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Hill v. Berryhill

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

January 14, 2019

Lee Ann Hill, Plaintiff,
v.
Nancy A. Berryhill, Acting Commissioner of Social Security, Defendant.

          REPORT OF MAGISTRATE JUDGE

          KEVIN F. MCDONALD UNITED STATES MAGISTRATE JUDGE.

         This 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 636(b)(1)(B).[1]

         The 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.

         ADMINISTRATIVE PROCEEDINGS

         The 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.

         In 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 seq.).
(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) and 416.920(f)).

         The 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.

         APPLICABLE LAW

         Under 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. §§ 404.1505(a), 416.905(a).

         To 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. §§ 404.1520(a)(4), 416.920(a)(4).

         A 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.

         Pursuant 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).

         EVIDENCE PRESENTED

         Evidence Before the ALJ

         The 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. 123).

         On 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.

         Dr. 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 markedly diminished.

(Tr. 564).

         When 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 pulses.

(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).

         In 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).

         After 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).

         On 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).

         On 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).

         On 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).

         On 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 (Tr. 742).

         On 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).

         On 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).

         On 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).

         On 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[2] and stated that the plaintiff needed an improved ability to cope along with effective management of her depression and anxiety (Tr. 571-72).

         On 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. 752-54).

         On 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 ...


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