Briggs v. Colvin
| Decision Date | 10 July 2014 |
| Docket Number | C/A No.: 1:13-1666-JFA-SVH |
| Court | U.S. District Court — District of South Carolina |
| Parties | Rosetta Briggs, Plaintiff, v. Carolyn W. Colvin, Acting Commissioner of Social Security Administration, Defendant. |
This appeal from a denial of social security benefits is before the court for a Report and Recommendation ("Report") pursuant to Local Civil 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 Disability Insurance Benefits ("DIB"). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the undersigned recommends that the Commissioner's decision be reversed and remanded for further proceedings as set forth herein.
On September 22, 2010, Plaintiff filed an application for DIB in which she alleged her disability began on February 24, 2009. Tr. at 116-117. Her application was denied initially and upon reconsideration. Tr. at 67-68 and 73. On November 20, 2012, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Carol Guyton. Tr. at 33-62. The ALJ issued an unfavorable decision on December 12, 2012, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 21-27. 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 1-3. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on April 25, 2013. [Entry #1].
Plaintiff was born on September 8, 1949, and she was 63 years old at the time of the hearing. Tr. at 25, 37. She completed the tenth grade. Tr. at 39. Her past relevant work ("PRW") was as a machine operator. Tr. at 27. She alleges she has been unable to work since February 24, 2009. Tr. at 116.
On January 30, 2010, Plaintiff presented to the emergency department, complaining of chest pain. Tr. at 180-84. She stated that she took no medications and displayed a full range of motion in all extremities, with no muscle weakness. Tr. at 182-183. Plaintiff was noted have abnormal blood pressure, and was discharged home with instructions to follow up with her physician for a nuclear stress test. Tr. at 187.
On September 30, 2010, Plaintiff visited the East Aiken Health Center, complaining of pain and soreness in her lower legs. Tr. at 197. She reported a history of nerve damage to the third and fourth fingers of her left hand. Id. Menopausal syndrome and sciatica were assessed. Tr. at 198. By October 11, 2010, she reported that the leg pain was resolving. Tr. at 196. Menopausal syndrome and iron deficiency anemia were assessed. Id.
On January 3, 2011, Plaintiff visited John A. Nicholson, M.D. for a consultative exam. Tr. at 199-205. Plaintiff's complaints included the following: history of crush injury to the left ring finger; "nerve problem" with left middle finger; right thumb pain with pressure; bilateral leg pain, worse with standing and walking; dizziness; hypertension; low iron; and occasional chest pain. Tr. at 199. Dr. Nicholson indicated that review of the medical records also indicates diagnoses of menopausal symptoms, sciatica and iron deficiency anemia. Id. She was noted to be obese, mildly anxious and in no obvious distress. Tr. at 200. Her weight was 232 pounds. Tr. at 202. She was noted to be 5' 3" tall. Id. Her blood pressure was elevated at 158/72. Id. Her bilateral hands demonstrated full range of motion and no abnormalities. Tr. at 200. Minimal effusion was noted in her bilateral knees. Id. Tenderness was noted in her posterior knees and upper calves bilaterally, with no palpable mass. Id. Manual muscle testing revealed normal strength in upper and lower limbs. Id. Sensory testing was normal in all four limbs. Id. Reflex testing was low normal, diminished at 1+ and symmetrical. Id.Plaintiff's gait was noted to be narrow-based with normal stance and swing pattern. Id. She was alert and oriented in all spheres. Id. Dr. Nicholson assessed bilateral lower limb pain without specific objective findings; left hand dysfunction, unusual description with no specific objective findings; history of noncardiac chest pain, no clear etiology; and history of subjective dizziness. Id.
Plaintiff presented to the emergency department at University Hospital on May 20, 2011, complaining of abdominal pain. Tr. at 211. She was diagnosed with diverticulitis. Tr. at 212. Plaintiff underwent noncontrast CT of the abdomen and pelvis. Tr. at 207. The cecum was noted to be mildly prominent in distention, with questionable adjacent stranding and small nonspecific lymph nodes. Id. There was an apparent transition in the mid-ascending colon, and underlying stricture or neoplasm could not be excluded. Id. An indeterminant low-density lesion was noted on the right lobe of the liver. Id. A small umbilical hernia was also noted. Id.
X-ray of the abdomen was also performed on May 21, 2011. Tr. at 228. Degenerative change of the hips and spine were noted. Id.
Plaintiff next presented to the emergency department at University Hospital on May 26, 2011, with complaints of lightheadedness and irritability. Tr. at 213. Discharge diagnoses included diverticulitis and dizziness. Tr. at 218. Abdominal x-ray indicated lumbar spine changes including hypertrophic change to the dorsal spine, slight lumbar dextroscoliosis, and hypertrophic changes of the lower lumbar facet joints. Tr. at 230. CT of the abdomen and pelvis indicated prominent cecum, small sigmoid diverticula, and small cyst to the liver. Tr. at 257.
On May 27, 2011, Lindsey Crumlin, M.D. completed a residual functional capacity assessment. Tr. at 234-240. The primary diagnosis was indicated to be musculoskeletal, and the secondary diagnosis was varicose leg veins. Tr. at 234. Other alleged impairment was level II obesity. Id. Dr. Crumlin indicated that the claimant could occasionally lift and/or carry 50 pounds; that she could frequently lift and/or carry 25 pounds; that she could stand and/or walk (with normal breaks) for a total of about 6 hours in an 8-hour workday; that she could sit (with normal breaks) for a total of about 6 hours in an 8-hour workday; that her ability to push/pull was unlimited; that she had no postural limitations; that she had no manipulative limitations; that she had no visual limitations; that she had no communicative limitations; and that she had no environmental limitations. Tr. at 235-238. Dr. Crumlin further indicated the following: Tr. at 239.
Plaintiff presented to surgeon John D. Cheape, M.D. on June 9, 2011, regarding abdominal pain and possible diverticulitis. Tr. at 255. Dr. Cheape indicated that he would refer her for colonoscopy. Id.
Plaintiff underwent colonoscopy on July 11, 2012, which revealed a right colon mass. Tr. at 248-249. X-ray of the chest performed on that date revealed a five millimeter pulmonary nodule overlying the right lower lobe. Tr. at 247.
On July 12, 2011, Plaintiff underwent hand-assisted laparoscopic right colectomy to remove her right colon tumor. Tr. at 244-245. The surgical pathology report indicatedlow-grade adenocarcinoma extending through the bowel wall into the pericecal fat (PT3), with clear margins, positive lymph nodes, and tumor deposits. Tr. at 242.
On July 19, 2011, Dr. Cheape sent a letter to oncologist Michael Shlaer, M.D. in which he indicated that he was referring Plaintiff to Dr. Shlaer for adjuvant chemotherapy. Tr. at 254. He indicated that he had concern for spread of the tumor based on imaging reports that indicated a two centimeter lesion on the liver and a small coin lesion on pre-op chest x-ray. Id.
Plaintiff followed up with Dr. Cheape on July 25, 2011, for drainage from her incision site. Tr. at 253. The incision was cleaned and opened, but it was determined not to be infected. Id.
CT of the chest was performed on August 1, 2011, and indicated pericardial effusion, suspicion for subtle hepatic metastases, and degenerative spine. Tr. at 251.
Plaintiff presented to oncologist Donald C. Townsend, M.D. on August 8, 2011. Tr. at 260-262. She indicated that she had done well postoperatively and that she continued to improve with no significant limitations in her activity. Tr. at 260. She denied most problems, but did complain of arthritis pain. Id. Her weight was 199.8 pounds. Tr. at 261. Dr. Townsend indicated Plaintiff's performance status to be 1, meaning "no physically strenuous activity, but ambulatory and able to carry out light or sedentary work (e.g., office work, light house work)." Id. Dr. Townsend indicated that Plaintiff had a moderately to well differentiated adenocarcinoma of the ascending colon with a 4.5 cm primary extending through the bowel wall into the pericolonic adipose tissue with 7 of 23 lymph nodes positive for metastatic disease and no evidence of spreadof the disease beyond except for the five millimeter nodule in the right lung, which remained unevaluated. Id. He indicated that Plaintiff's cancer was a stage IIIB (T3N2M0), but that it could also be stage IV if the lung nodule represented metastatic disease. Id. He indicated that the chemotherapy would be the appropriate course of action for treatment of stage III or stage IV metastatic disease. Id. Dr. Townsend recommended use of intravenous FOLFOX administered every two weeks for a total of thirteen doses. Tr. at 262. Plaintiff was referred for...
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