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Lewis v. Comm'r of Social Security Administration

United States District Court, D. South Carolina, Aiken Division

November 19, 2014

Vincent Ennis Lewis, Plaintiff,
v.
Commissioner of Social Security Administration, Defendant

For Vincent Ennis Lewis, Plaintiff: Beatrice E Whitten, LEAD ATTORNEY, Beatrice E Whitten Law Office, Mt Pleasant, SC.

For Commissioner of Social Security Administration, Defendant: Marshall Prince, 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"). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether he 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 June 4, 2010, Plaintiff protectively filed applications for DIB and SSI in which he alleged his disability began on January 1, 2005. Tr. at 137-38, 141-48. His applications were denied initially and upon reconsideration. Tr. at 63-66, 67-70, 75-76. On June 4, 2012, Plaintiff had a hearing before Administrative Law Judge (" ALJ") Augustus C. Martin. Tr. at 25- (Hr'g Tr.). The ALJ issued a partially-favorable decision on August 7, 2012, finding that Plaintiff was not disabled prior to June 4, 2010, but became disabled on that date and continued to be disabled through the date of the decision. Tr. at 9-22. 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 1-3. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on December 10, 2013. [ECF No. 1].

B. Plaintiff's Background and Medical History

1. Background

Plaintiff was 55 years old at the time of the hearing. Tr. at 31. He completed high school and nearly two years of college. Tr. at 32. His past relevant work (" PRW") was as an extruder machine operator and a mattress sewer. Tr. at 49. He alleges he has been unable to work since January 1, 2005. Tr. at 31.

2. Medical History

On March 9, 2005, Plaintiff presented to Roper Hospital with high blood sugar after having discontinued his diabetes medication. Tr. at 278. His glucose was 437 mg/dL and his creatinine was slightly elevated at 1.4 mg/dL, but his hemoglobin was normal at 17.0 g/dL. Tr. at 279. He was administered insulin and discharged home. Id.

Jason E. Berendt, M.D., treated Plaintiff for diabetes in March and April 2005. Tr. at 683-96. He prescribed medications, and Plaintiff's symptoms improved. Id. Although Plaintiff was diagnosed with renal insufficiency, Dr. Berendt noted that this was likely acute renal insufficiency secondary to volume depletion. Tr. at 693.

Plaintiff presented to Sophie Fowler, NP, on September 20, 2006, to establish treatment. Tr. at 751. Plaintiff indicated that he stopped taking his diabetes medications two years earlier when he lost his job and ran out of money. Id. He complained of blurred vision secondary to cataracts, but indicated that he could not have surgery for cataracts until his diabetes was controlled. Id. Plaintiff's blood sugar was 447, but the examination was otherwise normal. Id.

Plaintiff followed up with Ms. Fowler on September 29, 2006, regarding blood test results. Tr. at 750. Plaintiff indicated he was attempting to change his diet, but his blood sugars were running in the 200s to 300s. Id. Plaintiff's blood pressure was elevated, and Ms. Fowler indicated that she would consider adding blood pressure medication at his next visit. Id.

Plaintiff presented to E.M. Newton, M.D., on October 13, 2006. Tr. at 749. Dr. Newton indicated Plaintiff had been off all medications when Plaintiff presented to his office and that his A1C was 14.6 mg/dL and his blood sugars were in the 300s. Id. Dr. Newton prescribed 10 units of Lantus insulin in the morning. Id.

Plaintiff followed up with Dr. Newton on November 2, 2006. Tr. at 748. Dr. Newton noted that Plaintiff's blood sugar was decreasing. Id.

Laboratory testing on November 13, 2006, indicated normal blood urea nitrogen (" BUN") and creatinine. Tr. at 814.

Plaintiff followed up with Ms. Fowler on November 30, 2006. Tr. at 747. Ms. Fowler noted that Plaintiff's blood sugars were good and that his compliance had improved. Id.

On February 22, 2007, Plaintiff complained to Dr. Newton that he was having difficulty obtaining a job because of vision problems. Tr. at 746. Plaintiff's BUN and creatinine were normal. Tr. at 811.

Treatment notes from Robert E. Peyser, M.D., indicate Plaintiff was diagnosed with mild diabetic retinopathy, bilateral cataracts, and iridcyclitis. Tr. at 678-79. In a letter dated February 28, 2007, Dr. Peyser noted Plaintiff's vision was 20/25 in his right eye and 20/40 to 20/200 in the left eye. Tr. at 727. Dr. Peyser observed bilateral cataracts, worse on the left than on the right. Id. He performed left cataract surgery on March 15, 2007, and right cataract surgery on April 16, 2007. Tr. at 729, 730.

On April 5, 2007, Plaintiff reported to Dr. Newton that he could see much better following his left eye surgery. Tr. at 745. Dr. Newton noted that Plaintiff's A1C had decreased from 14.6 mg/dL in September 2006 to 9.1 mg/dL in February 2007. Id.

Plaintiff followed up with Dr. Newton on June 7, 2007. Tr. at 744. Although the treatment notes from this visit are largely illegible, [1] it appears that Dr. Newton prescribed a four-month supply of Plaintiff's medications. Id. Laboratory tests indicated Plaintiff's BUN was elevated at 26.0, but his creatinine was normal at 1.2. Tr. at 807.

In a letter dated June 29, 2007, Dr. Peyser wrote that Plaintiff had uneventful cataract surgery and that his vision was restored to 20/20 bilaterally. Tr. at 728.

Plaintiff presented to Dr. Newton complaining of back pain on October 11, 2007. Tr. at 743. Dr. Newton administered a Toradol injection and prescribed pain medication. Id.

Plaintiff followed up with Dr. Newton on October 15, 2007, and reported that his back was feeling much better. Tr. at 742. Dr. Newton refilled Plaintiff's prescriptions for diabetes and high blood pressure medications. Id. Lab tests indicated Plaintiff's BUN was slightly elevated at 23.0 mg/dL, but his creatinine and estimated glomerular filtration rate (" GFR") were normal at 1.2 mg/dL and 82.4 mL/minute, respectively. Tr. at 806.

Plaintiff presented to the emergency department at St. Francis Hospital on April 13, 2009, complaining of nausea, vomiting, and abdominal pain. Tr. at 269. His hemoglobin was slightly reduced at 11.5 g/dL. Tr. at 273. His BUN was normal at 22.0 mg/dL. Id. His creatinine was slightly high at 1.4 mg/dL. Id. His estimated GFR was normal at 68 mL/min. Id.

On April 15, 2009, Plaintiff presented Dr. Newton to follow up after his visit to the emergency room. Tr. at 325. Plaintiff reported a recent onset of decreased energy and feeling like he was going to black out. Id. Plaintiff's glucose was elevated at 405 mg/dL. Tr. at 799. However, his creatinine was normal at 1.2 mg/dL, his BUN was normal at 22.0 mg/dL, and his estimated GFR was normal at 81.8 mL/minute. Id.

Plaintiff followed up with Dr. Newton on April 17, 2009, reporting he had not taken his diabetes medication for over a year. Tr. at 324. His A1C was 13.4 mg/dL, but his creatinine was within normal range at 1.2. Id. Dr. Newton observed an abscess on Plaintiff's neck, but the examination was otherwise normal. Id. Dr. Newton prescribed medications, including insulin. Id.

Blood tests on April 27, 2009, revealed Plaintiff's creatinine to be high at 1.7 mg/dL and his BUN to be high at 32.0. Tr. at 784.

Plaintiff followed up with Dr. Newton on May 15, 2009. Tr. at 323. Dr. Newton indicated Plaintiff's A1C was elevated at 12.8 mg/dL and his creatinine had increased from 1.2 mg/dL to 1.7 mg/dL. Id. However, a blood test from May 15, 2009, indicates Plaintiff's creatinine had decreased to 1.4 mg/dL, and his estimated GFR was normal at 68.4 mL/minute. Tr. at 783. His BUN was elevated at 33.0 mg/dL. Id. Plaintiff's hemoglobin was 10.7 g/dL. Tr. at 323. Dr. Newton's examination of Plaintiff was otherwise normal. Id.

On June 15, 2009, Plaintiff followed up with Dr. Newton. Tr. at 322. His blood pressure was elevated at 164/88. Id. Although the treatment notes are somewhat illegible, it appears that Dr. Newton noted no abnormalities on examination. Id. Blood test results from this visit indicate Plaintiff's creatinine was high at 1.5 mg/dL and his BUN was high at 36.0 mg/dL, but his estimated GFR was within the normal range at 63.2 mL/minute. Tr. at 781.

Plaintiff followed up with Dr. Newton on July 15, 2009, who noted Plaintiff was " doing well." Tr. at 321. Dr. Newton noted a gradual decrease in Plaintiff's hemoglobin, which was 9.3 g/dL. Id., Tr. at 778. Plaintiff's creatinine was again elevated at 1.5 mg/dL and his BUN was elevated at 31.0 mg/dL, but his estimated GFR was within normal limits at 63.2 mL/minute. Tr. at 778-79.

Plaintiff followed up with Dr. Newton on August 12, 2009. Tr. at 320. Dr. Newton's notes, while largely illegible, indicate Plaintiff was " doing great." Id. His A1C had decreased to 7.7 mg/dL. Id. Plaintiff's creatinine was elevated at 1.7 mg/dL, his BUN was elevated at 37.0 mg/dL, and his estimated GFR had declined to 54.7 mL/minute. Tr. at 755. Plaintiff's hemoglobin had increased from 9.9 g/dL to 10.0 g/dL, and Dr. Newton noted no abnormalities during the physical examination. Tr. at 320.

Plaintiff followed up with Dr. Newton on October 12, 2009. Tr. at 319. Plaintiff's creatinine had increased to 2.2, his BUN had increased to 38.0 mg/dL, and his estimated GFR had decreased to 40.6 mL/minute. Tr. at 755.

Plaintiff presented to the emergency department at St. Francis Hospital on October 24, 2009, complaining of nausea. Tr. at 259. Plaintiff's hemoglobin was low at 8.8 g/dL. Tr. at 263. He had elevated BUN at 30.0 mg/dL, elevated creatinine at 1.7 mg/dL, and decreased GFR at 55.0 mL/minute. Id.

On November 20, 2009, Plaintiff followed up with Dr. Newton. Tr. at 318. Treatment notes from this visit are largely illegible. Plaintiff's A1C had decreased to 6.8 mg/dL. Id. His estimated GFR was 51.5 mL/minute, his creatinine was 1.7 mg/dL, and his BUN was 32 mg/dL. Tr. at 764-65. The record appears to indicate Dr. Newton referred Plaintiff to see Dr. Keogh, but Plaintiff had not yet seen him. Tr. at 318.

Plaintiff followed up with Dr. Newton on December 8, 2009. Tr. at 317. Dr. Newton indicated that Plaintiff's creatinine had previously increased from 1.5 g/dL to 2.2 g/dL, but that it had recently decreased to 1.7 g/dL. Id. However, testing on December 8, 2009, indicated Plaintiff's creatinine had again increased to 2.2 mg/dL. Tr. at 762. His estimated GFR had decreased to 38.2 mL/minute and his BUN had increased to 51.0 mg/dL. Id. Dr. Newton noted Plaintiff's hemoglobin was low at 8.0 and that he had been referred to a gastroenterologist to rule out blood loss. Tr. at 317. Dr. Newton assessed insulin-dependent diabetes mellitus, chronic renal insufficiency, iron-deficiency anemia, hematuria, and GERD. Id.

A capsule endoscopy performed on December 29, 2009, indicated no gross blood or bleeding site in the small bowel. Tr. at 752.

On January 8, 2010, Dr. Newton noted that Plaintiff's last hemoglobin was low at 8.0 g/dL and his last creatinine was increased from 1.7 mg/dL to 2.2 g/dL. Tr. at 316.

On February 12, 2010, Dr. Newton reported Plaintiff was " doing well." Tr. at 315. While his A1C was 6.1 and his creatinine had decreased from 2.2 to 1.7, his hemoglobin was low. Id. Dr. Newton referred Plaintiff to a hematologist. Id.

Plaintiff followed up with Dr. Newton on March 12, 2010. Tr. at 314. Treatment notes indicate Plaintiff " feels ok, " but was " a little tired." Id. Dr. Newton indicated Plaintiff's creatinine was increasing and ...


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