Whitfield v. Comm'r of Soc. Sec. Admin.
| Decision Date | 18 June 2015 |
| Docket Number | C/A No.: 1:14-3352-RBH-SVH |
| Court | U.S. District Court — District of South Carolina |
| Parties | Crystal Suzanne Whitfield, Plaintiff, v. 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 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 February 7, 2011, Plaintiff filed an application for DIB in which she alleged her disability began on June 16, 2009. Tr. at 91, 106-07. Her application was denied initially and upon reconsideration. Tr. at 92-94, 99-100. On January 3, 2013, Plaintiffhad a hearing before Administrative Law Judge ("ALJ") Ann G. Paschall. Tr. at 27-52 (Hr'g Tr.). The ALJ issued an unfavorable decision on February 21, 2013, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 11-26. 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 1-4. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on August 20, 2014. [ECF No. 1].
Plaintiff was 40 years old at the time of the hearing. Tr. at 30. She obtained bachelor's and master's degrees. Tr. at 31. Her past relevant work ("PRW") was as a purchaser and a human resource manager and professional. Tr. at 49. She alleges she has been unable to work since June 16, 2009. Tr. at 106.
On June 16, 2009, Plaintiff underwent cervical lymphadenopathy and biopsy of a right posterior cervical lymph node. Tr. at 257-59.
Plaintiff consulted with Szabolcs Batizy, M.D. ("Dr. Batizy"), for Hodgkin's lymphoma on June 19, 2009. Tr. at 254-56. He assessed lymphocyte-rich Hodgkin's disease. Tr. at 255. He indicated the course of treatment would be to proceed with a staging workup consisting of a PET scan, CTs, laboratory tests, bone marrow aspiration, and biopsy. Tr. at 256.
On July 1, 2009, Plaintiff underwent placement of a left subclavian vein Port-A-Cath. Tr. at 260-61.
When Plaintiff followed up on July 15, 2009, Dr. Batizy indicated the work-up revealed stage II-B disease. Tr. at 263. Dr. Batizy wrote that Plaintiff tolerated her first cycle of ABVD chemotherapy well. Id. Plaintiff complained of some transient bone pain, and Dr. Batizy indicated it was related to Neupogen injections. Id. Dr. Batizy noted prominent adenopathy in Plaintiff's neck and prominence of her right tonsillar region. Id. He scheduled Plaintiff for the next two cycles of ABVD, encouraged her to stop smoking, and prescribed Bactrim to be taken over the weekend. Id.
On July 29, 2009, Plaintiff reported to Dr. Batizy that her night sweats had decreased and that she was tolerating ABVD chemotherapy well. Tr. at 264. Dr. Batizy noted that Plaintiff had stopped smoking. Id. Plaintiff complained of some tenderness around her Port-A-Cath, but noted that tenderness in her neck had improved. Id. Dr. Batizy observed a minimal degree of edema around the Port-A-Cath. Id. He indicated Plaintiff should continue ABVD; obtain a neck CT, chest x-ray, and pulmonary function tests to monitor for Bleomycin pulmonary toxicity; and continue taking Bactrim on Saturdays and Sundays to prevent pneumocystis pneumonia. Tr. at 264-65.
Plaintiff followed up with Dr. Batizy on August 19, 2009, and indicated her fevers and night sweats had resolved. Tr. at 266. She indicated she had presented to the emergency room on August 7, when she developed a low-grade fever and swelling in her chest wall, neck, and left arm. Id. Dr. Batizy noted no abnormalities on examination and indicated Plaintiff should continue with chemotherapy as scheduled. Tr. at 266-67.
On September 16, 2009, Plaintiff indicated to Dr. Batizy that she had tolerated chemotherapy with minimal nausea, but developed slight hyperpigmentation related to Bleomycin. Tr. at 268. Dr. Batizy observed no abnormalities, indicated Plaintiff's Hodgkin's disease appeared to be in remission, and ordered Plaintiff to continue with ABVD chemotherapy. Tr. at 268-69.
Plaintiff followed up with Dr. Batizy on October 14, 2012, and reported recent fever, chills, and discomfort in her Port-A-Cath area. Tr. at 270. Dr. Batizy ordered multiple tests and instructed Plaintiff to follow up with T. Steven McElveen, M.D. ("Dr. McElveen"). Id. He indicated that Plaintiff appeared to be in remission clinically and that he had not yet decided whether she should undergo radiation treatment. Tr. at 271.
On November 18, 2009, Dr. Batizy indicated Plaintiff developed bilateral pulmonary infiltrates and had reduced diffusing capacity in her lungs. Tr. at 272. Plaintiff described some mild dyspnea on exertion. Id. Dr. Batizy ordered chemotherapy to be put on hold and Plaintiff to undergo a gallium scan. Id.
On November 25, 2009, Dr. Batizy indicated the gallium scan revealed some interstitial changes in her lung. Tr. at 274. He ordered Plaintiff's chemotherapy to remain on hold until the source of the problem could be determined. Id.
Plaintiff presented to Charles A. Thompson, M.D. ("Dr. Thompson"), on December 1, 2009. Tr. at 251. Dr. Thompson assessed abnormal chest x-ray or CT and ordered bronchoscopy with biopsy. Tr. at 253.
Plaintiff followed up with Dr. Batizy on December 2, 2009. Tr. at 277-78. He indicated that the bronchoscopy suggested some inflammatory changes, but no evidenceof lymphoma. Tr. at 277. He stated it was unclear if Plaintiff had resolving pneumonia or a Bleomycin effect, but that her condition was improving. Id. Dr. Batizy discontinued use of Bleomycin and ordered that Plaintiff finish chemotherapy. Id. He also indicated Plaintiff should undergo a PET scan in two weeks. Id.
On December 16, 2009, Dr. Batizy observed Plaintiff's dyspnea to be markedly improved. Tr. at 279. He assessed Hodgkin's disease as being in remission. Tr. at 280.
On January 27, 2010, Dr. Batizy indicated Plaintiff had completed chemotherapy and that her dyspnea and respiratory status were improved. Tr. at 281.
On April 12, 2010, Plaintiff followed up with Dr. Batizy for re-evaluation of Hodgkin's disease. Tr. at 232. Dr. Batizy indicated Plaintiff appeared to be in remission and that her pulmonary function tests indicated stability and some degree of improvement. Id. He noted that Plaintiff was asymptomatic and able to go up and down stairs without a problem. Id. He assessed resolving pulmonary toxicity and Hodgkin's disease in remission and instructed Plaintiff to follow up in three months. Tr. at 232-33.
Spirometry testing on April 19, 2010, revealed Plaintiff to have a minimal obstructive lung defect and a moderate decrease in diffusing capacity. Tr. at 230. A chest x-ray indicated no abnormalities. Tr. at 231.
Plaintiff followed up with Dr. Batizy on August 4, 2010, and reported experiencing exhaustion and fatigue at work. Tr. at 215. Dr. Batizy observed Plaintiff to be anxious and upset and recommended she consult a counselor. Id. He indicated there was no evidence of recurrence of Hodgkin's disease. Id.
On October 16, 2010, Plaintiff presented to Charles K. Edsall, M.D. ("Dr. Edsall"), with complaints of shortness of breath and a non-productive cough. Tr. at 238. Dr. Edsall diagnosed and prescribed medications to treat an upper respiratory infection. Id.
On December 22, 2010, Dr. Batizy indicated Plaintiff was "extremely frantic and worried about a generalized pruritis and rash." Tr. at 285. He noted Plaintiff had partial improvement of symptoms with use of Prednisone and observed a fading rash on Plaintiff's chest, torso, and back. Id. He indicated that it was unclear if the rash was related to Hodgkin's disease, but he referred Plaintiff to a dermatologist and for a CT scan. Id.
On February 4, 2011, Dr. McElveen indicated that Plaintiff had no clinical symptoms consistent with thrombosis and that a venous duplex of the jugular vein was negative for deep venous thrombosis. Tr. at 244. He indicated the radiologist likely overread the CT scan and that no further follow up was needed. Id.
Plaintiff followed up with Dr. Batizy on February 9, 2011, who indicated the adenopathy in Plaintiff's neck region was likely reactive in nature and had resolved. Tr. at 286. He indicated there was no evidence of recurrence of Hodgkin's disease and that Plaintiff remained in remission. Id.
On April 14, 2011, Rebecca W. Norris, M.D. ("Dr. Norris"), indicated Plaintiff's mental diagnoses included depression and anxiety. Tr. at 287. She noted Plaintiff was prescribed Citalopram, Buspar, and Alprazolam to treat her mental conditions. Id. She indicated Plaintiff was oriented to time, person, place, and situation; had intact thoughtprocesses; had appropriate thought content; had normal mood/affect; and had adequate attention/concentration and memory. Id. She described Plaintiff's work-related limitation in function as slight and indicated that psychiatric care had not been recommended. Id. An undated form contained similar impressions, but Dr. Norris instead described Plaintiff's mood/affect as worried/anxious. Tr. at 307.
Plaintiff presented to Dr. Norris on May 2, 2011, with a fever and possible urinary tract infection ("UTI"). Tr. at 314. Plai...
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