Hernandez v. Saul

District Court, N.D. Illinois·Decided April 27, 2021·No. 1:19-cv-00364·Unknown

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

MARIE H., ) ) Plaintiff, ) ) No. 19 C 364 v. ) ) Magistrate Judge Gabriel A. Fuentes ANDREW M. SAUL, Commissioner ) of Social Security, 1 ) ) Defendant. )

MEMORANDUM OPINION AND ORDER2

Plaintiff, Marie H.,3 applied for Disability Insurance Benefits (“DIB”) on November 5, 2015, alleging a disability onset date of December 2, 2014, when she was 39 years old. (R. 183.) After her applications were denied initially and on reconsideration, the ALJ held a hearing on December 21, 2017. (R. 39.) On February 16, 2018, the ALJ issued an opinion denying Plaintiff’s application for benefits. (R. 15.) On December 10, 2018, the Appeals Council denied Plaintiff’s request for review of the ALJ’s decision (R. 1-2), making the ALJ’s decision the final decision of

1 The Court substitutes Andrew M. Saul for his predecessor, Nancy A. Berryhill, as the proper defendant in this action pursuant to Federal Rule of Civil Procedure 25(d) (a public officer’s successor is automatically substituted as a party).

2 On February 19, 2019, by consent of the parties and pursuant to 28 U.S.C. § 636(c) and Local Rule 73.1, this case was assigned to a United States Magistrate Judge for all proceedings, including entry of final judgment. (D.E. 14.) On May 31, 2019, this case was reassigned to this Court for all proceedings. (D.E. 21.)

3 The Court in this opinion is referring to Plaintiff by her first name and first initial of her last name in compliance with Internal Operating Procedure No. 22 of this Court. IOP 22 presumably is intended to protect the privacy of plaintiffs who bring matters in this Court seeking judicial review under the Social Security Act. The Court notes that suppressing the names of litigants is an extraordinary step ordinarily reserved for protecting the identities of children, sexual assault victims, and other particularly vulnerable parties. Doe v. Vill. of Deerfield, 819 F.3d 372, 377 (7th Cir. 2016). Allowing a litigant to proceed anonymously “runs contrary to the rights of the public to have open judicial proceedings and to know who is using court facilities and procedures funded by public taxes.” Id. A party wishing to proceed anonymously “must demonstrate ‘exceptional circumstances’ that outweigh both the public policy in favor of identified parties and the prejudice to the opposing party that would result from anonymity.” Id., citing Doe v. Blue Cross & Blue Shield United of Wis., 112 F.3d 869, 872 (7th Cir. 1997). Under IOP 22, both parties are absolved of making such a showing, and it is not clear whether any party could make that showing in this matter. In any event, the Court is abiding by IOP 22 subject to the Court’s concerns as stated. the Commissioner. Prater v. Saul, 947 F.3d 479, 481 (7th Cir. 2020). Plaintiff has now moved to remand the ALJ’s decision (D.E. 22), and the Commissioner has moved to affirm. (D.E. 30.)4 I. Administrative Record Plaintiff is considered obese at 5’7” tall and between 206 and 224 pounds. (R. 25, 615,

662.) In January 2014, she was taking naproxen, hydrocodone (narcotic) and Flexeril (muscle relaxant) and receiving physical therapy (“PT”) for neck and back pain. (R. 304, 309.) In July, Plaintiff reported to her primary care doctor, Mukhtar Nandra, M.D., that she was losing sleep due to the pain (R. 354), and from August through November, she was treated by a chiropractor for pain on the top left side of her head and moderately severe left side neck pain. (R. 328-29.) In November 2014, Plaintiff also developed floaters in her eye and dizziness, but a brain MRI was negative. (R. 229-30, 335-39, 344, 573.) Plaintiff returned to PT for neck pain and decreased cervical (neck/upper back) range of motion (“ROM”) in November. (R. 557.) Plaintiff reportedly stopped working (as a warehouse machine operator) on December 2, 2014 due to neck and back pain. (R. 207, 215.)

In February 2015, after 12 sessions of PT, plaintiff reported that her neck pain and headaches were 50 percent better. (R. 402-03.) An MRI of her cervical spine showed disc bulging and moderate foraminal stenosis (spinal canal narrowing) at multiple levels. (R. 406.) In March, Plaintiff began visiting Valley West Hospital pain management clinic (“Valley West”). On examination, Advanced Practice Nurse (“APN”) Jeannine Fair found Plaintiff had cervical muscle spasm, painful ROM and tenderness over her upper spine and neck muscles. (R. 443.) Plaintiff reported taking ibuprofen with no relief; APN Fair prescribed Flexeril. (R. 442-43.) On March 30,

4 The ALJ found Plaintiff did not have severe mental impairments (R. 23), and Plaintiff does not raise the issue of her mental impairments in her briefing. Consequently, the Court does not discuss them in this opinion. 2015, Plaintiff received trigger-point injections and an occipital nerve block to address her upper back and neck pain. (R. 477.) On April 3, 2015, Plaintiff visited neurologist Ashley Holdridge, D.O., complaining of daily headaches and throbbing facial pain. (R. 455.) Plaintiff reported that Flexeril helped slightly

but made her very tired. (R. 456.) Dr. Holdridge’s examination showed neck tenderness, and Dr. Holdridge felt Plaintiff had cervicogenic headaches (pain that develops in the neck) given her spinal tenderness. (R. 457.) On April 15, Plaintiff returned to PT; the therapist noted Plaintiff had moderate tightness and tenderness and reduced ROM in her cervical spine. (R. 561-62.) On April 16, 2015, Plaintiff told APN Fair that she had no relief from the injections and nerve block; her pain was constant and made it hard to sleep. (R. 432, 435.) In addition to neck and head pain, Plaintiff presented with lumbar (lower back) pain, which APN Fair attributed to radiculopathy (nerve pain) and myofascial (muscle) pain. (R. 436.) She prescribed gabapentin (nerve pain medication) and Flexeril. (R. 434.) In May, Plaintiff reported that her pain improved with gabapentin, and she denied side effects from it. (R. 428-30.) APN Fair increased her dose of

gabapentin and discontinued Flexeril. (R. 431.) In June, however, Plaintiff told Dr. Holdridge that she had daily headaches that throbbed and ached for 30 minutes at a time. (R. 453.) Dr. Holdridge prescribed Imitrex (for migraines). (R. 454.) In July, Plaintiff reported that her neck pain was radiating to her head, and she had right arm tingling and numbness. (R. 461.) On September 15, 2015, Plaintiff visited neurologist Henry Echiverri, M.D., at Edward- Elmhurst Health pain management clinic (“Edward”) for her headache and neck pain. (R. 581.) Dr. Echiverri diagnosed cervical myofascial pain syndrome, acute cervical strain and chronic post- traumatic headache. (R. 582.) He prescribed Tizanidine (muscle relaxer) and Midrin for headache pain relief. (Id.) In October, Plaintiff followed up at Valley West for her low back and cervical spine pain. (R. 504.) APN Carmen Janich listed Plaintiff’s pain medications as Tylenol with codeine and gabapentin. (R. 506.) Examination showed limited neck ROM and cervical nerve pain. (R. 508.) On October 14, 2015, an MRI of Plaintiff’s lumbar spine showed multilevel disc bulge with facet hypertrophy (joint swelling), causing moderate to severe neuroforaminal stenosis at L4-

5 and moderate neuroforaminal stenosis at L3-4 and L5-S1. (R.

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