Valdez v. Commissioner of Social Security

Filing 16

ORDER affirming the Commissioner's decision and directing the clerk to enter judgment in favor of the Commissioner and close the file. Signed by Magistrate Judge Patricia D. Barksdale on 3/4/2016. (LPB)

United States District Court
Middle District of Florida
Jacksonville Division
CHRISTOPHER VALDEZ,
Plaintiff,
v.

NO. 3:14-CV-1328-J-PDB

COMMISSIONER OF SOCIAL SECURITY,
Defendant.

Order Affirming Commissioner’s Decision
This is a case under 42 U.S.C. § 405(g) to review a final decision of the
Commissioner of the Social Security Administration denying Christopher Valdez’s
claim for disability-insurance benefits. He seeks reversal; the Commissioner,
affirmance. The Court incorporates the record summarized by the Administrative
Law Judge (“ALJ”), Tr. 11–20, and the parties, Doc. 14 at 1–8; Doc. 15 at 1–5, 8–12.
Issue
Valdez presents one issue: whether the ALJ erred in weighing the medical
evidence by failing to state the weight she gave his treating physicians’ opinions.
Background
Valdez was 52 at the time of the ALJ’s decision. Tr. 19, 21, 29. He last worked
in March 2011. Tr. 29–30. He completed two years of college and has experience as a
computer consultant and a network systems director. Tr. 32–33, 247. He alleged he
had become disabled in August 2010 (amended to March 2011) due to sacroiliac joint

dysfunction, gout, neuropathy, diabetes, high blood pressure, mitral valve prolapse,
acid reflux, back pain and spasms, and bursitis in his left shoulder. Tr. 29, 202, 246.
His last-insured date for his eligibility for benefits was December 31, 2015. Tr. 11, 13,
276. He proceeded through the administrative process, failing at each level. Tr. 1–3,
8–21, 49–58, 60–69. This case followed. Doc. 1.
ALJ’s Decision
At step two, 1 the ALJ found Valdez has severe impairments of osteoarthritis
and obesity. Tr. 13. At step three, she found none of his impairments, individually or
in combination, meet or equal the severity of any impairment in the Listing of
Impairments, 20 C.F.R. Part 404, Subpart P, App’x 1, including Listing 1.02 (major
dysfunction of a joint) and 1.04 (disorders of the spine). Tr. 13–14. After stating she
had considered the entire record, she found Valdez has the residual functional
capacity to perform light work as defined in 20 C.F.R. § 404.1567(b)2 with the
additional limitations he (1) can stand for 2 hours; (2) can only occasionally conduct
1The

Social Security Administration uses a five-step sequential process to
decide if a person is disabled, asking: (1) is he engaged in substantial gainful activity;
(2) does he have a severe impairment or combination of impairments; (3) does the
impairment meet or equal the severity of anything in the Listing of Impairments, 20
C.F.R. Part 404, Subpart P, App’x 1; (4) given his residual functional capacity (RFC),
can he perform any of his past relevant work; and (5) given his RFC, age, education,
and work experience, are there a significant number of jobs in the national economy
he can perform. 20 C.F.R. § 404.1520(a).
2“Light

work involves lifting no more than 20 pounds at a time with frequent
lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted
may be very little, a job is in this category when it requires a good deal of walking or
standing, or when it involves sitting most of the time with some pushing and pulling
of arm or leg controls. To be considered capable of performing a full or wide range of
light work, you must have the ability to do substantially all of these activities.” 20
C.F.R. § 404.1567(b).
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overhead reaching; (3) must avoid exposure to concentrated temperate extremes,
vibrations, and hazards; (4) cannot climb ramps, stairs, ladders, ropes, or scaffolds;
(5) can only occasionally stoop, crouch, crawl, and kneel; and (6) must be able to
switch between sitting and standing at will. Tr. 14.
The ALJ observed Valdez received treatment at Baymeadows Primary Care
for his general healthcare needs and his treatment consisted mainly of “medication
management and refills.” Tr. 15. She summarized the treatment notes for his visits
there from his alleged onset date, March 2011, to his most recent office visit before
her decision, September 2012. 3 Tr. 15–18. He struggled with weight gain and high
blood pressure. 4 Tr. 15. While he reported back pain in April 2011, she observed his
treating physician made no objective finding regarding back pain, identified weight
gain and vital signs as the only abnormalities, and prescribed Valium. Tr. 15. He
continued to suffer from back pain and his diabetes was uncontrolled in July 2011.
Tr. 16. He was referred for bilateral hand radiographs at his October 2011 visit

3Valdez

saw various practitioners at Baymeadows Primary Care, including
Talat Imam, M.D., Hussain Imam, M.D., and William Finan, D.O. Tr. 361–408, 423,
431–70. The ALJ refers only to Dr. Imam and Dr. Imam, at times mentioning no
treating physician and twice mentioning the wrong one. See Tr. 17 (Valdez saw Dr.
Finan, not Dr. Imam, in May 2012, Tr. 438–40, and Barbara Steplock, P.A., not Dr.
Imam, in September 2012, Tr. 453–56). Because Valdez does not make any particular
argument as to each provider, the Court generically refers to “the treating physician”
as the provider who saw him on that particular visit.
4The

ALJ cited the following measurements: 303 pounds with a blood pressure
of 115/72 (March 2011); 313.6 pounds with a blood pressure of 147/83 (April 2011);
305 pounds with a body mass index (BMI) of 39.2 and a blood pressure of 151/91
(December 2011), 280 pounds with a BMI of 36 (May 2012), and 280 pounds with a
BMI of 36 and a blood pressure of 171/103 (September 2012). Tr. 15–17.
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because he had swelling in both hands but no bone or joint abnormalities or carpal
tunnel syndrome. Tr. 16. In December 2011, he had normal cardiac function, a slow
gait with a limp, decreased range of motion, and back pain. Tr. 16. He was diagnosed
with non-insulin dependent diabetes, chronic low back pain, gastroesophageal reflux
disease (GERD), and hypertension (high blood pressure). 5 Tr. 16. He had not followed
his diet and exercise regimen by February 2012, and his follow-up examination was
identical to his previous one. Tr. 16.
In May 2012, he had normal muscle tone and strength, was neurologically
intact, still had a limp, demonstrated mild diffuse gastrointestinal pain, and had
decreased range of motion in his back, pain with flexion and extension, and
hyperesthesia (abnormal acuteness of sensitivity to touch, pain, or other sensory
stimuli). Tr. 16. The next month there were no significant musculoskeletal deficits or
evidence of clubbing, cyanosis (bluish coloring of the skin and mucous membrane due
to a lack of oxygen), ischemia (local anemia due to mechanical obstruction of the blood
supply), or infection, and his gait and deep tendon reflexes were normal. Tr. 16. In
July 2012, his gait was slow, and he had decreased range of motion and pain in his
back. Tr. 16. He reported pain relief in his lower back with medication in September
2012, although he had compliance issues following up as directed, getting consistent
lab work, and performing home-blood-glucose monitoring. Tr. 17. He also received
prescription refills at this appointment. Tr. 17.

5All

parenthetical definitions of medical terms are from STEDMAN’S MEDICAL
DICTIONARY (William R. Hensyl et al. eds., 25th ed. 1990).
4

The ALJ found the evidence supported his suffering from low back pain;
however, she observed his doctors treated him conservatively with medication rather
than physical therapy or surgery. Tr. 17. She observed his doctors recommended
weight loss and found his claims he could not exercise from right leg pain and
neuropathy inconsistent with his May, June, and July 2012 exams revealing a normal
(though slow) gait, no need to use a cane, and reported relief from neuropathy due to
medication (Lyrica and later Gabapentin). Tr. 17. She found his activities of daily
living (taking care of his personal hygiene, watching television, listening to the radio,
taking care of his dogs, cooking, cleaning, walking, and using the computer for email
and Facebook) greater than expected of a disabled individual and his claim of
suffering at least ten bad days a month questionable because he never reported that
to his physicians, attempted to seek treatment for any issues with his lower
extremities, or did anything beyond sitting exercises to alleviate pain. Tr. 17.
The ALJ summarized the findings of Lynn Harper-Nimock, M.D., from a July
2011 internal-medicine examination. Tr. 15. Dr. Harper-Nimock made the following
observations: (1) Valdez weighed 301 pounds, had a BMI of 42, blood pressure of
160/98, and an abnormal gait; (2) he had a normal stance and his joints were stable;
(3) he appeared to be in mild distress, could not walk on his heels or toes, or squat,
and walked with a cane; (4) he did not need help changing for the examination but
had difficulty getting on and off the examination table; (5) his chest and lungs were
normal; (6) his cervical and lumbar spine showed decreased flexion, extension, lateral
flexion, and decreased rotary motion bilaterally; (7) he had decreased range of motion

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of the wrists, hips, knees, ankles, and shoulders bilaterally; (8) he had full strength
in his upper and lower extremities; and (9) he had intact hand and finger dexterity
and full grip strength bilaterally. Tr. 15–16. She “offered diagnostic impressions of
sacroiliac joint deformity, degenerative disc disease with radiculopathy, non-insulindependent diabetes, degenerative joint disease, gout, peripheral neuropathy,
hyperlipidemia, obesity, previous myocardial infarction, hypertension, and carpal
tunnel syndrome” and gave Valdez “a poor prognosis.” Tr. 16.
Dr. Harper-Nimock opined Valdez “had moderate limitations for prolonged
sitting, standing, walking, climbing, heavy lifting, pushing, or pulling.” Tr. 16. The
ALJ gave these opinions great weight and accounted for them in her residualfunctional-capacity finding, including his abnormal gait (the sit-stand option and the
two-hour standing limitation); his decreased cervical and lumbar spine flexion and
extension, decreased rotary motion, positive straight-leg raise, and decreased range
of motion in his shoulders, wrists, hips, knees, and ankles (limiting exposure to
extreme temperatures, vibrations, and hazards); and the mild effusion in both knees
(restricting climbing and limiting stooping, crouching, crawling, and kneeling). Tr.
18. The ALJ concluded the remaining findings supported “a wide range of ability,”
including full strength in his extremities and grip, no muscle atrophy, and intact
hand and finger dexterity. Tr. 18.
The ALJ considered and rejected Valdez’s obesity as an impairment precluding
all work activity. Tr. 18. She found no evidence of a mental impairment interfering
with daily functioning despite a Valium prescription for anxiety. Tr. 18. After

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observing the opinions of non-examining state-agency physicians do not deserve as
much weight as examining or treating physicians, she found they deserve some
weight, “particularly in a case like this in which there exist a number of reasons to
reach similar conclusions.” Tr. 18. They found he was not disabled because he was
capable of a reduced range of light work but observed he was limited in overhead
reaching and postural manipulations. Tr. 18–19. The ALJ incorporated the limitation
into her residual-capacity-finding. Tr. 14, 18–19. She found these assessments
consistent with the greater weight of the evidence, including Dr. Harper-Nimock’s
findings. Tr. 19. She also included the sit-stand option to account for his foot pain,
which the state-agency physicians did not address. Tr. 19.
The ALJ also credited Valdez’s testimony he cannot lift over 15 to 20 pounds
or anything above his shoulders, finding these limitations compatible with her
residual-functional-capacity finding. Tr. 19. Based on his residual functional
capacity, she determined he could perform no past relevant work. Tr. 19. Relying on
the testimony of a vocational expert, she concluded he had skills transferable to
sedentary work. Tr. 19. She found he could perform jobs (help-desk representative,
surveillance-systems monitor, and order clerk) and thus was not disabled. Tr. 20.
Standard of Review
A court’s review of an ALJ’s decision is limited to determining whether the ALJ
applied the correct legal standards and whether substantial evidence supports his
findings. Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005). Substantial
evidence is “less than a preponderance”; it is “such relevant evidence as a reasonable
person would accept as adequate to support a conclusion.” Id. The court may not
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decide facts anew, reweigh evidence, make credibility determinations, or substitute
its judgment for the Commissioner’s judgment. Id.
Analysis
A medical opinion is a statement reflecting judgment about the nature and
severity of an impairment and what a claimant can still do despite it. 20 C.F.R.
§ 404.1527(a)(2). An ALJ must evaluate each medical opinion regardless of its source,
20 C.F.R. § 404.1527(c), and state with particularity the weight he gives it and the
reasons why, Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011);
Shafarz v. Bowen, 825 F.2d 278, 279 (11th Cir. 1987). An ALJ must give considerable
weight to a treating physician’s opinion unless he shows good cause for not doing so.
Phillips v. Barnhart, 357 F.3d 1232, 1240 (11th Cir. 2004). Good cause exists if (1)
the evidence did not bolster the opinion, (2) the evidence supported a contrary finding,
or (3) the opinion was conclusory or inconsistent with his own medical records. Id. at
1240−41. If an ALJ disregards the opinion, he must clearly articulate his reasons. Id.
Substantial evidence must support those reasons. Id.
An ALJ must consider all record evidence in making a disability
determination. 20 C.F.R. § 404.1520(a)(3). “[T]here is no rigid requirement that the
ALJ specifically refer to every piece of evidence in his decision, so long as the ALJ’s
decision … is not a broad rejection which is not enough to enable [the Court] to
conclude that [the ALJ] considered [the claimant’s] medical condition as a whole.”
Dyer v. Barnhart, 395 F.3d 1206, 1211 (11th Cir. 2005) (quotations omitted). An ALJ’s
determination may be implicit, but the “implication must be obvious to the reviewing

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court.” Tieniber v. Heckler, 720 F.2d 1251, 1255 (11th Cir. 1983). An ALJ has a
heightened duty to discuss medical opinions and may not implicitly reject them where
the reasons are not obvious. McClurkin v. Soc. Sec. Admin., 625 F. App’x 960, 963
(11th Cir. 2015).
If an ALJ fails to state the weight given to medical opinions, the error is
harmless if the opinions do not contradict the ALJ’s findings. Wright v. Barnhart, 153
F. App’x 678, 684 (11th Cir. 2005). An error is harmless if it does not affect the
outcome or a party’s substantial rights. Perry v. Astrue, 280 F. App’x 887, 893 (11th
Cir. 2008). “[T]he burden of showing that an error is harmful normally falls upon the
party attacking the agency’s determination.” Shinseki v. Sanders, 556 U.S. 396, 409
(2009).
Valdez argues that although the ALJ reviewed the treatment notes from his
physicians, she failed to state the weight she gave their opinions. Doc. 14 at 6–7. He
argues she relied on their treatment notes from after Dr. Harper-Nimock’s July 2011
evaluation, in May, June and July 2012, to support her decision he is not disabled.
Doc. 14 at 7. He observes the ALJ cited notes indicating he did not have clubbing,
cyanosis, ischemia, or infection, he had a normal gait and deep tendon reflexes, and
intact neurological function, and he did not require a cane. Doc. 14 at 7. But he argues
“these notes from the treating doctors paint a different picture of” him: in May 2012
he walked with a limp, had decreased range of motion in the back, hyperesthesia,
seemed to be in severe pain, was lethargic and anxious; in June 2012, his symptoms
were “quite severe” and he presented with chronic low back pain, characterized as

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constant and radiated to the buttocks and thighs; in July 2012, he again presented
with chronic low back pain and the treating physician noted his gait was slowed, he
had decreased range of motion and pain with movement in the back. Doc. 14 at 7–8.
While he acknowledges the ALJ need not discuss every medical note, he argues her
analysis should be an accurate summary of the findings “particularly when these
notes from the basis for the decision and more importantly when the notes are from
the treating physician.” Doc. 14 at 8. He argues the ALJ discussed Dr. HarperNimrock’s opinions “in rather explicit detail,” assigning them great weight, even
though they were entitled to less weight than his treating physicians because she was
a consulting examiner. Doc. 14 at 8–9. He similarly argues the ALJ gave the stateagency non-examining physicians great weight but failed to mention the weight given
to the treating physicians, which is not harmless because her notes summary was
inaccurate. Doc. 14 at 9.
The Commissioner responds not all treatment notes are medical opinions. Doc.
15 at 7. She argues the ALJ’s discussion of the treatment notes, while not a verbatim
repetition of every statement made in them, “is fully consistent with the
corresponding records.” Doc. 15 at 8. She argues Valdez failed to prove the treating
physicians offered opinions regarding his functional limitations greater than the
ALJ’s residual-functional-capacity finding. Doc. 15 at 8. She argues they offered no
opinions about his ability to work. Doc. 15 at 8 (citing Tr. 438–48). As to the May 2012
treatment notes, she observes not only was he in severe pain and lethargic, he was
diagnosed with an acute upper respiratory infection, chills, cough, fever, and fatigue.

10

Doc. 15 at 8 (citing Tr. 439). She argues the treatment records are consistent with Dr.
Harper-Nimock’s findings. Doc. 15 at 9–10. She observes Valdez does not challenge
the weight the ALJ afforded Dr. Harper Nimock’s opinions. Doc. 15 at 10 n.3. She
argues that even if the ALJ failed to sufficiently articulate the weight she gave the
treatment notes, the failure is harmless because the ALJ accounted for the clinical
findings in her residual-functional-capacity finding. Doc. 15 at 10–11. She argues an
ALJ may give non-examining physicians weight greater than the opinions of treating
or examining sources under certain circumstances and did so here because their
opinions were consistent with the other evidence. Doc. 15 at 11–12. She concludes the
ALJ properly weighed the evidence to determine Valdez’s residual functional capacity
and substantial evidence supports the decision. Doc. 15 at 12.
Valdez does not specify any particular disabling condition the treatment notes
addressed but the ALJ disregarded. The treatment notes do not appear to contain
medical opinions as defined under 20 C.F.R. § 404.1527(a)(2) because they do not
contain judgments about the nature and severity of Valdez’s chronic low back pain
(or other conditions) and what he can still do despite it. His physicians’ observations
do not relate to his ability to work despite suffering from pain and other impairments.
To the extent the Court can construe the physicians’ notes as medical opinions, the
ALJ did not explicitly state she gave them great weight but did so implicitly by
recognizing treating physicians are entitled to significant weight, Tr. 18, discussing
their treatment notes in great detail, Tr. 15–18, and finding a residual functional
capacity consistent with their observations, Tr. 14–19.

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Valdez recognizes the treatment notes formed the basis of the ALJ’s decision.
Doc. 14 at 8. He nevertheless disagrees the treatment notes cited support the ALJ’s
findings based on his interpretation of the evidence. Although he cites the treating
physician’s observation during the May 2012 visit he seemed to be in severe pain,
that was a general observation. Tr. 439. He ignores the musculoskeletal and
neurologic observations the ALJ specifically referenced in her decision, Tr. 16–17,
439, and that he sought care that day for a fever and related symptoms, Tr. 439. At
both his June and July 2012 visits, he was in no apparent distress and sought
medication refills. Tr. 441, 443, 445, 447. The Court cannot reweigh the evidence and
focus only on Valdez’s chronic low back pain in isolation as he suggests rather than
reviewing the notes in context and in light of his overall treatment plan as the ALJ
did. See Moore, 405 F.3d at 1211. She accounted for his pain with the sit-stand option,
declining to impose any greater limitation because his physicians treated his
condition conservatively, with medication and a weight-loss recommendation. Tr. 17.
Substantial evidence supports the decision. Tr. 432, 436, 444, 448, 456.
Valdez does not explain the significance of the ALJ citing treatment notes after
Dr. Harper-Nimock’s evaluation or recognize she also cited treatment notes from
before the evaluation. He does not explain how the state-agency physicians’ opinions
were inconsistent with the greater weight of the evidence. His argument can be
reduced to the ALJ’s failure to write that she was giving the treating physician
records great weight when the law does not require that degree of particularity. See
Jamison, 814 F.2d at 589. Even had the ALJ erred in failing to explicitly state she

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gave great weight to the treating-physician opinions in the record, he must show such
error was harmful. See Shinseki, 556 U.S. at 409. He failed to meet that burden as it
is apparent she gave their opinions great weight and whether she said so explicitly
would not change the outcome.
Conclusion
The Court affirms the Commissioner’s decision denying Valdez’s claim for
benefits and directs the clerk to enter judgment in favor of the Commissioner and
close the file.
Ordered in Jacksonville, Florida, on March 4, 2016.

c:

Counsel of Record

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