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Stanifer v. Colvin

United States District Court, N.D. Indiana, Hammond Division, Lafayette

February 3, 2015

CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.


JON E. DEGUILIO, District Judge.

On July 31, 2013, Plaintiff Robert E. Stanifer, Jr., filed his Complaint in this Court seeking review of the final decision of the Defendant Commissioner of Social Security (Commissioner). [DE 1.] The Commissioner filed an Answer on December 17, 2013. [DE 13.] On March 3, 2014, Stanifer filed his opening brief [DE 20], to which the Commissioner responded on May 30, 2014. [DE 26.] Stanifer filed a reply on June 30, 2014. [DE 33.] Accordingly, the matter is now ripe for decision. Jurisdiction is predicated on 42 U.S.C. ยง 405(g).

I. Procedural History

Stanifer filed an application for disability insurance benefits on December 23, 2010. (Tr. 121.) His application was denied initially on March 4, 2011, and again upon reconsideration on May 25, 2011 (Tr. 74, 77.) On June 28, 2012, a hearing was held before Administrative Law Judge Laurel Greene. (Tr. 39-67.) On August 27, 2012, ALJ Greene issued a decision denying the claim. (Tr. 19-33.) The Appeals Council denied a request for review on May 29, 2013, making the ALJ's decision the final decision of the Commissioner. (Tr. 1-3.).

II. Facts

Stanifer was born on December 1, 1952 and was 59 years old on the date the ALJ rendered her decision. (Tr. 33, 121.) Stanifer reported a lengthy work history as a maintenance facilitator, maintenance manager, and maintenance mechanic. (Tr. 163). By May 2009, he earned a two year associate degree in applied sciences, but he relied on his wife to help him because it was very difficult for him to complete the program. (Tr. 42, 46.) Stanifer alleges a disability onset date of July 1, 2009, and the ALJ found that Stanifer's severe impairments included residuals from a stroke, obstructive sleep apnea, and attention deficit hyperactivity disorder (ADHD). (Tr. 21.)

A. Medical Background

As the ALJ pointed out in her opinion and as Stanifer's medical history demonstrates, Stanifer suffers from a host of non-listing level ailments, including: history of a stroke, polyneuropathy, asthma, myalgia, arthragia, high blood pressure, tinnitus, gout, diverticulitis, hyperlipidemia, burning and swelling of the feet, knee pain, arthritis of the fingers, right shoulder pain, chest pain, sleep apnea, irritable bowel syndrome, headaches, vertigo, fatigue, ADHD, loss of concentration, and lack of focus (Tr. 208-399, 432-515, 518-627.) Stanifer also uses a cane as needed when his legs and knees hurt. (Tr. 161, 177.) Most important to this appeal is Stanifer's claim that despite the ALJ's discussion of his many problems, the ALJ did not adequately account for Stanifer's physical limitations with respect to his ability to walk/stand and Stanifer's mental limitations with respect to his ability to sustain attention.

Records show that as early as 1996 Stanifer sought work accommodations for his diagnosis of ADHD. (Tr. 208.) At the time, a clinical social worker indicated that it would be significantly helpful if Stanifer was in charge of his own duties and responsibilities, had an organized and clear communication system in place, and was provided times of privacy to complete tasks. His medical history also indicates that Stanifer had a diagnosis of polyneuropathy in October 2006 and a history of myalgia and arthralgia from February 2006. He also suffered from right knee pain as of August 2006. (Tr. 210.)

Medical records from 2007 indicate that Stanifer was being followed for a diagnosis of neuropathy by primary care physician, Dr. Mark Duvall. (Tr. 287, 288) At the time, Stanifer complained of burning in his hands and feet. While the etiology of the problem was undetermined, Stanifer had already been evaluated by two different neurologists. Stanifer continued to followup with Dr. Duvall for his pain issues. For instance, on April 15, 2008, he reported to Dr. Duvall that his feet were swelling and he had headaches and blood shot eyes. Myalgias were noted. Stanifer also expressed concern about memory problems. (Tr. 298)

Stanifer underwent a physical consultative examination by Dr. Luella Bangura on February 7, 2011. (Tr. 401-404.) On examination, she noted that Stanifer had decreased sensation and burning in his feet. Her diagnostic impressions were: ADHD, peripheral neuropathy, asthma, hypertension, bilateral tinnitus, chronic bilateral knee pain, gout, diverticulitis and sleep apnea. Dr. Bangura stated that Stanifer needed a psychiatric evaluation, an EMG for his lower extremities, an x-ray of his bilateral knees, and a pulmonary function test. She also recommended a hearing study, a uric acid study, and a repeat sleep study. Dr. Bangura offered the opinion that Stanifer would have difficulty standing and walking for long periods of time, but would not have difficulty sitting, carrying, lifting, speaking, handling objects, or seeing. She noted that he had a mental impairment that would affect his ability to sustain memory, concentration, and social interactions.

At the request of the Indiana Disability Determination Bureau, Stanifer underwent a psychological evaluation on February 12, 2011 by Licensed Psychologist Caryn Brown. (Tr. 405-408). During the examination, Dr. Brown noted that Stanifer had demonstrated some impairment in his ability to sustain concentration and attention. He had trouble staying on task and keeping information in working memory. Dr. Brown felt that Stanifer was cooperative, albeit irritable, and opined that the examination results were valid and reliable. His opinion was that Stanifer suffered a depressive disorder (NOS), a personality disorder with passive aggressive personality traits (NOS), and assigned a Global Assessment of Functioning Score (GAF) of 50.[1]

On February 15, 2011, state agent, Dr. Joelle Larson, Ph.D, filed a psychiatric review technique form indicating that Stanifer's mental impairments were not "severe." (Tr. 410-423). Dr. Larson did note that Stanifer suffered from depression, personality disorder with passive aggressive traits, and a history of ADHD. She opined that Stanifer was mildly limited in his ability to engage in activities of daily living, maintain social functioning, and maintain concentration, persistence, or pace. Ultimately, she believed that Stanifer was more limited by his physical impairments, rather than his psychological problems. Reviewing state agent William Shipley, Ph.D, affirmed Dr. Larson's opinion on May 23, 2011. (Tr. 516.)

On February 28, 2011, Dr. Richard Wenzler, completed a physical RFC[2] assessment, opining that Stanifer could lift 50 pounds occasionally and 25 pounds frequently, and stand/walk 6 hours and also sit about 6 hours in an 8 hour workday. (Tr. 424-431.) Dr. Wenzler did not believe Stanifer suffered any restrictions with his ability to push/pull hand or foot controls. Dr. Wenzler indicated that Stanifer had no postural limitations (except he could not climb ladders, ropes, or scaffolds), and no upper extremity manipulative limitations, visual limitations, communicative limitations, or environmental limitations (except that he could not work around unprotected heights). Dr. Wenzler noted that the claimant was credible with respect to his history of neuropathy, but not credible with respect to the alleged severity or the date of onset. Reviewing state agent J. Sands, M.D., affirmed Dr. Wenzler's opinion on May 25, 2011.

On July 20, 2011, Stanifer was seen in the emergency room at IU Arnett Hospital for headaches. He felt like the room was spinning. He reported being fatigued and that he had worsening fatigue for the past several years. (Tr. 518, 523.) He reported having trouble focusing and remembering things. A CT scan of the head was normal. Stanifer's blood pressure was quite high upon admission. The vertigo improved some with a dose of meclizine. He was admitted to the hospital. (Tr. 522, 530.) The next day an MRI was conducted and findings included a band of encephalomalacia (softening or loss of brain tissue following brain injury) involving the posterior and medial left temporal lobe extending into the left occipital lobe. It was noted that this may reflect an old infarct. (Tr. 531.) Further, the MRI showed mild cerebral atrophy with mild periventricular small vessel disease.

On September 9, 2011, Stanifer was again seen in the emergency room for stroke symptoms. (Tr. 538-539.) He had a watering eye, double vision, and a right sided headache. He was diagnosed with acute nonspecific cephalagia (headache) and diplopia (double vision). He was discharged as stable and the report indicated that he already had an appointment with a neurologist in the coming week. (Tr. 542.)

Stanifer saw neurologist, Dr. Sara Huffer, on September 13, 2011. (Tr. 595.) She noted a number of neurologic problems including a transient episode of amnesia in 2004, an episode of left sided numbness and tingling, several weeks of headache and vertigo in July 2011, and the recent episode of right eye tearing and vertical diplopia. Her notes indicate that Stanifer was given propranolol for headaches and it was having an impact on his exercise tolerance. Stanifer was also complaining of worsening concentration. (Tr. 595) He was still having headaches and what Dr. Huffer described as neurologic dysfunction that may be TIA (transient ischemic attacks) or other. She noted the brain lesion discovered in the July MRI. She also diagnosed axonal polyneuropathy. He was told to continue with the propranolol to keep the headaches and blood pressure under control.

On September 14, 2011, Stanifer underwent a diagnostic sleep study at the Indiana University-Arnett Sleep Center. (Tr. 575-576, 600.) The testing showed severe central sleep apnea with unsuccessful titration of the CPAP/BiPAP due to persistent central events. Dr. Wu reviewed the findings and noted that Stanifer had in the past refused the CPAP. Stanifer was told not to drive until the sleep apnea was controlled. On October 17, 2011, Stanifer underwent another sleep study due to his hypersomnia to titrate a new BiPAP machine. (Tr. 565-567.) In late 2011, it was also noted that Stanifer's fatigue might be related to his testosterone levels. (546.)

B. Hearing Testimony

Stanifer, his wife, Lee Stanifer, and the vocational expert, Thomas Gusloff (VE), all testified at the hearing on June 28, 2012, and Stanifer was represented by counsel. (Tr. 39-67.) Stanifer indicated that he previously worked for many years as a maintenance mechanic and maintenance manager, and in 2009 he had received an associate degree after much difficulty and reliance on his wife. Stanifer indicated that until 2009, he had learned ways to deal with his ADHD, but since then he has been unable to remain on task, stay organized, and deal with other people. Physically, he has had increased difficulty with walking, and has caught himself almost falling many times. Stanifer explained how his feet and knees swell up and hurt, causing him to have some good days and some bad days. Stanifer testified that when his feet and knees aren't hurting, which is about half of the time, he is able to stand for about 45 minutes at a time. Otherwise, he can stand/walk for only up to 10 minutes at a time, for a total of 2 to 3 hours in an 8 hour day, and he must alternate positions between sitting and standing. Stanifer uses ice, medicine, and lotion to help with his foot and knee pain. Stanifer further explained how his hands cramp up with use, he frequently has headaches, his memory ...

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