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Williams v. Saul

United States District Court, D. South Carolina

July 19, 2019

Loretta J. Williams, Plaintiff,
v.
Andrew M. Saul, [1]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) 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 he 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 or about July 3, 2012,[2] Plaintiff filed an application for SSI in which she alleged her disability began on June 24, 2012. Tr. at 207-12. Her application was denied initially and upon reconsideration. Tr. at 96, 114-19, 123-25. On July 6, 2016, Plaintiff had a video hearing before Administrative Law Judge (“ALJ”) Chris L. Gavras. Tr. at 35-81. (Hr'g Tr.). The ALJ issued an unfavorable decision on August 4, 2016, finding Plaintiff was not disabled within the meaning of the Act. Tr. at 17-34. Subsequently, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 1-6. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on February 16, 2018. [ECF No. 1].

         B. Plaintiff's Background and Medical History

         1. Background

         Plaintiff was 46 years old at the time of the hearing. Tr. at 43. She completed the tenth grade. Id. She has no past relevant work (“PRW”). Tr. at 43-45. She alleges she has been unable to work since June 24, 2012. Tr. at 207.

         2. Medical History

         On June 21, 2011, magnetic resonance imaging (“MRI”) of Plaintiff's lumbar spine reflected a shallow central protrusion at L5-S1, with mild bilateral facet arthropathy, and moderate bilateral facet arthropathy at L4-L5, with lumbar facet syndrome considered, but no stenosis. Tr. at 352.

         On August 11, 2011, Plaintiff presented to the Pain Center of First Choice (“First Choice”) with complaints of continued back pain. Tr. at 342-44. She complained of back pain of 10/10 that started suddenly, persisted for three years, increased, ached, burned, and throbbed, radiated to her legs, and was aggravated by exertion and prolonged standing or sitting. Id. Plaintiff also reported her husband had “hit her in the back of her neck several times with his fist, ” causing pain with stiffness and her friend has stolen some of her medication. Id. Plaintiff denied medication side effects. Id. Kerri Frey, P.A. (“P.A. Frey”), found Plaintiff was oriented and had a normal gait, strength, mood, and affect, but she was tender to palpation (“TTP”) at 7 of 18 fibromyalgia points with tenderness, muscle spasms, and restricted range of motion (“ROM”) in her back. Id. The attending physician assessed lumbosacral neuritis, lumbago, brachial neuritis, muscle spasm, and multiple-site joint pain, ordered a cervical spine MRI, administered injections in the lumbar spine, and prescribed Norco, Flexeril, and Lyrica. Id.

         On September 9, 2011, Plaintiff presented to the emergency room at Lexington Medical Center (“LMC”) after an alleged assault. Tr. at 320-23. Plaintiff reported despite having a restraining order against her ex-husband, who had attacked her the prior night, choking and hitting her multiple times. Tr. at 326. Plaintiff requested to be evaluated and noted nose pain, facial bruises, and neck soreness. Id. A maxillofacial skeleton computed tomography (“CT”) scan reflected acute nasal bone fracture associated with some subcutaneous emphysema within the anterior face, but a brain CT scan reflected no significant abnormalities from the acute blunt trauma. Tr. at 320-21. A right-hand x-ray reflected no traumatic or pathologic changes and a neck x-ray was negative. Tr. at 322-23. Sally Herpst, M.D. (“Dr. Herpst”), found visible swelling and discoloration on Plaintiff's face and bruising on her neck over the left anterolateral, with TTP and posterior paracervical muscle soreness. Tr. at 326-27. Dr. Herpst administered medication for pain and assessed closed head, facial, and right-hand contusions, comminuted nasal fracture, and neck bruising. Tr. at 327.

         On September 28, 2011, Plaintiff presented to Kershaw Health Urgent Care (“Urgent Care”) with complaints of a severe cough. Tr. at 375-77. The attending physician diagnosed acute bronchitis, prescribed Promethazine with Codeine and Ciprofloxacin, instructed Plaintiff to stop smoking, and provided a work excuse for one day. Id.

         On October 3, 2011, Robert E. Roberts, (“Dr. Roberts”), at First Choice, assessed lumbago and lumbosacral spondylosis and administered a lumbar facet medial branch block. Tr. at 341.

         On December 1, 2011, Plaintiff presented to First Choice with complaints of continued back pain. Tr. at 338-40. She reported back pain of 7/10 that increased, ached, burned, and throbbed, radiated to her legs, and was aggravated by exertion and prolonged standing or sitting. Id. Plaintiff reported her pain had not changed since her prior visit and the medication was “somewhat effective, ” without side effects, but an additional dose at night would be beneficial. Id. Plaintiff was able to perform her activities of daily living (“ADLs”), but complained of neck muscle spasms. Id. The attending physician noted Plaintiff did not demonstrate any aberrant behavior and found TTP at 7 of 18 fibromyalgia points with tenderness, muscle spasms, and restricted ROM in her back, but normal gait, strength, mood, and affect. Id. The attending physician assessed lumbosacral spondylosis, lumbago, brachial neuritis, muscle spasm, and multiple site joint pain, ordered a transcutaneous electrical nerve stimulation (“TENS”) unit for Plaintiff's chronic pain, and prescribed Tizanidine, Lyrica, and Norco. Id.

         On January 17, 2012, Plaintiff presented to Lexington County Mental Health Center (“LCMH”), reported that her children were taken away the prior year for missed school days and that she had anxiety and panic attacks, and requested assistance. Tr. at 310-14, 655-59. Plaintiff also reported a prior history of rape and abuse by her husband, uncle, and grandfather. Id. She stated she had previously been treated for an Adderall addiction, but had been clean for one year. Id. Plaintiff had overactive motor activity, expansive and tearful affect, anxious and depressed mood, circumstantial thought process with ideas of hopelessness, poor decision-making judgment, and inability to understand, but she was oriented to person, place, time, and situation, able to concentrate, and had intact memory and cooperative attitude, with average fund of knowledge. Id. Charles L. Griffin, LPC (“Mr. Griffin”) assessed poly-substance abuse dependence and anxiety disorder and assigned a global assessment of functioning (“GAF”)[3] score of 58.[4] Tr. at 313. Mr. Griffin noted Plaintiff did not “appear to have [a severe and persistent mental illness], ” and he referred her “to other services to meet her needs.” Tr. at 314.[5]

         On February 15, 2012, Plaintiff presented to the emergency room at LMC with complaints of coughing, wheezing, and postnasal drainage for a few days. Tr. at 325. Theresa Prince, A.P.R.N. (“Nurse Prince”), assessed asthma exacerbation and acute bronchitis, prescribed an inhaler and medication, and advised Plaintiff to quit smoking. Id.

         On March 1, 2012, Plaintiff presented to First Choice with complaints of continued back pain and increasing left knee pain. Tr. at 332-34. Plaintiff reported thoracic pain when she took a deep breath, and her back pain was 7/10, ached, burned, pierced, and radiated to her legs, and her symptoms were aggravated by exertion and prolonged standing or sitting. Id. The attending physician found normal gait, strength, mood, and affect, but tenderness, muscle spasms, and restricted ROM in her back. Tr. at 333. The attending physician assessed brachial and lumbosacral neuritis, lumbosacral spondylosis, thoracic spine pain, and lumbago, prescribed Norco, Flexeril, and Lyrica, and ordered a knee MRI. Tr. at 334. Plaintiff tested positive for Barbiturates, Marijuana, and Oxycodone. Id.

         On April 5, 2012, Plaintiff presented to LMC with complaints of right knee pain for one week after a fall. Tr. at 440-51. Joel Waldrop, M.D. (“Dr. Waldrop”), found Plaintiff's right knee was tender, assessed knee pain, ordered a knee immobilizer and crutches, prescribed Norco, and recommended follow up with Lexington Orthopaedics. Id. A work restriction note provided Plaintiff could return to work that day, but should not drive or operate heavy machinery due to her medication. Tr. at 445.

         On April 11, 2012, Plaintiff presented to T.J. Daley, P.A.-C. (“P.A. Daley”), at Lexington Orthopaedics, for right knee treatment. Tr. at 364-65. Plaintiff reported she fell while walking, her knee pain was 9/10, narcotic medication had not provided significant relief, and she had trouble with all ADLs and could not walk “very much.” Tr. at 364. P.A. Daley noted Plaintiff was previously seen for left knee pain two years prior and found she was alert and oriented with appropriate mood and affect, but walked with an antalgic gait, “seem[ed] to be in [a] fair amount of distress, ” and her right knee was globally tender and TTP. Id. P.A. Daley expressed concern that Plaintiff exhibited drug-seeking behavior and ordered a knee MRI to be conducted prior to prescribing medication. Id.

         On April 16, 2012, Plaintiff presented to LMC with continued right knee pain. Tr. at 452-63. Robert Kosclusko, M.D. (“Dr. Kosclusko”), found knee swelling, diagnosed knee pain, knee sprain, and overuse syndrome, prescribed Flexeril and Percocet, and provided a work excuse for two days. Tr. at 354, 455.

         On April 19, 2012, a right knee MRI reflected a non-displaced fracture of the patella's inferior pole with mild patellar tendinosis and peritendinous edema, vague contusion of the tibial plateau without fracture, and discoid lateral meniscus without tear. Tr. at 353.

         On April 26, 2012, Plaintiff presented to P.A. Daley for review of her right knee MRI. Tr. at 363. P.A. Daley noted the MRI showed fluid in the inferior pole of the patella and fracture. Id. He placed her knee in an immobilizer for three weeks and anticipated recovery in 6-8 weeks. Id.

         On May 10, 2012, Plaintiff presented to P.A. Daley with continued complaints of knee pain. Tr. at 362. P.A. Daley found no swelling or deformity, but Plaintiff demonstrated restricted ROM to thirty degrees, TTP at the patella's inferior pole, and global tenderness. Id. A right knee x-ray reflected a patellar fracture without significant change or displacement. Id. He noted Plaintiff would continue in her immobilizer for three weeks and continue narcotic medications. Id. P.A. Daley stated he could not “explain all of [Plaintiff's] global pain from her patellar fracture, but she [did] have pathology” and scheduled Plaintiff for a return visit in three weeks for updated x-rays and to begin physical therapy. Id.

         On June 7, 2012, Plaintiff presented to P.A. Daley with complaints of continued knee pain. Tr. at 361. Plaintiff reported her knee was “doing somewhat better.” Id. P.A. Daley noted Plaintiff had not been wearing her brace, but did some physical therapy at home. Id. He found tenderness in the patella's inferior pole and medial joint line pain, but no outward signs of swelling or deformity. Id. P.A. Daley noted Plaintiff was taken out of her splint earlier than desired and could not drive to physical therapy, such that he recommended at-home exercises and recognized it may take longer for recovery. Id. He was concerned that he did not see “tons of healing” on a recent x-ray and recommended she return in six weeks for an updated x-ray. Id.

         On June 22, 2012, Plaintiff presented to P.A. Daley with complaints of continued knee pain. Tr. at 359-60. P.A. Daley noted Plaintiff did some physical therapy at home, as she was unable to attend an outpatient physical therapy program. Id. He found no soft tissue swelling, but tenderness in the anterior, posterior, and inferior aspect of the patella. Id. P.A. Daley noted Plaintiff's disagreement and confusion regarding her prior and future knee treatments and recommended she obtain a second opinion. Id.

         On June 24, 2012, Plaintiff presented to Urgent Care with complaints of upper extremity pain due to a fall down her basement stairs. Tr. at 369-74, 378. X-rays reflected bilateral wrist fractures. Tr. at 372. The attending physician prescribed Oxymorphone and referred Plaintiff to Midlands Orthopedics for treatment. Id.

         On June 25, 2012, Plaintiff presented to LMC with complaints of bilateral arm pain after falling over the weekend. Tr. at 464-82. She reported that she was unable to fill the prescriptions received from Urgent Care, her pain had worsened, and she used splints for her wrists. Tr. at 468. She also reported she needed assistance with her ADLs and requested pain relief. Tr. at 477. The attending physician reviewed x-rays, diagnosed wrist pain and fractures, prescribed Percocet and Phenergan, and referred Plaintiff to Lexington Orthopaedics. Tr. at 476.

         On June 27, 2012, Plaintiff presented to LMC with complaints of continued arm pain and new rib and lung pain. Tr. at 483-503. Plaintiff explained her arm pain had previously distracted from her chest pain. Id. A pelvis CT scan reflected a fractured rib. Tr. at 486, 496, 500-02. Plaintiff paced and argued with her significant other during her visit and complained that her family was unwilling to help her. Tr. at 490. The attending physician diagnosed rib fracture and blunt abdominal trauma, prescribed Ciprofloxacin and Motrin, and referred Plaintiff to Lexington Orthopaedics. Tr. at 489.

         On June 29, 2012, Plaintiff presented to Midlands Orthopaedics with complaints of bilateral wrist pain of 10/10. Tr. at 398-402. Plaintiff reported the pain was aggravated by carrying, twisting, pushing, pulling, weightbearing, exercising, changing clothes, getting out of bed, and switching from sitting to standing and caused weakness, numbness, tingling, swelling, warmth, and chills. Tr. at 400. Plaintiff also reported muscle aches, weakness, back pain, dizziness, depression, fatigue, and cold intolerance. Id. Coleman Fowble, M.D. (“Dr. Fowble”), found Plaintiff to be alert, oriented, and ambulatory with moderate swelling on the left wrist and mild swelling on the right. Id. Dr. Fowble reviewed Plaintiff's wrist x-rays and noted large radial styloid pieces in both wrists, but the left was worse than the right. Tr. at 401. Dr. Fowble assessed fractures in both wrists, applied short arm casts, and prescribed Vicodin for forearm pain. Id.

         On July 30, 2012, Plaintiff presented to Midlands Orthopaedics with complaints of severe wrist pain. Tr. at 395-98. Plaintiff reported she was concerned because an emergency room doctor opined she would need surgery. Tr. at 397. Plaintiff also reported muscles aches, joint and back pain, numbness, and depression. Id. Dr. Fowble found Plaintiff to be alert and oriented, but noted swelling in her wrists when her casts were removed. Id. Dr. Fowble reviewed recent x-rays and noted Plaintiff's wrists were healing satisfactorily, but decided to keep Plaintiff's left wrist in a cast and placed a Velcro wrist splint on the right wrist. Id.

         On August 23, 2012, Plaintiff presented to Midlands Orthopaedics with complaints of bilateral wrist pain of 10/10. Tr. at 392-95. Plaintiff reported arm pain on exertion, muscle aches and weakness, joint and back pain, numbness, depression, and sleep disturbances. Id. Dr. Fowble found Plaintiff was alert and oriented, ambulatory with a nonantalgic gait, and both wrists looked “good clinically with moderate swelling on the left, ” but had diffuse TTP on the left wrist, mild tenderness on the right, and stiff wrists and hands. Id. Dr. Fowble noted, “Both wrists seem to be well aligned radiographically. She is quite stiff. Unfortunate[ly], she does not have the financial capabilities to do therapy.” Tr. at 395. Dr. Fowble also noted he wanted Plaintiff to “work aggressively on [ROM] of both the wrists and hands bilaterally, ” provided a foam ball, and placed her left wrist in a Velcro splint. Id. Dr. Fowble assessed radius and ulna fractures and hand and forearm joint pain and ordered a wrist x-ray. Tr. at 395.

         On September 17, 2012, Plaintiff presented to Midlands Orthopaedics with left foot pain. Tr. at 389-92. Plaintiff reported she tripped and fell on a tile floor and was diagnosed with a Jones fracture. Id. Plaintiff also reported arm pain on exertion, muscle aches and weakness, joint and back pain, extremity swelling, depression, sleep disturbances, and bruising easily. Id. Lauren P. Leander, P.A.-C. (“P.A. Leander”), found TTP over the dorsal forefoot and erythema at the base of the fifth metatarsal. Tr. at 391. A foot x-ray reflected nondisplaced fifth metatarsal avulsion fracture. Id. P.A. Leander assessed ankle and foot joint pain and metatarsal fracture, ordered a foot x-ray, prescribed Lortab for pain, and instructed Plaintiff to wear a boot walker for three weeks. Id.

         On September 25, 2012, Plaintiff presented to Midlands Orthopaedics and reported left foot pain, arm pain on exertion, muscle aches and weakness, joint and back pain, extremity swelling, numbness, bruising easily, depression, and sleep disturbances. Tr. at 386-89. P.A. Leander found TTP over the base of the fifth metatarsal with swelling that had improved. Tr. at 388. P.A. Leander noted Plaintiff reported increased pain and an x-ray showed a nondisplaced fracture at the base of the fifth metatarsal, but she had clinically improved. Tr. at 389. She instructed Plaintiff to wear the boot walker and scheduled a follow-up visit. Id.

         On October 1, 2012, Plaintiff presented to Midlands Orthopaedics to follow up on her joint, ankle, and foot pain. Tr. at 384-86. Plaintiff reported night sweats, arm pain on exertion, muscle aches and weakness, and joint and back pain. Tr. at 385. William C. James, III, (“Dr. James”), found mild swelling over the left foot and ankle with tenderness over the lateral aspect of the midfoot around the base of the fifth metatarsal and mild pain with pronation and supination of the midfoot. Id. An ankle x-ray showed a fracture healing satisfactorily. Id. He assessed ankle and foot joint pain and metatarsal fracture. Tr. at 386. Dr. James noted Plaintiff's fracture appeared stable and she could continue weightbearing as tolerated with her walker, scheduled a follow up in three weeks, and prescribed Hydrocodone. Id.

         On October 8, 2012, Plaintiff presented to Sri N. Arora, M.D. (“Dr. Arora”), at Brookland-Cayce Medical Practice (“B-C Med”). Tr. at 413-14, 428-29. Plaintiff reported she was out of Lisinopril for hypertension and took Paxil and Klonopin for depression. Id. Plaintiff also reported a diagnosis of carpel tunnel syndrome, she previously saw Dr. Fowble, and she had scoliosis in her back. Id. Dr. Arora noted Plaintiff wore wrist and hand splints, assessed essential hypertension, scoliosis, carpal tunnel syndrome, and depression, refilled prescriptions, and ordered bloodwork. Id.

         On November 13, 2012, Plaintiff presented to B-C Med with complaints of pelvic and back pain. Tr. at 409-13, 415-17, 424-28, 430-35. Tonna Coleman, P.A.-C. (“P.A. Coleman”), found Plaintiff had TTP in her back and pain with external hip rotation. Id. P.A. Coleman assessed lower back and pelvic pain, ordered tests, referred Plaintiff for a hip x-ray, and prescribed medication. Id.

         On November 25, 2012, Plaintiff presented to LMC with complaints of right hip pain and lower back pain. Tr. at 504-15. The attending physician found Plaintiff had decreased active ROM and tenderness in her right hip. Tr. at 506. The attending physician diagnosed hip pain, prescribed Anaprox and Prednisone, and referred Plaintiff to Lexington Medicine Associates. Tr. at 508-09.

         On November 28, 2012, Plaintiff presented to LMC with complaints of increased right hip pain. Tr. at 516-29. The attending physician found Plaintiff had decreased active ROM and tenderness in her right hip, but ambulated with a steady gait. Tr. at 518, 522. A right femur x-ray did not reflect a fracture. Tr. at 528. The attending physician diagnosed hip pain and prescribed Percocet and Phenergan. Tr. at 521.

         On February 7, 2013, Plaintiff presented to Dr. Arora to have her prescriptions refilled. Tr. at 408-09, 423-24. He noted Plaintiff was “doing [the] same, ” with no complaints or new problems and denied any issues with her medications. Id. He assessed essential hypertension, scoliosis, carpal tunnel syndrome, and depression, prescribed Lisinopril, Paxil, and Klonopin, and scheduled a follow-up visit in three months. Id.

         On February 28, 2013, Plaintiff presented to LMC with chronic right hip pain. Tr. at 530-41. Plaintiff reported she saw an orthopedist, but requested pain medication. Tr. at 532. Plaintiff also reported she was unable to attend pain management due to insurance issues. Tr. at 537. The attending physician informed Plaintiff “that if her ortho doc won't give her any pain meds, she need[ed] to see her [primary care provider], ” as the LMC did not treat chronic pain. Tr. at 533. Plaintiff ambulated with a slight limp. Tr. at 537. The attending physician assessed hip pain, prescribed Anaprox, and referred Plaintiff to Dr. Arora. Tr. at 535.

         On March 12, 2013, Plaintiff presented to LMC with complaints of back and abdominal pain, but left before completing treatment due to transportation issues. Tr. at 542-50.

         On April 25, 2013, Plaintiff presented to LMC with complaints of two days of back and chest pain. Tr. at 551-65. A chest x-ray showed no acute process. Tr. at 564. The attending physician assessed back and chest wall pain, and prescribed Flexeril, Naprosyn, and Vicodin. Tr. at 556.

         On May 1, 2013, Plaintiff presented to LMC with continued myalgias. Tr. at 566-78. The attending physician assessed myalgias, prescribed Naprosyn, Phenergan, and Ultram, and noted Plaintiff could not drive or operate heavy machinery due to her medications. Tr. at 571.

         On May 14, 2013, Plaintiff presented to B-C Med for follow up. Tr. at 407-08, 422-23. Dr. Arora noted Plaintiff had multiple issues and had attended pain management, but could no longer do so and needed to see a psychiatrist because she had depression and took Klonopin. Id. He found Plaintiff was alert and oriented. Tr. at 407. He assessed essential hypertension, scoliosis, carpal tunnel syndrome, and depression, referred Plaintiff to a psychiatrist, and prescribed Paxil, Lisinopril, and Klonopin. Tr. at 407.

         On May 18, 2013, Plaintiff presented to LMC with complaints of abdominal, pelvic, and back pain with nausea. Tr. at 579-85. The attending physician performed bloodwork and diagnosed abdominal pain, backache, and hypertension. Tr. at 582-84.

         On June 10, 2013, Plaintiff presented to LMC with complaints of nausea and abdominal and pelvic pain. Tr. at 586-604. She reported her chronic right pelvic pain had worsened, radiated down her leg, and may require a hip replacement, but she had lost her insurance and was waiting for it to resume. Tr. at 587. The attending physician noted multiple pain-related visits and found an overall normal physical exam, but TTP along the right pelvic bone with painful hip ROM. Tr. at 588-89. A right hip x-ray reflected osteoarthritic changes without evidence of acute osseous abnormality. Tr. at 597. An abdominal CT scan showed no acute abdominal or pelvic finding. Tr. at 598. The attending physician assessed worsened degenerative hip arthritis. Tr. at 592.

         On June 17, 2013, Plaintiff presented to LMC with continued complaints of right groin pain that radiated to her lower back and leg. Tr. at 605-10. She reported she had multiple visits for the pain and had lost her insurance, such that she was unable to follow up with her orthopedist. Tr. at 606. Plaintiff also reported the pain was moderate and medications had not provided relief. Tr. at 607. The attending physician noted Plaintiff was oriented, had a steady gait, and normal mood, affect, and behavior, but a prior CT scan reflected a torn pelvic muscle and there was tenderness in her abdomen. Tr. at 606, 608. The attending physician also noted the exam suggested occult hernia and provided medication. Tr. at 608.

         On July 9, 2013, James F. Bethea, M.D. (“Dr. Bethea”), conducted a consultative orthopedic examination due to Plaintiff's bilateral wrist pain, back arthritis, right hip fracture surgery, and right knee pain. Tr. at 612-16. Plaintiff reported treatment for a hip fracture, patellar fracture, left foot fracture, and wrist fractures in 2003 and 2012, with a history of fibromyalgia. Tr. at 614. She reported these injuries limited her abilities to stand to 5-10 minutes at a time, walk around the house to two minutes at a time, disturbed her sleep, caused her to avoid lifting more than a ring of keys, and prevented her from doing household chores. Tr. at 614-15. She described her pain as 9/10 at times, but indicated she could ambulate effectively enough to perform ADLs and did not mention any issues with reasoning. Id. Dr. Bethea noted Plaintiff was pleasant and cooperative, but “appeared quite uncomfortable at all times, ” which made her examination difficult. Tr. at 615. Dr. Bethea also noted Plaintiff did “not even attempt tandem walking, toe/heel walking, [or squatting] because of pain” and her gait was abnormal. Id. Dr. Bethea found Plaintiff had limited motion in both wrists and shoulders and limited rotation in her hips, but a straight leg raise (“SLR”) test was negative and there were no neurological findings. Id. Dr. Bethea reviewed prior imaging from 2011 and 2012 and assessed “[m]ultiple musculoskeletal complaints out of line with objective findings, ” “[h]istory of multiple fractures, ” and lumbosacral osteoarthritis. Id. Dr. Bethea concluded, “[h]er complaints of some pain during my examination makes determination of work capacity difficult. However, I would think that she would be able to work at a medium demand level.” Tr. at 616.

         On August 3, 2013, Cherilyn Y. Taylor, Ph.D. (“Dr. Taylor”), performed a consultative mental status evaluation. Tr. at 618-21. Dr. Taylor made general observations and reviewed Plaintiff's records, complaints, history of present illness, legal history, ADLs, social functioning, drug and alcohol use, mental status, and capability. Tr. at 618-20. Plaintiff reported she dropped out of high school when she became pregnant with her first child in the tenth grade, her children were placed in the Department of Social Services' (“DSS”) custody due to her husband's criminal domestic violence charges, she had worked numerous temporary jobs, and she received treatment for her substance abuse issues. Id. Dr. Taylor assessed polysubstance dependence and adjustment disorder, with mixed anxiety and depressed mood, and assigned a GAF score of 75.[6] Tr. at 621. She concluded Plaintiff had a history of substance abuse problems and currently experienced mood dysfunction associated with adjusting to family discord, but she was able to maintain many of her basic ADLs and interact appropriately with the examiner. Id. Dr. Taylor opined,

[Plaintiff] reported that she is capable of performing most [ADLs] independently. During the evaluation, [Plaintiff] demonstrated the ability to relate adequately and reported no major social dysfunction. [Plaintiff's] general level of intelligence is estimated to be in the low average range, and she appeared to have no significant cognitive limitations. It is likely [Plaintiff] would be capable of performing a number of work-related functions at a modified pace. [Plaintiff] would benefit from clinical intervention to address her substance abuse issues, family system problems and current mood dysfunction. With clinical intervention to address these problems, the prognosis for improvement is fair.

Tr. at 621.

         On August 6, 2013, Edward Waller, Ph.D. (“Dr. Waller”), a state agency psychologist, reviewed the record and completed a psychiatric review technique (“PRT”) assessment. Tr. at 88-89. Dr. Waller opined Plaintiff had mild restrictions of ADLs and difficulties in maintaining concentration, persistence, pace, and social functioning. Id.

         On August 13, 2013, Darla Mullaney, M.D. (“Dr. Mullaney”), a state agency physician, reviewed the record and completed a physical residual functional capacity (“RFC”) assessment. Tr. at 90-93. Dr. Mullaney opined Plaintiff could lift, carry, push, or pull twenty pounds occasionally and ten pounds frequently, stand or walk for four hours and sit for about six hours in an eight-hour workday, and occasionally climb ramps or stairs, balance, stoop, kneel, crouch, or crawl, but never climb ladders, ropes, or scaffolds and must avoid concentrated exposure to fumes, odors, dusts, gases, poor ventilation, or hazards. Id.

         On November 17, 2013, Plaintiff was admitted to the South Carolina Department of Mental Health's inpatient program at Columbia Hospital for treatment of paranoid and disorganized mania. Tr. at 625-48. A psychological assessment reflected Plaintiff had separated from her husband because he was physically abusing her, her judgment was poor, and she denied illness, but was found wandering the streets and experiencing hallucinations. Tr. at 639. Plaintiff had been hospitalized and treated for mental illness ten years prior, “was floridly manic on admission and her speech was virtually unintelligible, ” with a GAF score of 30, [7] but she improved rapidly on Olanzapine 5 mg and became well organized, without any paranoia. Tr. at 627, 637, 639, 642.

         The following day, Robert Breen, M.D. (“Dr. Breen”), noted Plaintiff's appearance was well groomed, she denied suicidal or homicidal thoughts, hallucinations, and paranoia, and she was partially oriented, but her speech was rapid, her mood was “happy, but a little sad, ” her affect was labile and incongruent, her thought process was very disorganized and evasive at times, she was obsessed with her ex-husband, believed she had “been set free, ” was not aware of current events, had poor concentration and judgment, impaired immediate recall, and absent insight, as she was “in total denial of her illness.” Tr. at 646-47. Dr. Breen diagnosed bipolar disorder, manic episode, and past history of polysubstance dependence and assigned a GAF score of 25. Tr. at 648. Dr. Breen noted Plaintiff's only medical issue was shortness of breath from asthma that responded well to an inhaler. Id.

         At discharge on November 26, 2013, the attending physician noted Plaintiff's condition was improved, as she was no longer manic, paranoid, or disorganized, diagnosed bipolar disorder, manic episode, and assigned a GAF score of 51, with court-ordered outpatient psychiatric treatment at LCMH.[8]Tr. at 625, 627. Dr. Breen prescribed Olanzapine and an albuterol inhaler. Tr. at 628.

         On January 31, 2014, Plaintiff presented to LCMH for treatment. Tr. at 679-81. Plaintiff reported her uncle and mother's boyfriend sexually abused her as a child and her second husband physically abused her. Tr. at 679. Plaintiff also reported she had been hospitalized in November 2013 and diagnosed with bipolar disorder, but had not taken her medication since that time. Tr. at 681. Joy Dalley, L.I.S.W. (“Ms. Dalley”), found Plaintiff's appearance was clean, her attitude was cooperative, her thought process and content were normal, she was oriented, and able to concentrate and do simple math, but her mood was anxious and depressed, judgment was poor, and insight was limited. Tr. at 680-81. Ms. Dalley noted Plaintiff would need treatment to regulate her medication, gain insight into her mental illness, and address her history of trauma, noting Plaintiff was moving between relatives' homes and her children had been in foster care for three years. Tr. at 681.

         On February 7, 2014, John Dewey Hynes, M.D. (“Dr. Hynes”), performed a consultative orthopedic examination for vocational rehabilitation. Tr. at 660-68. Dr. Hynes noted Plaintiff's prior injuries included broken wrists, rib, hip, foot, and knee fractures, back pain, fibromyalgia, depression, and anxiety that caused constant pain and limited her abilities to sit, walk, or stand, such that she could not “do anything with anything anymore.” Tr. at 660-61. Dr. Hynes noted lumbosacral spine x-rays indicated moderate degenerative changes with osteophyte formation. Tr. at 661. Dr. Hynes also noted Plaintiff appeared alert and cooperative, but cried during a large portion of the examination. Tr. at 662. He found some normal results, but Plaintiff's ankles were limited in flexion, her joints were diffusely TTP, she had marked pain with light palpation over the knees with limited flexion, and her wrists were limited in flexion. Tr. at 662-63. Plaintiff “voice[d] pain with every maneuver of her right hip” that caused limited abduction, adduction, flexion, and rotation, and marked TTP over the anterior aspect, and her left hip was minimally TTP. Id. Plaintiff also “voice[d] neck pain at the outer limits of abduction, ” her cervical spine was TTP at all levels with limited extension, the thoracic spine was TTP, with limited flexion and extension, and the lumbar spine was TTP, with “distal lumbosacral spinous processes causing shouts and tears due to voiced pain.” Id. Dr. Hynes noted Plaintiff tandem walked with poor balance and a slight valgus deviation of her feet and she was unable to heel-toe walk due to pain and a slight limp on the right side, but did not require an ambulatory device and could squat to 70 degrees. Tr. at 663. Dr. Hynes noted Plaintiff's report of pain in her wrists, back, hip, right foot, and knees, found TTP and limited ROM in certain areas, and relayed Plaintiff had been treated by Dr. Ogburu and Dr. Cooper for fibromyalgia, at LMC for depression, and was not taking medication for her anxiety. Tr. at 663-64.

         On March 19, 2014, Plaintiff presented to Ms. Dalley at LCMH for treatment with goals to achieve stability ...


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