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Knight v. Berryhill

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

April 23, 2018

NANCY A. BERRYHILL,[1] Acting Commissioner, Social Security Administration DEFENDANT



         Plaintiff, 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. § 405(g).

         I. Procedural Background:

         Plaintiff 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.[2] (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).

         In a 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, except that:

[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 concrete.

(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).

         Subsequently, 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).

         The 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 necessary.

         II. Evidence Submitted:

         At the 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).

         Prior 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).

         Medical 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).

         Dr. 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. (Tr. 346).

         On 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. 354).

         On 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 ...

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