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Morales v. Berryhill

United States District Court, M.D. Tennessee, Nashville Division

June 6, 2017

BLAS MORALES, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          Honorable Aleta A. Trauger, United States District Judge

          REPORT AND RECOMMENDATION

          JOE B. BROWN UNITED STATES MAGISTRATE JUDGE

         Plaintiff brings this action under 42 U.S.C. § 405(g), seeking judicial review of the Social Security Commissioner's denial of his applications for disability insurance benefits and supplemental security income under Titles II and XVI of the Social Security Act. For the following reasons, the Magistrate Judge RECOMMENDS that Plaintiff's Motion for Judgment on the Administrative Record (Doc. 14) be DENIED and the Commissioner's decision be AFFIRMED.

         I. PROCEDURAL HISTORY

         This is Plaintiff's second application for disability benefits. (AR, p. 66).[1] His current applications were denied initially and on reconsideration. (Id. at 65-126, 130-131, 142, 191-206). An administrative hearing was convened on August 19, 2014. (Id. at 33-63). The administrative law judge (“ALJ”) issued an unfavorable decision on November 7, 2014. (Id. at 13-32). The Appeals Council declined to review the ALJ's decision. (Id. at 1-6). Plaintiff appealed the Commissioner's decision to this Court. (Doc. 1). The matter was referred to the Magistrate Judge. (Doc. 18). Presently pending is the fully briefed Plaintiff's Motion for Judgment on the Administrative Record. (Docs. 14, 15, 16, 17).

         II. REVIEW OF THE RECORD

         A. Medical Records

         1. Saint Thomas Health Services

         Plaintiff presented to Saint Thomas Health Services on October 22, 2010, for alcohol abuse assistance. (AR, p. 333). He reported depression, dizziness, loss of sleep, numbness, muscle problems in his feet and legs, stomach pain, bleeding gums, blurred vision, nosebleeds, a breast lump, alcoholism, and drug use. (Id. at 335-336). On January 20, 2011, Plaintiff complained of shortness of breath and asked for help with alcohol withdrawal. (Id. at 331). He was assessed with alcohol abuse, GERD, and COPD. (Id.).

         2. Summit Medical Center

         Plaintiff was admitted to the Summit Medical Center emergency room on November 15, 2010, for alcohol withdrawal with seizures, a shoulder contusion, and pancreatitis. (Id. at 272). He was later admitted for alcohol withdrawal on March 14, 2014, abdominal pain on May 11, 2014, and alcohol withdrawal on May 13, 2014. (Id. at 663, 685, 699). An abdominal ultrasound on May 12, 2014, showed moderately echogenic portions of the liver compatible with fatty infiltration. (Id. at 678). A chest x-ray that same day showed mild degenerative changes in the mid and lower spine and no acute cardiopulmonary process. (Id. at 680). During Plaintiff's May 13, 2014, visit, Plaintiff stated he was unable to walk, but when his doctor said he would most likely be discharged the next day, he sat up and stood without any problems. (Id. at 663). When discharged, he was alert and oriented, had a full range of motion in his extremities, ambulated independently, had a steady gate, had no weakness or joint pain, and had intact sensation. (Id. at 692, 704). His mood and affect were appropriate, and he had no recent limitation in performance of activities of daily living. (Id. at 692-693, 704).

         3. SunCrest Home Health

         From November 2010 to December 2010, Plaintiff received at-home physical and occupational therapy from SunCrest Home Health for muscle weakness, gait abnormality, history of falls, chronic pancreatitis, and alcoholic Hepatitis. (Id. at 273-328). When he was discharged from physical therapy, he was at a moderate risk of falling with no recent falls, and his strength and range of motion were within functional limits. (Id. at 284). He was discharged from occupational therapy having increased his endurance to within functional limits and achieving the ability to perform activities of self-care with minimal assistance. (Id. at 298).

         4. Nashville General Hospital

         Plaintiff presented to the Nashville General Hospital emergency department on October 9, 2011, complaining about an alcohol problem. (Id. at 365). He was ambulatory and displayed normal mental and neurologic abilities. (Id. at 366). Physical examination revealed no neurologic deficits, full range of motion in all extremities without edema, and normal mood and affect with anxiety. (Id. at 367). Primary diagnosis included asthma, alcoholism, nervousness, and moderate elevation of systolic blood pressure. (Id.).

         On April 3, 2012, Plaintiff complained of numbness in his feet for the past three years and reported pain in his feet and lower back. (Id. at 371, 373). He was diagnosed with affective disorder and sensory neuropathy related to alcohol consumption. (Id. at 372). A nerve conduction study on July 31, 2012, was suggestive of polyneuropathy. (Id. at 382).

         In an outpatient physical therapy evaluation on August 16, 2012, Plaintiff complained of numbness in his feet beginning in 2003 or 2004. (Id. at 386). He was oriented and able to follow directions. (Id. at 387). The active range of motion of his back, arms, and legs was within functional limits except for reduced motion in his ankles. (Id.). His hip and knee strength were fair to good, and his ankle strength was poor. (Id.). Plaintiff reported he could ambulate up and down a flight of stairs and down a ramp. (Id. at 388). He was also independent while performing extreme and prolonged standing. (Id. at 389).

         On July 7, 2014, Plaintiff complained of weakness when trying to stand up and numbness and coldness in his left leg which was exacerbated by standing and alleviated by sitting. (Id. at 715). A July 16, 2014, MRI of Plaintiff's lumbar spine showed mild multilevel disc bulge and facet arthropathy, no central spinal canal stenosis, and mild neuroforaminal narrowing at ¶ 3-L4, L4-L5, and L5-S1. (Id. at 712). A MRI of Plaintiff's thoracic spine showed mild multilevel degenerative disc disease without cord compression or significant central spinal canal stenosis. (Id. at 714).

         5. United Neighborhood Health Services/Downtown Clinic

         From 2011 to 2014, Plaintiff received care from a series of providers at United Neighborhood Health Services, including from Morgan McDonald, M.D, and Jennifer Strickland, LPC-MHSP.[2] (Id. at 396-456, 511-530, 537-542, 549-656).

         Plaintiff's records reveal an inconsistent variety of symptoms and functional limitations. Plaintiff complained of back and joint pain, muscle weakness, gait disturbance, numbness and decreased sensation in his foot and ankle, anxiety, depression, and difficulty concentrating. (Id. at 398, 401, 403, 406, 416-417, 422, 424, 426, 444, 454-455, 519, 522, 529, 537, 559, 584, 589, 592, 601, 611-612, 616, 631, 644, 649, 651, 655). Records also show no back or neck pain, no muscle weakness, normal gait, normal range of motion, muscle strength, and stability in all extremities with no pain, full orientation, appropriate mood and affect, no numbness, no anxiety or depression, and normal ability to concentrate and maintain attention span. (Id. at 398-399, 403-404, 406-407, 416-417, 420, 425, 435-436, 439, 455, 519, 529, 589, 605).

         With respect to his exertional abilities, Plaintiff reported a moderate activity level and that he exercised by walking two to three times a week. (Id. at 443). In December 2012, Plaintiff stated he was helping his mother fix up her house. (Id. at 527). He reported using Albuterol when he went out on walks and that he was exercising more in December 2013. (Id. at 555). On January 2, 2014, Plaintiff reported he was collecting cans for exercise but had difficulty due to neuropathy in his leg. (Id. at 549). He also reported worsening asthma with weather changes and that he was using Albuterol more while moving furniture for his brother. (Id.).

         6. Southern Hills Medical Center

         Plaintiff presented to Southern Hills Medical Center on July 15, 2012, complaining of a seizure. (Id. at 340). Physical examination of Plaintiff revealed normal findings, including normal range of motion and normal neurological and psychological findings. (Id. at 341). A CT of his head was unremarkable. (Id. at 349).

         B. Opinion Evidence

         In a function report dated October 5, 2012, Plaintiff stated he needs reminders to take his medicine, he prepares frozen meals, and he does not perform house and yard work by choice. (Id. at 236-237). He goes grocery shopping but rarely stays out for two hours. (Id. at 237). His hobby consists of watching television. (Id. at 238). He reported trouble lifting, squatting, bending, standing, walking, sitting, kneeling, and understanding. (Id. at 239). He stated he can walk a quarter of a mile before needing a five to ten minute break. (Id.). He can pay attention for three minutes, he does not finish what he starts, and he follows written instructions. (Id.).

         Scott Greene, M.D., completed a consultative examination on November 3, 2012. (Id. at 464). A pulmonary function report showed mild restrictive ventilator defect. (Id. at 459). Physical examination revealed Plaintiff was alert and oriented and displayed normal intellectual functioning, gait, station, and ability to grasp and manipulate objects. (Id. at 466). He could get up out of a chair and get on and off the examining table without difficulty. (Id.). Plaintiff had full strength in all major muscle groups, and he displayed a normal range of motion in his spine, shoulders, elbows, wrists, hips, knees, and ankles. (Id. at 467-469). Neurologic testing was negative. (Id. at 469-470). Dr. Greene diagnosed Plaintiff with neuropathy per patient but found his bilateral ...


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