United States District Court, N.D. Florida, Gainesville Division
REPORT AND RECOMMENDATION
R. JONES, UNITED STATES MAGISTRATE JUDGE.
appeals to this Court from a final decision of the Acting
Commissioner of Social Security (the
“Commissioner”) denying Plaintiff's
application for Period of Disability and Disability Insurance
Benefits pursuant to Title II of the Social Security Act
(“the Act”) and for Supplemental Security Income
pursuant to Title XVI of the Act. (ECF No. 1.) The
Commissioner has answered, ECF No. 8, and both parties have
filed briefs outlining their respective positions. (ECF Nos.
19, 22.) For the reasons discussed below, it is recommended
that the Commissioner's decision be affirmed.
filed her Title II and Title XVI applications on May 16,
2013, alleging a disability onset date of August 12, 2012.
(R. 20, 63, 71, 158-69.) Plaintiff alleged that she could no
longer work due to lupus, depression, and hypertension. (R.
63, 71, 105, 111.) Her applications were denied initially and
upon reconsideration. (R. 63-78, 81-102, 105-17, 123-34.) On
July 2, 2015, an administrative law judge (“ALJ”)
issued a decision unfavorable to Plaintiff. (R. 20-30.) The
Appeals Council denied Plaintiff's request for review on
December 22, 2016. (R. 1-4.) Plaintiff then filed the instant
appeal. (ECF No. 1.)
STANDARD OF REVIEW
Commissioner's findings of fact are conclusive if
supported by substantial evidence. See 42 U.S.C.
§ 405(g) (2000). Substantial evidence is more than a
scintilla, i.e., the evidence must do more than merely create
a suspicion of the existence of a fact, and must include such
relevant evidence as a reasonable person would accept as
adequate to support the conclusion. Foote v. Chater,
67 F.3d 1553, 1560 (11th Cir. 1995) (citing Walden v.
Schweiker, 672 F.2d 835, 838 (11th Cir. 1982);
Richardson v. Perales, 402 U.S. 389, 401 (1971));
accord Edwards v. Sullivan, 937 F.2d 580, 584 n.3
(11th Cir. 1991).
the Commissioner's decision is supported by substantial
evidence, the district court will affirm, even if the
reviewer would have reached a contrary result as finder of
fact, and even if the reviewer finds that the evidence
preponderates against the Commissioner's decision.
Edwards, 937 F.2d at 584 n.3; Barnes v.
Sullivan, 932 F.2d 1356, 1358 (11th Cir. 1991). The
district court must view the evidence as a whole, taking into
account evidence favorable as well as unfavorable to the
decision. Foote, 67 F.3d at 1560. However, the
district court will reverse the Commissioner's decision
on plenary review if the decision applies incorrect law, or
if the decision fails to provide the district court with
sufficient reasoning to determine that the Commissioner
properly applied the law. Keeton v. Dep't Health
& Human Servs., 21 F.3d 1064, 1066 (11th Cir. 1994).
defines disability as the inability to do any substantial
gainful activity by reason of any medically determinable
physical or mental impairment that can be expected to result
in death, or has lasted or can be expected to last for a
continuous period of not less than twelve months. 42 U.S.C.
§§ 416(I), 423(d)(1); 20 C.F.R. § 404.1505
(2005). The impairment must be severe, making
Plaintiff unable to do his previous work, or any other
substantial gainful activity which exists in the national
economy. 42 U.S.C. § 423(d)(2); 20 C.F.R. §§
must follow five steps in evaluating a claim of disability.
20 C.F.R. §§ 404.1520, 416.920. The claimant has
the burden of proving the existence of a disability as
defined by the Social Security Act. Carnes v.
Sullivan, 936 F.2d 1215, 1218 (11th Cir. 1991). First,
if a claimant is working at a substantial gainful activity,
he is not disabled. 20 C.F.R. § 404.1520(b). Second, if
a claimant does not have any impairment or combination of
impairments which significantly limit his physical or mental
ability to do basic work activities, then he does not have a
severe impairment and is not disabled. 20 C.F.R. §
404.1520(c). Third, if a claimant's impairments meet or
equal an impairment listed in 20 C.F.R. Part 404, Subpart P,
Appendix 1, he is disabled. 20 C.F.R. § 404.1520(d).
Fourth, if a claimant's impairments do not prevent him
from doing past relevant work, he is not disabled. 20 C.F.R.
§ 404.1520(e). Fifth, if a claimant's impairments
(considering his residual functional capacity
(“RFC”), age, education, and past work) prevent
him from doing other work that exists in the national
economy, then he is disabled. 20 C.F.R. § 404.1520(f).
SUMMARY OF THE RECORD
medical records cover the time period from 2011 to 2015 and
are from Gainesville Family Physicians, North Florida
Regional Medical Center, Shands Hospital, Alachua County
Health Department, Meridian Behavioral Healthcare, and
Vascular Interventional Physicians. Because the issue on
appeal relates to Plaintiff's credibility, the relevant
portions of the medical record, the opinion evidence, the
hearing testimony, and the ALJ's findings are summarized
and 2012 Plaintiff visited Dr. Jackson at Gainesville Family
Physicians. Her lab results revealed diagnoses of Vitamin B
deficiency, lupus erythematosus, and hypertension. Other
diagnoses included migraines, tension headaches, lumbago,
neck pain, rash, abdominal pain, right upper quadrant pain,
and chest pain. Her physical examinations, however, revealed
overall normal findings other than some moderate tenderness
and aching in the cervical area and legs at times and some
occasional limited range of motion at the hip and neck.
Imaging in 2011 revealed transitional lumbsacral segment with
partial lumbarization of S1-S2, and a hip exam showed
degenerative changes without acute fracture. But
Plaintiff's other tests and exams were normal. Plaintiff
was prescribed various medications and referred to physical
therapy to decrease pain and improve range of motion. (R.
254-92, 360-75, 797-857.)
visited North Florida Regional Medical Center in August 2012
where her discharge diagnoses included severe headache and
severe back and neck pain. Her physical exam findings during
her stay were normal, aside from mild tenderness in the
cervical spine, upper right abdomen, and neck as well as
appearing in pain. An MRI of the cervical spine revealed a
nonspecific chronic-appearing lesion at C2, but it did not
require any treatment. The chest x-rays and head CT were
normal. The impression was acute headache, and Plaintiff was
given medication and told to avoid exertional activities for
only a week. (R. 296-354, 734-92.)
returned to North Florida Regional Medical Center in 2013
regarding right upper quadrant abdominal pain. Her physical
exam findings were normal other than distress and tenderness
from pain in that area, and her abdomen CT and chest exams
were unremarkable. She experienced relief from medications
and was discharged. (R. 388-402.)
also visited Shands at the University of Florida in 2012 and
2013. In October 2012 her discharge diagnoses included chest
pain that was likely musculoskeletal, SLE, and hypertension,
and her discharge physical exam was normal. Her other testing
revealed no acute cardiopulmonary disease. Notably, an SLE
flare up was thought to be unlikely, and her lupus was noted
as stable. She returned in November 2012, complaining of leg
pain. Her physical exam findings were normal apart from
tenderness and swelling in the right thigh. The clinical
impression was a muscle strain. (R. 407-27, 459-526,
January 2013 Plaintiff again complained of chest pain. Her
physical exam findings were normal as were her chest x-rays.
Her diagnosis included nonspecific chest pain, but it was
noted that she had a normal myocardial heart test and normal
cardiac enzymes. Then in April 2013 Plaintiff complained of
pain on her right side and was diagnosed with acute right
flank pain. Her physical exam findings were normal other than
tenderness in the right upper quadrant, and her CT scan of
the abdomen and pelvis did not contain findings to explain
the right-sided flank pain. (R. 527-91, 1040-44.)
2013, however, Plaintiff again presented with chest pain,
among other things, but her discharge diagnosis was viral
gastroenteritis causing dehydration and syncope. She had a
normal EKG and CT scan of her head. Additionally, a lupus
flare was ruled out by blood test. Then Plaintiff returned at
the end of May, complaining of headache, fever, and swollen
neck. Her physical exam findings were normal, and she was
diagnosed with a headache and viral illness. (R. 527-632.)
returned in July 2013, complaining of abdominal pain, and she
was diagnosed with right upper quadrant pain. Yet other than
tenderness in that area, her physical exam findings were
normal. Her chest x-ray revealed underinflated lungs without
acute cardiopulmonary abnormality, and she had no acute
abdominal abnormality. (R. 697-716.)
clinical visits from the Alachua County Health Department in
2012 and 2013 revealed overall normal physical exam findings.
Her diagnoses varied throughout her visits, and they included
benign essential hypertension, unspecified chest pain,
unspecified back ache, right upper quadrant abdominal pain,
lump or mass in breast, bronchitis, probable phlebitis and
thromophlebitis of deep veins of lower extremities,
unspecified hyperlipidemia, and situational depression. (R.
428-53, 636-67, 681-91.)
regard to Plaintiff's mental health, Plaintiff also
underwent mental health screening in May 2013 at the Alachua
County Health Department. She was diagnosed with depressive
affective disorder, single episode, severe, without mention
of psychotic behavior. She complained of worsening depression
in August, but her mood and affect were appropriate during
her mental status examination. (R. 634-35, 684.)
also visited Meridian Behavioral Healthcare at the Crisis
Stabilization Unit from July 29, 2013, to August 1, 2013,
voluntarily due to depression. She was diagnosed with ...