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 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 reversed and remanded for further proceedings as set forth herein.
I. Relevant Background
A. Procedural History
On February 3, 2011, Plaintiff filed applications for DIB and SSI in which he alleged his disability began on June 15, 2004. Tr. at 74, 76, 157-63, 164-71. His applications were denied initially and upon reconsideration. Tr. at 81-82, 85-86, 94, 96. On September 6, 2012, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Ronald Fleming. Tr. at 28-72 (Hr'g Tr.). The ALJ issued a partially-favorable decision on September 26, 2012, finding that Plaintiff was not disabled before his date last insured ("DLI") of December 31, 2006, but that he became disabled on June 27, 2011. Tr. at 9-23. 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 1-3. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on March 17, 2014. [ECF No. 1].
B. Plaintiff's Background and Medical History
Plaintiff was 54 years old at the time of the hearing. Tr. at 35. He completed the ninth grade. Tr. at 37. His past relevant work ("PRW") was as a pipe insulator. Tr. at 61. He amended his alleged onset date during the hearing and alleges he has been unable to work since October 1, 2006. Tr. at 34, 37.
2. Medical History
a. Before DLI
On February 25, 2005, Plaintiff presented to Marolyn Baril, APRN ("Ms. Baril"), at Margaret J. Weston Community Health Center ("MJWCHC") for elbow pain and prescription refills. Tr. at 304. He indicated that his elbow pain was a chronic problem, but had worsened three to four days earlier. Id. Ms. Baril observed large, hot, reddened epicondyle edema in Plaintiff's bilateral elbows. Id. She assessed hypertension, gouty arthritis, and epicondylitis and prescribed Allopurinol and Colchicine. Id.
Plaintiff followed up with Ms. Baril for medication changes and refills on May 6, 2005. Tr. at 303. Ms. Baril noted that both of Plaintiff's elbows had tophaceous deposits and that his left big toe was inflamed, red, and painful. Id. She assessed chronic gouty arthritis and hypertension and prescribed Lotrel, Colchicine, and Allopurinol. Id.
On January 3, 2006, Plaintiff presented to the Medical University of South Carolina ("MUSC"), complaining of severe knee pain and swelling that had lasted for weeks. Tr. at 393. He indicated that he had taken Allopurinol and Colchicine, but had obtained no relief. Id. Plaintiff had swelling and decreased sensation in his left knee. Tr. at 388. He was diagnosed with gout and prescribed Prednisone. Tr. at 391, 392. An x-ray of his left knee indicated a small suprapatellar spur and unicompartment osteoarthritic change. Tr. at 395.
On December 6, 2006, Plaintiff presented to MJWCHC complaining of gout in both of his legs. Tr. at 302. He indicated his right foot was very painful and was causing him trouble when he walked. Id. Plaintiff reported that he had been managing his pain by taking his brother's medications, but that his brother died. Id. The provider observed Plaintiff to have "large deposits" in both elbows, inflammation in multiple joints, tenderness in his right great toe and ankle, severe tenderness in his bilateral elbows and knees, and 2-3 edema in his knees, ankles, and feet. Id. The provider diagnosed gouty arthritis and hypertension, refilled Colchicine, prescribed a Medrol dose pack and Darvocet, and administered an injection of DepoMedrol and Toradol. Id.
b. After DLI
On March 13, 2007, Plaintiff presented to MJWCHC complaining of a gout flare in his right foot. Tr. at 301. The provider assessed an acute gout flare and prescribed medications. Id.
Plaintiff presented to the emergency department at Aiken Regional Medical Center ("ARMC") on March 21, 2007, complaining of fever and redness to his right foot that had been ongoing for one week. Tr. at 261. A review of symptoms was normal, with the exception of Plaintiff's right lower extremity. Id. An x-ray of his right foot revealed gouty arthritis involving the first metatarsophalangeal joint and the fifth metatarsophalangeal joint to a lesser extent. Tr. at 263. It also indicated moderately severe osteoarthritic chances of the tarsus. Id. Plaintiff was diagnosed with cellulitis of the right foot. Tr. at 261. Plaintiff followed up at ARMC on March 23, 2007. Tr. at 257. He had significant erythema in his right foot, which was painful to palpation. Id. When Plaintiff followed up two days later, the cellulitis was "resolving, " and he had significantly less erythema. Tr. at 254.
On May 8, 2007, Plaintiff presented to ARMC complaining of elbow pain and fever. Tr. at 247. Abnormalities were noted in his left upper extremity, but the examination was otherwise normal. Id. Plaintiff was diagnosed with acute left elbow pain and gout. Id.
Plaintiff followed up with MJWCHC for medication refills and a blood pressure check on February 18, 2008. Tr. at 300. He reported gout flares every few months. Id. Abnormalities were noted in Plaintiff's bilateral elbows and in the interphalangeal joint of his right middle finger. Id. The provider assessed gout and advised Plaintiff to stop smoking. Id.
On February 26, 2008, Plaintiff followed up with MJWCHC and reported that his knee pain was not relieved by the prescribed medications. Tr. at 299. The provider observed no crepitus, warmth, or erythema, but noted some swelling on the medial aspect of Plaintiff's right knee. Id. The provider prescribed Naproxen and Darvocet N100, administered an injection of DepoMedrol and Toradol, and diagnosed bursitis. Id.
Plaintiff followed up with MJWCHC on April 7, 2008. Tr. at 298. He reported his knee pain improved with medication. Id. The provider noted no crepitus, warmth, or erythema. The provider continued Plaintiff's medications, increased his Lisinopril dosage, and added prescriptions for Norvasc 10 mg and Chantix. Id.
On June 18, 2008, Plaintiff followed up with MJWCHC for left hip pain, knee swelling, and shoulder pain. Tr. at 297. The provider administered trigger point injections and refilled Plaintiff's medications. Id.
Plaintiff presented to MJWCHC for follow up and medication refills on March 19, 2009. Tr. at 296. He stated that he had been out of medications for a month, but had borrowed some from his sister. Id. He complained of pain in his shoulder and hip that was worse on the right than on the left. Id. The provider refilled Plaintiff's medications, prescribed Darvocet N100, and administered trigger point injections. Id.
On June 9, 2009, Plaintiff followed up with MJWCHC for medication refills and pain in his right arm, elbow, shoulder, and neck. Tr. at 294. He rated his right shoulder and elbow pain as 10 out of 10. Id. The provider observed Plaintiff to have muscle spasms, prescribed Clonidine and a topical cream, and administered trigger point injections. Id.
Plaintiff presented to Lexington Medical Center ("LMC") Urgent Care on August 10, 2009, complaining of shortness of breath and pleuritic right chest pain. Tr. at 272-73. A CT was ordered to rule out pulmonary embolus. Tr. at 273. The CT indicated no evidence of pulmonary embolus, aneurysm, or dissection, but revealed pulmonary nodules. Tr. at 268. A chest x-ray was normal. Tr. at 270. An EKG indicated sinus tachycardia, possible left atrial abnormality, left axis deviation, and septal ST elevation. Tr. at 274. Plaintiff was diagnosed with acute bronchospasm, bronchitis, chest pain, and pulmonary nodules. Tr. at 273. The physician prescribed Albuterol, Amoxil 1 gm, Lortab 5 mg, and a four-day taper of Prednisone, instructed Plaintiff to use the Albuterol in a nebulizer machine every four hours, and directed him to stop smoking. Id. The provider also instructed Plaintiff to obtain a follow-up chest CT in two months to determine the stability of the nodules observed on the CT scan. Id.
Plaintiff presented to MJWCHC for prescription refills on September 3, 2009. Tr. at 293. S. Grace, L.P.N., assessed hypertension and low back pain. Id.
Plaintiff followed up at MJWCHC for left shoulder and ankle pain on October 22, 2009. Tr. at 292. The provider assessed shoulder pain, leg/ankle pain, and muscle spasm and prescribed Lortab 5/500 mg. Id.
On August 19, 2010, Plaintiff presented to MJWCHC for follow up for hypertension and gout and for medication refills. Tr. at 279-82. Plaintiff reported a gout flare and indicated he had been "bedridden for days." Tr. at 279. A review of systems indicated arthralgias, swelling, and joint stiffness localized to one or more joints, but no soft tissue swelling. Tr. at 280. Erin Beaudry, APRN ("Ms. Beaudry"), observed swollen joints in Plaintiff's right middle finger, right knee, right elbow, and left foot. Tr. at 280. She noted limited and antalgic range of motion in the affected joints. Id. She refilled Plaintiff's medications for hypertension and gout. Id.
Plaintiff presented to Ms. Beaudry on June 7, 2011, complaining of nausea and stomach pain and requesting medication refills. Tr. at 283. Ms. Beaudry refilled Plaintiff's medications and ordered laboratory testing that revealed an elevated serum LDH level. Tr. at 283, 284-85.
On June 27, 2011, Plaintiff presented to Vasant L. Garde, M.D., for a comprehensive orthopedic examination at the direction of the disability examiner. Tr. at 309-15. Plaintiff complained of hypertension, breathing trouble, and pain in his knees, ankles, right hip, and bilateral wrists and elbows. Tr. at 309. He complained of gout and arthritis in most of his joints. Id. He stated the joints on his right side were more painful than those on his left side. Tr. at 310. Dr. Garde observed that Plaintiff walked with a right-sided limp and used a cane. Tr. at 311. Plaintiff had swelling over both olecranon areas and the proximal interphalangeal joints of the right third finger. Id. He had limited range of motion of the cervical spine, right shoulder, right knee, right wrist, and right hip. Id. He had limited dorsiflexion in his bilateral ankles. Id. Plaintiff's grip strength was 5/5 in his left hand, and Dr. Garde indicated Plaintiff's ability to carry out fine and gross manipulation with the left hand did not seem compromised. Id. However, Plaintiff had 3-4/5 grip strength on the right side, and Dr. Garde noted "his ability to carryout fine and gross manipulation seem[s] somewhat compromised because of discomfort." Tr. at 312.
State agency medical consultant William Lindler, M.D., completed a physical residual functional capacity assessment on July 1, 2011, in which he indicated Plaintiff was limited as follows: occasionally lift and/or carry 20 pounds; frequently lift and/or carry 10 pounds; stand and/or walk about six hours in an eight-hour workday; sit about six hours in an eight-hour workday; occasionally climb ramps/stairs, balance, stoop, kneel, crouch, and crawl; never climb ladders/ropes/scaffolds; occasionally reach overhead; frequently handle and finger with the right hand; and avoid concentrated exposure to extreme cold, extreme heat, humidity, fumes, odors, dusts, gases, poor ventilation, and hazards. Tr. at 319-26. Dr. Lindler indicated that there was insufficient evidence to assessment Plaintiff's RFC prior to his DLI due to a lack of medical evidence. Tr. at 324.
Plaintiff followed up with Ms. Beaudry for right knee and hip pain on September 7, 2011. Tr. at 344. Ms. Beaudry assessed hypertension, gout, and wheezing. Tr. at 341. She refilled Plaintiff's existing prescriptions and prescribed Albuterol. Id. Plaintiff requested that she prescribe a Canadian crutch, but she indicated that she needed to determine the criteria for use and discuss it further at his follow up visit. Id.
On September 26, 2011, state agency medical consultant James Haynes, M.D., completed a physical residual functional capacity assessment, in which he indicated Plaintiff was limited as follows: occasionally lift and/or carry 20 pounds; frequently lift and/or carry 10 pounds; stand and/or walk about six hours in an eight-hour workday; sit about six hours in an eight-hour workday; occasionally climb ramps/stairs, balance, stoop, kneel, crouch, and crawl; never climb ladders/ropes/scaffolds; occasionally reach overhead; frequently handle and finger with the right hand; and avoid concentrated exposure to extreme cold, extreme heat, humidity, fumes, odors, dusts, gases, poor ventilation, ...