United States District Court, W.D. Arkansas, Fort Smith Division
JOHN A. NEAL PLAINTIFF
ANDREW M. SAUL, Commissioner Social Security Administration DEFENDANT
MAGISTRATE JUDGE'S REPORT AND
ERIN L. WIEDEMANN UNITED STATES MAGISTRATE JUDGE.
John A. Neal, 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. §
protectively filed his current applications for DIB and SSI
on March 2, 2016, alleging an inability to work since January
27, 2016, due to heart attacks with stents and continued
pain, uncontrolled diabetes, high blood pressure, high
cholesterol, arthritis, shortness of breath, fatigue, panic
attacks, depression and bilateral upper extremity pain. (Tr.
78, 232, 234). An administrative hearing was held on May 1,
2017, at which Plaintiff appeared with counsel and testified.
written decision dated December 28, 2017, the ALJ found that
during the relevant time period, Plaintiff had an impairment
or combination of impairments that were severe. (Tr. 14).
Specifically, the ALJ found Plaintiff had the following
severe impairments: ischemic heart disease; diabetes
mellitus; hypertension; osteoarthritis; bilateral shoulder
pain; diabetic neuropathy; and obesity. 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. 15). The ALJ found Plaintiff retained the residual
functional capacity (RFC) to:
perform light work as defined in 20 CFR 404.1567(b) and
416.967(b), except he is able to lift and or carry 20 lbs.
occasionally, lift and or carry 10 lbs. frequently, stand
and/or walk 6 hours out of an eight hour workday, sit 6 hours
out of an eight hour workday, push and pull pursuant to
lift/carry limitations; reach on a bilateral basis
frequently; handle and finger on a bilateral basis
frequently; foot control operation on a bilateral basis
frequently; able to perform work where interpersonal contact
is incidental to the work performed; complexity of tasks is
learned and performed by rote, with few variables and little
judgment; supervision required is simple, direct and
(Tr. 16). With the help of a vocational expert, the ALJ
determined Plaintiff could perform work as a deli
cutter/slicer, a patch worker or an air purifier servicer.
then requested a review of the hearing decision by the
Appeals Council, which denied that request on June 5, 2018.
(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.
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.
Administrative hearing held before the ALJ on May 1, 2017,
Plaintiff, who was fifty-three years of age, testified that
he obtained a high school education. (Tr. 35).
Plaintiff's past relevant work consists of work as a
dispatcher, a telephone answering service operator, a truck
dispatcher broker and an armed guard. (Tr. 61).
to the relevant time period Plaintiff sought treatment for
various impairments including but not limited to coronary
artery disease, hypertension, diabetes, hyperlipidemia,
depression and anxiety.
pertinent medical evidence before the ALJ during the relevant
time period reflects the following. On January 26, 2016,
Plaintiff presented to the emergency room with complaints of
lower abdominal cramping. (Tr. 459-464). Plaintiff reported
nausea, vomiting, diarrhea and fever. Plaintiff indicated
that he had been sick for the past week. Plaintiff noted his
glucose fluctuated between 95 and 260. Plaintiff was
diagnosed with abdominal pain and prescribed medication.
Plaintiff was to follow-up with his primary care physician in
one to two days.
March 14, 2016, Plaintiff was seen at the Good Samaritan
Clinic complaining of sharp pain in his feet for the past two
months. (Tr. 500-501). Plaintiff reported he recently lost
his job. Treatment notes indicate Plaintiff's last
primary care visit was October 2015, and his last cardiology
visit was one and one-half years ago. After examining
Plaintiff, the examiner diagnosed Plaintiff with Type 2
diabetes mellitus, hypertension, depression, coronary artery
disease, hyperlipidemia, neuropathy and tobacco addiction.
Plaintiff was continued on his medication with the addition
of Neurontin. It was recommended that Plaintiff stop smoking.
April 4, 2016, Plaintiff was seen for a diagnostic evaluation
at Western Arkansas Counseling and Guidance Center. (Tr.
503-506). Plaintiff presented with issues pertaining to
anxiety and depression. Plaintiff reported he was very
stressed and thought stress increased his blood pressure. Mr.
Clay Connelly, LAC, recommended Plaintiff participate in
individual therapy and medication management.
April 6, 2016, Plaintiff was seen at the Good Samaritan
Clinic for a follow-up. (Tr. 509-510). Plaintiff complained
of pain across his chest and down his legs. Plaintiff
reported pain when he got up and moved around. After
examining Plaintiff, the examiner assessed Plaintiff with
diabetic neuropathy and opined that peripheral vascular
disease was probably causing pain in Plaintiff's legs and
feet. Plaintiff was to continue taking aspirin but stop
taking Plavix. The examiner noted that it was much more
important for Plaintiff to stop smoking.
April 19, 2016, Dr. Kristin Jarrard, a non-examining medical
consultant, completed a RFC assessment opining that Plaintiff
could occasionally lift or carry twenty pounds, frequently
lift or carry ten pounds; could stand and/or walk for a total
of 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 and environmental
limitations were not evident. (Tr. 85-86).
April 20, 2016, Plaintiff was seen at the Russellville Family
Clinic for a follow-up visit. (Tr. 518-521). Dr. Ben Kriesel
noted Plaintiff presented with Type 2 diabetes complicated by
nephropathy. Plaintiff was not on insulin. Dr. Kriesel noted
Plaintiff's compliance with treatment had been poor as
Plaintiff did not follow a diet or exercise regimen.
Plaintiff reported experiencing a mild degree of depression
and that he was doing well on medication without any
significant symptoms. Upon examination, Dr. Kriesel noted
Plaintiff had a normal gait and normal tone and muscle
strength. Plaintiff was assessed with Type 2 diabetes,
depression, hypertension, gastrointestinal reflux disease and
acute sinusitis. Medications were refilled and Plaintiff was
to follow-up in three months.
April 21, 2016, Dr. Diane Kogut, a non-examining medical
consultant, completed a Mental RFC Assessment opining that
Plaintiff was moderately limited in some areas of
functioning. (Tr. 86-89). On the same date, Dr. Kogut
completed a Psychiatric Review Technique form opining that
Plaintiff had mild restriction of activities of daily living;
moderate difficulties in maintaining social functioning;
moderate difficulties in maintaining concentration,
persistence and pace; and no episodes of decompensation, each
of an extended duration. (Tr. 84). Dr. Kogut opined Plaintiff
was able to perform work where interpersonal contact is
incidental to work performed; complexity of tasks is learned
and performed by rote, few variables, little judgment; and
supervision required is simple, direct and concrete
(unskilled). On August 25, 2016, after reviewing the records,
Dr. Laurie Clemens affirmed Dr. Kogut's opinion. (Tr.
2, 2016, Plaintiff was seen at Western Arkansas Counseling
and Guidance Center for a psychiatric assessment by James
Gattis, APRN. (Tr. 555-558). Plaintiff was self-referred for
worrying. Plaintiff reported over the past year he had panic
attacks with symptoms including shortness of breath, chest
tightness, palpitations and nausea. Plaintiff also reported
getting down on himself. Plaintiff reported he took
medication for his depression and found the medication
helpful at first. Plaintiff was assessed with major
depressive disorder with melancholic features and a
generalized anxiety disorder. Plaintiff was prescribed
medication and the importance of CPAP use was discussed with
Plaintiff. Plaintiff was to continue with therapy.
12, 2016, Plaintiff was seen in the Mercy Hospital Fort Smith
emergency room complaining of high blood sugar. (Tr. 523-539,
553). Plaintiff reported difficulty controlling his blood
sugars and that he had not been feeling well. Plaintiff
complained of intermittent dizziness and chest pain and
increased neuropathy and falling. Plaintiff reported recent
emotional stress and a blood blister on his abdomen that was
oozing and smelled. Plaintiff reported he continued to smoke.
Plaintiff was assessed with uncontrolled blood glucose, an
abscess of the abdominal wall and sleep disturbance.
10 2016, Plaintiff was seen in the Mercy Hospital Fort Smith
emergency room complaining of high blood sugar. (Tr.
540-552). Plaintiff's blood sugar was noted to be 520.
Plaintiff reported he had eaten a piece of apple pie earlier
in the evening. Upon examination, Plaintiff was found to have
normal range of motion in his neck and spine. Plaintiff was
noted to have a normal mood and ...