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Jones v. Colvin

United States District Court, N.D. Illinois, Eastern Division

May 30, 2014

CAROLYN W. COLVIN, Acting Commissioner of Social Security Administration, Defendant.


MICHAEL T. MASON, Magistrate Judge.

Claimant Shauntel Jones ("Jones" or "claimant") brings this motion for summary judgment seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner"). The Commissioner denied Jones's claim for Supplemental Security Income ("SSI") under Section 1614 of the Social Security Act (the "Act"). 42 U.S.C. § 1382c(a)(3)(A). This Court has jurisdiction to hear this matter pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). For the reasons set forth below, claimant's motion for summary judgment [10] is granted and this case is remanded for further proceedings consistent with this opinion.

I. Background

A. Procedural History

Claimant applied for SSI benefits on January 15, 2009. (R. 160.) She alleges that she has been disabled since January 1, 2005, due to asthma, tendinitis of muscles and joints, depression, anxiety, headaches, memory loss, allergies, sinuses, joint and back pain, insomnia, and anemia. (R. 102, 160-62.) The claim was initially denied on March 30, 2009, and upon reconsideration on October 9, 2009. (R. 79, 81.)

On December 1, 2009, claimant filed a written request for a hearing. (R. 103.) Jones appeared and testified at a hearing before Administrative Law Judge ("ALJ") Jose Anglada on September 24, 2010. (R. 37.) Richard Hamersma, a vocational expert ("VE"), also testified at the hearing. ( Id. ) On November 29, 2010, ALJ Anglada issued an opinion finding that claimant was not disabled under the Act. (R. 94.)

On January 18, 2011, Jones filed a request for a review of the ALJ's decision. (R. 159.) On May 21, 2012, the Appeals Council initially denied claimant's request. (R. 1-3.) On October 18, 2012, the Appeals Council set aside its May 21, 2012 denial to consider additional information. (R. 5-8.) The Appeals Council subsequently found no reason to review the ALJ's decision after considering that information, and again denied Jones's request for review. (R. 1-3.) Claimant then filed this action in the District Court. The parties consented to the jurisdiction of this Court on July 21, 2013 [18] pursuant to 28 U.S.C. § 636(c).

B. Medical Evidence

1. Treating Physicians

a. Dr. Kanayo Odeluga

In July of 2008, Jones began seeing Dr. Kanayo Odeluga for joint pain and pain in her hands. (R. 307.) Dr. Odeluga diagnosed claimant with multiple joint pain, asthma, rheumatoid arthritis, and depression, and he prescribed various medications. ( Id. ) On September 19, 2008, Jones visited Dr. Odeluga for a follow-up visit, and he diagnosed her with asthma. (R. 306.) Dr. Odeluga prescribed Diflucan and Effexor, and noted that he would refer claimant to a rheumatologist when she is ready. ( Id. )

Dr. Odeluga performed an independent medical evaluation of claimant on March 13, 2009. (R. 311-20.) At that time, Jones complained that her low back pain began a few years prior and had worsened in the last two years. (R. 311.) Jones described the pain as "sharp, constant, and moderate in intensity, " and reported that the pain is exacerbated by walking, lying down, bending, lifting, and doing household chores. ( Id. ) Jones also complained of tremors, headaches, numbness in both her hands and feet, asthma and wheezing. (R. 312.) She told Dr. Odeluga that she obtains brief relief with Tramadol and Naprosyn. (R. 311.)

Dr. Odeluga's evaluation noted that Jones was an obese female who weighed 196 pounds and was 64 inches tall. (R. 312.) Dr. Odeluga performed a musculoskeletal examination and found that claimant's spine was normal and that she had a full range of motion. (R. 313.) Dr. Odeluga noted spinous and paraspinal tenderness over the lumbar segment. ( Id. ) Dr. Odeluga examined claimant's upper and lower extremities and found no anatomic deformity, swelling, stiffness, effusion, skin discoloration, or increased skin warmth. ( Id. ) Dr. Odeluga also found that claimant had full range of motion in each joint and grade 5/5 strength in all major muscle groups. ( Id. ) Claimant also had negative straight leg raises on both lower extremities. ( Id. ) Dr. Odeluga noted that Jones had no difficulty with getting on and off the exam table, tandem walking, walking on toes, walking on heels, or hopping. (R. 314.) She did have mild difficulty squatting. ( Id. ) Based upon her history, physical examination, and medical records, Dr. Odeluga found that Jones appeared to have chronic low back pain, asthma, depression, and allergic rhinitis. ( Id. )

b. Dr. Mark Williams

On November 18, 2009, Jones saw Dr. Mark Williams for an annual physical exam. (R. 401.) At her appointment, Jones complained of asthma and joint pains. ( Id. ) Dr. Williams's physical examination revealed normal alignment and mobility of the spine, ribs, and pelvis, and normal gait. (R. 403.) Dr. Williams noted that Jones had a number of problems, including polyarthralgia, temporomandibular joint ("TMJ"), anxiety and depressive disorder. ( Id. ) Dr. Williams ordered a comprehensive metabolic panel, and instructed Jones to continue taking Advair, Diskus, Ventolin, Ferrous Sulfate, and Naproxen. (R. 404.)

On January 6, 2010, Jones returned to Dr. Williams with complaints of body pain, joint pain, and stiffness. (R. 414.) Jones denied back pain, joint swelling, muscle cramps, muscle weakness, and arthritis. ( Id. ) Dr. Williams ordered Vitamin B12/folate, serum panel, and a hepatitis panel. (R. 415.)

On February 25, 2010, Jones complained to Dr. Williams that she had bluish discoloration and pain in her hands and feet. (R. 431.) Dr. Williams made a note regarding Raynaud's Syndrome, and referred Jones to Dr. Adrienne Burford-Foggs, a rheumatologist, for further evaluation and treatment. (R. 432.)

c. Dr. Adrienne Buford-Foggs

Over the next few months, Jones saw Dr. Burford-Foggs for her joint pain on six occasions. On March 1, 2010, Jones complained that she had experienced pain in her elbows, hands, knees, and feet for approximately ten years. (R. 433.) Jones also complained of stiffness in the morning lasting three hours, episodic swelling of the wrists, hands and ankles for approximately ten years, and that her hands and feet become cold and turn blue with cold exposure for the past three years. ( Id. ) Jones reported that her pain is exacerbated by activity and carrying grocery bags. ( Id. ) Jones also stated that her pain is relieved by Tramadol and muscle relaxers. ( Id. ) Following the physical exam, Dr. Burford-Foggs found that Jones had normal range of motion and no joint enlargement or tenderness in her extremities. (R. 435.) There was also no musculoskeletal abnormalities. ( Id. ) Dr. Burford-Foggs ordered a Vitamin D lab, and instructed Jones to continue taking her Tramadol as prescribed, to keep her hands and body warm, and to return in two months. ( Id. ) She assessed that Jones suffered from Raynaud's syndrome, arthralgia, and anemia. (Id. )

On April 5, 2010, Jones complained of swelling in her feet and hands, cramps in her legs and feet, severe back pain, and morning joint stiffness lasting three hours. (R. 444.) Dr. Burford-Foggs noted the "presence of arthralgias, fatigue, stiffness, and markedly elevated ANA suggested SLE [systematic lupus erythematosus], however, additional tests are warranted." (R. 446.) Dr. Burford-Foggs reported plans to "check anti-ds-DNA, C2, C4, repeat CBC" and instructed claimant to continue Prednisone and Vitamin D as prescribed. ( Id. )

Jones returned to see Dr. Burford-Foggs on April 19, 2010. (R. 454.) Dr. Burford-Foggs reported "Patient with UCTD [undifferentiated connective tissue disease][1] treated with Prednisone and Plaquenil, comes in for treatment. Her joint pain is controlled. Her review of systems is unremarkable." ( Id. ) Dr. Burford-Foggs also reported that claimant "denies anorexia, chills, dizziness, fatigue, fevers, headache, malaise, sweats, and weight loss." ( Id. ) Jones was instructed to continue taking Plaquenil and Prednisone. (R. 456.)

On May 3, 2010, Jones returned to Dr. Burford-Foggs, complaining of swelling in her feet, low back pain, and leg cramps for approximately two months. (R. 458.) Dr. Burford-Foggs noted that claimant is improving with the exception of Prednisone, ...

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