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Jayne v. Berryhill

United States District Court, C.D. Illinois, Springfield Division

July 26, 2019

LISA LOUISE JAYNE, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          OPINION

          TOM SCHANZLE-HASKINS, U.S. MAGISTRATE JUDGE.

         Plaintiff Lisa Louise Jayne appeals from the denial of her application for Social Security Disability Insurance Benefits (DIB) under Title II and Supplemental Security Income (SSI) under Title XVI of the Social Security Act (collectively Disability Benefits). 42 U.S.C. §§ 416(i), 423, 1381a and 1382c. This appeal is brought pursuant to 42 U.S.C. §§ 405(g) and 1383(c). Jayne filed a Motion for Summary Judgment (d/e 16). The Defendant Commissioner filed a Motion for Summary Affirmance (d/e 19). The parties have consented to proceed before this Court. Consent to the Exercise of Jurisdiction by a United States Magistrate Judge and Reference Order entered November 9, 2018 (d/e 15). For the reasons set forth below, the Decision of the Commissioner is affirmed.

         STATEMENT OF FACTS

         Jayne was born on July 27, 1966. She secured a GED. She previously worked as an animal caretaker, home health attendant, and security guard. She suffers from degenerative disc disease of the cervical spine, right shoulder bursal surface tearing with tendonitis and osteoarthritic changes; moderate degenerative changes in the right hip; remote right knee meniscus tear; and depression and anxiety. R. 22, 29, 75, 351.

         On December 31, 2012, Jayne saw Dr. Daniel OConnor, M.D., to establish care after her previous doctor retired. She reported shoulder pain that did not radiate. She also reported insomnia. She said the pain in her shoulder interfered with her sleep. R. 318-19. On examination, Jayne had no swelling or weakness, normal gait, normal mobility and curvature in her spine, full range of motion in all her extremities with no swelling, erythema, or effusion. She had no sensory loss. Jayne was oriented and demonstrated appropriate mood and affect. R. 321. Dr. OConnor renewed Jayne's prescription for Norco (hydrocodone-acetaminophen) at a reduced dosage. Dr. OConnor noted, “No early refill, and maybe no refill at all. I strongly recommend use of ibuprofen, but since she thinks she gets no results, it seems unlikely that she will take it.” Dr. OConnor discontinued the prescription for tramadol because it made her “feel odd” and she reported that it provided no benefit. R. 318.

         On January 23, 2013, Dr. OConnor wrote a letter regarding Jayne's work limitations due to her condition. Dr. OConnor recommended that Jayne should not lift more than 20 pounds and should not stand for more than two hours without a 10-minute break. R. 336.

         On March 11, 2013, Jayne saw Dr. OConnor. Dr. OConnor noted,

For a person in “severe” pain she sure looks comfortable and is able to move pretty well. This is starting to look like she may not need nearly so much medication, so I think the next time she comes back, if her records don't show some crippling radiography, we will begin scaling back her narc supply.

R. 322. On examination, Jayne displayed normal spine mobility and curvature, full range of motion in all extremities with, “Seemingly no limitation of movement.” Her memory was intact, she was oriented, and she demonstrated appropriate mood and affect. R. 324. Dr. OConnor renewed her prescription for hydrocodone-acetaminophen and added a prescription for Ambien. R. 322.

         On May 1, 2014, Jayne saw Dr. Natalie Greene, D.O., for high blood pressure. Dr. Greene noted that Jayne drank “about a 6 pack of beer per nigh (sic) especially on weekends.” Dr. Greene also noted that Jayne was taking hydrocodone for pain. R. 327. On examination, Jayne had normal pulses and no edema. She was oriented; she had normal insight and judgment; and she demonstrated appropriate mood and affect. R. 329. Dr. Greene discontinued the prescriptions for hydrocodone and Ambien. She prescribed meloxicam (an NSAID) and gabapentin. R. 325.

         On May 15, 2014, Jayne saw Dr. Greene. Jayne reported right arm pain. She said the pain was burning. She also felt numbness. She said the pain went from her neck to her elbow. She said the gabapentin made her “queezy (sic).” She said she was taking Vicodin (hydrocodone-acetaminophen) that she got from a friend. Dr. Greene did not order further testing because Jayne did not currently have insurance. R. 331. On examination, Jayne had normal gait, normal spine mobility and curvature, sensation, and strength in both arms. She had moderately reduced range of motion and severe crepitus in her right shoulder. No. edema was present. Jayne was oriented, had normal insight and judgment, and had appropriate mood and affect. R. 334. Dr. Greene renewed her prescriptions for meloxicam and gabapentin. Dr. Greene stated that if the NSAID did not improve her shoulder in a month, she would give Jayne a steroid injection. R. 331.

         On June 30, 2014, Jayne protectively filed for Disability Benefits. She alleged that she became disabled on November 30, 2012. R. 19.

         On October 16, 2014, Jayne saw state agency psychologist Dr. Stephen Vincent, Ph.D., for a mental status assessment. R. 351-53. Upon completing the examination, Dr. Vincent concluded, in part:

She has co-morbid symptoms and signs of anxiety and depression, with no history of any formal psychological and/or psychiatric treatment. She currently takes no prescribed antidepressant or anti-anxiety medications. She has not been psychiatrically hospitalized. She is currently not involved in any counseling efforts. She does prefer to withdraw and isolate. Cognitively she is intact.

         Dr. Vincent assessed clinical impression was major depression, with anxious distress. R. 353.

         On the same day October 16, 2014, Jayne saw state agency physician Dr. Raymond Leung, M.D., for a consultative physical examination. R. 354-57. Jayne denied any illegal drug use. She said she drank six to eight beers on weekends. She said she was taking meloxicam and hydrocodone. On examination, Jayne walked with a minimal limp without her cane. With the cane, “she would just lift the cane and was not using it to walk.” She could walk 50 feet unassisted. She had difficulties walking on her heels and on her toes. She could squat ¼ of the way down. Straight leg raising bilaterally was to 35 degrees. She had decreased range of motion in her lumbar spine and shoulders. She had 5/5 strength in her left arm and hand. She had 4 strength in her right arm and hand. She had 4 strength in her legs. Her sensations were in normal limits. She had no edema. R. 356. Dr. Leung's mini mental examination results were normal. R. 355. Dr. Leung assessed slight right arm weakness, full range of motion in her cervical spine and limited range of motion in her lumbar spine and walking with a slight limp without her cane. 356-57.

         On October 24, 2014, Jayne prepared a Function Report-Adult form. R. 245-52. Jayne reported that she lived alone in a house. Jayne said she could not work because of her back, neck, and shoulder pain. She also said she experienced nausea and headaches when she left home. She said she had panic or anxiety attacks when she was around a group of people or when she had appointments. R. 245.

         Jayne said that in a typical day she got up, made coffee, took her meds, took care of her dog, watched television, took a nap, and played games on her phone. She also read the newspaper. She said that on a good day she would “try to tidy up the house or make a ‘decent' meal.” She said that two individuals Melissa Medders and Keith Vaughn help her take care of her pets. R. 246. Jayne said she did laundry, mowing, dusting, and cleaning once a week, but some weeks she did not perform these activities due to fatigue or pain. R. 247-49.

         Jayne said she went outside once a day. She went out alone. She said that she drove. She went shopping once a month for groceries, toiletries, and cleaning supplies. She was able to pay bills, count change, handle her savings account, and use her checkbook. R. 248.

         Jayne said that two or three times a week she communicated with “a few people I associate with” by phone, email, and text. She also attended occasional barbeques with others. She said that twice a month she listened to music with close friends. R. 249.

         Jayne reported that lifting more that 20 pounds caused pain. She said that squatting, bending, and kneeling caused pain and she occasionally fell if she did not have something to hold onto. She said that standing and walking caused pain and fatigue. She indicated climbing stairs caused pain and fatigue. She said she had trouble concentrating and understanding. She could walk less than a block before she had to rest for 20 to 30 minutes. R. 250. Jayne said she used a cane to walk distances or when she was in a strange place. She wore a knee brace when she drove her riding mower or when she had to lift heavy objects. R. 251.

         She did not follow written instructions well and she followed spoken instructions fairly well if she looked directly at the person who gave the instructions. R. 250. Jayne said she had issues with authority figures in the past. She said that stress caused nervousness, headaches, and vomiting. Changes in routine made her paranoid. R. 251.

         On November 15, 2014, state agency psychologist, Dr. Donald Henson, Ph.D., prepared a Psychiatric Review Technique. R. 85-56. Dr. Henson opined that Jayne suffered from an affective disorder and an anxiety disorder. Dr. Henson also opined that her mental impairments caused moderate limitations on her activities of daily living, her ability to maintain social functioning, and her ability to maintain concentration, persistence, or pace. R. 85.

         On November 19, 2014, state agency physician Dr. Julio Pardo, M.D., prepared a Physical Residual Functional Capacity Assessment. Dr. Pardo opined that Jayne could occasionally lift 50 pounds and frequently lift 25 pounds, could stand and/or walk six hours in an eight-hour workday, and could sit six hours in an eight-hour workday. Dr. Pardo found that Jayne had no other physical functional limitations. R. 87-88.

         On January 5, 2015, Jayne saw Dr. Greene. Jayne reported that she had pain in her neck, shoulders, and arms. Jayne said pushing and rotation aggravated her condition. She described the pain as aching, piercing, and tingling. She reported some loss of grip strength. Jayne also said she just received her medical card. R. 344-45, 381-82. On a review of symptoms, Dr. Greene said that Jayne was negative for anxiety and depression. R. 345, 382. On examination, Jayne's cervical spine was tender and had mildly reduced range of motion. Her thoracic spine was tender. Jayne had positive compression tests right and left. She had normal grip strength bilaterally. Her gait was normal. She had mildly decreased sensation. She was oriented, had normal insight and judgment, and had normal mood and affect. R. 346, 383. Dr. Greene discontinued the prescriptions for meloxicam and hydrocodone-acetaminophen and continued her prescription for gabapentin. Dr. Greene ordered an MRI of Jayne's neck. R. 344, 381.

         On January 14, 2015, Jayne had an MRI of her cervical spine. The MRI showed multilevel degenerative changes in her cervical spine with most pronounced foraminal and canal stenosis at ¶ 5-C6 with right worse than left. No. definite cord signal abnormality was identified. R. 349.

         On February 12, 2015, Jayne completed another Function Report-Adult form. R. 266-73. She said she could not work because she could not sit or stand for long periods; she could not lift or bend; she could not walk long distances; and she could not drive for any length of time. R. 266. During a typical day she made coffee, took medications, watched television, showered, did light housework, let her pets outside, and ate. R. 267. Jayne prepared meals with a microwave and crockpot. She had no desire to make major meals, and reheated leftovers daily. R. 268. She also played games on her cell phone and occasionally read. R. 270. She said she could not do major housework. R. 267. She left the house to check the mail, mow, and go to appointments. She drove, but had difficulty getting in and out of the car. She went shopping twice a month. R. 269 She said she had problems with her sleep because of pain, anxiety, and panic attacks. R. 267. She later reported that she did all the housework, but no ironing or home repairs. She mowed with a riding mower. She said she did a little housework every day. R. 268. She chatted daily with friends over the phone and on her computer and friends sometimes visited her in her home. R. 270.

         Jayne said she could pay bills, count change, handle a savings account, and use a checkbook. She did not need reminders to go places and did not need anyone to go with her. She did not have any problems getting along with others. She said that she finished what she started, and she understood written and spoken instructions. R. 269-71.

         Jayne said that her condition limited her ability to lift, stand, walk, bend, sit, concentrate, and climb stairs. She became short of breath when she climbed stairs. She did not know how far she could walk. She had to rest over 30 minutes after a walk and did not know how long she could pay attention. R. 271. She said she used a back brace and a cane. The devices were not prescribed but suggested. R. 272.

         Jayne reported that she did not handle stress or changes in routine well. She said that she was terminated from a job at Global Security because she had problems with co-workers. She had fears of dying or sickness. R. 272.

         On March 23, 2015, Jayne saw Dr. Greene. R. 384-86. Dr. Greene noted a history of moderate neck pain. She reported that she saw an orthopedic surgeon who told her she was not a candidate for surgery. R. 384. On a review of symptoms, Dr. Greene stated that Jayne was negative for anxiety and depression. R. 385. On examination, Jayne had normal gait, normal spine, and normal extremities. She was also oriented with normal judgment and insight, and appropriate mood and affect. R. 386. Dr. Greene scheduled Jayne an appointment with Pain Management. Dr. Greene discontinued prescriptions for gabapentin and prescribed tramadol. R. 384.

         On April 8, 2015, state agency psychologist Dr. David L. Biscardi, Ph.D., prepared a Psychiatric Review Technique for Jayne. R. 111-12. Dr. Biscardi opined that Jayne suffered from an affective disorder and an anxiety disorder. Dr. Biscardi opined that her mental impairments caused mild limitations in her activities of daily living and her ability to maintain social functioning, and moderate limitations in her ability to maintain concentration, persistence, or pace. R. 112.

         On April 23, 2015, Jayne saw Dr. Greene. Jayne said she went to pain management. The pain management heath care professional offered her physical therapy, but she refused. The pain management health care professional refused to give her narcotic pain medication because Jayne had a history of cocaine addiction in her past. The pain management providers also set Jayne up for spinal injections. Jayne complained of continuing pain in her right shoulder. She reported that she could not lift her right arm above her head. R. 388. On a review of symptoms, Dr. Greene said that Jayne had little interest or pleasure in doing things, but did not feel down, depressed, or hopeless. R. 389. On examination, Jayne's gait, spine, and extremities were normal, except her shoulders. Jayne's right shoulder had decreased range of motion and crepitus and her left shoulder had crepitus but better range of motion. Jayne was oriented with normal insight and judgment and appropriate mood and affect. R. 390.

         Dr. Greene ordered an MRI of her right arm and also started Jayne on Zoloft for depression. Jayne was also taking trazadone ...


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