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