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Martinez v. Astrue

February 24, 2010

ANITA MARTINEZ PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY DEFENDANT.



The opinion of the court was delivered by: Michael T. Mason, United States Magistrate Judge.

MEMORANDUM OPINION AND ORDER

Plaintiff Anita Martinez ("Martinez" or "claimant") filed a motion for summary judgment seeking judicial review of the final decision of the Commissioner of Social Security (the "Commissioner") denying her claim for Supplemental Security Income ("SSI") benefits pursuant to 42 U.S.C. §§ 416(i), 423(d) and 1382. The Commissioner filed a cross motion for summary judgment asking this Court to uphold the decision of the Administrative Law Judge ("ALJ"). We have jurisdiction to hear this matter pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). For the reasons set forth below, the Commissioner's motion for summary judgment is granted and Martinez's motion is denied.

I. PROCEDURAL HISTORY

Martinez filed an application for benefits on September 8, 2004. (R. 66-69). In that application, Martinez alleged a disability due to manic depression, rheumatoid arthritis and fibromyalgia with an onset date of December 30, 2003. (R. 35, 66). The Social Security Administration denied her claim initially and again upon reconsideration.

(R. 32-41). Martinez filed a timely request for a hearing to review the denial of her claim. (R. 31). ALJ Alice Jordan ("ALJ Jordan") presided over that hearing on October 16, 2007. (R. 378-424). On October 31, 2007, the ALJ issued a decision concluding that Martinez was not disabled and denying her request for benefits. (R. 16-23). Martinez then filed a timely request for review. (R. 10-12). On March 27, 2008, the Appeals Council denied that request and ALJ Jordan's decision became the final decision of the Commissioner. (R. 4-6); Nelms v. Astrue, 553 F.3d 1093, 1097 (7th Cir. 2009).

II. BACKGROUND

A. Medical History

Claimant submitted medical records from 1996 to 2007*fn1 in support of her claim for SSI benefits. (R. 137-371). On April 15, 1996, Martinez presented to Holy Cross Hospital ("Holy Cross") after a prescription drug overdose. (R. 155). The same day, Dr. Christine Aruguete ("Dr. Aruguete"), Martinez's primary care physician, ordered a psychiatric consultation. (Id.). On April 23, 1996, a registered nurse performed a "social service psychiatry and substance abuse assessment." (R. 146-50). The nurse found claimant's overdose to be "reactive to overwhelming stress" associated with caring for her two small children and the recent birth of her third child. (R. 147). During the assessment, claimant reported a prior suicide attempt, at age fifteen, when she slit her wrists "for attention." (R. 146)

On September 27, 1998, Martinez arrived at Advocate Christ Hospital and Medical Center ("Christ Hospital") and reported bilateral ear pain, an inability to chew or swallow and radiating pain in the jaw and neck. (R. 137-39). The attending physician noted Martinez's history of depression and use of Prozac. (Id.). Martinez returned to Christ Hospital on October 26, 2000, complaining of a sharp and aching pain in her neck. (R. 164-66). Treatment records indicate that Martinez was "pregnant and refuse[d] any x rays." (R. 165).

Dr. Charles Alston ("Dr. Alston") delivered claimant's fifth child on June 11, 2001. (R. 156-61). Approximately six weeks later, on July 26, 2001, Martinez returned to Christ Hospital and reported complications from a tubal ligation performed the previous week. (R. 162-63). An attending physician noted mild tenderness in claimant's abdomen, diagnosed cellulitis, and ordered claimant to follow up with Dr. Alston within 24-48 hours. (R. 163).

On February 4, 2002, Martinez received treatment at Christ Hospital after overdosing on Vicodin and Flexeril. (R. 167-77). An attending physician noted that claimant suffered from "chronic depression" that "has usually been worse in the post-partum period." (R. 173). Claimant voluntarily admitted herself for psychiatric treatment. (R. 169). On or around February 5, 2002, Dr. Piyush C. Buch ("Dr. Buch") performed a psychiatric assessment based on the Diagnostic and Statistical Manual of Mental Disorders (the "DSM-IV") (R. 171-72). During that assessment, Martinez expressed feelings of depression; described thoughts of suicide, helplessness, and hopelessness; and reported a history of depression in her extended family. (R. 171).

Claimant stated that "this is her third overdose . . . she has been living with her five children and she is feeling very stressed out, feeling that life is not worth living." (Id.). Dr. Buch diagnosed recurrent major depression, noted the acute conditions of Vicodin and Paxil overdose and chronic back pain, and assigned Martinez an Axis V Global Assessment of Functioning ("GAF") score of 30. (R. 171). The doctor elected to treat Martinez with individual psychotherapy and Effexor XR. (R. 172).

Dr. Nenita R. Irabagon ("Dr. Irabagon") completed a medical history and physical examination of claimant on June 18, 2003. (R. 210-12, 226). During Dr. Irabagon's exam, Martinez recalled that she had an intrauterine device ("IUD") set in place in 1998.

(R. 210). Claimant stated that she underwent a vaginal hysterectomy on April 18, 2003 at St. James Hospital in Chicago Heights for chronic prolonged and heavy menses, and claimed that "her ovaries were not removed during the hysterectomy." (Id.). Dr. Irabagon diagnosed "controlled" depression, abdominal and rectal pain, chromic anemia secondary to prolonged heavy menstrual periods, and a retained IUD. (R. 212).

Also on that date, Dr. Sam F. Flosi ("Dr. Flosi") performed a surgery consultation. (R. 225-27). He noted a "lost IUD" and recommended a laparoscopy. (R. 227). According to the reviewing radiologist, a June 18, 2003 x-ray of claimant's abdomen revealed a contraceptive device in the lower abdomen at S1 "which appears to be high positioned in relation to the expected location of the uterus." (Id.). Dr. Flosi performed an open laparoscopy on June 19, 2003. (R. 213-14). According to his report, the laparoscopy showed that "perhaps an [IUD] was noted, however, it was uncertain." (R. 214). After consulting with Dr. Barbara Krueger ("Dr. Krueger"), a general surgeon, Dr. Flosi ordered an exploratory laparotomy of claimant's pelvis. (R. 214).

Dr. Krueger performed the laparotomy on June 19, 2003. (R. 215-16). Dr. Krueger's exam showed no evidence of the IUD in the pelvis, beneath or behind the ovaries. (R. 215-16). However, an exploration of the abdomen revealed the IUD "encased in the very distal aspect of the omentum." (R. 216). After removing the IUD, Dr. Krueger discharged Martinez with prescriptions for Vicodin and Motrin. (R. 209).

Martinez returned to the emergency department at Christ Hospital on July 15, 2003, complaining of persistent pelvic pain over the past three days. (R. 188-96). The attending physician noted that claimant's abdomen was slightly tender over the lower left quadrant. (R. 189). Claimant received a CT scan of her pelvis on July 16, 2003, and a second CT scan and ultrasound of her pelvis on July 18, 2003. (R. 270-74). The physician who reviewed the CT scans determined that the "tubular fluid filled structure seen in the examination on 7/16 [wa]s significantly smaller in the [7/18] study." (R. 270). He found a "suggestion of a boggy mass in the pelvis," but no distinct abscess. (Id.). A second physician reviewed the ultrasound and noted a "somewhat ill-defined hypoechoic area probably adjacent to the left ovary" of "unclear" significance. (R. 271).

Dr. Jeffrey H. Port ("Dr. Port") provided a gastroenterology consultation on July 20, 2003. (R. 278-79). He described Martinez as a "30-year-old-woman with [a] long complicated mental history" and "status post hysterectomy because of irregular menstrual periods," who "is now being evaluated for recurrent episodes of abdominal pain." (R. 278). During Dr. Port's examination, claimant reported two kinds of pain, a "vague pain in the left lower quadrant . . . associated with movement" and "a pain in the rectum" that precedes and follows bowel movements. (Id.). Dr. Port performed a colonoscopy with biopsy on August 16, 2003. (R. 181-82). That procedure revealed a "[i]rritable, spastic colon without mucosal abnormalities." (R. 181). Dr. Port concluded that Martinez "appears to have irritable, spastic colon," and recommended mild antispasmodic agents and/or mild antidepressants to relieve her pain. (R. 182). The biopsy did not reveal any malignancy, and the reviewing physician noted a postoperative diagnosis of hemorrhoids. (R. 180).

On February 17, 2004, Martinez received treatment from Dr. Robert J. Andina ("Dr. Andina"), one of Dr. Aruguete's partners. (R. 337). Claimant reported bone and joint pain in her shoulders, hands and left leg, which had been present for the last three months. (Id.). Martinez stated that she managed her pain with Aleve. (Id.). Dr. Andina recommended an x-ray of the lumbar spine. (Id.). According to the reviewing radiologist, that x-ray revealed a "normal lumbar spine" with no fracture, dislocation or other abnormality. (Id.).

Martinez then sought treatment from Dr. Daniel J. Hirsen ("Dr. Hirsen"), a rheumatologist. (R. 243-48). In a March 10, 2004 letter to Dr. Aruguete, Dr. Hirsen noted claimant's report of morning stiffness lasting two hours, a history of major depression, and a family history of rheumatoid arthritis. (R. 243). Dr. Hirsen described claimant's general physical exam as "normal." (R. 244). His exam showed "a question of trace swelling in the MCP and PIP joints of the hands," and that claimant's hips were "painful anteriorly on rotation" (Id.). The doctor observed "very subtle yet definite evidence of a true inflammatory process," which he termed "inflammatory polyarthritis." (Id.). Dr. Hirsen opined that claimant's condition was "not well developed enough to label as seronegative rheumatoid arthritis," and prescribed Plaquenil, a "very benign long-acting anti-inflammatory drug, for daily use." (Id.).

Martinez returned to Dr. Aruguete on March 16, 2004, and reported two recent falls due to a loss of sensation in her right leg. (R. 336). Dr. Aruguete noted a "normal examination" and diagnosed arthralgia. (Id.). Martinez sought treatment from the emergency department of St. Mary's Hospital ("St. Mary's") on August 8, 2004 after she fell down the stairs and injured her right ankle. (R. 251-57). An x-ray revealed no definitive acute fracture or other bony abnormality. (R. 255-56).

On August 27, 2004, claimant underwent a magnetic resonance imaging ("MRI") and magnetic resonance angiography ("MRA") study of her brain. (R. 249-50). Claimant's clinical history indicates that the purpose of the exam was to "rule out multiple sclerosis." (R. 250). According to the reviewing radiologist, the "essentially negative" MRI revealed only an "incidental note . . . of mild mucosal thickening involving maxillary sinuses bilaterally." (R. 249). He also described the MRA as "essentially negative." (R. 250).

Martinez returned to Dr. Aruguete on November 1, 2004, seeking treatment for pain in her left hip and knee, both ankles and right shoulder. (R. 335). Martinez reported "trouble sleeping" due to the pain. (Id.). She had stopped taking Plaquenil due the side effects of blurred vision, nausea, and abdominal pain. (Id.). Dr. Aruguete noted claimant's depression and arthritis, and prescribed Naprosyn for pain, inflammation and stiffness. (Id.). In a November 9, 2004 letter to the "Illinois Office of Rehab Services Disability Determination," Dr. Aruguete stated that claimant "has been under [her] medical care intermittently since 1996," and currently has "severe arthralgia[], both at rest and on minimal exertion." (R. 334). The doctor relayed Martinez's claim of "pain during the night" and an inability to function "due to her discomfort." (Id.). Finally, Dr. Aruguete noted that claimant "was advised to follow-up with her Rheumatologist, since she was unable to tolerate Plaquenil." (Id.).

Claimant's medical records also include the narrative results of a psychological examination performed by Erwin J. Baukus ("Dr. Baukus"), a licensed clinical psychologist, on December 16, 2004 and authorized by the Bureau of Disability Determination Services ("DDS"). (R. 280-84). Dr. Baukus examined claimant for 1.1 hours and reviewed her medical records. (R. 280). He observed that claimant drove herself to the examination and that her "balance, gait, and gross motor functioning were unremarkable." (Id.). Dr. Baukus noted Martinez's current medication: Seroquel, Effexor XR, generic Naprosyn, generic Colace, and generic Motrin. (R. 282).

During the exam, claimant reported "depressive symptoms" of sleep disturbance (delayed onset), decreased energy, feelings of worthlessness, difficulty concentrating and thinking, and thoughts of suicide. (Id.). Martinez also stated that she "independently takes care of her activities of daily living such as toileting, washing and personal hygiene," and "takes care of her children." (Id.). Finally, Martinez stated that she regularly attends church, takes care of chores around the apartment, does her own grocery shopping, and "gets around the neighborhood by walking, driving, and having others give her a ride." (Id.).

Dr. Baukus observed that claimant's affect, which he defined as the "emotional tone underlying her observed behavior," was "stable" and her mood "euthymic (normal range - absence of depressed or elevated mood)." (R. 283). Based on the clinical examination and his review of the available medical records, Dr. Baukus diagnosed Martinez ...


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