United States District Court, D. South Carolina
V. HODGES UNITED STATES MAGISTRATE JUDGE.
pro se 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 Margaret B. Seymour dated April 12,
2016, referring this matter for disposition. [ECF No. 12].
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
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 affirms the Commissioner's
January 15, 2013, Plaintiff protectively filed applications
for DIB and SSI in which she alleged her disability began on
October 20, 2012. Tr. at 81, 82, 221-28, and 229-37. Her
applications were denied initially and upon reconsideration.
Tr. at 149-53, 157-58, and 159-60. On September 9, 2014,
Plaintiff had a hearing before Administrative Law Judge
(“ALJ”) Carl B. Watson. Tr. at 32-56 (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 9-31. 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 1-7. Thereafter,
Plaintiff brought this action seeking judicial review of the
Commissioner's decision in a complaint filed on April 8,
2016. [ECF No. 1].
Plaintiff's Background and Medical History
was 53 years old at the time of the hearing. Tr. at 36. She
obtained a bachelor's degree. Id. Her past
relevant work (“PRW”) was as a security guard and
a personal banker. Tr. at 52-53. She alleges she has been
unable to work since October 20, 2012. Tr. at 221 and 229.
was admitted to Marymount Medical Center on October 19, 2007,
after presenting to an urgent care facility with bilateral
leg edema. Tr. at 377. She reported chest pain and a two-week
history of shortness of breath that was worsened by exertion.
Id. An echocardiogram (“echo”) showed
Plaintiff to have normal left ventricular systolic function;
normal wall motion; an ejection fraction of 55%; no
pericardial effusion; no interatrial septum shunt; no mitral
valve prolapse; a normal aorta; trace mitral regurgitation;
and mild tricuspid regurgitation. Tr. at 389. Cardiologist
Rachna Garg, M.D. (“Dr. Garg”), examined
Plaintiff and reviewed diagnostic studies on October 20,
2007. Tr. at 380-82. He ruled out myocardial infarction, but
recommended Plaintiff undergo a Persantine stress test and
venous duplex study. Tr. at 382.
presented to cardiologist Israel D. Garcia, M.D. (“Dr.
Garcia”), on January 6, 2011, with complaints of chest
pain, shortness of breath, and leg edema. Tr. at 440. Dr.
Garcia ordered an echo, a cardiolite stress test, a 24-hour
Holter monitor, a carotid ultrasound, and multiple blood
tests. Tr. at 442. On January 10, 2011, the Holter monitor
report showed sinus rhythm and a few premature ventricular
and premature atrial contractions. Tr. at 438-39. On January
14, 2011, an echo showed Plaintiff to have an ejection
fraction of 69%; normal bilateral ventricular size and
function; no significant valve disease; and mild mitral and
tricuspid regurgitation. Tr. at 435-37. On January 20, 2011,
Plaintiff's nuclear stress test was abnormal with
myocardial ischemia. Tr. at 431- 32. On February 3, 2011, a
cardiac catheterization showed normal coronary arteries and
normal left ventricular function. Tr. at 446-47. Plaintiff
followed up with Dr. Garcia on February 17, 2011. Tr. at
428-30. Dr. Garcia ruled out acute diastolic heart failure,
indicated Plaintiff's essential hypertension and chest
pain had improved, and assessed her history of congestive
heart failure as stable. Tr. at 430. On February 23, 2011, a
carotid ultrasound showed Plaintiff to have normal arteries
with no stenosis. Tr. at 420-21.
presented for an initial physical therapy evaluation on March
16, 2011. Tr. at 452. She complained of pain in her bilateral
hips and lumbar spine and plantar fasciitis in her left foot.
Id. Physical therapist Dustin R. Barrett (“Mr.
Barrett”), observed Plaintiff to present with a limp
and increased lordosis in her lumbar region. Id.
Plaintiff stated she felt better with movement and worse when
she stood still. Id. She reported being active and
walking five miles on three days per week. Id. Mr.
Barrett recommended skilled rehabilitative therapy and a home
exercise program. Tr. at 454.
received treatment in March and April 2011 for high myopia
and increased ocular pressure. Tr. at 470-76. On August 17,
2011, she indicated her visual acuity was good, but continued
to complain that she had difficulty reading fine print and
that objects at a distance appeared blurry. Tr. at 747.
was discharged from physical therapy on May 12, 2011,
secondary to noncompliance with attendance. Tr. at 967-68.
August 18, 2011, Dr. Garcia indicated Plaintiff was stable
from a cardiovascular standpoint. Tr. at 517.
reported improved visual acuity on September 2, 2011. Tr. at
August 3, 2012, Plaintiff reported to Jimmie Ryals, APN
(“Mr. Rials”), that stress and anxiety were
causing her heart rate to increase. Tr. at 626. She indicated
she had chronic stress and anxiety, but that it had increased
over the prior two-week period. Id. Mr. Rials
observed Plaintiff to be alert; oriented to time, place, and
person; and anxious. Tr. at 627. He assessed palpitations and
anxiety disorder, not otherwise specified
(“NOS”), prescribed Buspirone, and referred
Plaintiff for an electrocardiogram (“EKG”).
October 15, 2012, Plaintiff presented to Kayla Norman, APN
(“Ms. Norman”), with a one-week history of lower
back pain that had begun after her employer kicked her chair.
Tr. at 550. Ms. Norman noted Plaintiff demonstrated
tenderness to palpation and spasm in her lower lumbar spine,
but had full range of motion (“ROM”) and normal
gait, balance, motor strength, and sensation. Tr. at 551. She
prescribed Flexeril, Naproxen, and Prednisone and referred
Plaintiff for x-rays. Id.
reported her pain had improved on October 17, 2012. Tr. at
548. Ms. Norman indicated Plaintiff had full ROM in her
spine, but muscle spasms and tenderness to palpation in her
lower lumbar spine. Tr. at 549.
December 3, 2012, Plaintiff presented to Amanda Moorhouse,
APN (“Ms. Moorhouse”), with complaints of pain in
her left knee, weakness in her hips, and popping in her head,
neck, and lower back. Tr. at 546. Ms. Moorhouse observed
Plaintiff to have full, but painful ROM of her spine; no
edema; no deformities; intact pedal pulses; decreased ROM on
flexion and extension of the neck; bilateral sacroiliac joint
tenderness; full ROM of the bilateral lower extremities; and
intact sensation and pedal pulses. Tr. at 547.
December 19, 2012, magnetic resonance imaging
(“MRI”) of Plaintiff's cervical spine showed
multilevel degenerative changes. Tr. at 534. It also
indicated a moderate disc protrusion associated with
osteophyte formation at ¶ 5-6 that resulted in moderate
central canal stenosis and moderate-to-severe right-sided
exit foraminal narrowing. Id. An MRI of
Plaintiff's lumbar spine indicated mild facet joint
degenerative changes, but no evidence of any significant
bulge or herniation. Tr. at 535. An MRI of Plaintiff's
thoracic spine was negative. Tr. at 639.
followed up with Ms. Moorhouse to discuss the MRI results on
December 28, 2012. Tr. at 544. Ms. Moorhouse observed
Plaintiff to have full, but painful ROM of her spine; no
edema; decreased ROM on flexion and extension of her neck;
bilateral sacroiliac joint tenderness; full ROM of her
bilateral lower extremities; and intact sensation and pedal
pulses. Id. She referred Plaintiff to a
followed up with Ms. Norman on February 4, 2013, for allergic
rhinitis. Tr. at 540. She requested that her prescription for
Lasix be refilled. Id. Ms. Norman indicated
Plaintiff had no sign of infection. Tr. at 541. She refilled
Lasix for edema. Id.
presented to East Tennessee Brain and Spine Center for an
assessment on January 22, 2013. Tr. at 654. She reported that
she had begun to experience neck stiffness in August and had
developed occasional fleeting pain into her right shoulder.
Id. She denied paresthesias in her hands and gait
disturbance. Id. Will Beringer, D.O. (“Dr.
Beringer”), diagnosed cervical spondylosis. Tr. at 655.
He indicated Plaintiff did not show evidence of a fixed
cervical radiculopathy. Id. He noted that she had
low back pain, but no sciatic symptoms and a normal thoracic
MRI. Id. He informed Plaintiff that she had
“nothing dangerous in the cervical spine” and
referred her to physical therapy for traction and
strengthening exercises. Id.
presented to Juduan Alison, M.D. (“Dr. Allison”),
on February 5, 2013, with complaints of pressure behind her
eyes and blurred vision. Tr. at 523. Dr. Alison indicated
Plaintiff's right acuity without glasses was 20/20 and
her left acuity without glasses was 20/25. Tr. at 525. He
assessed glaucoma, pseudophakia, and posterior vitreous
detachment in both eyes and instructed Plaintiff to follow up
in four months. Id.
February 28, 2013, Plaintiff informed physical therapist
Theresa Huff (“Ms. Huff”), that she felt like
physical therapy was aggravating her pain and visual
disturbances. Tr. at 675. Ms. Huff indicated Plaintiff
“did not seem to give full effort” during manual
muscle testing. Tr. at 676. She referred Plaintiff back to
Dr. Beringer for further assessment of her pain complaints.
March 4, 2013, state agency medical consultant Thomas Thrush,
M.D. (“Dr. Thrush”), assessed Plaintiff's
physical residual functional capacity (“RFC”).
Tr. at 65-67. He indicated Plaintiff had the following
limitations: occasionally lift and/or carry 50 pounds;
frequently lift and/or carry 25 pounds; stand and/or walk for
about six hours in an eight-hour workday; sit for about six
hours in an eight-hour workday; and reach overhead with the
bilateral upper extremities no more than frequently.
Id. State agency psychological consultant Andrew
Phay, Ph. D. (“Dr. Phay”), indicated Plaintiff
had failed to establish any medically-determinable mental
impairment. Tr. at 64.
March 5, 2013, Dr. Beringer noted that Plaintiff had some
spondylotic problems at ¶ 5-6 and C6-7 that were
“mild at best.” Tr. at 670. Plaintiff informed
Dr. Beringer that her neck pain had worsened since she had
been injured in a car accident on February 1, 2013,
that she was hardly able to move her neck. Id. Dr.
Beringer observed Plaintiff to have very limited ROM of her
neck and to be tender over the posterior cervical regional,
but to have good strength in her arms. Tr. at 671. He placed
Plaintiff in a cervical collar and referred her for a
computed tomography (“CT”) scan. Id. The
CT scan indicated minor cervical spondylosis at ¶ 5-6
and asymmetrical facet arthropathy on the left at ¶ 4-5,
but no acute injury. Tr. at 696.
March 20, 2013, Plaintiff reported neck pain that
“throbs like a toothache.” Tr. at 944. Dr.
Beringer indicated Plaintiff's CT scan showed some minor
spondylosis at ¶ 5-6, but no evidence of a fracture or
subluxation. Tr. at 945. He ordered flexion and extension
x-rays of Plaintiff's neck and indicated they did not
show any significant ligamentous injury. Tr. at 946. He
stated Plaintiff did not require the cervical collar and
should resume physical therapy. Id. He indicated he
would consider administering injections if Plaintiff's
physical therapy was ineffective. Id.
March 29, 2013, Plaintiff indicated she was using a cervical
collar because the vibration of walking aggravated her neck
pain. Tr. at 663. She stated she was unable to move her head
to a neutral position. Id. She also complained that
she had pressure in her head and eyes, shooting pain into her
right hip, and was unable to walk straight. Tr. at 663. Dr.
Beringer observed Plaintiff to have decreased cervical and
bilateral upper extremity ROM and decreased strength. Tr. at
664. He noted that Plaintiff did not appear to provide full
effort. Tr. at 665.
April 18, 2013, Plaintiff sought treatment for neck pain and
reported that Dr. Beringer had discharged her from his
practice. Tr. at 871. Steven Gardner, P.A. (“Mr.
Gardner”), observed Plaintiff to have decreased ROM and
decreased effort when he assessed the ROM of her neck. Tr. at
presented to Johnson City Medical Center on April 27, 2013,
for abdominal pain and rectal bleeding. Tr. at 683. She was
diagnosed with gastrointestinal bleeding and a urinary tract
infection. Tr. at 679.
presented to Jomar Roberts I, M.D. (“Dr.
Roberts”), for a comprehensive orthopedic examination
on June 1, 2013. Tr. at 702. She reported constant cervical
pain that she rated as a nine on a 10-point scale.
Id. She denied bowel and bladder incontinence, but
reported leg weakness that had caused her to fall roughly 20
times over the past year. Id. She stated her neck
pain was exacerbated by a car accident that occurred in
February 2013. Id. She indicated she had last worked
in a call center in September 2012, but stated she did not
leave the job because of her health. Id. Dr. Roberts
observed Plaintiff to ambulate with a normal gait; to have
normal grip strength; to have normal ROM of the lumbar spine,
shoulders, elbows, forearms, wrists, hips, knees, and ankles;
to have lateral flexion and bilateral rotation of the
cervical spine reduced to 10 degrees; negative straight-leg
raising test; normal abilities to walk on heels and toes, to
squat, and to perform heel-to-toe tandem gait.; normal mental
status; 20/40 visual acuity on the right and 20/70 visual
acuity on the left, without glasses; 5/5 motor strength in
all muscle groups; intact sensation; and normal reflexes. Tr.
at 704-05. He assessed cervicalgia, but indicated Plaintiff
gave “deliberate poor effort through ROM portion of
cervical exam.” Tr. at 705.
24, 2013, state agency medical consultant Irene Richardson,
M.D. (“Dr. Richardson”), assessed Plaintiff's
RFC. Tr. at 111-14. She indicated the following limitations:
occasionally lift and/or carry 50 pounds; frequently lift
and/or carry 25 pounds; stand and/or walk for about six hours
in an eight-hour workday; sit for about six hours in an
eight-hour workday; no more than frequently lifting overhead
with the bilateral upper extremities; and restricted from
work requiring full visual fields for function and safety.
28, 2013, state agency psychological consultant Manhal
Wieland, Ph. D. (“Dr. Wieland”), noted that
Plaintiff repeatedly denied depression and anxiety and did
not allege any mental impairments on her initial or
reconsideration applications. Tr. at 110. He concluded there
was no evidence for any medically-determinable mental
presented to Richard Young, M.D. (“Dr. Young”),
with urinary urgency and leakage on July 24, 2013. Tr. at
900-04. She denied back pain and stated she did not know the
source of her incontinence. Tr. at 900. Plaintiff indicated
she experienced urinary frequency every two hours and needed
to use the restroom two to three times during the night.
Id. Dr. Young prescribed Vesicare. Tr. at 903.
was admitted to McLeod Loris/Seacoast Hospital on August 6,
2013, after presenting with chest pain. Tr. at 752.
Plaintiff's chest x-ray showed a mildly enlarged cardiac
silhouette, but no acute findings. Tr. at 754. Her EKG was
normal, aside from episodes of sinus bradycardia in the 50s.
Id. Nathan Almeida, M.D. (“Dr.
Almeida”), recommended an exercise nuclear stress test
and an echo. Id. Both the stress test and the echo
showed normal results. Tr. at 760. Plaintiff was discharged
on August 8, 2013, with diagnoses of chest pain,
hypertension, hypothyroidism, and bradycardia. Id.
August 14, 2013, Plaintiff reported to Dr. Young that she had
only taken one dose of Vesicare. Tr. at 907. Dr. Young
continued Plaintiff's prescription and instructed her to
follow up in one month. Id.
followed up with Dr. Almeida on August 28, 2013. Tr. at 976.
She reported a couple of episodes of retrosternal chest
pressure per week. Id. She complained of excessive
daytime sleepiness and fatigue and inadequate sleep quality.
Id. Dr. Almeida observed no abnormalities on
examination. Tr. at 976-77. He noted Plaintiff had symptoms
of obstructive sleep apnea and referred her for a sleep
study. Tr. at 977.
September 18, 2013, Plaintiff reported that Vesicare provided
some relief, but that she continued to wear three to four
thin pads per day. Tr. at 910. Dr. Young continued her
treatment and instructed her to follow up in six months. Tr.
November 13, 2013, an esophagogastroduodenoscopy
(“EGD”) showed erosion and erythema in the antrum
and was consistent with gastritis. Tr. at 881 and 887- 88.
Although mucosa was consistent with Barrett's
esophagitis, a biopsy was negative. Id. A
colonoscopy indicated mild diverticulosis with several
diverticula and non-bleeding internal hemorrhoids.
November 21, 2013, Dr. Almeida observed Plaintiff to have
mildly decreased ROM in her upper and lower extremities, but
no other abnormalities. Tr. at 973-74. He stated Plaintiff
had atypical chest pain that was likely related to
gastroesophageal reflux disease (“GERD”). Tr. at
974. He indicated Plaintiff's blood pressure was
well-controlled on low-dose Lisinopril and that her lipids
were at their goal. Id. He noted Plaintiff had good
aerobic functional capacity, as demonstrated by a recent
stress study. Id. He stated a recent sleep study was
negative for sleep apnea. Id. Dr. Almeida encouraged
Plaintiff to continue regular aerobic exercise and weight
presented to Jessica Thasitis, FNP (“Ms.
Thasitis”), for treatment of GERD on December 3, 2013.
Tr. at 881. She noted Plaintiff had been walking a
mile-and-a-half on most days, without reduced exercise
tolerance, chest pain, or shortness of breath. Id.
Plaintiff reported one episode of right lower quadrant
abdominal pain during the prior week, but indicated it
resolved on its own. Tr. at 882. Ms. Thasitis provided
samples of Dexilant to Plaintiff and instructed her on a
reflux diet and the benefit of small, frequent meals. Tr. at
884. She stressed to Plaintiff the need to be compliant with
her medication for hypothyroidism. Id.
March 12, 2014, Plaintiff reported that Vesicare helped her
incontinence, but indicated she had to discontinue the
medication for a month while she was in the process of
switching insurance plans. Tr. at 914.
complained of hemorrhoidal discomfort on March 24, 2014. Tr.
at 877. She indicated she had noticed incomplete defecatory
emptying, bright red blood, a lump around her rectum, and
mild reflux with burping. Id. Ms. Thasitis indicated
Plaintiff's rectal discomfort was likely caused by an
external hemorrhoid. Tr. at 879. She recommended Plaintiff
start taking a daily fiber supplement with Miralax.
Id. She noted Plaintiff's breakthrough GERD
symptoms were likely the result of a medication change and
suggested Plaintiff should continue her reflux diet and
restart Dexilant. Id.
presented to Coastal Eye Group for a glaucoma evaluation on
March 27, 2014. Tr. at 988. She complained of decreased
visual acuity at night. Id. She stated she saw light
flashes at night that looked like laser beams and that caused
headaches. Id. Carl F. Sloan, M.D. (“Dr.
Sloan”), indicated Plaintiff had full motility, but
restricted visual field. Tr. at 988. His impression was
open-angle glaucoma. Tr. at 989.
April 25, 2014, Plaintiff complained of nose bleeds and
increased blood pressure associated with Vesicare and Flomax.
Tr. at 920. Dr. Young discussed multiple treatment options
with Plaintiff, prescribed Toviaz, and encouraged her to
perform Kegel exercises and to follow up in one month. Tr. at
presented to Thomas Anderson, M.D. (“Dr.
Anderson”), on May 13, 2014, complaining of pain all
over. Tr. at 931. She reported a history of two automobile
accidents that had caused pain in her neck and middle and
lower back. Id. She complained of constant numbness
in her hands and feet. Id. She stated she had
received no treatment for her neck or back in the last six
months. Id. Dr. Anderson observed Plaintiff to have
normal strength and reflexes in her bilateral upper and lower
extremities. Tr. at 932. He indicated he would review an MRI
of Plaintiff's cervical spine before determining the best
course of action. Id.
followed up with Dr. Almeida on May 15, 2014. Tr. at 969. She
reported occasional retrosternal chest discomfort when
engaging in physical activity in the heat of the day, and but
indicated she was able to engage in aerobic exercise at the
gym without difficulty. Id. Dr. Almeida observed
Plaintiff to have mildly decreased ROM in her upper and lower
extremities, but found no other abnormalities on physical
examination. Tr. at 970. He assessed non-cardiac chest pain,
stable bradycardia, well-controlled hypertension, moderate
GERD, and improved sleep apnea. Id. He recommended
Plaintiff use a proton-pump inhibitor for GERD, but indicated
she did not require aspirin because there was no evidence of
coronary artery disease. Id.
reported improved symptoms with Toviaz on June 4, 2014, but
indicated she continued to have occasional trouble with
urinary urge incontinence. Tr. at 926. Dr. Young refilled
Toviaz and indicated he would consider urodynamic testing if
Plaintiff's symptoms worsened. Tr. at 928.
underwent an MRI of the brain on September 25, 2014, that
revealed a single nonspecific T2 white matter hyperintensity
in the right frontal lobe. Tr. at 991-93.
hearing on September 9, 2014, Plaintiff testified she last
worked in December 2012. Tr. at 36. She stated she worked for
three or four days, but that she left the job because her
vision problems were causing her to mistake numbers.
Id. She indicated her last successful job was as a
personal banker for Bank of America in 2009 or 2010. Tr. at
36-37. She testified she was fired from a job at Dairy Queen
because she made mistakes as a result of difficulty reading
the order screen. Tr. at 37. She indicated she worked for a
couple of months as a data entry clerk, but was laid off from
that job because of a slow-down in work. Id. She
testified her PRW also included jobs as a customer care
representative, a security guard, and a news reporter. Tr. at
stated she had moved from Tennessee to the South Carolina
coast because she felt threatened by her ex-husband and
desired to improve her son's asthma symptoms. Tr. at
42-43. She indicated she ...