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 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.
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].
Plaintiff's Background and Medical History
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. Tr. at 250.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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. Tr. at 493 and 495.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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
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.
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.
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
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.
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.
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.
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.
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.