The opinion
UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF FLORIDA
TAMPA DIVISION
RUEBEN OLIVARES,
Plaintiff,
v. Case No.: 8:23-cv-1027-DNF
COMMISSIONER OF SOCIAL
SECURITY,
Defendant.
OPINION AND ORDER
Plaintiff Rueben Olivares seeks judicial review of the final decision of the
Commissioner of the Social Security Administration (“SSA”) denying his claim for
a period of disability and disability insurance benefits. The Commissioner filed the
Transcript of the proceedings (“Tr.” followed by the appropriate page number), and
the parties filed legal memoranda setting forth their positions. As explained below,
the decision of the Commissioner is AFFIRMED under § 205(g) of the Social
Security Act, 42 U.S.C. § 405(g).
I. Social Security Act Eligibility, Standard of Review, Procedural
History, and the Commissioner’s Decision
A. Social Security Eligibility
The law defines disability as the inability to do 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 twelve months. 42 U.S.C. §§ 416(i), 423(d)(1)(A),
1382c(a)(3)(A); 20 C.F.R. §§ 404.1505(a), 416.905(a). The impairment must be
severe, making the claimant unable to do his previous work, or any other substantial
gainful activity which exists in the national economy. 42 U.S.C. §§ 423(d)(2)(A),
1382c(a)(3)(A); 20 C.F.R. §§ 404.1505–404.1511, 416.905–416.911.
B. Standard of Review
The Commissioner’s findings of fact are conclusive if supported by
substantial evidence. 42 U.S.C. § 405(g). “Substantial evidence is more than a
scintilla and is such relevant evidence as a reasonable person would accept as
adequate to support a conclusion. Even if the evidence preponderated against the
Commissioner’s findings, we must affirm if the decision reached is supported by
substantial evidence.” Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1158 (11th
Cir. 2004). In conducting this review, this Court may not reweigh the evidence or
substitute its judgment for that of the administrative law judge, but must consider
the evidence as a whole, taking into account evidence favorable as well as
unfavorable to the decision. Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1178
(11th Cir. 2011) (citation omitted); Foote v. Chater, 67 F.3d 1553, 1560 (11th Cir.
1995); Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990). Unlike findings of
fact, the Commissioner’s conclusions of law are not presumed valid and are
reviewed under a de novo standard. Keeton v. Dep’t of Health & Hum. Servs., 21
F.3d 1064, 1066 (11th Cir. 1994); Maldonado v. Comm’r of Soc. Sec., No. 20-14331,
2021 WL 2838362, at *2 (11th Cir. July 8, 2021); Martin, 894 F.2d at 1529. “The
[Commissioner’s] failure to apply the correct law or to provide the reviewing court
with sufficient reasoning for determining that the proper legal analysis has been
conducted mandates reversal.” Keeton, 21 F.3d at 1066.
The Commissioner must follow five steps in evaluating a claim of disability.
20 C.F.R. §§ 404.1520, 416.920. At the first step, the Commissioner must determine
whether the claimant is currently engaged in substantial gainful employment. 20
C.F.R. § 404.1520(a)(4)(i), (b); 20 C.F.R. § 416.920(a)(4)(i), (b). At step two, the
Commissioner must determine whether the impairment or combination of
impairments from which the claimant allegedly suffers is “severe.” 20 C.F.R. §
404.1520(a)(4)(ii), (c); 20 C.F.R. § 416.920(a)(4)(ii), (c). At step three, the
Commissioner must decide whether the claimant’s severe impairments meet or
medically equal a listed impairment. 20 C.F.R. § 404.1520(a)(4)(iii), (d); 20 C.F.R.
§ 416.920(a)(4)(iii), (d). If the Commissioner finds the claimant’s severe
impairments do not meet or medically equal a listed impairment, then the
Commissioner must determine whether the claimant has the residual functional
capacity (“RFC”) to perform his past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv),
(e)–(f); 20 C.F.R. § 416.920(a)(4)(iv), (e)–(f).
If the claimant cannot perform his past relevant work, the Commissioner must
determine at step five whether the claimant’s RFC permits him to perform other
work that exists in the national economy. 20 C.F.R. §§ 404.1520(a)(4)(v), (g),
416.920(a)(4)(v), (g). At the fifth step, there are two ways in which the ALJ may
establish whether the claimant is capable of performing other work available in the
national economy. The first is by applying the Medical Vocational Guidelines, and
the second is by the use of a vocational expert. Phillips v. Barnhart, 357 F.3d 1232,
1239-40 (11th Cir. 2004); Atha v. Comm’r, Soc. Sec. Admin., 616 F. App’x 931, 933
(11th Cir. 2015).
The claimant bears the burden of proof through step four. Atha, 616 F. App’x
at 933. If the claimant meets this burden, then the burden temporarily shifts to the
Commissioner to establish the fifth step. Id.; 20 C.F.R. § 404.1520(a)(4)(v), (g); 20
C.F.R. § 416.920(a)(4)(v), (g). If the Commissioner presents evidence of other work
that exists in significant numbers in the national economy that the claimant is able
to perform, only then does the burden shift back to the claimant to prove he is unable
to perform these jobs. Atha, 616 F. App’x at 993.
C. Procedural History
Plaintiff applied for a period of disability and disability insurance benefits on
February 2, 2021, alleging disability beginning January 18, 2021. (Tr. 71, 180-90).
The application was denied initially and on reconsideration. (Tr. 71, 72). Plaintiff
requested a hearing and on October 17, 2022, a hearing was held before
Administrative Law Judge Glen H. Watkins (“ALJ”). (Tr. 34-54). On December 23,
2022, the ALJ entered a decision finding Plaintiff had not been disabled from
January 18, 2021, through the date of the decision. (Tr. 17-28). On April 4, 2023,
the Appeals Council denied Plaintiff’s request for review. (Tr. 1-5).
Plaintiff began this action by Complaint (Doc. 1) filed on May 9, 2023, and
the case is ripe for review. The parties consented to proceed before a United States
Magistrate Judge for all proceedings. (Doc. 13).
D. Summary of ALJ’s Decision
In this matter, the ALJ found Plaintiff meets the insured status requirements
of the Social Security Act through December 31, 2025. (Tr. 19). At step one of the
sequential evaluation, the ALJ found that Plaintiff had not engaged in substantial
gainful activity since January 18, 2021, the alleged onset date. (Tr. 19). At step two,
the ALJ found that Plaintiff had the following severe impairments: “anxiety
disorder; major depressive disorder; post-traumatic stress disorder (PTSD); lumbar
disc disease; left foot calcaneal spur; osteoarthritis of the ankles, feet, knees, and
hands; and left thumb trigger finger.” (Tr. 19). At step three, the ALJ found that
Plaintiff did not have an impairment or combination of impairments that meets or
medically equals the severity of any of the listed impairments in 20 C.F.R. Part 404,
Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526). (Tr. 19).
Before proceeding to step four, the ALJ found that Plaintiff had the following
RFC:
After careful consideration of the entire record, the
undersigned finds that the claimant has the residual functional
capacity to lift up to 20 pounds occasionally and lift and carry
up to 10 pounds frequently and light work as defined in 20
[C.F.R. §] 404.1567(b). The claimant can stand and/or walk for
approximately 6 hours per 8-hour workday and sit for
approximately 6 hours per 8-hour workday. All postural
positions are limited to occasional including climbing ladders,
ropes, or scaffolds, climbing ramps or stairs, balancing,
stooping, crouching, kneeling and crawling. Gross
manipulation bilaterally is limited to frequent. The claimant
can understand, remember, carry out and perform simple
routine tasks and instructions and with reasoning level 1 or 2.
(Tr. 22).
At step four, the ALJ determined that Plaintiff was not capable of performing
his past relevant work as a bus driver, tractor trailer truck driver, and HVAC installer.
(Tr. 27). At step five, the ALJ found that considering Plaintiff’s age (51 years old on
the alleged disability onset date), education (at least high school), work experience,
and RFC, there were jobs that existed in significant numbers in the national economy
that Plaintiff could perform. (Tr. 27). Specifically, the vocational expert testified that
a person with Plaintiff’s limitations could perform such occupations as:
(1) Small products assembler, DOT1 706.684-022, light, SVP 2
(2) Scale operator, DOT 555.687-010, light, SVP 2
1 DOT refers to the Dictionary of Occupational Titles.
(3) Collator operator, DOT 208.685-010, light, SVP 2
(Tr. 28). The ALJ concluded that Plaintiff had not been under a disability from
January 18, 2021, through the date of the decision. (Tr. 28).
II. Analysis
On appeal, Plaintiff raises four issues:
(1) Whether the ALJ failed to develop the record;
(2) Whether the ALJ’s RFC assessment for light work is supported by
substantial evidence;
(3) Whether the ALJ failed to properly consider Plaintiff’s credibility and
subjective complaints; and
(4) Whether the ALJ failed to consider a combination of impairments.
(Doc. 26, p. 3).
A. Duty to Develop the Record
Plaintiff contends that even though the SSA sent Plaintiff to a physical
consultative examination and a mental consultative examination, neither provider
supplied a function-by-function assessment. (Doc. 26, p. 3-7). Plaintiff argues that
the ALJ failed to develop the record by not recontacting these providers to obtain
function-by-function assessments and argues the record does not contain the
necessary information for the ALJ to assess an RFC. (Doc. 26, p. 3-7). Without this
type of analysis, Plaintiff argues that the ALJ had no basis to find Plaintiff able to
perform light work with additional limitations. (Doc. 26, p. 3). The Court finds no
basis for remand on this issue.
A plaintiff bears the burden of proving he is disabled and is responsible “for
producing evidence in support of his claim.” Ellison v. Barnhart, 355 F.3d 1272,
1275 (11th Cir. 2003). Even so, “[i]t is well-established that the ALJ has a basic duty
to develop a full and fair record.” Id. See 20 C.F.R. § 416.945(a)(3) (“However,
before we make a determination that you are not disabled, we are responsible for
developing your complete medical history, including arranging for a consultative
examination(s) if necessary, and making every reasonable effort to help you get
medical reports from your own medical sources.”).2
Even though an ALJ has this duty, he “is not required to order a consultative
examination as long as the record contains sufficient evidence for the administrative
law judge to make an informed decision.” Ingram v. Comm’r of Soc. Sec. Admin.,
496 F.3d 1253, 1269 (11th Cir. 2007). Further, the ordering of a consultative
examination or recontacting a consultative examiner is a discretionary matter for the
ALJ and should be sought “‘to try to resolve an inconsistency in the evidence or
when the evidence as a whole is insufficient to support a determination or decision’
2 When a claimant is not represented at a hearing and has not waived her right to representation,
then the ALJ has a “special duty” to develop the record. See Brown v. Shalala, 44 F.3d 931, 934-
35 (11th Cir. 1995). In this case, Plaintiff was represented at the hearing and thus the ALJ only
had a basic duty to develop the record. (Tr. 34-54).
on the claim.” Banks for Hunter v. Comm’r, Soc. Sec. Admin., 686 F. App’x 706,
713 (11th Cir. 2017) (quoting 20 C.F.R. § 416.919a(b)).
On August 21, 2021, Ladapo Shyngle, M.D. from Newsome Medical
conducted a consultative examination of Plaintiff. (Tr. 473-80). On examination, he
found Plaintiff had a generally normal exam with “no pain discomfort,” except: mild
to moderate tenderness in the lift hip, right knee, right ankle; moderate cervical
tenderness; moderate difficulty with tandem walk, heel walk, toe walk, squatting;
and was unsteady to hop. (Tr. 475-76). His impression was, “[c]laimant has
moderate restriction for strenuous physical activities because of his musculoskeletal
pains.” (Tr. 477).
In the decision, the ALJ thoroughly summarized Dr. Shyngle’s report. (Tr.
25). The ALJ found his opinion, “that the claimant has moderate restrictions for
strenuous physical activities due to musculoskeletal pains is not persuasive. The
moderate restrictions and strenuous activities were not defined by Dr. Shyngle.
Therefore, supportability and consistency cannot be determined (6F).” (Tr. 26).
While Dr. Shyngle did not supply a function-by-function analysis, the State
agency medical consultant, Gordon Couch, M.D. did. (Tr. 59-61). Dr. Couch found
Plaintiff able to stand or walk about 6 hours in an 8 -hour workday, sit for 6 hours
in an 8-hour workday, was limited to frequently climbing ramps or stairs,
occasionally climbing ladders/ropes/scaffolds, and limited right handling. (Tr. 59-
60). To reach these limitations, Dr. Couch considered the medical evidence of
record, which included a detailed summary of Dr. Shyngle’s consultative
examination. (Tr. 61).
In the decision, the ALJ considered Dr. Couch’s findings and found them
partially persuasive. (Tr. 26). The ALJ noted that Dr. Couch assessed light exertion
with postural and manipulative limitations, but found Plaintiff more limited:
The prior administrative findings are supportable and
inconsistent [sic] in terms of the light exertion. However, the
undersigned finds that the evidence supports slightly more
restrictive postural limitations and also bilateral limitations for
gross manipulation rather than just the right upper extremity.
The prior administrative findings were made in September
2021, and there are a number of subsequent records including
from Gessler Clinic in 2021 and 2022, as well as a lumbar spine
MRI from December 2021 which support the more restrictive
limitations herein.
(Tr. 26). Thus, the ALJ considered Dr. Couch’s findings – which included a review
of Dr. Shyngle’s examination findings – and incorporated some of these findings,
but also considered more recent medical evidence to add additional limitations in the
RFC. Plaintiff failed to show that the evidence as a whole was insufficient to support
the ALJ’s RFC assessment for physical limitations.
Likewise, Plaintiff argues that the ALJ should have obtained a function-by-
function report on Plaintiff’s mental limitations because the consultative
psychological evaluator did not provide this analysis. (Doc. 26, p. 4-7). On August
23, 2021, Maria R. Otero-Suria, Psy.D. conducted a psychological evaluation. The
evaluation showed a generally normal mental evaluation, with some recent memory
and slow speech issues. (Tr. 506-509). Dr. Otero-Suria found that Plaintiff’s “mental
health symptoms based on report and clinical observations appear to be moderately
impacting activities of daily living, vocational performance, and interpersonal
interactions. Current prognosis for Mr. Olivares is fair.” (Tr. 509).
In the decision, the ALJ summarized in detail Dr. Otero-Suria’s psychological
evaluation. (Tr. 25, 26-27). The ALJ determined that “the opinion of Dr. Otero-Suria
who opined that mental health symptoms appeared to be moderately impacting
activities of daily living, vocational performance, and interpersonal interactions, is
not persuasive. The term moderate was not defined, and no specifics were provided
in regard to how they impact activities of daily living, vocational performance or
interpersonal interactions.” (Tr. 26-27).
In the decision, the ALJ noted that Dr. Otero-Suria found Plaintiff had
impaired recent memory and slow speech, as well as findings of anxious mood and
restless behavior/motor reported in other medical records from 2022. (Tr 26). As a
result, the ALJ decided that these medical records support limitations to simple
routine tasks and instructions and with reasoning level 1or 2. (Tr. 26). Thus, even
though the ALJ did not find all of Dr. Otero-Suria’s opinion persuasive, the ALJ still
adopted some of the evaluation findings, which lead to including additional
limitations in the RFC based on Dr. Otero-Suria’s evaluation and other medical
evidence of record. Plaintiff failed to show that the evidence as a whole was
insufficient to support the ALJ’s RFC assessment as to mental limitations.
B. Light Work
Plaintiff argues that substantial evidence does not support the ALJ’s RFC
assessment that Plaintiff could perform the standing and walking requirements of
light work, based on his complaints of low back pain radiating down his right leg,
bilateral knee pain, and bilateral hand pain. (Doc. 26, p. 8). Plaintiff also contends
that he cannot meet the light level work requirements of lifting or carrying 20 pounds
occasionally, and 10 pounds frequently, and standing or walking for 6 hours in an 8-
hour day. (Doc. 26, p.8). The Court finds the ALJ properly considered the RFC
assessment.
An individual’s RFC is his ability to do physical and mental work activities
on a sustained basis despite limitations secondary to his established impairments.
Delker v. Comm’r of Soc. Sec., 658 F. Supp. 2d 1340, 1364 (M.D. Fla. 2009). In
determining a claimant’s RFC, the ALJ must consider all relevant evidence
including non-severe impairments. Barrio v. Comm’r of Soc. Sec., 394 F. App’x 635,
637 (11th Cir. 2010). Furthermore, the ALJ must “‘scrupulously and conscientiously
probe into, inquire of, and explore for all relevant facts.’” Henry v. Comm’r of Soc.
Sec., 802 F.3d 1264, 1267 (11th Cir. 2015) (quoting Cowart v. Schweiker, 662 F.2d
731, 735 (11th Cir.1981)). In other words, ALJs “are by law investigators of the facts
and are tasked not only with the obligation to consider the reasons offered by both
sides, but also with actively developing the record in the case.” Id.
In support of his argument, Plaintiff cites treatment records and the physical
consultative examination which showed that he complained of low back pain,
bilateral leg pain, knee pain, and hand pain. (Doc. 26, p. 8-11). Plaintiff also cites an
abnormal February 2022 MRI that showed, among other things, mild or moderate
disk bulging, a radial tear, bilateral facet hypotrophy with severe impingement, disk
desiccation, a herniated portion of a disk, and severe impingement on the bilateral
lateral recesses. (Doc. 26, p. 10 (citing 541-42)). After the MRI, Plaintiff was
referred to a neurosurgeon, Jonathan S. Hall, M.D. (Doc. 26, p. 11). At this visit, Dr.
Hall found tenderness to palpation over the cervical and lumbar spine, with some
limited range of motion. (Doc. 26, p. 11; Tr. 640).
At the same time – as the ALJ noted and Plaintiff concedes – Dr. Hall found
Plaintiff could ambulate in and out of the office without difficulty and without an
assistive device. (Tr. 640; Doc. 26, p. 11). Dr. Hall also found focal motor testing,
including an assessment of hand, wrist, biceps, triceps, and deltoids, as well as
dorsiflexion, plantar flexion, knee flexion, knee extension, and iliopsoas were all
5/5. (Tr. 640). Dr. Hall recommended limited lumbar epidural injections to provide
relief, but noted Plaintiff may eventually need surgery for definitive care. (Tr. 641).
The ALJ considered all the relevant evidence of record, both the evidence in
support of Plaintiff’s complaints as well as other evidence in reaching an RFC
assessment. And as discussed above, the ALJ relied in part on the State agency
medical consultant’s opinion on Plaintiff’s physical functional limitations. (Tr. 26).
In essence, Plaintiff invites the Court to reweigh the evidence, which it cannot do. A
court may not decide the facts anew, reweigh the evidence, or substitute its judgment
for that of the Commissioner. Mitchell v. Comm’r, Soc. Sec. Admin., 771 F.3d 780,
782 (11th Cir. 2014). Even if the evidence preponderates against the
Commissioner’s decision, the Court must affirm if substantial evidence supports the
Commissioner’s decision. Buckwalter v. Acting Comm’r of Soc. Sec., 5 F.4th 1315,
1320 (11th Cir. 2021). Substantial evidence supports the ALJ’s RFC assessment for
light work.
C. Subjective Complaints
Plaintiff argues that the ALJ inaccurately considered Plaintiff’s subjective
complaints. (Doc. 26, p. 17). Plaintiff complained of pain in his hands, low back,
knees, hips, and feet at almost every office visit, which he argues conflicts with the
ALJ’s finding that treatment records did not show consistent complaints of the
symptoms Plaintiff alleged were disabling. (Doc. 26, p. 17). Plaintiff further argues
that the ALJ cited treatment records that showed the absence of abnormal findings
for imbalance, moving about the exam rooms, difficulty getting up from chairs, or
up and down from exam tables, but no record supports a finding that he could stand
or walk for 6 hours in an 8-hour workday. (Doc. 26, p. 17). Plaintiff also argues that
the ALJ failed to properly consider the severity of the objective medical evidence,
including the results of a February 2022 MRI. (Doc. 26, p. 18). Finally, Plaintiff
contends that the ALJ failed to properly consider Plaintiff’s subjective complaints
of his mental health conditions, such as anxiety, depression, post-traumatic stress
syndrome, and sleep disorders. (Doc. 26, p. 20-21).
Generally, a claimant may establish that he is disabled through his own
testimony of pain or other subjective symptoms. Ross v. Comm’r of Soc. Sec., 794
F. App’x 858, 867 (11th Cir. 2019) (citing Dyer v. Barnhart, 395 F.3d 1206, 1210
(11th Cir. 2005)). In such a case, a claimant must establish:
“(1) evidence of an underlying medical condition and either (2)
objective medical evidence that confirms the severity of the
alleged pain arising from that condition or (3) that the
objectively determined medical condition is of such a severity
that it can be reasonably expected to give rise to the alleged
pain.”
Id. (quoting Dyer, 395 F.3d at 1210).
When evaluating a claimant’s testimony, the ALJ should consider: (1) the
claimant’s daily activities; (2) the location, duration, frequency, and intensity of the
claimant’s pain or other symptoms; (3) precipitating and aggravating factors; (4) the
type, dosage, effectiveness, and side effects of any medication to alleviate pain or
other symptoms; (5) treatment other than medication for relief of pain or other
symptoms; (6) any measures a claimant uses to relieve pain or other symptoms; and
(7) other factors concerning a claimant’s functional limitations and restrictions due
to pain or other symptoms. 20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3); Ross v.
Comm’r of Soc. Sec., 794 F. App’x 858, 867 (11th Cir. 2019).
The ALJ should consider these factors along with all the evidence of record.
Ross, 794 F. App’x 867. If the ALJ discredits this testimony, then the ALJ “‘must
clearly articulate explicit and adequate reasons for’ doing so.” Id. (quoting Dyer, 395
F.3d at 1210). The ALJ may consider the consistency of the claimant’s statements
along with the rest of the record to reach this determination. Id. Such findings “‘are
the province of the ALJ,’ and we will ‘not disturb a clearly articulated credibility
finding supported by substantial evidence.’” Id. (quoting Mitchell v. Comm’r of Soc.
Sec., 771 F.3d 780, 782 (11th Cir. 2014)). A decision will be affirmed as long as the
decision is not a “broad rejection which is not enough to enable [a reviewing court]
to conclude that the ALJ considered [the claimant’s] medical condition as a whole.”
Dyer, 395 F.3d at 1211 (quotation and brackets omitted).
In the decision, the ALJ summarized Plaintiff’s allegations of pain and his
limitations. (Tr. 23). The ALJ recounted that Plaintiff alleged disability largely based
on pain, such as pain in his back, knees, feet, and hands, which limited him in sitting,
standing, walking, lifting, carrying, fine and gross manipulations, reaching, postural
activities, and most activities of daily living. (Tr. 23). The ALJ summarized
Plaintiff’s hearing testimony when he described radicular back pain down the lower
extremities, loss of feeling in his toes, tingling and burning of the feet, the use of a
cane, difficulty holding and grasping objects, and difficulty with self-care and simple
daily activities. (Tr. 23). The ALJ also summarized Plaintiff’s mental complaints,
such as difficulty concentrating and focusing, getting along with others, and
difficulty sleeping, causing sleeping during the day. (Tr. 23). Finally, the ALJ
discussed side effects of Plaintiff’s medications, but found Plaintiff no longer took
the medication causing side effects. (Tr. 23).
The ALJ then determined that Plaintiff’s medically determinable impairments
could reasonably be expected to cause the alleged symptoms, but his statements
concerning the intensity, persistence, and limiting effects of these symptoms were
not entirely consistent with the medical and other evidence of record for the reasons
explained in the decision. (Tr. 23). The ALJ then explained his subjective complaint
findings in more detail:
As for the claimant’s statements about the intensity,
persistence, and limiting effects of his symptoms, they are
inconsistent because treatment records do not show that the
claimant has consistently complained of the symptoms he
alleges are disabling. The records do not show that a cane is
prescribed or regularly used, and do not report findings of
obvious discomfort on office visits. The undersigned further
notes the absence of numerous abnormal findings such as
imbalance, difficulty moving about the examination rooms,
and difficulty getting up from chairs or up and down from
examination tables, among others. Additionally, a number of
objective examination findings are largely normal and in
marked contrast to the very severe limitations alleged.
Specifically, the records discussed below repeatedly report
findings of no acute distress, normal gait and station, normal
range of motion, normal sensory, and normal mental findings
which are inconsistent with the physical and mental limitations
alleged. With regard to alleged difficulty sleeping and sleeping
during the day the treatment records are generally devoid of
abnormal findings such as the appearance of sleepiness or
drowsiness, impaired focus or otherwise.
(Tr. 23).
Following the subjective complaint findings, the ALJ discussed the objective
medical evidence from Plaintiff’s various office visits as well as the objective
testing, such as MRI results. (Tr. 24-26). He considered in detail the consultative
exam conducted by Dr. Shyngle as well as the mental health records from Peace
River Center and Dr. Otero-Suria’s consultative evaluation. (Tr. 25). The ALJ also
considered Plaintiff’s alleged sleep issues from PTSD caused by Plaintiff witnessing
traumatic events while a tow-truck driver. (Tr. 23). The ALJ found that the treatment
records generally lack abnormal findings, including any appearance of sleepiness,
drowsiness, or impaired focus. (Tr. 23). The ALJ considered Plaintiff’s daily
activities, the location and intensity of his pain, the side effects of any medication,
the treatment he received, as well as the objective medical and other evidence of
record. In short, the ALJ considered all the relevant evidence of record, clearly
articulated explicit and adequate reasons for finding Plaintiff’s subjective statements
not entirely consistent with the medical and other evidence of record, and considered
Plaintiff’s medical condition as a whole. As stated above, the Court cannot reweigh
the evidence, or substitute its judgment for that of the Commissioner. Mitchell v.
Comm’r, Soc. Sec. Admin., 771 F.3d 780, 782 (11th Cir. 2014). Substantial evidence
supports the ALJ’s subjective complaint analysis.
D. Mental Limitations in RFC
Plaintiff claims that even though the ALJ found Plaintiff’s anxiety disorder,
major depressive disorder, and PTSD severe impairments, the ALJ did not account
for these impairments in the RFC. (Doc. 26, p. 22). Plaintiff claims that the ALJ
barely mentioned Plaintiff’s mental impairments in his RFC assessment. (Doc. 26,
p. 22).
In the decision at step two, the ALJ found Plaintiff had severe impairments,
including anxiety disorder, major depressive disorder, and PTSD. (Tr. 19). By
definition and as the ALJ noted, severe impairments “significantly limit the ability
to perform basic work activities as required by SSR 85-28.” (Tr. 16); see 20 C.F.R.
§ 404.1520(c). “[B]eyond the second step, the ALJ must consider the entirety of the
claimant’s limitations, regardless of whether they are individually disabling.” Griffin
v. Comm’r of Soc. Sec., 560 F. App’x 837, 841-842 (11th Cir. 2014) (internal
citations omitted). As explained above, an RFC assessment reflects an individual’s
ability to do physical and mental work activities on a sustained basis despite his
established impairments. Delker v. Comm’r of Soc. Sec., 658 F. Supp. 2d 1340, 1364
(M.D. Fla. 2009). To assess an RFC, the ALJ must consider all relevant evidence.
Barrio v. Comm’r of Soc. Sec., 394 F. App’x 635, 637 (11th Cir. 2010).
In the decision, the ALJ discussed Plaintiff’s mental impairments. He noted
that Plaintiff was treated at Peace River Center3 briefly from February 2022 to July
2022, a clear indication that the ALJ considered these records. (Tr. 25). He
summarized one such mental status examination, which had largely normal findings:
“demeanor, cognition, memory, insight, judgment, thought content and thought
process were all within normal limits. The undersigned does note findings of anxious
mood, and restless behavior/motor.” (Tr. 25). The ALJ also thoroughly summarized
Dr. Otero-Suria’s psychological evaluation noting largely normal findings, except
for impaired recent memory and slow speech. (Tr. 25). He considered Plaintiff’s
alleged sleep difficulties because of PTSD, but found that the treatment records do
not reflect an appearance of sleepiness, drowsiness, or impaired focus. (Tr. 23). In
addition, the ALJ discussed Plaintiff’s activities of daily living as reported to Dr.
Otero-Suria. (Tr. 25). Plaintiff reported he could drive independently for short
distances, prepare basic food without assistance, complete basic household chores
that do not require bending, and manage money if needed. (Tr. 25).
3 Plaintiff previously noted that he was treated at Peace River Center by a Licensed Mental Health
Counselor. (Doc. 26, p. 19). Plaintiff acknowledged that a Licensed Mental Health Counselor is
not an acceptable medical source under the regulations. (Doc. 26, p. 19); see 20 C.F.R.
§ 404.1502(a).
Lastly, the ALJ discussed the State agency psychological consultant’s
opinion. He found it unpersuasive based partially on Dr. Otero-Suria’s opinion who
found Plaintiff had impaired recent memory and slow speech. (Tr. 26). The ALJ then
determined, “[t]he mental residual functional capacity and limitation for simple
routine tasks and instructions and with reasoning level 1 or 2 is supported by the
consultative examination and the treatment records from Peace River Center.” (Tr.
27).
Here, the ALJ considered the entirety of Plaintiff’s limitations, including his
alleged mental impairments. The ALJ thoroughly considered the medical and other
evidence of record that related to his alleged mental impairments. After
consideration of the evidence of record, the ALJ assessed Plaintiff’s RFC and limited
him to light work with additional limitations and to jobs that have simple routine
tasks and instruction and a reasoning level 1 or 2. (Tr. 22, 27). Substantial evidence
supports the ALJ’s RFC assessment.
III. Conclusion
For the reasons discussed above, the Court finds that the decision of the
Commissioner is supported by substantial evidence and the Commissioner applied
the correct legal standard. The decision of the Commissioner is AFFIRMED. The
Clerk of Court is directed to enter judgment consistent with this opinion, terminate
all deadlines, and close the case.
DONE and ORDERED in Fort Myers, Florida on July 12, 2024.
nou ILAS N. ERATIER
UNITED STATES MAGISTRATE JUDGE
Copies furnished to:
Counsel of Record
Unrepresented Parties