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Robert W. v. Commissioner, Social Security Administration

United States District Court, N.D. Georgia, Atlanta Division

August 20, 2019

ROBERT W., Plaintiff,



         Plaintiff in the above-styled case brings this action pursuant to § 205(g) of the Social Security Act, 42 U.S.C. § 405(g), to obtain judicial review of the final decision of the Commissioner of the Social Security Administration (“SSA”) which denied his application for disability insurance benefits (“DIB”). For the reasons set forth below, the Court REVERSES and REMANDS to the Commissioner for further proceedings.[1]

         I. Procedural History

         The claimant filed an application for a period of DIB on February 23, 2015, alleging that he became disabled on July 17, 2013. [Record (“R.”) 166-74 / Exhibit 1D]. After his application was denied initially and on reconsideration, an administrative hearing was held by video conference on May 15, 2017. [R. 32-52]. An impartial Vocational Expert (“VE”), Lane Westcott, was present and testified at the hearing. The Administrative Law Judge (“ALJ”) issued a decision denying Plaintiff's application on September 12, 2017, and the Appeals Council denied Plaintiff's request for review on February 21, 2018. [R. 1-6, 12-31]. Plaintiff filed his complaint in this court on March 8, 2018, seeking judicial review of the Commissioner's final decision. [Doc. 1]. The parties have consented to proceed before the undersigned Magistrate Judge.

         II. Facts

         The decision of the ALJ [R. 17-26] states the relevant facts of this case as modified herein as follows:

         The claimant alleges disability since July 17, 2013, due to degenerative disc disease, diabetes mellitus, obesity, obstructive sleep apnea, generalized anxiety disorder, major depressive disorder, and attention deficit hyperactivity disorder (“ADHD”).

         Claimant's Hearing Testimony

         During the hearing, the claimant testified to measuring approximately 69 inches tall and weighing approximately 310 pounds. He described his primary symptoms as follows: chronic neck, back, shoulder, and knee pain, decreased range of motion in his shoulder (e.g., cannot shave himself), burning/tingling/stinging of the extremities due to neuropathy (prescribed Gabapentin), chronic headaches, difficulty bending, difficulty lifting/reaching, difficulty ambulating, fluctuating blood sugar levels, difficulty with attention/concentration (prescribed Adderall), a long history of frequent panic attacks (prescribed Klonopin), chronic underlying anxiety, social withdrawal, difficulty working/getting along with others, and sleep disturbance. The claimant testified that he experiences drowsiness as a side effect of his medications. He stated that he must lie down due to exhaustion, especially on days when he has to leave the house for medical appointments and the like.

         The claimant testified that he had suffered from chronic pain for approximately ten years. [R. 39]. He was previously administered injections in his shoulder and reported needing shoulder surgery. [R. 39]. According to the claimant, his pain is present “all the time” and not only during exertion. [R. 39]. He stated that his left shoulder pain was due to arthritis that needed to be scraped and that the pain in his neck, lower back, and knees was caused by his diabetic neuropathy. [R. 39 (“From the knees down, I'm burning all the time. And it goes into my hands too.”)]. Plaintiff testified that he had been taking medication to help his pain for over eight years. He takes a high dose of Lortab (an opioid) and muscle relaxers. [R. 40].

         The claimant uses “a grabber thing” for reaching and picking things up. [R. 40]. He represented that he has used a cane on and off for around five years. [R. 40-41]. Plaintiff brought the cane with him to the video hearing. [R. 41]. Without use of the cane, Plaintiff stated that he could typically only walk about four or five feet. [R. 41].

         At the time of the hearing, the claimant was living with his girlfriend, and the claimant reported that his girlfriend does basically everything. [R. 42]. For instance, given his difficulty bending and reaching, the claimant's girlfriend helps him get his shoes and socks on and even helps him in the restroom. [R. 42]. The claimant has a friend come over to cut his hair and shave him once every couple of weeks. [R. 42].

         According to the claimant, he has experienced “problems all [his] life with anxiety, but . . . kept it hid [sic]” until he got older and was faced with other medical conditions. [R. 43]. The claimant testified that being around people terrifies him and that his anxiety and panic interfered with his job at Avon. [R. 43]. He takes Klonopin for anxiety and testified that, without it, he cannot function at all and would have multiple panic attacks. [R. 44].

         The claimant testified that he does not participate in activities outside of the house and that his typical day consists of watching TV. [R. 44, 46]. He lays down and props his head up with a pillow to watch TV between 65 and 70 percent of the time. [R. 47]. If he is required to be out of the house, he is exhausted by the time he gets back home and has to lay down as soon as he returns. [R. 47].

         Medical Evidence of Record

         The evidence of record reflects primary care notes from Kaiser Permanente (“KP”). On the alleged onset date of July 17, 2013, the claimant presented to KP with decreased neck range of motion. However, he exhibited full, painless lumbar range of motion with no tenderness. Straight leg raise tests were negative although a leg lift test was positive for low back pain. He displayed full range of motion of the hips and knees. Motor, sensation, and gait findings were normal. Cervical spine x-rays showed no significant abnormalities. In contrast, lumbar spine x-rays revealed facet arthropathy at ¶ 4-L5 with no significant change since comparison imaging from 2007. The lumbar spine otherwise showed normal alignment, normal curvature, and preserved disc heights. [Exhibit 2F at 135].

         As seen at KP through early 2015, the claimant intermittently reported moderate pain and / or was seen for routine, acute matters. [Exhibit 2F at 9, 36]. On most occasions, however, physical exam findings were generally unremarkable. [Exhibit 2F at 13, 19, 44, 75, 80-81, 89]. On at least one occasion, sacroiliac tenderness was present, but lumbar, gait, motor, and sensation findings were normal. [Exhibit 2F at 53]. KP records also reflect a history of panic attacks. [Exhibit 2F at 5-9].

         In March 2015, KP records reflect an exacerbation of back pain reportedly caused by overexertion when the claimant helped some people move the previous week. The claimant was already taking prescribed Hydrocodone and Soma, but he “self increased” his dosage “based on need.” On examination, he appeared “unwell” and seemed to be “in moderate to severe pain.” He demonstrated decreased range of motion of the neck and lower back with “[t]ender knotted musculature.” The provider continued the claimant on oral medications. [Exhibit 4F at 1-7].

         On April 23, 2015, John Shih, D.O. (“Dr. Shih”), performed a consultative “all systems” examination of the claimant. On examination, head, ear, eye, nose, and throat findings were within normal limits. As for cardiovascular findings, Dr. Shih noted “1 edema” of the lower extremities with left leg varicosities and claudications. All other cardiovascular findings were unremarkable. Pulmonary and chest findings were unremarkable. Abdominal findings were normal. The “claimant allege[d]” tenderness of both knees, both wrists, both elbows, and the right shoulder. There was tenderness to palpation of the cervical, thoracic, and lumbosacral spines. The claimant's gait was wide-based and antalgic, and he presented with the use of a cane. However, the claimant was able to get on and off of the exam table independently and successfully heel-to-toe walk. He demonstrated only mild (four out of five, or 4/5) deficits of motor strength. Likewise, he demonstrated 4/5 handgrip strength, which is typically considered only a mild deficit despite being documented as “moderate.” Notably, the claimant demonstrated full (5/5) pinch strength bilaterally. Range of motion was decreased in most areas, and the claimant indicated that he was unable to complete back range of motion testing. Dr. Shih observed signs of depression but nonetheless found the claimant to be fully oriented with no memory problems. [Exhibit 3F at 1-6]. Dr. Shih opined that the claimant could perform activities of daily living. Dr. Shih further opined that the claimant needed assistance with personal care tasks once per week, that he could not reach, push, or pull due to back pain, that he could not stand for long periods of time due to back pain and leg cramps, and that he could not bend at the waist or turn his head. Dr. Shih cited various findings and subjective reports in support of these opined limitations, including leg cramps, decreased range of motion of the bilateral ankles, decreased range of motion of the bilateral hips, positive sitting and supine straight leg raising, decreased range of motion of the bilateral shoulders, “severely decreased” neck and back range of motion, and decreased strength. Finally, Dr. Shih indicated that the claimant experienced “anxiety and panic attacks due to traumatic past.” [Exhibit 3F at 6].

         The claimant returned to KP in early May 2015 for a routine follow-up visit. He reported that he felt jittery on Celexa and inquired about splitting his dosage. The provider agreed and made this change. Objective exam findings were completely normal, and the provider continued the claimant on conservative treatment with medications. [Exhibit 4F at 13-21].

         On May 7, 2015, Norman Lee, Ph.D. (“Dr. Lee”), performed a consultative psychological evaluation of the claimant. [Exhibit 5F]. The claimant reported that his primary mental difficulties involved anxiety and attention / concentration deficits. The claimant reported that he rarely socializes with others and that he has one close friend, and he reported difficulties with socialization and getting along with others due to his anxiety around crowds. The claimant endorsed a history of childhood trauma due to both witnessing traumatic events, including the death of his father (homicide), and suffering abuse. He endorsed ongoing symptoms since that time, including excessive generalized worry, restlessness, fatigue, concentration problems, irritability, difficulties with sleep, panic attacks, and frequent racing thoughts. Dr. Lee observed clinical signs, including a markedly anxious mood, restricted affect, and a tense appearance. The claimant's performance on objective testing “suggested weaknesses in his global cognitive functioning.” [Exhibit 5F at 4]. Mental status exam findings were variable but mostly fair. Dr. Lee found the claimant “sincere in his presentation” and consistent throughout the evaluation with “no significant evidence of any exaggeration or magnification of symptoms.” [Exhibit 5F at 3]. Dr. Lee assessed the claimant with generalized anxiety disorder and rule-out borderline intellectual functioning and recommended more comprehensive psychological testing to confirm suspected borderline intellectual functioning. [Exhibit 5F at 4]. Dr. Lee noted that the claimant's prognosis related to his psychological conditions was “guarded, given the longstanding nature of his mood difficulties.” [Exhibit 5F at 4]. Dr. Lee opined that the claimant was capable of understanding, remembering, and carrying out basic directions but mildly to moderately limited in doing so with more complex directions, moderately limited in concentrating, persisting, or maintaining pace on “more difficult tasks, ” moderately to markedly limited in interacting adequately with coworkers and the general public, and moderately to markedly limited in adapting to work-related stressors. [Exhibit 5F at 4].

         The claimant returned to KP three times in August 2015. On August 6, 2015, the claimant reported frequent panic attacks and said that his Celexa was not working. He appeared anxious and stressed but exam findings were otherwise unremarkable. The claimant was continued on prescription medication. [Exhibit 6F at 30-37]. On August 24, 2015, he presented for his first behavioral health visit with Rick Stallings, M.D. (“Dr. Stallings”). A mental status exam and diagnostic screening yielded variable results. Dr. Stallings assessed the claimant with major depressed disorder, generalized anxiety disorder, and panic disorder, and he assigned the claimant a Global Assessment of Functioning (“GAF”) rating of 55, which is generally indicative of moderate overall functional limitations at the time of assessment.[2] Dr. Stallings prescribed continued treatment with Citalopram and Clonazepam, at increased dosages. [Exhibit 6F at 38-41]. Three days later, on August 27, 2015, the claimant returned for a primary care check-up with Sean Murphy, M.D. (“Dr. Murphy”), and physical exam findings were normal throughout though chronic lower back pain was noted. Dr. Murphy noted, “General Impression: Healthy adult male. Normal [p]hysical.” Dr. Murphy continued the claimant on a conservative treatment regimen with several medications. [Exhibit 6F at 42-48].

         On September 15, 2016, Dr. Stallings verified his treatment of the claimant since August 2015 for major depression, generalized anxiety disorder, and panic disorder. [Exhibit 8F]. According to Dr. Stallings, the claimant's “conditions are chronic and severe, and result in ...

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