Washington v. Saul, C/A No.: 1:17-3365-CMC-SVH
| Decision Date | 10 July 2019 |
| Docket Number | C/A No.: 1:17-3365-CMC-SVH |
| Court | U.S. District Court — District of South Carolina |
| Parties | James Washington, Jr., Plaintiff, v. Andrew M. Saul, 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 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 he 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.
Plaintiff initially filed applications for SSI and Disability Insurance Benefits ("DIB") on August 26, 2009, alleging disability beginning July 16, 2009. Tr. at 81-96. Plaintiff's applications were denied initially, upon reconsideration, and by an Administrative Law Judge ("ALJ"). Id. The Appeals Council affirmed the ALJ's decision on March 14, 2013, and Plaintiff declined to appeal. Tr. at 111.
Plaintiff protectively filed a second application for SSI2 on March 22, 2013, in which he alleged his disability began July 17, 2009.3 Tr. at 283-88. The claim was denied initially and upon reconsideration. Tr. at 149-52, 156-57. On November 20, 2014, Plaintiff had a video hearing before ALJ Edward T. Morriss. Tr. at 53-80. The ALJ issued a partially-favorable decision on February 9, 2015, finding that Plaintiff was disabled as of June 30, 2014. Tr. at 127-43. On July 19, 2016, the Appeals Council affirmed the ALJ's decisionthat Plaintiff was disabled as of June 30, 2014, but vacated the decision with respect to the issue of disability prior to June 30, 2014. Tr. at 49-51. The Appeals Council directed the ALJ to offer the claimant an opportunity for a hearing, take any further action needed to complete the administrative record, and issue a new decision on the issue of disability prior to June 30, 2014. Tr. at 50-51.
On December 12, 2016, Plaintiff had a second video hearing before ALJ Morriss. Tr. at 33-45. The ALJ issued a second partially-favorable decision on May 3, 2017, finding that Plaintiff was not disabled prior to June 30, 2014. Tr. at 12-31. On October 30, 2017, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 1-6. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on December 14, 2017, concerning the period of March 22, 2013, through June 30, 2014. [ECF No. 1].
Plaintiff was 51 years old at the time of the most recent hearing. Tr. at 37. He completed high school. Id. His past relevant work ("PRW") was as a landscaper and a truck driver. Tr. at 77. He alleges he was unable to work between March 22, 2013, and June 30, 2014. Tr. at 79-80.
On July 17, 2009, an electrocardiogram ("ECG") showed Plaintiff to have left ventricular ejection fraction of 20% or less. Tr. at 477-78. Plaintiff subsequently underwent a persantine stress test on July 22, 2009, that reflected left ventricular ejection fraction of 21%. Tr. at 479-80. On February 21, 2011, Plaintiff had another abnormal ECG. Tr. at 535.
On November 15, 2011, Plaintiff presented to Williamsburg Regional Hospital ("WRH") with a three-day history of worsening shortness of breath. Tr. at 656. He admitted to having been noncompliant with his heart and blood pressure medications for several months. Id. James J. Thomy, M.D. ("Dr. Thomy"), noted Plaintiff's blood pressure was extremely elevated at 248/144 mm/Hg. Id. He admitted Plaintiff for acute pulmonary edema and acute hypertensive emergency. Id. Dr. Thomy indicated test results showed "end organ damage to involve the heart, lungs and renal system." Id. Plaintiff responded well to intravenous medication. Id. By the following morning, Plaintiff "was asymptomatic, alert and oriented." Id. An ECG on November 17, 2011, revealed left ventricular ejection fraction of approximately 15%. Tr. at 660. Plaintiff was discharged on November 17, 2011, with diagnoses of acute pulmonary edema, acute hypertensive emergency, acute renal insufficiency, acute hypokalemia (corrected), history of noncompliance, and history of chronic alcohol use. Tr. at 658. Dr. Thomy instructed Plaintiff tofollow a low salt diet and to follow up with Nigel Taylor, M.D. and Advanced Cardiology. Id. He prescribed Lasix 40 mg, Potassium Chloride 10 mEq, Enalapril 10 mg, Labetalol 200 mg, and Clonidine 0.1 mg. Id.
Plaintiff followed up with internal medicine and cardiovascular disease specialist Ian Smith, M.D. ("Dr. Smith"), prior to discharge. Tr. at 661-62. Dr. Smith indicated he had previously treated Plaintiff. Tr. at 661. He noted Plaintiff was noncompliant with the medical regimen and rarely showed up for office appointments. Id. Dr. Smith indicated he believed Plaintiff to be an alcoholic and suggested Plaintiff likely had alcoholic cardiomyopathy. Id. He discontinued Labetalol and Lasix and prescribed Torsemide. Tr. at 662.
On January 14, 2013, Plaintiff presented to the emergency room ("ER") at WRH with shortness of breath. Tr. at 433-56, 462-76, 481-94, 500-23. He stated his symptoms had persisted for months and were worse at night. Tr. at 437. The attending nurse observed Plaintiff to demonstrate moderate respiratory distress, with rales, decreased air movement, and pedal edema. Tr at 438. She assessed acute shortness of breath, pulmonary edema or congestive heart failure, and acute on chronic renal failure with hypertensive urgency. Id. An ECG was abnormal and showed sinus tachycardia, possible left atrial enlargement, and left ventricular hypertrophy with repolarization abnormality. Tr. at 452. A chest x-ray reflected probable congestive heart failure with more significant infiltration in the right chest than the left. Tr.at 456. Lab work showed elevated blood urea nitrogen ("BUN")4 and creatinine levels and low glomerular filtration rate ("GFR"). Tr. at 495. It also showed significantly elevated B-type natriuretic peptide.5 Tr. at 476. Plaintiff was transferred to Carolinas Hospital System ("CHS") for additional treatment. Tr at 454.
Upon admission to CHS, attending physician Venugopal Govindappa, M.D. ("Dr. Govindappa"), found Plaintiff to be in mild respiratory distress with bilateral crackles and an ejection systolic murmur. Tr. at 460-61. He assessed severe cardiomyopathy, with worsened shortness of breath that was "most likely . . . decompensation of his heart failure," "acute on chronic" renal failure, and complex renal cyst. Tr. at 461.
Plaintiff consulted with internal medicine and cardiovascular disease specialist Thomas L. Stoughton, M.D. ("Dr. Stoughton"), on January 15, 2013. Tr. at 458. Dr. Stoughton noted Plaintiff had "an ejection fraction in the 15% range with chronic class III to IV heart failure symptoms." Id. Plaintiff indicated symptoms of heart failure had prevented him from performing daily physical activities. Id. Dr. Stoughton observed Plaintiff to be "chronically illappearing" and noted few bibasilar rales, 1/6 systolic murmur, and trace lower extremity edema. Tr. at 458. He assessed dilated cardiomyopathy with left ventricular ejection fraction in the 15% range with class III to IV congestive heart failure, hypertension, chronic renal failure, anemia, and complex renal cyst by ultrasonography. Tr. at 459. He stated "[f]rom a cardiovascular standpoint, I believe him to be completely and permanently disabled." Id.
Plaintiff consulted with urologist J. Kevin O'Kelly, M.D. ("Dr. O'Kelly"), on January 16, 2013, for a left complex renal cyst. Dr. O'Kelly assessed acute renal failure and left renal complex cyst. Tr. at 457. He recommended additional testing. Id.
On January 21, 2013, Plaintiff was examined by cardiovascular disease specialist Prabal Guha, M.D. ("Dr. Guha"). Tr. at 591-93. Plaintiff informed Dr. Guha that "financial reasons" had prevented him from following up with a physician or refilling his heart medications over the prior two-year period. Tr. at 591. Dr. Guha noted Plaintiff's blood pressure to be 161/103 mm/Hg. Tr. at 592. He observed a systolic murmur, but noted no edema. Id. Dr. Guha planned to adjust Plaintiff's medications and monitor their effects on his conditions. Id. He mentioned potential defibrillator implantation and recommended temporary use of a Life Vest. Id. Plaintiff declined the LifeVest "because of financial issues." Id.
Plaintiff was discharged from CHS on January 25, 2013, with diagnoses of stage four chronic kidney disease, severe cardiomyopathy, and hypertension. Tr. at 525-34, 536-62, 589-90. At the time of discharge, Plaintiff's blood pressure was 130/78 mm/Hg, his chest was bilaterally clear to auscultation, he had no edema, and he was in fair condition. Tr. at 525. Dr. Govindappa noted the results of the MRI had not been reported, but that Plaintiff may require outpatient follow up with Dr. O'Kelly.6 Id. The abdominal MRI report showed a left renal cyst measuring approximately seven millimeters. Tr. at 576.
On February 22, 2013, Dr. Guha noted Plaintiff had improved with treatment. Tr. at 604. Plaintiff reported fatigue, shortness of breath, near syncope, chest pressure, chest tightness, palpitations, dizziness, and muscle weakness. Tr. at 605. Dr. Guha observed Plaintiff to have "quiet, even and easy respiratory effort" and no edema. Tr. at 605-06. Dr. Guha noted Plaintiff's congestive heart failure was ...
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