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Tiller v. Colvin

United States District Court, D. South Carolina, Florence Division

December 8, 2016

MONROE J. TILLER, Plaintiff,
v.
CAROLYN W. COLVIN, Commissioner of Social Security; Defendant.

          REPORT AND RECOMMENDATION

          THOMAS E. ROGERS, III UNITED STATES MAGISTRATE JUDGE

         This is an action brought pursuant to Section 205(g) of the Social Security Act, as amended, 42 U.S.C. Section 405(g), to obtain judicial review of a “final decision” of the Commissioner of Social Security, denying Plaintiff's claim for disability and disability insurance benefits (DIB). The only issues before the Court are whether the findings of fact are supported by substantial evidence and whether proper legal standards have been applied.

         I. RELEVANT BACKGROUND

         A. Procedural History

         Plaintiff filed an application for DIB on May 8, 2012, alleging inability to work since May 11, 2012. (Tr. 81-82). His claims were denied initially and upon reconsideration. Thereafter, Plaintiff filed a request for a hearing. A hearing was held on July 1, 2014, at which time Plaintiff and a vocational expert (VE) testified. (Tr. 30). The Administrative Law Judge (ALJ) issued an unfavorable decision on September 23, 2014, finding that Plaintiff was not disabled within the meaning of the Act. (Tr. 9-22). Plaintiff filed a request for review of the ALJ's decision, which the Appeals Council denied on October 14, 2015, making the ALJ's decision the Commissioner's final decision. (Tr. 1-4). Plaintiff filed this action on December 10, 2015.

         B. Plaintiff's Background and Medical History

         1. Introductory Facts

         Plaintiff was born January 8, 1961, and was fifty-one years old at the time of the alleged onset. (Tr. 148). Plaintiff completed his education through twelfth grade and has past relevant work experience as a textile supervisor, plumber's helper, and truck driver. (Tr. 180). Plaintiff alleges disability due to kidney carcinoma, diabetes type 1, thyroid, high blood pressure, stress, anxiety, high cholesterol, spinal stenosis, heart stints, vision problems, and back pain. (Tr. 81, 179).

         2. Medical Records and Opinions

         On May 2, 2011, Plaintiff had a heart attack and had stints placed. (Tr. 264-282, 286-87). In July 2011, Plaintiff was seen by James R. Story, M.D. of Cardiology Consultants, P.A.. Dr. Story noted that Plaintiff was stable on medication, his EKG was normal, and he was scheduled for a follow-up in a year. (Tr. 283-84).

         On April 13, 2012, Plaintiff was seen by Carol A. Kooistra, M.D. for lower back pain. Dr. Kooistra's diagnosis was lumbar spondylosis and polyneuropathy. (Tr. 380-81). On May 2, 2012, Dr. Kooistra noted a lumbar MRI showed moderate to severe spinal stenosis at ¶ 34 and a mass on kidney. Dr. Kooistra noted uncertainty as to whether the back pain was caused by the kidney cancer or the spine issues. (Tr. 382).

         In August 2012, Plaintiff had surgery to remove his left kidney. (Tr. 305-79). On August 27, 2012, Plaintiff was seen by Robert G. Britanisky, M.D. for a post-kidney operation office visit. Dr. Britanisky noted that Plaintiff was doing well and denied any significant pain or discomfort. Dr. Britanisky stated: “He can go back to work at the 6-week mark.” (Tr. 401).

         On October 9, 2012, Plaintiff had a consultative examination by Jeremy Burns, O.D. regarding Plaintiff's eyes. The examination noted: 20/20 vision with correction in right eye, 20/200 vision with correction in left eye, cataract, dermatocholosis, poor vision in left eye, no diabetic retinopathy, and no working conditions to be avoided. (Tr. 434-41).

         On October 31, 2012, Plaintiff was seen by Kameron Klosterman, M.D. of Pacolet Family Medicine. Dr. Klosterman noted no chest pains, no medication side effects, no symptoms of hypothyroidism, and compliance with hypothyroid medications. Dr. Klosterman noted that Plaintiff poorly controlled his diabetes and needed to keep a diet, exercise, and sugar log. (Tr. 444-58).

         On November 25, 2012, Plaintiff had a mental consultative examination with Caleb Loring, IV, Psy. D.. The examination noted: situational stress, no thought process problems, no significant social problems, and no concentration or memory problems. Plaintiff stated the medications helped and he had never been hospitalized for psychiatric reasons. Loring stated that Plaintiff walked abnormally and seemed to be in a moderate degree of pain. Loring concluded that Plaintiff would be capable of working at a job with public contact. (Tr. 459-61).

         Records show history of cataract surgery on January 19, 2013. (Tr. 492). On January 21, 2013, a lumbar spine MRI performed due to low back pain revealed L3-4 severe spinal stenosis and L4-5 moderate spinal stenosis. (Tr. 462-65). Plaintiff was still experiencing back pain in February 2013. (Tr. 472). On February 13, 2013, Dr. Kooistra referred Plaintiff to a surgeon due to spinal stenosis. (Tr. 479-80).

         On February 19, 2013, Dr. Britanisky noted Plaintiff's complaints of chronic back pain, numbness, and tingling. (Tr. 492-95).

         On February 23, 2013, Plaintiff was seen by Robert Westrol, M.D., Pain Management Associates. Plaintiff complained of moderate to severe lower back pain for eight months and the pain was exacerbated by stairs, walking, and lifting. Dr. Westrol noted moderate edema of lower legs and low back restricted in flexion, extension, and side bending. (Tr. 475-78).

         On February 26, 2013, Dr. Westrol performed venous duplex bilateral screening exam and Plaintiff was positive for deep venous insufficiency. (Tr. 507-08). On March 19, 2013, Dr. Westrol noted Plaintiff had pain in lower back that worsened by stairs, walking, and lifting. (Tr. 509).

         On March 29, 2013, Plaintiff had facet steroid injections into his spine by Jeffrey P. Smith, M.D. (Tr. 502).

         On April 15, 2013, Plaintiff was seen by Timothy R. Monroe, M.D. with symptoms of low back pain, leg pain, and swelling. Dr. Monroe planned decompression and instrumented fusion surgery. (Tr. 498-99). On May 30, 2013, Plaintiff had decompression and fusion surgery. (Tr. 513-17).

         On November 4, 2013, a scan of Plaintiff's right kidney revealed a soft tissue nodule that was stable but had first appeared on August scan. (Tr. 522, 526). On November 14, 2013, Dr. Kooistra noted that Plaintiff's back pain was “way better than prior to surgery, ” but that he still had issues on his right side and was still using prescription pain medication. (Tr. 530-31).

         On December 2, 2013, Plaintiff was seen by Dr. Monroe for six-month post-operation follow-up. Dr. Monroe noted that Plaintiff had shown improvement in activity level and symptoms and his musculoskeletal assessment was normal in motor and strength. (Tr. 537-38).

         On March 5, 2014, Dr. Smith noted Plaintiff had pain for years in back, legs, and hips that was aggravated by daily activities. Dr. Smith stated surgery helped but Plaintiff was unable to return to his previous job. Dr. Smith noted: “Pain well controlled on current medication regimen.

         Medications allow patient to stay active.” (Tr. 582-83).

         On March 13, 2014, Plaintiff was seen by Dr. Kooistra “for his chronic pain attributed to polyneuropathy and lumbar spine disease.” Plaintiff was prescribed Norco through his pain management doctor, and Dr. Kooistra noted Plaintiff ...


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