United States District Court, W.D. Arkansas, Fort Smith Division
MAGISTRATE JUDGE'S REPORT AND
ERIN L. WIEDEMANN UNITED STATES MAGISTRATE JUDGE
Marion Knight, 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) 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. §
protectively filed his current application for DIB and SSI on
December 4, 2014, alleging an inability to work since
November 5, 2014, due to the following conditions: head
injury' issues with memory, vision, ability to focus, and
ability to concentrate; issues with confusion and completing
simple tasks; headaches; difficulty making decisions; and
trouble sleeping. (Tr. 70, 84, 100-101, 114-115). For DIB
purposes, Plaintiff maintained insured status through
December 31, 2018. (Tr. 70, 100). An administrative hearing
was held on January 25, 2016, at which Plaintiff appeared
with counsel and testified. (Tr. 31-49). Barbara Hubbard,
Vocational Expert (VE), also testified. (Tr. 49-53).
written opinion dated May 26, 2016, the ALJ found that the
Plaintiff had the following severe impairments: headaches,
anxiety, and cognitive disorder. (Tr. 14). However, after
reviewing the evidence in its entirety, the ALJ determined
that the Plaintiff's impairments did not meet or equal
the level of severity of any listed impairments described in
Appendix 1 of the Regulations (20 CFR, Subpart P, Appendix
1). (Tr. 14-17). The ALJ found Plaintiff retained the
residual functional capacity (RFC) to perform light work,
[H]e can do simple, routine, repetitive tasks in a setting
where interpersonal contact is incidental to the work
performed. He can respond to usual work situations, routine
work changes and supervision that is simple, direct and
(Tr. 17-21). With the help of VE testimony, the ALJ
determined that Plaintiff was unable to perform his past
relevant work as a truck driver. (Tr. 22). However, based on
the Plaintiff's age, education, work experience, and RFC,
the ALJ determined that Plaintiff was capable of work as a
hotel cleaner, routing clerk, and marking clerk. (Tr. 22-23).
Ultimately, the ALJ concluded that the Plaintiff had not been
under a disability within the meaning of the Social Security
Act from his alleged onset date of November 5, 2014, through
June 1, 2016, the date of the ALJ's decision. (Tr. 23).
Plaintiff requested a review of the hearing decision by the
Appeals Council, which was denied on May 26, 2017. (Tr. 1-4).
Plaintiff filed a Petition for Judicial Review of the matter
on July 13, 2017. (Doc. 1). Both parties have submitted
briefs, and this case is before the undersigned for report
and recommendation. (Docs. 15, 16).
Court has reviewed the transcript in its entirety. The
complete set of facts and arguments are presented in the
parties' briefs and are repeated here only to the extent
hearing before the ALJ on January 25, 2016, Plaintiff
testified that he was born in 1967 and had obtained his GED.
(Tr. 33). Plaintiff's past relevant work consisted of
work as a truck driver. (Tr. 50).
to the relevant time period, Plaintiff was treated
conservatively on two occasions for depression and
hyperlipidemia, and on another occasion, he was also treated
conservatively for a common cold, abdomen pain, and nausea.
(Tr. 320, 324, 328-329).
evidence during the relevant time period reflects that on
April 14, 2015, Plaintiff underwent a Mental Diagnostic
Evaluation by Dr. Terry Efird. (Tr. 342-346). Dr. Efird's
notes reveal that Plaintiff reported the following: that he
was in a motor vehicle accident in 2011; that he currently
had difficulty with memory and confusion; that he suffered
from depression; that he had a decreased interest in
activities; that he had sleep problems; that he had problems
concentrating and making decisions; that he had problems with
anxiety/nervousness; that he endorsed feeling detached from
others; that he endorsed feelings of irritability,
hypervigilance, and an exaggerated startle response. (Tr.
342). Plaintiff denied any history of inpatient or outpatient
mental health treatment; reported that he had been on
psychiatric medications for approximately fourteen years;
reported that he exercised a couple hours per day; and
reported that his current psychiatric medication was
beneficial and had no side effects. (Tr. 343). Plaintiff also
reported that he had obtained a GED; that he had the ability
to perform basic self-care tasks independently; and that he
had the ability to perform household chores slowly but
adequately. (Tr. 343). Plaintiff reported that he had
primarily worked as a truck driver; that he last worked
full-time in November 2014 when he was terminated from his
employment; that he had not worked since that time; and that
he had some difficulty in his relationships with coworkers
and supervisors. (Tr. 343).
Efird's report reflected that Plaintiff had moderate to
marked difficulty with cognitive efficiency; that Plaintiff
reported significant symptom-based criteria for a diagnosis
of PTSD; and that Plaintiff had some features of depression.
(Tr. 345). Dr. Efird diagnosed Plaintiff with cognitive
disorder, PTSD, and depressive disorder, with a GAF score of
39-49. (Tr. 345). Dr. Efird opined that Plaintiff
communicated and interacted in a reasonably socially adequate
manner; however, he also noted that Plaintiff's cognitive
struggles and degree of frustration would likely limit his
range of social interactions. (Tr. 345). Dr. Efird opined
that Plaintiff communicated most basic information in a
reasonably intelligible and effective manner; however,
difficulty communicating complex types of information
effectively would be considered highly probable. (Tr. 345).
Dr. Efird opined that Plaintiff had the capacity to perform
basic cognitive tasks required for basic work like
activities; however, remarkable difficulty with complex types
of cognitive tasks was probable. (Tr. 345). Dr. Efird noted
difficulty sustaining attention and concentration over long
time frames was probable. (Tr. 345). Dr. Efird opined that
Plaintiff generally completed most tasks under the structured
and supportive conditions of the evaluation; however,
difficulty persisting with tasks over longer time frames was
considered probable. Dr. Efird also found that
Plaintiff's mental pace of performance was moderately to
markedly slow at times and that he would have difficulty
consistently performing basic work like tasks within a
reasonable time frame. (Tr. 346). Lastly, Dr. Efird opined
that Plaintiff was able to manage funds without assistance.
April 15, 2015, Plaintiff saw Dr. Thinh Nguyen at River
Valley Primary Care to establish care and to obtain refills
on his medications. (Tr. 352). Plaintiff's physical
examination, as well as his mental status exam, were normal.
(Tr. 353). Plaintiff was assessed with hyperlipidemia,
depression with anxiety, and traumatic brain injury. Dr.
Nguyen refilled Plaintiffs medication for anxiety and ordered
a CBC with differential, a comprehensive metabolic panel, a
lipid test panel, and a follow up visit in six months. (Tr.
April 22, 2015, Plaintiff saw Dr. Nguyen for a follow up on
his cholesterol and lab work. (Tr. 351). Dr. Nguyen noted
that Plaintiff had been on medication to lower his
cholesterol (simvastatin) in the past, but that the
medication had an adverse effect. (Tr. 351). However,
Plaintiff reported that he would like to get back on a statin
drug. (Tr. 351). Plaintiff's physical examination, which
included a mental status ...