Agustin Q. v. Saul
| Decision Date | 12 May 2020 |
| Docket Number | No. 18 C 7416,18 C 7416 |
| Parties | AGUSTIN Q., Plaintiff, v. ANDREW M. SAUL, Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Northern District of Illinois |
MEMORANDUM OPINION AND ORDER2
Plaintiff, Agustin Q.,3 applied for Disability Insurance Benefits ("DIB") and Social Security Income ("SSI") in 2014, alleging he became disabled on July 1, 2010, when he was 38 years old. (R. 21.) After a hearing, an administrative law judge ("ALJ") issued a written opinion denying his applications for benefits. The Appeals Council denied Plaintiff's request for review of the ALJ's decision (R. 1), making the ALJ's decision the final decision of the Commissioner.Jozefyk v. Berryhill, 923 F.3d 492, 496 (7th Cir. 2019). Plaintiff seeks remand of the Commissioner's decision denying his applications for benefits (D.E. 16), and the Commissioner has asked the Court to affirm the decision. (D.E. 22.) The matter is now fully briefed.
Plaintiff received treatment from various medical providers at SU Salud Medical Center in Cicero, Illinois and occasional emergency room visits. The medical record begins in July 2012 with normal x-rays of Plaintiff's left hip and knee, despite pain. (R. 354.) The following year, in June 2013, thoracic and lumbar imaging showed degenerative changes but no acute findings, despite Plaintiff's lower back pain. (R. 362.) On July 12, 2014, Plaintiff underwent a state agency consultative medical examination. He reported sleeping a lot but still feeling fatigued. (R. 330.) The examiner noted he was obese at 69 inches tall and weighing 309 pounds, and his lungs were significant for decreased breath sounds. (Id.) Plaintiff had moderate difficulty squatting, mild difficulty walking on his toes, and decreased sensation to vibration at his toes, but he had a normal gait and normal range of motion in all joints except his knees. (R. 331.) On July 24, the non-examining state agency reviewer opined Plaintiff had the physical residual functional capacity ("RFC") to perform light work, occasionally lift or carry up to 20 pounds and frequently lift or carry up to 10 pounds; and stand, walk and sit about six hours in an eight-hour work day with some additional postural limitations. (R. 92-94.)
On July 23, 2014, Plaintiff underwent a state agency consultative mental status evaluation. Plaintiff reported hearing voices and having trouble sleeping; he had been taking the antidepressant Zoloft. (R. 346-48.) The examiner noted that Plaintiff's mood and affect were somewhat flat and he was "somewhat . . . intellectually limited" and had "some memory issues." (R. 348, 350.) OnAugust 5, 2014, the non-examining state agency mental health reviewer opined that Plaintiff had an affective disorder that caused mild limitations. (R. 90.)
At a doctor's visit on July 28, 2014, Plaintiff reported continued lower back and hip pain (R. 421), and he underwent an MRI of his lumbar spine on August 5, 2014. The MRI showed disk herniation at the L4-5 that was causing "severe stenosis of the spinal canal and mass effect on the transiting L5 nerve," and mild degenerative changes at other levels. (R. 415.)
Throughout 2015, Plaintiff was prescribed Norco (a narcotic) for his back pain as well as 800 mg of ibuprofen. (R. 411-12, 510, 515, 619.) A July 2, 2015 MRI of Plaintiff's lumbar spine showed no change from his previous MRI. (R. 450.) In August 2015, after reviewing additional medical evidence provided by Plaintiff on reconsideration, non-examining state agency physicians affirmed the previous year's state agency physical and mental RFC opinions. (R. 108-16.)
Plaintiff reported worsening back pain in 2016. In June 2016, in addition to Norco and ibuprofen 800 mg, Plaintiff was taking gabapentin, a nerve pain medication. (R. 503.) Plaintiff was also taking medication for diabetes, hypertension and hypercholesterolemia, and he continued to take Zoloft for depression. (Id.)
In August 2016, Plaintiff went to a rehabilitation hospital for treatment of his lower back pain. He described the pain as alternating between sharp and throbbing; the pain extended down his bilateral lower extremities. (R. 433.) Plaintiff also complained of bilateral foot numbness and tingling, which he attributed to his diabetes. (Id.) The physician observed that Plaintiff had some difficulty going from a sitting to standing position, tenderness in his lumbar spine, his gait was slow and cautious, lumbar flexion was slightly decreased, lumbar extension was significantly decreased and straight leg test was positive bilaterally (indicating lower back pain). (R. 434.)
On August 19, 2016, Plaintiff received a lumbar epidural injection for his lumbar radiculopathy (nerve pain) and spinal stenosis. (R. 453.) However, at a doctor's visit the following day, Plaintiff reported that he did not feel any change with the injection. (R. 498.) His doctor added a prescription for Flexeril (a muscle relaxant, once a day) in addition to ibuprofen 800 mg (three times per day) and Norco (every six hours, as needed). (R. 499.)
On September 24, 2016, Plaintiff visited his doctor "for follow up of low back pain with sharp needle like pain and tingling and numbness of both legs." (R. 496.) Plaintiff reported difficulty sitting or standing for more than 30 to 40 minutes at a time, and the doctor observed that he appeared uncomfortable when sitting and was constantly shifting. (R. 496-97.) In addition to his medications, the doctor recommended Plaintiff follow up with a pain clinic. (R. 497.)
On October 17, 2016, Plaintiff attempted to return to work driving a forklift, but he stopped working after six weeks because of back pain. (R. 489.) On December 10, 2016, Plaintiff rated his back pain as an eight out of 10 despite taking ibuprofen, Flexeril, gabapentin and Norco. (Id.) Plaintiff's physician told him to stop taking Norco. (R. 490.) At a follow-up medical visit in March 2017, Plaintiff continued to complain of severe back pain; his medications were not helping to relieve the pain. (R. 485.) Examination showed Plaintiff had lumbar muscle spasm, decreased lumbar range of motion, and positive bilateral leg raising test. (R. 485.) Plaintiff's physician gave Plaintiff a prescription for tramadol (a narcotic), in addition to his other medications. (R. 486.)
At the July 6, 2017 hearing before the ALJ, Plaintiff testified that he had tried to go back to work in October 2016 because he briefly felt better after his August 2016 lumbar injection. (R. 68.) However, he stopped working about two months later because he "couldn't take the pain anymore, [] of working." (R. 53.) Plaintiff testified that he had lower back pain that ran down bothhis legs and sharp pain going down his left arm (id.); the pain lasted for hours every day. (R. 58.) Sometimes his medication helped relieve his pain, but at other times his back continued despite additional ibuprofen and tramadol. (R. 58-59.) Plaintiff took Flexeril morning and at night, which made him sleepy (R. 54), and he still felt tingling despite taking gabapentin. (R. 66-67.)
Plaintiff testified that he could walk slowly up to two blocks, sit for 45 minutes, and stand for about an hour (R. 59), but he had extreme pain after standing about 15 minutes. (R. 70-71.) His wife did all the housework; she also tied his shoes for him and sometimes helped him dress due to his back pain. (R. 61, 64.) Plaintiff used a cane (not prescribed) to help him walk and stand straight (R. 61); he used his hands to lean on something when he stood up from a sitting position. (R. 72.)
The vocational expert ("VE") testified that Plaintiff's past work included assembly line hand packager and forklift operator. (R. 75.) The VE stated that no light work would be available for a person who needed to sit or stand alternately at will. (R. 78.) Regarding sedentary jobs with a sit/stand option, the VE testified that, in his experience (as the Dictionary of Occupational Titles does not discuss sit/stand options), there were "bench jobs" available, (R. 78-79.) In addition, that person's off-task time should not exceed six minutes per hour in addition to normal breaks. (R. 80.) Plaintiff's attorney clarified that a person who needed to lean on both hands while standing would be off task while standing. (R. 81.)
On December 6, 2017, the ALJ issued a written opinion finding that Plaintiff was not under a disability within the meaning of the Social Security Act from his alleged onset date of July 1, 2010, through the date of the decision. (R. 22.) At Step One, the ALJ found Plaintiff had notengaged in substantial gainful activity during this time period. (R. 23.) At Step Two, the ALJ found Plaintiff had the following severe impairments: lumbar spinal stenosis, lumbar radiculitis with disk herniation, and peripheral neuropathy. (Id.) The ALJ determined Plaintiff's diabetes and morbid obesity were not severe because they did not cause more than minimal limitations in his ability to function. (R. 24.) In addition, the ALJ found that Plaintiff's mental impairment did not cause him any limitations; the ALJ recognized that Plaintiff reported feeling agitated, depressed and hearing voices but noted he "did not seek any mental therapy." (Id.) At Step Three, the ALJ found Plaintiff's impairments did not meet or medically equal the severity of a listing. (R. 24-25.)
Next, the ALJ assigned Plaintiff an RFC to perform sedentary work provided he could: sit and stand at will without being off task, operate foot controls occasionally and hand controls with his right hand frequently; and stoop, kneel and crouch occasionally. (R....
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