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Martin v. Commissioner of Social Security

United States District Court, W.D. Louisiana, Lafayette Division

March 7, 2015

GERALD JAMES MARTIN
v.
COMMISSIONER OF SOCIAL SECURITY

REPORT AND RECOMMENDATION

C. MICHAEL HILL, Magistrate Judge.

This social security appeal was referred to me for review, Report and Recommendation pursuant to this Court's Standing Order of July 8, 1993. Gerald James Martin, born September 8, 1958, filed applications for a period of disability, disability insurance benefits, and supplemental security income on December 1, 2010, alleging disability as of December 31, 2008, [1] due to seizure disorder; history of leg, hip, and knee surgeries; leg weakness; hip and leg pain; history of stroke; affected speech; off balance; memory problems; medication side effects, and wrist and left hand pain.

FINDINGS AND CONCLUSIONS

After a review of the entire administrative record and the briefs filed by the parties, and pursuant to 42 U.S.C. ยง 405(g), I find that there is not substantial evidence in the record to support the Commissioner's decision of non-disability.

In fulfillment of F.R.Civ.P. 52, I find that the Commissioner's findings and conclusions regarding claimant's disability is not supported by substantial evidence, based on the following:[2]

(1) Records from Our Lady of Lourdes Regional Medical Center ("OLOL") dated January 1, 2009 December 22, 2009.

On January 1, 2009, claimant presented with leg pain after a trailer backed into him while he was working on a farm. (Tr. 269). He sustained a distal femur fracture. On January 2, 2009, Dr. Harold Granger performed an open reduction internal fixation of his left femur. (Tr. 275).

On January 6, 2009, claimant was admitted after a fall secondary to alcohol abuse. (Tr. 243, 245). He presented with a complaint of altered mental status. (Tr. 245). He had a significant history of alcohol abuse.

Claimant appeared to be in delirium tremors. (Tr. 251). His drug screen was positive for benzodiazepine and opiates. (Tr. 253). An EEG showed nothing to suggest epilepsy or confirm a seizure disorder. (Tr. 263).

Claimant suffered a fractured clavicle, a left leg fracture, and two intraparenchymal hemorrhages in the right temporal and parietal lobe. He was discharged with a followup visit to University Medical Center ("UMC"), and prescribed Dilantin, Valium and Lortab. (Tr. 243). He was also counseled on the benefits of alcohol and smoking cessation.

Claimant was referred to Dr. Ilyas Munshi for his head injuries. (Tr. 249). A CAT scan of the head showed minimal contusions to the brain. Dr. Mushi recommended seizure medication.

On December 19, 2009, claimant was admitted after falling down a flight of stairs at home. (Tr. 238). He sustained a right hip fracture and a nonoperative patellar fracture (Tr. 230, 234). He was taking Dilantin, Valium and Lortab. (Tr. 235, 238). He stated that he was no longer drinking everyday. (Tr. 234).

On December 23, 2009, Dr. Neil Romero performed an open reduction internal fixation of the right femur. (Tr. 230, 278). A nondisplaced right patella fracture was treated inoperatively in a knee immobilizer.

(2) Records from UMC dated February 10, 2010 to March 29, 2011.

On February 10, 2010, claimant complained of left hand pain and swelling after falling while walking up the stairs the night before. (Tr. 364-65). X-rays showed a left hand fracture. (Tr. 365). Followup x-rays taken on March 4, 2010, showed a healing fracture. (Tr. 285).

Lab results from UMC dated February 10, 2010, February 20, 2010, May 24, 2010, and February 7, 2011, indicate that claimant's Dilantin/Phenytoin levels were sub-therapeutic. (Tr. 357, 370, 375, 382). An EEG taken on March 29, 2011, was normal. (Tr. 380).

Knee x-rays taken on March 11, 2011, showed a well-healed supracondylar fracture of the distal femur. (Tr. 391). Right hip x-rays taken on March 11, 2011, were unremarkable without any significant degenerative changes. (Tr. 392).

(3) Records from American Legion Hospital dated November 25-28, 2010.

Claimant presented to the emergency room after being found by the police department in an intoxicated condition. (Tr. 308). His alcohol level was elevated and his Dilantin level was low. (Tr. 308). He also had underlying anxiety. His medical history was also significant for a previous cerebrovascular ...


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