United States District Court, M.D. Tennessee, Nashville Division
Honorable Aleta A. Trauger, United States District Judge
REPORT AND RECOMMENDATION
BROWN UNITED STATES MAGISTRATE JUDGE
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.
Plaintiff's second application for disability benefits.
(AR, p. 66). 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).
REVIEW OF THE RECORD
Saint Thomas Health Services
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.).
Summit Medical Center
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
SunCrest Home Health
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).
Nashville General Hospital
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.).
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).
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).
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
United Neighborhood Health Services/Downtown Clinic
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. (Id. at 396-456, 511-530,
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).
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.).
Southern Hills Medical Center
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).
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.).
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 ...