Opinion
Civil Action No. 6:16-1320-PMD-KFM
07-21-2017
Angela D. Mills, Plaintiff, v. Nancy A. Berryhill, Acting Commissioner of Social Security, Defendant.
REPORT OF 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).
A report and recommendation is being filed in this case, in which one or both parties declined to consent to disposition by the magistrate judge.
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 filed applications for disability insurance benefits ("DIB") and supplemental security income ("SSI") benefits on May 20, 2010, alleging that she became unable to work on February 9, 2008. Both applications were denied initially and on reconsideration by the Social Security Administration. On April 5, 2011, the plaintiff requested a hearing. The administrative law judge ("ALJ"), before whom the plaintiff appeared on October 9, 2012, considered the case de novo, and on November 1, 2012, found that the plaintiff was not under a disability as defined in the Social Security Act, as amended. The plaintiff filed a request for review of the hearing decision on December 21, 2012, which the Appeals Council granted on March 6, 2014. The Appeals Council subsequently vacated the hearing decision and remanded the case back to the ALJ to take additional testimony about the plaintiff's alleged impairments, including the testimony of a vocational expert (Tr. 184-88). A supplemental hearing was held on July 10, 2014, in Charlotte, North Carolina, at which the plaintiff and Jacquelyn Merrit Kennedy, an impartial vocational expert, appeared and testified. On October 15, 2014, the ALJ issued a decision finding that the plaintiff was not under a disability as defined in the Social Security Act, as amended (Tr. 22-36). 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 March 7, 2016 (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 September 30, 2011.
(2) The claimant has not engaged in substantial gainful activity since February 9, 2008, the alleged onset date (20 C.F.R §§ 404.1571 et seq., and 416.971 et seq.).
(3) The claimant has the following severe impairments: spinal stenosis, rheumatoid arthritis, depression, and anxiety disorder (20 C.F.R. §§ 404.1520(c) and 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 and 416.926).
(5) After careful consideration of the entire record, I find that the claimant has the residual functional capacity to perform light work as defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b). She additionally requires a sit/stand option with the ability to sit
and/or stand at will. She can occasionally reach overhead. She is limited to simple, routine, repetitive tasks with only occasional contact with coworkers, supervisors, and the public.
(6) The claimant is unable to perform any past relevant work (20 C.F.R. §§ 404.1565 and 416.965).
(7) The claimant was born on October 16, 1965, and was 42 years old, which is defined as a younger individual age 18-49, on the alleged disability onset date (20 C.F.R. §§ 404.1563 and 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 and 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 and 416.969(a)).
(11) The claimant has not been under a disability, as defined in the Social Security Act, from February 9, 2008, through the date of this decision (20 C.F.R. §§ 404.1520(g) and 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 supported by substantial evidence. Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).
EVIDENCE PRESENTED
The plaintiff was 42 years old on her alleged disability onset date (February 9, 2008) and was 48 years old on the day the ALJ issued his decision (October 15, 2014). She last worked on February 8, 2008, and she was last insured for Title II benefits on September 30, 2011. The plaintiff took some college classes studying nursing and obtained Certified Nurse Assistant ("CNA") certification (Tr. 91). She has past relevant work experience as a CNA, operations manager, and restaurant worker (Tr. 34).
On June 11, 2007, Martin M. Henegar, M.D., performed an unsuccessful right C6-7 microendoscopic foraminotomy on the plaintiff (Tr. 409-10, 413-16). On December 3, 2007, Dr. Henegar reviewed a cervical spine MRI showing persistent or recurrent disc bulge at C6-7 (moderate degenerative change with possible tiny disc extrusion); a hemangioma of C6; no obvious neural compression lesion; and no other findings (Tr. 417-18).
On June 5, 2009, the plaintiff visited the Chester Regional Medical Center ("CRMC") emergency department for unrelated complaints (Tr. 429-38). On examination, the plaintiff ambulated independently; could perform all daily activities without assistance; and had normal strength, normal joint range of motion ("ROM"), and no swelling or deformities. The plaintiff was anxious but alert and oriented and demonstrated normal and appropriate behavior (Tr. 431).
On September 30, 2009, the plaintiff saw Jacques Days, M.D., for neck and shoulder pain. Her neck pain started with a bulging cervical disc and was associated with an unsuccessful attempt at surgical intervention. On examination, the plaintiff had pain in her shoulders but no neurologic symptoms. Dr. Days assessed the plaintiff with cervicalgia and gave her Toradol and Solu-Medrol injections. Her prescriptions were refilled (Tr. 467).
On November 3, 2009, the plaintiff saw Rupal N. Badalyan, M.D., for her chronic pain. On examination, the plaintiff had tenderness in her neck muscles. She had no deformities, normal gait, and normal balance. Dr. Badalyan assessed her with worsening cervicalgia, gave her a Solu-Medrol injection, and refilled prescriptions (Tr. 468-69).
On December 8, 2009, the plaintiff saw Dr. Badalyan, again for her chronic neck and back pain. The plaintiff reported that she was doing much better on pain medications. She reported new left hip pain. On examination, the plaintiff had diffuse muscle tightness in her neck and was tender to palpation of left sciatic nerve. She was assessed with depression, sciatica, and cervicalgia, and her Lortab was refilled (Tr. 470-71).
On February 1, 2010, the plaintiff saw Dr. Days for left hip, neck, and back pain that radiated to her left upper extremity. On examination, the plaintiff was tender over lumbar muscles and had left side sciatica. She was assessed with left hip pain, paresthesias in the left upper extremity, cervicalgia, and left side sciatica. Her prescriptions were refilled (Tr. 472-73).
On February 22, 2010, saw Dr. Days for neck pain with stiffness and hip and back pain. The plaintiff described the pain as aching in the lower neck that was at a five out of ten on the pain scale. She stated that the pain was worse when she first woke up and was aggravated by prolonged walking, standing, sitting, and lifting. On examination, the plaintiff had diffuse muscle tightness and tenderness in her neck but had no midline tenderness and no reproduction of arm symptoms with palpation of her cervical spine. She was tender over her lumbar muscles with reproduction of left side sciatica with palpation over left gluteal region. The plaintiff was assessed with left hip pain, cervicalgia, and sciatica (Tr. 474).
On March 11, 2010, the plaintiff had a followup with Dr. Days for chronic left hip pain associated with poor pain control. She described the pain as sharp and hurting. The plaintiff stated that she had relief with Lortab, but that the relief was incomplete and transient. The plaintiff stated that the longer her pain lasts, the more intense it is and the more depressed she becomes. On examination, the plaintiff had tender neck muscles and midline cervical tenderness. She had pain with ambulation and pain upon ROM in her left hip. Dr. Days assessed the plaintiff with chronic depressive disorder, chronic left hip pain, chronic cervicalgia, and chronic left sciatica (Tr. 478). She was prescribed hydromorphine and Neurontin (Tr. 479).
On April 8, 2010, the plaintiff returned to Dr. Days for treatment of chronic left hip and back pain associated with poor pain control. The plaintiff found relief with Lortab more effective than relief from hydromorphine. The plaintiff reported depression with no known underlying cause but aggravated by chronic pain. On examination, the plaintiff had tender neck muscles and midline cervical tenderness. Her left hip pain reproduced with passive ROM. Dr. Days assessed the plaintiff with depressive disorder, left hip pain, and left sciatica (Tr. 480). She was prescribed Icy Hot patch, Lortab, and nortriptyline (Tr. 481).
On April 28, 2010, the plaintiff returned to CRMC emergency department with pain complaints all over her body (Tr. 439-49). On examination, although the plaintiff rated her pain as a ten, she ambulated independently, had normal joint ROM, and had no swelling or deformities (Tr. 441). The plaintiff was diagnosed with chronic pain and rheumatoid arthritis ("RA") and was given medications. She was alert and oriented with normal, appropriate behavior but appeared nearly incapacitated with anxiety (Tr. 441, 448-49). The plaintiff also saw Dr. Days and Lissette Maduro, M.D., on this date. During this visit, the plaintiff reported chronic, sharp left hip pain and back pain. The plaintiff stated that the pain was so intense that she used more of the Lortab than prescribed. She stated that she did not take the Pamelor (nortriptyline) because she was unsure if the doctor knew she was taking Prozac. She reported depression aggravated by chronic pain. The plaintiff was assessed with arthralgia, chronic left hip pain, and elevated blood pressure (Tr. 482). The plaintiff was given Toradol and Solu-Medrol injections and prescribed ibuprofen (Tr. 483).
On May 6, 2010, the plaintiff saw Dr. Days for her chronic hip and back pain. The pain was associated with blood tests showing abnormal rheumatoid factor ("RF") and erythrocyte sedimentation rate ("ESR"). On examination, the plaintiff had left hip pain reproduced with passive ROM and left hip pain with ambulation. She was tender over lumbar muscles with reproduction of left sciatica with palpation over left gluteal area and had pain with elevation of shoulders. Dr. Days assessed the plaintiff with unspecified inflammatory polyarthropathy. She was prescribed famotidine (Pepcid), oxycodone-acetaminophen, and prednisone (Tr. 484).
On June 30, 2010, the plaintiff saw Dr. Maduro for severe headaches and prescription refills. On examination, it was noted that the plaintiff was obese. She had tenderness over her cervical spine and mid-back. The plaintiff was assessed with unspecified inflammatory polyarthtopathy (Tr. 454).
On July 9, 2010, the plaintiff was treated by Dr. Days for chronic pain. Upon examination, the plaintiff had left hip pain with ambulation, was tender over her lumbar muscles, had left side sciatica, and pain with passive abduction of shoulders. Dr. Days assessed unspecified inflammatory polyarthropathy, uncontrolled. The plaintiff was given Phenergan and Solu-Medrol injections and prescribed Dilaudid (Tr. 452-53).
On August 11, 2010, the plaintiff saw Dr. Days for a disability form related to her arthralgias and depression and a prescription refill. The plaintiff stated that she was concerned about worsening back pain over the last three weeks. She had depression due to chronic illness. Dr. Days assessed the plaintiff with chronic left hip pain, chronic cervicalgia, recurrent left sciatica, chronic back pain, and depressive disorder, improving. She was prescribed oxycodone-acetaminophen, and Dr. Days completed her disability form (Tr. 515-16).
In the form, Dr. Days opined that the plaintiff's pain frequently interfered with her concentration and attention and that she had a severe limitation in her ability to deal with work stress (Tr. 385). Dr. Days also opined that the plaintiff could only sit for less than 15 minutes before needing to stand or walk for at least 30 minutes; could stand or walk for three hours before needing to lie down or recline in a supine position for approximately two hours; stand or walk for a total of two hours not including time spent lying down or reclining supine; and needed to elevate her legs to at least chest height when sitting (Tr. 385-87). Dr. Days added that the plaintiff needed more breaks than a "normal" person and that she would need to rest, lie down, or recline in a supine position for three hours in an eight-hour workday (Tr. 387). Dr. Days further opined that the plaintiff could lift or carry five pounds occasionally; balance and reach frequently; flex and/or rotate her neck, handle, and finger occasionally; and never stoop (Tr. 388-89). Dr. Days stated that the plaintiff would likely be absent from work for more than three days per month (Tr. 390). Dr. Days found that the plaintiff did not need a handheld assistive device to walk or stand (Tr. 389).
On August 31, 2010, the plaintiff returned to Dr. Henegar with persistent neck pain complaints, as well as headaches and depression (Tr. 486-87). On examination, Dr. Henegar found that the plaintiff had decreased ROM of her cervical spine secondary to pain, giveaway on strength testing in her upper extremities, negative Tinel's sign, brisk upper-extremity reflexes, absent knee jerks, compromised gait and station, and decreased upper-extremity sensation (mostly in hands) (Tr. 486).
On September 9, 2010, the plaintiff saw Dr. Days for followup of arthralgias and depression associated with chronic back, neck, and hip pain. The plaintiff rated her pain as nine and half out of ten. She reported that oxycontin was too strong and made her sleepy. She wanted to return to Lortab. She had depression because of chronic illness. On examination, ROM in her neck was diminished by pain. She had cervical and mid-back spinal and paraspinous tenderness and pain with passive ROM in her left hip. Dr. Days' assessment was chronic left hip pain, chronic back pain, and fatigue. The plaintiff received a B-12 injection and was prescribed Lortab (Tr. 517-18).
On September 27, 2010, state agency psychologist Paula Kresser, Ph.D., opined that the plaintiff was moderately limited in her ability to understand and carry out detailed instructions, maintain attention and concentration for extended periods, complete a normal workday/workweek without interruptions from psychologically-based symptoms, perform at a consistent pace without an unreasonable number and length of rest periods, and interact appropriately with the general public (Tr. 490-91). Dr. Kresser added that the plaintiff had a mild restriction in daily activities; mild difficulties in maintaining social functioning; and moderate difficulties in maintaining concentration, persistence, or pace (Tr. 501). She further opined that the plaintiff had deficits in concentration but retained the ability to perform at least simple, repetitive tasks despite depressive symptoms (Tr. 489).
On September 28, 2010, state agency physician Michael Perll, M.D., opined that the plaintiff could frequently lift or carry ten pounds; stand and/or walk and sit for six hours each in an eight-hour workday; frequently climb ramps or stairs, balance, stoop, kneel, crouch, or crawl; and never climb ladders, ropes, or scaffolds (Tr. 505-06). He added that the plaintiff should have no overhead reaching (Tr. 506).
On October 5, 2010, the plaintiff saw Dr. Days' associate, Shelaila Villamor, D.O., for refills and coughing up sputum. The plaintiff reported stable symptoms with pain medication. On examination, Dr. Villamor noted that the plaintiff was obese, had diminished ROM in her neck, and had cervical and mid-back spinal and paraspinous tenderness. Lortab, Tussionex and a Z-pac were prescribed (Tr. 519-20).
On November 24, 2010, the plaintiff saw Dr. Days for lab work followup, prescription refills, and acid reflux. She had depression caused by chronic illness. On examination, the plaintiff had cervical and mid-back spinal and paraspinous tenderness. She had pain with passive ROM of her left hip. Dr. Days assessed the plaintiff with gastroesophageal reflux, left hip pain, cervicalgia, left sciatica, paresthesias of left upper extremity, and depressive disorder. She was prescribed famotidine and Lortab (Tr. 521-22).
On December 2, 2010, the plaintiff saw Dr. Days chiefly for prescription refills. She had arthralgias associated with RA. The plaintiff had new onset right ankle pain and left wrist pain. The wrist pain was in the tendons proximal to the dorsal thumb. The ankle pain was intermittent, but her wrist pain persisted. On examination, the plaintiff's neck ROM was diminished by pain. She had a negative Finklestein's test, but there was tenderness with passive wrist flexion and flexion against resistance. The plaintiff had cervical and mid-back spinal and paraspinous tenderness. She had pain with passive left hip ROM, no pain with ankle ROM, and no ankle tenderness. Dr. Days assessed the plaintiff with recurrent arthralgia, new right ankle pain, and new left wrist tendinitis. She was prescribed an ankle strap, Lortab, and a wrist support (Tr. 523-24).
On December 23, 2010, the plaintiff was seen by Dr. Days for followup. The plaintiff reported pelvic pain involving joints and soft tissues and other general pain. On examination, the plaintiff's neck ROM was diminished by pain. She had cervical and mid-back spinal and paraspinous tenderness and pain with passive left hip ROM and no costovertebral angle tenderness ("CVAT"). Dr. Days assessed the plaintiff with new pelvic pain, chronic unspecified inflammatory polyarthropathy, chronic back pain, and depressive disorder. The plaintiff received a Toradol injection and was prescribed Dilaudid. Lortab was stopped (Tr. 525-26).
On January 3, 2011, the plaintiff saw Dr. Days for review of fasting lab work and her complaints of chronic pain. The plaintiff said she found relief with the Dilaudid, but it caused headaches that she could not tolerate. On examination, it was noted that the plaintiff was obese. She had neck ROM diminished by pain, cervical and mid-back spinal and paraspinous tenderness, hip pain upon passive ROM, no CVAT, and her plantar flexion strength was intact. Dr. Days assessed her with hyperlipidemia and chronic unspecified inflammatory polyarthropathy. The plaintiff was given Toradol and Solu-Medrol injections and prescribed oxycodone, oxycodone-acetaminophen, and prednisone (Tr. 527-28).
On January 27, 2011, the plaintiff saw Dr. Days for followup of chronic pain that had gotten worse in the last month. She also reported pain-induced insomnia. On examination, it was noted that the plaintiff had reflux and heartburn and depression. Her neck ROM was diminished by pain. She had cervical and mid-back spinal and paraspinous tenderness, hip pain upon passive ROM, no CVAT, and her plantar flexion strength was intact. The plaintiff was assessed with RA, chronic back pain, insomnia, and chronic fatigue. She was given Toradol and Solu-Medrol injections and prescribed oxycodone, oxycodone-acetaminophen, and prednisone (Tr. 529-30).
On February 23, 2011, the plaintiff saw Dr. Days for prescription refills and flu-like symptoms. On examination, Dr. Days noted that the plaintiff was obese. She had limited neck ROM. The plaintiff had cervical and mid-back spinal and paraspinous tenderness, hip pain upon passive ROM, no CVAT, and her plantar flexion strength was intact. Her affect was slightly dysphoric. Dr. Days assessed the plaintiff with streptococcal pharyngitis and acute bronchitis (Tr. 668-69).
On March 22, 2011, the plaintiff saw Dr. Days for followup for worsening chronic back and flank pain. It was noted that the plaintiff had reflux, heartburn, diarrhea, and depression. On examination, it was noted that the plaintiff was obese, and ROM was diminished in her neck by pain. She had cervical and mid-back spinal and paraspinous tenderness, hip pain upon passive ROM, no CVAT, and her plantar flexion strength was intact. The plaintiff' s affect was slightly dysphoric. The plaintiff was assessed with RA, diarrhea, and abdominal pain (Tr. 666-67).
On March 30, 2011, state agency psychologist Xanthia Harkness, Ph. D., opined that the plaintiff had a mild restriction in daily activities and mild difficulty in maintaining social functioning and concentration, persistence, or pace (Tr. 556). Also on this date, state agency physician Ted Roper, M.D., opined that the plaintiff could lift or carry 20 pounds occasionally and ten pounds frequently, could stand and/or walk and sit for six hours each in an eight-hour workday, and had limited ability to push and/or pull in her upper extremities (Tr. 561). Dr. Roper further opined that the plaintiff could frequently climb ramps and stairs, balance, stoop, kneel, and crouch; occasionally crawl; occasionally reach overhead; and never climb ladders, ropes, or scaffolds (Tr. 562-63). He added that the plaintiff should avoid even moderate exposure to hazards (Tr. 564). Dr. Roper found that plaintiff could perform light work (Tr. 565).
On April 15, 2011, the plaintiff saw Dr. Days for chronic pain and depression. On examination, Dr. Days noted that the plaintiff was obese. She had limited neck ROM. The plaintiff had cervical and mid-back spinal and paraspinous tenderness, hip pain upon passive ROM, no CVAT, and her plantar flexion strength was intact. She was slightly dysphoric. Dr. Days assessed the plaintiff with RA, chronic back pain, insomnia, and adjustment reaction with mixed mood. The plaintiff was assessed with worsening depression, uncontrolled RA, worsening left hip pain, worsening cervicalgia, worsening back pain, diarrhea, and abdominal pain. She was prescribed Percocet (Tr. 664-65).
On May 12, 2011, the plaintiff saw Dr. Days for followup of her chronic pain and depression. On examination, Dr. Days noted that the plaintiff was obese and had limited neck ROM. The plaintiff had cervical and mid-back spinal and paraspinous tenderness, hip pain upon passive ROM, no CVAT, and her plantar flexion strength was intact. She was slightly dysphoric. Dr. Days assessed the plaintiff with RA, chronic back pain, insomnia, and adjustment reaction with mixed mood. She was prescribed doxycycline, Percocet, and Zoloft (Tr. 662-63).
On June 9, 2011, the plaintiff saw Dr. Days for chronic pain in her hips, knee, hands, shoulders, wrists, and back. She reported insomnia and depression. On examination, the doctor noted that the plaintiff was obese, had neck ROM that was diminished by pain, cervical and mid-back spinal and paraspinous tenderness, hip pain upon passive ROM, no CVAT, and her plantar flexion strength was intact. The plaintiff was assessed with RA (Tr. 660-61).
On July 6, 2011, the plaintiff saw Dr. Days for her chronic pain and prescription refills. On examination, the plaintiff was in mild distress secondary to pain. She walked slowly and was tearful. Dr. Days assessed her with RA and noted that she was to follow up with him in a month (Tr. 713).
On July 20, 2011, the plaintiff visited the emergency department at Piedmont Medical Center ("PMC") for complaints of chest pain that had lasted for the past three days. She also reported abdominal pain. The plaintiff was diagnosed with walking pneumonia and advised to follow up with her private physician (Tr. 569-87, 594-97). The plaintiff ambulated without assistance (Tr. 569, 584). On examination, she had normal ROM, normal strength, no appreciable muscle atrophy, normal sensation, and no tenderness. The plaintiff was alert and oriented with a grossly appropriate mood and affect (Tr. 571-72).
On July 26, 2011, the plaintiff saw Dr. Days for a consult. She stated that she felt her RA was getting worse and would like to be started on Embrel. The plaintiff also reported depression. She had acid reflux, diarrhea, nausea, and vomiting. On examination, the plaintiff was in mild distress secondary to pain. She was walking slowly and was tearful. The plaintiff was assessed with aphthous stomatis (canker sore), dysphagia, and abnormal chest x-ray. The doctor referred her to oncology/hematology and prescribed Percocet and xylocaine (Tr. 711-12).
On August 10, 2011, the plaintiff saw Dr. Days for RA joint pain. She also had chronic back pain and was depressed. She had acid reflux, diarrhea, nausea, and vomiting. On examination, the plaintiff was in mild distress secondary to pain. She was assessed with arthralgia, back pain, depression, and gastroesophageal reflux. The doctor prescribed Compazine for nausea and Zoloft (Tr. 709-10).
On August 30, 2011, the plaintiff had a consult with Dr. Days regarding worsening joint pain and depression. She reported acid reflux, diarrhea, nausea and vomiting. On examination, the plaintiff was in mild distress secondary to pain. She had pain in her neck with ROM. The plaintiff had an antalgic gate and marked pain with joint ROM. Dr. Days assessed depression, arthralgia, and RA. The plaintiff was prescribed fentanyl and Percocet (Tr. 707-08).
On September 30, 2011, the plaintiff saw Dr. Days for assessment of her response to medication, chronic pain, depression, and nausea. The plaintiff stated she found inadequate relief from Percocet. She reported that her worsening pain symptoms made it difficult for her to walk and interfered with her sleep. On examination, the plaintiff was in mild distress secondary to pain and had pain in her neck with ROM. Her gait was antalgic, and she had marked pain with joint ROM. The plaintiff also had point tenderness over soft tissue inferior and anterior to right medial malleolus and no edema. Dr. Days assessed her with paresthesias in left upper extremity, right ankle pain, RA, and abnormal chest x-ray. The plaintiff was given a flu shot and pneumovax injection and was referred to a pulmonologist for indeterminate pulmonary nodules on a chest CT (Tr, 704-05)
On October 5, 2011, after a fall, the plaintiff had x-rays performed at CRMC. The x-rays of the plaintiff's right foot showed no fracture and no evidence of abnormality. A prominent plantar calceneal spur ("heel spur") was noted (Tr. 591-92). On November, 15, 2011, the plaintiff again had x-rays at CRMC for an injury to her right foot. There was no acute fracture to her foot, and the heel spur was noted (Tr. 589).
On November 9, 2011, the plaintiff saw Lalonda Graham, M.D., for a possible urinary tract infection ("UTI") and prescription refills. The plaintiff reported nausea and vomiting, contracture and cramping of hands, and a four pound weight loss since September 2011. Examination was normal. Dr. Graham assessed malignant hypertension, microscopic hematuria (blood in urine), chronic RA, back pain, insomnia, and hyperlipidemia. The plaintiff was started on high blood pressure medication, and other medications were refilled (Tr. 701-03).
On December 6 and 9, 2011, the plaintiff saw Dr. Days for paperwork and controlled chronic pain. She had contracture and cramping of her hands and back pain. Her mood was much better, and she had improved energy. She reported well-controlled pain with medications and water exercise (Tr. 697, 699). The plaintiff had normal examinations and was assessed with chronic RA, otitis media, and back pain (Tr. 697-700). On December 6th she was prescribed fentanyl, Percocet, Restoril, Zestoretic, and Zithromax (Tr. 700).
On December 10, 2011, the plaintiff was seen by Melissa D. Johnson, M.D., at PMC for evaluation of five weeks of intermittent posterior chest wall and bilateral flank pain. She was diagnosed with an ovarian cyst and chest wall pain (Tr. 600-13, 615-19). The plaintiff described the pain as throbbing and aching and as an eight out of ten on the pain scale (Tr. 602). The plaintiff ambulated without assistance (Tr. 610-11). On examination, she had normal ROM, normal strength, no appreciable muscle atrophy, normal sensation, and no tenderness. The plaintiff was alert and oriented with a grossly appropriate mood and affect (Tr. 603).
On January 12, 2012, the plaintiff saw Dr. Days for chronic pain attributed to RA and spinal stenosis. She had a normal examination and was assessed with ovarian cyst, arthralgia, insomnia, depression, and hypertension. Dr. Days referred the plaintiff to a psychiatrist for depression. Her prescriptions for fentanyl, Percocet, and Restoril were refilled (Tr. 695-96)
On March 5, 2012, the plaintiff saw Dr. Days for chronic pain attributed to RA and spinal stenosis. Her mood was much better, and her energy was improved. The plaintiff was assessed with arthralgia, insomnia, depression, and controlled hypertension. She was prescribed fentanyl, Librium, and Percocet (Tr. 693-94).
On April 3, 2012, the plaintiff saw Dr. Days chiefly for refills. She complained of chronic pain as a result of her RA and spinal stenosis. The plaintiff stated she found relief with Percocet and fentanyl, but the doctor was concerned with the plaintiff's explanation with respect to abnormal urine drug screens. Dr. Days decreased the fentanyl and referred the plaintiff to a pain clinic. The plaintiff was assessed with left hip pain, uncontrolled lower back pain, and uncontrolled hypertension (Tr. 691-92).
On May 3, 2012, the plaintiff was seen at PMC by John Lee, M.D. (Tr. 621-32). The plaintiff's chief complaint at this visit was vaginal bleeding and abdominal pain that had lasted for two weeks (Tr. 622, 626). The plaintiff stated that she had been diagnosed with an ovarian cyst several months ago, but she never followed up with OB/GYN (Tr. 623). Dr. Lee prescribed Motrin and Vicodin, and the plaintiff was advised to follow up with Rock Hill OB/GYN (Tr. 626, 630-32). At this visit, the plaintiff ambulated without assistance (Tr. 622). On examination, the plaintiff had normal ROM, normal strength, no appreciable muscle atrophy, normal sensation, and no tenderness. The plaintiff was alert and oriented with a grossly appropriate mood and affect (Tr. 623).
On April 18 and May 30, 2012, the plaintiff went to Premier Clinic for pain complaints. On examination, plaintiff had multiple joint tenderness and restricted ROM (Tr. 721, 723). The plaintiff was assessed with polyarthritis, polyarthralgia, cervical degenerative disc disease, cervical spondylosis, and chronic pain syndrome. During these visits, the plaintiff was alert and oriented (Tr. 721). She was assessed with adjustment disorder with anxiety and depression and psychological insomnia (Tr. 721, 723). The plaintiff was prescribed mood stabilizer and insomnia medications and encouraged to exercise for 30 minutes a day, five days per week (Tr. 721, 724).
On August 27, 2012, back x-rays showed chronic changes but nothing acute (Tr. 635). Left hip x-rays showed osteoarthritis (Tr. 636).
The plaintiff visited Brian R. Snyder, D.O., on August 27, September 24, and October 3, 2012, for pain complaints and to complete disability paperwork (Tr. 647-56). Although the plaintiff acknowledged joint pain, she denied ROM limitation (Tr. 652, 655). On examinations, the plaintiff walked with a cane at one visit, could stand without difficulty and had normal ROM, no joint crepitus, no tenderness to palpation, no edema, mild pain with joint motion, normal upper extremity strength but decreased lower extremity strength, normal muscle bulk and tone, no atrophy, no abnormal movements, and a slightly antalgic-to-normal gait (Tr. 649, 653). Dr. Snyder assessed the plaintiff with RA and spinal stenosis (Tr. 653), and prescribed pain medication (Tr. 649-50, 653, 656). Specifically, Dr. Snyder would not refill the plaintiff's pain medication on October 3, 2012, because the plaintiff's pain management facility would not accept her because of a failed drug test (marijuana) (Tr. 650). The plaintiff denied anxiety, depression, or altered mental status (Tr. 652, 655). On examination, the plaintiff had normal attention and concentration, a normal mood, and an appropriate affect (Tr. 649, 652, 656). Dr. Snyder assessed the plaintiff with depressive disorder and prescribed medication (Tr. 649, 653)
On September 12, 2012, the plaintiff was seen by Jean M. Boyd, M. Ed., at Catawba Mental Health ("CMH") and was assessed with posttraumatic stress disorder ("PTSD"), panic disorder without agoraphobia, and a history of sexual and physical abuse. She was prescribed medication (Tr. 639-642, 644). On September 26, 2012, the plaintiff saw Mahir I. Shaw, M.D., for an initial assessment. On examination, the plaintiff was alert, oriented, cooperative, and pleasant with good eye contact, normal speech, normal thought processes and content, intact attention and concentration, no hallucinations or delusions, poor-to-good judgment and insight, improved memory, average fund of knowledge, no psychomotor abnormalities, a blunted-to-appropriate affect, depressed mood, and no suicidal ideation (Tr. 643-44).
On October 4, 2012, the plaintiff saw Ms. Boyd, M. Ed., at CMH. The plaintiff had good eye contact. She complained of anxiety, worry, anger, and moodiness. She had crying spells and denied homicidal or suicidal ideation (Tr. 838). On November 8, 2012, the plaintiff was transferred to Kim Sconyers, MRC, for therapy at CMH. The plaintiff was struggling with anxiety and stress because she had to ask her mother to leave the plaintiff's home. Her affect was congruent with her mood (Tr. 839).
On October 23, November 20, and December 17, 2012, the plaintiff treated with Sanjay Nandurkar, M.D., at Piedmont Interventional Spine and Pain Center for chronic RA symptoms. On examination, the plaintiff had functional joint ROM, normal extremities, no deformities, no midline tenderness, some low back tenderness, pain restriction of lumbar ROM, some cervical spine tenderness and ROM restriction, painful ROM in knee and shoulder joints, normal muscle strength, grossly intact sensation, and a negative straight leg raise test. Dr. Nandurkar created a treatment plan that included medications, stretching, physical therapy, and lifestyle modifications. He noted that the large dosage of narcotics prescribed by the plaintiff's primary care physician was inappropriate (Tr. 760-67).
The plaintiff visited the Carolina Center for Rheumatology & Arthritis Care, PA, on October 25, 2012 (Tr. 754-56). On examination, the plaintiff had no hand or wrist joint synovitis, deformity, or restricted motion; no elbow contracture; negative gross synovitis in her shoulders, hips, knees, ankles, and toes; mild toe spreading and tenderness; decreased passive shoulder ROM but otherwise full; intact distal motor strength; and a normal gait (Tr. 755). The plaintiff was assessed with chronic pain syndrome (i.e., fibromyalgia and underlying pain syndrome rather than systemic inflammatory arthritis) (Tr. 755).
On January 3, 2013, the plaintiff saw Ms. Sconyers for therapy at CMH. The plaintiff was very tearful and felt hopeless and helpless. She reported depression and being overwhelmed. Ms. Conyers noted that the plaintiff was cooperative, alert and oriented, less sedated, and goal-oriented. The plaintiff was not sleeping or eating and was having trouble making decisions and staying focused. She felt like Cymbalta was not working (Tr. 841-42). On January 17, 2013, Ms. Sconyers noted that the plaintiff had very poor self-worth, was very depressed, was hopeless, had poor health, but denied suicidal and homicidal ideation (Tr. 843). During a counseling session on March 28, 2013, Ms. Sconyers noted that it was difficult to gauge the plaintiff's progress because Ms. Sconyers was not convinced of the plaintiff's compliance. Ms. Sconyers noted that the plaintiff "has a very dramatic family and she tends to be dramatic as well" (Tr. 848).
On January 14 and February 13, 2013, the plaintiff saw Dr. Nandurkar for pain in multiple joints. On examinations, the plaintiff had functional joint ROM, normal extremities, no deformities, no midline tenderness, some low back tenderness, pain restriction of lumbar ROM, some cervical spine tenderness and ROM restriction, painful ROM in knee and shoulder joints, normal muscle strength, grossly intact sensation, and a negative straight leg raise test. She was assessed with RA, chronic pain syndrome, depression, opioid dependence, and fibromyalgia. Dr. Nandurkar created a treatment plan that included medications, stretching, physical therapy, and lifestyle modifications. He advised the plaintiff to remain active within her pain limits. The plaintiff reported that her pain symptoms reduced and her daily activities improved with the medications (Tr. 799-802).
On March 13, 2013, the plaintiff saw Dr. Nandurkar for neck and back pain. On examination, the plaintiff had functional joint ROM, normal extremities, no deformities, no midline tenderness, some low back tenderness, pain restriction of lumbar ROM, some cervical spine tenderness and ROM restriction, painful ROM in knee and shoulder joints, normal muscle strength, grossly intact sensation, and a negative straight leg raise test. She was assessed with chronic pain syndrome, depression, and fibromyalgia. Dr. Nandurkar created a treatment plan that included medications, stretching, physical therapy, and lifestyle modifications. He advised the plaintiff to remain active within her pain limits. The plaintiff reported that her pain symptoms reduced and her daily activities improved with the medications (Tr. 797-98).
On April 30, 2013, the plaintiff saw Christie D. Williamson, M.D., at CMH. On examination, the plaintiff was alert, oriented, cooperative, and pleasant with good eye contact, normal speech, normal thought processes and content, intact attention and concentration, no hallucinations or delusions, poor-to-good judgment and insight, improved memory, average fund of knowledge, no psychomotor abnormalities, a blunted-to-appropriate affect, depressed mood, and no suicidal ideation. The plaintiff's primary diagnosis was PTSD. She had a history of sexual and physical abuse. Dr. Williamson further noted that she addressed the plaintiff's noncompliance with taking Celexa and the addictive potential of using fentanyl/Norco/Xanax (Tr. 850-51). On May 9, 2013, Dr. Williamson noted that the plaintiff was willing to try another antidepressant and that she attended therapy and participated (Tr. 853).
On May 15, 2013, the plaintiff saw Dr. Nandurkar for neck and back pain. On examination, the plaintiff had functional joint ROM, normal extremities, no deformities, no midline tenderness, some low back tenderness, pain restriction of lumbar ROM, some cervical spine tenderness and ROM restriction, painful ROM in knee and shoulder joints, normal muscle strength, grossly intact sensation, and a negative straight leg raise test. She was assessed with chronic pain syndrome, RA, depression, opioid dependence, cervical DDD, and fibromyalgia. Dr. Nandurkar created a treatment plan that included medications, stretching, physical therapy, and lifestyle modifications. He advised the plaintiff to remain active within her pain limits (Tr. 795-96).
On May 16, 2013, the plaintiff attended therapy with Ms. Sconyers, who noted that little progress was made. The plaintiff had her grandchildren and was unable to do good work. The plaintiff continued to be involved in family drama, which she appeared to like and thrive on (Tr. 852).
On June 4, 2013, the plaintiff returned to Carolina Center for Rheumatology & Arthritis Care, PA. On examination, the plaintiff had no hand or wrist joint synovitis, deformity, or restricted motion; no elbow contracture; negative gross synovitis in her shoulders, hips, knees, ankles, and toes; mild toe spreading and tenderness; decreased passive shoulder ROM but otherwise full; intact distal motor strength; and a normal gait (Tr. 757). The plaintiff was assessed with chronic pain syndrome (i.e., fibromyalgia and underlying pain syndrome rather than systemic inflammatory arthritis) (Tr. 757).
On June 24, 2013, the plaintiff saw Marianna E. Torbert, R.N., at CMH. Her symptoms included depression, insomnia, and fatigue. The plaintiff stated she had stopped taking Paxil because it made her feel weird. She stated that her depression was improving and that Xanax helped her anxiety (Tr. 854-55).
On July 17, 2013 , the plaintiff saw Dr. Nandurkar for neck and back pain. On examination, the plaintiff had functional joint ROM, normal extremities, no deformities, no midline tenderness, some low back tenderness, pain restriction of lumbar ROM, some cervical spine tenderness and ROM restriction, painful ROM in knee and shoulder joints, normal muscle strength, grossly intact sensation, and a negative straight leg raise test. She was assessed with chronic pain syndrome, depression, and fibromyalgia (Tr. 793-94).
On July 26, 2013, the plaintiff was treated by Ms. Sconyers with individual therapy and medication. Ms. Sconyers noted that the plaintiff was a poor advocate, she was very passive, and was increasingly depressed (Tr. 818).
On September 5, 2013, Dr. Williamson noted that the plaintiff had missed an appointment. Dr. Williamson refilled Xanax for the plaintiff until she could make her next appointment and noted that the plaintiff still cared for her three small grandchildren (Tr. 819).
On September 11, 2013, the plaintiff saw Dr. Nandurkar for neck and back pain. On examination, the plaintiff had functional joint ROM, normal extremities, no deformities, no midline tenderness, some low back tenderness, pain restriction of lumbar ROM, some cervical spine tenderness and ROM restriction, painful ROM in knee and shoulder joints, normal muscle strength, grossly intact sensation, and a negative straight leg raise test. She was assessed with chronic pain syndrome and fibromyalgia. Dr. Nandurkar created a treatment plan that included medications, stretching, physical therapy, and lifestyle modifications and advised the plaintiff to remain active within her pain limits (Tr. 791-92).
On September 30, 2013, the plaintiff saw Dr. Williamson who noted that the plaintiff had a history of anxiety and was busy caring for three small grandchildren in her home. The plaintiff was tearful, felt overloaded, and had more stress since her daughter had moved back into her home from jail. On examination, the plaintiff was alert, oriented, cooperative, and pleasant with good eye contact, normal speech, normal thought processes and content, intact attention and concentration, no hallucinations or delusions, poor-to-good judgment and insight, improved memory, average fund of knowledge, no psychomotor abnormalities, a blunted-to-appropriate affect, depressed mood, and no suicidal ideation. (Tr. 820-21). The plaintiff's primary diagnosis was PTSD. She had a history of sexual and physical abuse. She was prescribed Xanax and Cymbalta (Tr. 821).
On October 10, 2013, the plaintiff saw Ms. Conyers for group therapy at CMH. The plaintiff reported being somewhat depressed, and she was crying. The plaintiff reported increased stress at home because her daughter had moved back and now five people lived in her small two bedroom home. The plaintiff had fair insight and judgment, was goal-oriented, and denied drug use. Her mood was poor due to anxiety. She had no suicidal or homicidal ideation (Tr. 821-22). The plaintiff attended group therapy again on October 25, 2013. The plaintiff continued to take Xanax (Tr. 823). On December 30, 2013, the plaintiff had another therapy session with Ms. Conyers who noted that the plaintiff was doing much better. Her thought content was better, and she was more positive (Tr. 826).
On November 13, 2013, the plaintiff returned to Dr. Nandurkar concerning her neck. On examination, the plaintiff had functional joint ROM, normal extremities, no deformities, no midline tenderness, some low back tenderness, pain restriction of lumbar ROM, some cervical spine tenderness and ROM restriction, painful ROM in knee and shoulder joints, normal muscle strength, grossly intact sensation, and a negative straight leg raise test. She was assessed with chronic pain syndrome and fibromyalgia (Tr. 789-90). Dr. Nandurkar created a treatment plan that included medications, stretching, physical therapy, and lifestyle modifications and he advised the plaintiff to remain active within her pain limits (Tr. 790).
On January 9, 2014, the plaintiff saw Dr. Williamson and Ms. Conyers. She reported doing better on Zoloft. The plaintiff was still caring for her grandchildren (Tr. 827-28). On January 31, 2014, the plaintiff saw Dr. Williamson again who diagnosed her with panic disorder without agoraphobia, PTSD, and a history of sexual and physical abuse. On examination, the plaintiff was alert, oriented, cooperative, and pleasant with good eye contact, normal speech, normal thought processes and content, intact attention and concentration, no hallucinations or delusions, poor-to-good judgment and insight, improved memory, average fund of knowledge, no psychomotor abnormalities, a blunted-to-appropriate affect, depressed mood, and no suicidal ideation. Dr. Williamson noted that the plaintiff had less frequent panic attacks, and she was much calmer on Zoloft (Tr. 829-30).
On January 15 and March 12, 2014, the plaintiff returned to Dr. Nandurkar concerning her neck. On examinations, the plaintiff had functional joint ROM, normal extremities, no deformities, no midline tenderness, some low back tenderness, pain restriction of lumbar ROM, some cervical spine tenderness and ROM restriction, painful ROM in knee and shoulder joints, normal muscle strength, grossly intact sensation, and a negative straight leg raise test. She was assessed with chronic pain syndrome and fibromyalgia. Dr. Nandurkar created a treatment plan that included medications, stretching, physical therapy, and lifestyle modifications and advised the plaintiff to remain active within her pain limits (Tr. 784-85, 787-88). The plaintiff reported that her pain symptoms reduced and her daily activities improved with the medications (Tr. 784, 787). In March, Dr. Nandurkar noted that the plaintiff's blood work did not suggest RA (Tr. 785).
On April 18, 2014, the plaintiff saw Nurse Torbert at CMH for medical monitoring. The plaintiff reported she was having pain that made her have bad days and that she had more depression/stress related to her mother and grandchildren (Tr. 831-32).
The plaintiff visited the emergency department on five occasions from May 2013 to May 2014 for pain complaints (Tr. 860-66, 868-82, 885-95, 897-903, 908-14). The plaintiff was consistently ambulatory without assistance during these visits (Tr. 860, 868, 885, 897, 908). On examinations, the plaintiff had some left hip tenderness and pain with ROM, moderate tenderness over her thoracic and lumbar spine, and a gait with a limp. She had grossly normal strength (4/5 lower extremity strength at one visit), no appreciable muscle atrophy, grossly intact sensation, right knee full ROM with minimal tenderness, left hip full ROM with tenderness, thoracic ROM with no tenderness, and tenderness to palpation of the left sciatic notch (Tr. 862, 870, 898, 909).
On February 8, 2014, the plaintiff had thoracic spine x-rays that showed mild thoracic scoliosis with moderate hypertrophic degenerative change (Tr. 887) and lumbar spine x-rays that showed mild lumbar scoliosis and hypertrophic degenerative change with osteophytic spurring (Tr. 888). She had an April 2014 pelvic MRI that showed no significant osteoarthritis, mild left greater trochanter tendinopathy, and a left anterior labral cyst (Tr. 905). The plaintiff also had a negative May 2014 pelvic x-ray (Tr. 910), and lumbar spine x-rays showed degenerative changes without disc extrusion or nerve impingement (Tr. 815). The plaintiff's diagnoses included left hip and knee contusions, left hip joint pain, myalgia, back pain, spinal osteoarthritis, and a headache (Tr. 865, 882, 886, 894, 902, 912).
The plaintiff visited Catherine Elisabeth Dodds, M.D., at Novant Health Medical Group in March and April 2014 for chronic pain symptoms (Tr. 806-14). On examinations, the plaintiff had back pain with a stiff, antalgic gait (Tr. 807, 811). Dr. Dodds assessed the plaintiff with chronic pain syndrome and continued pain medications (Tr. 807, 812).
On May 14, 2014, the plaintiff was discharged from CMH for non-compliance with therapy (Tr. 833-34). Her Global Assessment of Functioning ("GAF") score had increased from 55 to 65 at the time of her discharge (Tr. 834).
A GAF score is a number between 1 and 100 that measures "the clinician's judgment of the individual's overall level of functioning." See Am. Psychiatric Ass'n, Diagnostic & Statistical Manual of Mental Disorders, 32-34 (Text Revision 4th ed. 2000) ("DSM-IV"). A GAF score between 61 and 70 indicates some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well. Id. A GAF score between 51 and 60 indicates moderate symptoms or moderate difficulty in social, occupational, or school functioning. Id. The court notes that the fifth edition of the DSM, published in 2013, has discontinued use of the GAF for several reasons, including "its conceptual lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice." See Am. Psychiatric Ass'n, Diagnostic & Statistical Manual of Mental Disorders, 16 (5th ed. 2013) ("DSM-V").
On May 27, 2014, Dr. Dodds opined that the plaintiff could sit for about four hours and stand and/or walk for less than two hours in an eight-hour workday. Dr. Dodds also opined that the plaintiff would need a sit-stand option. She stated that the plaintiff would need one to two unscheduled, 15 minute breaks (Tr. 917) and noted that the plaintiff did not need a cane. Dr. Dodds further opined that the plaintiff could occasionally lift and/or carry less than ten pounds; rarely lift and/or carry ten pounds, twist, and climb stairs; and never stoop, crouch, squat, and climb ladders. She added that the plaintiff had no significant reaching, handling, or fingering limitations (Tr. 918). Dr. Dodds opined that, although the plaintiff would be off-task for 20 percent of the day and would miss about four days of work per month, she could tolerate moderate stress (normal work) (Tr. 919). Dr. Dodds noted that no emotional factors contributed to the alleged severity of the plaintiff's symptoms and functional limitations (Tr. 916).
On September 17, 2014, the plaintiff visited the Carolina Medical Center with a back pain complaint due to a fall (Tr. 923-27). On examination, the plaintiff had a diffusely tender back to palpation, no midline tenderness, normal coordination, an antalgic gait, and a negative straight leg raise test (Tr. 926). She was diagnosed with a back strain and was discharged in stable condition (Tr. 923, 926).
On June 25, 2010, the plaintiff reported that she personally cared for herself (with pain), cared for pets, prepared simple meals daily, did household chores sitting, went outside three to four times per week, went grocery shopping, handled finances, sewed, read, watched television, and talked on the phone daily (Tr. 345-48). The plaintiff added that she handled stress "very well" (Tr. 350).
On a third-party adult function report dated June 30, 2010, the plaintiff's daughter reported that the plaintiff cared for herself (with difficulties in dressing, haircare, and shaving); helped care for her husband and children; cared for pets; prepared simple meals; went outside; grocery shopped; used the computer; handled finances; sang; read; watched television; talked on the phone; visited with family; and went to church weekly (Tr. 354-57).
At the administrative hearing, the ALJ sought testimony from a vocational expert to determine whether an individual with the plaintiff's age, education, work experience, and residual functional capacity ("RFC") was capable of performing other work that existed in significant numbers in the national economy (Tr. 66). The vocational expert responded that such an individual could perform the representative unskilled, light occupations of marker and small products assembler, along with other light jobs that fit the hypothetical question (Tr. 66-70).
ANALYSIS
The plaintiff argues that the ALJ erred by (1) failing to properly consider her treating physicians' opinions, (2) finding she retained the RFC to performed unskilled light work, (3) failing to consider her nonexertional limitations when finding that she could perform light work, (4) finding a significant number of jobs existed in the national economy that she could perform, and (5) failing to set forth all of her impairments in the hypothetical question posed to the vocational expert (see doc. 21).
Medical Opinions
The plaintiff first argues that the ALJ erred in failing to give controlling weight to the opinions of treating physicians Drs. Days and Dodds and in finding that she retained the RFC to perform unskilled light work (doc. 21 at 4-7). The regulations require that all medical opinions in a case be considered, 20 C.F.R. §§ 404.1527(b), 416.927(b), and, unless a treating source's opinion is given controlling weight, weighed according to the following non-exclusive list: (1) the examining relationship; (2) the length of the treatment relationship and the frequency of the examinations; (3) the nature and extent of the treatment relationship; (4) the evidence with which the physician supports his opinion; (5) the consistency of the opinion; and (6) whether the physician is a specialist in the area in which he is rendering an opinion. Id. §§ 404.1527(c)(1)-(5), 416.927(c)(1)-(5). See also Johnson v. Barnhart, 434 F.3d 650, 654 (4th Cir. 2005). The opinion of a treating physician is entitled to controlling weight if it is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in the case. See 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2); Mastro v. Apfel, 270 F.3d 171, 178 (4th Cir. 2001).
These regulations apply for claims, like the plaintiff's, filed before March 27, 2017. See 20 C.F.R. §§ 404.1527, 416.927. For claims filed on or after March 27, 2017, a new regulatory framework for considering and articulating the value of medical opinions has been established. See id. §§ 404.1520c, 416.920c. See also 82 FR 5867, 2017 WL 168819 (revisions to medical evidence rules dated Jan. 18, 2017, and effective Mar. 27, 2017).
On August 11, 2010, Dr. Days opined that the plaintiff's pain frequently interfered with her concentration and attention; she had a severe limitation in her ability to deal with work stress; could only sit for less than 15 minutes before needing to stand or walk for at least 30 minutes; could stand or walk for three hours before needing to lie down or recline in a supine position for approximately two hours; could stand or walk for a total of two hours not including time spent lying down or reclining supine; needed to elevate her legs to at least chest height when sitting; needed more breaks than a "normal" person; would need to rest, lie down, or recline in a supine position for three hours in an eight-hour workday; could lift or carry five pounds occasionally; balance and reach frequently; flex and/or rotate her neck, handle, and finger occasionally; and never stoop. Dr. Days further stated that the plaintiff would likely be absent from work for more than three days per month (Tr. 384-90).
Both the plaintiff and Commissioner cite the date of Dr. Days' opinion as August 11, 2011 (doc. 22 at 14; doc. 21 at 4). However, a review of the treatment note from August 11, 2010, shows that the plaintiff requested that Dr. Days fill out the form on that date, and he did so (Tr. 515-16). Further, Dr. Days stated in the medical source statement that he had treated the plaintiff for 11 months, which corresponds to the August 11, 2010, date as his earliest treatment notes in the record are from September 2009 (Tr. 384, 467). --------
On May 27, 2014, Dr. Dodds opined that the plaintiff could sit for about four hours; stand and/or walk for less than two hours in an eight-hour workday; would need a sit-stand option; would need one to two unscheduled, 15 minute breaks; could occasionally lift and/or carry less than ten pounds; rarely lift and/or carry ten pounds, twist, and climb stairs; never stoop, crouch, squat, and climb ladders; had no significant reaching, handling, or fingering limitations; and would be off-task for 20 percent of the day and would miss about four days of work per month, but she could tolerate moderate stress (normal work). Dr. Dodds noted that no emotional factors contributed to the alleged severity of the plaintiff's symptoms and functional limitations (Tr. 916-19).
The ALJ considered these opinions, but he found that they were not entitled to controlling weight because they were inconsistent with the overall evidence of record. Specifically, the ALJ stated that the "severe restrictions and limitations are not consistent with the physical examinations and the claimant's reported activities of daily living" (Tr. 33-34). This finding is supported by substantial evidence and is without legal error.
Notably, the plaintiff only visited Dr. Dodds twice prior to her May 2014 opinion (Tr. 916). As the ALJ noted, the plaintiff treated with Dr. Days at the North Central Family Center from September 2009 through April 2012 (Tr. 29-30; see Tr. 452-53, 467, 472-75, 478-84, 515-18, 521-22, 524-30, 660-69, 691-700, 704-13). Although Dr. Days found that the plaintiff had neck range of motion diminished by pain, cervical and mid-back spinal and paraspinous tenderness, lumbar spine tenderness with left sciatica, left hip pain, pain with shoulder elevation, and wrist tenderness and pain, he repeatedly found that the plaintiff had negative straight leg raise tests, normal-to-antalgic gait (with marked joint range of motion pain), no deformities, and intact plantar flexion strength (Tr. 452, 467, 472, 474, 478, 480, 484, 516-17, 522-23, 525-27, 530, 660, 662, 664, 667-69, 696-97, 700, 705, 708, 712-13). Also, as the ALJ noted, the plaintiff specifically reported well-controlled pain with medications and water exercise in December 2011 (Tr. 29; see Tr. 697, 699). Further, Drs. Badalyan, Maduro, Villamor, and Graham (Dr. Days' colleagues) consistently found that the plaintiff had no deformities with a normal gait, balance, and motor strength; negative straight leg raise test; diffuse neck muscle tightness; neck range of motion diminished by pain; cervical spine and mid-back spinal and paraspinous tenderness; left hip pain with passive range of motion; and left sciatic nerve tenderness to palpation (Tr. 29-30; see Tr. 454, 468, 470, 519-20, 702).
Further, as argued by the Commissioner, the ALJ accounted for the plaintiff's limiting pain by limiting her to light work with a sit/stand option and only occasional overhead reaching. As outlined in the evidence evaluated by the ALJ (Tr. 28-34), the record is replete with examination findings inconsistent with Drs. Days' and Dodds' opinions that the plaintiff could perform less than sedentary work: the plaintiff consistently ambulated independently (Tr. 431, 441, 569, 584, 601, 610-11, 622, 860, 868, 885, 897, 908) and had normal strength; normal joint range of motion; no swelling or deformities; no appreciable muscle atrophy; normal sensation; no hand or wrist synovitis or restricted range of motion; no elbow contracture; negative gross synovitis in her shoulders, hips, knees, ankles, and toes; mild toe spreading and tenderness; decreased passive shoulder range of motion but otherwise full; intact distal motor strength; and negative straight leg raise tests (Tr. 431, 441, 571-72, 603, 623, 649, 653, 755, 757, 760-61, 763-64, 766, 784-85, 787, 789, 791-92, 794-802, 862, 870, 898, 909, 926).
Further, Dr. Nandurkar advised the plaintiff to remain active within her pain limits (Tr. 32; see Tr. 785, 788, 790, 792, 794, 796, 798, 800, 802), and the plaintiff reported to Dr. Nandurkar that her pain symptoms reduced and her activities of daily living improved with medication (Tr. 32; see Tr. 784, 787, 789, 797, 799, 801). Moreover, the ALJ noted that the plaintiff reported to Dr. Nandurkar that she had no side effects from her pain medications (Tr. 32; see Tr. 784, 787, 789, 791, 793, 795, 797, 799, 801).
Also, as argued by the Commissioner, diagnostic tests were inconsistent with Drs. Days' and Dodds' overly restrictive opinions: October, November, and December 2011 right foot and ankle x-rays were normal, with only a plantar calcaneal spur in October (Tr. 589-92); August 2012 back x-rays showed chronic changes but nothing acute (Tr. 635) and left hip x-rays showed osteoarthritis (Tr. 636); February 2014 thoracic spine x-rays showed only mild thoracic scoliosis with moderate hypertrophic degenerative change (Tr. 887), and lumbar spine x-rays showed only mild lumbar scoliosis and hypertrophic degenerative change with osteophytic spurring (Tr. 888); April 2014 pelvic MRI showed no significant osteoarthritis, mild left greater trochanter tendinopathy, and a left anterior labral cyst (Tr. 905); May 2014 x-ray of the pelvis and left hip showed no acute fracture or malalignment, joint spaces were maintained, and soft tissues were unremarkable (Tr. 910), and lumbar spine x-rays showed degenerative changes without disc extrusion or nerve impingement (Tr. 815).
The plaintiff notes that state agency physician Dr. Perll also opined that she was limited to sedentary work (doc. 21 at 7). For similar reasons as discussed above, the ALJ afforded little weight to Dr. Perll's opinion (Tr. 34; see Tr. 505-06), finding it was not supported by the medical evidence of record. Notably, state agency physician Dr. Roper opined that the plaintiff could perform a range of light work (Tr. 561-65).
Further, as the ALJ found, the plaintiff's daily activities were inconsistent with Drs. Days' and Dodds' opinions that she would be limited to less than sedentary work (Tr. 34). For example, the plaintiff personally cared for herself, cared for her three small grandchildren, cared for pets, prepared simple meals daily, did household chores sitting, went outside three to four times per week, grocery shopped, handled finances, sewed, read, watched television, and talked on the phone daily (Tr. 345-48, 819-20, 827, 850). The plaintiff's daughter added that the plaintiff helped care for her husband and children, used the computer, visited with family, and went to church weekly (Tr. 354-57).
Based upon the foregoing, the undersigned finds that the ALJ's assessment of the medical opinions and finding that the plaintiff could perform a reduced range of unskilled light work was based upon substantial evidence and was without legal error.
Nonexertional Limitations
The plaintiff next argues that the ALJ "erred in not considering [her] nonexertional limitations when finding she could perform light work" (doc. 21 at 7-8). Specifically, the plaintiff argues that her mental impairments cause nonexertional limitations, including an inability to concentrate, maintain focus, or function in a workplace setting, that were not considered by the ALJ (id.).
However, the RFC assessment did include limitations to account for the plaintiff's mental impairments. Specifically, the ALJ limited the plaintiff to simple, routine, repetitive tasks with only occasional contact with coworkers, supervisors, and the public (Tr. 27). In so doing, the ALJ cited evidence showing that, while the plaintiff suffered from depression and anxiety, her mental status examinations showed that she was alert and oriented with no psychomotor abnormalities; intact memory, attention, and concentration; and no hallucinations, delusions, or thoughts of suicide (Tr. 32-34). As the ALJ discussed, the plaintiff underwent individual therapy and medication management at Catawba Mental Health, reporting decreased symptoms on medication (Tr. 32; see Tr. 818-19, 822-23, 825-28, 831-32, 838-43, 845-49, 852-57). On examinations, the plaintiff was alert, oriented, cooperative, and pleasant with good eye contact, normal speech, normal thought processes and content, intact attention and concentration, no hallucinations or delusions, poor-to-good judgment and insight, improved memory, average fund of knowledge, no psychomotor abnormalities, a blunted-to-appropriate affect, depressed mood that improved, and no suicidal or homicidal ideations (Tr. 641-43, 820-21, 829-30). The plaintiff's GAF score increased from 55 (indicating moderate symptoms or functional difficulties) to 65 (indicating only mild symptoms or functional difficulties) (consistently having GAF scores in the 60s) (Tr. 32; see Tr. 642, 644, 821, 830, 834, 851, 855). Furthermore, no state agency psychologists provided greater restrictions than those found in the ALJ's RFC assessment (Tr. 26; see Tr. 489-91, 501, 556). As the ALJ further noted, the plaintiff's daily activities, including caring for her three small grandchildren, provide support for mental limitations included in the RFC assessment (Tr. 43; see Tr. 345-48, 356-57, 819-20, 827, 850).
Based upon the foregoing, the undersigned finds that the RFC assessment is based upon substantial evidence and is without legal error.
Vocational Expert
The plaintiff argues that the ALJ erred in finding that there are jobs that exist in significant numbers in the national economy that she can perform (doc. 21 at 9-10). In response to the hypothetical question containing the RFC found by the ALJ, the vocational expert identified two jobs: Marker (Dictionary of Occupational Titles ("DOT") No. 209.587-034) and Assembler - Small Products I (DOT No. 706.684-022) (Tr. 67-68). The vocational expert testified that there were over 300 Marker jobs in South Carolina and approximately 45,000 jobs nationally and over 150 Assembler jobs in South Carolina and 15,000 nationally (Tr. 68, 70). Based upon this testimony, the ALJ found at the fifth step of the sequential evaluation process that there are jobs that exist in significant numbers in the national economy that the plaintiff can perform (Tr. 35-36).
The plaintiff contends that the vocational expert did not identify a significant number of jobs that she can perform (doc. 21 at 9-10). However, as the plaintiff concedes, there is no rule setting a minimum number that constitutes a "significant" number of jobs (doc. 21 at 9). However, the Fourth Circuit has found as few as 110 local jobs to be significant. Hicks v. Califano, 600 F.2d 1048, 1051 n.2 (4th Cir. 1979) ("We do not think that the approximately 110 jobs testified to by the vocational expert constitute an insignificant number [of jobs in the region]."). See also Hodges v. Apfel, No. 99-2265, 2000 WL 121251, at *1 (4th Cir. Jan.28, 2000) (finding 153 jobs was a significant number) (citation omitted); Hyatt v. Apfel, No. 97-2225, 1998 WL 480722, at *3 (4th Cir. Aug. 6, 1998) (finding that 650 jobs in SC constituted significant number) (citation omitted); Patterson v. Astrue, No. 8:07-1602-HFF-BHH, 2008 WL 2944616, at *5 (D.S.C. July 31, 2006) (finding that vocational expert's testimony regarding 200 surveillance systems monitor jobs in SC and 28,0000 nationally was substantial evidence for the ALJ to conclude that the job appeared in significant numbers) (citation omitted). Accordingly, this allegation of error is without merit.
The plaintiff also argues that the ALJ failed to fully develop the record as he was obligated to do by failing to be "clear as to what medical conditions, exertional limitations, or non-exertional limitations were being addressed in the hypothetical question" posed to the vocational expert (doc. 21 at 11). Specifically, the plaintiff argues that the vocational expert testified that limitations imposed by impairments to the upper extremities would eliminate the identified jobs (id.). In the hearing, upon cross-examination, the plaintiff's counsel asked the vocational expert whether a limitation to only occasional use of the upper extremities would eliminate the jobs identified in response to the ALJ's hypothetical question, and the vocational expert stated that it would (Tr. 75).
The plaintiff's argument here relies on her argument that the ALJ did not properly formulate the RFC assessment. However, substantial evidence supports the ALJ's finding that the plaintiff's upper extremity limitations were fully accounted for by limiting her to only occasional overhead reaching (Tr. 27). Treatment notes show that the plaintiff had normal strength; normal joint range of motion; no swelling or deformities; no appreciable muscle atrophy; normal sensation; no hand or wrist synovitis or restricted range of motion; no elbow contracture; negative gross synovitis in her shoulders; decreased passive shoulder range of motion but otherwise full; and intact distal motor strength (Tr. 431, 441, 571-72, 603, 623, 649, 652, 755, 757, 760-61, 763, 766, 785, 787, 789, 791-92, 797, 799-802, 862, 870, 898, 909, 926). Further supporting the ALJ's finding is the opinion of state agency physician Dr. Roper, who opined that the plaintiff was limited to occasional overhead reaching due to her neck surgery and pain (Tr. 563). The plaintiff has failed to demonstrate that the ALJ's determination concerning the RFC finding is unsupported by substantial evidence. Therefore, this argument also fails. See Rutherford v. Barnhart, 399 F.3d 546, 554 (3d Cir.2005) (noting that "the ALJ must accurately convey to the vocational expert all of a claimant's credibly established limitations") (emphasis in original); Walker v. Bowen, 889 F.2d 47, 50 (4th Cir.1989) ("In order for a vocational expert's opinion to be relevant or helpful, it must be based upon a consideration of all other evidence in the record, and it must be in response to proper hypothetical questions which fairly set out all of [the] claimant's impairments.") (internal citations omitted).
Based upon the foregoing, the ALJ's finding at step five of the sequential evaluation process was based upon substantial evidence and was without legal error.
CONCLUSION AND RECOMMENDATION
The Commissioner's decision is based upon substantial evidence and is free of legal error. Now, therefore, based upon the foregoing,
IT IS RECOMMENDED that the Commissioner's decision be affirmed.
IT IS SO RECOMMENDED.
s/Kevin F. McDonald
United States Magistrate Judge July 21, 2017
Greenville, South Carolina