Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Simpson v. Saul

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

August 26, 2019

CARLO SIMPSON, JR., Plaintiff,
v.
ANDREW M. SAUL, [1] Commissioner of Social Security, Defendant.

          MEMORANDUM AND ORDER

          PATRICIA L. COHEN UNITED STATES MAGISTRATE JUDGE

         Plaintiff Carlo Simpson, Jr. seeks review of the decision of Defendant Commissioner of Social Security, Andrew Saul, denying his applications for Disability Insurance Benefits and Supplemental Security Income under the Social Security Act. For the reasons set forth below, the Court affirms Defendant's denial of Plaintiff's applications.

         I. Background and Procedural History

         On March 17, 2015, Plaintiff, then forty-six years old, filed applications for Disability Insurance Benefits and Supplemental Security Income alleging that he was disabled as of June 1, 2011 due to: HIV, neuropathy in feet and hands, fatigue, depression, joint pain, lack of energy and motivation, low self-esteem, and inability to stand for a very long time. (Tr. 11, 73-74) The SSA denied the claim on September 21, 2015, and Plaintiff filed a timely request for a hearing before an Administrative Law Judge (ALJ). (Tr. 82, 91-93) The SSA granted Plaintiff's request for review and conducted a hearing on May 19, 2017, at which Plaintiff and a vocational expert appeared and testified. (Tr. 47-72)

         In a decision issued on June 19, 2017, the ALJ found that Plaintiff “has not been under a disability, as defined in the Social Security Act, from March 17, 2015, the date the application was filed.” (Tr. 21) Plaintiff filed a request for review of the ALJ's decision with the SSA Appeals Council, which denied review on May 10, 2018. (Tr. 1-7, 147) Plaintiff has exhausted all administrative remedies, and the ALJ's decision stands as the SSA's final decision. Sims v. Apfel, 530 U.S. 103, 106-07 (2000).

         II. Evidence before the ALJ

         A. Hearing

         At the administrative hearing in May 2017, Plaintiff testified that he was forty-eight years old. (Tr. 53-54) Plaintiff had a high school education and worked as a dishwasher at a restaurant until June 2011, when he became sick with “the flu and pneumonia.” (Tr. 54) Plaintiff testified that he had been homeless since March 2015. (Tr. 53)

         Plaintiff testified that his most serious impairment was HIV. (Tr. 55) His symptoms included lack of energy, dizziness, fatigue, depression, migraines, and numbness and burning in his fingers and toes. (Tr. 54, 63) Plaintiff stated that, as a result of the “neuropathy and nerve damage” in his feet, “I can't even walk a block without having to stop. . . . everything's like in slow motion.” (Tr. 56) Plaintiff testified that, when his fingers were not numb, he suffered a burning sensation, which “fe[lt] like liquid acid or something” and occurred two to three times per week for “two or three hours maybe.” (Tr. 57-58) Plaintiff experienced migraines “every day” and they lasted “two or three hours.” (Tr. 63)

         When his hands were not “burning, ” Plaintiff was able to dress himself, tie his shoes, put on a belt, and eat with utensils. (Tr. 57-59) When Plaintiff was “moving from house to house, ” he would “occasionally…take out the trash, something like that.” (Tr. 64) Plaintiff affirmed that when he was “in these homes, ” he also prepared meals and did laundry. (Id.)

         Plaintiff estimated that he had lost “about 40 pounds” since March 2015. (Tr. 66) Plaintiff believed his impairments affected his ability to “stick with things and concentrate” and he had “troubles [sic] speaking.” (Id.) He did not believe he could resume working as a dishwasher because “of my endurance and my speed. . . . Like I say I move real slow now. If I overexert myself, I almost black out.” (Id.)

         A vocational expert testified at the hearing. (Tr. 67, 228) She explained that Plaintiff's previous work as a dishwasher was “unskilled” and required “medium exertion.” (Tr. 68) The ALJ asked the vocational expert to consider a hypothetical individual who:

[c]ould perform at the light exertion level; [can] occasionally climb ramps and stairs, [but not] ladders, ropes, or scaffolds…could engage in frequent handling and fingering;…limited to performing simple, routine tasks, but not at a fast pace; could have occasional interaction with coworkers and the public. No. concentrated exposure to extreme heat, cold, dust, fumes, or other pulmonary irritant.

(Tr. 68-69) The vocational expert testified that such an individual could not perform Plaintiff's past work, but could perform “light, unskilled” jobs available within the national economy such as a merchandise marker or a collator operator. Id. When the ALJ modified the hypothetical to “no interaction with the public and now at sedentary level, ” the vocational expert opined that such an individual could work as an addressing clerk or document preparer. (Tr. 70-71)

         B. Relevant Medical Records[2]

         Plaintiff established care with Dr. Summers, his primary care physician, in August 2014. (Tr. 233) Plaintiff informed Dr. Summers that he was first diagnosed with HIV in 1993 and had “not taken medicine or had labs in several years, as he has been homeless.” (Tr. 245) Plaintiff was 5'10” tall and weighed 122.4 pounds, and he complained of significant weight loss, worsening fatigue, thrush, and “a persistent right jaw abscess.” Id. Plaintiff denied depression, dizziness, and bone/joint pain. (Tr. 234-35) Upon examination, Dr. Summers noted that Plaintiff was “emaciated” with “shoddy anterior cervical, axillary and inguinal lymphadenopathy, oral thrush, right mandibular abscess, and firm palpable mass in the inferior pole of right testicle.” (Tr. 246) Dr. Summers prescribed fluconazole, Bactrim, and Amoxil. (Tr. 245)

         Plaintiff returned to Dr. Summers' office two weeks later. (Tr. 250) Plaintiff had gained eight pounds and his oral thrush and jaw abscess had resolved. (Id.) Plaintiff denied fatigue, dizziness, headaches, and bone/joint pain. (Tr. 248) Dr. Summers noted: “At [Plaintiff's] last visit, he was found to have a viral load of 378, 000[3] and a CD4 cell count of less than 20.[4] He was started on Bactrim and presents now to start on antiretrovirals.” (Tr. 250). Dr. Summers observed that Plaintiff “appears intoxicated, ” advised against smoking, and recommended outpatient treatment for alcohol and drug abuse. (Id.) Plaintiff's neurological examination and examination of his extremities were normal. (Tr. 251)

         At Plaintiff's follow-up appointment with Dr. Summers in September 2014, his weight had decreased to 121 pounds and his review of systems was positive for decreased appetite, weight loss, heartburn, fatigue, thrush, and lymphadenopathy. (Tr. 253) In regard to the medications, Plaintiff reported “100% compliance with no side effects.” (Tr. 255) At his next appointment, in November 2014, Plaintiff's weight had increased to 144 pounds, and he denied fatigue, dizziness, and bone/joint pain. (Tr. 258)

         When Plaintiff saw Dr. Summers in January 2015, Plaintiff complained of back and knee pain, weight loss, and thrush. (Tr. 260) Dr. Summers noted: “At last visit, [Plaintiff's] ¶ 4 cell count remained less than 20 and his viral load had decreased from 377 to 135. He reports good compliance with medication since that time.” (Tr. 260) Plaintiff denied “any significant health problems” and his neurological examination and examination of his extremities were normal. (Tr. 262, 264) Dr. Summers recommended tobacco cessation. (Tr. 264)

         At his follow-up appointment with Dr. Summers in April 2015, Plaintiff complained of peripheral neuropathy. (Tr. 266) Dr. Summers noted: “His last viral load went from 135 down to 25 and CD4 cell count went from less than 20 up to 21. His last creatinine was 1.38. He's been struggling with housing and diet and has lost 12 pounds. His only other complaint is of worsening peripheral neuropathy in the hands and feet.” (Id.) Plaintiff's review of systems was positive for weight loss, and Dr. Summers observed that Plaintiff appeared thin with lipoatrophy. (Tr. 266) Dr. Summers continued Plaintiff's medication and added gabapentin. (Tr. 266)

         When Plaintiff returned to Dr. Summers' office in July 2015, Plaintiff reported “worsening heartburn” and that the gabapentin “has helped slightly with his peripheral neuropathy, but [he] is interested in increasing the dosage.” (Tr. 278) Plaintiff's last viral load was undetectable, his “CD4 cell count increased from 21 up to 108, ” his last creatinine level was 1.38, and his weight was 135.4 pounds. (Tr. 278) Dr. Summers increased Plaintiff's gabapentin. (Id.)

         At Plaintiff's follow-up appointment with Dr. Summers in October 2015, Plaintiff complained of depression, “general sense of weakness, ” and “inability to gain weight.” (Tr. 320) Dr. Summers noted: “He has been compliant with medication; his last viral load was undetectable and CD4 cell count increased from 108 to 216.” (Id.) Dr. Summers prescribed Phenergan for nausea, mirtazapine for depression and appetite, and continued Plaintiff's Prilosec for stomach pain. (Id.)

         In January 2016, Dr. Summers noted that Plaintiff “was advised to return after one month, but has returned after 3 months.” (Tr. 318) Plaintiff's depression was “better, though not perfect” and his weight had increased twelve pounds. (Tr. 318) Dr. Summers noted that Plaintiff was “compliant with medications, without side effects, ” and Plaintiff's “last viral load was undetectable, CD4 cell count 289…and creatinine 1.56.” (Id.) Dr. Summers discontinued Plaintiff's Bactrim “as his CD4 cell count is persistently elevated” and “strongly advised on tobacco cessation.” (Id.) Plaintiff's neurological examination and examination of his extremities were normal. (Tr. 319)

         When Plaintiff returned to Dr. Summers' office in April 2016, Plaintiff reported that he had stopped taking gabapentin “due to lack of effectiveness” and he “continue[d] to have problems with a burning and tingling sensation in both hands and feet.” (Tr. 316) Dr. Summers prescribed Lyrica and ordered upper and lower extremity nerve conduction studies. (Id.) He also noted that Plaintiff's last viral count was undetectable, his CD4 cell count was 322, and his creatinine level was 1.55. (Id.)

         In July 2016, Plaintiff presented to Dr. Summers' office for his annual physical examination. (Tr. 292) Plaintiff reported “some mild problems with depression, despite being on medication, ” and denied fatigue, change in appetite, headaches, dizziness, abdominal pain, and nausea. (Tr. 292-93) Dr. Summers did not note any complaints about peripheral neuropathy. Plaintiff's last viral load was undetectable and his CD4 cell count was 343. (Tr. 293) Plaintiff continued to smoke. (Id.)

         At Plaintiff's follow-up appointment in November 2016, Plaintiff stated he “continues to have neuropathy in his feet and he wishes that further evaluation [sic]. He does get benefit from Lyrica, but his insurance will not cover it.” (Tr. 290) Dr. Summers provided Plaintiff samples of Lyrica and referred Plaintiff to BJC's neurology department for a nerve conduction test of the lower extremities.[5] (Tr. 289) Plaintiff denied fatigue, headaches, change in appetite, abdominal pain, and nausea. Plaintiff “admit[ted]” coughing and shortness of breath but ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.