United States District Court, D. South Carolina
REPORT AND RECOMMENDATION
V. HODGES, Magistrate Judge.
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. Â§ 405(g) and Â§ 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.
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].
Plaintiff's Background and Medical History
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. Tr. at 31-32.
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
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
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.
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.
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
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.
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.
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
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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,
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.
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.
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.
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.
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