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Smith v. Berryhill

United States District Court, D. South Carolina

March 6, 2019

Donna Smith, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant.



         This 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.[1] For the reasons that follow, the undersigned recommends that the Commissioner's decision be affirmed.

         I. Relevant Background

         A. Procedural History

         On 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].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff 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.

         2. Medical History

         a. Medical Evidence Submitted to the ALJ

         On 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.

         On 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. at 360-61.

         On 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. Id.

         On 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.

         On 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.

         On 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. Id.

         On 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 Klonopin. Id.

         On 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.

         On 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 Clonazepam. Id.

         On 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.

         On 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[2] 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 560-61.

         On June 7, 2011, [3] 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. Id.

         On June 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. Id.[4]

         On July 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.

         On January 8, 2013, [5] 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. Id.

         On 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.

         On 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.

         On 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.

         On May 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. Id.

         On July 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.

         On July 9, 2013, dorsal and lumbar spine MRIs were negative for metastatic disease, disc herniation, canal stenosis, and foraminal narrowing. Tr. at 648, 650.

         On July 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.

         On 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 therapy. Id.

         On 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. Id.

         On September 26, 2013, a lumbar spine x-ray showed no acute abnormality. Tr. at 649.

         On 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 medication. Id.

         On 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.

         On 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.

         On 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.

         On 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, [6] 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.

         On 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.

         On 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.

         An 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.

         On June 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.

         On June 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 567.

         On September 22, 2014, Dr. Delfino evaluated Plaintiff after a hospital visit for sciatic pain.[7] 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.

         On 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.

         On 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 falling.” Id.

         Dr. 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 assignments.

Tr. at 436.

         On 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.

         On 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 spine. Id.

         Dr. 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] moderately impaired.


         On 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.

         On 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.

         On 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.

         On 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.

         On 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, 129-31.

         On 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.

         On 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 (“Acetaminophen”). Id.

         On 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.

         On 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.

         On April 29, 2015, a bilateral mammogram showed no suspicious abnormality. Tr. at 459-61, 550-51.

         On June 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.

         On 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.

         On 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 630-32.

         On 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.

         On 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.

         On 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. Id.

         On July 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).

         On July 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.

         On 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.

         On 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).

         On 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 675-78.

         On 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.

         On 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.

         b. Medical Evidence Submitted to Appeals Council[8]

         On 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 ...

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