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Powers v. Berryhill

United States District Court, D. South Carolina

July 20, 2017

Trenna E. Powers, Plaintiff,
v.
Nancy A. Berryhill, [1] Acting Commissioner of Social Security Administration, Defendant.

          ORDER

          Shiva V. Hodges, 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 David C. Norton, United States District Judge, dated March 6, 2017, referring this matter for disposition. [ECF No. 11]. 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. 10].

         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 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 April 25, 2012, Plaintiff filed an application for SSI in which she alleged her disability began on January 1, 2011. Tr. at 170-75. Her application was denied initially and upon reconsideration. Tr. at 90-92 and 99-102. On May 1, 2015, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Nicholas Walter. Tr. at 29-72 (Hr'g Tr.). The ALJ issued an unfavorable decision on June 23, 2015, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 6-28. 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 1-4. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on November 25, 2016. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 43 years old at the time of the hearing. Tr. at 22. She completed the tenth grade. Tr. at 38. She had no past relevant work (“PRW”). Tr. at 66. She alleges she has been unable to work since January 1, 2011. Tr. at 39.

         2. Medical History

         Plaintiff presented to the emergency room (“ER”) at Stephens County Hospital on September 21, 2011, with a complaint of left-sided chest pain. Tr. at 302. She was diagnosed with a hiatal hernia and anxiety. Tr. at 305.

         State agency consultant Glenda Scallorn, M.D. (“Dr. Scallorn”), reviewed the record and completed a psychiatric review technique form (“PRTF”) on July 23, 2012. Tr. at 276-89. She found that Plaintiff had mild restriction of activities of daily living (“ADLs”), mild difficulties in maintaining social functioning, and mild difficulties in maintaining concentration, persistence, or pace and that her anxiety-related impairment was non-severe. Tr. at 286 and 288.

         Plaintiff presented to Ashok K. Kancharla, M.D. (“Dr. Kancharla”), for a disability examination on July 25, 2012 Tr. at 290. She reported panic attacks and neuropathy and restlessness in her legs. Id. Range of motion testing was normal. Tr. at 293-96. Dr. Kancharla identified no abnormalities and indicated Plaintiff was able to ambulate without an assistive device and to get on and off the examination table without difficulty. Tr. at 291.

         Plaintiff presented to Oconee Medical Center on August 15, 2012, with left arm pain and numbness. Tr. at 340. The attending physician diagnosed cervical radiculopathy. Tr. at 341.

         On October 29, 2012, Plaintiff presented to the ER at Stephens County Hospital with right-sided chest pain. Tr. at 319. The attending physician diagnosed atypical right chest wall pain and chronic cholecystitis. Tr. at 322.

         Plaintiff presented to Oconee Medical Center on November 2, 2012. Tr. at 347. She complained of five-day history of intermittent chest pain, after having sustained a fall and bruised her arm. Tr. at 348. X-rays of Plaintiff's right wrist revealed mild degenerative joint disease of the first metacarpal-carpal joint. Tr. at 367. A chest x-ray showed streaky densities of the left mid-lung field that likely represented subsegmental atelectasis or scarring. Id. Juan Cabanero, M.D. (“Dr. Cabanero”), diagnosed a non-ST-elevation myocardial infarction, hypertension, dyslipidemia, and tobacco abuse. Tr. at 371-72. He referred Plaintiff for a left heart catheterization based on an abnormal troponin level and T-wave inversion. Tr. at 349. The heart catheterization revealed unstable angina and severe native coronary artery disease consisting of 90% left anterior descending (“LAD”) coronary artery stenosis. Tr. at 364. Plaintiff was transported to St. Francis Hospital, where she underwent percutaneous coronary intervention and stenting of the LAD artery. Tr. at 374. She was discharged on November 4, 2012, with instructions to follow a diet low in saturated fat, salt, and cholesterol; to do no heavy lifting, straining, stooping, or squatting for five days; to monitor her incision site for signs of bleeding and infection; and to follow up with Dr. Cabanero in two weeks. Tr. at 377.

         Plaintiff presented to nurse practitioner Shannon Robinson, CNP (“Ms. Robinson”), on November 9, 2012, to establish treatment and to follow up from her surgery. Tr. at 393. She denied chest pain and shortness of breath. Id. Ms. Robinson indicated Plaintiff's hypertension was controlled on medication. Id. She continued Plaintiff on Viibryd for anxiety. Id.

         Plaintiff followed up with Ms. Robinson on November 30, 2012. Tr. at 400. Ms. Robinson indicated Plaintiff was doing well and that she should continue her current medications. Tr. at 401.

         On December 22, 2012, Plaintiff presented to the ER at Oconee Medical Center with chest pain. Tr. at 444. She reported feeling “swimmy headed and dizzy.” Tr. at 447.

         The attending physician indicated that Plaintiff's hypertension medication dosage was likely too high, and the cardiologist concluded that Plaintiff's chest pain was not cardiac-related. Tr. at 447-48.

         Plaintiff reported she was doing well on January 7, 2013. Tr. at 398. Ms. Robinson noted some sinus-related abnormalities and diagnosed a sinus infection and dysuria. Tr. at 399.

         On March 7, 2013, Plaintiff complained of heartburn, burning, and a pulling sensation in her chest that had persisted for several weeks. Tr. at 396. She reported left arm pain, numbness, and tingling during the night. Id. She stated she had not been taking Lipitor or Effient because she could not afford them. Id. Ms. Robinson authorized prescription refills. Tr. at 397.

         On May 3, 2013, state agency medical consultant Charles Jones, M.D. (“Dr. Jones”), evaluated the evidence and determined Plaintiff had the physical residual functional capacity (“RFC”) to 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 reach and handle; and must avoid concentrated exposure to humidity and hazards. Tr. at 82-84.

         On June 3, 2013, Plaintiff reported occasional chest pressure. Tr. at 482. She indicated it occurred at night and was relieved by rest and Flexeril. Id. Ms. Robinson recommended Plaintiff use Nitroglycerin when she experienced symptoms. Id. She replaced Lipitor with Pravastatin because Plaintiff was unable to afford Lipitor. Id. She noted that Plaintiff was oriented to time, place, person, and situation and demonstrated the appropriate mood and affect. Id.

         Plaintiff presented to Justin Huthwaite, Psy. D. (“Dr. Huthwaite”), for a psychological consultative examination on June 28, 2013. Tr. at 405-10. She reported that she had been enrolled in special education classes from kindergarten through fifth grade, but had subsequently transferred to a private school that had no special education department. Tr. at 406. She indicated she had done well with reading, but had struggled with math, science, and social studies. Id. She stated she had repeated the first grade and had typically earned Cs and Ds. Id. She indicated she had worked for a week at Arby's, but had quit because she could not learn how to operate the cash register. Id. She stated she had worked for a year at a nursing home, but had been fired after her patient fell. Id. Plaintiff denied a history of psychiatric treatment. Tr. at 407. She indicated that Citalopram had effectively treated her symptoms. Id. She reported occasional bouts of depression and indicated she felt hopeless and cried at times. Id. She endorsed decreased sleep, variable appetite, and low energy. Tr. at 408. She reported symptoms of anxiety that were triggered by being in crowded places and riding in vehicles, but denied having experienced anxiety symptoms while in her home. Id. Dr. Huthwaite described Plaintiff as having normal speech; showing no signs of delusions or hallucinations; demonstrating a mildly anxious mood and affect; and having adequate insight and judgment. Id. He indicated Plaintiff had some problems recalling objects after a delay. Id. He assessed depressive disorder, not otherwise specified (“NOS”) and anxiety disorder, NOS. Tr. at 409. He indicated a provisional diagnosis of borderline intellectual functioning. Id. He stated “[g]iven her reported learning difficulties in school as well as on the job, it is recommended that she undergo cognitive testing.” Id.

         On July 8, 2013, Plaintiff requested that Pravastatin and Flexeril be refilled. Tr. at 479. Ms. Robinson observed Plaintiff to have left shoulder tenderness. Tr. at 479. She noted Plaintiff was oriented to time, place, person, and situation and demonstrated the appropriate mood and affect. Tr. at 480. She refilled Plaintiff's prescriptions for Lisinopril and Pravastatin and prescribed Tramadol for left arm pain. Id.

         Plaintiff presented to Oconee Medical Center on July 16, 2013, with abdominal pain that radiated into her right jaw and was associated with dizziness, nausea, and pain with inspiration. Tr. at 419. She was diagnosed with acute cholecystitis. Tr. at 423. She indicated a desire to proceed with laparoscopic cholecystectomy. Tr. at 428. However, after reviewing her medication list and discovering that she was on Effient and aspirin for coronary artery disease, Michael Paluzzi, M.D., indicated it would be best to defer surgery. Id.

         On July 30, 2013, state agency consultant Fran Shahar, Ph. D. (“Dr. Shahar”), reviewed the record and completed a PRTF. Tr. at 80-81. She considered Listings 12.02 for organic mental disorders, 12.04 for affective disorders, and 12.06 for anxiety-related disorders and determined that Plaintiff had mild restriction of ADLs, mild difficulties in maintaining social functioning, and moderate difficulties in maintaining concentration, persistence, or pace. Id.

         On September 3, 2013, Ms. Robinson noted that Plaintiff presented with anxious/fearful thoughts, depressed mood, and diminished interest or pleasure, but denied fatigue and suicidal thoughts. Tr. at 476. She noted that Plaintiff's anxiety was triggered by conflict or stress. Id. She observed that Plaintiff was oriented to time, place, person, and situation and demonstrated the appropriate mood and affect. Tr. at 477.

         Plaintiff reported that her impairments were controlled on October 7, 2013. Tr. at 473. She denied fatigue and suicidal thoughts and indicated her functioning was not difficult. Id. She was oriented to time, place, person, and situation and demonstrated an appropriate mood and affect. Tr. at 474.

         On April 1, 2014, Plaintiff presented with concerns over elevated blood pressure. Tr. at 470. She indicated that her depressive symptoms were controlled and that she was functioning without difficulty. Id. She endorsed anxious and fearful thoughts, but denied fatigue. Id. She indicated she was responding well to Citalopram. Id. Ms. Robinson observed that Plaintiff was oriented to time, place, person, and situation and demonstrated appropriate mood and affect. Tr. at 471. She increased Plaintiff's dosage of Lisinopril to 40 mg. Tr. at 472.

         On July 17, 2014, Plaintiff reported worsening hypertension. Tr. at 490. Ms. Robinson noted no abnormalities on examination and described Plaintiff as being oriented to time, place, person, and situation and demonstrating the appropriate mood and affect. Tr. at 491.

         On July 23, 2014, Karen Frank, D.O. (“Dr. Frank”), and Ms. Robinson completed a clinical assessment of pain form. Tr. at 488. In response to a question regarding the significance of Plaintiff's pain, they circled “[p]ain is present to such an extent as to be distracting to adequate performance of daily activities or work.” Id. In response to a question regarding the extent to which physical activity would increase Plaintiff's experience of pain, they selected “[g]reatly increased pain is likely to occur, and to such a degree as to cause distraction from the task or even total abandonment of the task.” Id. In response to a question about the effects of prescribed medications, they indicated “[s]ignificant side effects can be expected to limit the effectiveness of work duties or the performance of such daily tasks such as driving an automobile, etc.” Id. They also completed a medical opinion form regarding Plaintiff's ability to perform work-related physical tasks. Tr. at 489. They noted Plaintiff's maximum ability to sit during an eight-hour workday would be about two hours. Id. They indicated her maximum ability to stand/walk during an eight hour workday would be about two hours. Id. They stated Plaintiff needed the opportunity to shift at will from sitting to standing/walking. Id. They noted that Plaintiff would sometimes need to elevate her feet at unpredictable intervals during a work shift. Id. They denied that Plaintiff would need to lie down to relieve pain during a normal workday and indicated she did not require a cane to ambulate. Id. They estimated Plaintiff would be absent from work an average of three days per month. Id.

         On May 14, 2015, Plaintiff's attorney received a letter from Dr. Frank. Tr. at 496. Dr. Frank indicated that Plaintiff's continued tobacco use following the placement of a cardiac stent in November 2012 had likely led to blockage of the stent. Id. She stated she felt that Plaintiff had decreased exercise endurance and increased shortness of breath and was in need of immediate cardiac attention. Id. She stated Plaintiff had been unable to obtain the care she needed because of her lack of health coverage and inability to work. Id.

         C. The Administrative Proceedings

         1. The Administrative Hearing

         a. Plaintiff's Testimony At the hearing on May 1, 2015, Plaintiff testified that she had dropped out of school in the eleventh grade because she had to earn income to support her mother. Tr. at 38. She indicated she was able to read and write, but later noted that she could not read, write, or perform mathematical calculations well. Tr. at 38 and 57. She stated she had stopped working around 1990 to care for her diabetic parents. Tr. at 39.

         Plaintiff testified she was unable to work because she had experienced a heart attack, had pain and swelling in her legs, and always felt tired. Tr. at 40. She indicated she needed to elevate her legs for five or ten minutes two to three times per day to reduce the swelling. Tr. at 42 and 51. She endorsed pain in her left arm that had caused difficulty with lifting and carrying items and reaching overhead. Tr. at 42 and 48. She indicated the swelling in her legs and fatigue had begun after her heart attack, but noted that her fatigue was worsened by her current medication regimen. Tr. at 42 and 43.

         Plaintiff testified that she felt nervous when she was around a lot of people. Tr. at 44. She recalled incidents in which she had left Walmart and a restaurant because she felt overwhelmed by the number of people around her. Tr. at 45. She endorsed some memory problems. Tr. at 62-63. She stated she was able to follow a recipe, but would have to reread it. Tr. at 63. She indicated her mental health problems were being treated by her primary care physician. Tr. at 47. She stated her doctor had recommended she see a counselor, but she had been unable to afford to do so. Id.

         Plaintiff estimated that she could sit, stand, and walk for five to ten minutes each before she would begin to feel pain in her legs and back. Tr. at 49-50. She denied having dropped things from her left hand, but indicated her left arm would become weak after 10 minutes of use. Tr. at 61. She indicated she ...


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