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Vaughn v. Commissioner Social Security Administration

United States District Court, D. Oregon, Portland Division

March 29, 2017

ANDREA NICOLE VAUGHN, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          OPINION AND ORDER

          Youlee Yim You, United States Magistrate Judge.

         INTRODUCTION

         Plaintiff, Andrea Nicole Vaughn (“Vaughn”), seeks judicial review of the final decision by the Social Security Commissioner (“Commissioner”) denying her application for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (“SSA”), 42 U.S.C. §§ 401- 33. This court has jurisdiction to review the Commissioner's decision pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3). All parties have consented to allow a Magistrate Judge to enter final orders and judgment in this case in accordance with Fed R. Civ. P. 73 and 28 U.S.C. § 636(c). ECF #12. For the reasons set forth below, the Commissioner's decision is reversed and this matter is remanded pursuant to sentence four, 42 U.S.C. § 405(g), for further administrative proceedings.

         ADMINISTRATIVE HISTORY

         Vaughn protectively filed for DIB on April 12, 2012, alleging a disability onset date of March 15, 2007. Tr. 12.[1] Her application was denied initially and on reconsideration. Tr. 51- 69. Vaughn requested a hearing before an Administrative Law Judge (“ALJ”). Tr. 74-75. On April 21, 2014, ALJ Riley Atkins conducted a hearing at which Vaughn, her husband, and her mother testified. Tr. 25-49. A vocational expert (“VE”), Robert Gaffney, also appeared at the hearing, but did not testify. Tr. 25, 28. The ALJ issued a decision on May 12, 2014, finding Vaughn not disabled. Tr. 9-24. The Appeals Council denied Vaughn's request for review. Tr. 1-4. Because the Appeals Council denied Vaughn's request for review, the ALJ's decision is the Commissioner's final decision subject to review by this court. 20 C.F.R. §§ 404.981, 422.210.

         BACKGROUND

         Born in 1971, Vaughn was 42 at the time of the hearing before the ALJ. Tr. 120. She has an eleventh grade education and past relevant work experience as a cosmetologist. Tr. 135, 138. Vaughn alleges that she is unable to work due to the combined impairments of interstitial cystitis, overactive bladder, bladder spasms, anxiety, and migraine headaches. Tr. 137.

         MEDICAL RECORDS

         The time period at issue in this case is from the alleged onset date, March 15, 2007, through Vaughn's date last insured, December 31, 2011. Tr. 21, 46-47. On March 16, 2007, Vaughn was seen in the emergency room. Tr. 267-69. The chart note reads in relevant part:

Chief Complaint - ANXIETY. It has been constant. This started 1 week ago. Is still present. Has been upset (tearful). The patient has had insomnia (difficulty falling asleep). She has had moderate anxiety. No anger or suicidal thoughts. Did not attempt suicide. Did not overdose. She has experienced situational problems related to significant other. The symptoms are described as moderate. Pt c/o anxiety and headache for one week secondary to relationship problems with her ex-husband and current husband. Pt in ED with her ex-husband. One year ago pt left her husband and got remarried. Now she is having problems with her current husband and says he uses drugs, is unemployed, etc. For the last month and a half she has been back with her ex-husband and now feels very stressed out because her current husband says he wants her back. For the last week and a half she has been extremely stressed out, crying constantly, she quit her job this morning. She denies suicidal ideation but c/o severe headache that started today. Not eating or sleeping well.

Id.

         Vaughn reported a past history of migraine headaches, carpal tunnel syndrome, anxiety, attention deficit disorder, and interstitial cystitis. Tr. 267. She was taking Adderall (for years), Ativan, and Premarin. Tr. 268. The doctor diagnosed an anxiety reaction and headache, and prescribed Ativan and Morphine.

         About six weeks later, on May 6, 2007, Vaughn returned to the emergency room with constant dysuria and bladder pain of two days duration. Tr. 265. She described her symptoms as moderate and worse with urination. Vaughn was described as anxious and in moderate distress, and was prescribed Pyridium and Norco and instructed to follow up with her urologist that week. Tr. 266.

         On October 24, 2007, Robert J. Hehn, M.D., performed a bladder cystoscopy for symptomatic interstitial cystitis with pelvic pain and frequency. Tr. 208-23. Dr. Hehn noted Vaughn saw Dr. Steven Lee for pain control and she took Endocet every five hours, as well as Adderall, Premarin, and Xanax. At that time, Vaughn's “bad days” occurred more often than her “good days.” Tr. 208. Her last bladder dilation was more than a year prior, and Vaughn thought it was time to redilate.

         Dr. Hehn repeated the surgery one year later, on October 29, 2008. Tr. 228. Vaughn again had worsening symptoms and stated that the bladder dilations help her “for a period of time.” Id. Vaughn was taking Percocet 7.5 milligrams four times a day and wearing a fentanyl patch. Tr. 230.

         On May 24, 2009, Vaughn established care with Thomas Hickerson, M.D. Tr. 401-03. Dr. Hickerson noted Vaughn was on chronic pain management for interstitial cystitis with chronic hematuria. She was on a Duragesic (fentanyl) patch “which only lasts 48 hours on her, ” and Endocet, six daily, as well as Xanax for anxiety and Adderall for hyperactivity. Tr. 402. Dr. Hickerson stated Vaughn would be seen every two weeks for pain management. The following month Vaughn reported increased pain. Tr. 398-99. In July 2009 Dr. Hickerson noted Vaughn's pain medication “has done well, ” and in August 2009 Dr. Hickerson reported Vaughn's pain medication “seems to be working well.” Tr. 396, 394. By September, however, Dr. Hickerson recorded increasing pain and Vaughn was scheduled for another cystoscopy which occurred in October 2009. Tr. 389, 226. Vaughn continued to have increased pain through October and reported on November 23, 2009 that surgery “gave her a lot of relief.” Tr. 384.

         In January 2010 Dr. Hickerson changed Vaughn's Endocet to Vicodin. Tr. 381. The following month Vaughn reported increased migraine headaches, and in March 2010 Vaughn had increased stress and pain. Tr. 376. On June 25, 2010, Vaughn reported hematuria of four day duration. Tr. 368. In September 2010 Vaughn was taking eight hydrocodone per day and changing her fentanyl patch every 48 hours, and by October reported increased pain. Tr. 365, 364.

         On November 1, 2010, Vaughn established care with Kent C. Toland, M.D., a urologist. Cheri Springer, Ph.D., P.A.-C., worked in Dr. Toland's practice. Dr. Springer examined Vaughn who reported daytime urgency and frequency of every 30 minutes and nocturia times four. Tr. 248. The Pelvic Pain and Urinary Urgency Frequency (“PUF”) Patient Symptom Scale is a diagnostic tool to screen patients with chronic pelvic pain. The PUF questionnaire combines a symptom score and bother score for a total PUF score. Scores range between 0 and 35, and a score greater than 12 is indicative of significant symptoms. Dr. Springer noted Vaughn's PUF score was severe at 26. Vaughn reported bladder pain, spasm, bloating, dysuria and pain through her pelvis. Dr. Springer noted Vaughn was tired from lack of sleep and thin, prescribed Enablex, Pyridium, and Lidocaine, and scheduled a cystoscopy and hydrodistention for November 15, 2010. Tr. 250.

         On November 5, 2010, Dr. Hickerson administered a chronic pain inventory in which Vaughn reported a pain level of 5/10 continuously and 8/10 at the worst. Tr. 360. Vaughn stated her pain interfered with her general activities 60% of the time, her mood 40% of the time, her normal work (including outside the home and housework) 40% of the time, her relations with other people 40% of the time, her ability to concentrate 50% of the time, and her appetite 50% of the time. Id.

         By mid-January 2011 Vaughn reported increased pain. In March 2011 Vaughn told Dr. Springer that Enablex helped to moderate urgency, but she had urinary hesitation, dysuria, pelvic floor spasm, and pain with bladder filling. Tr. 240. Dr. Springer prescribed vaginal valium and Rapaflo. On April 1, 2011, Vaughn reported her pain medications gave her 80-90% relief, with her average pain at 5/10 and most severe pain at 7/10. Tr. 354. By late May Vaughn reported increased bladder pain and increased sleep disruption. Tr. 351.

         Vaughn saw Dr. Springer in October 2011 with increasing bladder pain, urgency, frequency and spasm. Tr. 238. Dr. Springer increased Vaughn's Enablex prescription and scheduled another hydrodistention. Tr. 238-39. Vaughn was taking Enablex, Norco every three to four hours, a fentanyl patch every 48 hours, Adderall, Xanax, Fioricet, lidocaine, Pyridium, and valium. On December 2, 2011, Vaughn reported pain at 4/10 aggravated by activity. Tr. 339. On December 5 Dr. Toland performed a urethral dilation and cystoscopy. Tr. 235.

         Vaughn saw Dr. Hickerson regularly through 2012, reporting increased low back pain in July and increased bladder pain and frequency in October. Tr. 330, 325. In January 2013 Vaughn told Dr. Hickerson she could not afford another surgery, and reported to Dr. Springer increased nocturia up to ten times per night with a flare and normally five to six times per night. Tr. 322, 283. Dr. Springer prescribed Bladder ease.

         On February 28, 2013, Dr. Springer noted Vaughn “receives significant improvement” from periodic hydrodistention and wanted another surgery. Tr. 294. Dr. Springer said Vaughn received a reduction in bladder symptoms for several months after the procedure that allowed her to function at “a bit higher level but even this leaves her with significant baseline symptoms.” Id. Vaughn's symptoms had increased for several months, she was unable to concentrate and required help with cooking and cleaning. Her sleep was disrupted with pain greater than 7/10 daily. She spent hours a day on the toilet. Vaughn had been unable to afford Enablex for several months and had urinary frequency of every ten minutes. Dr. Springer noted Vaughn previously worked as a cosmetologist but had to retire early due to her medical condition. Vaughn had another urethral dilation surgery on March 18, 2013. The following month Vaughn reported hourly urinary urgency and frequency, with baseline pain of 5/10 “but she is able to function at this level.” Tr. 286. Dr. Hickerson saw Vaughn through 2013, with increased pain in December. Tr. 303.

         On January 14, 2014, Vaughn returned to Dr. Springer requesting another surgery. Tr. 279. Dr. Springer noted Vaughn's deteriorating symptoms, and that Vaughn typically wore sweat pants to avoid putting pressure on her lower abdomen. Vaughn had trouble eating due to severe pain, and Vaughn's mother brought her meals. She had constant urgency despite Enablex and was unable to make social plans because she could not predict how she would feel. Vaughn was unable to complete any household chores even on a good day, and during a flare her urinary frequency was 25-30 times with hourly nocturia. Her pain level ranged from seven to ten. Dr. Springer wrote that Vaughn was “suffering with end state IC, ” assessed her prognosis as “poor, ” and explained that, patients at this stage “experience daily elevated pain levels, have poor quality of life and low levels of functioning. The pain at this stage has been compared to that of cancer pain in the literature and the quality of life comparable to that of kidney dialysis.” Tr. 281. Dr. Springer noted there is no cure for the condition, and Vaughn had financial barriers to additional treatments, including the implantation of an Interstim device to stimulate the sacral nerves with mild electrical pulses. Vaughn reported increased pain to Dr. Hickerson in February, and had another surgery on March 20, 2014. Tr. 298.

         In April 2014, Dr. Springer wrote to the ALJ stating Vaughn had been a patient at the practice since November 2010 for treatment of interstitial cystitis. Tr. 768-69. Dr. Springer stated interstitial cystitis flares and recedes over time, and with progression patients experience baseline symptoms that feel similar to a urinary tract infection. She opined that Vaughn had severe and constant daily pain affecting her ability to concentrate, and took medication with cognitive effects. Tr. 769. Dr. Springer stated Vaughn would “certainly” average more than two days per month in which she would be absent from work, and that this had been the case since she was first seen by Dr. Springer in November 2010.

         In June 2014 Dr. Springer reviewed the ALJ's decision denying Vaughn's application for disability benefits, and wrote a second letter to the ALJ repeating her opinion as to Vaughn's condition, citing her own doctoral dissertation research on the effect of anxiety on a patient's PUF score, pain levels and other indictors of severity of disease. Tr. 770-71. Dr. Springer completed and submitted to the ALJ a Medical Source Statement in which she assessed multiple severe and disabling limitations. Tr. 772-75.

         DISABILITY ...


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