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Leah Myles v. Michael J. Astrue

September 4, 2012


The opinion of the court was delivered by: Hon. Maria Valdez United States Magistrate Judge

Magistrate Judge Maria Valdez


This action was brought under 42 U.S.C. § 405(g) to review the final decision of the Commissioner of Social Security denying Plaintiff Leah Myles' claim for Disability Benefits and Supplemental Security Income 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, Myles' motion for summary judgment [Doc. No. 21] is granted in part and denied in part. The Court finds that this matter should be remanded to the Commissioner for further proceedings.



On August 28, 2007, Plaintiff Leah Myles ("Plaintiff," "Myles," or "Claimant") filed an application for a period of disability and disability insurance benefits, as well as an application for supplemental security income. (R. 9.) Plaintiff alleged disability beginning August 9, 2007 due to mini-stroke, back pain, diabetes, suicidal ideation, depression, and arthritis in her back, wrists, and shoulders. (R. 169.) Plaintiff's claims were denied initially on December 13, 2007, and upon reconsideration on April 1, 2008. (R. 9.) On April 22, 2008, Plaintiff failed a timely request for a hearing. (Id.) Plaintiff, represented by counsel, testified at a video teleconference hearing held on January 29, 2010. (Id.) Also appearing and testifying at the hearing was an impartial vocational expert, Glee Ann Kehr. (Id.)

On February 19, 2010, the ALJ denied Plaintiff's claim and found her "not disabled" under the Social Security Act. (R. 16.) The Social Security Administration Appeals Council denied Plaintiff's request for review on May 26, 2011. (R. 1.) The ALJ's decision thus became reviewable by the District Court under 42 U.S.C. § 405(g), see Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005).


A. Plaintiff's Background and Testimony

Plaintiff was born on September 25, 1951, and was fifty-six years old on August 9, 2007, the date in which she claims her disability period began. (R. 135.) Plaintiff claims that chronic back pain, headaches, and other ailments have prevented her from working since July 2007. (R. 26.) Before Plaintiff's alleged disability onset date, she was a shipping specialist for a telecommunications company. (R. 170.) Plaintiff has been prescribed the following medications: Ambien, albuterol, amitriptyline, Altace, hydrocodone, fluoxetine, Lexapro, Lidoderm, metformin, nabumetone, Seroquel, clonazepam, citalopram, tizanidine, tramadol, and trazadone. (R. 174, 362-63.) Plaintiff has no medical insurance, (R. 31), and no unemployment insurance benefits. (R. 26.) Plaintiff receives food stamps and one hundred dollars per month from the state. (R. 25.) Plaintiff was evicted from her apartment and lives with her sister, (R. 34), does not own a car, (R. 25), and depends on her friends and siblings for much of her needs. (R. 25, 34-36).

Plaintiff testified that she worked as a shipping specialist for ten years before she quit because of her inability to perform her job duties. (R. 26.) Plaintiff's duties included picking, pulling and packing orders for customers, driving forklifts, and loading trucks. (Id.) Plaintiff claimed that she stopped working because the workload was too heavy and the hours were long. (R. 28.) She testified that she could not stand for long periods of time and lift seventy-five pounds regularly, as required by her position. (Id.)

Plaintiff explained that she lives with her sister. (R. 34.) When asked what household chores she is able to complete, Plaintiff said that she is able to cook and keep her room together. (R. 36.) Plaintiff testified that her brother and sister help her with most of the chores. (R. 32-37.) When asked what she does with most of her days, Plaintiff explained that she sleeps a lot because her medications put her to sleep. (R. 39.) Plaintiff also said that she "sits around" and "walks around the block." (R. 40.)

When questioned by her attorney, Plaintiff testified that she had suffered a stroke, and that a 2005 CAT scan taken of her brain revealed an abnormal signal.

(R. 43.) Plaintiff claimed that she experiences frequent headaches and regular migraine headaches. (Id.) Plaintiff testified that she has problems with her hips, and that she has problems with her back "everyday, all day." (R. 45.) Plaintiff also testified that she has arthritis through most of her body, (R. 47), she is regularly fatigued, (R. 48), she experiences shortness of breath, (R. 47), and she suffers from anxiety and depression. (R. 38).

B. Medical Evidence

On May 23, 2005, Plaintiff underwent a chest x-ray. (R. 275.) The results showed no abnormalities in the chest, as well as no active lesions in the lungs. (Id.) The heart, aorta, diaphragm, and hilus showed no significant abnormality. (Id.) On May 24, 2005, Plaintiff underwent computerized cranial tomography. (R. 277.) The results revealed that a small hypodense area in the right cerebellum had the appearance of an old lacunar infarction. (Id.) Because of the absence of previous examinations for comparison, follow-up studies, including magnetic resonance imaging (MRI) of the brain, was recommended. (Id.) On May 25, 2005, Plaintiff underwent an MRI of the brain. (R. 276.) A small area of abnormal signal was noted within the right cerebellar hemisphere. (Id.) The reporting physician, Dr. Thomas Hoess, reported that it may be due to an old infarct, trauma or infection. (Id.) On May 25, 2005, Plaintiff also underwent a Cardiolite Myocardial Perfusion Spect scan. (R. 273.) The examination revealed that both resting and post-stress images of the myocardium was unremarkable other than a slight breast artifact in the small anterior apical zone. (Id.) On February 7, 2006, an x-ray of Plaintiff's chest revealed that her heart was enlarged, her aorta "tortuous," and her lungs "essentially clear."

(R. 272.) Findings from a February 9, 2006 Cardiolite Myocardial Perfusion Spect scan were unremarkable "other than slight breast and bowel artifacts. Gated images demonstrate normal systolic myocardial thickening with a normal left ventricular ejection fraction of 57%." (R. 268.) On May 25, 2006, Plaintiff underwent an MRI of her hip. (R. 297.) The findings revealed that her osseous structures were intact at the time of the examination. (Id.) An April 24, 2007 bone density and vertebral assessment report indicates normal findings for Plaintiff's AP spine, femoral neck, total hip, total forearm, 1/3 forearm, and UD forearm, as well as normal findings for all of Plaintiff's vertebral levels. (R. 263.)

The record reveals that from January 25, 2005 until May 14, 2007, Plaintiff saw Dr. Debra Zack at St. Catherine Hospital. (See R. 226-62.) On April 8, 2005, Dr. Zack made note of Plaintiff's obesity, depression, fatigue, and anemia. (R. 260.) Dr. Zack prescribed Wellbutrin XL for Plaintiff's depression. (Id.) On May 4, 2005, Plaintiff complained of fatigue, and pain in her lower back, right hip, right thigh and groin. (R. 257.) Plaintiff claimed that the pain was constant. (Id.) Dr. Zack noted Plaintiff's back pain and reported that Plaintiff's Relafen prescription was "not working." (R. 258.) She also prescribed Cymbalta for Plaintiff's depression. (Id.) On September 9, 2005, Plaintiff complained of back pain. (R. 249.) Dr. Zack noted Plaintiff's obesity, anemia, and hyperlipidemia. (R. 250.) On October 14, 2005, Dr. Zack noted Plaintiff's hyperlipidemia, acute bronchitis, and asthma, and prescribed albuterol. (R. 248.) On January 20, 2006, Dr. Zack noted Plaintiff's asthma again.

(R. 246.) On April 14, 2006, Plaintiff complained of pain in her groin, hip and leg, and reported that she was "unable to stand." (R. 243.) On June 13, 2006, Plaintiff complained of weakness, headache, and vomiting. (R. 239.) On October 24, 2012, Plaintiff reported that her fatigue had improved. (R. 235.) On January 29, 2007, Plaintiff complained of leg pains as well as cold symptoms. (R. 231.) On May 14, 2007, Plaintiff reported stress and anxiety; she also explained that she had "no energy," and did not "feel like doing anything." (R. 229.) Dr. Zack noted Plaintiff's obesity, fatigue, hyperlipidemia, and referred Plaintiff to Dr. Arif based on Plaintiff's depression. (R. 230.)

From February 14, 2006 until April 13, 2007, Plaintiff saw Dr. Keith Reich. (See R. 282-88.) On February 14, 2006, Plaintiff complained of lower back pain, and right hip pain around the groin area. (R. 288.) Plaintiff also reported chest pain, breathing problems, stomach pain, joint pain, headaches, depression, anxiety, and anemia. (R. 289.) Dr. Reich noted that multiple co-morbid conditions, and diagnosed Plaintiff with rotator cuff tendonitis, diabetes, GERD, and anxiety. (R. 288.) Dr. Reich diagnosed physical therapy, increased socialization, and Ambien CR. (Id.) On May 23, 2006, Plaintiff complained of increased hip and groin pain, as well as vision problems, stomach pain, joint pain, headaches, depression, anxiety, and anemia. (R. 286-87.) Dr. Reich reported that Plaintiff had a flexion restriction on her right hip, and determined that Plaintiff "needs to see a pain specialist" because her Vicodin intake could lead to liver damage. (R. 286.) Dr. Reich also referred Plaintiff for an MRI to check for bursitis and indicated that Plaintiff may need physical therapy or injections for pain. (Id.) On September 6, 2006, Plaintiff reported that she was experiencing "a lot of pain." (R. 285.) Plaintiff also reported problems with stomach pain, joint pain, headaches, depression, and anemia. (Id.) On April 13, 2007, the doctor reported that Plaintiff suffered from multiple joint pain, arthritis, and muscle pain and spasms. (R. 283.)

Plaintiff attended therapy sessions at Daybreak Behavioral Health Clinic at St. Catherine's Hospital from May 31, 2007 until July 31, 2007. (See R. 300-13.) She saw Ms. Carmen Rodriguez, a therapist, and Dr. A. Arif, a psychiatrist. (Id.) A May 15, 2007 progress report notes Plaintiff's anxiety attacks, insomnia, diabetic attacks, tearfulness, and depression. (R. 305.) A May 21, 2007 progress report notes Plaintiff's fatigue, (R. 304), and a June 4, 2007 progress report notes Plaintiff's extensive crying, "significant depression," and suicidal ideation. (Id.) On May 31, 2007, Ms. Rodriguez reported that Plaintiff was well-groomed, had a normal gait, that her thought process was goal directed, and that her thought content was appropriate. (R. 313.) Ms. Rodriguez also reported Plaintiff's depressed mood, flat affect, mild anxiety, and emotional and "very tearful" communication. (Id.) Ms. Rodriguez noted that Plaintiff denied being either suicidal or homicidal. (Id.) On June 4, 2007, Plaintiff complained of a very bad headache. (R. 312.) Plaintiff explained that she had suffered from headaches for as long as she could remember. (Id.) Plaintiff also complained about stress caused by her work and about her difficulty with her sleep patterns. (Id.) Ms. Rodriguez noted Plaintiff's depressed mood, flat affect, mild anxiety, and tearfulness. (Id.) On June 15, 2007, Plaintiff complained that she had no energy. (R. 311.) Ms. Rodriguez noted Plaintiff's depressed mood, flat affect, moderate anxiety, and emotional speech. (Id.) On June 26, 2007, Dr. Arif diagnosed Plaintiff with major depressive disorder, anxiety, and insomnia. (R. 302.) A July 16, 2007 progress report notes Plaintiff's daytime grogginess and fatigue. (R. 303.) On July 17, 2007, Dr. Arif reported that Plaintiff was experiencing nightmares, and that Plaintiff still had "anxiety / depression, but less." (R. 301.) On July 19, 2007, Plaintiff reported that she was very sleepy. (R. 309.) Ms. Rodriguez noted Plaintiff's depressed mood, flat affect, mild anxiety, and reported that Plaintiff seemed tired and in pain. (Id.) On July 31, 2007, Dr. Arif reported Plaintiff's continued nightmares, acute anxiety, poor sleep, and increased stress at work. (R. 300.) On August 6, 2007, Plaintiff explained that she was "struggling with a lot of fatigue now." (R. 306.) Plaintiff also reported that it was very difficult for her to cope with the pressure she feels at work. (Id.) Ms. Rodriguez noted Plaintiff's depressed mood, flat affect, and mild anxiety. (Id.) Ms. Rodriguez also noted that Plaintiff was tired. (Id.)

On November 13, 2007, Dr. B. Saavedra performed a consultative examination of Plaintiff. (See R. 322-26.) Dr. Saavedra noted that Plaintiff was fifty-six years old and had experienced a mini-stroke about a year and a half prior to the examination. (R. 322.) She recounted Plaintiff's complaints of "constant headaches, tingling in fingers, shortness of breath, and tightness in the chest." (Id.) The doctor also mentioned that Plaintiff began experiencing back pain in 2000 when "she was thrown off a machine and landed on her back." (Id.) She reported that x-rays taken of Plaintiff's back and hip revealed a bulging disc and a hairline fracture in her right hip. (Id.) Dr. Saavedra reported that Plaintiff underwent physical therapy on and off from 1995 to 2005 and had received three injections with no relief. (Id.) The doctor also reported that Plaintiff had been diagnosed with diabetes and was prescribed oral medication, but Plaintiff was "unable to buy it at this time." (Id.) The doctor ...

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