United States District Court, D. South Carolina, Florence Division
REPORT AND RECOMMENDATION
E. ROGERS, III UNITED STATES MAGISTRATE JUDGE
an action brought pursuant to Section 205(g) of the Social
Security Act, as amended, 42 U.S.C. Section 405(g), to obtain
judicial review of a “final decision” of the
Commissioner of Social Security, denying Plaintiff's
claim for disability insurance benefits (DIB) and
supplemental security income(SSI). The only issues before the
Court are whether the findings of fact are supported by
substantial evidence and whether proper legal standards have
filed an application for DIB and SSI on August 14, 2014,
alleging inability to work since November 1, 1999. (Tr. 20).
Under Albright v. SSA, 174 F.3d 473 (4th Cir. 1999),
the earliest onset date was November 5, 2011. Plaintiff had
amended his onset date to August 14, 2014, and then revoked
the amendment. (Tr. 20). His claims were denied initially and
upon reconsideration. Thereafter, Plaintiff filed a request
for a hearing. A hearing was held on November 16, 2016, at
which time Plaintiff and a vocational expert (VE) testified.
(Tr. 20). Plaintiff was represented by an attorney at that
time. The Administrative Law Judge (ALJ) issued an
unfavorable decision on March 3, 2017, finding that Plaintiff
was not disabled within the meaning of the Act. (Tr. 20-32).
Plaintiff filed a request for review of the ALJ's
decision, which the Appeals Council denied on June 27, 2017,
making the ALJ's decision the Commissioner's final
decision. (Tr. 1-3). Plaintiff, proceeding pro se, filed this
action on July 14, 2017. (ECF No. 1).
Plaintiff's Background and Medical History
was born on December 18, 1971 and was forty-four years old at
the time of the alleged onset. (Tr. 30). Plaintiff completed
his education at least through high school and had past
relevant work experience as a tire technician, construction
worker, landscape laborer, kitchen helper, warehouse laborer,
and auto detailer. (Tr. 30). Plaintiff alleges disability
initially due to back problems, borderline personality
disorder, diabetes, neuropathy, learning disability, and
MRSA. (Tr. 64).
are documents in the record for the same address as Plaintiff
that may be records of his mother or some other relative.
(Tr. 635, 646-47; 1142; 1174). There are multiple bills and
explanation of benefits in the record, which will not be
summarized individually as they are not pertinent to the
issues raised by Plaintiff. It is noted Plaintiff's
medical indemnity plan did not cover many services and
several bills were for thousands of dollars each. (Tr.
648-54, 657, 661-62, 681-84). There is a letter in the record
from Change Healthcare that offered help for patients with
little or no medical insurance. (Tr. 671). In October 2016,
Grand Strand Medical Center denied Plaintiff's charity,
write-off request because he had not sent the financial
assistance application. (Tr. 680). Also, Plaintiff was in the
Welvista Medication Assistance program. (Tr. 685).
are records in 2010, outside of the applicable time period,
that mention Dr. King: “In March, while at South Strand
emergency room, his AST was 36, ALT 39, bilirubin 1.4, and
alkaline phosphatase 81. These are again all essentially
normal with the exception of the bilirubin. He states that
Dr. King, who now is apparently dead and with whose office we
have been unable to get records, apparently he was doing some
evaluation for ‘high enzymes' as well. He has never
had a liver biopsy. He has not had an ultrasound until just
during his last hospitalization. He has never placed on any
medications. There was no diagnosis made in the past, but he
reports that his elevated enzymes prevented him from working
with a local fire department.” (Tr. 805-06). In 2010,
Plaintiff had a normal CT scan with no hepatic mass seen.
(Tr. 830). A 2010 MRI showed mild splenomegaly, a small
simple cyst in the right lobe of the liver, mild diffuse
fatty infiltration throughout the liver, no focal hepatic
lesions or biliary obstruction, and no adenopathy. (Tr.
832-33). In 2010, Plaintiff was seen for elevated LFTs, with
history stating: “He had previously been followed by
Dr. John King locally and apparently has not been seen by him
in some time as his physician has died and he was not even
aware of that.” (Tr. 834).
are no relevant records for 2011 from November 5, 2011, the
onset date, forward.
show Plaintiff worked in 2012 for at least ten different
employers. (Tr. 268).
January 22, 2012, Plaintiff was seen in the emergency room.
(Tr. 749). Plaintiff reported sharp chest pain. Plaintiff was
lifting dishes at work. EKG was unremarkable. History was:
“Noteworthy for elevated liver function tests, which
had been worked up in the past with an MRCP; hepatitis
studies, ultrasound, all which were negative and just
basically showed fatty liver.” (Tr. 749). Medications
were Lantus, metformin (brand name Glucophage), and
ibuprofen. Diagnosis were atypical chest pain, diabetes, and
elevated liver function tests with “total bili 2.6, AST
of 54, ALT of 536.” (Tr. 750). The emergency room
doctor further stated: “As far as the diabetes, he
states that his sugars normally run in the low 100s, both in
the morning and in the evening, and I suggested that given
his sugars are running so well, just to stay on Lantus and
stop his Glucophage, since this works through the liver, and
hopefully this will help his elevated liver function test. I
also advised him to try to seek out a physician, locally.
During his last admission in 2010, his hepatitis studies were
negative, as well as hemochromatosis study. He never did
follow up with Dr. Ballou. He was advised to stop his
Glucophage, continue his Lantus, and follow up with a local
physician.” (Tr. 750). Plaintiff stated a family
history of two sisters dying from polycythemia. “He
does not know if he has this diagnosis himself, although, he
has been admitted in the past with quite elevated
LFTs.” (Tr. 752). A work excuse from Waccamaw Community
Hospital dated January 22, 2012, states Plaintiff could
return to work on January 24, 2012. (Tr. 527).
March 24, 2012, Plaintiff was seen in the emergency room with
complaints of a wound infection. (Tr. 970). Plaintiff was
given a work excuse for the same day. (Tr. 972).
10, 2012, Plaintiff was seen in the emergency room for a wasp
sting with early infection. (Tr. 966-69).
hospital work excuse directed to Olive Garden dated June 13,
2012, states Plaintiff must elevate his right hand due to
burns. (Tr. 528).
23, 2012, Plaintiff was seen in the emergency room for cold
symptoms. (Tr. 742). Past history reported by Plaintiff was
polycythemia. Plaintiff was given a work note. (Tr. 744).
Chest x-ray was normal. (Tr. 748).
11, 2012, Plaintiff was seen in the emergency room for fever.
(Tr. 958). Strength upon exam was 5/5. (Tr. 959). Plaintiff
was given a two day work release. (Tr. 963).
hospital work excuse dated August 4, 2012, stated Plaintiff
could work with the accommodations of no lifting more than
ten pounds, ground level work, and no repetitive bending,
stooping, squatting, pushing, jerking, twisting, or bouncing.
September 12, 2012, Plaintiff received a work excuse for one
day due to dental pain. (Tr. 1056).
October 3, 2012, Plaintiff was seen in the emergency room for
foot pain; he dropped a cement block on his foot. (Tr. 954).
Plaintiff was out of metformin. (Tr. 954). Plaintiff was
diagnosed with a foot bruise. (Tr. 955).
December 8, 2012, Plaintiff presented to the emergency room
for a right chin abscess; it was incised and drained. (Tr.
December 11, 2012, Plaintiff presented to the emergency room
for a wound recheck for a right chin abscess. (Tr. 733).
Plaintiff stated he was taking Lantus, vibramycin, and
Vicodin. Plaintiff had no complaints. (Tr. 733). Plaintiff
was given a refill of Glucophage and increased Levemir
prescription; Plaintiff had a blood sugar result of 420. (Tr.
734). Plaintiff had asymptomatic, insulin-dependent
hyperglycemia. (Tr. 734).
February 18, 2013, Plaintiff was seen by Dr. Adler, reporting
he needed a physical and mental evaluation for vocational
rehabilitation. (Tr. 853). Plaintiff reported arm pain, back
pain, headache, and leg pain. (Tr. 854). Upon exam, Plaintiff
ambulated normally and was healthy appearing. Plaintiff had
normal mood, affect, and memory. (Tr. 854). Upon palpation,
Plaintiff's liver was nontender. (Tr. 855). Motor
strength and tone was normal. Plaintiff had limited range of
motion in joints and back and lower extremities were tender.
(Tr. 854). Plaintiff reported as problems: “hepatitis
delta without mention of active hepatitis b disease with
hepatic coma, ” diabetes, arthritis, polycythemia,
secondary, disorders of autonomic nervous system, and chronic
pain syndrome. (Tr. 853). Plan was aggressive treatment for
diabetes. Plan was pain management and limit physical
activity. (Tr. 855).
March 3, 2013, Plaintiff was seen in the emergency room for
high blood sugar after being arrested. (Tr. 950). His back
was nontender with full range of motion.
September 15, 2013, Plaintiff was seen in the emergency room
for an abscess. (Tr. 945).
records from a detention center, under assessment for liver
and hepatitis, it states “no;” it states
“yes” for diabetes. (Tr. 881).
show Plaintiff earned over $8, 000 working in 2014 for at
least nine different employers. (Tr. 259, 267).
2, 2014, Plaintiff was seen in the emergency room for an
abscess. (Tr. 939). Plaintiff reported being out of insulin
for two months. Upon exam, his abdomen was nontender. (Tr.
939). A work excuse from Conway Medical Center dated May 2,
2014, stated Plaintiff could return to work on May 4, 2014.
(Tr. 530, 942).
19, 2014, Plaintiff was seen in the emergency room. (Tr.
932). Plaintiff complained of acute leg pain beginning the
prior week. Strength was 5/5. (Tr. 933). Plaintiff had normal
range of motion in back. (Tr. 933). Discharge diagnosis were:
abscess, hyperglycemia, incision, drainage, and lumbosacral
radiculopathy. (Tr. 935). Work release was to be that same
day. (Tr. 935). Imaging showed diffuse spondylosis with disc
space narrowing and osteophyte formation with facet
hypertrophy greatest at L4-S1. Impression was diffuse
degenerative change. (Tr. 938).
August 16, 2014, Plaintiff presented to the emergency room.
(Tr. 927). Plaintiff reported he had back pain and could not
get Medicaid. (Tr. 927, 1022). Upon exam, Plaintiff had
painful range of motion of back without tenderness or spasm.
(Tr. 927). Discharge stated lumbosacral strain and chronic
back pain. (Tr. 929). A work excuse from Conway Medical
Center dated August 16, 2014, stated Plaintiff could return
to work on August 16, 2014. (Tr. 529).
October 25, 2014, Plaintiff's mother completed a function
report for Plaintiff. (Tr. 390). Plaintiff reported he had
uncontrolled diabetes and was unable to buy medication. (Tr.
381, 383). Plaintiff reported he was diagnosed by Dr. John
King(deceased) with polycythemia and has been unable to get
records proving. (Tr. 381). Plaintiff alleges his liver is
very compromised and his lower spine is deteriorated.
Plaintiff reported his knees collapse and his eyesight has
worsened. (Tr. 381). Plaintiff alleged he could make his bed,
take out the trash, wash clothes, bathe, and shop. (Tr. 382).
Plaintiff reported dizziness. (Tr. 382). Plaintiff does not
cook due to back, leg, and foot pain. Plaintiff cannot stand
for long. (Tr. 383). Plaintiff does light cleaning thirty
minutes per week. Plaintiff can drive but not at night or
when dizzy. (Tr. 384). Plaintiff cannot manage an account due
to his learning disability. (Tr. 384). Plaintiff rarely
fishes due to walking and standing. (Tr. 385). Plaintiff
reported he talks on the phone, texts, and has short visits
with others. (Tr. 385). Plaintiff can walk two blocks. (Tr.
386). Plaintiff cannot pay attention long. (Tr. 386).
Plaintiff has difficulty getting along with others. (Tr.
387). Plaintiff reported management being afraid he would
hurt a coworker. (Tr. 389). Plaintiff stated he needed a knee
brace and glasses but could not afford. (Tr. 389). Plaintiff
reported he had been turned down several times because his
records from Dr. John King have been destroyed and Dr. John
King was going to send him to MUSC for a blood draining
procedure. Plaintiff reported his sister died from
polycythemia at age 42. (Tr. 390).
November 11, 2014, Plaintiff filled three prescriptions:
mupirocin, metformin, and Clindamycin. (Tr. 531). On November
11, 2014, Plaintiff was seen in the emergency room for leg
swelling. (Tr. 1018). Diagnosis were cellulitis, abscess, and
hyperglycemia. Plaintiff was given a two day work release
form. (Tr. 1020).
December 15, 2014, Plaintiff presented to the emergency room
with complaints of lumbar pain with onset of one week. (Tr.
1029). Plaintiff reported that he did a lot of bending and
lifting for his job. (Tr. 1041). There is a two day return to
work excuse dated December 18, 2014. (Tr. 1079, 1041).
December 22, 2014, Plaintiff was examined by state agency
examiner, Dr. Akoury. (Tr. 1057-60). Plaintiff reported he
suffered from chronic pain in his lower back and neuropathy
with numbness. Plaintiff reported last working in 2014. (Tr.
1057). Plaintiff exhibited slow mental functioning and that
Plaintiff was “unable to give best effort during
examination.” (Tr. 1058). Plaintiff had no tenderness
upon exam of abdomen. Examination of Plaintiff's
musculoskeletal and extremities was normal with full range of
motion and normal gait. (Tr. 1059). Impression was
“neuropathy by history, chronic lower back pain,
diabetes, and slow mental functioning.” (Tr. 1059).
“Patient is capable to take care of self, he is however