United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
JEFFREY COLE, Magistrate Judge.
Lori Beth Zolno seeks review of the final decision of the Commissioner of the Social Security Administration ("Commissioner"), denying her application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act"), §§ 42 U.S.C. 416(I), 423. Ms. Zolno asks the court to reverse the Commissioner's decision, or in the alternative remand for a supplemental hearing. The Commissioner asks that the decision be affirmed.
Ms. Zolno applied for DIB on March 26, 2010, alleging that she became disabled in August 2008, due to multiple sclerosis ("MS"), headaches, and allergies. (R. 132-38, 166, 171). Her claim was denied initially and upon reconsideration. (R. 96-96, 105-08). Ms. Zolno subsequently requested an administrative hearing. An administrative law judge ("ALJ") presided over the hearing on July 27, 2011, at which Ms. Zolno, represented by counsel, appeared and testified. Dr. Jeffrey Lucas also testified by telephone as a vocational expert. (R. 56-95). On August 24, 2011, the ALJ issued a decision denying Ms. Zolno's application for DIB, finding that she was not disabled because her MS and allergies were not so severe as to render her unable to do past relevant work as an office and retail clerk or counselor. (R. 8-22). This became the final decision of the Commissioner when the Appeals Council denied Ms. Zolno's request for a review on October 2, 2012. (R. 1-5). See 20 C.F.R. §§ 404.955; 404.981. Ms. Zolno has 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 EVIDENCE OF RECORD
THE VOCATIONAL EVIDENCE
Ms. Zolno was born on April 29, 1975, which made her thirty-six at the time of the ALJ's decision. (R. 132). She is unmarried, with no children, and currently resides with her mother and stepfather. (R. 410). Her highest level of education is a Bachelor of Arts in Sociology. (R. 60). At the time of the administrative hearing, Ms. Zolno weighed approximately 125 pounds at a height of 5'3". (R. 80). She has prior employment working as a data clerk for the Gateway Foundation and as a counselor for a half-way house and facility for disabled children. (R. 172). More recently, Ms. Zolno worked for Walgreens as a data clerk. (R. 63, 172). She lost that job when she was arrested and incarcerated for attempted criminal sexual assault with a minor who had been a client at Gateway. (R. 130, 410, 171).
THE MEDICAL EVIDENCE
Ms. Zolno was first diagnosed with MS in 1998 when she was 23 years old. (R. 410). Her symptoms began with the development of some blurred vision. (R. 398). She began seeing an ophthalmologist, who felt her examination was abnormal. He sent her to a neurologist, who performed an MRI, which revealed a possible demyelinative disorder. (R. 398). Ms. Zolno's doctors declined to initially diagnosis her with MS out of caution, and prescribed Prednisone which temporarily remedied her symptoms. (R. 398). In 2001, however, Ms. Zolno began to have numbness in her legs and was sent for another MRI on February 6, 2001. (R. 398). The results of the second MRI were consistent with a demyelinative disorder that had progressed since the 1998 MRI. (R. 398). She was then officially diagnosed with MS. (R. 399). At the time, she reported allergies to cat dander and hayfever, and had chronic headaches. (R. 399). At the time of her diagnosis, examination revealed her mental state, motor functions, reflexes, sensation, coordination, and gait were all normal. (R. 400).
The record is silent on Ms. Zolno's condition between 2001 and 2004. By 2004, she was seeing Dr. Trelka and participating in physical therapy, which was helping her condition, although her gait was reported as "slow" and her tandem gait as "fair." (R. 394). Her upper extremities appeared normal. (R. 394). She reported she was doing very well in February 2005. Her gait and coordination were slightly slowed. (R. 393). In September 2005, her gait remained intact, and her condition was well controlled with medication - Avonex and Baclofen. (R. 392).
An MRI was done on December 12, 2005, after Ms. Zolno complained of fatigue and slurred speech. (R. 388). The MRI revealed lesions and edema consistent with MS. (R. 388-89). By December 27th, following a steroid dose, Ms. Zolno was essentially back to normal. (R. 388). In the following years, reports by Dr. Trelka revealed further incidents of fatigue, slurred speech, and difficulty sleeping. (R. 377-87). Gait and coordination generally remained intact. (R. 378, 380, 383-84, 386). Her main difficulty appeared to be recurrent problems with speech. (R. 377-87).
Ms. Zolno had an MRI of her back on March 29, 2008. It revealed a slight disc dessication at L4-L5, plus a L4-L5 degenerative disc bulge. (R. 421). The rest of the lumbar discs were reported as functionally normally. (R. 421).
Dr. Allen prepared a medical report dated July 16, 2008 regarding Ms. Zolno in anticipation of her incarceration. (R. 418). Dr. Allen had been treating Ms. Zolno for approximately a year at the time. (R. 418). The letter described her back pain, the results of her MRI scans, weakness in her lower extremities, weakness on right foot eversion, intermittent slurring of speech, and some fatigue as a result of MS. (R. 418). The doctor set forth specific limitations for Ms. Zolno's prison work details and sleeping arrangements while incarcerated: a period of rest no less than 10 minutes per hour, a lower bunk, the avoidance of prolonged standing for more than 20-30 minutes, avoidance of heat greater than 85 degrees Fahrenheit, a carrying restriction of 10 pounds, total climbing restriction, and that she be permitted only light work detail, specifically restricted from laundry duties. (R. 418).
On June 4, 2010, Ms. Zolno had a consultative exam with Dr. Weiss for the Bureau of Disability Determination Services. (R. 429). Dr. Weiss's report discussed Ms. Zolno's complaints of daily headaches, which she has had since she was 18 years old and which worsen on snowy and rainy days. (R. 439). The doctor reported normal spinal movement and a broad-based gait, and observed Ms. Zolno had no difficulty getting on and off the exam table, sitting, standing, or squatting to 40 degree knee flexion. (R. 431-32). Ms. Zolno had only mild difficulty in heel-walking and toe-walking, had an unsteady tandem gait, and was unable to do a single leg balance. (R. 432). Grip strength and dexterity were normal. (R. 432). Her muscle strength was generally 5/5 everywhere except her hip flexors (3/5) and knee flexors (4/5) bilaterally. (R. 432). Reflexes were normal. (R. 432). Dr. Weiss reported claimant's mental status seemed normal: she was alert, remembered her medical history, and seemed capable of handling funds in her own interest. (R. 432).
Dr. Calixto Aquino reviewed Ms. Zolno's medical record on behalf of the disability agency on June 29, 2010. The doctor stated Ms. Zolno could occasionally lift 20 pounds, frequently lift 10 pounds, stand/walk or sit with normal breaks for approximately 6-hours in a normal 8-hour work day, and had unlimited mobility for pushing and pulling (within the pound restrictions). (R. 437). The doctor felt that she could occasionally climb ramps and stairs, and occasionally perform balancing, stooping, kneeling, crouching, and crawling. (R. 438). She could not climb ropes, ladders, or scaffolds. (R. 438). She had no manipulative limitations, such as reaching, feeling, handling, and fingering, visual limitations, or communicative limitations. (R. 439-40). Her environmental limitations included avoiding concentrated exposure to extreme cold, extreme heat, wetness, humidity and fumes, but she had no noise or hazards limitations. (R. 440). He noted that she had weakness in both her legs, but only slight gait abnormalities. (R. 437).
On March 25, 2008, Ms. Zolno had a spastic gait, fatigue, and some left leg weakness, but no numbness. (R. 425). She had right foot drop. (R. 425). She got daily headaches. On May 28, 2008, there was weakness in her right foot on eversion, but she had no other weakness, and no numbness or tingling; she reported that her leg got stiff. Her speech was less slurred. (R. 420). On July 16. 2008, exam revealed right foot weakness on eversion. (R. 417). It was noted that she should avoid prolonged standing, climbing, heat, and could carry less than 10 pounds. (R. 417). On August 25, 2008, it was noted that Ms. Zolno had fatigue, spasticity, and that she had difficulty balancing and walking. (R. 326). An unsteady gait was noted on November 21, 2008. (R. 330).
On April 28, 2010, Ms. Zolno reported fatigue, blurred vision in her left eye, but no weakness or numbness. Her gait was noted to be spastic. (R. 416). Ms. Zolno had a brain MRI on July 17, 2010. (R. 444). The MRI revealed that the presence of white-matter, and atrophy was greater than expected for someone of Ms. Zolno's age. (R. 444-47).
Ms. Zolno began receiving free medical treatment from the Ark in March of 2010. (R. 61, 411).. She began psychiatric treatments there in April of 2010 for her anxiety and depression. (R. 412). As the psychiatric treatments continued, most of the medical reviews described her mood as "stable" with no excessive anxiety. (R. 407-10, 459, 461). She was prescribed Xanax and Prozac after these visits. (R. 459, 461). Ms. Zolno also got refills from Ark for medications for her MS, allergies, and lower back pain. (R. 408, 460).
THE ADMINISTRATIVE HEARING ...