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Whitecotton v. Berryhill

United States District Court, W.D. Arkansas, Fort Smith Division

April 20, 2018

RICHARD R. WHITECOTTON PLAINTIFF
v.
NANCY A. BERRYHILL, Commissioner Social Security Administration DEFENDANT

          MAGISTRATE JUDGE'S REPORT AND RECOMMENDATION

          HON. ERIN L. WIEDEMANN, UNITED STATES MAGISTRATE JUDGE

         Plaintiff, Richard R. Whitecotton, 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) and supplemental security income (SSI) benefits under the provisions of Titles II and XVI 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. § 405(g).

         I. Procedural Background:

         Plaintiff protectively filed his current applications for DIB and SSI on July 17, 2014, alleging an inability to work since March 31, 2012, due to severe refractory hypertension; sleep apnea; atherosclerotic cerebrovascular disease; high blood pressure; pain in the legs, hips and arms; and knots under the skin. (Tr. 85, 199, 206). An administrative hearing was held on October 28, 2015, at which Plaintiff appeared with counsel and testified. (Tr. 55-82).

         By written decision dated April 22, 2016, the ALJ found that during the relevant time period, Plaintiff had an impairment or combination of impairments that were severe. (Tr. 21).

         Specifically, the ALJ found Plaintiff had the following severe impairments: essential hypertension, coronary artery disease, congestive heart failure, peripheral vascular disease, obesity and an adjustment disorder. 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. (Tr. 22). The ALJ found Plaintiff retained the residual functional capacity (RFC) to:

perform sedentary work as defined in 20 CFR 404.1567(a) and 416.967(a) except he is able to perform work limited to simple, routine and repetitive tasks, involving only simple, work-related decisions with few, if any workplace changes and no more than incidental contact with co-workers, supervisors and the general public.

(Tr. 24). With the help of a vocational expert, the ALJ determined Plaintiff could perform work as an addresser, a stuffer, and an escort vehicle driver. (Tr. 29).

         Plaintiff then requested a review of the hearing decision by the Appeals Council, which denied that request on July 3, 2017. (Tr. 1-6). 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. 14, 15).

         The 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.

         II. Evidence Presented:

         Plaintiff participated in an administrative hearing before an ALJ on October 28, 2015. (Tr. 55-82). Plaintiff's past relevant work consists of a work as a maintenance mechanic and a construction worker I. (Tr. 77).

         The pertinent medical evidence during the relevant time period reflects the following. On November 6, 2012, Plaintiff was seen by Dr. John Urban to establish care. (Tr. 382-383). Plaintiff complained of an elevated blood pressure, fatigue, chest pains and dizziness. Plaintiff reported he stopped taking his hypertension medication six to seven years ago. Plaintiff reported experiencing chest pain and pain into his left arm over the past few week. Plaintiff was assessed with benign essential hypertension and prescribed medication.

         On November 13, 2012, Plaintiff was seen by Dr. Urban for a follow-up for his high blood pressure. (Tr. 380-382). Plaintiff reported a very mild bout of chest pain. Plaintiff also complained of chronic calf pain. Plaintiff denied experiencing depression or anxiety. After examining Plaintiff, Dr. Urban diagnosed Plaintiff with benign essential hypertension, knee joint pain and essential hypertriglyceridemia.

         On April 29, 2013, Plaintiff was seen for a follow-up for his blood pressure, a medication refill and back and hip pain. (Tr. 379-380). Dr. Urban noted Plaintiff reported that his blood pressure ran a little high at times but he had not taken nitroglycerin. Plaintiff reported daily caffeine consumption and smoking. Plaintiff denied dyspnea, but reported occasional chest pain but not severe enough to take nitroglycerin. Plaintiff was assessed with benign hypertension and chest pain or discomfort. Plaintiff was referred for a cardiac stress test to be performed on May 14, 2013.

         On February 10, 2014, Plaintiff entered the Mercy Hospital Fort Smith emergency room complaining of shortness of breath. (Tr. 310-320). Plaintiff denied experiencing chest pain and reported he had not been taking his blood pressure medication. Plaintiff denied fatigue, leg swelling, myalgias, back pain, chest pain, weakness, headaches or confusion.

         Plaintiff reported that he smoked one package of cigarettes daily. Upon examination, Dr. Stephen Nelson noted Plaintiff's heart had a normal rate and heart sounds with no evidence of gallop, friction rub or murmur. Plaintiff had normal breath sounds and he was not in respiratory distress. Plaintiff's musculoskeletal exam revealed Plaintiff had normal range of motion. Plaintiff was found to have normal coordination. Plaintiff was diagnosed with hypertension, an abnormal EKG, dyspnea and tobacco abuse. Plaintiff was prescribed medication and discharged.

         On February 17, 2014, Plaintiff reported that he was concerned about his elevated blood pressure. (Tr. 378-379). Dr. Thinh Nguyen noted Plaintiff was started on hypertension medication by an emergency room doctor one week ago. Plaintiff reported that he continued to feel lightheaded and shaky. Upon examination, Dr. Nguyen noted Plaintiff had a normal heart rate and rhythm. Plaintiff had abnormal heart sounds and a murmur was heard at 2/6 SEM best at RUSB. There was no edema present. After examining Plaintiff, Dr. Nguyen ...


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