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 affirmed.
September 27, 2010, Plaintiff protectively filed applications
for DIB and SSI in which she alleged her disability began on
July 1, 2008. Tr. at 91, 92, 120-26, and 127- 32. Her
applications were denied initially and upon reconsideration.
Tr. at 97-100, 103- 05, and 106-07. On April 26, 2012,
Plaintiff had a hearing before Administrative Law Judge
(“ALJ”) Gregory M. Wilson. Tr. at 42-70 (Hr'g
Tr.). The ALJ issued an unfavorable decision on July 20,
2012, finding that Plaintiff was not disabled within the
meaning of the Act. Tr. at 11-41. The Appeals Council denied
Plaintiff's request for review on August 20, 2013. Tr. at
brought an action seeking judicial review, and the court
issued an order on May 8, 2014, reversing the
Commissioner's decision and remanding the matter for
further administrative proceedings pursuant to 42 U.S.C.
§ 405(g). Tr. at 654-60. The Appeals Council
subsequently remanded the case to the ALJ on September 17,
2014. Tr. at 661-66.
the instant case was pending, Plaintiff filed another
application for benefits on August 26, 2014. Tr. at 673. On
April 13, 2015, the Social Security Administration
(“SSA”) issued a decision finding Plaintiff
disabled as of August 26, 2014. Tr. at 673.
appeared for a second hearing on May 19, 2015. Tr. at 520-49.
The ALJ issued a partially favorable decision on September 3,
2015, finding that Plaintiff became disabled on August 26,
2014, but was not disabled prior to that date. Tr. at
686-729. On June 9, 2016, the Appeals Council issued an order
remanding the case to the ALJ. Tr. at 730-35.
attorney subsequently waived Plaintiff's right to appear
for a third hearing. Tr. at 804. The ALJ issued an
unfavorable decision on February 15, 2017, finding that
Plaintiff was not disabled within the meaning of the Social
Security Act from July 1, 2008, through August 25,
2014. Tr. at 490-519. Thereafter, Plaintiff
brought this action seeking judicial review of the
Commissioner's decision in a complaint filed on April 14,
2017. [ECF No. 1].
Plaintiff's Background and Medical History
Plaintiff was 52 years old at the time of the first hearing
and 55 years old at the time of the second hearing. Tr. at 49
and 535. She completed three years of college. Tr. at 49. Her
past relevant work (“PRW”) was as a rural mail
carrier. Tr. at 65. She alleges she has been unable to work
since July 1, 2008. Tr. at 497.
presented to the emergency room (“ER”) at AnMed
Health on March 2, 2008, with complaints of abdominal pain,
nausea, and vomiting. Tr. at 251. The attending physician
diagnosed pneumonia and discharged Plaintiff with
prescriptions for Azithromycin and Phenergan. Id.
reported achiness, diffuse malaise, and polyarticular pain on
June 10, 2008. Tr. at 312. Stephen F. Worsham, M.D.
(“Dr. Worsham”), observed Plaintiff to have some
inspiratory wheezing and counseled her on smoking cessation.
Id. Plaintiff indicated she had decreased her
tobacco usage. Id. Dr. Worsham noted diffuse
polyarticular pain in Plaintiff's hands, forearms, and
shoulders that he considered to be consistent with a
worsening symptomatology complex of fibromyalgia.
Id. He referred Plaintiff for lab work. Id.
August 11, 2008, Dr. Worsham noted that lab work had shown a
positive rheumatoid factor. Tr. at 310. Plaintiff complained
of diffuse pain. Id. She indicated her medication
provided relief, but wore off before the end of the day.
Id. Dr. Worsham observed pressure point tenderness
in Plaintiff's posterior cervical and upper thoracic
shoulder areas that he found to be consistent with a
diagnosis of fibromyalgia. Id. He noted bilateral
wheezing and some rhonchi in Plaintiff's lung fields.
Id. He advised Plaintiff to stop smoking and
recommended that she start Remicade for rheumatoid arthritis.
Id. Plaintiff declined treatment with Remicade
because she lacked insurance coverage, and Dr. Worsham added
a prescription for Ultram. Id.
reported increased fibromyalgia-related pain on September 15,
2008. Tr. at 311. Dr. Worsham noted that Plaintiff had lost
weight for the third month in a row. Id. He observed
Plaintiff to have inspiratory wheezing and indicated her
fibromyalgia and degenerative disc disease were severe.
Id. He assessed migraine headaches and
October 14, 2008, Dr. Worsham observed Plaintiff to have
signs of pain in her low back, upper thoracic spine, and
bilateral shoulders. Tr. at 309. He described her as having a
depressed affect and prescribed Pristiq. Id.
November 10, 2008, Dr. Worsham noted that Plaintiff was
feeling slightly down because she had separated from her
husband of seven years. Tr. at 308. He indicated no
additional abnormalities on examination and remarked that
Plaintiff seemed to be doing fairly well. Id.
February 27, 2009, Dr. Worsham observed Plaintiff to have
signs of pain in her neck and back that were consistent with
cervical degenerative disc disease and fibromyalgia. Tr. at
304. He referred her for x-rays and lab work. Id.
March 27, 2009, Plaintiff reported that she had stopped
taking Zanaflex because it made her feel dizzy. Tr. at 303.
She complained of spasms in her cervical spine and upper
back. Id. Dr. Worsham noted that Plaintiff's
blood pressure might be elevated because of her pain.
Id. He discontinued Zanaflex and prescribed
April 29, 2009, Dr. Worsham noted that Plaintiff was doing
fairly well and that her functional ability had improved. Tr.
at 302. Plaintiff indicated her stress level had decreased as
she was coming to terms with her marital separation.
Worsham observed Plaintiff to have mild wheezing on June 19,
2009. Tr. at 300. He noted that Plaintiff's chronic neck,
back, and fibromyalgia-related pain appeared to be
“doing fairly well, ” that her depression seemed
to be “fairly stable, ” and that her anxiety was
“fairly well controlled.” Id.
Worsham observed Plaintiff to have posterior cervical
spasm-related pain on July 17, 2009, and prescribed Baclofen.
Tr. at 305. On September 30, 2009, he noted that Plaintiff
“seem[ed] to be doing quite well compared to her
baseline.” Tr. at 298. He observed Plaintiff to have
sinus pressure and pain, but noted no other abnormalities.
November 25, 2009, Dr. Worsham observed Plaintiff to have
posterior cervical tenderness and sinus drainage. Tr. at 296.
He reduced her dosage of Roxicodone from four to three times
a day and prescribed 100 mg of Neurontin. Id.
presented to Greenville Memorial Medical Center
(“GMMC”) with a severe headache on January 5,
2010. Tr. at 1054. The attending nurse observed that
Plaintiff appeared lethargic, had slightly slurred speech,
and appeared to be under the influence of some form of
chemical. Tr. at 1057. The attending physician provided the
Review of DHEC PMP indicates no Rx for the year for pt Tammy
Wilson with birthdays listed as 3/8/60, 3/8/61 and multiple
residences in GV, Easley and Belton. SS given by pt as
[ending in xx23] which is apparently a “new
issue” number (one that would go to a young child). She
has another SS# [ending in xx07] with the name Tammy Brady.
DHEC report on that name indicates 10/28/08 Rx for oxcodone
[sic] written by Dr. Worsham. There were no medical records
(although the pt is in the system) under either of the SS#.
Given the discrepancies in the pt info, I called Dr. Worsham,
who was very familiar with the pt. He had a pain contract
with her, which she broke not once but twice. The last RX he
wrote was on 11/25/09 (the ones filled at Fred's
pharmacy) to taper her off her narcs/benzos and referred her
to Oaktree Medical Pain Mgt. He remains her PCP for her other
When this information was discussed with the pt, she admitted
to appt with Oaktree (1/11), but denied that Dr. Worsham had
ever stopped giving her the pain meds. She kept repeating,
“I've been on these for 7 years.” According
to the pharmacy record, she would be out of the last rx as of
12/25. Her UDS indicates no narcs, does show benzos, and
amphetamines. Pt does not appear to be in withdrawal, with
essentially normal VS.
She was offered Ultram po and Rx. She asked about Xanax. She
was told she would have to get that from Oaktree, as Dr.
Worsham had been very specific about the reasons for no
longer prescribing these meds for her. (She apparently had
her meds “stolen” at least twice by a family
Tr. at 1055-56. The attending physician further noted that
Plaintiff left after she was informed that she would not
receive narcotics or benzodiazepines. Tr. at 1056.
presented to Pain Management Associates on February 24, 2010,
for treatment of chronic pain. Tr. at 443. She reported she
was out of Roxicodone and had been taking Lortab.
Id. She endorsed withdrawal symptoms and stated
“I don't want to have to get anything off the
street, but when you're desperate you'll do
anything.” Id. A urine drug screen at
Plaintiff's prior visit was positive for methamphetamine,
Xanax, Valium, Restoril, Lortab, and Propoxyphene.
Id. Plaintiff indicated she has received Xanax and
Lortab from her primary care physician and Darvocet from her
dentist, but had no explanation for the other substances.
Id. The provider informed Plaintiff that he would
not prescribe narcotic medications and instructed her that
she should follow up after undergoing electrodiagnostic
underwent electromyography (“EMG”) and nerve
conduction studies (“NCS”) of her upper
extremities on March 11, 2010. Tr. at 437-42. Jay Patel, M.D.
(“Dr. Patel”), indicated the results showed
extremely severe median mononeuropathy across Plaintiff's
right wrist and severe median mononeuropathy across her left
wrist and suggested a right C6 radiculopathy. Tr. at 429.
followed up with Kenneth A. Marshall, M.D. (“Dr.
Marshall”), on March 24, 2010. Tr. at 431-32. Dr.
Marshall observed generalized mild tenderness over
Plaintiff's neck and shoulder girdle. Tr. at 431.
Spurling's test was negative for arm pain, but positive
for neck pain. Id. Dr. Marshall assessed carpal
tunnel syndrome, neck pain, and low back pain. Id.
He referred Plaintiff to Dr. Cordas for possible carpal
tunnel surgery and indicated she might be a candidate for
cervical epidural steroid injections. Tr. at 432.
March 26, 2010, an MRI of Plaintiff's cervical spine
showed a posterior disc bulge and bilateral facet arthropathy
that were more pronounced on the right at C 3-4. Tr. at 257.
Radiologist Frank Oliver, M.D. (“Dr. Oliver”),
indicated the disc bulge and facet arthropathy caused
bilateral foraminal narrowing, but were most likely not
compressing the exiting roots. Id. The MRI also
indicated a midline posterior disc bulge without evidence of
nerve root compression or spinal stenosis at C 4-5 and a
minimal posterior disc bulge without nerve root compression
or spinal stenosis and mild facet hypertrophy on the right at
C 5-6. Id.
was admitted to AnMed Health on October 28, 2010, for
suicidal ideation. Tr. at 348. She indicated she had
experienced increased depression and anxiety over the prior
six-month period. Id. She stated she been unable to
visit her doctor or obtain medication because she had lost
her job and no longer had health insurance. Id.
Plaintiff reported sleep disturbance, anxiety, anhedonia,
nervousness, restlessness, hopelessness, helplessness,
worthlessness, apathy, poor grooming and hygiene, and weight
gain. Id. Abdalla Bamashmus, M.D. (“Dr.
Bamashmus”), observed Plaintiff to appear somewhat
disheveled; to have fair grooming and hygiene; to demonstrate
a depressed mood; to have poor eye contact; to demonstrate
thoughts that were logical and goal-directed, but somewhat
slowed; and to show no evidence of hallucinations, delusions,
or paranoia. Tr. at 348-49. He noted that Plaintiff was alert
and oriented in all spheres; had intact recent and remote
memory; demonstrated a normal fund of knowledge; and had fair
insight and judgment. Tr. at 349. He diagnosed recurrent,
moderate major depressive disorder without psychotic features
and indicated a need to rule out generalized anxiety
disorder. Id. He prescribed Prozac, Remeron, and
Vistaril and assessed a global assessment of functioning
(“GAF”) score of 30. Id. Ernest Martin, M.D.
(“Dr. Martin”), discharged Plaintiff on November
1, 2010, with instructions to follow up at the mental health
center in one week. Tr. at 350. He assessed a GAF score of
at the time of discharge. Id.
December 8, 2010, state agency consultant Philip Walls, M.D.
(“Dr. Walls”), reviewed the record and completed
a psychiatric review technique form (“PRTF”). Tr.
at 374-86. He considered Listings 12.04 for affective
disorders and 12.06 for anxiety-related disorders.
Id. He found that Plaintiff's mental impairments
had resulted in one or two episodes of decompensation and
caused mild restriction of activities of daily living
(“ADLs”), mild difficulties in maintaining social
functioning, and moderate difficulties in maintaining
concentration, persistence, or pace. Tr. at 384. Dr. Walls
also completed a mental residual functional capacity
(“RFC”) assessment. Tr. at 370-72. He determined
that Plaintiff was moderately limited in her abilities to
complete a normal workday and workweek without interruption
from psychologically-based symptoms and to perform at a
consistent pace without an unreasonable number and length of
rest periods. Tr. at 371. He stated Plaintiff retained the
following abilities: “to understand and carry out
simple and detailed tasks”; “to complete a normal
workday and workweek when taking medication”; to
“interact successfully with others”; and
“to adapt to changes in simple routines.” Tr. at
372. He noted that Plaintiff would have “[m]ore than
minimal limitation of” concentration, persistence, or
pace “due to residual symptoms of anxiety and
presented to Stuart M. Barnes, M.D. (“Dr.
Barnes”), for a comprehensive medical examination on
December 28, 2010. Tr. at 390-93. She reported diagnoses of
rheumatoid arthritis, bilateral carpal tunnel syndrome,
fibromyalgia, cervical disc bulge, and major depression. Tr.
at 390. Dr. Barnes observed that Plaintiff appeared slightly
depressed; demonstrated normal communication skills;
remembered two of three objects after a delay; spelled
“world” and “dog” backward and
forward; counted down by serial threes; calculated a simple
cash transaction; and remembered the date, day, location, and
president. Tr. at 391. He noted that Plaintiff ambulated with
a normal gait and without an assistive device. Id.
Plaintiff demonstrated normal range of motion
(“ROM”) in her bilateral shoulders, elbows,
wrists, and fingers. Tr. at 392. Dr. Barnes stated that
Plaintiff had no significant joint swelling and no nodules or
nodes on her hands. Id. Plaintiff demonstrated
normal strength in all major muscle groups of both upper
extremities. Id. She had normal strength and ROM of
her bilateral hips, knees, and ankles. Id. She was
able to perform a full squat and demonstrated no crepitus or
edema. Id. She had normal ROM to flexion, extension,
and lateral flexion of her cervical spine. Id. Her
left rotation was reduced to 80 degrees and her right
rotation was reduced 70 degrees. Id. She had normal
flexion, extension, and lateral flexion in her lumber spine.
Id. A neurological examination was normal.
Id. X-rays of Plaintiff's lumbar spine showed
hypertrophic degenerative changes at ¶ 2-3, L3-4, and
L4-5 that were most pronounced at ¶ 3-4. Tr. at 389.
Plaintiff also had narrowed disc space as a result of
degenerative changes at ¶ 2-3 and possibly at ¶
1-2. Id. She had a straightening of lordosis.
Id. Dr. Barnes assessed history of fibromyalgia,
mental health issues, mild cervical degenerative disc
disease, and history of rheumatoid arthritis with no
detectable overt signs. Id. He stated Plaintiff had
a negative Tinel's sign and recommended she undergo NCS
to evaluate for carpal tunnel syndrome. Tr. at 392.
presented to Family Practice Associates of Easley with
complaints of anxiety, pain, and fibromyalgia on April 29,
2011. Tr. at 420. The provider observed Plaintiff to be
anxious and depressed, but noted no other abnormalities.
Id. He indicated he would review Plaintiff's
records before prescribing any medication. Id.
presented to Spurgeon N. Cole, Ph.D. (“Dr.
Cole”), for a psychological consultative examination on
May 12, 2011. Tr. at 398. Dr. Cole observed that Plaintiff
appeared “slightly disheveled” and tended to
mumble when she spoke. Id. However, he indicated
that her speech improved as the examination progressed.
Id. He noted that Plaintiff displayed an adequate
range and depth of affect and normal movements and
mannerisms. Id. He stated that Plaintiff had
satisfactory social and communication skills and no evidence
of psychosis. Id. He indicated Plaintiff was in
moderate emotional distress. Id. He estimated
Plaintiff's cognitive ability to be average and described
her memory for recent and remote events as satisfactory.
Id. He indicated Plaintiff had adequate ADLs and
would be able to work with others on a satisfactory basis.
Tr. at 400. He stated Plaintiff could learn simple and
complex instructions, but would have a moderate problem with
concentration, pace, and persistence because of anxiety,
pain, and depression. Id. He diagnosed moderate
major depression with features of anxiety. Id. He
stated Plaintiff was capable of handling funds in her own
best interest. Id.
20, 2011, state agency medical consultant Robert H. Heilpern,
M.D. (“Dr. Heilpern”), reviewed the evidence and
concluded that fibromyalgia, rheumatoid arthritis,
degenerative disc disease, migraine headaches, and carpal
tunnel syndrome were not severe impairments. Tr. at 401.
Estock, M.D. (“Dr. Estock”), completed a PRTF on
May 20, 2011, and considered Listing 12.04. Tr. at 402-15. He
found that Plaintiff had experienced one or two episodes of
decompensation and had moderate restriction of ADLs, mild
difficulties in maintaining social functioning, and moderate
difficulties in maintaining concentration, persistence, or
pace. Tr. at 412. He assessed Plaintiff's mental RFC and
determined that she was moderately limited in her abilities
to understand and remember detailed instructions; to 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; to perform at a consistent
pace without an unreasonable number and length of rest
periods; and to respond appropriately to changes in the work
setting. Tr. at 416-18. However, he specified that Plaintiff
was capable of understanding, remembering, and carrying out
simple instructions over an eight-hour workday with routine
breaks and interacting appropriately with coworkers,
supervisors, and the general public. Tr. at 418. He suggested
that Plaintiff would respond better if workplace changes were
introduced slowly. Id.
presented to Sherri L. Cheek, APRN (“Ms. Cheek”),
for fibromyalgia on May 31, 2011. Tr. at 425. She complained
of increased pain in her neck and shoulder area and
intermittent flu-like symptoms. Id. Ms. Cheek
observed Plaintiff to have full ROM of both upper and lower
extremities without weakness. Id. She was unable to
document any pressure points, but noted tenderness over
Plaintiff's cervical spine with flexion and extension.
Id. She noted no abnormalities on neurological,
sensory, and reflex examinations. Tr. at 426. She assessed
chronic neck pain of uncertain etiology, questionable
degenerative disc disease of the cervical spine, possible
fibromyalgia, and osteoarthritis. Id. Ms. Cheek
increased Plaintiff's dosage of Neurontin to 300 mg three
times a day and prescribed Ultracet. Id.
underwent an MRI of her cervical spine on June 6, 2011, that
showed hypertrophic degenerative facet changes at ¶ 3-4
that were mild on the left and moderate on the right, as well
as severe posterior osteophyte formation and mild generalized
disc bulge. Tr. at 423. It further showed mild left and
severe right neural foraminal impingement at ¶ 3-4.
Id. The MRI indicated mild hypertrophic degenerative
facet change and generalized disc bulge with mild motion
artifact at ¶ 4-5. Id. It noted mild posterior
osteophytes and mild bilateral neural foraminal impingement.
Id. The MRI showed posterior osteophyte formation,
generalized disc bulge, and hypertrophic degenerative facet
change of a mild degree bilaterally at ¶ 5-6.
Id. It indicated moderate right and mild left neural
foraminal impingement. Id. It revealed generalized
disc bulge and posterior osteophyte formation with mild
bilateral neural foraminal impingement at ¶ 6-7.
Id. Radiologist Kyle Coreen Bryans, M.D. (“Dr.
Bryans”), stated the MRI showed an increase in severity
of cervical spondylosis and facet osteoarthritis that was
most pronounced at ¶ 3-4, C4-5, and C5-6. Tr. at 424.
14, 2011, Eric P. Loudermilk, M.D. (“Dr.
Loudermilk”), indicated that the MRI of Plaintiff's
cervical spine showed extensive cervical spondylosis and
neuroforaminal stenosis. Tr. at 422. He noted “[t]his
could certainly account for a lot of the pain she is
experiencing in her neck and shoulders.” Id.
He stated that Plaintiff had neglected to fill her
prescription for Ultracet because of its cost. Id.
He indicated a urine drug screen was negative for illicit
substances. Id. He declined Plaintiff's request
that he prescribe narcotic medications, and Plaintiff agreed
to try Ultracet. Id.
August 17, 2011, Dr. Loudermilk noted that Plaintiff did not
have health insurance and could not afford to undergo
epidural steroid injections or physical therapy. Tr. at 421.
He indicated Plaintiff had repeatedly requested that he
prescribe Lortab, but that he did not feel comfortable
prescribing narcotic medication for fibromyalgia.
Id. He discontinued Ultracet and prescribed Ultram
50 mg. Id. He increased Plaintiff's dosage of
Diclofenac to 75 mg twice a day and increased Neurontin to
600 mg three times a day. Id.
presented to Kent Jenkins, M.D. (“Dr. Jenkins”),
on November 1, 2011. Tr. at 483. Dr. Jenkins observed
Plaintiff to be mildly tender to palpation in her posterior
neck. Id. He prescribed Trazodone, Flexeril, and
Vitamin D. Id.
presented to Kashfia Hossain, M.D. (“Dr.
Hossain”), on February 13, 2012, with complaints of
depressed mood, anhedonia, hopelessness, low energy, restless
sleep, variable appetite, reduced motivation, and low
self-esteem. Tr. at 485. Dr. Hossain observed that Plaintiff
was casually dressed, clean in appearance, alert, oriented
times four, and cooperative. Tr. at 486. She indicated
Plaintiff had normal speech and maintained good eye contact.
Id. She described Plaintiff's mood as
“depressed and nervous” and her affect as
“anxious, sad, [and] restricted in range.”
Id. Plaintiff demonstrated a goal-directed thought
process and denied suicidal and homicidal ideation,
hallucinations, paranoia, and compulsions. Id. Her
cognition was grossly intact and she had adequate insight and
judgment. Id. Dr. Hossain diagnosed recurrent major
depressive disorder and assessed a GAF score of 55.
Id. She increased Plaintiff's dosage of Prozac
to 40 mg and prescribed Ativan for anxiety and Ambien for
April 11, 2012, Plaintiff reported that she had felt very
anxious over the prior two- to three-week period. Tr. at 487.
She indicated her depression had improved slightly with the
increased dose of Prozac, but stated Ativan had been
ineffective. Id. Dr. Hossain noted that Plaintiff
had a restricted range of affect and a “stressed”
mood, but noted no other abnormalities on mental status
examination. Id. She discontinued Ativan and
prescribed Xanax. Id.
complained of bilateral carpal tunnel pain on August 21,
2012. Tr. at 1047. She requested that her medications for
depression and pain be refilled. Id. Lee Hall, M.D.
(“Dr. Hall”), observed Plaintiff to have
bilateral positive Tinel's and Phalen's signs.
Id. He assessed depression and carpal tunnel
syndrome. Id. He prescribed bilateral wrist splints
and refilled Plaintiff's medications. Id.
presented to the ER at AnMed Health on October 9, 2013, for
left-sided rib pain and left neck pain. Tr. at 951. She
stated she injured herself while installing a light and
moving boxes for a friend. Tr. at 958. The attending
physician diagnosed a rib strain and administered a Toradol
injection. Tr. at 951.
presented to the ER at AnMed Health on October 27, 2013. Tr.
at 939. She indicated she had not taken Neurontin, Remeron,
or Prozac for almost six months. Id. She endorsed
suicidal thoughts, depressed mood, decreased energy,
anhedonia, and feelings of hopelessness, helplessness, and
worthlessness. Id. She also reported symptoms of
hypomania. Id. Dr. Bamashmus observed Plaintiff to
be alert and oriented times three; to have a depressed mood
and a congruent affect; to demonstrate intact recent and
remote memory; to have a logical and goal-directed thought
process; and to show limited insight and judgment.
Id. He indicated a need to rule out bipolar disorder
and assessed a GAF score of 25. Tr. at 940. Plaintiff
improved over the course of treatment and was discharged on
November 1, 2013, with a GAF score of 60. Tr. at 941.
complained of bilateral carpal tunnel pain and requested a
surgical referral on November 4, 2013. Tr. at 1043. Dr.
Jenkins observed Plaintiff to be tender to palpation at the
distal flexor crease and to have 4/5 grip strength.
Id. He prescribed Accupril, continued
Plaintiff's other medications, and referred her for an
orthopedic consultation. Id.
presented to GMMC on December 21, 2013, with complaints of
neck and back pain following a motor vehicle accident. Tr. at
1068. She reported pain in the center of her chest and in her
right upper groin. Id. The attending physician
observed Plaintiff to have poor concentration, anxious
affect, diffuse tenderness in her neck, and severe, bilateral
anterior tenderness in her chest. Tr. at 1070. A chest x-ray
was normal. Tr. at 1075. An x-ray of Plaintiff's right
hand revealed proximal interphalangeal joint arthritis in her
fourth finger. Tr. at 1076.
returned to the ER at GMMC on January 2, 2014, with
complaints of chest pain and body aches. Tr. at 1144. The
attending physician noted that Plaintiff “essentially
wants her Lortab, Prozac, Remeron and Xanax refilled.”
Tr. at 1146. He refused to fill narcotics and
benzodiazepines, but filled Plaintiff's other
presented to Anderson-Oconee-Pickens Mental Health Center for
an initial clinical assessment on January 7, 2014. Tr. at
1153-54. She reported symptoms that included appetite change,
hyperactivity, mood disturbance, anxiety, low energy,
hopelessness, impaired concentration, and recent stressors.
Tr. at 1153. The counselor provided a diagnostic impression
of mood disorder, not otherwise specified
(“NOS”). Tr. at 1154. He indicated Plaintiff was
in need of mental health services. Id.
agency consultant Silvie Kendall, Ph. D. (“Dr.
Kendall”), completed a PRTF on January 30, 2014. Tr. at
625-27. She considered Listings 12.04, 12.06, and 12.09 for
substance addiction disorders. Id. She found that
Plaintiff had no episodes of decompensation, mild restriction
of ADLs, mild difficulties in maintaining social functioning,
and moderate difficulties in maintaining concentration,
persistence, or pace. Tr. at 626. Dr. Kendall found Plaintiff
to be moderately limited with respect to the following
abilities: to understand and remember detailed instructions;
to carry out detailed instructions; to maintain attention and
concentration for extended periods; to complete a normal
workday and workweek without interruptions from
psychologically-based symptom; and to perform at a consistent
pace without an unreasonable number and length of rest
periods. Tr. at 631-32. She concluded that Plaintiff was able
to understand and remember simple instructions; to carry out