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Richard Garfield Jones v. Commissioner of Social Security

February 27, 2012

RICHARD GARFIELD JONES , PLAINTIFF,
v.
COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Honorable Freda L. Wolfson United States District Judge

OPINION

Richard Garfield Jones (ʺPlaintiffʺ) appeals from the final decision of the Commissioner of Social Security (ʺCommissionerʺ), denying Plaintiff Dis ability Insurance Benefits and Supplemental Security Insurance Benefits under the Social Security Act (ʺActʺ). The Court has jurisdiction to hear this matter pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). On appeal, Plaintiff contends that the substantial evidence in the Administrative Record (ʺARʺ) establishes eligibility for and entitlement to the benefits for which Plaintiff applied. Specifically, Plaintiff argues, inter alia, that the Administrative Law Judge ("ALJ") failed to combine Plaintiff's several medical impairments in conducting his Step Three analysis. After reviewing the administrative record, this Court finds that remand is required for the ALJ to more fully explain his Step Three determination.

I. OVERVIEW

A. Procedural History

Plaintiff applied for disability insurance benefits on August 23, 2007, alleging that the following impairments rendered him disabled as of February 2nd of that year: residuals of a stroke, psychiatric and psychological conditions, visual conditions, sleep apnea and hypertension. The application was denied initially on March 4, 2008, and again on reconsideration on May 2, 2008. Therafter, Plaintiff requested a hearing before an ALJ in a timely manner and the hearing took place before ALJ Richard West on September 22, 2009. The ALJ denied Plaintiffʹs application on October 23, 2009. Plaintiff next filed a Request for Review with the Appeals Council, and the council affirmed the ALJ's ruling on January 8, 2011. Plaintiff subsequently filed the instant matter with the District Court, seeking further review of the ALJ's decision.

B. Background and Medical History

1. Medical Evidence

On February 1, 2007, Plaintiff was hospitalized at Bayshore Community Hospital for a stroke, also referred to as an acute cerebrovascular accident ("CVA"). Id. at 145‐82. While there, he was treated by Padmarekha Rao, M.D., a psychiatrist and neurologist, and Antonios Tsompanidis, D.O. for a right facial droop and poor handgrip on his right side that was consistent with his CVA. Not long after he had first been admitted, Dr. Tsompanidis noted in a February 11, 2007 discharge summary that Plaintiff "improved tremendously since [admission]." Id. at 146. Plaintiff was then transferred to the John F. Kennedy Medical Center for rehabilitation. He was discharged from that facility on February 15, 2007 as having "achieved goals," id. at 146, 183‐98, and was directed to continue with outpatient care. Id. at 187.

Several months later, on April 7, 2007 and April 26, 2007, Plaintiff presented to the emergency room at Bayshore Community Hospital with complaints of vertigo. He was successfully treated with medication and adjustment of his Coumadin levels. Id. at 217‐31. Later that same year, on October 16, 2007, Plaintiff was diagnosed with hypertension by Fazal R. Panezai M.D., a cardiologist. Id. at 273. At that time, Dr. Panezai noted that Plaintiff had "no obvious neurological impairment." Id. at 273. However, a November 2007 MRI and MRA ("magnetic resonance angiography") of the brain showed residual areas of infarction in the left posterior inferior cerebellar artery ("PICA"), right superior cerebellar artery, left midbrain, and left thalamic regions. Id. at 199. Those tests further showed flow void in the basilar artery and that the carotid artery and the great vessels were within normal limits. Id. Moreover, there was no evidence of luminal irregularity of the vertebral artery. Id.

From March 2007 to February 2008, Plaintiff also saw Ophthalmic Physicians of Monmouth. Treatment notes from that practice indicated that Plaintiff had controlled hypertension, 20/20 vision bilaterally, and double vision when looking left or down. Id.

at 274‐84.

On March 14, 2008, Dr. Rao, Plaintiff's treating physician, noted that Plaintiff continued to experience mild double vision ("diplopia") to left lateral gaze, intermittent gait instability, and symptoms of cognitive dysfunction, with poor short‐term recall. Id. Dr. Rao completed a neurological examination that revealed mild diplopia in the left lateral gaze and mild weakness of the right facial muscles with a slight droop in the right angle of the mouth. Id. Based on the neurological examination, and the aforesaid MRI and MRA results, Dr. Rao concluded that Plaintiff had multiple ischemic infarcts (strokes) in the posterior circulation due to dissection of the vertebral artery and that he had residual neurological symptoms. Id. Dr. Rao advised Plaintiff to continue taking aspirin as an antiplatlet agent and concluded that Plaintiff did not need any further neurological care. Id.

Around the same time that Plaintiff was being treated by Dr. Rao, on March 4, 2008, a non‐examining state agency doctor reviewed the examinations from Drs. Rao, Panezai, and the Ophthalmic Physicians of Monmouth. According to the state doctor, the treating doctors' examinations revealed that Plaintiff's abilities were within normal limits, which meant that Plaintiff was not severely impaired. Id. at 287. On April 16, 2008, another state doctor confirmed this assessment of Plaintiff's impairments. Id. at 288.

Thereafter, Plaintiff's counsel requested a consultative evaluation of Plaintiff by Richard Schuster, Ph.D., on November 24, 2008. See id. at 291‐302. According to Dr. Schuster, Plaintiff lost focus or "just stared blankly ahead" at various times during the evaluation. Id. at 296‐97. "At other times, when engaged in assignments that required verbal memory he displayed severe difficulties, lamenting his poor performance." Id. Dr. Schuster concluded:

It can be conservatively estimated even from [Plaintiff's] current functioning that he is an individual of at least average inherent intelligence. Basic cognitive tests still are solidly within the average range. The one conspicuous and abnormal performance is noted on tests of verbal memory, both short‐term and delayed. Nevertheless immediate attending in either visual or auditory modalities is also within the average range. Visual memory is also within the average range. Processing speed is inconsistent; motor skills are inconsistent, with below expectations; tests emphasizing conceptual shifting and response inhibitions are also only marginally within expected parameters.

Id. at 299. Dr. Schuster then suggested that further examination was required:

These latter realms may represent areas of neuropsychological deficiency but require additional neuropsychological investigation to confirm. Clearly, his history, presentation and test results highlight significant deficits with verbal memory. There are also concerns in regard to dizziness affecting his ability to work in a physically‐oriented job. The extent of his dizziness and vertigo problems should also be investigated in greater detail. Possibly, vestibular training may be helpful in this regard. Cognitive retraining may also be beneficial.

Id.

Approximately a year following Dr. Schuster's examination, on October 8, 2009, Dr. Rao noted that Plaintiff had reported continued symptoms of diplopia to left lateral gaze.

Id. at 303. Dr. Rao further noted that Plaintiff continued to complain of intermittent episodes of dizziness, and that certain movements of the head and external noises seemed to aggravate his symptoms. Id. at 303. Moreover, Plaintiff complained of tremors in his left hand and explained that he was unable to concentrate on the computer for extended periods of time. Id. Dr. Rao concluded that Plaintiff's mental status was normal, that there was no evidence of disorientation or impaired concentration, that his speech was fluent with intact comprehension and, notably, that his short‐term recall, remote memory, and fund of knowledge were intact. Id. However, Plaintiff's diplopia on left lateral gaze with weakness of abduction of the left persisted. Id. Other neurological tests were normal with the exception of tandem walking and Romberg testing. Id. at 303‐04. Based on these findings, Dr. Rao concluded that Plaintiff had "continued neurological dysfunction with poor coordination, diplopia to left lateral gaze, and gait instability. He is disabled permanently on account of his residual neurological dysfunction." Id. at 304.

2. Testimonial Evidence

Plaintiff, a former HVAC refrigeration technician and a carpenter, testified at the hearing that he was born in 1968 and achieved a tenth grade education. Id. at 30‐31. According to Plaintiff, he has been disabled since February 2, 2007, after having suffered from the aforementioned stroke. Following the stroke, Plaintiff began to experience headaches and difficulty rotating his head. Id. at 32‐39. In addition, Plaintiff claims that he would become light‐headed if he suddenly dealt with aggravation or stress or stared at a computer screen, certain colors, or lights, for over 15 minutes. Id. at 32‐39. Plaintiff further claims that he becomes easily agitated and, notably, that he experiences short‐term memory loss. Id. at ...


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