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Chham v. Commissioner of Social Security

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

April 27, 2018

SARIN CHHAM, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          John R. Adams Magistrate Judge.

          REPORT AND RECOMMENDATION

          JAMES R. KNEPP II UNITED STATES MAGISTRATE JUDGE.

         Introduction

         Plaintiff Sarin Chham (“Plaintiff”) filed a Complaint against the Commissioner of Social Security (“Commissioner”) seeking judicial review of the Commissioner's decision to deny disability insurance benefits (“DIB”) and supplemental security income (“SSI”). (Doc. 1). The district court has jurisdiction under 42 U.S.C. §§ 1383(c) and 405(g). This matter has been referred to the undersigned for preparation of a report and recommendation pursuant to Local Rule 72.2. (Non-document entry dated August 3, 2017). Following review, and for the reasons stated below, the undersigned recommends the decision of the Commissioner be affirmed in part, and reversed and remanded in part.

         Procedural Background

         Plaintiff filed for DIB and SSI in May 2014, alleging a disability onset date of October 1, 2013. (Tr. 187). His claims were denied initially and upon reconsideration. (Tr. 124-30, 135-39). Plaintiff then requested a hearing before an administrative law judge (“ALJ”). (Tr. 142). Plaintiff (represented by counsel), and a vocational expert (“VE”) testified at a hearing before the ALJ on May 4, 2016. (Tr. 36). On July 6, 2016, the ALJ found Plaintiff not disabled in a written decision. (Tr. 19). The Appeals Council denied Plaintiff's request for review, making the hearing decision the final decision of the Commissioner. (Tr. 1-6); see 20 C.F.R. §§ 404.955, 404.981, 416.1455, 416.1481. Plaintiff timely filed the instant action on August 3, 2017. (Doc. 1).

         Factual Background

         Personal Background and Testimony

         Plaintiff was born in May 1962, making him 52 years old on his application date, and 51 on his alleged onset date. (Tr. 208). Plaintiff had a second-grade education and completed a machine shop class in 1985. (Tr. 213). Plaintiff lived with his wife, and had two adult children who did not live in the home. (Tr. 43). Through an interpreter, Plaintiff testified he participated in basic household chores, and helped his wife cut the grass in the front yard with a few rest breaks. (Tr. 33). He testified the front yard measured approximately 20 feet by 30 feet. Id.

         Plaintiff drove a car, but only when necessary or in case of an emergency. (Tr. 44). He stated this limitation was due to “tingling of [his] hand[s] and feet”. Id. When asked by his attorney whether these symptoms “have gotten worse, or better, or about the same”, Plaintiff replied, “[i]t's just getting worse”. (Tr. 50).

         On a normal day, Plaintiff “exercise[d] and stud[ied] a little bit and watch[ed] movie[s] a little”. (Tr. 46). Plaintiff stated he was not working, but helped his wife at a flea market food stand on weekends. Id. He provided companionship and assisted with small chores. Id. Further, Plaintiff testified the heaviest thing he lifted when helping were jugs of water weighing five to ten pounds. Id.

         Plaintiff last worked in a restaurant in 2013. (Tr. 46). He testified his duties included everything from cleaning to cooking to waiting tables. Id. He worked approximately six hours per day, seven days per week. (Tr. 46-47). Plaintiff estimated he lifted approximately ten pounds at a time. (Tr. 48). Before his condition worsened, he could lift a 50-pound box of chicken with no problems. Id.

         Finally, Plaintiff testified he worked with his brother in a neon light business from 1997 to 2000. (Tr. 49). Plaintiff worked with glass tubes, and lifted less than five pounds at a time. Id.

         Relevant Medical Evidence

         Just prior to his alleged onset date, Plaintiff underwent cataract surgery in his left and right eyes on August 28, 2013, and October 2, 2013, respectively. (Tr. 323, 333).

         In September 2013, during a visit with Lisa Roth, DPM, Plaintiff was diagnosed with diabetic neuropathy of the feet. (Tr. 325-26). Plaintiff complained of “some numbness in toes and feet and pain up to the waist”, but denied any particular foot problems. (Tr. 326). Dr. Roth recommended Plaintiff follow up with his primary care provider. Id.

         In mid-October 2013, Plaintiff was seen by Seshadri Jagannathan, M.D., for a follow-up visit to his cataract surgeries. (Tr. 316-18). Plaintiff reported he was “doing well” after the surgeries. (Tr. 317). Plaintiff's blood sugar was 250 during the visit, but he reported no related symptoms. Id. Dr. Jagannathan observed pitting edema of the legs, and diagnosed diabetes mellitus with a history of pneumonia status post syndrome of inappropriate antidiuretic hormone secretion (“SIADH”). (Tr. 317-18).

         In November 2013, Plaintiff saw ophthalmologist Alex Yuan, M.D., who diagnosed macular edema and diabetic retinopathy. (Tr. 311-12). Plaintiff reported his vision was “a lot better” since the surgeries. (Tr. 312).

         In December 2013, Plaintiff followed up with Dr. Jagannathan, and complained of numbness and tingling in both hands and legs. (Tr. 307). Dr. Jagannathan diagnosed Plaintiff with diabetes mellitus and hypertension. (Tr. 308).

         Plaintiff followed up with Dr. Yuan in April 2014. Plaintiff reported no new complaints with his vision, and reported that “I think the shot helped a little.” (Tr. 299-300). Dr. Yuan administered injections in each eye to help with Plaintiff's macular edema. (Tr. 300). Plaintiff received another set of injections in May 2014. (Tr. 296-98).

         In May 2014, Plaintiff saw Chloe Castro, M.D., for a follow-up visit regarding his blood pressure. See Tr. 293-96. During the visit, Plaintiff reported he was “increasingly forgetful”. (Tr. 294). Dr. Castro referred Plaintiff to a neurologist to address memory concerns. (Tr. 296).

         Neurologist Marc Winkelman, M.D., examined Plaintiff in late May 2014 for complaints of memory problems. See Tr. 291-93. During the visit, Plaintiff reported he forgot what his wife told him to do, misplaced or lost things, locked keys in a car, and locked himself out of the house. (Tr. 291). Plaintiff reported feeling depressed. Id. Plaintiff scored 23 out of 28 on a mini-mental status examination (“MMSE”). (Tr. 293). Dr. Winkelman diagnosed Plaintiff with depression and noted the MMSE results were indicative of dementia, however, the poor performance could be due to a language or cultural problem. Id. Dr. Winkelman ordered an MRI, which revealed mild brain atrophy. (Tr. 371).

         In June 2014, Plaintiff was seen for an internal medicine follow-up. See. Tr. 439-42.[1]During the visit, Kashyap Chandrashekar, M.D., reported Plaintiff “look[ed] well” and his diabetes and blood pressure were “well controlled”. (Tr. 441-42). Dr. Chandrashekar found Plaintiff had decreased sensation of the lower extremities, below the knee, and pedal edema. (Tr. 441).

         Plaintiff followed up with Dr. Winkelman in June 2014. See Tr. 436-39.[2] Plaintiff reported feeling depressed due to financial problems and diabetes. (Tr. 437). Dr. Winkelman noted Plaintiff's coordination and gait were “OK”, and Plaintiff was alert. (Tr. 438). Plaintiff declined both medication and a referral for psychiatric treatment for his depression. Id. Dr. Winkelman told Plaintiff to follow-up in six months. Id.

         In July 2014, Plaintiff followed up with podiatrist, Sean McMillin, DPM. See Tr. 493-95. Plaintiff reported his diabetes was controlled with medication and insulin. (Tr. 493). A musculoskeletal examination showed full muscle strength and pain-free range of motion in the subtalar joint and metatarsophalangeal joint of the foot. (Tr. 495). Range of motion of the ankle joint was reduced, but pain free. Id. Dr. McMillin prescribed diabetic shoes. Id.

         Two months later in September 2014, Plaintiff saw Maryanne Haddad, D.O., stating he was unable to work due to his chronic leg pain. (Tr. 425). Plaintiff told Dr. Haddad he applied for disability due to the pain. Id. Plaintiff was diagnosed with “very advanced” polyneuropathy during the visit and was referred for a disability exam. (Tr. 427).

         In December 2014, Plaintiff saw Travis Cleland, D.O., for a nerve conduction and electromyography (EMG) test. See Tr. 562-63. The testing showed severe sensory motor peripheral polyneuropathy, which affected the lower extremities. Id.

         In January 2015, Plaintiff returned to Dr. Winkelman and reported continuing memory issues. (Tr. 661). Plaintiff declined neuropsychological tests to assess his memory problems, and Dr. Winkelman prescribed the antidepressant Celexa. (Tr. 663).

         Plaintiff underwent a podiatry exam with Dr. McMillin in March 2015, which revealed mild edema of the feet. (Tr. 670). Plaintiff was diagnosed with pain, edema, and neuropathy of the feet. Id.

         Three days after his podiatry exam, Plaintiff returned to Dr. Winkelman and reported little improvement with Celexa, and continuing memory issues. (Tr. 675). Dr. Winkelman continued his diagnosis of depressive pseudo-dementia and increased Plaintiff's Celexa dosage. (Tr. 677).

         Plaintiff was admitted to MetroHealth Hospital from March 27-29, 2015 due to nausea and vomiting. See Tr. 681-82. Plaintiff was diagnosed with severe hyponatremia due to volume depletion and SIADH caused by the Celexa, which was discontinued. (Tr. 681, 689, 691).

         Plaintiff returned to Dr. Winkelman in May 2015. (Tr. 741). He reported feeling his memory was no better or worse after stopping Celexa. Id. Dr. Winkelman diagnosed Plaintiff with “subjective memory loss - depressive pseudo-dementia v dementia”, and ordered further neuropsychological testing. Id.

         In August 2015, Eric Berko, Ph.D., conducted a mental health assessment See Tr. 765-70. Dr. Berko was “[n]ot quite sure why [Plaintiff] was here today.” (Tr. 766). Plaintiff reported worsening memory issues. Id. Plaintiff also reported a traumatic head injury he received as a child in Cambodia where he fell out of a second-story window. Id. Plaintiff further reported stress regarding his family, work, health conditions, and financial situation. Id. Dr. Berko assigned a global assessment of functioning (“GAF”) score of 51-60, which ...


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