United States District Court, W.D. Pennsylvania
MAURICE B. COHILL, Senior District Judge.
Pending before this Court is an appeal from the final decision of the Commissioner of Social Security ("Commissioner" or "Defendant") denying the claims of Elmer Darnell Roberson ("Plaintiff' or "Claimant") for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("SSA"), 42 U.S.C. §§ 1381 et. seq. (2012). Plaintiff argues that the decision of the Administrative Law Judge ("ALJ") should be reversed or remanded because the ALJ failed to properly evaluate Plaintiff's mental impairments, the ALJ failed to develop the record at the hearing, the ALJ failed to assess the Plaintiff's Physical Residual Functional Capacity ("RFC"), and the ALJ failed to take into consideration Plaintiff's obesity. For these reasons Plaintiff asserts that the ALJ's decision to deny benefits was not supported by substantial evidence as required by 42 U.S.C. § 405(g) [See generally ECF No. 12].
To the contrary, Defendant argues that the record was fully developed under the law, and the ALJ properly reviewed all of the evidence. Despite the functional limitations identified by the ALJ, the Vocational Expert ("VE") was able to present representative occupations which showed Claimant could perform in a gainful occupation and, therefore, the ALJ's decision should be affirmed. The parties have filed cross motions for summary judgment pursuant to Rule 56(c) of the Federal Rules of Civil Procedure.
For the reasons stated below, the Court will grant the Plaintiff's Motion for Summary Judgment affirming. In turn, the Court will deny the Defendant's Motion for Summary Judgment.
II. Procedural History
On April 23, 2010, Plaintiff filed an application for SSI and DIB alleging disability beginning April 22, 2010 (R. at 29). The claim was initially denied on September 9, 2010 (R. at 29). On November 12, 2010, Claimant filed a written request for a hearing (R. at 29). A hearing was held before an Administrative Law Judge on January 20, 2012 (R. at 29). Charles M. Mohen, Ph.D., an impartial Vocational Expert, also appeared during the hearing (R. at 29). The Claimant chose to appear and testify pro se (R. at 29). On March 23, 2012, the ALJ, Guy Koster, determined that Plaintiff was not disabled under Sections 1614(a)(3)(A) of the Social Security Act (R. at 39). The ALJ stated that, "Based on the testimony of the vocational expert, I conclude that, considering the claimant's age, education, work experience, and residual function capacity, the claimant is capable of making a successful adjustment to other work that exists in significant numbers in the national economy." (R. at 39). On April 13, 2012 Plaintiff submitted a timely written request for review by the Appeals Council (R. at 25). The Appeals Council denied Plaintiff's request for review thus making the Commissioner's decision final under 42 U.S.C. § 405(g) (R. at 1-5).
III. Medical History
Plaintiff's is a 50 year old man and approximately 5'9" tall weighing up to 300 pounds [ECF No. 16 at 22]. He graduated from high school in 1984 and completed technical training as a Patient Care Technician. He worked as a housekeeper for a cleaning company from 1983 to 2010 (R. at 187-188). The ALJ found the Claimant to have the following severe impairments: (1) Hypertension; (2) degenerative disc disease of the lumbosacral spine; (3) osteoarthritis; (4) asthma; (5) history of right rotator cuff tear and repair; (6) history of pulmonary hypertension; (7) major depressive disorder; (8) bipolar disorder; (9) psychotic disorder; and (10) substance abuse (cannabis) in remission (R. at 31). In his Disability Report Plaintiff reports that he is mentally depressed because he is hearing voices, having thoughts of hurting people and of hurting himself (R. at 178). He also states, "I feel like I'm [sic] losing my mind. I can read but don't understand what I read." (R. at 178).
Plaintiff describes a typical day as the following: "I wake up through the night with shoulder, neck, and headaches. My days start off [sic] with taken [sic] my meds for high blood pressure and chest pain then I eat breakfast. Also forgot to mention lower back pain. I take little walks when I can other than that not too [sic] much." (R. at 197). The Plaintiff indicates that he and his wife take their grandchildren to the park as long as he can sit on a bench (R. at 198). His wife prepares the meals, though he can prepare frozen dinners (R. at 199). Plaintiff asserts he can walk short distances but cannot walk up hills (R. at 199). He says he needs help tying his shoes and putting on his clothes (R. at 199). Plaintiff is still able to drive (R. at 200). Plaintiff states he does not handle stress well (R. at 203). Plaintiff claims that his conditions affect lifting, squatting, bending, standing, reaching, walking, sitting, kneeling, stair climbing, completing tasks, and using hands (R. at 202).
Plaintiff reports he receives treatment from Therapist Nancy Ritsko at Homestead House for his conditions of hearing voices, mind racing, and panic attacks (R. at 179). Plaintiff reports treatment from Patrick J. McMahon, MD, for his rotator cuff tear, clavicle injury, and pinched nerves (R. at 190). Dr. Jeannette South-Paul is Plaintiff's primary care physician ("PCP") (R. at 191). Plaintiff reports the following medications: Lisinopril for his heart, Naprozen for his pain (R. at 180), Hydroclorothiazide for his heart, and Percocet for pain (R. at 190).
On December 4, 2007 Plaintiff presented to UPMC Mercy with right knee pain and swelling for the past 4 days with no related trauma (R. at 228). He was prescribed Vicodan for severe pain, and was to continue with nonsteroidal anti-inflammatory medications ("NSAID"). He was referred to an orthopedic doctor or his PCP for follow up (R. at 230).
On February 16, 2008 Plaintiff visited UPMC Mercy Hospital with complaints of 3 days of throbbing right foot pain and swelling (R. at 228). Plaintiff was diagnosed with acute gouty arthritis. He was discharged with outpatient follow up and should continue with NSAIDs (R. at 228).
On September 29, 2009 Plaintiff presented to UPMC Braddock Emergency Room with acute chest pain and was admitted to the hospital (R. at 248). Plaintiff had an x-ray performed on his chest (R. at 237). The findings of the x-ray were unremarkable (R. at 237). On the same day Plaintiff had a CT scan of his head/brain without contrast due to headache and hypertension to evaluate for intracranial hemorrhage (R. at 238). The CT was unremarkable with the exception of diffuse paranasal sinus disease (R. at 238). Plaintiff also had a NM Cardiology Cardiac Stress Test (R. at 240). The test was terminated because of fatigue and there was no induced chest pain. The test concluded with findings of normal functional capacity (R. at 240).
On September 30, 2009 Plaintiff underwent a Radiopharmaceutical Administration. The Cardiolite SPECT study revealed a small area of apical ischemia. In the short-axis projection there was perfusion defect involving the basal portion of the anteroseptal wall and also inferior wall whereas in the horizontal long-axis projection there was no significant perfusion defects evident and therefore, this may be artifactual. The resting gated scans revealed mild diffuse hypokinesis with left ventricular ejection fraction of 45% (R.at 367). Plaintiff had a cardiology consult with Aiysha Chatha, MD regarding his chest pain and hypertension (R. at 245). Plaintiff was placed on hydrochlorothiazide and amlodipine to control blood pressure. He also was placed on topical nitrates and baby aspirin (R. at 246). Plaintiff was discharged on October 1, 2009 (R. at 251).
On October 12, 2009 Plaintiff underwent an Echocardiogram which showed the following: Dilated left ventricle with mild hypertrophy; diffusely hypokinetic left ventricle with left ventricular ejection fraction of about 45%; mildly dilated left atrium; mild pulmonary hypertension with peak pulmonary systolic pressure of 39 mmHg - there is mild tricuspid insufficiency; and there is Doppler evidence for mild diastolic left ventricular dysfunction (R.at 366).
October 16, 2009 Plaintiff had a follow-up visit with Dr. South-Paul. Plaintiff complains of intense headaches since starting his new medications, a sore sternum, and difficulty breathing when he walks around after meals (R. at 332). Several laboratory tests were ordered, however, it was determined that complaints may be attributable to eating habits.
December 11, 2009 Plaintiff returned to Dr. South-Paul's office for a recheck/routine visit (R. at 326). The main health concerns are urinary frequency and obesity (R. at 328). Medications prescribed were: Timethoprim-Sulfamethoxazole, Hydrochlorothiazide, Lisinopril, Isosorbide Mononitrate, Aspirin, Pseudoephedrine, and Tramadol (R. at 329).
January 22, 2010 Plaintiff had a routine office visit with Dr. South-Paul. Plaintiff complained of back and shoulder pain related to a fall on the ice that occurred about a year before. He hadn't had any treatment for the pain (R.at 320). The Doctor prescribed the following medications: Naproxen, Hydrochlorothiazide, Lisinopril, Isosorbide Mononitrate, Aspirin, Pseudoephedrine, and Tramadol (R. at 322).
On April 8, 2010 Plaintiff had his initial visit with orthopedist, Dr. Patrick McMahon and said he had fallen on the ice and described a constant sharp pain and numbness in his shoulder and collar bone, tingling in the fingers, and pop/crack/clicking sounds (R. at 284). Dr. McMahon's assessment was bursae and tendon disorders shoulder region unspecified, intervertebral disc degeneration cervical (R. at 291). The Doctor prescribed pain medication of Percocet and a follow-up with MRI and x-ray (R. at 291).
On April 12, 2010 JRMC Diagnostic Services performed a cervical MRI to address Plaintiff's neck pain (R. at 281). The findings were a mild C5-C6 and to a lesser extent C6-C7 degenerative disc disease (R. at 281). The final impression was: Areas of moderate to advanced neural foraminal narrowing; mild to moderate central canal stenosis at the C6-C7 level due to posterolateral disc osteophyte causing moderate lateral recess narrowing and mild abutment of the cord along with advanced right neural foraminal narrowing, moderate to advanced neural foraminal narrowing elsewhere in the cervical spine (R.at 282).
On April 12, 2010 a MRI of the right shoulder was performed and the impression was a 1 em full-thickness tear supraspinatus tendon, mild AC degenerative ...