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Fredenhagen v. Astrue

October 4, 2010


The opinion of the court was delivered by: Susan E. Cox U.S. Magistrate Judge

Magistrate Judge Susan E. Cox


Plaintiff, Mary Fredenhagen, seeks judicial review of an Administrative Law Judge's decision denying her application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act.*fn1 Plaintiff has filed a motion for summary judgment in favor of reversal and remand of the decision while the defendant, the Commissioner, has filed a cross-motion for summary judgment to affirm the decision. For the reasons herein, plaintiff's motion for remand is granted [dkt 17] and defendant's motion is denied [dkt 19].


On June 26, 2006, plaintiff filed an application claiming a period of disability beginning on April 4, 2004.*fn2 She claimed disability on the basis of bipolar disorder, high blood pressure, and Graves' disease.*fn3 The Social Security Administration ("SSA") denied plaintiff's application on December 12, 2006 and again on April 18, 2007.*fn4 The SSA subsequently granted her request for a hearing before an Administrative Law Judge ("ALJ"). On December 3, 2008, plaintiff appeared before ALJ Kenneth Stewart.*fn5 The ALJ determined that plaintiff was not disabled as of April 4, 2004*fn6 , and on June 19, 2009, the Appeals Council of the SSA denied her request for review.*fn7 As a result, plaintiff filed this claim for judicial review of the ALJ's decision.


Plaintiff was born on March 15, 1949 and was fifty-nine years old when she appeared before the ALJ.*fn8 By April 4, 2004, the alleged date of disability onset, plaintiff was fifty-five and thus had reached advanced age for Social Security purposes.*fn9 She graduated from high school in 1967.*fn10 Plaintiff's most recent sustained employment was from 1985 to 2004 as a switchboard operator and receptionist for a bank.*fn11 She described the work as "fast-paced" and claims to have enjoyed the busyness of the job.*fn12 It is unclear why plaintiff left her job initially, but she has not sustained employment since April 4, 2004.*fn13 She claims that difficulty concentrating and fatigue associated with her conditions keep her from being able to work.*fn14

A. Medical History

The court record does not contain plaintiff's full medical history. Medical records from the Hinsdale Family Medical Center ("HFMC") contain a chart listing plaintiff's medications from June 2, 1997 to October 9, 2006 and notes from doctor's visits covering the period of April 8, 2004 to October 27, 2006.*fn15 These records confirm that plaintiff was receiving treatment for bipolar disorder, Graves' disease, sinusitis, and hypertension.*fn16 Bipolar disorder is a mood disorder characterized by alternating periods of depression and manic episodes.*fn17 Graves' disease is a disorder characterized by the overactivity of the thyroid gland, which controls metabolism.*fn18 Sinusitis is an inflammation of the sinuses caused by a viral, bacterial, or fungal infection.*fn19 Hypertension is the term used to describe high blood pressure.*fn20 Smitha Rajasekhar, M.D. was plaintiff's primary care provider at HFMC at least since the spring of 2006, though the record is unclear on exactly how long plaintiff has been seeing this provider.*fn21

Plaintiff was diagnosed with bipolar disorder around 1987, following the birth of her third child.*fn22 Her physicians have been able to control her condition through the prescription of lithium, which plaintiff has been taking for roughly twenty-five years.*fn23 The dosage has remained unchanged during that time and the patient described her symptoms as "very controlled."*fn24

On June 26, 2006, plaintiff underwent a thyroid scan confirming bilateral thyroid enlargement compatible with Graves' disease.*fn25 At an appointment on June 16, 2006 the plaintiff indicated to her physician that she had been fatigued for the last six months.*fn26 Following the scan and diagnosis, she began treatment with propylthiouricil.*fn27 After June 2006, the HFMC medical records do not indicate complaints of fatigue.*fn28 By March 2007, plaintiff's thyroid profile tested in the normal range.*fn29

Plaintiff's medical records indicate that she sought treatment for chronic sinusitis and jaw pain at various times from 2006 to 2008.*fn30 An MRI on April 16, 2007, confirms mucosal thickening in the left maxillary sinus consistent with sinusitis.*fn31 Records from a visit with Marie Shelton, D.O., in March 2008, report that recurrent sinus infection, trauma, and facial pain are related to injuries plaintiff sustained in a 1979 motor vehicle accident.*fn32 Dr. Shelton notes that symptoms include facial tenderness and nasal congestion.*fn33 Plaintiff has tried multiple medications, but has not had surgery to alleviate the congestion and pain.*fn34

On November 15, 2006, plaintiff was examined by an internist, Zain Syed, M.D., for the purposes of Social Security proceedings.*fn35 Dr. Syed noted plaintiff's major complaints were fatigue and lack of concentration, which he found could both be related to her bipolar disorder. He mentioned her history of Graves' disease, hypertension, and a possible diagnosis of tachycardia.*fn36

On November 27, 2006, psychiatrist Joseph Nemeth, M.D., conducted a psychiatric evaluation of plaintiff for the SSA.*fn37 With regard to her bipolar disorder, she reported feeling "more stable" on Lithium, but also admitted that she has had periods of poor concentration, depression, and lack of energy.*fn38 Dr. Nemeth noted that her sleep and mood seemed stable and recommended that plaintiff was capable of handling her own funds.*fn39

On December 8, 2006, psychologist R. Leon Jackson, Ph.D., completed a Psychiatric Review Technique report for the SSA.*fn40 He indicated mild limitations in plaintiff's activities of daily living, social functioning, concentration, persistence, and pace.*fn41 He also reported that plaintiff had one or two episodes of decompensation.*fn42 Dr. Jackson checked the box declaring plaintiff's bipolar disorder "not severe,"*fn43 while noting that she may be limited to "simple and routine work."*fn44 In his notes he reports the following: no evidence that the alleged mental impairment is sufficient severe to prevent the claimant from participating in handling her own funds or participating in simple and routine work activities; therefore, based upon the medical evidence in record the alleged mental impairment does not meet, equal, or functionally equal the severity of functional limitations. The current application is assessed to be non-severe.*fn45

Also on December 8, 2006, Frank Jimenez, M.D., completed a physical residual functional capacity assessment form for plaintiff's SSA disability application.*fn46 He reported that she could occasionally lift fifty pounds, frequently lift twenty-five pounds, stand and walk six hours in an eight-hour day, and had no limits in her ability to push and pull.*fn47 Dr. Jimenez noted no other limitations to plaintiff's physical ability to work.*fn48

Dr. Rajasekhar completed a medical evaluation form on January 3, 2007, from the Illinois Department of Human Services.*fn49 Dr. Rajasekhar managed plaintiff's bipolar disorder and plaintiff would only see a psychiatrist as needed.*fn50 With regard to plaintiff's bipolar disorder, Dr. Rajasekhar indicated no limitations to plaintiff's activities of daily living, mild limitations on social functioning, concentration, persistence, and pace and no episodes of decomposition.*fn51

B. December 3, 2008, Hearing before the ALJ

Plaintiff appeared before ALJ Stewart on December 3, 2008. She was represented by counsel, Marcie Goldbloom. Medical Expert ("ME") John Cavenagh, M.D., testified as well as Vocational Expert ("VE") Thomas Gusloff.*fn52 Plaintiff first responded to questions by the ALJ and her attorney about her previous work. Plaintiff described her most recent long-term employment from 1998 to 2004 as a receptionist and switchboard operator for a bank.*fn53 She interacted with customers and employees, routed calls to the appropriate departments, and was occasionally tasked with training others on the switchboard.*fn54 Then the ALJ questioned the VE only about plaintiff's previous employment. The VE testified that the exertional level for a receptionist and switchboard operator is sedentary and the skill level was at the upper end of semi-skilled.*fn55 That was the extent of the VE's testimony. Plaintiff's counsel chose not to question the VE further.

The ALJ also questioned plaintiff about her bipolar disorder. She testified that she has had the disorder for more than twenty-five years.*fn56 While she said she has seen a psychiatrist in the past, her primary care physician has been able to manage the illness for many years.*fn57 Plaintiff reported ...

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