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.

James H. v. Saul

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

September 10, 2019

JAMES H., Plaintiff,
v.
ANDREW M. SAUL,[1] Commissioner of Social Security Administration, Defendant.

          MEMORANDUM AND ORDER

          JOHN M. BODENHAUSEN UNITED STATES MAGISTRATE JUDGE

         This action is before the Court pursuant to the Social Security Act, 42 U.S.C. §§ 401, et seq. ("the Act"). The Act authorizes judicial review of the final decision of the Social Security Administration denying Plaintiff James H.'s ("Plaintiff) application for disability benefits under Title II of the Social Security Act, see 42 U.S.C. §§401 et seq. and supplemental security income under Title XVI, see 42 U.S.C. §§ 1381 et seq. All matters are pending before the undersigned United States Magistrate Judge with the consent of the parties, pursuant to 28 U.S.C. § 636(c). Substantial evidence supports the Commissioner's decision, and therefore it is affirmed. See 42 U.S.C. § 405(g).

         I. Procedural History

         On May 4, 2015, Plaintiff filed applications for disability benefits (Tr. 252-59), arguing that his disability began on April 9, 2015, as a result of depression, possible bipolar disorder, heart condition, chest pains, and syncope.[2] (Tr. 150, 189) On September 29, 2015, Plaintiff s claims were denied upon initial consideration. (Tr. 180-86) Plaintiff then requested a hearing before an Administrative Law Judge ("ALJ"). Plaintiff appeared at the hearing (with counsel) on March 16, 2017, and testified concerning the nature of his disability, his functional limitations, and his past work. (Tr. 79-116) The ALJ also heard testimony from Dr. Michael McKeeman, a vocational expert ("VE"). (Tr. 107-14, 368-70) The VE opined as to Plaintiff s ability to secure other work in the national economy, based upon Plaintiff s functional limitations, age, and education. (Id.) After taking Plaintiffs testimony, considering the VE's testimony, and reviewing the evidence of record, the ALJ issued a decision on September 25, 2017, finding that Plaintiff was not disabled, and therefore denying benefits. (Tr. 7-23)

         Plaintiff sought review of the ALJ's decision before the Appeals Council of the Social Security Administration ("SSA"). (Tr. 1-5) On June 12, 2018, the Appeals Council denied review of Plaintiff s claims, making the September 25, 2017, decision of the ALJ the final decision of the Commissioner. Plaintiff has therefore exhausted his administrative remedies, and his appeal is properly before this Court. See 42 U.S.C. § 405(g).

         In his brief to this Court, Plaintiff raises three related issues. First, Plaintiff challenges the weight the ALJ accorded to Carol Greening's opinions in her medical source statement as his treating board certified psychiatric nurse practitioner, and Dr. Adam Samaritoni's opinion in his medical source statement as his treating doctor. Next, Plaintiff argues that the ALJ's Residual Function Capacity ("RFC") determination is not supported by substantial evidence. The Commissioner filed a detailed brief in opposition.

         As explained below, the Court has considered the entire record in this matter. Because the decision of the Commissioner is supported by substantial evidence, it will be affirmed.

         II. Third Party Statements (Tr. 278, 302-09, 356-61)

         The administrative record before this Court includes an undated "To Whom It May Concern" letter written[3] by the executive director of his last employer describing Plaintiffs employment as a cook. The letter generally described Plaintiffs past work as a cook, his problems at work, and the circumstances associated with Plaintiff quitting his job on April 9, 2015, three days before his alleged disability onset date. (Tr. 278)

         The administrative record also contains third-party statements regarding Plaintiffs ability to do daily and work-related activities from Toni Hall, his wife, and from Carrie Hall, his sister-in-law. Carrie Hall stated that Plaintiff is not able to do anything due to his mental health problems and joint pain. Toni Hall indicated that Plaintiff cannot complete work or tasks due to his chronic obstructive pulmonary disease ("COPD"), and he cannot be around crowds of people due to his mental health. There is also a Function Report Adult - Third Party completed by Wayne Rodgers, Plaintiffs former brother-in-law, generally supporting Plaintiffs allegations of disability.

         III. Medical Records

         The administrative record before this Court includes medical records concerning Plaintiffs health treatment from April 15, 2014, through January 17, 2017. The Court has reviewed the entire record. The following is a summary of pertinent portions of the medical records relevant to the matters at issue in this case.

         A. Clarity Healthcare - Carol Greening, APRN (Tr. 530-55, 637-41)

         Between January 22 and June 8, 2015, Nurse Carol Greening ("Nurse Greening"), a psychiatric nurse practitioner licensed by the State of Missouri, treated Plaintiff on five occasions and then again on January 17, 2017, at Clarity Healthcare. Nurse Greening completed a psychiatric diagnostic evaluation with medical services on the first visit and then medication management without psychotherapy on the following visits.

         On January 22, 2015, Nurse Greening saw Plaintiff for a psychiatric evaluation to establish treatment. Plaintiffs chief complaint was "I really need to stay on my medicine." (Tr. 549) Plaintiff reported having along history of psychiatric illness and being hospitalized in December 2014, for suicidal ideation. Plaintiff indicated that he was under a great deal of financial stress. Plaintiff reported that his mood was stabilizing he had no further suicidal ideation, and his energy and motivation were improving. Mental status examination showed Plaintiff to be alert, oriented x3, and cooperative, and to have good hygiene, adequate concentration and attention, intact memory, adequate insight and judgment, and average intellectual functioning. Nurse Greening's diagnoses included major depressive disorder, antisocial personality (per history), and psychosocial/environmental problems. Nurse Greening continued Plaintiffs current medication regimen and explored coping strategies with Plaintiff

         In follow-up treatment onFebruaryl8, 2015, Plaintiff complained of sleeping issues and experiencing irritable mood at times. Plaintiff reported having a history of depression with depressed mood, low energy and motivation, difficulty with concentration, and previous symptoms of manic episode including talkativeness, racing thoughts, distractibility, difficulty finishing things, and increased socialization. During the fifteen-minute session, Nurse Greening found Plaintiff to be alert and oriented, cooperative, appropriate dress and grooming and able to maintain appropriate eye contact with his speech spontaneous with normal rate and rhythm. Nurse Greening noted that Plaintiff had no psychotic symptoms; his thought process seemed to be rational, relevant, and goal-oriented; his concentration and attention were adequate; his memory intact; and his insight and judgment were adequate. Nurse Greening added the diagnosis of bipolar I depression and adjusted Plaintiff s medications.

         Although Plaintiff was to follow up in a week, he next received treatment on March 16, 2015, and reported having a poor response to his medications. Plaintiff reported that his anger was under better control and sleeping through the night, and his motivation and energy were improved. Plaintiff indicated that he had been working in the yard, and he would return to work in a month. Nurse Greening observed Plaintiff to be alert and oriented x3 and cooperative, appropriate in his dress and grooming and his mood more upbeat, his thought processes rational and memory intact, and insight and judgment were adequate. Nurse Greening adjusted his medications.

         On May 19, 2015, Plaintiff reported having health issues including several periods of passing out and receiving treatment in the emergency room resulting in $9, 000 hospital bill. Plaintiff reported sleeping well, experiencing financial stress, and having fairly stable mood but was mildly depressed. Plaintiff reported no side effects from his medication adjustment. Nurse Greening observed Plaintiff to be alert and oriented X3 and cooperative, appropriate in dress and grooming, and to have depressed mood, adequate concentration and attention, memory intact, and adequate insight and judgment. Plaintiff reported experiencing periods of chest pain and passing out and continued smoking. Nurse Greening continued Plaintiffs medication regimen.

         In follow-up treatment on June 8, 2015, Plaintiff reported his medication regimen made him more irritable. Plaintiff reported experiencing high stress due to his finances and lack of health insurance. Plaintiff indicated that he experienced some mood swings, mild depression, and sleeping problems. Nurse Greening observed Plaintiff to be alert and oriented x3 and cooperative, appropriate in his dress and grooming rational thought processes and relevant and goal-oriented, adequate concentration and attention, and insight and judgment. Plaintiff reported having COPD and still smoking. Nurse Greening adjusted Plaintiff s medication regimen by adding Latuda.

         Plaintiff returned on January 17, 2017, to transition his care from Hannibal Free Clinic after obtaining Medicaid. Plaintiff reported improvement in his health issues since using new inhalers. Plaintiff indicated that his energy and motivation were adequate. Plaintiff reported experiencing high stress because he cannot work and waiting for disability hearing. Plaintiff denied having any side effects from his medications. Plaintiff indicated that he had difficulty with impulse control especially when confronted by others. Nurse Greening observed Plaintiffs appearance to be within normal limits, and he was cooperative. Nurse Greening continued Plaintiffs medication regimen.

         B. Hannibal Free Clinic (Tr. 565-70, 576-601, 608-22)

         From March 24 to October 19, 2016, Plaintiff received treatment at the Hannibal Free Clinic.

         In the March 24, 2016, Nurse Screening Plaintiff listed COPD, bipolar, and depression as his current medical issues and no current medications. Plaintiff explained that he had to stop his treatment with Nurse Greening due to his financial status.

         On April 13, 2016, a nurse practitioner completed a psychiatric evaluation. Plaintiff reported having a long history of psychiatric illness and antisocial personality behavior, being hospitalized for suicidal ideation, and having low energy and motivation. Plaintiff indicated that he had been off his medications for a month and that Latuda effectively treated his symptoms. The nurse practitioner found his behavior to be appropriate and his attention/concentration was good. During a medication evaluation on May 18, 2016, Plaintiff reported that his mood was stable on his current dosage of Latuda and denied having any side effects. Plaintiff indicated that he had occasional mood swings caused by situational stressors. Mental status evaluation showed Plaintiffs mood was normal and his memory good.

         On July 13, 2016, Plaintiff reported doing fairly well and not having any severe mood swings. The nurse practitioner found Plaintiffs mood was stable and prescribed Latuda.

         During follow-up treatment on September 14, 2016, Plaintiff denied having any severe mood swings and any side effects from his medications. On October 19, 2016, Plaintiff reported that Latuda had been effective in treating his mood swings but he had experienced some new stressors such as transmission failure and lost cell phone. The treating doctor found Plaintiffs mood was stable and continued his medication regimen.

         C. Hannibal Regional Medical Group (Tr. 572-75, 623-27)

         From March 24 through December 14, 2016, Plaintiff received treatment with a nurse practitioner and Dr. Adam Samaritoni at Hannibal Regional Medical Group.

         On March 24, 2016, Plaintiff received treatment for his COPD with a nurse practitioner. Plaintiff reported that his symptoms were moderate in severity and unchanged. Plaintiff indicated that he had been experiencing difficulty breathing, shortness of breath, wheezing and chest pain and he requested an inhaler. Plaintiff indicated that he is a heavy tobacco smoker and he no current medications. During treatment, Plaintiff was cooperative and well groomed. Plaintiff was diagnosed with bronchitis with COPD and prescribed an inhaler.

         In treatment on August 11, 2016, Plaintiff returned "to go over his disability paper work for his COPD and Bipolar Depression." (Tr. 574) Chest and lung examination showed even and easy respiratory effort with normal breathing sounds and no wheezing. Dr. Samaritoni found Plaintiff to be alert and oriented x3 with appropriate judgment and insight and completed his disability paperwork.

         On November 14, 2016, Plaintiff returned to establish care after having been treated at the free clinic. Plaintiff reported being a current every day smoker. Dr. Samaritoni's chest and lung examination showed even and easy respiratory effort with normal breathing sounds and no wheezing. During follow-up treatment on December 14, 2016, Plaintiff reported that using the inhaler has helped. Chest and lung examination revealed quiet, even and easy respiratory effort, normal breath sounds, and no wheezes.

         D. Hannibal Regional Hospital (Tr 383-529)

         On April 15, 2014, Plaintiff received treatment in the emergency room at Hannibal Regional Hospital for nausea, vomiting and epigastric pain. Plaintiff reported not having recent depression and no suicidal thoughts. Plaintiff reported being an every day smoker. Psychiatric examination showed no depression, memory loss, or suicidal ideas. Neurological examination showed no syncope. The treating doctor noted that his general appearance to be well-groomed and well-oriented. Although Plaintiff has a history of smoking he reported no shortness of breath.

         On June 13, 2014, Plaintiff presented in the emergency room complaining of right foot/ankle pain after stepping in a hole. Plaintiff reported not having recent depression or suicidal thoughts. Plaintiff reported being a ...


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.