United States District Court, D. South Carolina
Trenna E. Powers, Plaintiff,
Nancy A. Berryhill,  Acting Commissioner of Social Security Administration, Defendant.
V. Hodges, Magistrate Judge
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].
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
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].
Plaintiff's Background and Medical History
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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 ...