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Brady v. Berryhill

United States District Court, D. South Carolina

January 9, 2018

Tammy Lynn Brady, Plaintiff,
Nancy A. Berryhill, Acting 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 affirmed.

         I. Relevant Background

         A. Procedural History

         On 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 1-7.

         Plaintiff 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.

         While 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.

         Plaintiff 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.[1] Tr. at 730-35.

         Plaintiff's 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.[2] 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].

         B. Plaintiff's Background and Medical History

         1. Background

          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.[3] Tr. at 497.

         2. Medical History

         Plaintiff 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.

         Plaintiff 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.

         On 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.

         Plaintiff 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 anxiety/depression. Id.

         On 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.

         On 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.

         On 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.

         On 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 Flexeril. Id.

         On 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. Id.

         Dr. 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.

         Dr. 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. Id.

         On 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.

         Plaintiff 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 following note:

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 medical issues.
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 member.).

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.

         Plaintiff 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 studies. Id.

         Plaintiff 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.

         Plaintiff 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.

         On 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.

         Plaintiff 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”)[4] score of 30.[5] 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 58[6] at the time of discharge. Id.

         On 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 depression.” Id.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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.

         On May 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.

         Robert 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.

         Plaintiff 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.

         Plaintiff 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.

         On June 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.

         On 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.

         Plaintiff 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.

         Plaintiff 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 sleep. Id.

         On 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.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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 medications. Id.

         Plaintiff 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.

         State 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 ...

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