McCleary v. Colvin (187 F. Supp. 3d 497, 2016)

ORDER

John E. Jones III, United States District Judge

AND NOW, upon consideration of the Report and Recommendation of United States Magistrate Judge Gerald B. Cohn (Doc. 18), recommending that the Commissioner’s final decision denying Timothy Mc.Gleary’s application for benefits be affirmed and the appeal be denied, and, after an independent review of the record, and noting that the Plaintiff filed objections, to which the Commissioner responded (Docs. 19 and 20) and the Court finding Judge Cohn’s analysis to be extremely thorough, well-reasoned, and fully supported by the record, and the Court further finding Plaintiffs objections to be without merit and squarely addressed by Judge Cohn’s report IT IS HEREBY ORDERED THAT:

1. The Report and Recommendation of Magistrate Judge Cohn (Doc. 18) is ADOPTED in its entirety.

2. The Clerk of Court shall enter judgment in favor of the Commissioner and against Timothy McCleary as set forth in the following paragraph.

3. The decision of the Commissioner of Social Security denying Timothy McCleary disability insurance benefits is affirmed.

4. The Clerk of Court shall CLOSE this case.

REPORT AND RECOMMENDATION TO DENY PLAINTIFF’S APPEAL

REPORT AND RECOMMENDATION

GERALD B. COHN, UNITED STATES MAGISTRATE JUDGE

I. Procedural Background

On July 13, 2009, Timothy McCleary (“Plaintiff’) filed as a claimant for disability insurance benefits under Title II of the Social Security Act; 42 U.S.C. §§ 401-34, 1181-1183f, with a date last insured of September 30, 2014, with an amended disability onset date of July 13, 2009. (Administrative Transcript (hereinafter, “Tr.”), 540-41).

After the claim was denied at the initial level of administrative review, the Administrative Law Judge (ALJ) held a hearing on January 25, 2011. (Tr. 28-70). On March 18, 2011, the ALJ found that Plaintiff was not disabled within the meaning of the Act. (Tr. 12-27). On April 28, 2011, Plaintiff sought review of the unfavorable decision, which the Appeals Council denied on April 1, 2013. (Tr. 1-5). On May 28, 2013, Plaintiff appealed the decision of the Commissioner of the Social Security Administration denying social security benefits in McCleary v. Colvin, 1:13-cv-01434-CCC. In McCleary v. Colvin, 1:13-cv-01434-CCC, the Commissioner requested that the case be remanded stipulating that, “[o]n remand, the administrative law judge will update the record; hold a supplemental hearing; issue a new decision; and, in the decision, specifically explain the consideration given to the Veterans Administration’s disability rating(s).” McCleary v. Colvin, 1:13-cv-01434-CCC, at ECF No. 15. On January 2, 2014, the case was remanded for further proceedings. McCleary v. Colvin, 1:13-cv-01434-CCC, at ECF No. 16, 17. On February 7, 2014, the Appeals Counsel remanded the matter (Tr. 641-645) mandating for the ALJ to:

Further evaluate the claimant’s medically determinable impairments- in accordance with 20 C.F.R. § 404.1520, and in so doing, specifically explain the consideration provided the Veterans Administration disability rating and indicate the weight assigned such , opinion evidence. If needed, further consider the claimant’s maximum residual functional capacity and provide appropriate rationale with specific references to evidence of record in support of the assessed limitations (20 CFR 404.1545 and Social Security Ruling 85-16 and 96-8p).

If warranted by the expanded record, obtain supplemental, evidence from a vocational .expert to. clarify the effect of the assessed limitations on the claimant’s occupational base (Social Security Ruling 88-14). The hypothetical questions should reflect the specific, capacity/limitations established by the record as a whole. The Administrative Law Judge will ask the vocational expert to identify examples of appropriate jobs and to state the incidence of such jobs in the national economy (20 CFR 404. 1566). Further, before relying on the vocational expert evidence the Administrative Law Judge will identify and resolve any conflicts between the occupational evidence provided by the, vocational expert and information in the Dictionary of Occupational Titles (DOT) and its companion publication, the Selected Characteristics of Occupations (Social Security Ruling ,00-4p).

(Tr. 643-44). On June 13, 2014, the ALJ held another hearing (Tr. 555-600) and on September 30, 2014, the ALJ found that Plaintiff was not disabled within the meaning of the Act (Tr. 537-554). Ón January 26, 2015, Plaintiff filed the above-captioned action pursuant to 42 U.S.C. § 405(g) and pursuant to '42 U.S.C. § 1383(c)(3), to appeal a decision of the Commissioner of the Social Security Administration denying social security benefits. ■ (Doc; 1). On April 10, 2015, the Commissioner (“Defendant”) filed an answer and an administrative transcript of proceedings. (Doc. 9,10). In the Answer, Defendant “clarifies that jurisdiction and venue are conferred upon this Court pursuant to 42 U.S.C. § 405(g) of the Social Security Act.” (Doc. 9). On May 25, 2015, Plaintiff filed a brief in support of the appeal. (Doc. 12 (“Pl.Brief”)). On June 25, 2015, Defendant filed a brief in response. (Doc. 14 (“DefiBrief”)). On June 29, 2015, the Court referred this case to the undersigned Magistrate Judge. On July 2, 2015, ,Plaintiff filed a reply brief. (Tr. 15 (“Reply”)).

II. Relevant Facts in the Record

Plaintiff was born in May 1982, and thus was classified by the regulations as a younger person through the date of last insured, December 31, 2013. (Tr. 22);. 20 C.F.R. § 404.1563(c). Plaintiff took special education classes and graduated high school in 2002.. (Tr. 133). Plaintiff had an Individualized Education Plan (“IEP”) for extra time to take tests and for to help with reading and spelling. (Tr. 134). Plaintiff served in the Army from June 2004 to December 2007. (Tr. 249). Plaintiffs past relevant work includes a fast food worker, a heat and air conditioning helper and a laborer. PI. Brief at 3. (Tr. 548)..

A. VA Rating Decision

Plaintiff was issued a VA rating decision on August 19, 2012. (Tr. 1043-44). The rating decision does not include an explanation or analysis and the following information is generally the entirety of what information was included in the rating decision. The rating specialist assigned Diagnostic Code 9411 for Plaintiffs PTSD .and determined that Plaintiffs PTSD impairment was 50% disabling from December 15, 2007, pnward. (Tr. 1043). The rating specialist assigned Diagnostic Code 5257 for “chronic lumbar strain (formerly rated as upper and lower back strain)” and determined that the back impairment was: 1) 10% disabling from December 15, 2007, to April 19, 2009; 40% disabling from April 20, 2009 to March 31, 2010, and; 20% disabling from April 1, 2010, onward. (Tr. 1043). The rating specialist assigned Diagnostic Code 6260 for Plaintiffs tinnitus and determined that impairment was 10% disabling from December 15, 2007, onward. (Tr. 1043). The rating specialist assigned Diagnostic Code 5257 for Plaintiffs “left knee strain with no evidence of chondro-malacia patellae (previously diagnosed as right knee strain with chondromalacia patellae),” and determined that the impairment was 0% disabling from December 15, 2007 to April 25, 2010; and 10% disabling from April 26, 2010, onward. (Tr. 1043). A’ rating specialist assigned' Diagnostic Code 5257 for Plaintiffs “right knee strain with ho evidence of chondromalacia patellae (previously diagnosed as right knee strain with chondromalacia patellae),” and determined that the impairment was 0% disabling from December 15, 2007 to April 25, 2010; and 10% disabling from April 26, 2010, onward. (Tr. 1044). The rating specialist assigned Diagnostic Code 6100 for Plaintiffs “bilateral hearing loss),” and determined that the impairment was 0% disabling from December 15, 2007, onward. (Tr. 1044). Plaintiffs initial “combined evaluation for compensation” was 60% from December 15, 2007. (Tr. 1044). After submitting successive claims for increased compensation based on purported increase of impairment, Plaintiff had the following combined evaluations: 70% from April 20, 2009; 60% from April 1, 2010, and; 70% from April 26, 2010, onward. (Tr. 1044). The rating specialist also noted that Plaintiffs claim of sciatic spams of the lower back was not diagnosed and denied Plaintiffs claim for Total Disability Based on Unemployablity (“TDIU”). (Tr. 1044). .

B. Relevant Treatment History, Medical, and Other Source Opinions

1. VA Treatment Records: Gary T. Budd, Staff Prosthetist, PSAS; James W. Kee, MPT; Morris B. Field, radiologist; Martin P. Fleming, M.d.; Sutton T. Ulman, M.S.W.; Marshall F. Sinback, P.A.-C.; Colleen M. Sluder, D.O.; Cynthia S. Shump, N.P.; Patricia A. Wright, R.N.; David W. Braithwaite, R.N.; Elizabeth L. Putnam, P.A.; Beth E. Nease, P.A.-C.; Anthony K. Rice, M.D.; Denease L. Stec, L.P.N.; Shawn M. Neff, D.C.; Abdolali Elmi, M.D.; Adrienne L. Gray; Deborah D. Willis, R.N.; Mark E. Meany, M.D.; Ali Asghar, M.D.; Manjula Kataram, M.D.; Marsha L. Martin, L.P.N.; Thomas A. Kidd, P.A.; Fezan H. Rizvi, M.D.; Sutton T. Ulman, M.S.W.; Wafa I. Rizk, M.D.; Khusro Y. Arastu, M.D.; Manjula Kataram, M.D.; Joseph Canvin, M.D.; Hojoon Jung, M.D.; Jung Joo Suh, M.D.; Marta J. Cha-plynsky, M.D.

On August 27, 2008, Plaintiff was a new patient with Dr. Sluder and complained of bilateral shoulder pain and bilateral knee pain which was not constant and was not accompanied with weakness. (Tr. 332-33, 339-40). Plaintiff reported occasional restriction of motion, . (Tr. 333). Upon examination, Dr. Sluder observed crepitus in bilateral knees. (Tr. 334). Dr. Sluder noted that for a depression screening questionnaire, Plaintiff scored an 18 which suggested moderately severe depression. (Tr. 334). Plaintiff reported almost daily experiencing little interest or pleasure in doing things; feeling down, depressed, or hopeless; trouble falling asleep or sleeping too much; feeling tired or with little energy; feeling bad about himself or a failure; trouble concentrating; and, experiencing some difficult taking care of tasks at home or getting along with people. (Tr. 334-35). Plaintiff reported drinking alcohol monthly or less and no more than two drinks at a time. (Tr. 340^41).

On September 3, 2008, Plaintiff saw Ms. Nease for an initial evaluation and treatment of depression .and anxiety. (Tr. 331). Plaintiff reported that he left the military in order to care for his child since his ex-wife wanted a divorce and did not want to keep the child. (Tr. 331). Plaintiff added that he missed the military. Plaintiff stated when things weren’t going, well, he would get depressed. (Tr. 331). With regards to anxiety, Plaintiff reported that he experiences times when his heart races and he feels fidgety. (Tr. 331). Plaintiff reported that he usually avoids crowds and experiences flashbacks, nightmares, and hypervigilance to a degree. (Tr.' 331). Ms. Nease wrote:

He had been living in Virginia with his girlfriend and they broke up and he moved back to Chambersburg where he has family support. His mother died in May of this year. He was especially close to her .... But he has good support system with his one sister. He still doesn’t have a job which was a problem inVA.

He has problems going to .sleep and staying asleep. I asked about the rem-eron and he admitted he slept well with it; but thought he slept too deep and wouldn’t know if the house caught on fire. We agreed on benedryl [sic] which he will buy.

Dressed casually and had copies of some of medical history from TN with him. Speech—difficulty finding the right word at times. Thought process linear. Mood slightly anxious but stable. Affect is mood congruent. Denies SI/HI/AVH. Due to time constraints I was not able to complete his mental status which I will do at his next.appt. [sic]

(Tr. 331). Ms. Nease assessed Plaintiff as having adjustment disorder with anxiety and prescribed Paxil for depression and anxiety. (Tr. 331).

A letter dated September 10, 2008, indicated that Plaintiff was a “no-show” for a scheduled appointment. (Tr. 330).

On September 23, 2008, Dr. Fleming reviewed images of Plaintiffs bilateral knees and bilateral shoulders and concluded that the bilateral knees and shoulders were “normal.” (Tr. 229-31).

On September 23, 2008, Plaintiff reported a history of bilateral knee pain with the right knee much worse than the left. (Tr. 258, 328). Plaintiff reported that he experienced intermittent left knee pain but has a lot difficulty with the right knee. (Tr. 258, 328). Plaintiff reported that while in Afghanistan he had to do “long tracks during a 24 hour period upwards to 12-13 miles.” (Tr. 258, 328). Mr. Sinback noted that Plaintiff did not give “any specific history of acute injury,” reporting rather that the pain progressively developed primarily in his right knee while in Afghanistan. (Tr. 258). Plaintiff reported that he sought medical attention while in the military and had an MRI scan which was unremarkable. (Tr. 258). Plaintiff reported currently working in a warehouse which required frequent squatting and prolonged standing. (Tr. 258). Upon physical examination, Mr. Sinback observed- that Plaintiff exhibited full extension and flexion of 130 degrees. (Tr. 259). Mr. Sinback observed that Plaintiff had a negative McMurray’s sign bilaterally and his knees were stable to valgus, varus, and AP stress. (Tr. 259). Mr. Sinback further observed that:

The q angles are normal. He has excellent tracking of his patella with flexion and extension without evidence of sub-luxation. He has exquisite tenderness in the right retropatellar area including the medial and lateral facets to deep palpation. This is less so on the left side but also he has patellofemoral tenderness there as well. The remainder of the knee exam is unremarkable. X-rays were taken today which are unremarkable.

(Tr. 259). Mr. Sinback assessed Plaintiff to have “[pjrobafele bilateral patellofemoral syndrome right greater than left.” (Tr, 259). For treatment Mr. Sinback recommended a set of exercises, to continue the use of shoe inserts and to undergo a physical therapy consult to review the exercise program for his knees. (Tr. 259). Mr. Sinback opined that Plaintiffs “problem at this time should be considered nonsurgical” and that for pain medication he could “continue the use of NSAIDS” when needed. (Tr. 259).

On September 26,2008, a letter was sent to inform Plaintiff that his medical providers have been unable to contact him for follow-up care. (Tr. 338).

On October 9, 2008, Dr. Field interpreted radiographs taken to investigate complaints of chronic intermittent bilateral hand pain and right ankle pain. (Tr. 226-28). Dr. Field observed no fracture or subluxation. (Tr. 226-27). Dr. - Field wrote that for the left hand the “interpha-langeal joints appear well-maintained. The Carpometacarpal joints appear well-aligned. A' small sclerotic area within the capitate is demonstrated. The sclerotic area appears benign and likely represents a bone island. There is no subcutaneous emphysema or radiopaque foreign body.” (Tr. 226-27). The primary diagnostic code was “minor abnormality” for the left hand. (Tr. 227). For the right hand Dr, Field observed that there was “no fracture or subluxation”.’ The interphalangeal joints appear well-maintained. The Carpometa-carpal joints appear well-aligned. A small sclerotic area within the capitate is demonstrated. There is no subcutaneous emphysema or radiopaque foreign body. (Tr. 227-28). The primary diagnostic code was “normal” for the right hand. (Tr. 228).

On October 9, 2008, Dr. Field also interpreted images of Plaintiffs right ankle due to complaints of pain, (Tr. 228); For the right ankle Dr. Field observed that there was “no fracture or dislocation.. The ankle mortise appears well-maintained. There are no sclerotic or lytic lesions demonstrated. There is no subcutaneous emphysema or radiopaque foreign body.” (Tr. 228). The primary diagnostic code was “normal” for the right ankle. (Tr. 229).

On October 10, 2008, Plaintiff sought follow-up mental health therapy with Ms. Nease. (Tr. 294-95). Ms, Nease observed that Plaintiff was a “somewhat poor historian.” (Tr. 294). Plaintiff reported that he continued to live with his child, grandparents, his sister, her husband and seven children. (Tr. 294). Plaintiff reported that it was easy to be drawn into a verbal confrontation with any of the adults in the household, (Tr. 294). Plaintiff reported that he enjoyed his work at a distribution center. (Tr, 295). Plaintiff stated that a couple of times he had startled when someone walked up behind him and he told his supervisor about his PTSD and that “he was OK as long as he didn’t have a flashback and harm someone.” (Tr. 295). Plaintiff reported that he was still dealing with his mother’s death. (Tr. 295). Plaintiff reported that he was having nightmares every night about the same military incident. (Tr. 295). Ms. Nease offered Plaintiff prazosin but Plaintiff “refused thinking he has low blood pressure.” (Tr. 295).

Ms. Nease observed that Plaintiff was “[djressed casually but out of season. Had on shorts and thin tee. shirt.” (Tr. 295). Ms. Nease observed that Plaintiff had difficulty finding the right word at times, his mood was “slightly anxious but stable,” Plaintiffs “[ajffect is mood congruent,” and his memory was intact. (Tr. 295). Ms. Nease observed that Plaintiff had the ability to concentrate, had difficulty with abstract thinking, and exhibited fairly good insight and judgment. (Tr. 295). Ms. Nease assessed Plaintiff with adjustment disorder with anxiety. (Tr. 295).

On October 24, 2008, Plaintiff saw Ms. Nease for a “walk-in” mental health visit. (Tr. 291). Plaintiff stated that his mood was much better and that he was sleeping better. (Tr. 291). Plaintiff reported that he talked with his boss at work and they were going to put him on a lesser anxiety ridden type job. ' (Tr. 291). Ms. Nease wrote:

He was telling me how anxious he feels. I questioned about caffeine: at least 1-2 pots a day along with several bottles of pop. I talked to him about the need to wean off the caffeine slowly. He does not want to do that. I pointed out he was complaining about his anxiousness but then refuses to treat it.

(Tr. 291). Plaintiff stated that he was out of paxil and Ms. Nease wrote that she told him it had been mailed on October 14, 2008, and he should have received it. (Tr. 291). Ms. Nease noted that she would submit a new refill. (Tr. 291). Ms. Nease observed that Plaintiffs mood was anxious but stable and his affect was “brighter.” (Tr. 291).

On October 30, 2008, Mr. Kee noted that Plaintiff • had cancelled two physical therapy sessions and another session was canceled. (Tr. 252). On December 9, 2008, it was noted that Plaintiff failed to return several calls and that physical therapy would be cancelled until he did a new consultation. (Tr. 252-288).

On October 31, 2008, Mr. Ulman noted that he was left a message for Plaintiff. (Tr. 288). In a treatment record dated November 7, 2008, Mr. Ulman reviewed Plaintiff records and noted that while serving in the military, he was deployed to Afghanistan between March 2006 and July 2007. (Tr. 249, 285-86). Plaintiff reported that he came under enemy attack and experienced fear for his life and feelings of helplessness. (Tr. 249). Mr. Ulman noted that Plaintiff remained unavailable after multiple calls and messages. (Tr. 249, 285-86).

Letters dated November 20, 2008, stated that Plaintiff missed scheduled appointments. .CIV. 284-85).

On February 27, 2009, Plaintiff sought mental health treatment with Ms. Nease. (Tr, 274-75). Ms. Nease noted that Plaintiff had not been compliant with his medication (specifically Paxil). (Tr. 275). Plaintiff reported experiencing side effects from the medications yet “admitted] he didn’t take it long enough and didn’t refill because he couldn’t find the bottle, etc.,” to which Ms. Nease suggested that he could have called to get the refill. (Tr. 275). Plaintiff reported that his ex-wife wanted custody of their 7 year old child; however, she would agree to give custody if he promised not to move. (Tr. 275). ’ Plaintiff reported that his work was “going OK,” but he was still anxious and stated that he would like to try hydroxyzine. (Tr. 275). Ms. Nease advised that he could not take it for work due to drowsiness and past records indicated that he had taken it before. (Tr. 275). Ms. Nease indicated that he would take hydroxyzine and discontinue the Paxil. (Tr. 275). Ms. Nease observed that Plaintiff was casually dressed with uncombed hair and that Plaintiffs speech was normal. Ms. Nease noted that Plaintiffs thought process was linear, mood was anxious but otherwise stable, and exhibited no suicidal or homicidal ideation. (Tr. 275).

On February 24, 2009, Plaintiff sought treatment for a viral sinus infection and a migraine that he has had since February 19, 2009. (Tr. 275-76, 279-81). Plaintiff reported that the last time he experienced similar symptoms was three to four years ago. (Tr. 276). Plaintiff reported going to the emergency room on February 22, 2009. (Tr. 276). On February 27, 2009, Plaintiff reported that he felt “75% better” and wanted to return to work on March 2, 2009. (Tr. 278).

On March 6, 2009, Plaintiff sought treatment for his back pain stating that on March 2, 2009, his back started hurting after moving boxes at work. (Tr. 266). Plaintiff went to the emergency room that evening and was treated with toradol and cyclobenzaprine. (Tr. 266). Plaintiff reported that his back is getting better and he has been trying to relax. (Tr. 266). Plaintiff stated that since military service his back has been stiff and he does not have a heating pad. (Tr. 266). Plaintiff requested' a letter for his work to not return until March 9, 2009. (Tr. 266-67). Ms. Shump noted that Plaintiff was ambulatory, answered questions freely, and reported experiencing a level of four out of ten for pain. (Tr. 267). Ms. Shump ordered a heating pad to alleviate Plaintiffs back pain symptoms. (Tr. 267).

On March 25, 2009, Plaintiff reported experiencing back pain and experiencing back spasms earlier in the month. (Tr. 262). Plaintiff requested a refill of muscle relaxant medication which he reported worked well and reported using the heating pad with good results. (Tr. 262). Dr. Sluder observed “hypertonicity left para-spinal muscles; no vert point tenderness.” (Tr. 263). Dr. Sluder assessed Plaintiff with back and knee pain and that Plaintiffs PTSD was stable and Plaintiff did not experience suicidal or homicidal ideation. (Tr. 263). Dr. Sluder instructed Plaintiff to bend and lift carefully with the knees and to avoid rapid twisting motions. (Tr. 263).

On March 2, 2009, Plaintiff sought emergency room treatment reporting that he experienced pain in his left lower back going down to his buttocks and rate his pain at a level 8. (Tr. 271). Plaintiff explained that he lifts boxes at work all day. (Tr. 271). Ms. Putnam observed that Plaintiff had palpable spasms in the left lumbar area, decreased range of motion on flexion and extension and straight leg raise pain at thirty degrees. (Tr. 272). Ms. Putnam assessed Plaintiff with low back pain due to spasms, PTSD, anxiety, and migraine headaches. (Tr. 272). On March 3, 2009, Mr. Braithwaite noted that Plaintiff met pain relief goal of a pain score of 3 upon discharge. (Tr. 270-71).

On April 15, 2009, Mr. Budd fitted Plaintiff with an elastic back brace. (Tr. 214-15). On April 15, 2009,- Mr. Kee was consulted to address Plaintiffs reported.back pain symptoms. (Tr. 216-220). Mr. Kee noted that Plaintiff was issued a TENS unit, a lumbar-sacral cushion, and elastic back brace. (Tr. 216). Plaintiff reported that the onset of the back pain was the year prior when his job required him to lift seventy pounds. (Tr. 216-19). Plaintiff reported that at best, his pain is 5 out of 10, and at worse, it is 9 out of 10. (Tr. 216-219). Plaintiff reported that the medication marginally alleviates pain ■ symptoms. (Tr. 217, 220). Mr. Kee observed that Plaintiff had a guarded posture, thoracic and lumbar mobility was moderately restricted with some stiffness in the end ranges. (Tr. 217). Plaintiffs straight leg raise was positive bilaterally at 35 degrees with mild tightness in hamstrings. (Tr. 217). Upon palpation, Plaintiff exhibited “moderate plus” muscle spasm in thoracic area and especially in the lumbar sacral paraspinal area. (Tr. 217). Mr. Kee observed that Plaintiffs gait had a “moderate minus antalgic appearance.” (Tr. 217). Mr. Kee opined that Plaintiff would, benefit from rehabilitation for five weeks. (Tr. 217).

A letter dated April 22, 2009, indicated that Plaintiff missed a schedule appointment. (Tr. 536).

On June 2, 2009. Ms. Nease noted that: [Plaintiff] called and wanted his medication refilled. I explained he had refills but had not been taking them. He stated' he got depressed after he lost his job because of his back and “went into a .shell.”

.... [Plaintiff] wanted to know why he didn’t have depression as a diagnosis and I told him he had not presented with those symptoms.

(Tr. 524).

On July 9, 2009, Dr. Sluder noted that the day prior Plaintiff requested for a functional work assessment form to be completed for him to return to work, however, by the time she could respond, Plaintiff indicated that he no longer had the job. (Tr. 522).

On August 24, 2009, Ms. Nease wrote that during a phone conversation Plaintiff stated that:

His new wife left him for the second time the first of August. He states they moved too fast. She left in June and they worked it out and she came back; but now he isn’t sure where she is.

He has been drinking and having black out spells. Recently he stated he had been drinking and was in a blackout and beat up his neighbor. He has been arrested.

He is having financial difficulties. He has his own place not living with grandparents. His ex-wife signed custody papers for his daughter.

I asked about why he quit taking medication. His answer was they didn’t work. I explained he wasn’t on them long enough to give them a good trial. He didn’t call me with any of the problems.

He is unable or unwilling to tell me how much he is drinking. I explained if he is having blackout’s that’s an indication of heavy drinking/tolerance.

He was tearful at times. He denies any SI/HI. He is depressed. He is willing to try some new medication. I stressed to him he has to stay on it long enough for it to work.

(Tr. 519-20).

On September 4, 2009, Plaintiff sought treatment for coughing up blood intermittently for three or four days and stated that he wished to quit smoking. (Tr. 517). Plaintiff reported experiencing a level of 4 out of 10 for pain. (Tr. 517). . Ms. Wright noted that Plaintiff had “no functional concerns/needs involving eating, dressing, walking, using a wheelchair or using the bathroom” at the time. (Tr. 518). Plaintiff responded to a questionnaire that he had “never” drank alcohol in the past year. (Tr. 518). Ms. Wright indicated in a suicide assessment that Plaintiff previously attempted suicide by hanging when he was 14-years-old and was currently a medium risk for suicide. (Tr. 516,19).

On September 4, 2009, Plaintiff sought treatment for a cough which started “about a week and a half ago” and was tinged with blood. (Tr. 513-14). “Plaintiff reported experiencing sore throat, wheezing, sinus/nasal congestion, and shortness of breath .when climbing stairs and on awakening.” (Tr. 514). Plaintiff rated back pain at 4 on the pain scale and stated that he takes. Tylenol and naproxen for pain but without much relief. (Tr. 514). Ms. Shump assessed Plaintiff with Bronchitis. (Tr. 515-16). On September 28, 2009, Dr. Sluder noted that after five visits from “Summit Physical Med & Rehab” the back pain of 3 to 6 out of 10 and the knee pain of 3 out of 10 stayed about the same. (Tr. 513).

On October 6, 2009, Plaintiff sought follow-up treatment with Ms. Nease (Tr. 512-13). Ms. Nease noted that Plaintiff had “not been taking his medication as prescribed.” (Tr. 512). Plaintiff stated when he took 1/2 pill bid he had chest pain and stated that he had palpitations and pain in middle of chest. (Tr. 512). Plaintiff reported that he had not been drinking and that he realized he could not drink responsively. (Tr. 512). Plaintiff discussed his attempts to obtain a divorce from his estranged wife and “talked about some of his PTSD issues.” (Tr. 512). Plaintiff reported experiencing nightmares about 4 nights a week, not liking crowds, and that he had been secluding himself in his house most of the time. (Tr. 512). Ms. Nease assessed Plaintiff with “PTSD 309.81,” “Alcohol Dependence 303.90,” and “Non-compliance with treatment V15.81.” (Tr.- 512). Also, in response to what appeared to be “hickies” on his chest, Plaintiff replied that he “was a great -lover.” (Tr. 513).

On October 27, 2009, Plaintiff complained of chronic discomfort in neck, hips and legs and reported difficulty in obtaining and marinating an erection over the past two weeks. (Tr. 497, 501). Plaintiff reported worsening of symptoms since weather had changed. (Tr. 497). Dr. Slu-der noted that Plaintiffs CT spine and lumbar X-rays were all normal. (Tr. 497). Plaintiff reported experiencing a pain of 7 out of 10. (Tr. 499). Dr. Sluder observed “no vertebral point tenderness; no hyper-tonic muscles. [Plaintiff] was able to rotate head when speaking to girlfriend or me though stated it hurt to look down.” (Tr. 499). Dr. Sluder also noted “normal vertebral alignment and no vertebral point tenderness; [Plaintiff] expressed pain on just about' every movement of legs.” (Tr. 499). Dr. Sluder ordered a knee brace to address Plaintiffs knee pain and noted that Plaintiffs erectile dysfunction (“ED”) was “likely strong anxiety component, possible med side effect;” (Tr. 499). Plaintiff reported that he was very pleased with venlaxafine regarding mental health symptoms and did not want to switch medication, if possible. (Tr. 499). Plaintiff stated that he was acutely ill a couple of weeks ago and feels may his ED was secondary to acute illness. (Tr. 499). With regards to PTSD, Dr. Sluder wrote that Plaintiff stated that his symptoms were “very well controlled on venlaxafine and [did] not want to stop this medication.” (Tr. 499).

On November 13, 2009, Plaintiff complained of continued back and knee pain, reporting a level of pain of 8 out of 10 after taking medication. (Tr. 495-96). Plaintiff returned after two weeks after starting etodolac (an NSAID) and reported no significant improvement after taking the new medication for a few days. (Tr. 492). Plaintiff reported that mostly the right knee pain concerned him and that the knee gives out on him. (Tr. 492). In response to a questionnaire, Plaintiff reported that although adhering to current treatment plan, the pain interfered with his mood, sleep, relationships, chores, ability to work, and enjoyment of life. (Tr. 496). Dr. Sluder advised to continue etodolac and noted that Plaintiff would have a prosthet-ics consultation for his knee brace and an orthopedic consultation. (Tr. 493). Dr. Sluder observed that there was no edema, no calf tenderness, no knee effusions from bilateral knees, no crepitus, and no pain on palpation along the meniscal lines. (Tr. 492-93). Dr. Sluder noted no vertebral point tenderness, no muscle spasm appreciated, and no focal, motor or sensory deficits. (Tr. 493).

Although Plaintiff denied illicit drug use and reported minimal alcohol use (Tr. 492), when Dr, Sluder requested a urine toxicology, Plaintiff responded that the test would be positive for marijuana. .(Tr. 493). Dr. Sluder advised against drug, use and Plaintiff declined a substance abuse referral stating that he was just having a ‘rough day1 the prior Monday. (Tr. 493-94). Plaintiff was no longer using the using treatment to quit smoking and indicated that he was not ready to quit smoking. (Tr. 494). Dr. Sluder noted that Plaintiffs depression as stable on. current medications. (Tr. 494).

Once, to twice a week from November 19, 2009 to December 22, Plaintiff sought chiropractic treatment for low. back pain, neck pain and headaches. (Tr. 481-82, 484, 485). Plaintiff reported that physical therapy temporarily relieved some of the pain. (Tr. 485). Each time that Plaintiff underwent chiropractic manipulation, he stated that he felt better after the manipulation.. (Tr. 484, 490). Dr. Neff noted pain on palpation and muscle spasms. (Tr. 488).

On December 1, 2009, Plaintiff sought an orthopedic surgery consult with Dr. Elmi. (Tr. 485). Upon examination Dr. Elmi noted that his knee and hip were normal, there was tenderness in the mid-thoracic spine, Plaintiff had a negative SLR, and no radiating symptoms. (Tr. 485). Dr;-Elmi noted that the knee X-ray was normal, LS spine normal, thoracic spine showed small upper left thoracic scoliosis, and a questionable compression deformity in D5 or 6 which he would wait for the radiologist’s report. (Tr. 485). Dr. Elmi concluded that Plaintiff had a normal knee examination and the bilateral small thoracic scoliosis with “most likely little clinical significance.” (Tr. 485). Dr. Elmi also opined that he believed that Plaintiffs “PTSD has a lot to do with his symptoms,” and encouraged him to follow up with his PTSD treatments. (Tr. 485).

On December 7, 2009, Plaintiff reported that the venlafaxine wears off by evening and depression symptoms return. (Tr. 483). Plaintiff reported that he spends his day in bed due to back pain. (Tr. 483). Although Ms. Nease wrote “He continues not to drink,” Plaintiff was assessed with alcohol dependence. (Tr. 483). ■ ■

On December 20, 2009, Plaintiff sought ER treatment after falling on ice and injuring his back and also complained of shortness of breath. (Tr. 470^481). Plaintiff reported that his pain was a 10 from a scale of 1-10. (Tr. 480). Plaintiff had a homicidal plan to go to a “gas station where Middle Easterners are working” and hurt them. (Tr. 477, 480). There were no specific problems causing this homicidal feeling. (Tr. 480). Plaintiff denied a history of alcohol, denied using street drugs, and denied abusing prescription drugs. (Tr. 480). Ms. Gray observed that Plaintiff did not have an impaired gait and did not have any ambulatory aid. (Tr. 480-81). Upon examination Plaintiff demonstrated lumbosacral spine tenderness to left paraspinal muscles, some spasm to left, and “negative SLR/CLR/SNT.” (Tr. 472). Plaintiff could actively dorsiflex and plantarflex. (Tr. 473). Plaintiff had “no sensory or motor deficits appreciated. Reflexes [were] 2+ in LEs, Strength [was] 5/5 in LEs.” (Tr. 473). Plaintiff was diagnosed with “[fjall with exacerbation of chronic low back pain d/t paraspinous muscle spasm,” “reactive airway disease, tobacco use disorder,” and “sinusitis, odon-talgia.” (Tr. 468, 473). Dr. Chaplynsky interpreted radiographic images of the chest and spine from December 20, 2009, and concluded that Plaintiffs chest was normal; there was no evidence of fracture of malalignment, with normal disc spaces, and “unremarkable” soft tissues. (Tr. 392-94).

On December 29, 2009, Plaintiff reported injuring himself after falling on some ice on December 20, 2009. (Tr. 460.464).

On January 13, 2010, Plaintiff sought emergency treatment to address his anxiety due to “domestic issues with fiancé.” (Tr. 450-457). On January 14, 2010, Dr. Asghar noted that Plaintiffs alcohol dependence had been in remission since August. (Tr. 445). Plaintiff reported that he had been taking his medications regularly and that the medication is not effective in controlling his anxiety and still experiences nightmares and flashbacks. (Tr. 445). Plaintiff reported that he currently lived with a 'friend. (Tr. 445). Dr. Asghar opined that Plaintiffs memory was intact and judgement was fair. (Tr. 445). Dr. Asghar assessed Plaintiff with a GAF score of 58. (Tr. 445).

A pulmonary diagnostic study report dated January 21, 2010, revealed normal findings. (Tr. 922-23). Spirometry was normal, there was no acute response to inhaled bronchodilators, flow volume loop was normal, and “volume time curve demonstrated good reproducibility indications good patient effort.” (Tr. 923).

In a treatment record dated March 23, 2010, it was noted that Plaintiff requested a medication refill and that previous time he had seen Ms. Nease was December 8, 2009. (Tr. 419). In a noted dated May 4, 2010, Ms. Nease noted that Plaintiff again cancelled a mental health appointment and stated that he had been seeing psychiatrists and getting medication at another VA location. (Tr. 419). Ms. Nease informed Plaintiff of the importance of having just one metal health provider. (Tr. 419).

On May 15, 2010, Mr. Budd, the staff prosthetist noted that Plaintiff was wearing the knee braces backwards and ruined the hinges. (Tr. 413). On May 18, 2010, and May 26, 2010, Plaintiff underwent an MRI of the bilateral knees for compensation purposes.’ (Tr. 390-92). Dr. Suh concluded that the left knee was normal and Dr. Jung concluded the MRI of the right knee was “unremarkable.” (Tr. 391).

On June 5, 2010, Plaintiff called requesting an extension of physical therapy services and Mr. Kee wrote that due to Plaintiffs non-compliance, he would not recommend any further treatment sessions. (Tr. 523-24).

On October 1, 2010, Plaintiff sought follow-up treatment for PTSD and it was noted that he was last seen on January 14, 2010, and that his girlfriend reported that he took his medication irregularly. (Tr. 398). Plaintiff reported that his last use of alcohol was in July and the last time he got drunk was in February 2010. (Tr. 398). Plaintiff reported that he had been taking his medication regularly and denied using drugs or alcohol, at the time. (Tr. 398-99). Dr. Asghar observed that Plaintiffs memory was intact, judgement was fair, and assessed Plaintiff with a GAF score of 58. (Tr. 399).

On August 24, 2010, Plaintiff reported that he was in the process of losing his housing and it was noted that Plaintiff applied for 100% compensation due to un-employability (TDIU). (Tr. 404).

On June 20, 2011, sought emergency room treatment for right shoulder pain, slight chest pain, black out spells where he does not pass out, and headaches. (Tr. 918-919). Plaintiff reported that he does not lose consciousness, however, it “goes black” and his wife catches him and Plaintiff is aware that it is happening! (Tr. 913). Plaintiff reported that these episodes last for seconds and recalled that he had seizure as a child due to low iron. (Tr. 913). Plaintiff denied alcohol or drug use. (Tr. 913). Ms. Willis observed that Plaintiff was ambulatory and able to move all extremities. (Tr. 919). Plaintiff reported experiencing pain of a level 4 out of 10. (Tr. 914-15). Dr. Meany observed that Plaintiffs gait was “ok” and Plaintiff was ambulatory, the back had no costoverte-bral angle tenderness or point tenderness (Tr. 915). Dr. Meany observed normal bilateral reflexes for upper and lower extremities, and the right shoulder had no crepitus and ROM was within normal limits. (Tr. 916). Dr. Meany assessed Plaintiff with chest pain, right shoulder pain, and anxiety. (Tr. 916).

On June 29, 2011, Plaintiff sought follow-up 'mental health treatment after a break in treatment since October 1, 2010. (Tr. 907). Plaintiff reported that he was feeling drowsy on venlafaxine and stopped using it although it helped with his anxiety and depression. (Tr. 907). Plaintiff reported that he continued to experience PTSD symptoms of nightmares and flashbacks, sleeps two to three hours, and denied alcohol or drug use. (Tr. 907). Dr. Asghar opined that Plaintiffs memory was intact, attention was fair, intelligence was average, thoughts were logical, linear, and goal directed, and; judgment was fair. (Tr. 907). Dr. Asghar diagnosed Plaintiff with PTSD, depressive disorder and alcohol dependence in remission. (Tr. 907). Dr. Asghar assessed that Plaintiff was not presently suicidal or homicidal, not acutely psychotic or manic, not intoxicated or under the influence of drugs or alcohol. (Tr. 908). Dr. Asghar opined that Plaintiff was “psychiatrically stable” and assessed him with a GAF score or 58. (Tr. 908). Dr. Asghar reviewed laboratory results, which included a negative drug screen from June 20, 2011. (Tr. 909). Dr. Asghar opined that the use of an atypical antipsychotic agent would be appropriate to address Plaintiffs mood swings and depression. (Tr. 911). Dr. Asghar found Plaintiff to pose a medium risk of suicide. (Tr. 913).

On October 25, 2011, Plaintiff was evaluated by Dr. Manjula. (Tr. 902-906). Plaintiff reported experiencing a level 7 pain primarily in his right shoulder and stated that it is off and on pain which he treats with Tylenol. (Tr. 903-04). Plaintiff denied experiencing • shortness of breath, syncope, and dizziness. (Tr. 904). For social history it is noted that Plaintiff drank beer twice a week. (Tr. 905). Dr. Manjula observed no tenderness in the spine, no swelling, and that range of motion in the spine was normal. (Tr. 906).

On November 1, 2011, Plaintiff received hearing aids. (Tr. 902). On December 30, 2011, Plaintiff sought emergency room treatment for G.I. pain. (Tr. 864). Ms. Martin observed that Plaintiff was ambulatory, did not have an impaired gait, and able to move all extremities. (Tr. 864-65). Plaintiff reported that his last alcoholic drink was a month ago and denied any drug abuse. (Tr. 865).

On March. 15, 2012, Plaintiff reported experiencing depression, fatigue, generalized weakness, and low sex drive. (Tr. 857). Plaintiff reported that flexeril and ibuprofen were not significantly reducing his pain. (Tr. 857). Plaintiff was assessed to be at low risk for suicide. (Tr. 858). Mr. Kidd noted that Plaintiff requested the pain medication of tramadol, and it was discussed with Plaintiff that his pain symptoms were likely depression. (Tr. 861).

On April 18, 2012, Plaintiff had a “telep-sychiatry consult” with Dr. Rizvi. (Tr. 850-56). Dr. Rizvi noted that Plaintiff was last seen by Dr. Asghar on June 29, 2011 and was diagnosed with PTSD, alcohol dependence, and depression. (Tr. 851). Plaintiff reported that the Aripiprazole helped with his mood swings and Hydroxy-zine helped for anxiety that he would like to go restart these medications. (Tr. 851). Plaintiff reported sleeping poorly due to PTSD nightmares and although in the past Trazodone helped with sleep, he felt drowsy the next day. (Tr. 851). Plaintiff denied using drugs or alcohol at the time of the consultation. (Tr. 851). Dr. Rizvi noted that Plaintiffs fiancé was pregnant. (Tr. 851). Dr. Rizvi noted that Plaintiff appeared appropriately groomed, his mood went “up and down,” and he had an anxious affect. (Tr. 851). Dr. Rizvi noted that Plaintiff was alert and oriented to all spheres and his attention was fair. (Tr, 851). Dr. Rizvi diagnosed Plaintiff with PTSD. with mood swings and assessed Plaintiff with a GAF score of 55. (Tr. 852). Dr. Rizvi reviewed laboratory results which included a negative drug screen from Dec. 20 2011. (Tr. 854). Dr. Rizvi opined that Plaintiff was “psychiat-rically stable.” (Tr. 852). Dr. Rizvi recommended for another Tele-Psych visit in 3 to 4 Months. (Tr. 852).

On May 5, 2012, Plaintiff called very upset'at the news that his grandmother just passed away and wanted to medication to alleviate his anxiety. (Tr. 848-50). From a phone conversation Mr. Ulman noted that Plaintiff “sounded essentially stable and coherent ... with appropriate range of affect that included sobbing, appropriate to the context, and some laughing, also appearing appropriate and in context.” (Tr. 849). Plaintiff denied feeling suicidal, hopeless, or helpless at the time, stating “I’m not suicidal. I can’t think straight. I can’t help my sisters with making arrangements. I’m at my grandmother’s home,” (Tr. 849). Plaintiff said that his flaneé could drive him 1 hour to pick up the anti-anxiety medication. (Tr. 849).

On August 3, 2012, Plaintiff sought emergency treatment for severe right should and right lower neck pain. (Tr. 840-843). Dr. Rizk observed that Plaintiff was splinting right arm with elbow flexed against the chest but was observed that he used it to get out of bed. (Tr. 840). Plaintiff could not recall any injury and had been experiencing the pain for the prior two weeks. (Tr. 840). Dr. Rizk observed that “[with] distraction c-spine and both shoulders are normal.” (Tr. 842). Dr. Rizk also observed that Plaintiff’s gait was normal and that his large joints were not inflamed or tender. (Tr. 842). Dr. Rizk stated that the images of Plaintiffs C-spine and right shoulder were “unremarkable,” had the impression of right shoulder bursitis, and continued Plaintiff on ibuprofen and added a Medrol dose pack. (Tr. 842).

On October 9, 2012, Plaintiff sought follow-up treatment for mood swings which are not fully controlled by Ability, which he reports helps to some extent. (Tr. 835). Plaintiff was last seen on April 18, 2012 by Dr. Rizvi, (Tr. 835). Plaintiff reported that the trazodone helped with falling asleep but did not keep him asleep. (Tr. 835). Plaintiff reported that he regularly takes his medications and has cut down his caffeine intake to four cups a day and he drinks one beer a month, (Tr. 835). Dr. Arastu observed that Plaintiff was oriented to all spheres, had fair attention, was anxious, and generally unremarkable appearance, thought, and attitude. (Tr. 836). Dr. Arastu assessed Plaintiff with a GAF score of 60. (Tr. 836). A drug screen from March 15, 2012, was negative and it was noted that Plaintiff pain rating was zero out of ten. (Tr. 838).

On February 27, 2013, Plaintiff sought follow-up treatment for chronic lower back and knee pain. (Tr. 828-831). Plaintiff reported experiencing pain at a level of seven out of ten. (Tr. 831). Plaintiff reported that it was painful to walk. (Tr. 830). Dr. Kataram noted that Plaintiff walked with a cane. (Tr. 830). Dr. katar-am observed that there was no right knee swelling, erythema, tenderness, and range of motion flexion and extension was normal. (Tr. 830). Dr. Kataram observed no focal motor or sensory deficits, SLR test was negative and Plaintiff was able to dor-siflex great toes and feet against resistance. (Tr. 830). Dr. Kataram observed no tenderness, swelling, or rigidity in the lumbar spine. (Tr. 830). Dr. Kataram noted that the MRI was normal and assessed Plaintiff with chronic right knee arthralgia and chondromalacia patella. (Tr. 830).

On April 11, 2013, Plaintiff sought consultation for low back and bilateral knee pain which he reported was exacerbated by walking up steps. (Tr. 825). Plaintiff reported to experience intermittent pain and relief with a TENS unit. (Tr. 825). Dr. Canvin observed:

Alert male in no acute distress. He arrives 45 minutes late for the examination today. He is walking with a cane, but walks fíne without it: He is able to cross legs and bend at the waist to pick an object dropped off the floor. He appears well rested and comfortable. Knee examination is unremarkable. Low back examination show pain in all planes with ROM testing. Motor is 5/5. Reflexes symmetric and normal. No muscle atrophy. Tight heel cords, hamstrings and hip flexors.

(Tr. 827). Dr. Canvin assessed Plaintiff with a “mild” case of patellofemoral knee pain, and myofascial low back pain. (Tr, 827), Dr. Canvin opined:

No one should be off work due to either of these problems' or both of them together; There is nothing worrisome on the examination, and no neurologic deficits found. He needs to plug himself back into life and become more active. To this end I will order him physical therapy. Medications, [NSAID] or Tylenol as needed. He should not be wearing the low back brace and he was told to stop. . He was told of the expectation for him to fully participate in therapy and to do the HEP every day.

(Tr. 827). Dr. Canvin recommended that Plaintiff commence physical therapy and regarding pathophysiology, Plaintiff needed to “start work and be more active.” (Tr. 827).

After nearly .a year, Plaintiff sought treatment from the VA on March 7, 2014, for abdominal pain that had persisted for three weeks which was diagnosed as a small uncomplicated reducible umbilical hernia. (Tr. 820-24). A surgery consultation concluded that surgery for hernia repair was not recommended. (Tr. 819-820).

In a pain consultation on Plaintiff reported a pain of two on a scale from zero to ten after taking his medication and responded yes for the entire questionnaire regarding whether his pain- interfered with his sleep, relationships, work, chores, ability to walk, enjoyment of life, and mood. (Tr. 941). Plaintiff reported drinking one to two drinks once a month. (Tr. 940).

On May 2, 2014, Plaintiff sought followup treatment for chronic conditions. (Tr. 935-40). Plaintiff refused physical therapy and Dr. Kataram advised to avoid prolonged sitting. (Tr. 937). Dr. Kataram noted that Plaintiff last saw a mental health professional in May 2013, had not been taking psychiatric medications and had his prescriptions were last filled in February 2013. (Tr. 937, 939). Dr. Ka-taram recommended that Plaintiff continue NSAIDs to alleviate pain. (Tr. 937).

2. VA Compensation and Pension Examination (“ C & P Examination”) for Bilateral Knees, October 2008: William E. Dalton, P.A.-C.; Gracia Z. Santos, M.D.

On October 9, 2008, Plaintiff underwent a C & P examination with Mr. Dalton and cosigned by Dr. Santos. (Tr. 297-308, 1010-1021). It was noted that Plaintiff served in the Army from June 2004 to December 2007, working as a back hoe operator and heavy equipment operator. (Tr, 297). Plaintiff was currently being treating for PTSD and “probable chondro-malacia patellae bilateral knees.” (Tr. 297). Plaintiff reported smoking one pack of cigarettes a day, minimal alcohol use, and worked as a receiving clerk at a loading dock. (Tr. 298). Plaintiff stated that “because of his bilateral knees pain he must work at a slower pace than is usual for anyone performing the duties of his current occupation.” (Tr. 298).

Plaintiff reported that he first noticed pain in both knees, with the right knee worse than the left, while running as part of training in the fall of 2004. (Tr. 298). He sought treatment and was given Motrin 800 mg 1 three times a day for pain and did not receive any other treatment and no other evaluation was done and no-x-rays were done. (Tr. 298). Plaintiff reported that his knee pain eventually resolved after a couple of weeks. (Tr. 298). Plaintiff reported that his knee pains flared up off and on with running for approximately 18 months until he shipped out to Afghanistan in March of 2006. (Tr. 298). In April 2007, as he was descending a staircase, his right knee gave out and he fell and his sergeant who was with him caught him and broke his fall. (Tr. 298). According to Plaintiff, his right knee hurt for the next four weeks and he experienced intermittent pain the left knee. (Tr. 298). He was again treated with Motrin 800 mg and returned to regular duty which he finished nine months later and returned to the U.S. in October 2006. MRIs and X-rays of his right knee taken around May of 2007 revealed that his right knee was “within normal limits.” (Tr. 298-99). In 2007 Plaintiff was diagnosed with chondro-malacia patella of both knees. (Tr. 299). On August 7, 2008, Plaintiff was seen by an orthopedic specialist at the VA and diagnosed with “probable bilateral patello-femoral syndrome right worse than left.” (Tr. 299).

Plaintiff reported that he always has some pain in bilateral knees on a daily basis, and it is usually a 4/10 intensity. (Tr. 299). According to Plaintiff, his pain is usually less in the morning and worsens as the day progresses and he has daily flare-ups of increased pain, to 6-7/10 in his knees, sometimes without any precipitating factors and at other times is secondary to performing the duties of his current job. (Tr. 299). Rest, applying ice packs, and taking Extra Strength Tylenol alleviate his pain. (Tr. 299). Plaintiff also is prescribed 375 mg naproxen twice daily and Plaintiff does riot report any side effects from these medications. (Tr. 299). Plaintiff uses bilateral orthotic shoe inserts and he “has not been advised to limit his activities.” (Tr. 299).

According to Plaintiff he has moderate limitations in the ability to accomplish chores, shopping, and recreation; and severe limitations in the ability to travel and engage in sports. (Tr. 299). Plaintiff reported that because of his bilateral knee pain, he cannot climb stairs or ladders and he cannot do, roofing work, siding work, or general construction work of any type. (Tr. 299).

Plaintiff also reported sometimes experiencing stiffness and pain in his lower back and bilateral shoulders. (Tr. 300). Plaintiff did not identify any precipitating factors for his complaints of his back and shoulders pain. (Tr. 300). Plaintiff reported that he takes Tylenol to alleviate his back pain and that the problems resolve on their own. (Tr. 300). Plaintiff reports experiencing constant stiffness in his back and that he also gets flare-ups of pain in his lower back about every 2 months that may last as long as a week. (Tr, 300). Plaintiff denied any precipitating factors for the exacerbations in back pain and reported that ice packs and Tylenol alleviate his pain. (Tr. 300).

Plaintiff reported that these back problems do not affect his job other than it slows down his pace of work. (Tr. 300). Plaintiff reported that sometimes his arms and legs go to sleep if he sleeps with his arms flexed. (Tr. 300). Mr. Dalton noted that this was “self limiting and resolves with activity.” (Tr. 300). Plaintiff also reported of intermittent stiffness and soreness in.his hands and fingers, especially over the MCP joint of the index fingers bilaterally with the right worse than the left. (Tr. 300).

Plaintiff reported that he constantly has hand and finger pain which get worse with weather changes. (Tr. 300). Plaintiff did not report any precipitating factors for his hands pain, except if he does a lot pulling of boxes and handling boxes at work, which increases pain in his hands, especially the left hand; (Tr. 300).

Plaintiff also :reported experiencing constant pain in the right ankle, for which he takes Tylenol. (Tr. 300). Plaintiff reported that the ankle pain does not impair his ability to do his job except for slower pace of work. (Tr. 300). Upon examination Mr. Dalton observed:

Gait is normal. He can heel and toe stand and squat fully without difficulty. Spine: Cervical spine is nontender, with good range of motion, both active and passive, in all directions and without pain complaints. There is tenderness over the thoracolumbar spine area and the paravertebral muscles of this area with guarding of the bilateral paraverte-bral musculature of the thoracolumbar spine on the right more than the left. Forward flexion is 0-90 degrees, extension 0-30 degrees, right lateral flexion 0-30 degrees, left lateral flexion 0-30 degrees, right rotation 0-30 degrees, left rotation 0-30 degrees. Otherwise spine has full range of motion in all directions with active , and passive motion in all directions, and without pain complaints. All four extremities with full range of motion in all directions. Bilateral shoulders with flexion from 0-180 degrees, abduction 0-180 degrees bilaterally, internal rotation 0-90 degrees, external rotation 0-90 degrees bilaterally: Elbow flexion 0-145 degrees bilaterally. Forearm pronation 0-80 degrees bilaterally. Forearm supination 0-85 degrees bilaterally. Wrist dorsiflexion 0-70 degrees, extension wrist palmar flexion 0-80 degrees bilaterally. Wrist ulnar deviation 0-45 degrees, radial deviation 0-20 degrees bilaterally, upper extremities. Knee flexion and extension bilaterally 0-140, extension 140-0. Hip flexion bilaterally is 0-125 degrees.

(Tr. 301). Mr. Dalton concluded:

Otherwise all extremities have full range of motion- in all directions with active and passive motion in all'directions, and .without pain complaints. Sensory to light touch intact and equal bilateral upper and lower extremities. Deep tendon reflexes intact and equal bilateral upper extremities including biceps, triceps, brachioradialis, bilateral 2+ /4 and lower extremities, knee jerks, ankle Jerks 2-1-/4 bilaterally. Laseague’s is negative bilateral lower extremities. Waddell’s test is negative. There is point tenderness upon palpation of the bilateral hands, especially the MCP joints of the thumbs,- right worse than left. Lower extremities: Lachman’s test is positive in the right knee. Sensory to light touch- and vibration is- intact, bilateral ■upper and lower extremities.

(Tr. 302); Mr. Dalton reviewed X-ray reports from Dr. Field of Plaintiffs right ankle, and right and left hands. (Tr. 304-06). In an addendum dated October 23, 2008, Dr. Santos wrote that “[rjepetitive motion of all joint/spine .ROM’s as discussed above showed no change in motion.” (Tr. 307). Regarding diagnoses, Dr. Santos wrote:

1) Chondromalacia patella, both knees with no limitation of motion, symptomatic.

2) Chronic lumbar strain with no limitation of motion.

3) Normal cervical spine exam.

4) Subjective complaint of pain, both shoulders with normal exam and normal x-ray.

5) Subjective complaint of pain, both hands with normal x-rays.

6) Chronic right ankle strain, with no limitation of motion. Additional info on right ankle: No flare-ups, no assistive device, no effect on daily activities or occupation., No walking or standing limitation. Exam: No deformity. No tenderness. Range of motion full with dorsiflexion 0-20 without pain, Plantar flexion 0-45 without pain with no change on repetition.

(Tr. 307).

3. VA Mental Health C & P Examination, October 2008: Vicki D. Verdeyen, Ed.D.

On October 9, 2008, Plaintiff underwent an additional mental health C & P examination with Dr. Verdeyen. (Tr. 308-328, 877-887). With regards to educational history Plaintiff reported that he graduated from high school in 2002, has dyslexia, cared about making good grades, and worked hard in order to do well. (Tr. 309). Plaintiff reported that he drank alcohol once a week while watching football. (Tr. 309, 312).. Plaintiff detailed his experience being under combat fire for the first time in June 2006. (Tr. 309-10). Plaintiff stated that he felt helpless, hopeless, and scared during the first surprise attack. (Tr. 310). Plaintiff recalled several times when he saw injured soldiers returning to base and while he was in Afghanistan, no one died that he knew. (Tr. 310). Dr. Verdeyen noted that Plaintiff did not sustain any combat wounds. (Tr. 311).

Dr. Verdeyen noted that Plaintiff lives with eleven other relatives in the home and Plaintiff said that it' was difficult to find a quiet space. (Tr. 312). Plaintiff reported that he talks to his friends, but doesn’t socialize outside the home. (Tr. 312). Plaintiff reported that he spends time with his daughter and. interacts with people on the internet. (Tr. 312). Plaintiff reported that his leisure activities consist of watching his favorite TV shows. (Tr. 312). Dr. Verdeyen noted that Plaintiff had no history of suicide attempts or history of violence. (Tr. 312). Dr. Ver-deyen wrote that Plaintiff:

has been employed for one month at a K-mart distribution center. He indicated that the work environment suits him because he works by himself in a trailer. He noted that, the other day his boss came up behind him and startled him. He turned around and “almost swung at him, but didn’t.” He doesn’t like his job. He stays to himself, except for one per: son he knows through a friend. His job performance is satisfactory.

(Tr. 312). Dr. Verdeyen noted that in November 2007 and February 2008 Plaintiff received outpatient treatment for “Adjustment Disorder with