Williams v. Saul

PATRICIA D. WILLIAMS, Plaintiff, v. ANDREW M. SAUL, Commissioner of Social Security, Defendant.

No. 2:19-CV-88 RLW

UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI NORTHERN DIVISION

March 31, 2021

MEMORANDUM AND ORDER

Plaintiff Patricia D. Williams brings this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) for judicial review of the Commissioner's final decision denying her applications for disability insurance benefits (DIB) under Title II of the Social Security Act, 42 U.S.C. §§ 401, et seq., and for supplemental security income (SSI) under Title XVI of the Act, 42 U.S.C. §§ 1381, et seq. For the reasons that follow, the decision of the Commissioner is reversed.

I. Procedural History

Plaintiff filed her application for DIB on April 4, 2017, and on May 6, 2017, she filed for SSI. (Tr. 200-8). Plaintiff alleged she had been unable to work since March 6, 2017, due to pancreas divism, irritable bowel syndrome (IBS), migraines, fibromyalgia, sphincter of the oddi dysfunction, depression, and anxiety. (Tr. 237). Plaintiff later amended her onset date to May 5, 2017. (Tr. 220). Plaintiff's application was denied on initial consideration, and she requested a hearing before an Administrative Law Judge ("ALJ"). Plaintiff and counsel appeared for a hearing on October 25, 2018. (Tr. 66-102). Plaintiff testified concerning her disability, daily activities, functional limitations, and past work. Id. The ALJ also received testimony from vocational expert ("VE") Elizabeth Wheeler. Id. On March 15, 2019, the ALJ issued an unfavorable decision finding Plaintiff not disabled. (Tr. 15-28). On May 14, 2019, Plaintiff filed a request for review of the ALJ's decision with the Appeals Council. (196-96). On October 28, 2019, the Appeals Council denied Plaintiff's request for review. (Tr. 1-6).

In this action for judicial review, Plaintiff claims that the ALJ's decision is not supported by substantial evidence on the record as a whole. Specifically, Plaintiff argues that the ALJ improperly weighed the opinion evidence from her treating physician. Plaintiff also argues that the ALJ erred in assessing her RFC and that it was not properly supported by evidence in the record. Plaintiff requests that the decision of the Commissioner be reversed, and that the matter be remanded for an award of benefits or for further evaluation.

II. Evidence Before the ALJ

A. Relevant Medical Evidence¹

Relevant medical evidence in the record indicates that on September 6, 2016, plaintiff presented to J. Tod Sylvara, D.O., at the LaPlata Family Clinic for sore throat and feeling rundown.² At the time she was being prescribed Zoloft, Ambien, Naprosyn, and Buspar. Plaintiff was assessed as having an abscess and was referred to an ENT. (Tr. 379).

On February 24, 2017, Plaintiff underwent a fiberoptic larngopharngoscopy, the results of which were normal. Plaintiff's chief complaint was swollen lymph nodes on both sides of her neck. It was noted in the treatment records that Plaintiff complained of daily flu-like symptoms since August 2016. (Tr. 420)

On February 27, 2017, plaintiff was seen at urgent care at Complete Family Medicine complaining of general muscle aches, joint pain, and fatigue which were ongoing for seven months. (Tr. 452). Plaintiff was prescribed Vivlodex and referred for an appointment with a rheumatologist. (Tr. 455)

On March 7, 2017, Plaintiff was seen by Veysel Tahan, M.D., at the UP-Digestive Health Clinic with a chief complaint of diarrhea, which had started in August 2016. She was referred for a colonoscopy and stool study. (Tr. 414)

Plaintiff return to Dr. Sylvara on March 13, 2017, for body aches, joints hurting, extreme fatigue, headaches and dizziness. Some of Dr. Sylvara's notes are illegible, and for Plaintiff's assessment the doctor wrote, "HRN." (Tr. 377). The Court is unfamiliar with this abbreviation.

Plaintiff was seen in the ER on March 20, 2017, for abdominal, joint, and back pain. She described the pain as unbearable. She stated that she attempted to see her attending doctor but was referred to the ER. The ER ran some laboratory tests, which were unremarkable. Plaintiff was given PO Norco for pain. A follow up was scheduled with a rheumatologist. (Tr. 408).

An endoscopy and colonoscopy were performed in March 2017. Results from pathology noted Plaintiff had benign duodenal mucosa with changes suggestive of chronic duodenitis. She also had benign colonic mucosa with no histopathologic abnormality, and mild chronic antral and oxyntic gastritis without activity. (Tr. 398, 403).

On April 1, 2017, Plaintiff returned to Dr. Sylvara for chest pain. She stated it hurt to take deep breaths, and she was unable to eat and keep food down. She was assessed as having gastroenteritis and was treated with Zofran, Tylenol, and increased fluids. (Tr. 375).

Plaintiff was seen by Bhagirath Katabamna, M.D., at the Hannibal Clinic on April 6, 2017. (Tr. 479). Plaintiff complained of nausea and loose stools. The physician wrote "She probably has some sort of functional dyspeptic type symptoms. She is also was worried about connective tissuedisease and that she might have lupus. A sphincterotomy of the minor papula." (Tr. 480). The treatment plan was for Plaintiff to take Lactaid every day for a week and antinausea medication.

On April 18, 2017, Plaintiff was seen by Celso Raul Velazquez, M.D., for a rheumatology consult. Plaintiff's chief complaint was chronic pain. Dr. Velazquez wrote the following summary of Plaintiff's history:

[Plaintiff] is a 42-year-old Caucasian lady who describes fatigue and feeling rundown since last year August and pain all over her body since the beginning of this year. She describes pain in her joints including ankles, knees, hips, elbows primarily but then all her joints hurt on and off. She also describes pain in her muscles from her neck up to back, arms and thighs. She describes the pain in her joints as dull ache which is present both in the morning and in the evening. Physical activity makes it worse. Nothing seems to make it better. She also describes tingling in her hands on and off. She has noticed burning of her skin as well now and then and sometimes her clothes hurt as well. She also has been having difficulty in concentrating and memory. She describes extreme fatigue and low-grade fever of 99-100. She has also noticed night sweats and difficulty falling and staying asleep and weight gain of 15 pounds over the last 6-7 months. ... She denies any chest pain but endorses shortness of breath and cough productive of occasional brownish phlegm. She has history of IBS and gets abdominal pain associated with nausea, vomiting and heartburn. She also gets diarrhea on and off but no hematochezia. No history of Dysuria or hematuria. She gets almost daily headaches since the beginning of this year in the front or occipital region. ...

(Tr. 385-86).

On physical exam, Plaintiff had "exquisite tenderness to palpation in the upper back, mid back, lower back, arms, thighs and legs. Tenderness to palpation in bilateral hands, wrists, elbows, feet and ankles. No synovitis of any joint noted. Range of motion of all joints is within normal limits." (Tr. 387). Dr. Velazquez wrote he believed Plaintiff's symptoms were most suggestive of fibromyalgia. (Tr. 388). Different treatment options were discussed, including atrial for Cymbalta. It was noted that Plaintiff may benefit from either gabapentin or Lyrica. Nonpharmacological treatments were also discussed, including regular exercising, stretching, and water therapy. (Tr. 388).

On April 26, 2017, Plaintiff presented to the Complete Family Medicine Clinic for muscular skeleton pain over her entire body. Plaintiff was seen by a nurse practitioner, Donna Whitely, FNP. "Plaintiff states that she was seen by her rheumatologist with no relief. She states that she will need refills if we don't change up her medications." (Tr. 444). She was prescribed Amitriptyline, cyclobenzaprine, and Neurontin. (Tr. 445).

Plaintiff returned to the Complete Family Medicine Clinic on May 2, 2017, and she underwent an EKG and bloodwork. (Tr. 439). Plaintiff returned on May 10, 2017, for follow up with lab tests. It was noted in her chart that there was an onset of fibromyalgia_one month ago. (Tr. 432). Plaintiff stated she could sleep 24 hours a day. Plaintiff had elevated triglycerides, a vitamin D deficiency, and thrush.

Plaintiff was seen by Umar Daud, M.D., at the Hannibal Clinic as a new patient on May 19, 2017, "to rule out lupus." (Tr. 484). Plaintiff complained of body aches and joint pain in her elbows, knees, ankles, and hips. She complained of muscle pain, numbness and tingling, elevated blood pressure, low grade fever, puffy eyelids, fatigue, migraines, ringing in her ears, dry eyes, dizziness, tongue tingling, dropping things, and trouble with formation of speech. (Tr. 485). Upon exam, Plaintiff's strength was five out of five in all extremities and equal in distribution, with no spinal tenderness. The doctor reviewed the test results and medical records Plaintiff brought with her. He wrote that Plaintiff had positive ANA with multiple symptoms. "Some are suggestive of autoimmune disease and some are suggestive of chronic pain syndrome and fibromyalgia." (Tr. 487). Dr. Duad referred Plaintiff for further lab testing and wrote that a follow up plan would be developed following the results.

Plaintiff returned to Complete Family Medicine on June 9, 2017, for a nurse visit with Ms. Whitley. She complained of musculoskeletal pain and vomiting. She stated the severity level was moderate, and that the pain was constant in her back, arms, legs, and shoulders. The pain was alsodescribed as piercing and sharp, with no injury. "Associated symptoms include decreased mobility and limping." (Tr. 492). Plaintiff was instructed to discontinue use of ibuprofen and to use Tylenol instead when taking Mobic. She was instructed to return to the clinic if her symptoms worsened. Plaintiff's...