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 his 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 the Commissioner's decision be reversed and
remanded for further proceedings as set forth herein.
about October 17, 2014, Plaintiff filed an application SSI in
which he alleged his disability began on January 1, 2013. Tr.
at 238-43. His application was denied initially and upon
reconsideration. Tr. at 144, 164, 168-71, 175-78. Plaintiff
subsequently amended his alleged onset date to September 5,
2014. Tr. at 43, 332. On February 27, 2017, Plaintiff had a
hearing before Administrative Law Judge (“ALJ”)
John T. Molleur. Tr. at 37- 85 (Hr'g Tr.). The ALJ issued an
unfavorable decision on June 13, 2017, finding that Plaintiff
was not disabled within the meaning of the Act. Tr. at 15-36.
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 July 5, 2018. [ECF No. 1].
Plaintiff's Background and Medical History
was 46 years old at the time of the hearing, completed the
twelfth grade, but did not graduate or obtain a GED. Tr. at
45. His past relevant work (“PRW”) was as a
fabricator in New York doing welding and janitorial work. Tr.
at 45-47. He alleges he has been unable to work since
September 5, 2014. Tr. at 43, 332.
September 5, 2014, Plaintiff presented to Montefiore Medical
Center in New York, with complaints of blurry vision and
dizziness for two days and reported noncompliance with his
blood pressure and diabetic medication for two years. Tr. at
340-433, 365, 751-94, 803-35. A head computed tomography
(“CT”) scan was abnormal, and a brain magnetic
resonance image (“MRI”) reflected extensive white
matter signal abnormality highly suggestive of demyelinating
disease. Tr. at 345-46, 352-56. A chest x-ray reflected no
acute cardiopulmonary disease, but an electrocardiogram
(“ECG”) was abnormal. Tr. at 354, 386-87. Sofia
Turner, M.D. (“Dr. Turner”), noted
Plaintiff's symptoms had resolved after medication was
administered and had improved his blood pressure. Tr. at 360,
363. Dr. Turner diagnosed malignant hypertension, referred
Plaintiff to neurology due to his head CT scan and brain MRI
results, and admitted him. Tr. at 363. An ophthalmology
consultation was performed that found cotton wool spots on
exam, likely secondary to uncontrolled hypertension. Tr. at
September 6, 2014, Deepa Kannaditharayil, M.D. (“Dr.
Kannaditharayil”), performed a neurology consultation
and assessed demyelinating disease, possibly multiple
sclerosis, and blurry vision, likely related to his vascular
risk factors. Tr. at 373-76. Cervical and thoracic spine MRIs
showed no evidence of demyelinating disease within the spine,
but there were C4-C5 paracentral disc protrusion indents
causing canal and right foraminal stenosis. Tr. at 405-08. A
face and neck MRI reflected no optic neuritis. Tr. at 409.
Renal and bladder ultrasounds revealed echogenic kidneys,
consistent with renal parenchymal disease. Tr. at 410-11. An
abdominal venous duplex reflected no evidence of thrombosis;
a carotid duplex showed a high resistant left vertebral
artery waveform and intermittent cardiac arrythmia; and a
renal artery duplex was normal, but resistive in the left
mid-renal artery. Tr. at 388-95.
September 9, 2014, Pranav Patel, M.D. (“Dr.
Patel”), performed an unsuccessful lumbar puncture. Tr.
at 370-71. Renee S. Monderer, M.D. (“Dr.
Monderer”), reviewed test results, noted Plaintiff had
poorly-controlled hypertension, diabetes mellitus, and
obstructive sleep apnea, found his blurry vision had
improved, and ordered additional tests. Tr. at 377. However,
Plaintiff left the hospital to travel home to South Carolina
with his mother. Tr. at 519, 523.
September 13, 2014, Plaintiff presented to Memorial Health
University Medical Center (“Memorial Health”) in
Georgia, with complaints of headache and hypertension and was
admitted for treatment. Tr. at 474-90, 504-08, 525, 840-63.
The attending physician noted Plaintiff was
“occasionally slow to respond, ” but he was
uncertain “whether or not [Plaintiff was] reluctantly
ignoring to answer the questions or if it [was] secondary to
[central nervous system (“CNS”)]
pathology.” Tr. at 532. A head CT scan reflected remote
appearing infarcts in the bilateral basal ganglia and right
superior frontal lobe and soft tissue density. Tr. at 525-26.
A brain MRI and intracranial magnetic resonance angiogram
(“MRA”) showed no significant stenoses or
occlusions. Tr. at 527.
September 16, 2014, Plaintiff was discharged with diagnoses
of malignant hypertension secondary to medication
noncompliance, possible syncopal episode, diabetes mellitus
type 2, chronic kidney disease stage III- IV, mild
dyslipidemia, obstructive sleep apnea, and abnormal white
matter changes, felt secondary to chronic uncontrolled
hypertension and small vessel ischemia, with multiple
sclerosis felt less likely. Tr. at 506, 795-802.
on September 16, 2014, Plaintiff presented to Coastal
Carolina Medical Center (“Coastal Carolina”) in
South Carolina and various tests were performed. Tr. at
448-68. Plaintiff's mother reported Plaintiff had slurred
speech, slow mentation, headache, and left facial droop onset
for forty minutes and she had been transporting him from a
hospital in New York to South Carolina. Tr. at 455. Prior to
arriving in South Carolina, she observed weakness episodes in
the car and transported Plaintiff to Memorial Health where
she said he was diagnosed with cerebrovascular accident
(“CVA”) and malignant hypertension. Id.
An ECG was abnormal. Tr. at 461. A brain CT scan reflected
infarcts. Tr. at 463-64. A chest x-ray reflected no acute
cardiopulmonary disease. Tr. at 464. Plaintiff's
condition worsened when he arrived in South Carolina and he
was transferred back to Memorial Health for treatment. Tr. at
September 17, 2014, Plaintiff returned to Memorial Health for
further evaluation and underwent numerous tests. Tr. at
491-503, 509-601, 679-81, 836-39. On September 21, 2014, Amy
Archer, M.D (“Dr. Archer”), performed a
consultation due to Plaintiff's rehabilitation diagnosis
of CVA with left hemiparesis. Tr. at 561. Dr. Archer reviewed
Plaintiff's recent medical history and noted Plaintiff
reported left-sided weakness. Tr. at 562. Dr. Archer found
Plaintiff was alert and oriented and had speech, cognition,
function for simple questions and answers, and ability to
follow simple directions, but his affect was “somewhat
flat.” Tr. at 563. Plaintiff exhibited 4/5 strength in
his left extremities and excellent alternating movements.
[Plaintiff] has seen physical and occupational, as well as
speech therapy in the acute setting. Patient is at a very
high level in terms of mobility, self-care, abilities, and
even cognition functioning. Speech Therapy does note mild
delays with cognition. [Plaintiff] was able to ambulate 200
feet with contact guard assistance of the physical therapist
[and] was actually able to walk around his room with this
clinician today with no assistance and demonstrated no loss
of balance. His mother is amenable to taking him. He lives
with his mother, father, and several adult siblings. If
financial resources were available, home health or outpatient
[physical therapy]/speech therapy would be best to maximize
his mobility and cognitive function. If financial resources
are not available, [Plaintiff] should do fine, but recovery
will be slower than with [physical therapy]/speech therapy
and this was explained to his mom. It is doubtful he would
need any durable medical equipment
Tr. at 564-65.
September 22, 2014, Jeffrey G. Taylor, M.D. (“Dr.
Taylor”), summarized Plaintiff's treatment,
diagnosed CVA, possibly secondary to paroxysmal atrial
fibrillation though no atrial fibrillation documented,
multiple CVAs, hypertension, hyperlipidemia, diabetes
mellitus type 2, obstructive sleep apnea, and tobacco abuse.
Tr. at 519. Dr. Taylor noted an echocardiogram reflected
ejection fraction of 65-70% with mild biatrial enlargement; a
brain MRI showed findings compatible with multiple emboli
consistent with embolic infarction without significant mass
effect and minimal petechial straining in the right middle
cerebral distribution; a carotid ultrasound showed no
significant stenoses; a lumbar puncture a few days prior had
negative studies; and a urine drug screen was positive for
cocaine. Tr. at 519. Dr. Taylor noted,
[Plaintiff] is a 43-year-old . . . who was discharged to a
hospital with bilateral internal capsule infarcts and
accelerated hypertension. He was discharged on September
16th. He actually insisted on leaving although he was not
required to sign out [against medical advice
(“AMA”)]. After leaving, he developed some
left-sided weakness, decreased verbal output, and some
tearfulness. He was taken to Coastal Carolina where the CT
showed anterior right internal capsular infarct. [Plaintiff]
was transferred to Memorial. MRI here was consistent with
multiple embolic infarcts. His urine drug screen was positive
for cocaine raising the possibility that these infarcts could
have been cocaine-related. He had [a lumbar puncture] done,
which was not consistent with multiple sclerosis. A
[transesophageal echocardiography report (“TEE”)]
was done, which did not show any embolic source. We never
documented atrial fibrillation, but it was felt that it was
wisest to anticoagulate him despite his cocaine use. He was
cautioned about using cocaine. He was also cautioned as to
the importance of taking his blood pressure medicines as well
as his Coumadin. He was discharged on Coumadin 5 mg a day in
addition to his Lovenox.
Tr. at 519, 523. Dr. Taylor prescribed Coreg, Lovenox,
Hydralazine, Norvasc, Enteric-coated aspirin, Mevacor, and
Coumadin, scheduled a follow up at Curtis V. Cooper Health
Clinic (“Cooper Health”) for reevaluation and
Beaufort Memorial for outpatient rehabilitation with physical
and occupational therapy. Tr. at 523.
September 23, 2014, Plaintiff presented to Memorial Health
due to nausea and vomiting shortly after discharge the prior
day. Tr. at 678, 682- 711. The attending physician conducted
additional tests, assessed status-post embolic CVAs,
accelerated hypertension, and atrial fibrillation, and
modified Plaintiff's prescriptions. Id.
September 24, 2014, Plaintiff was discharged from physical
therapy at Memorial Health because he was at baseline and
“safe for mobility.” Tr. at 602-13. Outpatient
treatment was recommended for speech therapy. Tr. at 613.
October 17, 2014, Plaintiff presented to Beaufort Memorial.
Tr. at 639-45, 649-51. Angela Bandola (“Ms.
Bandola”), the treating clinician noted,
[Plaintiff] currently demonstrates normal [active range of
motion (“ROM”)] and strength of [bilateral upper
extremity]. He and his mother report no limitations in
completion of [activities of daily living
(“ADLs”)] at this time. [Plaintiff]
demo[nstrates] normal cognitive functioning as per
mini-mental exam. [Plaintiff] is slow to respond to
questions or instructions. [Plaintiff's] mother reports
intermittent issues with speech that might be treated. At
this time skilled [Occupational Therapy] is not appropriate.
Tr. at 639. Plaintiff was discharged because the
“maximal level [was] reached.” Tr. at 640. Also,
Plaintiff presented to Susan Mastromauro, D.P.T.
(“Therapist Mastromauro”), and “denie[d]
significant impairments beyond [his lower left extremity]
weakness and feeling as though his lower extremities fatigue
quickly.” Tr. at 645. Plaintiff had impaired gait and
balance and decreased lower extremity strength, activity
tolerance, and functional mobility. Id. Therapist
Mastromauro prescribed physical therapy for Plaintiff's
lower extremities for eight weeks. Tr. at 646, 651.
October 29, 2014, Plaintiff presented to Good Neighbor Clinic
with complaints of fatigue, headaches, left-sided weakness,
and delayed speech. Tr. at 621. Plaintiff's mother
provided his history. Id. The attending nurse noted
Plaintiff's gait was normal and he was able to heel, toe,
and squat walk and scheduled a follow up visit in two weeks.
November 11, 2014, Plaintiff presented to Good Neighbor
Clinic for a check up and provided his recent treatment
records from September 2014. Tr. at 619. The attending nurse
assessed uncontrolled hypertension, untreated diabetes
mellitus, and renal insufficiency, ordered laboratory tests,
prescribed Metoprolol, and scheduled a follow-up appointment
in one week. Id.
November 18, 2014, Plaintiff presented to Good Neighbor
Clinic for a follow-up visit and reported weakness in his
left arm and leg, slurred speech, short-term memory
difficulty, and cognitive impairment. Tr. at 618. The
attending physician noted Plaintiff received physical and
speech therapy, prescribed medications, and recommended
follow up in three to four weeks. Id.
November 24, 2014, Plaintiff presented to Beaufort Memorial
and reported he was sore from “working out” at
home. Tr. at 647-48. Plaintiff ambulated without an assistive
device, was able to “high level balance” without
upper extremity support, and could dribble a basketball while
weaving in and out of cones. Tr. at 647. Therapist
Mastromauro discharged Plaintiff from physical therapy. Tr.
November 25, 2014, Plaintiff presented to Cooper Health. Tr.
at 669-674. On exam, Plaintiff had left-sided weakness and
walked with a dragging gait. Tr. at 674. The attending
physician assessed CVA with left hemiparesis, hypertension,
and anticoagulation, updated Plaintiff's medications, and
scheduled a follow up in one week. Id.
December 2, 2014, Plaintiff presented to Good Neighbor Clinic
for follow up. Tr. at 617, 660. The attending physician
assessed left hemiparesis and continued physical therapy for
three weeks. Id.
December 2, 2014, Plaintiff presented to Beaufort Memorial
with difficulties in speech production. Tr. at 626-29,
634-37. Plaintiff had “mild receptive and expressive
language skills significant for decreased speech during
conversation, moderate apraxia of speech during volitional
speech tasks, decreased repetition skills, and reduced object
naming abilities.” Tr. at 628. Id. Angela
Hammond, the treating clinician, recommended skilled speech
and language services to increase receptive and expressive
language and speech production and ordered therapy twice a
week for six weeks. Tr. at 628-29.
December 10, 2014, Plaintiff presented to Beaufort Memorial
due to weakness in his left hand. Tr. at 630-33. Plaintiff
and his mother reported he was “able to perform all of
his basic ADLs.” Tr. at 630. Plaintiff also reported he
walked for an hour a day, but he had trouble sleeping at
night due to sleep apnea. Id. Ms. Bandola noted
Plaintiff demonstrated full strength and active ROM in his
bilateral upper extremities, with his left hand gripping
stronger than his right. Id. Ms. Bandola also noted,
“[h]e is reportedly independent with all ADL's
except that he has not returned to some form of work.”
Id. She recommended therapy was not warranted and
provided a hand strengthening home program “only
because he state[d] he [was] not doing anything with his
hands at home.” Id. No further treatment was
rendered, but cardiac rehabilitation was suggested due to
Plaintiff's mother's report that he could not
participate in vocational rehabilitation due to a heart
condition. Tr. at 631, 633.
January 6, 2015, Plaintiff presented to Good Neighbor Clinic
to follow up on bloodwork. Tr. at 637-38, 659, 731. Plaintiff
reported no changes, he was “doing well, ” and
attended physical therapy twice a week at Memorial Health.
Id. The attending physician assessed left
hemiparesis, atrial fibrillation, and increased lipids and
weight. Tr. at 650. He continued Plaintiff's
prescriptions and physical therapy. Tr. at 659.
February 19, 2015, Plaintiff presented to Cooper Health for
follow up of his blood pressure. Tr. at 675-77, 717-19.
Plaintiff reported compliance with his medication, except
Hydralazine that he had not taken for weeks, his blood
pressure was elevated, and he experienced blurry vision.
Id. The attending physician assessed hypertension
and diabetes and scheduled a follow up in three months. Tr.
April 14, 2015, Plaintiff presented to Good Neighbor Clinic
and reported frustration with memory loss. Tr. at 729-30.
Plaintiff also reported he reviewed his medication dosages
with his mother and slept a lot during the day. Id.
The attending physician assessed status-post CVA, high blood
pressure, atrial fibrillation, increased lipids, and obesity.
Id. He modified Plaintiff's medication and
instructed him to walk and diet. Id.
30, 2015, Jessica Hannah, M.D. (“Dr. Hannah”),
performed a consultative examination. Tr. at 713-15.
Plaintiff reported vision, speech, and memory issues with
left-sided weakness. Id. Plaintiff also reported his
mother had to remind him of things and he no longer drove.
Id. Dr. Hannah found Plaintiff had 4/5 left-sided
weakness, but normal gait and ability to rise from a seated
position without assistance, bend, and squat. Tr. at 714. She
also found adequate fine motor movements, dexterity, ability
to grasp objects bilaterally, and mild weakness in his
left-hand grip. Id. Dr. Hannah noted Plaintiff was
alert, oriented, and cooperative and was not depressed or
anxious, but communicated with expressive aphasia and
“did poorly on [the Mini-Mental State Exam
(“MMSE”)], only scoring 21/30.”
Id. Plaintiff's visual acuity was 20/50 in his
left eye and 20/30 in his right eye without correction.
Id. Dr. Hannah assessed cardioembolic CVAs with
residual left-sided weakness and numbness, but noted
Plaintiff's most problematic deficit was his cognition.
Tr. at 715. Dr. Hannah concluded Plaintiff “should be
able to sit and walk, ” but he was “not reliable
to remember and carry out more than one step
instructions” and was “not safe to drive”
given his cognitive deficits. Id.
9, 2015, Isabella McCall, M.D. (“Dr. McCall”), a
state agency physician, reviewed the record and provided a
residual functional capacity (“RFC”) assessment.
Tr. at 136-39. Dr. McCall opined Plaintiff could lift, carry,
push, or pull twenty pounds occasionally and ten pounds
frequently; stand, walk, or sit about six hours in an
eight-hour workday; frequently push or pull with the left
upper extremity; frequently handle and finger on the left;
occasionally climb ramps or stairs; frequently balance,
stoop, kneel, crouch, or crawl; never climb ladders, ropes,
or scaffolds; and must avoid concentrated exposure to
23, 2015, Plaintiff presented to Cooper Health with
complaints of headache, left-sided weakness, and increased
blood pressure, despite compliance with medications. Tr. at
720-24, 896-99, 910. The attending physician assessed
anticoagulation and hypertension and prescribed Hydralazine.
25, 2015, Cashton B. Spivey, Ph.D. (“Dr.
Spivey”), performed a psychological evaluation. Tr. at
735-38. Plaintiff reported left-sided weakness and memory
deficits, such as he misplaced objects, forgot to take
medications, forgot conversations, and left the stove on.
Id. Plaintiff also reported he had lost the ability
to read and perform simple arithmetic since his CVA, but his
mother managed his finances. Id. Dr. Spivey reviewed
Plaintiff's education, employment, medical, psychiatric,
arrest, substance abuse, marital, developmental, and family
histories. Tr. at 735-39. Plaintiff reported he believed he
was capable of operating an automobile, but did not have a
license. Tr. at 736. He also reported he lived with his
mother and was responsible for light cooking, the dishes, and
cleaning his room. Id. Dr. Spivey noted Plaintiff
was cooperative and compliant, such that the evaluation
appeared to represent an accurate assessment of his
intellectual, cognitive, and academic functioning. Tr. at
737. Plaintiff's mood was mildly sad; his affect was
slightly blunted; his thought processes were logical and
coherent with no evidence of overt psychosis; his attention
and concentration functioning were fair; his speech was
normal; he engaged in appropriate eye contact; and his
psychomotor functioning was within normal limits, but he
appeared to display a mild reduction in energy level. Tr. at
737. Dr. Spivey administered the Wechsler Adult Intelligence
Scale, Fourth Edition (“WAIS-IV”) and Wide Range
Achievement Test, Fourth Revision (“WRAT-4”).
Id. Plaintiff had a full-scale IQ of 61, a
processing speed of 59, and reading and math skills at a
third-grade level. Id. Dr. Spivey found Plaintiff
had an “extremely low general intelligence with