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Montgomery v. Colvin

United States District Court, S.D. Mississippi, Eastern Division

March 31, 2015



KEITH STARRETT, District Judge.

This cause is before this Court on Defendant's Motion [10] to affirm the decision of the Commissioner, the Report and Recommendations [13] of Magistrate Judge Michael T. Parker, the Objections [14] to the Magistrate Judge's Report and Recommendations, the Commissioner's Response [15] thereto, Plaintiff's Reply [16], and the record and pleadings currently on file herein, and the Court after considering the same does hereby find as follows, to-wit:


On March 12, 2010, [1] Plaintiff filed applications for disability insurance benefits and supplemental security income, alleging a disability onset date of February 4, 2009. (Administrative Record [8], at 31; 139-146.)[2] These applications were denied both initially and upon reconsideration. (8] at 119-124; 127-129.) Thereafter, Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"). ([8] at 134-135.)

On January 21, 2011, a hearing was convened before ALJ Charles C. Pearce. ([8] at 50-98.) The ALJ heard testimony from Plaintiff and Thomas J. Stewart, a vocational expert ("VE") ([8] at 88-94.) On February 10, 2011, the ALJ issued a finding that Plaintiff was not disabled. ([8] at 28-45.) Plaintiff appealed this decision and submitted additional evidence to the Appeals Council. The Appeals Council denied Plaintiff's request for review, rendering the ALJ's decision the final decision of the Commissioner. ([8] at 23-25).[3]

Plaintiff filed his Complaint on December 9, 2013, requesting an order from this Court reversing the Commissioner's final decision and directing the Commissioner to award benefits to the Plaintiff. Complaint [1] at 2. The Commissioner answered the Complaint, denying that Plaintiff is entitled to any relief. Answer [7]. The parties having briefed the issues in this matter pursuant to the Court's Scheduling Order [3], the matter is now ripe for decision.


Plaintiff was forty-five years old at the time of the ALJ's decision on February 10, 2011. ([8] at 28, 139.) Plaintiff has a high school education and work experience as a butcher, electrician's helper, electrician and jailer. ([8] at 173; 200-07.) In his disability report, Plaintiff alleged that he has been unable to work since February 4, 2009, due to anxiety, depression, obsessive-compulsive disorder, social phobia, sleep apnea, cardiovascular disease, ulcers, acid reflux, hypertension, blurred vision, impaired hearing, dislocated disc, inflamed prostate, allergies, suicidal tendencies, and "hearing voices." ([8] at 172.)

The administrative record in this case contains voluminous medical documents from the Veteran's Affairs (VA) hospital in Jackson. Many of these documents reference Plaintiff's previous conditions and treatments, although those earlier records are not included. For instance, although there is no record, Plaintiff has reported that he had spinal surgery in a civilian hospital in 2001 or 2002, with a good result. He claims that the operation was microdiskectomy in the lumbar area. ([8] at 311). Plaintiff also claims that he sustained a skull fracture in 2004, although there is no record of treatment. Plaintiff claims that he also suffers from ulcers, but, likewise, his recent medical records do not reflect any treatment for ulcers.

VA Records from 2008 reflect that Plaintiff has been diagnosed with sleep apnea and uses a c-pap to sleep. ([8]-832; 861). However, Plaintiff had a somnoplasty performed in March 2009 and bilateral turbinate reduction performed in April 2009, and both procedures seemed to improve his sleep apnea. ([8] at 929; 944).

Beginning in February 17, 2009, Plaintiff began monthly psychological and psychiatric treatment at the VA Mental Health Out-Patient Clinic in Jackson. ([8] at 960; see generally B6F & B7F). At the clinic, Plaintiff has been treated for obsessive-compulsive disorder, anxiety and panic disorder.[4] Multiple physicians noted that Plaintiff reported obsessive-compulsive behavior, such as using only one trash can in the house, vacuuming after anyone walks into his home, and turning on the kitchen light three times. ([8] at 850; 928). The physician notes show that Plaintiff's symptoms were eased by going to church and ([8] at 778) and playing with his niece and nephew ([8] at 783; 791).

On January 25, 2010, Dr. Brandin Ross examined Plaintiff in connection to complaints about rapid heart beat. Dr. Ross's notes from that appointment reflect that in 1987, Plaintiff had been diagnosed with sinus tachycardia due to using A frin nasal spray and was advised to discontinue use.[5] Dr. Ross noted that Plaintiff used several medications to control his blood pressure, heart rate and hypertension. Dr. Ross conducted an echocardiogram and noted that it failed to reveal cardiomegaly or ventricular hypertrophy, and the Plaintiff denied any chest pain. Plaintiff's pulse was 53 beats per minute. Dr. Ross concluded that Plaintiff's hypertension was well-controlled and that his tachycardia was asymptomatic. ([8] at 1029-1031).

Dr. Todd Coulter performed a consultative examination of Plaintiff on May 1, 2010. The report reflects that Plaintiff complained of a dislocated lumbar, a history of degenerative disc disease and lower back pain. Dr. Coulter noted that Plaintiff used a single prong cane, but that the cane was not prescribed. Under the diagnosis section of the report, Dr. Coulter listed "degenerative joint disease in the lumbosacral spine." Under the functional assessment section, Dr. Coulter opined that Plaintiff had no conditions that would impose limitations. Dr. Coulter found that Plaintiff was limited to climbing, balancing, stooping, kneeling, crouching and crawling only occasionally, but that Plaintiff had no manipulative activities or environmental limitations. He found that Plaintiff could stand or walk six hours in an eight hour day, and carry fifty pounds occasionally and twenty pounds frequently. However, in a contradictory finding, Dr. Coulter opined that Plaintiff needed a cane for balance in all types of terrain. ([8] at 255-59).

At some point in May 2010, Plaintiff was diagnosed with Type II diabetes mellitus and hypertriglyceridemia.[6] ([8] at 682). However, on August 25, 2010, Plaintiff was discharged from the diabetes clinic, as his diabetes was well-controlled. ([8] at 605).

On May 20, 2010, Plaintiff was examined by state agency medical consultant Dr. Martha D'Ilio, who completed a Comprehensive Medical Status Examination. At the interview, Plaintiff reported that he could bathe and dress himself without assistance, slept six hours a night, and prepared his own meals. Plaintiff reported that he cared for his dogs and goes to the VA, church and the grocery store every week. He reported that due to his obsessive compulsive disorder, he frequently cleans his house.

Dr. D'Ilio noted that Plaintiff was appropriately dressed and groomed, that he drove himself to the interview, and that he made adequate eye contact throughout the interview. His speech was clear, logical and goal oriented. She noted that Plaintiff was taking a substantial number of medications. There was no evidence of a formal thought disorder, psychotic features, or anxiety. Plaintiff did report some symptoms of depression, claimed he thought of suicide innumerable times, and asserted that he has a repeating hallucination in which he sees a hand coming through the door. However, Dr. D'Ilio found that Plaintiff's thought processes were coherent and content appropriate. Dr. D'Ilio indicated that Plaintiff's mood disorder might stem from the extensive medications he was taking and due to his chronic pain. Dr. D'Ilio concluded that Plaintiff would have moderate difficulty performing routine, repetitive tasks, interacting with coworkers, or receiving supervision due to his current mental state. ([8] at 262-67).

On May 21, three weeks after the examination with Dr. Coulter in which he brought an nonprescribed cane, Plaintiff went to the VA hospital and requested a prescription for a cane. He was given one. ([8] at 408).

On June 14, 2010, Plaintiff was examined by state agency medical consultant Dr. James Griffin, who completed a Physical Residual Functional Capacity Assessment. Dr. Griffin assigned Plaintiff a primary diagnosis of mild degenerative disc disease, and a secondary diagnosis of obesity. Dr. Griffin opined that Plaintiff could frequently lift twenty-five pounds and occasionally lift and/or carry fifty pounds. Dr. Griffin also opined that Plaintiff could stand, walk and sit for a total of about six hours in an eight-hour workday. Dr. Griffin noted that Plaintiff had no manipulative, visual, communicative or environmental limitations. ([8] at 268-75). However, Dr. Griffin found that Plaintiff should be limited to only occasional kneeling or crouching due to his alleged pain. Dr. Griffin noted that Dr. Coulter had previously found that Plaintiff needed a cane for balance and pain purposes, but indicated that this finding was inconsistent with Dr. Coulter's opinion that Plaintiff could carry 50 pounds and occasionally and twenty pound frequently. ([8] at 268-75).

Between May 27, 2010 and June 17, 2010, Plaintiff received treatment three times at the VA hospital, twice as a walk-in and once for a medication management appointment, in which he encountered Dr. James Clayton Brister.[7] At the first visit on May 27, Dr. Brister noted that Plaintiff was seen as a walk-in, and that Plaintiff stated he was worried that his diabetes may be linked to Risperidone, a medication that he was taking. Dr. Brister recommended discontinuing the medication to observe if there was any symptom change. ([8] at 659-60). The June 14, 2010 encounter was another walk-in visit. The record is signed by Dr. Brister, and reflects that Plaintiff was "doing well" and denied any psychotic symptoms, but gave a long history of his obsessive-compulsive symptoms and complained that a certain medicine was making him hungry. Dr. Brister noted that Plaintiff was alert, very neat, goal oriented and suffered from no hallucinations or delusions. He recommended a different medication in response to Plaintiff's complaints. ([8] at 644-45). The June 17, 2010 visit was for medication management. The record reflects that Dr. Brister co-signed the record of Plaintiff's visit with Dr. Maria A. Scarbrough, and thus it is unclear as to who ...

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