Shannon M. v. Saul
| Decision Date | 17 January 2020 |
| Docket Number | No. 18 C 7074,18 C 7074 |
| Parties | SHANNON M., Plaintiff, v. ANDREW SAUL, Commissioner of Social Security, Defendant. |
| Court | U.S. District Court — Northern District of Illinois |
MEMORANDUM OPINION AND ORDER
Shannon M. applied for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("Act"), 42 U.S.C. §§ 1381a, 1382c, in January of 2015. (Administrative Record (R. 171-77). She claimed that she became disabled as of December 30, 2011 (R. 171), due to a number of complaints, including: fibromyalgia, myalgia myosis, hypothyroidism, GERD, hiatal "heredia [sic]," anemia, asthma, allergies, insomnia, bipolar disorder, anxiety, and "arthritis - everywhere." (R. 212). Her claim was denied at every level: initial, reconsideration, administrative law judge (ALJ), and appeals council. It is the ALJ's decision, from September 8, 2017, that is before the court for review. See 20 C.F.R. §§404.955; 404.981. Plaintiff filed suit under 42 U.S.C. § 405(g) on October 22, 2017, and the parties consented to the jurisdiction of a Magistrate Judge pursuant to 28U.S.C. § 636(c) on December 7, 2018. [Dkt. # 10]. The case was then reassigned to me after it was fully briefed, several months later, on August 22, 2019. [Dkt. #25]. Plaintiff asks the court to reverse and remand the Commissioner's decision, while the Commissioner seeks an order affirming the decision.
Plaintiff was born on June 16, 1975, and so was just 36 years old when she claims she became unable to work ever again, and 42 at the time of the ALJ's decision. She worked only sporadically prior to that. She didn't work at all from age 21 through 25, age 29 through 34, or age 39 on. (R. 191-92). She used heroin regularly from age 35 through 39. (R. 560-61,708,720). In terms of whether she continues to use heroin or not, she's a completely unreliable historian. She's told her doctors her last use was in the fall of 2014, but she clearly continued to use the drug in early 2015 and the fall of 2015. (R. 464, 631). And at least one of her doctors indicated she continued using heroin into 2017. (R. 699, 704).
In terms of medical evidence, the record is large, spanning almost 400 pages. (R. 340-737). But, as is also usually the case, very little of it is significant in determining whether plaintiff can work or is disabled. Indeed, the plaintiff only points to about 20 pages of that evidence as supporting her claim for SSI. [Dkt. #20, at 11-15]. The medical record shows that plaintiff has, and has been treated for, fibromyalgia since at least 2013. (R. 521). But over the course of the medical record, findings are generally benign, and the examinations are normal. For example, at the first examination plaintiff points to in her brief in January 2013 [Dkt. # 20, at 2], plaintiff reported thatshe was feeling well. (R. 505). Her treating physician, Dr. Adrian, noted no tenderness anywhere upon examination, no neurological symptoms, and no symptoms in plaintiff's extremities. (R. 506). In April 2013, Dr. Adrian again reported normal findings - no swelling, redness, or tenderness. (R. 521). The record goes on like this, with the vast majority of clinical findings reported as normal, without limitations, without tenderness, etc. (R. 340-42, 509-510, 513, 516, 518-19, 521, 525-26, 529-30, 533, 536, 539, 543-44, 547, 549-50, 624, 626-29, 631, 636-37, 640, 648-49, 711, 715-16, 721).
There are a few exceptions, of course, as few people feel great every day. But there is nothing significant enough to suggest disability. On March 29, 2010, plaintiff complained of back pain over the prior 5 days, although there was no tenderness upon examination. (R. 518-19). On May 1, 2013, Dr. Adrian noted moderate ankle tenderness, but normal strength, range of motion, and no swelling. (R. 526). On June 5, 2013, Dr. Adrian noted lower abdomen tenderness. (R. 536). Plaintiff reported constipation, heartburn and abdominal pain on July 17, 2013. (R. 543). On March 26, 2014, Dr. Adrian noted inflammation where plaintiff had last injected heroin. (R. 516). On May 1, 2014, there was tenderness from bruising on plaintiff's shoulder. (R. 530). Dr. Adrian reported tenderness to palpation along the cervical, thoracic, and lumbar spine, the clavicle, upper legs, and ankles on August 19, 2015. (R. 443). On July 12, 2016, there was moderate tenderness and decreased grip strength and range of motion in plaintiff's hands. (R. 640). There was tenderness along plaintiff's spine on December 14, 2016, and February 3, 2017, but range of motion and all other findings were normal. (R. 654, 716, 721).2
Treatment records regarding plaintiff's mental status aren't much different, although they are fewer and farther between. Plaintiff went to the ER on October 28, 2014, after cutting her left forearm with scissors in response to an argument with her husband. (R. 357-58). She was transferred for psychiatric treatment (R. 581-82), where she was assessed with a GAF score of 45-50 upon admission and diagnosed with major depression before discharge on October 31st. (R. 584-85). There is no record of any further treatment until a year later in October 2015 (R. 440, 569), when she was admitted for symptoms of depression. (R. 569). Group therapy and counseling were offered at that time, but there is no record of plaintiff continuing with counseling. (R. 569). On November 25, 2015, Dr. Stanley Tomczyk noted that plaintiff was going to 12-step meetings, 3-4 times a week. (R. 628). Dr. Tomczyk prescribed Adderil for depression on December 23, 2015. (R. 626). Dr. Gaonkar, a psychiatrist, reported on April 4, 2017, that he had seen plaintiff every month since November 2015, but after November 15, 2015, there appear to be no notes of his treatment, and plaintiff does not direct the court to any. (R. 699); [Dkt. 320, at 2-8]. The single notefor November 15, 2015, consists solely of Dr. Gaonkar's assessment of plaintiff's GAF score as 45-50. So, there is no longitudinal record of plaintiff's psychological condition, symptoms, or limitations.
Following the administrative hearing - at which the plaintiff, represented by counsel, testified along with a vocational expert - the ALJ determined the plaintiff was not disabled. The ALJ found that the plaintiff had the following severe impairments: "fibromyalgia, spinal disorder, asthma, obesity, bipolar disorder and history of heroin and opiate abuse." (R. 18). The ALJ embarked on a lengthy summary of the medical evidence and determined that plaintiff's impairments, either singly or in combination, did not meet or equal a listed impairment assumed to be disabling in the Commissioner's listings. (R. 18-22).
The ALJ then determined that plaintiff could perform:
sedentary work . . . except . . . can never climb ladders, ropes or scaffolding. [Plaintiff] is to perform no more than occasional climbing of ramps/stairs, balancing, stooping, crouching, crawling, kneeling, bending or twisting. [Plaintiff] is to reach overhead no more than on a frequent basis with the right upper extremity, and should be allowed a sit-stand option allowing her to stand 1-2 minutes after sitting for 30 minutes. [Plaintiff] is to avoid concentrated exposure to lung irritants, cold temperature extremes, hot temperature extremes, and work hazards such as unprotected heights and dangerous moving machinery. [Plaintiff] should be allowed to use a cane as needed to get to/from the work station. [Plaintiff] is limited to understanding, remembering and carrying out no more than simple routine tasks performing the same tasks day in and day out. [Plaintiff] is to have no public contact for work-related purposes and no more than occasional contact with coworkers and supervisors. [Plaintiff] should not be required to travel to different work sites to complete job task(s) and should not have strict quotas (claimant should not perform work where someone checks up on her throughout workday to see if she is on pace with a goal/quota or with other employees) but she can perform work where performance is measured by what is completed by the end of the work day.
(R. 26-27).
In addition to the medical evidence, the ALJ considered plaintiff's subjective complaints about her symptoms and limitations. The ALJ said that she found that plaintiff's "medically determinable impairments could reasonably be expected to cause the alleged symptoms, however, the [plaintiff]'s statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely consistent with the medical evidence and other evidence in the record for reasons explained in this decision." (R. 27). The ALJ compared plaintiff's allegations to the medical findings and noted they were not supported. The ALJ also noted some inconsistencies in plaintiff's statements to doctors and her allegations. The ALJ then went into depth regarding how her residual functional capacity finding accounted for each of plaintiff's limitations to the extent they were credible. (R. 22-28).
Next, the ALJ went through the medical opinion evidence. She gave no weight to the opinions of plaintiff's treating physician, Dr. Adrian, who opined that there was very little plaintiff was capable of doing and, in fact, she had to lie down for 30-40 minutes frequently throughout the day. (R. 24-25). She could only sit for 20-30 minutes at a time. (R. 25). But, as the ALJ explained, the doctor's treatment notes lent no support for such severe limitations, and that plaintiff's statements to Dr. Adrian, which appear to have formed the basis for Dr. Adrian's opinion, were not consistent with those she made to other doctors or elsewhere in the record. (R. 24-25).
Similarly, the ALJ rejected the opinion from Dr. Amdur, who examined plaintiff one time at her attorney's office. (R. 26, 559) The ALJ noted he was not a treating source, talked with the plaintiff on one occasion at her attorney's office, and...
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