United States District Court, D. South Carolina, Greenville Division
REPORT OF MAGISTRATE JUDGE
F. MCDONALD UNITED STATES MAGISTRATE JUDGE.
case is before the court for a report and recommendation
pursuant to Local Civil Rule 73.02(B)(2)(a)(D.S.C.),
concerning the disposition of Social Security cases in this
District, and Title 28, United States Code, Section
plaintiff brought this action pursuant to Sections 205(g) and
1631(c)(3) of the Social Security Act, as amended (42 U.S.C.
405(g) and 1383(c)(3)), to obtain judicial review of a final
decision of the Commissioner of Social Security denying her
claims for disability insurance benefits and supplemental
security income benefits under Titles II and XVI of the
Social Security Act.
plaintiff filed an application for disability insurance
benefits (“DIB”) on February 7, 2014. She also
filed an application for supplemental security income
(“SSI”) benefits on March 7, 2014. In both
applications, the plaintiff alleged that she became unable to
work on September 23, 2013. Both applications were denied
initially and on reconsideration by the Social Security
Administration. On October 28, 2014, the plaintiff requested
a hearing. The administrative law judge (“ALJ”),
before whom the plaintiff and Janette Clifford, an impartial
vocational expert, appeared at a video hearing on June 23,
2016, from Greenwood, South Carolina, considered the case
de novo, and on October 4, 2016, found that the
plaintiff was not under a disability as defined in the Social
Security Act, as amended (Tr. 106-25). The ALJ's finding
became the final decision of the Commissioner of Social
Security when the Appeals Council denied the plaintiff's
request for review on October 23, 2017 (Tr. 1-4). The
plaintiff then filed this action for judicial review.
making the determination that the plaintiff is not entitled
to benefits, the Commissioner has adopted the following
findings of the ALJ:
(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
activity since September 23, 2013, the alleged onset date (20
C.F.R §§ 404.1571 et seq., 416.971 et
(3) The claimant has the following severe impairments:
history of cerebrovascular accident, right knee
chrondromalacia, migraines, bilateral corneal
neovascularization/pannus, obesity, depression, and anxiety
(20 C.F.R. §§ 404.1520(c), 416.920(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,
416.920(d), 416.925, 416.926).
(5) After careful consideration of the entire record, the
undersigned finds that the claimant has the residual
functional capacity to perform no more than light work as
defined in 20 C.F.R. 404.1567(b) and 416.967(b). She can lift
and/or carry 20 pounds occasionally and ten pounds
frequently. She can stand and/or walk six hours in an
eight-hour work day. She can sit six hours in an eight-hour
work day. She can frequently push or pull. She can never
climb ladders, ropes, or scaffolds. She can occasionally
climb ramps or stairs, balance, stoop, kneel, crouch, and
crawl. She must avoid concentrated exposure to excessive
noise and hazards. She can frequently use near and far
acuity. She is limited to simple, routine tasks performed two
hours at a time in a work environment free of fast paced
production requirements involving only simple, work-related
decisions with few, if any, workplace changes.
(6) The claimant is capable of performing past relevant work
as a housekeeper/cleaner. This work does not require the
performance of work-related activities precluded by the
claimant's residual functional capacity (20 C.F.R.
§§ 404.1565, 416.965).
(7) The claimant has not been under a disability, as defined
in the Social Security Act, from September 23, 2013, through
the date of this decision (20 C.F.R. §§ 404.1520(f)
only issues before the court are whether proper legal
standards were applied and whether the final decision of the
Commissioner is supported by substantial evidence.
42 U.S.C. § 423(d)(1)(A), (d)(5) and §
1382c(a)(3)(A), (H)(i), as well as pursuant to the
regulations formulated by the Commissioner, the plaintiff has
the burden of proving disability, which is defined as an
“inability to do any substantial gainful activity by
reason of any medically determinable physical or mental
impairment which can be expected to result in death or which
has lasted or can be expected to last for a continuous period
of not less than 12 months.” 20 C.F.R. §§
facilitate a uniform and efficient processing of disability
claims, the Social Security Act has by regulation reduced the
statutory definition of “disability” to a series
of five sequential questions. An examiner must consider
whether the claimant (1) is engaged in substantial gainful
activity, (2) has a severe impairment, (3) has an impairment
that meets or medically equals an impairment contained in the
Listing of Impairments found at 20 C.F.R. Pt. 404, Subpt. P,
App. 1, (4) can perform his past relevant work, and (5) can
perform other work. Id. §§ 404.1520,
416.920. If an individual is found not disabled at any step,
further inquiry is unnecessary. Id. §§
claimant must make a prima facie case of disability
by showing he is unable to return to his past relevant work
because of his impairments. Grant v. Schweiker, 699
F.2d 189, 191 (4th Cir. 1983). Once an individual
has established a prima facie case of disability,
the burden shifts to the Commissioner to establish that the
plaintiff can perform alternative work and that such work
exists in the national economy. Id. (citing 42
U.S.C. § 423(d)(2)(A)). The Commissioner may carry this
burden by obtaining testimony from a vocational expert.
Id. at 192.
to 42 U.S.C. § 405(g), the court may review the
Commissioner's denial of benefits. However, this review
is limited to considering whether the Commissioner's
findings “are supported by substantial evidence and
were reached through application of the correct legal
standard.” Craig v. Chater, 76 F.3d 585, 589
(4th Cir. 1996). “Substantial evidence” means
“such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion; it consists of
more than a mere scintilla of evidence but may be somewhat
less than a preponderance.” Id. In reviewing
the evidence, the court may not “undertake to re-weigh
conflicting evidence, make credibility determinations, or
substitute [its] judgment for that of the
[Commissioner].” Id. Consequently, even if the
court disagrees with Commissioner's decision, the court
must uphold it if it is supported by substantial evidence.
Blalock v. Richardson, 483 F.2d 773, 775
(4th Cir. 1972).
Before the ALJ
plaintiff was 38 years old on her alleged disability onset
date (September 23, 2013) and 41 years old at the time of the
ALJ's decision (October 4, 2016). She completed high
school and has past relevant work experience as a sewing
machine operator; sales representative, recreation and
sporting goods; housekeeper/ cleaner; and office manager (Tr.
March 9, 2012, the plaintiff underwent a consultative
examination performed by Tony Rana, M.D., for complaints of
pain in her lower extremities, especially in her ankle and
foot over the last ten years. Dr. Rana noted that the
plaintiff reported her pain gradually began in the bottom of
her feet and had progressed to the point that she had
problems bearing weight on her feet and was in daily pain.
Dr. Rana also noted that the plaintiff “walked on the
outside of her feet to prevent significant pain.” She
described the pain as sharp and shooting, experiencing
excruciating discomfort in certain areas of her feet.
Rana stated that the plaintiff had to take multiple
medications to get some relief. She also complained of
problems with her right upper arm. Dr. Rana noted that in
2006, the plaintiff had a ulnar nerve transposition performed
to correct pain in her hand, however, it left her unable to
completely straighten her elbow. She was also unable to
straighten her third, fourth, and fifth fingers and reported
having recurring pain in her arm. Dr. Rana observed that
there was “quite a bit of weakness on this hand”
(Tr. 561-62). Upon physical examination, Dr. Rana observed:
Wrist movements are intact, flexion and extension. There is
no soft tissue masses noted in the forearm, caliber of the
forearm and upper arm is preserved without atrophy. There is,
however, some Dupuytren's type swelling which is very
minimal present over the left hand at the base on the palmar
aspect of the ring finger, which is nontender. There is no
ganglion cyst present of the wrist or hands, other than the
soft tissue Dupuyten's on the left hand. There is also
some suggestion of possible subcutaneous tiny fibroma on the
base of the right thumb over the thenar eminence. There are
no callosities in the hands. Grip on the right side is
examining the plaintiff's feet, Dr. Rana observed:
Tendo Achillis bilaterally are nontender without any
extruding swelling or osteophytic growths. She, however, has
subcutaneous fibromas, right foot greater than the left.
These are present over the plantar feet and a few are present
over the medial aspect of the calcaneum, get more prominent
on standing which is understandable possibly subcutaneous
mobile nature of the growth. These are variable size from a
pea to a dime. There are approximately four or five [sic]
lesions on the right, and about three to four on the left one
present at this time. . . . She is able to demonstrate normal
toe walking for about three to four steps, but heel walking
is decreased. I was afraid because she did present with lot
of swaying and the patient was taking plenty of Lortab and
Valium. I feel that she maybe unsteady. She has therefore a
positive Romberg sign due to having narcotic use.
Incidentally, I also noticed that her pupil was a bit
constricted and reacting as well. . . . It is possible at
this time she has normal dorsalis pedis and posterior tibial
(Tr. 564-65). Dr. Rana's impression was a history of
fibromyalgia without significant muscle tenderness of the
major muscle groups; soft tissue fibromas at the plantar
feet, do not appear infected; chronic use of narcotics and
sedative medications; history of attention deficit disorder;
weak right hand grip secondary to traumatic ulnar neuropathy;
and early semblance of Dupuytren's formation in the left
hand without contracture (Tr. 565).
September 2013, the plaintiff was seen at the Laurens County
Memorial Hospital emergency room with complaints of
left-sided weakness and facial numbness following a migraine
headache the previous day. It was noted that while in the
emergency room, the plaintiff was “found with signs of
possible stroke” and was subsequently admitted to the
hospital. She was examined by Andrey Ilyasov, M.D., who noted
that the plaintiff had been working at the knitting factory
three days prior when she began to feel overheated and
developed a headache that resembled a migraine. She reported
taking “Goody powders” that reduced her headache
from a nine to a five on a scale of one to ten and that she
had improved, but still had weakness. She related a family
history of strokes and was admitted for further workup. She
reported the headache lasted three days until she woke up the
morning she was admitted to the hospital with
“heaviness in her left arm and left leg and then a few
hours later she developed weakness/numbness on the left side
of her mouth.” She also reported associated blurriness
of the left eye. Dr. Ilyasov noted that the plaintiff's
symptoms were mild and gradually improving. He noted that an
EKG was negative for acute myocardial damage, an artery
ultrasound was unrevealing, and an MRI and magnetic resonance
angiography (“MRA”) were normal with no evidence
of a stroke. A brain CT did not reveal evidence of a stroke.
She was ultimately diagnosed with acute cerebrovascular
accident and migraine/possibility of Todd's paralysis.
She was started on statins. She was discharged the next day
and was “strongly advised” to stop smoking. Dr.
Ilyasov further recommended that the plaintiff discontinue
Adderall (Tr. 641-55, 665-68).
her discharge from the hospital, the plaintiff began seeing
neurologist Anthony Holt, M.D. In his initial evaluation of
the plaintiff on October 3, 2013, Dr. Holt noted:
Patient states that approximately one week ago she started
experiencing headaches in the right side of her head. She was
also experiencing left arm and leg weakness at that time. She
was admitted to the hospital and underwent a stroke workup.
The MRI of her brain did not reveal a stroke. She continues
to have some left-sided weakness although it has improved.
She has taken aspirin 81 mg b.i.d. She has unrelenting
headache. It mostly involves the right side of her head
including the temporal and occipital region.
(Tr. 765). On examination, the plaintiff was in no acute
distress and was oriented to person, place, time, and
situation. She had normal language and attention, normal
calculation and concentration as she could perform serial
sevens, and had intact recent and remote memory. She had
normal fund of knowledge, full motor strength throughout her
body, intact sensation, normal reflexes, normal coordination,
and normal gait. No. other neurological abnormalities were
noted on examination. Dr. Holt performed an occipital nerve
block and prescribed Toradol 30mg and Topamax 50mg. Dr. Holt
noted that while all testing results did not point to a
stroke, he opined that the plaintiff most likely suffered
from a “migraine headache with any
hemiplegia/hemiparesis, ” which appeared to be the
equivalent to a migraine. Dr. Holt stated he would
re-evaluate her in one week (Tr. 763-66).
October 9, 2013, the plaintiff returned to Dr. Holt for
followup complaining of continued left-sided weakness and
headaches. She reported no relief with the Topomax. Physical
examination revealed no short term or long term memory loss,
normal judgment and insight, normal hearing and vision,
normal coordination and gait, no language difficulties,
intact facial sensation, full 5/5 motor strength, and intact
reflexes. Dr. Holt ordered a magnetic resonance angiogram
(“MRA”) of the brain and a transcranial doppler.
He also prescribed amitriptyline and instructed her to
discontinue Lortab as he had no doubt this was causing some
of her headaches (Tr. 761).
October 29, 2013, the plaintiff had an initial consultation
at Pain Management Associates in Greenwood, South Carolina.
She reported she had been experiencing pain in her hips,
legs, and feet for several years. She stated that the pain
began gradually and had become worse as of late. She
described the pain as achy, burning, gnawing, stabbing, and
constant. She rated her pain an eight out of ten on the pain
scale. It was noted that at the time of the consultation that
the plaintiff was working as a machine operator and walked on
concrete floors for an eight to ten-hour shift. She reported
that she had seen a podiatrist for plantar fibromas, but
surgery was not recommended (Tr. 746-47).
November 5, 2013, the plaintiff underwent a brain MRA that
was an “unremarkable appearing MRA of the head, with no
evidence to suggest aneurysm, vasospasm, or AV malformation
within the anterior and posterior intracranial
circulations” (Tr. 756, 768-69).
November 11, 2013, the plaintiff underwent a nerve conduction
study that revealed “the unilateral absence of the
right peroneal F wave may be indicative of a more proximal
nerve problem. There was no evidence to suggest an acute or
chronic lumbar radiculopathy or a peripheral
neuropathy.” It was recommended that the plaintiff
undergo an MRI of the lumbar spine to confirm this result
November 13, 2013, the plaintiff was seen for followup by
Sybil Reddick, M.D., at Pain Management Associates. Dr.
Reddick noted that the plaintiff had a stroke since her last
visit and was seeing a neurologist. She continued to report
having sharp, aching, and burning pain and headaches. Upon
physical examination, Dr. Reddick noted that the plaintiff
had metatarsophalangeal joint (“MTP”) callus of
the right and left lower extremities, worse on the left. She
also noted the presence of calf tenderness with mild plantar
fascia origin tenderness and mild plantar fascia distal
tenderness with mild greater trochanteric tenderness. Dr.
Reddick prescribed Neurontin 300mg and hydrocodone 7.5/325
and asked the plaintiff to return in a month (Tr. 739-41).
November 20, 2013, in followup with Dr. Holt, the plaintiff
reported continued left-sided weakness and headaches that
occurred on a daily basis. She confirmed that she had no loss
of consciousness and denied new focal neurological symptoms.
Dr. Holt noted that the plaintiff had tried Topomax,
amitriptyline, and clonazepam without any relief and that she
admitted to depression and anxiety. Dr. Holt stated “at
one time she was taking Abilify [sic] along with an
anti-depressant and this helped her mood significantly. She
is now experiencing shaking spells.” Dr. Holt opined
that although he did not detect any left-sided weakness of
her arm or leg, he believed that her depression and anxiety
were probably the cause of her left-sided weakness as well as
why her headaches were not improving. Dr. Holt subsequently
prescribed Zoloft 50mg as well as Seroquel 50mg to be taken
at night, referred the plaintiff to see a psychiatrist, and
ordered her to undergo an EEG to rule out atypical seizures
due to her sudden onset of shaking in addition to her
left-sided weakness. Dr. Holt opined that “at this
time, I do not see how she can work because of experiencing
headaches on a daily basis.” She was advised to follow
a headache diet and avoid caffeine (Tr. 755-57).
December 11, 2013, the plaintiff returned to Dr. Reddick and
reported that the medication was working well. She stated
that without medicine her pain was a nine out of ten but with
her medicine it was a seven out of ten (Tr. 736).
January 2, 2014, the plaintiff consulted with a mental health
counselor at Western Carolina Psychiatric Associates. At that
evaluation, she was seen by Adrienne Logan. Ms. Logan noted
that the plaintiff was neat and clean in her appearance but
appeared anxious. She stated that the plaintiff reported
depression symptoms of loss of interest, crying spells,
fatigue, poor concentration, indecisiveness, guilt, and
irritability. Ms. Logan also stated that the plaintiff had
anxiety symptoms of worrying, nervousness, palpitations,
shortness of breath, and sense of impending doom and tremors.
The plaintiff stated that she prayed every night because she
was afraid she was going to die. Ms. Logan stated that the
plaintiff did have trouble finding her words but otherwise
appeared logical with sound decision making. Ms. Logan's
diagnosed the plaintiff with depression and anxiety. She
indicated a Global Assessment of Functioning
(“GAF”) score of 55 and stated that the plaintiff
needed an improved ability to cope along with effective
management of her depression and anxiety (Tr. 571-72).
January 7, 2014, the plaintiff reported to Dr. Holt that she
still had significant anxiety and some depression. She stated
that she was unable to focus on tasks and therefore could not
work. She reported that she continued to have headaches on a
daily basis but did not report any new focal neurological
symptoms. She had medically unexplained weakness.
Neurological examination was essentially benign and
documented normal orientation and concentration, intact
recent and remote memory, normal judgment and insight, no
language difficulties, intact facial sensation, full 5/5
motor strength, intact reflexes, and normal coordination and
gait. Dr. Holt increased the plaintiff's Zoloft to 100mg.
He instructed her to remain on the Seroquel at night, but to
wean herself off the Zanaflex and begin taking Depakote ER
500mg at night. Dr. Holt also referred her to another
psychiatrist in hopes that she would be seen soon (Tr.
January 8, 2014, the plaintiff saw Dr. Reddick again with
complaints of increased pain in her left leg. She reported
that the pain increased when anything touched her leg;
therefore, she had been ...