Villarreal v. Social Security Administration Commissioner

Filing 15

FINAL JUDGMENT REVERSING THE DECISION OF THE COMMISSIONER AND REMANDING THIS CASE TO THE COMMISSIONER FOR FURTHER CONSIDERATION PURSUANT TO SENTENCE FOUR of 42 U.S.C. 405(g). Signed by Honorable Mark E. Ford on July 29, 2016. (hnc)

IN THE UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF ARKANSAS
FORT SMITH DIVISION
TAMMIE VILLARREAL
V.

PLAINTIFF
CIVIL ACTION NO. 2:15-CV-2152-MEF

CAROLYN W. COLVIN, Commissioner,
Social Security Administration

DEFENDANT

FINAL JUDGMENT
This cause is before the Court on the Plaintiff’s complaint for judicial review of an
unfavorable final decision of the Commissioner of the Social Security Administration denying her
claim for disability benefits. The parties have consented to entry of final judgment by the United
States Magistrate Judge under the provisions of 28 U.S.C. § 636(c). The Court, having reviewed
the administrative record, the briefs of the parties, the applicable law, and having heard oral
argument, finds as follows, to-wit:
Consistent with the Court’s ruling from the bench following the parties’ oral argument, the
decision of the Commissioner of Social Security is reversed and remanded for further proceedings
pursuant to sentence four of 42 U.S.C. § 405(g).
The Court finds that substantial evidence is lacking to support the ALJ’s determination that
the Plaintiff can perform a full range of medium work. The record makes clear that the Plaintiff
has been diagnosed with hepatitis C and suffers from severe fatigue, thrombocytopenia, abdominal
pain, severe portal hypertension, an enlarged liver and spleen, ascites, and varices. Plaintiff’s
treating source, Nurse Stephanie Davis at Sophia Meyer Family Medicine, opined Plaintiff could
essentially perform a limited range of sedentary work involving limited reaching, handling,
fingering, feeling and exposure to extremes, noise, dust, vibration, humidity/wetness, hazards,
fumes, odors, chemicals, and gases. However, Nurse Davis also concluded she could not climb,

balance, kneel, kneel, crouch, or crawl. She then identified Plaintiff’s diagnosis of
thrombocytopenia as the basis for her decision, explaining that it causes extreme fatigue and could
lead to random bleeding and/or bruising, general malaise, and weakness. Although the ALJ is
correct in stating that the record documents no episodes of random bleeding, the fact that her
condition makes her susceptible to this requires that her RFC assessment take this possibility into
account. The RFC assessment should also take into account the chronic fatigue resulting from her
impairments. Because the current RFC does not do so, the Court finds remand necessary to allow
the ALJ to reconsider the Plaintiff’s RFC.
Because the ALJ does not feel that an RFC assessment from Nurse Davis is sufficient to
establish the Plaintiff’s limitations, on remand, the ALJ is directed to obtain an RFC assessment
from Dr. Ihab Herraka. If Dr. Herraka is unwilling or otherwise unable to complete an RFC
assessment, then the ALJ is directed to order a consultative gastroenterology examination,
complete with a thorough RFC assessment. In so doing, all of the Plaintiff’s medical records,
including lab results, should be forwarded to the consultative examiner for review and
consideration. Upon receipt of this additional evidence, the ALJ is directed to reformulate the
Plaintiff’s RFC. He should then pose a properly phrased hypothetical question to a vocational
expert to ascertain whether work exists in significant numbers in the national economy that the
Plaintiff remains capable of performing.
IT IS SO ORDERED AND ADJUDGED on this the 29th day of July, 2016.
/s/ Mark E. Ford
HON. MARK E. FORD
UNITED STATES MAGISTRATE JUDGE

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