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Roche v. Berryhill

United States District Court, N.D. Ohio, Eastern Division

December 12, 2017

JUSTIN ROCHE, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          JAMES GWIN JUDGE.

          REPORT AND RECOMMENDATION

          Jonathan D. Greenberg United States Magistrate Judge.

         Plaintiff, Justin Roche (“Plaintiff” or “Roche”), challenges the final decision of Defendant, Nancy A. Berryhill, [1] Acting Commissioner of Social Security (“Commissioner”), denying his applications for Child's Insurance Benefits and Supplemental Security Income (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 416(i), 423, 1381 et seq. (“Act”). This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned United States Magistrate Judge pursuant to an automatic referral under Local Rule 72.2(b) for a Report and Recommendation. For the reasons set forth below, the Magistrate Judge recommends that the Commissioner's final decision be VACATED and the case REMANDED for further consideration consistent with this decision.

         I. PROCEDURAL HISTORY

         In December 2013, Roche filed applications for Child's Insurance Benefits and SSI, alleging a disability onset date of September 26, 2010 (later amended to December 16, 2013) and claiming he was disabled due to “lung problems, asthma, foot ankle deformity on both feet, trouble balancing and standing due to severe pain, anxiety, severe asthmatic, [and] bronchitis.” (Transcript (“Tr.”) 17, 196-197, 202-203, 210, 217.) The applications were denied initially and upon reconsideration, and Roche requested a hearing before an administrative law judge (“ALJ”). (Tr. 137-139, 140-142, 161-162.)

         On December 8, 2015, an ALJ held a hearing, during which Roche, represented by counsel, and an impartial vocational expert (“VE”) testified. (Tr. 36-64.) On February 2, 2016, the ALJ issued a written decision finding Roche was not disabled. (Tr. 17-34.) The ALJ's decision became final on January 3, 2017, when the Appeals Council declined further review. (Tr. 1-4.)

         On January 26, 2017, Roche filed his Complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 11, 12.) Roche asserts the following assignments of error:

(1) The ALJ violated the treating physician rule by failing to give good reasons for rejecting Dr. Ravakhan's [sic] opinions.
(2) The ALJ failed to give appropriate weight to the opinions of non-treating, consultative physicians.

(Doc. No. 11.)

         II. EVIDENCE

         A. Personal and Vocational Evidence

         Roche was born in August 1994 and was nineteen (19) years-old at the time of his amended onset date and twenty-one (21) years old at the time of his administrative hearing, making him a “younger” person under social security regulations. (Tr. 26.) See 20 C.F.R. §§ 404.1563(c) & 416.963(c). He has a limited education and is able to communicate in English. (Tr. 26) He has no past relevant work. (Id.)

         B. Relevant Medical Evidence[2]

         On June 22, 2012, Roche began treatment with Keyvan Ravakhah, M.D. (Tr. 532-536.) Roche reported a past history of asthma, ankle problems, losing his balance, and numbness in his fingers. (Tr. 532.) During this visit, he complained of progressive low back pain and bilateral ankle pain, as well as a rash on his hands and legs. (Tr. 532-533.) On examination, Dr. Ravakhah observed normal pulses, sensation, reflexes, coordination, and muscle strength and tone. (Tr. 534.) He also noted hyperlaxity of both ankles. (Tr. 534.) Dr. Ravakhah diagnosed possible obstructive sleep apnea, asthma, biliary colic, contracture of ankle and foot joint, and obesity. (Tr. 535.) He advised Roche to undergo a sleep study, prescribed asthma medication, and referred Roche to a podiatrist for his ankle and foot issues. (Id.)

         Roche presented to podiatrist Michael B. Canales, D.P.M., on July 17, 2012. (Tr. 492-493.) Dr. Canales recorded Roche's complaints as follows:

The patient is referred to me . . . for painful ankles and feet bilaterally. This has been a problem for this young man almost his entire life. It is getting unbearable. He is unable to stand in the shower or stand for long periods of time. It is very difficult for him to walk. He is a new patient. The patient rates the pain as 10/10. The pain is described as throbbing and aching. The patient is experiencing calf pain, chest pain, and shortness of breath. The patient states that walking, standing, stairs, and running (can't run) exacerbate the pain. Rest makes it feel better. The patient has seen no one for the treatment of this problem and had no treatments. The pain is preventing him from doing everyday things. The patient's goals of treatment are to ease the pain and walk with no pain. The patient denies any other history of musculoskeletal, foot or ankle problems, but his lower back hurts due to ankles.

(Tr. 492.) On examination, Dr. Canales found intact sensation, no peripheral edema, normal reflexes, and 5/5 manual muscle testing for all major muscle groups. (Tr. 492-493.) He also noted (1) “severe collapse of the medial longitudinal arch” on weightbearing examination; (2) reducible deformity; (3) normal subtalar joint range of motion; (4) mild peroneal tendon spasm; and (5) “decreased dorsiflexion with the knee extended and knee flexed consistent with gastroc-soleal equinus.” (Id.) X-rays of Roche's bilateral feet taken that date showed “severe uncovering of the talus, ” transverse plane deformity, severe plantar flexion of the talus, and decreased calcaneal pitch. (Id.)

         Dr. Canales diagnosed (1) “severe pes valgo planus with concomitant gastoc-soleal equinus (severely flexible flatfoot deformity, which is symptomatic);” and (2) obesity. (Id.) He concluded “[t]his is a significant deformity that may require surgery in the future;” however, he advised first trying “functional bracing.” (Id.) Dr. Canales believed the braces would help Roche's functioning, but noted Roche “is likely looking at surgical intervention in the future.” (Id.) He also “had a frank discussion” with Roche about the importance of weight loss. (Id.)

         On April 5, 2013, Roche presented to the emergency room (“ER”) with complaints of swollen hands. (Tr. 311-317.) He reported “he woke up at around midnight with swelling of his hands and some paresthesias and burning sensation, ” and indicated his “symptoms have persisted.” (Tr. 314.) Roche also reported extremity pain, but denied difficulty walking. (Tr. 315.) ER records indicate Roche ambulated with a “steady gait.” (Tr. 312.) On examination of Roche's hands, ER physician Ewald Kundtz, M.D., noted intact sensation, strength, and pulses, as well as good capillary refill. (Tr. 316.) No edema, erythema, or weakness was observed. (Id.) Dr. Kundtz diagnosed bilateral hand paresthesias of unclear etiology, and discharged Roche with instructions to follow up with his primary care physician. (Tr. 317.)

         Roche returned to Dr. Canales on September 10, 2013. (Tr. 491.) Roche reported the foot braces were “too painful.” (Id.) Examination findings were the same as the previous visit. (Id.) Dr. Canales also noted Roche was “walking with a cane at this time.” (Id.) He prescribed a prefabricated arch support and Vicodin. (Id.) Dr. Canales also “expressed to the patient's father that we may need to discuss surgical intervention if conservative management has failed as this is affecting his son's activities of daily living.” (Id.)

         Roche next presented to Dr. Canales on October 15, 2013. (Tr. 490.) Roche reported the arch supports “helped him significantly” and reduced his pain by 50%. (Id.) Dr. Canales was “pleased to see that Justin is doing well with his foot orthotics” and noted “it will take him 3-4 months to get the maximum benefit of the arch supports.” (Id.) He further stated “[i]f we need to move forward with surgical intervention, it is something I am very comfortable with.” (Id.)

         Roche was hospitalized the following month, from November 24 through November 27, 2013, for bronchitis and an asthma exacerbation. (Tr. 303-310, 331-336, 328-330, 325-327, 320-324, 318-319.) Examination revealed wheezing in both lungs, and fine crackles in the left lung base. (Tr. 318.) A chest x-ray taken on the date of admission, November 24, 2017, showed (1) left basal airspace disease; and (2) “mild prominence of perihilar markings, consider reactive airways disease.” (Tr. 553.) Roche underwent an additional chest x-ray two days later, which showed “persistent basal airspace disease, without significant interval change.” (Tr. 552.)

         On December 13, 2013, Roche returned to Dr. Ravakhah with complaints of cough, chest pain, and a rash. (Tr. 412-418.) Dr. Ravakhah noted Roche's recent hospitalization and indicated he was “improved but still . . . symptomatic.” (Tr. 412.) Dr. Ravakhah also remarked Roche “still has some pain in his ankles when he stands up.” (Id.) Examination revealed mild shortness of breath, mild tachychardia, and tenderness in Roche's bilateral ankles. (Tr. 412-413.) Dr. Ravakhah assessed asthma, obstructive sleep apnea, rosacea, ankle pain, obesity, and high blood pressure. (Tr. 415-416.) He referred Roche to a pulmonologist, and advised him to undergo a sleep study “ASAP.” (Tr. 415.) Dr. Ravakhah also “discussed the importance of regular exercise and recommended starting or continuing a regular exercise program for good health.” (Tr. 416.) He encouraged Roche to lose weight. (Id.)

         Roche presented to Ohio Chest Physicians on December 19, 2013. (Tr. 399-401.) The physician's name is illegible and the treatment note is difficult to read; however, it appears Roche was continued on his asthma medications and again advised to undergo a home sleep study. (Tr. 401.)

         On January 24, 2014, Roche returned to Dr. Ravakhah with complaints of bilateral ankle, knee, and lower back pain. (Tr. 407-411.) Roche rated the pain a 5 on a scale of 10, and indicated this was “baseline for him.” (Tr. 407.) On examination of Roche's extremities, Dr. Ravakhah found 5/5 motor strength, intact reflexes, and normal sensation. (Id.) He also noted Roche wore bilateral ankle braces. (Id.) Dr. Ravakhah advised Roche to continue his pain medications (Tramadol and Vicodin), and counseled him regarding weight loss and exercise. (Tr. 410-411.)

         Several weeks later, on March 14, 2014, Roche presented to the ER with complaints of abdominal pain. (Tr. 293-302.) An x-ray of his abdomen was unremarkable, and Roche was discharged home in stable condition with a diagnosis of constipation. (Tr. 296, 301, 551.) Roche returned to the ER on April 7, 2014 with flu-like symptoms and shortness of breath. (Tr. 283-292.) His lungs were clear on examination, with no wheezes, rales, or rhonchi. (Tr. 289.) Roche underwent an EKG, which was normal. (Tr. 291.) A chest x-ray showed improved left lower lobe infiltrate with residual minimal plate atelectesis and/or scarring. (Tr. 291, 550.) Roche was discharged home with a prescription for steroids. (Tr. 291.)

         Roche returned to Dr. Ravakhah on May 23, 2014 with complaints of hives and swelling in his bilateral forearms, sore throat, and body ache. (Tr. 471-475.) Dr. Ravakhah described Roche's knee and back pain as stable and advised him to continue his medications. (Tr. 475.) He also stated Roche was “disabled from my standpoint, ” and completed a disability form for Roche on that date. (Id.)

         In the disability form (entitled “Medical Source Statement: Patient's Physical Capacity”), Dr. Ravakhah described Roche's pain as “moderate.” (Tr. 470.) He concluded Roche's abilities to lift/carry, stand, and walk were affected by his impairments; i.e., his ankle, knee, and spinal pain. (Tr. 469.) Although the form asked for specific limitations in these areas, Dr. Ravakhah declined to specify any particular restrictions or limitations on Roche's abilities to lift/carry, stand, and/or walk. (Id.) Dr. Ravakhah concluded Roche's ability to sit was not affected by his impairments. (Id.) He found, however, Roche could only occasionally climb and kneel, and rarely balance, stoop, crouch, and crawl, due to his “joint issues.” (Id.)

         With regard to manipulative limitations, Dr. Ravakhah found Roche could frequently engage in reaching and fine manipulation; occasionally engage in gross manipulation; and rarely push or pull. (Tr. 470.) He concluded Roche was restricted from working around heights, moving machinery, temperature extremes, and pulmonary irritants. (Id.) He noted Roche had been prescribed a cane, and found he would need to be able to alternate between sitting, standing, and walking at will in order to “help him with balance [as] he uses a cane.” (Id.) Dr.

         Ravakhah also found Roche would require additional unscheduled rest periods during an 8 hour workday (outside of normal breaks). (Id.) Finally, Dr. Ravakhah opined Roche's pain would interfere with his concentration, take him off task, and cause absenteeism. (Id.) On July 8, 2014, Roche returned to Dr. Canales with complaints of severe foot pain. (Tr. 489.) He reported the pain had “steadily gotten worse, ” and had progressed to the point “that he cannot even stand in the shower without significant pain.” (Id.) Roche indicated the braces were “providing little relief.” (Id.) Dr. Canales noted intact sensation, 5/5 muscle strength, and normal reflexes. (Id.) On orthopedic examination, he found severe collapse of the medial longitudinal arch with forefoot abduction, and “decreased dorsiflexion with the knee extended and knee flexed consistent with gastroc-soleal equinus.” (Id.) Dr. Canales also noted Roche was “unable to perform a double limb heel rise test or single limb heel rise test.” (Id.) He diagnosed (1) pes planus with posterior tibial tendon dysfunction; and (2) flatfoot deformity (moderate to severe). (Id.) Dr. Canales concluded as follows:

I believe the patient would benefit from surgical intervention, as does his father. The patient is in agreement. This would be a major reconstructive undertaking approximately a year to a year and a half recovery for each foot. The patient would require surgical intervention for this operation and this would be performed under general anesthesia for approximately 2 ½ hours per operation. He would be following up with Dr. Joseph Sopko in the upcoming weeks for pulmonary evaluation. I would like to see the patient back in one month. I did provide him a prescription for Vicodin. He is permitted one tablet at night as needed for pain. I have also written a prescription for physical therapy for functional evaluation and capacity evaluation in addition to a prescription for a shower chair. This patient is so young and his painful deformities have affected his life in a negative way.

(Id.)

         Roche presented for an orthopedic evaluation for purposes of physical therapy on July 23, 2014. (Tr. 516-520.) Roche reported he began using a single point cane in approximately 2010, and stated he used a rolling walker for long distances such as the grocery store. (Tr. 516.) He also reported balance deficits, including “multiple falls with about 2 per week.” (Id.) He complained of “constant, throbbing” ankle, knee and lower back pain, which he rated a 9 on a scale of 10. (Tr. 517.)

         Physical therapist Brittany Nelson noted intact sensation and impaired, antalgic gait. (Tr. 516, 518.) She also found (1) reduced (i.e., 2-3/5) hip strength on extension and abduction; (2) reduced (i.e., 3) knee strength on flexion; and (3) reduced (i.e., 2-3/5) ankle strength on plantar flexion, dorsiflexion, inversion, and eversion, bilaterally. (Tr. 517-518.) Ms. Nelson also noted tenderness to palpation of Roche's bilateral plantar fascia, and impaired balance. (Tr. 518.) She concluded Roche's “foot and ankle ability measure 13%, indicating 87% functional impairment.” (Id.) Roche's “problem list” included decreased endurance, decreased range of motion, decreased strength, fall risk, impaired ambulation, impaired balance, impaired posture, pain, impaired functional level, and impaired functional mobility. (Tr. 519.) Some exercises were performed during this session, although Ms. Nelson noted Roche was unable to perform certain exercises due to pain. (Id.) Roche's rehabilitation potential was assessed as “good.” (Tr. 520.)

         Roche presented for physical therapy on August 6 and August 26, 2014. (Tr. 560-561, 562-563.) On both occasions, he reported foot pain which he rated an 8 on a scale of 10. (Id.) On August 6th, the physical therapist noted Roche “performed very slowly and was quickly fatigued.” (Tr. 560.) She also noted that, during certain exercises, Roche complained of foot numbness and hand pain. (Id.) On August 26th, Roche reported having fallen due to his ankle buckling. (Tr. 562.) The therapist again noted several of the exercises were “very challenging, ” and indicated a balance exercise was “discontinued due to very challenging with whole body tremors due to weakness and fatigue.” (Id.) A treatment note from September 2014 indicated Roche's physical therapy was “put on hold by MD.” (Tr. 564.)

         On August 22, 2014, Roche returned to Dr. Ravakhah. (Tr. 537-542.) He reported frequent asthma attacks (three per week) “because of the hot weather.” (Tr. 540.) Roche also complained of bilateral knee and ankle pain, which he described as “throbbing” and rated a 7-10/10. (Id.) He stated the pain was worse with activity and indicated that “after 5 minutes he has to lay down and rest for it to go away.” (Id.) Roche also reported bilateral hand pain for the previous two to three months. (Id.) He also suffered from bilateral hand weakness, indicating it was hard for him to grip things and type. (Id.) Finally, Roche reported experiencing headaches “when trying to concentrate.” (Tr. 541.)

         On examination, Dr. Ravakhah noted (1) tremor in both hands when arms are extended; (2) painful PIP and DIP joints in both hands; (3) pain with thumb abduction; (4) decreased range of motion in Roche's bilateral lower extremities; (5) decreased muscle strength; (6) normal pulses; and (6) unstable gait. (Tr. 541.) Dr. Ravakhah assessed arthritis and ordered blood work. (Tr. 538.)

         Roche returned to Dr. Canales on August 26, 2014. (Tr. 543.) Examination findings were the same as his previous visit. (Id.) Dr. Canales noted Roche had not yet obtained a pulmonary consultation and indicated “I do believe the patient could benefit from surgical intervention but I will not move forward until appropriate medical consultations have been made.” (Id.) He further indicated “I do not think that this problem will improve with nonoperative measures, as the deformity is severe.” (Id.)

         On September 16, 2014, Roche presented to the ER with complaints of shortness of breath, cough, and chest pain. (Tr. 565-576, 605-614.) On examination, Roche's lungs were clear and his respirations were unlabored, although he was “slightly tachychardic.” (Tr. 573.) Examination of his extremities was normal, with full range of motion, intact sensation and motor, no tenderness or edema, and normal gait. (Id.) A chest x-ray taken that date showed no radiographic evidence of acute cardiopulmonary process; however, ER physician Dr. Kundtz interpreted it to show a right lower lobe infiltrate. (Tr. 549, 575-576.) Dr. Kundtz decided to treat Roche for pneumonia and admitted him to the hospital overnight. (Tr. 576.)

         Roche returned to Ohio Chest Physicians on October 9, 2014. (Tr. 652.) He was again advised to schedule a home sleep study. (Id.) Roche subsequently underwent the sleep study on October 31, 2014. (Tr. 653.) This study revealed (1) mild obstructive sleep apnea; and (2) mild noctural hypoxia secondary to sleep apnea. (Id.)

         On November 11, 2014, Roche returned to Dr. Canales with complaints of “debilitating foot pain that continues to get worse.” (Tr. 651.) Dr. Canales noted intact sensation, 5/5 muscle strength, and normal reflexes. (Id.) On orthopedic examination, he found severe collapse of the medial longitudinal arch with forefoot abduction, and “decreased dorsiflexion with the knee extended and knee flexed consistent with gastroc-soleal equinus.” (Id.) Dr. Canales also noted Roche was “unable to perform a double limb heel rise test or single limb heel rise test.” (Id.) Dr. Canales again stated Roche would benefit from surgical intervention. (Id.) He ordered a CAT scan for surgical planning, and advised Roche to return “in three weeks for full surgical consultation in the presence of his mother and father who are here today.” (Id.)

         Roche next presented to Dr. Canales on January 27, 2015. (Tr. 650.) Examination findings were the same as the previous visit, with the additional finding that “on weightbearing examination, the patient's medial malleolus is purchasing the ground.” (Id.) Dr. Canales noted Roche was having difficulty obtaining the CT scan, which Dr. Canales felt was “instrumental in surgical planning.” (Id.) He advised him to return the following week for further surgical consultation. (Id.)

         On May 29, 2015, Roche began treatment with rheumatologist Isam Diab, M.D. (Tr. 643-648.) He complained of “stiffness and pain all over, ” particularly in his neck and back. (Tr. 643.) On examination, Dr. Diab noted Roche's lungs were clear with normal breathing sounds, and no wheezing, crackles or crepitus. (Id.) He also found as follows:

Musculoskeletal exam: Muscle strength. Difficult to evaluate because of stiffness, but 4-5/5 in shoulder and hip girdle muscles, normal flexor muscles of the neck, normal grips. Modest tenderness over cervical, thoracic, and lumbar spine, mainly spinous process, moderate tenderness over SI joints, right more than the left. Tender achilles tendons and the heels, bilaterally. Shober's test is positive. Moderate decrease in range of motion of cervical and thoracolumbar spine in all directions. Also tender over multiple enthesis at different joints.

(Id.) Dr. Diab assessed seronegative spondylopathy with “no sign of opthalmologic or other organ involvement.” (Id.) He noted “thoracic and lumbar spondylosis should be kept in mind as a cause for current symptoms.” (Id.) Dr. Diab also diagnosed “mechanical derangement, both ankles, using special orthotic.” (Id.) He ordered x-rays of Roche's spine and SI joint; prescribed Naprosyn and Omeprazole; and recommended exercises. (Id.)

         Roche underwent x-rays of his SI joint, lumbar spine, and thoracic spine that same day. (Tr. 648, 649, 638.) The SI joint x-ray was negative. (Tr. 648.) The lumbar spine x-ray showed “slight narrowing of the posterior disc . . . at ¶ 3 and L4 disc level as well as the L2 level which could indicate early degenerative changes.” (Tr. 649.) The thoracic spine x-ray showed “moderate to mild convex-right scoliosis in the midthoracic spine.” (Tr. 638.)

         Roche returned to Dr. Diab on July 10, 2015. (Tr. 664.) He reported he was “doing the same more or less, 20% better, still having modest upper and lower back stiffness, minimal pain off-and-on, more so with in the morning and with inactivity, also increase with bending and lifting, no radiation to lower limbs.” (Id.) On examination, Dr. Diab reported the same musculoskeletal findings as the previous visit, and also observed the following:

Modest synovitis, at first, second, and third PIP joints, right hand more than the left with some synovial thickening. Mild decrease in flexion at PIP's. Mild synovitis and synovial thickening at second MCP right hand, third MCP left hand. Modest synovitis with moderate tenderness over medidal side of the right wrist more than the left, with modest synovial thickening. Mild synovitis, swelling and warmth with modest tenderness anterior right ankle more than the left, tarsal joint and metatarsophalangeal joints bilaterally.

(Tr. 664.) He diagnosed seronegative sypondylopathy, peripheral polyarthritis, kyphoscoliosis, and mechanical derangement of both ankles. (Id.) Dr. Diab recommended stretching, isometric, range of motion, and water exercises, but advised Roche to avoid lifting or pushing heavy objects. (Id.) He continued Roche on Naprosyn and Omeprazole, and added a prescription for Sulfasalazine. (Id.)

         Roche next returned to Dr. Diab on September 25, 2015. (Tr. 663.) Examination findings and diagnoses were the same as the previous visit. (Id.) Dr. Diab discontinued Roche's prescription for Sulfasalazine due to side effects, including tremors in Roche's tongue. (Id.) Roche also reported migraines and imbalance, causing Dr. Diab to refer him for a neurological consultation. (Id.)

         On October 14, 2015, Roche began treatment with neurologist Howard Tucker, M.D. (Tr. 674-678.) Roche reported having “blackout spells which occur for 1 or 2 seconds, ” losing his words, and “episodes in which his tongue feels as if it is going back.” (Tr. 674.) He also complained of ringing in his ears, “a peculiar sensation on the top of his head, ” migraine headaches three to four times per month, and episodes of “zoning out.” (Id.) On neurologic examination, Dr. Tucker noted no focal deficits, and normal reflexes, coordination, muscle strength, and tone. (Tr. 676.) He indicated Roche “cannot walk without the bracing and does use a cane. Strength is good throughout and there is no limb ataxia. Tendon reflexes are hypoactive throughout and toes signs are flexor.” (Tr. 677.) Dr. Tucker diagnosed (1) seizure disorder, complex partial; (2) migraine headache; (3) arthritis; (4) lumbago; (5) obesity; and (6) contracture of ankle and foot joint. (Tr. 677-678.) He ordered an MRI of Roche's brain and an EEG, and prescribed Keppra and Sulfadiazine. (Id.)

         Roche returned to Dr. Tucker on November 2, 2015. (Tr. 670-673.) He reported “the Keppra has reduced the frequency of the headaches but he cannot state whether or not these spells have diminished.” (Tr. 670.) Roche underwent an EEG that date, which was normal. (Tr. 670, 679.) On examination, Dr. Tucker noted clear lungs, normal pulses, “no deformity or scoliosis noted with normal posture and gait, ” and “no clubbing, cyanosis, edema, or deformity . . . with normal full range of motion of all joints.” (Tr. 672.) Dr. Tucker started Roche on Dilantin and noted “Keppra will be gradually reduced and eliminated.” (Tr. 670.)

         On December 18, 2015, Roche presented to Dr. Tucker with complaints of “staring spells [that] occur multiple times each day, ” during which he “loses track of time.” (Tr. 666.) Roche's mother indicated Roche “sits at the table and just stares and . . . stays in his room oftentimes and won't come out because he is aware of them.” (Id.) Roche also reported lower back pain, which he rated a 7 on a scale of 10. (Tr. 667.) On examination, Dr. Tucker noted normal reflexes, coordination, muscle strength and tone. (Tr. 668.) He indicated Roche “walks with a cane but there is no ataxia nor nystagmus to suggest drug toxicity.” (Id.) Dr. Tucker increased the dosage of Dilantin and concluded Roche “should be followed more closely to try and get these staring spells under control.” (Tr. 666.)

         C. State Agency Reports

         1. Physical Impairments

         On April 8, 2014, Roche underwent a consultative physical examination with Hasan Assaf, M.D. (Tr. 457-467.) Roche reported a history of asthma and stated his symptoms included shortness of breath, wheezing, and cough. (Tr. 457.) He stated he was hospitalized at the age of two for pneumonia and blood infection, and kept in an induced coma for 1 ½ months. (Id.) Roche indicated he underwent physical therapy when he was discharged and “probably was taught in a wrong way because he started developing foot deformity in both feet as well as pain on standing and walking.” (Id.) Roche stated “the pain is an aching pain if he is not weightbearing, but becomes 10/10 pain if he walks for more than three to five minutes.” (Id.) He reported the pain mainly involves his ankles, worse on the right than the left. (Id.)

         Roche also reported pain in his knees and low back since the age of two. (Tr. 458.) He indicated “the pain in the knees is not present if he is not weightbearing, but occurs if he stands and walks for more than five minutes.” (Tr. 458.) Roche's low back pain “comes and goes, but is constantly present if he is sitting for a long time, standing for a long time, or walking as well as bending and lifting.” (Id.) Roche also complained of frequent headaches, and stated he was told he had fatty liver and gallbladder disease. (Id.)

         On examination, Dr. Assaf found as follows:

The claimant walks with abnormal gait. He has a flat foot gait. He also walks slightly bent forward. The claimant states that he cannot walk on heels and toes because of his feet. Squat is limited to 30 degrees. The claimant's stance is abnormal in that he stands slightly bending forward. The claimant uses a cane. He uses it for pain and weightbearing. He uses it all the time. It is self-prescribed. In my opinion, the use of the cane is medically necessary. Needed no help changing for exam or getting on and off exam table. Able to rise from chair without difficulty.

(Tr. 459-460.) Dr. Assaf noted no scoliosis, kyphosis, or abnormality in Roche's thoracic spine. (Tr. 460.) Straight leg raise was negative bilaterally, and Roche's joints were stable and nontender except for tenderness over the right and left ankles and knees. (Id.) An x-ray of Roche's right ankle showed increased talocalcaneal angle, and pes planus (i.e., flat feet). (Tr. 461, 463.)

         Manual muscle testing of Roche's shoulders, elbows, wrists and fingers was normal, as was his grasp, manipulation, pinch, and fine coordination. (Tr. 464.) Range of motion testing of Roche's cervical spine, shoulders, elbows, wrists, and hands/fingers was also normal. (Tr. 465-466.) Roche did show reduced range of motion on flexion and extension of his dorsolumbar spine; flexion of his right hip and knee; and plantar flexion and inversion of his right and left ankles. (Tr. 466-467.)

         Dr. Assaf diagnosed the following conditions: (1) asthma; (2) right and left ankle pain, right more than left; (3) bilateral flat feet; (4) right and left knee pain, cause unknown; (5) low back pain, probably lumbar strain; (6) history of chronic constipation; (7) history of fatty liver; and (8) obesity. (Tr. 461.) He opined “[t]here are marked ...


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