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Cruz v. Berryhill

United States District Court, D. South Carolina, Beaufort Division

March 23, 2018

Elaine Cruz, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of the Social Security Administration, Defendant.


          R. Bryan Harwell United States District Judge

         Plaintiff Elaine Cruz (“Plaintiff”) seeks judicial review, pursuant to 42 U.S.C. § 405(g), of a final decision of the Commissioner of the Social Security Administration (the “Commissioner”) denying her claim for disability insurance benefits (“DIB”) under Title II of the Social Security Act (the “Act”). The matter is before the Court for review of the Report and Recommendation (the “R&R”) of United States Magistrate Judge Bristow Marchant, made in accordance with 28 U.S.C. § 636(b)(1) and Local Civil Rule 73.02(B)(2) for the District of South Carolina. The Magistrate Judge recommends affirming the Commissioner's decision. [ECF #27].

         Factual Findings and Procedural History

         This Court is tasked with reviewing the denial of Plaintiff's application for disability benefits. Plaintiff applied for disability insurance benefits (“DIB”) on September 19, 2012, alleging disability due to hip osteoporosis, emphysema, chest pain, a thyroid problem, and back and leg pain. Plaintiff's claim was denied initially and upon reconsideration. After she requested and was granted a hearing, the ALJ denied her claim on September 23, 2015. At the hearing, Plaintiff amended her alleged onset date to October 3, 2013. Plaintiff's request for a review by the Appeals Council was denied, making the findings and determination of the ALJ the final decision of the Commissioner.

         Briefly stated, In May of 2009, Plaintiff was treated by Palmetto Pulmonary and Critical Care Associates and Upstate Cardiology for Plaintiff's complaints regarding recurrent chest pains, shortness of breath, and coronary artery disease. She was diagnosed with chronic obstructive pulmonary disease at that time. [ECF #11-1, Ex. 1F]. Plaintiff underwent a left heart catheterization, selective coronary angiography, and left ventriculargram by John Bittrick, M.D. from May 6, 2008 to May 21, 2009. [ECF #11-1, Ex. 2F]. Plaintiff also sought medical care from October 2009 through November 2010 for left shoulder pain, back pain, and neck pain at Hillcrest Memorial Hospital. [ECF #11-2, Ex. 6F]. From February 2010 until October of 2010, Plaintiff's treating physician, Dr. Mohammed Rashid, treated her for hip pain, lower back pain, arthralgia, hypothyroidism, dyslipidemia, and osteopenia. [ECF #11-2, Ex. 7F]. Dr. Rashid then referred Plaintiff to Dr. Amir Agha, and in August of 2010, Dr. Agha founds her left hip to be tender, but otherwise unremarkable. He diagnosed Plaintiff with left trochanteric bursitis. [ECF #11-2, Ex. 7F]. Dr. Rashid treated plaintiff through September 2012 for hypothyroidism, dyslipidemia, osteopenia, fibromyalgia, bipolar disorder, as well as other mental conditions, such as depression. [ECF #11-2, Ex. 7F], and he again treated her through July 2013 for chest pain, fatigue, dizziness, shortness of breath, depression, suicidal ideations, homicidal ideations, athralgia, neck pain, back pain, osteopenia, and fibromyalgia. [ECF #11-3, Ex. 15F; ECF #11-4, Ex. 21F]. Dr. Rashid prescribed Lortab to Plaintiff to manage her pain. He continued to see Plaintiff through December 2014.

         In June and July of 2013, Plaintiff received physical therapy for her pain. [ECF #11-5 and 11-6, Ex. 22F]. She also sought treatment at the Center for Rehabilitation and Pain Management for fibromyalgia, chronic neck pain, back pain, insomnia, anxiety, chronic headaches, and spondylosis. [ECF #11-9, Ex. 25F]. From April through December of 2014, she was treated for chronic anxiety disorder, fibromyalgia, and opioid dependence at the Center for Rehabilitation and Pain Management. [ECF #11-11, Ex. 28F]. During this time, Plaintiff was also treated by Piedmont Psychiatric Services for depression and anxiety. [ECF #11-2, Ex. 10F]. Her treatment at Piedmont Psychiatric Services continued through March 7, 2013. The medical notes reveal that Plaintiff suffered from crying spells, scattered concentration, and sleep disturbances, as well as reports that she tried to kill herself. [ECF #11-3, Ex. 14F]. She was diagnosed with major depression. Plaintiff also sought treatment for mental illness at Piedmont Health Center through November 2014, where she was diagnosed with borderline personality disorder and admitted medicating with Lortab and Valium. [ECF #11-4, Ex. 18F; ECF #11-7, Ex. 23F].

         From July 21, 2006 through September 24, 2010, Plaintiff was treated at Greenville Memorial Hospital for shortness of breath, nausea, and chest pain on multiple occasions. [ECF #11-1, Ex. 3F]. She presented to the emergency room at Greenville Memorial Hospital at least two times in 2012 for chest pain, left arm numbness, and depression. [ECF #11-3, Ex. 11F]. From May 16, 2013 through July 17, 2013, Plaintiff sought treatment again at Hillcrest Memorial Hospital for neck pain, hip pain, and back pain that she alleged occurred after a fall and was prescribed Lortab. [ECF #11-4, Ex. 20F]. In March of 2014, Plaintiff sought treatment at Greenville Medical Center for chronic interstitial lung disease and pneumonia. [ECF #11-8, Ex. 24F]. She sought treatment In May and September of 2014 at Hillcrest Memorial Hospital for chronic back pain, chest pain, shortness of breath, left hip pain, and lower back pain. [ECF #11-10, Ex. 26F]. Plaintiff presented to Greenville Memorial hospital in February and March of 2015 and was diagnosed with recurrent congestive heart failure, rheumatic heart disease with mitral stenosis, and mitral regurgitation. [ECF#12-1, Ex. 30F]. During this time period she began treatment at Carolina Radiology and at Cardio Thoracic Surgery. Plaintiff underwent miltral valve surgery at Cardio Thoracic Surgery. [ECF #12-2, Ex. 33F]. Plaintiff was treated again in May and September 2015 at Hillcrest Memorial Hospital for chronic lower back pain and a degenerative joint in her foot. [ECF #12-5, Ex. 36F]. She was also treated in June and September of 2015 at Greenville Memorial Hospital for chest pain, chronic back pain, shoulder pain, coronary artery disease, hypertension, rheumatic heart disease, mitral stenosis, pneumonia, pulmonary edema, and blood in her cough. [ECF #12-7, Ex. 37F].

         On January 26, 2011, Matthew Fox, M.D. conducted a consultative examination of Plaintiff and concluded she should avoid concentrated exposure to fumes, odors, dust, gases and poor ventilation, and stated she was limited to medium work. [ECF #11-2, Ex. #8F]. On November 5, 2012, Bruce Kofoed, M.D. conducted a consultative examination and concluded that Plaintiff had bipolar disorder and her stress tolerance and concentration were poor. [ECF #11-3, Ex. #12F]. On November 18, 2012, Roland Knight, M.D. conducted a consultative examination and diagnosed Plaintiff with obesity and polyarticular athralgia. [ECF #11-3, Ex. 13F]. On May 1, 2015, Charles, Parke M.D. conducted a consultative examination shortly after her mitral valve replacement surgery and installation of a pacemaker. He noted that it was premature to evaluate Plaintiff for a disability and that she should be re-evaluated in a few months. However, he provided limitations with respect to her ability to climb, stoop, crouch and crawl. [ECF #12-3, Ex. 34F].

         The ALJ reviewed all of the medical history in the record, as well as Plaintiff's testimony at the hearing. The ALJ subsequently came up with several findings.

         The ALJ's findings were as follows:

(1) The claimant meets the insured status requirements of the Social Security Act through December 31, 2018.
(2) The claimant has not engaged in substantial gainful activitysince October 3, 2013, the amended onset date (20 C.F.R. 404.1571 etseq.).
(3) The claimant has the following severe impairments: bilateral hip bursitis/steoarthritis, osteopenia, rheumatic heart disease status-post March 23, 2015 pacemaker, affective disorder, anxiety disorder and personality disorder (20 C.F.R. 404.1520(c)).
(4) The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. 404.1520(d), 404.1525 and 404.1526).
(5) After careful consideration of the entire record, I find that the claimant has the residual functional capacity to perform sedentary work as defined in 20 C.F.R. 404.1567(a) except she can never climb ladders, ropes, or scaffolds. She can occasionally climb ramps and stairs, crouch and crawl. She can frequently balance, stoop, and kneel. The claimant can occasionally be exposed to hazards associated with unprotected dangerous machinery or unprotected heights. She is able to understand, remember and carry out simple, routine tasks in a low stress work environment (defined as being free of fast-paced or team-dependent production requirements), involving simple work-related decisions and occasional independent judgment skills and occasional work place changes. She must have less than occasional interaction with the general public, and occasional interaction with co-workers. She can respond appropriately to frequent supervision. The claimant should not be openly exposed to controlled ...

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