United States District Court, W.D. Louisiana, Lafayette Division
REPORT AND RECOMMENDATION
PATRICK J. HANNA, Magistrate Judge.
Before the Court is an appeal of the Commissioner's finding of non-disability. Considering the administrative record, the briefs of the parties, and the applicable law, it is recommended that the Commissioner's decision be reversed and remanded for further consideration consistent with this report and recommendation.
The claimant, Glen Warren Darby, was born on August 23, 1963. On March 29, 2011, when he was forty-seven years old, Mr. Darby applied for a period of disability, disability insurance benefits, and Supplemental Security Income benefits, alleging a disability onset date of December 30, 2010 due to heart problems, high blood pressure, and high cholesterol. Mr. Darby has a high school equivalency diploma or GED and has not worked since December 30, 2010. Prior to that date, however, Mr. Darby worked as a lead man in a dairy, as a plant manager for a beauty supply manufacturer, and as a scaffold builder for construction companies.
The claimant has had longstanding heart disease. According to a history given to his primary care physician, Mr. Darby had stents placed in his coronary arteries in June 2007 and again in August 2007. He may have had stents placed as early as 2004. The record also contains a reference to a possible stent placement in 2009.
On June 25, 2010, Mr. Darby saw his primary care physician, Dr. David B. Ware. Mr. Darby denied chest pain or shortness of breath but complained of fatigue, which Dr. Ware attributed to his severe obstructive sleep apnea. Dr. Ware also diagnosed hypertension, hyper-cholesterol, and coronary artery disease.
On October 21, 2010,  a stress echocardiogram was performed at University Medical Center in Lafayette, Louisiana. The test was stopped because of fatigue but it was negative for ischemia and was interpreted to be a normal exam. "Myocardial ischemia occurs when blood flow to your heart muscle is decreased by a partial or complete blockage of your heart's arteries (coronary arteries)."
Just a month later, on November 17, 2010, Mr. Darby was again seen at University Medical Center and selective coronary angiography was performed.
A month after that, on December 10, 2010, Mr. Darby had an outpatient consultation at the Cardiothoracic Surgery Clinic at the Medical Center of Louisiana in New Orleans. The history he gave at that time indicated that the previous August he had begun having unstable angina with nocturnal pain and pain with exertion during the day. He had undergone cardiac catheterization the previous August and was found to have severe two-vessel coronary disease with in-stent stenosis of the stent that was placed in 2007. He was referred for coronary bypass surgery, which was scheduled for January 4, 2011.
Mr. Darby underwent coronary artery bypass surgery on January 4, 2011. Instead of the expected triple bypass, however, he underwent a quadruple bypass. Four weeks later, it was noted that he was doing well and would be followed by his primary care physician.
Just two months after the bypass surgery, on March 10, 2011, Mr. Darby was seen at the Cardiology Center at University Medical Center. He complained of pain in his left leg, chest pain under his left arm, and soreness in his underarm area as well as decreased strength in his left arm, coldness, and dizziness on getting up, the last three symptoms having been experienced since the recent surgery.
Two months after that, on May 12, 2011, Mr. Darby was again seen at the Cardiology Clinic at University Medical Center. He was experiencing "on and off" palpitations, shortness of breath, and hot flashes and had experienced pain in his teeth for about three weeks. His hypertension was not at goal, and he was diagnosed with anxiety, high cholesterol, hypertension, and coronary artery disease.
A nuclear stress test was performed on June 7, 2011 because of chest pain complaints. The test showed reversible ischemia involving the anterior wall and a mildly low ejection fraction of 48%.
On July 7, 2011, clinical psychologist Dr. David E. Greenway, evaluated Mr. Darby at the request of Disability Determination Services and prepared a psychological report. He found that Mr. Darby has a mild adjustment disorder with depression.
On September 1, 2011, Mr. Darby was again seen in the Cardiology Clinic at University Medical Center. Although he did not complain about chest pain, he did complain of intermittent pain in his teeth and left arm once or twice per week.
Another catheterization of his heart, also referred to as selective coronary angiography, was performed at University Medical Center on September 21, 2011.
Less than two months later, on November 8, 2011, Mr. Darby underwent yet another cardiac catheterization at Medical Center of Louisiana in New Orleans. The procedure was performed because the coronary angiogram previously performed at University Medical Center "found [Mr. Darby] with atretic LIMA, totally occluded SVG to diagonal, patent SVG to OM1 and OM2, and [he] was sent for evaluation of the disease in the LAD and left circumflex." The procedure confirmed total occlusion of a coronary artery, and a stent was placed in the artery.
Mr. Darby followed up with Dr. Ware, his primary care physician, on November 15, 2011. Dr. Ware noted that Mr. Darby had undergone quadruple bypass surgery in January and had had a stent put in approximately one week before this visit. Mr. Darby did not complain of chest pain or shortness of breath, but he did complain of numbness in his arm, dizziness when moving, and having trouble reading. Dr. Ware noted that Mr. Darby's coronary artery disease is "fairly aggressive in nature" and that he "has required multiple intervention (restenosis)." An EKG was performed, which was within normal limits. Dr. Ware also diagnosed dizziness and severe obstructive sleep apnea.
On January 10, 2012, Mr. Darby was seen at the Cardiovascular Institute of the South. He complained of dizziness, increased shortness of breath on exertion, intermittent episodes of hot flashes, and periodic chest discomfort as well as back pain radiating to his left leg with numbness and tingling. The diagnoses were coronary artery disease, hypertension, and dyslipodemia.
A week later, Mr. Darby saw cardiologist Dr. Veerina at the Cardiovascular Institute of the South on January 16, 2012, The records from that visit are confusing. First, there is a note indicating that a scheduled stress test was canceled because Mr. Darby's blood pressure was too high at 162/108. Second, there is a report indicating that a stress test was performed, which showed a normal EKG, good functional capacity, and normal heart recovery rate; however, the test was terminated because of ...