Burrell v. Colvin
Filing
20
Order entered that the decision of the Commissioner of Social Security denying Plaintiffs claim for a period of disability, disability insurance benefits, and supplemental security income be AFFIRMED.. Signed by Magistrate Judge Sonja F. Bivins on 12/12/2014. (mjn)
IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
NORTHERN DIVISION
MICHAEL BURRELL,
*
*
Plaintiff,
*
*
vs.
*
*
CAROLYN W. COLVIN,
*
Commissioner of Social Security,*
*
Defendant.
*
CIVIL ACTION NO. 14-00036-B
ORDER
Plaintiff Michael Burrell (hereinafter “Plaintiff”) brings
this action seeking judicial review of a final decision of the
Commissioner of Social Security denying his 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 December
4, 2014, the parties waived oral argument and consented to have
the undersigned conduct any and all proceedings in this case.
(Docs.
16,
17).
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.
Upon
careful
consideration
of
the
administrative record and the memoranda of the parties, it is
hereby
ORDERED
AFFIRMED.
that
the
decision
of
the
Commissioner
be
I.
Procedural History
Plaintiff filed an application for a period of disability,
disability insurance benefits and supplemental security income
on July 29, 2011.
(Tr. 111-24).
Plaintiff alleged that he has
been disabled since April 17, 2011, due to right knee problems,
diabetes, high blood pressure, back pain, sleeping disorder, and
vision problems.
were
denied,
(Id. at 30, 168).
and
upon
timely
Plaintiff’s applications
request,
he
was
granted
an
administrative hearing before Administrative Law Judge Carl B.
Watson (hereinafter “ALJ”) on August 23, 2012.
(Id. at 28).
Plaintiff attended the hearing with his counsel and provided
testimony related to his claims.
expert
(“VE”)
also
appeared
testimony.
(Id. at 47).
unfavorable
decision
(Id. at 23).
at
(Id. at 31).
the
hearing
A vocational
and
provided
On October 4, 2012, the ALJ issued an
finding
that
Plaintiff
is
not
disabled.
The Appeals Council denied Plaintiff’s request for
review on December 12, 2013.
(Id. at 1).
Thus, the ALJ’s
decision dated October 4, 2012, became the final decision of the
Commissioner.
Having
exhausted
his
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
properly before this Court pursuant to 42 U.S.C. §§ 405(g) and
1383(c)(3).
2
II.
Issue on Appeal
Whether the ALJ erred in failing to give
controlling weight to the opinions of
Plaintiff’s treating physician?
III. Factual Background
Plaintiff was born on February 11, 1980, and was thirty-two
years of age at the time of his administrative hearing on August
23, 2012.
(Tr. 28, 111).
Plaintiff testified that he was first
diagnosed with diabetes when he was thirteen years old and that
he takes insulin daily. 1
(Id. at 32).
problems with high blood pressure. 2
In addition, he has
(Id. at 32-33).
Plaintiff
stated that he was hospitalized for three days in February 2012
and again in June 2012 because of high blood pressure and high
blood sugar.
(Id. at 32-34).
According to Plaintiff, he has
problems with numbness and pain in his feet, which he rated as a
seven
or
eight
on
a
ten-point
pain
scale.
(Id.
at
34).
1
Plaintiff testified that his blood sugar usually runs between
230 and 240.
(Tr. 32). 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.
2
Plaintiff testified that he was hospitalized in February 2012
with a blood pressure of 240/118. (Tr. 32-33). A normal blood
pressure is below 120/80 mm Hg. See http://www.mayoclinic.org
/diseases-conditions/high-blood-pressure/basics/tests-diagnosis/
con-20019580.
3
Plaintiff also has problems with his right knee and had surgery
in November 2009 for a torn meniscus.
(Id. at 36-37, 211).
Plaintiff rated his knee pain as a seven on the pain scale.
(Id. at 37).
Plaintiff also has low back pain, which he rated
as an eight on the pain scale.
(Id. at 37-38).
Plaintiff
testified that he has kidney problems and may need dialysis in
the future.
(Id. at 38).
Plaintiff testified that he can stand or sit about fifteen
to thirty minutes and that he can walk the length of a football
field.
(Id. at 34-35).
Plaintiff also testified that he has to
nap for approximately four hours during the day
medications make him drowsy.3
At
the
hearing
and
because his
(Id. at 35).
in
his
Disability
Report,
Plaintiff
stated that he completed two years of college and worked as a
correctional officer for eight years from 2003 to 2011.
39-41, 169).
(Id. at
According to Plaintiff, he can no longer perform
the correctional officer job because he cannot stand or walk
well, nor can he climb into the tower or ride in a truck because
of
his
back.
4
(Id.
at
39-41).
Prior
to
his
job
as
a
3
Plaintiff testified that he is taking Lasix and Clonidine.
(Tr. 35, 38). In addition, he reported to the Agency that he is
taking Carvedilol (for blood pressure and heart), Amlodipine
(for blood pressure), and Lisinopril (for blood pressure). (Id.
at 203).
4
Plaintiff stated in his Disability Report that he quit working
because of his medical conditions and for “other reasons,” which
4
correctional
officer,
Plaintiff
worked
on
putting together dashboards for Mercedes
an
assembly
Benz.
line
He also has
prior work as a cook in a pizza restaurant, a stocker in a
grocery store, a machine operator/warehouse worker in a plastic
container business, and as a member of a clean up crew in a fish
factory.
(Id. at 42, 45-46).
Plaintiff
testified
that
he
is
a
single
father
of
two
children, a seven-year-old son and a twelve-year-old daughter,
and
that
his
daughter
lives
with
him.
(Id.
at
42-44).
Plaintiff further testified that he drives and does laundry.
(Id. at 38, 43, 160-63).
In addition, in his Function Report,
Plaintiff stated that he takes care of his children, including
helping
with
school
work;
he
performs
household
chores,
including laundry, ironing, and some cooking; he cares for his
personal needs; he drives and shops weekly; he handles his own
financial affairs, including paying his bills and maintaining
his bank accounts; and he fishes, attends football games, and
spends time with others.
(Id. at 160-63).
Plaintiff stated
that he has no problem paying attention, following instructions,
or getting along with authority figures. (Id. at 164-65).
IV.
Analysis
A.
Standard of Review
included that he “was let go for something [he] did not do and
due to many write ups.” (Tr. 169).
5
In reviewing claims brought under the Act, this Court’s
role
is
a
limited
determining
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
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
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).
6
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
U.S.C.
§§
404.1505(a),
416.905(a).
provide
five-step
a
423(d)(1)(A);
The
see
Social
sequential
also
20
Security
evaluation
§§
regulations
process
determining if a claimant has proven his disability. 6
6
C.F.R.
for
20 C.F.R.
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
7
§§ 404.1520, 416.920.
In the case sub judice, the ALJ determined that Plaintiff
has not engaged in substantial gainful activity since April 17,
2011,
the
alleged
impairments
of
onset
date,
diabetes,
chondromalacia, 7 and obesity.
and
that
he
has
(Tr. 16).
severe
right
hypertension,
the
knee
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.
(Id. at 18).
The
ALJ
concluded
that
Plaintiff
retains
the
residual
functional capacity (hereinafter “RFC”) to perform light work,
except that he cannot climb ladders, ropes or scaffolds; he can
occasionally
kneel,
unprotected heights.
while
Plaintiff’s
reasonably
be
crouch
and
crawl;
(Id. at 19).
medically
expected
to
and
must
avoid
The ALJ also determined that
determinable
produce
he
the
impairments
alleged
could
symptoms,
his
statements concerning the intensity, persistence and limiting
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)).
7
Chondromalacia patella is a general term indicating damage to
the cartilage under the kneecap, caused by overuse, injury, or
other factors. See http://www.mayoclinic.org/diseases-conditions
/chondromalacia-patella/basics/definition/con-20025960.
8
effects of the alleged symptoms were not credible to the extent
that they were inconsistent with the RFC.
Given
Plaintiff’s
RFC,
the
ALJ
(Id. at 20).
found
that
Plaintiff
is
capable of performing his past work as an assembler (which is
light and unskilled) and as a cook (which is light and semiskilled). (Id. at 22).
is not disabled.
Thus, the ALJ concluded that Plaintiff
(Id.).
Also pertinent to this appeal are the findings made by the
ALJ in reaching his decision that Plaintiff is not disabled.
Id.).
In determining that Plaintiff did not meet any Listing,
the ALJ made the following relevant findings:
With diabetes mellitus . . . we evaluate
cardiac arrhythmias, coronary artery disease
and peripheral vascular disease under 4.00
and intestinal necrosis under 5.00 [as well
as] cerebral edema and complications of
severe hypoglycemia . . . under 11.00[;]
[r]ecurrent
episodes
of
diabetic
ketoacidosis . . . under 12.00[;] diabetic
peripheral neurovascular disease . . . under
1.00[;] diabetic retinopathy under 2.00[;]
diabetic gastroparesis . . . under 5.00[;]
diabetic nephropathy under 6.00[;] poorly
healing bacterial and fungal skin infections
under
8.00[;]
diabetic
peripheral
and
sensory neuropathies under 11.00 and altered
mental status . . . under 12.00.
There is
no evidence of record to suggest that the
claimant meets or equals any of these
listings.
As for the claimant’s hypertension, the
undersigned has considered this condition
through its effects on other body systems
such as the heart, brain, kidneys and eyes.
In
August
2012,
the
claimant’s
renal
9
function
was
stable.
(Exhibit
17F).
Additionally, his vision is 20/40 in both
eyes without glasses. (Exhibit 9F). He has
been assessed with hypertension but recent
treatment notes from 2012 document that this
condition is reasonably well controlled.
(Exhibit 17F).
The claimant’s right knee chondromalacia has
been considered under Listings 1.02 and
1.03. . . . At a consultative examination in
October
2011,
the
claimant
had
normal
unaided gait.
(Exhibit 9F).
He has not
received any orthopedic treatment for a knee
problem since the alleged onset date.
As
such,
his
history
of
right
knee
chondromalacia does not meet or equal the
requirements of Listings 1.02 or 1.03.
Regarding the claimant’s obesity, . . . he
weighs 324 pounds and is 6 feet 4 inches
tall. This equates to a body mass index of
39.4. Despite his obesity, the claimant has
been able to move about generally well and
sustain
consistent
function.
At
a
consultative examination in October 2011,
the claimant had a normal, unaided gait.
(Exhibit 9F).
There has been no showing
that the claimant suffers from significant
sleep
apnea
and
although
he
has
hypertension, treatment notes from 2012
document that this condition is reasonably
well-controlled with medication.
(Exhibit
17F). Furthermore, there is no showing that
the claimant’s ability to manipulate has
been negatively impacted by the presence of
adipose tissue.
After a thorough review of
the evidence of record, the undersigned
finds that the claimant’s obesity has not
had an effect above the residual functional
capacity set forth below.
(Tr. at 18-19).
Further, in assessing Plaintiff’s RFC, the ALJ made the
following relevant findings:
10
After careful consideration of the entire
record, the undersigned finds that the
claimant
has
the
residual
functional
capacity to perform light work as defined in
20 CFR 404.1567(b) and 416.967(b) except
that he cannot climb ladders, ropes or
scaffolds; he can occasionally kneel, crouch
and crawl; and he must avoid unprotected
heights.
. . .
The evidence of record documents that the
claimant was diagnosed with diabetes when he
was 13-years old. He takes insulin but has
not been to an endocrinologist.
The
claimant has reported that he is on an 1800
calorie diet and checks his blood sugar
levels two times per day. In October 2011,
the
claimant
stated
that
his
last
hospitalization for a blood sugar level
problem had not been since 2009.
(Exhibits
7F and 9F).
At his hospitalization in
February 2012 for elevated blood pressure
levels, the claimant reported that his
diabetes was normally well-controlled but
his sugars had recently risen to over 500.
He
was
diagnosed
with
hyperglycemia.
(Exhibit 14F). The claimant has not had any
further hospitalizations for hyperglycemic
or hypoglycemic events since this time. The
longitudinal evidence of record documents
that the claimant’s diabetes is adequately
controlled
with
medication,
with
the
exception of one hyperglycemic event in
February 2012. The limitation to light work
with the above-noted postural restrictions
adequately accommodates any symptoms he may
experience from diabetes.
As for his hypertension, treatment notes
document that this condition is adequately
controlled with medication. In March 2012,
the claimant’s blood pressure was elevated
with a reading of 166/89. He had recently
been hospitalized for poorly controlled
11
hypertension.
(Exhibit
17F).
Hospital
treatment notes from February 2012 confirm a
hospitalization for a blood pressure reading
of 220/140.
(Exhibit 14F).
Dr. Gurich
increased the claimant’s prescription for
Lisinopril
to
40
mg
twice
daily
and
increased his Norvasc to twice daily. At a
follow-up appointment in April 2012, the
claimant’s blood pressure log revealed that
his pressure was under excellent control.
His reading upon examination was 130/60.
Likewise, in August 2012, the claimant’s
blood pressure was for the most part wellcontrolled.
The
claimant
endorsed
some
medication side effects such as drowsiness
and lower extremity edema. (Exhibit 17F).
The evidence of record from 2011 also
demonstrates that the claimant was noncompliant
with
his
blood
pressure
medication,
likely
accounting
for
his
elevated pressure levels. By way of example,
in September 2011, the claimant’s blood
pressure at his consultative examination was
250/140 and Dr. Robidoux informed him that
he needed to go to the emergency room
immediately. The dates on his medication
bottles demonstrated that he did not take
his blood pressure medication as directed
and he was diagnosed with poor medical
compliance. (Exhibit 7F).
Overall, the
evidence
of
record
relating
to
the
claimant’s hypertension demonstrates that
this condition is reasonably well controlled
with minimal side effects that are accounted
for
in
the
above
residual
functional
capacity.
Treatment
notes
also
confirm
that
the
claimant underwent arthroscopic surgery on
his right knee in 2009. (Exhibit 9F). At a
consultative examination in October 2011,
the claimant had normal range of motion of
the bilateral knees. He exhibited a normal,
unaided gait and was able to squat and rise.
(Exhibit 9F). Since the alleged onset date,
the claimant has not had any orthopedic
treatment for a knee problem. There is no
12
indication that he has trouble ambulating or
requires the use of an assistive device. As
such, the undersigned finds that he is
capable of performing light work with the
above-noted postural restrictions.
At the hearing, the claimant testified that
he was 324 pounds 6 feet 4 inches tall. This
equates to a body mass index of 39.4.
Despite his obesity, the claimant has been
able to move about generally well and
sustain
consistent
function.
At
a
consultative examination in October 2011,
the claimant had a normal, unaided gait.
(Exhibit 9F).
There has been no showing
that the claimant suffers from significant
sleep
apnea;
and
although
he
has
hypertension, treatment notes from 2012
document this condition is reasonably well
controlled with medication. (Exhibit 17F).
Furthermore, there is no showing that the
claimant’s ability to manipulate has been
negatively impacted by the presence of
adipose tissue. After a thorough review the
evidence of record, the undersigned finds
that the claimant’s obesity has not had an
effect
above
the
residual
functional
capacity set forth below.
(Tr. 19-21)
In discussing the medical opinions contained in the record,
the ALJ made the following relevant findings:
Pursuant to 20 CFR §404.1527, §416.927, and
Social Security Rulings 96-6p and 96-2p, the
undersigned
has
considered
the
medical
opinions
of
the
claimant’s
treating
physicians, evaluating physicians, and the
state
agency
medical
consultants.
Specifically, the undersigned has considered
Dr.
Robidoux’s
opinion.
Dr.
Robidoux
concluded in October 2011 that the claimant
had no limitations in sitting, standing,
walking,
lifting,
carrying,
climbing,
13
crawling, handling objects, using hand and
foot
controls,
talking,
listening
and
traveling. (Exhibit 9F). This opinion has
been accorded some weight although the
undersigned
finds
that
the
claimant’s
combination of impairments would limit him
to light work with the above-noted postural
restrictions. However, the undersigned has
considered
Dr.
Robidoux’s
findings,
particularly the claimant’s normal range of
motion of the knees and ability to walk with
a normal gait and accord these findings
significant weight.
Additionally, the undersigned has considered
the opinions provided by Dr. Judy Travis.
Dr. Travis concluded that the claimant could
only work 4 hours per day, stand 15 minutes
at one time, sit 4 hours at one time, lift
20
pounds
occasionally
and
5
pounds
frequently. (Exhibit 13F).
Additionally,
Dr. Travis concluded in January 2012 that
the claimant could sit 4 hours total during
an 8-hour day, and stand/walk less than one.
She
noted
that
the
claimant
could
occasionally lift up to 25 pounds and
occasionally carry up to 20 pounds.
She
recommended
limitation
of
postural
activities to no more than occasional and
stated that the claimant would likely miss
more than three days of work per month.
Regarding
pain,
she
stated
that
the
claimant’s pain was present to such an
extent that it was distracting to adequate
performance
of
daily
activities
with
significant
side
effects
rendering
him
unable to work.
(Exhibit 11F).
These
opinions have all been accorded little
weight. As set forth above, the claimant’s
diabetes has been adequately controlled with
medication for a large portion of the
alleged period of disability, with the
exception of one hyperglycemic event in
February 2012. The claimant is not receiving
treatment
from
an
endocrinologist.
Additionally, his gait, station and knee
range of motion are within normal limits and
14
his
hypertension
has
recently
been
adequately controlled with increases in
prescription
medication.
As
such,
Dr.
Travis’s opinions are not consistent with
the substantial medical evidence of record.
Lastly, the undersigned has considered the
opinions
of
the
State
Agency
medical
consultants
who
provided
medical
evaluations. In November 2011, Dr. Harper
concluded that the claimant had no severe
impairments.
(Exhibit 10F).
This opinion
has been accorded little weight as the
undersigned finds the claimant’s diabetes,
hypertension,
history
of
right
knee
chondromalacia and obesity cause more than
minimal
functional
limitations.
The
undersigned has limited the claimant to
light work with no climbing ladders/ropes/
scaffolds and only occasional kneeling,
crouching and crawling. Additionally, the
undersigned has limited the claimant to no
exposure to unprotected heights.
(Tr. at 21-22).
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 failing to
give controlling weight to the opinions
of Plaintiff’s treating physician?
Plaintiff
argues
that
the
ALJ
erred
in
not
giving
controlling weight to the opinions of his treating physician,
Dr. Judy Travis, that he could work for only four hours a day. 8
8
As discussed herein, the record shows that the ALJ gave “little
weight” to the opinions of Dr. Travis set forth in the January
25, 2012 and May 30, 2012 Medical Source Statements (“MSS”) and
the January 25, 2012 Clinical Assessment of Pain (“CAP”) form.
(Tr. 21, 307, 328).
15
(Doc. 13 at 4).
The Commissioner counters that the ALJ properly
discounted Dr. Travis’s opinions because they are inconsistent
with
the
Having
record
evidence
in
this
carefully
reviewed
the
case.
record,
(Doc.
the
14
Court
at
6-8).
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
accord
of
is
776
internal
must
a
claimant’s
shown
F.2d
quotation
substantial
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
evidence, or where the evidence supports a contrary finding.”
Hogan
v.
Astrue,
2012
U.S.
Dist.
9
LEXIS
108512,
*8,
2012
WL
“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).
16
3155570, *3 (M.D. Ala. 2012).
“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
from
2007
to
Plaintiff
case
2012
shows
for
that
Dr.
various
Travis
ailments
treated
including
diabetes, hypertension, stomach pain, back pain, sore throat,
and medication refills.
(Tr. 219-31, 342-43).
On January 25,
2012, Dr. Travis completed a Medical Source Statement (“MSS”)
form in which she opined that Plaintiff could sit for only one
hour
at
a
time
for
a
total
of
four
hours
in
an
eight-hour
workday, and that Plaintiff could stand/walk for less than one
hour a day.
(Id. at 307).
On that date, Dr. Travis also
completed a Clinical Assessment of Pain (“CAP”) form in which
she stated that Plaintiff’s pain is “present to such an extent
as
to
be
distracting
to
adequate
performance
of
daily
activities;” that physical activity will increase the pain “to
17
such
an
extent
that
bed
rest
and/or
medication
[will
be]
necessary;” and that significant side effects from Plaintiff’s
medications “may be expected which may limit effectiveness of
work duties or performance of everyday tasks.”
(Id. at 309).
On May 30, 2012, Dr. Travis completed a second MSS form in which
she opined that Plaintiff could work for only four hours in an
eight-hour workday; that he could stand for only fifteen minutes
at one time; and that he could sit for four hours at one time.
(Id. at 328).
Having reviewed the record at length, the Court
finds,
ALJ
as
the
found,
that
Dr.
Travis’
opinions
are
not
supported by the record.
First, as the ALJ articulated, Dr. Travis’ opinions are
inconsistent with the medical evidence in this case, including
her own treatment records.
Dr. Travis opined in her January 25,
2012, CAP form, that Plaintiff’s disability was the result of
“severely labile diabetes 10 with peripheral neuropathy.”
310).
However,
Dr.
Travis’
treatment
records
(Id. at
show
that
Plaintiff’s diabetes was adequately controlled during the period
in
question,
2012. 11
except
during
(Id. at 20, 278).
his
hospitalization
in
February
Dr. Travis’ treatment notes reflect
10
Labile diabetes is another name for brittle or unstable
diabetes.
See
http://rarediseases.info.nih.gov/gard/11900/
brittle-diabetes/resources/1.
11
In fact, on September 28, 20ll, Plaintiff told consultative
examiner, Dr. Stephen Robidoux, M.D., that he had been on
18
that when she had Plaintiff admitted to Bryan Whitfield Hospital
in February 2012 for high blood pressure, high blood sugar, and
complaints
of
severe
Plaintiff’s
diabetes
headaches,
was
she
“normally
well
expressly
noted
controlled.”
that
(Id.
at
332). As the ALJ noted, none of Plaintiff’s treating physicians,
including Dr. Travis, ever referred him to an endocrinologist or
a specialist of any kind for his diabetes.
In addition, Dr. Travis opined in the January 2012 MSS form
that Plaintiff could sit for only one hour at a time.
307).
(Id. at
Interestingly, four months later in the May 2012 MSS
form, she opined that he could sit for four hours at one time.
(Id. at 328).
In addition, Dr. Travis opined that Plaintiff
could stand/walk for only fifteen minutes at one time, for a
total
of
less
Plaintiff’s
than
pain
one
was
hour
present
in
to
an
eight-hour
such
an
workday;
extent
as
that
to
be
distracting to the adequate performance of daily activities; and
that physical activity would increase his pain to such an extent
that bed rest or medication would be necessary.
328).
(Id. at 308-09,
Yet, her own treatment notes from Plaintiff’s February
2012 hospitalization show that while Plaintiff’s blood pressure
was elevated and he reported muscle weakness on right side of
face, his examination revealed normal cardiovascular function,
insulin for diabetes since he was thirteen years old and that he
had not been hospitalized for diabetes since 2009. (Tr. 278).
19
normal respiration, full range of motion of all joints, good
muscle mass bilaterally, “[a]ll muscles functioning well,” no
atrophy, and no swelling. 12
Dr.
Travis’
treatment
(Id. at 334-35).
records
from
In addition, while
Plaintiff’s
subsequent
hospitalization in June 2012 for abdominal pain and vomiting
reflects a blood pressure of 170/100 and epigastric tenderness,
upon examination, Plaintiff had normal chest and heart function,
normal
lungs,
extremities,
full
no
range
swelling,
of
motion
good
muscle
of
all
mass
atrophy, and normal neurological function. 13
342).
joints
in
bilaterally,
all
no
(Id. at 336, 339,
These findings are simply not consistent with the extreme
limitations listed by Dr. Travis in the January and May 2012 MSS
and CAP forms.
(Id. at 307-09, 328).
In addition to being inconsistent with her own treatment
records, Dr. Travis’ opinions are inconsistent with the findings
and
opinions
of
consultative
examiner,
Dr.
Stephen
Robidoux,
M.D., who examined Plaintiff on September 28, 2011 and October
24, 2011.
The record shows that Dr. Robidoux suspended the
examination on September 28, 2011 and instructed Plaintiff to go
12
Dr. Travis diagnosed Plaintiff with “malignant hypertension
with chest pain,” “hyperglycemia with Type 1 insulin dependent
diabetes,” obesity, and anxiety/stress.
(Tr. 332). After five
days of medication treatment, she transferred Plaintiff to DCH
Hospital for an assessment of his heart. (Id.).
13
Dr. Travis treated Plaintiff with antibiotics for two days and
then discharged him. (Tr. 336, 339).
20
to the emergency room because Plaintiff’s blood pressure was
extremely high (250/140). (Id. at 280).
October
24,
2011,
and
advised
Dr.
Plaintiff returned on
Robidoux
that
he
was
not
hospitalized on September 28, 2011, but was given Clonidine (for
high blood pressure). (Id. at 299-300).
He also reported that
he had not seen any other medical providers in the interim.
(Id.). Plaintiff reported that his blood sugar on October 24,
2011, was 145.
(Id.).
Dr. Robidoux’s examination revealed normal range of motion
in all extremities, including knees, ankles, hips, shoulders,
elbows, wrists, and fingers, normal arches in his feet, and no
atrophy or muscle weakness in his thighs.
(Id. at 303).
Dr.
Robidoux stated: “full range of motion upper and lower with no
joint effusions, no redness, no deformities, no cyanoses, no
clubbing,
touch;”
no
cellulites,
“normal
no
heat,
proprioception;”
no
“normal
edema;”
“normal
vibratory
fine
sensation”
except in left great toe; normal cold discrimination.
(Id.).
In addition, Plaintiff had normal range of motion in his back.
(Id.).
Plaintiff was able to flex toward his toes, with full
range of motion and no muscle tenderness.
leg and bent leg raising was normal.
(Id.).
(Id.).
His straight
Dr. Robidoux noted
that Plaintiff was “[a]ble to lay flat back and get straight up
on examining table.”
(Id.).
Plaintiff had a “normal unaided
gait” and was “able to squat and raise, normal toe walking.”
21
(Id.).
In addition, Dr. Robidoux’s examination revealed normal
findings related to Plaintiff’s lungs, heart, and abdomen, and
his neuromuscular examination was completely normal.
(Id. at
304).
Dr. Robidoux assessed Plaintiff with severe hypertension,
poor medical compliance, and diabetes.
(Id.).
Dr. Robidoux
concluded:
Mr. Burrell presents with poor compliance to
medical care. His blood pressure was very
high when he came here on 9/28/11 for a
disability evaluation and was sent to the
emergency room at Demopolis, Alabama. He
still hasn’t been back to his family doctor.
He was strongly advised to see his family
doctor. I find no limitations on his
evaluation for age to sitting, standing,
walking,
lifting,
carrying,
climbing,
crawling, handling objects, using hand and
foot
controls,
talking,
listening
and
travel. He has a drivers license.
(Id. at 304).
As the ALJ found, Dr. Travis’ opinions in the
January and May 2012 MSS and CAP forms regarding the degree of
limitations caused by Plaintiff’s hypertension, diabetes, and
other medical impairments are inconsistent with this evidence.
In addition to being inconsistent with her own treatment
notes and the opinions of consultative examiner Dr. Robidoux,
Dr. Travis’ opinions are also inconsistent with the treatment
records of Plaintiff’s other treating physicians.
As the ALJ
found,
transferred
the
Plaintiff
to
record
shows
DCH
Hospital
that
on
after
Dr.
February
22
Travis
22,
2012,
Dr.
Inkil
Hwangpo,
D.O.,
“hypertensive
examined
urgency,
Plaintiff
not
and
diagnosed
malignant
“uncontrolled” type 2 diabetes.
him
with
hypertension”
and
(Id. at 312-14).
Dr. Hwangpo
found Plaintiff’s cardiovascular functioning to be normal, and
his stress test was negative.
(Id. at 314).
In addition,
radiographic imaging showed normal kidneys and bladder with “no
evidence of medical renal disease or hydronephrosis.”
314, 319).
(Id. at
Dr. Hwangpo discharged Plaintiff after two days,
noting that Plaintiff “did well during hospital stay;” that he
was started on multiple blood pressure medications; and that he
was to follow up with outpatient nephrology.
(Id. at 314).
Dr.
Hwangpo also noted that Plaintiff’s condition on discharge was
“improved,” and instructed him that he “[m]ay return to usual
activity level as tolerated.”
(Id. at 315).
Likewise, Plaintiff’s other attending physicians during his
February 2012 hospitalization, Dr. Robert Sheppard, M.D., and
Dr. Lawrence Lee, M.D., noted that Plaintiff had “hypertensive
urgency” but that he did not have “any evident acute end organ
damage.”
(Id. at 316-17).
They also noted that Plaintiff’s
diabetes was a “chronic problem”
but stated that they
continue his home insulin and start him on a statin.
would
(Id.).
They found that Plaintiff had normal strength bilaterally in his
upper and lower extremities.
(Id. at 317).
On March 13, 2012, Plaintiff was referred to Dr. Richard
23
Gurich, M.D., for hematuria, proteinuria, and hypertension.
(Id. at 348).
14
Dr. Gurich’s examination revealed normal head,
eyes, ears, nose and throat, normal lungs, normal heart, normal
abdomen,
normal
back,
normal
extremities
normal neurological function.
Plaintiff
had
been
referred
(Id.).
for
with
no
edema,
and
Dr. Gurich noted that
chronic
kidney
disease
and
poorly controlled hypertension and that Plaintiff’s normal blood
pressure
was
169
over
90,
which
was
too
high.
(Id.).
He
increased Plaintiff’s medication and instructed him to return in
three weeks.
Dr.
Gurich
excellent
(Id.).
noted
Plaintiff returned on April 3, 2012, and
that
control.”
Plaintiff’s
(Id.
at
blood
347).
He
pressure
further
was
“under
opined
that
Plaintiff’s peripheral edema was being caused by medication, not
congestive
heart
failure.
(Id.).
He
prescribed
Lasix
and
instructed Plaintiff to return in four months to repeat his lab
work.
(Id.).
Plaintiff returned to Dr. Gurich on August 7,
2012, and his examination again revealed a normal heart, normal
lungs,
normal
abdomen,
a
head,
eyes,
normal
neurological function.
back,
ears,
good
nose,
throat,
circulation,
(Id. at 346).
14
and
and
a
normal
normal
Dr. Gurich diagnosed
Hematuria
refers
to
blood
in
the
urine.
See
http://www.mayoclinic.org/diseases-conditions/blood-in-urine
/basics/definition/con-20032338.
Proteinuria refers to protein
in the urine.
See http://www.mayoclinic.org/symptoms/proteinin-urine/basics/definition/sym-20050656.
24
Plaintiff
with
chronic
function to be “stable.”
Plaintiff’s
blood
drowsiness
from
disease
(Id.).
pressure
controlled.” (Id.).
of
kidney
but
found
his
renal
Dr. Gurich further noted that
was
“for
the
most
part
well
Dr. Gurich noted that Plaintiff complained
Clonidine
and
lower
extremity
edema
from
Norvase and indicated that he would try a different medication
to
address
the
side
effects.
treatment notes in the record.
is
likewise
inconsistent
(Id.).
These
are
the
final
As the ALJ found, this evidence
with
the
disabling
functional
limitations set forth by Dr. Travis in the January and May 2012
MSS and CAP forms.
Last, as the ALJ articulated, the record shows that Dr.
Travis’
opinions
regarding
his
are
inconsistent
activities
of
daily
with
Plaintiff’s
living.
At
the
testimony
hearing,
Plaintiff testified that he could walk the length of a football
field.
his
(Id. at 34).
twelve-year-old
In addition, he stated that he lives with
daughter;
he
drives
and
shops;
he
does
laundry and ironing; he cooks; he helps with school work; he
handles his own personal care; he handles his own bills and
finances; he fishes, attends football games, and spends time
with
others.
(Id.
at
38,
42-44,
160-63).
This
evidence
regarding Plaintiff’s daily activities contrasts greatly with
Dr. Travis’ opinion that Plaintiff can only stand for fifteen
minutes and sit for a total of four hours in an eight-hour work
25
day.
(Id. at 307, 328).
Based on the foregoing evidence, the Court finds that Dr.
Travis’ opinions set forth in the January and May 2012 MSS and
CAP forms are inconsistent with the record evidence
in this
case.
to
Therefore,
the
ALJ
did
not
err
controlling weight to those opinions.
in
failing
give
The substantial medical
evidence in this case supports the ALJ’s finding that Plaintiff
can perform his past work as an assembler or cook.
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 12th day of December, 2014.
/s/ SONJA F. BIVINS
UNITED STATES MAGISTRATE JUDGE
26
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