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Crawley v. Commissioner, Social Security Administration

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

September 17, 2019

WILLIAM C., Plaintiff,
v.
COMMISSIONER, SOCIAL SECURITY ADMINISTRATION, Defendant.

          FINAL OPINION AND ORDER

          JANET F. KING, UNITED STATES MAGISTRATE JUDGE.

         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”) and supplemental security income (“SSI”). For the reasons set forth below, the court ORDERS that the Commissioner’s decision be AFFIRMED.[1]

         On September 30, 2013, Plaintiff William C. (“Plaintiff” or “the claimant”) filed applications for DIB and SSI alleging that he became disabled on September 4, 2013. [Record (“R.”) 215–229 / Exhibits 1D, 2D]. After Plaintiff’s applications were denied initially and on reconsideration, an administrative hearing was held on July 26, 2016.[2][R. 37–89]. The Administrative Law Judge (“ALJ”) issued a decision denying Plaintiff’s application on August 14, 2017. [R. 7–27]. The Appeals Council denied Plaintiff’s request for review on May 25, 2018. [R. 1–6]. Having exhausted his administrative remedies, Plaintiff filed a complaint in this court on July 13, 2018, seeking judicial review of the final decision of the Commissioner. [Doc. 1]. The parties have consented to proceed before the undersigned Magistrate Judge.

         I. Statement of Facts

         The ALJ found the following facts [R. 12–22] as modified herein.

         Plaintiff, born October 24, 1975, alleges disability and seeks both DIB and SSI due to hypertension, hyperlipidemia, mild spondylosis of the cervical spine, mild degenerative disc disease of the lumbar spine, obesity, and chronic pain. Plaintiff’s prior work history includes lubrication servicer, materials handler, and tire technician. [R. 21]. The claimant last worked full time in September 2013. The records reveal that the claimant weighed 286 pounds and possessed a BMI (body mass index) of 38.79, increased to 39.4 by October 2016, which constitutes obesity. [Exhibits 4F, 11F].

         Plaintiff’s Testimony

         The claimant is married and testified that he and his wife and their three children (six-year-old twin boys and a ten-year-old daughter) were living with his wife’s parents.[3] [R. 63]. According to Plaintiff, he is physically unable to perform any household chores, as he experiences pain all over his body. [R. 64–65]. For instance, Plaintiff testified that, if he gets up and takes a shower, he has to sit down and rest because he hurts so bad. [R. 64]. Plaintiff asserted that his medical providers have advised him that the pain he experiences is due to the “tumor” taking over the main nerve in his back.[4] [R. 64]. Plaintiff testified that the tumor is inoperable due to its location and risk of paralyzing or killing him. [R. 64, 66–67]. Plaintiff testified that, when Dr. Guo first discovered the tumor, she told him that he would not be able to work again and that the tumor was the cause of all of his complications, including causing his blood pressure to spike. [R. 68–69, 71].

         Regarding specific limitations, the claimant testified that he could sit for less than an hour and “then it just kills [him and he has] a hard time getting comfy.” [R. 77]. He stated that sitting during the hearing was hurting him and that “the pressure [was] going all through [his] body.” [R. 77]. The claimant described the pain as “unbearable.” [R. 77]. The claimant also reported that he had a hard time sleeping at night due to pain and that he tosses and turns and is up and down all night. [R. 77–78]. He testified that he is able to walk approximately one hundred feet (i.e., from the parking lot handicapped space and into the store) before having to stop and rest due to pain. [R. 78]. Plaintiff also stated that a couple of times when walking his legs have given out on him and caused him to fall. [R. 64]. According to the claimant, during his typical day, he gets up and eats breakfast and then sits and watches television. He may get up and go outside for a little bit and then sit again to watch the kids. [R. 78]. He stated that he is up and down standing or sitting throughout the day and then he “get[s] to hurting so bad” that he has to lay down in the bed. [R. 78]. The claimant represented that he cannot lift much (i.e., gallon of milk, a cooking pan) due to his hands locking up and dropping things. [R. 79–80]. The claimant also testified that he is prescribed glasses and requires his wife’s help with reading. [R. 80–81].

         During the hearing, the claimant testified that he receives ongoing treatment and takes medications for his impairments. As of the hearing date, the records submitted to the ALJ did not include treatment records beyond 2013, with the exception of a neurology visit at Piedmont Physicians Neurology in July 2014. [R. 47–48; Exhibit 6F]. The ALJ requested medical records with the claimant’s permission, and the record has been supplemented since.

         Plaintiff testified that he takes the following medications: Lisinopril and Amlodipine at bedtime (for high blood pressure), Cyclobenzaprine (as needed for pain), Ibuprofen (as needed for pain), Hydrocodone-Acetaminophen / Vicodin (as needed for pain), Ranitidine at bedtime (for stomach), Sumatriptan (as needed for migraines), Clonidine (as needed for blood pressure), Chlortab (for allergies), and Chlorpheniraminei Maleate (for allergies). [R. 59–60; Exhibit 12E].

         Medical Evidence of Record

         In September 2013, the claimant presented to Piedmont Newnan Hospital’s Emergency Room (“ER”) for complaints of pain. [Exhibit 2F]. The claimant reported a history of headache radiating down the neck. He rated his pain level as five out of ten, with ten being the most severe pain. Although the claimant was assessed with having hypertension, his blood pressure level was 128/78 on September 4, 2013. A chest x-ray showed that there were no acute cardiopulmonary findings. [Exhibit 2F at 9]. A Computed Tomography (“CT”) scan of the claimant’s head (without contrast) demonstrated no acute intracranial abnormality. A CT scan of the claimant’s cervical spine depicted evidence of degenerative changes. In addition, an MRI of his cervical spine showed evidence of “minimal” disc bulge, but there were no other abnormalities. The records revealed that the claimant was assessed with having “mild” spondylosis of the cervical spine, and he received an injection for pain. There was evidence of edema, but the records described the claimant as being in no acute distress and the ER notes show that the claimant was stable throughout and that the hospital was “without objective evidence for acute process requiring urgent intervention or hospitalization.” [Exhibit 2F at 21]. The clinical impression was documented as chest pain and paresthesia (i.e., tingling and numbness; loss of sensation). The claimant was counseled on specific conditions that would warrant his return to the ER.

         The claimant was treated by Xiaoyan Guo, M.D. (“Dr. Guo”), a board certified neurologist with Piedmont Medical Care, from September 2013 through approximately September 2015.[5] [Exhibit 4F]. On September 5, 2013, the claimant presented for a consultation to address persistent headaches, neck pain, and paresthesia symptoms. [Exhibit 4F at 22]. The claimant complained of headaches located in the occipital, temporal, and frontal areas. He rated the severity of his pain as a ten and characterized the pain as aching, shooting, and throbbing. [Exhibit 4F at 13]. The claimant described the onset of his headaches as gradual. He reported no prior similar headaches and no relief with medication. Plaintiff also complained of neck pain and represented experiencing intermittent tingling, numbness, and muscle cramps on the upper and lower extremities. The claimant denied gait disturbances and reported no falls. The claimant reported an ER visit the day prior due to headache pain. In addition, the claimant reported a prior CT of the brain that showed no structural abnormalities and a CT of the C spine at the ER that showed degenerative changes on the C3-4 level. As of October 2013, according to the claimant, his prior medical history included diagnoses for the following conditions: myocardial infarction, hypertension, tendonitis of the hands and feet, carpal tunnel syndrome, arthritis, heart attack, coronary artery disease, bone spur (neck), herniated cervical disc, migraine, and pneumonia. [Exhibit 4F at 7]. Subsequent records reveal that the claimant reported chronic pain that may have been due to fibromyalgia.[6]

         On October 4, 2013, Dr. Guo restricted the claimant from working temporarily due to persistent pain and headaches. In response to the claimant’s complaints of severe pain in his head and neck, the record shows that Dr. Guo initially recommended the claimant for a twenty-hour work week and excused him from work for only four days. [Exhibit 4F at 15]. Dr. Guo opined that the claimant could resume performing full-time work if he is doing well.[7] The claimant was to continue on Lyrica, continue B12 injections, and call if symptoms worsened or if he experienced new symptoms. After the claimant reported that his employer would not allow part time work, Dr. Guo changed her position and directed that the claimant not work at all. Dr. Guo’s progress notes read: “He is not able to go back to job since his employer does not let him try out the part time first.” [Exhibit 4F at 9].

         On October 25, 2013, the claimant again rated his neck pain as a ten. The claimant continued with his prescribed medication regimen, with the exception of Lyrica as the claimant did not report any benefit. [Exhibits 12E, 2F, 4F at 9–10, 15, 23, and Exhibit 10F].

         On October 21, 2013, Plaintiff was seen in the ER at Piedmont Fayette Hospital for chest pain and headache. [Exhibit 3F]. The ER addressed the claimant’s blood pressure and examined him. The claimant also had an MRI. The imaging showed no acute abnormality and no high-grade stenosis, aneurysm, or other abnormality. ER progress notes report that the claimant was “[a]mbulatory in ED without difficulty.” [Exhibit 3F at 42]. The claimant was prescribed medicine for pain and discharged to home the following day.

         On May 5, 2014, the claimant was seen by Dr. Guo for follow up due to persistent headaches over the past several months. [Exhibit 6F at 11]. Dr. Guo’s progress notes state that the claimant’s overall symptoms remain about the same, that the claimant still experiences the pain on a daily basis, and that the claimant is not able to function due to the pain. [Exhibit 6F at 11].

         On May 14, 2014, Dr. Guo conducted an EMG and Nerve Conduction Study to evaluate possible causes for the claimant’s reported tingling, numbness, and pain on both lower extremities. [Exhibit 6F at 8–9]. Dr. Guo’s impression of the nerve conduction study reads:

1. There is no electrophysiological evidence of any large fiber sensory motor polyneuropathy on both lower extremities.
2. No. evidence of myopathy.

[Exhibit 6F at 9].[8]

         Plaintiff also underwent testing with Southern Vein Care TCR, affiliated with Piedmont Healthcare, on May 14, 2014. [Exhibit 6F at 10]. Dr. Guo ordered the study of the claimant’s reported “[b]ilateral leg claudication and rest pain.” [Exhibit 6F at 10]. According to the Lower Extremity Arterial Physiologic Report, “[t]he patient states that his feet will turn a reddish blue color while walking and will go away with rest.” [Exhibit 6F at 10]. The claimant’s bilateral lower extremity arterial testing reflected no evidence of arterial disease at rest. [Exhibit 6F at 10]. The quality of the study was noted to be “excellent.” [Exhibit 6F at 10].

         On June 24, 2014, the claimant underwent a fluoroscopy lumbar puncture “to check the opening pressure due to the suspicion of pseudotumor cerebri.” [Exhibit 6F at 2–5]. The lumbar puncture was unremarkable and revealed “[n]o evidence of pseudotumor cerebri” and “no evidence of CNS infection.” [Exhibit 6F at 6]. And the claimant tolerated the procedure well. Upon physical examination, the claimant possessed normal strength, normal sensory, and a normal gait despite his spinal impairments. [Exhibit 6F].

         On July 2, 2014, the claimant saw Dr. Guo for follow up and to discuss results of the lumbar puncture. [Exhibit 6F at 2–5]. The claimant continued to complain of frequent severe headaches along with neck pain and intermittent tingling, numbness, and muscle cramps on the upper and lower extremities. The claimant again denied having any gait disturbances or falls. [Exhibit 6F at 5]. According to Dr. Guo, the claimant reported no relief despite use of both over-the-counter and prescribed pain medications and that a one-time injection of Toradol also did not provide the claimant with adequate relief. Dr. Guo’s progress notes state that the claimant’s lumbar puncture and CTA of the brain and neck were all unremarkable. Dr. Guo noted that the claimant’s previous MRI of the brain showed no structural abnormalities and that MRI of the C spine showed mild spondylosis. Dr. Guo’s neurological examination of the claimant was normal and / or appropriate in all areas. With respect to recent labs and evidence of any stroke activity, Dr. Guo noted in pertinent part:

Radiologist mentioned about old infarct on the left basal ganglia region, I reviewed the film. I do not think patient has a[n] old infarct, the lesion on the left basal ganglia region represents the small choroidal cyst.

[Exhibit 6F at 6].[9] Dr. Guo’s assessment identified headache, chronic pain. [Exhibit 6F at 6 (“The diffuse pain most likely suggests the diagnosis of fibromyalgia.”)]. Dr. Guo did not prescribe any additional medications and recommended that the claimant continue use of his continuous positive airway pressure (“CPAP”) machine and continue B12 injections. Dr. Guo wrote, “No work for now due to the persistent pain and headaches” and recommended follow up in three months. [Exhibit 6F at 6]. On July 9, 2014, Dr. Guo authored a letter stating that the claimant was still under her care but that the claimant has not been able to work since on or about September 5, 2013, due to his medical condition. [Exhibit 6F at 1].

         On September 24, 2015, Dr. Guo provided another brief, one-page letter stating that the claimant is a patient of hers and describing the cause for treatment of the claimant as “a history of intractable headaches, and chronic pain which involves neck, lower back, upper and lower extremities.” [Exhibit 7F]. No. treatment or progress notes were included. According to Dr. Guo, the clamant has been treated with medication “without good response.” [Exhibit 7F at 1]. Dr. Guo opined that the claimant “is totally disabled due to constant severe pain” and is unable to work. [Exhibit 7F]. The ALJ assigned the opinion of Dr. Guo little weight. [R. 16].

         The claimant was also treated by Marie Judith Cauvin, M.D. (“Dr. Cauvin”), with Piedmont Physicians Premier Medical, from 2013 until 2017. [Exhibit 7F at 2; R. 55]. According to Dr. Cauvin, the claimant has a fat tumor that is wrapping around his spinal cord causing him to experience severe pain. Dr. Cauvin indicated that the claimant’s pain medications are unable to help him due to the location of the tumor. Dr. Cauvin noted that the claimant has transient ischemic attacks due to high blood pressure and that there was also a history of mini strokes. [Exhibits 11F, 12F]. On September 24, 2015, Dr. Cauvin authored a one-page letter on Plaintiff’s behalf stating her opinion that the tumor wrapping around Plaintiff’s spinal cord at L5 causes him severe pain and raises his blood pressure and that, as a result of elevated blood pressure, the claimant has had a few TIA (mini strokes). [Exhibit 7F at 2]. According to Dr. Cauvin, the claimant suffers from insomnia due to pain and is unable to sit, stand, or walk for long periods of time. Dr. Cauvin opined that the claimant is at “great risk of paralysis and death” and is “totally disabled.” [Exhibit 7F at 2].

         On April 26, 2017, in a brief, one-page letter, Dr. Cauvin again described the claimant as being “totally disabled and unable to work.” [Exhibit 7F at 2]. Dr. Cauvin did not attach any treatment or progress notes. The ALJ assigned the opinion Dr. Cauvin little weight. [R. 16]. The ALJ noted that there was no objective medical evidence to support the claimant’s assertions of a fat tumor or Dr. Cauvin’s opinion that the tumor and related pain was a precipitating factor in the claimant’s high blood pressure and hypertensive episodes. [R. 20].

         On March 29, 2016, the claimant received follow up treatment for reported back pain that radiated to his extremities and increased blood pressure. However, the records describe the claimant as being in no distress. At times, the claimant’s blood pressure was elevated at 170/107. He was also assessed with having mixed hyperlipidemia, and the claimant was counseled on his diet and exercise. The claimant’s blood pressure fluctuated and was also noted as low as 130/78.

         On April 22, 2016, an MRI of the claimant’s lumbar spine reflected evidence of a shallow right sub-articular disc protrusion at the L5-S1 level, but there was minimal contact with the right S1 nerve root and no significant nerve displacement or central canal stenosis. The claimant’s prominent ventral epidural fat was noted with a congenitally diminutive L5-S1 spinal canal. There was also “minimal” disc bulge and facet degeneration. Overall, there was no significant central canal stenosis at any level and no abnormal enhancement. [Exhibits 9F, 11F].

         State Agency Consultants

         The claimant’s medical records were reviewed by State agency physicians and psychologists.[10] [Exhibits 1A–8A]. On November 22, 2013, Bettye Stanley, D.O. (“Dr. Stanley”), conducted an initial review of the claimant’s medical record and assessed all alleged physical impairments as non-severe. [Exhibit 1A at 10]. Dr. Stanley noted that the claimant does not appear fully credible and that the medical evidence does not support his statements. [Exhibit 1A at 10]. Spurgeon Cole, Ph.D. (“Dr. Cole”), opined as to the claimant’s mental impairments and related functioning. [Exhibit 1A at 10–16]. According to Dr. Cole, the claimant was limited in the areas of understanding and memory capacities and sustained concentration and persistence. Dr. Cole did not find any limitations in social interaction or adaptation. More specifically, Dr. Cole opined that the claimant was moderately limited in his ability to carry out detailed instructions, in his ability to make simple work-related decisions, and in his ability to maintain concentration, persistence, or pace.[11] [Exhibits 1A, 5A]. The additional explanation of the proposed mental RFC (as to Questions “A&B”) reads as follows:

A&B: CLAIMANT CAN UNDERSTAND, REMEMBER, AND CARRY OUT SIMPLE, BUT NOT DETAILED INSTRUCTIONS. ATTENTION IS VARIABLE. CLAIMANT MAY HAVE EPISODIC PROBLEMS W/CONCENTRATION FOR EXTENDED TASKS. CLAIMANT SHOULD BE CAPABLE OF CONCENTRATION FOR UP TO TWO HOURS WITH BREAKS. PACE MAY BE EPISODICALLY SLOWED SECONDARY TO PSYCH SYMPTOMS.

[Exhibit 1A at 14 (emphasis in original)].

         On March 28, 2014, the initial mental RFC assessment was affirmed on reconsideration and adopted by Steven Kaye, Ph.D. (“Dr. Kaye”), with no change. [Exhibit 5A]. On reconsideration, in terms of physical impairment and related functional limitations, the State agency physicians opined that the claimant can frequently lift 25 pounds as well as sit, stand, and walk for six hours out of an eight-hour workday. Although the claimant possessed postural and manipulative limitations, the DDS noted that he did not have any visual, ...


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