Lindsey v. Comm'r of Soc. Sec. Admin., CASE NO. 1:18CV2158
| Decision Date | 04 October 2019 |
| Docket Number | CASE NO. 1:18CV2158 |
| Parties | ANITA LINDSEY, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant. |
| Court | U.S. District Court — Northern District of Ohio |
MEMORANDUM OPINION & ORDER
Plaintiff Anita Lindsey ("Lindsey") seeks judicial review of the final decision of Defendant Commissioner of Social Security ("Commissioner") denying her application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). Doc. 1. This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned Magistrate Judge pursuant to the consent of the parties. Doc. 13.
As set forth below, the ALJ did not sufficiently explain or support his decision with respect to the opinion of Lindsey's treating physician, Dr. Tone, and Lindsey's use of an assistive device. Accordingly, the Commissioner's decision is REVERSED and REMANDED for proceedings consistent with this opinion.
In February 2015, Lindsey filed applications for DIB and SSI, alleging a disability onset date of July 26, 2014. Tr. 15, 1316. She alleged disability based on the following: fecal incontinence and osteoarthritis. Tr. 1321. After denials by the state agency initially (Tr. 1131, 1132) and on reconsideration (Tr. 1167, 1168), Lindsey requested an administrative hearing. Tr. 1193. A hearing was held before an Administrative Law Judge ("ALJ") in December 2016; that ALJ subsequently became unavailable to adjudicate the claim and Lindsey had a second hearing before a different ALJ on December 15, 2017. Tr. 15, 1056-1112. In his February 28, 2018, decision (Tr. 15-29), the ALJ determined that there are jobs that exist in the national economy that Lindsey can perform, i.e., she is not disabled. Tr. 28-29. The Appeals Council denied Lindsey's request for review, making the ALJ's decision the final decision of the Commissioner. Tr. 1-4.
Lindsey was born in 1967 and was 47 years old on her alleged disability onset date. Tr. 27. She previously performed work as a hand packager, security guard, cashier, laborer, and nurse assistant. Tr. 27. She has a GED and last worked in 2014. Tr. 1065, 1077.
In February 2014, an x-ray of Lindsey's cervical spine showed limited discogenic disease at C4-5. Tr. 1583. She was diagnosed with cervical spondylosis without myelopathy; her other diagnoses at the time included benign hypertensive heart disease, insomnia, and chronic pain syndrome. Tr. 1583. She saw a pain management doctor, took medications, and her last visit was about four months prior. Tr. 1583.
On April 18, 2014, Lindsey visited the emergency room after she fell and injured her left knee. Tr. 1705. She also reported that her knees had been locking up for the past two days. Tr. 1705. An x-ray was normal and she was diagnosed with a knee sprain. Tr. 1703. On April 22, she followed up with pain management. Tr. 1703. Upon exam of her knee, she had mildswelling, no warmth compared to her right knee, tenderness, flexion and extension limited due to pain, negative stress tests, a positive McMurray's sign, patellar grind, and, in her upper and lower extremities, normal reflexes, sensation, and fine coordination. Tr. 1705. An MRI was ordered to rule out a meniscal injury and she was prescribed physical therapy for both knees, bilateral knee sleeves, Percocet, and an Ace bandage was applied. Tr. 1705. A few hours later she saw physical medicine and rehabilitation; she was noted to be a fall risk due to an unsteady/shuffling gait or crutch. Tr. 1703.
On May 5, Lindsey began physical therapy. Tr. 1701. Her status was full weight bearing and she reported bilateral knee pain worse with weight bearing. Tr. 1701. She reported difficulty with any activities that required her to stand still for an extended period of time. Tr. 1701. Upon exam, she had mild edema in her left knee and was wearing a brace on it, she had tenderness in both knees, decreased weight bearing on the left lower extremity, intact sensation, decreased range of motion in her left knee compared to her right, and decreased functional mobility. Tr. 1702. Her prognosis was good. Tr. 1702. By June 30 she ambulated with a normal gait and without an assistive device. Tr. 1695.
In July 2014 she visited her primary care physician for a blood pressure check. Tr. 1544. She reported that her Neurontin was not working as well as before for her neck and back pain. Tr. 1544. Upon exam, she had a decreased range of motion in her cervical spine and bony tenderness. Tr. 1546.
On August 12, 2014, Lindsey went to the emergency room for fecal incontinence. Tr. 1690. She followed up with a neurologist, who referred her to gastroenterology, whom she saw in September. Tr. 1685-1687; 1676-1678. She also was seen by urology and gynecology. Tr. 1620. She was diagnosed with fecal incontinence and prescribed incontinence supplies. Tr.1664-1666, 1687. She continued to visit the emergency room for this problem. See, e.g., Tr. 1666.
At her final physical therapy appointment on December 19, her gait was grossly within functional limits and not antalgic. Tr. 1631-1632. Her left knee strength and range of motion was significantly improved and she had improved functional mobility patterns; her goal for pain was not met. Tr. 1633. She was discharged independent with her home exercise program and deemed capable of self-management with her home exercise program. Tr. 1632.
On February 3, 2015, Lindsey received an epidural steroid injection to her cervical spine at level C6-7. Tr. 1830.
On February 6, Lindsey saw internal medicine for a follow up and reported feeling down and asked to see a psychiatrist. Tr. 1826. She was taking Wellbutrin for smoking cessation and depression. Tr. 1826.
On February 26, Lindsey visited the medical clinic for a follow up complaining of pain and fecal incontinence. Tr. 1619. Her incontinence was getting worse; she had a part-time job at McDonald's and she did not feel that she could "hold [her job] down for now" due to her symptoms. Tr. 1619. Upon exam, she had a normal, "not unsteady" gait that was slow due to pain. Tr. 1620. She was assessed with diffuse pain that did not seem to be related to her cervical spine problem for which she received injections. Tr. 1620. She had an upcoming rheumatology appointment. Tr. 1620. She requested a cane; a cane was ordered and she was referred to physical therapy to learn how to use the cane correctly. Tr. 1620.
On March 11, 2015, Lindsey saw a rheumatologist complaining of body pain all over: back, arms, legs, feet, fingers. Tr. 1616. She sometimes could not get out of bed. Tr. 1616. It had been ongoing for two years on and off, worse with cold. Tr. 1616. She could not walk forlong distances and was unable to sit more than 20 minutes without shooting pain down her legs. Tr. 1616. She was tired all the time and did not sleep well. Tr. 1616. Upon exam, she had diffuse tender points, restricted range of motion of her neck and shoulders, and otherwise no limitations in the range of motion in her joints and no swelling or warmth. Tr. 1618. The rheumatologist felt she had a central sensitization syndrome with severe fatigue and multiple tender points suggesting fibromyalgia. Tr. 1618. She was recommended to exercise on a daily basis, improve sleep hygiene/have a sleep study, and consider switching antidepressants. Tr. 1618.
On March 16, 2015, Lindsey visited the pain management clinic; she was noted to be a fall risk due to her use of a cane. Tr. 1611. Upon exam, she had tenderness in her cervical spine with some evidence of spasm and muscle tightness, normal neck flexion and extension but rotation was limited due to pain. Tr. 1614. Her knees had mild swelling, no warmth, were tender to palpation, had a decreased range of motion due to pain, and a positive McMurray's sign and patellar grind test. Tr. 1614. Her sensation, motor strength, and fine coordination were normal. Tr. 1614. She was diagnosed with chronic bilateral knee pain secondary to degenerative changes and chronic cervical spine pain most likely due to degenerative changes and exacerbated by poor posture and muscle spasm. Tr. 1614.
On March 19, Lindsey underwent an endoanal ultrasound and urodynamics evaluation for urinary and fecal incontinence. Tr. 1790-1791, 1797. She was found to have a hypersensitive bladder of low normal bladder capacity and normal compliance; she was not a candidate for sphincteroplasty (a surgical procedure) and was diagnosed with mixed incontinence. Tr. 1790, 1798. The next day Lindsey saw her internal medicine doctor complaining of insomnia. Tr. 1787. She complained of new pain in both hands. Tr. 1787. Her physician noted that herfibromyalgia was likely made worse with depression and, per the rheumatologist's recommendation, he switched Lindsey's antidepressant to Cymbalta. Tr. 1787.
On April 27, Lindsey underwent a hysterectomy, which she requested due to ongoing dysmenorrhea. Tr. 1774, 1780, 1783.
On May 22, 2015, Lindsey had a follow-up in the URO/GYN department and was doing well. Tr. 1762-1763. Then she had a neurology visit; her neurological exam was normal and she had a narrow-based, antalgic gait. Tr. 1768. The impression was fibromyalgia. Tr. 1769. The next day she had a pain management visit. Tr. 1758. She stated that she had lost the last Vicodin prescription she had received, but the provider found that it had been filled and that Lindsey had had two more prescriptions since then; therefore, the provider did not refill her prescription. Tr. 1759. Upon exam, she had tenderness of her cervical spine at C7 level, some evidence of spasm and focal muscle tightness; mild swelling of her knees; her left knee had pain on range of motion, tenderness to palpation, and a positive McMurray's sign; and her neurological exam was normal. Tr. 1762. The impression was bilateral knee pain...
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