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Gibson v. Colvin

United States District Court, D. South Carolina

December 13, 2016

Vernanza C. Gibson, Plaintiff,
v.
Carolyn W. Colvin, Acting Commissioner of Social Security Administration, Defendant.

          ORDER

          Shiva V. Hodges, United States Magistrate Judge

         This appeal from a denial of social security benefits is before the court for a final order pursuant to 28 U.S.C. § 636(c), Local Civ. Rule 73.01(B) (D.S.C.), and the order of the Honorable Bruce Howe Hendricks dated July 14, 2016, referring this matter for disposition. [ECF No. 9]. The parties consented to the undersigned United States Magistrate Judge's disposition of this case, with any appeal directly to the Fourth Circuit Court of Appeals. [ECF No. 8].

         Plaintiff files this appeal pursuant to 42 U.S.C. § 405(g) of the Social Security Act (“the Act”) to obtain judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying the 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 court reverses and remands the Commissioner's decision for further proceedings as set forth herein.

         I. Relevant Background

         A. Procedural History

         On April 18, 2012, Plaintiff protectively filed applications for DIB and SSI in which he alleged his disability began on January 1, 2009. Tr. at 98, 99, 237-43, and 244- 49. His applications were denied initially and upon reconsideration. Tr. at 142-46, 147- 51, 157-59, and 160-62. On April 17, 2014, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Peggy McFadden-Elmore. Tr. at 30-61 (Hr'g Tr.). The ALJ issued an unfavorable decision on October 29, 2014, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 8-29. 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 March 1, 2016. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 47 years old at the time of the hearing. Tr. at 34. He was promoted to the tenth grade, but did not complete it. Tr. at 36. His past relevant work (“PRW”) was as a welder. Tr. at 37. He alleges he has been unable to work since January 1, 2009. Tr. at 237 and 244.

         2. Medical History

         Plaintiff presented to the emergency room (“ER”) at Palmetto Health Baptist (“PHB”) on August 1, 2009. Tr. at 335. He reported fleeting thoughts of suicide, but was laughing and smiling. Id. Ricky A. Ladd, M.D. (“Dr. Ladd”), assessed alcohol intoxication and depression and referred Plaintiff to the Lexington/Richland Alcohol and Drug Abuse Council (“LRADAC”). Tr. at 336.

         Plaintiff again presented to the ER at PHB on April 8, 2010, with symptoms of pancreatitis. Tr. at 340. He indicated he continued to drink alcohol, despite a history of pancreatitis. Id. Hubert D. Sammons, M.D. (“Dr. Sammons”), urged Plaintiff to stop drinking and smoking cigarettes and prescribed Phenergan and Vicodin. Tr. at 341.

         Plaintiff presented to the ER at Palmetto Health Richland (“PHR”) complaining of left foot pain on June 11, 2010. Tr. at 343. Jeremy Ryan Smith, M.D. (“Dr. Smith”), indicated Plaintiff had a history of coronary artery disease and myocardial infarction. Id. He observed Plaintiff to have some tenderness over the third and fourth metatarsals of his left foot. Tr. at 344. Dr. Smith assessed a chronic healing scar and advised Plaintiff to follow up with his primary care doctor. Id.

         On July 10, 2010, Plaintiff returned to PHR with worsening of the left foot wound. Tr. at 351. He stated he felt like something was inside the wound and had “seen what had appeared to be worms crawling out” of it. Id. Jeter P. Taylor, III, M.D. (“Dr. Taylor”), observed the wound to have some mild erythema surrounding it and to have larvae within it. Tr. at 352. Catherine L. Loflin, M.D. (“Dr. Loflin”), performed a shallow debridement procedure. Tr. at 355-56. She indicated Plaintiff should change his wound dressings twice a day and should use postoperative shoes, but would not require vascular follow up. Tr. at 356.

         Plaintiff was hospitalized at Morris Village Alcohol and Drug Addiction Treatment Center (“Morris Village”) from August 31 through October 4, 2011. Tr. at 389. He indicated he had started drinking at the age of 12 and that his drinking had become problematic at age 30. Id. He indicated he had a history of alcohol-related seizures and had recently developed distortions of his face, mouth, and eyes. Id. Upon discharge, Plaintiff was encouraged to attend Alcoholics Anonymous Meetings, to obtain a sponsor, to seek individual or group therapy, to secure a group home, and to get a job and practice responsible behaviors. Tr. at 402.

         Plaintiff visited Pamela Carlton, Ph. D. (“Dr. Carlton”), for an adult psychological evaluation on August 28, 2012. Tr. at 361-68. He reported symptoms of depression and described a history of abuse and tragic deaths within his family. Tr. at 362. He denied problems getting along with coworkers and supervisors. Tr. at 364. He stated he enjoyed making people laugh, but had no friends and preferred to keep to himself. Id. After interviewing claimant and assessing his intelligence quotient (“IQ”) on the Fourth Edition of the Wechsler Adult Intelligence Scale (“WAIS-IV”) and his mathematical and reading levels on the Fourth Edition of the Wide Range Achievement Test (“WRAT-4”), Dr. Carlton concluded that he appeared to have mild difficulties handling typical ADLs; would likely have difficulty concentrating and persisting at a task for more than an hour; and would likely require assistance to handle funds.[1] Tr. at 367. However, she noted Plaintiff had no limitations in his ability to function in a socially-appropriate manner in a work setting. Id. She assessed alcohol dependence in remission; cognitive disorder, not otherwise specified (“NOS”); and post-traumatic stress disorder (“PTSD”). Id.

         Plaintiff presented to Damon Daniels, M.D. (“Dr. Daniels”), for a consultative examination on August 30, 2012. Tr. at 370-73. He reported having sustained a heart attack nine years earlier. Tr. at 370. He endorsed progressive shortness of breath and chest pain with exertion. Id. He reported a history of chronic abdominal pain and pancreatitis. Id. He endorsed a history of alcohol abuse, but indicated he had been clean since his hospitalization at Morris Village, aside from a brief relapse. Id. He reported tremors and cramps in his feet. Tr. at 371. He stated he smoked half a pack of cigarettes daily and had last consumed alcohol six months earlier. Id. Plaintiff weighed 136 pounds and was 5' 11 ½” tall. Id. He had 1 pitting edema in his bilateral lower extremities. Id. He moved from the chair to the exam table without difficulty, but was unable to tandem or heel-to-toe walk and had difficulty squatting. Id. He had normal range of motion in his cervical spine, lumbar spine, shoulders, elbows, wrists, knees, hips, and ankles. Tr. at 372. He had 4/5 grip strength and intact fine and gross manipulation bilaterally. Id. He had 4/5 strength in the proximal and distal muscle groups of his upper extremities and 3/5 strength in the proximal and distal muscle groups of his lower extremities. Id. He had diminished sensation to light touch and pinprick on the dorsal and plantar surfaces of his bilateral feet. Id. He scored 22 of out 30 points on the Mini-Mental State Exam (“MMSE”) and demonstrated deficits in attention, calculation, recall, and language. Id. Dr. Daniels assessed coronary artery disease, alcohol abuse, chronic pancreatitis, memory loss, and alcoholic neuropathy. Id. He stated Plaintiff's “primary issues are that of his balance and gait.” Tr. at 373.

         On September 4, 2012, Jody Lenrow, Psy. D. (“Dr. Lenrow”), completed a psychiatric review technique form (“PRTF”). Tr. at 67-71. She considered Listings 12.02 for organic mental disorders, 12.04 for affective disorders, 12.06 for anxiety-related disorders, and 12.09 for substance addiction disorders and determined that Plaintiff had moderate restriction of activities of daily living (“ADLs”), mild difficulties in maintaining social functioning, and moderate difficulties in maintaining concentration, persistence, or pace. Tr. at 67-68. Dr. Lenrow wrote the following:

CL has long hx of alcohol dependence as well as PTSD, BIF[2]/cognitive d/o NOS, and hx of mood px associated w alcohol. He reports he is no longer consuming alcohol. CE notes IQ scores ranging 65-74 with consistent achv scores. Functionally, he has a long work hx, including welder, landscaper, and meat cutter/stocker. He has no px socially, mild to moderate px with ADL's, but some moderate px with CP&P. He retains the ability to perform simple repetitive work related tasks.

Tr. at 69. She also indicated she found Plaintiff's statements about his impairments and functional limitations to be partially credible because his unusual answers during the consultative examination raised the possibility that he might not have been putting forth adequate effort. Tr. at 70. She cited Plaintiff's work history and daily activities and concluded that he was likely “functioning at the BIF level” and would likely have problems with written instructions and keeping up pace with his coworkers. Tr. at 70-71.

         However, she concluded Plaintiff was capable of performing simple, repetitive tasks. Tr. at 71. She found that Plaintiff was moderately limited with respect to the following mental abilities: to understand and remember detailed instructions; to carry out 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 sustain an ordinary routine without special supervision; 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 respond appropriately to changes in the work setting; and to set realistic goals or make plans independently of others. Tr. at 73-75. Timothy Laskis, Ph. D. (“Dr. Laskis”), indicated the same degree of limitation and restrictions in a PRTF and mental RFC evaluation on February 21, 2013. Tr. at 106-08 and 113-15.

         Plaintiff presented to the ER at Providence Hospital on September 10, 2012, with a complaint of left foot pain. Tr. at 375. Cale Michael Davis, M.D. (“Dr. Davis”), observed Plaintiff to have soft tissue tenderness and erythema in his left foot. Tr. at 378. He diagnosed early cellulitis and prescribed an antibiotic. Id.

         On September 26, 2012, state agency consultant Lindsey Crumlin, M.D. (“Dr. Crumlin”), reviewed the evidence and assessed Plaintiff's physical residual functional capacity (“RFC”). Tr. at 72-73. She indicated Plaintiff was capable of performing work with the following limitations: 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 for a total of about six hours in an eight-hour workday; occasionally climb ramps and stairs, balance, stoop, kneel, crouch, and crawl; and never climb ladders, ropes, or scaffolds. Id. Darla Mullaney, M.D. (“Dr. Mullaney”), assessed the same physical RFC on February 21, 2013. Tr. at 111-13.

         Plaintiff presented to Kim E. Davis, D.O. (“Dr. Davis”), to establish care on October 29, 2012. Tr. at 415-22. He complained of a wound on his left foot that had failed to heal, bilateral foot numbness, chest pain, shortness of breath, dyspnea on exertion, orthopnea, and vitiligo. Tr. at 416. Dr. Davis debrided and cleaned a six-centimeter wound to Plaintiff's left foot and referred him for a deep debridement procedure. Tr. at 419. She prescribed Coreg and instructed Plaintiff to obtain it through Well Vista. Tr. at 420.

         On November 5, 2012, Plaintiff underwent surgical wound exploration and excision of a two-centimeter left foot abscess. Tr. at 409. He followed up with Dr. Davis on November 21, 2012. Tr. at 423. He reported his left foot wound was feeling much better. Id. He complained of paresthesias in his bilateral distal toes. Tr. at 424. Dr. Davis debrided some necrotic tissue at the base of Plaintiff's wound. Tr. at 425. She refilled Plaintiff's prescription for Doxycycline for two more weeks and instructed him to continue using wet-to-dry dressings. Tr. at 423. She noted Plaintiff had not started Coreg because he had neglected to apply for Well Vista. Tr. at 424. She referred Plaintiff to a cardiologist to address his complaints of chest pain, shortness of breath, orthopnea, and dyspnea on exertion. Id.

         On November 29, 2012, Plaintiff reported having sustained a fall and injured his left side on the prior day. Tr. at 429. Dr. Davis noted that Plaintiff had not been taking his antibiotic medication, despite the fact that it was available for free at Publix and was not taking Coreg because he had not completed the paperwork for Well Vista. Tr. at 429 and 430. Plaintiff informed Dr. Davis that he was not taking aspirin because his family members would not lend him a dollar to purchase it. Tr. at 430. Dr. Davis debrided Plaintiff's left foot wound and changed his dressing. Tr. at 431. She noted Plaintiff's sensation was diminished to pinprick in his bilateral distal toes. Id.

         Plaintiff followed up with Dr. Davis on January 16, 2013. Tr. at 434. He reported he was unable to obtain his prescribed medications and indicated Doxycycline was no longer free at Publix. Id. However, Dr. Davis noted that Plaintiff filled his prescription for Percocet and continued to drink alcohol. Id. Plaintiff complained of paresthesias in his bilateral feet. Id. Dr. Davis observed Plaintiff's left foot wound to be “[m]uch improved over previous.” Tr. at 436.

         Plaintiff presented to the ER at Providence Hospital on April 8, 2014, complaining of abdominal pain, nausea, and vomiting. Tr. at 447. He stated he developed symptoms after having consumed alcohol four days earlier. Tr. at 450. Joshua Philip Baird, M.D. (“Dr. Baird”), diagnosed acute pancreatitis. Tr. at 453. Georges T. Postic, M.D. (“Dr. Postic”), discovered a gastric mass, but indicated it was likely benign. Tr. at 456.

         C. The Administrative Proceedings

         1. The Administrative Hearing

         a. Plaintiff's Testimony

         At the hearing on April 17, 2014, Plaintiff testified he worked as a welder at CMC Steel Fabricators. Tr. at 37. He indicated the work was placed in front of him and he operated the welding equipment. Tr. at 47. He stated he left the job because the plant shut down. Tr. at 37. He denied having worked or collected unemployment benefits since January 1, 2009. Id.

         Plaintiff testified that he had recently been hospitalized for pancreatitis. Tr. at 41. He described his pancreatitis as causing pain and cramping and indicated his symptoms occurred nearly every other day and were exacerbated by bending down. Tr. at 49. He endorsed pain in his feet and his back. Tr. at 45. He endorsed problems with concentrating and completing tasks. Tr. at 46. He stated his mind often wandered. Id. He indicated he experienced hallucinations approximately twice a month. Tr. at 47. He stated his right hand was shaky. Tr. at 47-48. He indicated he had numbness and sharp pain in his bilateral feet. Tr. at 48. He testified he had sustained some falls and had blackouts or fainting spells two to three times per month. Tr. at 48 and 50.

         Plaintiff testified that his driver's test had been administered orally. Tr. at 49. He denied having the ability to read the questions on the driver's examination. Id. He indicated he could perform ...


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