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 that the Commissioner's decision
April 29, 2014, Plaintiff filed an application for SSI in
which she alleged her disability began on May 29, 2008. Tr.
at 226-35. Her application was denied initially and upon
reconsideration. Tr. at 118, 133, 136-54. On March 8, 2017,
Plaintiff had a hearing before Administrative Law Judge
(“ALJ”) Ann G. Paschall. Tr. at 82-98. The ALJ
issued an unfavorable decision on April 19, 2017, finding
Plaintiff was not disabled within the meaning of the Act. Tr.
at 62-81. 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 1-7. Thereafter, Plaintiff brought
this action seeking judicial review in a complaint filed on
February 7, 2018. [ECF No. 1].
Plaintiff's Background and Medical History
was 53 years old at the time of the hearing. Tr. at 86-87.
She completed high school and had no past relevant work
(“PRW”) for Social Security purposes. Tr. at 74,
86-87. She alleges she has been unable to work since May 29,
2008. Tr. at 65.
Medical Evidence Submitted to the ALJ
August 27, 2008, Davis Mitchell, M.D. (“Dr.
Mitchell”), evaluated Plaintiff for complaints of knee
and back injuries from falling off a deck three months prior.
Tr. at 367-69. She reported the pain was continuous, traveled
down her back into her left leg, and prevented restful sleep.
Id. Dr. Mitchell noted Plaintiff had tight
hamstrings, a full range of motion (“ROM”) in her
hips, and normal knees and ankles, but tenderness in her left
lower back near the sacroiliac (“SI”) joint.
Id. A flexion, abduction, and external rotation
(“FABER”) test and lumbar spine magnetic
resonance imaging (“MRI”) were negative, with no
evidence of disc herniation or spinal stenosis. Tr. at 359,
367-69. Dr. Mitchell assessed low back, hip, and knee pain
and prescribed Lortab. Tr. at 369.
September 2, 2008, Plaintiff reported continued pain in her
knee and back. Tr. at 365-66. Dr. Mitchell noted Plaintiff
had a 1 Lachman test, with medical and lateral joint line
tenderness, but no instability on a stress test. Id.
Dr. Mitchell ordered a left knee MRI, which was negative. Tr.
September 16, 2008, Plaintiff presented to Dr. Mitchell and
reported a “popping” sensation in her left SI
joint, with continued stiffness and pain in her left lower
extremity. Tr. at 362-64. Dr. Mitchell prescribed physical
therapy to strengthen the SI joint and stretch the extremity.
October 1, 2008, a combined nerve conduction study and
electromyography test (“NCS/EMG”) of Plaintiffs
lower extremities revealed no significant lumbosacral
radiculopathy or sciatic neuropathy. Tr. at 373-74.
March 20, 2009, Plaintiff presented to Mark Knifper, M.D.
(“Dr. Knipfer”) and reported she was out of
sciatic pain medication and the prescribing doctor, Phillip
G. Esce, M.D. (“Dr. Esce”), was out of town. Tr.
at 389-90. Dr. Knipfer found Plaintiff had tenderness in her
low back that radiated down her left leg. Id. Dr.
Knipfer assessed panic disorder and sciatic neuralgia and
prescribed Zoloft, Klonopin, Lorcet, and Lyrica. Id.
April 7, 2009, Dr. Knipfer evaluated Plaintiff for complaints
of back pain. Tr. at 386-87. Plaintiff reported she had been
referred to a pain clinic, but had to wait two weeks for an
appointment and requested pain medication. Id. Her
physical examination revealed tenderness near her SI joint,
but a negative straight leg raise (“SLR”) test.
Id. Dr. Knipfer assessed panic disorder and sciatic
neuralgia and prescribed Ibuprofen, Lorcet Plus, and Lyrica.
September 9, 2009, Dr. Knipfer evaluated Plaintiff for
sleeplessness, tearfulness, and an inability to eat. Tr. at
384-85. Dr. Knipfer assessed depression with anxiety,
prescribed Xanax, continued Zoloft, and discontinued
October 7, 2009, Dr. Knipfer evaluated Plaintiff for
complaints of depression, but noted improvement since she
restarted Klonopin and Zoloft, and her “pain [was]
doing OK with meds she takes from Dr. Esce.” Tr. at
382-83. Dr. Knipfer assessed panic disorder and depression
with anxiety and refilled Klonopin. Id.
December 11, 2009, Plaintiff reported crying spells, a sad
mood, and stress due to a divorce. Tr. at 380-81. Dr. Knipfer
assessed low back pain and depression with anxiety, continued
Norco, Flexeril, Ibuprofen, and Zoloft, and prescribed
January 12, 2010, Husam Mourtada, M.D. (“Dr.
Mourtada”), evaluated Plaintiff upon Dr. Knipfer's
request. Tr. at 403-05. Plaintiff reported pain across her
lower back that radiated to the back of her lower left leg
and bottom of her foot with tingling, but no numbness or
muscle spasms. Id. Plaintiff reported sharp pain
that waxed and waned, worsened when sitting, standing,
bending, or lifting, but improved when resting or using
Biofreeze and ice packs. Id. Dr. Mourtada noted
severe focal tenderness of the SI joint, the pain worsened
with flexion and extension, and a positive standing and
marching test on the left, but good ROM in the lumbar spine
and a negative SLR test. Id. Dr. Mourtada discussed
treatment options with Plaintiff, but could not assist her
further due to a lack of insurance, and he recommended a
long-acting narcotic for her back pain. Id.
August 11, 2010, Dr. Esce evaluated Plaintiff for lower back
pain and bilateral leg pain. Tr. at 560-61. Dr. Esce noted
Plaintiff had been treated through Dr. Blackwell's office
and pain management through Pain Management Associates. Tr.
at 560. Plaintiff reported multiple injections with minimal
relief through pain management and that her leg pain had
worsened, causing a burning sensation in her left leg and
lateral portion of her right foot and posterior. Id.
Dr. Esce noted Plaintiff came to an upright position with
minimal difficulty and had a normal station, gait, heel and
toe walk, but had increased pain along the posterior portion
of her right leg with the toe walk. Id. Plaintiff
had a positive right SLR test and decreased sensation over
the posterior portion of her right leg and lateral portion of
her right foot. Id. Dr. Esce informed Plaintiff that
medications were only written postoperatively and recommended
she obtain an MRI and continue pain management. Tr. at
7, 2011,  Plaintiff was evaluated at an emergency
room for complaints of pain in her spine, tailbone, and legs.
Tr. At 539-49, 552-57. Plaintiff reported worsened pain since
she fell several years ago, she was unable to afford her pain
medication for the prior year, and she was “less able
to do her [activities of daily living
(“ADLs”)].” Id. The attending
physician diagnosed sciatica, prescribed medications, and
instructed Plaintiff to follow up with a local pain clinic.
22, 2011, Plaintiff was evaluated at an emergency room for
chronic pain and suicidal ideations, but ambulated with a
steady gait. Id. Plaintiff was provided a pain
rehabilitation referral and prescribed medications.
3, 2011, Plaintiff was evaluated at an emergency room after
she stepped in front of a vehicle in an attempt to harm
herself. Tr. at 497-519. Plaintiff reported knee and chronic
back pain, but she had a steady gait, and an x-ray showed an
unremarkable lumbosacral spine. Id. Plaintiff was
prescribed Prozac. Tr. at 509.
January 8, 2013,  Robert E. Jackson, M.D. (“Dr.
Jackson”), evaluated Plaintiff for complaints of
sciatica that radiated from her left buttock to her left leg.
Tr. at 425. Plaintiff reported she had suffered these
problems for years and “received epidural injections
and multiple other types of Cortisone injections without
relief.” Id. Plaintiff also reported she
“had a problem with [a] Lortab addiction for a number
of years” and “[o]f all the medications that she
took, Lyrica seemed to be the most helpful.”
Id. Dr. Jackson noted Plaintiff had “marked
tenderness” of the left lower back, side notch, and
greater trochanter, assessed sciatica, and prescribed Lyrica.
February 8, 2013, Dr. Jackson evaluated Plaintiff, who
complained of persistent low back pain that radiated to the
left leg without improvement. Tr. at 424. She also reported a
lesion in her right breast. Id. Dr. Jackson noted
Plaintiff had tenderness in the left lower back, just above
the pelvic brim, and palpation there radiated into the left
lateral leg. Id. Dr. Jackson recommended a
computerized tomography (“CT”) scan of the lower
back, noting Plaintiff had new insurance and she would
discuss it with her husband. Id. He also recommended
a mammogram. Id. He increased Plaintiffs Lyrica
dosage and prescribed Percocet. Id.
March 12, 2013, Barry Hird, M.D. (“Dr. Hird”),
evaluated Plaintiff for a newly-diagnosed invasive ductal
carcinoma of the breast. Tr. at 392-94.
March 28, 2013, Sarah Vidito, D.O. (“Dr.
Vidito”), evaluated Plaintiff for breast cancer. Tr. at
672-74. Dr. Vidito discussed treatment options and monitored
Plaintiffs progress throughout her treatment with visits in
April, May, and June. Tr. at 662-70, 685-88.
28, 2013, Plaintiff presented to Dr. Jackson for a follow up
of her sciatica. Tr. at 418. Dr. Jackson noted Plaintiff had
completed three of four chemotherapy sessions for breast
cancer and her CT scan was postponed until her chemotherapy
was complete. Id. Dr. Jackson also noted Plaintiff
obtained Lyrica from the pharmaceutical company, “which
has been a blessing to her, ” and “help[ed]
control the sciatica symptoms to a large degree.”
Id. Dr. Jackson's musculoskeletal exam revealed
Plaintiff still had “marked tenderness in the lower
back in the midline which radiate[d] in the left leg.”
Id. He assessed sciatica, breast cancer, depression,
and anxiety and continued Percocet, Prozac, and Clonazepam.
2, 2013, Dr. Vidito evaluated Plaintiffs breast cancer
treatment. Tr. at 658-61. Dr. Vidito noted Plaintiff
completed four cycles of chemotherapy and had a steady gait,
but reported thoracolumbar pain. Tr. at 661. Dr. Vidito
recommended an MRI. Id.
9, 2013, dorsal and lumbar spine MRIs were negative for
metastatic disease, disc herniation, canal stenosis, and
foraminal narrowing. Tr. at 648, 650.
24, 2013, Amy Baruch, M.D. (“Dr. Baruch”),
produced a surgical pathology report that indicated
Plaintiffs breast did not have a residual tumor after her
lumpectomy. Tr. at 639-41.
August 5, 2013, Dr. Vidito evaluated Plaintiffs breast cancer
treatment. Tr. at 651-57. Plaintiff reported moderate
fatigue, generalized weakness, anxiety, and depression, but
denied an unsteady gait. Id. Dr. Vidito noted
Plaintiff “maintained] a good quality of life and
functional independence” and continued radiation
August 27, 2013, Plaintiff presented to Dr. Jackson's
office for review of her medications and chronic back pain
and was seen by Michael T. Latzka, M.D. (“Dr.
Latzka”). Tr. at 414-15. Dr. Latzka noted Plaintiff
denied malaise and fatigue, but reported lower back pain and
anxiety without panic attacks. Id. Dr. Latzka also
noted Plaintiff appeared in no acute distress and was
“doing well on current medication with no side
effects.” Id. He continued Plaintiffs
medications because her depression and sciatica were stable.
September 26, 2013, a lumbar spine x-ray showed no acute
abnormality. Tr. at 649.
September 27, 2013, Plaintiff presented to Dr. Jackson and
complained of severe sciatica and back pain. Tr. at 412-13.
She reported she could not sit comfortably, had constant pain
that radiated in the left lateral leg to her foot, and Lyrica
and Percocet were inadequate for managing pain, but her mood
was stable using Prozac and Klonopin. Id. Upon exam,
Plaintiff had generalized tenderness of the lower back and
sacral area, palpation of the left sciatic notch reproduced
her pain, and she walked with a pronounced limp favoring the
left leg. Id. Dr. Jackson noted Plaintiff was
“[n]ot doing well” on medication for her sciatica
and referred her to pain management. Id. However, he
noted Plaintiff was stable and doing well on her depression
December 23, 2013, Plaintiff presented to Dr. Jackson and
complained of chronic sciatic pain in the left hip and leg.
Tr. at 410-11. Dr. Jackson noted Plaintiff had no insurance
and could not “avail herself of any other treatment
options at this time other than taking pain
medication.” Id. He also noted Plaintiffs mood
and depression were stable. Id. Upon exam, Plaintiff
had tenderness in the left-sided notch and palpation caused
radiating pain into the left lateral leg. Id. Dr.
Jackson noted Plaintiff was not doing well on her sciatic
medication, referred her to pain management, and was
considering radiation therapy for further treatment of prior
breast cancer. Id.
December 26, 2013, Plaintiff presented to Dr. Vidito for
clinical monitoring and reported a “very poor quality
of life due to lumbar pain.” Tr. at 690-93. Dr. Vidito
noted Plaintiff ambulated unassisted with a steady gait,
advised her to establish a primary care physician, and
instructed her to return in six months. Id.
January 24, 2014, Tena Leonard at Dr. Jackson's office
noted Plaintiff was not doing well on her sciatic medication
and changed Percocet to Norco due to cost. Tr. at 409.
February 18, 2014, Dr. Mourtada evaluated Plaintiff for back
pain that radiated to her feet, with weakness and tingling,
but no numbness. Tr. at 400-02. Plaintiff reported sharp pain
of 7/10 that waxed and waned and worsened when sitting,
standing, bending, or lifting, but improved with rest.
Id. Plaintiff also reported no relief with Percocet,
nerve blocks by Dr. Ringles,  or a spinal injection.
Id. Dr. Mourtada noted Plaintiffs breast cancer was
in remission and she had quit smoking. Id. Plaintiff
was very tender across her lumbar spine with limited ROM and
her deep tendon reflexes (“DTRs”) were 1 for
both ankles and knees, but her gait was normal, she had full
motor strength and no focal sensory deficits in the lower
extremities, and a negative SLR. Id. Dr. Mourtada
explained he could not provide details of a treatment plan
without an updated MRI. Id.
February 20, 2014, Plaintiff was admitted to Spartanburg
Regional Healthcare System after reportedly drinking
antifreeze mixed with iced tea two days prior. Tr. at 694-96.
She acknowledged her actions were a suicide attempt secondary
to years of chronic sciatic pain and headaches that were
“driving [her] crazy.” Id. Vonda
Gravely, M.D. (“Dr. Gravely”), diagnosed
Plaintiff with recurrent major depression, severe with a
recent suicide attempt and generalized anxiety disorder and
admitted her. Id. She noted Plaintiff was
“attention-seeking dramatic and medication
seeking” and complained of poor sleep due to leg pain
throughout the night. Id. She decreased Plaintiffs
Klonopin and Lyrica dosages, and Plaintiff stated it
“made the pain much harder to manage, ”
requesting pain medication before group therapy. Tr. at 695.
When discharged, Plaintiff was fully oriented, pleasant,
cooperative, and fluent with goal-directed speech and had an
average fund of knowledge, improved mood, fair judgment, and
normal memory. Id. Dr. Gravely prescribed
Clonazepam, Prozac, Norco, and Lyrica and referred Plaintiff
to a pain clinic in Greenville, but the clinic declined
seeing her at that time. Id.
March 18, 2014, Plaintiff reported she did not appreciate
that her dosages of Xanax and Lyrica had been decreased. Tr.
at 407-08. Dr. Jackson noted Plaintiff did not appear
depressed or overly anxious, but she continued to complain of
inadequate pain management. Id. He noted Plaintiff
was “[d]oing well” and stable on her depression
medication, but noted she was not doing well on her sciatic
medication. Id. Dr. Jackson continued Prozac, but
modified Clonazepam, Norco, and Lyrica. Id.
ultrasound of Plaintiffs breasts on April 3, 2014, and a
bilateral breast MRI on April 25, 2014, showed benign
findings in the right breast and negative findings in the
left breast. Tr. at 642-47.
7, 2014, Plaintiff presented to a hospital and complained of
chest pain associated with shortness of breath. Tr. at
432-33. Madhavi Allu, M.D. (“Dr. Allu”), noted
Plaintiffs “major complaint was dyspnea with activity,
” she was “a bit vague, ” stating she had
tried to exercise prior to injuring her toe, and was
“very concerned about the fact she has been unable to
pick up her chronic medications.” Id. Dr. Allu
added, “We will note that [Plaintiff] while in the
hospital asked for pain medication frequently. Also at the
time of discharge, she was rather adamant about wanting
another prescription for Klonopin for her anxiety.”
Id. Dr. Allu noted Plaintiffs serial cardiac enzymes
were negative, her tomographic images showed no significant
fixed defect, and her chest x-rays were normal. Id.
20, 2014, Matthew J. Delfino, M.D. (“Dr.
Delfino”), evaluated Plaintiff. Tr. at 565-67. Dr.
Delfino noted Dr. Jackson did not accept Medicaid and
Plaintiff wanted to establish care with him for chronic
lumbago with sciatica and dysthymia. Id. Plaintiff
reported her “pain and anxiety and depression [were]
well controlled on curre[n]t meds except she used to take
baclofen and that provided additional relief.”
Id. Plaintiff also reported arthralgias, stiffness,
and motor disturbances. Id. Plaintiff had tenderness
to palpation (“TTP”) on her back and foot, muscle
spasms in the right lumbar paraspinal, and her left foot was
in an orthopedic shoe with ecchymosis, but a SLR test was
negative and her feet showed no abnormalities. Id.
In addition, she had no sensory abnormalities, no dysfunction
on a motor exam, ascended the table easily, and had normal
gait and stance. Id. Dr. Delfino assessed lumbago
with sciatica and depression with anxiety. He prescribed
Norco, Lyrica, Clonazepam, Fluoxetine, and Meloxicam. Tr. At
September 22, 2014, Dr. Delfino evaluated Plaintiff after a
hospital visit for sciatic pain. Tr. at 562-65. Dr. Delfino
noted Plaintiff “ran out of pain meds and went to the
ER, ” and reminded her that she was to see him for pain
management under their pain contract. Id. Plaintiff
reported trouble with anxiety and depression, but her pain
was “well controlled on current meds” and
reported the same symptoms as her prior visit. Id.
On exam, Plaintiff had no peripheral edema, sensory exam
abnormalities, or dysfunction, but a SLR test was positive,
she had TTP on her back, and muscle spasms of the right
lumbar paraspinal. Id. Her gait and stance were
abnormal, with limping and forward flexion to avoid weight
bearing and full extension of the left hip. Id. Dr.
Delfino assessed depression with anxiety and lumbago with
sciatica. Id. He renewed Plaintiffs prescriptions
for Clonazepam, Lyrica, Norco, and Fluoxetine, and he
scheduled a follow-up appointment. Id.
October 22, 2014, Plaintiff presented to an emergency room in
North Carolina with pain of 10/10 down her back and leg. Tr.
at 489-96. Plaintiff reported she had been out of pain
medication since moving from South Carolina and her pharmacy
was unable to transfer her prescription. Id.
Plaintiff ambulated with a slow, steady gait and was hunched
over. Id. Lumbar spine x-rays reflected “very
minimal” degenerative disease when compared to her July
2011 x-ray. Id. Plaintiff was diagnosed with chronic
pain syndrome and discharged with a referral for chronic pain
management. Tr. at 493.
November 5, 2014, Ernest K. Akpaka, Ph.D. (“Dr.
Akpaka”), a state agency psychologist, performed a
consultative examination of Plaintiff. Tr. at 434-36.
Plaintiff reported her difficulties were depression, anxiety,
prior breast cancer, and knee and back issues from
degenerative disc disease and injuries from a fall in 2008.
Id. She also reported that she “hurt all the
time” and had difficulty with standing, extended
sitting, and ambulating. Id. Plaintiff stated she
was easily overwhelmed, constantly worried, felt nervous and
uncomfortable around people, and had crying spells.
Id. She reported difficulty concentrating and
performing physical activities. Id. Her ADLs
included resting, watching television, and interacting with
family, but she rarely left the house, had minimal hobbies
and interests, did not perform household chores, and slowly
performed self-care activities “to keep from
Akpaka noted Plaintiff had a normal gait, but had constricted
affect and was “moderately anxious” with a
“depressed mood” and tearful. Id. Dr.
Akpaka also noted Plaintiff was “in good contact with
reality” and “alert and responsive” and had
a normal speech rate, rhythm, and volume with a
“coherent, logical, and goal directed” thought
process. Id. Her immediate retention and recall,
recent and remote memory, fund of information, abstract
thinking, and judgment were fair. Id. Dr. Akpaka
assessed major depressive disorder and generalized anxiety
disorder. Id. Dr. Akpaka concluded,
From observations and as reflected on the test data,
[Plaintiff] is capable of understanding, retaining, and
following simple instructions, and sustaining enough
attention to perform simple repetitive tasks and routine, but
her mood symptoms may impede her ability to relate to others
including relating to coworkers and supervisors and limit her
ability to perform tasks that require sustained concentration
and persistence as well as to tolerate the stress associated
with day-to-day regular work activity. She reported
significant medical problems that may place additional
limitations on her ability to perform work-related
Tr. at 436.
November 7, 2014, Plaintiff presented to the emergency room
with lower back pain that radiated down her leg. Tr. at
482-88. Dennis Tranel, P.A. (“Mr. Tranel”), spoke
with Plaintiffs nephew and noted, “[h]e stated that
patient [was] ‘highly addicted' to pain medications
and that she [was] swapping klonopin on the street for
oxycodone.” Tr. at 487. The nephew added Plaintiff
“acted as if she was hurting bad” when EMS
arrived and the family “ha[d] attempted to get her help
for her addiction.” Id. Mr. Tranel had a
“lengthy discussion with [Plaintiff], ” provided
her with a referral, and noted her report that she did not
have money or insurance to obtain her pain medications.
Id. Gwendolyn Carter, R.N. (“Nurse
Carter”), noted Plaintiff complained of sciatic pain of
10/10 and “walk[ed] around bent over holding [her] left
hip area, ” but had a steady and balanced gait when
discharged a half hour later. Id. Plaintiff was
diagnosed with back pain and provided back exercise
instructions. Tr. at 484.
November 18, 2014, Alan Cohen, M.D. (“Dr.
Cohen”), a state agency physician, performed a
consultative examination of Plaintiff. Tr. at 438-41. Dr.
Cohen noted Plaintiff had breast cancer the prior year and
“as far as she knows is free of disease.”
Id. Plaintiff reported sciatic nerve pain with lower
back pain into her left leg that throbbed and ached, making
it difficult to sit or stand for a long period of time.
Id. Plaintiff also reported joint pain, stiffness,
spasms, sensory changes, paresthesias, anxiety, and
depression, but denied other symptoms. Id. Upon
exam, Plaintiffs sensation to pain, touch, and proprioception
and deep tendon reflexes were normal. Id. She had no
muscle tenderness, atrophy, or fasciculations; could sit,
stand, squat, and ambulate; had a steady gait, normal
station, 5/5 muscle strength; and could raise her arms
overhead. Id. Plaintiff also had no spine
tenderness, her SLR test was negative, and she had “no
apparent discomfort” in lying down or rising.
Id. Plaintiff had no edema, her peripheral pulses
were intact for all extremities, and all ROM testing was
normal, except for forward flexion of her thoracolumbar
Cohen's diagnosis and prognosis were stable status post
left lumpectomy and chemotherapy for stage II carcinoma,
stable chronic lower back pain without signs of
radiculopathy, and major depressive disorder, anxiety, and
somatization. Tr. at 440. Dr. Cohen also noted,
[Plaintiff was] able to walk a block at a reasonable pace on
a rough/uneven surface. [Plaintiff was] able to climb a few
steps at a reasonable pace with the use of a single handrail.
[Plaintiff] does have full use of the other upper extremity
for carrying objects. [Plaintiffs] ability to sit, stand,
move about, handle objects, hear, speak, and travel [was] not
impaired. [Plaintiffs] ability to lift and carry [was] mildly
impaired. [Plaintiffs] ability to [maintain] stamina [was]
November 21, 2014, Lillian Horne, M.D. (“Dr.
Horne”), a state agency physician, opined Plaintiff
would be able to lift, carry, push, or pull twenty pounds
occasionally and ten pounds frequently and stand, walk, or
sit about six hours in an eight-hour workday due to her
history of sciatic nerve pain, lower back pain, breast
lumpectomy, and chemotherapy. Tr. at 113-14.
November 24, 2014, Plaintiff returned to the emergency room
and requested prescription refills and a Toradol shot for her
back pain. Tr. at 476-81. Tammy Koonce, R.N. (“Nurse
Koonce”), noted Plaintiff had a steady gait, but
reported chronic pain. Tr. at 479-80. Plaintiff received an
injection, Percocet, Prozac, and Elavil, but was instructed
to follow up with a pain management doctor for long-term
treatment of her chronic back pain and mental health for her
depression. Tr. at 481.
December 1, 2014, Ken M. Wilson, Psy. D. (“Dr.
Wilson”), a state agency psychologist reviewed
Plaintiffs record and provided a psychiatric review technique
(“PRT”) questionnaire and mental residual
functional capacity (“MRFC”) assessment. Tr. at
111-12, 114-16. Dr. Wilson opined Plaintiff had mild
restrictions of ADLs and difficulties in maintaining social
functioning, moderate difficulties in maintaining
concentration, persistence, or pace, and no repeated episodes
of decompensation of extended duration. Tr. at 111. Dr.
Wilson opined Plaintiff “may have occasional deficits
in sustained concentration, but is capable of carrying out
instructions and has the ability to maintain attention and
concentration for 2 hours at a time as required for the
completion of work-related tasks” and she could
“take instructions and directions from a supervisor,
” “get along with co-workers, ” and
“adapt to changes at work.” Tr. at 114-16.
January 4, 2015, Plaintiff presented to the emergency room,
reported back and sciatic pain exacerbated by “heavy
lifting” the prior day, and requested prescription
refills for Klonopin, Amitriptyline, and Prozac. Tr. at
465-75. Plaintiff ambulated with a steady gait upon arrival
and at discharge. Tr. at 470, 472. A lumbar spine x-ray
reflected no acute bony abnormality, fracture, or subluxation
and normal alignment. Tr. at 474. Plaintiff received
prescriptions for Clonazepam, Amitriptyline, and Prozac and
was referred for an appointment with the Cumberland County
Health Department. Tr. at 471-72.
January 13, 2015, Jessica Anderton, Psy. D. (“Dr.
Anderton”), a state agency psychologist affirmed Dr.
Wilson's initial PRT and MRFC assessments that Plaintiffs
mental impairments did not preclude work. Tr. at 125-26,
January 26, 2015, Ellen Huffman-Zechman, M.D. (“Dr.
Huffman-Zechman”), a state agency physician, affirmed
Dr. Horne's initial RFC assessment that Plaintiff was
capable of light work. Tr. at 127-29.
January 31, 2015, James H. Maxwell, M.D. (“Dr.
Maxwell”), evaluated Plaintiff as a new patient with
complaints of depression. Tr. at 452-58. Dr. Maxwell noted
Plaintiff had taken pain medication since 2008, lost her home
in South Carolina, and moved in with her sister in North
Carolina in October 2014. Tr. at 454. Plaintiff reported her
anxiety and depression symptoms improved with medication.
Id. Upon exam, Plaintiff had limited ambulation,
orientation to time, place, and person, good judgment, and
normal mood and affect, recent and remote memory, motor
strength and tone, and gait and station. Id.
Plaintiff also had grossly intact cranial nerves and
sensation, but a left sciatic notch and abnormal lordosis.
Tr. at 455-56. Dr. Maxwell noted Plaintiff felt “great
as long as she [was] on her medication.” Tr. at 456.
Dr. Maxwell assessed depressive disorder, disorder
characterized by back pain, and chronic back pain.
Id. He prescribed Prozac, Clonazepam, Amitriptyline,
Lyrica, and Acetaminophen 300 mg-Codeine
March 6, 2015, Dr. Maxwell evaluated Plaintiff for chronic
back pain that radiated to the left buttock and leg with
tingling, but no numbness of the legs or feet. Tr. at 447-51,
462-63. Dr. Maxwell noted Plaintiff had poor pain control
with Tylenol-Codeine and more Codeine was needed. Tr. at 449.
Plaintiffs physical exam was comparable to her prior exam,
but she had a positive SLR test and a limp that favored one
side. Tr. at 450. Dr. Maxwell assessed chronic back pain,
chronic pain syndrome, degeneration of lumbosacral
intervertebral disc, and long-term drug therapy. Tr. at 451.
He prescribed Acetaminophen, Codeine Sulfate, and Lyrica. Tr.
at 443, 451.
April 4, 2015, Dr. Maxwell evaluated Plaintiff for chronic
back pain, with no tingling or numbness of the legs or feet.
Tr. at 443-47. Plaintiff's physical exam was comparable
to her prior exam. Tr. at 445-46. Dr. Maxwell assessed
chronic back pain, chronic pain syndrome, degeneration of
lumbosacral intervertebral disc, long-term drug therapy, and
screening for malignant neoplasm of breast. Id. He
prescribed Acetaminophen. Tr. at 446.
April 29, 2015, a bilateral mammogram showed no suspicious
abnormality. Tr. at 459-61, 550-51.
16, 2015, Dr. Jackson completed a one-page impairment
questionnaire that stated Plaintiff would not be able to
engage in more than sedentary work and it was most probable
that she would have problems with attention and concentration
sufficient to frequently interrupt work tasks due to sciatica
and radiculopathy since at least 2013. Tr. at 559.
August 7, 2015, Rochelle Carson, P.A. (“Ms.
Carson”), at Dr. Maxwell's office evaluated
Plaintiff. Tr. at 633-37. Ms. Carson assessed a routine
general examination and instructed Plaintiff to keep her next
chronic care appointment. Id.
August 22, 2015, Dr. Maxwell evaluated Plaintiff for anxiety,
depressive disorder, chronic pain syndrome, degeneration of
lumbosacral intervertebral disc, and back pain. Tr. at
630-33, 638. Plaintiff reported her anxiety and depression
did not interfere with her ADLs, she was able to maintain
relationships, she slept well and maintained functionality,
but had high irritability. Tr. at 632. Dr. Maxwell assessed
anxiety and depression and prescribed Clonazepam. Tr. at
November 20, 2015, Amy Lockett, P.A. (“Ms.
Lockett”), at Dr. Maxwell's office evaluated
Plaintiff for anxiety and depression. Tr. at 626-30.
Plaintiff reported her symptoms had improved, they did not
interfere with her ADLs, and she was able to maintain
relationships with no crying spells, but had fatigue, sleep
disturbances, and occasional headaches. Tr. at 628. Upon
exam, Plaintiff ambulated normally, had good judgment,
orientation to time, place, and person, and normal mood,
affect, motor strength, gait, station, recent and remote
memory, and tone with no edema. Tr. at 628-30. Ms. Lockett
assessed stable anxiety, stable depressive disorder, and
chronic back pain, noting Plaintiff was unable to afford
Lyrica at that time and an assistance application and coupon
for Acetaminophen were provided to her. Tr. at 629. In
addition, Plaintiff was scheduled to see Dr. Maxwell on
February 21, 2016. Tr. at 630.
February 22, 2016, Plaintiff presented to the emergency room
with complaints of chest pain due to a cough. Tr. at 585-609.
Medication was administered until Plaintiff found the pain
tolerable. Tr. at 591. A chest x-ray revealed no acute cardio
pulmonary process, and a chest CT angiogram revealed no acute
pulmonary embolus. Tr. at 593-94. The attending physician
found outpatient management appropriate and discharged
Plaintiff. Tr. at 600.
April 2, 2016, Dr. Maxwell evaluated Plaintiff for a chronic
care visit. Tr. at 621-26. Plaintiff reported she
participated in moderate exercise and her pain intensity was
4/10, but her pain was aggravated if she stood for long
periods of time and relieved by rest and ice, not her
medication. Tr. at 623. Plaintiff also reported being without
Clonazepam, which made her nervous with tremors. Id.
Plaintiff was happy and content and noted her anxiety was
under control, but she wanted to discuss her pain medication.
Id. Plaintiff had fatigue and back, joint, and leg
pain, with no numbness or tingling. Tr. at 623-24. She
ambulated normally and had normal tone, but abnormal
strength, numerous trigger points, and was in withdrawal. Tr.
at 624. Dr. Maxwell assessed stable depressive disorder and
chronic pain syndrome. Tr. at 624-25. He prescribed
Clonazepam, Amitriptyline, and Acetaminophen and instructed
Plaintiff to exercise at least thirty minutes most days.
6, 2016, Plaintiff presented to an emergency room due to
weakness, dizziness, and chronic back and sciatic pain. Tr.
at 568-84. She was admitted to the Roxie Detox and
Stabilization Center (“Roxie”) two days prior for
“anxiety (out of meds)” and discharged the next
day with medications. Tr. at 578. Plaintiff reported her
medications were stolen and she “want[ed] chronic pain
med[ications] (morphine).” Id. Medications
were administered and Plaintiff's pain decreased from
10/10 to 0/10. Tr. at 574. Plaintiff was ambulatory and had a
steady gait. Tr. at 571, 573. The attending physician
assessed chronic pain syndrome and anxiety, prescribed
Cephalexin, and referred her for mental health. Tr. at 580,
582-84 (providing lab results).
23, 2016, Kelly Wilkins, N.P. (“Nurse Wilkins”),
at Dr. Maxwell's office evaluated Plaintiff for
depression and back pain. Tr. at 617- 21, 638. Plaintiff
reported she had started a new job and her anxiety and
depression were improving, as they did not interfere with her
ADLs and she was able to maintain relationships, but her back
still hurt “down to her feet.” Tr. at 618-19.
Nurse Wilkins noted Plaintiff had been to Roxie due to
anxiety. Tr. at 619. Upon exam, Plaintiff had good judgment,
was active and alert, ambulated normally, and had normal
gait, station, and curvature of her thoracolumbar, but she
was anxious. Tr. at 620. Nurse Wilkins assessed depressive
disorder and chronic pain syndrome and prescribed Prozac,
Amitriptyline, Lyrica, and Acetaminophen. Id.
August 13, 2016, Nurse Wilkins performed an adult health
examination, described Plaintiff as a “well woman,
” and noted a medical examination without abnormal
findings. Tr. at 613-617.
October 7, 2016, Nurse Wilkins evaluated Plaintiff, who
reported she went to the emergency room earlier that week due
to dehydration. Tr. at 610-13. Plaintiff reported no fatigue,
she was happy or content, had a normal activity level, was
able to move all extremities well, had no numbness, weakness,
or tingling, and no depression or anxiety, but she had joint
and back pain. Id. Upon exam, Plaintiff ambulated
normally and had a normal gait and station. Id.
Nurse Wilkins assessed anxiety and chronic pain syndrome,
prescribed Clonazepam, and ordered additional screening
tests. Tr. at 613, 697-702 (providing various lab results,
with a note that Codeine, Hydrocodone, Morphine, and
Clonazepam tested high).
January 11, 2017, Plaintiff established care at St.
Luke's Free Clinic, and her prescriptions for Prozac,
Amitriptyline, Lyrica, and Clonazepam were refilled. Tr. at
February 3, 2017, Plaintiff presented to the South Carolina
Department of Mental Health for an initial clinical
assessment with Katherine Garland (“Ms.
Garland”). Tr. at 679-84. Plaintiff reported she had
been prescribed Prozac and her moods were stable, but she
desired Klonopin and explained she had obtained it from a
family member since her prior prescription expired in October
2016. Tr. at 680. Plaintiff stated she had panic attacks
while driving, had difficulty focusing, became nervous in
crowds, and was previously diagnosed with post-traumatic
stress disorder. Id. Ms. Garland noted
Plaintiff's panic attacks and depression were well
controlled with medication, but her “thoughts [were]
consumed with not being able to get Klonopin.” Tr. at
682-83. Ms. Garland reviewed the controlled medication
agreement with Plaintiff, urged her to attend therapy
sessions, and noted she would see a psychiatrist for
evaluation, but was not guaranteed to receive a prescription
for Klonopin. Tr. at 680, 683-84.
February 27, 2017, Plaintiff presented to an emergency room
due to injuries sustained in a car accident. Tr. at 703-06. A
work excuse letter stated Plaintiff could return to work on
March 2, 2017. Tr. at 703.
Medical Evidence Submitted to Appeals Council
April 14, 2017, Alfred R. Moss, M.D. (“Dr.
Moss”), conducted an NCS/EMG and noted Plaintiff
complained of “constant bilateral distal lower
extremity pain and paresthesias, more prominent on the
plantar and dorsal surfaces of the feet.” Tr. at 53.
Plaintiff reported “severe burning in her feet, ”
“difficulty sitting, sleeping, and standing due to her
chief complaint, ” and “significant lumbar spinal
pain with radiation into the left lower extremity.”
Id. Dr. Moss noted he had been asked “to
perform an electrodiagnostic examination to differentiate a
possible Lumbar radiculopathy and/or mono or
polyneuropathy.” Id. His impressions were:
1. Technical difficulties due to patient edema may have shown
decrease in motor nerve responses.
2. Mild to moderate bilateral sural sensory neuropathy in
the region of ...