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Harris v. Berryhill

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

August 7, 2017

JOHN WILLIS HARRIS PLAINTIFF
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY DEFENDANT

          ORDER

          F. Keith Ball, United States Magistrate Judge

         I. Introduction

         John Willis Harris filed for a period of disability, disability insurance benefits, and supplemental security income on December 11, 2013, alleging an onset date of May 16, 2011. His application was denied both initially and upon reconsideration. He requested and was granted a hearing before an ALJ, which was held on March 17, 2016. On April 19, 2016, the ALJ issued a decision finding that Harris was not disabled. The appeals council denied review. Harris now brings this appeal pursuant to § 205(g) of the Social Security Act, 42 U.S.C. § 405(g). Having considered the memoranda of the parties and the administrative record, the Court concludes that the decision of the Commissioner should be affirmed.

         II. Facts and Evidence before the ALJ

         Harris was born on July 25, 1961, and was 54 years of age at the time of the decision of the ALJ. He has an eleventh grade education and past relevant work experience as a truck driver and as a general clerk. In his applications, he alleged disability due to bulging discs, shoulder surgery, neck surgery, hypertension, cervical injury, gout, arthritis, acid reflux, borderline diabetes, high cholesterol, right leg pain, and limited use of his right arm and hand.

         The medical record indicates that Plaintiff underwent cervical surgery at the age of 25. R. 368, [8] at 372. In May of 2011, he sustained an injury at work; thereafter he experienced neck and right shoulder pain. R. 272, [8] at 276. EMG and nerve conduction studies revealed right C8 radiculopathy. R. 273, [8] at 277. An MRI of the right shoulder indicated degenerative disease in the AC joint. R. 304, [8] at 308. In January of 2012, Dr. Larry Field performed right rotator cuff surgery. R. 224, [8] at 228. By May of 2012, following post-operative physical therapy, his shoulder was doing well; however, he continued to complain of neck and periscapular symptoms, as well as elbow pain. R. 216, [8] at 220. An MRI of the right elbow in June of 2012 was normal, and Dr. Field released him with a six percent impairment rating for his shoulder. R. 288, 215, [8] at 292, 219.

         On October 22, 2012, Dr. David Gandy, an orthopedic surgeon, performed an independent medical examination of Plaintiff's neck and right shoulder. Plaintiff had full rotation in his neck to the left and right, with pain on extremes of motion. R. 371, [8] at 375. Sensation in his upper extremities was normal, as was strength. Id. Plaintiff had tenderness to palpation of the medial and lateral epicondyles bilaterally, with full range of motion and full strength. Id. He had no tenderness and had normal range of motion in his right shoulder. Id. Dr. Gandy's assessment was cervical spondylosis without myelopathy, spinal stenosis in the cervical region, sprain and strain of the supraspinatus muscle, partial tear of the rotator cuff, epicondylitis of the elbow, and benign essential hypertension. Id.

         Plaintiff sustained a fall in December 2013. A few weeks later he saw Dr. David Smith for his annual physical and complained of right hip pain radiating to his foot, right shoulder pain, and right arm weakness. R. 264, [8] at 268. Dr. Smith's diagnosis was lumbosacral radiculopathy and rotator cuff and shoulder syndrome. R. 266, [8] at 270.

         The records do not reveal any further evaluation or treatment until December of 2014, when he underwent a lumbar MRI. The MRI indicated degeneration and a disc bulge at ¶ 3-4 causing moderate to severe central spinal stenosis, and mild listhesis and disc bulge at ¶ 4-5. R. 295, [8] at 299. In January of 2015, Plaintiff began seeing Dr. Jennifer Gholson for his primary care. At his initial evaluation, he presented using a cane for ambulation and complaining of pain in the right hip, right knee, and right foot, as well as depression. R. 319, [8] at 323. He saw Dr. James Woodall in February of 2015 for complaints of neck pain, right shoulder pain, gait imbalance, and loss of fine motor skills. R. 316-17, [8] at 320-21. Cervical x-ray revealed dynamic instability at ¶ 4-5. R. 317, [8] at 321. Dr. Woodall's assessment was cervical spondylosis with myelopathy, lumbar disc degeneration, herniated cervical disc, and cervical disc degeneration. R. 318, [8] at 322. A cervical MRI showed central spinal stenosis.at C4-5 with mild cord flattening, as well as mild foraminal stenosis at ¶ 1-T2. R. 290, [8] at 294. On February 27, 2015, Dr. Woodall performed a cervical discectomy with placement of a PEEK interbody device and cervical plate and bone grafting at ¶ 4-5. R. 296, [8] at 300. At a follow-up visit on March 12, 2015, Plaintiff was doing well. R. 313, [8] at 317. Plaintiff reported cramping of his hands at an appointment in June of 2015. R. 327, [8] at 331. There is no further mention of upper extremity symptoms in the medical record. Examination of the cervical spine by Dr. Woodall in August of 2015 revealed good range of motion with some tenderness and palpable spasm. R. 310, [8] at 314. Plaintiff's shoulder was doing well with some muscular pain. Id. Dr. Woodall ordered a program of physical therapy. Id.

         On August 6, 2015, Plaintiff underwent a right total hip replacement. R. 306, [8] at 310. At a follow-up appointment the following October, his surgeon stated that Plaintiff was doing very well overall and that Plaintiff was happy with the right hip. R. 340, [8] at 344.

         Plaintiff's medications at the time the hearing were as follows: zolpidem (Ambien), cephalexin (an antibiotic), tizanidine (a muscle relaxer), hydralazine, duloxetine (Cymbalta), omeprazole, hydrocodone/acetaminophen, meloxicam, lisinopril, and amlodipine besylate. R. 210, [8] at 214.

         At the hearing, Harris testified as follows: He is unable to work because of neck pain, right shoulder pain, pain in the legs and feet, hip pain, and lower back pain. R. 34, [8] at 38. His worst problems are the pain in his shoulder, neck, hip, and right knee. Id. He also suffers from hypertension and depression. R. 34, 41; [8] at 38, 45. Plaintiff estimated that he is in pain about 80 percent of the time. R. 42, [8] at 46. He takes hydrocodone three times a day for his pain. R. 41, [8] at 45. He also uses heating pads to relieve his pain and soaks in a hot tub at least twice a day. R. 43, [8] at 47. In the past, Plaintiff enjoyed hunting and fishing and drove his church's bus, but he can longer participate in these activities. R. 36, 38; [8] at 40, 42. Instead, he stays home most of the time, although he is able to drive short distances. R. 35, 36, 38, 44; [8] at 39, 40, 42, 46. Plaintiff's household tasks are limited to occasional cooking and laundry and a little gardening in pots. R. 35-36, [8] at 39-40. He is unable to perform chores such as sweeping, vacuuming, or mopping because of his shoulder pain and difficulties standing. R. 36, [8] at 40. He has difficulty walking without a cane and has lost his balance several times. R. 39-40, [8] at 43-44. Plaintiff stated that he could lift 8-10 pounds, stand 10-15 minutes, and climb six stairs. R. 37, [8] at 41. He can kneel with pain but would need assistance to get up. R. 45, [8] at 49. He cannot stoop down and pick an object off the floor. Id.

         Also testifying at the hearing was a vocational expert (V.E.). The V.E classified Harris's past relevant work as a tractor trailer truck driver and a general clerk. R. 47-48; [8] at 51-52. According to the V.E., the truck driver position represents medium, semiskilled work, while the general clerk job is light and semi-skilled. Id. The ALJ posed two hypotheticals to the V.E. In the first, he described the following: An individual in the same age range and having the same education, work history, and transferrable skills as Plaintiff. He can lift 20 pounds occasionally and 10 pounds frequently and can walk or stand for four hours in an eight-hour day, 20 minutes at a time. He can occasionally stoop and climb but can never crouch, kneel, or crawl. Pushing/pulling is limited to less than ten pounds with the left upper and right lower extremities, and he cannot reach overhead with the left upper extremities. The V.E. testified that such a person could perform Plaintiff's past job of general clerk. R. 49, [8] at 53. In the second hypothetical, the ALJ added the limitations that the individual can lift 10 pounds occasionally, less than 10 pounds frequently, and can walk or stand only two hours in an eight-hour day, for only 15 minutes at a time. In response, the V.E. opined that the individual could perform the sedentary jobs of booth cashier at a self-service gas station and telephone solicitor. Id.

         III. The ...


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