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Goodwin v. Commissioner of Social Security Administration

United States District Court, D. South Carolina

February 9, 2017

Cassandra Ann Goodwin, Plaintiff,
Commissioner of Social Security Administration, Defendant.


          Shiva V. Hodges United States Magistrate Judge

         This 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.

         I. Relevant Background

         A. Procedural History

         On July 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].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff 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.

         2. Medical History

         Plaintiff 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.

         On 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. at 395.

         On June 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. Id.

         On 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.

         On 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.

         Plaintiff's 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.

         On 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. Id.

         Plaintiff 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.

         Plaintiff 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.

         Lab 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.

         Plaintiff 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.

         On 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.

         Plaintiff 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. Id.

         On 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.

         Plaintiff 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.

         Plaintiff 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. Id.

         On June 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 334.

         Plaintiff 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. Id.

         On 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.

         On 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.

         On 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.

         On 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.

         Plaintiff 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.[1] 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.[2] 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.” Id.

         On 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 hypertension. Id.

         State 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. at 109-11.

         Plaintiff 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 capacities:

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.


         On 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.

         On 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.

         On 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.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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 ...

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