Johns v. Comm'r of Soc. Sec.

1

BRUCE S. JOHNS, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.

No. 1:20-cv-02810

United States District Court, N.D. Ohio, Eastern Division

April 25, 2022

DAVID A. RUIZ DISTRICT JUDGE

REPORT AND RECOMMENDATION

AMANDA M. KNAPP UNITED STATES MAGISTRATE JUDGE

Plaintiff Bruce S. Johns (“Plaintiff” or “Mr Johns”) seeks judicial review of the final decision of Defendant Commissioner of Social Security (“Commissioner”) denying his application for Supplemental Security Income (SSI). (ECF Doc. 1.) This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This matter has been referred to the undersigned Magistrate Judge for a Report and Recommendation pursuant to Local Rule 72.2.

For the reasons set forth below, the undersigned recommends that the Court AFFIRM the Commissioner's decision.

I. Procedural History

Mr Johns filed his application for SSI on January 10, 2019. (Tr. 15, 85, 93, 163-68.) He asserted a disability onset date of March 1, 1992. (Tr. 15, 85, 163.) He alleged disability due to major depressive disorder, PTSD, anxiety disorder, panic disorder, antisocial personality disorder, and cocaine abuse. (Tr. 85, 106, 114, 184.) His application was denied at the initial level (Tr. 106-08) and upon reconsideration (Tr. 114-18). He then requested a hearing. (Tr. 119- 21.) A hearing was held before an Administrative Law Judge (“ALJ”) on January 28, 2020. (Tr. 30-59.)

On February 26, 2020, the ALJ issued an unfavorable decision, finding Mr. Johns had not been under a disability since January 10, 2019, the date the application was filed. (Tr. 12-29.) Mr. Johns requested review of the ALJ's decision by the Appeals Council. (Tr. 160-62.) On October 20, 2020, the Appeals Council denied Mr. Johns' request for review, making the ALJ's decision the final decision of the Commissioner. (Tr. 1-6.)

II. Evidence

A. Personal, Educational, and Vocational Evidence

Mr. Johns was born in 1959. (Tr. 25, 163.) He has his GED. (Tr. 236.) He was incarcerated for 20 years. (Tr. 40, 236.) He had been living independently in an apartment for two years as of January 2020. (Tr. 49.) He last worked in 2006, cleaning and painting pits in steel mills. (Tr. 37-40.)

B. Medical Evidence

1. Treatment History

i. Physical Impairments

On March 5 and June 6, 2018, Mr. Johns saw Antwon Morton, D.O. at MetroHealth for follow-up visits regarding back, right knee, and right Achilles pain. (Tr. 349, 351.) During the March visit, he rated his pain a 7/10. (Tr. 351.) In June, he rated his pain a 5/10. (Tr. 349.) At both visits, he reported that he managed his pain by taking Percocet 5/325 mg tablets twice a day. (Tr. 349, 351.) He was going to a gym but had not been consistent with a lower extremity strengthening program. (Tr. 349.) The March and June treatment notes contain a report from a June 27, 2014 MRI of the right ankle, which showed: degenerative changes in the ankle and hindfoot, tendinosis and partial tear of the Achilles tendon without complete rupture, probably chronic tear of the anterior talofibular ligament, mild posterior tibial tenosynovitis, and no occult fracture. (Tr. 349, 351.)

Examination findings at the March and June 2018 visits were similar. (Tr. 350, 352.) The back examinations showed mildly decreased range of motion in all planes, tenderness at the lumbosacral junction/interspace and lumbo-sacral spinal muscles bilaterally, and increased back pain bilaterally without radicular symptoms with straight leg raise. (Id.) There was normal lumbar lordotic curvature, no evidence of scoliosis, spasm, or trigger points, and provocative testing was negative. (Id.) Mr. Johns' joint examination in the right ankle was limited due to pain, and there some difficulty in the right lower extremity examination due to pain. (Id.) There was tenderness to palpation over the right Achilles tendon insertion. (Id.) Examinations of the right knee were normal. (Id.) Mr. Johns' neurological examinations were normal, and he demonstrated normal sensation and motor strength in the bilateral upper and lower extremities, normal fine motor coordination, and normal gait. (Id.)

Dr. Morton's impression at both visits was that Mr. Johns' low back pain, right knee pain, and right Achilles tendinopathy were “stable overall.” (Id.) At the March visit, Dr. Morton recommended an EMG to assess for right lower extremity weakness/atrophy, and recommended that Mr. Johns use Motrin 800 mg for pain. (Tr. 352.) Dr. Morton also refilled Mr. Johns' Percocet, to be used sparingly for severe pain, and recommended that Mr. Johns continue with daily home exercises for lower extremity strengthening. (Id.) During the June visit, Dr. Morton noted that EMG results were reviewed. (Tr. 350.) The treatment plan was not changed. (Id.) The record does not contain additional MetroHealth treatment records relating to Mr. Johns' low back, knee, or ankle pain.

On April 30, 2019, Mr. Johns presented to Circle Health Services (aka Centers (Tr. 381)) to establish care, complaining of hypertension and back and ankle pain. (Tr. 385.) He saw Daniel Gauntner, APRN, CNP. (Id.) He reported chronic ankle pain due to a torn Achilles that had not healed. (Tr. 386.) He complained that it hurt to walk. (Id.) He also complained of back pain that was worse when it rained. (Id.) During a musculoskeletal examination, Mr. Johns' range of motion was normal and he had no edema or tenderness. (Tr. 389.) Recommendations included increasing regular exercise to five days a week with more brisk walking, cardio, and weightlifting. (Tr. 390.)

Mr. Johns returned to CNP Gauntner on June 5, 2019, with his chief complaint being hypertension. (Tr. 399.) There were no complaints regarding his back or ankle pain and his musculoskeletal examination was normal. (Tr. 399, 402.)

Mr. Johns saw Rodney Trimble, D.O. at Centers on October 8, 2019 for follow up regarding his hypertension. (Tr. 408.) He did not complain of back or ankle pain and his musculoskeletal examination was normal. (Tr. 408, 412.)

ii. Mental Health Impairments

On June 24, 2016, Mr. Johns was assessed by Cassandra Klein, LSW at The Centers for Families and Children (“CFC”). (Tr. 234-39.) He reported that he was interested in resuming medications to treat his symptoms, which included getting aggressive more easily and anxiety with shortness of breath. (Tr. 235.) He reported a hospitalization in 2004 for suicidal ideation and prior mental health treatment. (Tr. 235-36.) Mr. Johns was diagnosed with PTSD due to flashbacks of past violence and anxiety disorder. (Tr. 234, 237-38.)

Mr. Johns continued treatment through CFC and saw Patrick Runnels, M.D. for a psychiatry visit on February 26, 2018. (Tr. 240-41.) His chief complaint was anxiety and depression. (Tr. 240.) He reported that the severity of his symptoms was “only somewhat interfering with getting through the day,” and reported that his primary issue with his anxiety was irritability and controlling his worrying. (Id.) He reported that he was very involved with narcotics anonymous (“NA”), attending several meetings each week. (Id.) Dr. Runnels diagnosed anxiety NOS, noting that Mr. Johns previously met the criteria for PTSD and was “clearly doing well, with residual symptoms.” (Tr. 241.) Dr. Runnels prescribed Seroquel for irritability and recommended follow up in twelve weeks. (Id.)

Mr. Johns returned to Dr. Runnels on May 21, 2018. (Tr. 242.) He reported that “things [were] going well . . . he [had] been doing a lot of travelling with friends who [were] helping him feel good about things.” (Id.) He reported that he continued traveling to NA conventions and speaking a lot, which was helping him feel less anxious. (Id.) He rated the severity of his anxiety symptoms as “mild to moderate in severity,” and reported doing “[b]etter than last time.” (Id.) He reported that his sleep was good, his depression was not a problem, and his anxiety was really only a problem when he was home alone, and that he went out more as a way to cope. (Id.) He stated Seroquel was helping with his irritability. (Id.) It was noted that Mr. Johns was processing his feelings relating to Dr. Runnels' departure. (Id.) Dr. Runnels continued to diagnose anxiety and prescribe Seroquel for irritability, noting that Mr. Johns was “clearly doing well, with mild residual symptoms.” (Tr. 243.)

During a September 26, 2018 walk-in behavioral health visit at Centers with Bonnie Kaput, APRN, CNP for a refill of Seroquel, Mr. Johns reported that he had been more agitated and not sleeping well since being out of medication for “about a week.” (Tr. 250.) He also reported “a little anxiety” but denied suicidal or homicidal ideation, hallucinations, paranoia, aggressive or violent behavior, recent hospitalizations, or adverse side effects. (Tr. 250, 251.)

On mental status examination, Mr. Johns' motor activity was described as restless and his reported mood was neutral, but his appearance was appropriate, he was generally relaxed and engaged with a bright affect and good eye contact, his insight and judgment were appropriate, his memory was grossly intact, and his intellect was average. (Tr. 251.) Risk of harm to himself or others was rated as low. (Id.) He was diagnosed with major depressive disorder recurrent moderate and avoidant personality disorder. (Id.) His Seroquel was continued for mood stabilization and sleep. (Id.) CNP Kaput stressed the importance of adherence to his medication and appointments. (Id.)

Mr Johns returned to Centers on April 15, 2019. (Tr. 381.) He saw Peter Koontz, APRN, CNP regarding his depression and anxiety. (Id.) He acknowledged missing follow-up appointments after last seeing CNP Kaput in September 2018. (Id.) He was initially agitated and angry about having to see multiple providers at Centers...