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Littleton v. Saul

United States District Court, D. South Carolina, Greenville Division

September 12, 2019

Carol Lynn Littleton, Plaintiff,
v.
Andrew M. Saul, Commissioner of Social Security, Defendant.

          REPORT OF MAGISTRATE JUDGE

          Kevin F. McDonald United States Magistrate Judge

         This case is before the court for a report and recommendation pursuant to Local Civil Rule 73.02(B)(2)(a)(D.S.C.), concerning the disposition of Social Security cases in this District, and Title 28, United States Code, Section 636(b)(1)(B).[1]

         The plaintiff brought this action pursuant to Sections 205(g) and 1631(c)(3) of the Social Security Act, as amended (42 U.S.C. 405(g) and 1383(c)(3)), to obtain judicial review of a final decision of the Commissioner of Social Security denying her claims for disability insurance benefits and supplemental security income benefits under Titles II and XVI of the Social Security Act.

         ADMINISTRATIVE PROCEEDINGS

         The plaintiff previously applied for disability benefits in 2006, which was denied (Tr. 138, 337-38). The plaintiff filed applications for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) benefits on January 14, 2015. In both applications, the plaintiff alleged that she became unable to work on July 1, 2008. Through her attorney, the plaintiff amended the alleged disability onset date to February 27, 2014. Both applications were denied initially and on reconsideration by the Social Security Administration. On November 24, 2015, the plaintiff requested a hearing. The administrative law judge (“ALJ”), before whom the plaintiff and Julie Bose, an impartial vocational expert, appeared in a video hearing[2] on June 29, 2017, considered the case de novo, and on August 31, 2017, found that the plaintiff was not under a disability as defined in the Social Security Act, as amended (Tr. 24-37). The ALJ's finding became the final decision of the Commissioner of Social Security when the Appeals Council denied the plaintiff's request for review on July 25, 2018 (Tr. 1-6). The plaintiff then filed this action for judicial review.

         In making the determination that the plaintiff is not entitled to benefits, the Commissioner has adopted the following findings of the ALJ:

(1) The claimant meets the insured status requirements of the Social Security Act through December 31, 2017.
(2) The claimant has not engaged in substantial gainful activity since February 27, 2014, the amended alleged onset date (20 C.F.R §§ 404.1571 et seq., 416.971 et seq.).
(3) The claimant has the following severe impairments: disorder of the back, degenerative joint disease, a history of traumatic brain injury, affective/mood disorder, post-traumatic stress disorder, and a history of drug use/dependence (20 C.F.R. §§ 404.1520(c), 416.920(c)).
(4) The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525, 416.920(d), 416.925, 416.926).
(5) After careful consideration of the entire record, I find that the claimant has the residual functional capacity to lift/carry/push/pull 20 pounds occasionally and 10 pounds frequently, stand and/or walk six hours total in an eight-hour workday, and sit for six hours total in an eight-hour workday. In addition, the claimant can occasionally climb ramps and stairs, can never climb ladders, ropes, or scaffolds, and can occasionally balance, stoop, kneel, crouch, and crawl. Further, she should have no more than occasional exposure to unprotected heights and dangerous machinery. Furthermore, the claimant retains the mental residual functional capacity to understand, remember, and carry out simple tasks and instructions; she can concentrate, attend, and persist on simple tasks; she can interact adequately with supervisors and co-workers, but never the general public; and she can respond appropriately to simple, routine, workplace changes. Finally, the claimant will miss an occasional day of work because of mental health issues, with occasional defined as once every one to two months. The claimant's physical limitations are based on the State agency assessments at ¶ 9A and B10A, while her mental limitations are based on the State agency assessments at ¶ 3A, B4A, B9A, and B10A.
(6) The claimant is unable to perform any past relevant work (20 C.F.R. §§ 404.1565, 416.965).
(7) The claimant was born on April 10, 1969, and was 44 years old, which is defined as a younger individual age 18-49, on the amended alleged disability onset date (20 C.F.R. §§ 404.1563, 416.963).
(8) The claimant has at least a high school education and is able to communicate in English (20 C.F.R. §§ 404.1564, 416.964).
(9) Transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that the claimant is “not disabled” whether or not the claimant has transferable job skills (See SSR 82-41 and 20 C.F.R. Part 404, Subpart P, Appendix 2).
(10) Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform (20 C.F.R. §§ 404.1569, 404.1569(a), 416.969, 416.969(a)).
(11) The claimant has not been under a disability, as defined in the Social Security Act, from February 27, 2014, through the date of this decision (20 C.F.R. §§ 404.1520(g), 416.920(g)).

         The only issues before the court are whether proper legal standards were applied and whether the final decision of the Commissioner is supported by substantial evidence.

         APPLICABLE LAW

         Under 42 U.S.C. § 423(d)(1)(A), (d)(5) and § 1382c(a)(3)(A), (H)(i), as well as pursuant to the regulations formulated by the Commissioner, the plaintiff has the burden of proving disability, which is defined as an “inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 20 C.F.R. §§ 404.1505(a), 416.905(a).

         To facilitate a uniform and efficient processing of disability claims, the Social Security Act has by regulation reduced the statutory definition of “disability” to a series of five sequential questions. An examiner must consider whether the claimant (1) is engaged in substantial gainful activity, (2) has a severe impairment, (3) has an impairment that meets or medically equals an impairment contained in the Listing of Impairments found at 20 C.F.R. Pt. 404, Subpt. P, App. 1, (4) can perform his past relevant work, and (5) can perform other work. Id. §§ 404.1520, 416.920. If an individual is found not disabled at any step, further inquiry is unnecessary. Id. §§ 404.1520(a)(4), 416.920(a)(4).

         A claimant must make a prima facie case of disability by showing he is unable to return to his past relevant work because of his impairments. Grant v. Schweiker, 699 F.2d 189, 191 (4th Cir. 1983). Once an individual has established a prima facie case of disability, the burden shifts to the Commissioner to establish that the plaintiff can perform alternative work and that such work exists in the national economy. Id. (citing 42 U.S.C. § 423(d)(2)(A)). The Commissioner may carry this burden by obtaining testimony from a vocational expert. Id. at 192.

         Pursuant to 42 U.S.C. § 405(g), the court may review the Commissioner's denial of benefits. However, this review is limited to considering whether the Commissioner's findings “are supported by substantial evidence and were reached through application of the correct legal standard.” Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996). “Substantial evidence” means “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance.” Id. In reviewing the evidence, the court may not “undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner].” Id. Consequently, even if the court disagrees with Commissioner's decision, the court must uphold it if it is supported by substantial evidence. Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).

         EVIDENCE PRESENTED

         The plaintiff was 44 years old on her amended alleged disability onset date (February 27, 2014) and 48 years old at the time of the ALJ's decision (August 31, 2017). She completed her education through two years of college, and she has past relevant work as a certified nursing assistant (“CNA”), telemarketer, and customer service clerk (Tr. 34, 52, 82-83, 342-43).

         On September 10, 2013, the plaintiff was seen at Baptist Hospital emergency room (“Baptist ER”) for an anxiety reaction because her ex-boyfriend had chased her while she was at Transitions, a homeless shelter. She was given Ativan and Zofran IV and had marked improvement. She was discharged to follow up with her primary care physician and Transitions staff (Tr. 1009-10).

         On February 27, 2014, the plaintiff was admitted to Richland Hospital after an assault by her boyfriend that caused jaw fractures and resulted in surgery to repair her jaw. A CT scan of her cervical spine revealed multilevel degenerative disc facet disease, especially at ¶ 5-6 and C6-7 with central canal narrowing, greatest at ¶ 6-7. There was neural foraminal narrowing bilaterally at ¶ 4-5 and on the right at ¶ 6-7 (Tr. 556, 591). On March 2, 2014, an MRI of her brain showed a diffuse axonal injury (Tr. 555).

         On March 19, 2014, the plaintiff was treated at Baptist ER for jaw pain because she had pulled a surgical wire out. She had taken Norco, was very sleepy, and complaining of chest pain (Tr. 1011-12).

         On April 12, 14, and 23, 2014, the plaintiff was seen at Richland Hospital for post-surgery jaw pain (Tr. 750, 753, 756). On April 14, 2014, she also sought treatment at Lexington Medical Center for facial pain after her boyfriend hit her in the chest and on the side of her face. On examination, she was alert and oriented. Her mood, affect, and behavior were normal. She was prescribed Percocet (Tr. 880-82). On April 15, 2014, she was seen at Baptist Hospital ER for an anxiety reaction after an altercation with her boyfriend. She was given Ativan, which made her feel much better (Tr. 1014).

         On May 5, 2014, the plaintiff was seen at Baptist ER after she ran away from someone and after having an altercation with her ex-husband. She was very anxious. She was given medication for anxiety and pain, and her symptoms improved (Tr. 1016). On May 6, 2014, she had anxiety attacks, palpitations, and face pain after being punched in the face by her ex-boyfriend. Examination was generally normal. She was slightly anxious. Diagnoses were anxiety and status post-assault with facial contusions. She was prescribed Norco and Ativan (Tr. 1018). On May 17, 2014, the plaintiff felt she was having tachycardiac spells due to anxiety or due to her supraventricular tachycardia (“SVT”). She had an EKG and was watched for two hours and had no tachycardic spells while on the monitors. Clinical impression was anxiety, and Vistaril was prescribed (Tr. 1020-21). On May 22, 2014, the plaintiff was seen at Baptist ER after she had taken five or six Ativan due to facial pain. She had an altered mental status due likely due to the medication. On first examination, she was drowsy and had slurred speech. Upon re-examination, she was alert and stated she could call her sister to pick her up. She was advised to take her medications only as prescribed and was discharged in stable and improved condition (Tr. 1024-25). On May 23, 2014, she was seen at Baptist ER for palpitations, chronic anxiety, and an abrasion on her right upper extremity. On examination, mild anxiety was noted. She received a prescription for Ultram, was discharged to home, and was asked to follow up with her primary care physician (Tr. 1029).

         On May 24, 2014, the plaintiff was seen multiple times within a 24-hour period at the Richland Hospital ER. She had vague complaints, which kept changing. She first claimed to have chest pain and that she had been bitten by animals, then complained of a bruise on her arm, and then complained that she had facial pain that had resolved. She was defensive and called the staff names when they asked her why she repeatedly returned to the ER. She was discharged with a clinical impression of “malingering” (Tr. 763-64). On May 26, 2014, the plaintiff was seen at the Richland Hospital ER for chest palpitations related to assaults and suicidal ideation. On examination, she was cooperative, and her behavior was appropriate. Her affect was constricted, and mood was congruent. She had normal speech. Thought process was linear, logical, and goal-directed. She had no delusions or hallucinations. Her insight and judgment were poor. Attention and concentration were good, and memory was intact. She was diagnosed with chronic depression. She was discharged and outpatient followup was best indicated (Tr. 769-73). She also went to Baptist ER on May 26th with abrasions on both knees. It was noted that she had a history of psychiatric disorders, was homeless, and could not find shelter from the rain. She was evaluated by psychiatry, who felt she was alright to go home. She received a dose of Flexiril and Tylenol, and her symptoms resolved (Tr. 1033-34).

         On May 28, 2014, the plaintiff was evaluated at the Columbia Area Community Mental Health Clinic (”CAMHC”) after walking into the path of a car. She heard voices that sounded like her own voice. Upon receiving records from Richland, it was noted that over the weekend and on the 28th her thoughts of self-harm varied with each clinician she talked to. There was no indication that she placed herself in front of the car (Tr. 1128-29).

         On June 6, 2014, at Richland ER, the plaintiff reported dental pain, and she had an anxious appearance. It was noted that she had more than a dozen visits to the ER over the past month. She was discharged home and advised to follow up with an oral surgeon (Tr. 776-77). On June 11 and 12, 2014, she returned to Baptist ER and Richland Hospital, respectively, for palpitations and anxiety (Tr. 779, 1037). On June 15, 2014, she was seen at Lexington Medical Center for facial pain. Examination was generally normal with facial pain upon palpation (Tr. 889-93).

         On June 16, 2014, the plaintiff was treated at CAMHC for suicidal ideation. She had depressive symptoms of insomnia, nightmares, and flashbacks. She had poor judgment and poor insight. Her ...


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