United States District Court, D. South Carolina
REPORT AND RECOMMENDATION
V. Hodges United States Magistrate Judge
appeal from a denial of social security benefits is before
the court for a Report and Recommendation
(“Report”) pursuant to Local Civ. Rule
73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action
pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to
obtain judicial review of the final decision of the
Commissioner of Social Security (“Commissioner”)
denying her 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 undersigned
recommends that the Commissioner's decision be reversed
and remanded for further proceedings as set forth herein.
17, 2012, Plaintiff filed applications for DIB and SSI in
which she alleged her disability began on December 31, 2010.
Tr. at 191-92 and 193-201. Her applications were denied
initially and upon reconsideration. Tr. at 130-34, 139-40,
and 141-42. On September 5, 2014, Plaintiff had a hearing
before Administrative Law Judge (“ALJ”) Gregory
M. Wilson. Tr. at 40-76 (Hr'g Tr.). The ALJ issued an
unfavorable decision on November 17, 2014, finding that
Plaintiff was not disabled within the meaning of the Act. Tr.
at 17-39. 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 June 7, 2016. [ECF No. 1].
Plaintiff's Background and Medical History
was 52 years old at the time of the hearing. Tr. at 46. She
completed high school. Id. Her past relevant work
(“PRW”) was as a cloth inspector, as a combined
security guard and schedule clerk, and as a combined kitchen
helper, sandwich maker, and fast food worker. Tr. at 71. She
alleges she has been unable to work since December 31, 2010.
Tr. at 191.
presented to Charles Stroup, M.D. (“Dr. Stroup”),
on May 25, 2010, and reported that she had stopped taking
Diovan for hypertension because it caused her to experience
hair loss and itching. Tr. at 296. Dr. Stroup prescribed 2.5
milligrams of Lozol and instructed Plaintiff to follow up for
a blood pressure check in two weeks. Id.
April 18, 2011, Plaintiff presented to the emergency room
(“ER”) at Spartanburg Regional Medical Center
with a complaint of chest pain. Tr. at 396. A myocardial
perfusion study showed Plaintiff to have a small perfusion
abnormality at the anterior wall that most likely represented
a breast attenuation artifact. Tr. at 377. Plaintiff's
resting left ventricular ejection fraction was estimated to
be 58% with visually normal wall motion. Id. A chest
x-ray suggested enlargement of the central pulmonary
arteries, but normal heart size. Tr. at 378. Plaintiff was
discharged to follow up with Dr. Stroup for hypertension. Tr.
14, 2011, Plaintiff informed Dr. Stroup that Lisinopril
caused her to develop a cough. Tr. at 296. Dr. Stroup
discontinued Lisinopril and prescribed Cozaar for
hypertension. Id. Plaintiff complained of a trigger
finger deformity in her right index finger. Id. Dr.
Stroup indicated he would refer Plaintiff to an orthopedist.
August 16, 2011, Plaintiff reported a two-day history of
headache. Tr. at 295. Dr. Stroup indicated Plaintiff's
blood pressure was elevated. Id. He refilled
Plaintiff's prescription for Cozaar 100 milligrams and
added five milligrams of Bystolic, which was to be increased
to 10 milligrams after seven days. Id.
August 30, 2011, Dr. Stroup informed Plaintiff that she had
impaired glucose tolerance and was at risk for diabetes. Tr.
at 295. He noted Plaintiff was not taking her medication for
hypertension. Id. Plaintiff weighed 275 pounds and
her blood pressure was 170/80. Id. Dr. Stroup
discussed dieting and stressed to Plaintiff that she needed
to reduce her weight because she was at risk for developing
diabetes and other complications. Id.
blood pressure had improved, but continued to be elevated on
October 11, 2011. Tr. at 294. Dr. Stroup noted that
Plaintiff's weight had continued to increase and that she
was likely 120 pounds overweight. Id. He indicated
Plaintiff had a history of thyroid problems and a goiter, but
was not taking her thyroid medication and was noncompliant
with diet. Id. He prescribed Lozol 2.5 milligrams
and instructed Plaintiff to lose four pounds over the next
four weeks. Id.
November 7, 2011, Dr. Stroup indicated Plaintiff's liver
enzymes were elevated. Tr. at 293. He ordered a hepatitis
panel, serum iron test, and complete blood count
(“CBC”). Id. He instructed Plaintiff to
return in two days to review the results. Id. He
noted Plaintiff had borderline high glucose and indicated it
could be a result of her weight and pre-diabetic situation.
reported feeling weak and having no energy on November 9,
2011. Tr. at 293. Dr. Stroup indicated Plaintiff's
hepatitis C panel was positive. Id. He noted
Plaintiff had no insurance and stated he would attempt to
refer her to an infectious disease clinic. Id.
presented to Theodore Joseph Grieshop, M.D. (“Dr.
Grieshop”), for an infectious disease consultation on
January 11, 2012. Tr. at 362. She indicated she typically
consumed two alcoholic beverages per day. Tr. at 363. Dr.
Grieshop indicated no abnormalities on physical examination.
Tr. at 364. Plaintiff demonstrated fluent speech; intact
cognition; normal cranial nerves; and normal cerebellar
function. Tr. at 365. She was able to squat, heel walk, and
toe walk. Tr. at 366. She had normal gait and normal strength
in her upper and lower extremities. Id. She had 1
deep tendon reflexes. Id. Dr. Grieshop discussed
treatment for hepatitis C. Id. He indicated he would
obtain Plaintiff's lab test results and that she should
follow up in four weeks. Id. He encouraged Plaintiff
to stop all alcohol use. Tr. at 367.
testing showed Plaintiff to have stage 4 fibrosis, which was
consistent cirrhosis of the liver, and grade A3 inflammation,
which was consistent with severe activity. Tr. at 524-25.
followed up with Dr. Grieshop on February 10, 2012. Tr. at
356. She reported having consumed four 24-ounce alcoholic
beverages over the last month. Tr. at 357. Dr. Grieshop
encouraged Plaintiff to avoid alcohol. Tr. at 359. He
discussed with Plaintiff the course of treatment for
hepatitis C. Id. He referred Plaintiff for an
ultrasound of her liver and abdomen and instructed her to
follow up after the ultrasound. Tr. at 360. He administered a
hepatitis B vaccine. Id.
February 17, 2012, an abdominal ultrasound indicated
coarsened echotexture of the liver that was consistent with
hepatocellular disease such as cirrhosis. Tr. at 435. It did
not indicate focal masses. Id. Plaintiff's main
portal vein was patent. Id. She had mild
splenomegaly and no ascites. Id.
complained of anxiety and nervousness on February 29, 2012.
Tr. at 350. Dr. Grieshop indicated he did not believe
Plaintiff was acutely depressed. Id. Plaintiff
reported back pain, but Dr. Grieshop indicated she would need
to discuss pain issues with her primary care physician.
Id. He indicated Plaintiff likely needed new
glasses, but could not afford to visit an eye doctor.
Id. He reviewed treatment of chronic hepatitis C
with Peginterferon, Ribavarin, and Telaprevir. Tr. at 358. He
explained that potential side effects included thinning of
hair, permanent vision loss, additional thyroid dysfunction,
cardiopulmonary problems, gastrointestinal problems,
musculoskeletal problems, dermatologic problems, anal-rectal
problems, hematologic problems, and psychiatric problems.
Id. He estimated Plaintiff had a 50% chance of
sustained viral response. Id. He stated she would
require 48 weeks of therapy with her history of cirrhosis.
March 29, 2012, Plaintiff reported symptoms that included
fever, insomnia, blurred vision, eye pain, occasional eye
burning, constipation, abdominal pain, and frequent
headaches. Tr. at 346-47. Dr. Grieshop noted no abnormalities
on physical examination. Id. He indicated Plaintiff
had tolerated her first two weeks of treatment reasonably
well. Tr. at 348.
complained of fatigue on April 18, 2012. Tr. at 340. She
reported constipation, dry skin, frequent headaches, memory
loss, and confusion. Tr. at 341-42. A physical examination
was normal. Tr. at 342-43. Dr. Grieshop indicated Plaintiff
was five weeks into treatment and was tolerating it
reasonably well. Tr. at 343.
reported feeling tired all the time on May 10, 2012. Tr. at
335. She endorsed symptoms that included fatigue, weight
loss, blurred vision, nausea, rash, frequent headaches,
depression, memory loss, confusion, and loss of appetite. Tr.
at 336- 37. Dr. Grieshop observed no abnormalities on
physical examination. Tr. at 337-38. He stated that Ribavarin
was decreased to 600 milligrams daily because lab results
from Plaintiff's last visit showed her to have developed
anemia. Tr. at 338. He indicated Plaintiff's cirrhosis
showed no apparent decompensation on therapy so far and that
Plaintiff was tolerating treatment reasonably well.
7, 2012, Plaintiff complained that she had experienced
frequent itching. Tr. at 330. She endorsed symptoms that
included anorexia, blurred vision, constipation, abdominal
pain, vaginal itching, and frequent headaches. Tr. at 331-32.
Dr. Grieshop observed no abnormalities on physical
examination. Tr. at 332-33. He noted that Plaintiff's lab
work showed her hemoglobin to have dropped to 9.6. Tr. at
333. He stated he was hopeful that some of Plaintiff's
side effects from Telaprevir would improve because she would
be completing the medication the next day. Tr. at 333 and
complained of constipation on July 5, 2012. Tr. at 323. She
also endorsed symptoms that included eye irritation,
abdominal pain, vaginal itching, frequent headaches,
excessive thirst, and loss of appetite. Tr. at 324-25. Dr.
Grieshop observed Plaintiff to have a two-centimeter soft
tissue mass under her skin in her medial left arm, but he
noted no neurological disturbance or signs of infection in
the area. Tr. at 326. He recommended Plaintiff use Dulcolax
for constipation. Id. He noted a diagnosis of
anemia, but stated he was hopeful that it would improve after
she stopped the Telapravir. Id. He recommended
Plaintiff follow up with her primary care physician regarding
her elevated blood pressure. Id. He indicated
Plaintiff had responded well to hepatitis C treatment and had
no apparent decompensation of cirrhosis on therapy thus far.
Tr. at 327. He administered a second hepatitis B vaccine.
August 2, 2012, Plaintiff reported blurred vision,
constipation, abdominal pain, muscle weakness, frequent
headaches, foot tingling or burning, depression, anxiety, and
memory loss. Tr. at 318-19. Dr. Grieshop noted Plaintiff was
tearful, but indicated no other abnormalities on examination.
Tr. at 320. He described Plaintiff's thrombocytopenia and
anemia as stable. Id. He noted Plaintiff had
responded well to her treatment thus far. Tr. at 321. He
prescribed Citalopram for depression. Id.
August 30, 2012, Plaintiff complained of blurred vision,
frequent headaches, depression, and memory loss. Tr. at
312-13. Dr. Grieshop noted no abnormalities on physical
examination. Tr. at 314. He administered a third hepatitis B
vaccine. Tr. at 315.
September 27, 2012, Plaintiff reported financial pressure and
a great deal of stress at home. Tr. at 305. She endorsed
symptoms that included fatigue and weakness, blurred vision,
sinus congestion, frequent headaches, depression, anxiety,
memory loss, loss of appetite, and hay fever. Tr. at 306-07.
Dr. Grieshop noted Plaintiff was tearful at times, but was
alert and cooperative with appropriate affect, normal
concentration, and normal attention span. Tr. at 308-09. He
indicated the most recent lab work showed Plaintiff to have
decreased thyroid-stimulating hormone (“TSH”) and
elevated thyroxine (“T4”). Tr. at 309. He
explained that thyroid dysfunction was a known adverse effect
of the treatment and that the effect might be permanent.
Id. Dr. Grieshop noted Plaintiff had lost some
weight on therapy and that her blood pressure had improved
with the weight loss. Id.
October 25, 2012, Plaintiff reported feeling better over the
prior four-week period and having less stress at home. Tr. at
299. She complained of insomnia and trouble staying asleep,
sore throat, constipation, back and joint pain, vertigo, and
unusual weight change. Tr. at 300-01. Dr. Grieshop observed
no abnormalities on examination. Tr. at 302. He indicated
Plaintiff had mild hypothyroidism, but was relatively
asymptomatic. Id. He assessed cirrhosis and
thrombocytopenia. Id. He noted Plaintiff's
depressed mood had improved with Citalopram. Tr. at 303. He
indicated he would obtain labs and planned to continue
Plaintiff's therapy for sixteen more weeks. Id.
presented to W. Russell Rowland, M.D. (“Dr.
Rowland”), for a consultative examination on November
19, 2012. Tr. at 468-73. She reported liver disease, thyroid
problems, high blood pressure, low back pain, left shoulder
pain, left lower extremity weakness, intermittent hand
stiffness without joint swelling, and one-to-two second
periods of dizziness/lightheadedness. Tr. at 468. Plaintiff
became tearful when talking about depression, but had good
communication skills; could spell “world”
backwards; could subtract serial threes from 100; understood
cash transactions; and was oriented to month, date, year,
day, location, and the name of the president. Tr. at 469. She
was 5' 11” tall and weighed 236 pounds. Tr. at 470.
She demonstrated normal range of motion (“ROM”),
had 5/5 strength, and had 5/5 grip strength in her upper
extremities. Id. She was able to flex her hips to 90
degrees and her knees to 140 degrees. Id. Her ROM was
otherwise normal. Id. She had 5/5 lower extremity
strength and squatted 40%. Id. She demonstrated no
crepitus, tenderness, joint effusion, or bony enlargement in
her knees. Id. She had normal spinal alignment with
no muscle spasm, tenderness, or sacroiliac tenderness.
Id. Her ROM was normal in her cervical spine.
Id. Plaintiff's lumbar flexion was reduced to 65
degrees and extension was reduced to 20
degrees. Id. A straight-leg raising test
was negative to 50 degrees bilaterally in the supine position
and was negative in the seated position. Id.
Plaintiff demonstrated 2 deep tendon reflexes in her upper
and lower extremities. Id. She had intact cranial
nerves; no tremor; a normal sensory examination in her upper
and lower extremities; and normal fine dexterity, rapid
alternating movements, heel walking, toe walking, tandem
gait, and finger-to-nose testing. Tr. at 471. An x-ray of
Plaintiff's lumbar spine showed early degenerative disc
disease at the L4-5 and L5-S1 levels and mild degenerative
disc disease in the lower thoracic spine. Tr. at 464. X-rays
of Plaintiff's bilateral knees indicated very subtle
narrowing of the patellofemoral and medial tibiofemoral joint
compartments, which suggested possible early chondromalacia.
Tr. at 465 and 466. Dr. Rowland's impressions were
hepatitis C, hypertension, chronic depression, past history
of removal of benign thyroid nodule, obesity, low back pain
with normal examination and no radiculopathy, normal
bilateral knee examination, chronic malaise, chronic
depression, and normal examination of the left shoulder. Tr.
at 471. He indicated Plaintiff should follow up at Regenesis
Clinic for hypertension and would benefit from having her
dosage of Celexa increased from 20 to 40 milligrams.
Id. He stated the following: “I think she
should go back to work, but she says she does not have the
strength. This could be related to depression.”
November 21, 2012, Plaintiff requested that Dr. Grieshop
prescribe medication for hypertension. Tr. at 508. She
reported some difficulty over the prior four-week period and
endorsed feeling stressed, depressed, jittery, and unsteady.
Id. She also complained of easy bruising.
Id. Dr. Grieshop noted a bruise on Plaintiff's
left upper extremity. Tr. at 511. He refilled Plaintiff's
prescription for Citalopram and added Atenolol for
agency medical consultant William Cain (“Dr.
Cain”), reviewed the record and completed a physical
residual functional capacity (“RFC”) assessment
on December 3, 2012. Tr. at 85-86. He rated Plaintiff's
RFC as follows: occasionally lift and/or carry 20 pounds;
frequently lift and/or carry 10 pounds; stand and/or walk for
a total of about six hours in an eight-hour workday; sit for
a total of about six hours in an eight-hour workday;
frequently balancing and climbing ramps/stairs; occasionally
stooping, kneeling, crouching, and crawling; and never
climbing ladders/ropes/scaffolds. Id. State agency
medical consultant Adrian Corlette, M.D. (“Dr.
Corlette”), assessed the same RFC on May 13, 2013. Tr.
presented to James N. Ruffing, Psy. D. (“Dr.
Ruffing”), for a mental status examination on December
18, 2012. Tr. at 476-78. She reported numerous physical
complaints and initially denied mental health problems. Tr.
at 476. However, she stated she liked to stay home and
sometimes felt depressed. Id. She indicated she felt
worried and sorry for herself. Id. She endorsed
abilities to care for her personal needs, to drive a car, to
visit the store, to pay bills, to visit with friends and
family, to order a meal at a restaurant, to prepare meals,
and to clean and do laundry. Tr. at 477. Dr. Ruffing
indicated Plaintiff completed the intake interview on her own
and was adequately groomed and dressed. Id. He
stated Plaintiff varied “from remaining calm with no
acute emotional distress [to] becoming tearful.”
Id. He indicated Plaintiff had “some
appropriate affect of normal range and intensity with a mild
depression observed.” Id. Plaintiff endorsed
symptoms of depression that included crying spells and
feelings of sadness, worthlessness, hopelessness,
helplessness, and uselessness. Id. She indicated she
had low energy, absent libido, disturbed sleep, and
anhedonia. Id. She denied having received inpatient
or outpatient mental health treatment. Id. She also
denied suicidal ideation and a history of suicidal behavior.
Id. Plaintiff was fully oriented and demonstrated
logical, relevant, coherent, and goal-directed thought
processes. Tr. at 478. She showed no indications of psychosis
or lack of reality contact. Id. Dr. Ruffing stated
Plaintiff was “able to attend and focus without
distractibility”; was able to recall three unrelated
words immediately and after a five-minute delay; demonstrated
adequate memory; showed abstract reasoning ability and
judgment; demonstrated good mastery of cognitive faculties;
had basic general knowledge; was able to perform simple
calculations; and scored 30 of 30 points on Folstein's
Mini-Mental Status Exam (“MMSE”). Id. He
suspected Plaintiff had a history of alcohol abuse that was
in remission and that her depressive symptoms could be either
a mild dysthymic or an adjustment disorder with depressed
mood. Id. He stated Plaintiff had the following
She is able to understand and respond to the spoken word. She
is able to attend and focus. She does show some depressive
symptomatology, which may limit her concentration,
persistence, and pace at times. She does appear capable of
managing her finances, if awarded benefits.
December 20, 2012, Plaintiff indicated she had been doing
“a little better.” Tr. at 501. Dr. Grieshop noted
Plaintiff's blood pressure was a little elevated, but
indicated she was not tachycardic and that the Citalopram
seemed to be helping. Id. Plaintiff reported blurred
vision, constipation, vertigo, frequent headaches,
depression, anxiety, and memory loss. Tr. at 503. A physical
examination was unremarkable. Tr. at 504. Dr. Grieshop noted
Plaintiff had some slight weight loss and multiple minor side
effects, but no apparent infections. Tr. at 505. He
prescribed Methimazole for hyperthyroidism. Id.
December 27, 2012, state agency consultant Michael
Neboschick, Ph. D. (“Dr. Neboschick”), reviewed
the record and completed a psychiatric review technique form
(“PRTF”). Tr. at 83-84. He considered Listings
12.04 for affective disorders and 12.09 for substance
addiction disorders. Tr. at 84. He found that Plaintiff had
mild restriction of activities of daily living
(“ADLs”) and mild difficulties in maintaining
social functioning and concentration, persistence, or pace.
Id. He indicated the preponderance of evidence in
the file suggested Plaintiff's alcohol abuse was in
remission and that her mental impairments were non-severe.
Id. State agency consultant Olin Hamrick, Jr., Ph.
D. (“Dr. Hamrick”), considered the same Listings
and assessed the same level of restriction on May 20, 2013.
Tr. at 108-09.
January 17, 2013, Plaintiff reported that she had experienced
headaches, blurred vision, and right-sided abdominal pain
over the prior four-week period. Tr. at 495. Dr. Grieshop
indicated Plaintiff had tolerated the medications well over
the prior month. Tr. at 499.
presented to the ER at Upstate Carolina Medical Center on
February 20, 2013, with a complaint of pain and swelling in
her right thumb. Tr. at 484. The attending physician observed
Plaintiff to have an abscess and diagnosed paronychia. Tr. at
486. He prescribed Cephalexin to treat the infection and
Tramadol for pain. Tr. at 488.
followed up with Dr. Grieshop on February 21, 2013. Tr. at
489. She reported symptoms that included night sweats,
blurred vision, earache, constipation, rash, wound drainage,
vertigo, depression, and anxiety. Tr. at 491. Dr. Grieshop
noted no abnormalities on examination. Tr. at 492. He
indicated Plaintiff had completed 48 weeks of therapy for
hepatitis C. Tr. at 493. He noted that Plaintiff had been
“about the same” over the last month and seemed
“to be tolerating medications reasonably well.”
Id. He indicated they would repeat the CBC, liver
function tests, and the end of therapy viral load to
determine if Plaintiff responded to therapy. Id. He
also stated he would check Plaintiff's antibody levels
and would repeat thyroid studies. Id. He indicated
that if Plaintiff's test results consistently showed
hypothyroidism, she may need to consider thyroid replacement
therapy. Id. He stated anemia and leukocytopenia
should improve. Id.
followed up with Dr. Grieshop on March 21, 2013, four weeks
after completing treatment for hepatitis C. Tr. at 533. She
reported good activity level and improved appetite, but
complained of a headache. Id. Dr. Grieshop indicated
the hepatitis C viral load was not detected in
Plaintiff's last test results. Id. He assessed
Hashimoto's thyroiditis, but indicated Plaintiff was
unable to afford a referral to an endocrinologist. Tr. at
537. He stated anemia ...