Bush v. Colvin, C/A No.: 1:14-4917-RMG-SVH
| Decision Date | 22 March 2016 |
| Docket Number | C/A No.: 1:14-4917-RMG-SVH |
| Court | U.S. District Court — District of South Carolina |
| Parties | Frank Bush, Plaintiff, v. Carolyn W. Colvin, Acting Commissioner of Social Security Administration, Defendant. |
This pro se appeal from a denial of social security benefits is before the court for a Report and Recommendation ("Report") pursuant to Local Civ. Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying his claim for Supplemental Security Income ("SSI"). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether 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 November 2, 2010, Plaintiff filed an application for SSI in which he alleged his disability began on March 1, 2001. Tr. at 175-80. His application was denied initially and upon reconsideration. Tr. at 108-11, 114-15. On May 30, 2013, Plaintiff had a hearing before Administrative Law Judge ("ALJ") William F. Pope. Tr. at 23-48 (Hr'g Tr.). The ALJ issued an unfavorable decision on July 15, 2013, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 5-22. 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 December 31, 2014. [ECF No. 1].
Plaintiff was 55 years old at the time of the hearing. Tr. at 28. He completed high school. Tr. at 29. He had no past relevant work ("PRW"). Tr. at 38. He alleges he has been unable to work since March 1, 2001.1 Tr. at 175.
Plaintiff presented to the emergency room ("ER") at Palmetto Health Richland on December 13, 2009, complaining of abdominal pain. Tr. at 278. He admitted to drinking heavily the night before and to drinking on a regular basis. Tr. at 278-79. The physician prescribed a gastrointestinal ("GI ") cocktail, and Plaintiff's abdominal pain resolved. Tr. at 279. The physician diagnosed Plaintiff with alcoholic gastritis and alcohol intoxication and instructed him to limit his alcohol intake and to take Zantac for 30 days. Id.
Plaintiff was hospitalized at Palmetto Health Richland from February 5 to February 11, 2010, after sustaining a trauma. Tr. at 253-55. He was noted to be intoxicated upon admission to the ER. Tr. at 256. He reported that he was assaulted from behind while walking down the road. Tr. at 248. However, a consultation note from Stephen Fann, M.D., indicates Plaintiff was struck by an automobile while walking. Tr. at 251. Plaintiff's diagnoses included left forehead hematoma, right occipital scalp laceration, hypothermia, altered consciousness, traumatic brain injury ("TBI") with subdural hemorrhage, nasal fracture, and mild bilateral arm weakness. Tr. at 253. A computed tomography ("CT") scan of Plaintiff's cervical spine showed mild cervical spondylosis, but no acute cervical spinal fracture. Tr. at 264. Magnetic resonance imaging ("MRI") of Plaintiff's cervical spine demonstrated no evidence of cord contusion or epidural hematoma in the cervical region; mild-to-moderate disc osteophyte complex at C3-4 that was eccentric to the right, with slight right foraminal narrowing; mild central disc osteophyte complex at C4-5, with mild right foraminal narrowing; a slight broad-based disc osteophyte complex at C5-6; and a mild central disc osteophyte complex at C6-7. Tr. at 282. A CT scan of Plaintiff's facial bones indicated nasal bone fractures and a fracture of the anterior squamous portion of the left temporal bone with extension into the sphenoid bone and central aspect of the left orbital roof, with resultant extraconal hematoma and left globe proptosis. Tr. at 268. A CT scan of Plaintiff's head showed a minute left subdural hematoma and cortical hemorrhagic contusions along the left temporal lobe, a fracture of the anterior squamous portion of the left temporal bone, and a soft tissue scalp hematoma along the left anterolateral scalp and right posterolateral scalp.Tr. at 270. The discharge summary notes that Plaintiff complained of inability to use his hands, but was observed by nursing staff to be feeding himself and using his hands without difficulty. Tr. at 254. Greg S. Swartzentruber, M.D. ("Dr. Swartzentruber"), stated a physical exam showed no evidence of upper extremity weakness and that Plaintiff had good grip strength and normal sensation bilaterally. Id. He indicated Plaintiff had refused to leave after being discharged because he stated that his 85-year-old mother could not take care of him. Id. Dr. Swartzentruber suggested that Plaintiff was capable of meeting his own needs because he was seen "ambulating around the entire length of the seventh floor" and feeding himself when he was not aware that he was being watched. Id.
Plaintiff followed up with Brenda E. Stokes, RN ("Ms. Stokes"), at Orthopaedic Center on February 17, 2010. Tr. at 362. He complained of pain in his head, neck, and shoulder. Tr. at 364. Ms. Stokes observed Plaintiff to have full range of motion ("ROM"), normal strength, and no localized tenderness or swelling. Tr. at 365. She removed the staples from Plaintiff's posterior scalp, refilled Lortab, and prescribed Valium for neck and shoulder pain. Id.
On March 8, 2010, a head CT showed resolution of the left-sided middle cranial fossa and frontal lobe subdural hematoma; slight residual soft tissue swelling of the left temporal soft tissues; healing fractures of the left zygomatic arch and maxilla; and minimal left sphenoid and right ethmoid sinus disease. Tr. at 283.
Plaintiff presented to the ER at Palmetto Health Richland on March 16, 2010, complaining of a rash. Tr. at 285. He indicated that he had developed the rash two daysearlier and denied trying new food, soap, or detergent. Id. Derick M. Wenning, M.D. ("Dr. Wenning"), prescribed steroids and antihistamines. Tr. at 286.
On March 23, 2010, Plaintiff presented to Ginny L. Gottschalk, M.D. ("Dr. Gottschalk"), at Palmetto Health Richland Family Medicine Center with a complaint of chronic head and shoulder pain. Tr. at 358-59. He reported that his hands were always cold and painful. Tr. at 359. Plaintiff indicated he was unable to open his jaw and insisted that it had been broken, but Dr. Gottschalk reviewed the CT scan and informed Plaintiff that his jaw was not fractured. Tr. at 359-60. Plaintiff became upset and said he'd been lied to about his jaw and that he was going to contact his lawyer. Tr. at 360. Plaintiff demonstrated 4/5 strength and decreased ROM in his bilateral upper extremities, but Dr. Gottschalk described his effort as poor. Tr. at 361. She stated Plaintiff was mildly hostile and moderately agitated. Id. She prescribed a one-month supply of Plaintiff's medications, referred him to physical therapy, and discharged him from the practice. Tr. at 361.
Plaintiff presented to Stephanie Chapman, DO ("Dr. Chapman"), at Internal Medicine Center on April 2, 2010, complaining of pain and numbness in his bilateral upper extremities. Tr. at 354. He indicated he had difficulty opening his jaw fully, experienced constant numbness from his elbows to his fingers, and had occasional pain and weakness in his hands. Id. Dr. Chapman observed that Plaintiff was unable to open his jaw fully on the left. Tr. at 355. She noted that Plaintiff had 4/5 strength proximally and distally and decreased ROM to about 120 degrees in his bilateral upper extremities, but she stated that Plaintiff gave "very poor effort." Id. Dr. Chapman referred Plaintiff todental care and physical therapy and ordered nerve conduction studies. Tr. at 356. She prescribed Neurontin and Ultram and instructed Plaintiff to follow up in two weeks. Id.
On April 12, 2010, an electromyography ("EMG") showed Plaintiff to have mild bilateral carpal tunnel syndrome. Tr. at 461. The physician who administered the EMG stated that he believed Plaintiff's main problems were musculoskeletal. Id.
Plaintiff followed up with Dr. Chapman on April 14, 2010. Tr. at 349. He endorsed pain and numbness in his bilateral shoulders and indicated his upper extremities were cold from his elbows to his fingers. Id. He stated his pain increased when he was lying down and that the numbness and cold feeling increased when he flexed at the elbows. Id. Plaintiff endorsed little improvement with Ultram and Neurontin. Id. Dr. Chapman observed that Plaintiff was unable to open his jaw beyond 15 to 20 millimeters. Tr. at 350. She described Plaintiff's judgment as impaired, but noted no additional abnormalities on physical or mental examinations. Tr. at 350-51. She instructed Plaintiff to continue taking Ultram and to make another appointment with physical therapy. Tr. at 351. She increased Plaintiff's dosage of Neurontin to 300 milligrams three times a day. Id.
On April 28, 2010, Plaintiff presented to Seejil S. Dan, M.D. ("Dr. Dan"), at Internal Medicine Center. Tr. at 344. He complained of persistent left-sided facial pain. Id. He endorsed continued shoulder pain, but indicated it had improved with pain medication and physical therapy. Id. He stated he was unable to fully open his mouth, but could not afford to visit an oral surgeon. Id. Dr. Dan observed that Plaintiff was unable tofully open his jaw, but noted no other abnormalities on the physical examination. Tr. at 346.
Plaintiff presented to Narmadha Kalyanaswamy, M.D. ("Dr. Kalyanaswamy"), at Internal Medicine Center...
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