United States District Court, D. South Carolina
Loretta J. Williams, Plaintiff,
Andrew M. Saul, Commissioner of Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
V. HODGES UNITED STATES MAGISTRATE JUDGE.
appeal from a denial of social security benefits is before
the court for a Report and Recommendation
(“Report”) pursuant to Local Civ. Rule
73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action
pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to
obtain judicial review of the final decision of the
Commissioner of Social Security (“Commissioner”)
denying her claim for Supplemental Security Income
(“SSI”). The two issues before the court are
whether the Commissioner's findings of fact are supported
by substantial evidence and whether 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.
about July 3, 2012, 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].
Plaintiff's Background and Medical History
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.
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
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.
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.
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.
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.
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.
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”) score of 58. 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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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. 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.
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.
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.
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,
she improved rapidly on Olanzapine 5 mg and became well
organized, without any paranoia. Tr. at 627, 637, 639, 642.
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.
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.Tr. at 625, 627. Dr. Breen prescribed
Olanzapine and an albuterol inhaler. Tr. at 628.
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.
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.
March 19, 2014, Plaintiff presented to Ms. Dalley at LCMH for
treatment with goals to achieve stability ...