United States District Court, N.D. Georgia, Atlanta Division
FINAL OPINION AND ORDER
F. KING, UNITED STATES MAGISTRATE JUDGE.
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
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.[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
Statement of Facts
found the following facts [R. 12–22] as modified
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].
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. [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. [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].
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].
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.
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].
Evidence of Record
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.
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. [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.
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. 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].
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].
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
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].
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].
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].
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].
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]. 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].
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].
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].
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].
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.
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].
claimant’s medical records were reviewed by State
agency physicians and psychologists. [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. [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)].
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, ...