Perez v. Chater
| Decision Date | 02 May 1997 |
| Docket Number | No. CV 96-0197(JG).,CV 96-0197(JG). |
| Citation | 17 F.Supp.2d 1115 |
| Court | U.S. District Court — Central District of California |
| Parties | Sylvia M. PEREZ, Plaintiff, v. Shirley CHATER, Commissioner of the Social Security Administration, Defendant. |
Lawrence D. Rohlfing, Santa Fe Springs, CA, for Sylvia M. Perez, plaintiff.
Nora M. Manella, U.S. Attorney, Leon W. Weidman, Assistant U.S. Attorney; Chief, Civil Division, Ira A. Daves, Assistant U.S. Attorney, Los Angeles, CA, for Shirley S. Chater, Commissioner of the Social Security Administration, defendant.
(Social Security)
Plaintiff has filed a complaint under 42 U.S.C. § 405(g) seeking review of the decision of the Commissioner of the Social Security Administration (Commissioner) denying her application for disability insurance benefits under Title II of the Social Security Act. Defendant has answered and the parties have filed cross-motions for summary judgment. For the reasons discussed below, I conclude that the Commissioner's decision should be reversed and the case remanded for further proceedings.
On July 30, 1992, plaintiff filed an application for disability benefits, claiming disability since September 12, 1990, due to carpal tunnel syndrome. (Administrative Record (A.R.) 96, 138.) Initially and upon reconsideration, her application was denied, and she received a hearing before an Administrative Law Judge (ALJ) on September 12, 1994. (A.R.31, 56-74.) In a written decision dated March 24, 1995, the ALJ found that plaintiff had the following impairments: severe back pain, status post carpal tunnel syndrome associated with degenerative changes of the hand, rheumatoid arthritis, venous insufficiency to the legs, chronic Bell's palsy,1 and chronic diarrhea. He concluded that plaintiff retained the residual functional capacity to perform a reduced range of light work. He further found that she had no transferable skills. (A.R.41.) Citing Rule 202.21 of the Medical-Vocational Guidelines, 20 C.F.R. Appendix 2, Subpart P (the "grids") and the testimony of a vocational expert, the ALJ found plaintiff not disabled at step five of the sequential evaluation process.2 (A.R.40, 41.) The Appeals Council denied plaintiff's request for review (A.R.4-5), and the ALJ's decision stands as the Commissioner's final decision in this case.
Born on April 27, 1945, plaintiff was 49 years of age when the ALJ's decision was issued, and had completed high school. (A.R.49.) She worked as a licensed cosmetologist from 1964-1979 (A.R.49), as a waitress from 1979-1981 (A.R.510), and as a bench machinist at Rockwell International from October 1981-September 1990, when she was placed on temporary disability due to carpal tunnel syndrome. (A.R. 60, 134, 186, 430, 510.) There is no evidence that she has engaged in substantial gainful activity since September 1990.
Plaintiff has an extensive medical history, having undergone multiple surgical procedures and other treatment for a variety of medical conditions. However, much of the treatment reflected in the record predates the alleged onset of disability (in September 1990) from carpal tunnel syndrome. In 1976, plaintiff had an intestinal bypass operation (for the treatment of morbid obesity3), performed by Dr. Kouri. (A.R.367.) In 1982, Dr. Bryan performed a series of urological procedures, including removal of a kidney stone. (A.R.201, 320, 394-412.) Plaintiff had foot surgery by Dr. Ahern in 1983. (A.R.366, 466.) Between 1984 and 1990, Dr. Kahn performed several surgical revisions of the intestinal bypass; a wound reclosure operation; and a surgical excision of an occipital mass. He also treated plaintiff for ongoing complications of her bariatric surgeries (including recurrent metabolic imbalances, diarrhea, and arthritic/pleuritic complaints), gynecological problems, depression, and hand and wrist pain. (A.R.321, 325, 367-373, 377-379, 388-393, 413-434.) During roughly the same period — from 1985 to 1990 — plaintiff saw several physicians at the Rosecrans and Mullikin Medical Groups (Drs.Wong, Bergscheider, Csepanyi, Grindstaff, Donaldson, Grizzell, Saunders, Taubman, Olson) for the following conditions: diffuse arthritis with history of erythema nodosum4; Bell's palsy; fatty liver; magnesium imbalance; vaginitis; lumbosacral strain; severe bilateral calluses, toe deformities, bunions, and corns; hemorrhoids; bronchitis and laryngitis; gas; and a left leg contusion. (A.R.456-485.)
On September 12, 1990, Dr. Kahn referred plaintiff to Dr. Co, a neurologist, who diagnosed right carpal tunnel syndrome (CTS) of moderate severity. (A.R.161-162.) Plaintiff was thereafter referred by her employer to Dr. Chen, an orthopedic surgeon, who diagnosed bilateral CTS. Dr. Padova, an independent medical examiner for the Workers' Compensation Appeals Board who evaluated plaintiff in December 1990, concurred with that diagnosis. (A.R.185-186, 203, 205, 188-206.)
Dr. Chen performed a total of three corrective surgeries on plaintiff's hands, ultimately discharging plaintiff from his care on May 8, 1992, when he concluded that her condition was "permanent and stationary," with "minimal permanent disability."5 (A.R. 431, 163-187, 208-217, 380-383.) His objective findings included a well-healed scar, slightly abnormal nerve conduction findings, and slight grip weakness. Subjective factors were mild to minimal pain, mild numbness, and morning stiffness of the right hand. (A.R.163, 166.)
Plaintiff underwent operations to remedy toe deformities in November 1991 and again in February 1992. (A.R.231-256.) In November 1992, plaintiff underwent a procedure to remove varicose veins, performed by Dr. Kuhn of Mulliken Medical Center. (A.R. 219-226, 303, 305, 306, 308.) In December 1992, Dr. Wilson, who performed two orthopedic examinations at Rockwell's request, opined that plaintiff had recovered from the effects of CTS, displayed minimal objective or subjective evidence of disability, and did not need vocational rehabilitation. (A.R.257-271.) One month later, in January 1993, Dr. Jaffin, an orthopedist who briefly treated plaintiff, concluded that the residual effects of plaintiff's CTS warranted a work restriction prohibiting repetitive squeezing, gripping, pinching, pushing, pulling, typing, and forceful grasping. (A.R.275, 272-297.) He also recommended vocational rehabilitation and access to future medical care. (A.R.274-275.)
Dr. Tamayo, an internist who examined plaintiff at the Commissioner's request in January 1993, diagnosed mild costochondritis, hypomagnesia, chronic diarrhea, back pain with decreased range of motion, venous insufficiency in both legs, chronic left Bell's palsy, and, by history, residual pain, weakness and numbness from CTS, and rheumatoid arthritis. (A.R.313.) She did not mention any specific functional restrictions. Another consultative examination was performed on behalf of the Commissioner in January 1993 by a psychiatrist, Dr. Paculdo, who opined that plaintiff could communicate effectively, sustain focused attention, follow and understand simple instructions, and adapt to common work stressors. (A.R.317.) His diagnosis was dysthymia and the prognosis was good. (A.R.318.)
Plaintiff consulted Mulliken physicians a total of three times in December 1992 and April 1993 (including, on two occasions, Dr. Wong) with complaints of musculoskeletal pain and tender nodules; the assessments noted were bypass arthropathy/dermatitis syndrome, fibromyalgia, hypomagnesia, and "muscle spasms — psychogenic." (A.R.300, 302, 307.) There is no record of treatment after plaintiff's April 5, 1993, visit to Dr. Wong.6
Dr. Mandel, an "agreed medical examiner" jointly selected by the parties to plaintiff's workers' compensation case, examined plaintiff in October 1993, reviewed plaintiff's voluminous medical records, and submitted a detailed, comprehensive twenty-three page report. (A.R.320-343.) Citing plaintiff's medical history (in particular, her use of "massive amounts" of steroidal and nonsteroidal drugs), Dr. Mandel opined that she had longstanding medical problems secondary to her intestinal bypass procedure "with its alteration in metabolic function," which in turn, affects nerve function and may cause musculoskeletal difficulties. (A.R.329, 330.) In plaintiff's case, the repetitive use of her hands at work "undoubtedly aggravated" her preexisting arthritic condition, precipitating CTS. Dr. Mandel characterized plaintiff as "temporarily totally disabled" from CTS from September 1990 until mid-November 1991 but suggested that she was "unemployed" as opposed to "disabled" thereafter. (A.R.332-333.)
While noting some discrepancies between the clinical data and plaintiff's subjective complaints, Dr. Mandel opined that a "subtle undefined metabolic problem ... coupled with the Raynaud's phenomenon7 and a neuropraxia" could be causing cold hands and difficulty grasping. (A.R.332) He concluded that plaintiff suffered an apportionable permanent disability; industrial exposure accounted for a grip loss of 30-32% in both hands, slight and intermittent pain, increasing to moderate with upper extremity use, tingling, numbness, easy fatigability, night pain, and a loss of sensory perception, while nonindustrial causes (, metabolic problems secondary to her bypass surgery) accounted for the remainder of her grip strength loss, cold hands, impaired capillary filling, and part of her pain and irritability.8 (A.R.333.) He recommended vocational retraining, noting that she would be subject to a work restriction against "repetitive picking up, pinching, grasping, twisting, or torquing." (A.R.333.) He felt that she would need only conservative care at six-month intervals for her work-related impairments, in that neither further surgery nor therapy was indicated; however, plaintiff required "considerable follow-up care" for her other impairments, (A.R.336.) Specifically, she needed...
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