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Sinko v. Colvin

United States District Court, M.D. Pennsylvania

April 20, 2017

MICHAEL ALLEN SINKO, Plaintiff
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant

          MEMORANDUM

          William J. Nealon United States District Judge

         On September 14, 2015, Plaintiff, Michael Allen Sinko, filed this instant appeal[1] under 42 U.S.C. § 405(g) for review of the decision of the Commissioner of the Social Security Administration ("SSA") denying his application for disability insurance benefits ("DIB") under Title II of the Social Security Act, 42 U.S.C. § 1461, ££ssq. (Doc. 1). The parties have fully briefed the appeal. For the reasons set forth below, the decision of the Commissioner denying Plaintiffs application for DIB will be affirmed.

         BACKGROUND

         Plaintiff protectively filed[2] his applications for DIB and SSI on July 22, 2012, alleging disability beginning on March 10, 2012, [3] due to a combination of degenerative disc disease, Bipolar Disorder, agoraphobia, Post Traumatic Stress Disorder ("PTSD"), Social Anxiety Disorder, and Alcoholism. (Tr. 13, 173).[4] The claim was initially denied by the Bureau of Disability Determination ("BDD")[5] on October 22, 2012. (Tr. 13). On November 23, 2012, Plaintiff filed a written request for a hearing before an administrative law judge. (Tr. 13). A hearing was held on December 16, 2013, before administrative law judge Patrick Cutter, ("ALJ"), at which Plaintiff and an impartial vocational expert Gerald W. Keating, ("VE"), testified. (Tr. 13). On February 22, 2014, the ALJ issued an unfavorable decision denying Plaintiffs applications for DIB and SSI. (Tr. 13). On April 23, 2014, Plaintiff filed a request for review with the Appeals Council. (Tr. 6). On July 13, 2015, the Appeals Council concluded that there was no basis upon which to grant Plaintiff s request for review. (Tr. 1-3). Thus, the ALJ's decision stood as the final decision of the Commissioner.

         Plaintiff filed the instant complaint on September 14, 2015. (Doc. 1). On December 21, 2015, Defendant filed an answer and transcript from the SSA proceedings. (Docs. 8 and 9). Plaintiff filed a brief in support of his complaint on February 4, 2016. (Doc. 10). Defendant filed a brief in opposition on April 11, 2016. (Doc. 13). Plaintiff did not file a reply brief.

         Plaintiff was born in the United States on June 28, 1971, and at all times relevant to this matter was considered a "younger individual."[6] (Tr. 169). Plaintiff did graduated from high school, and can communicate in English. (Tr. 172, 174). His employment records indicate that he previously worked as a baker, facilities manager, and sous chef. (Tr. 175).

         In a document entitled "Function Report - Adult" filed with the SSA on August 30, 2012, Plaintiff indicated that he lived in a house with friends. (Tr. 184). When asked how his injuries, illnesses, or conditions limited his ability to work, Plaintiff stated, "back injury prevents me from being able to work by limiting amount of time standing, sitting, bending, lifting and sometimes walking." (Tr. 184). From the time he woke up until he went to bed, Plaintiff prepared meals, exercised, cleaned, watched television, and played video games. (Tr. 185). Plaintiff had no problems with personal care, prepared "complete meals" for five (5) hours daily, cleaned, did the laundry, and shopped in stores for clothes and food one (1) to two (2) times a month for one (1) to two (2) hours at a time. (Tr. 187). He went outside every day, but was not able to go out alone due to Social Anxiety Disorder. (Tr. 187). His hobbies included watching television, playing video games, and building scale-model airplanes. (Tr. 188). He spent time with others one (1) time a month by talking or going out to lunch, and did not have difficulty getting along with others. (Tr. 188-189). On a daily basis, he went to counseling appointments and "Workabilities Clubhouse." (Tr. 188). He could walk for a quarter of a mile before needing to rest for ten (10) minutes. (Tr. 163). When asked to check what activities his illnesses, injuries, or conditions affected, Plaintiff did not check talking, hearing, seeing, memory, understanding, following instructions, using hands, or getting along with others. (Tr. 189).

         Regarding his concentration and memory, Plaintiff did not need special reminders to take care of his personal needs, take his medicine, or go places. (Tr. 186, 188). He could count change, handle a savings account, pay bills, and use a checkbook. (Tr. 187). He could pay attention for up to two (2) hours, was able to finish what he started, followed written instructions well, handled stress "not well, " and handled changes in routine "good." (Tr. 189-190).

         At the oral hearing on December 16, 2013, Plaintiff initially testified that, regarding his mental health impairments, he visited a psychologist every three (3) months, did not see a counselor or therapist, was not involved in group therapy, and was not a member of any addiction network. (Tr. 59). He testified that the reason he did not receive more treatment was because he could not obtain insurance. (Tr. 72). His medications, which included Lithium, Ability, Cogentin, and Klonopin, were "very effective" with the only stated side effect of tiredness from Klonopin and excitability from Ability. (Tr. 63-64). His mental health symptoms were aggravated by being in public and around people because it made him paranoid. (Tr. 64). He testified that, during the relevant time period, he was hospitalized once at the end of 2013. (Tr. 67). He experienced auditory hallucinations, such as hearing children playing outside and hearing music in his head that did not go away. (Tr. 67). He stated he had some difficulties getting along with others due to anxiety and paranoia, and had problems with memory and concentration. (Tr. 62, 69).

         In terms of activities of daily living, Plaintiff testified that he was able to take care of his personal needs, cook, clean, do the laundry, use the computer, play the guitar and video games, build scale models, hike, read, shop, and watch television. (Tr. 60-61). He was able to pick up an object weighing thirty (30) pounds, could raise his legs and put them down in a seated position, was able to raise his arms forward and bring them backward and reach overhead, was able to stand for about two (2) hours before needing to sit, was able to sit for about an hour, and was able to walk a couple of miles. (Tr. 62-63).

         MEDICAL RECORDS

         A. Medical Evidence

         1. Sunburv Community Hospital

         On May 28, 2012, Plaintiff presented to Sunbury Community Hospital ("Sunbury") due to lower back pain after slipping on the stairs in his home and striking his back. (Tr. 341). His physical examination revealed negative straight leg raise tests bilaterally, absent paralumbar tenderness and spasm, a non-focal sensorimotor exam, unremarkable deep tendon reflexes, and a normal dorsiflexion at the great toe bilaterally. (Tr. 341). The impression was that Plaintiff had a contusion of his middle and lower back, and Plaintiff was discharged home on the same day as presentation in a stable condition. (Tr. 341).

         On August 15, 2012, Plaintiff presented to the ER at Sunbury for lower back pain. (Tr. 449). A physical examination revealed a positive straight leg test on the right side; bilateral paraspinal tenderness and spasm; moderate tenderness to palpation of the lower lumbar spine; normal range of motion in his extremities; and symmetric deep tendon reflexes. (Tr. 450). Plaintiff was treated with Toradol and was discharged home with a diagnosis of acute sciatica. (Tr. 450).

         On September 14, 2012, Plaintiff presented to the ER at Sunbury for psychiatric symptoms. (Tr. 453). He reported having hallucinations. (Tr. 453). His examination revealed a non-tender spine and alertness and orientation to person, place, and time with a normal affect. (Tr. 454). Plaintiff was discharged home with a clinical impression of both mania and insomnia and was stable on discharge. (Tr. 455).

         On December 14, 2012, Plaintiff presented to the ER at Sunbury for "fleeting thoughts, " bizarre behavior, and an overdose of Klonopin. (Tr. 395). His physical examination revealed he was oriented to person, place, and time; had clear lungs with equal breath sounds bilaterally; had a non-tender spine; and had a mildly constricted affect, organized thoughts, appropriate thought content. (Tr. 396, 405). Plaintiff reported he had been experiencing racing thoughts, difficulty sleeping, depression, a lack of motivation, anhedonia, negative thinking, lability, and stress. (Tr. 399). It was noted that Plaintiff denied having suicidal thoughts and overdosing on Klonopin, that he "never meant to hurt himself, " that he felt safe and had improved coping skills with treatment from therapy, and that he had improvement in his mood and feelings of safety. (Tr. 399). Plaintiff was admitted to the Psychiatry Unit voluntarily. (Tr. 396, 399). His Seroquel and Lithium doses were increased, and Plaintiff was compliant with his medication. (Tr. 399). His Axis I diagnoses were Bipolar Disorder status post overdose, Obsessive Compulsive Disorder, Post-traumatic Stress Disorder, and Alcohol Dependence based on history. (Tr. 399). On December 20, 2012, Plaintiff was discharged in a stable condition with an improved mood; was instructed that he could perform unrestricted activities of daily living; was told that he should avoid alcohol and street drugs; and was instructed to continue on his medications, including Seroquel and Lithium Carbonate, as directed. (Tr. 397).

         From September 22 to September 26, 2013, Plaintiff was admitted to Sunbury due to suicidal ideations. (Tr, 644). It was noted that Plaintiff had Bipolar Disorder with depression and alcohol dependence in sustained remission for four and a half (4 V-i) years. (Tr. 644). Plaintiff reported that his roommate kicked him out due to his psychiatric problems, and that he wandered through people's backyards in his underwear, but when he came to his senses, he became "hopeless, helpless, and [had] suicidal ideations" that brought him to the ER. (Tr. 644). He reported that his mood at that time was melancholic, that some days he felt good and some depressed and sad, that he slept four (4) hours per night, that his energy was low, and that he had been having panic attacks up to two (2) times a day. (Tr. 644). Plaintiffs examination revealed clear lungs bilaterally; good eye contact; articulate speech; a sad and depressed mood; a restricted affect; positive suicidal ideations with no plans; linear and goal-directed thought processes; intact recent and remote recall; fair insight; intact judgment; and an adequate fund of knowledge. (Tr. 646). His Axis I diagnoses included Bipolar Disorder, depression, status post questionable psychotic episode, OCD by history, PTSD by history, and alcohol dependence in full sustained remission. (Tr. 646). Plaintiff was prescribed Celexa to improve his mood and anxiety, and Topamax to stabilize his mood and help with sleep. (Tr. 647). He remained in the hospital until September 26, 2013, when he was discharged with improvements in his thoughts, social functioning, and self-care. (Tr. 648). His discharge diagnoses included Bipolar disorder, depressed; Generalized Anxiety Disorder, improved; and Personality Disorder, not otherwise specified, improved. (Tr. 648).

         2. Dr. Pagnana-DeFazio

         On August 20, 2012, Plaintiff had an appointment with Dr. Pagnana-DeFazio due to complaints of a cough, congestion, and back pain. (Tr. 368). It was noted during the physical examination that Plaintiff had a normal gait; grossly intact sensation to light touch; brisk and symmetric patellar reflexes bilaterally; a normal mood and affect; grossly intact cranial nerves; negative straight leg raise tests; 5/5 muscle strength bilaterally; and bilateral muscle spasms and firmness in the lumbar spine. (Tr. 369). Plaintiff was diagnosed with lumbago, an upper respiratory infection, and otitis media. (Tr. 369). Plaintiff was prescribed a Medrol dose pack and Ultram. (Tr. 369).

         On September 17, 2012, Plaintiff had an appointment after an ER visit for mania. (Tr. 370). He reported that he was doing better, and that he did not have chest pain or shortness of breath, but did struggle with "discogenic disc disease" and mechanical back pain with radiculopathy bilaterally. (Tr. 370). His medications at this visit included Ultram, Lithium Carbonate, Seroquel, Benztropine Mesylate, and Klonopin. (Tr. 370). His physical examination revealed a normal gait; negative straight leg raise tests bilaterally; normal toe walk and heel walk; paraspinal muscle spasm and tenderness in the lumbar spine; sensation grossly intact to light touch; grossly intact cranial nerves; a normal mood and flat affect; and difficulty keeping a train of thought "online and on point." (Tr. 371). He was assessed as having Neuritis or Radiculitis of the thoracic or lumbosacral region, Bipolar Disorder, Post-Traumatic Stress Disorder, and Obsessive Compulsive Disorder. (Tr. 371).

         3. Northumberland Counseling Services

         On June 25, 2012, Plaintiff had an appointment at Northumberland Counseling Services ("NCS"). (Tr. 347). He reported that he had not been feeling well, that he had less interest and motivation, his focus was decreased, and that he had experienced a paranoid episode during which he could not leave the house because he thought people were taking pictures of him. (Tr. 347). It was noted that Plaintiff worked with his dad and cousins and "got paid for it." (Tr. 347). Plaintiffs mental status examination noted Plaintiff had the following: psychomotor retardation; normal speech; a dysthymic mood; a goal-directed thought process; an alert sensorium; impaired cognition; fair judgment; and no hallucinations. (Tr. 347). Plaintiffs Axis I diagnosis was Bipolar Disorder with psychosis and substance abuse. (Tr. 347).

         On July 16, 2012, Plaintiff called NCS due to depression, not sleeping well, and a start into a "rapid cycle." (Tr. 346). As a result, Plaintiffs Lithium dose was increased. (Tr. 346).

         On August 30, 2012, Plaintiff had an appointment at NCS. (Tr. 433). Plaintiff reported that the had been sober for three (3) years, had decreased focus and concentration, heard unusual music at night in his head, and could not talk on the phone in public. (Tr. 433). His mental status examination revealed appearance and behavior within normal limits; normal speech; a dysthymic mood and congruent affect; a goal-directed thought process; an alert sensorium; and fair judgment and impaired cognition. (Tr. 433).

         On September 20, 2012, Plaintiff called NCS for Seroquel samples. (Tr. 426). He reported that he was doing "extremely well mood-wise on the combination of Seroquel and Ability." (Tr. 426).

         On December 3, 2012, Plaintiff had an appointment at NCS. (Tr. 424). He reported that, for a week in November, he developed psychotic symptoms, including confusion, memory loss, seeing people who were not real sitting in front of him asking him questions, increased energy, increased OCD, and increased racing thoughts. (Tr. 424). His mental status examination revealed appearance and behavior within normal limits; normal speech; a dysthymic mood and congruent affect; a goal-directed thought process; an alert sensorium; and fair judgment and impaired cognition. (Tr. 424).

         On January 30, 2013, Plaintiff had an appointment at NCS. (Tr. 423). Plaintiff noted that he received an "A" on an online course. (Tr. 423). His mental status examination revealed appearance and behavior within normal limits; normal speech; an ...


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