Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-2_04-cv-02213/USCOURTS-arwd-2_04-cv-02213-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (SSID)

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(Rev. 8/82)

IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

FORT SMITH DIVISION

DEBRA J. GOFF PLAINTIFF

v. CIVIL NO. 04-2213

JO ANNE B. BARNHART, Commissioner

Social Security Administration DEFENDANT

MAGISTRATE JUDGE’S REPORT AND RECOMMENDATION

Plaintiff Debra J. Goff brings this action pursuant to 42 U.S.C. § 405(g) seeking judicial

review of a decision of the Commissioner of Social Security (Commissioner) finding she is no

longer entitled to disability benefits under the provisions of Title XVI of the Social Security Act

as of April 1, 2002, due to a medical improvement. 

Procedural Background:

Plaintiff filed an application for supplemental security income (SSI) benefits on

November 12, 1996, alleging an inability to work since September 1, 1996, due to hypertension,

borderline intellectual functioning and depression. (Tr. 36-40). By a written decision of an ALJ

dated June 21, 1998, plaintiff was found to be disabled and entitled to SSI. (Tr. 141-144). 

A continuing disability review was initiated in January of 2002. (Tr. 160-161). A

determination was made that plaintiff’s disability had ceased as of April 1, 2002, and that her

entitlement to SSI would end as of June of 2002. (Tr. 162-164).

Plaintiff filed a request for reconsideration. (Tr. 167-168). In a written decision dated

May16, 2003, a disability hearing officer (DHO) determined that due to a medical improvement,

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plaintiff was no longer disabled and that she was able to perform unskilled, medium work. (Tr.

176-180).

Plaintiff requested a hearing before an ALJ, which was held on October 28, 2003. (Tr.

481-519). Plaintiff was informed of her right to representation but chose to proceed with the

hearing on her own. (Tr. 516-517). 

In a written decision dated May 11, 2004, the ALJ found plaintiff had experienced a

medical improvement related to her ability to work. (Tr. 19). The ALJ further found plaintiff

retained the residual functional capacity (RFC) to lift twenty-five pounds frequently, fifty pounds

occasionally; to push/pull the same amounts; to sit, stand and walk a total of six hours each in

an eight-hour workday with regular breaks. (Tr. 19). The ALJ further found plaintiff must avoid

working at unprotected heights and around unprotected moving machinery. (Tr. 19). From a

mental standpoint, the ALJ found plaintiff can understand, remember and carry out more detailed

instructions with some limitations; and that she is limited to unskilled work, as defined by the

ability to perform work where interpersonal contact is incidental to work performed, complexity

of tasks is learned and performed by rote with few variables and little judgment and supervision

is simple, direct and concrete. (Tr. 19). With the help of vocational expert testimony, the ALJ

found plaintiff was able to perform were past relevant work as an inspector at a furniture factory.

(Tr. 20). 

Plaintiff appealed the decision of the ALJ to the Appeals Council. Plaintiff's request for

review of the hearing decision by the Appeals Council was denied on July 28, 2004. (Tr. 5-7).

When the Appeals Council declined review, the ALJ’s decision became the final action of the

Commissioner. Plaintiff now seeks judicial review of that decision. (Doc. #1). Plaintiff filed a

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We note that plaintiff proceeds pro se in this action and while she did submit a letter brief she did not cite any specific 1

 error on the part of the Commissioner. However, under 42 U.S.C. § 405(g), all that is necessary to trigger judicial

 review is the filing of a complaint and transcript. We then review the entire decision to ensure that there are no legal

 errors and that the findings of fact are supported by substantial evidence. Kenney v. Heckler, 577 F. Supp. 214, 216

 (N.D. Ohio 1983). 

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letter brief on April 18, 2005. (Doc. # 11). Defendant filed an appeal brief on May 9, 2005. 1

(Doc. # 12). The case is before the undersigned for report and recommendation.

Evidence Presented:

At the time of the administrative hearing on October 28, 2003, plaintiff was fifty years

of age and obtained an eighth grade education. (Tr. 488). Plaintiff testified she was able to read

and write and do basic arithmetic. (Tr. 489). With regard to working, plaintiff testified she had

worked for a furniture factory inspecting baby beds and then she had baby-sat for different

people off and on. (Tr. 490). 

When asked why she is unable to work, plaintiff testified her left knee gives way a lot,

she gets dizzy when she walks and she experiences chest pain every once in a while. (Tr. 493,

497-498). Plaintiff testified that she takes medication which helps with her depression. (Tr. 494).

Plaintiff testified her back pain had been relieved with steroids. (Tr. 496). Plaintiff explained

that she had an appointment for a second steroid shot but she did not think she would need it.

Plaintiff testified that her diabetes was under fairly good control, but she had one incident where

her blood sugar was too low and she passed out. (Tr. 499, 501). Plaintiff indicated medication

was also helping to treat her high blood pressure. (Tr. 502). 

On an average day, plaintiff testified she cleans her house, walks her dog, watches

television, works on plastic canvas and colors in coloring books. (Tr. 503, 508). Plaintiff

testified that she usually goes to church every Sunday but noted she had not gone for the past two

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or three weeks. (Tr. 509). Plaintiff testified she also reads the Bible and Christian books.

Plaintiff also goes to visits friends and has friends come to her house to visit. Plaintiff also

thought if she could find a job she would be able to work part-time. (Tr. 510). Plaintiff testified

that she can sit for a long period of time, can stand and walk but does have problems with

occasional dizziness and can lift things that are not real heavy. 

Mr. Edward Goff, plaintiff’s husband, testified plaintiff’s dizziness caused her to fall

once but he could not remember where and when this occurred. (Tr. 506). 

Mr. Dale Thomas, a vocational expert, testified plaintiff’s past relevant work as an

inspector at a furniture factory is considered light, unskilled work. (Tr. 513). After listening to

the ALJ’s hypothetical question (Tr. 513-514), Mr. Thomas testified the hypothetical individual

would be able to perform her past relevant work. (Tr. 514). 

The pertinent medical evidence in this case reflects the following. On August 25, 2000,

plaintiff reported that her medications weremaking her nauseated.(Tr. 286). Dr. Syed A. Hamid

noted plaintiff was started on Paxil on August 1, 2000. Plaintiff reported that the medication did

help with her anxiety but she also thought it caused diarrhea. Dr. Hamid noted plaintiff’s blood

sugars were under control. Upon examination, Dr. Hamid noted there was a postural drop in

plaintiff’s blood pressure and that plaintiff felt dizzy getting up. Dr. Hamid diagnosed plaintiff

with nausea and diarrhea, most likely from a viral gastroenteritis, severe dehydration due to poor

oral intake, hypertension, fairly well controlled non-insulin dependent diabetes mellitus

(NIDDM) and status post colon resection for colon cancer in 1999. Plaintiff was instructed to

discontinue the Paxil and to eat a soft diet and drink plenty of fluids. 

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Plaintiff returned to Dr. Hamid’s office for a follow-up appointment on August 30, 2000.

(Tr. 285). Plaintiff reported her diarrhea was better but she continued to be nauseous and dizzy.

Upon examination, Dr. Hamid noted plaintiff’s blood pressure was 128/86. He noted she was

still orthostatic and that plaintiff still complained of dizziness upon getting up. Plaintiff was

diagnosed with gastroenteritis. Due to plaintiff’s dehydration, Dr. Hamid also instructed plaintiff

to continue oral hydration. 

On September 1, 2000, plaintiff reported she had been drinking more fluids and was

doing a lot better. (Tr. 284). Dr. Hamid noted plaintiff’s gastroenteritis symptoms were gone,

that plaintiff’s blood sugars were running very low and that her hypertension was controlled. Dr.

Hamid recommended decreasing her does of Glucophage and to contact him if her blood sugars

started running higher than 120. 

On October 24, 2000, Dr. Hamid noted plaintiff’s blood sugar was under control. (Tr.

283). Plaintiff reported she was attending diabetic school and controlling her dietary intake. Dr.

Hamid noted plaintiff’s blood pressure had started to drop since she was paying attention to her

salt intake. Dr. Hamid diagnosed plaintiff with well controlled NIDDM and controlled

hypertension. 

Progress notes dated January 8, 2001, report plaintiff’s chemotherapy to treat Duke C

carcinoma of the colon in April of 2000. (Tr. 311). Plaintiff reported her most significant

problem is a recurrent urethral stone. Ms. Aida Jones, ANP, indicated that in terms of her cancer

she was doing well. Ms. Jones recommended plaintiff follow-up with Dr. Akkad. 

Progress notes dated January 22, 2001, report plaintiff’s blood sugars increased due to

plaintiff’s weight gain. (Tr. 282). Plaintiff also complained of dizziness off and on usually

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occurring when she blood pressure increased. Plaintiff was diagnosed with poorly controlled

NIDDM due to weight increase. Her medications were changed and she was to call in with her

blood pressure in a week. 

On March 12, 2001, plaintiff underwent a hepatobiliary scan with evaluation of the

gallbladder ejection fraction. (Tr. 359-360). The scan showed a normal hepatobiliary study with

no evidence of acute cholecystitis and a normal gallbladder ejection fraction. 

Progress notes on May 7, 2001, reported plaintiff was in for a follow-up of her Dukes C

carcinoma of the colon. (Tr. 305-306). Plaintiff reported that she had seen Dr. Akkad for

abdominal pain in March and underwent testing that was normal. At the time of this evaluation

she reported the pain had disappeared. Plaintiff complained of periods of tiredness and

weakness. Ms. Jones encouraged plaintiff to increase her activity as much as she could tolerate.

Ms. Jones noted there was no recurrence of cancer. 

Progress notes dated May 10, 2001, report plaintiff was in for a follow-up appointment

to check her blood sugar. (Tr. 281). Dr. Hamid noted plaintiff’s blood sugar was fluctuating

between 150 and 200. Plaintiff was diagnosed with NIDDM poorly controlled due to diet.

Glucophage was added to plaintiff’s medications.

On June 5, 2001, plaintiff complained of chest pain not related to activity. (Tr. 279). An

EKG was normal. Plaintiff was instructed to rest and to call back in two to three days. 

On June 8, 2001, plaintiff reported she continued to have chest pain. (Tr. 278). Plaintiff

was diagnosed with anterior chest wall pain and started on Darvocet. 

On June 19, 2001, plaintiff underwent a stress test that showed borderline positive stress

electrocardiogram, without symptoms. (Tr. 357-358). 

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On June 25, 2001, plaintiff reported her chest pain improved a lot with Darvocet but has

not completely relieved. (Tr. 277). Plaintiff was scheduled to undergo a stress test and a scan

on July 2 . Plaintiff was instructed to rest and to avoid caffeine and nicotine. nd

On July 2, 2001, plaintiff complained of left sided back pain. (Tr. 276). Plaintiff was

given Robaxin and instructed to rest and to use heat and massage. 

On this same date, plaintiff underwent a myocardial perfusion scan which revealed

minimal localized decrease in perfusion in the anterior wall of the left ventricle, present on both

stress and resting images. (Tr. 355). No segmental wall motion abnormalities were noted and

her ejection fraction of sixty-six percent. 

Progress notes dated July 10, 2001, report plaintiff’s complaints of chest discomfort,

exertional dyspnea and hot flashes. (Tr. 275). Due to her continued chest pain plaintiff was

started on Mobic on July 24, 2001. (Tr. 274). 

On August 2, 2001, plaintiff presented to the Sparks Regional Medical Center

complaining of a near-syncope episode two days ago and chest pain. (Tr. 347-353). The clinical

impression made was dizziness and chest wall pain. (Tr. 349). 

On August 31, 2001, presented to Dr. HollyHeaver Jennings office as a transfer from Dr.

Ahmad. (Tr. 319-320). Plaintiff reported she had NIDDM and that she had been waking up in

the middle of the night with night sweats for about the past two months. Plaintiff reported she

documented her blood sugars during her night sweats and they are generally between 55 and 70.

Plaintiff reported her blood sugars during the day are generally between 125 and 140. After

examining plaintiff, Dr. Jennings diagnosed plaintiff with NIDDM, hypertension, night sweats

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and status post TAH-BSO, not on hormone replacement therapy. Plaintiff was scheduled to

undergo blood tests, a bilateral mammogram and a DEXA scan. 

Progress notes dated September 4, 2001, returns for a follow-up of Duke’s C carcinoma

of the colon. (Tr. 301-302). After examining plaintiff, Ms. Jones encouraged plaintiff to keep

her appointment with Dr. Akkad and to continue to have her period colonoscopy as indicated.

Plaintiff underwent a DEXA scan on September 11, 2001. (Tr. 329). Dr. Raymond de

la Rosa found no evidence of osteoporosis or osteopenia of the lumbar spine and hip. 

On October 17, 2001, plaintiff underwent a colonoscopy which revealed no evidence of

recurrent cancer. (Tr. 340-346). 

On November 2, 2001, plaintiff returned to Dr. Jennings office for a follow-up

appointment. (Tr. 317). Plaintiff reported a new problem of a left-sided lumbar spasm. Plaintiff

reported spasm a few days the week before, but it had not bothered her during the past week.

Plaintiff also reported a numb feeling in her right hand. In terms of plaintiff’s NIDDM, Dr.

Jennings noted plaintiff was doing very well but did have an occasional outlier blood sugar.

Plaintiff’s blood pressure was also noted to be well controlled. Dr. Jennings recommended

plaintiff undergo EMG and NCV of the right upper extremity. 

On November 13, 2001, plaintiff underwent EMG and NCV studies of the right upper

extremity. (Tr. 290-291). The test results revealed no evidence of carpal tunnel or problems on

the right. Dr. Duane L. Birky noted plaintiff’s nerve conduction fell within normal limits but the

needle exam on the left revealed an abnormality in one muscle only, likely representing a left

chronic C7 radiculopathy. 

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Plaintiff returned for a follow-up of her Duke’s C carcinoma of the colon on January 15,

2002. Ms. Jones noted plaintiff underwent a colonoscopy in October of 2001, and no evidence

of recurrent disease was noted. Plaintiff reported she developed pain in her right mid quadrant

about a week ago and was being treated by Dr. Akkad for possible cholecystitis. 

Progress notes dated January 4, 2002, report plaintiff’s overall blood sugars have

improved. (Tr. 315). Dr. Jennings opined plaintiff’s blood sugar could be improved and her

medication was adjusted. 

Progress notes dated January 21, 2002, report plaintiff’s complaints of right flank pain.

(Tr. 294). Dr. John L. Lange recommended cysto with holmium laser fulguration of a right renal

stone.

Progress notes dated February 5, 2002, report plaintiff’s blood sugars were ranging from

88 to 135. (Tr. 314). Plaintiff reported she had not had any outliers or hypoglycemic episodes.

Plaintiff reported she was feeling fine. Dr. Jennings noted plaintiff’s improved control of her

NIDDM and controlled hypertension. 

On February 20, 2002, plaintiff entered the Sparks emergency room complaining of

abdominal and right flank pain. (Tr. 335-339). Plaintiff underwent a stent placement and was

discharged in home in improved condition. (Tr. 337, 339).

Plaintiff returned to the Sparks emergency room complaining of abdominal and right

flank pain in February 22, 2002. (Tr. 332). Plaintiff was given medication and discharged home

in improved condition. 

On March 27, 2002, plaintiff underwent a mental status examination performed by Dr.

Patricia J. Walz. (Tr. 361-364). Dr. Walz noted plaintiff arrived on time and her grooming and

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hygiene were appropriate. (Tr. 361). At the time of the evaluation, plaintiff was taking Premarin,

Atenolol, Glucovance, Amilor/HCTZ, Captopril and Calcium. Plaintiff reported no current or

past psychiatric illness and that she had not undergone psychiatric hospitalization or counseling

or taken psychotropic medication. Plaintiff reported that she did “pretty well” in school up until

the ninth grade. She also reported she was in special education classes and had attended an adult

education class. 

Dr. Walz noted plaintiff was cooperative and her vocabulary was limited. Plaintiff’s

thinking was logical and goal oriented but concrete in nature. Plaintiff reported she did not sleep

well and described her energy level as “sometimes I [am] tired and sometimes I can get up and

go all day.” Plaintiff reported no problems with memory or concentration but she did feel

depressed sometimes. Dr. Walz noted previous testing indicated plaintiff’s IQ was in the

borderline range and she agreed with these findings. (Tr. 363). Dr. Walz diagnosed plaintiff with

dysthmia and borderline intellectual functioning. 

With regard to adaptive functioning, Dr. Walz again noted plaintiff’s limited vocabulary.

As for plaintiff’s social functioning, plaintiff reported she had a lot of friends and that she gets

along with her neighbors. Plaintiff reported leaving the home several times a week to purchase

groceries. Plaintiff also reported going to help her husband’s 84 year old cousin a couple of times

a week. Plaintiff reported she did not need assistance with her activities of daily living and that

she did most of the cleaning in her home. Plaintiff also reported that she “puttered” in the flower

garden. To pass the time, plaintiff reported she worked puzzle books, colored, did sewing crafts

and worked with plastic canvas. Dr. Walz found plaintiff’s concentration, persistence and pace

to be appropriate. Dr. Walz also opined plaintiff probably had problems in academic functioning.

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While Dr. Walz did not think plaintiff could handle a complex budget, she did feel plaintiff

could handle her small check. 

On April 11, 2002, Dr. Kathryn M. Gale completed a mental RFC assessment stating that

plaintiff has moderate limitations in the following areas: in her ability to understand and

remember detailed instructions; in her ability to carry out detailed instructions; in her ability to

complete a normal workday and workweek without interruptions from psychologically based

symptoms and to perform at a consistent pace without an unreasonable number and length of rest

periods; and in her ability to interact appropriately with the general public. (Tr. 379-382). Dr.

Gale concluded that plaintiff is able to perform work where interpersonal contact is incidental

to work performed, e.g. assembly work; complexity of tasks is learned and performed by rote,

few variables, little judgment; and supervision required is simple, direct and concrete. (Tr. 381).

Dr. Gale also completed a psychiatric review technique form indicating plaintiff had mild

restrictions of her activities of daily living; mild difficulties in maintaining social functioning;

moderate difficulties in maintaining concentration, persistence or pace; and no episodes of

decompensation of extended duration. (Tr. 365-378).

On April 11, 2002, Dr. Alice Davidson, a non-examining, medical consultant, completed

a RFC assessment stating that plaintiff, could occasionally lift or carry fifty pounds, frequently

lift or carry twenty-five pounds; could stand and/or walk about six hours in an eight-hour

workday; could sit about six hours in an eight-hour workday; could push or pull unlimited, other

than as shown for lift and/or carry; and that no postural, manipulative, visual, communicative

or environmental limitations were evident. (Tr. 383-390). 

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On May 1, 2002, plaintiff complained of a three day history of low back pain. (Tr. 480).

Plaintiff reported her back bothered her most when she bent over. Plaintiff also wanted a recent

tick bite to be examined. Dr. Jennings noted plaintiff was doing well in regard to her NIDDM

and hypertension. Upon examination, Dr. Jennings noted straight leg raise was negative

bilaterally and her deep tendon reflexes were 2+ and symmetric at the knees and ankles

bilaterally. Plaintiff’s lower extremity muscle strength was intact bilaterally. Dr. Jennings

diagnosed plaintiff with lumbar spasm, a tick bite and NIDDM. Plaintiff was given a Zanaflex

prescription for muscle spasms and instructed to continue with her present medications. 

Progress notes dated June 5, 2002, report plaintiff’s complaints of an overall feeling of

not feeling well. (Tr. 477). Plaintiff reported she simply did not feel like she wanted to do

anything with friends and family. Dr. Jennings opined that plaintiff seemed to be suffering from

depression rather than from anything else. Dr. Jennings noted plaintiff’s blood sugars had been

“quite good” and her blood pressure had been well controlled. Dr. Jennings started plaintiff on

Zoloft and instructed her to follow-up in one month. 

On July 3, 2002, plaintiff returned for a follow-up for her depression. (Tr. 476). Plaintiff

reported that she felt as if she had improved a great deal on Zoloft but thought there was room

for improvement. Dr. Jennings noted plaintiff’s NIDDM was stable and her hypertension was

controlled. Dr. Jennings increased plaintiff’s Zoloft dosage to 100 mg. 

On July 9, 2002, plaintiff reported she had fallen while walking her dog the previous day

and had struck the right parietal area of her head on a rock. (Tr. 475). Plaintiff did not lose

consciousness but she did have a headache. Plaintiff denied experiencing any visual disturbances,

nausea or vomiting. Because plaintiff had a normal neurological examination and no loss of

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consciousness, Dr. Jennings did not think a CT scan was necessary. Plaintiff also showed Dr.

Jennings a wound on her knee that occurred while she was walking her dog. Plaintiff reported

her knee gave out and she struck a rock. Dr. Jennings noted the wound appeared to be healing

well. Plaintiff was instructed to let her know if her wound had not completely healed within the

next two weeks. 

On July 19, 2002, plaintiff complained that her knee was not healing properly. (Tr. 474).

Dr. David A. Dias cleaned plaintiff’s wound and instructed her to do the same twice a day. He

also started plaintiff on Amoxicillin. 

On July 23, 2002, plaintiff returned to Dr. Jennings office for a follow-up to an abrasion

on her left knee. (Tr. 473). Dr. Jennings noted plaintiff’s blood sugars continued to be excellent,

ranging from 99 to 130. Dr. Jennings noted that plaintiff’s abrasion appeared to be somewhat

pussy. Plaintiff was instructed to continue cleaning the wound twice a day. Dr. Jennings

discontinued the use of Amoxicillin and started plaintiff on Cipro. 

On September 4, 2002, plaintiff complained of pain around her knees, hips and lower

back. (Tr. 472). Plaintiff had been aware of the pain for several days and had not used any overthe-counter medication. After examining plaintiff, Dr. Jennings diagnosed plaintiff with

osteoarthritis of the knees and hips, NIDDM, hypertension and history of Duke C carcinoma of

the colon status post hemicolectomy and chemotherapy. Plaintiff was scheduled to undergo

bilateral mammograms and a colonoscopic follow-up with Dr. Masri. Dr. Jennings

recommended plaintiff use over-the-counter Aleve for her osteoarthritis. 

On October 18, 2002, plaintiff complained of right hand/arm pain. (Tr. 471). Dr. Dias

noted that it was very obvious that she had a positive Phalen and Tinel sign. Dr. Dias noted the

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first three and a half fingers were involved. Plaintiff was diagnosed with carpal tunnel syndrome

and placed her in a cock up wrist splint. Dr. Dias scheduled plaintiff for nerve conduction

studies and gave plaintiff Celebrex. 

On November 4, 2002, Dr. Robert M. Redd, a non-examining, medical consultant,

completed a RFC assessment stating that plaintiff, could occasionally lift or carry fifty pounds,

frequently lift or carry twenty-five pounds; could stand and/or walk about six hours in an eighthour workday; could sit about six hours in an eight-hour workday; could push or pull unlimited,

other than as shown for lift and/or carry; and that no postural, manipulative, visual,

communicative or environmental limitations were evident. (Tr. 393-400). 

Plaintiff underwent nerve conduction study on November 21, 2002. (Tr. 469-470). The

study was normal and there was no evidence of a nerve entrapment syndrome. 

On January 10, 2003, plaintiff complained of nausea for the past several weeks. (Tr. 468).

Dr. Jennings noted this was the first time plaintiff’s has had a blood pressure elevation of this

significance. Otherwise, the plaintiff was doing well. Dr. Jennings recommended a trial of

Metoclopramide and updating diabetic related laboratories. If plaintiff’s blood pressure

remained elevated, Dr. Jennings was going to consider increasing her Captopril dosage. Due to

plaintiff’s continued blood pressure elevation, plaintiff’s Captopril was increased on January 20,

2003. (Tr. 464). She was also started on Erythromyacin to treat her diabetic gastroparesis. 

On February 17, 2003, plaintiff underwent a second mental status evaluation performed

by Dr. Walz. (Tr. 403-407). Plaintiff reported “ I think I could probably go to work if I wanted

to. I do [not] think there [is] anything to keep me from working. I had to take care of my motherin-law but she died in 1998.” Plaintiff reported she went through a brief period of depression

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the previous year but Zoloft was helping. Plaintiff reported that her reading abilities were pretty

good. She likes reading mysteries and science fiction novels. Plaintiff also reported doing okay

with addition and subtraction. Plaintiff reported no problems with memory or concentration.

Plaintiff reported that she feels depressed sometimes and admitted to occasional thoughts of

wishing she were dead but has never made a suicide attempt. After examining plaintiff, Dr.

Walz estimated plaintiff’s IQ was in the low seventies. She diagnosed plaintiff with major

depression, single episode with psychosis, dysthmia and borderline intellectual functioning. 

With regard to adaptive functioning, Dr. Walz noted plaintiff had a slight lisp due to poor

dentition. As for plaintiff’s social functioning, plaintiff reported she had a lot of friends and that

she gets along with her neighbors. Plaintiff reported she was going to church regularly but now

has no transportation. Plaintiff reported leaving the house three or four times a week to see her

husband’s cousin. Plaintiff reported she did not need assistance with her activities of daily living

and cleans her home when she is not tired. Plaintiff reported that she planned to plant some

flowers when the weather turned warmer. To pass the time, plaintiff reported she worked puzzle

books, colored, did sewing crafts, worked with plastic canvas and watched television. Dr. Walz

found plaintiff’s concentration, persistence and pace to be appropriate. Dr. Walz also opined

plaintiff probably had problems in academic functioning. Dr. Walz did not think plaintiff could

handle her own finances. 

On March 4, 2003, Dr. Brad Williams completed a mental RFC assessment stating that

plaintiff has moderate limitations in the following areas: in her ability to understand and

remember detailed instructions; in her ability to carry out detailed instructions; in her ability to

maintain attention and concentration for extended periods; in her ability to complete a normal

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workday and workweek without interruptions from psychologically based symptoms and to

perform at a consistent pace without an unreasonable number and length of rest periods; in her

ability to accept instructions and respond appropriately to criticism from supervisors; and in her

ability to set realistic goals and make plans independentlyof others. (Tr. 422-425). Dr. Williams

concluded that plaintiff is able to perform work where interpersonal contact is incidental to work

performed, e.g. assembly work; complexity of tasks is learned and performed by rote, few

variables, little judgment; and supervision required is simple, direct and concrete. (Tr. 424). Dr.

Williams also completed a psychiatric review technique form indicating plaintiff had mild

restrictions of her activities of daily living; moderate difficulties in maintaining social

functioning; moderate difficulties in maintaining concentration, persistence or pace; and no

episodes of decompensation of extended duration. (Tr. 408-421).

Progress notes dated April 29, 2003, report plaintiff’s complaints of left lower extremity

pain. (Tr. 461). Dr,. Jennings noted plaintiff was tolerating the erythromyacin. She noted

plaintiff had not increased her blood pressure medication as instructed and her blood pressure

had increased. Plaintiff’s blood sugars were noted to be great. 

On May 30, 2003, plaintiff reported she was feeling fatigued but had been active. (Tr.

460). She denied dizziness or headaches. Plaintiff’s blood pressure was noted to be under good

control. Plaintiff reported she was still experiencing leg pain. 

On June 11, 2003, plaintiff complained of low back, left hip and left leg pain for the past

month. (Tr. 429-432). X-rays of plaintiff’s lumbar spine showed moderate degenerative disc

disease with vacuum disc phenomenon at L5-S1 with mild to moderate changes otherwise

throughout the lumbar spine. There was no evidence of fracture or spondylolosthesis. After

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examining plaintiff, Dr. Thomas E. Cheyne diagnosed plaintiff with lumbar radiculopathy with

underlying degenerative disc disease at L5-S1. Dr. Cheyne recommended plaintiff undergo a

MRI scan, that she continue her Clinoril and that she use hot bathes twice daily. 

On June 17, 2003, plaintiff underwent a MRI of the lumbar spine which showed

degenerative disc disease with some mild bulging at the lower two levels with no significant

central or foraminal stenosis. (Tr. 427). 

Plaintiff returned to Dr. Cheyne for a follow-up on June 25, 2003. (Tr. 426). Plaintiff

reported she continued to have significant symptoms. Dr. Cheyne temporarily stopped plaintiff’s

Clinoril and put her on Medrol-Dosepak. Once she completed the Dosepak, plaintiff was to

resume taking Clinoril. Dr. Cheyne recommended plaintiff continue hot showers and that

plaintiff stay active but protective of her back. 

On September 20, 2003, plaintiff entered the Sparks emergency room complaining of

chest pain, nausea, vomiting and diarrhea. (Tr. 449-451). An electrocardiogram demonstrated

normal sinus rhythm with a nonspecific T-wave abnormality. (Tr. 435). Plaintiff was admitted

to a telemetry bed. A chest x-ray showed no acute disease. (Tr. 440). On September 22 , plaintiff nd

underwent a myocardial perfusion study which showed a normal stress test, a normal gated

SPECT study, no evidence of perfusion defects in any segment of the left ventricle during stress

or rest and an ejection fraction of sixty-three percent. (Tr. 437-438). Plaintiff was discharged on

this date with instructions to follow-up with Dr. Jennings in two to four weeks. (Tr. 452). 

On September 30, 2003, plaintiff complained of chest pain, increased blood pressure and

increased blood sugars. (Tr. 459). Dr. Jennings diagnosed plaintiff with atypical chest pain,

hypertension and NIDDM. She made adjustments to plaintiff’s medications and scheduled

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plaintiff for a CT scan of the chest. Plaintiff underwent the CT scan on October 13, 2003, and

the results were normal. (Tr. 458). 

On October 3, 2003, plaintiff had a hypoglycemic episode while she was at a store.

Emergency services were dispatched. (Tr. 453-454). After drinking orange juice and eating cake

plaintiff’s blood sugar rose. Plaintiff did not want further evaluation and was advised to go and

eat and was left in the care of her husband. 

Progress notes dated October 29, 2003, report plaintiff’s complaints of chest pain and

possible GERD. (Tr. 457). After examining plaintiff, Dr. Jennings diagnosed plaintiff with

atypical chest pains and possible GERD. Dr. Jennings recommended plaintiff take Prevacid. She

further recommended plaintiff undergo a colonoscopy. 

Discussion:

This court's role is to determine whether the Commissioner's findings are supported by

substantial evidence on the record as a whole. Ramirez v. Barnhart, 292 F.3d 576, 583 (8th Cir.

2002). Substantial evidence is less than a preponderance but it is enough that a reasonable mind

would find it adequate to support the Commissioner's decision. The ALJ's decision must be

affirmed if the record contains substantial evidence to support it. Edwards v. Barnhart, 314 F.3d

964, 966 (8th Cir. 2003). As long as there is substantial evidence in the record that supports the

Commissioner's decision, the court may not reverse it simplybecause substantial evidence exists

in the record that would have supported a contrary outcome, or because the court would have

decided the case differently. Haley v. Massanari, 258 F.3d 742, 747 (8th Cir. 2001). In other

words, if after reviewing the record it is possible to draw two inconsistent positions from the

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evidence and one of those positions represents the findings of the ALJ, the decision of the ALJ

must be affirmed. Young v. Apfel, 221 F.3d 1065, 1068 (8th Cir. 2000).

The initial, crucial question in a case such as this is whether the claimant's condition has

improved since the prior award of disability benefits. Nelson v. Sullivan, 946 F.2d 1314, 1315

(8th Cir. 1991). "The claimant in a disability benefits case has a `continuing burden' to

demonstrate that [she] is disabled, . . . and no inference is to be drawn from the fact that the

individual has previously been granted benefits." Id. (internal citation omitted); 42 U.S.C. §

423(f). If a claimant meets this initial burden, the responsibility then shifts to the Commissioner

to demonstrate that the claimant is not disabled. Id. (citing Lewis v. Heckler, 808 F.2d 1293,

1297 (8th Cir. 1987)). "If the government wishes to cut off benefits due to an improvement in

the claimant's medical condition, it must demonstrate that the conditions which previously

rendered the claimant disabled have ameliorated, and that the improvements in the physical

condition are related to claimant's ability to work." Nelson, 946 F.2d at 1315; 20 C.F.R. §

404.1594 (b)(2)-(5).

According to regulations promulgated by the Commissioner, "medical improvement" is

defined as any decrease in the medical severity of an impairment which was present at the time

of the most recent favorable medical decision that the individual was disabled or continued to

be disabled. 20 C.F.R. § 416.994(b)(1); Nelson, 946 F.2d at 1315-1316. A determination that

there has been a decrease in medical severity must be based on changes in symptoms, signs,

and/or laboratory findings associated with the impairment. Id. Medical improvement is related

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Pursuant to the regulations, the Commissioner is required to follow specific steps in determining whether 2

 disability continues. The steps are: (1) Is the individual engaging in substantial gainful activity (SGA)(2)

 Does the individual have an impairment which meets or equals the severity of an impairment listed in 

 Appendix 1? (3) Has there been medical improvement? (4) If there has been medical improvement, is it 

 related to the ability to work? (5) Do any exceptions to the medical improvement standard apply if there 

 has not been a medical improvement or if the improvement is not related to the ability to work? (6) Does 

 the individual have a severe impairment or combination of impairments? (7) Can the individual do past 

 relevant work? (8) Can the individual do any other work? 20 C.F.R. § 404.1594(f).

20

to the ability to do work if there has been a decrease in the severity of the impairment and an

increase in the individual's ability to do basic work activities. Id. at § 404.1594(b)(3).2

In the present case, the ALJ found that plaintiff has severe impairments. The ALJ found

that plaintiff's impairment, or combination of impairments, do not meet or equal a Listing of

Impairments found in Appendix I, Subpart P, Regulation No. 4. The ALJ found that the medical

evidence establishes that plaintiff has experienced a decrease in the signs, symptoms and/or

laboratory findings related to plaintiff's impairments since May 21, 1998, the date of the

plaintiff's most recent favorable decision, which demonstrates medical improvement in her

condition. The ALJ further found that this medical improvement in plaintiff's condition is

related to her ability to work. The ALJ concluded that as of April 1, 2002, plaintiff possessed

the RFC to lift twenty-five pounds frequently, fifty pounds occasionally; to push/pull the same

amounts; to sit, stand and walk a total of six hours each in an eight-hour workday with regular

breaks. The ALJ further found plaintiff must avoid working at unprotected heights and around

unprotected moving machinery. From a mental standpoint, the ALJ found plaintiff can

understand, remember and carry out more detailed instructions with some limitations; and that

she is limited to unskilled work, as defined by the ability to perform work where interpersonal

contact is incidental to work performed, complexity of tasks is learned and performed by rote

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with few variables and little judgment and supervision is simple, direct and concrete. With the

help of vocational expert testimony, the ALJ found plaintiff was able to perform her past relevant

work as an inspector at a furniture factory. We believe there is substantial evidence of record

supporting the ALJ's determination.

As to plaintiff's current subjective complaints, the ALJ adequately evaluated the factors

set forth in Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir. 1984), and there is substantial

evidence supporting the ALJ's determination that plaintiff's complaints that her medical

condition continues to be disabling were not credible. 

The medical evidence in this case establishes plaintiff has been consistently treated for

NIDDM and hypertension. The records indicate plaintiff had occasional elevated blood sugars

and blood pressure; however, with a few adjustments to her medications and plaintiff’s

compliance in taking the medication as instructed these conditions have been controlled. See

Estes v. Barnhart, 275 F.3d 722, 725 (8th Cir. 2002) (citations omitted) (an impairment which

can be controlled by treatment or medication is not considered disabling). 

In September of 2002, plaintiff was diagnosed with osteoarthritis of the knees and hips.

Dr. Jennings instructed her to use over-the-counter medication such as Aleve. See Haynes v.

Shalala, 26 F.3d 812, 814 (8th Cir. 1994) ( lack ofstrong pain medication was inconsistent with

disabling pain). Plaintiff did complain of leg pain in April through June of 2003, but there is no

indication that plaintiff sought treatment for this pain after June of 2003. See Novotny v. Chater,

72 F.3d 669, 671 (8th Cir. 1995) (per curiam) (failure seek treatment inconsistent w/allegations

of pain). 

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After complaining of back pain in June of 2003, plaintiff underwent an MRI of the lumbar

spine which revealed degenerative disc disease with some mild bulging at the lower two levels

with no significant central or foraminal stenosis. Dr. Cheyne started plaintiff on a MedrolDosepak, instructed her to take hot showers or bathes twice a day and to stay active but to be

protective of her back. There is no indication that plaintiff sought treatment for back pain again.

In fact, at the administrative hearing in October of 2003, plaintiff testified that she was scheduled

for a second epidural steroid injection but was going to cancel the appointment because she did

not feel that she needed the second injection. Thus, while plaintiff may indeed have an injury to

her back and experience some degree of pain, the medical evidence indicates that her condition

is not of a disabling nature. See Lawrence v. Chater, 107 F.3d 674, 676 (8th Cir. 1997)

(upholding ALJ's determination that claimant was not disabled even though she had in fact

sustained a back injury and suffered some degree of pain). 

Plaintiff has also sought treatment for chest pain on occasion during the relevant time

period. In June of 2001 and EKG was normal. (Tr. 279). After complaining of chest pain, on

September 22, 2003, plaintiff underwent a myocardial perfusion study which showed a normal

stress test, a normal gated SPECT study, no evidence of perfusion defects in any segment of the

left ventricle during stress or rest and an ejection fraction of sixty-three percent. (Tr. 437-438)

Plaintiff also underwent the CT scan on October 13, 2003, and the results were normal. (Tr. 458).

Plaintiff’s treating physicians have placed no limitations on plaintiff’s activities due to chest pain.

Based on the record as a whole, we find substantial evidence supporting the ALJ’s determination

that plaintiff does not have disabling chest pain.

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The record establishes that the main reason plaintiff was originally found to be disabled

was because she met the Listing 12.04. A review of the record established that since May of

1998, plaintiff has not sought treatment from a mental health professional. See Gowell v. Apfel,

242 F.3d 793, 796 (8th Cir. 2001) (holding that lack of evidence of ongoing counseling or

psychiatric treatment for depression weighs against plaintiff’s claim of disability). Plaintiff did

complain of experiencing depression to her treating physicians but in July of 2002, plaintiff

reported to Dr. Jennings that Zoloft was helping to relieve her symptoms. Further, at both

examinations with Dr. Walz plaintiff reported thatshe sometimes experienced depression but the

medication was helping. Plaintiff also reported having many friends, being able to perform

household chores, plant flowers, do crafts, watch television and read. After reviewing the entire

record we find substantial evidence supporting the ALJ’s determination that plaintiff does not

have disabling depression. 

Plaintiff has also been diagnosed with borderline intellectual functioning. The ALJ

discussed plaintiff’s borderline intellectual functioning and made adjustments to plaintiff’s RFC

to account for these limitations. 

Plaintiff's subjective complaints are also inconsistent with evidence regarding her daily

activities. Plaintiff testified that on an average day, she cleans her house, walks her dog, watches

television, works on plastic canvas and colors in coloring books. Plaintiff testified that she

usually goes to church every Sunday but noted she had not gone for the past two or three weeks.

Plaintiff testified she also reads the Bible and Christian books. Plaintiff also goes to visit friends

and has friends come to her house to visit. Plaintiff also thought if she could find a job she

would be able to work part-time. 

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In both March of 2002, and February of 2003, plaintiff reported to Dr. Walz that she did

not need assistance with her activities of daily living and that she cleans her home when she is

not tired. Plaintiff reported in February of 2003, that she planned to plant some flowers when the

weather turned warmer. To pass the time, plaintiff reported she worked puzzle books, colored,

did sewing crafts, worked with plastic canvas and watched television. She also reported in March

of 2002 that she went to help her husband’s 84 year old cousin a couple of times a week. This

level of activity belies plaintiff’s complaints of pain and limitation and the Eighth Circuit has

consistently held that the ability to perform such activities contradicts a plaintiff’s subjective

allegations of disabling pain. See Cruze v. Chater, 85 F.3d 1320, 1324 (8 Cir.1996) (mowed th

lawn, shopped, odds jobs and visits town); See Hutton v. Apfel, 175 F.3d 651, 654-655 (8 Cir. th

1999) (holding ALJ’s rejection of claimant’s application supported by substantial evidence

where daily activities– making breakfast, washing dishes and clothes, visiting friends, watching

television and driving-were inconsistent with claim of total disability); See Polaski at 1322.

Furthermore, she told Dr. Walz “ I think I could probably go to work if I wanted to. I do [not]

think there [is] anything to keep me from working.” 

The ALJ also considered the testimony of plaintiff’s husband. After hearing his

testimony, however, the ALJ properly concluded that his testimony was not fully credible. As

the testimony of family members and friends need only be given consideration and need not be

considered credible, the ALJ properly discredited the testimony of the witnesses. Lawrence v.

Chater, 107 F.3d 674, 677 (8th Cir. 1997).

Therefore, although it is clear that plaintiff suffers with some degree of pain, she has not

established that she was unable to engage in any gainful activity. See Craig v. Apfel, 212 F.3d

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433, 436 (8th Cir. 2000) (holding that mere fact that working may cause pain or discomfort does

not mandate a finding of disability). Neither the medical evidence nor the reports concerning her

daily activities for the relevant time period support plaintiff’s contention of total disability.

Accordingly, we conclude that substantial evidence supports the ALJ’s conclusion that plaintiff’s

subjective complaints were not totally credible. 

We next turn to the ALJ's assessment of plaintiff's RFC. It is the ALJ’s responsibility to

determine a claimant’s RFC based on all the relevant evidence, including medical records,

observations of treating physicians and others, and a claimant’s own description of her

limitations. 20 C.F.R. §404.1596; Anderson v. Shalala, 51 F.3d 777, 779 (8 Cir. 1995); Reed th

v. Sullivan, 988 F.2d 812, 815-16 (8 Cir. 1993). The ALJ found plaintiff maintains the RFC to th

lift twenty-five pounds frequently, fifty pounds occasionally; to push/pull the same amounts; to

sit, stand and walk a total of six hours each in an eight-hour workday with regular breaks. The

ALJ further found plaintiff must avoid working at unprotected heights and around unprotected

moving machinery. From a mental standpoint, the ALJ found plaintiff can understand, remember

and carry out more detailed instructions with some limitations; and that she is limited to

unskilled work, as defined by the ability to perform work where interpersonal contact is

incidental to work performed, complexity of tasks is learned and performed by rote with few

variables and little judgment and supervision is simple, direct and concrete. Plaintiff's capacity

to perform this level of work is also supported by the fact that plaintiff's physicians placed no

restrictions on plaintiff's activities during the relevant time period. See Hutton v. Apfel, 175 F.3d

651, 655 (8th Cir. 1999) (lack of physician-imposed restrictions militates against a finding of

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total disability). Based on our above discussion of the medical evidence and plaintiff's daily

activities, we believe substantial evidence supports the ALJ's RFC assessment. 

Finally, we look to the ALJ's determination that plaintiff could perform substantial gainful

employment within the national economy. We find that the hypothetical the ALJ posed to the

vocational expert fully set forth the impairments which the ALJ accepted as true and which were

supported by the record as a whole. See Long v. Chater, 108 F.3d 185, 188 (8th Cir. 1997);

Pickney v. Chater, 96 F.3d 294, 296 (8th Cir. 1996). Accordingly, we find that the vocational

expert's testimony constitutes substantial evidence supporting the ALJ's conclusion that plaintiff

is not disabled as she is able to perform her past relevant work as an inspector at a furniture

factory. See Pickney, 96 F.3d at 296 (testimony from vocational expert based on properly

phrased hypothetical question constitutes substantial evidence).

Conclusion:

Based on the foregoing, we recommend, affirming the ALJ's decision, and dismissing

plaintiff's case with prejudice. The parties have ten days from receipt of our report and

recommendation in which to file written objections pursuant to 28 U.S.C. § 636(b)(1). The

failure to file timely objections may result in waiver of the right to appeal questions of fact.

The parties are reminded that objections must be both timely and specific to trigger de

novo review by the district court.

DATED this 28 day of February 2006. th

/s/ Beverly Stites Jones 

HON. BEVERLY STITES JONES

UNITED STATES MAGISTRATE JUDGE

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