Bishop v. Berryhill

          MEMORANDUM OPINION AND ORDER

          THE HONORABLE MICHAEL T. MASON, UNITED STATES MAGISTRATE JUDGE.

         Claimant Donna M. Bishop (“Bishop” 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 Bishop's claim for disability insurance benefits under Sections 216 and 223 of the Social Security Act (the “Act”), 42 U.S.C. §§ 416(I) and 423(d). The Commissioner filed a cross-motion for summary judgment, requesting that this Court uphold the decision of the administrative law judge (the “ALJ”). This Court has jurisdiction pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). For the reasons set forth below, Claimant's motion for summary judgment [23] is granted and the Commissioner's cross-motion [33] for summary judgment is denied. The case is remanded for further proceedings consistent with this Opinion.

         I. BACKGROUND

         A. Procedural History

         Bishop filed for period of disability, disability insurance benefits and disability for disabled widow's benefits on September 12, 2003. (R. 21.) Bishop alleges that she has been disabled since September 5, 2013 due to inflammatory arthritis, degenerative disc disease, a mixed connective tissue disease, fibromyalgia, and depression. (R. 24-26.) Both of Bishop's applications were initially denied on January 2, 2014, and upon reconsideration on June 23, 2014. (R. 21.) On July 7, 2014, Bishop filed a request for a hearing. (Id.) She appeared and testified at a hearing before ALJ Roxanne J. Kelsey on August 25, 2015. (R. 21-31.) The ALJ issued a decision denying Bishop's disability claim on November 18, 2015. (R. 31.) On January 17, 2016, Bishop requested review by the Appeals Council. (R. 6.) On May 25, 2016, the Appeals Council denied Bishop's request for review, at which time the ALJ's decision became the final decision of the Commissioner. (R. 1-3); Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). Bishop subsequently filed this action in the District Court.

         B. Relevant Medical Evidence

         1. Dr. Syed Rizvi - Rheumatologist

         Prior to her alleged disability onset date, Bishop had a number of visits with Dr. Syed Rizvi, a rheumatologist. During these early appointments, Claimant reported pain and stiffness in many areas including her back (447-48, 462-63, 503), neck (R. 482-483), right arm (R. 480-81), wrists (Id., R. 484-85), hands (R. 473-74), fingers (R. 516), knees (R. 480-81, 484-85), and joints (R. 455-56). On July 14, 2012, Dr. Rizvi gave Claimant a cortisone injection in her wrist. (R. 471.) Over the course of several visits, Dr. Rizvi diagnosed Claimant with seropositive rheumatoid arthritis (R. 448, 479, 515), fibromyalgia (R. 501, 507, 531), meralgia paresthetica (R. 501, 520, 534), idiopathic osteoporosis (R. 463, 501, 506), osteopenia (R. 448, 456, 501), osteoporosis of the left hip (R. 463, 466, 515), cervical and lumbosacral spondylosis (R. 448, 472, 515), unspecified internal derangement of the left knee (R. 485, 520, 534), restless leg syndrome (R. 448, 477, 516), and stage 3 chronic kidney disease (R. 508, 526).

         During appointments with Dr. Rizvi after her alleged September 5, 2013 onset, Claimant reported that she continued to experience pain in her neck, back, wrists, hands, joints, and all over her body. (R. 391, 564, 604, 611, 637.) She also reported that physical activity caused her pain to worsen. (R. 391, 564, 620.) At various appointments, Dr. Rizvi observed that Claimant had swelling and tenderness in the wrists, joints, shoulders and thumb. (R. 391, 480-81, 471.) Dr. Rizvi also observed that Claimant had full range of motion in her cervical spine and neck, a bilateral complete handgrip, and normal ambulation. (R. 481, 391-392.)

         2. Dr. Sheila Berndt - Primary Care Physician

         In August of 2013, Claimant reported chronic constipation, bloating, and abdominal pain to her primary care doctor, Dr. Sheila Berndt. (R. 444.) A pelvic ultrasound demonstrated fatty infiltration of Plaintiff's liver. (R. 433.) In September of 2014, she reported feeling depressed, having trouble sleeping, and experiencing anxiety. (R. 575.) She was tearful during examination. (R. 576.) Dr. Berndt diagnosed Claimant with depression, prescribed Sertraline and Zoloft, and referred her to a therapist. (R. 576-77.) Dr. Berndt again diagnosed her with depression in May of 2015. (R. 600-01.)

         3. Dr. Mahesh Shah - Internal Medicine Consultative Examiner

         On June 2, 2014, Claimant underwent an internal medicine consultative examination with Dr. Mahesh Shah, who noted that Claimant had a mild tenderness in her lower back, mild swelling of the joints and wrists, slight difficulty with heel and toe walking, and trouble squatting. (R. 551-54.) Claimant reported she was in good health until 2005 when she started having pain in her hips which then spread to her joints. (R. 551.) She also reported significant pain in her shoulders. (Id.) Dr. Shah noted that Claimant could walk into the office without assistance, she was able to move around with no problem, and she was able to get up from the chair and onto the examining table without difficulty. (R. 552.) Dr. Shah also noted full range of motion in all her joints and upper extremities and normal handgrip. (R. 553-54.) Dr. Shah diagnosed rheumatoid arthritis, mild fibromyalgia, and mild depression. (R. 554.)

         C. ...