United States District Court, D. South Carolina, Aiken Division
REPORT AND RECOMMENDATION
SHIVA V. HODGES, Magistrate Judge.
This appeal from a denial of social security benefits is before the court for a Report and Recommendation ("Report") pursuant to Local Civ. Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying her claim for Disability Insurance Benefits ("DIB"). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the undersigned recommends that the Commissioner's decision be reversed and remanded for further proceedings as set forth herein.
I. Relevant Background
A. Procedural History
On March 13, 2009, Plaintiff filed an application for DIB in which she alleged her disability began on April 1, 2007. Tr. at 61. Her application was denied initially and upon reconsideration. Tr. at 66-67, 81. On September 20, 2011, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Thomas G. Henderson. Tr. at 35-60 (Hr'g Tr.). The ALJ issued an unfavorable decision on October 7, 2011, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 15-26. Subsequently, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 1-5. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on September 18, 2013. [Entry #1].
B. Plaintiff's Background and Medical History
Plaintiff was 58 years old at the time of the hearing. Tr. at 61. She completed high school. Tr. at 282. She worked as a sewing machine operator, a cleaner, a hand packer, and a cafeteria attendant. Tr. at 51. She alleges she has been unable to work since April 1, 2007. Tr. at 61.
2. Medical History
On September 28, 2007, Plaintiff presented to Doctors Care with complaints of right ankle swelling and pain and left hip pain when ambulating. Tr. at 449.
Plaintiff presented to Doctors Care on May 4, 2008, regarding increased left hip pain. Tr. at 432. Plaintiff was referred to an orthopedist. Id.
On May 22, 2008, Plaintiff presented to Richard Zimlich, M.D., with complaint of left hip pain. Tr. at 332. Dr. Zimlich observed that Plaintiff had marked discomfort to hip flexion and internal rotation; limited internal and external rotation; and limited hip flexion. Id. X-rays revealed complete loss of Plaintiff's left hip joint space with marked sclerosis and subchondral cyst formation on both the acetabular and femoral heads. Tr. at 331-32. Dr. Zimlich recommended total hip arthroplasty. Tr. at 331.
On June 9, 2008, Michael Ragan, PA-C, completed a physician's statement in which he indicated that Plaintiff had "disabling arthritis" and that her disability was permanent. Tr. at 427.
Plaintiff was admitted to Trident Health System from June 23-26, 2008, where Dr. Zimlich performed total left hip arthroplasty. Tr. at 312.
Plaintiff presented to Dorchester Community Mental Health Center on July 28, 2008, to reestablish treatment. Tr. at 455-64. Her affect was flat and her mood was anxious, depressed, angry, and hopeless. Tr. at 462. Her thought process was disorganized at times and she had some excessive thoughts. Tr. at 463. Plaintiff's recent memory was poor and she was unable to do simple math. Id. She reported insomnia, decreased appetite/eating patterns, and both increased and decreased energy levels at times. Id.
On August 7, 2008, Dr. Zimlich indicated that Plaintiff was doing well and that she was full weight bearing without any difficulty. Tr. at 330.
On September 9, 2008, Plaintiff followed up with Dr. Zimlich, who noted that her left hip was doing well; that she should continue activity as tolerated; and that she should follow up on a yearly basis. Tr. at 329.
On October 22, 2008, Plaintiff presented to Trident Health System with complaints of depression and anxiety. Tr. at 317.
Plaintiff presented to Dr. Zimlich on January 8, 2009, complaining of lateral discomfort about the hip. Tr. at 329. Dr. Zimlich noted tenderness over the greater trochanter, but no erythema, no swelling, and good strength in abduction and forward flexion. Id.
Plaintiff visited psychiatrist Kimberly Bowers, M.D., on March 3, 2009, and indicated that she was experiencing difficulty sleeping, racing thoughts, and irritability. Tr. at 477. Dr. Bowers noted that Plaintiff was exhibiting some manic symptoms, and she assessed a GAF score of 51. Tr. at 478. Dr. Bowers prescribed Risperdal. Id.
On March 13, 2009, Plaintiff presented to the emergency room at Summerville Medical Center after having sustained a fall. Tr. at 548. She complained of mild right hip pain on weight bearing. Id. No abnormalities were noted. Id.
Plaintiff presented to Doctors Care on March 31, 2009, for low back pain and hypothyroidism. Tr. at 383. She indicated that she fell in the grocery store on March 13, 2009, and that her left hip pain had increased. Id.
On April 28, 2009, Plaintiff visited Doctors Care to follow up on hypothyroidism and with complaint of left hip pain. Tr. at 379. Plaintiff was instructed to follow up with her orthopedist regarding the left hip. Id.
On May 5, 2009, Plaintiff reported to Dr. Bowers that was taking Risperdal inconsistently because it caused daytime drowsiness. Tr. at 480. Dr. Bowers assessed a GAF score of 55 and noted that Plaintiff had limited insight into her illness. Tr. at 480-81.
Plaintiff presented to the emergency room at Summerville Medical Center on May 6, 2009, complaining of depression. Tr. at 543.
Plaintiff presented to the emergency room at Summerville Medical Center on May 13, 2009, complaining of anxiety-related symptoms. Tr. at 531.
Plaintiff followed up with Dr. Bowers on May 27, 2009, regarding recent panic attacks. Tr. at 482. Plaintiff reported that Geodon made her sleepy. Id. Dr. Bowers prescribed Klonopin and Invega and assessed a GAF score of 55. Tr. at 483.
Plaintiff presented to Doctors Care on July 8, 2009, with complaints of low potassium, high cholesterol, and muscle spasms in her legs. Tr. at 376. She was instructed to take over-the-counter fish oil and was prescribed Flexeril for muscle spasms. Id.
Plaintiff presented to Doctors Care on August 17, 2009, with complaint of left knee pain. Tr. at 375.
On August 25, 2009, Plaintiff followed up with Dr. Zimlich regarding left hip pain with prolonged activity and standing. Tr. at 328. Dr. Zimlich noted tenderness over Plaintiff's greater trochanter, but no tenderness to ranging of the hip and good range of motion. Id. He diagnosed trochanteric bursitis. Id. Dr. Zimlich issued permanent restrictions limiting Plaintiff to occasional climbing; alternating positions; and lifting no greater than 16-35 pounds. Tr. at 315.
On September 12, 2009, Plaintiff presented to the emergency room at Summerville Medical Center complaining of anxiety. Tr. at 524.
Plaintiff presented to Doctors Care on September 13, 2009, complaining of panic attack. Tr. at 373. Plaintiff was prescribed Xanax and instructed to follow up with a psychiatrist. Id.
Plaintiff followed up with Dr. Bowers regarding panic attacks on September 21, 2009. Tr. at 484. Plaintiff indicated that she had stopped taking Invega. Id. Plaintiff indicated that she was demonstrating rapid speech at work and that she was having difficulty paying attention. Id. Plaintiff also reported worry, tearfulness, anxiety, and sleep disturbance. Id. Dr. Bowers prescribed Seroquel and assessed a GAF score of 55. Tr. at 485.
Plaintiff presented to the emergency room at Summerville Medical Center on September 30, 2009, with complaints of anxiety and left hip pain with difficulty walking. Tr. at 518.
Plaintiff was hospitalized for stabilization at Palmetto Lowcountry Behavioral Health September 30 to October 3, 2009, following the death of her brother-in-law. Tr. at 349-50. Plaintiff's psychiatric diagnoses included bipolar affective disorder, mixed and anxiety disorder, not otherwise specified. Tr. at 349. Steven Lopez, M.D., assessed a GAF score of 55 upon discharge. Tr. at 350.
On November 28, 2009, Plaintiff presented to Doctors Care for anxiety and hypothyroidism. Tr. at 368.
Plaintiff followed up with Dr. Bowers on November 30, 2009. Tr. at 486. She reported a recent panic attack after running out of Klonopin. Id. Plaintiff denied tearfulness or depressed mood and indicated that her racing thoughts were reduced. Id. Dr. Bowers assessed a GAF score of 57. Tr. at 487.
On December 5, 2009, Plaintiff presented to the emergency room at Summerville Medical Center after having injured her right knee in an assault. Tr. at 488. A right knee x-ray indicated no fracture and normal alignment. Tr. at ...