United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OF OPINION AND ORDER
Jonathan D. Greenberg United States Magistrate Judge.
William Leon Bray (“Plaintiff” or
“Bray”), challenges the final decision of
Defendant, Andrew Saul,  Commissioner of Social Security
(“Commissioner”), denying his applications for a
Period of Disability (“POD”) and Disability
Insurance Benefits (“DIB”) under Title II of the
Social Security Act, 42 U.S.C. §§ 416(i), 423, and
1381 et seq. (“Act”). This Court has
jurisdiction pursuant to 42 U.S.C. § 405(g) and the
consent of the parties, pursuant to 28 U.S.C. §
636(c)(2). For the reasons set forth below, the
Commissioner's final decision is AFFIRMED.
October 2015, Bray filed an application for POD and DIB
alleging a disability onset date of January 1, 2012 and
claiming he was disabled due to heart failure, emphysema, and
chronic obstructive pulmonary disease (“COPD”).
(Transcript (“Tr.”) at 152, 202.) The
applications were denied initially and upon reconsideration,
and Bray requested a hearing before an administrative law
judge (“ALJ”). (Tr. 97, 104, 111.)
September 13, 2017, an ALJ held a hearing, during which Bray,
represented by counsel, and an impartial vocational expert
(“VE”) testified. (Tr. 29.) On February 22, 2018,
the ALJ issued a written decision finding Bray was not
disabled. (Tr. 12-28.) The ALJ's decision became final on
July 19, 2018, when the Appeals Council declined further
review. (Tr. 1.)
September 13, 2018, Bray filed his Complaint to challenge the
Commissioner's final decision. (Doc. No. 1.) The parties
have completed briefing in this case. (Doc. Nos. 17, 19.)
Bray asserts the following assignment of error:
Whether the ALJ's RFC finding is supported by substantial
evidence. (Doc. No. 17.)
Personal and Vocational Evidence
was born in February 1962 and was 55 years-old at the time of
his administrative hearing, making him a “person of
advanced age” under social security regulations. (Tr.
63.) See 20 C.F.R. §§ 404.1563(e). He has
a high school education and is able to communicate in
English. (Tr. 75.) He has past relevant work as a household
appliance sales person and a retail store manager. (Tr. 23.)
Relevant Medical Evidence
3, 2012, Bray visited primary care physician Mary K. Lane,
M.D. for a new patient visit. (Tr. 288.) He described poor
concentration and forgetfulness, dating back to the time of
his congestive heart failure diagnosis in 2005.
(Id.) He denied depression or anxiety.
(Id.) Bray reported a history of an ICD implant in
October 2005 and described dyspnea on exertion during hot
days and increased fatigue. (Id.) On examination,
Bray displayed no lower extremity edema, a normal gait,
intact sensation, and full motor strength. (Tr. 290.) His
affect was appropriate. (Id.) Dr. Lane concluded the
cause of Bray's concentration problems was unclear,
noting he displayed no neurological deficits on examination.
(Id.) She observed they were possibly related to his
congestive heart failure and ordered labwork to check
Bray's B12 levels. (Id.)
20, 2012, Bray underwent a transthoracic echocardiogram,
which revealed the following: (1) mildly globally reduced
left ventricular systolic function; (2) a left ventricular
ejection fraction of 45%; (3) no hemodynamically significant
valve disease; and (4) normal diastolic LV function. (Tr.
consulted with cardiologist Diyana Gunawardena, M.D., on
August 1, 2012. (Tr. 309.) Bray reported his history of
congestive heart failure and ICD placement, relaying his left
ventricular ejection fraction had been as low as 5% in the
past. (Id.) He denied any current medications,
including a beta blocker. (Id.) On examination, Bray
had a normal gait and no motor deficits. (Tr. 312.) Dr.
Gunawardena assessed Bray as being in class one of the New
York Heart Associational Functional Classification and
diagnosed heart failure with LV systolic dysfunction. (Tr.
313.) She prescribed Toprol and advised Bray to return in a
returned to Dr Lane on August 7, 2012. (Tr. 319.) He
indicated his poor concentration had resolved after he
reduced his work schedule to two days a week. (Id.)
He reported working in an electronics department, where there
was “gas burn off” from the new electronics.
(Id.) Bray relayed his co-workers complained of
syncope and migraines. (Id.) Dr. Lane assessed
Bray's concentration deficits as “resolved, ”
noting it was possibly related to stress or occupational
exposure. (Tr. 320.)
February 16, 2016, Bray visited primary care physician
Matthew Baltes, D.O. (Tr. 493.) He reported he was recently
told at a “disability exam” he had aphasia.
(Id.) Bray indicated he had been having difficulty
“finding the right words” for the past 10 years
and experiencing worsening memory issues. (Id.) He
requested a referral to a neurologist, which Dr. Baltes
provided. (Tr. 493, 494.)
consulted with neurologist Marc D. Winkelman on March 8,
2016, reporting aphasia and dementia. (Tr. 536.) He described
difficulty at work and keeping his train of thought.
(Id.) He indicated he had been having trouble
finding words since his chronic heart failure diagnosis.
(Id.) Bray reported incidents of locking his keys in
his car, locking himself out of his home, and difficulty
making decisions when stressed. (Id.) He indicated
he did “OK” at his job, and while his short-term
memory was poor, his long term memory was fine.
Winkelman conducted a mini mental status examination and Bray
obtained as score of 30/30. (Tr. 538.) Bray displayed no
aphasia on examination and his motor tone, bulk, power, and
coordination were all satisfactory. (Id.) Dr.
Winkelman observed while Bray felt he had anomia since 2005,
there was no anomia on examination. (Tr. 539.) Dr. Winkelman
further noted while Bray reported short term memory deficits,
his mini mental status examination was normal and he was able
to do his job. (Id.) Dr. Winkelman concluded
Bray's symptoms were likely due to a psychological issue,
such as an anxiety, rather than a neurological problem.
(Id.) Dr. Winkelman ordered a CT head scan.
22, 2016 CT head scan revealed no acute intracranial
abnormalities, but an old infarction in the left caudate
nucleus and compensatory enlargement of the left frontal
horn. (Tr. 576, 579.) There was no lesion or hemorrhage. (Tr.
followed up with Dr. Winkelman on April 12, 2016. (Tr. 579.)
He reported his symptoms were worse in the fall and improved
in the spring. (Id.) He indicated he was currently
seeing a nutritional specialist and had started an iron
supplement. (Id.) Dr. Winkelman reviewed the head CT
scan and determined Bray had likely suffered a stroke when
his “LVEF was low many [years] ago.”
(Id.) The doctor concluded “maybe [Bray's]
initial [symptoms] (aphasia) were due to that stroke, but he
has no neurological findings of it now.” (Id.)
State Agency Reports
January 4, 2016, Bray underwent a consultative psychological
evaluation with psychologist Deborah Koricke, Ph.D. (Tr.
281-286.) He reported he “had to eventually stop
working full time because of his physical health
issues.” (Tr. 282.) He described congestive heart
failure, COPD, and emphysema. (Id.) He denied ever
receiving treatment from a mental health professional, but
reported anxiety, depression, and worry. (Id.)
the evaluation, Bray had “mild to moderate difficulties
maintaining his focus and attention to the conversation at
hand, ” but he “was able to express himself in
fairly articulate terms” and had “no difficulty
understanding questions or instructions, including complex or
multi-step instructions.” (Tr. 283.) He had no
difficulty recalling his history, but he did struggle to stay
focused and would lose his train of thought. (Id.)
Dr. Koricke estimated Bray was functioning within the average
range of intelligence, but noted Bray “became confused
with the concept” of performing serial 7's. (Tr.
upon this examination, Dr. Koricke diagnosed Bray with
adjustment disorder with mixed anxiety and depressed mood.
(Id.) She noted Bray “exhibited some mild
problems with sustained attention today for mental status
tasks, but had no difficulty attending to the interview
conversation.” (Tr. 285.) Dr. Koricke then provided the
following assessment of Bray:
1. The claimant's mental abilities and
limitations in understanding, remembering,
and carrying out instructions.
Mr. Bray had no difficulty understanding questions or
instructions, including complex or multi-step instructions
and he possessed adequate memory for his history. He does not
show any problems with comprehension and I estimate his IQ
level to be in the average range. While he is likely
functioning within the average range of ability, his ability
to remember instructions may be negatively affected by his
lapses in attention. His lapses in sustained attention may
make it difficult for him to fully remember what he has been
told. William may have difficulty recalling what needs to be
done in the work place to following through with completing
tasks. Mr. Bray presents with adequate understanding of
real-world systems relevant to the workplace. Vocationally,
he did not report any difficulty learning specific job duties
while in the workplace.
2. The claimant's mental abilities and
limitations in maintaining attention and concentration,
persistence and pace to perform tasks and to perform
Mr. Bray's level of attention/concentration throughout
the interview was variable, and he tended to struggle to stay
focused at times. He was able to perform serial 7's
slowly, but after a few numbers, he became confused and lost
his train of thought. He completed 6 digits forward and 3
backward, indicating mild impairment in sustained
concentration. In sum, he showed some attention problems on
mental status tasks today, but he attended to the
conversation without difficulty. Mr. Bray reports difficulty
staying on task at home because of pain and distractibility
and he reports a lack of persistence due to pain, poor energy
and depressed mood.
3. The claimant's mental abilities and
limitations in responding appropriately to supervision and to
coworkers in a work setting.
Although cooperative and polite, Mr. Bray appears depressed
and anxious, feeling inadequate, worthless, and helpless.
Today, William was cooperative, but was somewhat difficult to
engage. He demonstrated difficulty relating to others during
this examination due to his anxiety and depression. Overall,
he presented as an anxious and passive individual who was
rather flat emotionally. He seemed tired, worried, in pain,
and was emotionally constricted. Thus rapport was difficult
to establish. He presents as having limitations in [his]
ability to respond to others in the work place because of his
4. The claimant's mental abilities and
limitations in responding appropriately to work pressures in
a work setting.
Mr. Bray is not currently in counseling. He described
stressors in his life to include his inability to work,
diminished quality of life, and inability to do things that
were once possible for him. Exposure to work pressures may
increase his depression and anxiety symptoms and he does not
have effective coping skills to manage emotional outbursts.
He is not looking for employment at this time due to his
January 19, 2016, state agency psychologist Jennifer Swain,
Psy.D., reviewed Bray's medical records and completed a
Psychiatric Review Technique (“PRT”). (Tr.
68-69.) She concluded Bray had (1) mild restrictions in
activities of daily living; (2) moderate difficulties in
maintaining social functioning; (3) moderate difficulties in
maintaining concentration, persistence, and pace; and (4) no
episodes of decompensation. (Tr. 68.) Dr. Swain also
completed a Mental Residual Functional Capacity
(“RFC”) Assessment. (Tr. 72-74.) She concluded
Bray was moderately limited in his ability to (1) understand,
remember, and carry out detailed instructions; (2) maintain
attention and concentration for extended periods; (3) work in
coordination with or in proximity to others without being
distracted by them; (4) make simple work-related decisions;
(5) interact appropriately with the general public; (6) get
along with coworkers or peers without distracting them or
exhibiting behavioral extremes; (7) maintain socially
appropriate behavior and to adhere to basic standards of
neatness and cleanliness; and (8) respond appropriately to
changes in the work setting. (Id.) She concluded
Bray was “not significantly limited” in all other
areas. (Id.) Dr. Swain explained the basis of her
conclusion as follows:
Can remember 1-5 step tasks. Can sometimes remember more
complex instructions but frequently would need reminders ...