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Jackson v. Colvin

United States District Court, D. South Carolina

May 31, 2016

Claudine Elizabeth Jackson, 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 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.

         I. Relevant Background

         A. Procedural History

         On May 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].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff 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 43.

         2. Medical History

         On 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. Id.

         Plaintiff 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.

         Plaintiff 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. Id.

         Plaintiff 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.

         On 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.

         Plaintiff 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. Id.

         On April 24, 2012, a pelvic ultrasound revealed small fibroids within the myometrium and endometrial thickening. Tr. at 336.

         Plaintiff 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.

         On May 8, 2012, Plaintiff underwent chemical neurolysis of the internal anal sphincter with Botox, posterior internal hemorrhoidectomy, and bilateral pudendal nerve block. Tr. at 395.

         Plaintiff 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 psychiatrist. Id.

         Plaintiff 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. Id.

         Plaintiff 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.

         On May 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.

         Plaintiff 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 orthopedist. Id.

         Plaintiff 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. Id.

         Plaintiff 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.

         On June 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. Id.

         On June 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.

         Plaintiff 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 rheumatologist. Id.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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. Id.

         Plaintiff 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 fibromyalgia. Id.

         Plaintiff 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. at 457.

         On July 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.

         On 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.

         State 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 hazards. Id.

         Plaintiff 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. Id.

         On 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.

         On 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.

         Plaintiff 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.

         On October 24, 2012, an x-ray of Plaintiff's lumbar spine indicated stable mild lumbar spondylosis and atheroscelorosis. Tr. at 448.

         Plaintiff 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.

         On 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 ...


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