Johnson v. Colvin

Decision Date28 March 2016
Docket NumberCIVIL ACTION FILE NO. 1:14-cv-03007-AJB
PartiesJEFFREY ANTHONY JOHNSON, Plaintiff, v. CAROLYN W. COLVIN, Acting Commissioner Social Security Administration, Defendant.
CourtU.S. District Court — Northern District of Georgia
ORDER AND OPINION1

Plaintiff Jeffrey Anthony Johnson ("Plaintiff") brought this action pursuant to section 205(g) of the Social Security Act, 42 U.S.C. § 405(g), to obtain judicial review of the final decision of the Acting Commissioner of the Social Security Administration ("the Commissioner") denying his application for Disability Insurance Benefits ("DIB") under the Social Security Act.2 For the reasons below, the undersignedREVERSES the final decision of the Commissioner AND REMANDS the case to the Commissioner for further proceedings consistent with this opinion.

I. PROCEDURAL HISTORY

Plaintiff filed an application for DIB on August 30, 2010, alleging disability commencing on June 30, 2008. [Record (hereinafter "R") 120-23]. Plaintiff's applications were denied initially and on reconsideration. [See R72-77, 80-82]. Plaintiff then requested a hearing before an Administrative Law Judge ("ALJ"). [R84-85]. An evidentiary hearing was held on June 13, 2012. [R26-52]. The ALJ issued a decision on August 15, 2012, denying Plaintiff's application on the ground that he had not been under a "disability" from June 30, 2008, the alleged onset date, through the date of the decision. [R14, 22]. Plaintiff sought review by the Appeals Council,and the Appeals Council denied Plaintiff's request for review on December 4, 2013, making the ALJ's decision the final decision of the Commissioner. [R5-8].

Plaintiff then filed suit in this Court on September 18, 2014, seeking review of the Commissioner's decision. [See Doc. 1]. The answer and transcript were filed on April 15, 2015. [See Docs. 8, 9]. On May 18, 2015, Plaintiff filed a brief in support of his petition for review of the Commissioner's decision, [Doc. 12], and on June 17, 2015, the Commissioner filed a response in support of the decision, [Doc. 13].3 The matter is now before the Court upon the administrative record, the parties' pleadings, and the parties' briefs, and it is accordingly ripe for review pursuant to 42 U.S.C. § 405(g).

II. STATEMENT OF FACTS4
A. Background

Plaintiff was born on October 13, 1961, and therefore was forty-six years old at the time of his alleged disability onset and fifty years old on the date of the ALJ's decision. [R22, 120]. He had completed two years of college. [R40, 137]. Plaintiffalleged disability due to depression; stress; arthritis; carpal tunnel syndrome; gastrointestinal problems; knee, hip, back and neck pain; leg numbness; and weakness and lethargy caused by medication. [R29, 137, 186].

B. Lay Testimony

At the hearing before the ALJ, Plaintiff complained of constant pain in his left hip, right knee, and lower back. [R30-31]. Plaintiff testified that he had difficulty washing dishes after "maybe five to ten minutes" due to his hands cramping up; that he could not lift a gallon of milk; that he could walk an hour before needing a break; and that he could stand for thirty to forty-five minutes before needing to sit down. [R32-34, 37]. He further indicated that he spends most of his day lying down due to pain and weakness. [R34]. Plaintiff reported that he had been prescribed pain medication in 2010 but because he did not have insurance, he was taking over-the-counter medication. [R42].

Plaintiff stated that he had last worked in 2008, doing warehouse work. [R41]. He testified that it was a temporary job that reached its end and that he had not sought work since then because he started experiencing health problems. [R41].

C. Administrative Records

In an adult function report dated September 27, 2010, Plaintiff reported that he lived in a motel with his wife. [R150-57]. He stated that on a typical day, he would try to make breakfast, then lunch, then dinner, and would read the newspaper, use his computer, try to exercise, and try to take a shower. [R151]. He reported that he did the cooking, laundry, ironing, cleaning, and shopping. [R151-52]. He stated that he shopped twice a week, for two to three hours at a time. [R153]. He said that he struggled with his personal care because of pain and side effects of his medication. [R151]. He also indicated that he could go out alone and could walk, ride in a car, and use public transportation but could not drive because he did not have a license. [R153]. He reported that he had been prescribed braces for his knee and wrist for use every day.[R156]. He stated that his medications included amitriptyline,5 propoxyphene,6 diclofenac,7 and naproxen.8 [R157].

In an adult function report dated February 21, 2011, Plaintiff reported the same living situation. [R178-85]. He stated that he did not know what he did all day and that his medication affected his sleep. [R179]. He also stated that he had no problems with personal care; that he prepared meals on a daily basis; and that he had no problemscleaning, ironing, or doing laundry. [R179-80]. He also stated that trazodone9 had been added to his medications. [R185]. His other responses were generally the same as in his September 2010 report. [R178-85].

D. Medical Records

Plaintiff presented to Vine Hill Community Clinic on May 12, 2010, with complaints of left-hip pain, right-knee pain, and numbness in both arms. [R194]. He reported that the arm and hand numbness had been going on for two months, the left-hip pain had started six months earlier, and the right-knee pain related to an injury from the 1980s. [R194]. Upon examination, a moderate amount of swelling was noted on the right knee, and there was obvious deformity of that knee, but no instability, subluxation, or laxity; he walked with a steady gait; and he demonstrated full strength in all extremities and normal deep tendon reflexes and coordination. [R195]. It was noted that Plaintiff asked "numerous questions about where to go and what to do" to obtain disability benefits. [R194-95]. The attending nurse assessed joint pain,prescribed Voltaren 75,10 and told Plaintiff that the clinic did not provide disability examinations. [R195].

On June 30, 2010, Plaintiff presented to Nashville General Hospital Clinic with complaints of right-knee pain, left-hip pain, and numbness and tingling in both hands. [R211]. Orthopedist Ronald Baker, M.D., evaluated Plaintiff's complaints. [R211]. Plaintiff stated that the right-knee pain had been present for several years and that he remembered injuring it while playing basketball in college. [R211]. Plaintiff also reported that the hip pain had been present for over a year and that the numbness and tingling in his hands had also been going on for a number of years. [R211]. Upon questioning, Plaintiff admitted to drinking a six-pack of beer each night. [R212].

Upon examination, it was noted Plaintiff had an antalgic gait with anteromedial and lateral joint line tenderness and a large amount of effusion of the right knee. [R212]. There was patellofermoral crepitus present and motor strength was 4+/5 on full knee extension. [R212]. The left hip was noted to have decreased range of motion and mild tenderness. [R212]. There was mild decrease in neck extension combined with lateral flexion and a positive carpal tunnel compression test bilaterally. [R212].There was also decrease in perception involving the median nerve distribution. [R212]. X-rays showed moderate degenerative joint disease in the left hip and moderate-to-severe degenerative joint disease involving the right knee, with obliteration of the lateral joint line interval. [R212]. There was also osteophyte formation present, and imaging was consistent with osteoarthritis. [R212, 219-20].

Dr. Baker assessed left-hip degenerative joint disease, right-knee moderately severe degenerative joint disease, rule-out bilateral carpal tunnel syndrome, and rule-out diabetes mellitus. [R213]. Dr. Baker aspirated the right knee, administered a steroid injection, provided a brace for the right knee, and prescribed naproxen and Darvocet11 for pain. [R213]. He also provided Plaintiff with splints to be worn at night and recommended follow-up in six weeks for reevaluation of the hand symptoms and to discuss possible surgical intervention for carpal tunnel syndrome or for consideration of an EMG.12 [R213].

On August 19, 2010, Plaintiff presented to Nandakumar Vittal, M.D., at the Nashville General Hospital Clinic for evaluation of the numbness in his hands. [R214]. Plaintiff complained of numbness in both arms and hands, neck pain, and low-back pain, but he denied weakness or difficulty with his legs. [R214]. Upon examination, it was noted Plaintiff presented with mild discomfort on neck movement and that on reflex there was absence of right biceps brachioradialis and triceps reflexes. [R214]. He was noted to a have a mild Hoffmann's sign,13 and his gait was noted to be "fairly normal." [R214]. Dr. Vittal suspected mild cervical myeloradiculopathy, probably from degenerative disk disease. [R214]. It was recommended that Plaintiff undergo an EMG nerve-conduction study for both upper extremities, as well as a CT scan of his neck. [R214-15].

A CT scan of the cervical spine performed in September 2010 showed no gross fracture or malalignment but did show moderate-to-severe multilevel degenerativechanges resulting in multilevel central canal and neural foraminal narrowing bilaterally. [R221]. It was noted that a component of the central canal stenosis was likely congenital in nature, with significant degenerative changes likely contributing. [R221]. It was also noted that there was an incidental probable C3-4 disc bulging. [R221].

On November 2, 2010, Plaintiff presented for a consultative examination with Harry Wright, M.D. [R197]. He complained of osteoarthritis in both hands and wrists, his right knee, left hip, and neck. [R197]. He indicated pain and numbness and weakness...

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