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Autman v. Colvin

United States District Court, N.D. Illinois

November 4, 2016

WILMA D. AUTMAN, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.


          Susan E. Cox United States Magistrate Judge

         Plaintiff Wilma Autman (“Plaintiff”) seeks judicial review of a final decision of the Commissioner of Social Security (“Commissioner”) denying Plaintiff disability insurance benefits or supplemental security income under Title II (“DIB”) and Title XVI (“SSI”) of the Social Security Act. The Court grants the Plaintiff's motion for summary judgment (Dkt. 29), [1]and denies the Commissioner's motion for summary judgment (Dkt. 30). The court reverses the Commissioner's decision and remands the case for further proceedings consistent with this opinion.


         I. Procedural History

         On April 8, 2011, Plaintiff filed an application for DIB and SSI, alleging an onset date of September 26, 2009, which was later amended to April 22, 2011. (R. at 137, 521.) She was forty-nine years old at the time of her application. (R. at 137.) After a hearing before an ALJ in June 2012, the ALJ issued an opinion denying Plaintiff's claim for benefits on August 29, 2012. (R. 100-115) The Appeals council denied review of Plaintiff's claim making the ALJ's decision the final decision of the Commissioner. (R. at 92-97.) Plaintiff then filed a civil action, pursuant to 42 U.S.C. §§ 405(g) and 1383(c). In April 2014, this court issued an order remanding Plaintiff's case for a new hearing. (R. at 478.)

         Plaintiff's second hearing in front of ALJ Spalo (“ALJ”) occurred on October 16, 2014. (R. at 52.) The ALJ denied granting SSI and DIB to Plaintiff. (R. at 23-45.) The ALJ's opinion found, inter alia, that: 1) Plaintiff met the insured status requirements of the Social Security Act through June 30, 2015; 2) Plaintiff had not engaged in substantial gainful activity since April 22, 2011; 3) Plaintiff's severe impairments were lumbago, obesity, asthma, diabetes mellitus, and plantar fasciitis of the right foot; 4) Plaintiff's impairments do not meet, either individually or in combination, the severity requirements of the listing in 20 CFR Part 404, Subpart P, Appendix 1; 5) Plaintiff had the residual functional capacity (“RFC”) to perform light work, with several restrictions; and 6) Plaintiff could perform her past relevant work as a supervisor and recreation aide. (R. at 26-40.) Plaintiff again requested review of the second ALJ's opinion, which was also denied, making ALJ Spalo's decision the final decision of the Commissioner. (R. at 1-3.) Plaintiff then filed this civil action pursuant to 42 U.S.C. §§ 405(g) and 1383(c).

         II. Medial Evidence

         In October of 2009 Plaintiff saw Dr. Caneva, a podiatrist, after a recent trip to the emergency room for pain in her right foot. (R. at 334.) Dr. Caneva diagnosed Plaintiff with plantar fasciitis and a bunion. (R. at 333.) Dr. Caneva took an x-ray of Plaintiff's foot, which revealed the ankle was intact and there was no fracture in the foot. (Id.) Dr. Caneva prescribed a treatment plan to Plaintiff and continued to see her through 2012 for her plantar fasciitis. ( 332-334.)

         In May 2011, Plaintiff visited the Will County Community Health Center self-reporting heaviness in her legs, numbness in part of her foot and headaches. (R. at357.) In a later visit to Will County in the same month, Plaintiff also reported foot and back pain, bilateral leg pain, migraines, and five slipped disks. (R. at 356.) The five slipped disks are not confirmed in any medical report contained within the record.

         In April 2011, Plaintiff saw Dr. Singh for the first time, where he diagnosed her with unspecific hypertension, diabetes mellitus, and mixed hyperlipidemia. (R. at 409.) Plaintiff treated with Dr. Singh through 2014, and he diagnosed her with impaired glucose, malaise, fatigue, plantar fasciitis. (R. at 406, 658.) During this time, Dr. Singh also noted that Plaintiff's gait was within normal limits and that no motor sensory loss was appreciated. (R. at 658.) Dr. Singh also noted that plaintiff had normal range of motion in the spine. (R. at 407.)

         In June 2011, Plaintiff received a consultative examination from Dr. Simon. (R. 377) Dr. Simon diagnosed Plaintiff with intermittent lower back pain, chronic right foot pain post surgery, and asthma. (R. at 380.) Dr. Simon also noted that Plaintiff's sensory exam to touch was satisfactory. (R. at 381.) Dr. Simon further noted that the Plaintiff's gait was normal and she was able to walk fifty feet without support. (Id.) Also in June 2011, Plaintiff received a venous duplex ultrasound which revealed no evidence of deep venous thrombosis. (R. at 365.) A further study revealed no significant arterial occlusive disease.

         On June 1, 2012, at the behest of the ALJ in anticipation of Plaintiff's first hearing, Dr. Sai Nimmagadda provided an opinion as a medical expert. Dr. Nimmagadda did not examine Plaintiff, but upon review of the records available to him at the time of the opinion, he determined that Plaintiff could sit for 2 hours, walk for thirty minutes and stand for one hour. (R. at 396.) He further opined that Plaintiff could sit, stand, and walk for up to six hours in an eight- hour work day. (Id.) Dr. Nimmagadda said Plaintiff could use her hands for all activity, her feet to operate foot controls, and have exposure to all environmental factors. (R.396-98)

         In 2013, Plaintiff went to Silver Cross emergency room twice in one week, both times related to a headache; a CT scan was done and indicated mild mucosal thickening in her sinuses. (R. at 815, 888-90.) In April 2014, Plaintiff went to St. Joseph emergency room for back pain radiating down to her legs. (R. at 896.) An MRI and CT scan were completed and Plaintiff was diagnosed with multilevel degenerative joint disease with stenosis and intractable back pain. (R. at 906-10.) When medication failed to improve Plaintiff's pain, she was admitted to the hospital. (R. at 897.) Plaintiff was admitted to the hospital on April 2, 2014, and was discharged on April 4, 2014; her diagnosis at the time of discharge included multilevel degenerative joint disease with stenosis and “intractable back pain.” (R. at 906.)

         Plaintiff returned to the emergency room within the same month for persisting back pain. (R. at 912.) After examination, Plaintiff was diagnosed with chronic back pain and increased radicular pain. (R. at 916.) Once again, Plaintiff's condition did not improve, and she was admitted to the hospital. While in the hospital, she was treated by Dr. Maen Martini, a pain specialist, who recommended an epidural steroid injection and facet block injections to alleviate the radiating pain, tingling, and numbness that Plaintiff reported; Plaintiff received an epidural steroid injection the following day. (R. at 916, 919.) Plaintiff was admitted to the hospital on April 30, 2014, and discharged on May ...

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