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Azar v. Berryhill

United States District Court, E.D. Missouri

June 4, 2019

STEVEN ANTHONY AZAR[1], Plaintiff,
v.
NANCY A. BERRYHILL, Deputy Commissioner of Operations for Social Security, [2] Defendant.

          MEMORANDUM AND ORDER

          E. RICHARD WEBBER, SENIOR UNITED STATES DISTRICT JUDGE

         This is a pro se action under Title 42 U.S.C. § 405(g) for judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying the application of Steven Azar (“Plaintiff”) for Supplemental Security Income (“SSI”) under Title XVI, 42 U.S.C. §§ 1383, et seq. For the reasons set forth below, the Court affirms the decision of the Commissioner.

         I. Procedural History

         Plaintiff filed his application for SSI on June 9, 2014.[3] (Tr. 10, 160-65.) Plaintiff claimed he became disabled on May 1, 2013, because of depression, anxiety, a pinched nerve in his right hip and leg, high blood pressure, and hernia surgery. (Tr. 258, 264.) Plaintiff was initially denied relief on July 16, 2014. (Tr. 65-80.) At Plaintiff's request, a hearing was held on May 23, 2016, before an Administrative Law Judge (“ALJ”). (Tr. 34-47.) Both Plaintiff and a vocational expert testified at this hearing. At the hearing, the ALJ ordered physical and psychological consultative examinations and requested medical source statements. Thereafter, the ALJ held another hearing at which Plaintiff, two medical experts and a vocational expert testified. (Tr. 48-61.) After the hearing, by a decision dated December 30, 2016, the ALJ found Plaintiff was not disabled. (Tr. 23-40.) Plaintiff requested the Appeals Council review the ALJ's decision, stating, “I think the decision was wrong because of my health conditions.” (Tr. 158.) On January 12, 2018, the Appeals Council denied Plaintiff's request for review of the ALJ's decision. (Tr. 1-6.) Thus, the ALJ's decision stands as the final decision of the Commissioner.

         In this action for judicial review, Plaintiff contends the Commissioner's decision was not based on substantial evidence in the record. In his complaint, Plaintiff claims he “feel[s he is] entitled to disability because of the nature and amount of illnesses that [he has].” (ECF 5 at 1.) Plaintiff alleges no other arguments in favor of reversal. Instead, Plaintiff provides only a list of his impairments and related symptoms. (ECF 17.) Defendant has filed a brief in support of the answer (ECF 22) and a statement of additional facts (ECF 22-1).

         II. Evidentiary Hearing Before the ALJ

         On May 23, 2016, Plaintiff testified about his vocational history at his administrative hearing. (Tr. 34-41.) His past work included the job of assembler. (Tr. 41, 42.) Plaintiff identified anxiety, depression, high blood pressure, and nerve pain in his leg as his medical conditions. (Tr. 44.) Plaintiff testified he took Glipizide and naproxen sodium for nerve pain and was also taking medication for anxiety and depression. (Tr. 44.) At the hearing, the ALJ observed there were no medical source statements in the record and determined additional evidence was needed to adjudicate the case. (Tr. 44-45.) Accordingly, the ALJ ordered consultative examinations and requested medical source statements. (Tr. 4.5.)

         The ALJ held a second administrative hearing on November 22, 2016. (Tr. 47-61.) At the hearing, Chukwuemeka Ezike, M.D., testified Plaintiff had the severe impairments of diabetes mellitus, obesity, and lumbar disc disease. (Tr. 52-53.) Dr. Ezike opined Plaintiff did not meet a listed impairment. (Tr. 53.) He stated Plaintiff could lift up to 50 pounds occasionally and 20 pounds frequently; he could sit for 6 hours per 8-hour workday; stand for 3 hours per 8-hour workday; and walk for 3 hours per 8-hour workday. (Tr. 54, 55-56.) Dr. Ezike stated Plaintiff could occasionally climb stairs or ramps, balance, bend, crawl, kneel, squat, and stoop, but never climb ropes, ladders, or scaffolds. (Tr. 53.) He opined Plaintiff had no manipulative, environmental, or foot-control limitations. (Tr. 53-54.)

         At this same hearing, James Reid, Ph.D., testified. (Tr. 56-59.) Based upon his review of the evidence, Dr. Reid noted that Plaintiff had anxiety and depression, but did not meet a listing. (Tr. 56.) He stated Plaintiff had mild limitations in activities of daily living; social functioning; and concentration, persistence, and pace. (Tr. 56-57.) Dr. Reid also noted Plaintiff had no episodes of decompensation.[4] (Tr. 57.) He concluded Plaintiff's mental impairments were non-severe and Plaintiff did not have mental work-related limitations. (Tr. 57.)

         A vocational expert also testified at the hearing. The ALJ asked the VE to assume a hypothetical individual of Plaintiff's age, education, and past work experience who can could lift and carry 50 pounds occasionally and 20 pounds frequently; stand up to 3 hours in an 8-hour workday; walk up to 3 hours in an 8-hour workday; and sit up to 6 hours in an 8-hour workday; never climb ladders, ropes, and scaffolds; occasionally climb ramps or stairs; occasionally balance, stoop, kneel, crouch, and crawl. The vocational expert testified a person with these restrictions could work at a light exertional level and could return to his past work as an assembler. (Tr. 54-55.)

         III. Medical Evidence

         On September 15, 2014, Plaintiff saw Dr. Gina McCrary-Smith, D.O., at North Central Community Health Center (NCCHC) for medication refills, right hip and leg pain, and nasal congestion. (Tr. 484-85.) Dr. McCrary-Smith indicated Plaintiff was alert and cooperative with normal muscle strength and tone throughout with no atrophy, spasticity, or tremors, and a normal gait and station. (Tr. 484-85.) Plaintiff's mental-status examination showed normal affect and speech. (Tr. 485.) Dr. McCrary-Smith assessed right hip pain; diabetes mellitus, type 2, uncomplicated; obesity; and allergic rhinitis. (Tr. 485.) She recommended Plaintiff follow-up in three months; continued norvasc (high blood pressure), lisinopril (high blood pressure), gabapentin (nerve pain medication), cyclobenzaprine (muscle relaxant), and lorazepam (benzodiazepine for anxiety); started loratadine (antihistamine) and flonase (steroid).

         Plaintiff returned to Dr. McCrary-Smith on December 15, 2014, for medication refills, a rash, anxiety, and depression. (Tr. 481-83.) Upon examination, Plaintiff was alert and cooperative with normal muscle strength and tone throughout with no atrophy, spasticity, or tremors, and a normal gait and station. (Tr. 481-82.) The mental-status examination showed a normal affect and speech. (Tr. 481-82.) Dr. McCrary-Smith assessed diabetes mellitus, type 2, uncomplicated; benign essential hypertension; anxiety and depression; and a skin abscess. (Tr. 482.) She started alprazolam (sedative for anxiety) and bactrim (for a skin/soft tissue abscess) and continued naproxen sodium (nonsteroidal anti-inflammatory drug), cyclobenzaprine, and loratadine. (Tr. 482.)

         On March 2, 2015, Plaintiff returned to Dr. McCrary-Smith for medication refills, anxiety, and blurred vision. (Tr. 473-75.) Upon examination, Plaintiff was alert and cooperative with normal muscle strength and tone throughout with no atrophy, spasticity, or tremors, and a normal gait and station. (Tr. 473-74.) The mental-status examination showed a normal affect and speech. (Tr. 474.) Dr. McCrary-Smith assessed diabetes mellitus with neurological manifestations; blurred vision; and anxiety. (Tr. 474.) She started metformin (anti-diabetic medication) and referred Plaintiff to a nutritionist; clinical pharmacist; and an eye doctor. Dr. McCrary-Smith continued alprazolam, lisinopril, norvasc, and gabapentin. (Tr. 474.)

         On April 30, 2015, Plaintiff saw clinical pharmacist, Justinne Guyton, PharmD, for diabetic care. (Tr. 471.) Plaintiff admitted his recent weight gain of 30 pounds had negatively impacted his blood glucose control. (Tr. 471.) He stated that he walked two-to-three miles to the grocery store several times each week. (Tr. 471.) Plaintiff was unwilling to start insulin. (Tr. 471.) The pharmacist increased metformin, started glipizide (anti-diabetic medication), and provided education on diabetes. (Tr. 471.)

         Plaintiff returned to Dr. McCrary-Smith for follow-up and medication refills on June 1, 2015 (Tr. 516). There was no physical examination. Id. Dr. McCrary-Smith refilled alprazolam (Tr. 516). A few days later, she prescribed citalopram for depression (Tr. 515).

         On July 17, 2015, Plaintiff returned to Ms. Guyton for diabetic care. (Tr. 513.) He reported that he had lost 15 pounds, walked 2-to-3 miles to the grocery store several times per week, biked 2-to-3miles daily, and lifted weights. (Tr. 513.) Ms. Guyton noted Plaintiff's blood glucose was improved on his new regimen and was also influenced by his increased exercise and weight loss. (Tr. 513.) His diabetes medications (metformin and glipizide) were continued. (Tr. 513.) A few weeks later, Dr. McCrary Smith made similar observations. (Tr. 512).

         On September 1, 2015, Plaintiff returned to Dr. McCrary-Smith, complaining of anxiety, depression, and elevated blood pressure. (Tr. 508-10.) Upon examination, Plaintiff was alert and cooperative with normal muscle strength and tone throughout with no atrophy, spasticity, or tremors, and a normal gait and station. (Tr. 508-09.) Plaintiff also had a normal mental-status examination. (Tr. 509.) Dr. McCrary-Smith continued Plaintiff's medications. (Tr. 509.)

         On December 16, 2015, Plaintiff saw Dr. McCrary-Smith, who noted Plaintiff was alert and cooperative; his peripheral vascular examination was normal; he had normal coordination and gait; and his diabetic foot examination was normal. (Tr. 502-03.) Dr. McCrary-Smith assessed diabetes mellitus, type 2, uncomplicated; anxiety; and depression. (Tr. 503.) She continued Plaintiff's medications and added tramadol. (Tr. 503.)

         On March 23, 2016, Plaintiff returned to NCCHC complaining of hypertension, diabetes, and right hip and back pain. (Tr. 610-12.) Upon examination, Plaintiff was alert and cooperative with normal muscle strength and tone throughout with no atrophy, spasticity, or tremors, and a normal gait and station. (Tr. 610-11.) Plaintiff had full range of motion (ROM), but stiff joints, no pain with palpation, nasal congestion with discharge, and numbness of the right leg with palpation and touch. (Tr. 611.) The mental-status examination showed a normal affect and speech. (Tr. 611.) Plaintiff was noted to exhibit good general health. (Tr. 610.) Dr. Carmel Boykin Wright assessed benign essential hypertension; diabetes mellitus with neurological manifestations, uncontrolled; blurred vision; peripheral neuropathy; sciatic nerve pain; and anxiety. (Tr. 610-12.) She continued his medications. (Tr. 611-12). Plaintiff was also prescribed singulair for his allergies. (Tr. 608.)

         On June 21, 2016, Plaintiff returned to NCCHC and saw a nurse practitioner. Plaintiff stated his medications were effective and he needed refills. (Tr. 606-08.) He also noted that his anxiety and depression were stable with medication. (Tr. 606.) Upon examination, Plaintiff was alert and oriented; the neurological examination was normal; his mood and affect were normal; and he had full ROM with no back pain upon palpation. (Tr. 606-07.) Plaintiff obtained refills on his medications. (Tr. 607-08.)

         On July 15, 2014, state-agency medical consultant Kyle DeVore, Ph.D., found Plaintiff had an anxiety-related disorder that caused no restrictions in his activities of daily living and social functioning; mild difficulties in maintaining concentration, persistence, and pace; and no episodes of decompensation. (Tr. 69.) ...


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