United States District Court, W.D. Arkansas, Fayetteville Division
MAGISTRATE JUDGE'S REPORT AND
ERIN L. SETSER UNITED STATES MAGISTRATE JUDGE
Keith Lamar Cole, brings this action pursuant to 42 U.S.C.
§ 405(g), seeking judicial review of a decision of the
Commissioner of the Social Security Administration
(Commissioner) denying his claims for a period of disability
and disability insurance benefits (DIB) under the provisions
of Title II of the Social Security Act (Act). In this
judicial review, the Court must determine whether there is
substantial evidence in the administrative record to support
the Commissioner's decision. See 42 U.S.C.
protectively filed his current application for DIB on March
24, 2012, alleging an inability to work since February 17,
2012, due to thumb problems, arthritis, osteoarthritis in the
back, heart problems and knee problems. (Doc. 11, pp. 192,
228). An administrative video hearing was held on October 24,
2013, at which Plaintiff appeared with counsel and testified.
(Doc. 11, pp. 102-133).
written decision dated April 4, 2014, the ALJ found that
during the relevant time period, Plaintiff had an impairment
or combination of impairments that were severe. (Doc. 11, p.
90). Specifically, the ALJ found Plaintiff had the following
severe impairments: aortic stenosis and osteoarthritis.
However, after reviewing all of the evidence presented, the
ALJ determined that Plaintiff's impairments did not meet
or equal the level of severity of any impairment listed in
the Listing of Impairments found in Appendix I, Subpart P,
Regulation No. 4. (Doc. 11, p. 91). The ALJ found Plaintiff
retained the residual functional capacity (RFC) to perform a
full range of light work as defined in 20 C.F.R. §
404.1567(b). (Doc. 11, p. 91). The ALJ, with the use of the
Medical-Vocational Guidelines (Grids), found Plaintiff was
not disabled. (Doc. 11, p. 97).
then requested a review of the hearing decision by the
Appeals Council, which after reviewing additional evidence
submitted by Plaintiff, denied that request on July 6, 2015.
(Doc. 11, pp. 5-11). Subsequently, Plaintiff filed this
action. (Doc. 1). Both parties have filed appeal briefs, and
the case is before the undersigned for report and
recommendation. (Docs. 9, 10).
Court has reviewed the entire transcript. The complete set of
facts and arguments are presented in the parties' briefs,
and are repeated here only to the extent necessary.
time of the administrative video hearing held before the ALJ
on October 24, 2013, Plaintiff was forty-eight years of age
and had a high school education and completed a computer
drafting program. (Doc. 11, pp. 102, 229). Plaintiff
testified that he last worked on February 17, 2012, when the
business he was working for closed. (Doc. 11, p. 111).
to the alleged onset date of February 17, 2012, Plaintiff was
treated for various issues which included an aortic valve
disorder; hypertension; osteoarthritis; dental caries; a
hernia repair; and neck, back, and knee pain. The medical
evidence during the relevant time period reflects the
February 23, 2012, Plaintiff was noted to have a tiny spot on
his lungs. (Doc. 11, p. 482, 679-681, 822). Dr. Maria
Cristina M. Judit recommended monitoring the spot. On March 2
2012, Plaintiff was admitted into the hospital after
complaining of wheezing, shortness of breath, and coughing.
(Doc. 11, pp. 398-482, 678-679, 696-697, 710, 734-822,
888-893, 900, 921-922). A review of systems indicated
Plaintiff denied chest pain, nausea, vomiting, weakness,
numbness or headache. (Doc. 11, p. 475). Plaintiff was
admitted with a clinical impression of pneumonia versus a
viral syndrome with fever. Plaintiff tolerated respiratory
treatments well. Plaintiff's aortic stenosis was noted as
stable. Plaintiff was noted to ambulate without difficulty,
and was able to sit on a bed and visit with other patients.
Plaintiff was discharged on March 6, 2012. Plaintiff was
asked to follow up with his primary care physician on March
March 8, 2012, Ms. Robin D. Cowan, RN, BSN, called Plaintiff
to check on his well-being following his hospital stay. (Doc.
11, pp. 735-737). Plaintiff reported that he was doing better
than he was prior to admission, and that he was taking all
medications as prescribed. Plaintiff voiced no questions or
March 20, 2012, Plaintiff called and spoke to Ms. Elizabeth
S. Mick, RN. (Doc. 11, pp. 732-733). Plaintiff wanted to
discuss the results from the cardiology consult that he
underwent in September of 2011. The medical records for this
September consult report the following:
He has mild aortic stenosis and enlargement of the ascending
aorta which does not reach surgical significance. I would
place him on low dose beta blocker, then Holter. He should
have a yearly echo, and his aorta should be followed with
serial CT scans.
(Doc. 11, p. 734). Nurse Mick told Plaintiff that he was
scheduled for an appointment on March 23rd, and
that his doctor would review the records at that time.
Plaintiff denied chest pain, shortness of breath or
March 23, 2012, Plaintiff underwent chest x-rays. (Doc. 11,
p. 677). No acute cardiopulmonary process was identified.
Plaintiff also underwent retinal image testing, and a Holter
Monitor test in April of 2012. (Doc. 11, pp. 701, 722, 888,
18, 2012, Plaintiff underwent a pulmonary function test.
(Doc. 11, pp. 104). The test results indicated a possible
thoracic obstruction, and a clinical correlation was
recommended to exclude extra-thoracic obstruction.
22, 2012, Plaintiff underwent a cardiac consultation for his
aortic stenosis. (Doc. 11, pp. 1044-1047). Plaintiff reported
little exercise due to his arthritis with instability of his
left knee and lower back. With the exception of pain with
coughing, Plaintiff denied any difficulty with chest pain.
Plaintiff reported occasional lightheadedness when standing.
Plaintiff's girlfriend reported Plaintiff snored and
sometimes stopped breathing at night. Plaintiff was diagnosed
with a bicuspid aortic valve with moderate stenosis and mild
aortic regurgitation; ascending aortic ectasia;
hyperlipidemia; chronic low back pain; and degenerative joint
disease of the knees. Dr. James As Haisten recommended that
Plaintiff maintain a low cholesterol diet; refrain from heavy
manual labor or lifting; start simvastatin; and return for
further bloodwork in one and three months. Plaintiff was also
to undergo an echocardiogram in one year.
12, 2012, Dr. Jerry Thomas, a non-examining medical
consultant, completed a RFC assessment stating that Plaintiff
could occasionally lift or carry twenty pounds, frequently
lift or carry ten pounds; could stand and/or walk about six
hours in an eight-hour workday; could sit about six hours in
an eight-hour workday; could push or pull unlimited, other
than as shown for lift and/or carry; and that postural,
manipulative, visual, communicative or environmental
limitations were not evident. (Doc. 11, pp. 945-952). After
reviewing all of the evidence of record, Dr. Sharon Keith
affirmed Dr. Thomas's assessment on January 23, 2013.
(Doc. 11, pp. 1160-1165).
13, 2012, Plaintiff presented to the emergency room with
complaints of a three day history of dull left anterior chest
pain. (Doc. 11, pp. 1025-1029, 1061-1071). Plaintiff denied
any increase in pain with exertion, but noted that he did not
do much due to his arthritis. Plaintiff underwent chest
x-rays that revealed no significant changes from previous
exams. Plaintiff was diagnosed with atypical chest pain.
telephone encounter note dated June 15, 2012, reveals
Plaintiff's report that his pain was not as intense.
(Doc. 11, pp. 1059-1060). Plaintiff denied pain associated
with nausea or diaphoresis, denied shortness of breath,
denied exercise induced pain, and denied radiation of pain.
Plaintiff reported that he wanted to undergo the recommended
sleep study, but indicated he did not have transportation.
August 21, 2012, Plaintiff underwent a CT scan of the thorax
that revealed no significant change. A non-calcified nodule
remained unchanged. (Doc. 11, pp. 1024-1025, 1057).
cardiology note dated August 23, 2012, reveals that Plaintiff
reported being reasonably physically active up until February
of 2012, but in the last six months he reported being less
active. (Doc. 11, pp. 1051-1057). Plaintiff complained of
lightheadedness with activity and standing. Plaintiff
reported experiencing a dull and sharp midsternal chest pain
in the past two months that would last from minutes ...