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Seegers v. Colvin

United States District Court, D. South Carolina

January 27, 2017

Michael O'dell Seegers, 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 Margaret B. Seymour dated April 28, 2016, referring this matter for disposition. [ECF No. 6]. 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. 5].

         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”). 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 November 13, 2012, Plaintiff protectively filed an application for DIB in which he alleged his disability began on April 8, 2008. Tr. at 63 and 131-36. His application was denied initially and upon reconsideration. Tr. at 85-88 and 90-95. On April 1, 2015, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Ann G. Paschall. Tr. at 29-49 (Hr'g Tr.). The ALJ issued an unfavorable decision on June 9, 2015, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 8-28. 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 1-6. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on April 25, 2016. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 59 years old at the time of the hearing. Tr. at 34. He completed the second grade. Tr. at 148. His past relevant work (“PRW”) was as a weaver. Tr. at 47. He alleges he has been unable to work since April 8, 2008. Tr. at 131.

         2. Medical History

         Plaintiff presented to Benjamin C. Pinner, M.D. (“Dr. Pinner”), for evaluation of hypothyroidism, hypertension, and hyperlipidemia on January 28, 2008. Tr. at 287. Dr. Pinner indicated Plaintiff's hypothyroidism was controlled with Synthroid and his hypertension was controlled by diet. Id. He stated Plaintiff's cholesterol was not at its goal. Id.

         On February 18, 2008, Plaintiff reported moderate pain after sustaining an on-the-job injury to his right fourth toe. Tr. at 284. Dr. Pinner diagnosed an ulcer, prescribed Lortab and a 10-day course of Doxycycline, gave Plaintiff a work excuse, and instructed him to return in four days. Tr. at 285-86. On, February 28, 2008, Dr. Pinner observed Plaintiff to have a small ulceration medially and erythema extending proximally to the base of the toe. Tr. at 278. He prescribed a four-day course of Doxycycline. Id.

         Plaintiff complained of dizziness and tinnitus on February 19, 2009. Tr. at 273 and 274. Dr. Pinner observed no abnormalities on examination. Tr. at 274-75. He prescribed Antivert for vertigo, Synthroid for hypothyroidism, Lisinopril for hypertension, and Prilosec for gastroesophageal reflux disease (“GERD”). Tr. at 275-76.

         Plaintiff followed up for hypertension, hypothyroidism, and GERD on July 12, 2010. Tr. at 269. He complained of back pain. Tr. at 270. A physical examination was unremarkable. Tr. at 270-71. Dr. Pinner recommended Plaintiff restart Synthroid for hypothyroidism. Tr. at 271. He prescribed Triamterene-HCTZ for hypertension and Omeprazole for GERD. Id.

         On September 13, 2010, Plaintiff reported chest pain and cramping in his lower back and leg. Tr. at 267. Dr. Pinner observed Plaintiff to have some lower paraspinal muscle tenderness. Tr. at 268. He stated he suspected Plaintiff's cramping pain may be a side effect of his blood pressure medication. Id. He discontinued Triamterene-HCTZ and prescribed Procardia XL. Id.

         Plaintiff followed up with Dr. Pinner regarding hypertension and hypothyroidism on September 15, 2011. Tr. at 261. A physical examination was unremarkable. Tr. at 261-62. However, Dr. Pinner reduced Plaintiff's dosage of Synthroid after reviewing lab test results. Tr. at 260.

         On December 19, 2011, Plaintiff complained of chest pain that radiated to his back and worsening hypertension. Tr. at 258. He reported fatigue and dyspnea. Id. Dr. Pinner indicated Plaintiff's symptoms sounded musculoskeletal, but he encouraged Plaintiff to schedule calcium scoring because of his risk factors for coronary artery disease. Tr. at 259. A chest x-ray showed Plaintiff to have poor inspiration, but was otherwise normal. Id. An electrocardiogram (“EKG”) was also normal. Id. Lab tests indicated Plaintiff's thyroid medication was working properly. Id.

         On August 21, 2012, Plaintiff complained that his hypertension was worsening and had caused him to experience headaches and chest pain. Tr. at 253. He reported his energy had decreased over the prior three-month period and that he had felt more anxious. Id. He complained of paresthesias. Id. Dr. Pinner described Plaintiff as having an anxious mood and affect, but noted no other abnormalities on examination. Tr. at 253- 54. He prescribed Xanax to be taken as needed and changed Plaintiff's hypertension medication from Procardia to Exforge. Tr. at 254.

         Plaintiff presented to Dr. Pinner on September 17, 2012, for hypertension and associated headache. Tr. at 251. Dr. Pinner noted no abnormalities on examination. Tr. at 251-52. He encouraged Plaintiff to work on reducing his weight to control his blood pressure and cholesterol. Tr. at 252.

         On April 8, 2013, Plaintiff followed up for hypertension and hypothyroidism. Tr. at 321. He reported a sore throat, increasing fatigue, and generalized muscle aches. Id. Dr. Pinner noted no abnormalities on examination. Tr. at 321-22.

         On April 29, 2013, an x-ray of Plaintiff's right knee showed a small joint effusion and mild degenerative changes of the medial and patellofemoral compartments. Tr. at 300. An x-ray of his left knee indicated minimal degenerative change of the medial knee joint compartment. Tr. at 302. An x-ray of Plaintiff's back showed mild disc degenerative changes at the T12-L1 and L5-S1 levels. Tr. at 301.

         Plaintiff presented to Branham Tomarchio, M.D. (“Dr. Tomarchio”), for a consultative examination on May 18, 2013. Tr. at 304-09. Plaintiff described chronic pain in his lumbar spine that was associated with some numbness and weakness in his lower extremities and burning in his legs. Tr. at 306. He also endorsed some pain in his knees and neck. Id. He reported abilities to dress and feed himself; to stand for 30 minutes at a time; to walk for two miles; to sit for 30 minutes; to lift 50 pounds; and to engage in activities of daily living (“ADLs”) that included driving, sweeping, mopping, vacuuming, washing dishes, shopping, climbing stairs, and mowing grass. Id. Dr. Tomarchio observed Plaintiff to ambulate from the office into the examination room; to shake his hand with a firm grip; to sit in the interview chair without difficulty; to rise to move to the examination chair without difficulty; and to hear and speak normally. Tr. at 308. He noted Plaintiff's spine showed no evidence of deformity and was not tender to palpation. Id. Plaintiff's extremities showed no evidence of edema, cyanosis, or clubbing. Id. His joints demonstrated no redness, swelling, or effusion. Id. He had 5/5 grip strength bilaterally. Id. Plaintiff demonstrated normal fine and gross manipulative skills. Id. He had normal range of motion (“ROM”) throughout his spine and extremities. Id. He was able to walk and squat without difficulty. Id. Plaintiff had normal motor strength and reflexes and his muscles showed no atrophy. Id. Dr. Tomarchio assessed chronic back pain, but indicated Plaintiff had “no objective evidence of significant functional capacity deficit.” Tr. at 309.

         State agency consultant Debra C. Price, Ph. D. (“Dr. Price”), reviewed the evidence and completed a psychiatric review technique form (“PRTF”) on June 4, 2013. Tr. at 56-57. She considered Listings 12.02 for organic mental disorders and 12.06 for anxiety-related disorders and found that Plaintiff had mild restriction of ADLs and difficulties in maintaining social functioning; moderate difficulties in maintaining concentration, persistence, or pace; and no episodes of decompensation that were of extended duration. Id. Dr. Price found that Plaintiff was moderately limited in his abilities to understand, remember, and carry out detailed instructions; to maintain attention and concentration for extended periods; to complete a normal workday and workweek without interruptions from psychologically-based symptoms; and to perform at a consistent pace without an unreasonable number and length of rest periods. Tr. at 58-60. She stated Plaintiff's symptoms and impairments were severe, “but would not preclude the performance of simple, repetitive work tasks.” Tr. at 60. She indicated Plaintiff could understand and remember simple instructions; carry out short and simple instructions; maintain concentration and attention for at least two hours; respond appropriately to coworkers, supervisors, and the general public; and be aware of normal hazards and take appropriate precautions. Id.

         On June 25, 2013, Plaintiff complained of a gradual onset of fatigue that had been occurring in a persistent pattern for months. Tr. at 317. He reported generalized muscle aches and pain in his bilateral knees and lower back. Id. Dr. Pinner observed Plaintiff to be anxious; to be tender to palpation over his left sacroiliac joint; and to have a coarse right knee. Tr. at 318. He prescribed Diclofenac Sodium for pain and Cymbalta for mood. Id. He recommended Plaintiff avoid exposure to the sun. Id.

         Plaintiff reported weight gain, fatigue, and dry skin on August 26, 2013. Tr. at 335. Dr. Pinner noted no abnormal findings on examination. Tr. at 335-36. He discontinued Diclofenac Sodium and prescribed Feldene for osteoarthritis in Plaintiff's knee. Tr. at 336. He increased Plaintiff's dosage of Cymbalta from 30 to 60 milligrams and refilled his prescriptions for Exforge and Synthroid. Id.

         On October 14, 2014, Plaintiff complained of hypertension, pain in his shoulders and knee, and depression. Tr. at 356. Dr. Pinner noted no abnormalities on examination. Tr. at 357. He diagnosed shoulder bursitis. Id. He refilled Plaintiff's prescription for Hydrocodone and indicated he could take the medication up to four times a day. Id.

         Plaintiff reported anxiety that was accompanied by insomnia and sleep disturbance on March 5, 2015. Tr. at 352. He complained of pain in his left shoulder that was radiating toward his upper back. Id. Dr. Pinner observed Plaintiff to have reduced ROM in his bilateral shoulders. Tr. at 353.

         3. Education Records

         Barbara Chapman of the Newberry County Adult Literacy Council drafted a letter on January 8, 2013, that indicated Plaintiff was enrolled in an Adult Basic Reading class from May 5, 2009, through February 2, 2012. Tr. at 166. She stated Plaintiff was able to increase his reading level from a first to a second grade level with one-and-a-half hours of one-on-one tutoring per week. Id.

         A test administered on January 14, 2013, showed Plaintiff to be reading on a third grade level. Tr. at 170.

         On March 24, 2014, Robert V. Shea, Jr., indicated in a sworn statement that he had served as a volunteer with the Newberry Literacy Society and had worked with Plaintiff during one to two hour sessions that took place twice a week for a period of six months to a year. Tr. at 223. He stated Plaintiff had difficulty learning words and recognizing known words in sentences. Id. He noted Plaintiff put forth good effort, but had a limited aptitude. Id. He stated Plaintiff's reading and writing skills were so limited that he would consider him illiterate. Tr. at 223-24.

         C. The Administrative Proceedings

         1. The Administrative Hearing

         a. Plaintiff's Testimony At the hearing on April 1, 2015, Plaintiff testified he was in special education classes and withdrew from school at the age of 15. Tr. at 34. He stated he attended a literacy class as an adult, but remained unable to read. Tr. at 35. He indicated he had obtained a driver's license because the test was administered orally. Id.

         Plaintiff testified he started working at American Fiber and Finishing when he was 16 years old. Tr. at 36. He indicated he worked as a weaver because his reading problems did not prevent him from performing the job. Id. He stated his employer closed down. Id. He indicated he had some physical problems performing his job before the job ended. Tr. at 37. He stated he looked for other work, but denied having worked anywhere since April 4, 2008. Id.

         Plaintiff testified he experienced pain in his knees, lower back, and shoulders. Tr. at 37. He indicated his back pain was exacerbated by bending and standing for too long. Tr. at 38. He stated he could walk for 15 minutes before he needed to stop and rest. Id. He indicated he could stand for less than 15 minutes at a time. Id. He testified he was unable to sit for a long period, but admitted that he had sat in the car for ...


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