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Weber v. Colvin

United States District Court, D. Minnesota

January 26, 2017

Donald W. Weber, Plaintiff,
v.
Carolyn W. Colvin, Acting Commissioner of Social Security, Defendant.

          Fay E. Fishman, Peterson & Fishman, (for Plaintiff)

          Gregory G. Brooker, Assistant United States Attorney, United States Attorney's Office, (for Defendant).

          REPORT & RECOMMENDATION

          Tony N. Leung United States Magistrate Judge

         I. INTRODUCTION

         Plaintiff Donald W. Weber brings the present case, contesting Defendant Commissioner of Social Security's denial of his application for disability insurance benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 401-34. This matter is before the undersigned United States Magistrate Judge on cross motions for summary judgment, Plaintiff's Motion for Summary Judgment (ECF No. 15) and the Commissioner's Motion for Summary Judgment (ECF No. 17). These motions have been referred to the undersigned for a report and recommendation to the district court, the Honorable Joan N. Ericksen, District Judge for the United States District Court for the District of Minnesota, under 28 U.S.C. § 636 and D. Minn. LR 72.1.

         Based upon the record, memoranda, and the proceedings herein, IT IS HEREBY RECOMMENDED that Plaintiff's Motion for Summary Judgment (ECF No. 15) be GRANTED IN PART and DENIED IN PART; the Commissioner's Motion for Summary Judgment (ECF No. 17) be DENIED; and this matter be REMANDED for further proceedings.

         II. PROCEDURAL HISTORY

         Plaintiff applied for DIB as well as supplemental security income (“SSI”) under Title XVI of the Social Security Act, 42 U.S.C. § 1382, on September 5, 2012, asserting that he has been disabled since May 28, 2009, due to ADHD; depression; eye disorders, specifically Fuchs' dystrophy, [1] glaucoma, and cataracts; knee and back problems, including degenerative disk disease; sleep apnea; and hypertension. (Tr. 69-70, 80-81, 95-96.) Plaintiff was determined to be disabled as of September 5, 2012, under Title XVI and began receiving SSI. (Tr. 93, 96.) Plaintiff's application for DIB, however, was denied initially, and again upon reconsideration. (Tr. 13, 79, 95.) Plaintiff appealed the reconsideration of his DIB determination by requesting a hearing before an administrative law judge (“ALJ”). (Tr. 13, 145-50.)

         The ALJ held a hearing on July 2, 2014. (Tr. 13, 26, 28; see also Tr. 105-47, 162-88, 193-99.) After receiving an unfavorable decision from the ALJ, Plaintiff requested review from the Appeals Council, which denied his request for review. (Tr. 1-25.) Plaintiff then filed the instant action, challenging the ALJ's decision. (Compl., ECF No. 1.) The parties have filed cross motions for summary judgment. (ECF Nos. 15, 17.) This matter is now fully briefed and ready for a determination on the papers.

         III. RELEVANT MEDICAL HISTORY

         As noted above, Plaintiff was found to be eligible for SSI as of September 5, 2012. In order to be entitled to DIB, Plaintiff must establish that he was disabled before his insurance expired. Moore v. Astrue, 572 F.3d 520, 522 (8th Cir. 2009) (citing Cox v. Barnhart, 471 F.3d 902, 907 (8th Cir. 2006)). It is undisputed that the date Plaintiff was last insured was June 30, 2010. (Tr. 15; Pl.'s Mem. in Supp. at 2, ECF No. 16; Def.'s Mem. in Supp. at 3, ECF No. 18.) Thus, Plaintiff must prove that he was disabled before June 30, 2010. Accordingly, the period presently at issue is May 28, 2009, the alleged onset date, through June 30, 2010, the date last insured. Nevertheless, “[e]vidence from outside the insured period can be used in helping to elucidate a medical condition during the time for which benefits might be rewarded.” Cox, 471 F.3d at 907 (quotation omitted).

         A. 2009

         Near the end of August 2009, Plaintiff met with Azber A. Ansar, M.D., at the VA Medical Center to reestablish primary care. (Tr. 484-85.) Plaintiff had several complaints, including knee and back pain, high blood pressure, a “feeling of hopelessness, ” and fatigue during the day accompanied by snoring at night. (Tr. 484.)

         With respect to Plaintiff's mental health, Dr. Ansar noted that Plaintiff had previously received treatment for depression in 2006, but would need to reestablish care. (Tr. 485.) Dr. Ansar also noted that Plaintiff had attempted suicide in 2003. (Tr. 485.) Dr. Ansar noted that Plaintiff's blood pressure was “uncontrolled” and prescribed hydrochlorothiazide/lisinopril[2] as well as dietary and lifestyle modifications. (Tr. 485; see Tr. 490-92.) Dr. Ansar noted that Plaintiff was obese and wanted to lose weight, and referred Plaintiff to a program. (Tr. 485.)

         As for Plaintiff's low-back and knee pain, Dr. Ansar noted that the pain was secondary to a fall Plaintiff experienced approximately six weeks before. (Tr. 485; see Tr. 308-10, 326.) Dr. Ansar prescribed diclofenac sodium and ordered x-rays of Plaintiff's right knee and lumbar spine. (Tr. 485; see Tr. 338-39.) Dr. Ansar also referred Plaintiff for a sleep study to evaluate whether Plaintiff has sleep apnea. (Tr. 485.)

         The same day, Plaintiff was also evaluated by Beret A. Skroch, Psy. D., L.P. (Tr. 486-88.) Plaintiff expressed interest in reconnecting with Alan Serposs, M.D., his prior psychiatrist. (Tr. 486; see Tr. 475.) Plaintiff reported that he last saw Dr. Serposs in 2006, at which time he was diagnosed with ADHD and depression and prescribed Wellbutrin.[3] (Tr. 486; see Tr. 475.) Plaintiff reported that “[h]e stopped taking psychotropic medications in 2006 and reported [a] stable mood since.” (Tr. 486.) Plaintiff “denied feeling depressed despite significant psychosocial stressors, ” including losing his driver's license for failure to pay child support which then resulted in the loss of his job as a taxi driver. (Tr. 486.) Plaintiff reported that he was “actively looking for work” and denied any hopelessness or suicidal or homicidal ideation, intentions, or plans. (Tr. 486.) Plaintiff also reported having “close friends for support.” (Tr. 487.)

         Skroch noted that Plaintiff was obese, was casually dressed, had fair grooming, and made good eye contact. (Tr. 487-88.) Plaintiff's affect was euthymic and his thought content was normal. (Tr. 488.) Plaintiff's motor functions were “calm” and his speech had normal rate, rhythm, and volume. (Tr. 488.) Plaintiff's insight, judgment, and impulse control were fair. (Tr. 488.) Skroch diagnosed Plaintiff with depressive disorder by history, but not currently symptomatic, and ADHD. (Tr. 488.) Plaintiff had a GAF score of 70.[4] (Tr. 488.) Skroch noted that Plaintiff “is not in need of, nor does he desire [mental health] services at present” and told him to contact Dr. Serposs in the future if needed. (Tr. 488.)

         Towards the end of September, Plaintiff participated in a sleep study. (Tr. 480-82.) Ultimately, Plaintiff was diagnosed with obstructive sleep apnea and instructed on the use of a continuous positive airway pressure (“CPAP”) unit. (Tr. 476-77, 480-81, 482.)

         At the end of September, Plaintiff was seen by Allan J. Boyum, M.D., for a follow-up regarding high blood pressure and back and knee pain. (Tr. 477.) Plaintiff reported that “[h]is back and knees are slowly getting better.” (Tr. 477.) Dr. Boyum noted that Plaintiff was alert and oriented and “[i]n [a] good mood.” (Tr. 479.) Plaintiff's gait was steady and at a normal pace. (Tr. 479.) Dr. Boyum continued Plaintiff's blood-pressure medication and prescribed diclofenac and cyclobenzaprine for Plaintiff's neck pain. (Tr. 480.)

         Plaintiff met with Dr. Serposs in early October for supportive psychotherapy and medication management in connection with his depressive disorder. (Tr. 475.) Dr. Serposs noted that he previously treated Plaintiff “in 2005-06 for . . . depressive disorder. [Plaintiff] dropped out of treatment and returned . . . this past August and reported some return of depressive symptoms.” (Tr. 475.) Dr. Serposs noted that, while Plaintiff “was ambivalent” about resuming mental-health treatment when he saw Skroch, “more recently [Plaintiff] called and asked to come in.” (Tr. 475.) Dr. Serposs noted that Plaintiff had “a number of current stressors, ” including the loss of his driver's license and job as a taxi driver as well as being “a few months behind on his rent” and having less contact with his teenage son. (Tr. 475; see Tr. 476.) Dr. Serposs noted that, while Plaintiff “faces the possibility of losing his housing[, ] . . . he is on good terms with his landlord who in fact may be able to find him work.” (Tr. 475.) Dr. Serposs noted Plaintiff's suicide attempt in 2003 and that Plaintiff was not presently suicidal. (Tr. 475.)

         Dr. Serposs observed that Plaintiff was casually dressed, adequately groomed, and fully cooperative with normal speech, logical thinking, and a moderately depressed mood. (Tr. 475.) Plaintiff's affect was appropriate. (Tr. 475.) Dr. Serposs noted that Plaintiff had previously responded to bupropion[5] and was willing to try this medication again. (Tr. 476.) Dr. Serposs prescribed bupropion and advised Plaintiff to return in three weeks. (Tr. 476.)

         When Plaintiff returned near the end of October, there was “little change” since his previous appointment. (Tr. 474.) Plaintiff was still actively looking for work and “his housing situation [wa]s precarious.” (Tr. 474.) Plaintiff again appeared casually dressed, adequately groomed, and fully cooperative with normal speech and logical thinking. (Tr. 474.) Plaintiff's mood was moderately depressed and his affect was appropriate. (Tr. 474.) Dr. Serposs increased the bupropion and advised Plaintiff to return in three weeks. (Tr. 474.)

         Plaintiff followed up with Dr. Boyum in early November for persistent back and knee pain. (Tr. 470-71.) Plaintiff reported that he had received some physical therapy “which does not seem to have been helpful.” (Tr. 471.) Plaintiff experienced some relief with diclofenac in the morning, but the pain returned by the afternoon. (Tr. 471.) Plaintiff was observed to be in a good mood with a normal pace and steady gait. (Tr. 472.) Dr. Boyum diagnosed Plaintiff with degenerative disk disease and degenerative joint disease. (Tr. 473; see Tr. 338-39.) Dr. Boyum increased the diclofenac, prescribed a back brace, and referred Plaintiff for a possible injection in his right knee. (Tr. 473.)

         Plaintiff met with Dr. Serposs again in mid-November and early December. (Tr. 468, 469.) Plaintiff remained much the same. He was under financial strain and continued to look for work. (Tr. 468, 469.) Plaintiff presented with a depressed mood each time. (Tr. 468, 470.) Dr. Serposs continued Plaintiff's bupropion prescription and, in December, Plaintiff reported “feel[ing] a bit more ‘get up and go.'” (Tr. 468, 470.)

         Plaintiff also had an orthopedic consult for his right knee in early December. (Tr. 466.) Plaintiff was seen by David Fey, M.D. (Tr. 467.) Plaintiff described “chronic wax[ing] and waning and popping and snapping in his knee especially with stairs.” (Tr. 467.) Plaintiff reported increased pain “especially with flexion and extension type motions” since his fall in July and “some numbness.” (Tr. 467.) Dr. Fey observed that Plaintiff had “a slightly antalgic gait, ” but

[t]here is no effusion. His knee is relatively stable to varus and valgus stress as well as Lachman's maneuvers. He had good range of motion. There is some nonspecific medial tenderness, no medial joint line tenderness. He does have some patellofemoral crepitants [sic]. He does describe some decreased sensation about the anterolateral patella.

(Tr. 468.) Dr. Fey also reviewed x-rays taken in August, which showed “minimal degenerative changes” but were “otherwise unremarkable.” (Tr. 468; see Tr. 338.) Dr. Fey diagnosed Plaintiff with “very mild degenerative arthritis of the patellofemoral joint” and prescribed a knee sleeve. (Tr. 468.)

         Plaintiff was seen for a routine eye exam at the end of December. (Tr. 462.) Plaintiff expressed concerns about glaucoma, noting a family history and increased pressure in his eye during an exam in July. (Tr. 462.) Glaucoma was suspected given Plaintiff's family history, borderline intraocular pressure, and “suspicious nerves” as well as the early stages of cataracts. (Tr. 463). Additional testing was recommended. (Tr. 463.)

         Plaintiff also had an appointment with Dr. Serposs at the end of December. (Tr. 461.) While Plaintiff remained unemployed, he reported doing “some odd jobs for his landlord thus he has a place to stay.” (Tr. 461.) Plaintiff also felt that the bupropion was improving his mood and Dr. Serposs noted some improvement as well. (Tr. 461.) Dr. Serposs continued Plaintiff's medication and directed him to return in five weeks. (Tr. 462.)

         B. 2010

         Plaintiff next saw Dr. Serposs at the beginning of February 2010. (Tr. 460.) Plaintiff reported that the increase in bupropion “has been helpful to his mood and outlook.” (Tr. 460.) Plaintiff also reported that he was planning to go to a job fair in the next week or so. (Tr. 460.) Plaintiff was casually dressed, adequately groomed, and fully cooperative with normal speech and a logical thought process. (Tr. 460.) His affect was appropriate and his mood was moderately depressed. (Tr. 460.) Dr. Serposs instructed Plaintiff to continue taking bupropion and return in one month. (Tr. 461.)

         Plaintiff had a follow-up ophthalmology appointment in mid-February. (Tr. 456.) After additional testing, Plaintiff was diagnosed with glaucoma and Fuchs' dystrophy. (Tr. 459.)

         Plaintiff met with Dr. Serposs a few weeks later, in the beginning of March. (Tr. 452.) Plaintiff reported that his mood was “fair despite the fact that he has still not found work.” (Tr. 452.) Plaintiff was doing “a few odd jobs for his landlord which gives him a little money and he continues to look for work.” (Tr. 452.) Plaintiff reported that the bupropion was “helpful.” (Tr. 452.) Dr. Serposs described Plaintiff's mood as mildly depressed. (Tr. 425.) Plaintiff was directed to return in four weeks. (Tr. 452.)

         Plaintiff saw Dr. Serposs again in the beginning of April. (Tr. 448.) Plaintiff continued to look for work and “felt quite discouraged in this regard.” (Tr. 449.) Plaintiff also continued to have financial difficulties. (Tr. 449.) Plaintiff's mood was depressed, but he continued to exhibit adequate grooming, full cooperation, normal speech, logical thinking and an appropriate affect. (Tr. 449.) Dr. Serposs added citalopram[6] to Plaintiff's medications and directed him to return in three weeks. (Tr. 449-50.)

         Around this time, Plaintiff's comprehensive treatment plan was updated. (Tr. 450-51.) Plaintiff's problems were described as depression, interpersonal conflict, and difficulty coping with chronic pain. (Tr. 450.) Plaintiff's goals and objectives were to (1) “[d]ecrease depressive symptoms through continued medication adjustment and therapy with Dr. Serposs”; (2) “[c]ontinue to work on finding a job”; (3) “[r]econnect with . . . [his teenage] son, ” whom he had not seen in one year and did not know where he was; and (4) reduce chronic pain through medication management. (Tr. 450.) Plaintiff's diagnoses were major depressive disorder and ADHD by history. (Tr. 451.) Plaintiff's current GAF score was 50.[7] (Tr. 451.)

         Plaintiff also followed up with ophthalmology in early April in connection with Travatan[8] eye drops he had begun six weeks ago. (Tr. 445-48.) Plaintiff's intraocular pressure had decreased with the drops. (Tr. 446.) Plaintiff reported some worsening of his vision. (Tr. 446.) Plaintiff was directed to continue using the drops and return in six months. (Tr. 446.)

         Plaintiff saw John E. Bassett, M.D., around the same time for back pain. (Tr. 442.) Dr. Bassett noted that Plaintiff had “chronic low back pain and wears a back brace.” (Tr. 442.) Plaintiff could not recall a particular incident leading to his back pain. (Tr. 442.) Plaintiff's pain was “localized, nonradiating, except for occasional, sharp, stabbing, burning pains in the infrascapular area midline.” (Tr. 442.) Neither diclofenac nor cyclobenzaprine helped with this pain. (Tr. 442.)

         Dr. Bassett noted that physical therapy was previously ordered by Dr. Boyum in August 2009. (Tr. 443.) Dr. Bassett offered to refer Plaintiff to physical therapy, but Plaintiff declined. (Tr. 443.) Upon examination, Plaintiff was “slightly tender in the midthoracic area below the scapula bilaterally.” (Tr. 443.) Plaintiff's range of motion was limited due to his back and knee braces. (Tr. 443.) Otherwise, Plaintiff's flexion was normal and his lateral flexion was “fairly normal bilaterally.” (Tr. 443.) Plaintiff could “stand on either leg supported without change in pain in his back.” (Tr. 443.) Dr. Bassett diagnosed Plaintiff with midthoracic back pain and chronic lumbar back pain. (Tr. 443.) Dr. Bassett prescribed a trial of hydrocodone/acetaminophen[9] for one month along with heat and massage if desired. (Tr. 443.) Dr. Bassett instructed Plaintiff to call back if he wanted physical therapy. (Tr. 443.) Dr. Bassett also instructed Plaintiff that “[h]e need not use cyclobenzaprine if it is not effective.” (Tr. 443.) Lastly, Dr. Bassett noted that both Plaintiff's blood pressure and cholesterol were “well controlled.” (Tr. 443.)

         Towards the end of April, Plaintiff had another appointment with Dr. Serposs. (Tr. 441.) Plaintiff reported “some benefit from the addition of citalopram” and stated that the Vicodin[10] prescribed by Dr. Bassett was helping. (Tr. 441.) While Plaintiff did “not have regular work yet, ” he continued to pick up odd jobs. (Tr. 441.) Dr. Serposs observed that Plaintiff was casually dressed, adequately groomed, and fully cooperative with normal speech, logical thinking, and an appropriate affect. (Tr. 441.) Dr. Serposs described Plaintiff's mood as moderately depressed. (Tr. 441.) Dr. Serposs increased Plaintiff's citalopram, continued bupropion, and instructed Plaintiff to return in one month. (Tr. 442.)

         Plaintiff had another ophthalmology appointment in May with complaints of changes in his distance vision. (Tr. 439; see Tr. 439.) Plaintiff's external eye exam was within normal limits. (Tr. 438.) Plaintiff was directed to continue the Travatan drops and given a new glasses prescription. (Tr. 438.)

         Between approximately mid-May through mid-September, Plaintiff continued to meet with Dr. Serposs on a monthly basis. (Tr. 431, 432, 434, 435, 436.) At each of these visits, Plaintiff reported that the combination of bupropion and citalopram was helpful. (Tr. 431, 434, 433, 435, 437.) Plaintiff remained without regular employment, but continued to work for his landlord. (Tr. 431, 434, 435, 437.) During this time, Plaintiff reported being “somewhat angry and hurt” when his son did not call on Father's Day. (Tr. 434.) Plaintiff also reported that his daughter, who was living in New York, had a baby boy, and he was “pleased” to be a grandfather. (Tr. 433.) During this time, Dr. Serposs noted that Plaintiff's mood fluctuated between moderately depressed and mildly depressed, but generally showed improvement. (Tr. 431, 433, 434, 435, 437.) Dr. Serposs continued Plaintiff's medications without adjustment. (Tr. 432, 433, 435, 436, 437.)

         In the middle of September, Plaintiff's blood pressure was taken in connection with his mental-health appointment. (Tr. 429.) Plaintiff's blood pressure was elevated and Plaintiff was instructed to “decreas[e] caffeine as [he] had eaten chocolate prior to [the] visit.” (Tr. 429.) Plaintiff was further instructed to recheck his blood pressure at home and call if it remained high. (Tr. 429.)

         At the end of September, Plaintiff had a follow-up appointment with Dr. Bassett. (Tr. 426.) Plaintiff continued to report low back and knee pain, but the knee pain was now greater in his left knee. (Tr. 436.) Dr. Bassett noted that Plaintiff had “rationed his Vicodin, ” and not taken any in the past two months. (Tr. 426.) Plaintiff continued doing odd jobs for his landlord. (Tr. 426.) Plaintiff remained estranged from his son. (Tr. 427.) Upon examination, Dr. Bassett noted:

An obese man who walks favoring his back, cannot get out of a chair without using his arms. Cannot balance on either knee. Knees can be fully extended. Flexion to 90 degrees. No effusion. No point tenderness in the medial, lateral, or peripatellar spaces.

(Tr. 427.)

         Dr. Bassett assessed Plaintiff with chronic back pain and continued the Vicodin. (Tr. 427.) Dr. Bassett noted Plaintiff was trying to pursue disability benefits. (Tr. 427.) Dr. Bassett continued Plaintiff's blood-pressure medication and “[s]trongly recommended greater dietary caloric restriction” as Plaintiff “is unlikely to be able to perform more physical exercise.” (Tr. 427.)

         Approximately one month later, Plaintiff had another follow-up appointment with ophthalmology, where he reported “a slight decrease in vision.” (Tr. 420, 424.) Plaintiff's intraocular pressure had again decreased. (Tr. 425.) Cosopt[11] drops were prescribed. (Tr. 422, 593.)

         The following day, Plaintiff met with a nurse for his mental-health appointment because Dr. Serposs was out of town. (Tr. 416.) The nurse noted:

He says his mood has been “up and down, ” depending on how he is feeling about his prospects for disability and his job situation. He has applied for service connection for his back and is waiting for a response, which he thinks should come soon, as it's been a year. In the mean-time [sic], he spends his days [playing] game “apps” on Facebook (“I may be addicted”), watching TV, doing some odd jobs for his landlord and looking for other work.

(Tr. 416-17; see Tr. 414, 589.) Plaintiff reported being in contact with his daughter regularly but felt bad that he was not able to go to New York to see the baby. (Tr. 417; see Tr. 414.) Plaintiff was still waiting to hear back from his son. (Tr. 416; see Tr. 414.) Plaintiff reported that his driver's license had been reinstated. (Tr. 417.) Plaintiff reported being worried about his “‘borderline Glaucoma.'” (Tr. 417.) Plaintiff continued to find bupropion and citalopram helpful without adverse side effects. (Tr. 417.)

         The nurse observed that Plaintiff had adequate hygiene and was pleasant and talkative. (Tr. 419.) Plaintiff smiled and laughed “readily.” (Tr. 419.) Plaintiff's speech was normal and there was no thought disturbance. (Tr. 419; see Tr. 589.) Plaintiff was “[a]lert with good eye contact and good recall of recent and remote events and details, ” and his judgment and insight were adequate. (Tr. 419.) The nurse noted that, approximately half way through the session, Plaintiff squirmed and “appear[ed] to try and stretch his back.” (Tr. 419.) The nurse described Plaintiff as “stable” on citalopram and bupropion. (Tr. 419.) She noted that Plaintiff did “not want to pursue vocational resources through [the] VA until he hear[d] about the [service-connection disability].” (Tr. 419; see Tr. 413-14, 589.) The nurse gave Plaintiff a GAF score of 50.[12] (Tr. 590.)

         Plaintiff had appointments with both Dr. Serposs and ophthalmology towards the end of November. (Tr. 407-12.) During his appointment with Dr. Serposs, Plaintiff reported that “his mood continues to be up and down some.” (Tr. 411.) Plaintiff was however, pleased to have his driver's license back and to be communicating with his daughter and grandson. (Tr. 411.) Plaintiff told Dr. Serposs that “he does not think he will return to driving [a] cab as he would have to retake coursework to get his cab license back and he does not have the money for this.” (Tr. 411.) Plaintiff was “planning to look for delivery driver jobs.” (Tr. 411.) Dr. Serposs described Plaintiff's mood as moderately depressed. (Tr. 411.) Dr. Serposs continued Plaintiff's medications without change. (Tr. 412.)

         Plaintiff was seen for a check of his intraocular pressure. (Tr. 407, 409.) Plaintiff reported that he felt his vision was declining. (Tr. 407, 409.) Plaintiff also reported that he did not mind using the eye drops, but did forget to use them one to two times per week. (Tr. 407.) Plaintiff's treatment providers remained concerned that Plaintiff's intraocular pressure “may still be too high” and discussed argon laser trabeculoplasty (“ALT”), which Plaintiff was willing to try. (Tr. 409, 587.)

         Around one month later, Plaintiff had follow-up appointments with Dr. Serposs and ophthalmology. (Tr. 402-07.) ALT was performed. (Tr. 405, 583-85.) Plaintiff's intraocular pressure decreased from 18 to 12 post-procedure. (Tr. 404, 405, 407.) Plaintiff was directed to continue using his eye drops and return in four to six weeks. (Tr. 405.)

         During his appointment with Dr. Serposs, Plaintiff “report[ed] his mood to be fair at this time.” (Tr. 402.) Plaintiff continued to look for work. (Tr. 402.) Dr. Serposs noted that Plaintiff “continues to experience some low back pain and is taking oxycodone for this which helps.” (Tr. 402.) Plaintiff was again described as casually dressed, adequately groomed, and fully cooperative with normal speech, logical thinking, and an appropriate affect. (Tr. 402.) Dr. Serposs described Plaintiff's mood as mildly depressed. (Tr. 402.) Plaintiff was directed to continue with his current medications and return in one month. (Tr. 403.)

         A few days later, Plaintiff had a follow-up appointment in ophthalmology. (Tr. 398.) Plaintiff underwent additional ALT. (Tr. 399, 577-79.) His intraocular pressure was 15 both before and after the procedure. (Tr. 399, 578-79.)

         C. 2011

         Plaintiff's next appointment with Dr. Serposs was on January 24, 2011. (Tr. 397.) Plaintiff again “report[ed] his mood to be fair overall” and he continued to look for work. (Tr. 397.) Plaintiff reported that “[h]e is trying to keep busy with odd jobs and computer games but finds himself getting bored.” (Tr. 397.) Dr. Serposs described Plaintiff's mood as mildly depressed. (Tr. 397.) No changes to Plaintiff's medications were made and Plaintiff was told to follow up in five weeks. (Tr. 397.)

         During his ophthalmology appointment the same day, Plaintiff reported a burning sensation and redness when using the Cosopt drops following ALT. (Tr. 392, 394, 572-74.) Plaintiff's intraocular pressure was 11, which was considered “acceptable.” (Tr. 392, 393, 396.) Plaintiff was directed to return in six months. (Tr. 393.)

         Plaintiff met with Dr. Serposs again at the end of February. (Tr. 390.) Plaintiff was much the same as his previous two appointments. He continued to look for regular employment while performing “some odd jobs here and there”; his mood remained fair; and Dr. Serposs described him as mildly depressed. (Tr. 391.) During this appointment, Plaintiff reported that “he is limited to what he can do owing to back problems.” (Tr. 391.) No medication changes were made and Plaintiff was to follow up in one month. (Tr. 391.)

         In the beginning of March, Plaintiff saw Dr. Bassett for a medication change “from oxycodone-acetaminophen to plain oxycodone for his back pain.” (Tr. 388; accord Tr. 570, 702.) Plaintiff reported chronic back pain, which he was treating with a back brace, back exercises, diclofenac, and oxycodone-acetaminophen. (Tr. 388, 570, 702.) Plaintiff reported that he recently aggravated his back when he slipped getting off a bus. (Tr. 388, 570, 702.) Plaintiff also reported that “[h]e has been relatively inactive and . . . could not help his landlord carry a . . . carpet upstairs due to pain.” (Tr. 388; accord Tr. 570, 702.)

         Upon examination, Dr. Bassett observed that Plaintiff walked “very stiffly” and was “wearing a substantial back brace.” (Tr. 389; accord Tr. 571, 703.) Dr. Bassett described Plaintiff's spine flexion as follows: “Reaches only to above knees and lateral flexion similarly. Extension is 20 degrees.” (Tr. 389; accord Tr. 571, 703.) Dr. Bassett additionally noted that Plaintiff's blood pressure was “adequately controlled.” (Tr. 389; accord Tr. 570, 703.) Dr. Bassett diagnosed Plaintiff with chronic low back pain due to degenerative disk disease; changed Plaintiff's medication from oxycodone-acetaminophen to plain oxycodone; and directed Plaintiff to continue doing back exercises and wearing his back brace. (Tr. 389, 571, 703.) If Plaintiff's condition did not improve, Dr. Bassett noted that Plaintiff could resume physical therapy and/or consider a neurosurgery consultation. (Tr. 389, 571, 703.)

         Between the end of March and mid-July, Plaintiff continued to meet with Dr. Serposs once per month. (Tr. 380, 383, 384, 385, 387; accord Tr. 560-68, 697-98, 699-700.) During these visits, Plaintiff generally described his mood as fair. (Tr. 381, 387, 697.) Plaintiff continued to reach out to his son and ultimately heard back, which helped lift Plaintiff's spirits. (Tr. 381, 383, 384, 385, 563, 565, 700.) Plaintiff talked positively about his grandson and hoped to visit him soon. (Tr. 381, 384, 387, 561, 568, 697.) Plaintiff's daughter was experiencing some medical issues, which was upsetting to Plaintiff. (Tr. 385-86, 566.) Plaintiff reported going to a movie with friends to celebrate his birthday. (Tr. 384, 565.) Plaintiff remained without full-time employment, doubting that he could work due to his back, but continued to perform jobs for his landlord. (Tr. 381, 383, 387, 561, 563, 568, 697, 700.) Plaintiff's back pain persisted, which he continued to treat with oxycodone and a back brace. (Tr. 384, 386, 387, 561, 563, 566, 568, 700.)

         Plaintiff believed that his mental-health medications were helpful. (Tr. 381, 561, 697.) During these visits, Dr. Serposs observed that Plaintiff was casually dressed, adequately groomed, and fully cooperative and had normal speech, logical thinking, and an appropriate affect. (Tr. 381, 383, 384, 387, 561, 563, 565, 568, 697, 700.) Plaintiff's mood ranged from mildly depressed to depressed. (Tr. 381, 383, 384, 387, 561, 563, 565, 568, 697, 700.) Dr. Serposs continued Plaintiff's medications without change. (Tr. 381, 384, 386, 387, 561, 563, 565, 697, 700.)

         At the July appointment, Plaintiff also underwent a pain evaluation. (Tr. 382-83, 698-99.) Plaintiff described his pain as “sharp, ” and stated that it was “[c]onstant, chronic.” (Tr. 382; accord Tr. 699.) When asked for the location of his pain, Plaintiff described it as “[g]eneralized joint pain.” (Tr. 382; accord Tr. 699.) Weather made his pain worse and medications helped alleviate it. (Tr. 382, 699.)

         In early August, Plaintiff had a six-month follow-up appointment with ophthalmology. (Tr. 376-80, 557-60, 694-96, 820-23.) Plaintiff reported that he had run out of the Travatan drops approximately one and one-half weeks ago. (Tr. 376, 379, 557, 694, 820.) Based on testing using the Humphrey Field Visual Analyzer (“HVF”), Plaintiff's right eye was “borderline overall” with “scattered defects, one dark black dot in [the] inferior nasal position but improved from the last test.” (Tr. 377; accord Tr. 558, 695, 821.) Plaintiff's left eye was within normal limits overall “with scattered defects nasally” and “stable overall from last test.” (Tr. 377; accord Tr. 559, 695, 821.) Plaintiff's intraocular pressure was described as “slightly high, ” but was thought to be due to the absence of the Travatan drops. (Tr. 377; accord Tr. 559, 695, 821.) Plaintiff was told to follow up in six months. (Tr. 378, 559, 695, 821.)

         Plaintiff had monthly appointments with Dr. Serposs in August and September. (Tr. 374, 375; accord Tr. 554, 556, 691, 693, 818-20.) Plaintiff reported feeling much the same as his previous appointments. (Tr. 374, 375; accord Tr. 555, 556, 693, 818, 819.) Plaintiff continued to experience back pain. (Tr. 374, 375; accord Tr. 555, 556, 691, 693, 818, 819.) Plaintiff reported that the pain “was especially noticeable when he went to southern Minnesota with a friend and had to drive back.” (Tr. 375; accord Tr. 556, 693, 819.) Plaintiff continued to have contact with his son and looked forward to seeing his grandson. (Tr. 375; accord 556, 693, 819.) Plaintiff described his mood as fair and reported that his mental-health medications were helpful. (Tr. 374, 375; accord Tr. 691, 693, 818, 819.) Plaintiff also mentioned possibly applying for Social Security benefits. (Tr. 374; accord Tr. 691, 818.) Dr. Serposs's observations were largely the same as previous visits and he described Plaintiff as moderately depressed. (Tr. 374, 375; accord Tr. 555, 556, 691, 693, 818, 819.) There were no adjustments to Plaintiff's medications. (Tr. 374, 375; accord Tr. 555, 556, 691, 693, 818, 819.)

         At the end of September, Plaintiff had an annual exam with Dr. Bassett. (Tr. 371, 549-54, 686-90, 811-17.) Plaintiff complained of constipation, which Dr. Bassett attributed to the oxycodone. (Tr. 371, 549, 686, 813.) Plaintiff reported that he had cut back on using his CPAP machine “because of reflux during the night, ” and elevated the head of his bed instead. (Tr. 371; accord Tr. 549, 686, 813.) Plaintiff continued to experience chronic pain. (Tr. 371, 549, 686, 813.) Plaintiff also continued to perform odd jobs for his landlord and told Dr. Bassett that he was considering applying for Social Security benefits. (Tr. 371, 550, 686, 814.)

         Dr. Bassett noted that Plaintiff

wakes up with stiffness in his hands and knees that lasts an hour. He wears a brace on his right knee and a back brace though when he went down to help a friend load a motorcycle onto a truck, he did not even take his ...

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