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Johnson v. Berryhill

United States District Court, E.D. Missouri, Eastern Division

May 29, 2019

ANGELA C. JOHNSON, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM

          DAVID D. NOCE UNITED STATES MAGISTRATE JUDGE.

         This action is before the court for judicial review of the final decision of the defendant Commissioner of Social Security denying the applications of plaintiff Angela C. Johnson for disability insurance benefits under Title II of the Social Security Act (Act), 42 U.S.C. §§ 401-434, and for supplemental security income benefits under Title XVI of the Act, 42 U.S.C. §§ 1381-1385. The parties have consented to the exercise of plenary authority by the undersigned United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, the final decision of the Commissioner is reversed and remanded.

         I. BACKGROUND

         Plaintiff was born on August 12, 1975 and was 42 years old at the time of her hearing. She filed her applications on September 16, 2016, alleging a July 17, 2014 onset date and alleging disability due to back problems, fibromyalgia, anxiety, and depression. (Tr. 90-91, 195-207.) Her applications were denied, and she requested a hearing before an Administrative Law Judge (ALJ). (Tr. 94-107.)

         On December 20, 2017, following a hearing, an ALJ issued a decision finding that plaintiff was not disabled under the Act. (Tr. 15-29.) The Appeals Council denied her request for review. (Tr. 1-3.) Thus, the decision of the ALJ stands as the final decision of the Commissioner.

         II. ADMINISTRATIVE RECORD

         The following is a summary of plaintiff's medical and other history relevant to this appeal.

         On September 23, 2012, an MRI of plaintiff's lumbar spine revealed degenerative disease at ¶ 5-S1, including a disk bulge with moderate central disk herniation/protrusion, without associated nerve root impingement or central canal stenosis; and mild bilateral neural foraminal stenosis or narrowing. Thomas F. Lieb, M.D., a physical medicine and rehabilitation specialist, noted plaintiff “certainly has the degenerative changes at the L5-S1 level. These are fairly significant with a moderate central bulge.… I certainly think this is the source of her back discomfort.” (Tr. 339-40.)

         On August 1, 2013, plaintiff was seen by Frederic A. Prater, D.O., family practitioner. Plaintiff stated that she was under a lot of stress in her new job. She reported difficulty staying on task while in a negative work environment, which exacerbated her difficulty in learning new tasks. Dr. Prater assessed fatigue, ADD, and anxiety. He prescribed Adderall for ADD and lorazepam for anxiety. (Tr. 418-19.)

         Plaintiff was treated by Richard M. DiValerio, M.D., a rheumatologist, on a regular basis from February 2014 through August 2017. During a February 25, 2014 office visit plaintiff reported degenerative disk disease in her low back originating from a fall off of a roof at age 13; chronic low back pain; chronic, mild anxiety; fatigue; diffuse joint and muscle pain; and thinning hair. She smoked a pack of cigarettes per day and had a smoker's cough. She was working two jobs for up to sixteen hours per day. She had some mild trigger point tenderness at the elbows, shoulders, posterior neck, and knees. Dr. Di Valerio diagnosed possible fibromyalgia, fatigue, and low back pain, and prescribed Xanax. (Tr. 383-84.)

         During an August 7, 2014 follow-up visit with Dr. DiValerio, plaintiff reported that she was about the same. She had a lot of stress at work, constant and severe chronic low back pain, and joint pain. On physical examination, she was in no acute distress. Her mood was normal and her affect was appropriate. Her insight and judgment were intact. Dr. Di Valerio noted slight tenderness to palpation of her spine. He diagnosed joint pain, and anxiety and long-term, current drug use from prescription narcotics. He prescribed hydrocodone and Xanax. (Tr. 377-78.)

         On February 13, 2015, plaintiff was doing about the same. She reported chronic low back pain, as well as continued fatigue and stress. Xanax helped her with stress. On physical examination, Dr. DiValerio noted slight tenderness to palpation of her spine. Her gait was normal. He diagnosed long-term, current drug use, arthralgia, fibromyalgia, and joint pain. He prescribed a fentanyl transdermal patch and hydrocodone. (Tr. 374-75.)

         On May 21, 2015, plaintiff reported that her energy and sleep were not great. She had continued chronic low back pain, joint pain, and fatigue. Her stress levels were still high. She reported that she had recently fallen in the shower and felt a “pop” in her lower back. Her physical examination was normal. Dr. DiValerio refilled her Xanax, hydrocodone, and Adderall. (Tr. 372-73.)

         During a September 4, 2015 appointment, plaintiff reported diffuse joint and muscle pain and fatigue. Her medication was providing partial relief. Examination revealed a normal mood and affect, intact insight and judgment, no tenderness, full motor strength and range of motion in her upper extremities, and a normal gait. Dr. DiValerio diagnosed long-term, current drug use, arthralgia, and fibromyalgia. He prescribed oxycodone, hydrocodone, and Xanax. (Tr. 370-71.)

         On December 1, 2015, plaintiff reported that she had pain, fatigue, and depression. Her sleep and energy were poor; she had diffuse joint and muscle pain, and severe low back pain. Dr. DiValerio observed that her mood and affect were tearful. Dr. DiValerio found no tenderness, weakness, or atrophy, and a normal gait. He diagnosed long-term, current drug use, arthralgia, cough, fibromyalgia, and back pain. He refilled her medications and added an antibiotic for her cough. (Tr. 367-68.)

         On February 25, 2016, plaintiff reported chronic, diffuse, severe, joint and muscle pain. Her energy and sleep were poor. Her anxiety and depression were uncontrolled. She was involved in a lawsuit and was experiencing significant stress and anxiety. Her low back pain was severe and she had difficulty sleeping. On physical examination, Dr. DiValerio noted her mood and affect were tearful. She had no tender or trigger points. She had full range of motion and motor strength in all of her extremities, and her gait was normal. He diagnosed long-term, current drug use, cough, fatigue, fibromyalgia, and joint pain. He refilled Xanax and oxycodone. (Tr. 364-66.)

         On May 20, 2016, plaintiff was the same. On physical examination, Dr. DiValerio noted her mood and affect were tearful and her hand grips were poor. Her lower back pain was chronic and constant. Her energy and sleep were not great. Her pain seemed worse overall. Dr. DiValerio refilled plaintiff's oxycodone. (Tr. 362-63.)

         On August 12, 2016, plaintiff reported significant stress from her lawsuit and that her low back pain was worse than ever. Her energy level and sleep were poor. She reported chronic, diffuse pain. She had intermittent tingling in the arms and legs and fatigue. Dr. DiValerio noted her mood and affect were tearful. She was alert and in no acute distress. She had no tenderness, weakness, or atrophy, and full range of motion and a ...


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