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Stephanie D. Watts v. Michael J. Astrue

August 1, 2012

STEPHANIE D. WATTS, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Byron G. Cudmore, U.S. Magistrate Judge:

E-FILED Wednesday, 01 August, 2012 03:52:55 PM Clerk, U.S. District Court, ILCD

OPINION

Plaintiff Stephanie Watts appeals from the denial of her application for Social Security Disability Insurance Benefits and Supplemental Security Income (collectively "Disability Benefits") under Titles II and XVI of the Social Security Act. 42 U.S.C. §§ 416(i), 423, 1381a, and 1382c. This appeal is brought pursuant to 42 U.S.C. §§ 405(g) and 1383(c). Watts has filed her Motion for Summary Judgment (d/e 15), and Defendant Commissioner of Social Security has filed a Motion for Summary Affirmance (d/e 17). The parties consented, pursuant to 28 U.S.C. § 636(c), to have this matter proceed before this Court. Consent to Proceed Before a United States Magistrate Judge, and Order of Reference entered October 14, 2011 (d/e 6). For the reasons set forth below, the decision of the Commissioner is affirmed.

STATEMENT OF FACTS

Watts was born on September 2, 1985. She has a tenth grade education and has worked as a personal assistant and a produce worker. She last engaged in substantial gainful activity in August 2008. After that time, she worked briefly part time as a cleaner in a elderly care home in May 2009. Answer to Complaint (d/e 12), attached Certified Copy of Transcript of Record of Proceedings (R.), at 53, 89.

Watts suffers from severe headaches. On August 22, 2007, Watts went to Blessing Hospital in Quincy, Illinois, complaining of headaches accompanied by nausea and vomiting. R. 363. She reported that she smoked. R. 363. Watts underwent CT scans on June 20, 2007, and August 21, 2007. Both showed a suspicious lesion in her brain. R. 363, 371. Watts told doctors that she had suffered from bad headaches since grade school. R. 365. She reported that she dropped out of school in the eighth grade. R. 365. An MRI without contrast showed no acute intra cranial process and did not reveal any major complications. R. 366, 368, 371. The emergency room doctors recommended an MRI with contrast. Watts declined and left the hospital on August 24, 2007, against medical advice. R. 368.

On September 8, 2008, Watts went to the emergency room at Pike County Memorial Hospital in Louisiana, Missouri, for headaches. R. 420-25. The diagram in the notes on September 8, 2008, showed the headache located on right side of the back of her head. She was advised to quit smoking. R. 421. The emergency room doctor instructed Watts to see a neurologist. R. 421. On September 9, 2008, the emergency room doctors administered migraine medication. Watts reported feeling better and was released. R. 424-25.

On September 13, 2008, Watts went to the Pike Medical Clinic in Louisiana, Missouri, for severe, chronic headaches. R. 374. She reported that she has been having headaches for three years. Watts reported that she had been scheduled to see a neurologist in January 2008, but did not go because she was managing her headaches on her own with Vicodin. The Clinic physician prescribed Nubain/Phenergan and Predniane and referred Watts to a neurologist. R. 374.

On September 20, 2008, Watts went to the emergency room at Pike County Memorial Hospital. She complained of a headache that had lasted for three days. R. 413. The diagram in the notes showed that the headache was on the right front side of her head and across the back of her head in the area above the ears. R. 415. She reported that she had scheduled an appointment with a neurologist. The emergency room doctor gave her an injection of Nubain, directed her to stay on her current medications, and released her. R. 417-18.

On September 22, 2008, she returned to the Pike Medical Clinic complaining of headaches. She reported that the medication was not working. The notes state that she must keep the scheduled appointment with the neurologist. Fioricet with codeine was added to her medication. R. 373.

On September 23, 2008, Watts went to the emergency room at Pike County Memorial Hospital again complaining of headaches. R. 384. She was again advised to quit smoking. A CT scan with and without contrast showed a nonenhancing hypodensity in the brainstem, which had not changed from previous studies in 2007. R. 392, 570. Watts left the emergency room against medical advice after refusing IV medication treatment for her headaches. R. 382.

On October 6, 2008, Watts went to see neurologist Dr. Cecile Becker, M.D., at Springfield Clinic in Springfield, Illinois. Watts complained of daily migraine headaches, dizziness, nausea, vomiting, sense sensitivity, right-eye blurry vision, and burning on the right side of her face. R. 570. The neurological assessment was normal. R. 571-72. She was counseled to discontinue caffeine and smoking. She was given prescriptions for Verapamil and Isometheptene. Dr. Becker recommended an MRI scan. R. 572. No MRI was performed at that time.

On December 30, 2008, Watts underwent a consultative psychological evaluation with a clinical psychologist, Dr. Frank Froman, Ed.D. R. 578-81. Watts told Dr. Froman that she dropped out of school her freshman year of high school. She reported that she was a "hell raiser" as a teenager who drank excessively. She reported that she had now settled down and no longer drank alcohol. She reported that she currently suffered from daily headaches. R. 578. She reported that she used no medication at the time because she could not afford them. R. 578. She reported that she could neither read nor write. R. 580. Dr. Froman opined that Watts was unlikely to be able to perform one and two-step assemblies at a competitive rate; she had minimal ability to relate adequately to co-workers and supervisors; she could understand oral instructions but not written ones; and she could withstand minimal stress associated with the work she was performing as a home health care worker. Dr. Froman opined that if she found a way to manage her headaches, she could expand her range of work. R. 580.

On July 29, 2009, Watts saw Dr. Joseph Kozma, M.D., for a consultative examination. R. 603-08. Watts reported frequent headaches that she has been having for at least a year. Watts reported that she was not taking any medication at the time of the examination. R. 603.

Dr. Kozma's examination was unremarkable, including the fact that he found no neurological deficits. R. 604-07. Dr. Kozma diagnosed Watts with mixed-type headaches, possibly predominantly migraine type but also tension headaches. R. 607-08.

On September 7, 2009, Watts went to the Illini Community Clinic in Pittsfield, Illinois. R. 649. The diagram in the notes showed that the headache was on the front of the right side of her head. R. 654. Watts was treated and released. R. 651-52.

On October 27, 2009, she returned to the Illini Community Clinic complaining of headaches. The diagram in the notes showed that the headache was on the front of the left side of her head. R. 675. She was given injections of Nubain and Phenergan and reported that her headache pain was resolved. R. 673.

On October 28, 2009, Watts went to the Pike County Hospital in Pittsfield, Illinois, for headaches, sinus congestion, and nausea. R. 717. Watts reported headaches on the left side of her head. R. 722. She reported that the pain started the day before on October 27. She was given Demerol, Zofran, Augmentin, Benadryl, Zyrtec, Flonase, and Ultram and released. R. 720-21.

On December 4, 2009, Watt's primary care physician Dr. Casey Jennings, M.D., completed a form entitled Headaches Residual Functional Capacity Questionnaire (R. 680-85). Dr. Jennings reported that he was her primary care physician since August 2007. He stated that he had seen Watts approximately four times a year. He stated that Watts had daily headaches. He stated that the approximate duration of her headaches was four years. R. 681. He stated that Watts was diagnosed with migraine headaches and an unspecified brain lesion. He stated that further imaging was needed for a diagnosis. He stated that she was taking Ibuprofen for her headaches at the time that he completed the questionnaire. He opined that she could not work while she had a headache. He opined that she would need unscheduled breaks once a day when she had headaches and the breaks ...


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