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Lynette C. v. Saul

United States District Court, N.D. Illinois, Eastern Division

October 23, 2019

LYNETTE C., Plaintiff,
ANDREW M. SAUL, Commissioner of the Social Security Administration[1], Defendant.


          Susan E. Cox, United States Magistrate Judge.

         Plaintiff Lynette C.[2] appeals the decision of the Commissioner of the Social Security Administration (“Commissioner”) denying her disability benefits. The parties have filed cross motions for summary judgment.[3] As detailed below, the Court grants Plaintiff's motion for summary judgment [dkt. 15], denies the Commissioner's motion for summary judgment [dkt. 23], and remands this matter for further proceedings.

         I. Background

         a. Procedural History

         Plaintiff applied for Disability Insurance Benefits on October 17, 2012, alleging a disability onset date of July 1, 2010, which she later amended to January 24, 2012. [R. 116, 226]. On April 21, 2015, after an administrative hearing, Administrative Law Judge (“ALJ”) Edward P. Studzinski issued an unfavorable decision. [R 23-40.] Plaintiff requested Appeals Council review, which was denied on October 21, 2016. [R. 1-4.] On December 20, 2016, Plaintiff filed an action in the Northern District of Illinois (No. 16-cv-11504), and on September 25, 2017, Magistrate Judge M. David Weisman found in favor of the Plaintiff and remanded the case for a new hearing and decision.[4] [R. 896-913.] Consequently, the Appeals Council remanded the case on December 18, 2017. [R. 919-22.] On April 11, 2018, Plaintiff again appeared with counsel and testified at a second hearing before ALJ Studzinski. [R. 825-867.] A vocational expert (“VE”) also testified, as well as a witness for Plaintiff. Id. On July 26, 2018, ALJ Studzinski issued another unfavorable decision, again determining that Plaintiff was not disabled. [R. 795-821.] On July 31, 2018, the Appeals Council issued a decision affirming the ALJ's July 26, 2018 decision. [R. 795-97.] Thus, the Decision of the Appeals Council is the final decision of the Commissioner. Plaintiff filed the instant action on November 12, 2018, seeking review of the Commissioner's most recent decision. [Dkt. 1.]

         b.Relevant Medical Background

         Plaintiff was born in 1963 and was 48 years old on her amended alleged disability onset date. [R. 227.] Plaintiff is a registered nurse, and throughout her work life has worked in that capacity, as well as working as a nurse practitioner, and teaching nursing classes at Morton Junior College; Plaintiff alleges she worked until she became unable to because of her symptoms. [R. 50, 463.] What follows is an abbreviated version of Plaintiff's medical history.

         In November 2009, Plaintiff reported to Dr. Kevin Reitsma, D.O. that she had been experiencing several months of burning left-sided pain. [R. 338.] Plaintiff was diagnosed with paresthesias, and by January 2010, the burning pain was lasting all day. [R. 338, 340.] Throughout 2010 and 2011 she saw specialists in neurology and rheumatology and was prescribed multiple medications, but found no significant relief. [R. 346-47, 350, 352, 356, 358, 360.] In late 2011 and early 2012, imaging showed degenerative cervical and lumbar spine changes, including bulging discs at ¶ 4-5, C5-6, and L5-S1; facet arthropathy at ¶ 1-L4, and L5-S1 causing bilateral neural foraminal narrowing at ¶ 5-S1; and a posterior annular tear at ¶ 5-S1. [R. 389, 395.] She also suffered insomnia and was prescribed Ambien, with varying benefit. [R. 352, 354, 356, 361.] Throughout 2012, Plaintiff continued to see Dr. Reitsma for burning pain and tingling, and insomnia [R. 363, 367-68, 370, 373.] In January 2012, Dr. Reitsma also diagnosed Plaintiff with skin dysesthesias and cervical disc herniations. [R. 363, 370, 373.]

         In January 2012, Plaintiff began seeing Dr. Donald Roland, M.D., a pain specialist. [R. 410.] Plaintiff reported constant burning pain all over, including her back, legs, feet, neck, shoulders, arms, and hands; weakness; difficulty sleeping; and dizziness and falls. [R. 410, 422, 436, 448, 452.] In February 2012, an EMG demonstrated C6 and L5 radiculopathy. [R. 435.] Dr. Roland diagnosed Plaintiff with dysesthesias, lumbago, sciatica, persistent low back pain, lumbar radiculopathy, thoracic pain, cervicalgia, unspecified brachia neuritis, myopathy, and possible myofascial pain syndrome or fibromyalgia pain. [R. 411, 436, 444, 449, 453.]

         In October 2012, Plaintiff was evaluated at Mayo Clinic by neurologist, Dr. Benn E. Smith, M.D. [R. 461.] Plaintiff let Dr. Smith know, inter alia, she had problems sleeping, had excessive daytime somnolence, and felt overwhelmed, tired, or fatigued. [R. 464.] Imaging of her thoracic spine demonstrated mild degenerative disc disease at ¶ 10-11 and T11-12, and a broad based disc bulge, at ¶ 11-12, minimally contouring the ventral thecal sac. [R. 733.] In her lumbar spine she had early changes of facet arthropathy at ¶ 1-2, L2-3, and L3-4; mild disc degeneration, a broad based disc bulge mildly narrowing the caudal aspect of the left neural foramen, and mild facet arthropathy, at ¶ 4-5; and at ¶ 5-S1, mild disc degeneration, a broad based disc bulge mildly narrowing the caudal aspects of the neural foramen, with posterior right annular tear, small disc protrusion, and mild bilateral facet arthropathy. Id. Her cervical spine demonstrated minimal central disc protrusions at ¶ 4-5 and C5-6. [R. 734.] Following an autonomic reflex screen and quantitative sensory testing, Dr. Smith assessed pure, or predominantly, small-fiber peripheral neuropathy. [R. 467.] Dr. Smith's next step was to try to determine and treat the cause, but he noted that 50-75% of the time, no specific etiology is found. Id. In early 2013 Plaintiff reported that her Zanaflex prescription helped manage her pain, but made her tired; other medications failed to provide relief. [R. 499.] Dr. Reitsma then assessed small-fiber peripheral neuropathy, with neuropathic pain, and autonomic dysfunction. [R. 518.]

         Plaintiff began treatment with Dr. Arpan Patel, M.D. at Premier Pain Specialists in January 2013. [R. 778.] During appointments through March 2015, she reported, inter alia, diffuse pain in her upper and lower extremities, abdomen, back, and chest; burning pain, which was worse with light touch; and trouble sleeping. [R. 778, 781, 783, 789.] Dr. Patel diagnosed Plaintiff with unspecified neuralgia, neuritis, and radiculitis; chronic pain syndrome; and thoracic spine pain [R. 779, 782, 783-84, 790.] He indicated Plaintiff was suffering from small fiber neuropathy, autonomic instability, and possibly sympathetically mediated pain involving mainly axial locations, [5] including the lumbar and thoracic spinal region and abdomen, of unknown etiology. Id. Dr. Patel opined there was a large component of both stress-induced and stress-mediated pain symptoms, and possibly somatoform disorder.[6] [R. 790.]

         Plaintiff also saw internist Dr. Lance Wallace, M.D., beginning in November 2013. [R. 521-22.] Plaintiff reported burning pain, difficulty sleeping, and had pain to light touch of the stethoscope. [R. 521; 523.] Dr. Wallace diagnosed Plaintiff with small-fiber polyneuropathy, chronic burning pain, neuralgia, radiculopathy, insomnia, and seizure. [R. 521, 523-24, 739.]

         Plaintiff continued to display many of the same symptoms following her date last insured. During appointments at Pain Specialists from April 2015 through February 2018 (the latest date for which we have records), Plaintiff had, inter alia, continued pain under her breast, radiating to her flank, her left side, abdomen, upper back, thoracic spine/mid back, lower back, and feet. [R. 792, 1098, 1542, 1546, 1550, 1554, 1557, 1560, 1563, 1566, 1569, 1572, 1575, 1578, 1581, 1584, 1587, 1590, 1592-93, 1596, 1599, 1603, 1607, 1610, 1613, 1616.] She also had continued complaints of difficulty sleeping, which caused her to feel groggy during the day. [R. 792, 1590, 1593, 1603.] Plaintiff was diagnosed with unspecified neuralgia and neuritis, fibromyalgia, chronic pain syndrome, thoracic spine pain, low back pain, uncomplicated opioid dependence, depression, small fiber neuropathy, autonomic instability, and possible sympathetically mediated pain (unsure etiology, involving mainly the thoracic and lumbar region and abdomen). [R. 793, 1098-1100, 1543, 1547, 1551, 1555, 1558, 1561, 1564, 1567, 1570, 1573, 1576, 1579, 1581-82, 1584-85, 1588, 1591, 1594, 1597, 1600, 1604, 1608, 1610-11, 1614, 1616-17.] A large component of pain was attributed to stress, and possibility some symptoms due to somatoform disorder. Id.

         c. The ...

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