Rector v. Commissioner of Social Security Administration

          ORDER

          Leslie A. Bowman United States Magistrate Judge

         The plaintiff filed this action for review of the final decision of the Commissioner for Social Security pursuant to 42 U.S.C. § 405(g). (Doc. 1, p. 2)

         The Magistrate Judge presides over this case pursuant to 28 U.S.C. § 636(c) having received the written consent of both parties. See Fed.R.Civ.P. 73; (Doc. 15)

         The ALJ in this case failed to give specific and legitimate reasons for discounting the opinion of the treating physician. The case is remanded for payment of benefits.

         PROCEDURAL HISTORY

         On January 17, 2014, Rector filed an application for disability insurance benefits pursuant to Title II of the Social Security Act. (Tr. 21) She alleged disability beginning on March 22, 2013, due to fibromyalgia, pacemaker, chronic pain, restless body syndrome, diverticulitis, anxiety, panic attacks, cognitive problems, forgetfulness-poor memory, and fatigue. (Tr. 179, 180)

         Her application was denied initially and upon reconsideration. (Tr. 106-113) Rector requested review and appeared with counsel at a hearing before Administrative Law Judge (ALJ) Yasmin Elias on September 19, 2016. (Tr. 36) In her decision, dated January 11, 2017, the ALJ found Rector was not disabled because, considering her age, education, work experience, and residual functional capacity, she could work as an accounts investigator or a store facility rental clerk. (Tr. 21-29)

         Rector appealed, but on September 22, 2017, the Appeals Council denied review making the decision of the ALJ the final decision of the Commissioner. (Tr. 1-4) Rector subsequently filed this action seeking review. (Doc. 1)

         Claimant's Work History and Medical History

         Rector was 44 years old at the hearing before the ALJ. (Tr. 42) She has an associates degree in nursing and worked as a certified nurse assistant, a registered nurse, and a nursing director. (Tr. 42) She stopped working on March 22, 2013 after an episode of pain, fatigue, lightheadedness, and dizziness. (Tr. 42-43) She also was having cognitive or memory problems. (Tr. 43)

         Rector subsequently sought treatment from her primary care physician, Jeffery Bushman, D.O., for what she believed was trouble with her pacemaker. (Tr. 340, 341, 343) On May 14, 2013, rheumatologist Augusto Posadas, M.D., observed 16 of 18 trigger points and diagnosed arthralgia (joint pain), fibromyalgia, and fatigue. (Tr. 290)

         On May 30, 2013, Bushman observed 16 of 18 trigger points and diagnosed cardiac dysrythmia, fibromyalgia, restless leg syndrome, and depression. (Tr. 338) The medical record contains additional treatment notes from May of 2013 through August of 2016. (Tr. 305-419, 458-487, 616-629) During this time, Bushman prescribed a series of medications in the hopes of ameliorating Rector's pain and other symptoms while minimizing adverse side-effects. Id. At various times, Rector was taking Cymbalta, Sinemet, Xanax, Norco, Butrans patches, Nortriptyline, Zoloft, hydrocodone, gabapentin, Fentanyl patches, Vicodin, Valium, Ambien, lamotrigine, clonazepam, Oxycontin, alprazolam, Flexeril, and Lyrica. (Doc. 18, pp. 3-7); see also (Tr. 26); (Doc. 17-3, p. 27)

         Rector was hospitalized from May 31 to June 3, 2014 for confusion resulting from a two-week incident of diarrhea. (Tr. 492-502) She presented to the emergency room on July 3, 2016 and again on July 9, 2016 for low back pain radiating to her legs. (Tr. 546, 540)

         On July 29, 2016, Rector was evaluated by Mateja de Leonni Stanonik, M.D., Ph.D., for progressive memory loss for over three years. (Tr. 693) Leonni Stanonik diagnosed idiopathic epilepsy, amnesia, adjustment disorder with anxiety, and cervical and lumbar spondylosis. (Tr. 694)

         In February of 2014, Bushman completed an assessment of Rector's physical abilities. (Tr. 296) He opined that she could lift and/or carry 20 pounds occasionally and less than 10 pounds frequently. (Tr. 296) She could stand and/or walk for less than 2 hours in an 8-hour day. (Tr. 296) She could sit for 4 hours in an 8-hour work day. (Tr. 296) She must alternate between sitting and standing every 30-60 minutes. (Tr. 296) She should never climb, balance, stoop, kneel, crouch, or crawl. (Tr. 297) She should only occasionally handle or reach with either hand. (Tr. 297)

         In July of 2014, Richard M. Palmer, M.D., examined Rector for the state disability determination service. (Tr. 420) He diagnosed fibromyalgia, implanted pacemaker, tachycardia by history, chronic low back pain and left sciatica, chronic right and left knee pain, chronic fatigue, sleep dysfunction, and “overweight.” (Tr. 424) He opined that she could lift 20 pounds occasionally and 10 pounds frequently. (Tr. 424-425) She could stand and/or walk for 6-8 hours in an 8-hour day. (Tr. 425) She could sit for 6-8 hours in an 8-hour day. (Tr. 425) She should never climb ladders, rope, or scaffolds. (Tr. 426) She should only occasionally climb ramps or stairs, kneel, crouch, or crawl. (Tr. 426)

         At the hearing before the ALJ, Rector testified that she has pain and fatigue. (Tr. 42) She has joint pain in her elbows, wrists, hips, knees, and ankles. (Tr. 44-45) This joint pain can flare up two or three times a month for typically two to three days at a time. (Tr. 45) Rector testified that she has good days as well as bad ones. (Tr. 46) But if she tries to work around the house on one of her good days, she will be in bed for the next day or so recuperating. (Tr. 46) Even on an average day, she must lie down three to four times for 30 minutes to an hour each time. (Tr. 54)

         Rector also has cognitive or memory problems. (Tr. 43) She could watch a movie with her husband and a week or two later forget that she saw it. (Tr. 36) She forgot to pick up her son at the bus stop a couple of times, thinking she already got him. ...