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Wallace v. Berryhill

United States District Court, D. Connecticut

September 6, 2018

JOHN K. WALLACE
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY[1]

          RULING ON THE PLAINTIFF'S MOTION TO REVERSE THE DECISION OF THE COMMISSIONER AND ON THE DEFENDANT'S MOTION FOR AN ORDER AFFIRMING THE DECISION OF THE COMMISSIONER

          ROBERT M. SPECTOR UNITED STATES MAGISTRATE JUDGE.

         This action, filed under § 205(g) of the Social Security Act, 42 U.S.C. § 405(g), seeks review of a final decision by the Commissioner of Social Security [“SSA”] denying the plaintiff Disability Insurance benefits [“DIB”] and Supplemental Security Income benefits [“SSI”].

         I. ADMINISTRATIVE PROCEEDINGS

         On or about December 6, 2010, the plaintiff filed an application for DIB and SSI benefits claiming he has been disabled since January 15, 2008, due to manic depression and bipolar disorder. (Certified Transcript of Administrative Proceedings, dated June 6, 2017 [“Tr.”] 344-56, 411). The plaintiff's application was denied initially (Tr. 234-41; see Tr. 242-45) and upon reconsideration. (Tr. 246-51). On January 19, 2012, the plaintiff requested a hearing before an Administrative Law Judge [“ALJ”] (Tr. 252-58), and on November 14, 2012, a hearing was held before ALJ Ronald J. Thomas, at which the plaintiff and the plaintiff's mother testified. (Tr. 44- 74). On December 27, 2012, ALJ Thomas issued an unfavorable decision denying the plaintiff's claims for benefits. (Tr. 206-28). On February 15, 2013, the plaintiff submitted a request for review of the hearing decision (Tr. 433-34), and on March 28, 2014, the Appeals Council granted the plaintiff's request, vacating the December 27, 2012 decision, and remanding the matter for subsequent proceedings.[2] (Tr. 229-33).

         A second hearing was held before ALJ Thomas on June 26, 2015, at which the plaintiff, his treating physician, Dr. John Nowicki, and Howard Steinberg, a vocational expert, testified. (Tr. 75-132). On October 27, 2015, ALJ Thomas issued an unfavorable decision denying the plaintiff's claim for benefits. (Tr. 9-43). The same day, the plaintiff requested review of the hearing decision (Tr. 7), and, on February 24, 2017, the Appeals Council denied the plaintiff's request for review, thereby rendering the ALJ's decision the final decision of the Commissioner. (Tr. 1-6).

         On April 24, 2017, the plaintiff filed his complaint in this pending action (Doc. No. 1), [3]and on June 26, 2017, the defendant filed her answer and administrative transcript, dated June 6, 2017. (Doc. No. 12). On July 12, 2017, the parties consented to the jurisdiction of a United States Magistrate Judge; the case was transferred to Magistrate Judge Joan G. Margolis. (Doc. No. 17). On January 8, 2018, the plaintiff filed his Motion to Reverse the Decision of the Commissioner (Doc. No. 21), and brief in support (Doc. No. 21-2 [“Pl.'s Mem.”]), [4] and on April 6, 2018, the defendant filed her Motion to Affirm (Doc. No. 29), and brief in support (Doc. No. 29-1 [“Def.'s Mem.”]). On May 1, 2018, this case was reassigned to this Magistrate Judge. (Doc. No. 30).

         For the reasons stated below, the plaintiff's Motion to Reverse the Decision of the Commissioner (Doc. No. 21) is granted such that the matter is remanded for further proceedings consistent with this Ruling, and the defendant's Motion to Affirm (Doc. No. 29) is denied.

         II. FACTUAL BACKGROUND

         A. HEARING TESTIMONY

         On the date of his second hearing, the plaintiff was fifty years old and living with his mother. (Tr. 79). The plaintiff has lived with his mother since he moved back to Connecticut from Los Angeles in 2009. (Tr. 80). The plaintiff has an MBA from DePaul University in Chicago and worked as an accountant in Los Angeles before he stopped working in 2007.[5] (Tr. 81-82). The plaintiff testified that his last long-term employment ended in 2006 when he was laid off; he started having panic attacks and was “so stressed out it was ridiculous.” (Tr. 97). However, it was not until January 2008 that the plaintiff “realized [he] had a problem[]” because he was “in denial before that.” (Tr. 98). In 2010, the plaintiff was treated for cardiac heart failure (Tr. 99), after which he suffered from “severe depression[.]” (Tr. 100). At the time of the hearing, the plaintiff reported that he had been sober for the past year (Tr. 84), and that he attended Alcoholics Anonymous meetings three times a week. (Tr. 85). According to the plaintiff, he suffers from panic attacks, which are “just as bad[]” now that he is sober, even with “the [fourteen] pills” he takes each day. (Tr. 86).

         The plaintiff testified that he does aqua classes three times a week and walks his dog “about a block” to keep his “heart going.” (Tr. 87, 89). According to the plaintiff, he is “bad” with hygiene. (Tr. 91). He makes simple meals and is not allowed to use the stove, and he gets “bored” or loses interest when doing chores. (Tr. 91; see also Tr. 103 (mows the lawn in “pieces and parts[]”)). He drives to the gym and grocery store, but he always uses a GPS because “[s]ometimes” he forgets where he is going. (Tr. 92). According to the plaintiff, he is “horrific in groups . . . [; he is] afraid of them.” (Tr. 94). He does not answer his phone; he tries “to avoid social interaction.” (Tr. 106). The plaintiff described his writing as “so horrific[, ]” “like, scribble[;]” he cannot complete tasks[;] he “screw[s] up with everything[, ]” and his short-term memory is “shot.” (Tr. 103-06).

         Dr. John Nowicki, who is the plaintiff's mother's first cousin, testified that he has been the plaintiff's primary care physician since 2008. (Tr. 109-10). Dr. Nowicki testified that the plaintiff has marked depression that “worsened after his hospitalization in February 2010[]” and “became bipolar.” (Tr. 111). According to Dr. Nowicki, the plaintiff has frequent panic attacks that affect his ability to function. (Tr. 111). As of result of his hospitalization in February 2010, during which he suffered from cerebral anoxia, he has suffered from a “decrease in his cognitive function[], ” and his IQ decreased by 40 points. (Tr. 111-14, 116). Additionally, Dr. Nowicki opined that the plaintiff's psychiatric treatment “seems to be somewhat successful, but not fully successful[, ]” as the plaintiff has “developed bipolar disorder” (Tr. 114), and he has difficulty concentrating and “following through.” (Tr. 116). According to Dr. Nowicki, the plaintiff has marked restrictions in activities of daily living, social functioning, and concentration, persistence, or pace, and the plaintiff's mental impairment meets Listing 12.03. (Tr. 118-19).

         The vocational expert testified that a person of the plaintiff's age, education, and work experience who is limited to the light exertional level of work could occasionally bend and balance, twist, climb, crawl, kneel, and squat; could sustain routine, simple, repetitive tasks not requiring teamwork or working closely with the public; could engage in occasional interaction with the public, supervisors, and coworkers; and could perform the following light, unskilled jobs: office helper with approximately 207, 000 jobs in the national economy; hotel housekeeper with approximately 137, 000 jobs in the national economy; and mail clerk with approximately 122, 000 jobs in the national economy. (Tr. 121-23).

         B. MEDICAL HISTORY[6]

         On August 4, 2008, the plaintiff was admitted at California Pacific Medical Center after presenting to the emergency room with reports of a seizure. (Tr. 755; see Tr. 755-57). He stated that he previously had a seizure in March, but attributed it to anxiety and did not seek medical attention. (Tr. 755). The plaintiff “actively denied any significant use of alcohol or any other drugs throughout the course of his hospital stay[, ]” and his partner, who accompanied him, reported that the plaintiff was “clearly minimizing his alcohol use.” (Tr. 755). Testing in the emergency room confirmed a blood alcohol level and the presence of cocaine. (Tr. 755). The plaintiff's seizure symptoms were diagnosed as “most consistent with alcohol withdrawal.” (Tr. 756). He was also diagnosed with alcoholic hepatitis and hypertension. (Tr. 756). The plaintiff was treated for alcohol withdrawal, but despite ongoing symptoms, by August 8, he was discharged upon request, as he was not considered “a candidate for hold” given that he was appropriately oriented. (Tr. 756). The plaintiff returned to the emergency room the next day for readmission; the attending doctor noted that when the plaintiff left the hospital the day prior, he “clearly went out and drank.” (Tr. 758-59). He was discharged with a diagnosis of alcohol withdrawal, a prescription for Ativan, and a referral for inpatient detoxification. (Tr. 759).

         Thereafter, the plaintiff was admitted for rehabilitation from September 10 to 24, 2008. (Tr. 451-56). He was discharged with the following diagnoses: alcohol dependence, anxiety not otherwise specified, and rule out panic disorder; he was prescribed medication for anxiety and hypertension. (Tr. 451-53). The plaintiff also had elevated liver function tests, seizures, sleep apnea, hypertension, and anemia. (Tr. 452). The plaintiff was directed to follow-up with a psychiatrist within two weeks. (Tr. 452).[7]

         On July 6, 2009, the plaintiff was treated at St. Vincent's Medical Center after he “was found down at the Bridgeport Train Station.” (Tr. 622, 1373-75; see generally Tr. 629-35 (normal x-rays, CT chest scan, CT head scan, CT abdominal scan)). After treatment of abrasions, the plaintiff was assessed as ready to be discharged “when he sobers up.” (Tr. 1374).

         On August 31, 2009, the plaintiff was admitted for residential treatment for chemical dependence relapse at Ocean Hills Recovery, where he was treated by Martin Pennington, Psy.D. (Tr. 470-73; see Tr. 463). Dr. Pennington, a psychologist, observed on a mental status examination that the plaintiff was of high intelligence with an intact memory, without thought disorder, and without delusions or hallucinations. (Tr. 470). The only diagnosis that Dr. Pennington noted was alcohol dependence. (Tr. 470).

         The plaintiff met with Dr. Pennington on a weekly basis for the month of September, starting on September 2, 2009. (Tr. 474).[8] The plaintiff reported that, at that time, he was “working on his C.P.A[, ]” and that he worked for Warner Brother's music “doing accounting and finance” when he lived in Los Angeles. (Tr. 474). According to the plaintiff, he underwent intensive outpatient treatment for alcohol dependence once before, for two weeks, following which he “stayed sober for a couple of months and then started binging.” (Tr. 474). A mental status examination was unremarkable, and the plaintiff was clean and appropriately dressed. (Tr. 474). He was cooperative; he had good eye contact and normal speech; his mood was happy; his memory was intact; his insight was good; his judgment was fair; and, his thought process was coherent. (Tr. 474). Dr. Pennington noted that the plaintiff had above average intelligence, and good attention and concentration. (Tr. 474). The plaintiff's goal was to “stop his binge drinking and stop drinking completely so that he can truly live his life.” (Tr. 474). By September 28, 2009, he was looking for a job and planning to return to California. (Tr. 469). He was discharged on October 1, 2009, in good condition, but Dr. Pennington noted his concern that the plaintiff needed thirty more days of treatment and had not fully accepted his alcoholism. (Tr. 463).

         From February 26 to March 6, 2010, the plaintiff was admitted to Western Medical Center in California. (See Tr. 477-571). The plaintiff presented with shortness of breath and heart palpitations; he was diagnosed with bilateral pneumonia (Tr. 479 (“septic pneumonia”)), then with cardiomegaly and cardiogenic shock. (Tr. 477). He was found to have major arterial blockages that required stenting. (Tr. 481). The plaintiff reported a history of anxiety disorder, and was noted to be “very anxious[]“ upon admission. (Tr. 481).

         During his cardiology consult, Dr. Arthur Selvan noted that an echocardiogram “revealed an enlarged left ventricle with severe generalized hypokinesis and markedly reduced indices of systolic performance: Estimated ejection fraction approximately 18-20%.” (Tr. 484-85). Dr. Selvan diagnosed “severe cardiomyopathy of unknown etiology with markedly diminished indices of left ventricular systolic performance . . . . Shock syndrome: probably cardiogenic; respiratory failure with bilateral infiltrates: probably congestive heart failure . . . .” (Tr. 485) (emphasis omitted). He assessed the plaintiff's prognosis as “[v]ery poor.” (Tr. 485). On February 28, 2010, Dr. Selvan inserted a Swan-Ganz thermodilution catheter and arterial line, and while hospitalized, the plaintiff underwent a catheterization and the insertion of stents. (Tr. 492, 494; see also Tr. 496-97).

         During his hospitalization, the plaintiff was very anxious, had chronic essential tremors, and was given medication for iron-deficiency due to anemia. (Tr. 477). In a psychiatric consultation subsequent to his cardiac surgery, the plaintiff reported that he had “always been a nervous, anxious guy, ” that he did not “drink that much anymore, ” and that he was “binge drinking but . . . was still able to work 60 hours a week.” (Tr. 486). The plaintiff denied ever having a psychiatric diagnosis or seeing a psychiatrist or psychologist other than for alcohol dependence, and he noted that he has “always been very functional throughout his life despite the alcoholism.” (Tr. 486-87). According to the plaintiff, he was “in between jobs secondary to the economy and frequent moving back and forth between the East Coast and different cities on the West Coast.” (Tr. 488). The plaintiff reported that he was currently drinking a few glasses of wine once or twice a week (Tr. 486), although at other points during the admission, the plaintiff said that he was drinking vodka. (Tr. 481, 490). The plaintiff stated that he had a brief period of panic attacks driving or going over bridges, for which he took Xanax, but that “this resolved[, ]”and although the consulting psychiatrist advised the plaintiff that he could receive psychological follow-up after discharge, the plaintiff saw “no need for psychiatric follow[-]up.” (Tr. 487-88).

         The plaintiff subsequently returned to Connecticut and began treatment at Cardiac Specialists, P.C., primarily under the care of Dr. Steven Kunkes. (See Tr. 678-87, 943-45).[9] On March 30, 2010, the plaintiff reported to Dr. Kunkes that he “now feels well - no [chest pain]” and that epigastric discomfort, which he had experienced, was “now better.” (Tr. 678).

         On June 14, 2010, the plaintiff presented to the emergency room for complaints of palpitations and pulsing in his veins lasting one day. (Tr. 577-82, 699-700). The plaintiff denied chest pain, shortness of breath, or nausea, but reported some lightheadedness. (Tr. 577, 699). He smelled of alcohol and had a breath level reading of 0.34. (Tr. 577, 699). Emergency room personnel noted that the “[plaintiff] appears to be an alcoholic[.] Mother tends to be confrontive [sic] and [intrusive].” (Tr. 588). The plaintiff reported that he was not working “because he is grieving the deaths of [two] friends.” (Tr. 588).

         Upon examination, the cardiologist felt that there was no cardiac indication for an admission (Tr. 573, 578, 1291, 129); the plaintiff was admitted, however, for alcohol detoxification. (Tr. 572-74, 1290-93; see Tr. 589-608). He reported that he had been binge drinking since college “to ‘self-medicate' for his high anxiety level, which he has suffered since childhood.” (Tr. 572). He also reported a long history of major depression, decreased appetite, anhedonia, and substance abuse. (Tr. 572). The plaintiff was treated for alcohol withdrawal, given Lexapro for depression, and was discharged three days later with instructions to see APRN Robert Krause for follow-up. (Tr. 573-74).[10]

         The plaintiff was seen at Cardiac Specialists on June 21, 2010; the plaintiff's coronary artery disease was noted as “stable.” (Tr. 684). The plaintiff's blood pressure was 80/60 sitting and 70/60 standing; medications were ordered and the plaintiff was instructed to “take salt.” (Tr. 684). The following day, the plaintiff returned with complaints of esophageal discomfort and a feeling of “pulsations” in the veins of his arm. (Tr. 683). In a letter dated the same day, Dr. Kunkes informed Dr. Nowicki[11] that the plaintiff's “current problems” were anemia, abnormal liver tests “which may be due to alcohol, and an elevated creatinine that may be due to dehydration.” (Tr. 751).

         On August 4, 2010, the plaintiff presented to the emergency room for complaints of right shoulder pain after he “ran into a door frame by accident.” (Tr. 640, 763, 1331; see Tr. 640-53, 763-68, 1131-36). He suffered a right shoulder fracture. (Tr. 642-44, 765-67).

         The plaintiff was seen for an orthopedic consultation for the shoulder fracture by Dr. David J. Martin on August 5, 2010; the plaintiff reported that he was “in fairly good health otherwise.” (Tr. 663-64; see Tr. 675). Dr. Martin recommended surgery pending cardiology clearance. (Tr. 664; see Tr. 665). In a Cardiac Specialists visit on August 10, 2010 for surgical clearance, the plaintiff smelled heavily of alcohol and had slurred speech. (Tr. 681). The plaintiff underwent the right shoulder surgical procedure on August 18, 2010. (Tr. 636-38, 674-76, 760-62, 1347, 1371-72; see Tr. 666-73).

         At his September 3, 2010 appointment with Cardiac Specialists, the plaintiff reported that he felt well. (Tr. 680). Two months later, on November 12, 2010, the plaintiff reported to Dr. Martin that he still had difficulty fully elevating his arm, but he was “trying to do a lot of things including playing football and raking leaves.” (Tr. 669). Dr. Martin advised the plaintiff to be patient, work daily on stretching, and “[n]o football.” (Tr. 669). On November 29, 2010, the plaintiff told Dr. Martin that he fell over the weekend and landed on his lower back and right elbow. (Tr. 670). Two weeks later, on December 13, 2010, the plaintiff reported that his back felt better, and there was no mention of his right elbow. (Tr. 672). The plaintiff reported, however, that he broke a rib while snowboarding a year ago and that recently, his rib pain was re-aggravated. (Tr. 672). He also reported increased shoulder pain. (Tr. 672). Dr. Martin observed that, on x-rays, the plaintiff's shoulder looked healed, but recommended a computed tomography scan of the shoulder to “make sure that we are not dealing with non-union.” (Tr. 672). He recommended that the plaintiff restrict his activities. (Tr. 672). The plaintiff was seen on the same day at Cardiac Specialists, where he reported that he stopped drinking alcohol. (Tr. 678). On December 17, 2010, the plaintiff underwent imaging of his right shoulder which revealed “[r]ight plueral effusion” for which “further investigation [was] warranted.” (Tr. 710, 732, 853).

         When the plaintiff returned to Cardiac Specialists on January 17, 2011, he mentioned being active in an exercise program, and that he felt better and was less depressed. (Tr. 724). On February 9, 2011, the plaintiff was seen for a neurological consultation with Dr. Philip Barasch for complaints of memory difficulties, most of which were brought to his attention by his mother, who told him that he did not pay attention and did not remember tasks he needed to do. (Tr. 706). His mother reported that the plaintiff had increased anger at home and that he had “not been the same person that he was previously.” (Tr. 706). She reported that he was also drinking alcohol too much, but the plaintiff denied this and said he only drank once a week. (Tr. 706). According to his mother, the plaintiff was somewhat “disinhibited[, ]” at times “delusional, ” and that he had not been telling her the “truth.” (Tr. 706). On examination, the plaintiff had intact language function, attention span, recall and concentration, and during conversational speech, the plaintiff “appeared quite tangential.” (Tr. 706). Dr. Barasch assessed the plaintiff as having “had a behavioral change, ” and it was unclear whether this represented a psychiatric disorder or “a possible neurological problem such as frontotemporal dementia given that he has not been working for at least the past five years for unclear reasons or alcohol abuse.” (Tr. 707). Dr. Barasch performed an electroencephalography, which was normal. (Tr. 705). He recommended a neuropsychological examination. (Tr. 707).

         Dr. Martin observed on February 15, 2011, that the plaintiff was doing better and had no pain. (Tr. 851). He advised the plaintiff to continue use of an Exogen stimulator and could resume a strengthening program including pulleys, but not to play football or “contact sports obviously.” (Tr. 851).

         On March 31, 2011, the plaintiff presented to the emergency room with complaints of ringing in the left ear for the past three weeks which became worse that night when he was drinking alcohol. (Tr. 769, 1342; see Tr. 769-72, 1342-45). The plaintiff thought that he may have been injured while “playing sports[.]” (Tr. 770). He denied significant alcohol intake or having a drinking problem, but his mother and brother reported that he had been very intoxicated each day for at least a week. (Tr. 770). The plaintiff's mother reported that the plaintiff told her to kill him and gave her a knife, and she demanded that he “be sent to detox because he is mentally imbalanced.” (Tr. 770). The plaintiff did not want to go to detox, and when his mother continued to demand admission, the plaintiff became angry and “got up and went straight to the door and left, no unsteady gait, clear intent, very aware of his action. He was calm and cooperative during his stay, was very clear in expressing his preferences. Mom was aggressive, somewhat belligerent and threatening.” (Tr. 771). The plaintiff's mother was advised that a person who was alert and oriented could not be forced into detox, but she repeatedly stated that the plaintiff was unbalanced and mentally unwell and should not be allowed to make his own decisions. (Tr. 771).

         On April 7, 2011, the plaintiff presented for a neuropsychological evaluation with Dr. Michelle Bobulinski. (Tr. 773-78).[12] Dr. Bobulinski assessed the plaintiff as having “[m]ild subcortical neurocognitive weaknesses, in the setting of a significant history of cardiovascular disease, psychological and emotional difficulties, and alcohol dependence.” (Tr. 773). A review of the plaintiff's records indicated that he left his corporate finance or accounting job to travel, but then could not find a job for the next one or two years. (Tr. 773). The plaintiff reported that he was laid off. (Tr. 773). He also noted, “He and his family are concerned that some of his personality changes may have resulted or been exacerbated by his cardiac condition, as he reportedly was deprived of oxygen for two days when he had congestive heart failure and was treated for pneumonia instead.” (Tr. 774). He admitted to using alcohol increasingly after he stopped working, and his family observed that his personality was significantly different and that he had been drinking alcohol in excess. (Tr. 774). He could go for a week or longer without using alcohol, but would then be triggered by something and have excessive use including periods of blacking out. (Tr. 774). The plaintiff reported that “[o]nce every two months, approximately, he experiences symptoms of vertigo[.]” (Tr. 774). Over the past year, the plaintiff had been independent in his daily living activities, however, he is “relatively isolated.” (Tr. 774). The plaintiff was recovering from a shoulder injury, and hoped to resume regular exercise. (Tr. 774). He was not aware of any obvious cognitive changes, but reported that his lifestyle changed so dramatically it was difficult for him to tell. (Tr. 774). He reported being increasingly depressed due to missing his friends and former lifestyle, and not having a job. (Tr. 774). The plaintiff stated that finding a job was his top priority, but he was “feeling some trepidation with respect to returning to work and question[ed] whether he [would] able to handle the same pace and lifestyle as before. Reportedly, he enjoyed his work lifestyle, which also included an intense 70 hour work week, including socializing for business.” (Tr. 774). The plaintiff reported a somewhat disturbed sleep routine, staying awake until four in the morning due to some depression and some anxious ruminations. (Tr. 774).

         Dr. Bobulinski noted the plaintiff's tremor and that he had a mildly anxious and depressed mood. (Tr. 775). The plaintiff recalled events with no apparent difficulty, and he had no observable evidence of thought disorder or psychosis. (Tr. 775). Testing results showed overall mild subcortical cognitive weaknesses, and Dr. Bobulinski noted that, given the plaintiff's estimated premorbid intellectual functioning, the current results “may actually represent[] a more significant change or dampening of neurocognitive functioning.” (Tr. 776). The plaintiff's self-reports of psychological functioning and personality showed a profile similar to individuals indicating somatic complaints and behavioral dysfunction. (Tr. 776). Assuming that physical origins of the plaintiff's reported neurological and gastrointestinal symptoms could be ruled out, the results suggested a potential somatoform disorder, although “alcohol/substance abuse also remains a significant area of concern, ” which further “increases risk to the patient's cognition and overall health and well-being, including vascular disease and potential progressive cognitive decline.” (Tr. 776). The plaintiff admitted to getting drunk at least once a week, as well as taking drugs or sleeping pills not prescribed by a doctor. (Tr. 776-77). Dr. Bobulinski had several recommendations, including an MRI of the plaintiff's brain, psychiatric evaluation, and psychotherapy, but Dr. Bobulinski also noted that the plaintiff's acting-out tendencies could result in treatment noncompliance. (Tr. 778).

         The plaintiff returned to Dr. Barasch on April 19, 2011. (Tr. 780-81). He stated that he ceased drinking alcohol and had been applying for work. (Tr. 781). He reported an improved memory and no major behavioral issues. (Tr. 781). The plaintiff's mother, who was interviewed separately, said that the plaintiff was “constantly lying” and that he continued to drink. (Tr. 781). After reviewing Dr. Bobulinski's evaluation, Dr. Barasch ordered an MRI which was done on April 28, 2011; the results revealed mild cerebral atrophy. (Tr. 779, 782).

         The plaintiff returned to Dr. Martin for his shoulder on April 27, 2011; he reported doing really well, with no pain. (Tr. 852). Dr. Martin recommended that the plaintiff return in a year and that he “can essentially do whatever he can tolerate.” (Tr. 852).

         The plaintiff's visits with Dr. Nowicki throughout 2011 focused on alcohol use (Tr. 935-37), and in late May, the plaintiff mentioned that he was exercising four times a week. (Tr. 937).

         On June 26, 2011, the plaintiff began treatment at the Pride Institute for “alcohol use, and depression[]” (Tr. 787); his admitting diagnosis was alcohol dependence. (Tr. 803-04). He was admitted for residential treatment until discharge on July 20, 2011. (Tr. 787-804). He reported that he had been heavily binging on alcohol three times a week for the past six months. (Tr. 808; see Tr. 794, 800). On July 2 and 6, his mood and affect were “neutral to positive” (Tr. 790-91), and, in his mental health consultation on July 4, 2011, the plaintiff's “[p]resenting [p]roblem” was that he “can't stop drinking.” (Tr. 792). On July 6, 2011, it was noted that his tremor was improving as was his insight and judgment. (Tr. 790; see also Tr. 806 (July 13, 2011, plaintiff reported tremor “is better”)). He also admitted to occasional cocaine use. (Tr. 792). When asked if he had mental health concerns, the plaintiff stated that he had regrets about a former relationship. (Tr. 792). His discharge diagnosis was alcohol dependence (Tr. 798; see also Tr. 793), although, in the discharge summary, the plaintiff reported “symptoms of depression and panic attacks.” (Tr. 794).

         On July 29, 2011, Dr. Kunkes informed Dr. Nowicki that the plaintiff had complaints of fatigue and was taking three different medications of the same type, which were adjusted. (Tr. 942). The plaintiff returned to Cardiac Specialists on December 8, 2011, at which time he reported that he was active, but not exercising. (Tr. 809). He complained of dizziness with vertigo and vomiting. (Tr. 809). His blood pressure medications were adjusted. (Tr. 809). His coronary artery disease was stable. (Tr. 809). On December 11, 2011, Dr. Kunkes wrote a letter to Dr. Nowicki to inform him that the plaintiff “has been adjusting his own medications” and consequently had relatively high blood pressure and elevated cholesterol, and his medications were being adjusted. (Tr. 940).

         On December 16, 2011, the plaintiff underwent a consultative evaluation with Bina Roginsky, Psy.D. (Tr. 814-17).[13] The plaintiff's mother reported that he had major changes in his cognition after his cardiac event, which she described as resulting in loss of oxygen to the brain. (Tr. 814). The plaintiff and his mother reported that he had not had any alcohol since he attended rehabilitation sometime in the last year. (Tr. 814). Dr. Roginsky observed that the plaintiff was detached and passive, many times was unable to provide details and frequently gave contradictory and illogical answers. (Tr. 815). The plaintiff was “difficult to understand, and he had trouble with speaking only English.” (Tr. 815). He often repeated words, ...


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