United States District Court, E.D. Missouri, Eastern Division
MEMORANDUM AND ORDER
CATHERINE D. PERRY UNITED STATES DISTRICT JUDGE
Randall Williams brings this action pursuant to 42 U.S.C.
§§ 401 and 1381 et seq. and 42 U.S.C.
§ 405(g) seeking judicial review of the
Commissioner's decision denying his applications for
disability insurance benefits and supplemental security
income. Because the Commissioner's final decision is
supported by substantial evidence on the record as a whole, I
will affirm the decision of the Commissioner.
filed applications for benefits on December 19, 2012. He
alleged he became disabled beginning February 15, 2012,
because of chronic obstructive pulmonary disease (COPD),
shortness of breath, an inability to stand or walk for
extended periods, knee dysfunction, chest pain, high blood
pressure, congestive heart failure, hand numbness, insomnia,
and anxiety. Plaintiff's insured status under Title II of
the Act expired on December 31, 2013.
applications were initially denied on March 28, 2013. After a
hearing before an ALJ on July 21, 2014, the ALJ issued a
decision denying benefits on December 1, 2014. On April 9,
2015, the Appeals Council denied plaintiff's request for
review. The ALJ's decision is thus the final decision of
the Commissioner. 42 U.S.C. § 405(g).
Evidence Before the ALJ
5, 2010, plaintiff was evaluated by internist Raymond Leung,
M.D. Williams reported having hypertension, coronary heart
failure, back and knee pain, numbness of the hands and feet,
decreased vision, and headaches. He used a cane to help him
walk because “he just had it.” Examination showed
normal cardiac rate and rhythm with no murmurs. Pulmonary
examination was clear to auscultation, with no rales,
rhonchi, or wheezes, and normal percussion and AP diameter.
Plaintiff's gait, without his cane, was stiff. Plaintiff
walked with a minimal limp with his cane. He was able to
tandem walk and hop, heel walk, toe walk, and squat. Straight
leg raising with the right leg was limited to 70 degrees and
85 degrees on the left leg. Plaintiff had a decreased range
of motion in his lumbar spine and knees, with no muscular
atrophy or spasms. His pinch, grip, arm, and leg strength
were 4, and plaintiff had no difficulties getting on and
off the exam table. Plaintiff had decreased sensation to pin
prick in his left hand and mild decreased vibratory sensation
in his feet. Proprioception in the toes was within normal
limits and his reflexes were normal. Plaintiff had no edema
and normal distal pulses in his extremities. After
examination, Dr. Leung's impression was hypertension
controlled, congestive heart failure with normal lung
examination, back and knee pain, numbness of the hands and
feet, decreased vision, and headaches. (Tr. 463-68).
October 16, 2012, plaintiff saw Vani Pachalla, M.D., for a
medication refill and follow up for his congestive heart
failure. Plaintiff's condition was noted to be stable.
Plaintiff reported chest pain, increased fatigue, orthopnea,
palpitations and shortness of breath, but no swelling,
frequent urination, impotence, irritability, ulcers, or
weight gain. Examination revealed normal respiratory sounds,
with clear lungs, and a normal heart rate and rhythm with no
murmurs, gallops, or rubs. Plaintiff had no abnormalities in
his back or spine but trace edema on his lower leg. Dr.
Pachalla noted that plaintiff was non-compliant with his
current therapy and medication regimen and had missed many of
his cardiac follow-up appointments. Plaintiff admitted
smoking and was diagnosed with nondependent tobacco use
disorder. Plaintiff and his wife were counseled on his
diagnosis, and Dr. Pachealla ordered lab work. (Tr. 308-10).
November 18, 2012, plaintiff went to the emergency room
complaining of chest pain. Examination revealed normal heart
rhythm, regular breath sounds, no edema in extremities, and a
full range of motion with no inflammation. A stress test
revealed abnormal myocardial perfusion with a small to medium
area of mild ischemia in the inferolateral wall and normal LV
systolic function. An echocardiogram showed normal systolic
function with an ejection fraction in the 55 to 65 percent
range. There were no regional wall motion abnormalities and
wall thickness was normal. A cardiac cath test was also
performed and revealed that the left ventricular function was
at the lower end of the normal range, with a visually
estimated ejection fraction of 45 to 50 percent. The coronary
arteries and left and right heart hemodynamics were normal.
There was minimal or mild mitral regurgitation. Plaintiff was
discharged on November 21, 2012, with the diagnoses of chest
pain, likely related to congestive heart failure or COPD,
COPD, systolic and diastolic congestive heart failure,
hypertension, hypersensitivity lung disease, tobacco abuse,
depression, and acute respiratory failure. (Tr. 316-79).
returned to the emergency room on December 7, 2012,
complaining of a headache and nausea. He said it had lasted
about a week, but he denied having a fever or vomiting. Upon
examination, plaintiff's breathing sounds were normal,
his heart rate and rhythm were regular, and he had no focal
pain in any muscle or joint groups. His reflexes, mood, and
affect were normal. A CT scan of his head was normal. He was
diagnosed with a headache and discharged. (Tr. 432-57).
January 24, 2013, plaintiff saw Susana Lazarte, M.D., for a
follow up visit for chest pain. Dr. Lazarte noted that
plaintiff's November test results showed only mild
ischemia, normal coronaries, and only mild diastolic
dysfunction. Plaintiff reported feeling depressed and worried
that he could have a serious disease. Plaintiff's
physical examination was within normal limits, but he
displayed a depressed affect, anhedonia, and anxiety. Dr.
Lazarte noted that plaintiff was compliant with his
medication regimen, his relative risk was improving, and he
was responding to current treatment. Dr. Lazarte adjusted
plaintiff's medication. (Tr. 569-72).
February 18, 2012, plaintiff saw cardiologist Alan Zajarias,
M.D. Plaintiff's diagnoses were listed as hypertension,
dyslipidemia, nonischemic cardiomyopathy, with a mildly
decreased ejection fraction, and tobacco abuse. Plaintiff
reported that he had stopped smoking. He complained of
migraine headaches and occasionally feeling winded but denied
angina, syncope, presyncope, orthopnea, or PND. Dr. Zajarias
noted that plaintiff's medical compliance was
intermittent. Physical examination was normal, with a regular
heart rate, clear breath sounds, and no edema in extremities.
Dr. Zajarias continued plaintiff's medications, ordered
lab work to check plaintiff's brain natriuretic peptide,
and referred him for a sleep study. Plaintiff's BNP test
results were all within normal limits.
3, 2013, plaintiff saw Maria Del Rosario Bobadilla for
depression. Plaintiff reported feeling anxious, fearful,
depressed, worthless, and indecisive. Plaintiff claimed he
had poor concentration, hallucinations, changes in appetite,
sleep disturbance, and thoughts of death or suicide.
Plaintiff was noted to have the symptoms of a major
depressive episode. Plaintiff reported having a history of
suicidal thoughts and claimed to hear voices telling him to
end his life, but he denied having a plan. He was encouraged
to take his medication and continue counseling. Clinical
assessment was unspecified psychosis and his GAF score was
43. (Tr. 565).
saw Miranda Coole, M.D. on June 19, 2013, for depression.
Plaintiff told Dr. Coole that he was having extreme
difficulties meeting home, work, and social obligations. He
reported depressed mood, diminished interest, fatigue,
feelings of guilt or worthlessness, changes in appetite,
sleep disturbance, and thoughts of death or suicide.
Plaintiff stated that had thoughts and plans of suicide, his
suicidal thoughts were “much worse” than they had
ever been before, and he was worried he might try to
electrocute himself or jump in front of a car. Physical
examination yielded normal results. Dr. Coole diagnosed
depression with anxiety and discussed emergency treatment
options for suicidal thoughts and plans. (Tr. 563-64).
Plaintiff went to the emergency room later that day for
increased depressive symptoms and suicidal ideations and was
hospitalized for bipolar disorder, major depressive disorder,
and cluster B traits until June 22, 2013. (Tr. 392). Physical
examination upon admission showed normal cardiac rhythm and
heart sounds, normal breath sounds, a normal range of motion,
no edema, and normal muscle tone. (Tr. 395).
saw Dr. Coole again on July 17, 2013, complaining of swelling
in his ankles and legs and joint pain. Plaintiff denied chest
pains, cough, orthopnea, or shortness of breath. Dr. Coole
noted plaintiff's history of congestive heart failure,
hypertension, non-ischemic cardiomyopathy, and positive ANA.
Dr. Coole observed edema in the extremities, but physical
examination was otherwise within normal limits. Dr. Coole
diagnosed congestive heart failure and increased his
medication. She also referred him to a rheumatologist and a
behavioral health specialist. (Tr. 555-57).
next visit on July 31, 2013, plaintiff told Dr. Coole that he
was having shortness of breath in the morning and at night.
His physical examination was normal, with no edema in the
extremities, regular heart rate and rhythm, and normal breath
sounds. Dr. Coole's assessment was congestive heart
failure. She renewed plaintiff's medications. (Tr.
began therapy for his depression with John Rajeev, LCSW, on
August 5, 2013. Plaintiff reported having mood swings,
irritability, and crying spells. Mr. Rajeev's assessment
was moderate, recurrent major depression and he assigned
plaintiff a GAF score of 50. (Tr. 542-43). Plaintiff had
sessions with Mr. Rajeev again in September and October of
2013. Plaintiff denied suicidal thoughts and was encouraged
to continue with his medications. His assessment and GAF
scores remained unchanged. (Tr. 528-32).
saw Dr. Coole for a medication refill on September 17, 2013.
At that visit, plaintiff reported feeling lightheaded,
claiming it affected his ability to lift, sit, stand, and
walk. He also reported falling, pain, and unsteadiness, but
he denied having chest pain, dizziness, dysphasia, fever,
gait change, numbness, or weakness. Plaintiff said he felt
sleepy during the day, dropped things for no reason,
sometimes lost his balance, snored, and had sleep apnea.
Plaintiff also stated he had joint pain with decreased
mobility, instability, limping, swelling, and tenderness. He
reported using a cane and told Dr. Coole that he wanted a
prescription for a cane so he could take it with him on a
trip. Physical examination yielded normal results, with
normal heart and breath sounds and no edema or tenderness.
Dr. Coole assessed plaintiff's congestive heart failure
as stable, gave him the requested prescription for a cane to
“use daily as directed for joint pain, ” and
ordered a sleep study. (Tr. 534-37).
December 13, 2013, plaintiff was evaluated for lupus by Julie
Unk, ANP. Plaintiff complained of shortness of breath, back
pain, knee pain, numbness and tingling of the hands, and
insomnia. Ms. Unk noted that he was seen in the clinic two
years before for an evaluation of lupus but never had the lab
work performed to determine a diagnosis. Ms. Unk noted a
positive ANA. Plaintiff denied having any rashes but did
report itchy skin. He said he had chest pains and shortness
of breath “daily since the 1990s.” Plaintiff
reported a history of depression and back pain, claiming that
he sometimes lost his balance because of pain and used a cane
for stability. Plaintiff also stated that he had constant
numbness and tingling of his hands which increased at night.
Plaintiff told Ms. Unk that he had an accident when he was in
20s, resulting in severed nerves in his left forearm and
permanent nerve damage. Plaintiff reported dropping objects
due to numbness and tingling. Plaintiff stated he injured his
right hand several times and now his hand turns cold and
changes color. Plaintiff said his knees were stiff and he had
difficulty bending forward to tie his shoes. Plaintiff
admitted smoking one pack of cigarettes every four days.
Physical examination revealed normal lung and heart sounds,
no motor or sensory defects with Tinel's maneuver failing
to increase numbness or tingling in hands, no edema, and a
normal functional range of motion with joints, wrists,
elbows, shoulders, knees, ankle, and feet all normal in
appearance. Imaging of plaintiff's knees, cervical spine,
and lumbar spine revealed minimal, bilateral joint space
narrowing of the knees, moderate multilevel cervical
degenerative disc disease most severe at ¶ 5-C6 through
C7-T1, and mild degenerative disc disease at ¶ 4-L5. Ms.
Unk assessed plaintiff with positive ANA, back pain, knee
pain, neck pain, and paresthesias in both hands. Ms. Unk
recommended plaintiff start B6 vitamins and stop smoking.
was seen by Edward Coverstone, M.D., on March 17, 2014, for a
cardiology follow-up. Dr. Coverstone reported that plaintiff
was doing “poorly” since his last visit with Dr.
Zajarias. Plaintiff reported having dyspnea with minimal
exertion, some chest pain and pressure with palpitations, and
some lightheadedness upon standing. Plaintiff stated that he
was compliant with his medications. Physical examination