Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_06-cv-00005/USCOURTS-alsd-1_06-cv-00005-0/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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IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

HATTIE EMANUEL, :

Plaintiff, :

vs. : CA 06-0005-C

JO ANNE B. BARNHART, :

Commissioner of Social Security,

:

Defendant.

MEMORANDUM OPINION AND ORDER

Plaintiff brings this action pursuant to 42 U.S.C. § 405(g), seeking

judicial review of a final decision of the Commissioner of Social Security

denying her claim for disability insurance benefits. The parties have consented

to the exercise of jurisdiction by the Magistrate Judge, pursuant to 28 U.S.C.

§ 636(c), for all proceedings in this Court. (Doc. 16 (“In accordance with the

provisions of 28 U.S.C. 636(c) and Fed.R.Civ.P. 73, the parties in this case

consent to have a United States Magistrate Judge conduct any and all

proceedings in this case . . . and order the entry of a final judgment, and

conduct all post-judgment proceedings.”); see also Doc. 17 (order of

reference)) Upon consideration of the administrative record, plaintiff's

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1 Any appeal taken from this memorandum opinion and order and judgment shall

be made to the Eleventh Circuit Court of Appeals. (See Doc. 16 (“An appeal from a judgment

entered by a Magistrate Judge shall be taken directly to the United States Court of Appeals for

this judicial circuit in the same manner as an appeal from any other judgment of this district

court.”))

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proposed report and recommendation, the Commissioner's proposed report and

recommendation, and the parties' arguments at the August 23, 2006 hearing

before the Court, it is determined that the Commissioner's decision denying

benefits should be reversed and remanded for further proceedings not

inconsistent with this decision.1

Plaintiff alleges disability due to status-post hysterectomy with surgical

complications (primarily bladder problems), depression, hypertension with

hypertensive heart disease, and status-post brain infarct with dizziness. The

Administrative Law Judge (ALJ) made the following relevant findings:

1. The claimant meets the nondisability requirements for a

period of disability and disability insurance benefits set forth in

Section 216(i) of the Social Security Act and is insured for

benefits through the date of this decision.

2. The claimant has not engaged in substantial gainful

activity since the alleged onset of disability.

3. The claimant has a depressive disorder and a history of

hysterectomy with surgical complications.

4. The claimant has been diagnosed with various

impairments. However, the mere diagnosis of an impairment

does not automatically reflect or establish the presence of

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functional restrictions. The medical evidence, as summarized

herein, clearly establishes that the claimant’s diagnosed

impairments do not reasonably result in more than minimal

limitations in her ability to successfully perform the demands of

work or work-like activities for a period of at least 12

consecutive months. There is a glaring absence of radiographic

studies, laboratory analyses and diagnostic evaluations

establishing any significant disease process that could be

expected to inhibit the claimant’s mental or physical functional

capacity for 12 months. Quite simply, the claimant experienced

complications from her hysterectomy, was treated for such

complications and has not experienced residual effects from her

surgeries that can objectively be found to result in long-term

functional restrictions.

5. It is the claimant’s responsibility to provide medical

evidence that supports her alleged disability. See Nathan L.

Ellison v. Jo Anne B. Barnhart, supra. The claimant has failed

to meet this burden in this cause.

6. The claimant does not have an impairment, or

combination of impairments, that has resulted in more than

minimal functional limitations for a period of at least 12

consecutive months; therefore, the claimant does not have a

“severe” impairment under the Act (20 CFR § 404.1520).

7. The hypothetical posed to the vocational expert by the

claimant’s representative was not objective in nature and is

unsupported by the totality of the clinical findings. As such, the

vocational expert’s response to this hypothetical question cannot

be given determinative weight.

8. The claimant was not under a “disability,” as defined in

the Act, at any time through the date of this decision (20 CFR §

404.1520(c)). 

(Tr. 35-36) The Appeals Council affirmed the ALJ's decision (Tr. 9-11) and

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thus, the hearing decision became the final decision of the Commissioner of

Social Security.

DISCUSSION

This Court must determine whether the Commissioner’s decision to

deny claimant benefits on the basis that she did not have a severe mental or

physical impairment for twelve consecutive months is supported by substantial

evidence. Substantial evidence is defined as more than a scintilla and means

such relevant evidence as a reasonable mind might accept as adequate to

support a conclusion. Richardson v. Perales, 402 U.S. 389, 91 S.Ct. 1420, 28

L.Ed.2d 842 (1971). "In determining whether substantial evidence exists, we

must view the record as a whole, taking into account evidence favorable as

well as unfavorable to the [Commissioner's] decision." Chester v. Bowen, 792

F.2d 129, 131 (11th Cir. 1986).

The Commissioner's severity regulation requires the claimant to make

a threshold showing that she has an impairment which significantly limits her

physical or mental ability to perform basic work activities. 20 C.F.R. §§

416.920(c), 416.921(a) (1998); Bowen v. Yuckert, 482 U.S. 137, 147 n.5, 107

S.Ct. 2287, 2294 n.5, 96 L.Ed.2d 119 (1987). Basic work activities include

functions such as walking, standing, sitting, lifting, pushing, pulling, reaching,

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2 It is clear that in Yuckert, the Supreme Court did not impose a standard higher

than the de minimis standard set out in Brady. See Stratton v. Bowen, 827 F.2d 1447, 1451 n.7,

1452 n.9, 1452-1453 (11th Cir. 1987).

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carrying, or handling; understanding, carrying out and remembering simple

instructions; use of judgment, responding appropriately to supervision, coworkers, and usual work situations; and dealing with changes in a routine work

setting. 20 C.F.R. § 416.921(b). An impairment can be considered not severe

"only if it is a slight abnormality which has such a minimal effect on the

individual that it would not be expected to interfere with the individual's ability

to work, irrespective of age, education, or work experience." Brady v.

Heckler, 724 F.2d 914, 920 (11th Cir. 1984); see Yuckert, supra, 482 U.S. at

153, 107 S.Ct. at 2297 ("The severity regulation increases the efficiency and

reliability of the evaluation process by identifying at an early stage those

claimants whose medical impairments are so slight that it is unlikely they

would be found to be disabled even if their age, education and experience were

taken into account").2

 

Inherent in a finding of a medically not severe impairment or

combination of impairments is the conclusion that the

individual’s ability to engage in SGA [substantial gainful

activity] is not seriously affected. Before this conclusion can be

reached, however, an evaluation of the effects of the

impairment(s) on the person’s ability to do basic work activities

must be made. A determination that an impairment(s) is not

severe requires a careful evaluation of the medical findings

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which describe the impairment(s) and the informed judgment

about its (their) limiting effects on the individual’s physical and

mental ability(ies) to perform basic work activities; thus, an

assessment of the function is inherent in the medical process

itself.

SSR 85-28. The claimant's burden at step two of the sequential evaluation

process is mild. McDaniel v. Bowen, 800 F.2d 1026, 1031 (11th Cir. 1986)

(“Step two is a threshold inquiry. It allows only claims based on the most

trivial impairments to be rejected."). 

The administrative record in this case is replete with evidence

establishing that the claimant suffered from a history of hysterectomy with

surgical complications for a period of twelve continuous months. (See

generally Tr. 135-1308) Emanuel was admitted to Springhill Memorial

Hospital on November 7, 2002 for an abdominal hysterectomy, which was

accomplished laparoscopically. (See id. at 137-139) Plaintiff’s bladder was

lacerated during the hysterectomy and initially sutured (Tr. 138); however, two

additional bladder surgeries were required before Emanuel was released from

the hospital on December 10, 2002 (compare Tr.1040 (“Recently at another

medical institution she underwent a hysterectomy complicated by bladder

injury. This required two subsequent surgical procedures to repair the bladder

injury.”) with Tr. 135 & 1048 (patient discharged from the hospital on

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3 On April 14, 2003, Dr. J. Carlton Hardwick, noted a history of congestive heart

failure and diagnosed hypertension with hypertensive heart disease. (Tr. 1086; see also Tr. 1089

(same noted on January 27, 2003))

4 Emanuel was discharged from the hospital on December 22, 2002. (Tr. 1038)

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December 10, 2002)). During her hospitalization, Emanuel experienced

congestive heart failure, acute renal failure, and respiratory failure; she was

placed on a ventilator for a three-week period. (See, e.g., Tr. 941, 1035, 1060

& 1076) Emanuel was readmitted to Springhill Memorial Hospital seven days

after her discharge, on December 17, 2002, with dyspnea (shortness of breath)

and tachycardia (racing heart); her admitting physician noted that she had

long-standing hypertension,3

 which was uncontrolled, and that she was “ill

appearing” and “frail[.]” (Tr. 1035 & 1038)4

On April 28, 2003, Dr. James W. Sewell, plaintiff’s primary treating

physician and the individual who performed her hysterectomy, opined that

plaintiff was unable to “work 40 hours a week at this time” given the

symptoms she was exhibiting (Tr. 1083); indeed, Sewell completed a Physical

Capacities Evaluation on this date and indicated thereon that Emanuel could

only sit a total of three hours in an 8-hour workday, stand and/or walk a total

of three hours in an 8-hour workday, and that she had a total restriction of

activities involving unprotected heights, driving automotive equipment, and

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5 On February 17, 2003, Dr. Sewell made the following observations on a social

security determination form: “[While in the hospital,] [s]he later developed ARDS (acute

respiratory distress syndrome) that very often causes death. She was on Life Support for several

weeks, developed kidney failure, requiring dialysis for several weeks. Following recovery, she

has been to rehab but still has marked muscular weakness, tremor of hands, and memory loss.

These will probably continue. She is still under the care of a Urologist & Internists[.]” (Tr. 1113) 

6 Plaintiff’s testimony that her bladder problems are attributable to complications

from her surgeries is supported by the diagnoses of numerous physicians in the late summer of

2003 into early 2004 of status-post bladder injury. (See, e.g., Tr. 1174 (Dr. W.T. Stevens’

impressions on August 25, 2003, consisted of the following: status post iatrogenic bladder

injury; overactive bladder; and hematuria); Tr. 1189 (Dr. W. Newton’s assessments on October

29, 2003 included iatrogenic bladder injury); Tr. 1241 (status-post total hysterectomy and

bladder injury with complications))

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exposure to dust fumes and gases (Tr. 1084).5 Beginning in early 2003, and

throughout the summer and fall of 2003 and into 2004, plaintiff consistently

complained of and was treated for bladder problems, including chronic cystitis

(bladder infection), abdominal pain, burning on urination, and urinary

frequency. (Compare Tr. 1156, 1159, 1172-1174 & 1189 with Tr. 43

(plaintiff’s hearing testimony on January 20, 2004, that the complications from

the surgery included “[f]requent urine, bladder spasms, lower abdominal pain

on the pelvic, raw intestines.”))6 While Dr. Sewell notified MetLife on

November 13, 2003, that Emanuel had recovered to return to normal activity

as of November 1, 2003, it is clear not only that Sewell noted that plaintiff

could not perform strenuous work but, as well, that the last time Sewell

examined plaintiff was on September 29, 2003. As established above, of

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7 This Court will not belabor the issue any more than necessary; however, in

addition to the fact that plaintiff clearly experienced bladder complications from her November,

2002 hysterectomy for at least a 12-month continuous period, she could have been found to

suffer from a number of other severe impairments including, the following: depression (Tr. 46,

1078-1081, 1218-1219 & 1284-1289); hypertension with hypertensive heart disease (Tr. 939,

948, 956, 1007, 1035-1038, 1086, 1089, 1090); and status-post brain infarct with dizziness (Tr.

1223-1224 & 1236; see also Tr. 1275). 

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course, plaintiff continued to be treated for bladder problems, as a

complication of her hysterectomy, well into 2004. 

Taking into account the foregoing evidence, it is impossible for this

Court to find that substantial evidence supports the ALJ’s determination that

plaintiff did not suffer from a severe physical or mental impairment for a

continuous 12 month period.7

 The evidence recited above clearly establishes

that, at the very least, plaintiff suffered from the severe impairment of statuspost hysterectomy with surgical complications, most notably severe bladder

problems. Dr. Sewell’s finding that plaintiff could return to normal activity,

albeit not strenuous work, as of November 1, 2003, fails to establish that

plaintiff’s impairment was not severe for a continuous period of twelve

months. In fact, Dr. Sewell’s finding establishes the contrary. By limiting

plaintiff from performing strenuous work plaintiff’s treating physician

provided a crucial piece of evidence, particularly when combined with the

evidence from other sources that plaintiff was still being treated for bladder

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8 The Court notes that plaintiff’s problems with urinary frequency and urgency

would certainly impact her ability to engage in work. (Cf. Tr. 51-52 (“Mr. Miller, I’d like you to

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problems, establishing that plaintiff’s post-surgical bladder problems

obviously did not constitute a slight or trivial impairment which had no more

than minimal functional limitations on her physical ability to perform basic

work activities for a period of 12 continuous months. While this information

may have been relevant to the ALJ’s analysis at the fourth and fifth steps of the

sequential evaluation process, it fails to inform the ALJ’s conclusion that

plaintiff did not have a severe impairment for 12 continuous months. In other

words, the issue at this step is not whether this impairment was disabling, see

42 U.S.C. § 423(d)(1) (“The term ‘disability’ means– inability to engage in

any substantial gainful activity by reason of any medically determinable

physical or mental impairment which can be expected to result in death or

which has lasted or can be expected to last for a continuous period of not less

than 12 months[.]”), but whether such impairment results in more than minimal

functional limitations and restrictions on a claimant’s ability to engage in

work-related activity; in this case, the clear answer is that plaintiff’s posthysterectomy bladder problems constituted more than a trivial impairment and

resulted in more than a minimal impact on her ability to engage in work and

work-like activity.8 The ALJ’s determination that claimant did not have a

Case 1:06-cv-00005-C Document 18 Filed 09/08/06 Page 10 of 12
assume a person the same age, education, and work experience as the claimant, further assume

such person suffers from coronary artery disease, diverticulosis, bladder problems manifesting

itself as frequent urination, and pain and depression. I’d like you to further assume that such

individual, because of the bladder problems, that they’re experiencing, would have to urinate

about two or three times an hour, and would have to be very close to the bathroom, and would

have one to two accidents a week with said individual would probably soil their clothes and have

to change their clothes. I would like you to further assume that such an individual suffers from

pain that is, at least, moderately severe for three hours during a normal workday. Assuming all of

those facts to be true, would there be jobs that exist in substantial numbers in the national or

regional economy that an individual with those impairments could perform? A I don’t believe

that there would be. Q What would the reasons for that be? A It would be a combination of the

moderately severe pain and the accidents somebody would have.”)) 

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severe impairment for 12 consecutive months is not supported by substantial

evidence.

CONCLUSION

The Court ORDERS that the decision of the Commissioner of Social

Security denying plaintiff benefits be reversed and remanded pursuant to

sentence four of § 405(g), see Melkonyan v. Sullivan, 501 U.S. 89, 111 S.Ct.

2157, 115 L.Ed.2d 78 (1991), for further proceedings not inconsistent with this

decision. The remand pursuant to sentence four of § 405(g) makes the plaintiff

a prevailing party for purposes of the Equal Access to Justice Act, 28 U.S.C.

§ 2412, Shalala v. Schaefer, 509 U.S. 292, 113 S.Ct. 2625, 125 L.Ed.2d 239

(1993), and terminates this Court’s jurisdiction over this matter.

DONE and ORDERED this the 8th day of September, 2006.

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s/WILLIAM E. CASSADY 

UNITED STATES MAGISTRATE JUDGE

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