Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-3_06-cv-00606/USCOURTS-azd-3_06-cv-00606-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:205 Denial Social Security Benefits

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WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Cecilia Tropp, 

Plaintiff, 

vs.

Jo Anne Barnhart, Commissioner of the

Social Security 

Defendant. 

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No. CV 06-0606-PCT-MHM

ORDER

Plaintiff Cecilia Tropp ("Plaintiff") seeks judicial review of the Administrative Law

Judge's ("ALJ") decision denying her claim for disability insurance benefits. 42 U.S.C. §

405(g). 

I. Procedural History

Plaintiff filed an application for Disability Insurance benefits under Title II of the

Social Security Act, 42 U.S.C. § 405(g), on February 19, 2003. (Tr. 80-82). The application

was denied initially and upon reconsideration. (Tr.62-65, 68-71). On November 10, 2004,

a hearing was held in front of an Administrative Law Judge ("ALJ"). (Tr.24). On March 22,

2005, the ALJ issued a decision denying Plaintiff's application. (Tr.24-32). On January 12,

2006, the Appeals Council denied Plaintiff's request for review. (Tr.5-7). On February 28,

2006, Plaintiff initiated the instant action for judicial review.

II. Background Facts

A. Plaintiff's Medical History

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Plaintiff asserts that she became unable to work due to her illnesses, injuries or

conditions on January 21, 2003. (Tr.85). On January 16, 2003, Plaintiff was examined by

Nannete Sharp ("P.A. Sharp"), a physician's assistant with the office of Sherif A. Nasef, M.D.

("Dr. Nasef"). Ms. Sharp's assessment of Plaintiff's complaints regarding her back, neck and

shoulder pain was musculoskeletal muscle spasm and osteoarthritis. (Tr.174). On January

21, 2003, Plaintiff had a neck/back pain assessment performed by Dr. Nasef. (Tr.171-72).

Dr. Nasef diagnosed myofascial back pain and continued the prescriptions of Skelaxin and

Relafen. (Tr.172). On January 27, 2003, P.A. Sharp also noted that Plaintiff complained of

spasm and tenderness on the left side of her lumber side. (Tr.169). P.A. Sharp assessed

Lumbosacral spine strain and osteoarthritis. (Id.). On February 7, 2003, P.A. Sharp recorded

that Plaintiff reported to be doing better with the back pain because of the physical therapy

but still complained of spasm, swelling and pain in the lower left area of her back. (Tr.165).

Physical therapy was continued and Plaintiff was continued to off-work status as she was

unable to perform the duties requested by her employer. (Id.). On March 3, 2003, PA Sharp

allowed Plaintiff to resume "light duty" when Plaintiff returned to work on March 7, 2003.

(Tr.158). However, on April 11, 2003, Plaintiff again was examined by P.A. Sharp after

Plaintiff presented with muscle spasms in her neck and shoulders and a pain that radiated

down her leg. (Tr.154). P.A. Sharp noted that she doubted that Plaintiff could be able to

continue her type of work and instructed Plaintiff to be off-work indefinitely. (Id.). 

On May 10, 2003, Plaintiff was examined by Dr. Nasef, who diagnosed bilateral

rotator cuff tendinitis, injected Plaintiff with a steroid injection in her right shoulder and

referred Plaintiff for physical therapy. (Tr.152). Dr. Nasef also diagnosed possible

osteoarthritis with degenerative disc disease of the cervical spine. (Id.). On June 21, 2003,

Plaintiff was again seen by Dr. Nasef who again diagnosed right rotator cuff tendinitis and

osteoarthritis and degenerative disc disease of the lumbar spine. (Tr.151). Plaintiff was again

given a steroid injection. (Tr.151). On July 7, 2003, Plaintiff was seen by M.A. Kazmi, M.D

("Dr. Kazmi"), a neurologist, upon referral from Dr. Nasef. (Tr.197). Dr. Kazmi diagnosed

Plaintiff with chronic backaches, neck and back pain and muscular spasm and they discussed

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treatment options. (Tr.199). On August 2, 2003, Plaintiff was again seen by Dr. Nasef who

noted an improvement in Plaintiff's symptoms. (Tr.147). Dr. Nasef continued with his

previous diagnosis and that Plaintiff would continue to follow up. (Id.). 

On August 19, 2003, P.A. Sharp performed a medical source statement regarding

Plaintiff's work related capabilities. (Tr.145-46). P.A. Sharp concluded that Plaintiff could

occasionally lift ten pounds and frequently lift less. (Id.). P.A. Sharp also concluded that

Plaintiff could stand and/or walk and sit about six hours in an eight-hour day. (Id.). On

September 13, 2003, Plaintiff was again seen by Dr. Nasef regarding the results of her MRI.

(Tr.142). Dr. Nasef noted a decreased range of motion of the cervical spine and lumbar

spine. (Id.). Dr. Nasef conducted a work related capabilities examination finding that

Plaintiff could occasionally lift up to ten pounds and frequently lift less. (Tr.143-44). Dr.

Nasef also concluded that Plaintiff could stand and/or walk for less than two hours in an

eight-hour work day and could only sit for 45 minutes to one hour in an eight-hour work day.

(Id.). 

On September 24, 2003, Plaintiff was again seen by Dr. Kazmi regarding Plaintiff's

complaints of left ankle and back pain. (Tr.195). Dr. Kazmi noted that Plaintiff had recently

twisted her ankle and recommended that Plaintiff use a cane to ambulate. (Id.). Dr. Kazmi

diagnosed left ankle pain, chronic backache, cervical muscle spasm, chronic pain, chronic

cervical pain musculoskeletal in nature, multiple muscle join pain and muscular spasm.

(Tr.196). On September 25, 2003, Plaintiff was seen by Marc Zimmerman, M.D. ("Dr.

Zimmerman"), upon which time it was determined that Plaintiff sustained a "nondisplaced

distal fibula fracture." (Tr.204). Plaintiff was directed to continue with a "pneumatic

walker." (Id.). On October 30, 2003, x-rays revealed that the fracture was healing and Dr.

Zimmerman directed that Plaintiff wean herself from the assisting devices such as canes.

(Tr.201-02). 

On December 23, 2003, Ray Hughes, M.D. ("Dr. Hughes") a state non-examining

physician performed a physical residual functional capacity assessment of Plaintiff. (Tr.205-

12). Dr. Hughes concluded that Plaintiff could occasionally lift up to ten pounds and

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frequently less. He also concluded that Plaintiff could stand and/or walk up to two hours in

an eight-hour day and sit with normal breaks for about six hours of an eight-hour day.

(Tr.206). 

On March 29, 2004, Plaintiff was examined by William Binder, M.D. ("Dr. Binder")

upon referral from Dr. Kazmi. (Tr.236-37). Dr. Binder noted that Plaintiff appeared to be

in discomfort and that the left leg appeared to be "cooler in the foot to palpation." (Tr.236).

Dr. Binder provided Plaintiff with an injection and it seemed to provide some temporary

help. (Tr.237). On April 6, 2004, Dr. Binder authored a letter to Dr. Kazmi noting that there

were "differential color and temperature differences in [Plaintiff's] leg consistent with reflex

dystrophic problems." (Tr.233). On April 23, 2003, Dr. Kazmi examined Plaintiff and

diagnosed reflex sympathetic dystrophy ("RSD"). (Tr.270). Dr. Kazmi noted that Plaintiff

had "a terrible time walking because of the pain." (Id).

On May 17, 2004, Plaintiff was examined by Mandeep Powar, M.D., ("Dr. Powar")

upon referral from Dr. Kazmi. Dr. Powar, upon examination, concluded that although

Plaintiff could have presented with symptoms of RSD they seemed to have resolved.

(Tr.248). Dr. Powar noted the Plaintiff's continued pain and discoloration of her leg. Dr.

Powar recommended an epidural steroid injection to control the pains shooting down her legs

and back spasms. (Tr.249). Plaintiff was administered the last of the three shots in August

of 2004. (Tr.242). Plaintiff returned to Dr. Powar on September 17, 2004, presenting with

shoulder and neck pains. Plaintiff received another steroid injection. (Tr.240). On October

6, 2004, Plaintiff was seen by Dr. Kazmi for neck and lower back pain. Dr. Kazmi diagnosed

musculoskeletal pain in the neck and possible radiculitis and multiple joint pains. (Tr.255).

B. Hearing Testimony

On November 10, 2004, at the hearing before the ALJ, testimony was given by the

Plaintiff and Maude Prall, a vocational expert. Plaintiff, age 49 at the time of the hearing,

testified to having a high school education and past work experience as a housekeeper,

receptionist at a campground, machine operator and line worker. (Tr.41-42). Plaintiff testified

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that she was unable to work due to pain in her neck, arms, hands, lower back, lower left hip,

and spine. (Id; Tr.48-49). Plaintiff complained of spasms resulting from the pain. (Id.). 

At the hearing, the vocational expert was posed several hypotheticals by the ALJ.

Specifically, the ALJ asked the vocational expert if an individual with the Plaintiff’s

educational level and work level could perform any work, assuming Plaintiff had difficulty

standing and walking for a long period of time, could perform only sedentary work,

occasional climb ramps and stairs, kneel, crouch, crawl and unable to climb ladders, ropes

and scaffolds with no exposure to extreme hot or cold. (Tr.57). The vocational expert

answered that there was work available as a line worker as well as noted that even with the

assistance of a cane to ambulate, this work was available. (Tr.57). Although it appears one

of the hypotheticals posed by the ALJ was not recorded, the transcript reveals the vocational

expert testified that no work was available for the Plaintiff if Plaintiff could not sit, stand and

walk for less than eight hours. (Tr.58). 

C . ALJ’s Conclusion

On March 22, 2005, the ALJ denied Plaintiff’s claim for disability benefits following

the five step sequential analysis. (Tr.24-32). At step one, the ALJ found that the Plaintiff had

not engaged in substantial gainful activity since her onset date of January 21, 2003. (Tr.25).

At step two, the ALJ concluded that Plaintiff’s impairments of osteoporosis, RSD,

musculoskeletal pain, and joint pain constituted severe impairments under the Social Security

Act. (Id.). At step three, the ALJ found that these severe impairments did not meet or equal

the criteria of any listed impairment pursuant to Appendix 1 of the Regulations, 20 CFR, Part

404, Subpart P, Appendix 1. (Tr.26). At step four, the ALJ concluded that the Plaintiff

possessed the residual functional capacity to "perform the full range of sedentary exertional

work" with some limitations including only occasionally climbing stairs or ramps, crouching,

crawling, and avoidance of extreme heat or cold. (Id.). In making this determination, the

ALJ gave significant weight to the December 23, 2003, residual functional capacity

assessment by Dr. Hughes, the state non-examining physician to the extent it was "consistent

with the substantive weight of the objective medical evidence. (Tr.31). The ALJ gave "no

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weight" to Plaintiff’s treating physician, Dr. Nasef’s, September 13, 2003, evaluation where

he opined that Plaintiff could only sit for 45 minutes to an hour in an eight-hour day because

of Plaintiff’s worsening pain. (Tr.30; 143-144). In rejecting Dr. Nasef’s findings, the ALJ

concluded that Dr. Nasef was "sympathetic to the claimant and based his opinion on her

subjective allegations of pain, which are not corroborated by his clinical findings on

examination or the objective medical evidence." (Tr.31). In addition, the ALJ rejected the

Plaintiff’s credibility as to the severity of her symptoms, or pain. The ALJ concluded that

her complaints were subjective and did not warrant any additional limitations beyond those

established in his previously determined residual functional capacity evaluation. (Tr.30).

Thus, at step five, based upon the ALJ’s findings regarding the Plaintiff’s capabilities, and

the hypothetical posed to the vocational expert, the ALJ concluded that Plaintiff could

perform her past relevant work as a line worker. (Tr.31). 

III. Standard of Review

This Court must affirm the ALJ’s findings if they are supported by substantial

evidence and free from reversible legal error. Marcia v. Sullivan, 900 F.2d 172, 174 (9th Cir.

1990). Substantial evidence means "more than a mere scintilla" and "such relevant evidence

as a reasonable mind might accept as adequate to support a conclusion." Richardson v.

Perales, 402 U.S. 389, 401 (1971); Clem v. Sullivan, 894 F.2d 328, 330 (9th Cir. 1990).

In determining whether substantial evidence supports a decision, the Court considers

the record as a whole. Richardson, 402 U.S. at 401; Tylitzki v. Shalala, 999 F.2d 1411, 1413

(9th Cir. 1993). If there is sufficient evidence to support the ALJ’s determination, the Court

cannot substitute its own determination. Young v. Sullivan, 911 F.2d 180, 184 (9th Cir.

1990). Where evidence is inconclusive, "questions of credibility and resolution of conflicts

in the testimony are functions solely of the [Commissioner]." Sample v. Schweiker, 694 F.2d

639, 642 (9th Cir. 1982). Therefore, if on the whole record before the Court, substantial

evidence supports the Commissioner’s decisions, this Court must affirm. Hammock v.

Bowen, 879 F.2d 498, 501 (9th Cir. 1989); 42 U.S.C. § 405(g). 

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An ALJ determines an applicant’s eligibility for disability benefits through the

following five stages:

(1) determine whether the applicant is engaged in "substantial gainful

activity;"

(2) determine whether the applicant has a "medically severe impairment or

combination of impairments;"

(3) determine whether the applicant’s impairment equals one of a number

of listed impairments that the Commissioner acknowledges as so severe

as to preclude the applicant from engaging in substantial gainful

activity;

(4) if the applicant’s impairment does not equal one of the "listed

impairments," determine whether the applicant is capable of performing

his or her past relevant work;

(5) if the applicant is not capable of performing his or her past relevant

work, determine whether the applicant "is able to perform other work

in the national economy in view of his [or her] age, education, and

work experience."

Bowen v. Yuckert, 482 U.S. 137, 140-41 (1987) (citing 20 C.F.R. §§ 404.1520(b)-(f)). See

20 C.F.R. § 416.920. At the fifth stage, the burden of proof shifts to the Commissioner.

Penny v. Sullivan, 2 F.3d 953, 956 (9th Cir. 1993). 

IV. Discussion

Plaintiff raises three issues on appeal: (1) whether the ALJ erred in rejecting the

opinion of Plaintiff’s treating physician, Dr. Nasef, regarding Plaintiff’s ability to perform

work related activities; (2) whether the ALJ erred in rejecting Plaintiff’s credibility as to the

severity of her symptoms; and (3) whether the ALJ erred in posing a hypothetical to the

vocational expert based upon the assessment of a non-testifying, non-examining state agency

physician. The Court will address these issues below. 

A. ALJ’s Rejection of Opinion by Dr. Nasef

Plaintiff takes exception with the ALJ’s rejection of the limitation asserted by

Plaintiff’s treating physician, Dr. Nasef, that Plaintiff could only sit for forty-five minutes

to an hour of an eight-hour work day due to Plaintiff’s pain associated with Plaintiff’s

degenerative disc and disease of the spine. (Tr.143-44). Plaintiff argues that the ALJ failed

to provide the requisite clear and convincing or even specific and legitimate reasons in

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rejecting Dr. Nasef’s findings. Defendant, on the other hand, contends that the controverted

findings of Dr. Nasef were properly rejected by the ALJ. 

"The ALJ may disregard the treating physician's opinion whether or not that opinion

is contradicted." Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir.1989). When presented

with conflicting medical opinions, the ALJ must determine credibility and resolve the

conflict. Matney v. Sullivan, 981 F.2d 1016, 1019 (9th Cir.1992). Greater weight must be

given to the opinion of treating physicians, and in the case of a conflict "the ALJ must give

specific, legitimate reasons for disregarding the opinion of the treating physician." Id. The

ALJ can meet this burden by setting out a detailed and thorough summary of the facts and

conflicting clinical evidence, stating his interpretation thereof, and making findings. Thomas

v. Barnhart, 278 F.3d 947, 957 (9th Cir. 2002) (quoting Magallanes v. Bowen, 881 F.2d 747,

751 (9th Cir.1989)).

In reviewing the record on this issue, the Court agrees with the Defendant that the ALJ

did meet his burden in rejecting Dr. Nasef’s opinion regarding Plaintiff’s limitation as to

sitting during an eight-hour day. Although the ALJ’s determination is somewhat short, the

ALJ adequately provided specific and legitimate reasons grounded in the record in rejecting

Dr. Nasef’s controverted findings. Most notably, the ALJ determined that Dr. Nasef’s

limitation was not supported by his "clinical findings" or the objective medical evidence.

(Tr.31). In reviewing Dr. Nasef’s records, it is apparent that the ALJ’s determination on this

point is supported by substantial evidence. For instance, in reviewing Dr. Nasef’s records

prior to his work related activities assessment on September 13, 2003, it is apparent that no

such drastic limitation regarding Plaintiff’s ability to sit for an extended period is suggested.

For instance, on Plaintiff’s May 10, 2003 visit, Dr. Nasef diagnosed possible osteoarthritis

with degenerative disc disease of the cervical spine as well as noted that Plaintiff presented

with "no acute distress." (Tr.152). In fact, the visits leading up to the September 13, 2003,

assessment by Dr. Nasef, including on the very day, suggest that Plaintiff did not appear to

be in distress to support such a drastic limitation. (Tr.151,147,142). Moreover, in Plaintiff’s

visits with Dr. Nasef the only notable limitations suggested a decreased or tender range of

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It is relevant to note that Dr. Hughes findings are also consistent with the work

related assessment performed by P.A. Sharp. (Tr.145-46).

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motion. (152, 151,147,142). None of Plaintiff’s treatment records with Dr. Nasef support

such a drastic limitation as to Plaintiff’s ability to sit during an eight-hour day. In addition,

as noted by the ALJ, in finding such a drastic limitation, Dr. Nasef appears to have relied on

Plaintiff’s subjective complaints of pain, rather than the medical record, which is a properly

considered relevant factor in discounting such an opinion. See Fair v. Bowen, 885 F.2d 597,

605 (9th Cir. 1991). Also, in rejecting Dr. Nasef’s findings, the ALJ afforded weight to the

opinion of the state non-examining physician, Dr. Hughes, (Tr.205-12), who found no such

significant limitations regarding Plaintiff’s ability to perform sedentary work. Contrary to

Plaintiff’s argument, the Court does not find any error with the ALJ’s reliance on this

determination from a non-examining physician as it appears consistent with the medical

record regarding Plaintiff’s limitations. See Morgan v. Apfel, 169 F.3d 595, 602 (9th

Cir.1999) (stating that "rejection of opinion of a treating or examining physician [may] be

based, in part, on the testimony of a nontreating, nonexamining physician.") (emphasis

original). In the instant case, the record reveals that the ALJ properly evaluated and rejected

the limitation stated by Dr. Nasef based upon the medical record and, in part, the opinion of

the state physician, Dr. Hughes.1

 Thus, the Court finds that the ALJ met his burden in

providing specific and legitimate reasons supported by the record in rejecting the significant

limitations suggested by Plaintiff's physician, Dr. Nasef. 

B. Rejection of Plaintiff’s Credibility as to Severity of Her Symptoms

Plaintiff also asserts that the ALJ committed error in rejecting the severity of

Plaintiff’s symptoms such as her pain level impacting her ability to work. Defendant, on the

other hand, contends that the ALJ sufficiently complied with his obligation in rejecting

certain aspects of Plaintiff’s testimony. 

"[I]f there is medical evidence establishing an objective basis for some degree of pain

and related symptoms, and no evidence affirmatively suggesting that the claimant was

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malingering, the Secretary's reason for rejecting the claimant's testimony must be clear and

convincing and supported by specific findings." Dodrill v. Shalala, 12 F.3d 915, 918 (9th

Cir. 1993). General findings are insufficient, rather the ALJ must identify what evidence is

not credible and what evidence undermines the claimant's complaints. Id. In the instant

case, there is no issue with the underlying impairments or the lack of evidence of

malingering, rather the issue centers on whether the ALJ provided the requisite clear and

convincing reasons supported by the evidence upon rejecting Plaintiff's credibility regarding

the severity of her symptoms.

In reviewing the record on this point, the Court finds that the ALJ properly considered

relevant factors in reaching his credibility determination. See Magallenes v. Bowen, 881

F.2d 747, 750 (9th Cir. 1989) (stating that "the ALJ is responsible for determining credibility

and resolving conflicts in medical testimony."). For instance, the ALJ cited multiple relevant

factors recognized by the Ninth Circuit in discounting Plaintiff’s testimony as to the severity

of her symptoms. See Bunnell v. Sullivan, 947 F.2d 341, 346-47 (9th Cir. 1991) (noting

relevant factors to include the nature, duration, location, onset, intensity of pain, functional

restrictions and claimant's daily activities.); see also SSR 96-7. The ALJ cited such factors

as the lack of objective medical evidence supporting Plaintiff’s testimony that she could not

sit for more than 30 minutes. As noted above, such a limitation is simply not supported by

the medical record. In addition, the ALJ cited contradictory testimony of Plaintiff to that of

the medical record regarding the usefulness of the epidural injections she received. (Tr.30;

242). Moreover, the ALJ noted that shortly after Plaintiff’s alleged onset date, P.A. Sharp,

recommended that Plaintiff return to "light" work. (Tr.160). Finally, the ALJ noted that

none of the recent doctors treating Plaintiff opined that Plaintiff was not capable of working.

While Plaintiff clearly disagrees with the ALJ’s determination, the Court’s review is limited

to whether the ALJ provided the requisite clear and convincing reasons to support his

determination. In reviewing the cited bases of the ALJ, the Court determines that the ALJ

met this obligation. 

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Plaintiff has also requested that this matter be remanded because of certain

"inaudible" notations in the transcript; however, in reviewing the record none of these

notations materially bear on this Court’s determination, thus making the requested remand

unnecessary. 

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C. ALJ’s Stated Hypothetical to Vocational Expert Re: Plaintiff’s

Limitations.

Lastly, Plaintiff contends that it was improper for the ALJ to rely on Dr. Hughes in

formulating his hypothetical to the vocational expert regarding the Plaintiff’s ability to

engage in work. Plaintiff contends that in no circumstances is it appropriate for an ALJ to

rely on a non-testifying non-examining physician in making an assessment of a claimant’s

limitations. Thus, in this case, Plaintiff contends that ALJ’s hypothetical to the vocational

expert based upon the Plaintiff’s ability to perform sedentary work was error as such a

determination arose from Dr. Hughes’ residual functional capacity assessment. (Tr.205-12).

However, as noted above, it is not error for any ALJ to rely on a non-examining physician

when his or her findings are supported by independent medical evidence in the record. See

 Morgan 169 F.3d at 602; see also Tackett v. Apfel, 180 F.3d 1094, 1101 (9th Cir. 1999)

(stating ALJ's depiction of limitations required to be accurate, detailed and supported by

medical evidence.). As discussed above, Dr Hughes’ findings as to Plaintiff’s ability to

perform sedentary work are supported as there is no credible evidence in the record

suggesting that Plaintiff is further limited. As such, the Court finds no error with the ALJ’s

reliance upon Dr. Hughes’ residual functional capacity assessment and ultimate conclusion

based upon the hypothetical posed to the vocational expert. 

V. Summary

The Court finds that the ALJ adequately complied with his obligation in rejecting

Plaintiff’s treating physician’s opinion and Plaintiff’s credibility as to the severity of her

symptoms. In addition, the ALJ properly relied, in part, upon the findings of the Dr. Hughes

in determinating Plaintiff’s residual functional capacity.2

 

Accordingly,

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IT IS HEREBY ORDERED denying Plaintiff’s Motion for Summary Judgment.

(Dkt.#14).

IT IS FURTHER ORDERED denying Plaintiff’s Motion for Remand. (Dkt.#15).

IT IS FURTHER ORDERED granting Defendant’s Motion for Summary Judgment.

(Dkt.#23). 

IT IS FURTHER ORDERED directing the Clerk to enter judgment accordingly.

DATED this 29th day of March, 2007.

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