United States District Court, D. South Carolina, Aiken Division
For Timothy Leroy Wilson, Plaintiff: Helen Tyler McFadden, LEAD ATTORNEY, Cades, SC.
For Commissioner of Social Security Administration, Defendant: Barbara Murcier Bowens, LEAD ATTORNEY, U.S. Attorneys Office, Columbia, SC.
REPORT AND RECOMMENDATION
Shiva V. Hodges, United States 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 his claim for Disability Insurance Benefits (" DIB") and Supplemental Security Income (" SSI"). 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 affirmed.
I. Relevant Background
A. Procedural History
On July 27, 2010, Plaintiff filed applications for DIB and SSI in which he alleged his disability began on July 10, 2010. Tr. at 117-20, 126-27. His applications were denied initially and upon reconsideration. Tr. at 59-63, 71-72. On March 6, 2012, Plaintiff had a hearing before Administrative Law Judge (" ALJ") Marcus Christ. Tr. at 26-54 (Hr'g Tr.). The ALJ issued an unfavorable decision on March 30, 2012, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 10-23. 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 1-6. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on August 15, 2013. [ECF No. 1].
B. Plaintiff's Background and Medical History
Plaintiff was 29 years old at the time of the hearing. Tr. at 29. He completed two-and-a-half years of college. Tr. at 36. His past relevant work (" PRW") was as a bagger, a cashier, a ride attendant, a short-order cook, a houseman, a sandwich maker, an assistant manager, and a fast foods worker. Tr. at 47. He alleges he has been unable to work since July 10, 2010. Tr. at 26. Plaintiff requested a closed period of disability from July 2010 through December 2011 and asked that his work after January 2012 be considered a trial work period. Tr. at 26-27.
2. Medical History
a. Records Before the ALJ
Plaintiff was hospitalized June 8-26, 2007, at McLeod Regional Medical Center. Tr. at 421. Scott D. Cohen, M.D., stated that Plaintiff's history of Crohn's disease contributed to development of Fournier's gangrene of the scrotum and rectal abscesses. Id. Plaintiff underwent debridement of the scrotum, skin graft, and ileostomy to divert his bowels. Tr. at 429.
Plaintiff presented to Grand Strand Regional Medical Center on July 10, 2010, complaining of abdominal pain and swelling around his ileostomy. Tr. at 223. Plaintiff's serum albumin was 2.1 g/dL and his hemoglobin was 9.0 g/dL. Tr. at 224. An abdominal CT showed a large gas and fluid filled area adjacent to the right-sided ostomy that appeared to be an abscess and other inflammatory changes just below the rectus muscle that suggested a possible early fistula. Tr. at 225. Plaintiff was transferred to McLeod Regional Medical Center to receive a higher level of care. Tr. at 226.
Plaintiff was hospitalized at McLeod Regional Medical Center July 11-19, 2010, for treatment of peristomal abscess and enterocutaneous fistula. Tr. at 251. Upon admission, Plaintiff weighed 52.2 kg. Tr. at 258. His serum albumin was 2.2 g/dL and his hemoglobin was 8.4 g/dL on July 12, 2010. Tr. at 248, 269. An IBD Serology 7 test showed results consistent with Crohn's disease. Tr. at 268. Plaintiff underwent a surgical procedure to drain and irrigate the abscess cavity. Tr. at 272-73.
On July 27, 2010, Plaintiff followed up with Mark A. Reynolds, M.D., who noted Plaintiff was feeling well and had a clean, granulating wound with little drainage. Tr. at 298.
On August 5, 2010, Plaintiff followed up with Dr. Reynolds. Tr. at 303. Dr. Reynolds observed a small amount of purulent material draining from Plaintiff's fistula, but his parastomal abscess wound was granulating well and there was no evidence of infection. Id.
On August 10, 2010, Plaintiff followed up with Dr. Reynolds. Tr. at 302. Plaintiff stated that his abscess cavity was not healing well and complained of a significant amount of purulent material draining from the area. Id. Dr. Reynolds observed a small amount of material draining from Plaintiff's enterocutaneous fistula. Id.
Plaintiff presented to John W. Gause, M.D., on August 24, 2010. Tr. at 301. He reported no pain, but constant drainage from the abscess site. Id. Plaintiff was noted to have an open wound where the enterocutaneous fistula was present. Id. He requested ileostomy takedown and was referred for colonoscopy to determine if he still had a stricture of the rectum. Id.
On August 31, 2010, Palmer Kirkpatrick, M.D., performed an enteroscopy and proctoscopy. Tr. at 305. Dr. Kirkpatrick removed a pseudopolyp from Plaintiff's ileum. Id. He noted slight inflammation in the ileum. Id. He observed several diverticula in Plaintiff's rectal stump, but there was no inflammation. Id.
Plaintiff followed up with Dr. Gause on September 7, 2010, and stated that he was doing better. Tr. at 300. Dr. Gause noted that he had referred Plaintiff for a colonoscopy, but that a barium enema was needed to obtain a better understanding of Plaintiff's colonic anatomy. Id. Dr. Gause noted that Plaintiff requested surgery to reverse his ileostomy, but that Plaintiff's prior stricture prevented surgery. Id.
A barium enema on September 13, 2010, showed no lesions or other abnormalities. Tr. at 304.
Plaintiff presented to Kingstree Family Medicine on September 15, 2010, to follow up on Crohn's disease and for evaluation of right flank pain. Tr. at 291. He weighed 112 pounds, and the record indicates that his weight was decreased by 28 pounds. Id. He complained of problems at the abscess site and requested a referral to a gastrointestinal doctor in Myrtle Beach. Id. Plaintiff had an ileostomy bag and a healing/granulating wound. Id.
On September 16, 2010, Plaintiff followed up with Dr. Gause for further evaluation and discussion of possible ileostomy takedown. Tr. at 297. Plaintiff acknowledged being noncompliant with medical therapy. Id. Barium enema revealed no strictures or evidence of involvement of the colon, and Plaintiff's fistula was well-controlled. Id. Dr. Gause indicated that Plaintiff was reluctant to undergo takedown of the ileostomy because he would have to be out of work for several weeks after surgery. Id. He was instructed to follow up in one month. Id. Plaintiff subsequently called Dr. Gause's office about scheduling surgery and was told that surgery would be scheduled at his next appointment. Tr. at 299.
Plaintiff presented to Conway Medical Center on October 13, 2010, complaining of swelling in his left knee. Tr. at 353. He was noted to be well-nourished and in no acute distress. Tr. at 363. He was diagnosed with knee effusion and arthralgia. Tr. at 357.
On October 24, 2010, Plaintiff presented to Conway Medical Center for pain and swelling in his left knee. Tr. at 346. He was described as well-developed and well-nourished. Id. A skin examination was negative for abscesses or cellulitis. Tr. at 348. Plaintiff weighed 111.99 pounds. Id. Plaintiff was diagnosed with a left knee effusion and discharged home with a prescription for Vicodin 5-500 mg and instructions to rest, ice, compress, and elevate (" RICE") his knee. Tr. at 349.
On October 28, 2010, state agency medical consultant Hugh Wilson, M.D., completed a physical residual functional capacity assessment in which he indicated Plaintiff had the following limitations: occasionally lift and/or carry 50 pounds; frequently lift and/or carry 25 pounds; stand and/or walk (with normal breaks) for a total of about six hours in an eight-hour workday; sit (with normal breaks) for a total of about six hours in an eight-hour workday; push and/or pull unlimited; frequently climb ramps/stairs, balance, stoop, kneel, crouch, and crawl; never climb ladders/ropes/scaffolds; avoid all exposure to hazards (machinery, heights, etc.); and close access to bathroom. Tr. at 333-40.
Plaintiff presented to Nigel Taylor, M.D., at Black River Health Care on November 29, 2010, complaining of pain. Tr. at 368. His skin was noted to be mostly normal, and he had no oozing, increased warmth, or discharge from the abscess site. Id. Dr. Taylor noted Plaintiff's condition was stable and that he had no evidence of Crohn's flare or current abscess. Id. Dr. Taylor indicated that Plaintiff planned to try again for disability so that he could obtain surgery to reverse his ileostomy. Id. He increased Plaintiff's Percocet dosage. Id. Plaintiff's serum albumin was 3.5 g/dL and his hemoglobin was 10.5 g/dL. Tr. at 377, 378.
Plaintiff followed up at Black River Health Care on December 13, 2010. Tr. at 367. He complained of pain in his right lower quadrant and drainage from beside the stoma of his ileostomy. Id. He stated that the problem was ongoing since his last visit, but had worsened that day. Id. Dr. Taylor assessed a likely recurrence of enterocutaneous fistula and iron-deficiency anemia. Id. Plaintiff's hemoglobin was 10.7 g/dL. Tr. at 369.
On December 14, 2010, Dr. Gause examined Plaintiff, who was not taking medication for his Crohn's and sought takedown for his ileostomy, which had already been scheduled at least once in the past. Tr. at 375. On examination, Dr. Gause observed Plaintiff's abdomen was soft and nontender and he had a fairly significant anal stricture. Id. Dr. Gause scheduled Plaintiff for an anoscopy and proctoscopy. Id.
Plaintiff also followed up with Dr. Reynolds on December 14, 2010. Tr. at 383. Dr. Reynolds noted Plaintiff's peristomal abscess had persisted as a fistula and that a recent CT scan demonstrated an extensive area of inflammatory changes in the right lower quadrant. Id. He stated that this area demonstrated no evidence of foreign body or residual drain, but did show a fistulous tract. Id. Dr. Reynolds indicated that Plaintiff was having difficulty affording treatment and maintaining employment because of his condition and that he was intermittently noncompliant with his medications. Id.
An anoscopy on December 22, 2010, revealed a very tight stricture. Tr. at 381. Proctoscopy was not performed because of the risk of perforation. Id. Dr. Gause indicated " [i]t is my opinion, at this time, that ileoscopy takedown is not a good option for this patient." Id.
Plaintiff followed up with Dr. Taylor on February 21, 2011, complaining of constant right abdominal pain that was an eight to ten. Tr. at 528. He weighed 119 pounds. Id. Dr. Taylor noted that the CT showed signs of wall thickening, but no definite fistula. Id. Plaintiff stated that he ran out of his prescription for Percocet three weeks earlier and that his pain was a lot better when he was taking Percocet. Id. Dr. Taylor noted some slight excoriation around the ileostomy site. Id. He refilled Plaintiff's prescription for Percocet and instructed him to follow up in two months. Id.
Plaintiff followed up with Dr. Taylor on March 2, 2011. Tr. at 529. He stated that he was doing well, but that he had experienced severe pain a few days before and was out of Percocet. Id. Dr. Taylor prescribed more Percocet. Id.
On March 8, 2011, state agency medical consultant William Cain, M.D., completed a physical residual functional capacity evaluation in which he indicated Plaintiff had the following limitations: occasionally lift and/or carry 20 pounds; frequently lift and/or carry 10 pounds; stand and/or walk (with normal breaks) for a total of about six hours in an eight-hour workday; sit (with normal breaks) for a total of about six hours in an eight-hour workday; push and/or pull unlimited; frequently balance; occasionally climb ramps/stairs, stoop, kneel, crouch, and crawl; never climb ladders/ropes/scaffolds; avoid all exposure to hazards; and close access to bathroom. Tr. at 481-88.
Plaintiff followed up with Dr. Taylor on March 21, 2011, indicating that he was going to a wound care clinic. Tr. at 530. He weighed 115 pounds. Id. He expressed frustration that many jobs would not allow him to work and care for his ileostomy site. Id. Dr. Taylor noted that Plaintiff's right lower quadrant ileostomy looked the best that it had looked since he was first seen in 2010. Id.
On April 28, 2011, Plaintiff again followed up with Dr. Taylor. Tr. at 531. He weighed 118 pounds. Id. Dr. Taylor noted that Plaintiff had periodic seepage from his wound site. Id. He stated Plaintiff was doing well with pain management. Id. Dr. Taylor indicated that the gastroenterologist was attempting to obtain Humira treatment for Plaintiff. Id. He observed that Plaintiff's ileostomy site appeared better than on the previous visit. Id.
On June 28, 2011, Dr. Taylor noted Plaintiff weighed 126 pounds and was prescribed Humira for treatment of Crohn's disease. Tr. at 532. Id. Plaintiff stated he felt better and Dr. Taylor noted that his ileostomy ...