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") 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.
22, 2012, Plaintiff protectively filed applications for DIB
and SSI in which she alleged her disability began on February
28, 2012. Tr. at 102, 104, 207-12, and 213-20. Her
applications were denied initially and upon reconsideration.
Tr. at 147-51, 156-57, and 172-73. On March 6, 2014,
Plaintiff had a hearing before Administrative Law Judge
("ALJ") Edward T. Morriss. Tr. at 36-67 (Hr'g
Tr.). The ALJ issued an unfavorable decision on May 6, 2014,
finding that Plaintiff was not disabled within the meaning of
the Act. Tr. at 15-35. 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,
2015. [ECF No. 1].
Plaintiff's Background and Medical History
was 52 years old at the time of the hearing. Tr. at 39. She
completed the sixth grade. Id. Her past relevant
work ("PRW") was as a waitress, a hotel maid, a
personal attendant, and a cashier. Tr. at 82-83. She alleges
she has been unable to work since February 28, 2012. Tr. at
March 1, 2012, Plaintiff complained of rectal pain that
caused painful bowel movements and difficulty, sitting,
standing, and walking. Tr. at 317. She also endorsed pain in
her lower back and buttocks. Id. Jill Peterson, M.D.
("Dr. Peterson"), described Plaintiff as walking in
pain and sitting at an angle. Id. She noted external
hemorrhoids, but no fissures, erythema, or active bleeding.
presented to T. Chadwick Eustis, M.D. ("Dr.
Eustis"), on March 6, 2012, for an initial consultation
regarding anal pain. Tr. at 332. She complained that her pain
had become almost unbearable over the last several days.
Id. Dr. Eustis observed Plaintiff to have external
decompressed hemorrhoids on the right and anterior sides of
her rectum, as well as tenderness to palpation posteriorly
and on the left side of her rectum. Id. He noted his
examination was limited by Plaintiff's pain and anxiety.
Id. He diagnosed anal or rectal pain, external
hemorrhoids, anal fissure, anal spasm, adjustment disorder
with anxiety, and rectal bleeding. Id. He prescribed
medications and recommended further evaluation with a
colonoscopy and anoscopy. Id.
underwent the colonoscopy on March 7, 2012. Tr. at 338. It
showed internal and external hemorrhoids, a bleeding anal
fissure, and a polyp in the splenic flexure. Id. Dr.
Eustis recommended Plaintiff start a high fiber diet and
prescribed Ciprofloxacin, Metronidazole, and Miralax.
presented to the emergency room at Roper Hospital on April 8,
2012, with a complaint of pain in her tailbone, after
sustaining a fall on a boat dock. Tr. at 431. Plaintiff
demonstrated mild-to-moderate tenderness at L4-5 and
mild-to-moderate lumbosacral paravertebral spasm on both
sides of her low back. Tr. at 433. J. Jenkins, M.D.,
diagnosed a coccyx fracture. Id.
April 10, 2012, Plaintiff presented to St. James-Santee
Family Health Center ("SJSFHC") regarding her
broken coccyx. Tr. at 314. She reported pain and requested
additional pain medication. Id. The provider
prescribed Lortab and refilled Paroxetine and Metaprolol.
Id. He authorized Plaintiff to remain out of work
until April 23. Id.
followed up with Dr. Eustis on April 19, 2012. Tr. at 390.
She reported that the topical ointment had lessened her
symptoms, but that her anal fissure had not healed.
Id. She indicated she had additional pain that was
associated with a fracture to her coccyx. Id. Dr.
Eustis told her that she could continue the topical
treatments, pursue Botox injections into the internal
sphincter, or undergo lateral internal sphincterotomy.
Id. He warned her of a 10% chance of permanent
incontinence with the lateral internal sphincterotomy, but
indicated it was the option with the best success rate.
April 24, 2012, a pelvic ultrasound revealed small fibroids
within the myometrium and endometrial thickening. Tr. at 336.
presented to SJSFHC on May 4, 2012, to follow up on the
fracture to her coccyx. Tr. at 311. Dr. Peterson referred
Plaintiff to a gynecologist for vaginal bleeding; order a
lipid panel; and refilled ibuprofen for osteoarthritis in her
right hip. Id.
8, 2012, Plaintiff underwent chemical neurolysis of the
internal anal sphincter with Botox, posterior internal
hemorrhoidectomy, and bilateral pudendal nerve block. Tr. at
presented to Charleston Mental Health Center on May 17, 2012,
after being referred from SJSFHC for worsening depression and
an inability to regulate her emotions. Tr. at 355. James
Zukauskas, LPC ("Mr. Zukauskas"), indicated
Plaintiff was cooperative and participated in the session,
but had an extensive history of trauma and symptoms of
post-traumatic stress disorder ("PTSD").
Id. He scheduled Plaintiff for a visit with a
followed up with Mr. Zukauska for an initial clinical
assessment on May 22, 2012. Tr. at 356-60. She reported
worsened depression over the past year and endorsed symptoms
that included irritability, anger, isolation, sleep
disturbance, anhedonia, pessimism, guilt, feeling
overwhelmed, fluctuating appetite, and hopelessness. Tr. at
356. She denied suicidal ideations, homicidal ideations,
mania, and psychosis. Id. She indicated she was
sexually molested by an older brother from the ages of 11 to
13 and was married to an abusive husband for 17 years.
Id. She stated her older brother killed her husband
in 1992 and died in jail. Id. Plaintiff indicated
she experienced nightmares, hyperarousal, hypervigilance,
emotional dysregulation with numbing, and avoidance.
Id. Mr. Zukauska indicated Plaintiff had poor
judgment and acknowledged, but failed to understand her
problems. Tr. at 359. A mental status examination was
otherwise normal. Id. He diagnosed PTSD.
presented to William Carroll, M.D. ("Dr. Carroll"),
for hip and tailbone pain on May 23, 2012. Tr. at 370. She
complained of lower back pain that radiated to her buttocks,
right lateral hip pain that radiated to her lateral thigh,
and left heel pain. Id. Dr. Carroll observed
Plaintiff to have no specific tenderness in her lumbar spine;
a negative straight leg raise test; slight groin pain with
range of motion ("ROM") of her hip; tenderness to
palpation of the greater trochanter bursa; and a bump
associated with Haglund's deformity on her left heel. Tr.
at 370. X-rays of Plaintiff's lumbar spine showed
osteophytic spurring and slight narrowing consistent with
mild degenerative disc disease and x-rays of the right hip
were consistent with mild osteoarthritis. Id. X-rays
of her left knee indicated moderate degenerative changes. Tr.
at 409. Dr. Carroll administered a Depo-Medrol injection,
referred Plaintiff for physical therapy and to a foot
specialist, and instructed her to follow up in four weeks.
Tr. at 371.
24, 2012, Plaintiff reported nearly constant epigastric pain
that did not worsen with eating. Tr. at 309. She complained
of chest pain and tightness that caused her to wake during
the night. Id. She endorsed radiation of the pain to
her back and indicated her breathing felt strained.
Id. Jane Cooper, RN, FNP, observed Plaintiff to have
some pain to palpation in her upper epigastric region and to
be anxious. Id. She prescribed Omeprazole for
Plaintiff's epigastric symptoms and Klonopin for anxiety
and instructed Plaintiff to follow up with Dr. Peterson in
one week. Id.
reported improvement in her chest pain on May 30, 2012. Tr.
at 308. She reported epigastric cramps, pain in her lower
back and hips, and anal fissures. Id. Dr. Peterson
instructed Plaintiff to continue Omeprazole for epigastric
symptoms, to start Pravastatin for high triglycerides, and to
follow up with her gynecologist, gastroenterologist, and
presented to Jeffrey Armstrong, M.D. ("Dr.
Armstrong"), with a complaint of left heel pain on May
31, 2012. Tr. at 368. Dr. Armstrong observed Plaintiff to
have pain in her left foot with forced dorsiflexion/plantar
flexion and along her Achilles tendon. Id. He
indicated Plaintiff had discomfort on weight bearing and on
lateral compression at the insertion point of the Achilles
tendon. Id. He noted a large palpable bump to the
posterior aspect of Plaintiff's left heel that was tender
to palpation. Tr. at 369. Dr. Armstrong indicated an x-ray
showed a large posterior heel spur on the calcaneus.
Id. He diagnosed Achilles bursitis or tendinitis and
calcaneal spur. Id. Plaintiff opted to proceed with
surgery to remove the spur and reattach the Achilles tendon.
telephoned Charleston Mental Health Center on June 1, 2012,
and reported increased anxiety because of her medical
appointments. Tr. at 353. Mr. Zukauskas discussed relaxation
and calming methods with Plaintiff. Id.
6, 2012, Plaintiff reported occasional right shoulder pain
and bilateral numbness and tingling in her hands. Tr. at 365.
Plaintiff indicated the steroid injection had failed to
decrease her pain and that she was unable to continue with
physical therapy because her insurance provider denied
coverage. Tr. at 366. Dr. Carroll encouraged Plaintiff to
continue physical therapy for right greater trochanteric
bursitis and referred her for an MRI of her lumbar spine.
14, 2012, an MRI of Plaintiff's lumbar spine showed facet
arthropathy that was greatest at L5-S1 and mild multilevel
degenerative disc disease with no central canal or foraminal
narrowing. Tr. at 361.
followed up with Dr. Carroll on June 20, 2012, and reported
occasional numbness and tingling in her bilateral legs. Tr.
at 363. Dr. Carroll reviewed the MRI findings, prescribed
Lortab for Plaintiff's joint pain, and referred her to a
presented to psychiatrist Scott D. Christie, M.D. ("Dr.
Christie"), on June 21, 2012. Tr. at 381-82. She
reported increased symptoms of anxiety, flashbacks, and
traumatic dreams. Tr. at 381. Dr. Christie assessed PTSD,
major depressive disorder, and panic disorder without
agoraphobia. Tr. at 381-82. He prescribed Klonopin,
Trazodone, and Effexor XR and indicated he would consider
adding Prazosin. Tr. at 382.
presented to Jennifer K. Murphy, M.D. ("Dr.
Murphy"), for a rheumatology consultation on June 27,
2012. Tr. at 413-16. She complained of a 10-year history of
joint pain. Tr. at 413. She reported dry mouth, dyspnea,
headache, paresthesia, and muscle weakness. Tr. at 414-15.
She complained of diffuse lower back pain to palpation, but a
straight leg raising test was negative. Tr. at 415. Dr.
Murphy indicated Plaintiff had pain with palpation and ROM of
her bilateral shoulders and positive patellar apprehension
tests in her bilateral knees. Id. Plaintiff
demonstrated 14 positive fibromyalgia tender points.
Id. Dr. Murphy assessed polyarthralgia, fatigue, low
back pain, and unspecified myalgia and myositis. Id.
She indicated Plaintiff's examination was not consistent
with a diagnosis of rheumatoid arthritis and that Plaintiff
likely had a combination of fibromyalgia and degenerative
changes. Id. However, she noted that fibromyalgia
was a "diagnosis of exclusion" and ordered lab work
to be certain that testing did not indicate another
diagnosis. Tr. at 415-16. She prescribed Neurontin and
instructed Plaintiff to walk every other day and to attempt
to lose weight. Tr. at 416.
underwent debridement of her left Achilles tendon and removal
of the posterior heel spur on June 28, 2012. Tr. at 393-94.
She presented to Dr. Carroll for her first postoperative
visit on July 5, 2012. Tr. at 464. She expressed no
complaints and indicated her pain was improving. Id.
Dr. Carroll observed Plaintiff to have some tenuous skin at
the inferior aspect of the wound and prescribed Keflex.
followed up with Dr. Murphy on July 11, 2012. Tr. at 422. She
indicated she fell on her right knee the day before and
complained of pain in her low back, right hip, and right
knee. Id. Dr. Murphy administered a Depo-Medrol
injection to Plaintiff's right knee. Id. She
recommended stretching and strengthening exercises for
Plaintiff's low back and prescribed Neurontin for
followed up with Dr. Christie on July 19, 2012. Tr. at
456-57. Dr. Christie noted that Plaintiff indicated she had
recently had heel surgery and was using a wheelchair. Tr. at
456. Plaintiff stated the surgery had increased her stress
and caused her to have several breakdowns over the last
month. Id. She endorsed increased appetite and
increased cigarette consumption. Id. Dr. Christie
prescribed Wellbutrin to address Plaintiff's increased
eating and smoking and increased Clonazepam for anxiety. Tr.
26, 2012, Plaintiff indicated to Dr. Armstrong that her foot
felt fine, but was still swollen. Tr. at 462. She admitted to
Dr. Armstrong that she had continued to smoke almost two
packs of cigarettes per day. Id. Dr. Armstrong
observed mild edema and bruising to the left foot and
discomfort with palpation at the surgical site, but Plaintiff
had no signs of infection, normal sensation, and good ROM.
Id. He removed Plaintiff's sutures, placed her
in a cam walker, and instructed her to gradually increase her
activity level. Id.
September 4, 2012, state agency consultant Olin Hamrick, Jr.,
Ph. D. ("Dr. Hamrick"), reviewed the record and
completed a psychiatric review technique form
("PRTF"). Tr. at 75-76. He considered Listings
12.04 for affective disorder and 12.06 for anxiety-related
disorders and found Plaintiff to have mild restriction of
activities of daily living ("ADLs"), moderate
difficulties in maintaining social functioning, and moderate
difficulties in maintaining concentration, persistence, or
pace. Tr. at 75. He found that Plaintiff appeared "to
have no more than Moderate limitations of work-related
functions due to her MH SX related to anxiety and
depression" and retained "the mental capacity to
perform simple unskilled work of the type she has done in the
past w/i the limits of her alleged physical conditions."
Tr. at 76. Dr. Hamrick subsequently completed a mental
residual functional capacity ("RFC") assessment in
which he indicated Plaintiff was moderately limited with
regard to the following abilities: to understand and remember
detailed instructions; to maintain attention and
concentration for extended periods; to perform activities
within a schedule, maintain regular attendance, and be
punctual within customary tolerances; to complete a normal
workday and workweek without interruptions from
psychologically-based symptoms; to perform at a consistent
pace without an unreasonable number and length of rest
periods; to interact appropriately with the general public;
to respond appropriately to changes in the work setting; and
to set realistic goals or make plans independently of others.
Tr. at 80-82. He concluded Plaintiff was "able to
understand and remember simple instructions but could not
understand and remember detailed instructions"; was
"able to carry out short and simple instructions but not
detailed instructions"; was "able to maintain
concentration and attention for periods of at least 2
hours"; "would perform best in situations
that" did "not require on-going interaction with
the public"; and was "able to be aware of normal
hazards and take appropriate precautions." Tr. at 82.
agency medical consultant William Cain, M.D. ("Dr.
Cain"), addressed Plaintiff's physical RFC on
September 5, 2012. Tr. at 77-80. He indicated Plaintiff could
occasionally lift and/or carry 20 pounds; frequently lift
and/or carry 10 pounds; stand and/or walk for about six hours
in an eight-hour workday; sit for about six hours in an
eight-hour workday; occasionally climb ramps/stairs, balance,
stoop, kneel, crouch, and crawl; never climb
ladders/ropes/scaffolds; frequently reach overhead with her
bilateral upper extremities; and must avoid all exposure to
complained to Dr. Murphy of pain in her hands, knees, and low
back on August 29, 2012. Tr. at 473. Dr. Murphy prescribed an
increased dose of Gabapentin and 100 milligrams of Tramadol.
Id. She noted Plaintiff had received no relief from
injections and referred her for physical therapy.
September 24, 2012, an MRI of Plaintiff's right knee
showed intrasubstance degenerative signal in the medial
meniscus, without a discrete tear; advanced patellofemoral
osteoarthritic changes laterally with seven millimeters of
lateral patellar subluxation; mild cartilage thinning and
irregularity in the medial and lateral femorotibial
compartments with some partial-thickness cartilage
fibrillation of the medial femoral condyle; and a small
ganglion cyst in the proximal tibia near the
acromioclavicular ligament insertion. Tr. at 476.
September 26, 2012, Plaintiff complained to Dr. Murphy of
increased pain throughout her body. Tr. at 469. She indicated
she had attempted to walk, but that walking increased her
pain. Id. Dr. Murphy noted that Plaintiff's
insurance would not cover physical therapy and that she
appeared depressed. Id. She observed Plaintiff to
have pain on palpation and ROM of her bilateral knees, mild
diffuse back tenderness to palpation, and several tender
fibromyalgia points. Tr. at 471. She instructed Plaintiff to
continue quadriceps strengthening exercises and regular
exercise with stretching and strengthening of her low back.
Id. She indicated Plaintiff should continue taking
Tramadol and Neurontin and should use ice and heat as needed.
Id. Dr. Murphy stated Plaintiff's depression was
more severe than she generally addressed in her practice and
that Plaintiff should follow up with her therapist for a
possible medication change. Id.
presented to SJSFHC on October 19, 2012, with complaints of
pain in her back, right knee, and hips. Tr. at 482. Walter
Bonner, M.D. ("Dr. Bonner"), observed Plaintiff to
have tenderness in her right knee and trochanteric bursa, but
also noted the knee was stable and had no effusion and that
her hips extended well. Tr. at 482. He administered a
Methylprednisolone Acetate injection. Tr. at 538.
October 24, 2012, an x-ray of Plaintiff's lumbar spine
indicated stable mild lumbar spondylosis and
atheroscelorosis. Tr. at 448.
reported pain in her hands and shoulders and urge
incontinence on November 7, 2012. Tr. at 480. Dr. Peterson
noted that Plaintiff was walking with a cane. Id.
She increased Plaintiff's dosage of Pravastatin for
elevated cholesterol and increased her dosage of Neurontin
for fibromyalgia. Id.
November 16, 2012, Dr. Peterson completed an application for
Plaintiff to receive a disabled placard and license plate and
issued a prescription for the same because of ...