Williams v. Colvin

Filing 22

MEMORANDUM AND ORDER (See Full Order) IT IS HEREBY ORDERED that the decision of the Commissioner is affirmed. A separate Judgment in accord with this Memorandum and Order is entered this date. Signed by District Judge Catherine D. Perry on 6/28/17. (EAB)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION
RANDALL WILLIAMS,
Plaintiff,
v.
NANCY A. BERRYHILL,
Acting Commissioner of Social Security,1
Defendant.

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No. 4:16 CV 690 CDP

MEMORANDUM AND ORDER
Plaintiff Randall Williams brings this action pursuant to 42 U.S.C. §§ 401
and 1381 et seq. and 42 U.S.C. § 405(g) seeking judicial review of the
Commissioner’s decision denying his applications for disability insurance benefits
and supplemental security income. Because the Commissioner’s final decision is
supported by substantial evidence on the record as a whole, I will affirm the
decision of the Commissioner.
I. Procedural History
Plaintiff filed applications for benefits on December 19, 2012. He alleged
he became disabled beginning February 15, 2012, because of chronic obstructive
pulmonary disease (COPD), shortness of breath, an inability to stand or walk for
1

On January 20, 2017, Nancy A. Berryhill became the Acting Commissioner of Social Security.
Under Fed. R. Civ. P. 25(d), Berryhill is automatically substituted for former Acting
Commissioner Carolyn W. Colvin as defendant in this action.

extended periods, knee dysfunction, chest pain, high blood pressure, congestive
heart failure, hand numbness, insomnia, and anxiety. Plaintiff’s insured status
under Title II of the Act expired on December 31, 2013.2
Plaintiff’s applications were initially denied on March 28, 2013. After a
hearing before an ALJ on July 21, 2014, the ALJ issued a decision denying
benefits on December 1, 2014. On April 9, 2015, the Appeals Council denied
plaintiff’s request for review. The ALJ’s decision is thus the final decision of the
Commissioner. 42 U.S.C. § 405(g).
II. Evidence Before the ALJ
Medical Records
On July 5, 2010, plaintiff was evaluated by internist Raymond Leung, M.D.
Williams reported having hypertension, coronary heart failure, back and knee pain,
numbness of the hands and feet, decreased vision, and headaches. He used a cane
to help him walk because “he just had it.” Examination showed normal cardiac
rate and rhythm with no murmurs.

Pulmonary examination was clear to

auscultation, with no rales, rhonchi, or wheezes, and normal percussion and AP
diameter. Plaintiff’s gait, without his cane, was stiff. Plaintiff walked with a
minimal limp with his cane. He was able to tandem walk and hop, heel walk, toe
2

To be entitled to disability insurance benefits under Title II of the Act, plaintiff had the burden
to show that he was disabled prior to the expiration of his insured status on December 31, 2013.
See Moore v. Astrue, 572 F.3d 520, 522 (8th Cir. 2009). To be entitled to supplemental security
income, plaintiff must show that he was disabled while his application was pending. See Steed
v. Astrue, 524 F.3d 872, 874 n.2 (8th Cir. 2008).
2

walk, and squat. Straight leg raising with the right leg was limited to 70 degrees
and 85 degrees on the left leg. Plaintiff had a decreased range of motion in his
lumbar spine and knees, with no muscular atrophy or spasms. His pinch, grip, arm,
and leg strength were 4+/5, and plaintiff had no difficulties getting on and off the
exam table. Plaintiff had decreased sensation to pin prick in his left hand and mild
decreased vibratory sensation in his feet. Proprioception in the toes was within
normal limits and his reflexes were normal. Plaintiff had no edema and normal
distal pulses in his extremities. After examination, Dr. Leung’s impression was
hypertension controlled, congestive heart failure with normal lung examination,
back and knee pain, numbness of the hands and feet, decreased vision, and
headaches. (Tr. 463-68).
On October 16, 2012, plaintiff saw Vani Pachalla, M.D., for a medication
refill and follow up for his congestive heart failure. Plaintiff’s condition was noted
to be stable. Plaintiff reported chest pain, increased fatigue, orthopnea, palpitations
and shortness of breath, but no swelling, frequent urination, impotence, irritability,
ulcers, or weight gain. Examination revealed normal respiratory sounds, with clear
lungs, and a normal heart rate and rhythm with no murmurs, gallops, or rubs.
Plaintiff had no abnormalities in his back or spine but trace edema on his lower
leg. Dr. Pachalla noted that plaintiff was non-compliant with his current therapy
and medication regimen and had missed many of his cardiac follow-up
3

appointments. Plaintiff admitted smoking and was diagnosed with nondependent
tobacco use disorder. Plaintiff and his wife were counseled on his diagnosis, and
Dr. Pachealla ordered lab work. (Tr. 308-10).
On November 18, 2012, plaintiff went to the emergency room complaining
of chest pain. Examination revealed normal heart rhythm, regular breath sounds,
no edema in extremities, and a full range of motion with no inflammation. A stress
test revealed abnormal myocardial perfusion with a small to medium area of mild
ischemia in the inferolateral wall and normal LV systolic function.

An

echocardiogram showed normal systolic function with an ejection fraction in the
55 to 65 percent range. There were no regional wall motion abnormalities and wall
thickness was normal. A cardiac cath test was also performed and revealed that the
left ventricular function was at the lower end of the normal range, with a visually
estimated ejection fraction of 45 to 50 percent. The coronary arteries and left and
right heart hemodynamics were normal.

There was minimal or mild mitral

regurgitation. Plaintiff was discharged on November 21, 2012, with the diagnoses
of chest pain, likely related to congestive heart failure or COPD, COPD, systolic
and diastolic congestive heart failure, hypertension, hypersensitivity lung disease,
tobacco abuse, depression, and acute respiratory failure. (Tr. 316-79).
Plaintiff returned to the emergency room on December 7, 2012, complaining
of a headache and nausea. He said it had lasted about a week, but he denied having
4

a fever or vomiting. Upon examination, plaintiff’s breathing sounds were normal,
his heart rate and rhythm were regular, and he had no focal pain in any muscle or
joint groups. His reflexes, mood, and affect were normal. A CT scan of his head
was normal. He was diagnosed with a headache and discharged. (Tr. 432-57).
On January 24, 2013, plaintiff saw Susana Lazarte, M.D., for a follow up
visit for chest pain. Dr. Lazarte noted that plaintiff’s November test results showed
only mild ischemia, normal coronaries, and only mild diastolic dysfunction.
Plaintiff reported feeling depressed and worried that he could have a serious
disease.

Plaintiff’s physical examination was within normal limits, but he

displayed a depressed affect, anhedonia, and anxiety.

Dr. Lazarte noted that

plaintiff was compliant with his medication regimen, his relative risk was
improving, and he was responding to current treatment. Dr. Lazarte adjusted
plaintiff’s medication. (Tr. 569-72).
On February 18, 2012, plaintiff saw cardiologist Alan Zajarias, M.D.
Plaintiff’s diagnoses were listed as hypertension, dyslipidemia, nonischemic
cardiomyopathy, with a mildly decreased ejection fraction, and tobacco abuse.
Plaintiff reported that he had stopped smoking.

He complained of migraine

headaches and occasionally feeling winded but denied angina, syncope,
presyncope, orthopnea, or PND.

Dr. Zajarias noted that plaintiff’s medical

compliance was intermittent. Physical examination was normal, with a regular
5

heart rate, clear breath sounds, and no edema in extremities.

Dr. Zajarias

continued plaintiff’s medications, ordered lab work to check plaintiff’s brain
natriuretic peptide, and referred him for a sleep study. Plaintiff’s BNP test results
were all within normal limits.
On June 3, 2013, plaintiff saw Maria Del Rosario Bobadilla for depression.
Plaintiff reported feeling anxious, fearful, depressed, worthless, and indecisive.
Plaintiff claimed he had poor concentration, hallucinations, changes in appetite,
sleep disturbance, and thoughts of death or suicide. Plaintiff was noted to have the
symptoms of a major depressive episode. Plaintiff reported having a history of
suicidal thoughts and claimed to hear voices telling him to end his life, but he
denied having a plan. He was encouraged to take his medication and continue
counseling. Clinical assessment was unspecified psychosis and his GAF score was
43. (Tr. 565).
Plaintiff saw Miranda Coole, M.D. on June 19, 2013, for depression.
Plaintiff told Dr. Coole that he was having extreme difficulties meeting home,
work, and social obligations. He reported depressed mood, diminished interest,
fatigue, feelings of guilt or worthlessness, changes in appetite, sleep disturbance,
and thoughts of death or suicide. Plaintiff stated that had thoughts and plans of
suicide, his suicidal thoughts were “much worse” than they had ever been before,
and he was worried he might try to electrocute himself or jump in front of a car.
6

Physical examination yielded normal results. Dr. Coole diagnosed depression with
anxiety and discussed emergency treatment options for suicidal thoughts and plans.
(Tr. 563-64). Plaintiff went to the emergency room later that day for increased
depressive symptoms and suicidal ideations and was hospitalized for bipolar
disorder, major depressive disorder, and cluster B traits until June 22, 2013. (Tr.
392). Physical examination upon admission showed normal cardiac rhythm and
heart sounds, normal breath sounds, a normal range of motion, no edema, and
normal muscle tone. (Tr. 395).
Plaintiff saw Dr. Coole again on July 17, 2013, complaining of swelling in
his ankles and legs and joint pain. Plaintiff denied chest pains, cough, orthopnea,
or shortness of breath. Dr. Coole noted plaintiff’s history of congestive heart
failure, hypertension, non-ischemic cardiomyopathy, and positive ANA. Dr. Coole
observed edema in the extremities, but physical examination was otherwise within
normal limits. Dr. Coole diagnosed congestive heart failure and increased his
medication. She also referred him to a rheumatologist and a behavioral health
specialist. (Tr. 555-57).
At his next visit on July 31, 2013, plaintiff told Dr. Coole that he was having
shortness of breath in the morning and at night. His physical examination was
normal, with no edema in the extremities, regular heart rate and rhythm, and

7

normal breath sounds. Dr. Coole’s assessment was congestive heart failure. She
renewed plaintiff’s medications. (Tr. 545-47).
Plaintiff began therapy for his depression with John Rajeev, LCSW, on
August 5, 2013. Plaintiff reported having mood swings, irritability, and crying
spells. Mr. Rajeev’s assessment was moderate, recurrent major depression and he
assigned plaintiff a GAF score of 50. (Tr. 542-43). Plaintiff had sessions with Mr.
Rajeev again in September and October of 2013. Plaintiff denied suicidal thoughts
and was encouraged to continue with his medications. His assessment and GAF
scores remained unchanged. (Tr. 528-32).
Plaintiff saw Dr. Coole for a medication refill on September 17, 2013. At
that visit, plaintiff reported feeling lightheaded, claiming it affected his ability to
lift, sit, stand, and walk. He also reported falling, pain, and unsteadiness, but he
denied having chest pain, dizziness, dysphasia, fever, gait change, numbness, or
weakness. Plaintiff said he felt sleepy during the day, dropped things for no
reason, sometimes lost his balance, snored, and had sleep apnea. Plaintiff also
stated he had joint pain with decreased mobility, instability, limping, swelling, and
tenderness.

He reported using a cane and told Dr. Coole that he wanted a

prescription for a cane so he could take it with him on a trip. Physical examination
yielded normal results, with normal heart and breath sounds and no edema or
tenderness. Dr. Coole assessed plaintiff’s congestive heart failure as stable, gave
8

him the requested prescription for a cane to “use daily as directed for joint pain,”
and ordered a sleep study. (Tr. 534-37).
On December 13, 2013, plaintiff was evaluated for lupus by Julie Unk,
ANP. Plaintiff complained of shortness of breath, back pain, knee pain, numbness
and tingling of the hands, and insomnia. Ms. Unk noted that he was seen in the
clinic two years before for an evaluation of lupus but never had the lab work
performed to determine a diagnosis. Ms. Unk noted a positive ANA. Plaintiff
denied having any rashes but did report itchy skin. He said he had chest pains and
shortness of breath “daily since the 1990s.”

Plaintiff reported a history of

depression and back pain, claiming that he sometimes lost his balance because of
pain and used a cane for stability.

Plaintiff also stated that he had constant

numbness and tingling of his hands which increased at night. Plaintiff told Ms.
Unk that he had an accident when he was in 20s, resulting in severed nerves in his
left forearm and permanent nerve damage. Plaintiff reported dropping objects due
to numbness and tingling. Plaintiff stated he injured his right hand several times
and now his hand turns cold and changes color. Plaintiff said his knees were stiff
and he had difficulty bending forward to tie his shoes. Plaintiff admitted smoking
one pack of cigarettes every four days. Physical examination revealed normal lung
and heart sounds, no motor or sensory defects with Tinel’s maneuver failing to
increase numbness or tingling in hands, no edema, and a normal functional range
9

of motion with joints, wrists, elbows, shoulders, knees, ankle, and feet all normal
in appearance. Imaging of plaintiff’s knees, cervical spine, and lumbar spine
revealed minimal, bilateral joint space narrowing of the knees, moderate multilevel
cervical degenerative disc disease most severe at C5-C6 through C7-T1, and mild
degenerative disc disease at L4-L5. Ms. Unk assessed plaintiff with positive ANA,
back pain, knee pain, neck pain, and paresthesias in both hands.

Ms. Unk

recommended plaintiff start B6 vitamins and stop smoking. (Tr. 470-73).
Plaintiff was seen by Edward Coverstone, M.D., on March 17, 2014, for a
cardiology follow-up. Dr. Coverstone reported that plaintiff was doing “poorly”
since his last visit with Dr. Zajarias.

Plaintiff reported having dyspnea with

minimal exertion, some chest pain and pressure with palpitations, and some
lightheadedness upon standing. Plaintiff stated that he was compliant with his
medications. Physical examination yielded normal results except for trace bilateral
pedal edema.

With respect to plaintiff’s nonischemic cardiomyopathy, Dr.

Coverstone found plaintiff euvolemic, continued him on his current medications,
and ordered testing given his New York Heart Association class II to III
symptoms. Dr. Coverstone assessed plaintiff with mild COPD, well-controlled
hypertension, dyslipidemia, and likely sleep apnea. (Tr. 476-77).
Three days later, plaintiff was evaluated for sleep apnea by Christopher
Petrey, D.O. Physical examination revealed grade 2 tonsils with narrowed airway,
10

some edema, and skin tautness of face, arms, and hands. Dr. Petrey concluded that
these symptoms, in combination with plaintiff’s excessive BMI and positive ANA,
were suggestive of sleep apnea with a component of GERD and questionable
esophageal motility disorder, and a possible underlying autoimmune disease. Dr.
Petrey noted that plaintiff also described symptoms suggestive of Raynaud’s
phenomenon and believed plaintiff should be evaluated by a rheumatologist and
his primary care physician. Dr. Petrey started plaintiff on titration with a CPAP.
(Tr. 575-77).
Plaintiff went to the emergency room on May 28, 2014, complaining of
tingling in his arms, blurred vision, numbness, weakness, and jaw pain. Plaintiff
reported smoking one-half pack of cigarettes daily. Physical examination showed
a normal heart rate and rhythm, normal breath sounds, a normal range of motion
with no edema or tenderness, normal strength and reflexes, normal Finger-NoseFinger Test, no pronator drift, normal gait, and 5/5 muscle strength. An EKG
yielded normal results. Plaintiff was diagnosed with diabetes mellitus and given
insulin. He was discharged the next day. (Tr. 481-87).
Testimony
Plaintiff testified at the hearing held on July 21, 2014. He stated that he
stopped smoking about one month before the hearing and was compliant with his
medications. At the time of the hearing, plaintiff was 5’6 ½” tall and weighed 200
11

pounds.

He testified as follows.

Plaintiff’s back problems keep him from

working. He can only sit for 20 minutes at a time before he slumps over. Plaintiff
has trouble standing because of weak joints, elbows, and knees. He can only stand
for 10-15 minutes before he has to lean against something or sit down. Plaintiff
has been using a cane for four to five years. He has daily numbness in his arms, so
he can’t lift anything. Plaintiff gets tired and feels weak. He has trouble breathing
because of anxiety and can’t ride in cars. He walks from his house to go fishing.
Plaintiff doesn’t like crowds and feels paranoid. He cleans the house and does
laundry, but he has to sit down when his arms and legs get numb. He feels
depressed and hopeless at least three times a week. Plaintiff has mood swings. His
heart is okay. (Tr. 48-65).
Legal Standard
A court’s role on review is to determine whether the Commissioner’s
findings are supported by substantial evidence on the record as a whole. Gowell v.
Apfel, 242 F.3d 793, 796 (8th Cir. 2001). Substantial evidence is less than a
preponderance, but is enough so that a reasonable mind would find it adequate to
support the ALJ’s conclusion. Prosch v. Apfel, 201 F.3d 1010, 1012 (8th Cir.
2000). As long as there is substantial evidence on the record as a whole to support
the Commissioner’s decision, a court may not reverse it because substantial
evidence exists in the record that would have supported a contrary outcome, id., or
12

because the court would have decided the case differently. Browning v. Sullivan,
958 F.2d 817, 822 (8th Cir. 1992). In determining whether existing evidence is
substantial, a court considers “evidence that detracts from the Commissioner’s
decision as well as evidence that supports it.” Singh v. Apfel, 222 F.3d 448, 451
(8th Cir. 2000) (quoting Warburton v. Apfel, 188 F.3d 1047, 1050 (8th Cir. 1999)).
Where the Commissioner’s findings represent one of two inconsistent conclusions
that may reasonably be drawn from the evidence, however, those findings are
supported by substantial evidence. Pearsall v. Massanari, 274 F.3d 1211, 1217
(8th Cir. 2001) (internal citation omitted).
To determine whether the decision is supported by substantial evidence, the
Court is required to review the administrative record as a whole and to consider:
(1) the credibility findings made by the Administrative Law Judge;
(2) the education, background, work history, and age of the claimant;
(3) the medical evidence from treating and consulting physicians;
(4) the plaintiff’s subjective complaints relating to exertional and nonexertional impairments;
(5) any corroboration by third parties of the plaintiff’s impairments;
and
(6) the testimony of vocational experts, when required, which is based
upon a proper hypothetical question.
Brand v. Secretary of Dep’t of Health, Educ. & Welfare, 623 F.2d 523, 527 (8th
Cir. 1980).
13

Disability is defined in social security regulations as the inability to engage
in any substantial gainful activity by reason of any medically determinable
physical or mental impairment which can be expected to result in death or which
has lasted or can be expected to last for a continuous period of not less than twelve
months.

42 U.S.C. ' 416(i)(1); 42 U.S.C. '1382c(a)(3)(A); 20 C.F.R. '

404.1505(a); 20 C.F.R. ' 416.905(a).

In determining whether a claimant is

disabled, the Commissioner must evaluate the claim using a five step procedure.
First, the Commissioner must decide if the claimant is engaging in
substantial gainful activity.

If the claimant is engaging in substantial gainful

activity, he is not disabled.
Next, the Commissioner determines if the claimant has a severe impairment
which significantly limits the claimant’s physical or mental ability to do basic
work activities. If the claimant’s impairment is not severe, he is not disabled.
If the claimant has a severe impairment, the Commissioner evaluates
whether the impairment meets or exceeds a listed impairment found in 20 C.F.R.
Part 404, Subpart P, Appendix 1. If the impairment satisfies a listing in Appendix
1, the Commissioner will find the claimant disabled.
If the Commissioner cannot make a decision based on the claimant=s current
work activity or on medical facts alone, and the claimant has a severe impairment,

14

the Commissioner reviews whether the claimant can perform his past relevant
work. If the claimant can perform his past relevant work, he is not disabled.
If the claimant cannot perform his past relevant work, the Commissioner
must evaluate whether the claimant can perform other work in the national
economy. If not, the Commissioner declares the claimant disabled. 20 C.F.R. '
404.1520; 20 C.F.R. ' 416.920.
When evaluating evidence of pain or other subjective complaints, the ALJ is
never free to ignore the subjective testimony of the plaintiff, even if it is
uncorroborated by objective medical evidence. Basinger v. Heckler, 725 F.2d
1166, 1169 (8th Cir. 1984). The ALJ may, however, disbelieve a claimant’s
subjective complaints when they are inconsistent with the record as a whole. See
e.g., Battles v. Sullivan, 902 F.2d 657, 660 (8th Cir. 1990). In considering the
subjective complaints, the ALJ is required to consider the factors set out by Polaski
v. Heckler, 739 F.2d 1320 (8th Cir. 1984), which include:
claimant’s prior work record, and observations by third parties
and treating and examining physicians relating to such matters
as: (1) the claimant’s daily activities; (2) the duration,
frequency, and intensity of the pain; (3) precipitating and
aggravating factors; (4) dosage, effectiveness and side effects of
medication; and (5) functional restrictions.
Id. at 1322. When an ALJ explicitly finds that the claimant’s testimony is not
credible and gives good reasons for the findings, the court will usually defer to the
ALJ=s finding. Casey v. Astrue 503 F.3d 687, 696 (8th Cir. 2007). However, the
15

ALJ retains the responsibility of developing a full and fair record in the nonadversarial administrative proceeding. Hildebrand v. Barnhart, 302 F.3d 836, 838
(8th Cir. 2002).
The ALJ’s Findings
The ALJ issued her decision that plaintiff was not disabled on December 1,
2014. She found that plaintiff had the severe impairments of degenerative disc
disease, congestive heart failure, non-ischemic cardiomyopathy, COPD, and major
depression with anxiety.

However, the ALJ found that plaintiff retained the

residual functional capacity (RFC) to perform medium work,3 with the exception
that he could only occasionally climb ladders, ropes, scaffolds, stairs or ramps, and
should avoid concentrated exposure to fumes, odors, dust, and gases. The ALJ
further found that plaintiff should not interact with supervisors, co-workers, or the
public more than frequently. In fashioning plaintiff’s RFC, the ALJ determined
that his impairments could be expected to produce some of his alleged symptoms;
however, she concluded that plaintiff’s statements concerning the intensity,
persistence, and limiting effects of those symptoms were not entirely credible to
the extent they were inconsistent with his RFC. The ALJ relied on a vocational
expert’s testimony to determine that plaintiff could work as a conveyor feeder
offbearer, machine feeder, and marker. Because the ALJ determined that these
3

Medium work involves lifting no more than 50 pounds at a time with frequent lifting or
carrying of objects weighing up to 25 pounds. 20 C.F.R. § 404.1567.
16

jobs exist in significant numbers in the national economy, she concluded that
plaintiff was not disabled.
Discussion
Plaintiff argues that substantial evidence does not support the ALJ’s
determination of his RFC because she did not properly consider all of his
limitations.

RFC is defined as “what [the claimant] can still do” despite his

“physical or mental limitations.” 20 C.F.R. ' 404.1545(a). “When determining

whether a claimant can engage in substantial employment, an ALJ must consider
the combination of the claimant=s mental and physical impairments.” Lauer v.
Apfel, 245 F.3d 700, 703 (8th Cir. 2001). The ALJ must determine a claimant’s
RFC based on all of the relevant evidence, including the medical records,
observations of treating physicians and others, and an individual ’s own description
of his limitations. McKinney v. Apfel, 228 F.3d 860, 863 (8th Cir. 2000) (citing
Anderson v. Shalala, 51 F.3d 777, 779 (8th Cir. 1995)). The record must include
some medical evidence that supports the RFC. Dykes v. Apfel, 223 F.3d 865, 867
(8th Cir. 2000). “Where the claimant has the residual functional capacity to do
either the specific work previously done or the same type of work as it is generally
performed in the national economy, the claimant is found not to be disabled. ”
Lowe v. Apfel, 226 F.3d 969, 973 (8th Cir. 2000) (internal citation omitted).

17

Plaintiff claims that the ALJ substantially erred when she determined that he could
perform a wide range of medium work despite his back and heart problems.
Here, the ALJ properly formulated plaintiff’s RFC only after evaluating his
credibility and discussing the relevant evidence, including his testimony, the
medical evidence, and his daily activities. After consideration of all this evidence,
the ALJ concluded that plaintiff retained the capacity to perform medium work,
with modifications tailored to his credible limitations. In so doing, she did not
substantially err.

In addition to the ALJ’s thorough assessment of plaintiff’s

credibility (discussed below), the ALJ also factored into her RFC assessment the
objective medical findings of record, including the diagnostic imaging results and
physical examination findings, which do not support plaintiff’s claimed limitations.
As the ALJ noted, most of plaintiff’s physical examinations were normal
despite his complaints of back and chest pain. For example, in October of 2012,
Dr. Pachalla saw plaintiff for his congestive heart failure. His condition was noted
to be stable at that time. Despite plaintiff’s complaints of chest pain, fatigue, and
shortness of breath, physical examination yielded normal heart rate and rhythm
with no murmurs, gallops, or rubs, normal breath sounds, and only trace edema in
his lower leg. However, plaintiff was noted to be non-compliant with his therapy
and medications and had missed many of his cardiac follow-up appointments. The
next month, plaintiff went to the emergency room complaining of chest pain.
18

However, examination revealed normal heart rhythm, regular breath sounds, no
edema in his extremities, and a full range of motion with no inflammation.
Plaintiff went back to the emergency room in December of 2012, but examination
showed normal heart rate and rhythm, normal breath sounds, no focal pain in any
muscle or joint groups, and normal reflexes. During plaintiff’s January 24, 2013,
visit with Dr. Lazarte for chest pain, Dr. Lazarte noted plaintiff’s diagnostic test
results showed only mild ischemia, normal coronaries, and only mild diastolic
dysfunction.

Plaintiff’s physical examination was normal, and Dr. Larazte

believed that as plaintiff was compliant with his medications, his relative risk was
improving because he was responding to current treatment. Plaintiff’s cardiologist,
Dr. Zajarias, examined plaintiff in February of 2013. Plaintiff’s examination was
again normal, with a regular heart rate, clear breath sounds, and no edema.
Plaintiff’s physical examination upon his admission to the emergency room
in June of 2013 for depression also showed normal cardiac rhythm and heart
sounds, normal breath sounds, a normal range of motion, no edema, and normal
muscle tone. Plaintiff saw Dr. Coole in July of 2013 for swelling and joint pain.
Although Dr. Coole observed some swelling in the extremities, plaintiff’s
examination was otherwise within normal limits. At his next visit with Dr. Coole
two weeks later, plaintiff’s edema was gone, and his physical examination was
within normal limits, with a regular heart rate and rhythm and normal breath
19

sounds. Dr. Coole’s examination of plaintiff in September of 2013 also yielded
normal results, with normal heart and breath sounds and no edema or tenderness.
She assessed plaintiff’s congestive heart failure as stable.
Plaintiff was evaluated for lupus in December of 2013. Once again, physical
examination revealed normal lung and heart sounds, no motor or sensory defects
with Tinel’s maneuver failing to increase numbness or tingling in hands, no edema,
and a normal functional range of motion with joints, wrists, elbows, shoulders,
knees, ankle, and feet all normal in appearance. Plaintiff’s next emergency room
visit was in May of 2014, just two months before his hearing with the ALJ, for
tingling in his arms, numbness and jaw pain. His physical examination at that time
showed a normal heart rate and rhythm, normal breath sounds, a normal range of
motion with no edema or tenderness, normal strength and reflexes, normal FingerNose-Finger test, no pronator drift, normal gait, and 5/5 muscle strength.
Plaintiff’s numerous normal physical examinations, despite his complaints
of back and heart problems, were properly considered by the ALJ as one factor
when formulating his RFC. See Goff v. Barnhart, 421 F.3d 785, 793 (8th Cir.
2005) (lack of corroborating medical evidence is one factor to consider when
evaluating subjective complaints of pain). Although plaintiff complains that none
of these evaluations included a “complete musculoskeletal or neurological

20

examination,”4 “there is no requirement than an RFC finding be supported by a
specific medical opinion.” Myers v. Colvin, 721 F.3d 521, 526-27 (8th Cir. 2013).
Moreover, plaintiff submitted no such opinion regarding his limitations. “The
burden of persuasion to prove disability and to demonstrate RFC remains on the
claimant, even when the burden of production shifts to the Commissioner at step
five.” Goff, 421 F.3d at 790. Here, where the RFC is supported by substantial
evidence on the record as a whole, the ALJ was not required to obtain a specific
“musculoskeletal or neurological examination” or a doctor’s opinion regarding
how much plaintiff can carry or how long he can stand or sit to determine his
work-related limitations. Hensley v. Colvin, 829 F.3d 926, 932 (8th Cir. 2016)
(ALJ not required to seek additional information from treating physicians or order
consultative examination where medical record is adequately developed); Martise
v. Astrue, 641 F.3d 909, 926-27 (8th Cir. 2011) (ALJ required to supplement
record only if the existing medical record does not provide sufficient evidence to
determine whether the claimant is disabled); Thornhill v. Colvin, 4:12CV1150

4

Although plaintiff argues that Dr. Leung’s evaluation was the only “detailed” evaluation in the
record, he admits that this examination was conducted almost two years before his alleged onset
date. As such, it was not error for the ALJ to rely on other, substantial evidence of record
regarding plaintiff’s limitations. Moreover, Dr. Leung’s examination also showed normal
cardiac rate and rhythm, clear lungs, normal reflexes, and no edema. Plaintiff was able to
tandem walk and hop, heel walk, toe walk, and squat. Although he had a decreased range of
motion in his lumbar spine and knees, he had no muscle atrophy or spasms, his pinch, grip, arm,
and leg strength were 4+/5, and he had no difficulties getting on and off the exam table. Thus,
even if this examination occurred during the relevant time period, it does not support the degree
of limitation claimed by plaintiff.
21

CEJ, 2013 WL 3835830, at *11-12 (E.D. Mo. July 24, 2013) (numerous
unremarkable physical examinations with normal gait and no evidence of
abnormalities in joints or spine or range of motion limitation or muscle tenderness
supported ALJ’s determination that claimant could perform a range of medium
work despite lack of specific opinion from doctor indicting claimant’s work-related
limitations).
Plaintiff points to his evaluation in March of 2014 by cardiologist Dr.
Coverstone -- who noted that plaintiff was doing “poorly” since his last visit with
Dr. Zajarias -- as evidence that the ALJ erred in her RFC assessment.5 However,
despite this notation plaintiff’s physical examination was again normal, except for
trace bilateral pedal edema. Dr. Coverstone ordered testing given plaintiff’s “New
York Heart Association class II to III symptoms.”6 While “[a] treating physician’s
opinion should not ordinarily be disregarded and is entitled to substantial weight,”
Cunningham v. Apfel, 222 F.3d 496, 502 (8th Cir. 2000), the Commissioner “may
discount or even disregard the opinion of a treating physician where other medical
assessments are supported by better or more thorough medical evidence.”
5

The ALJ considered this opinion when formulating the RFC, but mistakenly referred to it as the
opinion of Dr. Zajarias. Drs. Coverstone and Zajarias are both cardiologists in Washington
University’s Cardiovascular Division.
6

This means plaintiff’s symptoms were between slight (class II) and marked (class III).
However, “a NYHA classification does not correspond to any specific RFC finding.” Campbell
v. Colvin, 4:15CV1330 NCC, 2016 WL 3854538, at *4 (E.D. Mo. July 15, 2016). To the extent
plaintiff argues that his RFC is erroneous merely because his cardiac symptoms were described
by Dr. Coverstone as class II to class III, this argument is rejected.
22

Wildman v. Astrue, 596 F.3d 959, 964 (8th Cir. 2010) (quoting Goff, 421 F.3d at
790).

Here, Dr. Coverstone’s comment that plaintiff was doing “poorly” is

inconsistent with his examination of plaintiff, which yielded normal results, and his
assessment that plaintiff’s COPD was mild, his hypertension was “wellcontrolled,” plaintiff’s fluids were all normal with respect to his cardiomyopathy,
and his cardiac symptoms were only slight (class II) to marked (class III). As the
Eighth Circuit has recognized, a class III classification does not mandate a finding
of disability. KKC ex rel. Stoner v. Colvin, 818 F.3d 364, 372 (8th Cir. 2016)
(“Although a classification of . . . class III heart failure could support a finding of
disability, [claimant’s] classification did not require the ALJ to make such a
finding in this case.”). Here, where plaintiff’s symptoms were only described as
between class II – which indicates only slight symptoms – and class III, it was not
error for the ALJ to consider the record as whole and determine that plaintiff was
able to perform modified medium work. See Fentress v. Berryhill, 854 F.3d 1016,
1020-21 (8th Cir. 2017) (treating physician’s opinion properly discounted where
claimant had numerous normal physical examinations and diagnostic test results
demonstrated plaintiff’s symptoms were well-controlled when compliant with
treatment recommendations).
Plaintiff also argues that his use of, and prescription for, a cane is evidence
that the ALJ substantially erred in her assessment of his RFC. The ALJ considered
23

plaintiff’s use of a cane but ultimately discounted its significance in her
formulation of the RFC because plaintiff requested the prescription so he could
take his cane on an airplane.

Stated otherwise, Dr. Coole wrote plaintiff a

prescription for a cane he was already using at his request. Plaintiff admitted to
Dr. Leung back in 2010 that he used the cane because “he just had it,” not because
a doctor had prescribed its use for him. While Dr. Coole accommodated plaintiff
and gave him the requested prescription, his physical examination during that visit
was again normal, with normal heart and breath sounds and no edema or
tenderness. Dr. Coole assessed plaintiff’s congestive heart failure as stable at that
time. Given that plaintiff was found to have no motor or sensory defects, no
edema, and a normal functional range of motion with joints, wrists, elbows,
shoulders, knees, ankle, and feet in December of 2013 and a normal range of
motion with no edema or tenderness, normal strength and reflexes, normal gait,
and 5/5 muscle strength in May of 2014 (less than two months before his hearing
with the ALJ), the ALJ did not substantially err in her limited consideration of
plaintiff’s use of a cane when formulating his RFC. Moreover, the ALJ did not
simply adopt a medium work RFC wholesale, but rather modified it to reflect that
plaintiff should only occasionally climb ladders, ropes, scaffolds, stairs or ramps,
thereby reflecting plaintiff’s credible limitations. Under these circumstances, the
ALJ did not substantially err in formulating plaintiff’s RFC.
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The ALJ’s RFC was also substantially supported by plaintiff’s diagnostic
test results. Plaintiff’s tests from his emergency room visit in November of 2012
showed only mild ischemia, normal coronaries, and only mild diastolic
dysfunction. A CT scan of his head taken the next month was also normal, and
plaintiff’s BNP test results in February of 2013 were all within normal limits.
Imaging of plaintiff’s knees, cervical spine, and lumbar spine in December of 2013
revealed only minimal, bilateral joint space narrowing of the knees, moderate
multilevel cervical degenerative disc disease most severe at C5-C6 through C7-T1,
and mild degenerative disc disease at L4-L5. Plaintiff’s EKG taken in May of
2014 was normal. These objective findings support the ALJ’s determination that
plaintiff could perform a range of medium work with limitations. See Steed v.
Astrue, 524 F.3d 872, 875-76 (8th Cir. 2008) (diagnostic tests indicating claimant’s
back problems were mild to moderate supported ALJ’s RFC assessment despite
fact that medical evidence was “silent” as to work-related restrictions; claimant’s
failure to provide this evidence cannot be held against the ALJ where the medical
evidence supports the ALJ’s decision).
Plaintiff also argues that the ALJ failed to take into account his subjective
complaints of pain when formulating his RFC. Although an ALJ is never free to
ignore a claimant’s subjective complaints of pain, they may be discounted if there
are inconsistencies in the record as a whole. See Buckner v. Astrue, 646 F.3d 549,
25

558 (8th Cir. 2011). Here, the ALJ found plaintiff’s allegations regarding his
limitations to be less than fully credible, and her credibility analysis is wellsupported by substantial evidence on the record as a whole for the reasons
discussed below.

The ALJ’s RFC assessment takes into account plaintiff’s

credible limitations of record and is supported by substantial evidence on the
record as a whole.
Plaintiff also argues that the ALJ improperly assessed his credibility.
“The credibility of a claimant’s subjective testimony is primarily for the ALJ to
decide, not the courts.” Pearsall, 274 F.3d at 1218. I must defer to the ALJ’s
credibility determinations “so long as such determinations are supported by good
reasons and substantial evidence.” Vester v. Barnhart, 416 F.3d 886, 889 (8th Cir.
2005). A[T]he duty of the court is to ascertain whether the ALJ considered all of
the evidence relevant to the plaintiff’s complaints . . . under the Polaski standards
and whether the evidence so contradicts the plaintiff’s subjective complaints that
the ALJ could discount his or her testimony as not credible.@

Masterson v.

Barnhart, 363 F.3d 731, 738B39 (8th Cir. 2004). It is not enough that the record
merely contain inconsistencies. Instead, the ALJ must specifically demonstrate in
her decision that she considered all of the evidence. Id. at 738; see also Cline v.
Sullivan, 939 F.2d 560, 565 (8th Cir. 1991). Where an ALJ explicitly considers
the Polaski factors but then discredits a claimant’s complaints for good reason, the
26

decision should be upheld. Hogan v. Apfel, 239 F.3d 958, 962 (8th Cir. 2001).
Here, the ALJ properly evaluated plaintiff’s credibility based upon his own
testimony, the objective medical evidence of record, plaintiff’s daily activities, the
conservative nature of his treatment, his lack of compliance with treatment
recommendations, and the lack of restrictions set out by treating and examining
physicians.

The ALJ summarized plaintiff’s testimony regarding his daily

activities, subjective allegations of pain, as well as his admitted prolonged tobacco
use. The ALJ was not required to fully credit all of plaintiff’s assertions regarding
his limitations given his daily activities, which included preparing meals, cleaning
house, doing laundry, shopping, travel, and fishing. Johnson v. Chater, 87 F.3d
1015, 1017 (8th Cir. 1996).

Instead, she discounted plaintiff’s subjective

complaints only after evaluating the entirety of the record. In so doing, she did not
substantially err, as subjective complaints may be discounted if inconsistencies
exist in the evidence as a whole. Hinchey v. Shalala, 29 F.3d 428, 432 (8th Cir.
1994).
In assessing plaintiff’s credibility, the ALJ noted that no physician ever
rendered an opinion that he was unable to work. The lack of significant limitations
set out by treating and examining physicians is relevant to a determination of
disability. See Goff , 421 F.3d at 792. The ALJ also noted that plaintiff did not
seek or require aggressive treatment for his impairments. See Clevenger v. Social
27

Security Administration, 567 F.3d 971, 976 (8th Cir. 2009). The ALJ concluded
that plaintiff’s subjective complaints of pain were of limited credibility because
they were not supported by the objective medical evidence of record, an important
factor for evaluating a claimant’s credibility. Stephens v. Shalala, 50 F.3d 538,
541 (8th Cir. 1995). The ALJ also properly upon plaintiff’s non-compliance with
treatment recommendations when assessing his credibility.
Massanari, 253 F.3d 1088, 1092 (8th Cir. 2001).

See Holley v.

Despite his cardiac and

respiratory complaints, plaintiff continued to smoke despite being repeatedly
advised to quit. “[A]n ALJ may properly consider the claimant’s noncompliance
with a treating physician’s directions, including failing to take prescription
medications, seek treatment, and quit smoking.” Choate v. Barnhart, 457 F.3d 865,
872 (8th Cir. 2006) (internal citations omitted). The ALJ did not err in considering
plaintiff’s smoking when assessing his credibility.

The ALJ also properly

considered plaintiff’s poor work history and repeated applications for benefits in
her credibility assessment. See, Eichelberger v. Barnhart, 390 F.3d 584, 590 (8th
Cir. 2004) (ALJ may properly consider a claimant’s motivation for secondary gain
when assessing credibility); Julin v. Colvin, 826 F.3d 1082, 1087 (8th Cir. 2016)
(sporadic work history may properly be considered in ALJ’s credibility
assessment).
Where, as here, an ALJ seriously considers but for good reasons explicitly
28

discredits a claimant’s subjective complaints, the Court will not disturb the ALJ’s
credibility determination. Johnson v. Apfel, 240 F.3d 1145, 1147 (8th Cir. 2001).
Substantial evidence in the record as a whole supports the ALJ’s credibility
determination, so I will affirm the decision of the Commissioner as within a
“reasonable zone of choice.” Fentress, 854 F.3d at 1021 (citing Owen v. Astrue,
551 F.3d 792, 798 (8th Cir. 2008)).
Conclusion
Because substantial evidence in the record as a whole supports the ALJ’s
decision to deny benefits, I will affirm the decision of the Commissioner.
Accordingly,
IT IS HEREBY ORDERED that the decision of the Commissioner is
affirmed.
A separate Judgment in accord with this Memorandum and Order is entered
this date.

CATHERINE D. PERRY
UNITED STATES DISTRICT JUDGE
Dated this 28th day of June, 2017.

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