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Jones v. Astrue

June 1, 2010


The opinion of the court was delivered by: Richard Mills, U.S. District Judge


This case is before the Court on the Plaintiff's motion for summary judgment and the Defendant's motion for summary affirmance.

Defendant's motion is allowed.


On March 27, 2008, Plaintiff Matthew G. Jones applied for disability insurance benefits and supplemental security income under the Social Security Act. The Plaintiff alleged that he became disabled on February 19, 2008. The Plaintiff's applications were denied initially on June 30, 2008, and again upon reconsideration on August 8, 2008.

On August 20, 2008, the Plaintiff requested a hearing before an administrative law judge ("ALJ"). A hearing was held on November 3, 2008, where the Plaintiff and a vocational expert testified. After considering the evidence, the ALJ found that although the Plaintiff had "severe impairments," these impairments did not meet or equal any listed impairment. The ALJ found that Plaintiff could perform sedentary work as defined in the regulations, except that "he cannot climb ladders, ropes, or scaffolds; he can occasionally climb ramps/stairs, balance, stoop, kneel, crouch, and crawl; and he needs a sit/stand option."

In relying on the testimony of the vocational expert, the ALJ concluded that Plaintiff was not disabled because he could perform a significant number of jobs. The Plaintiff requested review of the ALJ"s decision. On February 27, 2009, the Appeals Council found no basis to review it. The Plaintiff timely sought judicial review pursuant to 42 U.S.C. § 405(g).


A. Pre-Onset Medical Evidence

The Plaintiff was born in 1981 and resides in Virden, Illinois. Prior to his alleged onset date, the Plaintiff sought treatment for head and back injuries sustained in an accident in October 2005. As of April 2007, he had no difficulty ambulating and his neurological examination was normal. Doctors diagnosed left lumbosacral radiculopathy based on the results of a June 2007 nerve study.

The Plaintiff reported ongoing neck and back pain on October 17, 2007, though his neurological examination remained normal. Although he told the doctor that the Army had restricted him to desk work and a shorter week, the Plaintiff told David J. Bitzer, M.D., over the course of three appointments less than one month later, that his typical duties in the Army required ten hours of mental and physical work daily and seven hours of heavy exercise per week.

On December 14, 2007, doctors found a "moderate sized arachnoid cyst" on the Plaintiff's brain.*fn1 Doctors also found mild narrowing in the Plaintiff's lower lumbar spine with the lowest grade of spondylolisthesis, a slight displacement of a vertebra. A cervical spine MRI was "[n]early normal," with only minimal disc protrusion. Doctors prescribed physical therapy for the Plaintiff's neck pain. During the course of treatment, the Plaintiff on one occasion stated that he had not done many of the recommended home exercises. On at least two occasions, his compliance with his exercises was termed "questionable."

By early December, the Plaintiff reported alternately that he "hardly ever gets headaches anymore" and that his neck and shoulders were "feeling much better;" that he still had headaches 1-2 times per week and "some neck pain;" and that he was 90% improved, but had lower back pain. The therapist noted that Plaintiff's neurological examination, neck range of motion, upper extremity strength, and upper extremity range of motion were all normal. The Plaintiff was discharged from physical therapy on December 7, though it was recommended that he continue the "postural re- education exercises at home."

On November 16, 2007, Lacie Shanks, M.D., treated the Plaintiff for complaints of depression, neck pain, back pain, and memory loss. Dr. Shanks opined that the memory loss symptoms were "most likely" due to stress and depression. The Plaintiff had a normal gait, stance and neurological examination. The Plaintiff denied any numbness or tingling, disorientation, dizziness, balance problems, nausea or blurred vision.

In a follow-up visit with Dr. Shanks, on December 4, 2007, the Plaintiff reported that his neck and back pain had "overall improved." However, he complained of "longstanding" numbness and tingling in his arms and hands, dizziness, memory loss, and nausea.

On January 16, 2008, the Plaintiff saw Dr. Shanks for complaints of fever, nausea and other symptoms. The doctor thought the Plaintiff may have been getting over the flu, based on his complaints, and noted "a question of whether or not he has "tru[]ly been sick."

At a January 30, 2008, appointment, the Plaintiff told Dr. Shanks that he had no new concerns and no side effects from his medications. Dr. Shanks found that Plaintiff had full range of motion and 5/5 strength in all joints, and exhibited a normal mood and affect.

B. Post-Onset Medical Evidence

On March 11, 2008, approximately three weeks after the Plaintiff alleges he became disabled, he sought treatment at a VA clinic for back pain, headaches, the arachnoid cyst, and other complaints. The Plaintiff did not report neck pain and his medical conditions were all "stable." The Plaintiff was being discharged from the Army due to a legal problem. The nurse practitioner found that Plaintiff had some weakness and decreased reflexes in his left leg, but a full range of motion in all extremities and could "sit, stand and ambulate without difficulty." Although the Plaintiff's depression screening was positive, the nurse practitioner determined that he had "[n]o mental health condition requiring further intervention." The Plaintiff told a social worker that he experienced disorientation, dizziness, memory loss, balance problems, and blurred vision.

On May 30, 2008, a state agency reviewer examined the Plaintiff's records and opined that his physical impairments were not severe. On June 2, 2008, a second state agency reviewer examined the Plaintiff's records and opined that his mental impairments were not severe. Any depression was controlled by medication and did not restrict the Plaintiff's functioning. Another state reviewer later affirmed both findings.

On March 18, 2008, the Plaintiff requested an eye exam because the long distance vision in his right eye was blurry. On May 23, the Plaintiff told a VA optometrist that he had never worn glasses before, but now had blurred vision, especially in his right eye. The optometrist found that Plaintiff had 20/20 vision in his right eye and 20/40 vision in his left eye.

On June 17, 2008, a VA social worker treated the Plaintiff for his "legal and marriage issues." She opined that Plaintiff has an adjustment disorder, marital problems, and paraphilia,*fn2 and a GAF score of 50.*fn3

In September 2008, the Plaintiff returned to SIU-Springfield with complaints of "pressure" in his head, balance problems, and sensitivity to light. The nurse practitioner found that Plaintiff could "sit, stand, and ambulate without difficulty" and had a full range of motion in all of his extremities. The Plaintiff's neurological examination was normal. The nurse practitioner recommended no treatment plan, testing or further follow-ups.

The record also contains an October 30, 2008, letter signed by Melissa Brown at Christian County Mental Health Association. Brown's letter does not state a medical specialty, job title, or any other credentials.*fn4 Brown's letter states that she began counseling the Plaintiff in July 2008 and refers to "symptoms" of depression and anxiety that caused Plaintiff to "struggle" with sleep and daily activities and with "returning to a fully functioning status." Brown's letter is not accompanied by any ...

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