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Brailsford v. Berryhill

United States District Court, D. South Carolina

February 13, 2019

Sharon Denise Brailsford, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant.


          Shiva V. Hodges United States Magistrate Judge

         This appeal from a denial of social security benefits is before the court for a final order pursuant to 28 U.S.C. § 636(c), Local Civ. Rule 73.01(B) (D.S.C.), and the order of the Honorable Terry L. Wooten, United States District Judge, dated February 23, 2018, referring this matter for disposition. [ECF No. 10]. The parties consented to the undersigned United States Magistrate Judge's disposition of this case, with any appeal directly to the Fourth Circuit Court of Appeals. [ECF No. 9].

         Plaintiff filed this appeal pursuant to 42 U.S.C. § 405(g) of the Social Security Act (“the Act”) to obtain judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying her claim for disability insurance benefits (“DIB”) and 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 court reverses and remands the Commissioner's decision for further proceedings as set forth herein.

         I. Relevant Background

         A. Procedural History

         On March 25, 2014, Plaintiff filed applications for DIB and SSI in which she alleged her disability began on February 8, 2009. Tr. at 194-204. Her applications were denied initially and upon reconsideration. Tr. at 108- 12, 114-19. On February 28, 2017, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Brian Garves. Tr. at 32-66 (Hr'g Tr.). The ALJ issued an unfavorable decision on April 11, 2017, finding Plaintiff was not disabled within the meaning of the Act. Tr. at 15-31. 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 1-6. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on February 6, 2018. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

Plaintiff was 44 years old at the time of the hearing. Tr. at 60. She completed high school. Id. Her past relevant work (“PRW”) was as a machine operator, machine cleaner, and deburrer. Tr. at 40-44. She alleges she has been unable to work since February 28, 2009. Tr. at 194.

         2. Medical History

         Plaintiff presented to the emergency room (“ER”) at Regional Medical Center (“RMC”) on April 18, 2012, with complaints of flu-like symptoms. Tr. at 398. Plaintiff also indicated she had been unable to obtain her diabetes medication. Id. The attending physician diagnosed bronchitis and discharged Plaintiff with prescriptions for Azithromycin, Tessalon Perles, and Metformin. Tr. at 401.

         Plaintiff presented to the ER at RMC on August 16, 2012, with complaints of intermittent left flank pain and elevated blood glucose levels due to an inability to refill medication. Tr. at 371. The attending physician diagnosed uncontrolled non-insulin dependent diabetes, hyperglycemia, and myalgia of left flank area, and he discharged Plaintiff with prescriptions for Glucophage and potassium chloride. Tr. at 378.

         Plaintiff presented to Alan Huellmantel, M.D. (“Dr. Huellmantel”), on May 22, 2013, complaining of right knee pain, chest pain, and intermittent left-hand tingling and numbness. Tr. 424. Dr. Huellmantel diagnosed hypersecretory gastropathy, diabetes mellitus, and localized primary osteoarthritis of the right knee. Id.

         Plaintiff reported right knee pain and swelling to James P. Marro, M.D. (“Dr. Marro”) on May 29, 2013. Tr. at 317-18. He noted good range of motion (“ROM”) with mild effusion and exquisite tenderness over the medial joint line. Id. He assessed arthritis and explained Plaintiff's obesity was a significant factor. Tr. at 319. He noted Plaintiff was not a candidate for steroid injections due to her uncontrolled blood glucose levels, but stated he would re-evaluate once Plaintiff's diabetes was better controlled. Id.

         Plaintiff followed up with Dr. Marro on September 18, 2013, reporting her right knee was still painful and her blood glucose levels were not controlled. Tr. at 320. Dr. Marro assessed degenerative joint disease and prescribed Daypro. Tr. at 321.

         Plaintiff returned to Dr. Marro on February 25, 2014, with complaints of continued right knee pain. Tr. at 322. She noted Daypro provided some relief, but did not last all day. Id. Dr. Marro observed pain and crepitus with ROM, mild effusion, and significant tenderness over the medial joint line. Id. Dr. Marro assessed arthritis and noted Plaintiff had symptoms of peripheral neuropathy needing further evaluation. Id.

         State agency medical consultant Jean Smolka, M.D. (“Dr. Smolka”), reviewed the record on September 26, 2014, and determined the evidence was insufficient to determine the severity of Plaintiff's impairments. Tr. at 79. Dr. Smolka determined Plaintiff was not disabled. Tr. at 81.

         Plaintiff presented to Kevin L. Ray, DPM (“Dr. Ray), on October 1, 2014, with complaints of heel pain. Tr. at 435. Dr. Ray observed pain on palpation on the plantar medial calcaneal tuber of the left heel. Id. X-rays and ultrasound indicated calcaneal spur and inflammation at the insertion of the plantar fascia. Id. He assessed plantar fasciitis, diabetes, and calcaneal spur, and administered injection therapy with Lidocaine, Marcaine, and Dexamethasone. Id.

         Plaintiff presented to Stephen Keen, PA-C (“Mr. Keen”), on October 14, 2014, with complaints of poorly-controlled diabetes and intermittent right knee pain, stable with over-the-counter NSAIDS. Tr. at 446. Mr. Keen assessed non-complicated, uncontrolled diabetes mellitus and unspecified osteoarthrosis. Tr. at 447.

         Plaintiff followed up with Dr. Ray on October 22, 2014, with complaints of heel pain. Tr. at 434. She reported she still had discomfort. Id. An ultrasound indicated inflammation at the insertion of the plantar fascia. Id. Dr. Ray assessed plantar fasciitis and calcaneal spur and discussed treatment options. Id.

         Plaintiff was examined by Monnieque Singleton, M.D. (“Dr. Singleton”), on October 28, 2014, for a follow-up on diabetes mellitus and Plaintiff's report of pain in her finger tips and toes. Tr. at 443. Dr. Singleton assessed uncontrolled diabetes mellitus and polyneuropathy, refilled Metformin, and prescribed Levemir, Glimepiride, and Neurontin. Tr. at 444.

         Plaintiff followed up with Dr. Ray for complaints of heel pain. Tr. at 459. On November 19, 2014, Dr. Ray discussed treatment options and prescribed Medrol and a night splint. Id. On December 11, 2014, Plaintiff reported the night splint provided some relief, but she continued to have discomfort. Tr. at 460. Dr. Ray administered injections. Id. On January 8, 2015, Plaintiff reported the injections were not helpful and she was still experiencing pain. Tr. at 461. Dr. Ray and Plaintiff discussed surgical and non-surgical options, and he advised Plaintiff to continue stretching. Id.

         A second state agency medical consultant, George Walker, M.D. (“Dr. Walker”), reviewed the record on January 9, 2015. He determined Plaintiff's medical conditions did not result in significant limitations in her ability to perform basic work activities and were not severe enough to be considered disabling. Tr. at 104-105.

         On January 12, 2015, Plaintiff presented to Margaret Beth Grossman, D.O. (“Dr. Grossman”), seeking medical clearance for left foot surgery. Tr. at 493. Dr. Grossman noted an abnormal electrocardiogram (“ECG”) and referred Plaintiff for additional cardiac evaluation. Tr. at 494. Plaintiff followed up with Lauren Murphy, P.A. (“Ms. Murphy”), on January 30, 2015. Tr. at 490. Ms. Murphy noted Plaintiff's repeat ECG was normal and cleared her for surgery. Tr. at 490-91.

         On February 2, 2015, Plaintiff presented to RMC for surgical consultation. Tr. at 568. The attending physician cleared Plaintiff for surgery and adjusted Plaintiff's medication to address her uncontrolled diabetes. Id. Plaintiff followed up with Dr. Ray on February 4, 2015. Tr. at 460. Plaintiff reported she was ready for surgical correction and, after reviewing Plaintiff's medical records, Dr. Ray scheduled surgery. Id.

         On February 6, 2015, Plaintiff was admitted to RMC for an endoscopic plantar fasciotomy and calcaneal ostectomy performed by Dr. Ray. Tr. at 506. Plaintiff was discharged with no complications. Id.

         On March 25, 2015, Plaintiff reported to Advanced Diagnostic Imaging Center for imaging of both knees. Tr. at 454. Leland D. Cropper Jr., M.D. (“Dr. Cropper”), indicated imaging of left knee was normal and imaging of right knee revealed mild osteoarthritis in the medial compartment. Tr. at 454-55.

         On April 2, 2015, Plaintiff returned to Dr. Ray. Tr. at 464. Plaintiff reported burning in the bottom of her feet that she attributed to elevated blood glucose levels. Id. Dr. Ray assessed neuritis and prescribed topical creams. Id.

         On April 30, 2015, Plaintiff presented to Dr. Ray with complaints of heel pain. Tr. at 465. Plaintiff reported she was doing better, but continued to experience mild discomfort. Id. Dr. Ray noted an ultrasound indicated minimal inflammation of the left heel. Id. He discussed with Plaintiff her post-operative course and advised her to continue stretching and icing. Id.

         On July 8, 2015, Plaintiff presented to Dr. Marro. Tr. at 607. She reported right knee pain and intermittent swelling with ambulating and bending. Id. Plaintiff indicated ibuprofen provided limited relief and requested an injection. Tr. at 607, 610. Dr. Marro assessed mild crepitus to range of motion, mild to moderate effusion, and generalized tenderness with palpitation over the medial joint line. Tr. at 609. Dr. Marro discussed risks associated with injection, and Plaintiff indicated a desire to proceed. Tr. at 610. Dr. Marro injected one cc of Triamcinolone, two cc of Lidocaine, and two cc of Marcaine into Plaintiff's right knee. Id.

         On October 21, 2015, Plaintiff followed up with Ms. Murphy regarding her diabetes mellitus and medication refills. Tr. at 485. Plaintiff reported fluid accumulation in her legs. Tr. at 485-86. Ms. Murphy assessed type 2 diabetes with hyperglycemia and mixed hyperlipidemia. Tr. at 486. On November 11, 2015, Plaintiff presented to Ms. Murphy, who referred her to a healthy living center for her morbid obesity, uncontrolled diabetes mellitus, and hyperlipidemia. Tr. at 482-83.

         On November 24, 2015, Plaintiff presented to Dr. Marro complaining of right knee pain. Tr. at 614. Plaintiff reported she had a few months' relief from injections, but her pain had returned. Id. Dr. Marro observed mild effusion, tenderness to palpation over the medial joint line, and discomfort with range of motion. Tr. at ...

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