United States District Court, M.D. Pennsylvania
MARTIN C. CARLSON, Magistrate Judge.
The plaintiff, Michael Bryant, appeals from the unfavorable decision of the Commissioner of Social Security denying him benefits under Titles II and XVI of the Social Security Act. The jurisdiction of this Court is invoked pursuant to 42 U.S.C. § 405(g) and 42 U.S.C. § 1383(c)(3). This matter has been referred to the undersigned United States Magistrate Judge for resolution on consent of the parties, pursuant to the provisions of 28 U.S.C. § 636(c) and Rule 73 of the Federal Rules of Civil Procedure. (Docs. 17, 18).
For the reasons stated herein, we order that the final decision of the Commissioner be AFFIRMED.
II. BACKGROUND AND PROCEDURAL HISTORY
At the time of this disability determination Michael Bryant was a younger individual under social security regulations, and was 46 years of age. On March 25, 2011, Bryant was assaulted while shopping. Bryant reported that he was hit in the head and back multiple times, and complained of headache, left mid back pain, and left thumb pain. (Admin Tr. 287-88). Bryant also stated that he had a tooth knocked out, and broke two ribs during the assault. (Admin Tr. 59). This assertion, however, is belied by several unremarkable diagnostic imaging studies performed that day, including a CT scan of Bryant's head, x-rays of his chest, an x-ray of his thumb, that showed no evidence of fracture. (Admin Tr. 280, 290-91). During a follow up appointment four days later, Bryant reported that he was feeling better, but continued to experience pain on the left side of his chest every time he took a deep breath. (Admin Tr. 280). Bryant was given an injection for the pain, and was provided with ibuprofen. Id.
On August 11, 2011, Bryant protectively filed Title II and Title XVI applications for Disability Insurance Benefits and Supplemental Security Income. In both applications Bryant alleged that he became unable to work on March 24, 2011, at the time of this assault, due to depression, right hip problems, back pain, and HIV. (Admin Tr. 220).
On October 13, 2011, almost seven months after the assault, Bryant presented to Certified Physician's Assistant ("PA-C") Anessa Inman with complaints of middle and lower back pain. (Admin Tr. 323). Bryant initially reported that this pain was of gradual onset, and that his pain began approximately nine years ago. Id . He later clarified this statement in a way which tied his complaints to the onset of his claimed disability, alleging that he had lower back pain with radiation to the hips prior to the assault, but that his pain became much worse after the assault. (Admin Tr. 295). On examination, Bryant had a normal gait, normal lumbar lordosis, no tenderness to the lumbar spine on palpation, and a normal range of motion in the lumbar spine. (Admin Tr. 323). Bryant's lower extremities were also normal on inspection, with normal palpation and range of motion, normal strength, and no joint instability - except that the straight leg raise test showed less than 60 degrees of flexion on the right side. Id . An x-ray of Bryant's lumbar spine taken five days later revealed only mild degenerative changes. (Admin Tr. 322).
On November 2, 2011, Bryant presented to Certified Registered Nurse Practitioner ("CRNP") Marcia Ludlow with complaints of chronic lower back pain. (Admin Tr. 321). Bryant also reported that he tested HIV positive in 1999. (Admin Tr. 321). Bryant was referred to orthopedics for treatment of his back pain, and was referred to infectious disease specialist Alina Popa for treatment of probable HIV exposure. (Admin Tr. 320). On November 21, 2011, it was confirmed that Bryant was HIV positive, but that he was asymptomatic. (Admin Tr. 320). In addition to providing treatment for Bryant's HIV, Dr. Popa also prescribed medications to treat Bryant's mental impairments. (Admin Tr. 317).
On December 9, 2011, at the Social Security Administration's behest, Bryant was examined by Dr. Thomas McLaughlin. During the examination, Bryant complained of low back pain with radiation to the hips, and intermittent neck pain without radiation or radicular symptoms. (Admin Tr. 295-96). Dr. McLaughlin noted that Bryant ambulated with a normal gait, was able to stand unassisted, rise from a seated position, and step up and down from the examination table without difficulty, but was not able to stand on one foot at a time. (Admin Tr. 297, 299). Dr. McLaughlin also noted that straight leg raise was positive on the right to fifty degrees of elevation. Id . Bryant was unable to heel walk, toe walk, or walk heel to toe, and did not attempt to squat. (Admin Tr. 299). Examination of the cervical spine revealed no tenderness, and no evidence of paravertebral muscle spasm. Id . Examination of the hips revealed no tenderness, redness, warmth, swelling, effusion, laxity, crepitus, or clicks. Id . Examination of Bryant's dorsolumbar spine revealed tenderness over the paravertebral muscle areas. Id . Based solely on his own observations from a one-time examination and without an opportunity to review any of Bryant's medical records, Dr. McLaughlin diagnosed Bryant with low back pain secondary to lumbar degenerative spine disease possible disc on the right, right hip pain likely secondary to trauma and degenerative joint disease, HIV positive, Asthma history (quiescent now), hypertension, and tobacco use. (Admin Tr. 300).
In a medical source statement, Dr. McLaughlin opined that Bryant could: frequently lift or carry 2-3 pounds and occasionally lift or carry ten pounds; stand and walk up to two hours per eight-hour workday; sit up to eight hours per workday with alternating sitting and standing at will; and never bend, kneel, stoop, crouch, balance, or climb. (Admin Tr. 302-03). Dr. McLaughlin also opined that Bryant could push or pull with his extremities within his lift/carry limitations without further restriction, and should avoid exposure to heights. Id.
Given this medical backdrop, Bryant's social security claims were denied initially on December 21, 2011. Thereafter, Bryant requested, and was granted, an opportunity to have his claims evaluated during an administrative hearing.
On January 10, 2012, prior to his administrative hearing, Bryant presented to the emergency department. (Admin Tr. 357). Bryant was voluntarily admitted for inpatient psychiatric care due to his worsening depression and suicidal thoughts that were exacerbated by the recent death of his mother. (Admin Tr. 352). On admission, a clinician initially assigned him a global assessment of functioning score of 25. (Admin Tr. 347). Hospital records reflect that Bryant had previously been admitted for inpatient care at the same facility in 2006, and Bryant reported several previous admissions in Georgia. Id . Bryant also reported a history of drug overdose in the late 1990's. Id . While receiving inpatient psychiatric care in 2012, Bryant was diagnosed with major depression and post-traumatic stress disorder, and was restarted on his medications. (Admin Tr. 344). His emotional and mental state rapidly improved and Bryant was discharged on January 12, 2012, with a GAF score of 65. Id.
On February 27, 2013, Bryant, with the assistance of counsel, appeared and testified at an administrative hearing in Harrisburg, Pennsylvania before Administrative Law Judge ("ALJ") Randy Riley. Impartial vocational expert ("VE") Paul A. Anderson also appeared and testified. Specifically, Bryant testified that he was unable to bend down and touch his toes, could not squat, could climb up to three flights of stairs, preferred not to climb ladders, could walk three blocks without resting, could stand up to ten minutes at one time, and could sit for up to one hour at a time. (Admin Tr. 56-58, 232-33, 235). Bryant also reported that the symptoms related to his mental impairments worsened after the March 2011 assault. (Admin Tr. 61-62). Bryant reported that he experiences anger, suicidal thoughts, auditory hallucinations, racing thoughts, lack of energy, focal deficits, and difficulty concentrating. (Admin Tr. 67-70, 232-33). Bryant also testified that, following the assault, he developed a mistrust of strangers. Id . Bryant asserted that he could not sit through an entire television program because "it gets boring after awhile, " but could read anything. (Admin Tr. 69, 232, 273). Despite his impairments, Bryant reported that he maintained his own personal hygiene, cooked "at times, " did dishes "at times, " did laundry, occasionally took out trash. (Admin Tr. 55-56, 228-29). Bryant also testified that he does not have a driver's license, and had a friend drop him off in Camp Hill, Pennsylvania at the Market Street Bridge and walked to his hearing in downtown Harrisburg, Pennsylvania, a significant distance to traverse on foot. (Admin Tr. 56).
On March 20, 2013, the ALJ denied Bryant's applications for benefits in a written decision. In so doing, the ALJ found that Bryant met the insured status requirement of Title II of the Social Security Act through December 31, 2012, and then proceeded through steps one through five of the five-step sequential evaluation process. At step one, the ALJ found that Bryant did not engage in substantial gainful activity between March 24, 2011, and March 20, 2013. (Admin Tr. 40). At step two, the ALJ found that Bryant has the medically determinable severe impairments of degenerative disc disease, HIV, depression, and post-traumatic stress disorder ("PTSD"). Id . At step three, the ALJ found that Bryant did not have an impairment or combination of impairments that met or medically equaled the severity of one of the impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix I. Id.
Before proceeding to step four, the ALJ found that Bryant had the residual functional capacity to perform light work as defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b) except that he requires:
a sit/stand option at will; is limited to occasional stairs, balancing, stooping, kneeling, crouching and crawling; should never climb ladders; must avoid concentrated exposure to hazards; and is limited to simple, routine, repetitive tasks, no interaction with the public and occasional interaction with coworkers but no tandem tasks.
(Admin Tr. 41-42). In doing so, the ALJ was required to weigh the medical and nonmedical source opinions of record in accordance with 20 C.F.R. § 404.1527 and SSRs 96-2p, 96-5p, 96-6p, and 06-3p. The record in this case contains only one such opinion, by nontreating physician Dr. McLaughlin.
At step four, relying on testimony by the VE, the ALJ found that Bryant was unable to perform his past relevant work as a fast food manager, warehouse worker, or cook because the physical or mental demands of each position exceeded what the ALJ ...