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Craig A. Robison v. Michael J. Astrue

April 5, 2012

CRAIG A. ROBISON, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT



The opinion of the court was delivered by: Magistrate Judge Jeffrey Cole

MEMORANDUM OPINION AND ORDER

Craig Robison seeks review of the final decision of the Commissioner ("Commissioner"), of the Social Security Administration ("Agency") denying his application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act"), 42 U.S.C. §§ 423(d)(2). Mr. Robison asks the Court to reverse the Commissioner's decision and remand for an award of benefits, or in the alternative, reverse and remand for further proceedings. The Commissioner seeks an order affirming it.

I. THE PROCEDURAL HISTORY OF THE CASE

Mr. Robison applied for Disability Insurance Benefits on December 1, 2005. (Administrative Record ("R.") 22). His claim was initially denied on May 31, 2006, and again upon reconsideration on August 17, 2006. (R. 22). He appeared and testified at a hearing held on November 14, 2007 before Richard Boyle, an Administrative Law Judge ("ALJ"). (R. 22). On May 22, 2008, the ALJ issued a decision that denied Mr. Robison's claim. (R. 22-29). Mr. Robison then requested review by the Appeals Council, which was denied on February 16, 2010. (R. 1-3). Mr. Robison sought to appeal the decision to the federal district court under 42 U.S.C §§ 405(g) and 1383(c). On December 2, 2010 the parties consented in writing to proceed before a magistrate judge pursuant to 28 U.S.C. § 636(c)

II. THE EVIDENCE

A. The Vocational Evidence

Mr. Robison was born on October 7, 1955, making him 49 at the time of the alleged disability onset date. (R. 28). At the time of the hearing, he was separated from his wife and their two children, ages 14 and 16, and living with his parents. (R. 401-02, 421). He is a college graduate and has a degree in geography. (R. 402). Mr. Robison was laid off from his last position as a bus driver in July 2005 after he left one day due to headaches and depression. (R. 403-04, 406-07). Before that, he worked at Kankakee Container for twenty years, first as laborer out of college, and then as a supervisor, until his position was "discontinued". (R. 404-07). He has not worked since July 2005, aside from infrequently helping his father clean carpets. (R. 406-07).

B. The Medical Evidence

The medical record indicates Mr. Robison saw Dr. Bedford in April 2003, approximately two years before his onset date. (R. 183). In that meeting, Mr. Robinson informed Dr. Bedford that he had been seeing a Dr. Reid previously, and was worried that he was taking "too much medicine."

(R. 183). Dr. Bedford diagnosed him with major depression and prescribed Prozac, Effexor, Nuerontin, Risperdal, Topamax, Pamelor, Trileptal, and Klonopin. (R. 183-84). A month later, it appeared his depression was under control, but Dr. Bedford was unsure if there were any other underlying issues other than depression and anxiety due to the extensive list of medications. (R. 182).

Mr. Robison then began seeing Dr. Win, a psychiatrist, on July 12, 2005. (R. 179-81). Dr. Win also diagnosed him with major depressive disorder, adjusted his medication and dosage, and recommended that he continue therapy. (R. 180). Later that month, Dr. Win had a follow up examination in which he opined that Mr. Robison's anxiety disorder and depressive episode were "stable." (R. 177). Another follow up examination was conducted in August 2005, in which Mr. Robison reported that he felt "better", and Dr. Win noted that his depression and anxiety were still "stable." (R. 175). In September 2005, Dr. Win noted that Mr. Robison's mood disorder was "intermittent" and adjusted his medication dosage. (R. 173). In October 2005, Dr. Win observed that Mr. Robison's mood disorder had improved and reduced his medication dosage. (R. 171). In November 2005, Mr. Robison complained that he felt "depressed" and Dr. Win assessed that the mood disorder was "intermittent". (R. 169). Mr. Robison continued to see Dr. Win every one to two months. (R. 326-42, 316-21). Although Dr. Win recommended therapy, he noted that Mr. Robison would not follow through because of financial reasons. (R. 337).

In February 2007, Dr. Win noted that Mr. Robison's mood disorder was "recurrent" and was hesitant to make many changes in his medication because he was not compliant with treatment. (R. 334). At the time, Mr. Robison had stopped taking Effexor and Seroquel, and so Dr. Win prescribed additional medications, Zyprexa and Alprazolam. (R. 335). In April 2007, Mr. Robison stated that he would reduce his checkups to every three months, because he was feeling better. (R. 330). In July 2007, Dr. Win notes that Mr. Robison's mother described him as "better overall in the last several months." (R. 328). In October 2007, Mr. Robison's mom noted that he has "emotional sadness," and his father stated that "he just sits all day on the sofa with his head down and [complains about] his pain." (R. 326). Dr. Win saw Mr. Robison's mood disorder as "unchanged" and suggested that Mr. Robison start talk therapy, or take up a hobby to distract himself from his worries. (R. 326-27).

In July 2005, Mr. Robison started seeing James Kelly, M.D. for his headaches. (R. 386). At that time, Mr. Robison reported that he was experiencing chronic, diffuse headaches that were exacerbated by stress, anxiety, and coughing. (R. 386). Mr. Robison reported that the headaches began acutely in February 2005 without any obvious cause, but Dr. Kelly noted that Mr. Robison was a "rather poor historian." (R. 386). Although Dr. Kelly suspected the headaches were of unclear etymology, he noted that Mr. Robison had been noncompliant with medication for hypertension and wanted to rule out hypertension headaches first. (R. 387-88). Two weeks later, with his blood pressure under control, Mr. Robison reported that the headaches were persisting. (R. 384). After examination, Dr. Kelly diagnosed possible supraorbital neuralgia and administered nerve blocks. (R. 385). Shortly thereafter, during a follow-up exam Mr. Robison described very significant improvement in the intensity of his headaches along with diminished frequency. (R. 383). However, Mr. Robison's headaches returned in September 2005, and he was administered further nerve blocks. (R. 381). Dr. Kelly noted a "gradual recurrence in pain which is significantly improved for extended periods" after previous nerve blocks and so nerve blocks were administered again in early December 2005 (R. 376). After this last round of nerve blocks, Mr. Robison noted "complete relief" of his headaches on discharge. (R. 376).

In late December, Mr. Robison reported his headache was still resolved. (R. 375). However, in late January 2006, Mr. Robison claimed his headaches had returned; more nerve blocks were given. (R. 370). In February 2006, Dr. Kelly again noted the return of dull, continuous headaches and prescribed a Durgasic patch. (R. 368). On March 3, 2006, Dr. Kelly performed more nerve blocks in response to reportedly increasingly severe headaches, as the procedure had been shown to be "quite effective" in the past of reducing Mr. Robison's pain and its intensity. (R. 367). Mr. Robison returned a week later, reporting only short-term relief and Dr. Kelly recommended trying a different treatment, pulsed radio frequency. (R. 366). In May 2006, Mr. Robison returned to Dr. Kelly and claimed his headaches had been completely resolved since he had stopped drinking diet soda. (R. 363).

In August 2006, the headaches had returned, and Dr. Kelly recommended trying a Duragesic patch again (Mr. Robison had previously stopped that medication while attempting to get a Commercial Driver's License). (R. 359). The headaches did not return until March 2007, when Mr. Robison was administered more nerve blocks. (R. 352). In May 2007, Mr. Robison reported intermittent headaches that were not particularly problematic at the time. (R. 350). In August 2007, Mr. Robison again complained of recently increasing headaches, but wanted to hold off on further injections as the Fentora he was taking was helping manage the pain. (R. 346). However, Mr. Robison asked for a stronger dosage of Fentora, as the current one was not always effective in completely relieving the pain. (R. 346).

Approximately one month later, on September 5, 2007, Mr. Robison again complained of headaches, which prompted Dr. Kelly to repeat the nerve blocks because "they have been quite helpful in the past." (R. 345). In the follow up to that injection on September 19, 2007, Mr. Robison self reported "modest improvement" and stated that the Duragesic patch had been "significantly beneficial" in controlling the headache pain. (R. 344). Mr. Robison returned for a follow up exam in October 2007, in which he stated that the Duragesic patch helped, but started to wear off too quickly, with its effectiveness gone after two days. (R. 343). Dr. Kelly refilled the prescription so that the patches could be applied every two days, instead of the regularly prescribed three days. (R. 343).

In additions to headaches, starting back in December 2005, Mr. Robison also complained to Dr. Kelly about increasing low back pain that radiated down into the buttocks. (R. 375). Since it was unclear what precipitated the back pain, Dr. Kelly sent him for an MRI of the lumbar spine.

(R. 375). In January 2006, the MRI revealed degenerative changes of the disks, most notably at L5-S1 and to a lesser degree at other levels, particularly L2-3. (R. 373). There was no definite disk herniation at any level, and the most prominent findings were the dehydration of the disk at L5-S1 with some posterior bulging and slight loss of disk height. (R. 373). Dr. Kelly assessed that Mr. Robison had degenerative disk disease with a possible component of lumbar radiculopathy and recommended proceeding with a trial of lumbar epidural steroid injections, which were administered later that month. (R. 374, 372).

In February 2006, Mr. Robison returned, stating a 50% improvement after the initial injection and Dr. Kelly administered another injection. (R. 369). During the follow-up exam, Mr. Robison reported that his low back pain was "significantly better" after the injections and later reported no low back pain in March 2006. (R. 368, 366). Nevertheless, in April 2006, Mr. Robison returned, citing the recurrence of severe low back pain and another epidural injection was given.

(R. 365, 364). In May 2006, Mr. Robison reported persistent low back pain stating that activities such as prolonged standing and walking increased the pain while sitting or lying down provided relief. (R. 363).

Dr. Kelly recommended continuing with the epidural injections and Mr. Robison received two that month. (R. 361-63). In June 2006, Dr. Kelly noted Mr. Robison had "virtually no pain" since the last injection and that the residual pain experience by him was intermittent and minimal.

(R. 360). At that point, Dr. Kelly documented a complete resolution of Mr. Robison's lumbar radicular pain. (R. 360). In September 2006, Mr. Robison returned to Dr. Kelly, complaining of a reoccurrence of intense low back pain which radiated down towards the buttock and hip. (R. 357). Mr. Robison reported that the pain was generally intermittent, but as related before, worsened when he sat or stood for prolonged periods. (R. 357). Dr. Kelly diagnosed left sacroiliac arthropathy, and recommended a left sacroiliac joint injection and an arthrogram which were both administered in December 2006. (R. 355, 356).

In February 2007, Mr. Robison had a follow up exam in which reported severe left lower back pain that radiated all the way down into his leg following a fall down the stairs. (R. 354). Dr. Kelly diagnosed post trauma pain, and recommended x-rays to determine the extent of the injury.

(R. 355). The X-rays showed no acute fracture and Dr. Kelly performed more epidural injections.

(R. 353). In May 2007, Mr. Robison again complained of flare-ups in his lower back and left buttock, leading Dr. Kelly to administer more epidural injections in June and July 2007. (R. 347-49). After those injections, Mr. Robison reported continuing improvement. (R. 347-48). In October 2007, Dr. Kelly noted that Mr. Robison was experiencing pain from his degenerative disc disease and the only recommendation was to continue taking pain medication and follow up in a month. (R. 343).

In May of 2006, Mr. Robison underwent a Psychiatric Review Technique with Patricia Beers, Ph.D. (R. 263-76). In her medical summary, she noted that Mr. Robison had non-severe impairments and coexisting non-mental impairments that require referral to another medical specialty. (R. 263). She noted that Mr. Robison has Depressive Psychosis based on Listing 12.04 for Affective Disorders and that it is "partially controlled with medication." (R. 263, 266). In terms of functional limitations, Dr. Beers found that Mr. Robison had mild limitations in activities of daily living and in maintaining social functioning, in maintaining concentration, persistence, or pace. (R. 273). She further reported he had experienced one or two episodes of decompensation of extended duration. (R. 273).

Also in May 2006, Mr. Robison was examined by Michael Nenaber, M.D, as part if a Physical Residual Functional Capacity Assessment. (R. 277-84). Dr. Nenaber noted that Mr. Robison had the following exertional limitations: occasionally lifting and/or carrying twenty pounds; frequently lifting and/or carrying ten pounds; standing and/or walking about six hours in an eight hour work day; sitting (with normal breaks) for about six hours in a work day and no limitation on pushing and/or pulling. (R. 278). Dr. Nenaber also noted that Mr. Robison had several environmental limitations -- namely that he should avoid concentrated exposure to: extreme heat or cold; wetness; humidity; noise; vibration; and fumes, odors, dusts, gases, poor ventilation, etc. (R. 281). Otherwise, Dr. Nenaber noted no postural, manipulative, visual, or communicative limitations.

(R. 279-81).

In January of 2008, after the administrative hearing and at the request of the ALJ, Erwin Baukus, Ph.D. performed a Psychological Mental Status Evaluation. (R. 390-97). Mr. Robison drove himself there, but "had to" bring his mother because, as he stated, he could not go anywhere without someone. (R. 390). Mr. Robison reported to Dr. Baukus that he had the following symptoms: pervasive loss of interest in almost all activities; sleep disturbance (fitful); tearfulness; decreased energy; feelings of guilt and worthlessness; difficulty concentrating and thinking; thoughts of suicide; generalized anxiety about inability to function independently outside of his parents' house; sour stomach; headache pain controlled with Fentanyl patch; and chronic lower back pain. (R. 392). Dr. Baukus noted that Mr. Robison had a labile affect, was easily moved to tears, ...


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