Mayfield v. Colvin

Filing 14

MEMORANDUM of DECISION AND ORDER denying 10 Plaintiff's Motion for Summary Judgment; granting 11 Defendant's Motion for Summary Judgment. The decision of the Commissioner is AFFIRMED. Signed by District Judge Martin Reidinger on 9/13/2017. (Pro se litigant served by US Mail.)(tmg)

THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF NORTH CAROLINA
STATESVILLE DIVISION
CIVIL CASE NO. 5:16-cv-00094-MR

BEATRICE MAYFIELD,

)
)
Plaintiff,
)
)
vs.
)
)
1, Acting
NANCY A. BERRYHILL
)
Commissioner of Social Security,
)
)
Defendant.
)
_______________________________ )

MEMORANDUM OF
DECISION AND ORDER

THIS MATTER is before the Court on the Plaintiff’s Motion for
Summary Judgment [Doc. 10] and the Defendant’s Motion for Summary
Judgment [Doc. 11].
I.

PROCEDURAL HISTORY
The Plaintiff Beatrice Mayfield filed a protective application for a period

of disability and disability insurance benefits on August 23, 2012, alleging an
onset date of March 27, 2012. [Transcript (“T.”) 10, 113]. The Plaintiff’s
claim was denied initially and on reconsideration. [T. 10, 76, 81]. Upon the
Plaintiff’s request, a hearing was held on August 26, 2014, before

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Nancy A. Berryhill is now the Acting Commissioner of Social Security. Accordingly,
pursuant to Rule 25(d) of the Federal Rules of Civil Procedure, Nancy A. Berryhill is
substituted for Carolyn W. Colvin as the Defendant herein. See 42 U.S.C. § 405(g).

Administrative Law Judge Theresa R. Jenkins (“ALJ Jenkins”). [T. 21-43].
The Plaintiff and her husband testified at the hearing. On December 23,
2014, ALJ Jenkins issued a decision denying the Plaintiff benefits. [T. 7-17].
The Appeals Council denied the Plaintiff’s request for review, thereby making
the ALJ’s decision the final decision of the Commissioner. [T. 1-5]. The
Plaintiff has exhausted all available administrative remedies, and this case
is now ripe for review pursuant to 42 U.S.C. § 405(g).
II.

STANDARD OF REVIEW
The Court’s review of a final decision of the Commissioner is limited to

(1) whether substantial evidence supports the Commissioner’s decision, see
Richardson v. Perales, 402 U.S. 389, 401 (1971), and (2) whether the
Commissioner applied the correct legal standards, Hays v. Sullivan, 907
F.2d 1453, 1456 (4th Cir. 1990). The Court does not review a final decision
of the Commissioner de novo. Smith v. Schweiker, 795 F.2d 343, 345 (4th
Cir. 1986).
The Social Security Act provides that “[t]he findings of the
Commissioner of any Social Security as to any fact, if supported by
substantial evidence, shall be conclusive. . . .” 42 U.S.C. § 405(g). The
Fourth Circuit has defined “substantial evidence” as “more than a scintilla
and [doing] more than creat[ing] a suspicion of the existence of a fact to be
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established. It means such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion.” Smith v. Heckler, 782 F.2d
1176, 1179 (4th Cir. 1986) (quoting Perales, 402 U.S. at 401).
The Court may not re-weigh the evidence or substitute its own
judgment for that of the Commissioner, even if it disagrees with the
Commissioner’s decision, so long as there is substantial evidence in the
record to support the final decision below. Hays, 907 F.2d at 1456; Lester v.
Schweiker, 683 F.2d 838, 841 (4th Cir. 1982).
III.

THE SEQUENTIAL EVALUATION PROCESS
In determining whether or not a claimant is disabled, the ALJ follows a

five-step sequential process.

20 C.F.R. §§ 404.1520, 416.920.

If the

claimant’s case fails at any step, the ALJ does not go any further and benefits
are denied. Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995).
First, if the claimant is engaged in substantial gainful activity, the
application is denied regardless of the medical condition, age, education, or
work experience of the applicant. 20 C.F.R. §§ 404.1520, 416.920. Second,
the claimant must show a severe impairment. If the claimant does not show
any impairment or combination thereof which significantly limits the
claimant’s physical or mental ability to perform work activities, then no severe
impairment is shown and the claimant is not disabled. Id. Third, if the
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impairment meets or equals one of the listed impairments of Appendix 1,
Subpart P, Regulation 4, the claimant is disabled regardless of age,
education or work experience. Id. Fourth, if the impairment does not meet
the criteria above but is still a severe impairment, then the ALJ reviews the
claimant’s residual functional capacity (RFC) and the physical and mental
demands of work done in the past. If the claimant can still perform that work,
then a finding of not disabled is mandated. Id. Fifth, if the claimant has a
severe impairment but cannot perform past relevant work, then the ALJ will
consider whether the applicant’s residual functional capacity, age, education,
and past work experience enable the performance of other work. If so, then
the claimant is not disabled. Id. In this case, the ALJ’s determination was
made at the fourth step.
IV.

THE ALJ’S DECISION
In denying the Plaintiff’s claim, the ALJ found that the Plaintiff meets

the insured status requirements of the Social Security Act through
September 30, 2015, and that she has not engaged in substantial gainful
activity since the alleged onset date of March 27, 2012. [T. 12]. The ALJ
then found that the medical evidence established that the Plaintiff has the
following severe impairments: hypertension and hypertensive heart disease.
[Id.]. The ALJ determined that neither of the Plaintiff’s impairments, either
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singly or in combination, met or equaled a listing. [T. 12-13]. The ALJ then
assessed the Plaintiff’s residual functional capacity (RFC), finding that the
Plaintiff had the RFC to perform medium work except that she should avoid
ladders, ropes, scaffolds, unprotected heights, and machinery with
dangerous parts. [T. 13-16]. Based on this RFC, the ALJ then determined
that the Plaintiff could still perform her past relevant work as a retail sales
associate and computer operator. [T. 16]. The ALJ therefore concluded that
the Plaintiff was not “disabled” as defined by the Social Security Act from the
alleged onset date through the date of her decision. [T. 17].
V.

FACTUAL BACKGROUND
On March 27, 2012, the Plaintiff presented to the emergency room due

to a rash from poison-ivy exposure, was treated with an injectable steroid,
and was discharged home the same day in stable condition. [T. 14, 222–25].
The Plaintiff returned to the emergency room the next day, reporting that she
had a longstanding history of hypertension but did not take medication for it;
that she had symptoms of “near syncope and chest pain” when she was
discharged the previous day; that the medications with which she was
treated made her dizzy; and that she became weak, with nausea and
dizziness that led to constant, sharp, severe chest pain. [T. 14, 206]. An
electrocardiogram (“EKG”) showed no signs of acute ischemia, and she had
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negative cardiac enzymes, but she was admitted for further evaluation and
treatment [T. 14, 203].
Upon discharge the following day, the treating cardiologist, Dr. Allan,
noted that the Plaintiff’s EKG showed low sinus tachycardia with minimal ST
depression and abnormal R-wave progression and that all other routine labs
were unremarkable. [T. 14, 204]. In particular, an echocardiogram showed
left-ventricular hypertrophy and normal left-ventricular systolic function, and
there was no cardiac enlargement and no significant valvular heart disease
[Id.]. Dr. Allan assessed acute dyspnea with associated chest pressure after
the Vistaril and Decadron injection due to contact dermatitis; poorly
controlled hypertension without medication and left-ventricular hypertrophy;
and a cardiac murmur on exam. [Id.].
In April 2012, the Plaintiff presented to her primary care physician, Dr.
Chi Kwong Lai, for a blood-pressure check and routine examination. At that
time, she complained of shortness of breath on exertion but not chest pain
or discomfort. [Tr. 15, 230]. In July 2012, the Plaintiff was examined by Dr.
Richard Scherczinger.

An EKG demonstrated normal sinus rhythm, a

normal heart rate, and a normal axis without significant ST-T wave
abnormality. [T. 15, 237]. Her physical examination was unremarkable
except that her blood pressure was elevated at 170/92.
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[Id.].

Dr.

Scherczinger noted that he and Plaintiff discussed her chest discomfort in
detail; he noted that the Plaintiff tended to have exacerbation with a cough,
suggesting a musculoskeletal etiology, and that she had postprandial
nausea, suggesting a possible gastrointestinal etiology. [T. 15, 238]. He
recommended that the Plaintiff restart her previously prescribed bloodpressure medication. [T. 238].
In August 2012, the Plaintiff underwent a cardiology consultation at
Iredell Memorial Hospital. A computed tomographic angiography of the
thoracic aorta was normal, and a chest x-ray showed pulmonary
hyperinflation with no acute pulmonary abnormality.

[T. 15, 240].

An

echocardiogram during treadmill testing was interpreted as indicating
probable ischemia along the left-anterior-descending (LAD) distribution. [T.
15, 244]. The Plaintiff underwent a heart catheterization that showed mild
disease of the LAD, no occlusive disease in the rest of the coronary arteries,
normal left-ventricle function by ejection fraction and left-ventricular-end
diastolic pressure, and no gradient across the aortic valve. [T. 15, 245-46].
The Plaintiff’s physical examination was unremarkable, except for a 2/6
systolic-ejection murmur at the left upper-sternal border. [T. 15, 242]. Dr.
Jerome Williams, Jr. opined that the Plaintiff’s chest pain was not due to a
coronary event. [Tr. 15, 249].
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In October 2012, the Plaintiff was examined by Dr. Aregai Girmay, a
consultative physician. [T. 15, 252-55]. The physical examination was
unremarkable, except that the Plaintiff’s blood pressure was elevated at
190/100. [T. 15, 254–55]. Dr. Girmay advised the Plaintiff to seek medical
attention, and she stated that she would take her blood pressure medicine.
[T. 254, 255]. Dr. Girmay assessed Plaintiff as having moderate physical
limitation, stating that the Plaintiff could walk 100 feet without difficulty. [T.
16, 255]. State agency consultant Dr. Evelyn Jimenez-Medina opined in
October 2012 that the Plaintiff had some postural and environmental
limitations. [T. 59-61]. However, another consultant, Dr. Margaret Parrish,
opined in January 2013 that the Plaintiff had no such additional limitations.
[T. 72].
The Plaintiff completed a function report in September 2012. The
Plaintiff indicated in that report that she has different levels of pain daily. She
reported throbbing pains in her chest that radiate up each side of her neck.
She reported that she plans her day, cooks, washes dishes, and then rests.
She stated that she can care for her own needs slowly and that she does not
take care of anyone else. She stated that she did not spend time with others
but has no difficulty getting along with family, friends, neighbors, or others.
She reported making notes to remind herself to take her medication. She
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reported that her husband does the grocery shopping but that she is able to
pay bills, count change, manage a savings account, and use a checkbook
and money orders. The Plaintiff reported that her impairments affected her
ability to lift, squat, bend, reach, walk, kneel, and climb stairs. She reported
that she does not lift anything over five pounds.

She stated that her

medication regimen consists of Tribenzor, Toprol, and baby aspirin, but that
the Tribenzor causes nausea. [T. 154-61]. The Plaintiff’s husband also
submitted a function report on her behalf, reporting similar limitations. [T.
138-45].

In another disability report, the Plaintiff indicated that she

experiences numbness and cramps in her left arm and leg that began in
November 2012. [T. 171].
The Plaintiff testified at the ALJ hearing that she can no longer work
because she has a burning sensation and pain on her left side from her neck
to her shoulder. [T. 32-33]. She testified that she was exposed to poison ivy
and received steroid shots that caused her to have shortness of breath and
rendered her semi-conscious. [T. 33-34]. She rated her heart pain as a four
on a scale from one to ten all of the time. [T. 34]. She also claimed to have
a burning sensation in her chest most of the time. [T. 33].

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VI.

DISCUSSION
The Plaintiff, who is proceeding in this matter pro se, has filed a hand-

written, two-page document entitled “Summary Judgment,” which the Court
construes as a motion for summary judgment. In her motion, the Plaintiff
does not specifically reference the ALJ’s decision or identify any errors that
the ALJ made in evaluating the record. Rather, she appears to make two
primary arguments, which the Court will address in turn.
In her first argument, the Plaintiff contends that her “case should not
be ‘dismissed’ because I am still sick.” [Doc. 10 at 2; see also Doc. 13 at 1
(“I was sick when I applied for disability and I still am.”)]. The question
presented to the Court, however, is not whether the Plaintiff is “sick.” Rather,
the issue before the Court is whether “substantial evidence” was presented
at the hearing before the ALJ to support the ALJ’s determination that the
Plaintiff is not “disabled” within the meaning of the Social Security Act. The
resolution of this issue requires a determination of not whether the Plaintiff
is sick but rather whether the Plaintiff’s medical conditions constitute severe
impairments which preclude her from engaging in substantial gainful activity.
See 20 C.F.R. § 404.1505(a).
Here, at step two of the sequential evaluation, the ALJ found that the
Plaintiff’s hypertension and hypertensive heart disease were both severe
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impairments that have had more than a minimal effect on her ability to do
basic work-related activities. [T. 12].
Plaintiff that she is sick.

As such, the ALJ agreed with the

After reviewing the record, however, the ALJ

concluded that, notwithstanding the Plaintiff’s condition, she was still capable
of performing medium work, with some postural and environmental
limitations, and therefore could perform her past relevant work. [T. 15-17].
There is substantial evidence in the record to support this decision. While
Dr. Girmay opined that the Plaintiff had “moderate” physical limitations, the
ALJ properly discounted Dr. Girmay’s opinion.

To the extent that Dr.

Girmay’s opinion is suggestive of limitations in excess of the ALJ’s RFC
finding, such opinion is inconsistent with his own examination findings, which
were consistently normal with the exception for the Plaintiff’s high blood
pressure, a condition which the ALJ properly noted was “secondary to the
[Plaintiff’s] non-compliance with her blood pressure medication.” [T. 16].
The ALJ’s decision is also supported by the opinions of the state
agency medical consultants, who concluded that the Plaintiff had the RFC to
perform medium work, albeit with some postural and environmental
limitations. [See T. 16, 59-61, 72]. The ALJ properly accounted for these
limitations by including in the RFC that the Plaintiff had to avoid ladders,
ropes, scaffolds, unprotected heights, and machinery with dangerous parts.
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[T. 13].

In sum, the medical evidence of record presents substantial

evidence to support the ALJ’s determination that the Plaintiff was able to
perform her past relevant work despite her limitations.
In her second argument, the Plaintiff argues that “[t]he file has been
altered, tampered with and made to benefit” the Defendant and that “[t]here
are many missing pages and altered conversations.

Such as . . . the

Charlotte ‘Based Hearing,’ pages missing . . . such as the ‘Confirmation
Letter,’ after the Application Interview.” [Doc. 10 at 2 (ellipses in original)].
The Plaintiff fails, however, to supplement the record or even to explain how
these allegedly missing documents are material to the determination of
disability. Without any further explanation as to how these documents could
have impacted the ALJ’s decision, the Court has no basis on which to
overturn the ALJ’s determination and thus must conclude that this
assignment of error is without merit.2
The Plaintiff also contends that her disability file contains false
statements regarding her mental condition. [Doc. 13 at 1]. This argument
appears to be in relation to certain statements added by a Social Security

2

In her motion, the Plaintiff also suggests that her medical condition may be the result of
medical malpractice and that the deficiencies in the record may be the product of
misconduct on the part of the Defendant. Such issues are beyond the scope of this
Court’s review in this case, particularly since there is no evidence in the record to support
such conjecture.
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Administration employee to the Plaintiff’s Disability Report, suggesting the
existence of a possible mental condition based on the employee’s
observations that the Plaintiff was erratic and incoherent in her responses to
questions; that her responses were disjointed; and that the information
provided was not relevant to the questions asked. [See T. 128].

The

inclusion of these statements in the record, did not adversely affect the
Plaintiff. In fact, the ALJ expressly gave no weight to these opinions, noting
that the employee was not qualified to make any such diagnosis regarding
the Plaintiff’s mental condition. [T. 16]. Moreover, the ALJ noted that the
employee’s opinions were inconsistent with the record as a whole, which
indicated that the Plaintiff has never claimed to have a mental illness nor has
she ever sought psychological treatment or required inpatient psychological
hospitalization. [Id.]. Accordingly, this assignment of error is also without
merit.
For all of the reasons set forth above, the Court concludes that there
is substantial evidence in the record to support the ALJ’s determination that
the Plaintiff is not disabled. Accordingly, the decision of the Commissioner
is affirmed.

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ORDER
IT IS, THEREFORE, ORDERED that the Defendant’s Motion for
Summary Judgment [Doc. 11] is GRANTED; the Plaintiff’s Motion for
Summary Judgment [Doc. 10] is DENIED; and the decision of the
Commissioner below is hereby AFFIRMED.
A judgment shall be entered simultaneously herewith.
IT IS SO ORDERED.
Signed: September 13, 2017

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