United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
SIDNEY I. SCHENKIER, Magistrate Judge.
Plaintiff Beani Conner has filed a motion seeking reversal or remand of a determination by the Commissioner of Social Security ("Commissioner") denying her Disability Insurance Benefits ("DIB") (doc. # 12). The Commissioner has filed a cross-motion for summary judgment seeking to affirm the denial of benefits (doc. # 17). For the following reasons, we grant Ms. Conner's motion for remand and deny the Commissioner's motion.
We begin with the procedural history. On March 18, 2008, Ms. Conner applied for disability insurance benefits, alleging disability beginning October 1, 2003 (R. 127-32, 134). Her application was denied initially on August 15, 2008, and upon reconsideration on January 20, 2009 (R. 78-79, 80-84, 87-90). She requested a hearing before an administrative law judge ("ALJ"), which was granted, and held subsequently on January 26, 2010 (R. 92-97, 38). At the hearing, Ms. Conner amended her onset date to October 31, 2006 (R. 43). On April 28, 2010, the ALJ issued a decision finding that from October 31, 2006 to December 31, 2008, the date last insured, Ms. Conner was not disabled under the Social Security Act ("the Act") (R. 21-33). The Appeals Council denied Ms. Conner's request for review (R. 1-6), making the ALJ's decision the final decision of the Commissioner. See Shauger v. Astrue, 675 F.3d 690, 695 (7th Cir. 2012).
We next review a brief background, a summary of the medical records during the relevant time period, Ms. Conner's hearing testimony, and the ALJ's written decision.
Ms. Conner was born on February 1, 1972 (R. 127). She has a bachelor's degree (R. 44). She worked as a benefits administrator for an insurance company from 1995 to 1998 (R. 46-47, 149). Ms. Conner had also worked part-time designing jewelry and selling Tupperware (R. 45-46). She has not worked since at least October 2006 due to "overwhelming fatigue, " "a lot of muscle pain, " and "brain function issues" (R. 48-49).
Ms. Conner was involved in two car accidents in September 2001 and June 2002 (R. 208). Between October 2002 and November 2004, she sought treatment from Dr. Bruce Montella, an orthopedic surgeon, for neck pain, headaches, and low back pain (R. 186-195, 201-08), and in April 2003, she was diagnosed with fibromyalgia by Dr. Kathryn Eubanks (R. 198).
In November 2006, Dr. David Edelberg became Ms. Conner's primary care physician, and at her initial visit, Ms. Conner complained that she had constant pain in her head, neck, upper back, knees, and right hip; pain limited her range of motion such that she could not raise her arms; and her shoulders went into spasms when she reached (R. 275). Ms. Conner also stated that she had fatigue, non-refreshing sleep, and brain fog (R. 276). She reported that she had taken Lexapro, which helped slightly, and Flexeril, which was not helpful (R. 275). Dr. Edelberg noted that she had full range of motion in her extremities (R. 276). He also found that 18 out of 18 tender points on Ms. Conner were "very painful to 4.4 kg of fingertip pressure" (R. 277). Dr. Edelberg opined that Ms. Conner had "manifestations of low serotonin disorder, " including depression and fibromyalgia ( Id. ).
From 2006 through 2010, Ms. Conner continued to see Dr. Edelberg regarding her fibromyalgia (R. 270-74, 336-40, 352). On November 29, 2006, Ms. Conner told Dr. Edelberg that Cymbalta and Vicodin had helped manage her pain, but that a Duragesic pain patch had caused nausea (R. 274). Dr. Edelberg prescribed a trial of Oxycontin with Vicodin for break-through pain ( Id. ). Ms. Conner told Dr. Edelberg that she was sleeping better, but she had been having lower back and pelvic pain during the prior six months that had escalated in the previous two weeks ( Id. ). Dr. Edelberg referred her to a general surgeon and prescribed physical therapy for her low back pain ( Id. ).
On January 10, 2007, Ms. Conner reported that her pain was about the same, and she was "quite tired" (R. 273). She had not started the Oxycontin because she had contracted the flu after the first dose, but that she intended to start it at that time ( Id. ). On June 5, 2007, Dr. Edelberg noted that Ms. Conner's "pain ha[d] been helped but not completely relieved by current dose of Oxycontin" (R. 272). Her fatigue was improved but her depression was "situational" ( Id. ). Dr. Edelberg increased her doses of Oxycontin and Cymbalta and prescribed a trial of Adderall XR ( Id. ).
On July 6, 2007, Ms. Conner visited Dr. Uzoma Okoli, a psychiatrist, with the chief complaint of depression (R. 228). At this examination, Ms. Conner reported feelings of sadness, excessive worrying, anhedonia, loss of energy, appetite loss, disrupted sleep, and difficulty concentrating ( Id. ). She admitted to having had thoughts of suicide two weeks prior to the visit ( Id. ). Dr. Okoli noted that Ms. Conner was coherent, fully communicative, and that her language skills were intact, but that she had signs of moderate depression and her demeanor was sad (R. 229). Further, Ms. Conner's short and long-term memory were intact, and she had the ability to abstract and do arithmetic calculations ( Id. ). Dr. Okoli diagnosed Ms. Conner with "major depressive disorder, recurrent, " and prescribed Effexor and Klonopin ( Id. ). In a follow-up visit on July 30, 2007, Dr. Okoli noted that Ms. Conner had not yet responded to treatment, though she had not started the Effexor as recommended and wanted to go back on Lexapro (R. 230). Dr. Okoli maintained the same diagnosis and prescribed Klonopin and Lexapro ( Id. ).
At an April 7, 2008 appointment with Dr. Edelberg, Ms. Conner reported that her fibromyalgia pain was "good and bad: so much better on the medication, " but "very (very!!)" severe without it (R. 270). Eighteen out of eighteen points on her body remained very tender, and Dr. Edelberg increased her dose of Oxycontin to 30 mg every 12 hours, with three Vicodin a day ( Id. ). With regard to her fatigue and depression, Ms. Conner reported that she was "doing better" on Lexapro and did not want to increase her Adderall XR prescription because of side effects ( Id. ). Ms. Conner complained that she had "increased pain in the small joints of the hands, knees and feet, " though a joint exam was negative ( Id. ). Dr. Edelberg noted that she might have inflammatory arthritis ( Id. ). Ms. Conner described continuing insomnia, with Lunesta helping but sometimes failing to remain effective throughout the night ( Id. ).
In connection with Ms. Conner's social security application, a number of state agency consultants opined on her physical and mental condition. On July 7, 2008, Dr. Scott Kale, an internist, conducted a physical examination of Ms. Conner for the Bureau of Disability Determination Services ("DDS"); Dr. Kale reported that he "spent 38 minutes with this claimant reviewing forms, formulating and dictating the evaluation report" (R. 282-85). Ms. Conner told Dr. Kale that she had such severe fatigue and fibromyalgia tenderness that even showering inflicted pain (R. 283). Dr. Kale noted that Ms. Conner's cervical spine, shoulder, elbow, wrist, and finger motion were normal, she had 5/5 grip strength, and she had no clubbing, cyanosis, or edema in her extremities (R. 284). Ms. Conner was able to stand up from a chair using both hands; she could stand on her heels and toes; and her gait was not antalgic ( Id. ). Ms. Conner had no atrophy, and her range of motion in her knees, ankles and hips was normal ( Id. ). In her lumbar spine, Ms. Conner had 50/60 flexion, 20/25 extension, and 20/25 lateral bending ( Id. ). Dr. Kale observed that Ms. Conner had tenderness in 18/18 tender points, fibromyalgia, hypertension, and "[f]ibro-fog by report, but no apparent cognitive abnormalities on examination" (R. 284-85).
On July 18, 2008, DDS physician Dr. Francis Vincent completed a residual functional capacity ("RFC") assessment of Ms. Conner based on Dr. Kale's examination, but without any treating or examining source statements (R. 287-94). Dr. Vincent opined that Ms. Conner could occasionally lift and/or carry twenty pounds; frequently lift and/or carry ten pounds; and stand, walk, or sit about six hours in an eight-hour workday, with an unlimited ability to push or pull and no postural, manipulative, or environmental limitations (R. 288-91). Dr. Vincent relied on Dr. Kale's findings that although Ms. Conner had 18/18 tender points and pain in her hands and knees, she had normal range of motion in all her joints with no atrophy, grip strength of 5/5, and normal gait ( Id. ). Dr. Vincent deemed Ms. Conner's allegations "partially credible" and stated that he had taken her pain into consideration ( Id. ). On January 15, 2009, Dr. Towfig Arjmand, a DDS medical consultant, reviewed the record and affirmed Dr. Vincent's RFC assessment, finding Ms. Conner capable of work at the light exertional level (R. 333-35).
On August 4, 2008, another state agency consultant, Michael Stempniak, Ph.D., a clinical psychologist, conducted an in-person psychological examination of Ms. Conner (R. 296-300). Ms. Conner reported that her relationship with her husband was strained because he wished to return to a church, which she believed was a cult (R. 297). Ms. Conner also stated that her sleep was not very good and she had previously had thoughts about suicide, but that she had taken no action and had no intentions (R. 298). Dr. Sternpiak noted that Ms. Conner was oriented and that her memory was in the ...