United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
REBECCA R. PALLMEYER, District Judge.
Plaintiff Milady Aquino seeks review of the Social Security Administration's decision to deny her application for Disability Insurance Benefits and Supplemental Security Income. After a hearing, an Administrative Law Judge ("ALJ") determined that, while Aquino has severe impairments of affective/mood disorder and hypertension, Aquino is not disabled because she still has the Residual Functional Capacity ("RFC") to perform light work. On May 23, 2012, the Appeals Council denied review, rendering the ALJ's decision the final and reviewable administrative decision of Defendant, Carolyn W. Colvin, Acting Commissioner of the Social Security Administration. In challenging the denial of benefits, Plaintiff argues that the ALJ (1) erred when he failed to find Aquino's fibromyalgia, dizziness, vertigo, and headaches to be severe impairments and (2) erred in determining Aquino's RFC in that he (a) failed to adequately address Plaintiff's fibromyalgia, (b) failed to consider all of Aquino's impairments in combination, (c) improperly discounted Aquino's testimony, and (d) improperly discredited the reports of Aquino's treating physician. The court agrees that the ALJ failed to consider Plaintiff's diagnosed fibromyalgia and failed to analyze her impairments in combination. Accordingly, the court grants Plaintiff's motion for summary judgment  and remands for further consideration.
Plaintiff, born on March 3, 1962, was forty-five years old at the alleged onset of her disability. (Certified Copy of Admin. Record , hereinafter "R., " 168.) Plaintiff has only a second grade education and is Spanish speaking: she understands, reads, and writes little English. ( See R. at 44-45, 62, 155.) Her last full-time job was as a cleaner in a muffler shop, where she worked from 1996 until the shop closed in 2007. (R. at 27-28, 157.) Plaintiff also sporadically worked as a hair dresser in 2007, but was unable to find a new full-time job. (R. at 24, 27-28.)
On December 19, 2008, Plaintiff filed an application for Supplemental Security Income, and on January 13, 2009 she filed an application for Disability Insurance Benefits. (R. at 22.) In both applications, Plaintiff alleged that she became disabled on June 30, 2007 by arthritis, depression, chronic chest pain, fibromyalgia, vertigo, an enlarged heart and other heart conditions, insomnia, anxiety, and Keratoconos. (R. at 22, 156.) The state agency denied Aquino's application on June 4, 2009, and again, after reconsideration, on January 29, 2010. Each time, the agency concluded that while the medical evidence did show "some restrictions in [Plaintiff's] ability to function, " she remained capable of performing the maintenance work she had done in the past. (R. at 72-81, 84-91.) Aquino then filed a timely Request for Hearing, which was held on February 3, 2011 before ALJ Jose Anglada. (R. at 15, 39.) The ALJ issued his written decision on February 25, 2011, similarly concluding that although the medical evidence revealed some functional restrictions, Aquino retained "the residual functional capacity to perform light work." (R. at 26.) On May 23, 2012, the Appeals Council denied review of the ALJ's decision, rendering that decision final and reviewable. (R. at 1-6.). On June 12, 2012, Aquino filed this action seeking review of the Commissioner's decision pursuant to 42 U.S.C. § 405(g). (Compl. .)
At the hearing before ALJ Anglada, Aquino presented several categories of evidence, which she asserts establish her disability: (1) her medical records, (2) results of consultative exams performed in connection to her disability application, and (3) her own testimony. The court reviews each category of evidence in turn.
I. Medical Records
Aquino alleges that she suffers from both mental and physical impairments. According to Aquino, her physical impairments include: (1) hypertension; (2) fibromyalgia and joint pain; (3) dizziness, vertigo, and headaches; (4) Keratoconus; (3) heart palpitations and chest pain; and (6) fatigue. (Pl.'s Opening Br. in Supp. of Mot. for Summ. J. , hereinafter "Pl. Br., " 2.) Aquino alleges that her physical impairments are worsened by her depression and anxiety. ( Id. at 12; R. at 704-07.)
A. Evidence of depression and hypertension
The parties agree that Plaintiff suffers from depression and hypertension, and the medical evidence amply supports that conclusion. Medical records reveal that Aquino's psychological problems date back to the mid-1990s. (R. at 237.) More recently, her depression was noted in her medical records in March of 2007 (R. at 351), and again in February of 2008, when she was prescribed Lexapro, a selective serotonin reuptake inhibitor, to treat depression. (R. at 359.) In early 2009, Plaintiff's treating physician, Dr. Sirois, again noted that Plaintiff suffered from depression and memory loss, but noted that she appeared less anxious, indicating that the medicines were effective. (R. at 372.) There is also evidence in the record that Plaintiff suffers from hypertension ( see e.g., R. at 359) (Alivio Medical Center record prescribing Metoprolol for high blood pressure), but as the ALJ noted, the hypertension is well controlled with medication. (R. at 351, 432, 713.)
B. Evidence of fibromyalgia and joint pain
The medical records support Plaintiff's assertion that she suffers from fibromyalgia and joint pain, as well. Although she apparently experienced some joint pain as early as 2005 ( see R. at 387, 432), Plaintiff first sought treatment for her muscle and joint pain in 2008. On May 26, 2008, at an appointment with Dr. Sirois, an internist at Alivio Medical Center, Plaintiff complained of shoulder pain. (R. at 366.) By October 23, 2008, Plaintiff had been referred by her primary care physician to Dr. Fernando and Dr. Hutchinson at the University of Illinois Medical Center at Chicago for an orthopedic evaluation. (R. at 499.) Notes of that evaluation show that Plaintiff complained of pain in her neck, "thoracic posterior, " both shoulders, both elbows, "bilateral humerus, " hands, and forearms that had lasted for a year, but she had not previously been evaluated for it. ( Id. ) She reported that she had been able to work-presumably as a hair dresser-and had "never missed a day, but the pain is getting a little bit in her way." ( Id. ) After examining her, the doctors determined that Plaintiff should take Naproxen "on a continuous basis" to relieve pain, should get physical therapy, and should have additional x-rays taken in order to rule out any neck or rheumatologic pathologies and determine whether she suffered from fibromyalgia. (R. at 500.) When Aquino returned on December 4, 2008, after completing the tests, Dr. Hutchinson did rule out other pathologies and assessed Plaintiff as a "female with fibromyalgia." (R. at 668.)
On December 23, 2008, Aquino also saw Dr. Shiva Arami-a rheumatologist-for an evaluation of her neck and shoulder pain. Dr. Arami recorded that Plaintiff had a disturbed sleep cycle associated with "tender points" that include the upper back, occipital region, and paresthesia that involved the hands and had in the past involved the feet. (R. at 677.) She noted that Plaintiff's pain was "possibly related to myofascial pain syndrome/fibromyalgia exacerbated by her job as a hairdresser, " which required her to elevate her arms for a few hours at a time. (R. at 675-76.) She recommended electromyography testing for other neuropathic symptoms (R. at 676), which ultimately showed normal results. (R. at 759.) She also recommended physical therapy to strengthen Aquino's upper body, a combination of Tylenol and Naproxen for pain, and Nortriptyline to help her sleep. (R. at 676.)
At the direction of Drs. Hutchinson and Arami, Aquino visited a physical therapist in March 2009 for the pain in her neck, back, and both shoulders. (R. at 720-23.) On March 10, 2009, physical therapist Stephen Shaffer recorded that Plaintiff felt "pain in her neck, back, and both upper extremities, " and that the problem had begun twenty years earlier. (R. at 720.) Shaffer's notes show that Plaintiff reported she had not received treatment in the past because her (unidentified) previous primary care physician believed her pain was associated with her depression. ( Id. ) Plaintiff described her pain as "heavy and pulsating." ( Id. ) She stated that she had not worked in seven months, though she had previously worked cleaning and cutting hair. (R. at 721.) Shaffer noted that Plaintiff's symptoms might be consistent with "chronic cervical/thoracic dysfunction." (R. at 722.) Shaffer identified three separate pathologies: "cervical, thoracic, and UE [upper extremities], " and concluded that Plaintiff's rehabilitation potential was "good." ( Id. ) At a follow-up visit on March 18, 2009, Shaffer recorded that Plaintiff was tolerating treatment "well, " but opined that her "usage of the pain scale may be scewed [sic]" (he did not say in which direction). (R. at 732.)
Dr. Janet Leon, a doctor associated with Dr. Arami, saw Plaintiff on March 31, 2009. Dr. Leon noted that Plaintiff's dispersed myalgia had improved, but that Plaintiff continued to experience soft tissue pain over her shoulders and neck. (R. at 733.) Dr. Leon observed that the pain is "possibly related to myofascial pain syndrome/fibromyalgia" and that it was "likely exacerbated by her job as a hairdresser." (R. at 734.) Dr. Leon increased Plaintiff's prescription of Nortriptyline to help her sleep and instructed her to continue with her treatment of Naproxen and Tylenol, and physical therapy for the pain. ( Id. ) Physical therapy was partially successful: after roughly three months, on June 22, 2009, physical therapist Shaffer concluded that the therapy had addressed Plaintiff's primary complaint of neck and thoracic pain, but had not sufficiently addressed Plaintiff's shoulder pain. (R. at 727.)
C. Evidence of dizziness, vertigo, and headaches
Aquino began experiencing dizziness, vertigo, and headaches in the late 1990s. ( See R. at 396, 413, 417.) On June 6, 2006, Aquino was seen at Alivio Medical Center for a variety of complaints including anxiety, lack of sleep, malnutrition, pelvic pain, dizziness, and allergies. (R. at 346.) On March 20, 2007, and again on June 28, 2007, Aquino complained to her doctors at Alivio Medical Center about "dizzy spells" and vertigo. (R. at 335, 351.)
As the medical records reflect, the dizziness worsened in 2008. Aquino complained of dizziness and chest pain on January 4, 2008 to her physicians at Alivio Medical Center. (R. at 358.) On May 14, 2008 she again complained of chest pains and dizziness, which she reported had been ongoing for at least two months. (R. at 363; see also R. at 365 (undated medical record indicating Aquino was hospitalized for chest pain and dizziness).) Based on her complaints of vertigo and headaches, her primary care physician, Dr. Sirois, referred her for a computerized tomography ("CT") scan. (R. at 510-11.) The CT scan, taken on May 31, 2008, revealed "punctate calcifications within the posterior right thalamus, subcortical region of the left frontal lobe, and periphery of the mid right cerebellar hemisphere." (R. at 510.) The report noted that findings suggested "possible chronic intracranial infection such as neurocysticercosis." (R. at 511.)
Aquino continued to complain of headaches and vertigo or dizziness from late 2008 through early 2009. Dr. Sirois recorded her complaints on August 28, 2008 (R. at 369, 450) and November 21, 2008. (R. at 370.) Her physical therapist recorded Plaintiff's complaint of dizziness and vertigo on March 10, 2009. (R. at 720.) On March 12, 2009, Aquino again complained of dizziness to her doctors at Alivio Medical Center. (R. at 790.) On March 25, 2009, Dr. Miriam Redleaf, an otolaryngologist (an ear, nose, and throat specialist) from the University of Illinois Medical Center at Chicago, noted that Plaintiff complained of a history of vertigo, with episodes occurring on a daily basis for several years. (R. at 746.) Plaintiff told Dr. Redleaf that the episodes last from a couple of seconds up to two minutes and were accompanied by nausea. ( Id. ) Dr. Redleaf noted that Plaintiff was not taking any medications, nor had she seen an otolaryngologist for the disorder. ( Id. ) Dr. Redleaf's impression was that Plaintiff's symptoms were "consistent with benign paroxysmal vertigo." (R. at 747.) During a consultation for heart palpitations with Dr. Shivaraju, a cardiologist at University of Illinois at Chicago on September 14, 2009, Plaintiff again complained of daily episodes of dizziness and vertigo lasting 30 minutes, both when resting and doing work. (R. at 748.) Dr. Shivaraju noted characterized these symptoms as "BPPV" (benign paroxysmal positional vertigo). (R. at 749.)
Plaintiff never received a definitive diagnosis for her dizziness and vertigo. Three months before the hearing, on November 11, 2010, Plaintiff went to St. Anthony Hospital complaining of a headache lasting several days, chest pain, fainting, and shaking episodes. (R. at 812.) Doctor Ashish Mukherjee stated that Plaintiff needed a neurological evaluation, including a possible MRI to evaluate her history of cysticercosis. ( Id. ) Again, Plaintiff had a CT head scan, which revealed no acute intracranial findings, but did show "a few small nodular calcifications along the cerebral and cerebellar cortex." (R. at 836.) Based ...