KRYSTAL L. GOINS, Plaintiff,
CAROLYN W. COLVIN,  Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER
JEFFREY COLE, District Judge.
Plaintiff, Krystal Lynn Goins ("Ms. Goins"), seeks review of the final decision of the Commissioner ("Commissioner") of the Social Security Administration ("Agency") denying her application for Supplemental Security Income ("SSI") under Title XVI, Section 1614(a)(3)(A) of the Act. Ms. Goins asks the court to reverse the Commissioner's decision and award benefits, or remand the decision for further proceedings. The Commissioner, in turn, seeks an order affirming the decision.
On November 28, 2008, Ms. Goins applied for SSI benefits, claiming that she became disabled on November 1, 2007, due to lower back pain. (Administrative Record ("R.") 204-206). On January 15, 2009, the Commissioner denied her application. (R. 93-98). On February 9, 2009, Ms. Goins filed a request for reconsideration. (R. 98-99). On April 22, 2009, Ms. Goins' request was denied. (R. 104-108).
On May 29, 2009, Ms. Goins requested an evidentiary hearing before an administrative law judge (R. 108-109). On October 4, 2010, administrative law judge Roxanne Kelsey ("ALJ") held an evidentiary hearing. (R. 36-80). At the hearing, attorney Edward Grossman represented Ms. Goins. (R. 36-80). Ms. Goins and vocational expert Julie Bose ("Ms. Bose") testified at the hearing. (R. 36-80).
On October 25, 2010, the ALJ found Ms. Goins to not be disabled and denied the claim. (R. 18-35). On December 2, 2010, Ms. Goins filed for a review of the hearing decision with the Social Security Administration's Appeals Council. (R. 15-17). On April 9, 2012, the Appeals Council denied the request for review. (R. 1-6). Thus, the ALJ's October 25, 2010 decision stands as the Commissioner's final decision. See 20 C.F.R. §§ 404.955; 404.981.
Ms. Goins appealed that decision to the federal district court under 42 U.S.C. § 405(g), and the parties have consented to the jurisdiction of a Magistrate Judge pursuant to 28 U.S.C. § 636(c).
The Vocational Evidence
Ms. Goins was born on April 7, 1981, making her twenty-nine years old at the time of the ALJ's decision. (R. 204). She lives in her father's house with her boyfriend in Lansing, Illinois. (R. 205, 59). She is 5'6" tall and weighs 220 pounds. (R. 249). Ms. Goins has a high school education and is able to speak, write, and understand English. (R. 249). She also completed a cooking and hospitality program in 2007 and received her associate's degree. (R. 41-42). She worked as a retail sales clerk, as a pharmacy technician, as a telemarketer, and as a caterer at the Loyola University Medical Center Human Resources. (R. 44-45). Ms. Goins explained that the catering position required her to stand on her feet for eleven or twelve hours each day and to constantly carry food that was fifty pounds or heavier. (R. 42-43). She added that she stopped working there because she could not stand for that long and because her doctor advised her not to go back. (R. 43). She has not worked since 2008. (R. 44).
The Medical Evidence
On October 13, 1998, Ms. Goins underwent a magnetic resonance imaging ("MRI") of her lumbar spine at Oak lawn MR & Imaging Center. (R. 315). The MRI revealed a small, right paracentral disc protrusion at L5-S1. (R. 315).
On November 3, 2007, Ms. Goins went to the emergency room at Oak Forest Hospital of Cook County (R. 316-321) where she complained of headache and low back pain. (R. 316-321). The report showed that Ms. Goins had a headache for four days and low back pain for a few days with a history of herniated disc. (R. 318). She was discharged that day and prescribed Vicodin. (R. 318).
On September 4, 2008, Ms. Goins visited her primary physician, Dr. Suneela Harsoor (Dr. Harsoor"), M.D. (R. 326). Again, she complained of significant lower back pain. (R. 326). Specifically, she stated that the pain is "burning and shooting in nature" and was constant. (R. 326). She described the pain as a 5 to 10 out of 10. She added that the pain is partially relieved by resting, but aggravated by any movement, change in position, standing, sitting, or walking. (R. 326).
Dr. Harsoor then completed a report conforming Ms. Goins' pain, but noting that on examination, Ms. Goins is able to walk with a slow guarded gait, is able to balance well on tiptoes and heels. Her lungs had clear breath sounds. There was mild paraspinal muscle tenderness and stiffness. There was no sacroiliac tenderness. There was a well-healed scar from liposuction in the abdomen. There were no other signs of inflammation. Her range of motion of the lumbar spine was normal. Her straight leg raise test was positive on the left at 60 degrees and on the right at 50 degrees. Her Patrick's test was negative. An examination of the lower extremities and sensation was normal. Her muscle strength was 5/5. Her tendon reflexes were 2. Her pulses were normal. (R. 326-327).
The report also confirmed the MRI of the lumbar spine that Ms. Goins underwent in October 1998. (R. 327). It also noted that Ms. Goins is currently taking Vicodin, which she received in November 2007 at the emergency room. (R. 326).
Dr. Harsoor made a diagnosis of lumbar disk herniation, lumbar radiculopathy, and myofascial pain. (R. 327). He then recommended conservative treatment and prescribed Lyrica and noted that the efficacy of epidural steroid injections will depend on Ms. Goins' response to the medication. (R. 327).
On that same day, September 4, 2008, Dr. Harsoor completed a nerve and hyper conduction study of Ms. Goins. (R. 339). The nerve conduction revealed impaired conduction of right L5 peroneal nerve very severe, bilateral S1 sural nerve marked and right S2 post femoral cutaneous nerve mild. (R. 339). Her hyper conduction testing showed bilateral L1 upper lumbar nerve -1 hyper and left L4 saphenous nerve -1 hyper. (R. 339).
On November 13, 2008, two months later, Ms. Goins returned to Dr. Harsoor's office and received a refill on Lyrica. (R. 345). During that visit, Dr. Harsoor encouraged home exercises. (R. 345). On September 11, 2009, claimant had an epidural steroid injection in the lumbar spine. (R. 348). On December 1, 2008 Dr. Harsoor submitted a letter stating that Ms. Goins is under his care for lower back and is unable to work due to lumbar disc protrusion. (R. 354).
On January 14, 2009, at the request of the Illinois Disability Determination Services ("DDS"), Dr. Reynaldo Gotanco ("Dr. Gotanco"), a State agency medical consultant, reviewed Ms. Goins' medical record and performed a physical residual functional capacity ("RFC") assessment. (R. 355-362). He found that Ms. Goins could occasionally lift fifty pounds and frequently lift twenty-five pounds. (R. 356). He also found that Ms. Goins could stand and/or walk (with normal breaks) for about six hours in an eight hour workday, and sit (with normal breaks) for about six hours in an eight hour workday. (R. 356).
On April 20, 2009, Dr. Virgilo Pilapil ("Dr. Pilapil"), M.D., another state agency medical consultant, reviewed Ms. Goins' medical history. (R. 362). Dr. Pilapil then affirmed Dr. Gotanco's RFC determination. (R. 365). He questioned the severity of Ms. Goins' allegations. (R. 365). Specifically, he noted that Ms. Goins reported worsening problems as of January 1, 2009 in that she cannot sit or stand for long and that she uses her cane more often. (R. 365). However, Dr. Pilapil noted that despite this claimed worsening condition, Ms. Goins continued to have no new medical evidence or treatment for it. (R. 365). Therefore, Dr. Pilapil found that Dr. Gotanco's opinion to be consistent with his own findings. (R. 365).
Other hospital visits
On February 3, 2010 Ms. Goins went to John H. Stroger Hospital. (R. 367-373). Her extremity examination showed no edema. (R. 367). She had tenderness in the thoracic spine with negative straight leg rising bilaterally. (R. 367). She had positive signs of leg weakness. (R. 367). She had 4/5 strength in the left lower extremity. (R. 367). She was referred to neurosurgery and physical therapy. (R. 369.) Her diagnosis at discharge was lumbar back pain. (R. 368)
On March 10, 2010, Ms. Goins presented at John H. Stroger Hospital for a second time. (R. 375). There, she underwent MRIs of her lumbar and cervical spines. (R. 375-379). The MRI of her cervical spine revealed mild multilevel degenerative disc disease and degenerative facet arthropathy, and a Chiari I malformation. (R. 376). MRI studies of the lumbar spine showed multilevel degenerative disc disease and degenerative facet arthropathy. (R. 378). There was L4-L5 circumferential disc bulge with posterocentral disc protrusion and partial posterior annular fissure effacing central thecal sac and abuts bilateral proximal L5 transversing nerve roots. (R. 378). The measurement of the central spinal canal reflected stenosis. (R. 378). There was L5-S1 diffuse posterior disc bulge with large posterocentral disc protrusions partially effacing ventral thecal sac and abuts bilateral proximal S1 transversing nerve root sleeves. (R. 378). The measurements of central spinal canal reflect stenosis. (R. 378).
The Administrative Hearing Testimony
The Plaintiff's Testimony
On October 4, 2010, ALJ Roxanne Kelsey convened a hearing, at which Ms. Goins, represented by counsel, appeared and testified. At the hearing, the ALJ inquired first about Ms. Goins' education and work experience. Ms. Goins testified that she graduated high school and completed a cooking and hospitality program and received an associate's degree. (R. 41-42). When asked why she was not working in that field, she stated that it was because of the long hours standing. (R. 42). Specifically, she stated that her last position was at a catering department at Loyola University Medical Center Human Resources. (R. 44-45). She explained that the catering position required her to stand on her feet for eleven or twelve hours each day, and to constantly carry food that were fifty pounds or heavier. (R. 42-43). She added that she stopped working there because she could not stand for that long and because her doctor advised her not to return to that job. (R. 43).
When asked if she worked after she became disabled in November 2007, Ms. Goins said "no." (R. 43). She stated that she became disabled around the time she worked at Loyola. Therefore, she added that if she worked at Loyola in 2008, she became disabled in November 2008. (R. 43).
She testified that she worked at Loyola from July 2008 to November 2008. (R. 44). When asked if she worked there on a full-time basis, she answered "no." (R. 44). She stated that at Loyola, although "everybody has to start part-time... her hours were definitely full-time." (R. 44).
Ms. Goins also testified about her previous positions as a retail sales clerk, as a pharmacy technician, and as a telemarketer. (R. 45). She testified that the retail sales clerk position, which she worked from 2003 to 2007, was seasonal. (R. 46.). When asked whether she knew what to do in that position, how to handle the questions, or how to direct people, Ms. Goins answered in the affirmative. (R. 46). But she stated "that was before I hurt myself definitely." (R. 46).
Regarding Ms. Goins' pharmacy technician position, she testified that she probably worked there for a year. (R. 46). She testified that she was not interested in pursuing that path as a career, and that she was not certified. (R. 46). Regarding her position as a telemarketer, she testified that she probably held that position for six months. (R. 47). When asked whether she sat down when she was doing that job, Ms. Goins said "yes." (R. 47). Ms. Goins stated she quit because she wanted to go to school. (R. 47).
Next, the ALJ inquired about Ms. Goins' impairments. Ms. Goins testified that she suffered from pain in her neck and lower back. (R. 48). The pain shot down to her foot on the left and right side. (R. 48). She also experienced numbness in her face and in her right arm from the shoulder to the elbow. (R. 48). She also had migraine headaches and panic attacks. (R. 48). When asked whether she had seen a doctor for her migraines and panic attacks, Ms. Goins said "yes." (R. 48). At that time, however, the ALJ noted that there were no records of treatment for the headaches and panic attacks. (R. 49). However, Ms. Goins conceded that she was given Xanax for her panic attack when she ...