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Stewart v. Berryhill

United States District Court, D. South Carolina

April 11, 2019

James Ansel Stewart, Plaintiff,
v.
Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant.

          REPORT AND RECOMMENDATION

          SHIVA V. HODGES UNITED STATES MAGISTRATE JUDGE.

         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) to obtain judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying his claim for Disability Insurance Benefits (“DIB”). 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 the Commissioner's decision be reversed and remanded for further proceedings as set forth herein.

         I. Relevant Background

         A. Procedural History

         On November 6, 2014, Plaintiff filed an application for DIB in which he alleged his disability began on February 26, 2014. Tr. at 196-99. His application was denied initially and upon reconsideration. Tr. at 93, 102, 117-18, 121, 126. On April 4, 2017, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Jerry W. Peace. Tr. at 39-74 (Hr'g Tr.). The ALJ issued an unfavorable decision on July 13, 2017, finding Plaintiff was not disabled within the meaning of the Act. Tr. at 13-35. 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 of the Commissioner's decision in a complaint filed on June 27, 2018. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 45 years old at the time of the hearing. Tr. at 48. He completed the twelfth grade. Tr. at 49-50. His past relevant work (“PRW”) was as a combination welder, heavy equipment operator, and dump truck driver. Tr. at 66-67. He alleges he has been unable to work since February 26, 2014. Tr. at 196-99.

         2. Medical History[1]

         a. Evidence Submitted to the ALJ

         On April 23, 2013, Plaintiff presented to Theresa Bishop, M.D. (“Dr. Bishop”), at Western Carolina Psychiatric Associates (“Western Carolina”), for a follow-up visit of recurrent depression and irritability. Tr. at 770-72. Plaintiff reported he was “overall doing significantly better than his last visit” and was less depressed. Id. Dr. Bishop noted Plaintiff reported low energy, but described “multiple enjoyable activities.” Id. Dr. Bishop assessed dysthymic disorder and recurrent major depression in partial remission. Id.

         On July 19, 2013, Plaintiff presented to Emerald City Chiropractic for neck and back pain and completed two therapeutic exercises. Tr. at 331; see also Tr. at 332-43 (providing four visits between January and June 2011).

         On July 22, 2013, Plaintiff presented to Dr. Bishop for depression, anxiety, and irritability. Tr. at 773-75. Plaintiff reported he was “[n]ot doing well, ” he had been more depressed and irritable over the prior two months, and he experienced stress at work, especially when he traveled out of town. Id. Plaintiff also reported he felt tired, had frequent headaches, and worsened concentration. Id. Dr. Bishop found Plaintiff had an adequate fund of knowledge and a linear thought process that was logical and goal-directed. Id. Dr. Bishop also found Plaintiff was appropriate, active, and alert, but his mood and affect were anxious, depressed, and restricted. Id. Dr. Bishop assessed dysthymic disorder, recurrent major depression in partial remission, and generalized anxiety disorder. Id.

         On August 1, 2013, Plaintiff presented to Dr. Bishop for follow up. Tr. at 776-78. Plaintiff reported he was “doing much better, ” was “less irritable, ” had not lost his temper, and his energy, concentration, and enjoyment had improved. Id. Plaintiffs physical and psychiatric exams were normal. Id. Dr. Bishop assessed dysthymic disorder, generalized anxiety disorder, and recurrent major depression in partial remission and continued his medications. Id.

         On September 5, 2013, Plaintiff presented to Dr. Bishop and reported “doing pretty well overall.” Tr. at 779-81. Dr. Bishop found Plaintiffs physical and psychiatric exams were normal, his mood and affect were less depressed and anxious, and he was progressing slowly towards his goal. Id. Dr. Bishop assessed dysthymic disorder, generalized anxiety disorder, and recurrent major depression in partial remission and continued his current medications. Id.

         On October 31, 2013, Plaintiff presented to Dr. Bishop and reported his mood had “been pretty stable, ” work was “going okay” and tolerable, he hunted with family and friends recently, and he continued to volunteer at the fire department. Tr. at 782-84. Plaintiffs physical and psychiatric exams were normal. Id. Dr. Bishop noted Plaintiffs anxiety and depression had improved and continued his current medications. Id.

         On January 22, 2014, Plaintiff presented to Family Healthcare Ware Shoals (“Ware Shoals”). Tr. at 348. His examination was normal for all results, including judgment, memory, and mood. Tr. at 350-51. Heather Owens, N.P. (“Nurse Owens”), assessed lumbar strain and prescribed Methylprednisolone. Tr. at 351.

         On February 26, 2014, Plaintiff presented to Dr. Bishop for follow up of his depression and anxiety. Tr. at 785-87. Dr. Bishop noted:

[Plaintiff is] [n]ot doing well. Very depressed. Mood swings from depressed to anxious to angry, changing within few hours. Has broken things out of anger. Wishes he could run away from everything and everybody. Feels that he has given up. Has had thoughts of cutting himself. Would kill himself if he could figure out a way to do this that would not look like suicide . . . very stressed by working out of town 2-3 weeks per month . . .

Tr. at 785. Plaintiff also reported worsened depression, anxiety, sleep, energy, concentration, and enjoyment with increased suicidal thoughts. Id. Dr. Bishop noted Plaintiff exhibited normal concentrating ability, intact memory and judgment, and adequate fund of knowledge, with a linear thought process that was logical and goal-directed. Id. However, Plaintiffs mood and affect were anxious, depressed, and restricted. Id. Dr. Bishop became concerned for Plaintiffs safety and scheduled an appointment for him to be admitted to the Carolina Center for Behavioral Health (“Behavioral Health”). Tr. at 787.

         Later on February 26, 2014, George Jacob, M.D. (“Dr. Jacob”), at Behavioral Health, noted:

[Plaintiff] states he has “thoughts of suicide” and “thoughts of shooting other people” . . . [Plaintiff] states “if something goes wrong I just go to pieces. If I'm having a good day I don't have these thoughts.” [Plaintiff] states he does not like to be around a lot of people, he does not like loud noises. He endorses having racing thoughts in the past.... [Plaintiff was] unsure if he hears voices or if it is [his] conscience. . . . [Plaintiff] states he has homicidal thoughts and anger, he states he wants to shoot people, but no one in specific. . . . [Plaintiff] reports feeling helpless, he does not have hope for the future. He reported feeling worthless. . . . His concentration sometimes is impaired . . . [Plaintiff] reports increased anxiety regarding work situation and finances. [Plaintiff] stated that he has been taking his medications as prescribed. [Plaintiff] has impaired [activities of daily living (“ADLs”)].

Tr. at 314, 317. Plaintiff “was admitted voluntarily for treatment of increased depression and agitation, he was stabilized through med[ication] management, group work, and psychoeducation, ” and “appeared to be at baseline [at] discharge” on March 5, 2014. Tr. at 314-15, 314-27. Plaintiff was discharged with medications, including Trazadone, Hydrochlorothiazide, Testosterone, Effexor, and Wellbutrin, and appointments to see his psychiatrist, Dr. Bishop, and his primary care provider, John Baker, M.D. (“Dr. Baker”). Tr. at 315. His GAF[2] score was 25[3] at admission and 50[4] at discharge. Tr. at 316, 319.

         On March 17, 2014, Plaintiff presented to Dr. Bishop for follow up after his recent hospitalization. Tr. at 788-90. Plaintiff reported he had been doing well until he became more anxious that day. Id. Plaintiff also reported panic attacks and nervousness, but “somewhat improved” depression symptoms. Id. Dr. Bishop observed Plaintiff's mood and affect were anxious, restricted, and less depressed, but he was appropriate, active, and alert. Id. Dr. Bishop also observed Plaintiff's judgment and insight were intact with a linear, logical, goal-directed thought process. Id. Dr. Bishop noted Plaintiff's depression and anxiety were improved, but not resolved and his anxiety worsened as he contemplated return to work the following month. Id.

         Later on March 17, 2014, Plaintiff reported to Emerald City Chiropractic for occasional neck pain and frequent low back pain and completed two therapeutic exercises. Tr. at 330.

         On March 18, 2014, Plaintiff presented to Ware Shoals to follow up on his “nerves” and chest pain. Tr. at 352-57. Plaintiff reported he was scheduled to return to work on April 3, 2014, felt overwhelmed, and had “bad thoughts, ” including suicide. Id. Dr. Baker noted Plaintiff appeared depressed and his general appearance was abnormal. Tr. at 353-54. Dr. Baker assessed morbid obesity, depression, gastroesophageal reflux disease (“GERD”), attention deficit disorder, lumbosacral disc degeneration, and fatigue. Tr. at 354, 386-92. An electrocardiogram (“ECG”) was abnormal. Tr. at 393-95.

         On March 19, 2014, Dr. Bishop completed a medical certification for Plaintiffs employer under the Family Medical Leave Act and stated he would not be able to return to work due to his major depression and generalized anxiety disorder. Tr. at 751-53. Based on her treatment of Plaintiff, Dr. Bishop estimated his period of incapacity began on February 26, 2014, and would end on April 3, 2014, with the additional treatment scheduled, including medications and weekly sessions. Id.

         On April 2, 2014, Plaintiff presented to Dr. Bishop and reported his overall mood was better, he felt more relaxed, and enjoyed things more often. Tr. at 791-93. Dr. Bishop noted Plaintiff's memory was intact, his attention and concentration were normal, he displayed adequate knowledge, he exhibited normal movement, his mood and affect were less depressed and anxious, his thought process was logical and goal-directed, and he exhibited no abnormal thoughts. Id. Dr. Bishop discussed Plaintiff's job, noting it had been the source of several depressive episodes. Id. Dr. Bishop concluded Plaintiff's depression and anxiety had improved overall, but he was overwhelmed at the thought of returning to work, and she extended his medical leave. Id., Tr. at 750.

         On April 17, 2014, Plaintiff presented to Ware Shoals for a check-up. Tr. at 358-63. Dr. Baker noted Plaintiff appeared depressed and his general appearance was abnormal. Id. Dr. Baker assessed benign essential hypertension, GERD, morbid obesity, acute prostatitis, depression, endocrine disorder, and fatigue, and he modified Plaintiff's medications. Id.

         On April 18, 2014, Dr. Bishop completed an attending physician's statement of continued disability for mental health claims through Plaintiff's employer. Tr. at 748-49. Dr. Bishop noted Plaintiff had been diagnosed with recurrent major depression, generalized anxiety disorder, and had a GAF score of 50. Id. Dr. Bishop noted Plaintiff was moderately groomed, he was cooperative, his thought process was logical, his insight was good, his psychomotor activity was within normal limits, but he had reading and writing difficulties and his attention and concentration had worsened with recent depression, with some improvement. Id. Dr. Bishop extended Plaintiffs leave from work for an additional six weeks because she did not feel Plaintiff could return to work, as the thought of returning increased his anxiety so much that he became suicidal. Id. Dr. Bishop noted Plaintiff would continue treatment with Michael Smith, M.D. (“Dr. Smith”), because she was leaving the practice. Id.

         On May 9, 2014, Plaintiff presented to Carolina Orthopaedic Center due to right shoulder pain upon referral by Dr. Baker. Tr. at 473-76. Plaintiff reported he had been excused from work due to depression issues and he injured his arm when he flipped a four-wheeler the prior month. Tr. at 475. Alan G. Posta, Jr., M.D. (“Dr. Posta”), performed a physical exam and reviewed radiographs and a magnetic resonance image (“MRI").[5] Tr. at 475. Dr. Posta noted Plaintiff had a restricted range of motion (“ROM”) in his cervical spine, an acromion with degenerative changes in the acromioclavicular (“AC”) joint, an abnormal signal in the rotator cuff consistent with a partial thickness cuff tear, AC joint arthritis, and fluid around the biceps tendon. Id. He assessed a rotator cuff tear, AC joint arthritis, and biceps tendinitis in the right shoulder, but ruled out a superior labral tear from anterior to posterior (“SLAP”). Id. He also assessed hypertension, hypercholesterolemia, hypertriglyceridemia, depression, GERD, and morbid obesity. Tr. at 475-76. Dr. Posta administered an injection and noted improvement. Tr. at 476. Dr. Posta prescribed Voltaren and Pennsaid, started Plaintiff on a home-exercise program, and scheduled a follow-up appointment. Id.

         On May 12, 2014, Plaintiff presented to Dr. Smith, at Western Carolina, regarding his depression and anxiety. Tr. at 794-97. Plaintiff and his wife reported his mood had improved slightly since his prior visit with Dr. Bishop. Id. Plaintiffs “[p]rimary fear [was] if [he] return[ed] to work at this time he may ‘go off and hurt someone.” Id. Plaintiff reported a low frustration tolerance. Id. Plaintiffs wife noted he seemed to be “okay as long as [she was] around.” Id. Plaintiff reported a depressed mood, nervousness, suicidal and homicidal thoughts, and worsened energy, concentration, and enjoyment. Id. Dr. Smith observed Plaintiff was fidgety, anxious, maintained poor eye contact, and was irritable, but he was alert and showed a linear, logical, and goal-directed thought process. Id. During the session, Plaintiff “became increasingly frustrated, ” his wife noted “he was confused and ready to go, ” and Dr. Smith terminated the session. Id. Dr. Smith assessed generalized anxiety disorder, suggested anger management, and continued Plaintiffs medical leave because he was “unable to attend safely to [the] job.” Tr. at 796.

         On May 20, 2014, Plaintiff presented to Sudie Clem, LISW-CP (“Ms. Clem”), at Western Carolina, for therapy. Tr. at 805-06. Plaintiff presented with a depressed mood and affect, reported sleep disturbances, loss of energy, anhedonia, and suicidal ideation. Id. Plaintiff reported increased depression and anxiety attacks, and he did not “feel ready to return to work.” Id. Ms. Clem assessed recurrent major depression, generalized anxiety disorder, and dysthymic disorder. Id.

         On May 21, 2014, Dr. Smith completed an attending physician's statement of continued disability for Plaintiffs employer. Tr. at 746-47. Dr. Smith noted Plaintiffs attitude was guarded and suspicious, his speech was halted, his psychomotor activity was agitated, and his attention and concentration were impaired, but his memory was intact, his thought process was logical and coherent, and his insight was fair. Id. Dr. Smith opined Plaintiff was distracted, irritable, and had poor attention, such that he was unable to return to work at that time. Id.

         On May 29, 2014, Plaintiff presented to Ware Shoals for prescription refills. Tr. at 364-69. Dr. Baker noted Plaintiff appeared depressed and his general appearance was abnormal. Id. Dr. Baker assessed benign essential hypertension, acute prostatitis, GERD, morbid obesity, fatigue, restless legs syndrome, lumbosacral disc degeneration, and renal or ureteral disease and modified Plaintiffs medications. Id.

         On June 9, 2014, Plaintiff presented to Dr. Smith and reported he was doing “OK” and at baseline, but continued to have temper and anger outbursts. Tr. at 798-801. Plaintiff expressed concern “that if he returned to work he might hurt himself or someone else . . . due to him losing his temper.” Tr. at 798. Plaintiff expressed he had difficulty paying the copay and had not been to therapy due to cost concerns, and Dr. Smith noted an indigent application was being processed. Id. Dr. Smith also noted Plaintiff had a depressed and unstable mood, hostility, frequent anger, and worsened energy, concentration, and enjoyment. Id. Dr. Smith observed Plaintiff was anxious, depressed, and irritable, but active and alert with normal eye contact. Id. He also observed Plaintiffs thought process was linear, but not concrete. Id. Dr. Smith assessed recurrent major depression, generalized anxiety disorder, and dysthymic disorder. Id.

         On July 14, 2014, Plaintiff presented to Dr. Posta and reported no improvement after a shoulder injection. Tr. at 472. Dr. Posta assessed rotator cuff tear, AC joint arthritis, and biceps tendinitis in Plaintiffs right shoulder. Id. He also assessed hypertension, hypercholesterolemia, hypertriglyceridemia, depression, GERD, morbid obesity, and endocrine abnormality. Id. Dr. Posta noted Plaintiff would be a candidate for shoulder arthroscopy, but his endocrine problems needed to be resolved first. Id.

         On July 15, 2014, Plaintiff presented to Dr. Smith for follow up and reported worsened mood, but denied thoughts of harm. Tr. at 802-04. Dr. Smith observed Plaintiffs mood and affect were depressed and he was irritable, but he had normal eye contact, was appropriately reactive, and pleasant, cooperative, and alert, with intact judgment and insight. Id. Plaintiffs thought process was logical, but not concrete. Id. Dr. Smith assessed recurrent major depression, generalized anxiety disorder, and dysthymic disorder. Id. Dr. Smith noted Plaintiff was scheduled to transition to a psychiatrist within his insurance plan in August. Id.

         On July 16, 2014, a brain MRI reflected a mucous retention cyst in the left maxillary sinus, but was otherwise unremarkable. Tr. at 558.

         On July 23, 2014, Plaintiff received a prescription for physical therapy to begin on August 11, 2014, after surgery on his right shoulder. Tr. at 407-11.

         On August 7, 2014, Plaintiff presented to Monique H. Lentz, M.D. (“Dr. Lentz”), for an initial evaluation. Tr. at 489-93. Plaintiff reported he had suffered from depression since childhood due to various events and had a history of fighting in high school. Tr. at 489. Plaintiff had severe depression, he could not “let things go, ” he was easily angered, and he had suicidal thoughts most days. Id. He reported he previously enjoyed hunting and fishing, but not as much now. Id. He also reported he had increased anxiety and panic attacks, moderate insomnia, and decreased energy. Id. Plaintiff believed coworkers talked about him and laughed at him. Id. Dr. Lentz noted Plaintiffs appearance was neat and casual, his grooming was fair, and his behavior was pleasant, cooperative, and calm. Tr. at 489-90. Dr. Lentz also noted Plaintiff had a logical and goal-directed thought process, normal attention, intact knowledge, and fair judgment and insight. Tr. at 490. However, Plaintiffs mood and affect were depressed. Id. Dr. Lentz diagnosed bipolar disorder with moderate depression, generalized anxiety disorder, and panic disorder and prescribed Depakote. Tr. at 491.

         On August 11, 2014, Plaintiff presented to the Optimum Life Center and his wife reported that the surgery repaired his labrum and “cleaned up the rest of his shoulder.” Tr. at 422. Plaintiff reported his pain ranged from 3/10 to 8/10. Id. Kelly Anderson, P.T. (“Ms. Anderson”), noted Plaintiff had a good prognosis, would benefit from physical therapy, and would be able to return to his prior level of physical function. Tr. at 423. Plaintiff attended various therapy sessions from August through October 2014. See Tr. at 412-61.

         On August 18, 2014, Plaintiff presented to Ware Shoals due to elevated laboratory results, a migraine, and tremor. Tr. at 370-75, 379-85. Nurse Owens found Plaintiffs judgment and insight were normal, but his mood and affect were abnormal and flat. Tr. at 372. Nurse Owens assessed benign essential hypertension, convulsions, headache, tremors, fatigue, and morbid obesity. Tr. at 373. Nurse Owens ordered bloodwork, adjusted Plaintiffs medications, and referred him to neurology. Id.

         On August 19, 2014, Plaintiff presented to Dr. Posta and reported shoulder soreness. Tr. at 471. Dr. Posta refilled Oxycodone, Ambien, and Voltaren and noted Plaintiff would continue with rehabilitation. Id.

         On August 27, 2014, Plaintiff presented to Dr. Posta and reported worsened pain. Tr. at 469-70. Dr. Posta found Plaintiffs active forward elevation of his right shoulder was 0 to 60 degrees and he had global right shoulder pain. Id. A radiograph showed no evidence of fracture and adequate decompression and acromioplasty. Id. Dr. Posta administered an injection and provided Oxycodone and Voltaren for pain relief. Id.

         On August 28, 2014, Plaintiff presented to Dr. Lentz and reported one panic attack that resulted in an outburst. Tr. at 485-88. Plaintiff also reported increased anxiety around people and that he was easily frustrated and confused. Id. Dr. Lentz noted Plaintiff was accompanied by his wife and he had a neat appearance and fair grooming. Id. Dr. Lentz also noted Plaintiffs behavior was pleasant, cooperative, and calm, with an “OK” mood and affect, his thought process was logical and goal-directed and his judgment and insight were fair. Id. Dr. Lentz adjusted Plaintiffs medications. Id.

         On August 29, 2014, Plaintiff presented to Neurodiagnostics of the Piedmont Health Group (“Piedmont Health”) for an electroencephalography (“EEG”) due to convulsions and tremors. Tr. at 396. The awake EEG was normal, but the absence of epileptiform discharges did not rule out the diagnosis of an epileptic disorder. Id.

         On September 10, 2014, Plaintiff presented to Dr. Posta. Tr. at 468. Dr. Posta noted Plaintiff was “doing much better” and would continue to rehabilitate his right shoulder, work on full motion and strength, and increase his activities. Id.

         On September 22, 2014, Plaintiff presented to Piedmont Health for a follow up of his convulsions and headaches. Tr. at 400-02. Plaintiff reported his headaches were controlled with Depakote, he had modified his diet, and his convulsions had ceased. Id. Plaintiff also reported he believed his prior symptoms were due to anxiety or panic attacks. Tr. at 400. Anthony Holt, D.O. (“Dr. Holt”), found Plaintiffs neurological exam was normal, but he had a wide-based and ataxic gait. Tr. at 402. Dr. Holt assessed convulsions and intractable chronic migraine, ordered bloodwork, and noted Plaintiff “most likely” experienced psychogenic seizures. Id.

         On September 29, 2014, Plaintiff presented to Dr. Lentz and reported increased mood swings, insomnia, nightmares, anxiety, and panic attacks. Tr. at 482. Plaintiff reported three panic attacks that lasted one to three hours and were triggered “when somebody sa[id] something” or while in a crowd. Id. Plaintiff also reported he had racing thoughts “all the time, ” tension, and an inability to relax, but decreased migraines. Id. Dr. Lentz noted Plaintiffs appearance was neat and casual and his grooming was good. Id. Plaintiffs behavior was pleasant, cooperative, and calm, but his mood and affect were terrible. Id. Dr. Lentz also noted Plaintiffs thought process was logical and goal-directed, but he had racing thoughts and paranoia, as he thought people were talking about him, including his wife. Id. However, Plaintiffs judgment and insight were fair. Id. Dr. Lentz modified Plaintiffs medications. Tr. at 482-83; Tr. at 484 (providing lab results).

         On October 10, 2014, Plaintiff presented to Optimum Life Center and reported his intermittent pain ranged from 1/10 to 2/10 and he was ready for discharge from physical therapy. Tr. at 456. Ms. Anderson noted Plaintiffs pain and disability index questionnaire was eight percent and Plaintiff was discharged “due to meeting his goals and making good progress with physical therapy along with having a final home program.” Tr. at 460.

         On October 20, 2014, Plaintiff presented to Dr. Posta for a follow up of his right shoulder after surgery and physical therapy. Tr. at 467. Dr. Posta found Plaintiff was an “alert pleasant gentleman ambulating without difficulty” and had mild, right shoulder pain with an active forward elevation of 0 to 170 degrees, passive elevation of 0 to 180 degrees, and external rotation of 50 degrees. Id. Dr. Posta noted Plaintiff would “rehab on his own” and assessed stable right shoulder post-arthroscopy, arthroscopic shoulder decompression (“ASD”), arthroscopic distal clavicle resection (“ADCR”), debridement of a SLAP tear, and post-op right shoulder sprain. Id.

         On November 24, 2014, Plaintiff presented to Dr. Lentz and reported he felt tense. Tr. at 480. Plaintiff had increased insomnia, one panic attack, and stressful holidays, but decreased mood swings. Id. He reported Seroquel worked, but made him sleepy during the day. Id. Dr. Lentz found his appearance was neat and casual with good grooming. Id. Dr. Lentz noted Plaintiffs behavior was pleasant, cooperative, and calm, but his mood and affect were up and down. Id. Plaintiff had slightly decreased paranoia, no suicidal or homicidal thoughts, and fair judgment and insight. Id. Dr. Lentz modified Seroquel, but continued other medications. Id.

         On December 1, 2014, Plaintiff presented to Dr. Posta and reported he was sore, particularly when he did overhead activity. Tr. at 466. Dr. Posta found Plaintiff was an “alert pleasant gentleman ambulating without difficulty” and his “active and passive forward elevation of the right shoulder [was] 0 to 180 degrees, ” with nontender joints, and 5/5 rotator cuff strength. Id. He prescribed Ultram, encouraged Plaintiff to do exercises, and believed “his symptoms [would] resolve with time and rehabilitation, ” with his progress to be assessed in six weeks.[6] Id.

         On December 2, 2014, Dr. Posta completed a work statement that provided Plaintiff was able to return to regular duty without physical restrictions. Tr. at 754.

         On December 29, 2014, Plaintiff presented to Dr. Lentz. Tr. at 478-79. Plaintiffs wife reported she felt Plaintiff was improving, but he was occasionally “grumpy” in the evening. Id. Plaintiff reported no panic attacks, his sleep was good, he was calm, and he had increased his social interaction, with no big mood swings. Id. The “holidays were better, ” but there was “no travelling.” Id. Dr. Lentz noted Plaintiffs appearance was neat and his behavior was pleasant, cooperative, and calm. Id. Plaintiffs mood and affect were “OK, ” but his judgment and insight were fair, with no thoughts of suicide or homicide. Id. Dr. Lentz adjusted Seroquel, continued Plaintiffs other medications, and recommended a healthy diet and exercise. Id.

         On January 6, 2015, Dr. Lentz completed a questionnaire for Disability Determination Services and stated she was a psychiatrist. Tr. at 496-97. Dr. Lentz noted Plaintiffs first visit was August 7, 2014, she saw him monthly, and his most recent visit was December 29, 2014. Tr. at 496. Dr. Lentz also noted Plaintiff was compliant, and his treatment was effective, as he had shown “slight improvement in some symptoms, ” but his condition was “chronic and full remission [was] not expected.” Id. Dr. Lentz provided Plaintiff's current diagnoses as bipolar disorder, generalized anxiety disorder, and panic disorder. Id. Dr. Lentz noted she had prescribed Seroquel, Depakote, Klonopin, and Effexor for Plaintiff's conditions. Id. Dr. Lentz also noted Plaintiff's grooming was appropriate, he was oriented, his thought process was normal, he had average cognitive ability, and fair attention and memory, but his affect was slightly anxious, his mood was slightly depressed, and he was slightly paranoid. Tr. at 497. Dr. Lentz opined Plaintiff's abilities to complete basic ADLs and simple, routine tasks were adequate. Id. However, his abilities to relate to others and complete complex tasks were between poor and adequate. Id. Dr. Lentz explained Plaintiff had anxiety around people, except close family members, increased agoraphobia, and difficulty making decisions and being around people due to paranoia, panic attacks, and mood swings. Id. Dr. Lentz also explained Plaintiff could not complete tasks due to racing thoughts, fatigue, or insomnia. Id.

         On January 28, 2015, Dale Van Slooten, M.D. (“Dr. Van Slooten”), a state agency physician, stated there was insufficient evidence in the file to complete a physical residual functional capacity (“RFC”) assessment. Tr. at 98. On January 29, 2015, Xanthia Harkness, Ph.D. (“Dr. Harkness”), a state agency psychologist, stated there was insufficient evidence in the file to provide a psychiatric review technique (“PRT”) assessment. Tr. at 99.

         On March 16, 2015, Plaintiff presented to Ware Shoals for a checkup and medication refills. Tr. at 510-15. Plaintiff reported he no longer had a tremor, but he was under the care of nephrology due to his kidney function. Id. Plaintiff had a normal physical exam, but his mood and affect were abnormal and flat. Tr. at 512. Nurse Owens assessed benign essential hypertension, depression, GERD, and essential hypertriglyceridemia. Id.

         On March 31, 2015, Plaintiff presented to Ware Shoals for elevated blood sugar. Tr. at 516-21. Plaintiffs physical and psychiatric examinations were normal. Tr. at 518. Nurse Owens assessed type two diabetes mellitus and diabetic neuropathy. Tr. at 519.

         On April 14, 2015, Plaintiff presented to Greg Swanson, Ph.D. (“Dr. Swanson”), for an initial evaluation with his wife. Tr. at 719-27. Plaintiff reported bipolar disorder, stress, anxiety, and uncontrollable anger that had caused other co-workers to become afraid of him. Id. Plaintiff also reported he had suffered from these issues his entire life, but they had worsened. Id. Plaintiff stated his issues made it difficult to cope with people or make correct decisions and made him want to hurt himself and others. Id. Through his responses to a questionnaire, Plaintiff reported he suffered symptoms, such as difficulty concentrating, from a variety of conditions, including depression, mania, psychosis, post-traumatic stress disorder (“PTSD”), anxiety, and intermittent explosions. Id. Dr. Swanson noted Plaintiff's GAF score was 45. Id. Dr. Swanson developed a plan that included individual therapy with him and coordination with Dr. Lentz to decrease Plaintiff's panic attacks, anxiety, anger, and depression. Id.

         On April 22, 2015, Nurse Owens completed a questionnaire for the Disability Determination Services regarding Plaintiff. Tr. at 522. Nurse Owens noted she had treated Plaintiff the prior month, his mental diagnosis was depression, he was prescribed Bupropion, the medications helped his condition, and she had not recommended psychiatric care. Id. Nurse Owens opined Plaintiff was oriented to time, had an intact thought process, appropriate thought content, and good attention and memory, but flat mood and affect. Id. Nurse Owens also opined Plaintiff had good abilities to complete basic ADLs, relate to others, and complete simple, routine, or complex tasks. Id.

         On April 30, 2015, Plaintiff presented to Dr. Swanson and reported suicidal thoughts and that little things made him angry. Tr. at 718. Plaintiff's GAF score was 45. Id. His goals were to decrease depression and anxiety, express anger more appropriately, cope with bipolar disorder, and decrease panic attacks. Id. Dr. Swanson continued therapy and the medications prescribed by Dr. Lentz. Id.

         On May 5, 2015, Dr. Lentz completed a handwritten statement that provided, “[Plaintiff] is being treated by me for psychiatric illness. He is unable to work and is totally [and] permanently disabled. He has been denied disability from work [and] is in the appeal process.” Tr. at 526.

         On May 13, 2015, Craig Horn, Ph.D. (“Dr. Horn”), a state agency psychologist, completed a PRT assessment upon reconsideration and opined Plaintiff had mild restrictions of ADLs, moderate difficulties in maintaining social functioning and concentration, persistence, or pace, and one or two repeated episodes of decompensation of an extended duration. Tr. at 109. Dr. Horn opined Plaintiffs mental impairments were severe, but would not preclude him from performing simple, unskilled work. Id. Dr. Horn completed a mental RFC assessment and found Plaintiff was moderately limited in his abilities to understand, remember, and carry out detailed instructions, maintain concentration for extended periods, or interact with the public. Tr. at 112-14.

         Also, on May 13, 2015, Matthew Fox, M.D. (“Dr. Fox”), a state agency physician completed a physical RFC assessment upon reconsideration and opined Plaintiff was capable of performing a range of medium work, but must avoid concentrated exposure to hazards such as machinery. Tr. at 111-12.

         On May 24, 2015, Plaintiff presented to Self Regional Healthcare (“Self Regional”) due to shortness of breath, weakness, confusion, and increasing chest tightness for five days. Tr. at 559-84. Plaintiff reported worsened depression and anxiety over the prior week, despite psychotherapy. Tr. at 563. Katherine G. Johnson, M.D. (“Dr. Johnson”), noted Plaintiff had been previously admitted to BHU.[7] Id. Plaintiff reported he had been unable to work due to his depression for one and a half years, but still fished and hunted, although he found less pleasure in these activities. Tr. at 564. Plaintiff also reported depression, anxiety, and feeling constantly fatigued, but denied pain. Id. Dr. Johnson found Plaintiff was alert with good insight and not acutely anxious or psychotic, but had a slightly flattened affect and was sad. Tr. at 565. Plaintiffs physical exam was unremarkable. Id. Dr. Johnson assessed chest tightness and palpitations, well-controlled hypertension, sleep apnea, hyperlipidemia, GERD, diabetes, and benign prostatic hypertrophy. Tr. at 565-66. Dr. Johnson also assessed depression, bipolar disorder, anxiety, and suicidal ideation. Id. She noted:

I think this is the likely etiology of his discomfort. This appears to be worsening despite his therapy of Effexor, Klonopin, Seroquel, and Depakote. Given that he does state that he is having some suicidal ideation that is worsening, I think a psychiatric consult in the morning would be very appropriate. I think he will likely benefit from some time in the BHU. . . . He is clearly refractory to treatment, and I think continued follow up with a psychiatrist in Augusta is prudent.... I will discuss this patient with BHU and psychiatric team in the morning. He may benefit from BHU once his cardiac assessment has been completed.

Tr. at 566. Plaintiff was admitted to the hospital. Id. Plaintiff had a normal ECG, and a chest x-ray reflected no acute cardiopulmonary process. Tr. at 582, 584.

         On May 27, 2015, Plaintiff presented to Ware Shoals for a follow up after his hospital visit. Tr. at 617-22. Plaintiff reported increased heart rate, chest pain, palpitations, and shortness of breath, but no other issues. Tr. at 617. Nurse Owens found a normal physical exam and normal judgment, insight, and memory, but Plaintiffs mood and affect were abnormal and flat. Tr. at 619-20. Nurse Owens assessed palpitations, chest pain, and shortness of breath, ordered an echocardiogram, stress test, and halter monitor, and modified his medications. Tr. at 620.

         On June 3, 2015, Plaintiff presented to Dr. Lentz. Tr. at 679. Plaintiff was accompanied by his wife, who felt he was “mean” while taking Depakote. Id. Plaintiff reported increased mood swings and anxiety, and he was easily frustrated and angered. Id. Dr. Lentz noted Plaintiffs appearance was neat and casual, his grooming was fair, and his behavior was pleasant, cooperative, and calm. Id. Dr. Lentz also noted Plaintiffs mood and affect were “up [and] down” and he had worsened paranoia. Id. Plaintiffs thought process was logical and goal-directed, and his judgment and insight were fair. Id. Dr. Lentz adjusted Plaintiffs medications. Tr. at 680.

         On June 4, 2015, Plaintiff presented to Self Regional for chest pain and dyspnea upon referral by Nurse Owens. Tr. at 585-99. Plaintiff underwent a stress test that reflected a normal ECG, fair exercise tolerance, and normotensive response to exercise. Tr. at 588-89. Plaintiff wore a halter monitor that reflected an overall normal study, no malignant arrhythmias, and no evidence of ischemia. Tr. at 590-95. A transthoracic echocardiography report (“TTE”) concluded the left ventricular size was normal with mild concentric hypertrophy and normal systolic function, with an estimated ejection fraction of 65%, mild diastolic dysfunction, and a mildly-dilated left atrial. Tr. at 596.

         On June 5, 2015, Plaintiff and his wife presented to Dr. Swanson. Tr. at 717. Plaintiffs wife reported his temper, anger, and anxiety had worsened, he did not wish to deal with anyone or anything, and his mood shifted from nice to mean within minutes. Id. Plaintiff reported, after a “rampage, ” he would get a headache, his mind would go blank, and he would sleep for days. Id. Plaintiff also reported he was hospitalized ten years prior and the prior February for mental health issues, but did not feel they helped at all and he thought it would be better for everyone if he was no longer around. Id. Dr. Swanson suggested physical activity to “burn off tension.” Id. Plaintiffs GAF score was 40. Id. His goals were to decrease depression and anxiety, express anger more appropriately, cope with bipolar disorder, and decrease anger and panic attacks. Id. Dr. Swanson continued therapy and the medications prescribed by Dr. Lentz. Id.

         On June 23, 2015, Plaintiff presented to Dr. Swanson and his wife accompanied him. Tr. at 716. Plaintiff reported he had suicidal thoughts since childhood due to his family's reputation. Id. Plaintiff also suffered from PTSD due to his involvement with a rescue squad during his teenage years. Id. Plaintiffs GAF score was 41. Id. Dr. Swanson continued therapy and the medications prescribed by Dr. Lentz. Id.

         On July 13, 2015, Plaintiff presented to Dr. Lentz and his wife accompanied him. Tr. at 681. Plaintiffs wife reported Plaintiff was “not as mean” since his medication was adjusted. Id. Plaintiff reported his disability through work was approved for three more months, but he had a decreased mood and increased agoraphobia. Id. Dr. Lentz noted Plaintiffs appearance was neat, his grooming was good, and his behavior was pleasant, cooperative, and calm. Id. Dr. Lentz also noted Plaintiffs thought process was logical and goal-directed ...


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