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Michelle M. v. Saul

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

December 5, 2019

Michelle M., Plaintiff,
Andrew Saul, Commissioner of Social Security, Defendant.


          Lisa A. Jensen, United States Magistrate Judge.

         Plaintiff Michelle M. alleges that ongoing pain, numbness, and tingling in her back, elbows, hips, hands, and feet prevent her from working full-time. Plaintiff's doctors have offered a series of possibly overlapping diagnoses to explain her symptoms-including degenerative disc disease, fibromyalgia, psoriatic arthritis, diabetes, and carpal tunnel syndrome in her right hand. But no single consistent diagnosis has yet been settled upon. Plaintiff's treatment mostly took place in the two years leading up to her hearing, and this treatment occurred on a parallel track with the progression of her legal case at the administrative level. For example, she first began seeing a pain management specialist just a month before the hearing. The late-breaking nature of this treatment complicated the adjudication of plaintiff's claim, mainly because 200 pages of treatment records were submitted after the State agency doctors rendered their opinions.

         The administrative law judge (“ALJ”) found that plaintiff was not disabled based on two main rationales: (1) the objective medical evidence-x-rays, MRIs, physical examination findings-indicated only mild problems; and (2) plaintiff had limited treatment that was likewise consistent with only mild problems. Plaintiff raises numerous arguments for remand, but her most encompassing argument is that the ALJ improperly “played doctor” repeatedly throughout the five-step analytical process. The Government's main counter-argument is that any possible errors were harmless. After reviewing the briefs, the Court does not agree with all or even most of plaintiff's contentions, but finds that overall plaintiff has raised enough-just enough- concerns and questions to justify a remand.


         Although plaintiff has stated that some of her problems may have been present since birth or even caused by a fall when she was six years old, the relevant medical history for our purposes begins in late December 2014 when plaintiff stopped working because of her health problems. Her primary physician was Dr. Schock. However, because plaintiff lost her health insurance when she stopped working, she had to switch doctors. R. 55. She then began seeing Dr. Dennis Norem who oversaw her care in 2015 and 2016. Plaintiff saw him six times in total.

         On March 17, 2015, plaintiff filed disability applications under Title II and XVI. Plaintiff was then 36 years old.

         On July 13, 2015, plaintiff was examined by Dr. K.P. Ramchandani, a consultative examiner, who prepared a report that was later relied on by the two State agency doctors. He made the following findings, among others:

[Plaintiff's] gait is normal, unassisted. She is able to walk on heels and toes. She is able to squat and get up from squatting position without support. She is able to get on and off the examination table without assistance and dress and undress without assistance. She is right-handed. Her grip is 5/5 bilaterally. She is able to make a fist, pick up objects, open and close the door, oppose the thumb to fingers, and flip pages.
Motor system: Power is 5/5 with normal tone and muscle mass in all 4 extremities. Sensory system: She has tingling in right hand on tapping the right flexor aspect of right wrist joint, no deficit to touch and pinprick in all 4 extremities. Deep tendon reflexes are 2, going down plantars bilaterally.

R. 368.

         On August 6, 2015, Dr. Towfig Arjmand, a State agency physician, opined that plaintiff had the residual functional capacity (“RFC”) to do medium work with certain limitations. Exs. 1A, 2A.

         On August 17, 2015, Dr. Norem completed a four-page RFC questionnaire, offering various assessments which, if credited, would support a finding of disability. Ex. 7F.[2]

         On September 23, 2015, Dr. Victoria Dow, another State agency physician, issued an opinion. Exs. 5A, 6A. Dr. Dow found that plaintiff had the RFC to do light work, which differed from Dr. Arjmand's finding that plaintiff could do medium work. Dr. Dow indicated that she had reviewed recent x-rays not reviewed by Dr. Arjmand. R. 101.

         Dr. Norem eventually referred plaintiff to Dr. Hovis, a rheumatologist. At a visit on September 23, 2015, plaintiff reported that she was taking several medications (Gabapentin, Tramadol, and Ibuprofen), but they had not been effective. R. 426. On examination, Dr. Hovis noted that plaintiff had no synovitis, pain, or impaired range of motion, but the doctor did observe a number of positive tender points. R. 429. Dr. Hovis noted that plaintiff had “[n]o active Psoriatic arthritis at this time” and concluded that her pain was “probably related to fibromyalgia.” R. 430. Dr. Hovis recommended Effexor to treat the fibromyalgia. Id.

         Plaintiff saw Dr. Hovis again on January 13, 2016, and reported that the Gabapentin and Effexor did not help and made her “feel foggy.” R. 421. Dr. Hovis again observed that there was no evidence of psoriatic arthritis but that there was ongoing fibromyalgia. R. 422. Dr. Hovis advised plaintiff to do low impact exercises. Id. It does ...

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