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Jeffrey L. Courtois v. Michael J. Astrue

September 13, 2012

JEFFREY L. COURTOIS, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Byron G. Cudmore, U.S. Magistrate Judge:

E-FILED

Friday, 14 September, 2012 03:55:08 PM Clerk, U.S. District Court, ILCD

OPINION

Plaintiff Jeffrey Courtois appeals from the denial of his application for Social Security Disability Insurance Benefits and Supplemental Security Income (collectively "Disability Benefits") under Titles II and XVI of the Social Security Act. 42 U.S.C. §§ 416(i), 423, 1381a, and 1382c. This appeal is brought pursuant to 42 U.S.C. §§ 405(g) and 1383(c). Courtois filed a Motion for Summary Judgment (d/e 8), and Defendant Commissioner of Social Security filed a Motion for Summary Affirmance (d/e 13). The parties consented, pursuant to 28 U.S.C. § 636(c), to have this matter proceed before this Court. Consent to Proceed Before a United States Magistrate Judge, and Order of Reference entered June 20, 2012 (d/e 11). For the reasons set forth below, the Decision of the Commissioner is AFFIRMED.

STATEMENT OF FACTS

Courtois was born on October 1, 1961. He completed the tenth grade and worked as a janitor and grocery store stocker. He stopped working on August 12, 2007. Answer to Complaint (d/e 6), attached Certified Transcript of Proceedings before the Social Security Administration (R.), at 39, 207, 2011. Courtois suffers from chronic obstructive pulmonary disease (COPD), hypertension, obesity, degenerative joint disease, venous peripheral insufficiency, back pain, and depression.

On June 27, 2007, Courtois went to see Dr. Michael R. Hambrick, M.D. Dr. Hambrick found that Courtois had swelling in his hands and feet, edema and venostasis dermatitis in his legs. Dr. Hambrick recommended compression stockings. Courtois also had marked diminished breath sounds. Courtois reported that he had smoked a pack of cigarettes a day for twenty years. Dr. Hambrick ordered pulmonary function tests, a chest x-ray, and an overnight oximetry study. Dr. Hambrick also found that Courtois was obese. Dr. Hambrick and Courtois talked about losing weight and exercising. R. 350-51.

On July 2, 2007, Courtois underwent a pulmonary function test. The test was performed by Dr. Nanjappa Somanna, M.D. The spirometry showed an FEV1 of 1.39 liters and an FVC of 2.58 liters.*fn1 After a bronchodilator therapy, Courtois had an FEV1 of 1.70 liters, a 22% improvement. Lung volume testing showed lung capacity of 93% predicted with an RV of 170% predicted. Dr. Somanna concluded that Courtois had severe obstruction with significant change after post-bronchodilator therapy. The lung volumes showed air trapping with DLCO mildly diminished.*fn2

Courtois saw Dr. Hambrick again on July 11, 2007, for a follow-up. The records indicate that he was 5 feet 9 inches tall and weighed 316 pounds. Dr. Hambrick stated that the pulmonary function test showed that Courtois had severe obstructive deficit that was significantly improved with bronchodilation. The oximetry study showed that Courtois needed oxygen during the night and probably during the day. R. 343, 353, 358, 360-61, 363-68.

On January 2, 2008, Courtois saw Dr. Jessica Town, D.O.

Dr. Town's notes indicate that Courtois previously used respiratory medication and oxygen, but currently could not afford either. Courtois reported that he was trying to quit smoking. He reported that he had been smoking three packs of cigarettes per day, but had cut down to one pack per day. Courtois reported that he could not walk upstairs or more than one block without shortness of breath. Dr. Town found markedly decreased breath sounds with prolonged expiration and expiratory wheezing, but no rhonchi or crackles. Dr. Town gave Courtois samples of medication and information on agencies to help pay for medication and oxygen. Dr. Town also discussed the importance of quitting smoking and using money to buy medication rather than cigarettes. Dr. Town also found that Courtois had some venous stasis ulcers on his legs that were healing.

R. 347-48.

On January 14, 2008, Courtois filed his claim for Disability Benefits.

He alleged that he was disabled on August 12, 2007, when he stopped working. R. 16.

On April 24, 2008, Courtois went to see Certified Nurse Practitioner Julie Barry at the Blessing Hospital Outreach Clinic in Quincy, Illinois.*fn3

R. 377-82. Courtois reported difficulty breathing at night and swelling in his hands and feet. Courtois also reported stiffness in both knees. Courtois was 5 feet 8 inches tall and weighed 336 pounds. Barry found edema in the legs, ankles and feet, and leg ulcers. Barry referred Courtois to the wound clinic for evaluation of the ulcers. R. 381-82. Barry also prescribed an inhaler and ordered a chest x-ray. The chest x-ray showed some mild atelectatic or fibrotic changes. R. 382, 386.

On April 25, 2008, Courtois saw Dr. Crystal Perry, M.D. at the Blessing Hospital wound clinic. Dr. Perry biopsied and dressed Courtois' leg ulcers. Dr. Perry told Courtois to elevate his legs whenever possible and to avoid salt. R. 393-94, 400, 410.

On May 2, 2008, Courtois went to see Dr. Perry. Courtois reported that his legs were much better. Courtois had been wearing his tubigrip compression stockings faithfully. On examination, Dr. Perry found significantly less edema and no open sores. R. 396.

On May 22, 2008, Courtois saw Barry again for a follow-up visit. Courtois said that his legs were better, but he complained of back and knee pain. He also complained of dyspnea with exertion. R. 376. Courtois saw Dr. Perry again on May 23, 2008. Courtois reported that he was doing well. Dr. Perry found that Courtois' ulcers had healed and a trace of edema in the lower extremities. R. 397.

On July 3, 2008, Courtois saw Barry again for a six-week follow-up visit. Courtois' weight was down to 317 pounds. Courtois had no swelling in his feet. He was finished with the wound clinic treatments on his legs.

He reported increased pain in his right knee with activity. He was taking ibuprofen and Tramadol for the pain. Courtois reported that his breathing was okay. On examination, Barry found that Courtois' skin was flaking, but well-healed. Barry observed wheezing at the posterior bases bilaterally. Barry also found crepitation in the right knee with movement. Barry discussed quitting smoking with Courtois, refilled his prescriptions, and ordered an MRI of the right knee. R. 435. The MRI was performed on July 8, 2008. The test showed chronic degenerative osteoarthritic changes in the right knee. R. 403, 433.

On July 12, 2008, Courtois saw Dr. Raymond Leung, M.D. for a consultative examination. Courtois reported that he had problems with veins in his legs and with COPD. Courtois said that he started smoking at the age of nine. He used to smoke four packs of cigarettes per day, but was now down to one pack per day. Courtois stated that his ability to walk varied due to his shortness of breath. Courtois said that he could lift fifty pounds. Courtois was 5 feet 81/2 inches. He weighed 314 pounds.

Dr. Leung noted healing wounds on both lower legs. Dr. Leung found decreased breath sounds, but no rales, rhonchi or wheezes. Dr. Leung found no use of accessory muscles for respiration at rest. R. 414.

Dr. Leung observed that Courtois' gait was within normal limits. Courtois could walk 50 feet unassisted. He could tandem walk, heel walk, toe walk, squat, and hop. Straight leg testing was to 40 degrees. Courtois had normal strength throughout his extremities. Dr. Leung found no lower extremity peripheral edema, lesions or ulcers. Dr. Leung diagnosed Courtois with COPD with decreased breath sounds on examination, but no respiratory distress. Dr. Leung stated that pulmonary function tests in Courtois' medical records showed borderline obstruction with severe restriction before bronchial medication and borderline obstruction with mild restriction after medication. R. 414.

On July 12, 2008, Courtois underwent another pulmonary function test. The record of the test submitted to the Social Security Administration consists of unsigned graphs with tables of data from the West Park Medical Clinic. The document does not identify the person who conducted the test. The table shows an FEV1 of 1.59 liters and an FVC of 2.40 liters before bronchodilation, and an FEV1 Of 1.98 liters and an FVC of 2.98 liters after bronchodilation. R. 416-17.

On July 25, 2008, Dr. Sandra Bilinsky, M.D., reviewed Courtois' medical records and completed a Physical Residual Functional Capacity Assessment (RFC Assessment). R. 419-26. Dr. Bilinsky opined that Courtois could lift 10 pounds frequently; stand and/or walk two hours in an eight-hour workday; sit six hours in an eight-hour workday; occasionally climb, but never balance; and avoid concentrated exposure to fumes, odors, dusts, gases, and poor ventilation. Dr. Bilinsky found no other physical limitations. R. 420-26.

On August 21, 2008, Courtois saw Barry again. Courtois' primary complaint was pain in his knees. Courtois reported swelling on occasion in his right knee. On examination, Barry observed that the right knee was larger than the left. Barry also found tenderness around the patella and crepitation with extension and flexion. Barry diagnosed Courtois with osteoarthritis with medial meniscus tear, right knee. Barry prescribed Celebrex for pain. Barry found Courtois' lungs to be clear to auscultation bilaterally. R. 433.

On September 25, 2008, Courtois saw Barry again for a follow-up visit. Courtois reported some benefit from his respiratory medicines. He reported that he was able to walk approximately one-half block before stopping with shortness of breath. Courtois reported that he still smoked two packs per day "but is not interested in smoking cessation at this point."

R. 431. Barry observed no peripheral edema. Courtois qualified for disability with Medicaid and, thus, would end his care at the Blessing Hospital Outreach Clinic and establish care at Quincy Family Practice.

R. 431.*fn4

On October 14, 2008, Courtois saw an orthopedist Dr. Ronald Wheeler, M.D.*fn5 Dr. Wheeler diagnosed Courtois with a possible tear in the right medial meniscus, probably degenerative, and degenerative joint disease in the right knee. Dr. Wheeler recommended conservative measures and exercise rather than surgery. R. 438.

On October 20, 2008, Courtois saw Dr. Town for COPD and knee pain. Courtois was using a rescue inhaler two to three times per day. Courtois was smoking one pack of cigarettes per day. Courtois was interested in trying Chantix to quit smoking, but reported recently starting therapy for depression and anxiety. He therefore was not given Chantix. Courtois reported continuing knee pain. Courtois said that he had knee pain for eight or nine years. He said that the pain increased in cold weather or when he did not move the knee. Dr. Town offered injections in the knee, but Courtois refused. Dr. Town referred Courtois for physical therapy and modified his COPD medication. R. 484.

On November 3, 2008, Courtois went to Blessing Hospital for a physical therapy evaluation. The evaluation states that Courtois walked with a straight cane that Courtois recently purchased. Courtois reported that the cane helped. The evaluation stated that Courtois had good rehabilitation potential to achieve stated therapy goals. The evaluation recommended physical therapy once a week for three to four weeks. Courtois reported that it was difficult to come to therapy because his family only had one car. R. 440-42. Courtois did not call or show for further therapy sessions. R. 443. Courtois was discharged from therapy on November 19, 2008, for failure to show for treatment or call. R. 443.

On November 5, 2008, Dr. Michael Nenaber, M.D., reviewed Dr. Bilinsky's RFC Assessment on reconsideration. Dr. Nenaber reviewed the medical records received through October 30, 3008, and affirmed the opinions of Dr. Bilinsky. R. 446-47.

On November 18, 2008, Courtois again saw Dr. Town. Courtois reported that he was trying to quit smoking, but was back up to two packs per day. Courtois was again interested in Chantix, but was still complaining of depression. Courtois reported crying, anhedonia, difficulty sleeping, increased hunger, and isolating himself. The notes state that the physical therapist who evaluated him felt that Courtois would not benefit from physical therapy without surgery. The notes do not indicate whether Courtois relayed this opinion from the therapist or Dr. Town spoke directly to the therapist. Dr. Town stated that Courtois had difficulty walking and used a cane. Dr. Town noted that Courtois had no edema. R. 482.

On December 18, 2008, Courtois saw Dr. Town again. Courtois had prolonged expiration with decreased breath sounds. Courtois was still smoking a pack of cigarettes a day. Courtois reported an increase in his "smoker's cough." Courtois also reported lower rib pain. Dr. Town continued Courtois' medications and ordered a chest x-ray. R. 480.

The x-ray showed no evidence of acute pulmonary disease. R. 517.

Courtois saw Dr. Town again on January 15, 2009. Courtois continued to walk with a cane. Dr. Town reported that, "He does not feel that he would be able to do any kind of job that involved lifting, walking, standing or sitting for long periods of time because of his knees, they lock and he cannot get up and walk." R. 515. Dr. Town also noted Courtois' continued problems with COPD. Courtois continued to smoke a pack of cigarettes per day. Courtois reported that his COPD medicines Advair and Spiriva were helpful. He stated that he did not need to use his rescue inhaler every day. Dr. Town found prolonged expiration with very little air movement. Dr. Town found pain with palpation of the patella bilaterally and with lateral and medial joint line, as well as pain with flexion and extension. Courtois was unable to fully flex his right leg, but could fully extend the left. Courtois was taking Tramadol and Celebrex for knee pain. R. 515.

On January 19, 2009, Courtois underwent another pulmonary function test. Dr. Somanna again performed the test. The spirometry showed an FEV1 of 1.78 liters and an FVC of 3.01 liters. After a bronchodilator therapy, Courtois had an FEV1 of 2.08 liters, a 16% improvement. Lung volume testing showed lung capacity of 92% predicted with an RV of 142% predicted.*fn6 Dr. Somanna concluded that Courtois had severe obstruction with significant change after post-bronchodilator therapy. The lung volumes showed air trapping with ...


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