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Walker v. Berryhill

United States District Court, N.D. Florida, Gainesville Division

January 2, 2018

GEORGE FRANKLIN WALKER, JR., Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          REPORT AND RECOMMENDATION

          GARY R. JONES UNITED STATES MAGISTRATE JUDGE

         Plaintiff appeals from a final decision of the Commissioner of Social Security (“the Commissioner”) denying his application for a Period of Disability and Disability Insurance Benefits under Title II of the Social Security Act. (ECF No. 1). The Commissioner has answered (ECF No. 8), and both parties have filed briefs outlining their respective positions. (ECF Nos. 17 & 18). For the reasons discussed below, the Commissioner's decision is due to be affirmed.

         I. PROCEDURAL HISTORY

         Plaintiff filed his applications for disability and supplemental income benefits on January 12, 2012, alleging a disability onset date of June 18, 2011, due to gout and anxiety. (R. 220.) Plaintiff's applications were denied initially and upon reconsideration. (R. 94-97, 126-46.) An administrative law judge (“ALJ”) conducted a hearing on December 17, 2013, and entered a partially favorable decision on January 16, 2014. (R. 98-117.) The Appeals Council granted Plaintiff's request for review, vacated the ALJ's decision, and remanded the case for further proceedings on November 9, 2015. (R. 119-23.)

         At a second hearing on May 26, 2016, Plaintiff amended the alleged onset date of disability to July 29, 2013. (R. 13.) Following the hearing, the ALJ issued an unfavorable decision on June 22, 2016, denying Plaintiff's claim. (R. 29-44, 9-28.) The Appeals Council denied Plaintiff's subsequent request for review on October 28, 2016. (R. 1-3.) Plaintiff then filed the complaint in this case on December 27, 2016. (ECF No. 1.)

         II. STANDARD OF REVIEW

         The Commissioner's findings of fact are conclusive if supported by substantial evidence. See 42 U.S.C. § 405(g) (2000). Substantial evidence is more than a scintilla, i.e., the evidence must do more than merely create a suspicion of the existence of a fact, and must include such relevant evidence as a reasonable person would accept as adequate to support the conclusion. Foote v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995) (citing Walden v. Schweiker, 672 F.2d 835, 838 (11th Cir. 1982), Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971)); accord Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir. 1991).

         Where the Commissioner's decision is supported by substantial evidence, the district court will affirm, even if the reviewer would have reached a contrary result as finder of fact, and even if the reviewer finds that the evidence preponderates against the Commissioner's decision. Edwards, 937 F.2d at 584 n.3; Barnes v. Sullivan, 932 F.2d 1356, 1358 (11th Cir. 1991). The district court must view the evidence as a whole, taking into account evidence favorable as well as unfavorable to the decision. Foote, 67 F.3d at 1560. However, the district court will reverse the Commissioner's decision on plenary review if the decision applies incorrect law, or if the decision fails to provide the district court with sufficient reasoning to determine that the Commissioner properly applied the law. Keeton v. Dep't Health & Human Servs., 21 F.3d 1064, 1066 (11th Cir. 1994).

         The law defines disability as the inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death, or has lasted or can be expected to last for a continuous period of not less than twelve months. 42 U.S.C. §§ 416(I), 423(d)(1); 20 C.F.R. § 404.1505 (2005).[1] The impairment must be severe, making Plaintiff unable to do his previous work, or any other substantial gainful activity which exists in the national economy. 42 U.S.C. § 423(d)(2); 20 C.F.R. §§ 404.1505-404.1511.

         The ALJ must follow five steps in evaluating a claim of disability. 20 C.F.R. §§ 404.1520, 416.920. The claimant has the burden of proving the existence of a disability as defined by the Social Security Act. Carnes v. Sullivan, 936 F.2d 1215, 1218 (11th Cir. 1991). First, if a claimant is working at a substantial gainful activity, he is not disabled. 20 C.F.R. § 404.1520(b). Second, if a claimant does not have any impairment or combination of impairments which significantly limit his physical or mental ability to do basic work activities, then he does not have a severe impairment and is not disabled. 20 C.F.R. § 404.1520(c). Third, if a claimant's impairments meet or equal an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1, he is disabled. 20 C.F.R. § 404.1520(d). Fourth, if a claimant's impairments do not prevent him from doing past relevant work, he is not disabled. 20 C.F.R. § 404.1520(e). Fifth, if a claimant's impairments (considering his residual functional capacity (“RFC”), age, education, and past work) prevent him from doing other work that exists in the national economy, then he is disabled. 20 C.F.R. § 404.1520(f).

         III. SUMMARY OF THE RECORD

         Plaintiff's medical records cover the time period from 2009 to 2015 and are from Helping Hands Clinic, the Alachua County Health Department, and Shands. Because Plaintiff's arguments on appeal relate to his gout and anxiety, the relevant portions of the medical record, hearing testimony, and the ALJ's findings are summarized below.

         A. Medical Evidence

         Because Plaintiff amended his alleged onset date at the hearing to July 29, 2013, the majority of his medical records are from prior to this alleged onset date.

         Plaintiff's records from Helping Hands Clinic from August 2009 through January 2012 reveal treatment for diabetes and high blood pressure, but there is no mention of gout or anxiety. Additionally, his records from June 6, 2011, state “no edema.” (R. 326-32.)

         His records from the Alachua County Health Department from February 2010 to February 2012 reveal findings of gout, but his physical examinations do not support the severity of his complaints. In February and March 2010 Plaintiff had no edema in any of his extremities. Then on June 18, 2010, Plaintiff complained of intermittent episodes of right ankle pain and stated that he “was told he had gout at [the emergency room] years ago.” On examination he did not have any swelling or erythema in the ankle. Then in July 2010 he was doing well. On October 14, 2010, Plaintiff complained of difficulty performing his job due to gout episodes and stated he had occasional leg numbness, but he presented in no acute distress and had no evidence of edema. (R. 333-59.)

         On September 13, 2012, Plaintiff visited the Shands Emergency Department and was diagnosed with a gout flare. The only treatment notes show that Plaintiff was prescribed medication. (R. 403.)

         Plaintiff returned to Helping Hands from 2013 until June 2015. In June 2013 Plaintiff complained of very painful gout, and the treating physician noted that Plaintiff complained that his medication was not helping and that his gout was preventing him from working. On exam he had mild stiffness, tenderness, and swelling of the right ankle, and the record discloses exacerbation of chronic gout. His medication was then switched. By July, however, there was no mention of gout, and Plaintiff complained of difficulties working due to breathing issues. In September 2013 Plaintiff presented for gout medication refills and told doctors he had “a few” gout flares in the last month. In October he told medical personnel that he had gout flares two times per week, but he stated that shortness of breath, not gout, impacted his ability to work. By December 2013 Plaintiff reported no flares in gout. (R. 396-402, 418-20.)

         In early 2014 Plaintiff reported doing well. His gout was well controlled and he said he had no acute flares in pain in the past year. In June 2014 Plaintiff complained that his gout medication was not working and complained of itchy feet, but in early July 2014 Plaintiff's gout was controlled. Later that month Plaintiff was seeking prescriptions for gout and complaining of edema in his legs and swollen feet as well as pain. The doctor, however, told Plaintiff that his pain is not gout. In September 2014 Plaintiff stated he has “chronic gout” and complained of recent upper extremity gout. But by May and June 2015, there is only mention of prescription refills for gout but not severe complaints of pain. Plaintiff did complain of ankle swelling in May, and in June edema was noted on lower extremities, but Plaintiff requested foot cream for itchy and peeling feet. (R. 407-20.)

         B. Opinion Evidence

         1 . Dr. Chodosh

         Dr. Chodosh performed a consultative examination on Plaintiff in April 2012. Plaintiff's chief complaints were diabetes, high blood pressure, gout, schizophrenia, and a heart condition. Regarding gout, Plaintiff complained of suffering from gout for approximately three years and stated he has almost constant pain in his ankles, toes, and hands. Additionally, Plaintiff complained of poor stamina, general weakness, and aches and pain that interfered with his ability to work. (R. 364.)

         During the physical examination of Plaintiff, Dr. Chodosh noted that there was no edema, cyanosis, clubbing, deformity, or varicosity in his extremities. Additionally, Plaintiff's range of motion was normal in the majority of the areas recorded. He also had grossly normal motor function in all four extremities with strength judged as 5/5, as well as normal manual dexterity and good ...


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