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Williams v. Berryhill

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

June 28, 2017

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



         Plaintiff 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.

         I. Procedural History

         Plaintiff 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.[2]

         Plaintiff's 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).

         II. Evidence Before the ALJ

         Medical Records

         On July 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).

         On 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).

         On 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).

         Plaintiff 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).

         On 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).

         On 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.

         On June 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).

         Plaintiff 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).

         Plaintiff 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).

         At his 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. 545-47).

         Plaintiff 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).

         Plaintiff 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).

         On 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. (Tr. 470-73).

         Plaintiff 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 ...

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