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Taylor v. Saul

United States District Court, D. Connecticut

August 19, 2019

CHRISTIAN LOUIS TAYLOR
v.
ANDREW M. SAUL, COMMISSIONER OF SOCIAL SECURITY[1]

          RULING ON THE PLAINTIFF'S MOTION TO REVERSE THE DECISION OF THE COMMISSIONER AND ON THE DEFENDANT'S MOTION TO AFFIRM 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” or “the Commissioner”] denying the plaintiff Social Security Disability Insurance [“SSDI”] benefits.

         I. ADMINISTRATIVE PROCEEDINGS

         On or about February 25, 2014, the plaintiff protectively filed an application for SSDI benefits claiming that he had been disabled since October 5, 2012, due to the following impairments: back injury; neck injury; tarsal tunnel syndrome; “painful weeping skin lesions, cysts in rectum, chronic”; compromised immune system; Raynaud's syndrome; diabetes; “candida albicans, chronic”; food and respiratory allergies; and nerve damage. (Certified Transcript of Administrative Proceedings, dated October 16, 2018 [“Tr.”] 138, 154; see Tr. 367-68). The Commissioner denied the plaintiff's application initially and upon reconsideration. (Tr. 138-53, 200-04; Tr. 154-69, 206-09). On September 4, 2014, the plaintiff requested a hearing before an Administrative Law Judge [“ALJ”] (Tr. 210-11), and on November 12, 2015, a hearing was held before ALJ Peter Alexander Borré, at which the plaintiff and a vocational expert, Howard Steinberg, testified. (Tr. 89-136; see Tr. 237-56, 259-84, 287-92). On March 17, 2016, the ALJ issued an unfavorable decision denying the plaintiff's claim for benefits. (Tr. 170-91). On March 28, 2016, the plaintiff requested review of the hearing decision (Tr. 296-98), and on May 4, 2017, the Appeals Council remanded the plaintiff's claim to the ALJ for another hearing. (Tr. 192-96).

         On October 24, 2017, ALJ Borré held a second hearing, at which the plaintiff and a vocational expert, Edmond Calandra, testified. (Tr. 47-88, 324-52, 355-60). On February 28, 2018, the ALJ issued another unfavorable decision denying the plaintiff's claim for benefits. (Tr. 9-37). The plaintiff requested review of the second hearing decision; however, on July 20, 2018, 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 September 11, 2018, the plaintiff filed his complaint in this pending action (Doc. No. 1), and on September 12, 2018, the Court granted his Motion for Leave to Proceed In Forma Pauperis (Doc. No. 7). On September 24, 2018, the parties consented to the jurisdiction of a United States Magistrate Judge, and the case was assigned to this Magistrate Judge. (Doc. No. 11). The defendant filed the Certified Administrative Transcript on November 13, 2018. (Doc. No. 13). On November 15, 2018, the plaintiff filed his Motion to Reverse the Decision of the Commissioner (Doc. No. 16), brief in support (Doc. No. 16-1 [Pl.'s Mem.]), Statement of Material Facts (Doc. No. 16-2), and three exhibits (Doc. Nos. 16-3-16-5). The defendant filed his Motion to Affirm the decision of the Commissioner on April 3, 2019 (Doc. No. 22), with brief in support (Doc. No. 22-1 [Def.'s Mem.]), and Statement of Material Facts (Doc. No. 22-2).

         For the reasons stated below, the plaintiff's Motion to Reverse the Decision of the Commissioner (Doc. No. 16) is DENIED, and the defendant's Motion to Affirm (Doc. No. 22) is GRANTED.

         II. FACTUAL BACKGROUND

         At the time of his alleged onset date of disability, October 5, 2012, the plaintiff was forty-eight years old. (See Tr. 138, 154). The plaintiff is married and resides with his wife. (Tr. 54). He dropped out of school when he was a sophomore in high school, but later obtained a GED and a certificate in electromechanical assembly. (Tr. 55). At the time of the second hearing, the plaintiff was fifty-three years old. (See Tr. 53). The plaintiff's date last insured is December 31, 2017. (Tr. 138, 154).

         A. MEDICAL HISTORY[2]

         1. THE RELEVANT EVIDENCE PRIOR TO THE PLAINTIFF'S ALLEGED ONSET DATE

         On October 20, 2006, Dr. Daniel E. Nijensohn evaluated the plaintiff, who presented to Dr. Nijensohn with a complaint of “pain at the base of the neck radiating into the right shoulder without numbness and/or weakness, resolving.” (Tr. 678). Dr. Nijensohn noted that “[t]he patient has x-ray and MRI evidence of cervical disc herniation at ¶ 4-5 and somewhat less at ¶ 5-6.” (Tr. 678). Following a physical examination, Dr. Nijensohn “told him to continue with conservative management including therapy and medications for as long as [that] works.” (Tr. 679). On March 6, 2008, Dr. Nijensohn evaluated the plaintiff again, noting that the plaintiff complained “of persistent neck pain for the past six months” and “lower back pain that has been bothering him for quite a long time[.]” (Tr. 681). X-rays and an MRI of the lumbar spine revealed “bilateral pars interarticularis defects at ¶ 5 with Grade I anterlisthesis and with a right L5-S1 disc protrusion and degenerative disc disease at ¶ 5-S1 and narrowing of the L5-S1 interspace.” (Tr. 681). The images also revealed “bilateral spondylosis with a Grade I spondylolisthesis at ¶ 5 on S1, and anterolisthesis, with a right posterolateral intraforaminal local disc protrusion at ¶ 5-S1, impinging upon the right L5 nerve root.” (Tr. 681). Dr. Nijensohn recommended that the plaintiff undergo cervical and lumbar spinal fusion surgeries. (See Tr. 682).

         On March 13, 2008, the plaintiff underwent an “excision of herniated discs at ¶ 4-5 and at ¶ 5-6, followed by anterior interbody cage fusion, and internal fixation with metal plating and screws.” (Tr. 683). On March 20, 2008, Dr. Nijensohn noted that the plaintiff had “done quite well” since the surgery and that the plaintiff ha[d] already noted improvement compared to the way he was preoperatively.” (Tr. 683). Specifically, the plaintiff had “a good range of motion of the neck” and good “[s]trength of the upper extremities[.]” (Tr. 683). Dr. Nijensohn evaluated the plaintiff again on April 17, 2008, at which time he noted that the plaintiff “recovered beautifully from the standpoint of cervical spine surgery.” (Tr. 684). Dr. Nijensohn explained that the plaintiff's “symptoms [were] gone[]” and that the plaintiff “fe[lt] real well.” (Tr. 684). The treatment note reflects that the plaintiff continued to complain of lower back pain and that Dr. Nijensohn believed it was “the time to proceed with the posterior fusion of the lumbar spine[.]” (Tr. 684).

         On May 1, 2008, the plaintiff underwent, inter alia, a “transforaminal posterior lumbar interbody fusion[.]” (Tr. 685). On May 8, 2008, Dr. Nijensohn evaluated the plaintiff and noted that he had “done beautifully” following surgery, “already feels much better, ” “woke up without pain into the right leg, ” “the sciatica is all gone[, ]” and “[h]is toes are not numb anymore as they were before the surgery.” (Tr. 685). Dr. Nijensohn added that the plaintiff was taking short walks, that his neck also “fe[lt] great[, ]” and that “he no longer ha[d] any nerve pains”; he concluded that the plaintiff was “happy and grateful and quite pleased with his progress.” (Tr. 685). During a July 17, 2008 examination, the plaintiff stated to Dr. Nijensohn that he “occasionally hears noises in the lower back.” (Tr. 686). Dr. Nijensohn advised the plaintiff to “wait a couple of months before returning back to work[, ]” but noted that “[t]he most recent x-rays look pretty good.” (Tr. 686).

         Following an examination on September 25, 2008, Dr. Nijensohn stated that the plaintiff was “doing excellent and ready to be discharged from [Dr. Nijensohn's] care.” (Tr. 687). The plaintiff was set to return to work within days and felt that he could “handle it.” (Tr. 687). Although Dr. Nijensohn advised the plaintiff to start work “on a part-time basis and then increase his activities as tolerated[, ]” he stated that “[x]-rays of the cervical and lumbar spine show excellent healing of the instrumented fusions and no complications or problems.” (Tr. 687).

         Moreover, on March 25, 2009, the plaintiff completed a tinnitus questionnaire, on which he answered questions regarding “head and ear noises[.]” (Tr. 590). He indicated on the form that he had experienced noises in his head and ears for two years and that the “quality of noise” included “ringing, whooshing, steam escaping, [and] pulsating[.]” (Tr. 590). The plaintiff indicated also that the noise was constant, varied in intensity, and occurred in both ears. (Tr. 590). The noise did not prevent the plaintiff from sleeping; however, he indicated that the noise was rated at a six on a scale of one to ten, with ten being “very loud” and seven or above being “noise that you feel you cannot live with.” (Tr. 590). The plaintiff explained that stress, such as lifting something heavy, increased the noises and that he had a history of noise exposure from work. (Tr. 590). He noted also that he thought he had hearing loss and that he had headaches, blurred vision, and “[h]ead or [n]eck [t]rauma.” (Tr. 590). The plaintiff completed a hearing test on April 1, 2009, which revealed that his hearing was within normal limits, but sloping to mild to moderate sensorineural hearing loss. (Tr. 595).

         2. STAYWELL HEALTHCARE RECORDS

         The plaintiff has an extensive treatment history with Staywell Healthcare [“Staywell”]. On March 12, 2014, the plaintiff presented to Staywell and complained of “pain in his neck and back” and “pain in multiple other sites throughout his body.” (Tr. 544). Dr. Monika Kaul evaluated the plaintiff. A review of the plaintiff's symptoms revealed that he had neck and back pain, but “[n]o lump or swelling in the neck[, ]” and that he had “no tinnitus.” (Tr. 545). A physical examination revealed that the plaintiff had “tenderness [in the] lumbar area” and that the “[c]ervical spine showed full range of motion limited.” (Tr. 546). His gait and stance were normal. (Tr. 546). Dr. Kaul referred the plaintiff to physical therapy for his neck and back pain (Tr. 573) and, following an examination on April 11, 2014, she referred the plaintiff to a neurosurgeon for cervical pain. (Tr. 547).

         The plaintiff underwent imaging of his spine on April 7, 2014, which revealed anterior fusion at ¶ 4-C5 and C5-C6, as well as “[d]egenerative changes with narrowing of the disc space at ¶ 7-T1 and C6-C7, as well as encroachment on the neural foramina in the oblique views at ¶ 6-C7 on the right and C4-C5 and C5-C6 on the left.” (Tr. 716). This imaging revealed also “[s]tatus post posterior lumbar fusion and decompression at ¶ 5/S1” but “[n]o significant degenerative disease above the level of fusion.” (Tr. 717). The plaintiff underwent a CT scan of his spine on May 21, 2014, which revealed, inter alia, the following: unremarkable findings in the thoracic spine (Tr. 559, 561); and “anterior cervical and incomplete intradiscal fusion at ¶ 4-C5 and C5-C6[, ]” as well as “[m]ild multilevel neuroforaminal stenosis involving the right C3-C4, right C4- C5, and bilateral C5-C6 and C6-C7 neuroforamen, ” but “no significant central spinal stenosis” in the cervical spine (Tr. 560).

         On July 7, 2014, the plaintiff presented to Staywell where Dr. Anna Timell completed an examination. (Tr. 706-07). The plaintiff complained of “back pain, pain travel on his shoulders and neck, also ha[d] problems with his metatarsal arch[.]” (Tr. 706). A review of the plaintiff's neurological system revealed that he had “dysethesias, numbness and tingling in the [left] forearm, [right] hand and arm in varying locations and at varying times, occasionally has sharp pain in the [right] 3rd and 4th fingertips.” (Tr. 706). Dr. Timell noted that the plaintiff “appeared uncomfortable” at the appointment. (Tr. 706). She noted also that the plaintiff's “[n]eck demonstrated a decrease in suppleness[, and that] he had good lateral rotation, [but] poor flexion and extension.” (Tr. 706). Dr. Timell stated that the plaintiff had “[a]bnormal movement of all extremities [and a] trigger nodule [at the] upper [right] trapezius.” (Tr. 707). She diagnosed the plaintiff with cervicalgia and muscle spasm, for which she prescribed medications. (Tr. 707).

         In August 2014, Dr. Timell examined the plaintiff again and noted that he had a “rigid back[, ]” but that his motor strength was normal and he rose “to heels and toes well.” (Tr. 736- 37). She diagnosed the plaintiff with, inter alia, lumbar spondylosis and prescribed a Lidoderm patch. (Tr. 737). On December 31, 2014, the plaintiff contacted Dr. Timell and stated to her that he was “upset at not being able to get the help that he feels he needs.” (Tr. 742). Dr. Timell noted that, “[a]fter some discussion, ” they “agreed [she] could help [the plaintiff] by writing a letter to support his SSD application.”[3] (Tr. 742). The plaintiff underwent an MRI of his thoracic spine in November 2014, which revealed (1) “T5-T6 mild left paracentral disc herniation, without canal narrowing[, ]” and (2) “T7-T8 tiny left paracentral disc herniation, without canal narrowing.” (Tr. 750). He also underwent an MRI of his cervical spine in November 2014, which showed (1) “[s]tatus post C4-C6 anterior fusion[, ]” (2) “C3-C4 mild central disc herniation[ with] [n]o central canal narrowing[, ]” and (3) “C3-C4 mild spondylotic right neural foraminal narrowing[, ] ¶ 5-C6 mild spondylotic right greater than left neural foraminal narrowing[, and] ¶ 6-C7 mild bilateral spondylotic neural foraminal narrowing.” (Tr. 752).

         The plaintiff returned to Dr. Timell on June 4, 2015 and complained that his “[l]egs are getting weaker, having difficulty walking[, ]” and that he wanted “his progressive disability documented for an upcoming SSD hearing.” (Tr. 743). Under the review of systems, Dr. Timell noted that the plaintiff had “neck and low back pain, especially if he tries to look down, or if he stands very long or tries to do household chores.” (Tr. 743). She added that the plaintiff “reported he can no longer mow his own lawn, ” and that “the pain appears to vary in intensity and sometimes puts him down on the floor.” (Tr. 743). She noted also that the plaintiff reported “muscle twitching and sensory disturbances [and] report[ed] burning pain in his [left] foot.” (Tr. 743). A physical examination revealed that the plaintiff's “[c]ervical spine did not show full range of motion - [right] anterior neck scar[ and] limited lateral rotation.” (Tr. 744). Examination of the plaintiff's lumbar spine “did not demonstrate full range of motion - all movement occur[red] above the level of his fusion, there was marked para-thoracic muscle spasm above the surgical scar with spontaneous twitching after attempted lateral flexion.” (Tr. 744). The plaintiff “walked well on heels and toes” but “ambulated antalgically with a stiff [left] knee and out-toeing, no Trendelenberg”; however, Dr. Timell opined that “the etiology of his gait disturbance [was] unclear to [her].” (Tr. 744).

         On October 29, 2015, Dr. Timell completed a form on which she opined about the plaintiff's ability to do physical activities. (Tr. 753-55). She indicated that the plaintiff's diagnoses were cervical spondylosis, lumbar spondylosis, and diabetes, and that his prognosis was “poor.” (Tr. 753). Dr. Timell opined that the plaintiff could walk one city block without rest, that he could sit continuously for forty-five minutes, and that he could stand continuously for thirty minutes. (Tr. 753). In an eight-hour workday, Dr. Timell believed the plaintiff could sit for “about 4 hours” and “stand/walk” for “about 2 hours.” (Tr. 753). She added that the plaintiff needed a job that permitted shifting positions “at will from sitting, standing or walking[, ]” and that he would need to take unscheduled breaks every thirty minutes and rest for about fifteen minutes before returning to work. (Tr. 753-54). Dr. Timell opined that the plaintiff could occasionally lift and carry up to ten pounds during the workday; however, he could never lift and carry more than ten pounds. (Tr. 754). Dr. Timell indicated that the plaintiff had “significant limitations in doing repetitive reaching, handling, or fingering[.]” (Tr. 754). Specifically, Dr. Timell noted that the plaintiff could do the following: use his hands to grasp, twist, and turn objects for ten percent of an eight-hour workday; use his fingers for fine manipulations for fifty percent of an eight-hour workday; and use his arms for reaching, including overhead reaching, for ten percent of an eight-hour workday. (Tr. 754). In addition, Dr. Timell opined that the plaintiff could never bend, twist, crouch, climb stairs, or climb ladders, and that he should avoid exposure to extreme cold and cigarette smoke. (Tr. 755). She thought that the plaintiff's condition would not be likely to produce good days and bad days, and in response to a question asking how often the plaintiff's impairments would cause him to the absent from work, Dr. Timell answered, “[C]an't work.” (Tr. 755).

         On February 11, 2016, Dr. Timell saw the plaintiff for a follow-up appointment after the plaintiff went to the emergency room the previous week due to back pain.[4] (Tr. 767-70). Dr. Timell noted that the plaintiff presented “with a litany of indigant complaints about doctors who haven't helped him, apparently a consulting MD has told [SSA] that [the plaintiff] is not disabled.” (Tr. 767). The plaintiff denied depression, but noted that he has “always been melancholy[.]” (Tr. 768). Under “review of symptoms, ” Dr. Timell noted neck pain and low and thoracic back pain. (Tr. 768). She noted also “[s]ensory disturbances [left] arm radicular pain to the index finger, [right] arm radicular pain to 4th and 5th fingers; [left] radicular pain radiating to 4th and 5th toes; all pain also assoc[iated] with paresthesias.” (Tr. 768). The plaintiff appeared at the appointment “wearing a soft neck colla[r].” (Tr. 769). A physical examination revealed that both the cervical and lumbosacral spine “did not demonstrate full range of motion.” (Tr. 769). In his lumbosacral spine, the plaintiff “had marked [right] parathoracic muscle spasm, he also had virtually no lateral flexion in thoracic or lumbar spines.” (Tr. 769). The plaintiff's strength was normal, he was able to walk on his heels and toes, had “no arm drift[, ]” normal grip, and normal interossei. (Tr. 769). The plaintiff's gait and stance were abnormal, as he limped with his right leg; his reflexes were abnormal, as his “[right] biceps jerk [greater than] [left].” (Tr. 769). Dr. Timell prescribed Cyclobenzaprine for the plaintiff's neck pain and referred the plaintiff for a nerve conduction study of his upper and lower extremities. (Tr. 770). The doctor who performed the nerve conduction test concluded that “[t]here is no definitive electrodiagnostic evidence for a neuropathy or radiculopathy in the arms or legs.” (Tr. 803).

         The plaintiff underwent a CT scan of his lumbar spine on March 4, 2016, which revealed postoperative changes “at L5-S1 status post laminectomy and posterior fusion. Grade 1 anterolisthesis of L5 on S1. Left L5 pedicle screw traverses the superior endplate with tip noted along the L4-L5 disc space. Hypertrophic changes of the posterior facets results in moderate right and mild left L5-S1 neural foraminal stenosis.” (Tr. 799).

         On April 11, 2016, Dr. Timell noted that, during a physical examination, the plaintiff “[sat] comfortably on the exam table, [and] move[d] about the room normally.” (Tr. 777). She also referred the plaintiff for a neurosurgical consultation to “advise if removal of the [left] pedicle screw would be advisable” (Tr. 777), as the plaintiff worried that the position of the screw might be the cause of his “ongoing intermittent sharp back pain that brings him to his knees” (Tr. 775).

         During a physical examination on April 13, 2017, Dr. Timell noted that the plaintiff “did not demonstrate full range of motion” in his thoracolumbar spine and had “[left] para-thoracic muscle spasms.” (Tr. 878). The plaintiff had the ability to stand on his heels and toes and had normal motor strength. (Tr. 878-79). However, Dr. Timell noted that the plaintiff had an abnormal gait and stance and that he walked with a cane in his left hand. (Tr. 879). Dr. Timell determined that the plaintiff's “deep tendon reflexes” were abnormal. (Tr. 879).

         On July 27, 2016 and August 29, 2017, Susan Murray, MA, LPC, LADC, the plaintiff's mental health treatment provider, submitted letters discussing the plaintiff's mental health treatment “in lieu of confidential psychiatric records[.]” (Tr. 823; Tr. 815). Ms. Murray noted that the plaintiff's current diagnosis was “Major Depressive Disorder, recurrent, severe, without psychotic features” (Tr. 815, 823), and that the plaintiff was prescribed Cymbalta and Buspirone (Tr. 815, 823), as well as Wellburtin SR (Tr. 823) to treat his condition. In the August 2017 letter, Ms. Murray noted that the plaintiff continued to participate in weekly, individual therapy and that he had participated in a “six-week psycho-educational group for Chronic Pain Management[.]” (Tr. 823). She added that the plaintiff “participated actively in his treatment and made appropriate clinical progress.” (Tr. 823).

         3. YALE NEW HAVEN HEALTH RECORDS

         Throughout the relevant period, the plaintiff also sought treatment with Yale New Haven Health [“Yale”]. On September 21, 2016, the plaintiff presented to Yale with complaints of “low back pain.” (Tr. 825). A physical examination of the plaintiff revealed “full strength throughout bilateral upper and lower extremities, normal tone. Able to heel and toe walk without difficulty. Full painless range of motion of the bilateral lower extremities. No. pain with bilateral hip range of motion. No. trochanteric bursa tenderness.” (Tr. 827). The examination revealed also that the plaintiff “ambulate[d] without antalgic gait” and “[did] not require assistive device for ambulation.” (Tr. 828). The physician's assistant who evaluated the plaintiff referred the plaintiff for a bone scan to check for pseudoarthrosis.[5] (Tr. 828).

         A physical examination on November 30, 2016 revealed the following with respect to the plaintiff's head and neck: “[n]o restriction in cervical flexion, extension, rotation, or lateral bending”; “[n]o pain with cervical flexion, extension, rotation, or lateral bending”; “[n]o tenderness to palpation over posterior cervical spine or trapezius muscles”; “[n]egative Spurling's maneuvers”; and “[n]egative Lhermitte's sign.” (Tr. 831). The examination revealed the following regarding the plaintiff's “spin/ribs/pelvis”: “[n]o tenderness to palpation over the spine or buttocks”; “[n]o previous incisions”; “[n]o restriction in thoracolumbar flexion, extension, rotation, or lateral bending”; “[n]o pain in back or legs with flexion or extension”; and “[n]o elevation of shoulders or pelvis.” (Tr. 831). Regarding the plaintiff's extremities, the examination revealed the following: “[n]ormal peripheral pulses with no edema, swelling, varicosities, or lymphadenopathy”; “[n]ormal alignment and muscle tone with no masses, asymmetric atrophy/hypertrophy, tenderness to palpation, ligamentous instability, or crepitus/effusions/subluxations of the major joints”; and “[n]egative straight leg raising tests.” (Tr. 831). The examination revealed also that the plaintiff had no difficulty heel and toe walking; however, he “require[d] an assistive device for ambulation” and had an antalgic gait. (Tr. 831). The plaintiff's strength, sensation, and reflexes were all normal.[6] (Tr. 831-32).

         The plaintiff underwent an MRI of his lumbar spine on April 11, 2017, which revealed “[s]tatus post lumbar fusion and decompression at ¶ 5/S1 with severe right neural foraminal narrowing at that level. No. focal disc herniation identified. No. significant narrowing of the central canal.” (Tr. 870-71). On June 27, 2017, the plaintiff underwent an x-ray of his entire spine, which revealed “bony consolidation across the disc space at ¶ 4-C5 and partially so at ¶ 5-C6 posteriorly.” (Tr. 872). The x-ray revealed also that there was “[n]o significant abnormality” and “no significant degenerative changes” of the thoracic spine. (Tr. 872). The x-ray showed that one of the pedicle screws in the plaintiff's lumbar spine “appeare[d] to breach the superior plate of L5” and that there was “[m]ild anterolisthesis of L4-L5 on S1.” (Tr. 872). The imaging report concluded that “there has been no significant interval change.” (Tr. 872). Dr. Luis Enrique Kolb discussed surgical and non-surgical options with the plaintiff on June 27, 2017 and August 8, 2017, following which the plaintiff opted to continue non-surgical interventions. (Tr. 857-61).

         4. CONSULTATIVE EXAMINATIONS

         On March 26, 2014, Dr. Yacov Kogan performed a consultative examination of the plaintiff for Connecticut Disability Determination Services. (Tr. 551-56). The plaintiff reported to Dr. Kogan “a history of chronic, intermittent and migratory pain affecting the entire posterior torso and the upper and lower extremities bilaterally and diffusely for several years.” (Tr. 551). Dr. Kogan noted the plaintiff's two spinal fusion surgeries and that the plaintiff had received cortisone injections in both feet for tarsal tunnel syndrome. (Tr. 551). The plaintiff stated to Dr. Kogan that “he has self diagnosed Raynaud's after comparing his symptoms to his wife's symptoms who has the diagnosis, but he has never received the diagnosis by a physician.” (Tr. 551). He reported also “a history of chronic and daily symptoms of congestion, sore throat, watery eyes, sneezing, subjective fevers, and wheezing with mild shortness of breath[, ]” which the plaintiff attributed to various allergies. (Tr. 551). The plaintiff told Dr. Kogan that “he has had a perianal cyst for about 6 months” and that “[t]he cyst hurts to touch.” (Tr. 551). Finally, the plaintiff noted “a history of diabetes mellitus[, ]” which “has been diet controlled” and for which the plaintiff “has never taken any medications[.]” (Tr. 552).

         Following a physical examination, Dr. Kogan provided a medical source statement. (Tr. 553-54). He stated that “there are no range of motion deficits and no neurological deficits that limit sitting, standing, walking, bending, lifting, carrying, reaching or fine finger manipulations”; however, such activities “are mildly limited due to generalized musculoskeletal pain.” (Tr. 554). Dr. Kogan concluded that “there is no evidence of Raynaud's in the fingers or toes[, ]” and that there were “no active rashes appreciated.” (Tr. 554). He added that there was “no congestion, no rhinorrhea, no lacrimation, no sneezing, [and that] the oropharynx [was] clear without erythema, there [was] no submandibular or cervical lymphadenopathy[, and] [t]he lungs [were] clear to auscultation bilaterally.” (Tr. 554). Lastly, Dr. Kogan determined that there was “no evidence of functional limitation stemming from ...


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