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United Statesn v. Morales

United States District Court, S.D. Iowa, Davenport Division

March 8, 2018

UNITED STATES OF AMERICA, Plaintiffs,
v.
ERIC GARCIA MORALES, Defendants.

          REPORT AND RECOMMENDATION[1]

          Helen C. Adams, Chief U.S. Magistrate Judge.

         Plaintiff Jared Stephenson seeks review of a final decision of the Commissioner of the Social Security Administration (“Commissioner”) denying his claims for disability insurance benefits (“DIB”) under Title II and Supplemental Security Income Benefits (“SSI”) under Title XVI of the Social Security Act, 42 U.S.C. §§ 401-34; 1381-85. This Court reviews the Commissioner's final decision pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). The case is before the undersigned for report and recommendation pursuant to 28 U.S.C. § 636(b)(1)(B). The Court considers the matter fully submitted on the briefs.

         I. PRIOR PROCEEDINGS

         Stephenson protectively filed his present claims for DIB and SSI benefits claim on January 21, 2014, alleging disability since October 15, 2007. (AR at 13, 80, 94, 108, 109).[2] He alleged disability due to a learning disorder and shakes and tremors. (AR at 80). The Social Security Administration (“SSA”) denied his claims initially and on reconsideration. (AR at 92, 106, 108, 109, 123, 138, 140-150, 156-173). Stephenson requested an administrative hearing. Administrative Law Judge (“ALJ”) Shreese M. Wilson conducted an administrative hearing on September 29, 2015. Stephenson appeared with his attorney Michael DePree; vocational expert Teresa McClain also appeared and testified. The ALJ found Stephenson was not disabled on February 2, 2016. (AR at 10-32). Stephenson requested a review of the ALJ's decision. (AR at 7). The Appeals Council denied the request for review and the ALJ's decision became a final decision on January 26, 2017. (AR at 1-5). Stephenson timely filed the Complaint [1] in this case on March 1, 2017.

         A. Educational and Vocational Factors

         Stephenson was 36 years old when he filed for benefits.[3] (AR at 80, 94). His highest level of education was the eleventh grade in high school. (AR at 50). He had worked as a sandwich maker, ticket taker, and hand packager. (AR at 340).

         B. Medical Evidence

         1. Medical Records

         Stephenson's medical records are limited. On February 12, 2009, Stephenson reported to Community Health Care (CHC) in Davenport, Iowa, complaining of “spells” of dizziness and the feeling of things moving, and that his limbs felt like they were twitching. (AR at 357). He also reported his hands were twitching all the time. The episodes had occurred six times in the previous two months. He did not lose consciousness or fall. He reported the episodes occurred when he was reading after about five minutes of reading. (Id.) His physical examination was normal but Dr. Oludamilola Ogunlesi referred him for an EKG, CBC, CMP, thyroid stimulating hormone, EEG and CT scan of the head. (Id.) The doctor requested that Stephenson follow up after the tests were done, but there is no record of any follow-up, only the test results. (Id.) The CT scan performed February 23, 2009, showed sinusitis, but otherwise was negative. (AR at 367). An EKG was normal, except for rate (AR at 368) and labs were normal. (AR at 358-359).

         Stephenson was next seen at CHC on September 22, 2010, and had a lumbar spine x-ray taken after he complained of back and left hip pain. (AR at 366). In comparison to an x-ray taken March 17, 2009, no compression fracture or malalignment was seen and there was an unchanged L5-S1 disk space narrowing, as well as asymmetry of the left iliac wing which was consistent with a “large incidental sessile osteochondroma.” (Id.) There are no other records concerning this visit. Stephenson followed up with a visit to the CHC clinic on September 30, 2010, complaining of continued pain in his lower back. (AR at 356). He told Dr. Ogunlesi he had pain daily in his left lower back that he rated at 10/10 in intensity. (Id.) No trauma had occurred and he had not been doing any heavy lifting. (Id.) Stephenson reported he sometimes had a tingling sensation in his left leg below the knee, but no numbness. (Id.) Dr. Ogunlesi reviewed the x-ray from September 22. On physical examination, Stephenson had tenderness over the left lower back immediately above the iliac crest, no midline tenderness and negative straight leg raise bilaterally. Neurologically, he was alert and oriented to time, place, and person and sensation was intact to both lower extremities. Dr. Ogunlesi's impression was low back pain most likely from acute strain. He prescribed Flexeril and ibuprofen as needed and did not believe there was a need for an MRI, as no radicular symptoms were present. (Id.)

         At a follow-up visit on October 7, 2010, Stephenson could ambulate, but stated it did not feel normal when he walked, that he needed to support himself when he initially got out of bed in the morning, but then could walk without support. He described intermittent paresthesias in his left lower extremity, but no incontinence. (AR at 355). On physical examination, Dr. Ogunlesi noted erythematous[4] in the left lower back, negative straight leg raise on the right, but pain in the lower back with straight leg raise to 60 degrees. Muscle strength was 5/5 in both lower extremities and there was no objective weakness or sensory loss. (Id.) Dr. Ogunlesi recommended further evaluation with an MRI of the lumbar spine and an x-ray of the left hip based on Stephenson's complaint of pain with external rotation of the left hip. (Id.)

         An MRI was performed on October 14, 2010. (AR at 363). It showed moderate to large central disk protrusion at ¶ 4-5 and moderate-sized lateral disk protrusion extending in to the neural foramen at ¶ 5-S1. (Id.) At a follow-up exam on October 15, 2010, Dr. Ogunlesi noted that the MRI showed a disc protrusion was compacting the lumbar nerve root. (AR at 354). He recommended Stephenson see a neurosurgeon for an opinion and started Stephenson on Tramadol for his pain. (Id.) There are no records concerning any follow-up on this medical issue.

         A final medical record from Dr. Ogunlesi was from a visit on July 3, 2011, after Stephenson cut his finger. (AR at 352-353). The cut was closed with stitches and Stephenson was discharged. (Id. at 353).

         Other records from Genesis Medical Center include an x-ray and treatment after Stephenson sustained a rolling injury to his right ankle on September 24, 2014. (AR at 446-50). Stephenson also was seen at Community Health Care on January 21, 2015, to assess his complaints of body tremors/shakes and low back pain. Labs were drawn to assess his tremors with further management dependent on results. (AR at 430-35). A lumbar spine x-ray on January 28, 2015, was normal. (AR at 428, 444).

         2. Mental Health Records

         Stephenson presented at Vera French Community Mental Health Center on August 4, 2014, complaining of depression. (AR at 390). Richard Quarton, Ph.D., interviewed Stephenson, who at that time was living with friends. He was unemployed “in part due to his medical issues.” Dr. Quarton noted Stephenson stammered at times, presented in a “somewhat anxious way and had some pressured speech.” (Id. at 390-91). Stephenson reported sleeping problems. He was disheveled in appearance, oriented to person, place, time, and situation, and demonstrated unremarkable behavior and psychomotor behaviors. His speech was slurred and he stammered. His affect was flat and his mood labile, anxious, and depressed. Stephenson's memory was intact, he had clear consciousness, and his intellect was average. (Id. at 391). His attitude was discouraged, attention was gained and maintained, reasoning and judgment fair, and impulse control and insight poor. (Id.) Stephenson's self-perception was realistic, his thought processes logical, thought content unremarkable, and he was not showing signs of suicidal or homicidal ideation. (Id.) Stephenson had been referred by his disability lawyer. He reported he was a social drinker, smoked cigarettes, and occasionally smoked marijuana. (Id.) Stephenson told Dr. Quarton he occasionally got angry and would throw himself into walls and sometimes blurted out negative comments to friends. Stephenson felt he was doing better with his temper. (Id.) He reported it hurt to walk and if he was active he experienced chest pains. He also stated he would “space out and forget things” and was a procrastinator. (Id.) Stephenson blamed himself for his father's suicide, had some symptoms of Adult ADHD, and cut himself as a youth. He was in foster care as a child for unknown reasons. (Id.) Dr. Quarton diagnosed Stephenson with Unspecified Depressive Disorder, moderate and to rule out unspecified ADHD. The goal of treatment was to assist with his depressive symptoms so they did not impair his daily functioning. (Id. at 392).

         On August 13, 2014, Stephenson returned for therapy. (AR at 393). He was depressed and angry and Dr. Quarton tried to identify the sources of Stephenson's anger. Stephenson still stammered, but was more relaxed, had better mood, and was more talkative. (Id.)

         Heidi Bradley, ARNP conducted a Psychiatric Evaluation of Stephenson on September 11, 2014. (AR at 395). His chief complaint was that he had an anger problem and “people say I'm depressed.” (Id.) Ms. Bradley noted Stephenson had “tremors and twitches” in the lower aspect of his face, which he reported he had had since he was a child. (Id.) His past psychiatric history included treatment at Vera French from the age of 9 for a diagnosis of ADHD, for which he received Prozac and Ritalin. (Id. at 396). He reported three past psychiatric hospitalizations at ages 13, 18, and in his early 20's when he had depression with suicidal ideation. (Id.) He also cut himself as a teenager and as a young adult had stabbed his arm when he got angry. (Id.) Stephenson reported he had an 11th grade education and was in special education classes in high school, but did not do well and had significant academic and behavioral issues. (Id.) He was unemployed and last worked at Burger King in 2008. (Id.) He reported past arrests for verbal assault, public intoxication, interfering with official acts, and failing to appear, but had no legal constraints at the time of the evaluation. (Id.) He reported pain in his left knee, but otherwise no other physical problems. (Id.) Stephenson reported past alcohol and marijuana use (as recently as one to four months before the evaluation respectively), drinking four to five caffeinated sodas daily, and smoking approximately a half pack of cigarettes a day. (Id. at 397). Stephenson told Ms. Bradley he had had been physically and emotionally abused by his stepfather and was molested by a cousin in the past. (Id.)

         On mental status exam, Stephenson was appropriately dressed and groomed. (AR at 397). He was slightly restless and he had some abnormal movements of his mouth and the lower aspect of his face. (Id.) His mood was neutral and affect slightly constricted, “appropriate to conversation, and congruent with mood.” His speech was of “normal rate, quantity, and volume” with some occasional stuttering when he tried to express himself. (Id.) Stephenson denied auditory hallucinations or paranoia, but acknowledged some odd thoughts such as he should “kick babies, ” thoughts on which he had not acted. His thought processes were logical and goal-directed with no loosening of associations. (Id.) He denied suicidal or homicidal ideation, but admitted to past harmful thoughts and attempts. (Id.) Stephenson was alert and oriented with fair eye contact and minimal insight into his current problem. He appeared to have fair to poor judgment. (Id.) His gait and station were unremarkable. His recent and remote memory were both impaired; his concentration and attention span slightly impaired. (Id.) Ms. Bradley could not determine whether Stephenson's inability to spell “world” backwards or to do serial 7's was based on his below average intellectual functioning or was secondary to poor concentration and attention. She could identify no language impairments or barriers. Stephenson's abstractive capacity was impaired and his intellectual functioning was below average.

         Ms. Bradley's impression was that Stephenson had “some elements of Antisocial Personality Disorder, ” unspecified depressive disorder, mild intellectual disability, and history of ADHD. (AR at 397). She recommended he start Zoloft along with Risperdal and he was to follow up in four weeks to evaluate the effectiveness of the medication. (Id. at 398).

         Stephenson returned to Vera French on October 9, 2014, to follow up on his depression. (AR at 400). He reported his friends thought he was more “mellow” and better, but he did not like the medications. He had improved eye contact and appeared less anxious. (Id.) Stephenson still had sleep difficulties. His affect was “a bit brighter” and he offered “more spontaneous conversation.” (Id.) On mental status exam, he was appropriately dressed and groomed and still slightly restless, but improved from before. (Id.) His facial movements appeared unchanged, but Stephenson thought they were worse. His mood was neutral and affect a little brighter. (Id.) His speech was normal rate, quantity, and volume with some occasional stuttering. He denied auditory hallucinations or paranoia and reported his thoughts about kicking babies were gone. (Id.) His thought processes were logical and goal-directed with no loosening of associations. He denied suicidal or homicidal ideation. Stephenson was alert and oriented with improved eye contact. He demonstrated limited insight into his current problem, his judgment was fair to poor. (Id. at 400- 01). Stephenson's gait and station were unremarkable. His concentration and attention span were within normal limits and he demonstrated no language impairments or barriers. (Id. at 401). Ms. Bradley reduced the amount of Risperdal in response to the complaint Stephenson's tremors/tics were worsened to see if that reduced the worsening, while remaining effective with respect to “intrusive, negative thoughts.” (Id.) His Zoloft prescription was continued and Ambien was added to help with sleep issues. Stephenson was to return for a medication check in a month. (Id.)

         On November 16, 2014, Stephenson reported for a scheduled appointment at Vera French. (AR at 403). He reported improved mood, he felt better and was “pleasantly surprised by the improvement.” (Id.) He reported some continued irritability after he ran out of medication, but had been compliant with medication before running out. (Id.) Stephenson reported his friends noticed when he had not taken his medication. His eye contact was improved and the tremors of his hands and lower jaw were minimal, Stephenson reporting they had improved with the reduction of Risperdal. (Id.) He denied intrusive thoughts, his affect was improved and he demonstrated some humor. Stephenson did not like the medications and did not know if he wanted to feel “mellow.” (Id.) He continued to have sleep difficulties and stopped taking Ambien as it was not helping. He requested an alternative sleep medication. (Id.) On mental status exam, Stephenson was appropriately dressed and groomed. His psychomotor activity was within normal limits with continued abnormal movements of his mouth and lower aspect of his face, unchanged from his initial visit. (Id.) His mood was euthymic, affect full, congruent with mood and appropriate to conversation. His speech was normal rate, quantity, and volume with some stuttering. He denied auditory hallucinations or paranoia and his past odd thoughts remained absent. His thought processes were logical and goal-directed with no loosening of associations. He denied suicidal or homicidal ideation. (Id.) Stephenson was alert and oriented with good eye contact, much improved. He had some insight into his current problem and fair judgment. His gait and station were unremarkable. His concentration and attention span were within normal limits and there were no language impairments or barriers. (Id. at 404). Ms. Bradley's impression was that Stephenson was much improved, less depressed, smiled easily, and had improved eye contact. (Id.) They discussed increasing his dosage of Zoloft to address the irritability and started Trazodone for sleep. (Id.)

         Stephenson returned to Vera French on December 4, 2014, for a scheduled appointment. (AR at 407). He reported increased difficulties after he ran out of his medication for about a week and did not know how to get it refilled. He felt more restless and irritable and his tics/twitches were more pronounced. (Id.) He felt the increase in Zoloft and addition of Trazodone had helped. (Id.) On mental status exam, Stephenson was appropriately dressed and groomed with restless and fidgeting psychomotor activity and some abnormal movements of his mouth and lower aspect of his face, which were more prominent than his last visit. (Id.) His mood was anxious with constricted affect, congruent with mood and appropriate to conversation. His speech was normal rate, quantity, and volume with some stuttering. He denied auditory hallucinations or paranoia, intrusive thoughts/delusions. His thought processes were logical and goal-directed with no loosening of associations. He denied suicidal or homicidal ideation. (Id.) Stephenson was alert and oriented with fair eye contact and some insight into his current problem. His judgment was fair. His gait and station were unremarkable. His concentration and attention span were within normal limits and he had no language impairments or barriers. (Id.) Ms. Bradley reviewed with Stephenson how to get refills and reviewed the importance of compliance with medications. (Id. at 408).

         At a December 9, 2014, individual therapy visit, his first with Dr. Quarton since mid-August, Stephenson requested referral to another therapist. (AR at 411). His mental status was unchanged. (Id.)

         Stephenson presented for a scheduled appointment at Vera French on January 19, 2015. (AR at 413). He reported doing “much better” after getting back on his medications. Ms. Bradley noted he appeared much more relaxed and his tics/tremors had improved. He felt his medication was beneficial, but was still having sleep problems. (Id.) On mental status examination, Stephenson was appropriately dressed and groomed. His psychomotor activity was within normal limits with some abnormal movements of his mouth and lower aspect of his face unchanged from his initial visit. (Id.) His mood was neutral with full affect, congruent with mood and appropriate to conversation. His speech was normal rate, quantity, and volume with some occasional stuttering. He denied auditory hallucinations, paranoia, or intrusive thoughts. His thought processes were logical and goal-directed with no loosening of associations. He denied suicidal or homicidal ideation. (Id.) Stephenson was alert and oriented with good, improved eye contact and some insight into his current problem. His judgment was fair. His gait and station were unremarkable. His concentration and attention span were within normal limits and there were no language impairments or barriers. (Id.) Ms. Bradley increased his dosage of Trazodone for sleep and increased his dosage of Zoloft. (Id. at 414).

         At a scheduled appointment at Vera French on February 16, 2015, Stephenson reported doing “pretty well” with an episode of going out with his brother, drinking alcohol, and getting into a fight. (AR at 416). He was feeling calm and was pleased with his medications, except Trazodone was not helping with sleep. His mental status examination was consistent with the previous month. (Id.) Ms. Bradley maintained Stephenson's dosages of Risperdal and Zoloft, discontinued Trazodone, and added a prescription for Restoril for sleep. (Id. at 417).

         On February 18, 2015, during a scheduled appointment at Vera French for individual therapy with Jerry Lowe, LISW, Stephenson reported having problems with grief during the month of January, a year after his mother died. (AR at 419). They discussed his issues with his father's death by suicide and Lowe provided support. (Id.) Lowe noted no change in Stephenson's mental status. (Id.)

         During a March 5, 2015, individual therapy session with Mr. Lowe, Stephenson had no change in mental status. (AR at 421). He reported he had received a letter from disability seeking specific information. He reported some interaction with his paternal uncle's family, that he was watching television and movies a great deal, and not going to sleep until 4:30 a.m. and sleeping until 9:30 or 10 a.m. (Id.)

         C. Medical Source Opinions/Evaluations

         Several consultative examination reports were part of the administrative record, including one from a prior benefits application.

         On April 22, 2009, Dr. Phillip L. Kent, licensed psychologist, assessed Stephenson. (AR at 452-56). Dr. Kent noted Stephenson had no prior treatment history. (Id. at 452). In an Adult Function Report provided to Dr. Kent, Stephenson indicated he was living in his grandfather's basement and was unemployed. He reported sleeping four hours a day, having difficulty with motivation, wearing the same clothes for a week, and did not have a driver's license. He liked to watch movies, play games, or go to the bar and watch wrestling. (Id.) Dr. Kent took a psychosocial history from Stephenson, which included a sporadic work history and use of marijuana when he had the money. (Id. at 453). On mental status examination, Stephenson was casually dressed in sweatpants and a hooded sweatshirt, maintained poor eye contact and chewed gum, slouched in his chair and had “somewhat of a defiant attitude.” (Id. at 454). His facial expression was flat and body movements appeared slowed. His affect was blunted and he experienced mood swings, from depression and not wanting to do anything to anger expressed in punching walls and throwing things. (Id.) He reported three hospitalizations. (Id.) Dr. Kent noted Stephenson did not have problems with attention span during the interview, his thinking was notably concrete, and intelligence appeared dull. (Id.) He lacked insight and blamed others for his problems. Dr. Kent noted Stephenson's fingers and fingernails were dirty, his clothes appeared to have been worn for several days and he needed a shave. (Id.) No obvious memory impairments were displayed nor were there unusual thought content or signs of psychosis. (Id.) Dr. Kent administered the Wechsler Adult Intelligence Scale-Fourth Edition on which Stephenson put forth “adequate effort.” (Id.) His full scale IQ was 72. His overall intellectual functioning fell in “the borderline range of intellectual functioning” and was consistent with his low academic achievement and behavior problems in school. The test results also indicated Stephenson thought “quite slowly compared to the general population.” (Id. at 455). Based on his interview and the test results, Dr. Kent assessed Stephenson with bipolar disorder, NOS, cannabis abuse, borderline intellectual functioning, personality disorder, NOS with negativistic and antisocial traits. His GAF was 55. (Id. at 456). Dr. Kent referred Stephenson to a local mental health center to address his mood disorder. (Id.). He indicated Stephenson did not appear to be impaired in his ability to understand directions, although he might have some difficulty remembering due to working memory and attention problems. Dr. Kent found it “noteworthy” Stephenson was able to work at a fast food restaurant for nearly a year as an indication that “if he really wants to, he likely is able to get along at least superficially with supervisors, co-workers, and exercise adequate judgment.” (Id.) Dr. Kent did not believe he could handle cash benefits. (Id.)

         Dr. Roger Mraz, Ph.D., conducted a psychological evaluation on April 2, 2014. (AR at 373-76). Dr. Mraz took a history similar to Dr. Kent's. (Id. at 373-74). On mental status exam, he noted Stephenson arrived on time and was “somewhat disheveled.” (Id. at 374). His speech was easy to understand and his thoughts goal-directed, with no evidence of loose associations or tangential thinking. His mood was depressed and affect restricted. (Id.) Stephenson scored 21 out of 30 on the Mini Mental State Exam. On the Beck Depression Inventory-II, Stephenson chose moderate to severe symptoms of depressions. (Id.) He reported a long history of anger control problems. (Id.) On the Connors Rating scale, Stephenson reported significant problems with attention span, hyperactivity and impulsivity. (Id. at 375). He had problems focusing his attention concentrating and remembering, and was easily distracted. He said he was impulsive and said and did things without thinking. Dr. Mraz found Stephenson's math skills at the early elementary school level and his reading and writing skills at late elementary school level. (Id. at 375). The results of the evaluation were consistent with a childhood diagnosis of ADHD and depression. His symptoms of Intermittent Explosive Disorder had a negative impact on his employability. Although Stephenson had moderate problems with delayed memory and working memory, he could remember and follow simple instructions, although the prior evaluation indicated an impairment in processing speed. (Id.) Dr. Mraz found his judgment to be poor and questioned Stephenson's ability to manage funds, particularly in view of his history of substance abuse. (Id.) His final diagnosis was Intermittent Explosive Disorder, Major Depressive Disorder, Attention-Deficit/Hyperactivity Disorder, Combined Type, Cannabis and Alcohol Abuse and Nicotine Dependence with Antisocial Personality Traits. (Id. at 376).

         Finally, on April 19, 2014, Dr. Stanley Rabinowitz, M.D., saw Stephenson for a physical examination. (AR at 378-84). Stephenson's chief complaint was “shakes and twitches.” (Id. at 380). He reported he had complained of these for years. Previous CT scan and EEG had been normal. (Id.) About two years before the examination he also started having left lower extremity numbness and low back pain, which radiated down his left leg and was prominent with activity. (Id.) He only took Ibuprofen for relief. His educational and social history were the same as reported to Drs. Kent and Mraz. (Id.) On physical examination, his speech was clear and understandable, hearing grossly normal, and he walked without help of an assistive device. (Id. at 381). Stephenson was obese. Range of motion testing of his joints and spine was performed; all were within normal limits. (Id. at 378, 384). Stephenson demonstrated no active joint inflammation, deformity, instability, contracture or paravertebral muscle spasm. (Id. at 382). Straight leg raising was negative at 90 degrees both sitting and supine. (Id.) Grip in both hands was normal and Stephenson's digital dexterity was not impaired. He had no difficulty getting up and down from the examining table, but had “mild difficulty” squatting three-quarters of the way down. His cranial nerves II-XII were grossly intact. (Id.) His reflex and motor strength testing was normal and there was no evidence of atrophy. (Id.) On mental status exam, Stephenson was fully oriented, his memory intact and his appearance appropriate. (Id.) He had no behavioral difficulties during the examination and was able to relate during the examination. (Id.) Dr. Rabinowitz believed Stephenson could handle his own funds. His final impression was history of tremulousness, etiology undetermined; chronic low back pain with questionable left lower extremity radiculopathy; history of learning disability; history of polysubstance abuse that was inactive and exogenous obesity. (Id.)

         D. Hearing Testimony

         At hearing on September 29, 2015, Stephenson was 38 years old. (AR at 45). He was 5'11” and weighed 289-290 pounds. He was right handed, but also used his left hand. (Id. at 46). Stephenson was single and had two children that he did not see; he had recently signed over parental rights to one child. (Id. at 46-47). He lived in a mobile home with friends. (Id. at 47). He did not have a driver's license and had never had one. (Id. at 47-48). Stephenson was transported by one of his roommates and before that by his mother. (Id. at 48). He smoked cigarettes and smoked marijuana, although not as often as he did not have the money to buy it. (Id. at 48-49). He estimated he smoked it once a month and only drank alcohol at poker games, which he had quit playing. (Id. at 49). In the last year he had played about five games when he got spotted money to get into the game. (Id.) Stephenson completed the eleventh grade and did not get his GED. (Id. at 50). The source of income to run the household where he lived was income from his roommates and food stamps from Stephenson. Stephenson had a state medical card which he obtained after talking to his attorney the first time, maybe May 2014. (Id. at 50-51).

         In the past, Stephenson had worked as a ticket taker for security companies and worked as a cook in a fast food restaurant. (AR at 51). The last time he worked was 2008 or 2009. (Id. at 52).

         At the time of hearing Stephenson was not taking pain medication for his back. (AR at 52- 53). He last saw a doctor for his back about a month before the hearing, but was told there was nothing wrong. (Id. at 53). No physical therapy or medication was prescribed. (Id. at 54). The pain fluctuated from his lower back to his left leg. There was nothing that caused his back pain to be more severe, but he was not as active now. (Id.) ...


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