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Bray v. Saul

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

July 12, 2019

ANDREW SAUL, Commissioner of Social Security, Defendant.


          Jonathan D. Greenberg United States Magistrate Judge.

         Plaintiff, William Leon Bray (“Plaintiff” or “Bray”), challenges the final decision of Defendant, Andrew Saul, [1] 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.


         In 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.)

         On 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.)

         On 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:

         (1) Whether the ALJ's RFC finding is supported by substantial evidence. (Doc. No. 17.)

         II. EVIDENCE

         A. Personal and Vocational Evidence

         Bray 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.)

         B. Relevant Medical Evidence[2]

         On July 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.)

         On July 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. 310.)

         Bray 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 month. (Id.)

         Bray 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.)

         On 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.)

         Bray 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. (Id.)

         Dr. 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. (Id.)

         A March 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. 576.)

         Bray 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.)

         C. State Agency Reports

         1. Mental Impairments

         On 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.)

         During 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. 284.)

         Based 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 multi-step tasks.
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 adjustment disorder.
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 medical issues.

(Tr. 285-286.)

         On 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 ...

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