United States District Court, S.D. Mississippi, Southern Division
DAVID A. WINSLOW PLAINTIFF
CAROLYN W. COLVIN, COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION DEFENDANT
KEITH BALL UNITED STATES MAGISTRATE JUDGE.
A. Winslow filed for supplemental security income on April
15, 2014. After his application was denied both initially and
upon reconsideration, he requested and was granted a hearing
before an ALJ. The hearing was held on June 23, 2015, and on
August 5, 2015, the ALJ issued a decision finding that
Winslow is not disabled. The appeals council denied review on
September 25, 2015. Winslow now brings this appeal pursuant
to § 205(g) of the Social Security Act, 42 U.S.C. §
405(g). Presently before the Court is his motion for summary
judgment . Having considered the memoranda of the parties
and the administrative record, the Court concludes that the
motion should granted, the decision of the Commissioner
reversed, and this matter remanded to the Commissioner.
Facts and Evidence before the Commissioner
was born on August 21, 1971, and was 43 years of age at the
time of the decision of the ALJ. He completed the eleventh
grade in special education and has past relevant work
experience as a sheet metal worker. Winslow alleges
disability due to obesity, diabetes, atrial fibrillation,
chronic kidney disease, hypertension, low back pain, knee
pain, leg pain, sleep apnea, and depression.
record indicates that Winslow suffers from several chronic
conditions. He has a history of atrial fibrillation and
hypertension, for which he takes Diltiazem, Digoxin, Xarelto,
Lopressor, and Lisinopril. He also is diabetic. Winslow
suffers from sleep apnea and uses a CPAP machine. He is
obese; at the time of his application, his weight was
approximately 430 pounds, see R. 306,  at 316,
and he weighed 374 pounds at the time of the hearing, R. 34,
 at 39. He has a history of ulcers and open wounds on his
lower extremities: In February of 2013, he was hospitalized
and treated for lower extremity cellulitis, and records in
April and May of 2014, September of 2014, October of 2014,
and February of 2015 indicate the presence of wounds. R.
373-74,  at 384-85; R. 393,  at 404; R. 407,  at
418; R. 418,  at 430. Winslow has also experienced
intermittent gastrointestinal problems. Following complaints
of rectal bleeding and abdominal pain, he underwent a
colonoscopy and EGD with biopsy in May of 2014. R. 300-302,
 at 310-12. Results showed minimal gastritis. Id.
In May of 2014 he underwent laparoscopic gall bladder surgery
without complications. R. 314,  at 324. A note from a
September 12, 2014 office visit indicates that he was
continuing to experience abdominal pain and bleeding. R. 399,
 at 410.
has a history of kidney disease and problems with fluid
retention. On September 12, 2014, his treating physician, Dr.
Rowe Crowder, noted that Winslow was in acute renal failure
and advised him to drink more water. R. 399-400,  at
410-11. Four days later, Winslow presented to the emergency
room complaining of shortness of breath and edema. R. 451,
 at 463. He was treated with Lasix IV. Id.
Impression included bilateral lower extremity edema, acute
renal failure secondary to dehydration, and hyponatremia.
Id. In a progress note dated October 7, 2014, Dr.
Crowder noted that Winslow was continuing to experience
problems with decreased urine output and that he had a mass
on his left kidney. R. 407,  at 418. Winslow went to the
emergency room again in January of 2015, where his diagnoses
included chronic kidney disease, decreased urination,
hematuria, left flank pain, uremia, and weakness. R. 434, 
at 446. In February of 2015, he underwent surgery for renal
cell carcinoma of the left kidney. R. 487,  at 499.
Discharge diagnoses were acute renal failure; renal cell
carcinoma; chronic kidney disease, stage three (moderate);
hypertension; and a leg ulcer. R. 418,  at 430. Winslow
was evaluated by a nephrologist, Dr. Erica Hopkins, in June
of 2015. R. 507-510,  at 519-22. Dr. Hopkins likewise
diagnosed him with chronic kidney disease, stage three
(moderate). R. 509,  at 521.
has complained of and undergone evaluation for pain in
several joints. X-rays performed on June 24, 2014, showed
mild degenerative changes of the lumbar spine and mild
tricompartmental osteoarthritis in the right knee. R. 343-44,
 at 353-54. In July of 2015, he was evaluated by Dr.
Elliot Nipper, an orthopedist, who diagnosed him with
bilateral knee varus degeneration. R. 517,  at 529. Dr.
Nipper noted that the only treatment available was physical
therapy and bracing, as any other intervention was
contraindicated by Winslow's other medical conditions.
September of 2014, Winslow began treatment at Gulf Coast
Mental Health Center for complaints of depression and
feelings of helplessness and hopelessness. Initial assessment
by a therapist was major depressive disorder, severe, single
episode, and a global assessment of functioning of 50. R.
382,  at 393 He was seen monthly thereafter and was
treated with Effexor, Seroquel, and Restoril. The most recent
case notes, from May of 2015, indicate that he was
experiencing mood swings and problems sleeping. R. 499, 
has undergone two consultative examinations. Dr. Michael
Zakaras performed a comprehensive mental evaluation of
Winslow on June 9, 2014. At the exam, Winslow reported that
he experienced sadness, daily crying spells, and problems
sleeping. R. 332,  at 342. His daily activities were
limited to watching television, sometimes walking a short
distance after supper, and trying to attend church once a
week. R. 331-32,  at 341-42. He indicated that he had
suicidal ideations at least once a week and that he had made
one suicide attempt approximately six months earlier. R. 332,
 at 342. Winslow's interpretation of proverbs was
poor; otherwise, his responses to questions in the the mental
status portion of the exam were unremarkable. Id.
Dr. Zakaras opined that the most appropriate diagnosis would
appear to be depressive disorder NOS. R. 333,  at 343.
Syed Sadiq performed a consultative physical examination of
Winslow on June 24, 2014. Dr. Sadiq noted that Winslow was
morbidly obese (418 pounds), was unable to take his shoes
off, experienced shortness of breath on walking a few steps,
and used crutches. R. 336,  at 346. His assessment of
Winslow's residual functional capacity was that Winslow
could carry less than 10 pounds occasionally, that he could
stand and walk less than two hours in an eight-hour work day
with no limitations on sitting, that he could climb, balance,
stoop, kneel, crouch and/or crawl occasionally as tolerated,
and that he had no manipulative restrictions. R. 339,  at
349. Dr. Sadiq also stated that the crutches used by Winslow
were objectively necessary. R. 338,  at 348.
hearing, Winslow testified that his daily activities consist
primarily of sitting in a recliner and watching television.
R. 41,  at 46. He testified that he tries to get up and
walk a little, but he can walk only about five feet without
crutches before his knees give out. R. 40,  at 45. He
stated that he has to make himself get up and go to the
bathroom, because otherwise he can go all day without
urinating. R. 41,  at 46. Winslow stated that his most
serious problem, in terms of his inability to work, is joint
pain. R. 32,  at 37. He explained that previously he had
taken Naproxen for his joint pain but that he can no longer
take it because of his kidney disease. Id.
Winslow's wife testified that Winslow “can't do
anything” and that she has to help him in and out of
the bed and onto and off of a toilet if it does not have
handicap rails. R. 42,  at 47. She stated that he is
unable to do any chores around the house because of his
inability to walk. Id. Ms. Winslow testified that
her husband was depressed most of the time. R. 43,  at 48.
She also corroborated his testimony that he can go all day
without urinating, and she stated that the swelling in his
feet prevents him from being able to wear regular shoes. R.
42-43,  at 47-48.
The Decision of the ALJ
decision, the ALJ worked through the familiar sequential
evaluation process for determining disability. She found that
Winslow has the severe impairments of obesity, low back pain,
diabetes, atrial fibrillation, and degenerative changes of
the foot. R. 13,  at 18. She found that Winslow's
hypertension, history of abdominal pain, sleep apnea on CPAP,
history of gastrointestinal bleed, kidney cancer status-post
nephrectomy, and depression were not severe impairments. R.
13-15,  at 18-20. At step three, the ALJ determined that
Winslow does not have an impairment or combination of
impairments that meets or medically equals an impairment
listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. R.
15-16,  at 20-21. The ALJ found that Winslow has the
residual functional capacity (RFC) to perform the full range
of sedentary work as defined by 20 C.F.R. § 416.967(a).
R. 16-21,  at 21-26. The ALJ considered Winslow's
subjective allegations of limitations but found that they
were not fully credible in light of the lack of objective and
clinical evidence. R. 17-20,  at 22-26. At step four, the