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Cornett v. Colvin

United States District Court, D. South Carolina

January 17, 2017

Harriet Darlene Cornett, Plaintiff,
Carolyn W. Colvin, Acting Commissioner of Social Security Administration, Defendant.



         This 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 No. 4].

         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 affirms the Commissioner's decision.

         I. Relevant Background

         A. Procedural History

         On 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].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff 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.

         2. Medical History

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff was discharged from physical therapy on May 12, 2011, secondary to noncompliance with attendance. Tr. at 967-68.

         On August 18, 2011, Dr. Garcia indicated Plaintiff was stable from a cardiovascular standpoint. Tr. at 517.

         Plaintiff reported improved visual acuity on September 2, 2011. Tr. at 745.

         On 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”). Id.

         On 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.

         Plaintiff 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.

         On 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.

         On 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.

         Plaintiff 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 neurosurgeon. Id.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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.

         On 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. Id.

         On 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.

         On 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, [1] and 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.

         On 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.

         On 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.

         On 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 872.

         Plaintiff 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.

         Plaintiff 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[2]; 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.

         On June 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. Id.

         On June 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 impairment. Id.

         Plaintiff 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.

         Plaintiff 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.

         On 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.

         Plaintiff 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.

         On 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. at 912.

         On 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. Id.

         On 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 loss. Id.

         Plaintiff 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.

         On 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.

         Plaintiff 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.

         Plaintiff 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.

         On 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 923.

         Plaintiff 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.[3] Id.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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.

         C. The Administrative Proceedings

         1. The Administrative Hearing

         a. Plaintiff's Testimony

         At the 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 37-38.

         Plaintiff 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 ...

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