United States District Court, S.D. West Virginia, Huntington Division
SHAWN D. MCCALLISTER, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.
PROPOSED FINDINGS AND RECOMMENDATIONS
A. Eifert, United States Magistrate Judge.
action seeks a review of the decision of the Commissioner of
the Social Security Administration
(“Commissioner”) denying Plaintiff's
application for a period of disability and disability
insurance benefits (“DIB”) under Title II of the
Social Security Act, 42 U.S.C. §§ 401-433. The
matter is assigned to the Honorable Robert C. Chambers,
United States District Judge, and was referred to the
undersigned United States Magistrate Judge by standing order
for submission of proposed findings of fact and
recommendations for disposition pursuant to 28 U.S.C. §
636(b)(1)(B). Presently pending before the Court are the
parties' briefs wherein they both request judgment in
their favor. (ECF Nos. 6, 7, 8).
undersigned has thoroughly considered the evidence, the
applicable law, and the arguments of counsel. For the
following reasons, the undersigned respectfully
PROPOSES that that the presiding District
Judge confirm and accept the findings herein and
RECOMMENDS that the District Judge
GRANT Plaintiff's request for judgment
on the pleadings, (ECF Nos. 6, 8), to the extent that it
requests remand of the Commissioner's decision;
DENY Defendant's request to affirm the
decision of the Commissioner, (ECF No. 7);
REVERSE the final decision of the
Commissioner; REMAND this matter pursuant to
sentences four and six of 42 U.S.C. § 405(g) for further
administrative proceedings consistent with this PF&R; and
DISMISS this action from the docket of the
30, 2013, Plaintiff Shawn D. McCallister
(“Claimant”) protectively filed an application
for DIB, alleging a disability onset date of December 18,
2012, due to “herniated disc, numbness in hands, muscle
spasms, sciatica, and knee problems” (Tr. at 312-18,
360). The Social Security Administration (“SSA”)
denied Claimant's application initially and upon
reconsideration. (Tr. at 134, 163-65, 172-74). Claimant filed
a request for an administrative hearing. He had an initial
hearing on July 22, 2015 and a supplemental hearing on
November 18, 2015 before the Honorable Robert M. Butler,
Administrative Law Judge (“ALJ”). (Tr. at
34-124). By written decision dated January 26, 2016, the ALJ
found that Claimant was not disabled as defined by the Social
Security Act. (Tr. at 15-28). The ALJ's decision became
the final decision of the Commissioner on December 13, 2016
when the Appeals Council denied Claimant's request for
review. (Tr. at 1-6).
timely filed the present civil action seeking judicial review
pursuant to 42 U.S.C. § 405(g). (ECF No. 1). The
Commissioner subsequently filed an Answer opposing
Claimant's complaint and a Transcript of the
Administrative Proceedings. (ECF Nos. 4, 5). Thereafter,
Claimant filed a Brief in Support of Judgment on the
Pleadings. (ECF No. 6.). Claimant argued, inter
alia, that the Commissioner's decision should be
reversed or remanded on the basis of a subsequent favorable
disability determination that was effective on the day after
the ALJ's decision presently under review. (Id.
contended that the “subsequent decision [awarding him
DIB benefits] constituted new and material evidence which
ought to allow for reversal and/or remand in this
matter.” (Id.). However, Claimant acknowledged
a body of case law, including Baker v. Comm'r of Soc.
Sec., 520 F. App'x 228, 229 n.1 (4th Cir. 2013),
which provided that, in a situation like Claimant's,
“new substantive evidence might constitute ‘new
and material evidence' necessitating remand, but the
underlying evidence, not the award, will determine the
propriety of a remand.” (Id. at 10).
Therefore, Claimant indicated that he would obtain a copy of
the file from his successful application and
“thereafter provide this Court with the basis/evidence
underlying [his] subsequent award of disability insurance
benefits.” (Id.). However, Plaintiff did not
file such additional evidence by the time that the
Commissioner filed her responsive brief. Consequently, the
Commissioner argued that Claimant “failed to meet his
burden of showing that the evidence relied on in reaching the
subsequent favorable [decision pertained] to the period under
consideration here.” (ECF No. 7 at 17).
later supplemented the record with a copy of a form notice
from the Social Security Administration confirming that
Claimant was granted disability benefits beginning on January
27, 2016 based upon a primary diagnosis of “Malignant
Neoplasm of Gallbladder and Extrahepatic Bile Ducts”
and a secondary diagnosis of “[Osteoarthritis] and
Allied Disorders.” (ECF No. 8-1 at 1). Claimant
asserted that such form made “at least a general
showing of the nature of the new evidence” and
demonstrated that “such new evidence pertain[ed] to the
period under consideration in this appeal.” (ECF No. 8
Order entered October 26, 2017, the undersigned advised
Claimant that while the form that he supplied demonstrated
that he was granted DIB benefits beginning on the day after
the ALJ's decision presently under review, it did not
constitute “new and material evidence necessary for
this Court to determine the propriety of remand.” (ECF
No. 9 at 2); see Baker, supra. Therefore, the
undersigned ordered Claimant to supply the Court with the
evidence underlying Claimant's subsequent award of
benefits. (Id. at 2-3).
response to the foregoing Order, Claimant responded that his
file that formed the basis of his subsequent disability award
contained “1, 000 plus pages of ‘new and
material' medical records.” (ECF No. 10 at 1).
Therefore, Claimant provided the Disability Case Document
Index on which he annotated the number of pages, which he
asserted, contained “new and material” evidence.
(ECF No. 10-1 at 1-3). Claimant also provided a Disability
Determination Explanation regarding his subsequent
application, which contained the findings of an agency
non-examining physician, Cindy Osborne, D.O., dated March 24,
2017. (ECF No. 10-2 at 1-10). Further, Claimant provided a
record of his visit with Gerrit A. Kimmey, M.D., at
Huntington Internal Medicine Group (HIMG) on February 14,
2017 and his visit with surgical oncologist Amanda K.
Arrington, M.D., at the Edwards Comprehensive Cancer Center
on February 15, 2017. (ECF Nos. 10-3 at 10-14, 10-4 at 4-8).
was 39 years old on his alleged disability onset date and 42
years old on the date of the ALJ's written decision. (Tr.
at 15, 38, 312). He communicates in English and has a high
school education. (Tr. at 359, 361). Claimant previously
worked as a sales agent for a pest control service,
electrician assistant, saw operator, and a machine operator
and laborer at a concrete block plant. (Tr. at 79-80, 361).
Summary of the ALJ's Decision
42 U.S.C. § 423(d)(5), a claimant seeking disability
benefits has the burden of proving a disability. See
Blalock v. Richardson, 483 F.2d 773, 774 (4th Cir.
1972). A disability is defined as the “inability to
engage in any substantial gainful activity by reason of any
medically determinable impairment which has lasted or can be
expected to last for a continuous period of not less than 12
months.” 42 U.S.C. § 423(d)(1)(A).
Social Security Regulations establish a five-step sequential
evaluation process for the adjudication of disability claims.
If an individual is found “not disabled” at any
step of the process, further inquiry is unnecessary and
benefits are denied. 20 C.F.R. § 404.1520. The first
step in the sequence is determining whether a claimant is
currently engaged in substantial gainful employment.
Id. § 404.1520(b). If the claimant is not, then
the second step requires a determination of whether the
claimant suffers from a severe impairment. Id.
§ 404.1520(c). If severe impairment is present, the
third inquiry is whether this impairment meets or equals any
of the impairments listed in Appendix 1 to Subpart P of the
Administrative Regulations No. 4 (the “Listing”).
Id. § 404.1520(d). If the impairment does, then
the claimant is found disabled and awarded benefits.
if the impairment does not meet or equal a listed impairment,
the adjudicator must determine the claimant's residual
functional capacity (“RFC”), which is the measure
of the claimant's ability to engage in substantial
gainful activity despite the limitations of his or her
impairments. Id. § 404.1520(e). After making
this determination, the fourth step is to ascertain whether
the claimant's impairments prevent the performance of
past relevant work. Id. § 404.1520(f). If the
impairments do prevent the performance of past relevant work,
then the claimant has established a prima facie case
of disability, and the burden shifts to the Commissioner to
demonstrate, as the fifth and final step in the process, that
the claimant is able to perform other forms of substantial
gainful activity, when considering the claimant's
remaining physical and mental capacities, age, education, and
prior work experiences. 20 C.F.R. § 404.1520(g); see
also McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir.
1983). The Commissioner must establish two things: (1) that
the claimant, considering his or her age, education, skills,
work experience, and physical shortcomings has the capacity
to perform an alternative job, and (2) that this specific job
exists in significant numbers in the national economy.
McLamore v. Weinberger, 538 F.2d 572, 574 (4th Cir.
the ALJ determined as a preliminary matter that Claimant met
the insured status requirements for disability insurance
benefits through December 31, 2017. (Tr. at 17, Finding No.
1). At the first step of the sequential evaluation, the ALJ
confirmed that Claimant had not engaged in substantial
gainful activity since December 18, 2012, his alleged
disability onset date. (Id., Finding No. 2). At the
second step of the evaluation, the ALJ found that Claimant
had the following severe impairments: “degenerative
disc disease of the cervical spine with herniation, lumbar
degenerative disc disease with radiculitis and disc
protrusion, obesity, chronic pain syndrome, degenerative
joint disease of both knees, and
costochondritis.” (Tr. at 17-18, Finding No. 3). The ALJ
also considered Claimant's diabetes mellitus, mild left
elbow degenerative joint disease, colon polyp, thyroid
nodule, hyperlipidemia, migraines, sleep apnea status-post
surgery, gastroesophageal reflux disease (GERD), small hiatal
hernia, history of left hand crush injury, neuroma in the
left foot and heel spur, bilateral hyperkeratosis of the
feet, bilateral carpal tunnel syndrome status-post release,
degenerative joint disease of the bilateral shoulders,
actinic keratosis, liver lesion, adjustment disorder,
seizure, and cannabis abuse, but found that the impairments
were non-severe. (Tr. at 18-19). Under the third inquiry, the
ALJ found that Claimant did not have an impairment or
combination of impairments that met or medically equaled any
of the impairments contained in the Listing. (Tr. at 19-20,
Finding No. 4). Accordingly, the ALJ determined that Claimant
[T]he residual functional capacity to perform a range of
light work as defined in 20 CFR 404.1567(b) consisting of:
lifting up to 20 pounds occasionally and 10 pounds
frequently, standing and walking for about 6 hours, and
sitting for up to 6 hours in an 8-hour workday, with normal
breaks. The claimant is able to perform occasional crawling,
crouching, kneeling, stooping, balancing and climbing ramps
or stairs. The claimant cannot climb ladders, ropes, or
scaffolds. The claimant is able to perform work that does not
involve even moderate exposure to moving machinery or
unprotected heights. The claimant is able to perform work
that does not involve concentrated exposure to extreme cold,
extreme heat, wetness, or excessive vibration.
(Tr. at 20-26, Finding No. 5).
fourth step, the ALJ found that Claimant was capable of
performing his past relevant work as a sales agent for a pest
control service. (Tr. at 26, Finding No. 6). Nevertheless,
the ALJ also reviewed Claimant's past work experience,
age, and education in combination with his RFC to determine
his ability to engage in other substantial gainful activity.
(Tr. at 26-27). The ALJ considered that (1) Claimant was
defined as a younger individual aged 18-49 on the alleged
disability onset date (2) he had at least a high school
education and could communicate in English; and (3)
transferability of job skills was not material to the
disability determination. (Tr. at 26). Given these factors
and Claimant's RFC, with the assistance of a vocational
expert, the ALJ concluded that Claimant could perform jobs
that existed in significant numbers in the national economy,
including document preparer, escort vehicle driver, and call
out operator, which were at the unskilled sedentary
exertional level. (Tr. at 27). Therefore, based upon the
above, the ALJ found that Claimant was not disabled and was
not entitled to benefits. (Tr. at 27-28, Finding No. 7).
Claimant's Challenges to the Commissioner's
raises numerous challenges to the Commissioner's
decision. First, Claimant challenges the ALJ's RFC
analysis and finding on the basis that the ALJ failed to
properly consider the medical source opinions and evidence in
the matter, did not properly evaluate his credibility, and
did not accept the testimony of the vocational expert that
there were no jobs in the national economy for an individual
who is off task 10 percent of the work day or absent one or
more days per month. (ECF No. 6 at 5-7). In another challenge
to the Commissioner's decision, Claimant argues that his
subsequent award of DIB effective the day after the ALJ's
decision constitutes new and material evidence justifying
reversal and/or remand of this matter because the subsequent
award of benefits is based on the same impairments alleged in
the instant case. (Id. at 9-10). Further, Claimant
argues that the Appeals Council did not properly consider the
“new and material evidence” that Claimant
submitted for consideration. (Id. at 8-9).
response to Claimant's challenges, the Commissioner
asserts that the ALJ properly analyzed the evidence, assessed
Claimant's credibility, and crafted Claimant's RFC.
(ECF No. 7 at 7-13). The Commissioner further argues that the
Appeals Council properly considered Claimant's
“after-submitted evidence.” (Id. at
13-15). Finally, as to the subsequent decision awarding
Claimant DIB, the Commissioner asserts that the “later
determination involved [Claimant's] condition during a
different time than the period under review by this Court and
did not affect the decision about [Claimant's] condition
in 2012.” (Id. at 16).
undersigned has reviewed all of the evidence before the
Court. The information that is most relevant to
Claimant's challenges is summarized as follows.
testified during his administrative hearing on July 22, 2015
that he served in the Navy from 1993 to 1994 before he was
medically discharged after falling down steps carrying a
drill press and injuring his knees. (Tr. at 104). He worked
thereafter, but stopped working in 2012 after he was laid off
as a machinist. He testified that prior to being laid off, he
was “already having problems” and could not
“even perform [that] job anymore.” (Tr. at
102-03, 106-07). He stated that his “back is gone,
” he has costochondritis, his shoulders “are
shot, ” and issues due to “damage in [his]
neck.” (Tr. at 112).
supplemental hearing on November 18, 2015, Claimant stated
that he had pain from “head to toe.” (Tr. at 57).
His chest pain from costochondritis felt like electricity of
“small explosions going off” that ran through his
chest, shoulders, and hands. (Tr. at 57). He also had right
foot pain in the ball of his foot and a bone spur in the
back. (Id.). On a daily basis, he experienced
tingling and numbness that felt like a “burning
sensation” in his legs from his sciatic nerve. (Tr. at
57-58). The severity of his symptoms depended on how long he
was on his feet and often required him to sit down. (Tr. at
58). He experienced knee pain for 20 years and wore braces on
his knees 75 percent of the time; he also wore a back brace
25 percent of the time; and he used a cane. (Tr. at 58-59).
He stated that all devices were prescribed to him by the VA
hospital. (58.). Finally, he stated that whenever he used his
hands to do anything, they hurt, became numb, or tingled a
lot; he experienced low back pain “every day, all
day;” and he reported having a constant headache,
including during the time that he was testifying. (Tr. at
60-61). His pain averaged a 5 and when it climbed higher, he
went to the VA for shots of a non-steroidal anti-inflammatory
drug, Toradol, and a narcotic pain reliever, Stadol. (Tr. at
August 10, 2012, Claimant presented to the VA with shoulder
pain. (Tr. at 672). He noted that he had been receiving
cortisone shots in his shoulders for degenerative joint
disease/osteoarthritis and recently had an increase in pain
after carrying a 50-pound “sack of feed” for 200
feet. (Id.; see Tr. 696, 698). Claimant
exhibited decreased range of motion in both arms.
(Id.). X-rays of Claimant's shoulders showed
degenerative changes. (Tr. at 485). He was given a
corticosteroid injection in his left gluteal muscle. (Tr. at
672). During an orthopedic consultation regarding his
bilateral shoulder pain later that month, on August 21, 2012,
Claimant was assessed with mild osteoarthritis. (Tr. at 524).
August 26, 2012, Claimant presented for follow up regarding
his chronic conditions and to review recent lab work. He had
normal results on his cardiovascular, respiratory, and
neurological examinations. (Tr. at 1134). He also had a
normal gait and blood pressure of 126/87. (Id.). For
Claimant's neck and low back pain, he was prescribed
Etodolac and referred to pain management. (Tr. at 1135). For
his type 2 diabetes and hyperlipidemia, he was prescribed
September 4, 2012, Claimant had an EMG study performed by
Ramon S. Lansang, Jr., M.D., which showed that Claimant had
mild right radiculitis emerging from the S1 nerve root with
evidence of very minimal spontaneous potentials indicative of
denervation and mild axonal loss. (Tr. at 774). The condition
was probably subacute to chronic. (Id.). Given the
mild nature of the findings, surgery was not indicated, but
epidural steroid injections were suggested to alleviate the
back pain, spasms, and mobility limitations. (Id.).
Additionally, Dr. Lansang noted that Claimant's MRI
suggested facet arthropathy and he could therefore benefit
from medial branch block injections. (Id.).
October 4, 2012, Claimant had an orthopedic consultation due
to his complaints of right hand pain, weakness, numbness, and
tingling. (Tr. at 520). Claimant, who was currently working
in a machine shop, stated that he had problems with his right
upper arm for “quite some time” and it
progressively worsened to the point that he had trouble
gripping a steering wheel or hammer or managing a
standard-size chain saw; at times, he felt that his right arm
was “going to fall off.” (Id.). It was
noted that his nerve conduction study and EMG in July were
positive for carpal tunnel syndrome in that extremity. (Tr.
at 520-21). On examination, Claimant could make a fist and
extend all of his fingers. (Id.). The impression was
carpal tunnel syndrome and tennis elbow in his right upper
extremity. (Id.). The plan was a short course of
cortisone; continue Etodolac, right carpal tunnel release
surgery, and no work for approximately two weeks after
surgery. (Tr. at 522).
October 11, 2012, a CT scan of Claimant's chest showed a
stable 4 millimeter nodule and a new 7 millimeter nodule in
the middle lobe of Claimant's right lung, a 1.6
millimeter hypodensity in Claimant's left kidney, and
possible thyroid nodules of less than a centimeter each. (Tr.
at 483). A follow-up ultrasound of Claimant's kidneys on
November 5, 2012, revealed that the density in Claimant's
left kidney was a cyst. (Tr. at 481-82). Claimant received a
corticosteroid injection to treat his right tennis elbow.
(Tr. at 657). It was noted that he was using a tennis elbow
strap and tried an oral cortisone, which was not helpful.
(Tr. at 660). He used a drill press at work, which made the
pain worse. (Id.). He was to continue Etodolac and
return as needed. (Id.).
December 19, 2012, Claimant had right carpal tunnel release
surgery and an injection to treat tennis elbow in his left
arm. (Tr. at 628). The following month, on January 11, 2013,
Claimant stated that he was doing better following carpal
tunnel release surgery, but still had some pain. (Tr. at
622). On February 25, 2013, Claimant had a thyroid
ultrasound, which showed that his cystic and solid nodules
were stable in size and character as compared to the November
5, 2012 examination. (Tr. at 478, 619).
April 30, 2013, Claimant presented for a physical examination
necessary to obtain his commercial driver's license. (Tr.
at 611). His blood pressure was 123/84 and his weight was 288
pounds. (612.). The plan was to switch his medication to the
non-steroidal anti-inflammatory drug (NSAID) Voltaren for his
arthralgias, obtain a MRI for his low back pain, and test
Claimant for thyroid dysfunction. (Tr. at 613). Claimant had
a chest CT scan at that visit, which showed borderline
expanded lungs, but no acute process in his lungs. (Tr. at
477). He stated that he quit smoking in March. (Tr. at 616).
14, 2013, Claimant had x-rays of his hips and pelvis to
evaluate his complaints of pain. (Tr. at 474). There was no
acute bone injury. (Id.). He also had a lumbar spine
MRI due to his complaints of low back pain and left extremity
numbness. (Tr. at 475). The MRI was compared to his previous
MRI on May 1, 2011. (Id.). The impression was that
Claimant had a five millimeter right paracentral disc
protrusion that was touching the ventral aspect of the right
S1 nerve root, but he did not have any significant central
spinal canal stenosis. (Tr. at 476). Claimant also had a
podiatry consultation for bilateral foot pain that was worse
on the left. (Tr. at 514). The assessment was that his pain
was caused by an impinged nerve and xerosis (dry skin).
following day, on May 15, 2013, Claimant presented to the
emergency room complaining of chest pain. (Tr. at 597). He
stated that he awoke in the morning with chest pain on the
right side that radiated to his back and worsened with
movement and deep breathing. (Tr. at 598). He stated that he
“moved a tree” the previous day and was coughing
that night. (Id.). He did not have shortness of
breath or wheezing and he recently quit smoking.
(Id.). The impression was chest wall pain and
costochondritis. (Tr. at 600). Claimant had a CT angiogram of
his chest, but there was no evidence of pulmonary embolism,
the test was negative for dissection or aneurysm, and there
was no acute process demonstrated in Claimant's chest.
(Tr. at 473). Claimant was administered a NSAID, Toradol, in
the emergency room. (Tr. at 600). He was discharged with
prescriptions for a muscle relaxer, methocarbamol; a
corticosteroid, methylprednisolone; and a narcotic-like pain
reliever, Tramadol. (Tr. at 601). It was also noted that
Claimant needed a stress test and costochondral injections
could be considered. (Id.). Claimant underwent his
stress test on June 19, 2013, which was normal. (Tr. at
24, 2013, Claimant was informed that his chest CT, CXR, and
hips x-rays were normal. (Tr. at 593). The MRI of his back
showed small bulging discs at ¶ 3-L4 and L4-L5, as well
as a broad disc bulge at ¶ 5-S1, which contacted the
right nerve root and was the likely cause of his pain.
(Id.). Claimant was advised that he needed an EMG
and was prescribed gabapentin to treat his nerve pain.
4, 2013, Claimant presented with low back pain. (Tr. at 588).
He stated that he had back pain for two years, but he
“aggravated” it two weeks earlier when he was
fishing and a “beaver took off with his line.”
(Tr. at 591). When he grabbed his pole, he felt like someone
stuck a knife through his back into his chest.
(Id.). Lab work was ordered and he received
prescriptions for Toradol and Depo Medrol. (Tr. at 589).
18, 2013, Claimant presented for an unscheduled visit because
he was nearly out of his medication for low back pain. (Tr.
at 576). He stated that he was carrying a chain and bending
and stretching, which exacerbated his back pain.
(Id.). He was given a 10-day supply of Tylenol with
codeine. (Tr. at 576). On that date, Claimant also had an
injection of a corticosteroid into his left elbow to relieve
swelling and inflammation from tennis elbow. (Tr. at 577,
580). He was still using his elbow brace and was on NSAIDS.
(Tr. at 580).
next day, on June 19, 2013, Claimant presented to the
emergency room with right ankle swelling and pain after he
tripped while performing yard work. (Tr. at 571). The
impression was no acute fracture or subluxation, but some
soft tissue swelling over the lateral malleolus. (Tr. at
470-71). X-rays of Claimant's knees showed minimal
narrowing of the medial compartment of each knee with small
effusions, but no acute fracture. (Tr. at 467).
26, 2013, Claimant again presented to the emergency
department stating that his low back pain was worse. (Tr. at
542). He was evaluated for physical therapy, stating that he
had low back pain for years with radicular symptoms in his
lower extremities, particularly on his right side. (Tr. at
509). Claimant also complained of muscle spasms in his back.
(Id.). Claimant presented in moderate distress with
a guarded gait and decreased trunk rotation. (Tr. at 510).
His range of motion was limited and painful in all ranges,
but his strength and neurological findings were normal.
(Id.). Claimant was noted to not be an appropriate
candidate for physical therapy because he was unable to
tolerate the activities due to pain. (Tr. at 511). He was
assessed to have degenerative disc disease and a herniated
disc. (Tr. at 544). He was administered Toradol and an
anti-inflammatory glucocortiocosteroid, Decadron, in each
hip. (Tr. at 542, 544).
August 12, 2013, Claimant had x-rays of his cervical spine
due to neck pain and headaches, which showed normal results
in the cervical spine and mild degenerative changes at ¶
6-C7. (Tr. at 810-11). Later that month, on August 21, 2013,
Claimant presented to the emergency room stating that he had
pain in his chest, both shoulders, and left elbow. (Tr. at
871). Claimant had chest x-rays to evaluate chest pain, which
showed no active disease. (Tr. at 809-10). The impression was
multiple somatic complaints of joint and soft tissue pain,
which could possibly be fibromyalgia. (Tr. at 874). He also
had degenerative joint disease of the spine and shoulders.
(Id.). He was given an anti-inflammatory
glucocortiocosteroid, Solumedrol, and Toradol.
August 30, 2013, Claimant had routine follow up of chronic
conditions. (Tr. at 863). His blood pressure was
“slightly high” at 133/91, but he was not sure if
he took his medication the previous night. (Tr. at 864-65).
Claimant had a thyroid ultrasound, which showed that his
thyroid nodules were unchanged since February 2013. (Tr. at
808). For diabetes, Claimant was started on metformin, given
aviva, and he was to continue Lisinopril. (Id.). It
was noted that Claimant's liver enzymes were elevated.
(Tr. at 866). The plan was to bring Claimant's diabetes
under control before addressing the concerns regarding his
liver. (Tr. at 865-66).
September 3, 2013, Claimant presented for chest wall and low
back pain. (Tr. at 819). The impression was costochondritis,
low back pain with lower extremity radiculitis that was worse
on the right, and lumbar degenerative disc disease. (Tr. at
823). Claimant was offered joint injections. (Id.).
The following day, he had a neurosurgery consultation at
which his motor strength was normal, but his deep tendon
reflexes were decreased in his lower extremities. (Tr. at
825-26). No surgical intervention was indicated for his low
back pain and a MRI would be obtained to evaluate his
shoulder pain. (Id.).
September 9, 2013, Claimant had a corticosteroid injection in
his left elbow. (Tr. at 853). He was recommended for left
carpal tunnel release surgery. (Id.). Later that
month, on September 16, 2013, Claimant had a MRI of his
thoracic spine without contrast, which showed disc extrusion
at ¶ 6-C7 with moderate spinal canal stenosis, but
Claimant's thoracic spine was intact. (Tr. at 807-08). On
September 18, 2013, Claimant had another corticosteroid
injection, this time in his sternum. (Tr. at 833).
underwent left carpal tunnel release surgery. On October 10,
2013, Claimant stated that he did not have pain or problems
following surgery, there was no sign of infection, and
Claimant had full range of motion in his hand and fingers.
(Tr. at 940-41). Claimant presented for additional follow up
on October 17, 2013 at which time he denied pain, tingling,
or numbness and his hand strength was good. (Tr. at 934).
October 11, 2013, Claimant presented to the hypertension
clinic. (Tr. at 935). He stated that he was taking his
HCTZ/Lisinopril daily as prescribed and was tolerating it
well. (Id.). He stated that his blood pressure at
home measured in the 120s/80s. (Id.). His blood
pressure measured 135/80 at the visit, which was borderline
above goal range. (Tr. at 935-36). No changes were made to
his medications. (Tr. at 936). Claimant recently gained
weight and was to begin dietary and lifestyle modifications,
including walking every day as tolerated. (Id.).
October 28, 2013, Claimant had fluoroscopic-guided lumbar
epidural steroid injections at ¶ 5-S1 due to back pain.
(Tr. at 926). However, the following day, Claimant reported
over the telephone that the injections did not alleviate his
pain at all. (Tr. at 922).
January 9, 2014, Claimant presented to the emergency room
stating that he fell and hit the back of his head two days
prior and suffered headaches, neck pain, and some nausea
thereafter. (Tr. at 1254-55). No issues were noted on the CT
scan of Claimant's head. (Tr. at 1020). He also had a CT
scan of his cervical spine, which showed mild degenerative
changes in the lower cervical spine, but no evidence of
fracture or malalignment. (Tr. at 1022). He was sent home
with a prescription for Toradol and he was advised that he
should take the naproxen that he had at home. (Tr. at 1257).
February 5, 2014, Claimant had a thyroid ultrasound, which
revealed a solid nodule in the mid-right lobe that was not
present in the previous August 30, 2013 ultrasound. (Tr. at
1019-20). The other multiple cystic and solid nodules were
March 6, 2014, Claimant had a mental health consultation in
preparation for bariatric surgery. Claimant reported
struggling with his weight most of his adult life and noted
that his weight fluctuated between 200 and 300 pounds even
while he was in the Navy. (Tr. at 1082). He was not
physically active due to chronic pain. (Id.). His
most recently recorded weight on February 27, 2014 was 299
pounds with a body mass index of 40.5. (Tr. at 1083). He was
advised that he had to be nicotine free for six weeks prior
to pre-bariatric surgery psychological evaluation and that he
had to remain nicotine free through the date of surgery.
(Id.). He would be tested for nicotine use on March
14 and April 25, 2014. (Id.).
March 18, 2014, Claimant had an ultrasound of his abdomen
during a pre-operative bariatric consultation. (Tr. at
1014-15). The ultrasound showed a solid lesion on
Claimant's liver that was not seen in his chest CT scan
in May 2013. (Tr. at 1015); see (Tr. at 593).
Therefore, a CT scan of Claimant's thorax was taken for
further evaluation. This CT scan showed a small density mass
in the upper/middle lobe of Claimant's right lung that
was stable as compared to a previous CT scan taken on October
11, 2012; severe fatty liver infiltration without
hepatomegaly (an enlarged liver); no adenopathy (large or
swollen lymph nodes) in the abdomen or pelvis; and no other
significant findings to suggest metastatic disease. (Tr. at
April 2, 2014, a MRI of Claimant's abdomen was taken to
evaluate the 1.6 centimeter liver mass that was seen during
his above-noted visit. (Tr. at 1012-14). The appearance of
the lesion on the MRI favored benign etiology. (Tr. at 1014).
Thus, it was recommended that Claimant receive a repeat
ultrasound in three months to ensure stability of the mass.
(Id.). Otherwise, the MRI showed that Claimant had
severe fatty liver infiltration and hepatomegaly, as well as
non-specific, non-enhancing small renal cysts.
April 7, 2014, Claimant had x-rays to evaluate his various
pain complaints. His shoulders showed the same early
degenerative changes with no significant change from the
August 10, 2012 examination. (Tr. at 1006). The x-rays of
Claimant's cervical spine showed mild degenerative
changes at ¶ 6-C7 that were unchanged from the August
10, 2012 radiographs, the same straightening of the normal
cervical lordotic curvature, and no acute fracture or
prevertebral soft tissue swelling. (Tr. at 1008).
Claimant's thoracic spine x-rays showed early
degenerative changes in the lower thoracic ...