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Valarie Galvan v. Michael J. Astrue

September 28, 2011


The opinion of the court was delivered by: Magistrate Judge Cox


Plaintiff, Valarie Galvan ("Galvan"), seeks judicial review of a final decision of the Commissioner of the Social Security Administration ("SSA") denying her application for a period of disability and for Social Security Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act").*fn2 Galvan has filed a motion for summary judgment [dkt. 24], seeking a judgment reversing or remanding the Commissioner's final decision. The Commissioner has in turn filed a cross-motion [dkt. 26]. For the reasons set forth below, the Commissioner's motion is granted and Galvan's motion is denied.

I. PROCEDURAL HISTORY On March 17, 2008, Galvan filed an application for DIB, alleging a disability onset date of

March 1, 2007.*fn3 The SSA denied her application initially, and again upon reconsideration.*fn4

Thereafter, Galvan filed a timely written request for a hearing, which was granted.*fn5 On June 15, 2009, a hearing was conducted before Administrative Law Judge ("ALJ") Daniel Dadabo in Peoria, Illinois.*fn6 During the hearing, the ALJ heard testimony from Galvan and vocational expert ("VE") Craig Johnston.

On September 1, 2009, the ALJ issued an unfavorable decision finding that Galvan was not disabled under the Act.*fn7 On September 9, 2009, Galvan appealed the ALJ's determination to the Appeals Council of the SSA.*fn8 The Appeals Council denied Galvan's request on June 25, 2010, making the ALJ's ruling the final decision of the Commissioner.*fn9 Galvan timely filed the instant action on August 2, 2010.*fn10


We now summarize the administrative record. We set forth the background evidence concerning Galvan's medical history, including the objective medical evidence considered by the ALJ. We then discuss the hearing testimony, before addressing the ALJ's opinion.

A. Introduction and Medical Evidence

Galvan was born on June 9, 1976, making her thirty-three years old on the date that the ALJ issued his decision.*fn11 Galvan graduated from high school in 1996, and completed a vocational training program in 2009.*fn12 Before suffering a gun shot wound to her left leg and buttock on January 22, 2000, Galvan worked as a cook and a machine operator, among other low-to-medium-skilled labor jobs.*fn13 After she was shot, Galvan sporadically wored similar part-time jobs, including one month as a dishwasher and several months as an inventory counter.*fn14 Galvan states that she left the dishwasher job because it required her to stand for six hours and to carry heavy trays of dishes, causing pain in her injured leg.*fn15 In 2009, Galvan was terminated from her position at the inventory job, when her leg injury became apparent to her employer.*fn16

Galvan has four biological children, three of whom were not living with her at the time of the hearing.*fn17 Due to Galvan's substance abuse problems, her eldest child had been adopted, while her second and third children lived elsewhere and received supervised visits.*fn18 Only Galvan's 16-month old infant daughter remained in her care.*fn19 Galvan has never married, though she receives some financial support from her infant's father.*fn20 In 2009, Galvan moved from Haymarket Center*fn21 to her brother's home in Cicero, in order to obtain childcare while attending vocational training.*fn22

Galvan claims she is disabled due to the gun shot wound to her left leg and buttock,*fn23 which resulted in the physical impairments of paresthesia,*fn24 foot drop,*fn25 and weakness in Galvan's left foot.*fn26 Galvan has also been diagnosed with anxiety and major depressive disorder without psychotic features,*fn27 arising from substance abuse,*fn28 her shooting, and childhood abuse.*fn29
We begin our review of Galvan's relevant medical history on March 16, 2005, when Galvan visited the Loretto Hospital emergency room ("ER") for a scalp laceration suffered during an assault.*fn30 Galvan arrived alone and ambulatory, and her wound was cleaned and dressed before discharge.*fn31 On February 8, 2008, near the birth of her infant, Galvan received a psychiatric evaluation from registered nurse Aurora Prado ("R.N. Prado") at the John H. Stroger, Jr. Hospital ("Stroger Hospital"),*fn32 after reporting a history of postpartum depression.*fn33 Galvan denied past psychiatric hospitalization, though she reported feeling depressed and anxious with isolative behavior, crying spells, insomnia, hypersomnia, and feelings of being trapped in social problems.*fn34

Galvan denied suicidal or homicidal ideation.*fn35 She reported that her step-father sexually molested her beginning at age seven, and she began abusing substances as a minor, including alcohol, crack cocaine, heroin, and marijuana.*fn36 Galvan reported that she had stopped abusing substances during her pregnancy, but relapsed shortly before the evaluation.*fn37

R.N. Prado found that Galvan was mentally oriented, maintained good eye contact, had an appropriate, hygienic appearance, was alert and cooperative, maintained good attention and concentration, and exhibited psychomotor activity and speech that were within normal limits.*fn38 R.N. Prado also found Galvan's affect appropriate, her thought process organized and goal directed, and her memory intact, though she noted Galvan had a congruent, anxious and depressed mood.*fn39

Galvan was prescribed Sertraline and Trazadone,*fn40 as well as Zoloft, for depression.*fn41

On March 11, 2008, Galvan received a psychiatric evaluation from Greg Waitkoff, M.S., at the Cicero Family Services Clinic.*fn42 Galvan presented as alert and cooperative, with intact memory and appropriate thought content, affect, and orientation, but sad mood.*fn43 Mr. Waitkoff noted Galvan's substance abuse and assigned a Global Assessment of Functioning ("GAF") score of 40.*fn44

He attributed this score in part to poor social adjustment, noting Galvan does not have friends because those around her were not "a good influence."*fn45 Mr. Waitkoff also noted that Galvan reported listening to music, writing songs, playing piano and doing Sudoku puzzles.*fn46

On March 17, 2008, and May 6, 2008, State agency psychologists, J. Flores and John Tomassetti, Ph.D.*fn47 described Galvan as having difficulty understanding, staying coherent, and concentrating due to being "out of it," and appearing very tired.*fn48 Dr. Tomassetti performed a Mental Residual Functional Capacity ("RFC") Assessment focused on Listings 12.04 (Affective Disorders), 12.06 (Anxiety-Related Disorders), and 12.09 (Substance Addiction Disorders).*fn49 Dr. Tomassetti found that Galvan was "moderately limited" in several areas, including the ability to: understand, remember and carry out detailed instructions; maintain attention and concentration for extended periods; perform activities within a schedule and to be punctual; complete a normal workday and workweek without interruptions from psychologically based symptoms; interact appropriately with the general public; and set realistic goals or make plans independently of others.*fn50

Dr. Tomassetti found no marked limitations, concluding instead that most of Galvan's mental functions -- such as the ability to remember locations, understand and remember simple instructions, and sustain an ordinary routine without special supervision -- were "not significantly limited."*fn51 Dr. Tomassetti noted Galvan's ability to care for herself and her child by preparing meals, cleaning, doing laundry and grocery shopping, using public transportation, and paying bills.*fn52

Dr. Tomassetti noted that Galvan was able to listen to music, ride bicycles, and write,*fn53 but her problems with substance abuse made her guarded and distrustful.*fn54

On May 1, 2008, Galvan received a medical examination from State agency physician, Debbie L. Weiss, M.D.*fn55 Dr. Weiss observed that Galvan arrived unaccompanied and complained of numbness and paresthesia, destabilizing foot drop, and cramping in her left foot after prolonged walking.*fn56 Dr. Weiss's examination showed that, consistent with a foot drop and a 0/5 score for dorsiflexion in her left foot, Galvan was unable to heel walk with her left foot.*fn57 Galvan's right mid-calf measured 34 centimeters in circumference, while her left mid-calf measured 29 centimeters.*fn58

Dr. Weiss described Galvan's finger and hand grasp as unimpaired in either hand.*fn59

Dr. Weiss also assessed Galvan's mental health. Galvan described a remote suicide attempt and worsening depression after being shot.*fn60 Galvan reported suicidal thoughts, but not plans, in the three months before the examination; her depression had improved since she began seeing a therapist every two weeks.*fn61 Galvan also described having panic attacks accompanied by chest pain, shortness of breath and hot flashes, which were relieved by splashing cold water on her face.*fn62

Galvan stated that she experienced confusion, inability to sleep without Trazadone, and poor memory.*fn63 Dr. Weiss noted that despite Galvan's reported history of depression and anxiety attacks, she did not seem depressed or anxious, and her orientation, memory, appearance, behavior and ability to relate were "entirely within normal limits."*fn64 Dr. Weiss concluded that Galvan's symptoms appeared to be controlled by Sertraline,*fn65 and listed Galvan's pain medications as Gabapentin and Ibuprofen.*fn66
On May 19, 2008, Calixto Aquinas, M.D., examined Galvan to complete a Physical RFC Assessment.*fn67 Dr. Aquinas opined that Galvan would be limited to lifting or carrying a maximum of 20 pounds occasionally or 10 pounds frequently.*fn68 He assessed Galvan as able to stand, walk or sit, with normal breaks, for a total of about 6 hours in an 8-hour workday. *fn69 Dr. Aquinas noted that Galvan would be limited in the operation of foot controls and precluded from climbing ladders, ropes or scaffolds.*fn70 He completed a Disability Determination and Transmittal Form ("SSA form 831").*fn71]

On May 29, 2008, another State consultant, Terry Travis, M.D., examined Galvan*fn72 and also completed an SSA form 831.*fn73 Dr. Travis noted Galvan's reports of left leg injury, depression, anxiety and painful toes, but affirmed the initial determination of Galvan's functional capacity because there was no worsening of any previously documented impairment, nor any new impairment or treatment, and because the prior determination, as well as the rationale for it, were correct.*fn74

Records from June through August 2008 show that Haymarket Center gave Galvan a psychiatric referral to Stroger Hospital.*fn75 There, a treating psychiatrist, Anne Strohm, Ph.D., noted Galvan's participation in a heroin, cocaine and alcohol detoxification program.*fn76 Dr. Strohm's notes reflect that Galvan suffered from nervousness, jitteriness, and difficulty concentrating when reading, which Dr. Strohm suggested may be symptoms of post-traumatic stress syndrome.*fn77 However, Dr. Strohm noted that Galvan's symptoms were controlled fairly well by her medications,*fn78 which Dr. Strohm re-prescribed.*fn79 On June 13, 2008, Dr. Strohm noted Galvan's complaints of twice-weekly chest pains,*fn80 which were unexplained by an electrocardiogram and x-ray.*fn81

On June 13, 2008, Galvan was treated at Stroger Hospital ER for swelling in her third toe.*fn82

A radiology report showed bony fragments near the cuboid bone of Galvan's left foot, possibly caused by ossicles or bone fragments from a donor site, but not osteomyelitis.*fn83 Galvan's medications were refilled, and she displayed good eye contact, but a flat affect.*fn84

Galvan began receiving treatment at Winfield Moody Health Center ("Winfield) on October 8, 2008. After an examination, Physician Assistant ("P.A."), Wasiu Durojaiye, measured Galvan's height (64 inches) and weight (170 pounds), and documented a body mass index of 29.29,*fn85 which was indicative of obesity.*fn86 P.A. Durojaiye found that Galvan had weakness in her left foot and a left foot drop, as well as a large surgical scar over the tibia and fibia of the left leg.*fn87 The right foot was normal.*fn88 While Galvan reported a history of drug abuse, no mental symptoms were noted.*fn89

P.A. Durojaiye again examined Galvan on October 17, 2008, finding that she had swelling of the left foot, peripheral neuropathy (nerve damage) and ankle pain, but that her pain was not affecting her activity level.*fn90 On November 4, 2008, Dr. Murad Abdel-Qader confirmed these findings, also observing general weakness in the left foot due to nerve injury.*fn91 Dr. Abdel-Qader instructed Galvan to treat her leg using rest, ice, compression, and elevation ("RICE") and physical therapy exercises, and instructed Galvan to return in three weeks for reevaluation.*fn92

On November 20, 2008, P.A. Durojaiye once more examined Galvan upon her complaint of diarrhea and muscle cramps in her arms and legs.*fn93 He prescribed Imodium for the diarrhea and Cyclobenzaprine, a muscle relaxant, for the cramps.*fn94 On November 25, 2008, P.A. Durojaiye noted that, although pain was affecting Galvan's activity level, the pain was due to the strengthening exercises, and Galvan reported feeling "70% better."*fn95

From June 17, 2008, until June 8, 2009, Galvan received psychological counseling, generally every two weeks, at the Mental Health Center of Cicero.*fn96 Clinicians' reports show that, although Galvan's mental issues initially caused hypervigilance while traveling at night, recurrent nightmares of sexual abuse and being shot, and conflicts with family members,*fn97 over time Galvan progressed to stable, "euthymic" mood and sobriety, less anxiety, better sleep and proactive engagement in relieving family tension.*fn98 These reports further noted Galvan's grief at being separated from her older children, but also her assertiveness in pursuing greater visitation rights to see them.*fn99 The reports also noted that Galvan, though subject to panic attacks around stressful events, had no urges to use drugs, fewer PTSD triggers, and no insomnia.*fn100

On November 10, 2008,Galvan reported that her part-time inventory job was going well, that she was enthusiastic about job training, and that she was considering employment with United Cerebral Palsy.*fn101 She verbalized commitment to sobriety and "getting her life on track."*fn102 Galvan reported feeling isolated, but acknowledged the risks of befriending substance abusers.*fn103

After complaining of irritation in the scar on her lower left leg, Galvan was referred by P.A. Durojaiye to Dr. George Sisson for surgical treatment.*fn104 On January 22, 2009, Dr. Sisson performed a pre-operative examination, which found that Galvan's cardiovascular system was unproblematic and her ...

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