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Whitfield v. Saul

United States District Court, N.D. Indiana, South Bend Division

August 5, 2019

ANDREW M. SAUL, Commissioner of Social Security, Defendant.



         Plaintiff Lorenzetta Whitfield appeals the denial of her claim for social security disability benefits. For the reasons stated below, the Court will remand this matter to the Commissioner for further proceedings.

         I. BACKGROUND

         Lorenzetta Whitfield (“Whitfield”) filed her initial application for disability benefits in June 2014 alleging that she became disabled on November 1, 2013. She filed the application due to neck and shoulder pain, carpal tunnel syndrome (“CTS”), forearm tendinitis, TMJ, diabetes, high blood pressure, glaucoma, sleep disorder, anxiety, and depression. Her application was denied initially, on reconsideration, and following an administrative hearing held on December 5, 2016.

         Originally from Los Angeles, California, Whitfield moved to Michigan City, Indiana, in September 2013 after becoming the victim of a violent crime. While in Los Angeles, she had worked for at least twenty years as a dispatcher for the Department of Transportation in Caltrans. When co-workers quit and Whitfield's job required her to work without breaks, she started suffering from dangerously high blood sugar, neck pain, and bilateral forearm/wrist/hand strain. She eventually had to stop working due to her health problems.

         During the administrative hearing, Whitfield explained that she continues to have bad days because of her pain. She has difficulty gripping and using her hands for any longer than fifteen minutes which then necessitates a lengthy break. It can take days for Whitfield and her sister (who is also very ill) to clean a single room. Whitfield also suffers from anxiety and depression which causes her to be forgetful. Whitfield testified that every day she takes an “antidepressant called Prozac” and that she has been waiting for authorization through her workers compensation program to attend treatment with a licensed psychiatrist or psychologist. Whitfield described how she is frequently given the runaround with getting treatment approved since having moved to Indiana. And despite being prescribed a host of medications, Whitfield tries to refrain from taking too much medication because she is in the process of donating a kidney to her sister. She has tried to seek out healthier, non-conventional therapies in order to avoid injuring her kidneys and liver.

         By way of history, in 2010, Whitfield developed pain in her cervical and thoracic spine, shoulders, and wrists. An EMG/nerve conduction study on June 28, 2011, revealed early diabetic peripheral neuropathy and a high suggestion of diffuse ulnar neuropathy at the cubital tunnel. Physical examinations were completed in early 2011 and 2012 (for workers compensation purposes) by orthopedic surgeon Dr. Lee Silver. Dr. Silver noted that Whitfield's subjective complaints and objective exam findings were consistent with her suffering from bilateral shoulder impingement and CTS, [1] along with early diabetic peripheral neuropathy and cervical and thoracic musculoligamentous strain/sprain. By January 2012, Dr. Silver opined that Whitfield had reached maximum medical improvement and that she was unable to perform repetitive cervical spine movements or repetitive “fine manipulation” for greater than thirty minutes without a five-minute break. It was recommended that she continue to receive treatment, including injections and surgical intervention.

         By November 2012, Whitfield's re-evaluation with orthopedic surgeon Dr. Philip Sobol resulted in his documenting that Whitfield was suffering from increased neck, shoulder, and CTS symptoms, in addition to experiencing stress, anxiety, depression, and difficulty sleeping. He believed that Whitfield was temporarily totally disabled. Whitfield returned to Dr. Sobol many times and continued to receive the same diagnoses. In January 2014, Dr. Sobol reported that Whitfield was restricted from bending and twisting her neck and from performing fine manipulation or engaging in repetitive use of her hands, including use of a keyboard or mouse.

         A consultative medical examination by Dr. R. Jao in August 2014, resulted in his impression that Whitfield had a history of cervical spine injury, CTS, tendinitis, TMJ, diabetes, glaucoma, high blood pressure, depression, and sleep disorder since at least 2010. He observed that Whitfield continued to have decreased grip strength despite being able to button, zip, and pick up coins. However, no specific functional limitations were charted.

         Whitfield continued to see nurse practitioners Brenda Winski and Nicolette Alexander throughout 2014 and 2015 for her continued ailments. Their documents reflect that Whitfield was suffering from mental health conditions, including PTSD, anxiety, depression, and psychotic paranoia. It was strongly recommended that Whitfield see a psychiatrist as opposed to her neuro-feedback therapist. A mental status examination from July 2014, which was conducted by state agent and licensed psychologist John Heroldt, indicated that Whitfield suffered from recurrent major depressive disorder. However, again, no specific functional limitations were charted.

         In January 2016, Whitfield was given a functional capacity summary regarding her physical conditions by physical therapist Charles Wolf. Mr. Wolf opined that Whitfield could physically perform work at the sedentary level, but he noted that she was unable to use her hands even occasionally for simple tasks. He further noted that Whitfield's range of motion and strength in her wrists were impaired, and he documented various physical limitations discovered while having her perform a series of non-material handling activities. Nurse Practitioner Alexander agreed with these limitations, which she opined dated back as far as July 2013 and could be expected to last at least twelve months.

         State reviewing agents opined in September 2014 and January 2015 that Whitfield suffered no severe physical impairments, and that her mental condition resulted in no restrictions in activities of daily living and only mild difficulties with maintaining social functioning and concentration, persistence, or pace.

         The administrative law judge (“ALJ”) concluded that Whitfield was not entirely credible with respect to her claimed restrictions and that she had the residual functional capacity[2] to perform sedentary work limited by the lifting of no more than ten pounds, frequent (but not constant) reaching, handling, and fingering, and occasional overhead reaching. The vocational expert (“VE”) indicated that given this assigned RFC, Whitfield could perform her former job as a dispatcher. However, if Whitfield were further limited to unskilled tasks, then she would not be able to perform her past work or other work given her age.

         II. ...

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