Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_06-cv-01802/USCOURTS-caed-1_06-cv-01802-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:1383 Review of HHS Decision

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28 References to the Administrative Record will be designated as “AR,” followed by the appropriate page 1

number.

1

UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

DONNA L. LANE, )

)

)

)

Plaintiff, )

)

v. )

)

MICHAEL J. ASTRUE, Commissioner )

of Social Security, )

)

)

Defendant. )

 )

1:06cv1802 OWW DLB

FINDINGS AND RECOMMENDATION

REGARDING PLAINTIFF’S

SOCIAL SECURITY COMPLAINT

BACKGROUND

Plaintiff Donna L. Lane (“Plaintiff”) seeks judicial review of a final decision of the

Commissioner of Social Security (“Commissioner”) denying her applications for Disability

Insurance Benefits and Supplemental Security Income (“SSI”) pursuant to Titles II and XVI of

the Social Security Act. The matter is currently before the Court on the parties’ briefs, which

were submitted, without oral argument, for Findings and Recommendation to the District Court. 

FACTS AND PRIOR PROCEEDINGS1

Plaintiff filed her applications on September 27, 2004, alleging disability since September

15, 2004, due to learning disabilities, back pain and high blood pressure. AR 72-80, 81-85, 135-

140. After being denied both initially and upon reconsideration, Plaintiff requested a hearing

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before an Administrative Law Judge (“ALJ”). AR 31-35, 41-46, 47. On February 8, 2006, ALJ

Christopher Larsen held a hearing, and on March 3, 2006, he denied benefits. AR 231-253, 10-

18. On October 13, 2006, the Appeals Council denied Plaintiff’s request for review. AR 5-8. 

Hearing Testimony

ALJ Larsen held a hearing in Fresno, California, on February 8, 2006. Plaintiff appeared

with her attorney, Robert Ishikawa. Vocational expert (“VE”) Tom Dachelet also appeared and

testified. AR 231. 

Plaintiff testified that she was 47 years old at the time of the hearing. She completed high

school in both regular and special education classes. AR 235-236. Plaintiff last worked on July

25, 2005, as weigher/inspector at a packing house. This was a seasonal position that she had

performed for 26 years. AR 236-238. Plaintiff stopped working because she was complaining

that her right arm was sore and “got laid off by a doctor” for three months. AR 238. She

explained that her arm hurt before her accident in June 2000, when she fell off her bike and broke

her collar bone. AR 239. The injury made her arm pain worse. AR 240.

Plaintiff testified that she could only lift her right arm “halfway” because “it’s dead.” She

can’t lift too much because she gets tired. AR 240. During the day, she watches television but

has to lie down because she’s too tired. She can’t write for very long and doesn’t write very well. 

AR 242. She tries, but is unable to do house work because she is too weak and tired. A R 243. 

She goes out and sees friends but doesn’t go to church anymore. She is able to drive about seven

blocks before she gets weak. AR 244. Plaintiff takes a medication for pain that makes her sleepy

in the morning. Her diabetes is “a little high.” AR 245.

When questioned by the ALJ, Plaintiff explained that in addition to her arm pain, she

cannot work because she also has knee and foot pain and is unable to stand. AR 248. 

For the first hypothetical, the ALJ asked the VE to assume a person of Plaintiff’s age,

education and past work experience, who could understand, remember and carry out simple oneor two-step job instructions, but can only occasionally reach, handle, finger or feel with her right

dominant upper extremity. This person could not perform Plaintiff’s past relevant work. AR

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251. VE Dachelet further explained that at the unskilled level, two hands are generally required

for production jobs. AR 252. 

Medical Record

On December 2, 2004, Plaintiff underwent a psychological evaluation by Richard Engeln,

Ph.D. Plaintiff reported that she has high blood pressure and diabetes but was not taking

medication. During the course of the examination, Plaintiff admitted that her alcohol use may be

heavier than she initially reported and explained that her bicycle accident in 2000 happened after

she had too many Long Island ice teas. AR 154-155. Her only medication was Advil. AR 155.

On mental status examination, Plaintiff was alert and oriented with no evidence of

delusions, hallucinations or confusion. Her verbal intelligence test scores were high in the mild

range of mental retardation, and visual intelligence was low borderline. IQ estimates were 66

verbal, 72 performance, and 65 full scale. Her academic skills were at the third grade level. The

Rey 15 Memory Test was positive for exaggeration. Dr. Engeln noted that “there was a great

deal of histrionic emphasis on inadequacy” and that the obtained protocol “appears to be an

underestimate of abilities, and instead, reflect attitudinal-emotional issues.” AR 156.

Dr. Engeln concluded that Plaintiff did not show evidence of any mental or emotional

illness and that her interview presentation suggested at least borderline intellectual skills. The

test results appeared to be influenced by many attitudinal-emotional issues, and did not appear to

be valid measurements of abilities. AR 157. He diagnosed exaggerated protocol, adjustment to

changes in medical-physical status, alcohol abuse, and academic delay, moderate to severe. 

Plaintiff was capable of job adjustment in a context where instructions are unidimensional and

normal supervision is provided. She could deal with the normal social exchanges of job

adjustment and she presented with skills adequate for entry level job adjustment in a setting

consonant with education, age and past job placements. She could perform one-to-two step

simple job instructions, but could not perform complex or technical instructions. Dr. Engeln

opined that there were no psychological restrictions to job adjustment as she had made such

adjustments in the past. AR 157. 

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On December 4, 2004, Plaintiff saw consultive examiner Steven Stoltz, M.D., for an

internal medicine evaluation. AR 164. Plaintiff complained of a history of aches and pains,

including pain in her right medial clavicular area, right arm, abdomen, chest and legs. She was

taking only Advil for pain relief. On physical examination, Plaintiff was well-developed and in

no acute distress. Her grip strength was slightly less on the left. Range of motion in the neck

was within normal limits, as was range of motion in her back and upper and lower extremities. 

There was no tenderness to palpation in her back or muscle spasms. Straight leg raising was

negative at 90 degrees. Hand grip was normal and finger approximation was intact. There was

no crepitus in her knees and no patellar instability. Her neurological examination was normal

and her gait was within normal limits. AR 164-168.

Dr. Stoltz diagnosed aches and pains, possible hypertension and a learning disability. 

However, he found no evidence of any ongoing medical disorders that would place any limits on

her activities. AR 168. 

On January 5, 2005, State Agency physician Allen Middleton, Ph.D., opined that Plaintiff

did not have any severe impairments. In making this determination, Dr. Middleton noted that

Plaintiff had an academic delay in reading and abused alcohol. She had mild restrictions in

activities of daily living, and mild difficulties in maintaining concentration, persistence or pace. 

AR 170-185. Both Dr. Middleton and State Agency physician Murray Mitts, M.D., opined that

Plaintiff could perform basic work activities and that her impairments were not severe. AR 185. 

This opinion was affirmed on June 2, 2005, by E. Murillo, Ph.D. AR 170.

On July 25, 2005, Plaintiff was seen at University Medical Center for her right arm pain. 

She was taken off work for two months and told to schedule a nerve conduction study as soon as

possible. AR 197. 

In September 2005, Plaintiff was seen at University Medical Center in follow-up for arm

pain. She also wanted forms filled out. Her arm strength was improved. She was diagnosed

with diabetes, hyperlipidemia and right arm neuropathy. AR 196. An “off of work” form was

given to Plaintiff and she was instructed to return as scheduled. 

On October 7, 2005, Plaintiff’s diabetes was under good control. 

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In October 2005, a progress note indicated that Plaintiff’s September 2005, EMG was

normal, with no evidence of neuropathy, radiculopathy or carpal tunnel syndrome. AR 224, 228-

229. 

On November 16, 2005, Plaintiff underwent a Qualified Medical Examination performed

by John G. Dallas, M.D. She complained of a right hand injury and reported that she last worked

on August 23, 2005. Plaintiff was not a good historian and did not describe any specific work

injury. Plaintiff described a constant, painful numbness in her right upper extremity. On

examination, there was slight atrophy of the right shoulder girdle musculature and

dyssynchronous right shoulder motion. Her passive right shoulder motion was unrestricted with

no definite crepitus or instability. She had unrestricted range of motion in her left shoulder. 

Examination of her hands and wrists revealed no obvious deformity or atrophy and range of

motion was within normal limits, although there was some difficulty producing the requested

motions. Neurologic testing revealed variable deep tendon reflexes and motor strength testing

revealed weakness in the right hand and wrist (graded approximately 4/5). There was diminished

sensation to light touch and pinprick profusely over the entirety of her right and left hands. AR

208-216.

Dr. Dallas diagnosed hypertension and diabetes, a history of dominant right

sternoclavicular joint dislocation and right acromioclavicular joint separation, and diabetic

peripheral neuropathy. He concluded that Plaintiff had no causal disability or impairment and

could perform her usual and customary work activities without restrictions. He opined that

Plaintiff had multiple medical problems but they were not causal or work-related. AR 215-218. 

In December 2005, Plaintiff was taking Neurontin. Treatment notes from University

Medical Center indicate that Plaintiff could not work for an additional three months. AR 221. 

On January 24, 2006, Plaintiff’s treating physician, Mitchell F. Jelen, M.D., wrote a letter

in response to Plaintiff’s attorney’s question. Dr. Jelen indicated that Plaintiff “would be able to

work in an appropriate limited capacity as most high school graduates do.” He continued, “Her

alcohol use as well as melancholy should be addressed by an appropriate facility.” AR 219. 

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ALJ’s Findings

ALJ Larsen determined that Plaintiff’s academic delay, alcohol abuse, right arm

neuropathy, diabetes and hyperlipidemia were medically-determinable impairments. AR 15. He

determined, though, that these impairments, either alone or in combination, did not significantly

limit her ability to perform basic work-related activities for 12 consecutive months and were

therefore not severe. Based on this, he found Plaintiff not disabled. AR 15-18.

SCOPE OF REVIEW

Congress has provided a limited scope of judicial review of the Commissioner’s decision

to deny benefits under the Act. In reviewing findings of fact with respect to such determinations,

the Court must determine whether the decision of the Commissioner is supported by substantial

evidence. 42 U.S.C. 405 (g). Substantial evidence means “more than a mere scintilla,”

Richardson v. Perales, 402 U.S. 389, 402 (1971), but less than a preponderance. Sorenson v.

Weinberger, 514 F.2d 1112, 1119, n. 10 (9th Cir. 1975). It is “such relevant evidence as a

reasonable mind might accept as adequate to support a conclusion.” Richardson, 402 U.S. at

401. The record as a whole must be considered, weighing both the evidence that supports and

the evidence that detracts from the Commissioner’s conclusion. Jones v. Heckler, 760 F.2d 993,

995 (9th Cir. 1985). In weighing the evidence and making findings, the Commissioner must

apply the proper legal standards. E.g., Burkhart v. Bowen, 856 F.2d 1335, 1338 (9th Cir. 1988). 

This Court must uphold the Commissioner’s determination that the claimant is not disabled if the

Secretary applied the proper legal standards, and if the Commissioner’s findings are supported by

substantial evidence. See Sanchez v. Sec’y of Health and Human Serv., 812 F.2d 509, 510 (9th

Cir. 1987). 

 REVIEW

In order to qualify for benefits, a claimant must establish that he is unable to engage in

substantial gainful activity due to a medically determinable physical or mental impairment which

has lasted or can be expected to last for a continuous period of not less than 12 months. 42

U.S.C. § 1382c (a)(3)(A). A claimant must show that he has a physical or mental impairment of

such severity that he is not only unable to do her previous work, but cannot, considering his age,

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28 All references are to the 2002 version of the Code of Federal Regulations unless otherwise noted. 2

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education, and work experience, engage in any other kind of substantial gainful work which

exists in the national economy. Quang Van Han v. Bowen, 882 F.2d 1453, 1456 (9th Cir. 1989). 

The burden is on the claimant to establish disability. Terry v. Sullivan, 903 F.2d 1273, 1275 (9th

Cir. 1990).

In an effort to achieve uniformity of decisions, the Commissioner has promulgated

regulations which contain, inter alia, a five-step sequential disability evaluation process. 20

C.F.R. §§ 404.1520 (a)-(f), 416.920 (a)-(f) (1994). Applying this process in this case, the ALJ 2

found that Plaintiff: (1) had not engaged in substantial gainful activity since the alleged onset of

her disability; and (2) does not have an impairment or a combination of impairments that is

considered “severe. AR 15.

Plaintiff argues that the ALJ erred in finding that her medical impairments were not

severe.

DISCUSSION

Plaintiff argues that the ALJ erred at step two by finding her “mental retardation” and

right arm neuropathy non-severe. 

Plaintiff bears the burden of proving that she is disabled. Meanel v. Apfel, 172 F.3d 1111,

1114 (9th Cir. 1999); 20 C.F.R. § 404.1512. A person is disabled if her impairments are severe

and meet the durational requirement of twelve months. 20 C.F.R. §§ 404.1505, 404,1520(a). A

severe impairment is one that significantly limits the physical or mental ability to perform basic

work activities. 20 C.F.R. § 404.1520(c). Examples of basic work activities include carrying out

simple instructions, responding appropriately to usual work situations, dealing with changes in a

routine work setting, and performing ordinary physical functions like walking and sitting. 20

C.F.R. § 404.1521(b). 

An impairment or combination of impairments is found “not severe” and a finding of “not

disabled” is made at step two if the medical evidence establishes only a slight abnormality or a

combination of slight abnormalities which would have no more than a minimal effect on an

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individual’s ability to work, even if the individual’s age, education, or work experience were

specifically considered (i.e., the person’s impairment(s) has no more than a minimal effect on his

or her physical or mental ability(ies) to perform basic work activities). SSR 85-28. In

determining whether an impairment or combination of impairments is “severe,” an ALJ should

carefully examine the medical findings that describe the impairments and make an “informed

judgment” about the limitations and restrictions the impairment and related symptoms impose on

the person’s physical and mental ability to do basis work activities. SSR 96-3p. 

In his decision, the ALJ reviewed the medical evidence, including Dr. Engeln’s finding

that Plaintiff did not have any mental or emotional impairment, Dr. Jelen’s opinion that Plaintiff

could work in an “appropriate limited capacity,” her normal EMG study, Dr. Stoltz’s finding that

Plaintiff had no impairment-related functional limitations, Dr. Dallas’ opinion that Plaintiff could

perform her usual and customary work activities without restriction, and the State Agency

physicians’ opinions that Plaintiff’s impairments were not severe. AR 16-17. He also set forth

the results of Dr. Engeln’s tests, which showed “exaggerated protocol.” AR 16. Based on the

overall medical record as cited by the ALJ, his determination that Plaintiff’s impairments did not

have more than a minimal effect on her ability to perform basic work activities was supported by

substantial evidence. Indeed, many of the examining physicians found that Plaintiff had no

impairments.

Insofar as Plaintiff argues that the evidence of her “mental retardation” was “undisputed”

and cites the test results of Dr. Engeln, this evidence can hardly be described as “undisputed.” 

Opening Brief, at 4. Dr. Engeln noted that the Rey 15 Memory Test was positive for

exaggeration and specifically opined that the obtained protocol “appears to be an underestimate

of abilities, and instead, reflect attitudinal-emotional issues.” AR 156. Dr. Engeln concluded

that Plaintiff did not show evidence of any mental or emotional illness and that the test results

did not appear to be valid measurements of abilities. AR 157. Examples of “basic work

activities” include carrying out simple instructions, responding appropriately to usual work

situations, dealing with changes in a routine work setting, and performing ordinary physical

functions like walking and sitting. 20 C.F.R. § 404.1521(b). In this regard, Dr. Engeln opined

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 Insofar as Plaintiff contends that had the ALJ continued with the sequential evaluation analysis, her

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mental retardation would have been found to meet or equal Listing 12.05C, her argument is belied by Dr. Engeln’s

conclusion that the test results were not accurate. 

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that Plaintiff could perform one-to-two step simple job instructions, was capable of job

adjustment in a context where instructions are unidimensional and normal supervision is

provided, and could deal with the normal social exchanges of job adjustment. AR 156-157. 

Contrary to Plaintiff’s suggestion, Dr. Engeln’s findings support the ALJ’s conclusion. 

3

As to her right arm impairment, Plaintiff contends that she was limited to “occasional

reaching, handling, fingering, or feeling with her right upper extremity.” Opening Brief, at 4. 

However, no such limitations were placed on Plaintiff. 

Additionally, although the medical records set forth objective evidence of a right

shoulder/arm impairment, substantial evidence supported the ALJ’s finding that the impairment

was not severe. In December 2004, Plaintiff complained of pain in her right arm and clavical

area, but Dr. Stoltz found no evidence of any ongoing medical disorders that would place any

limits on her activities. AR 168. On March 17, 2005, Plaintiff was seen in the emergency room

and complained of right arm pain for one month. She was treated with Naprosyn. AR 211. In

July 2005, Plaintiff was seen at University Medical Center. She had decreased grip strength in

her right hand and her right arm shook when she tried to close her hand. She had pain with

movement in all directions and was unable to perform full range of motion. Plaintiff was

diagnosed with right arm neuropathy and taken off work for two months. AR 197. When she

returned in September 2005, treatment notes indicate that her strength had improved. AR 196. 

The September 2005, EMG was normal, showing no signs of neuropathy, radiculopathy or carpal

tunnel syndrome. AR 224, 228-229. In November 2005, Dr. Dallas examined Plaintiff and

although he noted some symptoms related to her right arm and clavical area, he opined that she

could perform her usual and customary work activities, i.e., fruit sorter. AR 216. On December

21, 2005, Plaintiff returned to University Medical Center and treatment notes indicate that she

was “unable to work for 3 additional months.” AR 221. 

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Interestingly, the limitations composed are extremely inconsistent. The evidence relating

to Plaintiff’s right arm/shoulder symptoms falls on either one end of the limitation spectrum or

the other- either she has no related limitations or she is unable to work for months at a time. This

variation is somewhat suspect, especially given the normal EMG in September 2005, the

numerous opinions that she had no limitations, and Plaintiff’s questionable credibility. In

determining that Plaintiff’s impairments were not severe, the ALJ gave great weight to Dr. Stoltz

and Dr. Dallas, both of whom found no right arm-related limitations. AR 17. Pitzer v. Sullivan,

908 F.2d 502, 506 (9th Cir.1990); Gallant v. Heckler, 753 F.2d 1450 (9th Cir.1984). The ALJ

was entitled to give the examining physicians’ findings great weight, and Plaintiff does not

challenge this determination. The ALJ further found that Plaintiff’s allegations were not entirely

credible, a finding which Plaintiff also does not challenge. AR 17. 

Therefore, given the extreme differences in the medical evidence and Plaintiff’s lack of

credibility, the Court finds that the ALJ’s finding that her right arm impairment was not severe

was supported by substantial evidence. Substantial evidence is “such relevant evidence as a

reasonable mind might accept as adequate to support a conclusion.” Richardson, 402 U.S. at

401. Such evidence existed here.

RECOMMENDATION

Based on the foregoing, the Court finds that the ALJ’s decision is supported by

substantial evidence in the record as a whole and is based on proper legal standards. 

Accordingly, the Court RECOMMENDS that Plaintiff’s appeal from the administrative decision

of the Commissioner of Social Security be DENIED and that JUDGMENT be entered for

Defendant Michael J. Astrue and against Plaintiff Donna L. Lane.

These findings and recommendations will be submitted to the Honorable Oliver W.

Wanger, pursuant to the provisions of Title 28 U.S.C. § 636(b)(l). Within fifteen (15) days after

being served with these findings and recommendations, the parties may file written objections

with the court. The document should be captioned “Objections to Magistrate Judge's Findings 

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and Recommendations.” The parties are advised that failure to file objections within the

specified time may waive the right to appeal the District Court's order. Martinez v. Ylst, 951

F.2d 1153 (9th Cir. 1991). 

IT IS SO ORDERED. 

Dated: January 16, 2008 /s/ Dennis L. Beck 

3b142a UNITED STATES MAGISTRATE JUDGE

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