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Janine L. Fieldhouse v. Michael J. Astrue

February 8, 2012

JANINE L. FIELDHOUSE, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Magistrate Judge Maria Valdez

MEMORANDUM OPINION AND ORDER

This action was brought under 42 U.S.C. § 405(g) to review the final decision of the Commissioner of Social Security denying Plaintiff Janine Lee Fieldhouse's claim for Disability Benefits. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow, Fieldhouse's motion for summary judgment [Doc. No. 23] is granted in part and denied in part. The Court finds that this matter should be remanded to the Commissioner of Social Security for further proceedings.

BACKGROUND

I. PROCEDURAL HISTORY

Plaintiff Janine Lee Fieldhouse ("Plaintiff," "Claimant," or "Fieldhouse") originally filed an application for a period of disability and disability insurance benefits on November 7, 2005, alleging disability beginning June 17, 2005. (R. 54.) Plaintiff's claim was denied initially on March 30, 2006, and upon reconsideration on May 24, 2006. (Id.) Plaintiff timely filed a written request for a hearing by an Administrative Law Judge ("ALJ") on July 25, 2006. (Id.) On October 24, 2008, Plaintiff personally appeared and testified at the hearing and was represented by counsel. (Id.) An impartial vocational expert ("VE"), Dennis W. Gustafson, also appeared at the hearing. (Id.)

On November 12, 2008, the ALJ denied Plaintiff's claim and found her "not disabled" under the Social Security Act. (Id. at 62.) On January 16, 2009, Plaintiff requested review of the ALJ's decision. (Id. at 45.) In addition to the Request for Review of Hearing Decision / Order form, Plaintiff sent two Magnetic Resonance Imaging ("MRI") exam reports dated November 28, 2008 to the Social Security Administration Appeals Council ("Appeals Council") for consideration. (Id. at 44-50.)*fn1 The Appeals Council notified Plaintiff that it had granted the request for review on March 24, 2009.*fn2 (Id. at 21.) On June 2, 2009, the Appeals Council issued a decision, adopting the ALJ's findings or conclusions regarding whether Plaintiff was disabled. (Id.) The Appeals Council did not agree with the ALJ's finding that Plaintiff's date last insured for disability benefits was June 30, 2008; instead, the Appeals Council determined that the Plaintiff's date last insured was September 30, 2008. (Id. at 21-22.) In its decision, the Appeals Council noted that "[n]o comments or additional evidence have been received." (Id. at 21.) On June 16, 2009, Plaintiff requested that the matter be reopened due to the Appeals Council's failure to consider Plaintiff's new evidence. On August 28, 2009, the Appeals Council denied Plaintiff's request to reopen and change its June 2, 2009 decision. (Id. at 7.) The Appeals Council's June 2, 2009 decision is the final decision of the Commissioner of Social Security ("Commissioner"), and is reviewable by the District Court under 42 U.S.C. § 405(g). See Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005). Plaintiff filed the instant motion on June 9, 2010.

II. FACTUAL BACKGROUND

A. Fieldhouse's History

Fieldhouse was born on July 2, 1960, and was forty-four years old on June 17, 2005, the date on which she claims her disability period began. (R. 125.) Though not characterized as such, Plaintiff's precipitating injury seems to be a twisted ankle that she suffered on or around June 17, 2005 (Id. at 206) though some information in the record suggests that she experienced back and leg pain before then. (See, e.g., Id. at 267.) Fieldhouse claims that the illnesses, injuries or conditions that limit her ability to work include cellulitis in her right leg, a shifting disc in her back, and sciatica. (Id. at 162.) She explains that her back "goes out on [her] and [she] can barely walk." (Id.) She also says that she has trouble walking and has problems with her legs swelling up. (Id.) Plaintiff claims she stopped working because she was in too much pain from her leg and back condition to return to work. (Id.) Before her conditions made her leave her job, Plaintiff worked as a prep cook in a restaurant. (Id. at 163.)

Fieldhouse has taken Furosemide to prevent water retention, potassium and Klor-con to prevent leg cramps, (Id. at 166) and Lisinopril to treat hypertension. (Id. at 211.) She was prescribed Vicodin for her sprained ankle. (Id. at 207.) She was prescribed Levaquin, Unasyn, Vancomycin, and Gentamicin, in response to fever. (Id. at 211.) She has used over-the-counter medication for pain. (Id. at 193) She received a single cortisone injection in December of 2006. (Id. at 72-73.) She has seen Dr. Elizabeth Ritz ("Dr. Ritz") and Roger Miller ("Miller"), a chiropractor, for treatment. (Id. at 192.) Surgery has not been recommended for her back pain. (Id. at 58.)

B. Testimony and Medical Evidence

1. Fieldhouse's Testimony

In the hearing before the ALJ, Fieldhouse said that she could not work because of her cellulitis, sciatica and a shifting disc in her lower back. (Id. at 74, 79.) She indicated that she has constant low back pain and constant right leg pain or right leg numbness. (Id. at 86.) She explained that she cannot sit or stand for long periods of time, that it is hard to bend over, that she has a hard time sleeping at night, and that the maximum amount of weight that she could pick up at one time is five pounds. (Id. at 75-76, 78.) She also explained that when her disc shifts, she experiences a sharp pain and numbness in her leg that goes all the way to her toes, (Id. at 79-80) and that she experiences increased back pain when she lifts her arms. (Id. at 88.)

In terms of her daily activities, Fieldhouse testified that she usually gets up at 7:30 a.m. to get her son off to school, and then tries to do some housework. (Id. at 82.) She explained that she could only do a little bit at a time: "I will sit for five to ten to 15 minutes. I'll do a little bit of something, and then I'll go sit down and relax, and then I can't sit that long so I get up and walk around." (Id.) Plaintiff said that she fixes quick and easy meals and grocery shops for the family. (Id. at 84.) She said that she could take care of most of her personal hygiene needs, but that she sometimes needs help washing her hair, drying herself off, dressing herself and getting off of the toilet. (Id. at 85.)

2. Medical Evidence Before the ALJ

a. treating physicians

Beginning in September 2005 Fieldhouse received treatment from Dr. Elizabeth Ritz ("Dr. Ritz"). (Id. at 178.) On September 2, 2005, Fieldhouse was admitted to Illinois Valley Community Hospital with a high fever, and right lower extremity edema and pain. (Id. at 211.) Dr. Ritz diagnosed Plaintiff with cellulitis and abscess of the leg. (Id. at 209.) She also provided secondary diagnoses of phlebitis and thrombophlebitis of superficial vessels of lower extremity, unspecified congestive heart failure, essential hypertension, unspecified hyperlipidemia, tobacco use disorder, morbid obesity, personal history of venous thrombosis and embolism, and fever. (Id.) Dr. Ritz found that Plaintiff had 3 pitting edema bilaterally, and that her right lower extremity was erythematous to just below the knee. (Id. at 213.) A duplex and color-flow Doppler interrogation of the deep veins of the right lower extremity was performed; it showed normal flow augmentation, respiratory variation and compression from the proximal calf to the groin. (Id. at 241.) There was no evidence of a deep vein thrombosis. (Id.)

On a follow-up visit in November 2005, Dr. Ritz said that Plaintiff's cellulitis had resolved and that there were some hyper-pigmentation changes on her right lower extremity but no erythema. (Id. at 288.) Dr. Ritz suggested a sleep study due to Plaintiff's reports of daytime fatigue and poor sleep. (Id.) On December 9, 2005, Dr. Ritz reported that the sleep study results were normal. (Id. at 286.) A March 1, 2006 progress note indicates that Plaintiff returned to Dr. Ritz and complained of leg swelling and "burning up" and a lump on her leg. (Id. at 285.) On March 13, 2006, Dr. Ritz indicated that Plaintiff's leg pain, warmth and erythema had resolved and that her cellulitis had resolved. (Id. at 284.) On July 24, 2006, Dr. Ritz noted that Plaintiff was in the process of applying for disability. (Id. at 308.) She reported that any strenuous activity bothered Plaintiff's back, and said that she would need MRI exam results to look for evidence of nerve impingement. (Id.) On September 6, 2006, Dr. Ritz reported that Plaintiff continued to have terrible back pain, especially after packing up her things and painting the house. (Id. at 310.)

On May 31, 2008, Plaintiff went to the emergency room at Utica Medical Center and complained of cellulitis of her left lower leg. (Id. at 312.) She said that she was mowing the lawn and may have been bitten. (Id.) Dr. Ritz found that Plaintiff had erythema extending from the left ankle up the leg. (Id. at 313.) On October 15, 2008, Plaintiff visited Dr. Ritz because of her back pain. (Id. at 314.) Dr. Ritz found that she had normal posture, 5/5 normal muscle strength, a stiff gait, and limited range of motion in the lower extremities. (Id. at 315.)

Dr. Ritz wrote two letters concerning Plaintiff's condition and capacity for work prior to the ALJ hearing. In her September 6, 2006 letter, Dr. Ritz explained that Plaintiff takes Ibuprofen three to four times a day to cope with pain in her lower back and right leg. (Id. at 309.) Dr. Ritz also said that Plaintiff's inability to work "results from constant pain in her lower back radiating down her right leg and into her toes with activity. Her ability to sit is limited to 15 to 20 minutes, and her ability to stand is limited to 10 to 15 minutes." (Id.) Dr. Ritz also noted that Plaintiff has difficulty performing daily living activities due to her need to take frequent rest breaks to cope with her pain. (Id.) In her October 15, 2008 letter, Dr. Ritz said that Plaintiff's condition was gradually worsening as evidenced by Plaintiff's report of intensified chronic pain. (Id. at 318.) Dr. Ritz explained that, "[g]iven her difficulties in performing even simple tasks, Ms. Fieldhouse continues to be unable to work." (Id.)

Beginning on November 17, 2004, Fieldhouse received treatment from Roger Miller, a chiropractor. (Id. at 270.) During Plaintiff's consultation, Miller noted her complaints. (Id. at 267.) On December 29, 2005, Miller diagnosed Plaintiff with "possible lumbar disc herniation resulting in chronic sciatic radiculopathy." (Id. at 266.) Miller recommended that Plaintiff "have an MRI to rule out her sciatica / disc possibilities." (Id.) Miller opined that "it will be very difficult for [Fieldhouse] to do any occupation w/ her spinal disc problems w/o acute exacerbations." (Id.) In terms of his objective findings, Miller wrote, "see notes."*fn3 (Id.) On May 17, 2006, Miller diagnosed Plaintiff with "possible lumbar disc herniation w/ resultant sciatic radiculopathy and severe leg and back spasms." (Id. at 301.) Miller's objective findings included "subluxation L5-S1[,] sacroiliac dysfxn. Minor's sign, rigid @ L bilaterally." (Id.) Miller said that "Mrs. Fieldhouse is very restricted in her employment future. Lifting/bending will cause more damage. Sitting will also cause subjective sciatic exacerbations. A neurological exam is recommended." (Id.)

b. examining, non-treating physicians

On March 2, 2006, Plaintiff underwent a consultative internal medicine examination, performed by Dr. Phillip Budzenski ("Dr. Budzenski"). (Id. at 276.) Dr. Budzenski found that Plaintiff was able to bend over and attend to footwear without difficulty, and was able to get on and off the examination table without difficulty. (Id. at 277.) He reported that she ambulated with a mildly wide-based gait appropriate for body habitus, that her gait was not unsteady, lurching or unpredictable, and that she appeared comfortable in the seated and supine positions. (Id.) Dr. Budzenski's examination of Plaintiff's neck revealed no thromegaly, thyroid bruits, lymphadenopathy, or other palpable masses. (Id.) In terms of Plaintiff's chest, the doctor found that there was symmetrical excursion, no increased A/P diameter, and no accessory muscle use; however, he did find that the chest examination was notable for moderate mid-thoracic kyphosis. (Id.)

Dr. Budzenski noted that there were no venous stasis changes such as pigmentation, ulceration, or brawny edema. (Id. at 278.) He did find that Plaintiff exhibited a 3-plus pitting edema bilaterally, and that there was a mild diffuse redness associated with the skin in the leg below the knee on the right; there was no evidence for infection, and there was no excess heat generated from the site. (Id.) Dr. Budzenski also noted that Plaintiff was not wearing her recommended surgical stockings. (Id.)

Dr. Budzenski reported that examination of the cervical spine revealed no tenderness in the spinous processes or paravertebral muscle spasm. (Id.) He found that flexion of the cervical spine was limited to forty degrees, that extension of the cervical spine was limited to forty-five degrees, that lateral bend was preserved to forty-five degrees bilaterally, and that rotation was limited to seventy degrees bilaterally. (Id.) His examination of the dorsolumbar spine showed no apparent kyphosis or scoliosis; there was also no paravertebral muscle spasm or tenderness to palpation of the spinous processes. (Id.) Examination of the shoulders, elbows and wrists revealed no crepitus, tenderness, erythema, warmth, swelling ...


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