United States District Court, N.D. Ohio, Eastern Division
R. Adams Magistrate Judge.
REPORT AND RECOMMENDATION
R. KNEPP II UNITED STATES MAGISTRATE JUDGE.
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.
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).
Background and Testimony
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.
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).
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.
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.
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.
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).
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.
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.
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).
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).
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).
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).
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.
2014, Plaintiff was seen for an internal medicine follow-up.
See. Tr. 439-42.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).
followed up with Dr. Winkelman in June 2014. See Tr.
436-39. 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.
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.
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).
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
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).
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.
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).
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).
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
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 ...