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Littlejohn v. Commissioner of Social Security Administration

United States District Court, D. South Carolina

April 14, 2015

Charlotte Littlejohn, Plaintiff,
v.
Commissioner of Social Security Administration, Defendant.

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 June 4, 2011, Plaintiff filed an application for DIB in which she alleged her disability began on March 1, 2011. Tr. at 137-38. Her application was denied initially and upon reconsideration. Tr. at 124-27, 129-30. On December 18, 2012, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Gregory M. Wilson. Tr. at 46-71 (Hr'g Tr.). The ALJ issued an unfavorable decision on March 29, 2013, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 15-45. 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 1-4. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on July 24, 2014. [ECF No. 1].

B. Plaintiff's Background and Medical History

1. Background

Plaintiff was 39 years old at the time of the hearing. Tr. at 50. She obtained a bachelor's degree. Id. Her past relevant work ("PRW") was as an ingredient handler and a quality control clerk. Tr. at 67-68. She alleges she has been unable to work since March 1, 2011. Tr. at 137.

2. Medical History

On March 1, 2011, Plaintiff presented to Richard Ruffing, M.D. ("Dr. Ruffing"), complaining of upper and mid back pain and elevated blood pressure. Tr. at 257. Dr. Ruffing observed Plaintiff's mid back to be mildly tender, but Plaintiff had normal reflexes and negative straight-leg raise. Id. Dr. Ruffing prescribed Lortab, Ultram, and Soma. Id.

On March 9, 2011, Plaintiff complained to Dr. Ruffing of persistent mid back pain with bending and lifting. Tr. at 256. Dr. Ruffing observed Plaintiff to have moderate tenderness in her upper and lower extremities and back, but to have adequate strength. Id. He continued her prescriptions for Lortab, Ultram, and Soma and instructed her to remain out of work until after her next visit. Id.

Plaintiff followed up with Dr. Ruffing on March 21, 2011, and complained of persistent mid and upper back pain. Tr. at 256. Dr. Ruffing observed her to have diffuse tenderness in her back with adequate range of motion in her upper and lower extremities, adequate strength bilaterally, and normal reflexes. Id. He continued Plaintiff's prescriptions for Lortab, Ultram, and Soma, prescribed Tylox, and authorized Plaintiff to remain out of work until after her next visit. Id.

Plaintiff followed up with Dr. Ruffing on April 5, 2011, complaining of persistent back pain and stiffness and difficulty bending and lifting. Tr. at 254. Dr. Ruffing observed her to have tender back muscles with positive spasm, but noted she had full range of motion of her upper and lower extremities with adequate strength and normal reflexes. Id. He continued Plaintiff's prescriptions for Lortab and Ultram and prescribed Flexeril. Id.

Plaintiff followed up with Dr. Ruffing on April 15, 2011. Tr. at 254. She described persistent back pain, lightheadedness, dizziness, and elevated blood pressure. Id. Dr. Ruffing noted no abnormalities on examination. Id. He prescribed Zestoretic and Skelaxin and continued Plaintiff's prescription for Lortab. Id. He referred Plaintiff for an x-ray of her lumbar spine that indicated no abnormalities. Tr. at 215.

On May 10, 2011, Plaintiff complained to Dr. Ruffing of persistent pain in her knees and back, lightheadedness, dizziness, and hypertension. Tr. at 253. Dr. Ruffing observed Plaintiff's blood pressure to be elevated at 149/99. Id. He also noted mild swelling and tenderness in her right knee. Id. He increased her dosage of Zestoretic, refilled Lortab, and prescribed 600 milligrams of Daypro. Id.

Plaintiff presented to Upstate Carolina Medical Center on May 24, 2011, complaining that she felt sick after taking a few sips of an alcoholic beverage. Tr. at 206. She reported nausea, vomiting, dyspepsia, and elevated blood pressure. Tr. at 211. Her physical examination was normal and she was diagnosed with essential hypertension and acute cephalgia. Tr. at 207. She was prescribed Zantac and Zofran and discharged to her home. Id.

On May 26, 2011, Plaintiff indicated to Dr. Ruffing that she had recently been under some stress. Tr. at 253. She complained of pain and stiffness in her knees and hypertension. Id. Plaintiff's blood pressure was elevated at 145/98. Id. Dr. Ruffing prescribed Tribenzor and indicated Plaintiff should remain out of work until after her next visit. Id. In a physician's report he completed for Plaintiff's disability insurer, Dr. Ruffing indicated Plaintiff demonstrated exaggeration, inconsistent findings, and subjective complaints out of proportion to medical findings. Tr. at 246.

Plaintiff presented to Dr. Ruffing on June 6, 2011, to follow up on hypertension. Tr. at 252. She complained of pain and stiffness in her back and knees, particularly on the right. Id. Her blood pressure was elevated at 152/96. Id. Dr. Ruffing observed tenderness in Plaintiff's right knee and back. Id. Plaintiff had normal reflexes and negative straightleg raise. Id. Dr. Ruffing prescribed Tribenzor, Lortab, and Relafen and indicated Plaintiff should remain out of work until after her next appointment. Id.

Plaintiff followed up with Dr. Ruffing on June 21, 2011. Tr. at 252. She reported headaches, lightheadedness, dizziness, and pain in her knees, legs, and back. Id. Dr. Ruffing observed Plaintiff to have some crepitus and stiffness in her knees, but no edema in her legs. Id. Plaintiff's hypertension was improved and her blood pressure was 131/84. Id. Dr. Ruffing noted Plaintiff had "significant symptom magnification." Id. He prescribed Ultram, increased Plaintiff's dosage of Tribenzor, and continued her prescriptions for Lortab and Relafen. Id. He indicated Plaintiff should remain out of work until after her next visit. Id.

On July 13, 2011, Plaintiff complained to Dr. Ruffing of persistent headaches, dizziness, vertigo, and right knee stiffness. Tr. at 250. Her blood pressure was elevated at 154/100. Id. Dr. Ruffing observed Plaintiff to have crepitus in her right knee and adequate range of motion and strength. Id. He recommended an MRI of Plaintiff's right knee, prescribed Benicar, Lortab, and Antivert, and continued her prescription for Daypro. Id.

Dr. Ruffing completed an opinion statement on July 20, 2011, in which he indicated Plaintiff was diagnosed with hypertension, dizziness, and knee pain and had difficulty walking. Tr. at 239. Dr. Ruffing specified Plaintiff could continuously sit, balance, bend, reach at shoulder level, reach above shoulder level, drive, lift 10 pounds or less, carry 10 pounds or less, and push/pull 10 pounds or less; frequently stand, walk, and walk on uneven surfaces; and occasionally kneel, crawl, climb ladders and stairs, and lift and carry 11 to 50 pounds. Tr. at 240. Dr. Ruffing indicated Plaintiff was able to use her hands for repetitive, frequent, or occasional grasping, pushing/pulling, fine manipulation, and finger dexterity. Id.

Plaintiff returned to Dr. Ruffing on July 29, 2011, and complained of headaches, sinus pressure, pain and stiffness in her knees, and swelling in her ankles. Tr. at 250. Dr. Ruffing noted that Plaintiff's ANA test was positive. Id. He observed Plaintiff to have full range of motion of her upper and lower extremities, adequate strength bilaterally, normal reflexes, and diffuse tenderness, particularly over her knees and ankles. Id. He prescribed Keflex, Allegra, Imipramine, and Corgard and continued Plaintiff's prescriptions for pain medications. Id.

On August 11, 2011, state agency consultant Seham El-Ibiary, M.D., completed a physical residual functional capacity assessment in which he indicated Plaintiff could occasionally lift and/or carry 50 pounds; could frequently lift and/or carry 25 pounds; could stand and/or walk for about six hours in an eight-hour workday; could sit for about six hours in an eight-hour workday; could frequently climb ladders, ropes, and scaffolds; and could frequently crouch. Tr. at 110-11.

Plaintiff presented to Dr. Ruffing on August 18, 2011, complaining of increasing headaches and pain in her back and knees. Tr. at 248. Plaintiff's blood pressure was 130/79 and was indicated to be "pretty well controlled on her current medication." Id. Dr. Ruffing noted Plaintiff was unable to stand for an eight-hour day because of arthralgias. Id. He increased Plaintiff's dosage of Corgard to 40 milligrams daily and refilled her prescription for Lortab. Id.

Plaintiff followed up with Dr. Ruffing on September 6, 2011, and complained of pain and stiffness in her arms and knees. Tr. at 248. She reported severe unilateral headaches, diffuse myalgias, and hypersensitivity. Id. Dr. Ruffing observed Plaintiff to have diffuse large muscle tenderness. Id. He prescribed Tribenzor and Savella and continued Corgard and Lortab. Id.

Dr. Ruffing completed a medical source statement for Plaintiff's disability insurer on September 7, 2011, in which he indicated Plaintiff was unable to return to work in any capacity and that she was specifically limited as follows: continuously sit; occasionally stand; occasionally walk; lift, carry, and push/pull up to 10 pounds; and avoid balancing, bending, walking on uneven surfaces, kneeling, crawling, climbing (ladders, stairs, etc), reaching at shoulder level, reaching above shoulder level, driving, lifting, carrying, and pushing/pulling 11 pounds or more. Tr. at 233-34. Dr. Ruffing indicated Plaintiff had no difficulty using her hands for repetitive, frequent, or occasional grasping, pushing/pulling, fine manipulation, and finger dexterity. Tr. at 235. Dr. Ruffing completed another statement in September 2011 in which he indicated Plaintiff could occasionally lift, carry, and push/pull 11 to 20 pounds. Tr. at 238. Dr. Ruffing described Plaintiff's symptoms as including diffuse pain in her knee, hip, and back, as well as headaches. Tr. at 236. He indicated Plaintiff's recovery and return to work were complicated by a comorbid mental disorder such as anxiety, depression, etc. and exaggeration, inconsistent findings, and subjective complaints that were out of proportion to the medical findings. Tr. at 237.

On October 4, 2011, Plaintiff complained to Dr. Ruffing of pain in her knees, hands, and low back, as well as dizziness and headaches. Tr. at 304. Dr. Ruffing indicated Plaintiff had a lot of symptom magnification and complained of a lot of pain with minimal touch. Id. Plaintiff's blood pressure was elevated at 155/106. Id. Dr. Ruffing observed Plaintiff to have diffuse point tenderness. Id. He specified Plaintiff was tender in her lower back, wrist, and bilateral knees and that she had some trace edema of her lower extremities. Id. Dr. Ruffing continued Tribenzor and Savella. Id. He indicated Plaintiff could not work a regular job because of pain manifestations and her inability to stand for an eight-hour day. Id. He stated that he would refer Plaintiff to a rheumatologist. Id.

Plaintiff presented to Muthamma J. Machimada, M.D. ("Dr. Machimada"), for an initial evaluation on October 28, 2011. Tr. at 228-31. She complained of pain, swelling in her lower extremities, morning stiffness, tingling and numbness in her bilateral upper and lower extremities, pain with range of motion of her shoulders and elbows, and ongoing swelling involving the metacarpophalangeal ("MCP") and proximal interphalangeal ("PIP") joints of her hands. Tr. at 228. Dr. Machimada observed Plaintiff to have trace to moderate synovitis involving the second to fifth PIP joints, the MCP joints, and the wrists. Tr. at 230. Plaintiff complained of pain upon flexion and extension of her wrists and palpation of her shoulders. Id. She demonstrated tenderness to palpation of her cervical and lumbar spine, knees, and ankles. Id. Lab results indicated positive ANA and elevated sedimentation rate, but all other tests were normal. Tr. at 230-31. Dr. Machimada instructed Plaintiff to discontinue Daypro, but to continue taking Lortab and Soma. Tr. at 231. She prescribed Prednisone, ordered more testing, and indicated "[a]t this point, I am more concerned of the possibility of rheumatoid arthritis as a cause of her joint problems rather than an autoimmune disease process." Id.

On November 7, 2011, Plaintiff complained of pain and stiffness in her knees and little improvement with Savella. Tr. at 304. Dr. Ruffing again noted Plaintiff to have "lots of symptom magnification." Id. Plaintiff demonstrated adequate strength in her upper and lower extremities. Id. Dr. Ruffing continued Tribenzor, Savella, and Lortab. Id.

Plaintiff followed up with Dr. Machimada on November 15, 2011. Tr. at 225-26. Dr. Machimada indicated recent blood tests showed negative lupus anticoagulant, ANCA titers, rheumatoid factor, and anticardiolipin antibody titer. Tr. at 225. Plaintiff had a normal complete blood count ("CBC") and normal c-reactive protein. Id. Plaintiff informed Dr. Machimada that Prednisone did not ease much of her pain. Id. She complained that she experienced stiffness for one to two hours each morning and had persistent generalized myalgias. Id. She reported significant fatigue with nonrestorative sleep. Id. Plaintiff's blood pressure was elevated at 140/98. Id. Dr. Machimada found no evidence of synovitis involving Plaintiff's joints. Tr. at 226. She observed Plaintiff to have generalized myalgias with minimal palpation. Id. Dr. Machimada indicated "most of her pain seems to be arising from the fibromyalgia." Id. She scheduled Plaintiff for bilateral knee x-rays, ran an ANA panel, instructed Plaintiff to complete a Prednisone burst and taper, and prescribed 50 milligrams of Diclofenac Sodium. Id.

Plaintiff complained to Dr. Ruffing of pain and stiffness in her knees on December 1, 2011. Tr. at 303. She stated she had a lot of pain, but Dr. Ruffing indicated Plaintiff was doing reasonably well. Id. Dr. Ruffing observed Plaintiff to have knee crepitus on examination. Id. He prescribed Imipramine and refilled prescriptions for Corgard and Tribenzor. Id.

On December 5, 2011, state agency consultant Carl Anderson, M.D., completed a physical residual functional capacity evaluation in which he indicated Plaintiff was limited as follows: never climb ladders/ropes/scaffolds; frequently crawl; and avoid concentrated exposure to hazards. Tr. at 119-20.

On December 6, 2011, Dr. Machimada indicated Plaintiff's ANA panel showed a positive anti-RNP antibody[1] titer of 1:1; negative lupus anticoagulant; and negative ANCA, anti-Smith, anti-SSA, anti-SSB, anti-Scl-70, and anti-ds DNA antibody titers. Tr. at 299. Plaintiff complained of worsening pain, swelling, and buckling in her right knee. Id. Dr. Machimada noted that x-rays of Plaintiff's bilateral knees indicated mild narrowing of the medial joint compartment and a high-riding patella, but no narrowing of the patellofemoral joint space. Id. Plaintiff indicated that Diclofenac Sodium had eased some of her pain and discomfort, but that Prednisone was not helpful. Id. Plaintiff complained of some swelling and pain across her MCP and PIP joints and difficulty grasping objects and making a fist. Id. She indicated she experienced pain and swelling in her wrists and shoulder pain that caused her difficulty in lifting her arms. Id. She stated she had knee pain with prolonged standing and walking, but denied significant pain in her elbows, neck, lower back, ankles, and feet. Id. Plaintiff indicated she experienced stiffness for three to four hours each morning. Id. Dr. Machimada described Plaintiff as being in moderate discomfort. Id. She observed no synovitis in Plaintiff's distal interphalangeal ("DIP") joints, but trace synovitis in her second to fifth MCP and PIP joints. Tr. at 300. Plaintiff was restricted in her ability to make a fist due to trace to moderate synovitis in her wrists. Id. She had no synovitis in her elbows or shoulders and intact internal and external rotation of her shoulders. Id. Dr. Machimada noted no tenderness to palpation of Plaintiff's cervical, thoracic, or lumbar spine and no synovitis in her knees, ankles, or the metatarsophalangeal ("MTP") joints of her feet. Id. She increased Plaintiff's dosage of Lortab, refilled Diclofenac Sodium, and indicated she planned to prescribe Plaquenil at a future visit. Id.

On January 2, 2012, Plaintiff complained of pain and stiffness in her arms and legs. Tr. at 303. Dr. Ruffing observed Plaintiff to have good range of motion of her upper and lower extremities. Id. Because Plaintiff complained of heart palpitations, Dr. Ruffing replaced her prescription for Corgard with Lopressor and refilled Tribenzor. Id.

Plaintiff followed up with Dr. Machimada on January 12, 2012, and reported significant pain in the small joints of her hands and feet, morning stiffness lasting 30 to 45 minutes at a time, lower back and neck pain, and weakened grip strength. Tr. at 296. Dr. Machimada observed no evidence of synovitis in Plaintiff's DIP joints, but moderate synovitis in her MCP and PIP joints and trace to moderate synovitis in her wrists. Id. Plaintiff expressed pain when making a fist. Id. Dr. Machimada noted Plaintiff to have tenderness on palpation of the medial and lateral aspects of her elbows, but to have intact elbow flexion and extension. Id. She observed tenderness in the anterior aspect of Plaintiff's shoulders with pain on abduction and internal rotation. Id. Plaintiff was also tender to palpation in the paraspinal muscles around her neck and in her lower back. Id. Plaintiff had some intermittent tingling and numbness down her upper and lower extremities, but ...


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