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 her claim for 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 the Commissioner's decision be affirmed.
October 1, 2012,  Plaintiff filed an application for SSI in
which she alleged her disability began on February 1,
2006. Tr. at 138-44. Her application was denied
initially and upon reconsideration. Tr. at 53-84, 93- 94. On
July 28, 2016, Plaintiff had a hearing before Administrative
Law Judge (“ALJ”) Ann G. Paschall. Tr. at 33-52
(Hr'g Tr.). The ALJ issued an unfavorable decision on
October 7, 2016, finding Plaintiff was not disabled within
the meaning of the Act. Tr. at 17-32. 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 1-5.
Thereafter, Plaintiff brought this action seeking judicial
review of the Commissioner's decision in a complaint
filed on November 22, 2017. [ECF No. 1].
Plaintiff's Background and Medical History
was 42 years old at the time of the hearing and had obtained
a GED. Tr. at 36-37. Her past relevant work
(“PRW”) was as a machine operator. Tr. at 38. She
alleges she has been unable to work since October 1, 2012.
Tr. at 38.
2011 to 2014, Plaintiff was a patient of Asa Q. Hatfield,
Jr., M.D. (“Dr. Hatfield”). Tr. at 315-21,
601-05. Dr. Hatfield's treatment notes were handwritten
and terse, but indicated he prescribed Adderall, Lortab,
Valium, and Lorcet for Plaintiff. Id.
February 12, 2012, Plaintiff presented to the emergency care
center (“ECC”) of Self Regional Healthcare with a
laceration to her finger. Tr. at 329-34.
March 12, 2012, Plaintiff presented to the ECC of Self
Regional Healthcare with tooth pain and a headache. Tr. at
April 19, 2012, Plaintiff presented to Sybil Reddick, M.D.
(“Dr. Reddick”), at Pain Management Associates
with complaints of back pain. Tr. at 229-42. Plaintiff
reported her back pain began in 2006, but there was no
precipitating event. Tr. at 231. Plaintiff described the pain
as “achy, crampy, sharp, shooting, and throbbing”
in the lower lumbar region, radiating into both legs.
Id. Plaintiff described the pain as excruciating and
indicated she had other associated symptoms, such as
weakness, numbness, and tingling. Id. According to
Plaintiff, her symptoms were worse with walking, sitting,
standing, lying down, and changing positions. Id.
Plaintiff reported anti-inflammatories, massage therapy,
physical therapy, and chiropractor visits had not improved
her symptoms. Id. She had undergone a lumbar
laminectomy in 2010, but her pain had worsened since the
surgery. Tr. at 233. Dr. Reddick's physical examination
showed the following: mild tenderness in the midline lumbar
area, the left lumbar paraspinal area, and the right
paraspinal area; mild restriction of lumbar lateral flexion
on the right; generalized lower leg edema in both legs;
generalized crepitation in both knees; and restriction in
side-bending to the right in the low back. Tr. at 232-33.
Based on straight leg raise (“SLR”) tests,
Plaintiff was positive for low back and leg pain on the right
and positive for low back pain on the left. Tr. at 233. Dr.
Reddick noted tenderness to palpation over the bilateral,
lower lumbar paraspinals. Id. Although
Plaintiff's posture was altered due to an elevated pelvis
on her right, Dr. Reddick indicated Plaintiff's gait was
intact and she did not use mobility aids. Id. Dr.
Reddick desired to refer Plaintiff to therapy, but insurance
precluded that option and she declined to visit Proaxis in
Greenville due to finances. Id. Dr. Reddick
indicated she would try Gabapentin at a follow-up appointment
and consider a spinal cord stimulator. Id.
1, 2012, Plaintiff underwent a nerve conduction velocity
(“NCV”) and electromyography (“EMG”)
test upon referral by Dr. Reddick. Tr. at 243-49. The results
were abnormal. Tr. at 245. There was a poor response for
Plaintiff's right peroneal motor, as well as left and
right peroneals. Tr. at 246. While there was no evidence to
suggest an acute lumbar radiculopathy, there was a suggestion
of chronic changes on the right at ¶ 4/5 and L5/S1. Tr.
at 245; see also Tr. at 281-91, 417-20.
14, 2012, Plaintiff presented to the ECC at Self Regional
Healthcare after slipping and falling in her bathroom,
injuring herself. Tr. at 346-56. She complained of lower back
pain that went to her toes. Tr. at 349, 351. An x-ray of
Plaintiff's lumbar spine showed a posterior instrumented
fusion at ¶ 5-S1, but no acute injury. Tr. at 353.
Plaintiff was prescribed medications, including Norco,
Toradol, and Prednisone. Tr. at 352, 355. Plaintiff was
discharged after being directed to follow up with the
Carolina Neurosurgery and Spine Center and take her
medications as prescribed. Tr. at 355.
21, 2012, Plaintiff had a magnetic resonance imaging
(“MRI”) scan of her lumbar spine. Tr. at 357-60.
The recorded impressions of the MRI were as follows:
posterior lumbar fusion at ¶ 5 and S1 intact; posterior
surgical decompression at ¶ 4 and L5; and
moderate-severe bilateral L4 foraminal stenosis. Id.
letter to Dr. Hatfield on May 22, 2012, Gregory McLoughlin,
M.D. (“Dr. McLoughlin”) with Carolina
Neurosurgery and Spine Center, indicated Plaintiff's
recent MRI had demonstrated some mild to moderate
degenerative chances at ¶ 4-5 with some foraminal
stenosis, but nothing that would require surgery. Tr. at
250-51; see also Tr. at 609-10. Dr. McLoughlin noted
Plaintiff recently had an EMG and NCV study that demonstrated
“some element of chronic radiculopathy, ” but he
wanted to review the results for himself. Tr. at 250.
Accordingly, Dr. McLoughlin recommended pursuing all
conservative therapies, noting Plaintiff “may require
spinal cord stimulator due to her neuropathic pain that never
really responded to a neural decompressive procedure.”
Tr. at 250; see also Tr. at 267-80, 293-94, 312-13.
29, 2012, Plaintiff saw Dr. Reddick for a follow-up
appointment. Tr. at 252-56. Plaintiff reported the
medications prescribed to her by Dr. Hatfield were not
helping. Tr. at 252. Plaintiff stated her pain was worse, but
she was able to manage activities of daily living
(“ADLs”). Id. Dr. Reddick gave Plaintiff
a trial of Gralise. Tr. at 254. Dr. Reddick also prescribed
Oxycodone, noting that if it was not effective, then
Methadone could be considered. Id.; Tr. at 295-99.
19, 2012, Plaintiff saw Dr. Reddick for a follow-up visit.
Tr. at 257-62. Plaintiff wanted to discuss an increase of her
Oxycodone. Tr. at 257. Plaintiff also reported Gralise had
been effective, especially in combination with Oxycodone, and
she had been able to return to work in a sedentary position.
Tr. at 259. Dr. Reddick increased Gralise and refilled
Oxycodone. Id.; Tr. at 300-307.
10, 2012, Dr. McLoughlin wrote a letter indicating Plaintiff
was struggling with bilateral lower extremity pain, despite a
relatively reassuring MRI scan. Tr. at 311; see also
Tr. at 608. Based on Plaintiff's interest in a spinal
cord stimulator trial, Dr. McLoughlin referred her to pain
management. Id.; Tr. at 425. Dr. McLoughlin further
indicated he was going to start Plaintiff on Gabapentin again
because it had helped her in the past. Id.
August 17, 2012, Plaintiff presented to the ECC at Self
Regional Healthcare with complaints of severe back pain. Tr.
at 362-405. Plaintiff reported she had back surgery two years
prior, and her pain had been getting worse. Tr. at 366.
Plaintiff further reported numbness and tingling in her lower
extremities. Tr. at 367. Plaintiff described shooting pain
into both legs. Id. Plaintiff had difficulty walking
without assistance. Tr. at 368. The physical exam revealed
full range of motion (“ROM”) in all extremities,
but some paraspinous muscle tenderness and mild muscle spasms
in the lumbar spine. Id. Plaintiff was diagnosed
with lumbosacral radiculitis, laminectomy, and chronic low
back pain. Id. Plaintiff was medicated, received
prescriptions for Prednisone, Hydromorphone, and
Promethazine, and discharged. Tr. at 369, 371.
August 23, 2012, Plaintiff was seen by J. Kelby Hutcheson,
M.D. (“Dr. Hutcheson”), in the Pain Management
Center at Self Regional Healthcare, for complaints of back
and bilateral leg pain. Tr. at 406-411. As part of his
examination of Plaintiff's back, Dr. Hutcheson noted a
decreased ROM. Tr. at 413. Plaintiff could flex to 30 degrees
and extend to 10 degrees, causing pain in the L3-S1 region.
Id. Dr. Hutcheson noted Plaintiff was tender over
the L3-L4, L4-L5, L5-S1 facets and the right sacroiliac.
Id. Plaintiff's Patrick exam was positive on the
right. Id. Dr. Hutcheson noted Dr. McLoughlin had
recommended Plaintiff for spinal cord stimulation, but it was
not an option due to her insurance. Id. Dr.
Hutcheson also noted Plaintiff had been on a variety of pain
medications for her pain and had a history of over taking her
medications with Dr. Reddick, which she was cautioned about.
Id. Dr. Hutcheson planned to adjust Plaintiff's
medications, schedule an epidural steroid injection, and
consider spinal cord stimulation if her insurance status
changed. Id.; Tr. at 416. Dr. Hutcheson indicated
that if medications and injections were unsuccessful,
“there may not be much we can do to the help this
patient.” Tr. at 413.
September 13, 2012, Plaintiff had an epidural steroid
injection, and Dr. Hutcheson prescribed MS Contin. Tr. at
441-43, 426-28, 431, 435-37.
September 17, 2012, Plaintiff presented to Self Regional
Healthcare with a fever. Tr. at 444-47. Plaintiff had an
unremarkable chest x-ray. Tr. at 323. A lab report reflected
her A1C as 5.5, which was a good level for Plaintiff. Tr. at
322; see also Tr. at 493-94.
September 26, 2012, Plaintiff presented to the ECC at Self
Regional Healthcare with shortness of breath. Tr. at 448-84.
She was prescribed Azithromycin and discharged. Tr. at 459.
October 17, 2012, Plaintiff saw Jill Gilchrist, N.P.
(“Gilchrist”), in the Pain Management Center. Tr.
at 485-91. Plaintiff reported moderate back pain, which she
described as sharp and achy. Tr. at 489. Plaintiff reported
the MS Contin and Neurontin provided to her through the pain
clinic had significantly reduced her pain. Id.
Plaintiff further reported the injection had made her more
comfortable, providing 75% relief of her pain and lasting for
about two weeks. Id. Plaintiff explained the relief
she received from the injection had nearly worn off, and she
expressed interest in having another injection. Id.
Plaintiff reported the Baclofen had not reduced her muscle
spasms. Id. She had not discontinued Diazepam as it
had been provided to her for mood control, not for muscle
spasms. Id. Gilchrist renewed Plaintiff's
prescriptions for MS Contin and Neurontin, and scheduled
Plaintiff for another injection. Tr. at 490.
November 8, 2012, Plaintiff had an epidural steroid
injection. Tr. at 495-507.
December 20, 2012, Plaintiff saw Gilchrist at the Pain
Management Center. Tr. at 508-21. Plaintiff reported severe
back pain that radiated into her right leg. Tr. at 514.
Plaintiff's injection on November 8, 2012, had provided
some relief, reducing her back and leg pain on the left side
by 50%. Id. Plaintiff reported she could walk, sit,
stand, and perform all ADLs with greater ease. Id.
Plaintiff reported continued right lower extremity pain and
expressed interest in treatment to address the problem.
Id. Plaintiff indicated short-term relief with the
use of Neurontin and ongoing relief with the use of MS
Contin. Id. Gilchrist noted Plaintiff was able to
sit upright with slight distress. Tr. at 514-15. During the
physical exam, Plaintiff's lumbar spine was nontender,
and her SLR was positive on the right. Tr. at 515.
Plaintiff's gait was normal. Id. Plaintiff's
MS Contin prescription was renewed, and Gilchrist requested a
selective nerve root block from the right to be directed at
the right L3-4, 4-5, 5-S1 nerve roots.
January 10, 2013, Plaintiff reported to Self Regional
Healthcare for backpain. Tr. at 522-23.
February 18, 2013, Plaintiff was seen by Gilchrist at the
Pain Management Center. Tr. at 524-38. Plaintiff reported
moderate back pain that radiated into her right hip and leg.
Tr. at 528. Plaintiff described her pain as sharp, achy, and
burning. Id. Plaintiff reported MS Contin reduced
her pain considerably. Id. She denied associated
symptoms. Id. Plaintiff's MS Contin prescription
was renewed. Tr. at 529.
April 18, 2013, Plaintiff saw Gilchrist at the Pain
Management Center for a follow-up visit. Tr. at 540-54.
Plaintiff reported moderate to severe back pain, which she
described as sharp and achy. Tr. at 545. Plaintiff rated her
pain as 0 out of 10 when she was sitting. Id.
Plaintiff indicated MS Contin provided relief, but stated it
was much too sedating and requested a change in medication.
Id. Plaintiff indicated she had past success with
Lortab. Id. Plaintiff's gait was normal. Tr. at
546. Gilchrist indicated Plaintiff had over utilized her
medications, but Plaintiff denied such and stated she must
have lost a few pills. Id. Gilchrist discussed
Plaintiff's urine toxicology test performed in February
that showed large amounts of Hydrocodone. Id.
Plaintiff explained she had taken Hydrocodone provided by her
dentist. Id. Plaintiff expressed interest in
tapering off morphine altogether and promised to abide by all
prescriptive guidelines in the future. Id. Gilchrist
started Plaintiff on Lortab and planned to taper her
5, 2013, Plaintiff presented to the emergency department of
Self Regional Healthcare for bug bites on her shoulder and
reported a fall two weeks prior wherein she caught herself
with her arms. Tr. at 555-84. Plaintiff was “able to
ambulate with a steady gait without assistance and otherwise
exhibit[ed] developmentally appropriate mobility.” Tr.
at 566. Plaintiff had mild to moderate joint pain with
movement of the right scapula and posterior shoulder, and the
overall exam was consistent with a mild to moderate sprain or
strain. Tr. at 568. Plaintiff received prescriptions for
ibuprofen and neomycin sulfate. Tr. at 569.
23, 2013, Dr. Hatfield filled out a form regarding Plaintiff
and her mental status. Tr. at 587. Dr. Hatfield indicated
Plaintiff had been diagnosed with anxiety and she was being
treated with Valium, which had helped her condition.
Id. According to Dr. Hatfield, Plaintiff was
oriented to time, person, place, and situation. Id.
Her thought processes were intact, her thought content was
appropriate, and her mood and affect were normal.
Id. Her attention, concentration, and memory were
all adequate. Id. Dr. Hatfield did not provide any
work-related limitations due to Plaintiff's mental
condition. Id. Dr. Hatfield further indicated
Plaintiff was capable of managing her funds. Id.
November 7, 2013, David N. Holt, M.D. (“Dr.
Holt”), examined Plaintiff to provide a report with
regard to her claim for social security disability. Tr. at
588-97. Dr. Holt reviewed Plaintiff's medical history and
discussed her functional status with her. Tr. at 591-94. He
noted her restrictions to employment were pain and a limited
ability to sit, stand, walk, and do normal tasks. Tr. at 593.
Plaintiff reported her typical daily activities included
self-care, reading, and watching a little television.
Holt performed a physical examination of Plaintiff. Tr. at
589-90, 594-95. Dr. Holt recorded Plaintiff's gait as
mildly antalgic with more weight placed on the left, with a
cane in her right hand, moving slow and careful. Tr. at 594.
Plaintiff's posture was normal. Tr. at 595. She had 2
tenderness at ¶ 1-3, 4 from L4 down through the sacrum,
and 2 at the left and right S-1 areas without transmission.
Id. Plaintiff had normal range of motion in her
elbows, wrists, knees, and hips. Tr. at 589-90. Dr.
Holt's orthopedic examination of Plaintiff revealed the
following limitations: 40/50 degrees for flexion, 30/45
degrees for lateral flexion, and 70/80 degrees for rotation
in her cervical spine; 60/90 degrees for flexion, 20/25
degrees for extension, and 20/25 degrees for lateral flexion
in her lumbar spine; 140/150 degrees for abduction, 140/150
degrees for forward elevation, 70/80 degrees for internal
rotation, and 70/90 degrees for external rotation in her
shoulders; a normal SLR while sitting, but 80/90 and 85/90
degrees for a supine SLR for the left and right legs,
respectively; a normal examination for her left hand (except
for fine manipulation), but a 4/5 grip strength and abnormal
fine manipulation for her right hand; and 4/5 for tandem
walk, heel/toe walk, squat, gait disturbance, and ambulation
with an assistive device. Id.
Holt also performed a neurological examination, noting
presented as a large and overweight woman with a sweet
disposition and endless verbosity. [Review of symptoms]
brought out myriad minor problems. This distracted from the
allegation, the history of which was impressive in its effect
on her abilities. Physical findings were less impressive,
with most of her low back tenderness being sacral, possibly
more related to her falls than to the [degenerative disc
disease (“DDD”)]. Yet her symptoms do sound
progressive, and there has been a neurosurgical attempt to
Id. Dr. Holt summarized his findings as follows:
[Plaintiff] cooperated and gave her best effort. She was
talkative, and tended to have multiple minor complaints. She
is nevertheless disabled by her allegation of DDD, which with
her excessive weight has caused repeated falling in the tub.
Functionally, she needs help with bathing and dressing. She
feels limited to standing for 15 minutes, walking for
¼ mile with cane and a standby wheelchair, sitting for
15 minutes, and lifting just a quart of liquid in the left
hand, the right hand occupied by her cane. It can be carried
for 6 feet. She drives local necessary trips, does minimal
cooking and shopping, and in climbing 2 steps she will need
her cane and the husband's help.
Grip was 4 of 5 on the right, and a strong 5 of 5 on the
left. Gross manipulation was disrupted on the right by low
back pain. Fine manipulation was worse on the right but with
some problem on the left as well. Tinel's was normal, and
Phalen's brought out mild pain in the wrist on the left.
ROM loss was mild at the neck and at the lumbar spine. It was
mild at both shoulders, and [within normal limits] at the
hips. SLR was close to normal bilaterally. All three floor
exercises and squatting were graded 4 of 5. Motor exam was
normal. Sensory exam found deficits in right hand digits 1
and 2, and all the way down the right leg. Uncorrected vision
was 20/30 [right eye] and 20/20 [left eye].
Tr. at 596-97.
November 25, 2013, a state agency medical consultant Adrian
Corlette, M.D. (“Dr. Corlette”), reviewed the
record and found Plaintiff had the following physical
residual functional capacity (“RFC”) for
sedentary work: frequently lift and/or carry 10 pounds; stand
and/or walk (with normal breaks) for 2 hours and sit (with
normal breaks) for about 6 hours in an eight-hour workday;
and limited in pushing or pulling with her lower right
extremity (i.e., occasional use of pedals or foot controls
due to sensory deficits). Tr. at 61-64. In addition, Dr.
Corlette opined Plaintiff had postural limitations
(occasionally climbing ramps and stairs, balancing, stooping,
kneeling, crouching, and crawling, but never climbing
ladders, ropes, or scaffolds) and environmental limitations
(avoiding all exposure to hazards such as machinery or
heights). Id. Dr. Corlette explained the
environmental limitation was due to “Medication SE from
[chronic] narcotic use” and testing positive for
illicit drugs. Tr. at 63. She provided additional explanation
for the RFC by restating pertinent parts of the record and
concluding a medically-determinable impairment exists, as
Plaintiff “does exhibit limitations as demonstrated on
exam, however, the objective medical evidence would suggest
the above RFC would be appropriate with limitations and
restrictions as noted.” Tr. at 63-64.
December 4, 2013, state agency consultant Jody Lenrow, Psy.D.
(“Lenrow”), completed a Psychiatric Review
Technique (“PRT”) Assessment, noting Plaintiff
had mild restrictions of ADLs, difficulties in maintaining
social functioning, and difficulties in maintaining
concentration, persistence, or pace. Tr. at 59-61. A second
state agency consultant, Craig Horn, Ph.D. (“Dr.
Horn”) assessed the same PRT on March 26, 2014. Tr. at
March 30, 2014, Plaintiff presented to the ECC at Self
Regional Healthcare with complaints of left leg and eye pain.
Tr. at 642-64. Plaintiff reported a swollen and painful left
leg, but indicated she only felt pain in her leg when it was
squeezed or pressed. Tr. at 652. It was suspected Plaintiff
had deep venous thrombosis (“DVT”). Id.
The clinician's history indicated Plaintiff was
“reasonably active.” Id. The physical
exam showed lower extremity edema and tenderness on the left.
Tr. at 653. Plaintiff had a Vascular Lower Extremities DVT
Study Procedure, which showed no evidence of acute DVT in her
left extremity. Tr. at 680-83. The limited exam of her right
extremity revealed patent distal iliac and common femoral
veins with no evidence of acute DVT. Tr. at 682. Plaintiff
was diagnosed with strain of the calf muscle and acute
conjunctivitis. Id.; see also Tr. at 653.
She was medicated and given prescriptions before being
discharged. Tr. at 653, 656.
15, 2014, a state agency consultant physician Joseph Geer,
M.D. (“Dr. Geer”), reviewed the updated record
upon Plaintiff's request for reconsideration. Tr. at
77-79. Dr. Geer noted “[t]here [wa]s insufficient
evidence to evaluate the claim, ” but the explanation
of determination stated Plaintiff had failed to provide the
additional evidence requested and other attempts to obtain
the information requested were unsuccessful. Tr. at 77, 80.
Dr. Geer opined Plaintiff was limited to sedentary work based
on the seven strength factors of the physical RFC. Tr. at
25, 2014, Plaintiff presented to the ECC at Self Regional
Healthcare with complaints of shortness of breath, chest
pain, diarrhea, and nausea. Tr. at 684-735. These problems
began three days prior. Tr. at 693. A computed tomography
(“CT”) scan of Plaintiff's abdomen and pelvis
was negative for ureteral calculus or obstruction and showed
normal appearance of her kidneys, ureters, and urinary
bladder, but hepatic steatosis that had worsened from March
2013. Tr. at 735. Plaintiff was diagnosed with spasm of back