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Godfrey v. Colvin

United States District Court, D. South Carolina

January 26, 2016

Timothy Godfrey, Plaintiff,
v.
Carolyn W. Colvin, Acting 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 his claims 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 August 29, 2012, Plaintiff protectively filed applications for DIB and SSI in which he alleged his disability began on June 29, 2009. Tr. at 83, 96, 191-92. His applications were denied initially and upon reconsideration. Tr. at 144-48, 154-55, 156-57. On June 26, 2014, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Jerry W. Peace. Tr. at 27-82 (Hr'g Tr.). The ALJ issued an unfavorable decision on October 31, 2014, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 6-26. 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 1-3. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on May 15, 2015. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 53 years old at the time of the hearing. Tr. at 38. He completed high school. Id. His past relevant work ("PRW") was as a construction worker. Tr. at 76. He alleges he has been unable to work since June 1, 2011.[1] Tr. at 31-32.

         2. Medical History

         Plaintiff presented to the emergency room ("ER") at Spartanburg Regional Healthcare System on November 7, 2011, with complaints of back pain and nausea. Tr. at 357. Plaintiff's glucose was significantly elevated at 312 mg/dL. Tr. at 363. He was diagnosed with back pain and diabetes, prescribed Glucophage and Lortab, and instructed to follow a diabetic diet and to follow up with a clinic. Tr. at 359.

         On April 24, 2012, Plaintiff presented to St. Luke's Free Medical Clinic ("SLFMC") to establish primary care treatment. Tr. at 265, 270. He reported occasional right flank pain and requested that his prescription for Metformin be refilled. Tr. at 265. Blood tests indicated Plaintiff's hemoglobin A1c was elevated at 9.0 percent and his average glucose was estimated to be 212 mg/dL. Tr. at 267.

         On May 16, 2012, Plaintiff presented to Palmetto Eye and Laser Center for an examination. Tr. at 266. Leanne Wickliffe Keisler, M.D. ("Dr. Keisler"), indicated Plaintiff's eye exam showed his bilateral vision to be unaffected by diabetes, but indicated he had cataracts and nuclear sclerosis in his bilateral eyes. Id. Dr. Keisler prescribed new glasses. Id.

         Plaintiff followed up at SLFMC on May 22, 2012, and indicated Lisinopril was causing him to feel dizzy. Tr. at 264. The provider assessed uncontrolled blood pressure and uncontrolled diabetes mellitus. Id. He increased Plaintiff's dosage of Metformin for diabetes and discontinued Lisinopril and prescribed Diovan for hypertension. Id. Plaintiff's blood sugar was 199 mg/dL and he reported intermittent right-sided pain and tingling in his feet during the night. Id. Plaintiff indicated he was very depressed and did not desire to be around others. Id. The provider observed Plaintiff to have tenderness in his back, decreased pedal pulses, and decreased monofilament testing in his bilateral toes. Id. The provider assessed uncontrolled diabetes with neuropathy, hypertension, and situational depression. Id.

         Plaintiff presented to SLFMC on June 19, 2012, and reported pain, numbness, and tingling in his right arm, pain in his legs and feet, and elevated blood pressure. Tr. at 263. He stated Diovan had caused him to experience a "fainting" feeling. Id. He reported decreased interest in activities and increased stressors as a result of being unemployed and requested medication to treat depression. Id. The provider prescribed Metaprolol for hypertension and Citalopram (generic form of Celexa) for depression. Id.

         On June 20, 2012, an x-ray of Plaintiff's cervical spine indicated mild multilevel degenerative changes that were most prominent at C6-7. Tr. at 269.

         Plaintiff followed up at SLFMC on July 12, 2012, and reported a rash. Tr. at 262. The provider indicated the rash was likely a reaction to either Celexa or Metaprolol. Id. He recommended Plaintiff discontinue Celexa to see if his symptoms improved. Id. He indicated that Plaintiff should discontinue Metaprolol and resume Celexa if the rash remained five or six days after he discontinued Celexa. Id.

         On August 6, 2012, Plaintiff presented to SLFMC for a follow-up visit regarding diabetes and hypertension and to review his x-ray. Tr. at 261. Plaintiff reported continued numbness and tingling in his left arm. Id. Plaintiff also complained of pain and numbness in his right hand that radiated from his shoulder. Id. The physician noted that Plaintiff endorsed tingling in his feet and diagnosed diabetic neuropathy. Id. He stated degenerative changes were present on a computed tomography ("CT") scan and that Plaintiff may have nerve compression. Id. The provider increased Plaintiff's dosage of Metaprolol for depression and indicated Plaintiff's depression was stable without Celexa. Id.

         On August 21, 2012, magnetic resonance imaging ("MRI") of Plaintiff's cervical spine showed a disc herniation on the right at C6-7 that appeared to press on the exiting nerve root. Tr. at 321.

         Plaintiff presented to Pamela N. Davenport, M.D. ("Dr. Davenport"), for an initial office visit on October 8, 2012. Tr. at 334. Dr. Davenport noted that Plaintiff had limited access to insurance coverage in recent years and was unable to afford test strips for checking his blood sugar. Id. She stated Plaintiff had two recent syncopal episodes. Id. Plaintiff complained of paresthesias down his right arm that affected his thumb, index, and middle fingers. Id. He reported fatigue and daytime sleepiness. Id. He stated he had nausea and diminished appetite and had unintentionally lost 60 pounds. Id. He complained of tingling in his feet at night, cramps in his feet, and lower extremity pain associated with walking. Id. Dr. Davenport described Plaintiff as "appearing chronicallyill." Tr. at 337. She observed diminished pedal pulses in Plaintiff's bilateral feet. Id. A diabetic foot exam revealed a callus on the tip of Plaintiff's right second toe without ulceration, as well as diminished pulses and sensation. Id. Plaintiff had decreased sensation to vibratory sense in his hands and feet. Id. His sharp sensation was diminished in his right hand in the radial and ulnar distributions and in his left hand in the ulnar distribution. Id. He had diminished reflexes throughout. Id. Dr. Davenport indicated Plaintiff may have a neurologic component to his syncopal episodes and should be evaluated for carotid artery stenosis. Tr. at 338. She stated Plaintiff had diabetes mellitus with evidence of vascular and neurologic complications and indicated his poorlycontrolled diabetes had resulted in peripheral neuropathy. Id. She also noted Plaintiff likely had some component of peripheral arterial disease. Id. However, a carotid procedure on October 12, 2012, showed no evidence of hemodynamically-significant carotid stenosis. Tr. at 341-43. On October 31, 2012, Plaintiff followed up with Dr. Davenport, who noted that the carotid artery studies were within normal limits and that Plaintiff had experienced no additional syncopal episodes. Tr. at 348. Dr. Davenport reviewed Plaintiff's blood sugar logs and noted that there was room for improvement, but acknowledged that Plaintiff continued to complain of nausea and weight loss. Id. Dr. Davenport indicated she suspected Plaintiff had autonomic neuropathy in additional to diabetes-related peripheral neuropathy. Id. She also suspected possible gastroparesis and recommended Plaintiff undergo upper gastrointestinal endoscopy. Id.

         Plaintiff presented to Gordon Early, M.D. ("Dr. Early"), for a consultative examination on December 13, 2012. Tr. at 272-74. Plaintiff indicated he was primarily applying for disability benefits because of right shoulder pain. Tr. at 272. He reported that he had developed numbness and tingling two to three years earlier and had lost approximately 70 pounds over the last year. Id. Dr. Early indicated he suspected Plaintiff had developed diabetes approximately five years earlier, around the time of the onset of nocturia, and that it had gone untreated until one year earlier. Id. Plaintiff indicated that he had difficulty with his balance and limited standing tolerance because of numbness and tingling in his feet. Id. He stated he was very depressed. Tr. at 273. Dr. Early observed Plaintiff to be 5' 5" tall and to weigh 174 pounds. Id. Plaintiff's blood pressure was elevated at 182/96. Id. He had good range of motion ("ROM") in his upper extremities, but some osteoarthritic changes in the distal joints of his hands. Id. His right shoulder abduction was reduced and he had one positive impingement finding. Id. Plaintiff had 2 crepitus in his bilateral knees. Id. His pulses were intact in his feet. Id. He had positive Romberg's test and 1 positive tandem gait. Tr. at 273-74. Dr. Early indicated Plaintiff had right shoulder impingement, but that the exam was not particularly impressive. Tr. at 274. He stated that Plaintiff's shoulder impingement would prevent him from working with his hands over shoulder level as a carpenter. Id. He assessed diabetes with peripheral neuropathy and ataxia and indicated Plaintiff "may have an element of autonomic neuropathy with gastropathy and orthostatic syncope." Id. He stated Plaintiff had significant depression that may be contributing to his weight loss. Id. An x-ray of Plaintiff's lumbosacral spine was normal. Tr. at 277.

         On January 10, 2013, state agency medical consultant Dale Van Slooten, M.D., assessed the following limitations as part of a physical residual functional capacity ("RFC") assessment: occasionally lift and/or carry 50 pounds; frequently lift and/or carry 25 pounds; stand and/or walk for a total of about six hours in an eight-hour workday; sit for a total of about six hours in an eight-hour workday; frequently climb ramps/stairs, stoop, kneel, and crawl; occasionally climb ladders/ropes/scaffolds and balance; frequently reach overhead with the right upper extremity; and avoid concentrated exposure to hazards. Tr. at 89-91.

         Plaintiff presented to Caleb Loring, IV, Psy. D. ("Dr. Loring"), for a mental status examination on January 24, 2013. Tr. at 278-80. He indicated to Dr. Loring that he was depressed because of his inability to find a job. Tr. at 278. He also indicated he had diabetes, high blood pressure, nerve damage in his feet, and degenerative disc disease. Id. He stated that pain in his feet prevented him from standing for long periods. Id. He indicated that he took Prozac for depression, which did not seem to relieve his symptoms. Tr. at 279. He stated he had taken Effexor in the past and that it was more effective, but was not covered by his current insurance. Id. Dr. Loring observed that Plaintiff maintained appropriate eye contact and was pleasant and cooperative. Id. He stated Plaintiff was "perhaps moderately depressed." Id. He indicated Plaintiff had normal speech, thought process, and thought content. Id. He stated Plaintiff did not have problems with concentration and was alert and oriented. Id. He estimated Plaintiff's intellectual functioning to be in the low-average range. Id. He stated Plaintiff's "physical problems appear to be the primary issues." Tr. at 280. He assessed anxiety disorder, not otherwise specified ("NOS") and mood disorder due to a general medical condition with major depressive features. Id.

         On January 24, 2013, Plaintiff followed up with Dr. Davenport at the request of his family members who were concerned that he was not taking care of himself. Tr. at 312. Plaintiff indicated his blood sugars were running high and that his eating patterns were erratic. Id. A review of symptoms revealed numbness and pain in Plaintiff's feet and poor balance. Id. Dr. Davenport assessed diabetes mellitus with neurologic complications and poor motivation for self-care; peripheral neuropathy with increased pain; depression, probably interfering with quality of life; subsided nausea; and hypertension with a labile component. Id. She reviewed Plaintiff's blood sugar log and adjusted his dosages of Metformin, Neurontin, and Prozac. Id. She recommended Plaintiff obtain counseling through the mental health center. Id.

         On February 5, 2013, Dr. Davenport indicated that Plaintiff had been unable to increase his dosage of Neurontin because his drug plan and pharmacy could not accommodate the new dose at the same price as his previous dose. Tr. at 282. She noted that Plaintiff felt fatigued and depressed. Id. She indicated she had recommended Plaintiff pursue counseling at the mental health center, but Plaintiff had failed to follow through. Id. Dr. Davenport indicated Plaintiff's blood pressure showed no orthostatic drop during the examination. Id. She stated Plaintiff's fatigue, depression, and erectile dysfunction were possibly aggravated by his use of a beta blocker. Id. Dr. Davenport noted that Plaintiff had multiple neurologic complications from diabetes, including peripheral neuropathy and suboptimal control of pain. Id.

         State agency consultant Samuel Goots, Ph. D. ("Dr. Goots"), completed a psychiatric review technique form ("PRTF") on February 8, 2013, and considered Listings 12.04 for affective disorders and 12.06 for anxiety related disorders. Tr. at 87-88. He assessed Plaintiff as having mild restriction of activities of daily living, mild difficulties in maintaining social functioning, and moderate difficulties in maintaining concentration, persistence, or pace. Tr. at 87. He indicated Plaintiff was limited to unskilled work. Tr. at 88. Dr. Goots also completed a mental RFC assessment and assessed Plaintiff as moderately limited in his abilities to understand, remember, and carry out detailed instructions. Tr. at 91-93.

         On February 27, 2013, Plaintiff presented to Dr. Davenport's office for a blood pressure check. Tr. at 303. He complained of depression and lower back pain. Id. He indicated antidepressant medication had not improved his depression and Gabapentin caused him to feel terrible and provided no relief. Id. Amanda Brown, NP ("Ms. Brown"), observed bilateral lower lumbar tenderness to palpation and depressed affect, but noted no other abnormalities. Tr. at 306. She prescribed an increased dose of Lisinopril and instructed Plaintiff to decrease his sodium intake and to monitor his blood pressure. Tr. at 307. Ms. Brown indicated Plaintiff should do no heavy lifting, bending, or stooping. Id.

         On March 14, 2013, Plaintiff followed up with Ms. Brown. Tr. at 295-99. He shared a blood pressure log that showed his blood pressure to vary from 93/70 to 176/77 mg/dL. Tr. at 295. He reported several episodes of dizziness when Lisinopril was increased, but noted that the dizziness had stopped. Id. Ms. Brown observed no abnormalities on examination. Tr. at 297-98.

         On March 19, 2013, state agency consultant Xanthia Harkness, Ph. D. ("Dr. Harkness"), reviewed the evidence and completed a PRTF. Tr. at 116-17. She considered Listings 12.04 and 12.06 and concluded that Plaintiff had mild restriction of activities of daily living, mild difficulties in maintaining social functioning, and moderate difficulties in maintain concentration, persistence, or pace. Id. Dr. Harkness indicated in a mental RFC assessment that Plaintiff had moderately limited abilities to understand, remember, and carry out detailed instructions. Tr. at 121-23.

         State agency medical consultant Seham El-Ibiary, M.D. ("Dr. El-Ibiary"), assessed Plaintiff's physical RFC on March 19, 2013, and 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; frequently push/pull with the bilateral lower extremities, reach overhead with the right arm, climb ramps/stairs, stoop, kneel, crouch, and crawl; occasionally climb ladders/ropes/scaffolds and balance; and avoid concentrated exposure to hazards. Tr. at 118-21.

         On June 6, 2013, Dr. Davenport indicated Plaintiff's blood sugar log showed him to have good control. Tr. at 401. Plaintiff complained of positional paresthesias in his hands that were consistent with carpal tunnel syndrome and dysesthesias in his feet that were consistent with peripheral neuropathy. Id. Plaintiff indicated he was unable to work outside because of dizziness and lightheadedness; could not use his hands to paint because of carpal tunnel syndrome; and could not clip his own toenails safely because of peripheral neuropathy. Id. Plaintiff's blood pressure was elevated. Id. A diabetic foot exam showed diminished pedal pulses bilaterally; decreased sensation; and slight trauma to the cuticle of the left great toe. Id. Dr. Davenport recommended Plaintiff use wrist splints on his bilateral hands and apply antibiotic ointment to the injured cuticle and a lesion on his skin. Id. She authorized Plaintiff to receive a disabled parking placard and indicated on the form that he had "a substantial limitation in the ability to walk due to an arthritic, neurological, or orthopedic condition" that was permanent. Tr. at 405, 410.

         Plaintiff followed up with Ms. Brown on June 27, 2013. Tr. at 397. He reported occasional lightheadedness on the increased dose of Lisinopril. Id. He indicated his blood pressure ranged from 86/60 to 154/106 and his blood sugar ranged from 90 to 177 mg/dL. Id. Ms. Brown observed no abnormalities on physical exam. Tr. at 398-99.

         On July 18, 2013, Plaintiff followed up with Ms. Brown. Tr. at 392. He denied dizziness, but complained of more stress and poor sleep. Id. Ms. Brown observed no abnormalities on examination. Tr. at 394. She refilled Plaintiff's medications and instructed him to continue to monitor his blood pressure. Tr. at 394-95.

         Plaintiff presented to Dr. Davenport with multiple complaints on September 24, 2013. Tr. at 383. He reported leg pain, foot pain, leg cramps, back pain, stiffness, depression, and inability to obtain medical assistance. Id. He complained of excessive sedation while taking a high dose of Gabapentin, but indicated he was unable to sleep at night because of worry. Id. Dr. Davenport indicated Plaintiff's blood sugars ranged from 119 to 187 mg/dL, but Plaintiff reported no hypoglycemia or recent fainting spells. Id. Dr. Davenport noted that Plaintiff cried intermittently and was unable to maintain eye contact during the examination. Id. A diabetic foot exam revealed diminished pulse in Plaintiff's bilateral feet, a callus on the tip of the right second toe, and peripheral neuropathy. Id. Dr. Davenport indicated she offered to adjust Plaintiff's dosage of Gabapentin, but he did not want for her to do so. Id. She offered to adjust the Prozac, but Plaintiff was afraid his pharmacy would charge too much. Id. She recommended Plaintiff visit the mental health clinic, but he stated that the mental health clinic told him he would need to go to the ER. Id. Plaintiff also declined a referral to physical therapy because he said he did not have transportation. Id.

         Plaintiff underwent a vascular lower extremities arterial duplex and lower arterial plethysmography procedure on October 3, 2013. Tr. at 353-55. The study revealed bilateral lower extremity atherosclerotic disease and mild flow reduction in the bilateral lower extremities. Tr. at 353. Dr. Davenport's note from the next day indicated that Plaintiff's peripheral arterial disease should not cause pain at rest and that Plaintiff should walk "as best he can to promote improved circulation in nearby arteries" and should treat the pain from neuropathy with Gabapentin. Tr. at 388.

         On January 7, 2014, Plaintiff complained to Dr. Davenport of foot pain related to neuropathy and vascular disease. Tr. at 377. He stated his pain occurred mostly at night, but indicated his balance was compromised and that he staggered at times. Id. Dr. Davenport encouraged Plaintiff to take ...


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