Hanovich v. Astrue (579 F. Supp. 2d 1172, 2008)

ORDER

ANN D. MONTGOMERY, District Judge.

Before the Court is the Report and Recommendation of Magistrate Judge Janie S. Mayeron dated August 6, 2008. Having reviewed the files and records herein, and there being no objections to said Recommendation, IT IS HEREBY ORDERED THAT:

1. Plaintiffs Motion for Summary Judgment (Docket No. 8) is GRANTED IN PART and DENIED IN PART consistent with the Report and Recommendation;

2. Defendant’s Motion for Summary Judgment (Docket No. 11) is DENIED; and

3. This case is REMANDED to the SSA for further proceedings.

REPORT AND RECOMMENDATION

JANIE S. MAYERON, United States Magistrate Judge.

Defendant has denied Plaintiff Barbara Hanovich’s application for disability insurance benefits (DIB) under the Social Security Act, 42 U.S.C. § 423. Plaintiff has now instituted this action seeking review of the denial of benefits. The matter is now before the Court on cross-motions for summary judgment. Plaintiff is represented by Frank W. Levin, Esq. Defendant is represented by Lonnie F. Bryan, Assistant United States Attorney. This Court has jurisdiction of the matter pursuant to 42 U.S.C. § 405(g), and it is properly before the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c) and Federal Rule of Civil Procedure 72(b). For reasons discussed below, it is recommended that Plaintiffs Motion for Summary Judgment [Docket No. 8] be GRANTED in part and DENIED in part; and Defendant’s Motion for Summary Judgment [Docket No. 11] be DENTED.

I. PROCEDURAL BACKGROUND

Plaintiff protectively filed an application for social security disability benefits on February 18, 2003, alleging disability since December 31, 1987. (Tr. 61-64, 79). Plaintiff first met the insured status test on January 1, 1991, and her insured status expired on March 31, 1996. (Tr. 67, 94). Plaintiffs application was denied initially, and upon reconsideration. (Tr. 28-32, 35-39, 41-43). Plaintiff requested a hearing before an Administrative Law Judge. (Tr. 44). A hearing was held before Administrative Law Judge Diane Townsend-Anderson on March 23, 2005. (Tr. 1160— 1201). On October 24, 2005, the ALJ issued an unfavorable decision. (Tr. 18-25). The Social Security Administration Appeals Council denied a request for further review. (Tr. 6-8). The denial of review made the ALJ’s findings final. 42 U.S.C. § 405(g); Browning v. Sullivan, 958 F.2d 817, 822 (8th Cir.1992); 20 C.F.R. § 404.981.

Plaintiff has sought review of the ALJ’s decision by filing a Complaint with this Court pursuant to 42 U.S.C. § 405(g). [Docket No. 1]. The parties now appear before the Court on Plaintiffs Motion for Summary Judgment [Docket No. 8] and Defendant’s Motion for Summary Judgment [Docket No. 11].

II. PROCESS FOR REVIEW

Congress has prescribed the standards by which Social Security disability benefits may be awarded. “The Social Security program provides benefits to people who are aged, blind, or who suffer from a physical or mental disability.” 42 U.S.C. § 1382(a); Locher v. Sullivan, 968 F.2d 725, 727 (8th Cir.1992). The Social Security Administration shall find a person disabled if the claimant “is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment.” 42 U.S.C. § 1382c(a)(3)(A). The claimant’s impairments must be “of such severity that [the claimant] is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy.” 42 U.S.C. § 1382c(a)(3)(B). The impairment must last for a continuous period of at least 12 months or be expected to result in death. 42 U.S.C. § 1382c(a)(3)(A); see also 20 C.F.R. § 404.1509.

A. Administrative Law Judge Hearing’s Five-Step Analgsis

If a claimant’s initial application for benefits is denied, he or she may request reconsideration of the decision. 20 C.F.R. § 404.909(a)(1). A claimant who is dissatisfied with the reconsidered decision may obtain administrative review by an ALJ. 42 U.S.C. § 405(b)(1); 20 C.F.R. § 404.929. To determine the existence and extent of a claimant’s disability, the ALJ must follow a five-step sequential analysis, requiring the ALJ to make a series of factual findings regarding the claimant’s work history, impairment, residual functional capacity, past work, age, education and work experience. See 20 C.F.R. § 404.1520; see also Locher, 968 F.2d at 727. The Eighth Circuit described this five-step process as follows:

The Commissioner of Social Security must evaluate: (1) whether the claimant is presently engaged in a substantial gainful activity; (2) whether the claimant has a severe impairment that significantly limits the claimant’s physical or mental ability to perform basic work activities; (3) whether the claimant has an impairment that meets or equals a presumptively disabling impairment listed in the regulations; (4) whether the claimant has the residual functional capacity to perform his or her past relevant work; and (5) if the claimant cannot perform the past work, the burden shifts to the Commissioner to prove that there are other jobs in the national economy that the claimant can perform.

Dixon v. Barnhart, 353 F.3d 602, 605 (8th Cir.2003).

B. Appeals Council Review

If the claimant is dissatisfied with the ALJ’s decision, he or she may request review by the Appeals Council, though review is not automatic. 20 C.F.R. §§ 404.967-404.982. The decision of the Appeals Council (or of the ALJ, if the request for review is denied) is final and binding upon the claimant unless the matter is appealed to Federal District Court within 60 days after notice of the Appeals Council’s action. 42 U.S.C. §§ 405(g), 1383(c)(3); 20 C.F.R. § 404.981.

C.Judicial Review

Judicial review of the administrative decision generally proceeds by considering the decision of the ALJ at each of the five steps. The Court is required to review the administrative record as a whole and to consider:

1. The credibility findings made by the ALJ.

2. The plaintiffs vocational factors.

3. The medical evidence from treating and consulting physicians.

4. The plaintiffs subjective complaints relating to exertional and non-exer-tional activities and impairments.

5. Any corroboration by third parties of plaintiffs impairments.

6. The testimony of vocational experts, when required, which is based upon a proper hypothetical question which sets forth plaintiffs impairments.

Cruse v. Bowen, 867 F.2d 1183, 1185 (8th Cir.1989) (citing Brand v. Secretary of HEW, 623 F.2d 523, 527 (8th Cir.1980)).

The review by this Court is limited to a determination of whether the decision of the ALJ is supported by substantial evidence in the record as a whole. 42 U.S.C. § 405(g); Murphy v. Sullivan, 953 F.2d 383, 384 (8th Cir.1992). Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971) (quoting Consolidated Edison v. NLRB, 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938)); see also Culbertson v. Shalala, 30 F.3d 934, 939 (8th Cir.1994). “The substantial evidence test employed in reviewing administrative findings is more than a mere search of the record for evidence supporting the [Commissioner’s] findings.” Gavin v. Heckler, 811 F.2d 1195, 1199 (8th Cir.1987). “ ‘Substantial evidence on the record as a whole,’ ... requires a more scrutinizing analysis.” Id. In reviewing the administrative decision, “ ‘[t]he substantiality of evidence must take into account whatever in the record fairly detracts from its weight.’” Id. (citing Universal Camera Corp. v. NLRB, 340 U.S. 474, 488, 71 S.Ct. 456, 95 L.Ed. 456 (1951)).

In reviewing the record for substantial evidence, the Court may not substitute its own judgment or findings of fact. Woolf v. Shalala, 3 F.3d 1210, 1213 (8th Cir.1993). The possibility that the Court could draw two inconsistent conclusions from the same record does not prevent a particular finding from being supported by substantial evidence. Culbertson, 30 F.3d at 939. The Court should not reverse the Commissioner’s finding merely because evidence may exist to support the opposite conclusion. Mitchell v. Shalala, 25 F.3d 712, 714 (8th Cir.1994); see also Woolf, 3 F.3d at 1213 (the ALJ’s determination must be affirmed, even if substantial evidence would support the opposite finding). Instead, the Court must consider “the weight of the evidence in the record and apply a balancing test to evidence which is contradictory.” Gavin, 811 F.2d at 1199.

The claimant bears the burden of proving his or her entitlement to disability insurance benefits under the Social Security Act. See 20 C.F.R. § 404.1512(a); Thomas v. Sullivan, 928 F.2d 255, 260 (8th Cir.1991). Once the claimant has demonstrated he or she cannot perform prior work due to a disability, the burden of proof then shifts to the Commissioner to show that the claimant can engage in some other substantial, gainful activity. Martonik v. Heckler, 773 F.2d 236, 239 (8th Cir.1985).

III. DECISION UNDER REVIEW

A. The ALJ’s Findings of Fact

The ALJ concluded that plaintiff was not entitled to a period of disability or disability insurance benefits under Sections 216® and 223. (Tr. 23). The ALJ made the following findings:

1. The claimant met the disability insured status requirements of the Act on January 1, 1991, and continues to meet them only through March 31, 1996.

2. The claimant has not engaged in substantial gainful activity at any time since December 31, 1987, her alleged onset date of disability.

3. The medical record establishes that during the period from December 31, 1987 to March 31, 1996, the claimant was severely impaired by peptic ulcer disease, bilateral kerato-conus and keratoconjunctivitis sicca and bilateral cataracts, status post cataract extraction and lens implant, and corneal transplant, and degenerative disc disease of the cervical and lumbar spine, with disc herniation at L4-5, and arthralgia, possible systemic lupus erythematosus, with complaints of joint pain, and stress urinary incontinence, but that she did not have an impairment or combination of impairments that met or equaled the relevant criteria of any impairment listed at 20 C.F.R. Part 404, Subpart P, Appendix 1.

4. The claimant’s subjective complaints and functional limitations are inconsistent with the record as a whole on or before March 31,1996.

5. During the period from December 31,1987 through March 31, 1996, the claimant retained the residual functional capacity for work requiring lifting twenty pounds occasionally and ten pounds frequently, with no constant visual acuity such as that required by [an] individual using a microscope or computer an entire work day, no exposure to temperature or humidity extremes or bright sunlight, no work around heights, ladders, or scaffolds, no foot pedal manipulations, no power gripping, twisting or pounding, and only occasionally bending, stooping, crouching, crawling or twisting.

6. The claimant’s impairments precluded her from returning to her past relevant work from December 31, 1987 through March 31,1996.

7. During the period from December 31,1987 through March 31,1996, the claimant was a younger individual to an individual closely approaching advanced age, with more than a high school education, an elementary teaching certificate, and a history of skilled work.

8. Considering the claimant’s residual functional capacity, age, education, and past work experience, during the period from December 31, 1987 through March 31, 1996, there were other jobs existing in significant numbers in the national economy that the claimant would have been able to perform, including a classroom teacher, case aide, or food packager.

9.The claimant was not under a disability as defined in the Social Security Act at any time on or before March 31,1996.

(Tr. 24-25).

B. The ALJ’s Application of the Five-Step Process

At step one of the disability evaluation, the ALJ found that plaintiff had not engaged in substantial gainful activity. 20 C.F.R. § 404.1520(b). (Tr. 19). At the second step of the evaluation, the ALJ found that plaintiff had severe physical impairments of peptic ulcer disease, bilateral keratoconus and keratoconjunctivitis sicca and bilateral cataracts, status post cataract extraction and lens implant, and corneal transplant, and degenerative disc disease of the cervical and lumbar spine, with disc herniation at L4-5, and arthral-gia, possible systemic lupus erythemato-sus, with complaints of joint pain, and stress urinary incontinence. At the third step of the evaluation, the ALJ determined that plaintiff did not have an impairment or combination of impairments that met or equaled the relevant criteria of any impairment listed at 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 19).

At the fourth step of the evaluation process, the ALJ noted that plaintiff has been unable to work since December 31, 1987, based on subjective complaints of extreme fatigue, loss of vision, chest pain, joint and muscle pain, back and leg pain, muscle spasms, numbness in her hands and feet, swelling in her hands, and difficulty concentrating due to pain medication. (Tr. 19). Thus, the ALJ considered plaintiffs subjective complaints in light of the record as a whole and found that plaintiff had the following residual functional capacity:

“[Plaintiff could] perform work requiring lifting twenty pounds occasionally and ten pounds frequently, with no constant visual acuity such as that required by [an] individual using a microscope or computer an entire work day, no exposure to temperature or humidity extremes or bright sunlight, no work around heights, ladders, or scaffolds, no foot pedal manipulations, no power gripping, twisting or pounding, and only occasionally bending, stooping, crouching, crawling or twisting.

(Tr. 19-20).

In support of the RFC, the ALJ first addressed plaintiffs peptic ulcer disease and noted that there were significant gaps in treatment for this condition from January 1993 through November 1996. (Tr. 20). The ALJ noted that on the few occasions where plaintiffs abdominal pain was severe, it was related to her being out of, or noncompliant with her medication. Id. The ALJ also noted that plaintiff traveled quite a bit in this timeframe, and such excessive travel was inconsistent with incapacitating abdominal pain. Id.

Additionally, the ALJ cited evidence that, although plaintiff had a live-in housekeeper, she did much of the housework herself. (Tr. 20). The ALJ further noted that in 1991, one of plaintiffs physicians noted that she was remarkably productive despite her complaints of ongoing symptoms. Id. Plaintiff was hospitalized for epigastric pain on only one occasion in 1988; there were minimal objective findings of “a very benign appearing ulcer” in January 1990; and an active ulcer, which was 75% healed in April 1990; no ulcer was seen in August 1991, and biopsy was negative in October 1991. (Tr. 20-21). Further, although plaintiff was diagnosed with antral gastritis with ulceration in March 1996, erosions were noted only in April 1996. Id. The ALJ concluded that this evidence is inconsistent with a disabling impairment.

The ALJ next considered plaintiffs impairments of degenerative disc disease, ar-thralgia, and joint pain. (Tr. 21). The ALJ noted that when plaintiff saw a rheu-matologist, Dr. Paul Waytz, on November 12, 1986, examination revealed tenderness of the PIP, MCP and MTP joints, with very low grade, scattered synovitis, tenderness of the low back, and no effusion. Id. Plaintiff was diagnosed with arthralgia, and after treating with Plaquenil for one month, she was less achy, and had quite a bit of energy. Id. At that time, plaintiff had only some spasm of the low back, and no active synovitis. Id. Dr. Waytz noted that plaintiff was going to Southeast Asia at the end of February 1987.

Plaintiff did not return to Dr. Waytz until two years later, January 4, 1989, at which time she complained of arthralgia in her hands and feet, and had some muscle spasm in the upper back and neck, but no synovitis, and good range of motion of the joints. (Tr. 21). The ALJ noted that plaintiff did not return to Dr. Waytz with any further joint symptoms until March 7, 2001, five years after her disability insured status expired. Id. The ALJ then considered Dr. Waytz’s letter dated May 6, 2005, in which he opined that plaintiff would be unable to perform even simple unskilled sedentary work on a full-time sustained basis as of March 31, 1996. Id. However, the ALJ found this opinion to be inconsistent with Dr. Waytz’s treatment notes containing only minimal objective findings during three visits from November 1986 through January 1989. Id. Thus, the ALJ did not give Dr. Waytz’s opinion substantial weight. Id.

The ALJ noted that the record also contained a statement from Dr. Gerald Mullin, plaintiffs rheumatologist from 1975 through December 2000. (Tr. 21) Dr. Mullin opined plaintiff would have been unable to perform even simple unskilled sedentary work on a full-time sustained basis as of December 31, 1995. Id. The ALJ did not give this opinion substantial weight because the record did not contain any records from Dr. Mullin, and other medical evidence was inconsistent with complete disability. Id.

The ALJ next considered plaintiffs report of neck pain and foot fracture on July 16, 1996, three-and-a-half months after her insured status expired. (Tr. 21). The ALJ noted plaintiff had reported working four to five hours a week at her own travel agency, and denied any work restrictions. Id. The ALJ found that Dr. Kraker’s examination of plaintiff revealed tenderness of the cervical and thoracic spine, and left trapezius, but normal range of motion of the shoulders and neck, no muscle spasm, and normal strength, sensation, and reflex of the upper extremities. (Tr. 21-22). Plaintiffs lumbar spine was also tender, but with normal range of motion, normal strength, sensation, and reflexes. (Tr. 22). X-rays of her cervical spine showed degenerative disc disease at C6-7 and L4-5, with no evidence of ankylosing spondylitis. Id. Plaintiff was treated with a Medrol dose-pak and Vicodin. Id. In August 1996, plaintiff reported improvement of her pain. Id. She sought no further treatment until January 1998, almost two years after her insured status expired. Id. The ALJ found this evidence inconsistent with disabling neck, back, or joint pain on or before March 31,1996. Id.

The ALJ considered ongoing references in the record to plaintiffs frequent foreign travel. (Tr. 22) This included trips to Australia in November 1998, China the following week, Thailand in February 1999, Italy in June 1999, Quebec in April 1999, “recent trips to China, South America, and Florida reported in December 1999”, a trip to the Himalayas, a trip to the Baltics in May 2000, a trip to Turkey, Greece, and Egypt reported in November 2000, a trip to China in September 2001, a trip to Bangkok in December 2001, a trip to Italy in January 2002, a trip to Amsterdam in May 2002, a trip to China in July 2002, a trip to Thailand in November 2002, a trip to Thailand in December 2003, and a trip to Bangkok in May 2004. Id. The ALJ stated, “[tjhese trips are entirely inconsistent with ongoing disability since December 1987.” (Tr. 22).

The ALJ noted other evidence inconsistent with disabling levels of pain and fatigue. (Tr. 22). First, in October 1999, a physical therapist noted that plaintiffs compliance with her individual exercise program was questionable given her work and social calendar. Id. Second, in July 2001, a physician noted plaintiff was recently riding a jet ski. (Tr. 22). Third, in October 2001, plaintiffs physical therapy was interrupted by her being out of the country for extended periods of time. Id. Fourth, in August 2002, a physician noted plaintiff recently did some kayaking. Id. The same month, a physician commented that plaintiff was highly active athletically and professionally, running a travel escort and consultation service, and frequently traveling to Europe and Asia. Id. Fifth, the ALJ noted plaintiffs husband testified at the hearing that plaintiff did volunteer work for the Guthrie Theater and the American Heart Association. Id. The ALJ found this evidence to be inconsistent with disabling levels of pain and fatigue. Id.

The ALJ next addressed plaintiffs complaints of memory difficulties. (Tr. 22). The ALJ noted that plaintiff was not treated for memory difficulties until two years after her disability insured status expired. Id. Even then, the results of a neuropsy-chological examination were consistent with only mild memory impairment. (Tr. 22). The ALJ found that the record did not otherwise contain any complaints to treating sources of side effects from medication or reports of concentration difficulties. Id.

The ALJ considered plaintiffs visual impairments, with vision noted at 20/30 to 20/70 from January 1988 through August 1989. (Tr. 22-23). In this timeframe, plaintiff had cataract extraction and lens implant, and a corneal transplant. Id. In February 1996, she had left corneal transplant. (Tr. 23). Her next surgery, in August 1997, was more than a year after her insured status expired. Id. When considered in context of plaintiffs work as a travel escort, the ALJ found plaintiffs visual impairment was not a disabling impairment on or before March 31, 1996. Id.

The ALJ recognized that plaintiff had surgery for stress incontinence in August 1996, with follow-up bladder retraining. (Tr. 23). The ALJ noted that plaintiff did not require follow-up after January 1997, and reported being happy with the results of surgery. (Tr. 22).

The ALJ considered evidence of plaintiffs earnings records. (Tr. 23). Plaintiffs earnings after December 31, 1987, were consistent in that she never earned more than $6,000 a year. Id. The ALJ noted that plaintiffs earnings from work as a travel escort were not included in the record, and there are no references to this work activity in any of plaintiffs written reports. Id. The ALJ found this lack of documentation to reflect negatively on plaintiffs credibility. Id.

The ALJ considered the opinions of consulting state agency medical sources, who opined that plaintiff would be able to perform work involving lifting twenty pounds occasionally and ten pounds frequently, with standing/walking six hours in an eight-hour day, sitting six hours in an eight-hour day, and no visual work involving fine print or very close work. (Tr. 23). The ALJ found this to be consistent with the medical evidence in the record and granted it substantial weight. Id.

Thus, based on her analysis of the record as a whole, the ALJ found as of March 31, 1996, plaintiff had the residual functional capacity for work requiring lifting twenty pounds occasionally and ten pounds frequently, with no constant visual acuity such as that required by an individual using a microscope or computer an entire work day, no exposure to temperature or humidity extremes or bright sunlight, no work around heights, ladders, or scaffolds, no foot pedal manipulations, no power gripping, twisting or pounding, and only occasionally bending, stooping, crouching, crawling or twisting. (Tr. 23). In reaching this finding, the ALJ indicated that she had considered the testimony of plaintiffs husband, but found that it was inconsistent with the weight of the record as a whole. (Tr. 23).

Continuing to the fourth step in the evaluation process, the ALJ noted that Vocational Expert William Villa (VE) testified that with the residual functional capacity described above, the plaintiff could not perform her past relevant work as a special education teacher because such work generally exceeds the light exertional level. (Tr. 23-24). Therefore, at the fifth step of the evaluation, the ALJ determined, based on the VE’s testimony, that an individual with the residual functional capacity described above would have been able to perform other work such as a classroom teacher, case aide, or food packager. (Tr. 24). The ALJ also indicated that the VE testified plaintiff would not have been able to perform any competitive work if she was absent more than two days a month, if she could not maintain the pace and persistence due to medication side effects, or if she needed rest periods or naps in excess of standard work breaks. (Tr. 24). However, the ALJ determined that the record as a whole did not provide substantial support for these additional limitations, and therefore, she found that plaintiff was not entitled to a period of disability insurance benefits under the Act. Id.

IV. THE RECORD

A. Background

Plaintiff Barbara Hanovich was 42 years old on the alleged onset of disability date of December 31, 1987. (Tr. 28). Her date last insured is March 31, 1996. Id. She is married and has two grown children. (Tr. 300). She has an undergraduate degree, with some graduate work in the field of education. (Tr. 975). She has work experience as a special education teacher. (Tr. 975). She did some part-time physician recruiting from her home for a number of years. Id. On a part-time basis, she also ran a travel agency and tour escort business from her home during her alleged period of disability. Id. She alleges disability from lupus, degenerative disc disease, ankylosing spondylitis, fatigue, vision loss, and Sjogren’s and Raynaud’s disorders. (Tr. 29).

B. Medical Records Before Date Last Insured

Plaintiffs alleged onset of disability date is December 31, 1987. On July 20, 1983, plaintiff was seen by Dr. J. Douglas Cameron at the University of Minnesota Hospitals and Clinics, and was noted to have systemic lupus erythematosus and mild keratoconjunctivitis sicca. (Tr. 747). She was diagnosed with keratoeonus of the right eye. Id.

On November 12, 1986, plaintiff was evaluated by Dr. Paul Waytz on referral by Dr. Mullin for a history of joint and back pain. (Tr. 614). Dr. Waytz noted that plaintiff had a very complex history, beginning with joint problems in high school, and periodic problems with joint and chest pain through college. (Tr. 614). She had significant back problems when she was pregnant with her first and second children. Id. She also had periodic GI problems over the years. Id.

Dr. Waytz noted that over the last few years, plaintiff had progressive problems with joint symptoms, and low and mid-back discomfort. (Tr. 614). She had been on multiple anti-inflammatories. Id. Dr. Waytz also noted that plaintiff had recurrent gastric and duodenal ulcers, as recently as a couple of weeks ago. Id. Plaintiff described having symptoms typical of Raynaud’s and acrocyanosis of her hands, dry eyes, and dry mouth. Id. Dr. Waytz further noted that plaintiff had a disturbed sleep pattern, and had been on at least one anti-depressant, which she did not tolerate very well. Id. Dr. Waytz also noted that plaintiff did a lot of work which involves travel. Id.

On examination, plaintiff was thin and a bit pale. (Tr. 613-14). Dr. Waytz did not detect any skin rashes but he saw some mottling of the hands, arms, and legs. (Tr. 614). Plaintiff complained of multiple joint tenderness, and tenderness throughout the back. (Tr. 613). Dr. Waytz did not detect a lot of synovitis, or any effusions of the knees or ankles, and hip range of motion was normal. Id. Dr. Waytz noted that plaintiff had mild dorsal kyphosis, and was tender throughout the back both on and off the muscle and bone. (Tr. 613). Dr. Waytz diagnosed arthralgias and questioned whether plaintiff would be a candidate for Plaquenil. Id. Dr. Waytz ordered additional testing, and noted that he needed to talk to Drs. Mullin, Weinberg, and Warshawsky. Id.

On August 6, 1987, plaintiff called Dr. David Weinberg’s office at Digestive Disease Associates because she was suffering severe abdominal pain. (Tr. 179). Plaintiff sought a prescription for Demerol, because Tylenol 3 was not helping. (Tr. 179). She admitted that she had not been taking her medications on time or on a regular basis during a recent trip to Europe. Id. She had not been adhering to her diet or taking antacids. Id. Plaintiff was instructed to restart antacids. Id.

Dr. Weinberg saw plaintiff for worsening symptoms of peptic disease on November 23, 1987. (Tr. 199). She was noted to be on multiple medications for arthralgias. (Tr. 199). Dr. Weinberg diagnosed chronic gastritis. (Tr. 200). He prescribed Mi-soprostol. (Tr. 199).

On June 27, 1988, plaintiff was admitted to North Memorial Medical Center with peptic acid disease with associated nausea, vomiting and dehydration. (Tr. 201). Dr. Weinberg stated, “the patient is well known to me to have chronic peptic disease and some form of collagen vascular disease.” Id. He noted the many medications plaintiff was taking. Id. Dr. Weinberg’s impression was: “Antritis with superficial erosions of a significant degree. No well defined ulcers per se; that is, this patient has had evidence of active peptic disease, very likely drug induced.” (Tr. 197). Plaintiff was discharged on June 29, after rehydration. (Tr. 201).

On January 4, 1989, plaintiff saw Dr. Waytz. He noted she was off Prednisone and Plaquenil. (Tr. 611). Dr. Waytz reported that plaintiff apparently developed significant changes in densitometry. Id. She also had early cataracts and some bilateral conus. Id. Despite her variety of problems, her GI tract was stable. Id. Dr. Waytz also noted that plaintiff complained of arthralgia of the hands of feet, and upper back and neck pain. (Tr. 611). Plaintiff reported that her memory was worsening, and she had some episodes of exhaustion and confusion. Id.

On examination, plaintiffs joints did not show active synovitis. (Tr. 611). There was some muscle spasm of the upper back and neck, but range of motion of her joints was good. (Tr. 611). Dr. Waytz noted that he would check an “LML-30” and lupus profile, and that he needed to speak with Dr. Mullin. Id.

Plaintiff called Dr. Waytz in February 1989, because the medication Voltaren was not effective. (Tr. 611). Dr. Waytz prescribed Plaquenil, but then put plaintiff back on Voltaren the next month because her pain had increased. Id.

Plaintiff underwent endoscopy by Dr. Weinberg on January 29, 1990, to evaluate the status of her peptic ulcer disease. (Tr. 196). She was found to have “active antral ulcer well defined and of significant size, very benign appearing consistent with nonsteroidal anti-inflammatory induced vs. straight peptic disease.” Id. Plaintiff returned for evaluation eight weeks later, after discontinuing use of Prednisone and Naprosyn. (Tr. 193, 580). Examination showed the ulcer to be 75% healed. (Tr. 192, 581).

On August 9, 1991, plaintiff underwent an upper endoscopy for evaluation of chronic peptic ulcer disease, which at times caused severe pain. (Tr. 189). Dr. Coleman Smith summarized plaintiffs situation as follows:

This is a 45-year-old white female who has Lupus and is on numerous medications for this, including Aspirin. She’s known to have chronic peptic ulcer disease and has been demonstrated to have antral ulcers in the past, for a number of years. She has been on Prilosec, every other day, and increasing this to daily has not helped the recurrence of her pain. She finds that eating does relieve it to some extent, but at times the pain is so severe that she has been taking Demerol for this. To rule-out the possibility of a recurrence of peptic disease, upper GI endoscopy was scheduled.

(Tr. 189). Dr. Smith diagnosed antral ulcer. (Tr. 190).

Dr. Weinberg saw plaintiff in follow-up on October 18, 1991. (Tr. 152). He noted that plaintiff has rheumatologic problems for which she sees Dr. Mullin, and takes medications including Naprosyn, Aspirin, Plaquenil, and Cardizem. (Tr. 152). Her other medications include Carafate, Prilo-sec, Cytotec, Prozac, Pericolace, and Ma-crodantin. Id. Dr. Weinberg noted that plaintiff has intermittent healing of her ulcer disease but it was recently active. Id. Plaintiff was improved but still symptomatic after three weeks of taking 40 mg of Prilosec a day. (Tr. 152). Endoscopy showed diffuse antral gastritis with no evidence of ulcer disease, and plaintiff was kept on Prilosec. (Tr. 153).

Plaintiff had a total abdominal hysterectomy and bilateral salpingo-oophorectomy on June 12, 1992. (Tr. 572). She was discharged on June 17, 1992. (Tr. 571).

On November 4, 1992, plaintiff underwent another upper endoscopy by Dr. Weinberg, due to chronic use of Prilosec in high dose. (Tr. 288). Her esophagus, stomach, and duodenum were essentially normal. (Tr. 289). On the same day, a biopsy of plaintiffs stomach showed non-diagnostic benign gastric mucosa with no inflammation, atypia or ulceration. (Tr. 290).

On September 2, 1994, plaintiff was referred by Dr. Mullin to Dr. Weinberg for evaluation of persistent dyspepsia with increasing severity. (Tr. 286). An upper endoscopy indicated nonspecific esophagi-tis. Id. A gastric antral biopsy on the same day indicated superficial ulceration and erosion. (Tr. 285). Esophageal biopsies indicated “focal fungal and bacterial organisms.” Id.

On November 4, 1994, Dr. Mullin referred plaintiff to Dr. Weinberg for evaluation of iron deficiency anemia with a long history of abdominal pain and constipation. (Tr. 283). A colonoscopy was performed, and the findings were consistent with me-lanosis coli and internal hemorrhoids. (Tr. 282-83). The results of an upper abdominal ultrasound were normal. (Tr. 559). On November 14, 1994, plaintiff had a computed tomogram of the abdomen and pelvis, which was negative. (Tr. 273, 556).

Plaintiff had surgery for varicose veins on both legs on October 30, 1995. (Tr. 549).

On March 13, 1996, plaintiff had an antral biopsy by Dr. Thomas R. Arlander, which showed antral gastritis with ulceration. (Tr. 281). Helicobacter were not seen. Id. On April 9, 1996, mucosal biopsies of the right colon indicated melanosis coli. (Tr. 280). Terminal ileum and recto-sigmoid biopsies were normal. Id. The biopsies did not explain the etiology of plaintiffs iron deficiency anemia. (Tr. 279). Dr. Weinberg suspected that the anemia resulted from chronic NSAID and Aspirin use. Id.

C. Medical Records After Date Last Insured

On April 23, 1996, plaintiff underwent an upper endoscopy by Dr. Weinberg to evaluate response to treatment for active peptic ulcer disease. (Tr. 275-76). Antral biopsies were taken of possible erosions. (Tr. 276). The esophagus was normal. Id. The gastric antrum biopsy showed ulcer, negative for Helicobacter pylori. (Tr. 274).

Plaintiff was referred by Dr. Mullin to Dr. David Kraker at Midwest Spine Institute on June 16, 1996, for evaluation of chronic back and neck pain. (Tr. 298). Her pain began six to eight weeks earlier. Id. Plaintiff noted that she had fractured her foot and was not walking correctly, and wondered if that contributed to her pain. (Tr. 298). Aggravating factors of her pain were standing for a long time, and turning her head when reversing the car. (Tr. 299). A hot shower, heating pad, and massage helped reheve the pain. Id. She sometimes had difficulty sleeping. Id.

Plaintiff reported to Dr. Kraker that she owns a business called New Departures, and she worked four to five hours a week with no work restrictions. Id. Dr. Kraker noted that plaintiff has a long history of back pain, history of lupus, and history of possible early ankylosing spondylitis. (Tr. 301).

Upon examination, plaintiff had moderate thoracic kyphosis. (Tr. 301). She was tender at the cervical thoracic junction, the lower cervical spine, the left trapezius, and the midthoracic spine. Id. She had full cervical spine and shoulders range of motion. Id. Motor and sensory examination, and deep tendon reflexes were normal. Id. Range of motion and motor and sensory examination were also normal for her thoracic and lumbar spine, and lower extremities. (Tr. 302). X-rays indicated degenerative disc disease at C6-7, multi-level thoracic degenerative disc disease with moderate kyphosis, and severe degenerative disc disease at L4-5 and mild at L3-4. Id.

Dr. Kraker diagnosed degenerative disc disease, left low lumbar degenerative scoliosis, history of lupus, and history of possible ankylosing spondylitis. (Tr. 303). Dr. Kraker recommended a short dose of steroid “for her flare-up”, a Medrol dose-pak, physical therapy, and Vicodin “for this flare-up.” Id. Plaintiff saw Dr. Kraker in follow-up on August 27, 1996. (Tr. 297). She was improving with physical therapy and the Medrol Dosepak. Id.

On August 7, 1996, plaintiff had repair surgery by Dr. Jonathon Paley at North Memorial Medical Center for stress urinary incontinence, which had not responded to conservative treatment. (Tr. 379-81, 384-86, 521-29). Dr. Paley noted that plaintiffs medical history was most notable for systemic lupus erythematosus and some associated connective tissue disorders including Sjogren’s syndrome and an-kylosing spondylitis. (Tr. 524).

After surgery, plaintiff was discharged on August 12. (Tr. 379). On August 18, plaintiff returned to the hospital with pelvic pain. (Tr. 382). Plaintiff had gone into urinary retention, and she was shown how to use a catheter. Id. On September 10, 1996, plaintiff was allowed to resume her usual activities and told to follow up by phone before travelling again. (Tr. 353).

On August 5, 1997, plaintiff had an in-traocular lens exchange of the left eye. (Tr. 327).

Plaintiff saw Dr. Kraker again on January 6, 1998. (Tr. 295). She was having an increase in back and right leg pain. Id. Dr. Kraker noted an MRI of December 19, 1997, showed multi-level disc degeneration, most advanced at L4-5 with foraminal stenosis due to a combination of lateral disc herniation, scoliosis, and degenerative changes in her facets. (Tr. 295, 510-11). On examination, plaintiff had slight decreased sensation in the right anterior thigh and mild weakness in the right quad. (Tr. 295). Dr. Kraker explained that her pain appeared to be due to the foraminal narrowing at the right L4-5. Id. He recommended right L4 nerve root block. Id. He also recommended that she start on Daypro and physical therapy for her back and neck pain. (Tr. 295-96).

On January 20, 1998, Dr. Kraker noted that plaintiff had six hours of relief, followed by a 40% improvement of her pain after the right nerve root block. (Tr. 294). However, her neck pain was increasing. Id. Dr. Kraker recommended that plaintiff have another nerve root block before considering discectomy and fusion. Id. He also recommended an MRI of the cervical spine. Id. The MRI showed disc herniation at C6-7 with mild foraminal stenosis; C5-6 osteophyte formation with disc protrusion and foraminal stenosis; and C4-5 mild spondylosis and uncinate hypertrophy without neural foramina and similar changes at C3-4. (Tr. 657-58).

On February 17,1998, Dr. Kraker noted that plaintiff had relief from the second nerve root block, with 50-60% improvement after three weeks. (Tr. 293). Dr. Kraker recommended another nerve root block in March 1998. (Tr. 293). The MRI of her cervical spine showed central disc bulging at C4-5, C5-6, and C6-7, without cord or nerve compression. Id. Dr. Kraker recommended continuing physical therapy. Id.

On March 31, 1998, Dr. Kraker noted that plaintiff had 40-50% relief from her third nerve root block. (Tr. 291). She had recently been on several trips where she was in quite a bit of pain. Id. She described her current pain as moderate. Id. Dr. Kraker recommended continued physical therapy and home cervical traction. (Tr. 291). He recommended that plaintiff try to live with the pain and to use Darvocet and Vistaril for relief, using Vico-din only for severe pain. Id.

In May 1998, plaintiff told Dr. Kraker that did not feel she could live with her neck and low back pain, and asked him about surgery. (Tr. 691). Dr. Kraker did not recommend surgery for her cervical spine, but he felt decompression, discecto-my and fusion may be helpful for her lower back pain. Id. Plaintiff wanted to schedule her surgery after returning from a trip out of the country in the next few weeks. (Tr. 692). Dr. Kraker noted that plaintiff had a history of lupus and was on Relafen, Aspirin and Plaquenil, which she would not be able to stop in the postoperative period due to increased morning stiffness and pain. (Tr. 691). Dr. Kraker advised plaintiff that the use of anti-in-flammatories may increase her risk that fusion of her lower spine would be unsuccessful. Id.

On June 26, 1998, plaintiff underwent a preoperative history and examination, in preparation for decompression and fusion of her lumbar spine. (Tr. 483). Her medical history was significant for lupus, ankylosing spondylitis, chronic pain, peptic ulcer disease, Sjogren’s syndrome, Ray-naud’s syndrome, corneal transplants in the right and left eyes, cataracts removed. (Tr. 483). In addition to low back pain with radiculopathy, she was found to have chronic neck pain associated with degenerative arthritis. (Tr. 484). She has tho-racodorsal scoliosis. (Tr. 485).

Plaintiff was asked about her social history. She was noted to be married for 32 years to a cardiologist, and has two grown children. (Tr. 484). She has been a school teacher, and has a Master’s Degree in Education. Id.

Plaintiff underwent surgery for decompression and fusion on July 6, 1998. (Tr. 304-08, 481-82, 492-95, 1024-26). Post-operatively, she developed right leg and ankle pain, attributed to a flare-up of her lupus. (Tr. 304). She also had an episode of encephalopathy, which was felt to be at least in part due to her medications. (Tr. 304, 490). She had an MRI of her thoracic spine on July 13, which indicated moderate thoracic kyphosis, and moderate central disc protrusion at L2-3. (Tr. 501-02). Her pain improved with steroids and anti-in-flammatories. (Tr. 304). Plaintiff was discharged on Oxycontin and Oxycodone. Id.

On July 31, 1998, plaintiff saw Dr. Kraker and reported that she had not yet returned to work after surgery. (Tr. 690). She continued to have pain in the low back and right leg. Id. She was also recently experiencing fatigue and nosebleeds. Id. She was told to avoid driving for the next three to four weeks. Id.

Plaintiff went to physical therapy from August 4, 1998 through November 24, 1998. (Tr. 919-34). By September, plaintiff was doing quite well and hoping to travel to Portugal in six weeks. (Tr. 689). Dr. Kraker noted that compared to many fusion patients, plaintiff was ahead of schedule. Id. Plaintiff reported that she wanted to go to Portugal in six weeks, but Dr. Kraker wanted to evaluate her status before she decided whether to go on the trip. (Tr. 689).

When plaintiff saw Dr. Kraker in October 1998, she reported fatigue and loss of energy, especially if she was overactive or walked too much. (Tr. 688). Plaintiff also reported recently having a flare-up of her lupus. Id. Nevertheless, plaintiff planned to go to Australia in the next few weeks. Id. Dr. Kraker noted that plaintiffs fusion was consolidating well. Id. He recommended that plaintiff increase her walking on a daily basis. Id.

Plaintiff had a severe flare-up of back pain in November upon returning from a trip to Australia. (Tr. 687). Dr. Kraker felt the flare-up was due to the hardware from her surgery. Id. Plaintiff reported that she was scheduled to go to China as a tour guide the next week. Id. Dr. Kraker recommended that she fly first class so she could lie down and get up and walk around. Id.

In December of 1998, plaintiff underwent a neuropsychological evaluation by Dr. Steven Morgan at the Minneapolis Clinic of Neurology because she felt her memory was worsening over the last six months. (Tr. 975). She also described having severe headaches every two to three weeks for the last six to nine months. Id. Plaintiff was fully cooperative and well-motivated with neurocognitive testing. (Tr. 976). She demonstrated mild impairment in attention and concentration, fluid nonverbal reasoning, and visual and spatial construction skills. (Tr. 976). She demonstrated moderate impairment in nonverbal and visual memory. Id. Dr. Morgan opined that such a pattern suggests relative inefficiency of right cerebral functions. Id. He opined that her overall memory impairment was mild. (Tr. 977). He noted that plaintiff just led a tour group to China without major difficulties, suggesting that she was compensating adequately. (Tr. 977). However, he also noted that her MMPI suggests a personality style with a degree of denial or limited insight. Id.

Dr. Morgan indicated that given plaintiffs history of lupus, the possibility of related central nervous system involvement must be considered. (Tr. 976-77). Dr. Morgan also noted that the pattern of neurocognitive disorder plaintiff displayed is a pattern which can be seen with systemic lupus erythematosus. (Tr. 978).

On February 5, 1999, plaintiff saw Dr. Kraker. (Tr. 685). Plaintiff indicated that after a trip to Thailand where she was quite active, she was having an increase in pain. Id. On examination, Dr. Kraker found that plaintiff had moderate spasm in the right side of the back. Id. Dr. Kraker believed the aggravation was due to overuse, and from the hardware in her back. (Tr. 978). He suggested that she could have the hardware removed one year after surgery, if her pain did not improve. Id. Plaintiff saw Dr. Kraker a short time later on February 19, 1999, at which time she reported that her back pain was worse after returning from a trip to New York. (Tr. 684). Dr. Kraker recommended cutting back her activities. Id. He also recommended pool and physical therapy. Id.

Plaintiff had an MRI of her brain on February 16, 1999, because she was suffering memory loss. (Tr. 473). The MRI was normal. Id. Dr. Charles Horowitz at the Minneapolis Clinic of Neurology referred plaintiff to Dr. David Knopman at the University of Minnesota Department of Neurology. (Tr. 973-74).

In the letter referring plaintiff to Dr. Knopman, Dr. Horowitz stated:

Ms. Hanovich presents to you for evaluation of cognitive disturbance. Neurop-sychometric testing was performed on December 9, 1998, and did suggest a pattern of mild cognitive impairment, perhaps consistent with a history of systemic lupus erythematosus per Dr. Steven Morgan. Of concern is Barbara’s reported complaint of persistent and increasing memory disturbance. She has been extremely active in her life, participating in many executive boards, as well as running her own travel agency, and participating in very frequent travel around the world. In spite of the somewhat extreme circumstances she pushes herself to, she had definitely noted a change in her ability to remember and to think through problems.

(Tr. 973). Dr. Horowitz noted that he also asked plaintiff to see Dr. Gerald Mullin, her rheumatologist, for general lupus reevaluation, since she had not seen him in the last year. (Tr. 974).

On April 16,1999, Dr. Kraker noted that plaintiff reported constant back pain, unless she was in the water. (Tr. 683). On examination, she had muscle spasm and mild weakness on the right side of the low back. Id. She was able to walk ten to thirteen minutes before having to stop. Id. She also had increased arm and neck pain and intermittent paresthesias in the hands. Id. Plaintiff had positive Tinel’s sign at the wrist, so Dr. Kraker noted he would need to rule out carpal tunnel syndrome. Id. He also noted that plaintiff had known multi-level cervical degenerative disc disease with foraminal stenosis. Id. Dr. Kraker recommended EMGs done on both upper extremities. Id.

On May 14,1999, plaintiff saw Dr. Kraker and stated that she had developed more pain in the left leg. (Tr. 681). Dr. Kraker noted that she had bilateral spasm in the lumbar spine. Id. She was also noted to have a healed fracture of the right foot. Id. She was able to walk on the treadmill 25-40 minutes before having to stop with pain in the right leg. Id. Dr. Kraker recommended a CT scan of the lumbar spine. Id. Plaintiff had a CT scan of her lumbar spine on May 18, 1999, to rule out spinal stenosis. (Tr. 653).

Plaintiff returned to Dr. Kraker for evaluation on May 28, 1999, and reported increased weakness in the left arm, more weakness and discomfort in the right leg, and paresthesias in the hands and feet. (Tr. 679). Dr. Kraker reviewed the recent CT scan of her lumbar spine, and indicated that it showed a disc herniation at L2-3, which Dr. Kraker felt to be the cause of her right leg discomfort. Id. He recommended hardware removal and a microdis-cectomy at L2-3. Id. As to the weakness in her arms, an EMG had not shown any abnormalities. Id. Dr. Kraker recommended an MRI of the cervical spine. Id. The MRI did not show any significant changes since a scan on January 22, 1998. (Tr. 677, 986). Dr. Kraker noted that plaintiff would prefer to have surgery for hardware removal towards the end of June, because she planned to take a trip immediately before then. (Tr. 680).

On June 10, 1999, plaintiff saw Dr. Horowitz for a follow-up. (Tr. 969-70). Dr. Horowitz described plaintiff as having underlying lupus and progressive pain related to her lumbar spine. (Tr. 969). Dr. Horowitz also noted that plaintiff had neck pain, and her most recent evaluation was an MRI on June 8, 1999. Id. The MRI showed small C5-6 disc herniation, mildly compressing the C6 nerve root. Id. The MRI also showed advanced degenerative spondylosis at C6-7 with moderate bony foraminal stenosis. (Tr. 969). This study showed no significant changes from a study of January 22, 1998. Id. Dr. Horowitz stated that plaintiffs medications included Prevacid, Prozac, Indocin, occasional Tylenol with codeine, occasional Percocet, and Plaquenil. (Tr. 969). He noted “[p]laintiff has not had a true flare of lupus. She has not required steroids in the recent past.” (Tr. 970).

Dr. Horowitz also noted that plaintiff continued to have problems with her memory, although an MRI scan of her brain was normal, and Dr. Knopman did not find her to have evidence of dementia. (Tr. 970). Dr. Horowitz was concerned that lupus may be causing her memory decline. Id. Given her continuing neck and back pain, and numbness and weakness in her hands, which might be related to lupus versus nerve entrapment versus cervical spondylosis, Dr. Horowitz recommended that plaintiff reconsider her pending trip to Italy. Id.

On examination by Dr. Kraker on June 11, 1999, plaintiff had marked tenderness of the left sciatic notch, the left iliac bone graft site, and SI joint. (Tr. 677). Dr. Kraker thought this was unusual, but could be related to lupus. Id. He recommended a CT scan of the pelvis to evaluate a potential occult lesion. Id.

Plaintiff saw Dr. Ben Bache-Wiig as a new patient on June 14, 1999, for preoperative evaluation for back surgery scheduled for June 23, 1999. (Tr. 1149). Dr. Bache-Wiig noted plaintiffs history of systemic lupus erythematosus, diagnosed at age twenty-five and treated by Dr. Muffin. Id. Dr. Bache-Wiig noted that plaintiffs lupus primarily manifested by serositis and joint discomfort without severe deforming arthritis, with no renal involvement or central nervous system involvement. (Tr. 1149). He also noted her history of peptic ulcer disease, bilateral corneal transplants, Sjogren’s syndrome with sicca syndrome, and chronic back and leg pain. Id.

Dr. Bache-Wiig noted plaintiff fatigued easily, and has serositis with chest discomfort when her lupus flares. (Tr. 1149). Her energy was diminished, and she had chronic epigastric pain. (Tr. 1149). Because plaintiff had flare-ups of lupus with previous surgery, Dr. Bache-Wiig gave her a Medrol dosepak before surgery, and noted he would give her a stress dose of steroids around the time of surgery. (Tr. 1148).

On June 23, 1999, the day before plaintiffs surgery, Dr. Kraker noted that plaintiff just returned from a trip to Italy where she did a fair amount of walking, and she reported shaking in both legs when going up and down steps. (Tr. 676). Dr. Kraker noted that the CT scan of plaintiffs pelvis on June 14, 1999, was negative. Id. On examination, straight leg raise was positive on the left and right. Id. Dr. Kraker recommended hardware removal without discectomy because he felt some of her symptoms, which were not clear-cut and consistent, were due to lupus. (Tr. 676).

On June 24, 1999, plaintiff underwent surgery for hardware removal. (Tr. 309). Postoperatively, Dr. Kraker noted that plaintiff experienced significant pain, including pleuritic chest pain thought to be a flare-up of her lupus. (Tr. 309). She also experienced leg swelling and decreased sensation of her left lower extremity. Id. Her symptoms improved, and she was discharged on July 4, 1999. Id. Her postoperative diagnoses were solid posterior fusion, L4-5, and systemic lupus erythe-matosus flare-up. (Tr. 309).

On July 27, 1999, plaintiff saw Dr. Horowitz, who noted that she had become de-conditioned overall. (Tr. 967). She was experiencing fatigue and weakness in her upper extremities. (Tr. 967). Nonetheless, she was gradually healing and improving. Id. Dr. Horowitz recommended physical therapy and a Back to Fitness program. Id.

On July 30, 1999, plaintiff saw Dr. Kraker and indicated that her back pain increased after she fell down some stairs while travelling in Quebec. (Tr. 672). Plaintiff also reported being fatigued and taking naps during the day. (Tr. 672). Dr. Kraker agreed with Dr. Horowitz, who recommended that plaintiff continue with physical therapy. Id. She began a course of physical therapy on August 4, 1999. (Tr. 906-11). Dr. Kraker also noted that plaintiff was quite fatigued, and took frequent naps during the day. (Tr. 672). He opined that therapy should work on general conditioning. Id.

On September 17, 1999, Dr. Kraker noted that plaintiff had been quite active, making several trips prior to her check-up. (Tr. 671). Plaintiff reported having increased pain in the right ankle, which was consistent with past lupus flares. Id. She was using a cane, as her right leg was weak and had given out on her. Id. She also noted upper extremity symptoms, such as inability to hold# a toothbrush. Id. Dr. Kraker recommended continued pool therapy and beginning myofascial therapy. Id. He referred plaintiff to Dr. Horowitz for her upper extremity symptoms. Id.

Plaintiff had fourteen sessions of physical therapy ending on October 6, 1999. (Tr. 942-953). Physical Therapist Anthony Yurick opined that plaintiff had plateaued in her progress and was independent in home exercise, but with questionable compliance due to her work and social calendar. (Tr. 942). Plaintiff returned for physical therapy on August 15, 2001 through October 25, 2001, (Tr. 940), November 8, 2001 through December 27, 2001, (Tr. 939), April 24, 2002 through October 22, 2002, (Tr. 937).

Plaintiff saw Dr. Cynthia Pederson on October 11,1999, who noted plaintiff had a history of lupus. (Tr. 1139). Plaintiff complained of myalgias and joint pain, and discomfort with taking deep breaths. (Tr. 1139). Plaintiff described her symptoms as consistent with previous lupus flares. Id. She was treated with Predni-sone and Percocet. (Tr. 1139). A chest x-ray was obtained secondary to pleurisy, and was negative for signs of acute process. Id.

Plaintiff saw Dr. Horowitz on October 12, 1999. (Tr. 964). He noted that she just had a flare of lupus, which was evaluated by Dr. Pederson. Id. Plaintiff reportedly was pleased with the results of her recent physical therapy. (Tr. 964). However, she continued to have neck pain, pain in her hips, swelling ankles, and increasing weakness in her right arm. Id. On examination, she had restricted range of motion in the cervical spine, with variable strength, and mild and diffuse weakness. Id. She also had slight weakness in the legs, with mildly suppressed reflexes throughout, and absent at the ankle. Id. Dr. Horowitz did not recommend surgery unless absolutely necessary. (Tr. 965). He stated, “If [plaintiff] continues to progress in terms of neck symptomatology in spite of her treatment for lupus and in spite of physical therapy, then an MRI scan would be useful.” Id. Plaintiff began a course of physical therapy on November 10, 1999, ending on March 6, 2000. (Tr. 896-99).

On November 23, 1999, plaintiff went to the emergency room, and was admitted at North Memorial Health Care for increased back pain and abdominal pain. (Tr. 434, 436-43, 1020-22). On admission, she was noted to be “a 54-year-old white female with systemic lupus erythematosus.” (Tr. 1020). She complained of feeling poorly for three weeks, with abdominal and back pain becoming much worse in the last four to five days. (Tr. 1020). Dr. Krieger noted that although her lupus usually responded to steroids, she recently did not have any improvement with steroids. Id. An endoscopy indicated distal antral ulcer with multiple punctuate antral ulcers. (Tr. 443-44). Plaintiff was treated with Preva-cid and antacids. (Tr. 443). She was discharged on November 26, 1999. (Tr. 434).

Plaintiff saw Dr. Horowitz on December 10, 1999, after returning from trips to China, South America, and Orlando, Florida. (Tr. 962). On return, she had increasing symptoms of right-sided weakness. Id. Dr. Horowitz opined this may have been caused by a lupus flare over the last several weeks. Id. Plaintiff was also suffering visual disturbance and G1 bleeding. Id. Dr. Horowitz recommended that plaintiff continue with pool therapy and moderate her activities. (Tr. 963). He noted that plaintiff would see Dr. Mullin the next week, and she hoped to have an injection in her right hip, which had helped her in the past. Id.

On January 10, 2000, plaintiff saw Dr. Jerrold Stempl for an upper endoscopy to evaluate the healing of her ulcer. (Tr. 450-51). Dr. Stempl noted that plaintiffs history was:

Significant for hysterectomy. She’s had gastric surgery, selective vagatomy, bladder surgery, corneal transplant, back surgery, cataract surgery. She again has systemic lupus.

(Tr. 450). The endoscopy showed decreased size and depth of the antral ulcer. (Tr. 451).

Plaintiff saw Dr. Kraker on January 14, 2000. (Tr. 669). She had increased back pain and leg pain after falling while traveling in the Himalayas. Id. She was having difficulty carrying things. (Tr. 669). She had tingling in her hands associated with Raynaud’s phenomenon. Id. Dr. Kraker felt her arm symptoms may be a progression of her cervical disc degeneration. (Tr. 669). He noted that plaintiff had recently been hospitalized for a GI bleed and a lupus flare. Id. On examination, plaintiff had diminished range of motion of the cervical spine. Id. Motor strength and grip strength were diminished. Id. She had moderate spasm on the right side of the lumbar spine, with positive straight leg raise. Id. Plaintiff had a lumbar epidural injection. (Tr. 650). She had 70% relief of her bilateral low back pain. Id.

On January 25, 2000, plaintiff had an MRI of the cervical spine to rule out compression fracture. (Tr. 648). Compression fracture was ruled out, but the MRI showed multilevel degenerative disc disease of the cervical spine. Id. Plaintiff began physical therapy on February 2, 2000. (Tr. 900-01, 894-97).

On January 26, 2000, Dr. Bache-Wiig described plaintiffs lupus as fairly stable, and her chronic pain as well-controlled by Oxycontin. (Tr. 1133). Plaintiff saw Dr. Bache-Wiig again in March, 2000, and stated that she was suffering from increased fatigue. (Tr. 1132). Dr. Bache-Wiig hoped to improve her arthritis control with Vioxx, while moving away from narcotic painkillers. Id. Plaintiff feared the Vioxx would not be sufficient for pain during her trip to Bolivia. (Tr. 1129). Dr. Bache-Wiig switched her to Relafen. Id.

Plaintiff saw Dr. Horowitz for a followup on April 14, 2000. (Tr. 960). She had developed increasing stiffness and weakness