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 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.
August 10, 2011, Plaintiff protectively filed an application
for DIB in which she alleged her disability began on March
18, 2010. Tr. at 149-52. Her application was denied initially
and upon reconsideration. Tr. at 136-39, 141-42. On September
23, 2013, Plaintiff had a hearing before Administrative Law
Judge ("ALJ") John S. Lamb. Tr. at 32-74 (Hr'g
Tr.). The ALJ issued an unfavorable decision on March 14,
2014, finding that Plaintiff was not disabled within the
meaning of the Act. Tr. at 11-31. 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 1-5. Thereafter,
Plaintiff brought this action seeking judicial review of the
Commissioner's decision in a complaint filed on September
4, 2015. [ECF No. 1].
Plaintiff's Background and Medical History
was 46 years old on her date last insured ("DLI")
for DIB. Tr. at 39. She completed the eleventh
grade and obtained a certificate in cosmetology. Id.
Her past relevant work ("PRW") was as a
cosmetologist, a veterinary assistant, a filter assembler,
and a deli worker. Tr. at 62. She alleges she has been unable
to work since March 18, 2010. Tr. at 35.
spirometry report dated December 9, 2009, indicated Plaintiff
had severe pulmonary obstruction. Tr. at 244. A chest x-ray
revealed no significant abnormality, but noted degenerative
spurs in Plaintiff's lumbar spine. Tr. at 245.
January 4, 2010, Plaintiff presented to neurologist John
Absher, M.D. ("Dr. Absher"), for nerve conduction
studies ("NCS"). She complained pain in her
bilateral lower extremities that had been ongoing for over a
year and that increased after walking and during the night.
Tr. at 241. She also endorsed occasional numbness and
tingling in her bilateral feet, frequent cramps in her calf
muscles, and low back pain with radiating symptoms into her
bilateral lower extremities. Id. Dr. Absher reported
the NCS were normal. Tr. at 242.
presented to Michael Zeager, M.D. ("Dr. Zeager"),
on January 8, 2010, and reported a marked increase in
bilateral lower extremity pain. Tr. at 233. She stated her
chronic bronchitis had improved. Id. Dr. Zeager
observed Plaintiff to have tender lumbar spinous processes;
tenderness to palpation in her hamstrings, quadriceps, and
calves; and decreased Achilles reflexes bilaterally.
Id. He assessed sciatica and worsening
myalgia/myositis. Id. He prescribed 200 milligrams
of Lyrica and 50 milligrams of Savella, each to be taken
twice a day. Tr. at 233-34.
January 11, 2010, Dr. Zeager wrote that he had treated
Plaintiff for fibromyalgia and depression and described
Plaintiff's treatment history and limitations. Tr. at
January 15, 2010, Plaintiff reported to Dr. Zeager that she
had started experiencing syncopal episodes one month earlier
and had three episodes over the last week. Tr. at 231. She
described weakness and feeling "weird" before
losing consciousness. Id. She indicated the episodes
had occurred while she was standing, walking, and sitting and
had lasted for as long as 10 minutes. Id. Dr. Zeager
prescribed a Holter monitor and decreased Plaintiff's
dosage of Savella from 100 milligrams to 50 milligrams.
Id. The Holter monitor showed sinus tachycardia. Tr.
presented to Dr. Absher on February 3, 2010, for
electromyography ("EMG"). Tr. at 229. She
complained of pain in her bilateral legs and indicated she
had difficulty sleeping because she could not keep her legs
still at night. Id. Dr. Absher indicated the EMG of
Plaintiff's right leg was normal and that she may benefit
from treatment for restless leg syndrome. Id.
followed up with Dr. Zeager on February 8, 2010, to discuss
recent test results. Tr. at 227. Dr. Zeager indicated that
Plaintiff's depression was unchanged and that she
experienced anxiety, but noted she was presently off all
medications. Id. He stated Plaintiff's recent
EMG and NCS were normal. Id. He noted that a
neurologist prescribed Mirapex for Plaintiff's complaint
of sciatica, but that she discontinued the medication because
it caused nausea and vomiting. Id. Dr. Zeager
observed Plaintiff to have trapezius tenderness and decreased
Achilles reflexes bilaterally, but noted no other
abnormalities on examination. Id. He prescribed
Alprazolam for her depression and Savella, Lyrica, and
Nortriptyline for myalgia/myositis. Tr. at 227-28.
March 31, 2010, Plaintiff indicated to Dr. Zeager that she
did well with her current medication regimen for
myalgia/myositis, but that she required an average of six to
eight Lortab daily to control her pain. Tr. at 225. Dr.
Zeager observed Plaintiff to have tenderness in her trapezius
and lumbar muscles. Id. He discontinued
Plaintiff's prescription for Lortab and prescribed
Hydrocodone-Acetaminophen ("Norco") 10-325
milligrams. Id. He dispensed 180 pills and
instructed Plaintiff to take one to two tablets every four to
six hours. Id.
reported stable back pain on May 18, 2010. Tr. at 223. She
complained of chronic fatigue, cramping in the soles of her
feet, and ongoing numbness, tingling, and cramping in her
legs. Id. She indicated her leg and foot pain was
unimproved with Nortriptyline. Id. Dr. Zeager
observed Plaintiff to demonstrate tenderness in her trapezius
muscles, but to have normal range of motion
("ROM"), stability, tone, sensation, and strength.
Id. He diagnosed vitamin D deficiency and prescribed
25 milligrams of Nortriptyline for limb pain. Id.
10, 2010, Plaintiff reported to Dr. Zeager that she had
recently fainted after experiencing a coughing spell. Tr. at
219. Dr. Zeager noted that an electrocardiogram
("EKG") was normal. Tr. at 220. He prescribed
medication for Plaintiff's cough and nasal congestion.
September 30, 2010, Plaintiff presented to Dr. Zeager with a
cough and other upper respiratory symptoms that began three
days earlier. Tr. at 216. Dr. Zeager diagnosed sinusitis and
bronchitis, prescribed medications, and instructed Plaintiff
to follow up in two weeks if her symptoms persisted. Tr. at
216-17. Plaintiff followed up with Dr. Zeager for medication
refills on October 15, 2010. Tr. at 214. Dr. Zeager diagnosed
sinusitis and bronchitis and administered a flu vaccine.
January 14, 2011, Plaintiff reported to Dr. Zeager that she
had recently experienced an episode of syncope, after
returning from a grocery shopping trip and attempting to walk
around her car. Tr. at 211. She indicated she had also
experienced a brief period of syncope after coughing for an
extended period. Id. She reported being disoriented
for a few minutes after each episode. Id. Plaintiff
complained of gradually worsening diffuse myalgia-related
pain. Id. Dr. Zeager observed her to have some
trapezius tenderness, but noted no other abnormalities.
Id. He prescribed 50 milligrams of Savella and
refilled Plaintiff's prescriptions for
Hydrocodone-Acetaminophen 10-325 milligrams and Lyrica 200
milligrams. Id. He noted Plaintiff's EKG was
normal and indicated that he suspected Plaintiff's
syncope was related to vasodepressor and postmicturition
etiologies. Tr. at 212.
presented to Dr. Zeager for medication refills on February 1,
2011. Tr. at 209. She reported numbness and tingling in her
hands and feet and stated she had been dropping items since
her last visit. Id. She complained of left lateral
thigh pain and a sensation that her left lower extremity was
"giving way." Id. Plaintiff endorsed
anhedonia, anxiety, increased pain, and sleep disturbance.
Id. Dr. Zeager observed trochanteric bursa
tenderness in Plaintiff's left lower extremity, but noted
no other abnormalities on examination. Id. He
injected Plaintiff's left trochanteric bursa with a
combination of Marcaine and Kenalog. Id. He reported
Tinel's and Phalen's tests were negative in
Plaintiff's bilateral wrists. Id. He described
Plaintiff as having a mildly depressed affect and noted that
her depression and myalgia/myositis had worsened.
Id. He prescribed Savella for myalgia/myositis. Tr.
March 15, 2011, Plaintiff reported that her left hip pain had
resolved after she received the injection at her last visit.
Tr. at 207. She continued to report pain in her legs and
numbness and occasional throbbing in her hands. Id.
She indicated that over the past three weeks, she had
experienced cycles in which she was unable to sleep for two
to three days and then crashed for a day-and-a-half.
Id. Dr. Zeager observed Plaintiff to have increased
tone and tenderness in her bilateral trapezius muscles.
Id. He prescribed Savella for myalgia/myositis,
Nortriptyline and Citalopram for limb pain, and Zolpidem
Tartrate for insomnia. Tr. at 208.
March 30, 2011, Plaintiff complained of increased hip pain
that was related to cool and wet weather over the past two
months. Tr. at 205. She reported that her insomnia had
improved with the addition of Nortriptyline, but that she
continued to experience numbness and tingling in her
extremities. Id. Dr. Zeager observed Plaintiff to
have trochanteric bursa tenderness, but to have full ROM and
normal stability in her hip. Id. He injected
Plaintiff's hip with a combination of Marcaine and
Kenalog. Id. He indicated Plaintiff's
myalgia/myositis was improved and discontinued her
prescription for Citalopram. Tr. at 205-06. He prescribed
Pennsaid Transdermal Solution for bursitis and increased
Plaintiff's dosage of Nortriptyline from 25 milligrams to
50 milligrams for insomnia. Tr. at 205-06.
reported numbness in her hands and feet, headaches, and
swelling on April 26, 2011. Tr. at 203. She described a
sudden onset of headache and dizziness after dinner on April
24. Id. She indicated that she had improved with
Savella, but continued to experience severe disabling pain
diffusely over her back and in all four extremities.
Id. Dr. Zeager noted that Plaintiff's current
symptoms were likely the result of serotonergic syndrome that
was related to Nortriptyline and worsening depression.
Id. He assessed depressive disorder and referred
Plaintiff for psychiatric treatment. Id. He
discontinued Nortriptyline and prescribed Savella for
paresthesias. Tr. at 203-04.
presented to psychiatrist Jeffrey Smith, M.D. ("Dr.
Smith"), on May 4, 2011. Tr. at 258. She indicated that
she had a history of depression and had been hospitalized at
age 14, after being molested by her father and brother.
Id. She reported symptoms that included depressed
mood; decreased energy, motivation, and interest; difficulty
concentrating; feelings of sadness and hopelessness; frequent
crying spells; sleep loss/hypersomnolence; loss of libido;
appetite changes with weight gain; social withdrawal; and
inactivity. Id. Plaintiff indicated she was anxious,
jittery, constantly worried, on edge, unable to relax, and
overwhelmed. Id. She endorsed a history of panic
attacks, but denied any recent attacks. Id. She
stated she was easily angered, irritable, impulsive, and had
racing thoughts. Id. Dr. Smith observed that
Plaintiff's affect was "a bit flat" and that
her mood was "a bit depressed and anhedonic." Tr.
at 259. He described Plaintiff as pleasant during the
interview and noted that she was not agitated; did not
exhibit mania or psychosis; did not endorse suicidal or
homicidal ideations; had no gross cognitive deficits; had
normal concentration and focus; had average insight and
judgment; demonstrated normal gait, dress, hygiene, and
speech; had local thought processes; and was goal-oriented
toward treatment. Id. He assessed type II bipolar
disorder and fibromyalgia. Id. He discontinued
Celexa and Nortriptyline and prescribed Seroquel for mood and
26, 2011, Plaintiff presented to Joseph Friddle, P.A.
("Mr. Friddle"), who was supervised by Dr. Smith.
Tr. at 261. She reported that her sleep had improved and that
she had noticed mild improvement in her mood and
irritability. Id. She continued to endorse chronic
pain and stated she was concerned about her lack of energy
and weight gain. Id. Mr. Friddle noted that
Plaintiff's affect was brighter and that her mood was
more euthymic, but that she still appeared "a bit
fatigued." Id. He increased Seroquel to 200
milligrams, prescribed Phentermine for energy and weight
loss, and instructed Plaintiff to continue her other
reported to Rhett McCraw, M.D. ("Dr. McCraw"), on
May 31, 2011, for possible sleep apnea. Tr. at 256. She
indicated that she felt drowsy while watching television and
often struggled to stay awake. Id. She indicated she
had fallen asleep in church. Id. She stated she
awoke frequently during the night and had difficulty falling
asleep and going back to sleep after being awakened.
Id. Dr. McCraw assessed obstructive sleep apnea and
insomnia. Tr. at 257.
22, 2011, Dr. McCraw indicated that the sleep study revealed
mild sleep apnea. Tr. at 254. He ordered an auto-titrating
CPAP machine and recommended Plaintiff follow up in a few
weeks to discuss her use of the CPAP machine. Id.
23, 2011, Plaintiff reported to Mr. Friddle that she had
difficulty initiating sleep; was irritable and agitated; and
experienced low energy and fatigue during the day. Tr. at
262. Mr. Friddle observed that Plaintiff appeared frustrated
and fatigued and was more anhedonic. Id. He
discontinued Phentermine and Savella, added Pristiq for
depression, and continued Plaintiff's other medications.
28, 2011, Plaintiff complained to Dr. Zeager that the pain in
her lateral hips and legs had returned. Tr. at 201. She also
reported some paresthesias in her hands, after switching from
Savella to Pristiq. Id. Dr. Zeager noted that
Plaintiff was moderately obese and had gained three pounds
since her last visit. Id. He observed Plaintiff to
have tenderness and increased tone in her trapezius muscles.
Id. He also noted trochanteric bursa tenderness.
Id. Plaintiff's examination was otherwise
normal. Id. Dr. Zeager assessed hip bursitis and
myalgia/myositis. Id. He discontinued Pennsaid
Transdermal Solution, prescribed Meloxicam, and refilled
Lyrica and Hydrocodone. Tr. at 201-02.
14, 2011, Plaintiff reported that her sleep had improved,
after she started CPAP for sleep apnea and that her mood and
energy had improved on Pristiq. Tr. at 263. Mr. Friddle noted
that Plaintiff still appeared "a bit fatigued, "
but had a brighter affect and a euthymic mood. Id.
He continued Plaintiff's medications. Id.
August 4, 2011, Plaintiff reported to Dr. McCraw that she was
sleeping better and feeling more energetic during the day.
Tr. at 251. She indicated she was pleased with the
improvement in her sleep and desired to continue using the
CPAP machine. Id.
reported being under more stress and experiencing interrupted
sleep on August 25, 2011. Tr. at 264. She stated she was
caring for her daughter and granddaughter because her
daughter had experienced pregnancy-related complications.
Id. Plaintiff endorsed increased joint and
fibromyalgia-related pain since stopping Savella and
requested that she be allowed to resume the medication.
Id. Mr. Friddle noted that Plaintiff had a bright
affect, a euthymic mood, was in good spirits, and was coping
with stress well, but still appeared a bit fatigued.
Id. He prescribed Savella and continued
Plaintiff's other medications. Id.
August 25, 2011, Plaintiff indicated to Dr. Zeager that her
chronic fatigue had not improved on her current medication
regimen. Tr. at 300. She informed him that her blood pressure
was 90/50 in the pulmonologist's office. Id. Dr.
Zeager noted Plaintiff's insomnia and chronic bronchitis
were improved and her myalgia/myositis was stable on her
current regimen. Id. He indicated Plaintiff had
gained eight pounds since her last visit. Id. He
observed Plaintiff to have 2 tenderness over the trapezius
and paraspinous muscles without appreciable spasm, but noted
no other abnormalities on examination. Id.
September 8, 2011, state agency consultant Seham El-Ibiary
("Dr. El-Ibiary"), reviewed the record and assessed
Plaintiff's physical impairments as nonsevere. Tr. at
122-23. Dale Van Slooten, M.D. ("Dr. Van Slooten"),
similarly assessed Plaintiff's physical impairments as
nonsevere on October 31, 2011. Tr. at 131.
September 9, 2011, state agency medical consultant Xanthia
Harkness, Ph. D. ("Dr. Harkness"), reviewed the
record and completed a psychiatric review technique form
("PRTF"). Tr. at 123. Dr. Harkness considering
Listing 12.04 for affective disorders, but found that there
was insufficient evidence "to substantiate the presence
of a disorder" or to rate Plaintiff's restrictions
in activities of daily living ("ADLs"), social
functioning, or concentration, persistence, or pace.
Id. She stated "[t]he allegation of manic
depression appears to be somewhat credible, " but noted
she could not make a medical decision because "there is
no function information at the DLI." Id. Martha
Durham, Ph. D. ("Dr. Durham"), reached the same
conclusion on October 31, 2011. Tr. at 132.
reported increased frequency of lightheadedness with changes
of position, brief palpitations, shortness of breath,
fatigue, and poor exercise tolerance on September 15, 2011.
Tr. at 297. Dr. Zeager referred Plaintiff for lab work.
November 14, 2011, Plaintiff complained of being frustrated
by her inability to do things she used to do. Tr. at 278. She
reported increased stress and interrupted sleep. Id.
Mr. Friddle described Plaintiff as having a bright affect and
euthymic mood. Id. However, he increased Pristiq to
100 milligrams for depression. Id.
November 21, 2011, Plaintiff complained of acute lumbar pain.
Tr. at 294. She indicated the pain was worse with deep
breaths and trunk ROM. Id. Plaintiff's gait was
slow, cautious, and stiff. Id. Michael S. Atkinson,
M.D. ("Dr. Atkinson"), observed Plaintiff to be
tender to palpation over the left upper to midlumbar
lumbosacral paraspinous muscles. Tr. at 293. He indicated
Plaintiff experienced discomfort on general trunk ROM
testing, but had normal strength and tone. Id. Dr.
Atkinson diagnosed a sprain/strain and prescribed Tizanidine
reported being under more stress on December 12, 2011. Tr. at
277. She endorsed interrupted sleep and stated she was caring
for her daughter and granddaughter. Id. Mr. Friddle
described Plaintiff's mood as "fairly stable and
euthymic." Id. Plaintiff reported being less
emotional and having slightly more energy since her dosage of
Pristiq was increased. Id.
Zeager described Plaintiff's bipolar affective disorder,
myalgia/myositis, and palpitations as well-controlled on May
7, 2012. Tr. at 292. However, he noted Plaintiff continued to
have some hand tremors that were not completely controlled on
the medication. Id. He described Plaintiff's
gait as slow, cautious, and stiff. Id. Dr. Zeager
observed no abnormalities on examination and described
Plaintiff's mood and affect as normal. Id.
16, 2012, Plaintiff reported worsened mood as a result of
family stressors. Tr. at 276. She indicated she was taking
200 milligrams of Seroquel XR instead of 300 milligrams and
was unable to take Xanax because of its sedative effect.
Id. She stated she was more irritable, agitated, and
obsessive. Id. Mr. Friddle discontinued Xanax and
prescribed Ativan. Id.
complained to Dr. Zeager of blood pressure problems on July
2, 2012. Tr. at 291. She indicated she was experiencing dizzy
spells and numbness in her hands and feet. Id. She
stated she had difficulty breathing outdoors and had noticed
lightheadedness when changing positions. Id. Dr.
Zeager observed that Plaintiff ambulated with a slow,
cautious, and stiff gait. Id. He described her mood
and affect as normal. Id.
complained of sweats, swelling, chest pain, low blood
pressure, and fainting spells on July 16, 2012. Tr. at 290.
Dr. Zeager described Plaintiff's gait as slow, cautious,
and stiff. Id. He assessed orthostatic hypotension
and referred Plaintiff to a cardiologist. Id.
20, 2012, an echocardiograph ("echo") showed
moderate aortic regurgitation, but no other abnormalities.
Tr. at 268. On July 24, 2012, stress myocardial perfusion
imaging was normal. Tr. at 269. Plaintiff underwent a carotid
ultrasound on July 26, 2012, after reporting dizziness. Tr.
at 266. The ultrasound revealed normal antegrade flow in the
bilateral vertebral arteries, luminal plaque with no
significant disease in the bilateral ...