Aikman v. Commissioner of Social Security

CourtDistrict Court, S.D. Ohio
DecidedAugust 3, 2020
Docket2:19-cv-05421
StatusUnknown

This text of Aikman v. Commissioner of Social Security (Aikman v. Commissioner of Social Security) is published on Counsel Stack Legal Research, covering District Court, S.D. Ohio primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Aikman v. Commissioner of Social Security, (S.D. Ohio 2020).

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF OHIO EASTERN DIVISION

JUSTIN M. AIKMAN,

Plaintiff,

v. Civil Action 2:19-cv-5421 Magistrate Judge Jolson

COMMISSIONER OF SOCIAL SECURITY,

Defendant.

OPINION AND ORDER Plaintiff, Justin M. Aikman, filed this action seeking review of a decision of the Commissioner of Social Security (“Commissioner”) denying his applications for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”). The parties in this matter consented to the Undersigned pursuant to 28 U.S.C. § 636(c). (Docs. 4, 6). For the reasons that follow, the Commissioner of Social Security’s nondisability finding is REVERSED and REMANDED to the Commissioner and the ALJ under Sentence Four of § 405(g). I. BACKGROUND A. Prior Proceedings Plaintiff filed his application for DIB on August 18, 2015, and SSI on February 29, 2016, alleging disability beginning on December 3, 2011. (Doc. 7, Tr. 223–32). His applications were denied initially and again on reconsideration. After a video hearing was held on October 2, 2018 (Tr. 33–76), Administrative Law Judge Kevin Plunkett (“ALJ”) issued an unfavorable decision on December 19, 2018. (Tr. 15–26). The Appeals Council denied Plaintiff’s request for review making the ALJ’s decision the final decision for purposes of judicial review. (Tr. 1–6). Plaintiff filed this action on December 12, 2019 (Doc. 1), and the Commissioner filed the administrative record on February 18, 2020 (Doc. 7). This matter is now ripe for consideration. (See Docs. 8, 9, 12). B. Relevant Medical Background The ALJ helpfully summarized the relevant evidence:

[] the record documents the claimant had adverse symptoms of constipation resulting in an anal fissure, which was corrected by surgery (17F/23; 18F/11). Moreover, while treatment records often describe the claimant’s reports of back pain, there are no significant objective medical findings in the record to support more than minimal limitations on the claimant’s ability to perform work activities arising from this impairment. In particular, objective testing and examinations have revealed mild findings (4F/63; 11F/4–5, 7–9; 12F/10). Specifically, cervical spine imaging showed mild to moderate disc space narrowing at C5 to C6, and mild disc space narrowing at C7 to T1 (11F/4). Additionally, imaging of the thoracic spine showed minimal degenerative changes (11F/8). The record documents unremarkable findings as it relates to imaging of the bilateral knees, lumbar spine, and hips (11F/5; 12F/10). Moreover, the claimant has consistently demonstrated a normal gait, muscle strength, and range of motion of the spine on examination (4F/69; 5F/6, 11; 8F/3, 6–7; 9F/3; 21F/5; 23F/4). Since his symptoms did not significantly limit the claimant’s physical ability to perform work related activities, the undersigned finds that these impairments are non-severe (20 CFR 404.1521 and 416.921; SSR 96-3p).

The record documents a history of depression and anxiety, for which the claimant has been prescribed medication during the relevant period (10F/5; 13F/6; 15F/12; 16F/25). Although, while the consultative examiner diagnosed the claimant with unspecified anxiety disorder and unspecified depressive disorder, there is no evidence that he has ever engaged in any mental health treatment (10F/5). The State agency psychological consultants also found that the claimant’s psychological conditions were non-severe (2A/12; 3A/12; 6A/10; 7A/10).

(Tr. 18). [] The record documents the claimant underwent an ENT evaluation in December 2011 for various symptoms of sore throat, fevers, chills, night sweats, muscle aches and generalized fatigue (4F/118). He was initially assessed with a viral illness (4F/118). He was prescribed three courses of antibiotics and steroid injection with one antibiotic with return of his symptoms (1F/7; 2F/4).

2 The claimant underwent extensive testing for periodic fever syndromes without definite explanation for his symptomatology (13F/l). He was treated with prednisone which helped initially in regard to his fever episodes, but then subsequent courses did not relieve his symptoms (13F/l). In November 2016, the claimant presented to Cleveland Clinic with reported symptoms of sore throat, cough, chest pain, abdominal discomfort, constipation, arthralgias and rash on his back (13F/3). It was determined the claimant’s symptoms were consistent with a diagnosis of Adult Onset Stills Disease (13F/6). The claimant was initially prescribed methotrexate, which was ultimately discontinued, as it was ineffective (21F/2). In April 2017, the claimant was prescribed Kineret, a daily injectable biologic (17F/24). Subsequent evidence documents that his fever episodes have been far less frequent since he started this medication (21F/2). It was determined that the claimant’s symptoms of diffuse widespread pain, sleep problems and fatigue between flares were consistent with fibromyalgia (17F/29). He was advised that optimal sleep, regular aerobic exercise and treatment of depression were the cornerstones of therapy for fibromyalgia (17F/29). In July 2018, the claimant reported that his most prominent symptoms were musculoskeletal pain and that he only had breakthrough fevers when he was off his biologic medication (21F/5).

As for the claimant’s statements about the intensity, persistence, and limiting effects of his symptoms, they are inconsistent because physical examinations revealed negative to mild findings overall. In 2012, examination findings revealed the claimant’s lungs were clear to percussion, with no crackles, wheezes, rhonchi, stridor or pleural rubs (4F/4, 7). His abdomen was soft and non-tender (4F/7). In June 2013, the claimant’s left knee was tender at the medial collateral ligament, but he demonstrated normal range of motion and negative drawer testing (4F/16). Examination findings were otherwise unremarkable (4F/15). In March 2014, the claimant presented with symptoms of a cold (4F/27). He had scattered rhonchi of the lungs bilaterally both anteriorly and posteriorly, but was able to breath without effort (4F/29). Rheumatology clinic records, from 2015 and 2016, document normal examination findings with clear lungs, a soft, non-tender and non-distended abdomen, normal range of motion of all joints, no crepitus or synovitis in any of the joints, no obvious joint deformities and normal muscle strength in all muscle groups (4F/69; 5F/11; 9F/3). The claimant demonstrated normal coordination and gait with no focal neurological deficits.

The claimant underwent a consultative examination at the request of the State agency in June 2016 (see generally 8F). The examiner, Sushil M. Sethi, M.D., observed the claimant demonstrated some mild discomfort and decreased range of motion of the lumbar spine, but findings were otherwise unremarkable (8F /3, 7). In particular, the claimant demonstrated a normal gait; he was able to walk on his tiptoes and heels and could squat (8F/3). He could get on and off the examination table without difficulty. Straight leg raising test was negative at 80 degrees hip flexion bilaterally. Range of motion of the upper extremities was normal. There 3 was no muscle weakness or atrophy. The claimant had normal range of motion of the cervical spine, thoracic spine and upper extremities (8F/7).

Cleveland Clinic records, from November 2016, noted the claimant had good range of motion of the spine, arms, hips, knees and ankles, with limited flexion, extension and lateral rotation of the neck (13F/5).

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Aikman v. Commissioner of Social Security, Counsel Stack Legal Research, https://law.counselstack.com/opinion/aikman-v-commissioner-of-social-security-ohsd-2020.