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January 12, 2005.


The opinion of the court was delivered by: REBECCA PALLMEYER, District Judge


Plaintiff Linda Hoffman claims that she is disabled by a combination of impairments, including migraine headaches, back pain, abdominal problems, and depression. She filed this action seeking review of the final decision of the Commissioner of Social Security ("Commissioner") denying her application for a period of Disability Insurance Benefits ("DIB") and Supplemental Social Security Income ("SSI") under Titles II and XVI of the Social Security Act. 42 U.S.C. §§ 423(d) and 1381a. The parties have filed cross-motions for summary judgment. For the reasons set forth here, the case is remanded to the ALJ for further evaluation.


  Hoffman applied for DIB and SSI on April 10, 1998, claiming that she became disabled on January 26, 1998 due to ovarian cysts, abdominal pain, gastric ulcers, and an enlarged colon and intestines. (R. 99-101, 108.) The application was denied on May 18, 1998. (R. 63.) Hoffman did not file a request for reconsideration but instead submitted another application for DIB and SSI on August 12, 1999, this time claiming that she became disabled on February 9, 1998 due to dizziness, blackouts, double vision, anxiety, stress, shakiness, and neck and back pain. (R. 102-04, 138.) The application was denied initially and again on reconsideration. (R. 64-65, 70-73, 75-77.) Hoffman appealed the decision and requested an administrative hearing, which was held on September 8, 2000. (R. 21, 78.) On November 30, 2001, the Administrative Law Judge ("ALJ") denied Hoffman's claim for benefits. The ALJ found that Hoffman suffers from a history of migraine headaches, tension headaches, ovarian cysts, and endometriosis, as well as degenerative disk disease and depression, all of which are severe impairments under the Social Security Regulations. (R. 24.) The ALJ concluded that Hoffman nonetheless retains the functional capacity to perform light, unskilled work. (R. 25, 26.) On July 15, 2002, the Appeals Council denied Hoffman's request for review. (R. 13-14, 17.) Hoffman now seeks judicial review of the ALJ's decision, which stands as the final decision of the Commissioner.


  Hoffman was born on November 14, 1964 and was 35 years old at the time of the hearing before the ALJ. (R. 34.) She is a high school graduate who lives with her boyfriend and has no children. (Id.) Hoffman has worked as a front-end supervisor for a grocery store, and as a waitress, hostess, cashier, auto parts delivery person, night supervisor, sandwich maker, and cook for various other establishments. (R. 35-38, 40.) She last worked in February 1998 as a waitress and hostess. (R. 35.)

  A. Medical History

  1. Back Pain

  In February 1991, Hoffman injured her back at work and was diagnosed with a herniated disk. She underwent treatment for the condition until approximately June 1992. (R. 213-24.) The record indicates that Hoffman did not seek further medical assistance for her back or for any other condition until April 1997 when she began seeing internist Dr. Lubna Maruf for back pain. (R. 402-03.) Dr. Maruf prescribed Relafen, Vicodin, and Flexeril for Hoffman's back pain, and by April 23, 1997, her condition was "much improved."*fn1 (R. 402.) Dr. Maruf also referred Hoffman to a neurologist. (Id.) A November 19, 1997 X-ray of Hoffman's lumbosacral spine, however, showed "[n]o significant findings." (R. 406.)

  On January 2, 1998, Hoffman went to treating physician Dr. Pedro G. Palu-Ay, an emergency medicine and family practice specialist, complaining of neck and low back pain. (R. 394.) Two weeks later on January 17, 1998, Hoffman went to the emergency room at Victory Memorial Hospital ("VMH") and reported that she had fallen and injured her back the previous day. According to the attending physician, Hoffman did not receive any treatment at that time because she said she had to go to work. (R. 258.) Four days later on January 21, 1998, Hoffman went back to the VMH emergency room complaining of a cold and lower back pain from her fall. (R. 260.) Hoffman saw Dr. Palu-Ay on February 17, February 27, and June 6, 1998 for continuing back pain, and he diagnosed her with "Cervical and Lu[m]bar Disc Syndrome." (R. 383, 392-93.)

  Hoffman next sought treatment for her back pain at the VMH emergency room on January 2, 1999. (R. 285.) The attending physician noted that Hoffman had "frequent ER visits for pain med[ication] and Soma," a muscle relaxant; that she had "walked out in the past after receiving . . . narcotics"; that there was "[s]uspected drug seeking behavior"; that she was "[r]equesting Soma by name"; and that she "[c]laims to be unable to reach [her doctor] for refill." (R. 286.) The attending physician talked to Hoffman about the "appearance of drug seeking behavior" and stated that he was "uncomfortable giving her any drugs of abuse." (Id.) (emphasis in original). He discharged Hoffman with some Naprosyn (a form of the arthritis medication naproxen) for pain. (Id.; ids.htm.) On January 18, 1999, Hoffman went to the emergency room again, this time at Northwest Community Hospital ("NCH"). She reported back pain from slipping and falling on the ice and was given prescriptions for Vicodin and Flexeril. (R. 299-303.) On January 28, 1999, Hoffman told her treating neurologist, Dr. Jeffrey S. Farbman, that she planned to see a chiropractor for her back problems. (R. 233.) One month later, on February 27, 1999, Hoffman called Dr. Farbman's office but he was unavailable. The progress notes recorded by someone in Dr. Farbman's office indicate that Hoffman "called in wanting narcotic medicines. She has chronic back problems and is on Relafen and Soma. She is also on Depakote*fn2 for unclear reasons. I told her that I am not comfortable prescribing narcotics for her after hours on the weekend. I suggested that she go to the emergency room." (R. 234.)

  On April 3, 1999, Hoffman returned to the NCH emergency room complaining of back spasms and pain. She received prescriptions for naproxen, Flexeril, and Vicodin. (R. 306-10.) On November 19, 1999, Hoffman went to the VMH emergency room, again complaining of back pain radiating down her left leg. The hospital records indicate that the pain was "from an old accident," but it is not clear whether there was any further discussion of this issue. (R. 331-32.) The following month, on December 20, 1999, Hoffman underwent a cervical MRI which showed mild diffuse bulging of the intervertebral disk at C5-C6. (R. 374.) A December 21, 1999 lumbar spine MRI showed evidence of a small to moderate left forminal disc protrusion at L3-L4, and laminectomy defect on the right at L5-S1 with "[e]vidence of enhancing post-surgical scar ventral to the thecal sac at L5-S1 and to some degree likely entrapping the right S1 nerve root which is minimally displaced posteriorly." (R. 372-73.)*fn3 The MRI also indicated that "[a] residual diffuse mild degenerative bulging disc at L5-S1 is present." (R. 373.) During a January 19, 2000 office visit with Dr. Farbman, Hoffman reported continuing back pain which she treated with Neurontin*fn4 and Soma as needed. Dr. Farbman noted that Hoffman "was initially asked to attend physical therapy, but did not. I have encouraged her to attend physical therapy and she has agreed to do so." (R. 239.) Shortly thereafter on February 8, 2000, Hoffman began seeing Dr. Mariusz Milejczyk, a general and family practice physician, for her back pain and migraines, in addition to Dr. Farbman and Dr. Palu-Ay. (R. 415.) There is no evidence in the record, however, that Hoffman ever attended physical therapy.

  On March 23, 2000, Hoffman complained to Dr. Farbman of "one week of throbbing pain from the mid-back radiating down the left leg." Dr. Farbman ordered an EMG and MRI for this complaint. (R. 414.) Hoffman's April 6, 2000 MRI of the lumbar spine showed a small protrusion of the disc at L5 and L5-S1; moderate disc degeneration at L5 and S1; and degenerative arthritis of the facet joint*fn5 at L4-5 and L5-S1. (R. 409.) On April 14, 2000, Dr. Farbman reported that Hoffman continued to experience low back pain. He indicated that "[w]e will continue the present medicines [including Neurontin and Soma] and add Celebrex," an anti-inflammatory drug used to relieve osteoarthritis and rheumatoid arthritis pain. (R. 413; generic/coxib ids.htm.) On June 2, 2000, Dr. Milejczyk prescribed Vioxx, another medication used to manage osteoarthritis pain. (R. 417; ids.htm.) Most recently, a July 7, 2000 X-ray of the lumbosacral spine was normal. (R. 418.)

  2. Stomach Pain

  Hoffman first began complaining of abdominal pain on January 26, 1998 when she reported to the emergency room at Midwestern Regional Medical Center. She was given a prescription for Darvocet*fn6 and instructed to get an ultrasound, which she did upon returning to the emergency room the following day. (R. 171-72, 272-73.) The test showed that the endometrium was "slightly prominent." (R. 175.) In addition, the right ovary had "small follicular cysts" and the left ovary was enlarged with a "slightly thickened wall lobulated cystic density" and "smaller cysts." (Id.) Hoffman was advised to continue taking any medication as directed and to follow up with Dr. Palu-Ay. (R. 173.)

  Hoffman started seeing treating obstetrician/gynecologist Dr. Frank Sun for pelvic pain on February 3, 1998. (R. 205.) She had another ultrasound which again showed an enlarged left ovary but, according to Dr. Sun's notes, she did not receive any further treatment "[d]ue to lack of insurance and money." (Id.) Instead, Dr. Sun gave Hoffman a prescription for Tylenol #3 for pain. On February 5, 1998, Hoffman called Dr. Sun complaining that the Tylenol #3 was not helping her pain and he approved her request for Vicodin. Hoffman saw Dr. Sun once more on February 12, 1998. He refilled her Vicodin prescription at that time, and again at her request on February 16, 1998. (Id.) On February 25, 1998, Hoffman was dismissed as Dr. Sun's patient due to lack of money. The records indicate that Hoffman "w[ould] not be given any additional prescriptions for pain medication." (Id.)

  On March 2, 1998, Hoffman reported to the VMH emergency room complaining of abdominal pain. She told the nurse that she had been scheduled for surgery that day but that the doctor had canceled the procedure.*fn7 (R. 177.) Upon examination, Hoffman's abdomen was soft and tender and her blood count showed some abnormalities. (R. 177-78.) The next day, Hoffman returned to VMH complaining of itching and nausea and was diagnosed with ovarian cysts. She told the doctor that her pain medication was not working and that her symptoms were caused by the Darvocet she was taking. (R. 180-81.) The physician noted "? Drug seeking" and "advised [he] would not prescribe narcotics — especially if nauseated." (R. 181.) Two days later, on March 5, 1998, Hoffman went to the Midwestern Regional Medical Center emergency room complaining of lower abdominal pain. (R. 281-82.) This time the physician diagnosed endometriosis. (R. 282, 391.)

  Hoffman had an ultrasound on March 13, 1998 that was normal and showed "[n]o evidence of any ovarian cysts as seen on the prior outside ultrasound exam report dated 1/27/98." (R. 197.) Dr. Bonnie E. Wise, a gynecologist, performed a physical examination on Hoffman but it was limited due to discomfort and did not produce any notable results. (R. 200-01.) A few days later on March 19, 1998, Hoffman underwent an air contrast colon exam because of hardening of the stomach and bowels. The exam was normal. (R. 183.) Nevertheless, Hoffman went to the VMH emergency room on March 23, 1998 complaining of the same symptoms. (R. 185.) A March 26, 1998 air contrast upper gastrointestinal exam showed evidence of "a gastric ulcer in the antrum with some associated thickening of the folds in the antrum."*fn8 (R. 187.) The exam also showed evidence of duodenitis (inflammation of the first portion of the small intestine), and the physician, Dr. A. Saltiel, recommended further evaluation with endoscopy. (Id.; DORLAND'S, at 511.) Dr. Wise saw Hoffman again on March 27, 1998 and noted her abdomen was tender and softly diffuse. (R. 202.)

  On March 29, 1998, Hoffman again reported to the VMH emergency room with lower abdominal and pelvic pain. (R. 188-89.) At the time, Hoffman was taking Ultram, Doxycycline, and Advil.*fn9 (R. 189.) The attending physician noted that Hoffman ambulated with difficulty and apparent discomfort, and diagnosed trichomonas — a parasitic infection — and chronic abdominal and pelvic pain. (Id.; DORLAND'S, at 1742.) The physician also noted: "suspect drug seeking behavior" and sent her for a drug screen. (Id.) The first screen tentatively detected barbiturates, but the confirmation test registered "negative" in that and all other categories. (R. 193-95.)

  During a follow-up visit with Dr. Wise on April 14, 1998, Hoffman reported that she suffered from insomnia due to pain but that she had declined ibuprofen from another physician.*fn10 Dr. Wise made note of a "possible referral to pain clinic" for Hoffman. (R. 204.) On April 30, 1998, Hoffman had an ultrasound of the gallbladder, which was normal. (R. 284.) Two days later Dr. Palu-Ay completed a Bureau of Disability Determination Services form stating that Hoffman suffered from ovarian cysts and endometriosis, and was "unable to work at this time." (R. 208.) On June 23, 1998, Hoffman underwent an air contrast upper GI series exam which indicated "some thickening of the duodenal folds suggestive of some possible mild diffuse duodenitis." (R. 264.) An MRI of the cervical spine and an ultrasound of the pelvis performed on June 25, 1998 were both normal. (R. 225, 266.)

  Hoffman did not make any further complaints of abdominal pain until August 14, 1999 when she again reported to the Midwest Regional Medical Center emergency room. (R. 314-15.) Abdominal X-rays were normal but a pelvic ultrasound showed what "appear[ed]" to be a cyst on the left ovary. (R. 318-19.) There are no records of Hoffman's abdominal problems after that date. 3. Headaches

  Hoffman testified that she began having "a problem" with headaches in approximately February 1998. (R. 42.) It is not clear from the medical records when she first complained about the headaches, but she underwent an MRI of the brain on July 21, 1998, which was normal. (R. 226.) An EEG performed the next day due to Hoffman's complaints of dizzy spells, blackouts and migraine headaches was "abnormal," showing "spike-like waves appearing in the left posterior temporal region on occasion, asymmetrical theta and sharp activity arising in the occipital region." (R. 407.) The record indicates that the findings were "compatible with possible vascular or migraine type headaches and also with possible paroxysmal symptoms." (Id.)

  One week later, on July 29, 1998, Hoffman saw Dr. Farbman and reported experiencing blackouts, diplopia (i.e., double vision), vertigo, fainting, and headaches, which she said began shortly after a car accident a year and a half earlier. (R. 227; DORLAND'S, at 475.) Hoffman described the headaches, which typically developed when she awoke from a fainting spell, as "sharp and pounding," lasting anywhere from one hour to all day. She also complained of photophobia, sonophobia, and nausea associated with the headaches. (Id.) At the time of the examination, Hoffman was taking Soma, Phrenilin, Claritin, and Depo-Provera shots.*fn11 (Id.) Dr. Farbman indicated that Hoffman's symptoms "appear? most likely to be a combination of migraine with aura as well as common migraine." (R. 228.) He recommended that Hoffman begin prophylactic therapy with verapamil (a drug used to treat hypertension), and that she continue using Phrenilin "as an abortive agent," presumably meaning to help stop the migraines once they began. (Id.; Approximately one month later, on August 28, 1998, Hoffman called Dr. Farbman and reported that she could not tolerate the verapamil because it made her blood pressure drop too low. She discontinued that medication but continued taking Phrenilin and Soma. (R. 230.)

  Dr. Farbman saw Hoffman again on September 15, 1998 and noted that she was able to take a lower dosage of verapamil at that time. Hoffman reported no further episodes of loss of consciousness and stated that her tension headaches were being eased by Soma. She complained, however, of "nearly constant twitching of the left eye and mouth" since her car accident "approximately one and one-half years" earlier, and Dr. Farbman prescribed Klonopin to help control the spasms. Dr. Farbman instructed Hoffman to continue taking verapamil "with an eye toward eventually increasing it," and to follow-up with him in six weeks. (R. 231.) At her followup visit on October 26, 1998, Hoffman told Dr. Farbman that she only had two more episodes of loss of consciousness and was no longer taking Klonopin, but was otherwise doing well on the Depakote, Soma, and Calan (a brand name for verapamil). (Id.)

  On November 30, 1998, Dr. Farbman noted that Hoffman's Depakote level was 36 and increased her dosage.*fn12 Hoffman reported no episodes of loss of consciousness but complained of "frequent" left eye twitching, and daily migraines, which were relieved with Soma. (R. 233.) Dr. Farbman referred Hoffman for an EEG "to be certain that [the] eye twitching is not a seizure." (Id.) The January 6, 1999 EEG was normal. (R. 288.) Hoffman saw Dr. Farbman again on January 28, 1999, and reported that she continued to have "some tension headaches." Dr. Farbman indicated that Hoffman's "[l]ast Depakote level on November 30, was 55"*fn13 and instructed her to start taking Relafen in addition to the Depakote. (R. 233.) Hoffman returned to Dr. Farbman on March 19, 1999, still complaining of daily headaches and left facial twitching, in addition to "a bit of left hand shaking." (R. 235.) Hoffman reported that the headaches were "somewhat better on Depakote" and that the Relafen helped "a little bit" but irritated her stomach. With respect to the twitching, she admitted to being noncompliant with her Klonopin prescription. Dr. Farbman referred Hoffman to a headache clinic and told her to continue taking Depakote and Soma. (Id.) On May 19, 1999, Hoffman had a therapeutic drug monitoring test which revealed that her Depakote level was low at 22.1. (R. 251.) Dr. Farbman attempted to reach Hoffman on June 9, 1999 to notify her of the test result but her telephone had been disconnected. (R. 235-36.)

  On June 23, 1999, Hoffman saw Dr. Farbman and reported that she still had "constant headaches" but felt they were better than they had been in May. As of June 23, she was taking Depakote twice a day. (R. 236.) Her Depakote levels remained low, however, reading at 12.5 on June 24 and 13.3 on July 7, 1999. (R. 253-54.) On August 2, 1999, Hoffman told Dr. Farbman during an office visit that she continued to get headaches but was taking Depakote and Neurontin. She also stated that she was taking Soma "which helps her neck and back" pain. (R. 237.) Dr. Farbman referred Hoffman to Dr. Emmanuel Perakis, a psychiatrist, citing her complaints of "marked anxiety," which "appear[ed] to exacerbate the multiple complaints of headache." (Id.)

  After examining Hoffman again on October 11, 1999, Dr. Farbman noted that Hoffman continued to take Depakote and Neurontin, but that her Depakote level remained subtherapeutic at 12.2. Hoffman told Dr. Farbman that she had been vomiting from Serzone, an antidepressant prescribed by Dr. Perakis on August 23, 1999. (R. 238; Dr. Farbman ...

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