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Gomez v. Commissioner of Social Security Administration

United States District Court, M.D. Florida, Tampa Division

August 19, 2019

JUDITH GOMEZ, Plaintiff,
v.
COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, Defendant.

          MEMORANDUM OPINION AND ORDER [1]

          MONTE C. RICHARDSON UNITED STATES MAGISTRATE JUDGE

         THIS CAUSE is before the Court on Plaintiff's appeal of an administrative decision denying her application for Supplemental Security Income (“SSI”). Following an administrative hearing held on August 23, 2017, the assigned Administrative Law Judge (“ALJ”) issued a decision on November 15, 2017, finding Plaintiff not disabled since June 4, 2015, the alleged amended disability onset date. (Tr. 9-61.)

         In reaching his decision, the ALJ found that Plaintiff's aortic valve disease and epilepsy seizure disorder were severe impairments; that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments; and that Plaintiff retained the residual functional capacity (“RFC”) to perform light work with limitations. (Tr. 17-19.) Then, after determining that Plaintiff had no past relevant work, the ALJ concluded that there were jobs, existing in significant numbers in the national economy, that Plaintiff was able to perform. (Tr. 25.) Based on a review of the record, the briefs, and the applicable law, the Commissioner's decision is AFFIRMED.

         I. Standard of Review

          The scope of this Court's review is limited to determining whether the Commissioner applied the correct legal standards, McRoberts v. Bowen, 841 F.2d 1077, 1080 (11th Cir. 1988), and whether the Commissioner's findings are supported by substantial evidence, Richardson v. Perales, 402 U.S. 389, 390 (1971). “Substantial evidence is more than a scintilla and is such relevant evidence as a reasonable person would accept as adequate to support a conclusion.” Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004). Where 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 v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir. 1991); 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 v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995); accord Lowery v. Sullivan, 979 F.2d 835, 837 (11th Cir. 1992) (stating the court must scrutinize the entire record to determine the reasonableness of the Commissioner's factual findings).

         II. Discussion

         Plaintiff raises two issues on appeal. First, she argues that the ALJ failed to make a specific finding at step two of the sequential evaluation process[2] about the severity of her chest pain, extremity numbness, dizziness, headaches, and medication side effects, and failed to account for these impairments/symptoms and any resulting limitations in the RFC assessment. Plaintiff also argues that the ALJ failed to properly apply the pain standard.

         In the Eleventh Circuit, “[t]he finding of any severe impairment . . . is enough to satisfy step two because once the ALJ proceeds beyond step two, he is required to consider the claimant's entire medical condition, including impairments the ALJ determined were not severe.” Burgin v. Comm'r of Soc. Sec., 420 Fed.Appx. 901, 902 (11th Cir. Mar. 30, 2011). Therefore, even if the ALJ erred by not finding Plaintiff's chest pain, extremity numbness, dizziness, headaches, and/or medication side effects to be severe impairments, the error is harmless because the ALJ found at least one severe impairment. See Heatly v. Comm'r of Soc. Sec., 382 Fed.Appx. 823, 824-25 (11th Cir. 2010) (per curiam) (“Even if the ALJ erred in not indicating whether chronic pain syndrome was a severe impairment, the error was harmless because the ALJ concluded that [plaintiff] had a severe impairment: [sic] and that finding is all that step two requires. . . . Nothing requires that the ALJ must identify, at step two, all of the impairments that should be considered severe.”).

         At step two, the ALJ found that Plaintiff's aortic valve disease and epilepsy seizure disorder were severe impairments. Although Plaintiff's chest pain, extremity numbness, headaches, dizziness, or other medication side effects were not listed among the severe impairments, the ALJ did not ignore these impairments/symptoms. For example, in determining the RFC, the ALJ noted Plaintiff's testimony that she experienced chest pain without cause and headaches almost every day; numbness, tingling, and cramps in her hands and legs; and dizziness as a side effect of her medications. (Tr. 19-20.) The ALJ also noted that:

The evidence of record does not show symptoms or limitations from the claimant's impairments that would preclude work activity within the [RFC] assessment. For example, . . . treatment notes since the claimant's application date show complaints, such as headaches, palpitations, and chest pain, and physical examination findings of murmurs at times, bilateral lower extremity dysesthesias, greater on the right, below the knees, at times, and slight diminished sensibility along the entire right side of the claimant's body on July 24, 2017. Electrodiagnostic testing showed slowing of the motor conduction velocity across the fibular head on the peroneal nerves, bilaterally, compatible with the presence of a bilateral peroneal nerve palsy at the fibular head (Exhibit 15F). However, most physical examination findings since the claimant's application date are unremarkable and do not support limitations greater than those detailed in the [RFC]. Furthermore, the medical evidence of record does not show seizure activity that would preclude work activity within the [RFC].[3]

(Tr. 20.)[4] The ALJ then determined that the RFC assessment was “supported by the medical evidence of record, including the claimant's symptoms of chest pain consistent with [the] objective medical evidence of record, including physical examination findings . . ., lack of evidence of seizures after April of 2015, and treatment notes of Dr. Pizarro-Otero showing bilateral lower extremity dysesthesias, greater on the right, below the knees, but otherwise unremarkable examination findings, including 5/5 strength, a normal gait, no ataxia, no unsteadiness, no use of an assistive device, normal reflexes, and intact fine motor movement.” (Tr. 25.)

         As shown by the ALJ's decision, he adequately considered all of Plaintiff's impairments, both severe and non-severe, in combination. See Tuggerson-Brown v. Comm'r of Soc. Sec., No. 13-14168, 572 Fed.Appx. 949, 951-52 (11th Cir. July 24, 2014) (per curiam) (“[T]he ALJ stated that he evaluated whether [plaintiff] had an ‘impairment or combination of impairments' that met a listing and that he considered ‘all symptoms' in determining her RFC. Under our precedent, those statements are enough to demonstrate that the ALJ considered all necessary evidence.”).

         Moreover, the ALJ's findings are supported by substantial evidence. (See, e.g., Tr. 380-81 (noting “[n]o acute cardiac or pulmonary process” according to a chest X-ray from March 19, 2015, despite complaints of intermittent palpitations and fatigue[5]); Tr. 447 (noting “[n]o hemodynamically significant carotid stenosis” on March 21, 2015); Tr. 615 (noting chest tightness that resolved on its own as of March 22, 2015); Tr. 523 (noting no acute cardiopulmonary process according to a chest X-ray from March 24, 2015); Tr. 411 (noting that a March 25, 2015 EEG did not support a diagnosis of seizures[6]); Tr. 446 (noting a negative head CT scan from March 25, 2015); Tr. 494 (noting no acute intracranial abnormality according to CT scans of the head from March 25 and March 27, 2015); Tr. 493 (noting, on March 31, 2015, that Plaintiff's encephalopathy had resolved and no seizure activity was shown on the EEG); Tr. 667 & 807 (noting no acute intracranial abnormality according to a CT scan and an MRI of the head from April 16, 2015[7]); Tr. 842-45 (noting a murmur and chronic joint pain, but otherwise unremarkable examination on April 21, 2015); Tr. 369-70 (noting a normal examination, except “light touch BLE dysesthesias R>L below the knees, ” on May 6, 2015, despite complaints of headache and paresthesia); Tr. 644-46 (noting dizziness, intermittent chest pain, and fatigue, but otherwise stable examination on May 8, 2015); Tr. 838-41 (noting right-sided chest tenderness and murmur but otherwise unremarkable examination on June 1, 2015); Tr. 641-43 (noting occasional chest pain and right-sided chest discomfort, stable palpitations, headache, and dizziness as of June 3, 2015); Tr. 663 (noting no acute cardiopulmonary process as of June 8, 2015); Tr. 1261 (noting that a brain MRI from June 22, 2015 showed no evidence of acute infarct or intracranial mass); Tr. 751-53 (noting complaints of headache and paresthesia, but mostly unremarkable examination as of June 24, 2015); Tr. 638-40 (noting unremarkable examination despite dizziness and occasional palpitations as of July 1, 2015); Tr. 834-37 (noting lightheadedness and a murmur, but otherwise unremarkable examination on July 27, 2015); Tr. 763-65 (noting a normal examination on August 19, 2015, despite intermittent right-sided chest pains); Tr. 993-94 (noting a normal electromyographic study of both lower extremities, but an abnormal nerve conduction study, on September 25, 2015); Tr. 1076-80 (noting intermittent chest pain and palpitations, but mostly unremarkable examination on October 14, 2015); Tr. 966 & 974-77 (noting that Plaintiff was admitted on December 2, 2015 for generalized chest pain after lifting boxes, but the pain was musculoskeletal and improved without intervention; a CT scan of the head and neck showed no evidence of filling defect, vascular malformation, or aneurysm, and no acute intracranial findings; an X-ray showed no acute pulmonary disease; a CT scan of the chest showed aortic dissection protocol negative for acute findings; an MRI of the brain showed, inter alia, no evidence of acute ischemia); Tr. 1081-85 (noting a normal examination on February 17, 2016); Tr. 989 (noting, on February 26, 2016 that: “[Plaintiff] stopped the Amitriptyline since she states she is not needing it. She has been seizure free. She continues with headache 8 days per month and she did not take the Topiramate since it [caused] drowsiness. . . . The headaches resolve[d] with [D]ipyrone from Cuba.”); Tr. 1054-59 (noting a murmur, but otherwise unremarkable examination on April 7, 2016); Tr. 1050-53 (noting no symptoms and a normal examination on June 2, 2016); Tr. 1086-91 (noting precordial non-cardiac pain and palpitations, but a normal ECG on June 7, 2016); Tr. 1193-96 (noting no active complaints and a normal examination on November 1, 2016); Tr. 1185-88 (noting complaints of cramps on both arms and legs and occasional chest pain, but otherwise unremarkable examination on March 3, 2017); Tr. 1180-83 (noting occasional dizziness and a murmur, but otherwise unremarkable examination on March 31, 2017); Tr. 1176-79 (noting complaints of fatigue and headache, but mostly normal examination on May 16, 2017); Tr. 1243-44 (noting slight diminished sensibility along the right side of Plaintiff's body, but otherwise normal examination on July 24, 2017); Tr. 80 (noting “[n]o hemodynamically significant stenosis in the carotid or vertebral arteries” as of August 15, 2017); Tr. 79 (noting that the brain MRI of October 30, 2017 appeared stable compared to the scan from 2015); Tr. 64 (noting a November 9, 2017 unremarkable examination despite reports of weakness and dizziness); Tr. 71 (noting, on December 20, 2017, that Plaintiff's intermittent chest pain was musculoskeletal and should be referred to pain management).)

         As reflected in the ALJ's decision, he considered Plaintiff's impairments and incorporated into the RFC assessment only those limitations resulting from the impairments, which he found to be supported by the record. Therefore, Plaintiff's argument that the RFC assessment ...


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