Searching over 5,500,000 cases.

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Mustafic v. Berryhill

United States District Court, E.D. Missouri, Eastern Division

October 10, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1]Defendant.



         Plaintiff Fatima Mustafic brings this action under 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking judicial review of the Commissioner's final decision denying her applications for disability insurance benefits (DIB) under Title II of the Social Security Act, 42 U.S.C. §§ 401, et seq.; and for supplemental security income (SSI) under Title XVI of the Act, 42 U.S.C. §§ 1381, et seq. Because I find the Commissioner's decision to not be supported by substantial evidence on the record as a whole, I will reverse the decision and remand the matter to the Commissioner for further proceedings.

         Procedural History

         On August 19, 2013, Mustafic applied for DIB and SSI claiming she became disabled on May 30, 2013, because of osteoarthritis of the bilateral knees, obesity, depression, post-traumatic stress disorder, anxiety disorder, gastritis/epigastric pain, insomnia, hyperlipidemia, headaches, uterine myoma, and menorrhagia. The Social Security Administration denied both applications on October 3, 2013. At Mustafic's request, a hearing was held before an administrative law judge (ALJ) on May 19, 2015, at which Mustafic and a vocational expert testified. On June 2, 2015, the ALJ entered a written decision denying Mustafic's claims for benefits, finding her able to perform her past relevant work as a housekeeper. On May 20, 2016, after reviewing additional evidence, the Appeals Council denied Mustafic's request for review of the ALJ's adverse decision. The ALJ's decision is thus the final decision of the Commissioner. 42 U.S.C. § 405(g).

         In this action for judicial review, Mustafic contends that the ALJ's decision is not supported by substantial evidence on the record as a whole, arguing that the ALJ improperly discounted her subjective complaints and improperly weighed the opinion evidence of record. Mustafic also claims that the ALJ failed to explain the basis for the physical limitations included in his residual functional capacity (RFC) assessment. For the reasons that follow, I will reverse the decision and remand the matter for further proceedings.

         Evidence Before the ALJ

         Mustafic's Testimony

         At the hearing on May 19, 2015, Mustafic testified in response to questions posed by the ALJ and counsel. Mustafic, who is Bosnian, testified with the assistance of a Bosnian interpreter.

         At the time of the hearing, Mustafic was fifty-three years old. She stands five feet, six inches tall and weighs 192 pounds. (Tr. 33-34.) She lives in an apartment with her husband. She has three adult children who no longer live with her. (Tr. 38.) Mustafic came to the United States from Bosnia in 1988. (Tr. 41.) She does not speak or understand English. She communicates with her doctors through her husband and daughter, and was able to communicate at work through Bosnian co-workers. (Tr. 34, 42.) Mustafic went to school for two years in Bosnia. (Tr. 40.)

         Mustafic's Work History Report shows that she worked as a commercial housekeeper in 1998 and 1999, cleaning stadium seating. From 1999 to May 2013, she worker as a hotel housekeeper. (Tr. 191-93.) Mustafic testified that she can no longer work because she is unable to do anything. (Tr. 37.)

         Mustafic testified that she has knee and leg pain and experiences dizziness with both standing and sitting. (Tr. 37-38.) She takes medication but it does not help with her knee pain. (Tr. 43.)

         Mustafic testified that she experiences headaches and nightmares that interfere with her sleep. She sees Dr. Farzana who prescribes medication for her headaches. Her sleep disturbances are related to her memories of the Bosnian war and what happened to her father and brothers during the war. She testified that her brother's body was recently found and that he was to be buried sometime during the summer. Mustafic testified that she is also affected by her daughter's death, and especially when she sees her daughter's friends who are now grown and have families. Mustafic has crying spells two or three times a day.[2] (Tr. 42-43.) She also frequently forgets things and has trouble focusing and concentrating. She testified that her husband does not want her to be alone. (Tr. 38.)

         As to her exertional abilities, Mustafic testified that she can lift about a gallon of water. She can stand for short periods of time and has problems with both standing and sitting because of dizziness. She testified that her doctor told her not to walk a lot because of problems with her knees and veins. (Tr. 37-38.)

         As to her daily activities, Mustafic testified that she watches television, but only for the “pictures” because she does not understand English. She does not like to speak a lot when she is out. She prefers to stay home with her husband. She mostly sits throughout the day. She sometimes goes outside. She does not shower if she feels dizzy, and her husband sometimes walks with her to the bathroom because of her dizziness. Her daughters sometimes help her with personal hygiene. (Tr. 34, 37-39.) Mustafic does very little housekeeping; her husband and daughters perform most of the work. She sometimes cooks but is afraid to do so because she leaves the oven on. Mustafic does not have a driver's license, does not drive, and has never used public transportation. (Tr. 39-40.) Vocational Expert Testimony Dr. Robin Cook, a vocational expert, testified at the hearing in response to questions posed by the ALJ and counsel. Ms. Cook classified Mustafic's past work as a housekeeper as light and unskilled. (Tr. 22).

         The ALJ asked Ms. Cook to assume an individual of Mustafic's age with Mustafic's education and past relevant work. The ALJ asked Ms. Cook to assume that the person was limited to less than light work in that she can lift and carry up to 20 pounds occasionally and lift or carry up to 10 pounds frequently; stand and/or walk for six hours out of an eight-hour day and sit for six hours out of an eight-hour work day; never climb ladders, ropes, and scaffolds; can occasionally climb ramps and stairs, balance, kneel, crouch, and crawl; should never work at unprotected heights or with moving mechanical parts; can occasionally work in vibration.

         This individual would be limited to occupations that do not require fluency in the English language. And they can perform simple, routine tasks and have occasional interaction with supervisors, coworkers, and the general public. (Tr. 46.) Ms. Cook testified that such a person could perform Mustafic's past work as a housekeeper, both as actually performed and generally performed in the national economy. (Tr. 47.) Ms. Cook further testified that if the person also required a sit-stand option, she could not perform Mustafic's past work as a housekeeper but could perform other work in the national economy such as sewing machine operator, photocopy machine operator, and bakery worker. (Tr. 48-49.) She also testified that employers tolerate only one absence a month from work. (Tr. 51.) Medical Records Mustafic underwent a CT scan of the head and brain in February 2010 in response to her reports of lightheadedness, dizziness, and headaches. The results of the CT scan were unremarkable. (Tr. 329.)

         Mustafic visited Dr. Farida Farzana at Psych Care Consultants on January 21, 2013. She reported that her daughter was killed in a car accident in 2003 and that her father and brothers were killed in war. She currently was experiencing poor sleep and nightmares, and she wanted to isolate herself. She reported that she has bad headaches, dizziness, poor memory, and is unable to concentrate. She said that she works only a few days. Mental status examination showed Mustafic to have poor eye contact and to be sullen, guarded, and suspicious. She was observed to be sad, anxious, and depressed. Her affect was flat, blunted, and constricted. Her concentration and ability to perform serial sevens was impaired. Both recent and remote memory was also impaired. She appeared preoccupied. Dr. Farzana found Mustafic to have mildly impaired judgment and limited insight. Dr. Farzana diagnosed Mustafic with prolonged post-traumatic stress disorder (PTSD) and major depressive disorder and assigned a Global Assessment of Functioning (GAF) score of 31.[3] Mirtazapine (Remeron) was prescribed, and Mustafic was instructed to return in one month. (Tr. 238, 284-85.)

         Mustafic visited Esse Health on January 29, 2013, with complaints of pain and dizziness associated with heavy menstruation. Taking Tylenol helped. (Tr. 260-62.)

         Mustafic visited Dr. Farzana on February 18, 2013, and reported that she continued to not sleep well, was depressed and sad, and was worried about gynecological health problems. Dr. Farzana increased Mustafic's dosage of mirtazapine. (Tr. 283.)

         Mustafic returned to Esse Health on February 27, 2013, with complaints of dizziness. She reported that she almost collapsed and could not get up. She also reported having a ringing sensation in her ears for two to three months. Mustafic was diagnosed with labyrinthitis and was prescribed meclizine. (Tr. 254-57.)

         On March 18, 2013, Mustafic visited Dr. Farzana who noted her to be very distressed and depressed. Mustafic kept crying during her appointment. She reported that she was sick and was falling down and was worried about her health. She continued to grieve over her daughter's death. Mustafic reported that she stopped taking mirtazapine a week earlier because of concern about side effects. Dr. Farzana explained medication side effects and provided a three months' supply of medication. (Tr. 282.) On April 19, Mustafic reported to Dr. Farzana that she was constantly worried about her children having accidents and dying as her one daughter had. She also reported having severe headaches and dizziness. Mustafic was instructed to continue with her medication. (Tr. 281.)

         Mustafic went to the emergency room at St. Mary's Health Center on May 11, 2013, with complaints of right knee pain after falling at work the day before. It was reported that she continued to work the remainder of the day, but that she was currently unable to work. Mustafic reported the pain to be at a level eight on a scale of one to ten. She reported the pain to worsen with movement. Examination showed swelling and tenderness about the knee medially and laterally. An x-ray of the knee was negative. It was determined that Mustafic had a soft tissue injury and knee sprain, but leg injury could not be excluded. The knee was placed in an immobilizer and Mustafic was given Tramadol and ibuprofen for pain. She was instructed to ice the knee and to follow up with orthopedics. (Tr. 363-69.)

         On May 15, 2013, Mustafic visited Esse Health with complaints of right knee pain. It was noted that she was in no acute distress or discomfort. Esse Health explained that they could not examine or treat the injury because it was work-related. Esse Health offered to contact an orthopedist for follow up, but Mustafic's son indicated that they would check with Mustafic's employer and arrange to have her seen by a worker's compensation doctor. (Tr. 247.)

         Mustafic returned to Dr. Farzana on August 16, 2013. It was noted that she had recently traveled to Bosnia and was sad because of the several family members she had lost to the war. It was also noted that Mustafic always thinks of how her sixteen-year-old daughter was killed in an accident. Mustafic continued to report that she had severe headaches. Mental status examination showed Mustafic to have poor eye contact and to be sullen and guarded. She was depressed, sad, and anxious. Dr. Farzana noted Mustafic to be preoccupied. Mustafic reported feeling helpless and having low self-worth. Her concentration was noted to be impaired, as well her recent and remote memory. Mustafic's judgment was ...

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.