United States District Court, N.D. Ohio, Eastern Division
Y. PEARSON JUDGE
REPORT & RECOMMENDATION
M. Parker United States Magistrate Judge
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.
January 20, 2015, Sanders applied for DIB and SSI. (Tr.
271-80). 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.
Personal, Educational and Vocational Evidence
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).
Relevant Medical Evidence
Physical Health Records
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).
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)
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).
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.
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).
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).
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).
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).
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).
Mental Health Records
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.
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.
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).
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.
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).
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).
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).
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 ...