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Anderson v. Berryhill

United States District Court, D. South Carolina

February 12, 2018

Stephen Josef Anderson, Plaintiff,
v.
Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant.

          REPORT AND RECOMMENDATION

          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 his 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 August 15, 2013, Plaintiff protectively filed applications for DIB and SSI in which he alleged his disability began on February 1, 2013. Tr. at 226-33 and 234-42. His applications were denied initially and upon reconsideration. Tr. at 170-74, 177-80, and 181-84. On January 21, 2016, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) James R. McHenry, III. Tr. at 46-94 (Hr'g Tr.). The ALJ issued an unfavorable decision on June 30, 2016, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 7-38. 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 July 10, 2017. [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 54. He completed high school and two years of college. Tr. at 58. His past relevant work (“PRW”) was as a web press operator. Tr. at 84. He alleges he has been unable to work since July 9, 2013.[1] Tr. at 250.

         2. Medical History

         On October 16, 2012, Priyadarshini K. Mehta, M.D. (“Dr. Mehta”), noted that Plaintiff's hemoglobin A1c level was significantly elevated at 13.5 percent, likely as a result of prolonged steroid use. Tr. at 510. She changed Plaintiff's insulin dosage, encouraged him to maintain a blood sugar log and to bring it to his next visit, and referred him to a surgeon for an enlarged thyroid goiter. Id.

         Plaintiff presented to the emergency room (“ER”) at St. Francis Downtown (“SFD”) with back pain and difficulty swallowing on December 8, 2012. Tr. at 344. An x-ray of his neck showed marked abnormal soft tissue prominence encircling the region of the thyroid cartilage without discrete airway compression, as well as a possible goiter or neoplasm. Tr. at 352.

         Plaintiff returned to the ER at SFD with abdominal pain, nausea, and vomiting on December 10, 2012. Tr. at 362. His blood glucose was 550 mg/dL. Id. He endorsed a history of diabetes and indicated he had been using insulin since he was a teenager. Tr. at 368. He was admitted and transferred to the intensive care unit for routine progression of care. Tr. at 366. He was discharged on December 12, 2012, with a diagnosis of diabetic ketoacidosis. Tr. at 379. The discharging physician noted that Plaintiff had additional active problems that included atrial fibrillation, gastroparesis, hyperthyroidism, goiter, and coagulotherapy. Id.

         Plaintiff underwent fine needle biopsy of the thyroid on December 18, 2012. Tr. at 410. It showed an enlarged heterogeneous thyroid with no discrete nodules. Id.

         Plaintiff was hospitalized at SFD from January 1 to January 3, 2013, for atrial fibrillation with rapid ventricular response, left upper arm pain, goiter, noncompliance with medication regimen, and diabetes mellitus. Tr. at 417. He reported his left shoulder was extremely sore to the touch and worsened by movement. Id. An x-ray of his left shoulder showed no acute bony or joint findings. Tr. at 440.

         Plaintiff presented to the ER at SFD on January 26, 2013, for lower back pain that radiated to his abdomen. Tr. at 449. A computed tomography (“CT”) scan of Plaintiff's abdomen and pelvis showed no acute pathology. Tr. at 460-61. The attending physician assessed acute low back pain, proteinuria, and generalized abdominal pain. Tr. at 449.

         Plaintiff followed up with Dr. Mehta on January 29, 2013. Tr. at 503. He complained that he had not had a bowel movement in seven days. Id. Dr. Mehta indicated Plaintiff's abdominal pain likely resulted from constipation or impaction. Tr. at 505. She advised Plaintiff to use an enema, to take magnesium citrate, and to increase his water intake. Id. She referred Plaintiff for lab work for a rash on his feet and to an endocrinologist for a thyroid goiter. Tr. at 504.

         On February 5, 2013, Plaintiff reported malaise; pain, stiffness, and swelling in his neck; dysphagia; and depression. Tr. at 500. Dr. Mehta noted that Plaintiff's had a diffusely enlarged thyroid and a cervical mass. Id. The lesions on the palm and sole of Plaintiff's feet had markedly improved and his constipation had resolved. Tr. at 501. Dr. Mehta indicated she would attempt to refer Plaintiff to another endocrinologist. Id. She noted that Plaintiff's diabetes was uncontrolled because he was depressed about not having his goiter removed and had been noncompliant. Id.

         Plaintiff presented to Yuliya Yurko, M.D. (“Dr. Yurko”), for consultation regarding the thyroid goiter on February 19, 2013. Tr. at 686. He reported chronic fatigue, hoarseness, dysphagia with solid food, and a 15-pound weight loss. Id. Dr. Yurko referred Plaintiff for lab work and a CT scan of his neck. Tr. at 687.

         On February 22, 2013, an ultrasound of the soft tissues of Plaintiff's head and neck showed marked enlargement of the thyroid gland with heterogeneous appearance suggesting goiter. Tr. at 485. The radiologist indicated Plaintiff had a history of Graves' disease. Id. The ultrasound also indicated several small hyperechoic nodules that the radiologist considered to be insignificant. Tr. at 486.

         Plaintiff followed up with Brian Boland, M.D. (“Dr. Boland”), on March 19, 2013. Tr. at 682. Dr. Boland observed Plaintiff to have an enlarged thyroid that was easily visible and palpable and mild tenderness to palpation over the thyroid. Tr. at 683. He indicated he had discussed Plaintiff's impairment with another physician and that they had planned to perform a total thyroidectomy. Id.

         Plaintiff was hospitalized at Greenville Health System from May 13 to May 14, 2013, for Graves' disease, total thyroidectomy, and postoperative management. Tr. at 487. He followed up with Marc Zelickson, M.D. (“Dr. Zelickson”), on May 23, 2013. Tr. at 680. He denied pain and indicated he was feeling well. Id. He reported that his muscle and joint aches had completely resolved and requested permission to shave and mow the lawn. Id. Dr. Zelickson removed Plaintiff's stitches and indicated his incision was healing nicely. Id. He advised Plaintiff to follow up with his cardiologist to determine if atrial fibrillation had resolved and to return in six weeks for a check of his thyroid hormone levels. Id.

         Plaintiff presented to Dr. Mehta on June 11, 2013, for diabetes management and thyroidectomy follow up. Tr. at 491. He reported feeling well and being pleased with the removal of the thyroid goiter. Id. He stated his hoarseness from the surgery was slowly resolving, but denied other problems. Tr. at 492. Dr. Mehta noted no abnormalities on physical examination. Tr. at 492-93. She indicated that Plaintiff's atrial fibrillation had been caused by Graves' disease and discontinued Warfarin in light of his recent thyroidectomy.[2] Tr. at 493 and 495.

         On September 19, 2013, Plaintiff complained that he had no appetite and constantly felt tired. Tr. at 577. He reported elevated blood glucose readings in the late afternoon. Id. Dr. Mehta increased Plaintiff's morning insulin dose to 25 units and referred him for lab work. Tr. at 578-79.

         On October 15, 2013, x-rays of Plaintiff's right knee showed chondrocalcinosis, joint effusion, mild medial joint space narrowing, and findings compatible with depositional or degenerative arthropathy. Tr. at 564. X-rays of Plaintiff's lumbar spine indicated mild-to-moderate multilevel degenerative disc disease that was particularly evident at the anterior superior aspects of the L2 through L5 vertebral bodies; mild lower lumbar facet arthropathy without acute fracture; intact sacroiliac (“SI”) joints; and vasa deferentia and vascular calcifications that were possibly related to diabetes. Tr. at 565.

         Plaintiff subsequently presented to Larry R. Korn, D.O. (“Dr. Korn”), for a consultative examination on the same day. Tr. at 567-71. He complained of pain in his low back, knees, and left arm. Tr. at 567. He indicated his back pain did not occur daily, but was exacerbated by standing in place for a prolonged period, bending, and lifting. Id. He endorsed difficulty getting up and down and crouching because of knee pain. Id. He stated he could “walk all day long” if he was not required to bend. Id. He denied crepitus, clicking, and popping, but reported occasional swelling in his knees. Id. He described sensory disturbance above his left wrist and indicated he could not distinguish between coins in his hand and was unable to feel pills on the tips of his fingers. Id.

         Dr. Korn observed Plaintiff to have cervical flexion to 60 degrees, extension to 42 degrees, lateral flexion to 26 degrees on the left and 18 degrees on the right, and rotation to 40 degrees on the left and right. Tr. at 568. He noted lumbar flexion to 40 net degrees, extension to 20 net degrees, and normal bilateral lateral flexion. Id. He stated Plaintiff's pelvis tilted slightly upward and to the left. Id. He noted Plaintiff had a very mild sweeping scoliotic curve with apex in the mid to lower dorsal area to the right. Id. He indicated Plaintiff appeared to have increased dorsal kyphosis and flattening of lumbar lordosis. Id.

         Plaintiff demonstrated left shoulder abduction to 86 degrees, adduction to 24 degrees, flexion to 126 degrees, internal rotation to 30 degrees, and external rotation to 60 degrees. Id. He had right shoulder abduction to 118 degrees, adduction to 30 degrees, flexion to 118 degrees, internal rotation to 15 degrees, and external rotation to 50 degrees. Id. Dr. Korn indicated Plaintiff had no crepitus in either shoulder, but seemed to have some barrier to additional motion. Id. He also found Plaintiff to have notably diminished muscle bulk in the supraspinatus and infraspinatus areas and to a lesser degree in the trapezius and deltoids. Id. Dr. Korn described normal findings with respect to Plaintiff's elbows, wrists, hips, and ankles. Tr. at 569 and 570.

         Plaintiff demonstrated left knee flexion to 132 degrees and right knee flexion to 128 degrees with zero degrees of extension bilaterally. Id. Dr. Korn observed medial compartment click in the left knee and a little bit of lateral crepitus in the right knee with McMurray's maneuver. Tr. at 569. He noted good varus and valgus integrity and negative Lachman's in both knees. Id. Dr. Korn stated Plaintiff had some degenerative hypotrophy of the right second distal interphalangeal (“DIP”) joint. Tr. at 570. He indicated Plaintiff had fairly unremarkable dexterity and gross coordination. Id. Heel-toe walk was normal and tandem walk was normal with effort. Id. Plaintiff flexed to 136 degrees, but was unable to perform a full squat. Id. Dr. Korn estimated Plaintiff's strength to be 4/5, but indicated there were “no locations where his weakness [was] exceptionally noticeable.” Id. He stated Plaintiff had intact two-point discrimination, except at the pad of the left fifth finger. Id. He noted that Plaintiff had diminished sensation to light touch at his second toes on both feet. Id. He had normal reflexes in most places, but absent reflexes in his triceps and trace reflexes in his right Achilles. Id. Dr. Korn indicated Plaintiff had “rather obvious atrophy in the shoulder areas” and felt that he had significant generalized sarcopenia. Id.

         Dr. Korn assessed adhesive capsulitis versus degenerative joint disease of the bilateral shoulders; generalized sarcopenia and weakness secondary to recent Graves' disease, peripheral nerve trauma secondary to laceration of the left ulnar wrist, likely degenerative joint disease and meniscal damage to the medial compartment of the left knee, and right knee pain of uncertain etiology. Tr. at 570-71. He stated that Plaintiff's symptoms seemed to be consistent with Graves' disease and associated weight loss. Tr. at 571. He indicated Plaintiff's joint problems were potentially related to the significant reduction in his muscle bulk. Id. He stated that Plaintiff would likely require orthopedic treatment before being able to perform overhead manipulations with his arms. Id. He indicated Plaintiff's knees would limit him to occasional crouching and squatting. Id. He stated Plaintiff's knees and general strength would likely prevent him from lifting in excess of 20 pounds. Id.

         On November 7, 2013, state agency medical consultant Matthew Fox, M.D. (“Dr. Fox”), reviewed the record and completed a physical residual functional capacity (“RFC”) assessment. Tr. at 101-05. He found that Plaintiff had the following limitations: 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 pushing and pulling with the bilateral upper extremities, climbing ramps and stairs, stooping, and kneeling; occasionally crawling, crouching, and climbing ladders, ropes, and scaffolds; and occasionally reaching with the bilateral upper extremities. Id. Medical consultant Perry M. White, M.D. (“Dr. White”), reviewed Plaintiff's RFC assessment on November 18, 2013. Tr. at 573-74. He agreed with the limitations Dr. Fox assessed. Id. A third medical consultant, Seham El-Ibiary (“Dr. El-Ibiary”), assessed the same physical RFC on May 27, 2014. Tr. at 148-52.

         On December 19, 2013, Plaintiff reported positive results after having changed his diet. Tr. at 581. He reported feeling much better following the thyroidectomy, but continued to endorse poor appetite. Id. Dr. Mehta instructed Plaintiff to reduce his dosage of Propranolol, to increase his morning insulin dosage to 25 units, and to begin a 30-minute daily walking regimen. Tr. at 581-82. She counseled Plaintiff to stop smoking. Tr. at 582.

         On June 17, 2014, Plaintiff presented to Dr. Mehta following a hypoglycemic episode. Tr. at 606. He indicated that emergency medical services (“EMS”) had responded to his home after his mother found him to be unresponsive and had found his glucose level to be 37 mg/dL. Id. He complained of not feeling well and indicated he was experiencing headaches in the back of his head each morning. Id. He reported dizziness and lightheadedness. Id. He stated he had often experienced hypoglycemia in the morning and had reduced his evening dose of insulin to address it. Id. Plaintiff also endorsed a two-month history of left shoulder pain, numbness, and slight weakness. Id. He stated he was unable to raise his left arm above his shoulder level. Id. He endorsed occasional neck pain, as well. Id. Dr. Mehta decreased Plaintiff's evening dose of insulin to five units and instructed him to continue to use 20 units in the morning. Tr. at 608. She referred Plaintiff for x-rays of his left shoulder and cervical spine and prescribed Neurontin. Id.

         On July 15, 2014, x-rays of Plaintiff's left shoulder showed degenerative joint disease. Tr. at 612. X-rays of his cervical spine indicated spondylosis. Tr. at 613. X-rays of his right shoulder showed degenerative changes without evidence of acute bony abnormality. Tr. at 614.

         On September 17, 2014, Plaintiff reported that he had stopped taking Neurontin because it caused nosebleeds. Tr. at 630. His hemoglobin A1c level had increased to 9.7 percent. Id. He complained of neck pain that radiated down his left arm and indicated he had lost five pounds over the prior three-month period. Tr. at 630-31. Dr. Mehta prescribed Ultram for cervical intervertebral disc degeneration. Tr. at 632.

         Plaintiff complained of pain in his bilateral shoulders and right elbow on December 17, 2014. Tr. at 626. He indicated Ultram helped his neck pain, but caused him to feel sleepy. Id. He stated he was taking his insulin as directed, but was not following a diet or exercising. Id. He described his pain as radiating from his neck to his left arm, but indicated it occurred off-and-on. Tr. at 627. Dr. Mehta observed Plaintiff to have decreased range of motion (“ROM”) in his bilateral shoulders that was more significant on the left than the right. Tr. at 628. She prescribed Diclofenac and referred Plaintiff to an orthopedist and a physical therapist. Id.

         On January 21, 2015, Plaintiff complained of increased soreness and pain in his bilateral trapezii and shoulders. Tr. at 677. He rated his left shoulder pain as a seven on a 10-point scale and his right shoulder pain as a three to four. Id. The physical therapist noted that Plaintiff's posture improved significantly following the therapy session. Id.

         Plaintiff complained of frequent headaches and soreness in his bilateral shoulders and both sides of his neck on January 29, 2015. Tr. at 675. The physical therapist noted that Plaintiff reported less shoulder discomfort following the therapy session. Id.

         On February 4, 2015, Plaintiff reported that he was performing home exercises, but was not noticing any improvement. Tr. at 673. The physical therapist noted that Plaintiff's standing posture had improved. Id. She stated Plaintiff's left shoulder external rotation was reduced. Id. She noted that Plaintiff had less difficulty with exercises, but complained of stiffness in his left upper extremity throughout the session. Id.

         On February 11, 2015, Plaintiff reported that he was engaging in home physical therapy exercises three times a week. Tr. at 671. He complained of soreness in his entire upper body. Id. The physical therapist noted that Plaintiff's scapular mobility had improved, but remained limited. Id. She indicated his bilateral external rotation was limited, as well. Id. She noted that Plaintiff had not made significant progress with shoulder flexion and encouraged him to complete home exercises at least once a day to improve ROM. Id.

         On February 25, 2015, Plaintiff indicated he felt sorer and was uncertain as to whether he had improved. Tr. at 668. He rated his left shoulder pain as a four on a 10-point scale and his right shoulder pain as a one. Id. Kashmira Patel, PT (“Ms. Patel”), noted that Plaintiff's upper extremity strength was 4. Id. His ROM was decreased in his neck and bilateral shoulders. Id. Ms. Patel noted that Plaintiff had completed six physical therapy sessions. Id. She stated his ROM had improved, but he continued to have significant deficits. Id.

         On March 4, 2015, Dr. Langan observed Plaintiff to have left shoulder flexion to 160 degrees and abduction to 90 degrees. Tr. at 663. He stated Plaintiff had positive impingement and equivocal Neer's sign, but 5/5 rotator cuff strength. Id. He administered an intraarticular injection of Marcaine, Sensorcaine, and Kenalog. Tr. at 663-64.

         On March 11, 2015, Plaintiff reported that his shoulder pain had decreased, but the injection had significantly elevated his blood glucose level. Tr. at 661. The physical therapist noted that Plaintiff's kyphotic thoracic spine was limiting his scapular mobility and causing difficulty with overhead ROM. I ...


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