Haynes v. Social Security Administration, Commissioner

Filing 12

MEMORANDUM OPINION. Signed by Chief Judge Karon O Bowdre on 3/21/2019. (JLC)

FILED
2019 Mar-21 PM 02:59
U.S. DISTRICT COURT
N.D. OF ALABAMA

IN THE UNITED STATES DISTRICT COURT FOR THE
NORTHERN DISTRICT OF ALABAMA
MIDDLE DIVISION
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JERRY CHARLES HAYNES,
Claimant,
v.
NANCY A. BERRYHILL,
ACTING COMMISSIONER OF
SOCIAL SECURITY,
Respondent.

CIVIL ACTION
NO. 4:17-CV-00896-KOB

MEMORANDUM OPINION
I. INTRODUCTION
On July 27, 2011 the claimant, Jerry Haynes, applied for disability insurance benefits
under Title II of the Social Security Act. (R. 237-39). The claimant alleged disability beginning
October 15, 2009 because of depression, suicidal thoughts, low blood pressure, knee pain,
recurrent ear infections, and recurrent MRSA infections. (R. 88-91). The Commissioner denied
the claimant’s application for disability insurance benefits on November 17, 2011. (R. 124-29).
The claimant filed for a hearing before an Administrative Law Judge, and the ALJ held an initial
hearing February 26, 2014. (R. 133-34).
On May 9, 2014, the ALJ denied the claimant’s application, finding that the claimant was
not disabled at any time during the relevant period and was, therefore, ineligible for social
security benefits. (R. 100-14). The Appeals Council vacated the ALJ’s decision and remanded
with instructions for the ALJ to (1) consider additionally collected evidence and (2) pose

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complete hypothetical questions to the Vocational Expert. (R. 121-22). The ALJ held a second
hearing on May 4, 2016. (R. 79).
On August 11, 2016, the ALJ again denied claimant’s application. (R. 19-32). The
Appeals Council subsequently denied the claimant’s request for review on August 16, 2016. (R.
1-6). Accordingly, the second ALJ decision became the final decision of the Commissioner of
the Social Security Administration. The claimant has exhausted his administrative remedies, and
this court has jurisdiction pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). For the reasons stated
below, this court AFFIRMS the decision of the Commissioner.
II. ISSUES PRESENTED
The claimant presents the following four issues for review:
(1) whether substantial evidence supports the ALJ’s determination that the claimant’s
subjective testimony lacked credibility;
(2) whether the ALJ accorded proper weight to the opinions of treating physician Dr. Jose
Oblena and consulting physician Dr. David Wilson;
(3) whether substantial evidence supports the ALJ’s Residual Functional Capacity (RFC)
determination that the claimant could perform work in the national economy;
(4) whether substantial evidence supports the ALJ’s non-reliance on the Medical Vocational
Guidelines and limitations included in the hypotheticals he posed to the vocational
expert.
STANDARD OF REVIEW
The standard for reviewing the Commissioner’s decision is limited. This court must
affirm the Commissioner’s decision if the ALJ applied the correct legal standards and if

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substantial evidence supports his factual conclusions. See 42 U.S.C. § 405(g); Graham v. Apfel,
129 F.3d 1420, 1422 (11th Cir. 1997); Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
“No . . . presumption of validity attaches to the [Commissioner’s] legal conclusions,
including determination of the proper standards to be applied in evaluating claims.” Walker, 826
F.2d at 999. This court does not review the Commissioner’s factual determinations de novo. The
court will affirm those factual determinations supported by substantial evidence. “Substantial
evidence” is “more than a mere scintilla. It means such relevant evidence as a reasonable mind
might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 402
(1971).
This court must keep in mind that opinions, such as whether a claimant is disabled, the
nature and extent of a claimant’s residual functional capacity, and the application of vocational
factors, “are not medical opinions, . . . but are, instead, opinions on issues reserved to the
Commissioner because they are administrative findings that are dispositive of a case; i.e., that
would direct the determination or decision of disability.” 20 C.F.R. §§ 404.1527(d), 416.927(d).
Whether the claimant meets a listing and is qualified for Social Security disability benefits is a
question reserved for the ALJ, and the court “may not decide facts anew, reweigh the evidence,
or substitute [its] judgment for that of the Commissioner.” Dyer v. Barnhart, 395 F.3d 1206,
1210 (11th Cir. 2005). Thus, even if the court were to disagree with the ALJ about the
significance of certain facts, the court has no power to reverse that finding as long as substantial
evidence in the record supports it.
The court must “scrutinize the record in its entirety to determine the reasonableness of the
[Commissioner]’s factual findings.” Walker, 826 F.2d at 999. A reviewing court must not only
look to those parts of the record that support the decision of the ALJ, but also must view the

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record in its entirety and take account of evidence that detracts from the evidence relied on by
the ALJ. Hillsman v. Bowen, 804 F.2d 1179, 1180 (11th Cir. 1986).
III. LEGAL STANDARD
Subjective Pain Testimony
An ALJ considering a claimant’s pain and other subjective testimony must first determine
whether the claimant has “evidence of an underlying medical condition.” Holt v. Sullivan, 921
F.2s 1221, 1223 (11th Cir. 1991); see also 20 C.F.R. § 404.1529. Once a claimant shows an
underlying medical condition, he must show either: (1) “objective medical evidence that
confirms the severity of the alleged pain arising from that condition,” or (2) “that the objectively
determined medical condition is of such a severity that it can be reasonably expected to give rise
to the alleged pain.” Holt, 921 F.2d at 1223 (citing Landry v. Heckler, 782 F.2d 1551, 1553 (11th
Cir. 1986)). Subjective pain testimony can satisfy the pain standard, but only if medical evidence
supports that subjective testimony such that is “credited.” See Bloodsworth v. Heckler, 703 F.2d
1223, 1242 (11th Cir. 1983); Benson v. Schweiker, 652 F.2d 406, 408-09 (11th Cir. 1981).
If an ALJ discredits a claimant’s subjective testimony, he must articulate his reasons.
Brown v. Sullivan, 921 F.2d 1233, 1236 (11th Cir. 1991). The ALJ may consider the claimant’s
daily activities to discredit pain testimony. Harwell v. Heckler, 735 F.2d 1292, 1293 (11th Cir.
1984). A reviewing court will not disturb a clearly articulated credibility finding with supporting
substantial evidence in the record. Foote v. Chater, 67 F.3d 1553, 1561-62 (11th Cir. 1995).
Medical Opinions
An ALJ must state with particularity and explain the weight he gave different medical
opinions. Sharfarz v. Bowen, 825 F.2d 278, 279 (11th Cir. 1987). The ALJ must give “[t]he
testimony of a treating physician…substantial or considerable weight unless ‘good cause’ is

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shown to the contrary.” MacGregor v. Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986). But, a
doctor who examines a patient on only one occasion is not considered a “treating physician.”
McSwain v. Bowen, 814 F.2d 617, 619 (11th Cir. 1987).
Additionally, when objective medical evidence does not support the treating physician’s
opinion or it is wholly conclusive, the ALJ may discount the opinion. Crawford v. Comm’r of
Soc. Sec., 363 F.3d 1155, 1159 (11th Cir. 2004). When the ALJ articulates specific reasons for
failing to give controlling weight to a treating physician’s opinion, and substantial evidence
supports those reasons, the ALJ does not commit reversible error. Moore v. Barnhart, 405 F.3d
1208, 1212 (11th Cir. 2005). The ALJ is “concerned…with the doctors’ evaluations of [the
claimant’s] condition and the medical consequences thereof, not their opinions of the legal
consequences of his condition.” Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997).
Additionally, a claimant applying for disability insurance benefits must demonstrate that
he was disabled “on or before” the date he was last insured. Moore, 405 F.3d at 1211 (citing 42
U.S.C. § 423(a)(1)(A)). A medical opinion or examination that occurs after the “relevant
disability period” may be a “retrospective diagnosis that [is] not entitled to deference unless
corroborated by contemporaneous medical evidence of a disabling condition.” Mason v. Comm’r
of Soc. Sec., 430 F. App’x 830, 832 (11th Cir. 2011).
Residual Functional Capacity
A claimant’s RFC is the work that an individual “is still able to do despite the limitations
caused by his…impairments.” Phillips v. Barnhart, 357 F.3d 1232, 1238 (citing 20 C.F.R. §
404.1545(a)). The ALJ must first assess the claimant's functional limitations and restrictions and
then express his functional limitations in terms of exertional levels. See Castel v. Comm'r of Soc.
Sec., 355 F. App'x 260, 263 (11th Cir. 2009); Freeman v. Barnhart, 220 F. App'x 957, 959–60

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(11th Cir. 2007); see also Bailey v. Astrue, 5:11–CV–3583–LSC, 2013 WL 531075 (N.D.Ala.
Feb.11, 2013).
The ALJ must consider all of the relevant evidence in assessing the claimant's functional
limitations, including:
medical history, medical signs and laboratory findings, the effects of treatment,
including limitations or restrictions imposed by the mechanics of treatment (e.g.,
frequency of treatment, duration, disruption to routine, side effects of medication),
reports of daily activities, lay evidence, recorded observations, medical source
statements, effects of symptoms, including pain, that are reasonably attributed to a
medically determinable impairment, evidence from attempts to work, need for a
structured living environment, and work evaluations, if available.
SSR 96–8p at *4–*5.
Grid Rules and Vocational Experts
After the ALJ has determined that a person can no longer perform his former occupation
because of impairment, an ALJ has two avenues to assess whether that person can perform any
other work within the economy. Phillips, 357 F.3d at 1239-40. The first avenue that an ALJ may
use to make this determination is through application of the Medical Vocational Guidelines (grid
rules). Id. However, reliance on the grid rules is inappropriate “when a claimant has nonexertional impairment that significantly limits his basic work skills….” Wolfe v. Chater, 86 F.3d
1072, 1077 (11th Cir. 1996). Examples of non-exertional impairments “include ‘difficulty
maintaining attention or concentrating,’ and ‘difficulty understanding or remembering detailed
instructions.’” Id. at 1078. When a non-exertional impairment exists, the ALJ must consult a
vocational expert. Phillips, 357 F.3d at 1242.
For a vocational expert's testimony to constitute substantial evidence, the ALJ must pose
a hypothetical question that comprises all of the claimant's impairments. Vega v. Comm'r of Soc.
Sec., 265 F.3d 1224, 1229 (11th Cir. 2001). An ALJ is not required to include limitations or
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impairments unsupported by substantial evidence in the hypothetical posed to the vocational
expert. Turner v. Comm'r of Soc. Sec., 182 F. App'x 946, 950 (11th Cir. 2006).
IV. FACTS
The claimant was 54 years old at the time of the ALJ’s final decision. (R. 84). The
claimant completed the ninth grade and later obtained his GED. (R. 85, 325). The claimant has
eleven years of past relevant work as an eighteen-wheel truck driver but has not engaged in
substantial gainful activity since early October 2009. (R. 86, 238, 266). The claimant alleges
disability as of October 15, 2009, because of depression, suicidal thoughts, low blood pressure,
severe knee pain, chronic ear infections, and recurrent MRSA infections. (R. 88-91).
Physical and Mental Impairments
On July 27, 2009, the claimant’s wife called the police because she was afraid that the
claimant would cause bodily harm to himself. The police transported the claimant to the
emergency room at Teche Regional Medical Center. The claimant denied any suicidal thoughts
and told attending physician Dr. Ryan Bird that he had no plan to cause bodily harm to himself.
Dr. Bird’s records state that the claimant was alert, able to obey commands, and had a blood
pressure of 115/83. (R.540-547).
Two years later, on July 18, 2011, the claimant applied for disability insurance benefits
based on a primary complaint of mood and anxiety disorders. (R. 99). On August 10, 2011, the
claimant began outpatient treatment at Cheaha Mental Health Center. The claimant reported
sleep deprivation, a lack of motivation, and feelings of depression and helplessness. The
attending physician prescribed monthly therapy sessions for one-half to one hour “or as needed.”
(R. 434.)

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The claimant returned to the Cheaha Mental Health Center on August 23, 2011, and
September 27, 2011. At both visits, the claimant reported a feeling of general depression and
difficulty sleeping. At the August 23 visit, attending physician Dr. Christopher Stanley
prescribed 100 milligrams of Trazodone and 20 milligrams of Citalopram (Celexa), both
antidepressants. At the September 27 visit, Dr. Stanley added a prescription for 0.5 milligrams of
Clonazepam (Klonopin), also an anti-depressant. (R. 313, 432-33).
On October 19, 2011, Dr. Hasmukh Jariwala examined the claimant at the request of the
Social Security Administration. At the time of this examination, the claimant was forty-nine
years old. The claimant reported headaches, dizziness, and occasional blackout spells. Dr.
Jariwala noted that the claimant did “not appear to be severely or acutely ill”; that he had a
history of depression; that he was taking three anti-depressants for his depression; that his “ears,
canals, and tympanic membranes are bilaterally normal”; that he suffered from hypertension; 1
and that he could answer and respond to normal conversation, squat “with minimal difficulty,”
and had 5/5 strength in the major muscle groups. (R. 435-38).
The claimant also received a mental examination in connection with his application for
disability benefits at the request of the Social Security Administration. On October 25, 2011,
psychologist Robert Summerlin, PhD noted that the claimant’s wife was a commanding presence
in their relationship and often had to be reminded to “allow her husband to answer…questions;”
and that he was “oriented in regards to person, place, time, and circumstance.” The claimant
reported that he has three living siblings and two living children. (R. 440-41).
Dr. Summerlin asked the claimant to start at the number twenty and then count down,
subtracting three each time. The claimant’s responses were “17, 14, 11, 9, 6, 3” with one error
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The court is unclear why Dr. Jariwala reported a diagnosis of hypertension for the claimant. At the appointment,
Dr. Jariwala recorded the claimant’s blood pressure as 110/74, which is within the normal range. Additionally, a
diagnosis of hypertension contradicts the remainder of the claimant’s record.

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when subtracting three from the number eleven. Dr. Summerlin reported that the claimant had
intact memory function and “logical, coherent, focused, and concrete” thought processes. Dr.
Summerlin also noted that the claimant had the vocabulary and abstract thinking skills “of an
individual with low average intelligence and approximately a high school education.” The
claimant described his mood as “[g]rouchy” and “nervous.” (R. 441).
Next, the claimant and Dr. Summerlin discussed his daily physical activities. The
claimant stated that he could drive, perform simple home repairs, shop with his wife, and watch
television. The claimant’s stated hobby was using the computer. The claimant also reported
receiving around five hours of sleep each night and requiring assistance washing his hair and
shaving. (R. 441).
Dr. Summerlin concluded that the claimant had a mood disorder, nicotine dependence,
and moderate emotional symptoms affecting personal, social, and occupational functioning. Dr.
Summerlin deferred diagnosis for antisocial, avoidant, and paranoid personality symptoms. 2
Finally, Dr. Summerlin concluded that the claimant had “adequate ‘common sense’ to manage”
disability money benefits. (R. 442).
On November 17, 2011, at the request of the Social Security Administration, Dr. Samuel
Williams completed a RFC assessment of the claimant by reviewing his records. Dr. Williams
found that the claimant had no limitations in his ability to remember locations and work-like
procedures; understand and remember short and simple instructions; carry out short and simple
instructions; perform activities within a schedule, be punctual, and regularly attend work; sustain
a routine; make simple work-related decisions; complete a normal workweek or workday without
interruptions; ask simple questions; get along with coworkers; maintain appropriate behavior;
2

A deferred diagnosis is used when a patient exhibits some signs and symptoms of an actual diagnosis, but the
treating physician defers diagnosis until he has the opportunity to examine the patient’s symptoms on multiple
occasions.

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work around hazards and take precautions; travel in unfamiliar places; and set realistic goals. (R.
462-63).
Dr. Williams found that the claimant had moderate limitations in his ability to understand
detailed instructions; maintain attention for extended periods; work in close proximity to others
without getting distracted; interact with the general public; accept instruction; and respond
appropriately to changes in the work environment. (R. 462-63).
Dr. Williams noted that the claimant had marked limitations in his ability to carry out
detailed instructions. Dr. Williams concluded that the claimant could understand and carry out
simple, short tasks, but would have difficulty with complex or detailed tasks; could maintain
attention for at least two hours out of an eight hour day; should receive supervision “delivered in
a positive manner”; should have only casual contact with the general public; and should be in a
workplace where changes occur infrequently and gradually. (R. 464).
The Social Security Administration initially denied the claimant’s application for
disability on November 17, 2011. (R. 99).
The claimant returned to Dr. Stanley at the Cheaha Mental Health Center in January and
February, 2012. Dr. Stanley noted the claimant’s continued depression symptoms and noted new
symptoms of claustrophobia. The claimant also reported that he had witnessed the death of his
sister and felt like he was a burden on those around him. Dr. Stanley recommended that the
claimant stay on the same course of treatment with Celexa, Klonopin, and Trazadone. (R. 466,
470).
On February 17, 2012, the claimant went to the Emergency Room at Brookwood Medical
Center reporting suicidal thoughts and a potential nervous breakdown because of his sister’s
recent death. (R. 548). The claimant also reported that he had a plan to hang himself and that he

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had an open knife lying by his bed. (R. 569). Security monitored the claimant and labeled him as
a high risk for suicide. (R. 571). The emergency room doctors consulted with Dr. Stanley, who
recommended that the claimant remain hospitalized to stabilize his mental health. The claimant,
however, refused to remain hospitalized but his wife refused to let him sign a “Refusal of
Hospitalization” form. The claimant and his wife left the hospital. (R. 560).
The claimant again returned to Dr. Stanley on February 28, 2012. Dr. Stanley noted that
the claimant remained claustrophobic; represented that he had been shaking badly; was irritable;
and had a plan to harm himself. Dr. Stanley continued the Celexa and Trazodone but switched
the claimant from Klonopin to Xanax. (R. 467).
On March 18, 2012, the claimant went to the Northeast Alabama Regional Medical
Center in Anniston Alabama, because of depression and suicidal thoughts. After a short period of
time at the hospital, the claimant stated that he was no longer suicidal. The claimant’s wife
refused further care for the claimant, against the medical staff’s recommendation, and they left.
(R. 506).
The claimant then visited Dr. Stanley at Cheaha four times between March of 2012 and
February of 2013. At each visit, Dr. Stanley recommended continuing the same course of
treatment despite the claimant’s representations that he had not been taking his medicine because
he does not trust his family; he had a plan to jump off of a bridge but did not go to the hospital;
the anti-depressants were affecting his sexual libido; he had bad thoughts and anxiety; he was
unwilling to live in the same house as his daughter; he remained anxious “at times”; and he had
begun having bad dreams. (R. 468-69, 482-83).
On June 26, 2013, the claimant saw Dr. Richard Sanders at UAB Hospital for chronic
knee pain. Dr. Sanders performed an X-ray of the claimant’s knee that showed calcification in

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the patella tendon, but otherwise normal results. Dr. Sanders diagnosed this calcification as
chronic patellofemoral dysfunction and recommended treatment of “[s]traight leg raising and
hamstring stretching exercises.” (R. 526).
The claimant then sought treatment from the Oxford Clinic, LLC on July 3, 2013, from
Dr. Richard Snouffer for symptoms relating to low blood pressure, which was registered 85/59
on this date. The claimant also reported dizziness, ringing in the ears, tingling in his legs and
arms, and feeling like he was going to pass out. The claimant stated that he “works outside and in
the heat all day” and that his blood pressure had been dropping for the past four-weeks. Further,
the claimant had yellow drainage coming out of his right ear that had a strong odor. (R. 489-91).
Dr. Snouffer noted that the claimant was oriented and able to sit comfortably without any
noticeable pain but diagnosed him with depression, malaise, and fatigue. Dr. Snouffer also noted
that he suspected that the claimant suffered from symptomatic bradycardia, but the patient
refused admission to the emergency room to monitor this suspected condition. Dr. Snouffer
prescribed a steroid to the claimant and requested that he return in one-week for a follow-up. (R.
489-91).
On July 7, 2013, the claimant saw Dr. Lauren McDougald at UAB Hospital. 3 The
claimant complained of moderate chest pains with shortness of breath, heart palpitations, and
blurred vision. Dr. McDougald performed a cardiac work-up that came back negative and noted
that the claimant had a regular heart rate; no murmur; atypical symptoms of angina; and that the
pain was most likely related to chest wall pain. Dr. McDougald discharged the claimant and told
him to follow up as an outpatient with Birmingham Heart Clinic. (R. 516-18).
On July 9, 2013, the claimant returned to Dr. Stanley at the Cheaha Mental Health
Center. The claimant’s blood pressure was 80/64 and he reported that he was on steroids for his
3

The court is unclear if the claimant was referred to Dr. McDougald or if he sought attention on his own behalf.

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blood pressure; that he was taking only one trazadone per day; and that he was worried the
Xanax was affecting his blood pressure. The claimant also complained about his depression,
claustrophobia, and anxiety. Because he was only taking one per day, Dr. Stanley increased the
dosage of Trazadone from 100mg to 150mg. (R. 475).
The claimant followed up with Dr. Snouffer at the Oxford Clinic on July 10, 2013. Dr.
Snouffer recorded that the claimant continued to have low blood pressure that responded
modestly to the medication. Dr. Snouffer recorded the claimant’s blood pressure as 97/64. Dr.
Snouffer also reported that the claimant mowed “his own grass with a push mower, taking about
2.5 h[ours] each time,” noting that the last time the claimant mowed his lawn was three days
prior to the visit. Dr. Snouffer recommended a thyroid panel but the patient declined this
recommendation because he had inadequate finances. Dr. Snouffer told the patient to drink
plenty of water, prescribed a steroid, and suggested a follow-up visit within two to four weeks.
(R. 487-88).
Three weeks later, on July 31, 2013, the claimant followed up with Dr. Snouffer. The
claimant reported that he was no longer experiencing dizziness or lightheadedness. But, the
claimant also reported that his blood pressure was continuing to change daily. Dr. Snouffer’s
findings were that the claimant’s hypotension was “responding well to the hydrocortisone” and
that the claimant should continue taking the medication. Dr. Snouffer also found that the changes
in the claimant’s blood pressure seemed normal “especially given that he no longer feels the presyncopal feeling.” (R. 492-94).
The claimant visited the Emergency Room at Northeast Alabama Regional Medical
Center on December 27, 2013, complaining of an ear ache and drainage from his ear. Dr.
Summer Phelps diagnosed the claimant with Otitis Media, an inflammation of the middle ear.

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Dr. Phelps stated that this type of infection can occur shortly following a viral upper respiratory
infection. Dr. Phelps prescribed Amoxicillin and Tramadol for pain. Dr. Phelps recommended
that the claimant follow up with Dr. Jose Oblena at the Oxford Clinic within three days. (R. 50710).
On January 14, 2014, the claimant visited Dr. Jose Oblena at The Oxford Clinic, LLC to
follow up regarding his Otitis Media infection. At the time of this visit, the claimant’s blood
pressure was recorded as 106/70. Dr. Oblena reported that the claimant was well-developed and
had no cardiorespiratory distress. As to the claimant’s neurological abilities, Dr. Oblena stated
that the claimant had strength of 5/5 in “all muscle groups.” (R. 513). Further, the claimant was
“conscious, cooperative and well oriented to time, place and person;” had no mood swings or
psychotic features; and had good insight, memory, and judgment. (R. 513). Dr. Oblena
diagnosed the claimant with Acute Suppurative Otitis Media and ordered X-rays of his chest,
knees, and lower back that came back normal. (R. 511-13, 660-62).
On March 21, 2014, Dr. Oblena signed a letter stating the following: “Jerry Haynes…is a
patient of mine at the Oxford Clinic. It is my medical opinion that Mr. Haynes is fully disabled
from any type of employment because of his diagnosis of hypotension and his current mental
state.” (R. 535).
Dr. Oblena saw the claimant again for a follow-up appointment in June of 2014. The
claimant sought medication refills and reported that he “feels like it’s getting worse,” presumably
referring to his depression and anxiety. The claimant’s prescriptions at this appointment were
listed as Hydrocortisone, Vitamin B-12, Armour Thyroid, Ciprofloxacin antibiotics, Xanax,
Aspirin, Celexa, Meclizine (an antihistamine), and Trazadone. (R. 700).

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The claimant returned to Dr. Stanley on June 17, 2014, irritable, upset, anxious, and
suffering from symptoms of claustrophobia and depression. Dr. Stanley recommended staying
the course of treatment and maintained the prescriptions for Xanax, Celexa, and Trazadone. (R.
695). The claimant saw Dr. Stanley again on November 18, 2014. At this appointment the
claimant stated that he wanted to reduce his daily medicine intake. The claimant, however, still
claimed to be anxious and claustrophobic. Dr. Stanley recommended staying the current course
of treatment. (R. 697). The claimant revisited Cheaha on October 13, 2014 to obtain refills on his
medicine. (R. 620).
On December 17, 2014, the claimant admitted himself to the Emergency Room of
Northeast Alabama Regional Medical Center. Dr. Ronald Shiver saw the claimant in response to
complaints of an ear ache, a sore throat, and discomfort in his chest. The claimant’s ear ache was
described as a pain level of 10/10 and his ear was actively draining fluid. The hospital discharged
the claimant and described him as alert, oriented, and stable. Dr. Shiver prescribed
Azithromycin, an antibiotic, and two forms of steroid-based ear drops. Dr. Shiver also suggests
the claimant follow up with his primary care physician. (R. 667-672).
The claimant sought treatment at the Emergency Room of Citizens Baptist Medical
Center on January 11, 2015, complaining of vomiting, dizziness, and an earache. Dr. Pallavi
Sunkavalli recorded the claimant’s blood pressure as 133/96, diagnosed him with a stomach flu,
gave him an injection of Zofran, and discharged him from the hospital. (R. 594-617).
The claimant followed up with the Oxford Clinic on April 2, 2015 to obtain medicine
refills for his depression and ear infection. At this appointment, the claimant denied any chest
pain or shortness of breath, but stated that his ear pain had subsisted. (R. 623-26).

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On May 5, 2015, the claimant saw Dr. David Wilson at Gadsden Psychological Services,
LLC at the request of the claimant’s attorney. The claimant stated that he asked for disability
because he was “claustrophobic” and that when he was four years old he was “sexually abused”
and put into a “slavery camp.” The claimant stated that he contracted MRSA while transporting
hazardous materials as a truck driver; tried to seek treatment at a psychiatric hospital “but they
didn’t have a bed. I tried to commit suicide but they didn’t have no room;” and that the medicine
he was taking helped but that it did not fully relieve his symptoms. Further, the claimant’s wife
stated that his low blood pressure “bottoms out to 50/39”; his ear pain causes dizziness; and that
his knee needs replacing. She also stated that the claimant has thyroid and adenoid problems.
Finally, she noted that the claimant tried to commit suicide four times. (R. 626-27).
Discussing his mental status, the claimant stated that he drove to the clinic that day even
though both he and his wife have suspended driver’s licenses; he goes through spells where he
does not eat for four to five days; has hallucinations of his brothers and sisters and has
conversations with them during these hallucinations even though they are deceased; will not ride
in elevators because he is claustrophobic; is afraid of snakes and needles; often has panic attacks;
and is depressed every day. The claimant’s wife stated that the claimant “goes into outrages and
there is no stopping him. The least little thing triggers it – I have had to call the law.” Dr. Wilson
noted that the claimant’s speech was clear and normal in rate, but that he often interrupted the
doctor. (R. 628-29).
Discussing his daily activities, the claimant stated that he gets up at 3am, makes coffee,
and plays computer games; sometimes mows the lawn for fifteen minutes to an hour; maintains a
garden; and gets tired very easily. As to his memory, the claimant could count down from twenty
with one error, skipping the number sixteen and could perform simple math and a more complex

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calculation. The claimant was, however, unable to count backwards from 100 by seven or recall
any of three items after ten minutes. (R. 629-30).
Dr. Wilson concluded that the claimant was highly disturbed, depressed, paranoid, and
has recurrent panic attacks with an onset date of October, 2009. Dr. Wilson stated that the
claimant has a “highly impaired” ability to function within the pressures of an occupation and
“would have great difficulty with the task and interpersonal aspects of any job.” (R. 630)
The ALJ Hearing
On May 4, 2016, the ALJ held a hearing after the Appeals Council remand, at which the
claimant and vocational expert David Head testified. The claimant testified that he had a tenthgrade education and had not worked since 2009 because of suicidal thoughts and suicide
attempts. Additionally, the claimant stated that he drove to the hearing even though his license
was suspended because his wife cannot drive and is on disability because of “heart problems and
COPD.” (R. 84-86).
The claimant testified that he is struggling to accept and cope with the death of all of his
family members and experiences low blood pressure that has forced him to “do nothing but just
lie around” fifteen days out of a thirty-day period. On these days, he testified that he spends
about half to three-quarters of his day in bed and is unable to focus on a two-hour long movie.
(R. 89).
The claimant stated that he gets “aggravated” and wants “to go crazy” when someone
gives him direction, wants to “fight” and “throw stuff,” and cannot follow simple instructions
because he has to “do it [his] own way or…it won’t get done.” The claimant stated that treatment
at the Cheaha Mental Health Center helps control his emotions and cope with familial deaths, but

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that the doctors increased his medicine because it was “not working.” He is unable to go out
alone because he feels like people are making fun of him behind his back. (R. 89-90).
Next, the claimant testified that his knees often give out and he takes daily Advil for his
knee pain. He claimed to need knee surgery eventually, but cannot afford it because he lacks
insurance. The claimant testified that he has ear infections that are spreading to his thyroids,
adenoids, and tonsils and would eventually require surgery. Finally, the claimant testified that he
first contracted MRSA when transporting hazardous chemicals and that when his infections flare
up he has to go to the hospital to get the sores cut off. (R. 91-92).
Next, the claimant testified that he has an irregular sleep schedule; wakes at all hours of
the night because his sleep medicine is not working; only eats one meal per day; and does not
have the energy to function normally during an average day. (R. 92).
The ALJ then posed several hypothetical questions to the vocational expert Dr. Head.
The ALJ asked Dr. Head to assume a hypothetical individual with the same RFC as the claimant
who could occasionally push or pull with the lower extremities; occasionally climb ramps and
stairs; could perform simple routine and repetitive tasks; could deal with gradual changes in the
work place; could perform jobs that did not deal primarily with people; could not tolerate more
than occasional contact with the general public; could not climb ladders or scaffolds; must avoid
vibration, noise, and extreme heat and cold; and must avoid unprotected heights and hazards. (R.
94).
The ALJ then asked whether a person with these limitations could perform the claimant’s
past work as a truck driver. Dr. Head testified that the hypothetical person could not perform the
claimant’s post work but could perform light, unskilled work as a sorter, with 1,850 statewide
jobs and 93,000 jobs in the national economy; a housekeeper with 5,200 statewide jobs 215,000

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available jobs in the national economy; or an assembly line worker with 2,100 statewide jobs and
130,000 available jobs nationally. (R. 94-95).
Next, the ALJ added several limitations to the hypothetical, specifically the inability to
interact or respond appropriately with supervisors, coworkers, or the general public and the
inability to respond appropriately to changes in routine work pressures or a routine work setting.
Dr. Head testified that an individual with these additional limitations could not perform any
work. (R. 96).
Dr. Head testified that a person could miss only two days per month for a period of
several months without getting fired. He also testified that, if a person had to lie down fifteen
days a month, that person could not perform any work. (R. 96-97).
The ALJ Decision
On August 16, 2016, the ALJ found that the claimant was not disabled, within the
meaning of the Social Security Act, from October 15, 2009 through the date last insured. The
ALJ found that the claimant was last insured on December 31, 2013. The ALJ also found that the
claimant had not engaged in substantial gainful activity during the claimed disability period.
Additionally, the ALJ stated that the claimant had the following severe impairments:
hypotension, depression, anxiety, thyroid disorder, otitis media, and chronic patellofemoral
dysfunction of the left knee. The ALJ found that the claimant’s alleged MRSA infections were
not severe because the infections occurred prior to the alleged disability period and no evidence
showed that they have occurred since. (R. 20-21).
The ALJ then found that the claimant’s impairments or combination of impairments did
not meet the severity of a listed impairment in 20 C.F.R. Part 404, Subpart P, Appendix 1.
Specifically, the claimant’s hypotension did not evidence systolic or diastolic failure, persistent

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symptoms of heart failure, ischemic heart disease, coronary artery disease, or hypotension related
organ damage; his thyroid problem caused no changes in blood pressure or heart rate, weight
loss, or mood disorders; his otitis media did not impair hearing at a conversational level; and his
left knee impairment did not prevent normal ambulation, walking at a reasonable pace, or
utilization of public transportation. (R. 22).
The ALJ then looked to the claimant’s mental impairments, both individually and in
combination with his physical impairments, and found that the mental impairments also did not
meet the severity of any listing. (R. 22-23).
The ALJ stated that the claimant had only mild restrictions in his daily living. The ALJ
found that the claimant could perform personal hygiene, light housecleaning, and the laundry.
Additionally, the ALJ noted that the claimant could shop, pay his bills, cook simple meals, and
maintain a residence without supervision. The ALJ also found that the claimant’s testimony that
he was completely reliant upon his wife to perform even the simplest functions was inconsistent
with testimony that his wife was physically disabled; that he had previously told a doctor that he
mowed his own grass with a push mower; and that he does simple household repairs. (R. 23).
The ALJ found that the claimant has moderate difficulty in social settings. The claimant
testified that he was paranoid and anxious during social activities, such as shopping. But, the
claimant could also cooperate and communicate effectively with medical personnel. Thus, the
ALJ found that the evidence showed no more than a moderate limitation. (R. 23).
The ALJ then found that the claimant experienced moderate difficulty with concentration,
persistence, and pace. Specifically, the ALJ stated that although the claimant struggles with
short-term memory, his mental status exam shows he has intact memory and logical, focused
thought with no evidence of confusion, can sufficiently perform simple tasks timely and

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appropriately. (R. 23). Because the claimant’s physical and mental impairments did not meet a
severity listing, the ALJ next determined the claimant’s residual functional capacity.
The ALJ determined that the claimant has the residual functional capacity to perform
light work as defined in 20 C.F.R. § 404.1567(b), such that the claimant could occasionally push
or pull with the lower extremities, climb ramps and stairs, could perform simple routine and
repetitive tasks, could deal with gradual changes in the work place and could perform jobs that
did not deal primarily with people, but could not tolerate more than occasional contact with the
general public and could not climb ladders or scaffolds, needed to avoid vibration, noise, and
extreme heat and cold, and needed to avoid unprotected heights and hazards. (R.24).
To support this finding, the ALJ considered the claimant’s medical and non-medical
record. The ALJ concluded that, although the claimant’s medically determinable impairments
could reasonably be expected to cause the complained of symptoms, the claimant’s allegations
regarding the intensity, persistence, and limiting effects were not consistent with the evidence.
Specifically, the ALJ noted that the claimant alleged that his low blood pressure and medication
made him drowsy and sleepy but testified that he cannot sleep despite his prescription for sleep
medication. The claimant also testified that his driver’s license was suspended for not paying
child support, but that he drives as necessary because his wife is unable to drive because of her
disability; he has suicidal thoughts because of the death of his family, but the claimant still has
living children. The ALJ also noted the claimant’s current therapy at Cheaha Mental Health
Center, his testimony about needing surgery for his knees and ears, and his claim that he cannot
go out in public or handle criticism without losing his temper. (R. 24-25).
The ALJ found that the claimant’s alleged impairments have very little medical support
in the record near the time that he claimed the onset of these disabling conditions. Specifically,

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the ALJ pointed to treatment at the Teche Medical Emergency Room in July of 2009, when the
claimant’s wife reported that she was afraid he would harm himself. But, the records of this visit
show that the claimant was clean, ambulated without assistance, demonstrated normal moods,
and denied any suicidal thoughts. The ALJ then noted that, after this 2009 visit, the claimant did
not see another doctor for his alleged disabilities until after he filed his disability application in
July, 2011. Then, in August, 2011 the claimant reported to Dr. Stanley that he needed help with
“all my problems,” specifically depression, sleep deprivation, feelings of helplessness, and lack
of motivation. Dr. Stanley diagnosed the claimant with Generalized Anxiety Disorder and began
prescription treatment. (R. 26).
The ALJ next discussed the claimant’s medical history post-2011 and the inconsistencies
reported at these visits. The ALJ noted that at Dr. Jariwala’s visit in October of 2011, the
claimant complained of several impairments but his cardiac work-up was negative; his blood
pressure was in the normal range; he had no evidence of physical impairment; and he was not in
a reactive emotional state. (R. 26).
The ALJ accorded Dr. Summerlin’s opinion considerable weight. (R. 30).
The ALJ then discussed how at the claimant’s Social Security referred psychological evaluation,
Dr. Robert Summerlin noted that the claimant suffered from a moderate mood disorder that
suggested moderate difficulty in social or work functions but he had the common sense to
manage disability funds if found eligible for such funds. (R. 26-27).
Next, the ALJ discussed the claimant’s knee pain. The ALJ noted that no evidence
existed in the record that any doctor had recommended knee surgery for his chronic
patellofemoral dysfunction. But, the ALJ gave the claimant the “benefit of the doubt” regarding
the claimant’s knee calcification and thus limited the scope of the residual functional capacity to

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light work. But, the ALJ noted that the claimant reported in July, 2013, that the claimant could
cut his own grass, which was inconsistent with the testimony that he is unable to do any
household chores and could only lie around during the day. (R. 28-29).
Discussing the claimant’s low blood pressure, the ALJ noted that Dr. Snouffer prescribed
a steroid that was having the desired effect; that the claimant’s blood pressure had increased
slightly; and that he reported an end to his headaches, dizziness, and other symptoms of low
blood pressure. (R. 28).
As to the claimant’s mental imparities, the ALJ found that the claimant had stable overall
mental health with strong reactions to specific stressors, such as the death of his sister, the
potential for going to jail over child-support, and family issues with his daughter. To cope with
his irritability, the ALJ stated that the claimant should work primarily with things, not people.
Additionally, the ALJ noted that treatment records suggested that the claimant could remember
without difficulty and could carry out simple instructions. (R. 29).
The ALJ accorded little weight to the April, 2015, opinion of David Wilson, a consulting
psychologist. The ALJ noted that Dr. Wilson found that the claimant had difficulty
understanding, remembering, and carrying out short and simple instructions. But, the ALJ found
this opinion to be inconsistent with the record. (R. 29). Specifically, the ALJ discussed how Dr.
Summerlin reported that the claimant’s thought processes were logical, coherent, focused, and
concrete with responsive thought content. (R. 27). The ALJ found that the claimant’s treatment
records reflected intact concentration and memory with no indication of difficulty understanding,
remembering, and carrying out simple instructions or tasks. (R. 29).
The ALJ also accorded little weight to Dr. Jose Oblena. The ALJ noted that Dr. Oblena
saw the claimant only once and that at this appointment Dr. Oblena’s notes state that claimant

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was cooperative, well oriented, showed no signs of mood swings or psychotic features, and that
the claimant showed good memory function. The ALJ found that Dr. Oblena’s own notes
contradicted his March, 2014 conclusion that the claimant is disabled. (R. 29-30).
The ALJ accorded considerable weight to the opinion of Dr. Robert Summerlin that the
claimant had the common sense to manage disability benefits. (R. 30). The ALJ also accorded
considerable weight to the opinion of Dr. Samuel Williams, the Social Security administration’s
consultative psychiatrist. The ALJ stated that Dr. Williams’s opinions were well-supported by
the evidence despite not having the claimant’s full record at the time of examination.
Finally, the ALJ reported that he accorded little weight to the opinion of the claimant’s
wife. The ALJ found that the wife’s claim that her husband was completely dependent on her
was inconsistent with testimony that she is currently receiving disability benefits because of
physical disabilities. (R. 30).
The ALJ then discussed the claimant’s RFC and determined that a significant number of
jobs exist in the national economy that the claimant would be able to perform. The ALJ relied on
the vocational expert’s testimony that, given the claimant’s credible and supported limitations, he
could perform light work such as a sorter, housekeeper, or assembly line worker. Thus, the ALJ
found that the claimant was not disabled as of December 31, 2013, the date last insured. (R. 3032).
V. DISCUSSION
Issue 1: The ALJ’s Assessment of the Claimant’s Credibility
The claimant argues that the ALJ did not properly credit his subjective complaints about
the limiting effects of his knee pain and mental impairments. This court disagrees and finds that
the ALJ properly discredited the claimant’s subjective complaints.

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The ALJ properly articulated his reasons for discrediting the claimant’s subjective
testimony regarding his physical and mental disabilities. See Brown, 921 F.2d at 1236 (the ALJ
must articulate his reasons when making a credibility determination). The ALJ determined that
the claimant had medical impairments that could reasonably be expected to cause the alleged
symptoms, but that the claimant’s testimony regarding the limiting effects of these symptoms
was not consistent with the medical evidence. (R. 25). The ALJ first relied on the medical
evidence that partially contradicted the claimant’s testimony. Even though the claimant claimed
a disability as of 2009, the ALJ noted that the claimant had no medical records between his
alleged onset date of October, 2009, and August, 2011; that the claimant’s primary physician
described the claimant as irritated, anxious, and claustrophobic, but often recommended
continued treatment with anti-depressant drugs; that the claimant told his primary physician that
the anti-depressant drugs were helping; and that the claimant was often described as coherent,
ambulatory, and responsive to questions. (R. 25-28). The ALJ concluded that the medical
evidence did not support claimant’s testimony of having a debilitating mental illness and
described the claimant as “stable overall with occasional exacerbations related to specific
situational stressors.” (R. 29).
The ALJ also took the claimant’s testimony and past statements regarding his daily
activities into account when determining the credibility of the claimant’s subjective testimony.
The ALJ noted that medical records do not support the claimant’s testimony that the doctors told
him he needed knee surgery; instead Dr. Sanders recommended that he perform leg stretches and
leg raises. (R. 28). The ALJ also pointed to where the claimant told Dr. Snouffer in July, 2013,
that he could, and had recently, used a push mower to cut his lawn. (R. 29).

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The ALJ also identified inconsistencies in the record to support his findings discrediting
the claimant’s subjective statements about the limiting effects of his impairments. The ALJ noted
that the claimant said he slept for long hours, fifteen days per month, but also had difficulty
sleeping and was taking sleep medication; that he relied entirely on his wife for routine daily
activities, but his wife was physically disabled and suffered from COPD; and that he had low
blood pressure, but his blood pressure was often normal, was responding to treatment, and was
no longer causing symptoms. (R. 23-28).
The court finds that the ALJ properly articulated his reasons for discrediting the
claimant’s subjective complaints and substantial evidence supports this finding.
Issue 2: The ALJ’s Assessment of Treating and Consulting Physicians
The claimant next argues that the ALJ failed to accord the proper weight to the opinions
of Dr. Jose Oblena and Dr. David Wilson. This court finds that the ALJ properly articulated his
reasons for discrediting the opinion of Dr. Oblena and Dr. Wilson, and substantial evidence
supports these reasons.
The ALJ properly articulated his reasons for discrediting the opinion of Dr. Oblena, the
claimant’s treating physician. See Moore, 405 F.3d at 1212 (the ALJ must articulate his specific
reasons for failing to give controlling weight to a treating physician’s opinion, and substantial
evidence must support these reasons). The ALJ noted that the claimant had visited Dr. Oblena
only once, for a follow-up appointment for otitis media, on January 14, 2014, prior to Dr.
Oblena’s letter concluding that the claimant was disabled. (R. 29). The ALJ also noted that Dr.
Oblena’s notes from this visit state that the claimant was “cooperative and well oriented with no
mood swings or psychotic features” and had “good insight and intact memory and judgment.”
(R. 29-30). The ALJ also noted that the claimant’s blood pressure was responding to treatment

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and was recorded as 106/70 at the one visit with Dr. Oblena. (R. 30). These reasons constitute
substantial evidence to support the little weight the ALJ gave to the conclusory letter from Dr.
Oblena stating that the claimant was “fully disabled from any type of employment due to his
diagnosis of hypotension and his current mental state.”
The ALJ also properly articulated his reasons for discrediting the opinion of consulting
psychiatrist Dr. Wilson, and substantial evidence supports those reasons. That ALJ first noted
that Dr. Wilson’s consultation occurred two-years after the claimant’s last insured date. See
Mason, 430 F. App’x at 832 (A medical opinion or examination that occurs after the “relevant
disability period” is a “retrospective diagnosis that [is] not entitled to deference unless
corroborated by contemporaneous medical evidence of a disabling condition.”). Additionally,
the ALJ noted that Dr. Wilson reported that the claimant had difficulty understanding,
remembering, and carrying out short and simple instructions. But, the ALJ noted that this
testimony was contradicted by Dr. Summerlin’s report that the claimant’s thought processes
were logical, coherent, focused, and concrete with responsive thought content. Thus, the court
finds that substantial evidence supports the ALJ’s reasons for giving Dr. Wilson’s opinion little
weight.
Issue 3: The ALJ’s Assessment of Claimant’s Residual Functional Capacity
The claimant next contends that substantial evidence does not support the ALJ’s
assessment of the claimant’s residual functional capacity. This court disagrees and finds that
substantial evidence supports the ALJ’s residual functional capacity finding.
The ALJ determined that the claimant has the residual functional capacity to perform
light work. To support this finding, the ALJ discussed the medical record at length and stated
that he considered all symptoms and the extent to which these symptoms can reasonably be

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accepted as consistent with objective medical and non-medical evidence. The ALJ also stated
that he considered opinion evidence. As discussed in the court’s analysis for Issue 1, substantial
evidence supports the ALJ’s discrediting of the claimant’s subjective statements about the
limiting effects of his physical mental impairments. In his RFC finding, the ALJ correctly
accounted only for the limitations he found credible. See Ingram v. Comm’r of Soc. Sec., 496
F.3d 1253, 1270 (11th Cir. 2007) (noting that the hypothetical question must contain the
claimant’s impairments, but not “each and every symptom of the claimant.”). The court finds
that the ALJ properly considered the medical record as a whole in making his RFC determination
and that substantial evidence supports the ALJ’s assessment that the claimant has the residual
functional capacity to perform light work.
Issue 4: The ALJ’s Non-use of the Grid Rules and Hypothetical Questions
The claimant next contends that the ALJ failed to properly apply the grid rules to
determine whether work is available to the claimant in the national economy, instead relying on
the testimony of the vocational expert. Additionally, the claimant contends that substantial
evidence does not support the hypothetical questions the ALJ posed to the vocational expert. The
court disagrees and finds that substantial evidence supports both of the ALJ’s decisions.
The ALJ’s non-reliance on the grid rules was correct. Because the ALJ found that the
claimant had non-exertional limitations, the ALJ could not exclusively rely on the grid rules. See
Francis v. Heckler, 749 F.2d 1562, 1566 (11th Cir. 1985) (“Exclusive reliance on the grids is not
appropriate…when a claimant has non-exertional impairments that significantly limit basic work
skills.”) The ALJ stated that because of the claimant’s non-exertional limitations, he consulted a
vocational expert to determine whether jobs existed in the national economy that the claimant
could perform. (R. 31). See Jones v. Apfel, 190 F.3d 1224, 1229 (11th Cir. 1999) (when the

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claimant has non-exertional limitations, the preferred method to determine available work is
through the testimony of a vocational expert.) Because the claimant has non-exertional
limitations on his basic work skills, the ALJ properly consulted a vocational expert instead of
exclusively relying on the grid rules.
Substantial evidence supported the questions the ALJ posed to the vocational expert. The
first hypothetical question posed to the vocational expert included all of the limitations in the
ALJ’s residual functional capacity finding. (R. 24, 94-95). The vocational expert determined that
a person with these limitations could perform light, unskilled jobs in the national economy. (R.
95). As discussed in Issue 3, substantial evidence supports the ALJ’s assessment of the
claimant’s residual functional capacity. So, the ALJ properly relied upon the vocational expert’s
testimony in response to this hypothetical to determine that the claimant could perform light,
unskilled work. Thus, this court finds that the ALJ posed a proper hypothetical question to the
vocational expert that included all of the claimant’s credible impairments. See Graham v. Bowen,
790 F.2d 1572, 1576 (11th Cir. 1986) (when a claimant fails to prove certain impairments, the
ALJ is not required to include these impairments in the hypothetical question posed to the
vocational expert). Thus, the ALJ’s hypothetical questions to the vocational expert were proper,
and substantial evidence supports the ALJ’s finding on this issue.
CONCLUSION
For the foregoing reasons, the court concludes that the ALJ applied the proper legal
standards and substantial evidence supports his decision. The decision of the Commissioner
should be AFFIRMED.
The court will enter a separate order to that effect.

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DONE and ORDERED this 21st day of March, 2019.

____________________________________
KARON OWEN BOWDRE
CHIEF UNITED STATES DISTRICT JUDGE

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