Opinion ID: 2982728
Heading Depth: 3
Heading Rank: 2

Heading: Medical History After DLI

Text: On July 5, 2001, six days after the DLI, Claimant visited Dr. Taylor for re-evaluation because he was “not feeling well at all” and was “very tired, fatigued.” Claimant also experienced increased thirst and urination. Dr. Taylor diagnosed Claimant with hypertension, fatigue, polyuria, polydipsia, and weight loss. Her examination of Claimant revealed no -2- No. 14-5463 Seeley v. Comm’r of Soc. Sec. abnormal results. Claimant also complained of being chronically depressed, so Dr. Taylor prescribed Celexa. On July 19, 2001, Claimant visited Dr. Taylor, “complaining of blurred vision and to follow up on his diabetes.”1 Dr. Taylor reported that Claimant was “doing much better” and said “that he feels overall much better than he did the last time he was here.” Dr. Taylor diagnosed Claimant with diabetes that was under control and with visual changes. On October 10, 2001, Claimant visited Dr. Taylor, complaining that his nerves were “shot,” that he was eating “too much,” and that he was “under a lot of stress just from his illness and opening a new business.” When Dr. Taylor examined Claimant again on January 11, 2002, she noted that Claimant was “doing pretty well, [but] still having a lot of anxiety and says that if he has to do a detailed task that it makes him very temperamental and he just wants to go off.” However, Claimant’s physical examination was normal. Dr. Taylor also prescribed Xanax and Zoloft for Claimant’s anxiety. When Claimant returned to Dr. Taylor on February 1, 2002, Dr. Taylor noted that the “Zoloft has helped [Claimant] tremendously” and that Claimant was “basically doing well.” In June 2003, Claimant started seeing David M. Larsen, M.D. Claimant visited Dr. Larsen on October 13, 2003, to follow-up on his diabetes. Dr. Larsen noted, “[Claimant] is doing well. No particular problem or difficulty.” Dr. Larsen diagnosed Claimant with stable diabetes and hypertension. Claimant then met with Dr. Larsen on November 25, 2003, because Claimant was “going through a lot of stress” and was “increasingly irritable and having trouble over the last month.” Dr. Larsen noted that Claimant appeared slow, depressed, and “really 1 Although Dr. Taylor wrote that Claimant came in to “follow up on his diabetes,” it should be clarified that Dr. Taylor’s previous treatment note did not expressly diagnose Claimant with diabetes, indicate the type of diabetes from which he suffered, or prescribe medicine to treat diabetes. Indeed, nothing in the record expressly stated that Claimant suffered from diabetes until Dr. Taylor diagnosed that condition in her July 19, 2001 treatment note, notwithstanding her language suggesting otherwise. -3- No. 14-5463 Seeley v. Comm’r of Soc. Sec. unkempt.” Dr. Larsen diagnosed Claimant with depression and prescribed Effexor. When Claimant returned on December 16, 2003, for a follow-up on his depression, Dr. Larsen wrote that Claimant “doesn’t seem like he had improved considerably.” Dr. Larsen increased Claimant’s depression medication in response. When Claimant visited Dr. Larsen on January 30, 2004, Dr. Larsen wrote, “[Claimant] is doing well. Diabetes has really been doing well, no particular problems or difficulty.” On June 4, 2004, Dr. Larsen similarly observed that Claimant “is doing well at this point” and had “[n]o specific problems.” Dr. Larsen again wrote that Claimant was “doing well” after a December 3, 2004 evaluation, although Dr. Larsen did note that Claimant complained of “some abdominal wall pain with some cramps in the abdominal area . . . when he is sitting down.” Other than standard evaluations by Dr. Larsen throughout the subsequent years, the record provides no noteworthy treatment notes or medical evaluations between December 2004 and February 2011, when two medical professionals offered opinions suggesting that Claimant was disabled prior to his DLI. On February 1, 2011, Dr. Larsen completed a Medical Source Statement form (“MSS”) on behalf of the Social Security Administration, maintaining that Claimant’s osteoarthritis and diabetic neuropathy interfered with his ability to perform workrelated activities. Dr. Larsen indicated that Claimant could not lift or carry objects heavier than ten pounds, could not stand or walk more than two hours, and needed to alternate standing and sitting every 40 minutes. Dr. Larsen claimed that this disability predated Claimant’s DLI, writing “as of 6/1/01” in the top corner of the MSS. David Pickering, Ph.D., examined Claimant’s mental health on February 17, 2011. Dr. Pickering wrote that “the disability [Claimant] displays is primarily due to Generalized Anxiety Disorder and Major Depressive Disorder, Recurrent, Severe without Psychotic Features.” Claimant “displayed psychomotor -4- No. 14-5463 Seeley v. Comm’r of Soc. Sec. retardation, anxious, inhibited, and constricted affect, and apprehensive, despondent, and depressed mood.” Dr. Pickering further opined that Claimant had been unable to consistently hold a job “for about 12 years” and had “significant difficulty being able to interact with others.” Dr. Pickering concluded that Claimant’s “anxiety and depressive symptoms have increased in severity to the point where they significantly impact his ability to interact with others, and significantly impede his abilities to work.” However, while those two opinions alleged the existence of a disability before Claimant’s DLI, a review of the record shows no independent medical evidence indicating the existence of disabling impairments during the crucial time before and immediately after the DLI. Indeed, James N. Moore, M.D., a Social Security Disability Determination Services (“DDS”) Medical Consultant, reviewed Claimant’s medical history and determined that there was “insufficient evidence to assess [a] claim prior to [the] DLI of 6/30/01.” Denise P. Bell, M.D., another Social Security medical consultant, reviewed Dr. Moore’s opinion and confirmed that Dr. Moore’s “determination was substantively and technically correct.”