Sanders v. Commissioner of Social Security

          BENITA Y. PEARSON JUDGE

          REPORT & RECOMMENDATION

          Thomas M. Parker United States Magistrate Judge

         I. Introduction

         Plaintiff, Lavelle Sanders, seeks judicial review of the final decision of the Commissioner of Social Security, denying his applications for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XIV of the Social Security Act. This matter is before me pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3), and Local Rule 72.2(b). Because the Administrative Law Judge (“ALJ”) applied proper legal standards and reached a decision supported by substantial evidence, I recommend that the Commissioner's final decision denying Sanders' applications for disability insurance and supplemental security income benefits be AFFIRMED.

         II. Procedural History

         On January 20, 2015, Sanders applied for DIB and SSI. (Tr. 271-80).^[1] Sanders alleged that he became disabled on January 1, 2006, due to a “spot on his lungs that cause[d] bleeding, asthma, depression, anxiety disorder, cloister phob[ia], bones in body that break easily, [and] schizophrenia.” (Tr. 71, 85, 100, 119, 139, 157, 271, 275). The Social Security Administration denied Sanders' applications initially and upon reconsideration. (Tr. 71-173). Sanders requested an administrative hearing. (Tr. 197-98). ALJ Penny Loucas heard Sanders' case on September 25, 2017, and denied the claims in a January 30, 2018, decision. (Tr. 7-70). On June 27, 2018, the Appeals Council denied further review, rendering the ALJ's decision the final decision of the Commissioner. (Tr. 1-6). On August 23, 2018, Sanders filed a complaint to seek judicial review of the Commissioner's decision. ECF Doc. 1.

         III. Evidence

         A. Personal, Educational and Vocational Evidence

         Sanders was born on August 19, 1984, and he was 30 years old when he filed his applications. (Tr. 271). Sanders was in special education classes since the fourth grade, and he dropped out of high school in the tenth grade. (Tr. 27, 63, 604). Sanders did not have any past relevant work experience. (Tr. 41).

         B. Relevant Medical Evidence

         1. Physical Health Records

         On March 19, 2010, Jeffrey Conklin, MD, noted that Sanders had a history of pain in his shoulder due to a past wrestling injury, that he had asthma, and that he smoked one-third a pack of cigarettes per day. (Tr. 393). Sanders also told Dr. Conklin that he had anxiety, depression, difficulty concentrating, and excessive alcohol consumption. (Tr. 394). Dr. Conklin noted that Sanders had a normal gait, referred Sanders to physical therapy for his shoulder, and referred him to a social work service for his mental health problems, alcohol use, and tobacco use. (Tr. 395).

         On March 31, 2010, Sanders went to the emergency department for low back pain, urinary hesitancy, and a toothache. (Tr. 482). Sanders told Marymichael Werick, MD, that his back pain had lasted for two weeks and that it was worse with movement and stretching. (Tr. 482). On examination, Dr. Werick noted that Sanders had normal breathing; was awake, alert, and oriented; and did not have any apparent musculoskeletal issues. (Tr. 483). Dr. Werick prescribed Sanders pain medication and penicillin. (Tr. 483)

         On April 26, 2010, Sanders told Joseph Yonke, PA-C, that he had “progressive” back pain after a car wreck on April 21, 2010. (Tr. 469); see also (Tr. 475-74) (reporting only a facial injury and no spinal damage at the emergency department after April 21, 2010, car wreck). On examination, Yonke noted that Sanders' lumbosacral spine was tender, and an x-ray showed “mild levoscoliosis centered at ¶ 2/3.” (Tr. 470, 528). Yonke prescribed Sanders a pain killer and instructed him to follow up with the spine center for an MRI. (Tr. 470).

         On July 6, 2010, Sanders told Angela Parente, PA-C, that his back pain was worse after he was punched in his ribs one week earlier. (Tr. 462). He also stated that he had wheezing two days earlier, but his wheezing resolved after he used his inhaler. (Tr. 462). On examination, Parente noted that Sanders was alert, cooperative, conversant, and oriented. (Tr. 462-63). Parente prescribed Sanders pain medication. (Tr. 463).

         On April 10, 2012, Sanders told Brendan Hawthorn, MD, that he had hand, shoulder, and knee pain after a fight. (Tr. 388). He stated that he was able to ambulate after the fight. (Tr. 388). On examination, Dr. Hawthorn noted that Sanders had mild pain in his joints, had a normal gait, and was alert and oriented. (Tr. 389). An x-ray showed a healed fracture and chronic deformity in Sanders' hand. (Tr. 414).

         On January 2, 2013, Sanders told Valerie Lopez, MD, that he had back pain that had become progressively worse over the previous two weeks after he fell on ice. (Tr. 433). He stated that his pain was a 6/10 when resting and 10/10 with movement. (Tr. 433). On examination, Dr. Lopez noted that Sanders was alert and oriented, had full strength, had normal reflexes, and had an antalgic gait. (Tr. 434). An MRI showed that Sanders had mild lumbar levoscoliosis and straightened sagittal curvatures. (Tr. 514-15). Based on the MRI and observation, Robert Cagle, MD, determined that Sanders' spine was within normal limits and discharged him with instructions to follow up with the spine center to manage his pain. (Tr. 436).

         On January 3, 2013, Sanders told Danielle Hoover, DO, that he continued to have back pain, but it was better. (Tr. 438). On examination, Dr. Hoover noted that Sanders was alert, oriented, had full strength, had normal reflexes, and had an antalgic gait. (Tr. 439). An MRI showed “[d]egenerative changes most severe at ¶ 5-S1, ” but there was “[n]o abnormal enhancement.” (Tr. 512). Dr. Hoover diagnosed Sanders with lumbar back pain with degenerative changes and gave him pain medication. (Tr. 439).

         On February 5, 2016, Sanders told Donald Renuart, MD, that he had back and abdominal pain. (Tr. 773). On examination, Dr. Renuart noted that Sanders was alert and oriented, had no back or hip pain, and had an intact memory. (Tr. 776). Sanders declined admission. (Tr. 777).

         In addition to his back-pain complaints, medical records indicate that Sanders went to the emergency department numerous times between 2010 and 2016 due to toothaches, chest pain, shoulder pain, and injuries sustained during fights or nights out drinking. (Tr. 376, 378-83, 419-22, 424, 427, 441, 445, 45051, 456, 756, 797, 805-09, 858-63, 889, 908-10). During his emergency department visits, Sanders was able to effectively communicate his condition and his medical history with his providers. (Tr. 376, 378-83, 419-22, 424, 427, 441, 445, 45051, 456, 756, 797, 805-09, 858-63, 889, 908-10). Emergency department records show that, on examination, Sanders was regularly found to be alert, cooperative, conversant, pleasant, and oriented. (Tr. 376, 382, 419-22, 424, 427, 441, 445, 451, 456, 756, 807-08, 861-62, 889, 909-10). Records also indicate that he was regularly found to have a normal gait and range of motion; appropriate behavior and interaction; normal thought content and processes; normal speech; and fair-to-normal judgment and insight. (Tr. 376, 382, 419-22, 424, 427, 445, 756, 807-08, 861-62, 889, 909-10); but see (Tr. 388-82) (prescribing physical therapy because Sanders had pain and limited motion in his shoulder). On October 19, 2015, and February 4, 2016, Sanders called into a nursing phone line and was able to effectively describe his symptoms and concerns. (Tr. 884-85, 905-06).

         2. Mental Health Records

         On May 19, 2013, Sanders told Thomas Higgins, MD, that he had anxiety and panic attacks, and that his shortness of breath caused his anxiety to get worse. (Tr. 430); see also (Tr. 627-29). He stated that he also had chest pain, was under significant stress, and felt depressed. (Tr. 430). On examination, Dr. Higgins noted that Sanders was alert and oriented, and he had normal range of motion, mood, affect, and behavior. (Tr. 430-31). An x-ray showed no acute cardiopulmonary findings. (Tr. 509). Dr. Higgins determined that there were no signs that Sanders' pain was caused by cardiac etiology or indicated a risk for pulmonary embolus, and he diagnosed Sanders with anxiety and chest pain. (Tr. 431).

         On July 19, 2013, Sanders told Mallika Lavakumar, MD, that he had feelings of guilt, anxiety, and paranoia. (Tr. 384). He said that he felt hat people were out to get him for no apparent reason, he feared for his safety, and he believed he received messages from the media. (Tr. 384). He said that he had homicidal ideations in the past. (Tr. 384). He said that he had poor sleep, appetite, energy, memory, and concentration. (Tr. 384). Sanders said that he smoked up to one pack of cigarettes per day, actively consumed alcohol, and used marijuana, cocaine, PCP, and ecstasy. (Tr. 385). On examination, Dr. Lavakumar noted that Sanders was cooperative, depressed, guilty, overwhelmed, paranoid, and delusional. (Tr. 385). Dr. Lavakumar noted that Sanders he had had logical and organized thoughts, sustained memory and attention, and fair insight and judgment. (Tr. 385). Dr. Lavakumar diagnosed Sanders with psychosis, history of depression and anxiety, inadequacy of social support, relationship problems, unemployment, and stress. (Tr. 385). Dr. Lavakumar gave Sanders a GAF score of 51-60, indicating “[s]ome difficulty in functioning.” (Tr. 385). Dr. Lavakumar prescribed Sanders antipsychotic medication. (Tr. 385). Later, on the same day, Sanders told Melissa Tscheiner, MD, that he felt worthless, had vague suicidal thoughts, and felt like he wanted to hurt people. (Tr. 386). On examination, Dr. Tscheiner noted that Sanders was oriented, spoke quietly and slowly, and did not have tangential, flighty, or racing thoughts. (Tr. 387). Dr. Tscheiner concurred with Dr. Lavakumar's assessment. (Tr. 387).

         On December 15, 2014, Sanders saw Kimberly Hart-Ogburn, LPC, for counseling intake. (Tr. 538). Sanders told Hart-Ogburn that he had symptoms of anxiety - including shaking and shortness of breath - and that he felt lonely, depressed, low energy, and paranoid. (Tr. 538). Sanders said that he was a good worker when he had a job and he liked to play video games. (Tr. 539). He said that he had no learning difficulties, barriers to learning, or special communication needs. (Tr. 540). Hart-Ogburn noted that Sanders' functional problems included depression, anxiety, inattention, substance use, sleep problems, and stress. (Tr. 542). Hart Ogburn also noted that Sanders was cooperative, had average intelligence, and had a logical thought process. (Tr. 544). Hart-Ogburn diagnosed Sanders with severe major depressive disorder without psychotic features. (Tr. 537-50).

         On January 27, 2015, Mary Harrison, APN, saw Sanders for medication management. (Tr. 551-55). Sanders told Harrison that he was first hospitalized when he was 19 because he was “withdrawn and not coming out of his room for weeks at a time.” (Tr. 553). Sanders said that he did not take medication since his first hospitalization. (Tr. 553). Sanders said that his symptoms included self-isolation, crying, withdrawal, discouragement, and lack of motivation. (Tr. 553). He said that he had a long history of alcohol, crack, marijuana, and PCP use, but he tried to maintain his sobriety. (Tr. 553). On examination, Harrison noted that Sanders had clear speech, logical thought processes/content, and fair judgment and insight. (Tr. 553). Harrison gave Sanders a GAF score of 45, indicating serious impairment in social functioning. (Tr. 552). Harrison diagnosed Sanders with major depression and prescribed him antidepressant medications. (Tr. 554). At a follow-up on July 30, 2015, Edward Dutten, MD, did not note any significant changes in Sanders' condition and continued his medications. (Tr. 978).

         On June 23, 2015, police took Sanders to the emergency department and after he reported that he was depressed, anxious, and suicidal after his girlfriend broke up with him. (Tr. 570-71); see also (Tr. 566). Vincent Izediuno, MD, noted that Sanders was not compliant with his treatment. (Tr. 571). On examination, Dr. Izediuno noted that Sanders was depressed, anxious, logical, and oriented. (Tr. 571). Dr. Izediuno admitted Sanders to the psychiatric hospital. (Tr. 573). Upon admission, Sanders told Amit Mohan, MD, that he was depressed, stressed, and unable to sleep well. (Tr. 562). He said that he had racing thoughts and felt powerless, but he tried to work on developing coping skills. (Tr. 562). Dr. Mohan noted that Sanders was oriented and cooperative; had intact memory, concentration, and attention; and had linear and concrete thought. (Tr. 563). On June 26, 2015, Dr. Mohan discharged Sanders from the psychiatric hospital. (Tr. 585). In his discharge notes, Dr. Mohan noted that Sanders was alert, oriented and cooperative; he had intact memory; and he had fair attention and concentration. (Tr. 585).

         On August 28, 2015, Gary Wilkes, MD, noted that Sanders complained about his depression and sleep problems. (Tr. 599). Dr. Wilkes noted that sanders' speech was clear, but his mood was irritable, he was evasive, and he had poor insight and judgment. (Tr. 599). Dr. Wilkes noted that, although Sanders wanted to focus on his depression and anxiety, he did not appear to be either depressed or anxious. (Tr. 600). Instead, Dr. Wilkes stated that Sanders appeared angry, irritable, and bipolar. (Tr. 600). Dr. Wilkes adjusted Sanders' medications. (Tr. 600).

         On October 27, 2015, Bonnie Kaput, APN, noted that Sanders did not pick up the medication that Dr. Wilkes had prescribed in August 2015. (Tr. 968). Sanders told Kaput that he had mood swings and felt anxious, and Kaput noted that Sanders had clear speech and coherent thought processes. (Tr. 967). Kaput continued Sanders' medications. (Tr. 968). At a follow-up on December 15, 2015, Sanders told Kaput that he continued to have mood changes and suicidal ideation, and Kaput again continued his medications. (Tr. 963). On January 12, 2016, Kaput noted that Sanders had clear speech and coherent thought processes, but he continued to have poor judgment and insight. (Tr. 958). She noted that Sanders was not compliant with his medications, but he was compliant with his appointments. (Tr. 958).

         On July 13, 2016, Irene Shulga, MD, noted that Sanders was not compliant with his treatment. (Tr. 953). Sanders told Dr. Shulga that he was paranoid and depressed, and that his medications did not help him. (Tr. 953). On examination, Dr. Shulga noted that Sanders was superficially cooperative and had poor concentration. (Tr. 953). Dr. Shulga determined that Sanders' “vague and unspecific symptoms” did not meet criteria for a mood disorder, and that his unstructured daily life probably contributed to his unhappiness and depression. (Tr. 954). Dr. Shulga discontinued Sanders' antipsychotic and bipolar medications, prescribed him an antianxiety medication, referred him to individual counseling, and recommended that he would benefit from a vocational program. (Tr. 954). At a follow-up on October 19, 2016, Dr. Shulga noted that Sanders was evasive and appeared “preoccupied with numerous mobile devices in his possession” during his exam. (Tr. 947). Dr. Shulga noted that Sanders had ...