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Smith v. Berryhill

United States District Court, E.D. Arkansas, Northern Division

July 13, 2017

NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration DEFENDANT


         Plaintiff Elmer Smith (“Smith”) began this case by filing a complaint pursuant to 42 U.S.C. 405(g). In the complaint, he challenged the final decision of the Acting Commissioner of the Social Security Administration (“Commissioner”), a decision based upon findings made by an Administrative Law Judge (“ALJ”).

         Smith maintains that the ALJ's findings are not supported by substantial evidence on the record as a whole.[1] It is Smith's contention that his residual functional capacity was erroneously assessed. He so maintains for the following three reasons: 1) the record does not contain a physical or mental residual functional capacity assessment from a treating or examining physician, 2) there is nothing to support the ALJ's finding that Smith is capable of performing the standing and walking requirements of light work, and 3) Smith has greater mental limitations than the ALJ found.

         The ALJ is required to assess the claimant's residual functional capacity, which is a determination of “the most a person can do despite that person's limitations.” See Brown v. Barnhart, 390 F.3d 535, 538-39 (8th Cir. 2004). The assessment is made using all of the relevant evidence in the record, but the assessment must be supported by some medical evidence. See Wildman v. Astrue, 596 F.3d 959 (8th Cir. 2010). As a part of making the assessment, the ALJ must evaluate the claimant's subjective complaints. See Pearsall v. Massanari, 274 F.3d 1211 (8th Cir. 2001). The ALJ does so by considering the medical evidence and evidence of the claimant's daily activities; the duration, frequency, and intensity of his pain; the dosage and effectiveness of his medication; precipitating and aggravating factors; and functional restrictions. See Id. at 1218 [citing Polaski v. Heckler, 739 F.2d 1320 (8th Cir. 1984)].

         Smith alleged in his applications for disability insurance benefits and supplemental security income payments that he became disabled beginning on May 8, 2013. He alleged that he became disabled beginning on that date as a result of impairments that include depression, diabetes, neuropathy, hypertension, joint pain, right knee surgery, back pain, headaches, blurred vision, osteoarthritis, and degenerative disc disease. He ably summarized the testimonial, documentary, medical, and psychological evidence in the record, see Document 13 at CM/ECF 2-18, and the Commissioner did not challenge the summary or otherwise place any of it in dispute. The Court accepts the summary as a fair summation of all the evidence. The summary will not be reproduced, save to note several matters germane to the issues raised in the parties' briefs.

         On January 9, 2012, or approximately sixteen months before the alleged onset date, Smith was seen by Dr. Michael Spataro, M.D., (“Spataro”) for a consultative examination. See Transcript at 363-367. Spataro assessed Smith's mental status/psychiatric condition and found nothing remarkable. Spataro performed a physical examination and found evidence to substantiate Smith's complaints of pain in his shoulders, lower back, hips, knees, and feet. Spataro offered the following opinions regarding Smith's ability to perform work-related activities:

Based on today's examination, I believe the claimant has mild to moderate limitations to sit, walk, and stand for a full workday secondary to chronic lower back pain, hip pain, knee pain, and foot pain. He has mild to moderate limitations to routinely lift and carry heavy objects secondary to same, as well as intermittent neck pain and shoulder pain bilaterally. There are no limitations to hold a conversation and respond appropriately to questions. There are no limitations to carry out and remember instructions. ...

See Transcript at 366.

         Between October 12, 2012, and July 18, 2015, Smith was seen at the White River Medical Center on what appears to have been approximately sixteen occasions. See Transcript at 459-493 (10/12/2012-10/13/2012), 494-499 (12/09/2012), 506-510 (01/24/2013), 516-521 (04/14/2013), 528-535 (05/16/2013), 543-548 (05/19/2013), 550-558 (06/13/2013), 561-564 (10/03/2013), 369-379, 570-586 (10/31/2013-11/04/2013), 621-624 (04/30/2014), 827-832 (06/21/2014), 1032-1034 (11/11/2014), 987-992 (06/15/2015), 1040-1044 (07/05/2015), 1104-1108 (07/18/2015), 1099-1102 (10/08/2015). He was seen for complaints that included abdominal pain, elevated blood sugar, hallucinations, low back pain, headaches, right arm numbness, suicidal thoughts, dizziness, and leg pain.

         The White River Medical Center progress notes reflect, inter alia, that a CT scan of Smith's lumbar spine was performed on June 13, 2013, after he injured his back in a fall. See Transcript at 558. The results of the testing revealed arthritic changes with small disc bulges at the L3-4 and L5-S1 levels.

         Smith was hospitalized at the White River Medical Center from October 31, 2013, through November 4, 2013, after experiencing thoughts of suicide. See Transcript at 369-379, 570-586. A medical history was compiled and included the following self-reports and observations:

... [Smith] has had depression for some time now. He has multiple medical problems, including diabetes, chronic pain, osteoarthritis, degenerative disc disease, and neuropathy. At this time, he is unable to work, which has definitely made his mood worse. He expresses some hopelessness and helplessness. He is on a variety of different medications, and treatment of his pain has been complicated. Thankfully, he has not used opioid medications, and so this is not an issue; however, he would like to get some relief from his pain. He would certainly like to go back to work. He has not been able to get disability. He is currently taking aspirin, lisinopril, metformin and insulin; diclofenac for pain, amitriptyline for pain, Naprosyn for pain; simvastatin and fluoxetine.

See Transcript at 370. Dr. James Stanley, M.D., (“Stanley”) assessed Smith's mental status/psychiatric condition and observed that he was alert and fully oriented and exhibited a depressed mood, a congruent affect, and a goal-directed and logical thought process. Stanley observed that Smith “appear[ed] to function within the broad limits of average” cognitive ability. See Transcript at 371. Stanley additionally observed that Smith's gait was within normal limits. Stanley diagnosed, inter alia, a major depressive disorder. Stanley continued Smith's medication, advised him to follow-up with his primary care physician, and advised him seek mental health treatment.

         Smith presented to the White River Medical Center on April 30, 2014, complaining of back pain. See Transcript at 621-624. He reported that he had been experiencing pain for several years, and it was becoming progressively worse. He reported that it was not controlled with rest, activity modification, or medication. He reported that aggravating factors included walking and standing. Dr. Meraj Siddiqui, M.D., (“Siddiqui”) nevertheless observed that Smith had a normal gait and station and exhibited normal muscle strength and tone in his extremities. Siddiqui did observe, though, that palpation and hyperextension of Smith's lumbar facet joints produced low back pain. Siddiqui diagnosed back pain and recommended, inter alia, lumbar medial branch blocks.

         Smith presented to the White River Medical Center on June 15, 2015, complaining of lower extremity pain. See Transcript at 987-992. Upon physical examination, he was found to have a normal range of motion in his extremities and no neurologic ...

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