must consider the following four factors: (1) objective
medical facts and clinical findings; (2) diagnoses of examining
physicians; (3) evidence of pain; and (4) the claimant’s age,
education and work history.
Id.
Once a claimant meets this
burden, it becomes the Commissioner’s burden to prove at the
fifth step that the claimant is capable of engaging in another
kind
of
substantial
gainful
employment
which
exists
in
significant
numbers
in
the
national
economy,
given
the
claimant’s residual functional capacity, age, education, and
work history.
Sryock v. Heckler, 764 F.2d 834, 836 (11th Cir.
1985). If the Commissioner can demonstrate that there are such
jobs the claimant can perform, the claimant must prove inability
to perform those jobs in order to be found disabled. Jones v.
Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999). See also Hale v.
Bowen, 831 F.2d 1007, 1011 (11th Cir. 1987) (citing Francis v.
Heckler, 749 F.2d 1562, 1564 (11th Cir. 1985)).

6

osteoarthritis,

and

general

myalgias.

7

(Tr.

17).

The

ALJ

further found that Plaintiff does not have an impairment or
combination of impairments that meets or medically equals any of
the listed impairments contained in 20 C.F.R. Part 404, Subpart
P, Appendix 1.
The

ALJ

(Id. at 18).
concluded

that

Plaintiff

retains

the

residual

functional capacity (hereinafter “RFC”) to perform a full range
of light work.

(Id.).

The ALJ also determined that while

Plaintiff’s medically determinable impairments could reasonably
be

expected

to

produce

the

alleged

symptoms,

her

statements

concerning the intensity, persistence and limiting effects of
the alleged symptoms were not credible to the extent that they
were inconsistent with the RFC.
Given
unable

to

Plaintiff’s
perform

any

RFC,

(Id. at 19).

the

past

ALJ

found

relevant

that

work.

Plaintiff
(Id.

at

is

22).

However, utilizing the testimony of a VE, the ALJ concluded that
considering

Plaintiff’s

age,

education,

work

experience,

and

residual functional capacity for a full range of light work, a
finding

of

Rule 202.20.
In

7

“not

disabled”

was

directed

by

Medical–Vocational

(Id. at 22).

addition

to

the

The ALJ concluded that
disorder were non-severe.
challenged these findings.

foregoing,

the

ALJ

summarized

Plaintiff’s headaches and anxiety
(Tr. 18).
Plaintiff has not

7

Plaintiff’s testimony as follows:
The representative’s theory indicates the
claimant is disabled due to back problems,
uncontrolled
diabetes,
hypertension,
and
osteoarthritis with some anxiety.
At the
hearing, claimant testified she has not
worked
since
the
alleged
onset
date,
November 10, 2010. The claimant testified
she is unable to work due to “slipped disc,”
right leg numbness, and diabetes, which she
states includes sugar readings that are both
high and low, and hand cramps.
She
testified that her pain averages seven on a
scale of 1-10, and stated she frequently has
to lie down because of pain, but gets up to
take her medicine.
The claimant testified
she has a four-year old daughter to care
for, but indicates her mother assists in
caring
for
the
child.
The
claimant
reportedly has “bad days” three times a
week, despite medication.
She testified
that her diabetes escalates out of control,
about five times a week.
She indicated her
hypertension is controlled with medication,
but escalates on “bad days” due to pain.
She described cramping in her hands and
legs, which she relieves by shaking them
constantly to prevent pain and stiffness.
The claimant reported she is unable to run
errands on “bad days.”
She also reported
having undergone at least 25 epidurals in
the past by a pain management (sic), which
only made her pain worse.
The claimant
stated that a doctor wanted to perform back
surgery, but she decided against surgery
because of her daughter’s young age.
The
claimant
indicated
she
was
seeing
Dr.
Yearwood before she started seeing Dr.
Barnes, and explained she had difficulty
getting appointments to see Dr. Barnes. . .
.
(Tr. 19)
In discussing the relevant medical evidence, the ALJ stated

8

as follows:
Turning to the medical evidence, records
from Barnes Family Medical reflect a visit
on February 23, 2010, with the claimant
requesting pain medication for back pain and
myalgias.
Treating
physician,
Stanley
Barnes, M.D., prescribed Celestone, Toradol
injections, Percocet, and Xanax.
On April
1,
2010,
the
claimant
returned,
with
complaints of pain in the right leg, back,
arm and right shoulder.
However, she was
seen lifting and holding her daughter on her
right side and was noted as easily weighing
20 pounds (Exhibit B5F). Outpatient records
from
Evergreen
Medical
Center
reflect
treatment for bilateral lower leg pain on
January 5, 2011 after the claimant explained
that a metal shelf had fallen, striking her
legs and feet. However, on examination,
there was no evidence of bruising, swelling,
or redness noted. On January 25, 2011,
returned to the hospital and was diagnosed
with chronic low back pain; however, a
lumbar MRI showed only mild degenerative
facet
hypertrophy
at
L4-5
and
L5-S1.
Claimant was prescribed Prednisone 10 mg and
Mobic 25 mg (Exhibit B4F).
The claimant
returned to Dr. Barnes on March 21, 2011,
with persistent pain, including abdominal
complaints. He referenced the earlier MRI,
and diagnosed cervical spine disc disease,
osteoarthritis,
lower
back
pain
and
abdominal
pain
(probably
from
diabetic
hypertensive
medication).
The
claimant
presented to Barnes Medical Center on June
6, 2011, complaining of back pain, left hand
right leg pain, but denied injury.
A nurse
practitioner noted there was evidence of
cause for the claimant’s hand pain. All
vital signs were stable, and claimant was
advised to continue on current medicines
(Exhibit B10F). On January 30, 2012, she
returned to Barnes Family Medical with
additional pain complaints, but indicated
her pain level overall was 5/10.
The
claimant was administered a B12 and a

9

Toradol injection for pain (Exhibit B11F).
A follow up visit the following month for
back and leg pain referenced emergency
hospital treatment for a fractured right
great toe.
On March 8, 2012, the claimant
presented to Barnes Family Medical, with
complaints of pain and myalgias involving
her
back,
leg
and
shoulders,
but
on
questioning,
acknowledged
she
had
been
moving furniture around a lot at home, and
that her shoulder had been bothering her for
the last few days. On examination, the
claimant exhibited painful range of motion
of the left shoulder, but there was no
evidence of popping, crepitus, heat, redness
or swelling. The claimant was prescribed
Prednisone for seven days, and Flexeril 10
mg. She was given refills of Percocet, and
Xanax, and told to return in one to three
months, or as necessary (Exhibit B11F).
Although diagnostic imaging in January 2011
showed facet joint hypertrophy at L4-5 and
L5-S-1, those findings were mild in severity
(Exhibit B4F). Since then, the claimant has
not been observed to have ongoing neurologic
deficits in the upper or lower extremities,
such as reflex and sensory abnormalities,
motor
incoordination,
or
significant
decreased muscle strength.
Finally, there
is no indication of joint deformities, gait
abnormalities,
muscle
atrophy,
or
substantial
limited
range
of
motion
documented in the record.
As for the claimant’s alleged diabetes and
hypertension, an assessment of July 14, 2010
from
Barnes
Family
Medical
shows
the
claimant was started on medication for
elevated blood pressure without hypertension
(Exhibit B5F). On February 21, 2011, Dr.
Barnes diagnosed benign hypertension in
addition
to
diabetes
as
part
of
his
assessment.
The claimant indicated her
blood sugar had been dropping; but on
examination, there was no indication of
fever, chills, sweats, nausea or vomiting;
all of which are character symptoms (Exhibit

10

B5F).
Shortly thereafter, the claimant
began having recurring abdominal pain.
Dr.
Barnes noted on March 21, 2011, that the
claimant was a diabetic hypertensive and
indicated
her
medications
were
perhaps
responsible for the recurring abdominal
pain.
The
evidence
shows
where
the
claimant’s medicines were adjusted several
times over the course of treatment with Dr.
Barnes,
who
concluded,
based
on
his
established treating relationship
with the
claimant
that
she
was
an
“outpatient
management
failure”
(Exhibit
B10F).
Subsequently,
the
claimant
admitted
to
excessive use of Goody powders along with
her prescribed medicines, which ultimately
lead (sic) to noncompliance as contributing
to the claimant’s
abdominal and related
symptoms (Exhibit B11F). Dr. Barnes’ nurse
practitioner
noted
during
follow-up
on
November 28, 2011, that the claimant’s
vital signs were stable, including a blood
pressure of 120/70 (Exhibit B10F).
On
February 21, 2012, the claimant’s vital
signs were again stable, and her blood
pressure was 130/70 (Exhibit B11F).
There
is
no
indication
that
diabetes
or
hypertension
resulted
in
any
end-organ
damage causing a significant functional
impairment,
or
evidence
that
either
impairment failed to respond appropriately
to
properly
administered
conservative
treatment.
Medical
records
have
consistently shown that treatment for the
impairments has been effective when properly
administered.
Moreover,
the
claimant
acknowledged at the hearing, that while her
diabetes, treated by Dr. Yearwood remains
uncontrolled,
her
blood
pressure
was
controlled with medication.
Although the claimant testified that Dr.
Yearwood is her current treating physician,
the record is void of evidence until April
24, 2012, when Amrita Yearwood, M.D., a
primary care physician, advised she had
treated the claimant for several years.
In

11

referencing
the
claimant’s
history
of
hypertension, uncontrolled type II diabetes,
and back pain, Dr. Yearwood opined that,
“due to her multiple medical problems, Ms.
Nelms is unable to work” (Exhibit B13F). On
May 11, 2012, Dr. Yearwood completed a
Physical Capacities Evaluation, indicating
that during an 8-hour workday, the claimant
can lift/carry 5 pounds occasionally to 1
pound frequently.
She can sit, stand, walk
for a total of two hours out of eight.
Occasionally,
the
claimant
can
perform
pushing/pulling
movements with arms and/or
legs; can climb, balance, and can perform
gross and fine manipulations, and operate
motor vehicles.
Dr. Yearwood opined that,
on rare occasions, the claimant could bend,
stoop, reach in all directions, and work
with
environmental
problems,
such
as
allergies, dust, etc.
She indicated the
claimant could never work with or around
hazardous machinery.
She would likely miss
more than four days per month from work
because of impairments or treatment.
A
Clinical Pain Assessment indicates that the
claimant’s pain is severe enough to cause
distraction of daily activities or work,
cause
total
abandonment
of
task,
and
indicated that medication side effect were
severe enough to limit effectiveness due to
distraction, inattention, drowsiness, etc.
(Exhibit B15F).
As
for
the
claimant’s
subjective
allegations,
based
on
the
history
of
conservative
treatment,
essentially
consisting of routine physical examinations
and medication adjustments and refills, the
allegations are not fully credible.
The
claimant testified that her medicines make
her drowsy and sleepy[;] however, these
complaints are not substantiated in the
evidentiary record.
Rather, the current
medications fail to support any disabling
conditions.
I find the claimant is not
credible at all, as she basically does as
she pleases; then complains to doctors about

12

her back, which does not seem to stop her
from doing all kinds of activities, such as
moving furniture “a lot” (Exhibit B11F).
Evidence from Evergreen Medical Center,
including emergency room records in January
2011,
document
treatment
for
various
complaints (Exhibit B4F), but includes no
records from Dr. Yearwood, albeit her report
of April 24, 2012, states she had treated
the
claimant
for
several
years
prior
(Exhibit B13F).
Overall, medical evidence
from Dr. Barnes, the established primary
physician from April 2010 through February
2011, consistently references the claimant’s
complaints of back pain, but totally, the
subjective
complaints
resulted
in
assessments that showed little more than
generalized myalgias, benign hypertension,
and diabetes, capable of being managed
conservatively (Exhibits BSF, B10F, BllF).
In
considering
the
alleged
limitations
assigned by Dr. Yearwood, she notes the
claimant is able to climb ladders and stairs
one-third of a workday, yet indicates the
claimant can only stand for two hours and
can sit for two hours; and can rarely be
exposed to environmental factors (Exhibit
B15F);
however,
there
is
no
medically
documented
basis
for
the
limitations.
Nevertheless, in considering Dr. Yearwood’s
opinion that the claimant is unable to work
(Exhibit B13F); even if her records were
available,
her
opinion
is
completely
internally
inconsistent
with
the
other
substantial evidence of record.
It is
unfortunate in that Dr. Yearwood failed to
provide any basis to support the assigned
limitations, particularly since her records,
which includes a brief one-page report at
Exhibit
B15F
and
the
physical/pain
assessments, consisting of two-pages at
Exhibit B13F, certainly do not support her
opinion, which is given little weight.
Although Dr. Barnes has not offered a
specific opinion regarding the claimant’s
functional limitations, his statements merit

13

significant weight.
Based on Dr. Barnes’
longstanding treating relationship with the
claimant; and his familiarity (along with
that of his nurse practitioner) with the
Claimant’s overall medical condition and
limitations, based on his clinical findings;
observations;
and
consistent
treatment
notes, are all factors that give weight to
his opinion statements, which also supports
the residual functional capacity finding.
In
sum,
the
above
residual
functional
capacity assessment is supported by the
preponderance of the most credible objective
evidence of record, including the claimant’s
conservative treatment history and physician
treatment notes.
(Tr. 19-22).
The

Court

now

considers

the

foregoing

in

light

of

the

record in this case and the issue on appeal.
1.

Issue
Whether the ALJ erred in giving “little
weight” to the opinions of Plaintiff’s
treating physician?

Plaintiff

argues

that

the

ALJ

erred

in

“arbitrarily

substituting her own opinion for that of the treating physician,
Amrita Yearwood, M.D., without following proper legal standards
and without support of substantial evidence for her opposite
conclusion.” 8

(Doc. 13 at 3).

The Commissioner counters that

8

As discussed herein, the record shows that the ALJ gave “little
weight” to the opinions of Dr. Yearwood set forth in the April
24, 2012 letter opining that Plaintiff “is unable to work” and
in the May 2012 Physical Capacities Evaluation (“PCE”) and
Clinical Assessment of Pain (“CAP”) forms.
(Tr. 22, 342, 34748).

14

the ALJ had good cause to reject Dr. Yearwood’s opinions because
they are wholly unsupported and inconsistent with the record
evidence in this case and that the ALJ’s determination that
Plaintiff is not disabled is supported by substantial evidence.
(Doc. 14 at 3-4).

Having carefully reviewed the record, the

Court agrees with Defendant that Plaintiff’s claim is without
merit.
Generally speaking, “[i]f a treating physician’s opinion on
the nature and severity of a claimant’s impairments is wellsupported

by

medically

acceptable

clinical

and

laboratory

diagnostic techniques, and is not inconsistent with the other
substantial

evidence

in

controlling weight.” 9

the

record,

the

ALJ

must

give

it

Roth v. Astrue, 249 Fed. Appx. 167, 168

(11th Cir. 2007) (citing 20 C.F.R. § 404.1527(d)(2)).
“An

administrative

considerable

weight

physician

unless

Broughton

v.

1985)(citations

to

good

Heckler,
and

law

judge

the

opinion

cause

is

776

internal

must
of

accord
a

shown

F.2d
quotation

substantial

claimant’s
to

960,
marks

the

961

or

treating

contrary.”
(11th

omitted).

Cir.
“The

requisite ‘good cause’ for discounting a treating physician’s
opinion may exist where the opinion is not supported by the

9

“Controlling weight” is defined as a medical opinion from a
treating source that must be adopted. See SSR 96–2P, 1996 SSR
LEXIS 9, *3, 1996 WL 374188, *1 (1996).

15

evidence, or where the evidence supports a contrary finding.”
Hogan

v.

Astrue,

2012

U.S.

Dist.

3155570, *3 (M.D. Ala. 2012).

LEXIS

108512,

*8,

2012

WL

“Good cause may also exist where

a doctor’s opinions are merely conclusory, inconsistent with the
doctor’s medical records, or unsupported by objective medical
evidence.”

Id.

“[T]he weight afforded a treating doctor’s

opinion must be specified along with ‘any reason for giving it
no weight, and failure to do so is reversible error.’”

Williams

v. Astrue, 2009 U.S. Dist. LEXIS 12010, *4, 2009 WL 413541, *1
(M.D. Fla. 2009); see also Phillips v.

Barnhart, 357 F.3d 1232,

1241 (11th Cir. 2004) (“When electing to disregard the opinion
of a treating physician, the ALJ must clearly articulate [his or
her] reasons.”).
The

record

in

this

case

shows

that

Dr.

Yearwood

saw

Plaintiff on November 10, 2010, in the hospital emergency room
when Plaintiff sought treatment for uncontrolled hypertension,
low back pain, and right leg pain.

(Id. at 248, 252).

Dr.

Yearwood discharged Plaintiff approximately one hour later in
stable condition with Clonidine (for high blood pressure) and
Lortab (for pain).

(Id. at 248, 253).

The record next shows

that Dr. Yearwood treated Plaintiff on five occasions in 2012
(through

the

hospital

emergency

room

or

in

her

office)

for

various complaints including hypertension, diabetes, back pain,

16

cough, congestion, bronchitis, and medication refills. 10
347-48, 364, 367-69, 379-80).
16,

2012,

for

treatment

of

(Tr.

After an office visit on April
leg

and

back

pain,

Dr.

Yearwood

drafted a letter for Plaintiff on April 24, 2012, addressed “to
whom it may concern,” in which Dr. Yearwood opined that “due to
[Plaintiff’s]

multiple

medical

problems,

[she]

is

unable

to

work.” 11

(Id. at 342, 380).

Approximately two weeks later, on

May

2012,

completed

11,

Dr.

Yearwood

a

Physical

Capacities

Evaluation (“PCE”) form in which she opined that Plaintiff could
lift/carry

only

five

pounds

occasionally

and

one

pound

frequently, that she could sit for only two hours in an eighthour day, and that she could stand/walk for only two hours in an
eight-hour

day.

(Id.

at

347).

In

addition,

Dr.

Yearwood

completed a Clinical Assessment of Pain (“CAP”) form in which
she stated that Plaintiff’s pain is “present to such an extent

10

On April 1, 2012, Dr. Yearwood treated Plaintiff in the
emergency room for back pain and elevated diabetes and
discharged her approximately one and a half hours later with
Lortab and instructions to follow up with her family physician.
(Tr. 364-65). Three days later, on April 4, 2012, Dr. Yearwood
admitted Plaintiff to the hospital for two days for treatment of
bronchitis. (Id. at 368-70).

11

The letter, in full, consisted of five sentences and stated:
“Moneke Nelms has been a patient of mine for several years. She
has hypertension and uncontrolled type II Diabetes.
She has a
history of back pain, having had many epidurals done to relieve
her pain.
Due to her multiple medical problems, Ms. Nelms is
unable to work. If you have any questions, or if you need any
additional information, please contact my office.” (Tr. 342).

17

as

to

be

distracting

to

adequate

performance

of

daily

activities;” that physical activity will “greatly” increase the
pain “to such an extent as to cause distraction from tasks or
total abandonment of task[s];” and that “drug side effects can
be

expected

to

distraction,

be

severe

and

inattention,

to

limit

drowsiness,

effectiveness
etc.”

(Id.

at

due

to

348).

Having reviewed the record at length, the Court finds, as the
ALJ found, that Dr. Yearwood’s opinions are not supported by the
record.
First, as the ALJ articulated, there is absolutely nothing
in Dr. Yearwood’s treatment records to support the debilitating
limitations assigned to Plaintiff in the April 24, 2012 letter
and

the

treatment

May

11,

2012

records

conservative

and

reflect

treatment

and back pain.

PCE

of

CAP

nothing

forms.
more

Plaintiff’s

Dr.
than

Yearwood’s
occasional,

hypertension,

diabetes,

(Id. at 248, 364, 367, 380, 379).

In addition to being inconsistent with her own treatment
records,

Dr.

Yearwood’s

opinions

are

inconsistent

with

the

findings and opinions of Plaintiff’s other treating physician,
Dr.

Stanley

Barnes,

M.D.

The

record

shows

that

Dr.

Barnes

treated Plaintiff from 2008 to 2012 for diabetes, hypertension,
and

back

pain.

His

records

reflect

regular,

conservative

treatment of Plaintiff’s medical conditions with medications.
(Id. at 265, 272-94, 336-39).

Nothing in Dr. Barnes’ treatment

18

notes reflects that Plaintiff’s medical conditions resulted in
debilitating

limitations.

To

the

contrary,

on

February

21,

2011, Dr. Barnes assessed Plaintiff with “benign hypertension,
osteoarthritis, generalized myalgias, and diabetes,” for which
he simply adjusted her medications.
Dr.

Barnes’

records

reflects

(Id. at 272).

any

Nothing in

significant

functional

impairment caused by Plaintiff’s hypertension12 or diabetes.
As for Plaintiff’s back pain, on June 9, 2009, Dr. Barnes’
treatment
“nonspecific

notes

reflect

that

“in

place

pain”

one

prescribed pain medication.

Plaintiff
or

was

another,”

(Id. at 280).

for

reporting
which

he

Thereafter, Dr.

Barnes frequently noted that Plaintiff requested refills on her
pain

medication

too

“early.”

13

(Id.

at

277,

290-94,

328).

12

As noted previously, at her hearing, Plaintiff acknowledged
that her hypertension is controlled with medication. (Tr. 40).

13

On May 6, 2008, Dr. Barnes stated that he saw no reason to
keep Plaintiff on any pain medication and that he would “give
her [an] anti-inflammatory or something to that effect.”
(Tr.
285). On August 3, 2009, Dr. Barnes’ nurse practitioner noted
that Plaintiff “went to the ER over the weekend with leg pain
but they just gave her a Toradol shot and she didn’t get any
pain medicine so I told her she shouldn’t have needed any as it
is still early for her last pain medication.” (Id. at 290). On
January 25, 2010, Dr. Barnes stated, “Dr. Rainer [has]
recommended no further therapy.
He’s not really sure what’s
going to help her out. Now I want to put her on some Mobic and
before I could even get the words out of my mouth she claimed it
wouldn’t work so I don’t think she’s interested in getting any
kind of help or anything like that.
Unfortunately she has
succumbed to taking the narcotic analgesics. She’s here early.”
(Id. at 292).
On June 21, 2010, Dr. Barnes stated, “She needs
her pain medicine refilled. She is about 4 days early. I have
19

Plaintiff
were

claimed

that

ineffective.

testified
surgery,

that
but

(Id.

one
she

repeated

of

at
her

decided

daughter’s young age.

epidural

42,

281,

doctors
against

(Id. at 43).

injections

289,

for

pain

She

also

perform

back

291).

wanted
surgery

to

because

of

her

However, on March 18, 2009,

Dr. Barnes noted that Plaintiff wanted to be put in the hospital
for her back pain, but he “[saw] no medical reason to do that.”
(Id. at 282).

Dr. Barnes stated, “[h]er MRI Scan 14 didn’t show

much of anything so putting her in the hospital is certainly not
even a remote option.”

(Id.).

On July 6, 2009, Dr. Barnes

further noted that Plaintiff had “no back pain with straight leg
raises,”

“no

crepitus

swelling or edema.”
Barnes

noted

Plaintiff

for

that
her

in

the

joints,”

(Id. at 290).
the
back

orthopedist
pain,

Dr.

and

evidence

of

On February 23, 2010, Dr.
to

whom

Clay

told her that she is not to come in early.
days or not at all.” (Id. at 294).
14

“no

he

had

Rainer,

referred

M.D.,

had

It is going to be 30

On July 2, 2008, Dr. Barnes noted, “This patient comes in with
right hip pain. I’m not really sure what’s going on. We did a
scan on her.
Nothing bad.”
(Tr. 284).
On October 27, 2009,
Dr. Clay Rainer, M.D., the orthopedist to whom Dr. Barnes had
referred Plaintiff, noted that Plaintiff’s June 2008 MRI showed
“minimal facet degeneration at L4-5 and L5-S1.”
(Id. at 220)
(emphasis added).
Almost three years later, on January 25,
2011, an MRI of Plaintiff’s lumbar spine again showed “mild
degenerative facet hypertrophy at L4-5 and L5-S1.” (Id. at 270)
(emphasis added).

20

“basically released” her.
articulated,

in

addition

15

(Id. at 277).

to

being

Thus, as the ALJ

inconsistent

with

her

own

treatment notes, Dr. Yearwood’s opinions are inconsistent with
the treatment notes of Dr. Barnes and Dr. Rainer and the MRI’s
taken in June 2008 and January 2011.16
Last, as the ALJ articulated, the record shows that Dr.
Yearwood’s

opinions

are

inconsistent

Plaintiff’s activities of daily living.
April

1,

2010,

that,

despite

with

the

evidence

of

Dr. Barnes observed on

Plaintiff’s

complaints

of

leg,

back, arm, and shoulder pain, she was able to lift and hold her
daughter who “[was] probably a good 20 lbs. easily.”
293).

(Id. at

At the hearing, Plaintiff testified that she alone cares

for her four-year-old daughter, with the exception of help from
her mother approximately three days a week.

(Id. at 38).

Also, on March 8, 2012, Plaintiff reported to Dr. Barnes’ nurse
practitioner that her left shoulder was bothering her because

15

As noted, Dr. Rainer found on October 27, 2009 that Plaintiff
had only “minimal facet degeneration at L4-5 and L5-S1.”
(Tr.
220). Dr. Barnes’ treatment notes on January 25, 2010, reflect
that “Dr. Rainer [has] recommended no further therapy. He’s not
really sure what’s going to help her out.” (Id. at 292).

16

Dr. Yearwood’s opinions are also inconsistent with the
treatment notes of Dr. Stephen West, M.D., one of Dr. Barnes’
partners, who on March 11, 2009, noted that Plaintiff “wanted me
to write her a letter so that she could get out of community
service but I refused to.
There is nothing that she has that
would prevent her from doing it.
She can do all her community
service. (Tr. 282).

21

she had been “mov[ing] furniture around a lot at home.”
338).

This

evidence

is

inconsistent

with

Dr.

(Id. at

Yearwood’s

opinions, as discussed herein, particularly her opinion in the
PCE form that Plaintiff could only occasionally lift five pounds
and frequently lift one pound.

(Id. at 347).

Based on the foregoing evidence, the Court finds that Dr.
Yearwood’s opinions set forth in the April 24, 2012 letter and
the May 2012 PCE and CAP forms are inconsistent with the record
evidence
failing

in
to

this
give

case.

Therefore,

controlling

weight

the
to

ALJ
those

did

not

err

opinions.

in
The

substantial medical evidence in this case supports the ALJ’s
finding that Plaintiff can perform a full range of light work. 17

17

The Court also rejects Plaintiff’s argument that the ALJ’s
determination is not supported by substantial evidence because,
without Dr. Yearwood’s opinions, the record contains no opinion
from a consultative examiner or other medical expert as to
Plaintiff’s RFC. (Doc. 13 at 8). To the contrary, the ALJ has
the discretion to order a consultative examination where the
record establishes that such is necessary to enable the ALJ to
render a decision. Holladay v. Bowen, 848 F.2d 1206, 1210 (11th
Cir. 1988).
The ALJ is not required to order a consultative
examination where the record contains sufficient evidence to
permit the ALJ’s RFC determination.
Ingram v. Commissioner of
Soc. Sec. Admin., 496 F.3d 1253, 1269 (11th Cir. 2007) (“The
administrative law judge has a duty to develop the record where
appropriate but is not required to order a consultative
examination as long as the record contains sufficient evidence
for
the
administrative
law
judge
to
make
an
informed
decision.”).
Likewise, “[t]he ALJ’s RFC assessment may be
supported by substantial evidence, even in the absence of an
opinion from an examining medical source about Plaintiff’s
functional capacity.” Saunders v. Astrue, 2012 U.S. Dist. LEXIS
39571, *10, 2012 WL 997222, *4 n.5 (M.D. Ala. March 23, 2012)
(citing Green v. Soc. Sec. Admin., 223 Fed. Appx. 915, 923 (11th
22

Therefore, Plaintiff’s claim is without merit.
V.
For

Conclusion
the

reasons

set

forth

herein,

and

upon

careful

consideration of the administrative record and memoranda of the
parties,

it

is

hereby

ORDERED

that

the

decision

of

the

Commissioner of Social Security denying Plaintiff’s claim for a
period

of

disability,

disability

insurance

benefits,

and

supplemental security income be AFFIRMED.
DONE this 26th day of March 2015.
/s/ SONJA F. BIVINS
UNITED STATES MAGISTRATE JUDGE

Cir. 2007) (unpublished)); see also Packer v. Astrue, 2013 U.S.
Dist. LEXIS 20580, *7, 2013 WL 593497, *2 (S.D. Ala. February
14, 2013) (the fact that no treating or examining medical source
submitted a physical capacities evaluation “does not, in and of
itself, mean that there is no medical evidence, much less no
‘substantial evidence,’ to support the ALJ’s decision.”). Thus,
Plaintiff’s contention that the absence of a physical RFC
evaluation by a medical source means that the ALJ’s RFC
assessment is not based on substantial evidence is simply
incorrect. Moreover, as noted supra, the record contains
substantial evidence, including the treatment records of Dr.
Barnes, from which the ALJ was able to render a decision.

23