United States District Court, D. Oregon, Portland Division
OPINION AND ORDER
Yim You, United States Magistrate Judge.
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.
protectively filed for DIB on April 12, 2012, alleging a
disability onset date of March 15, 2007. Tr.
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,
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.
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.
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
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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
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.