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Sally Mae White v. Michael J. Astrue

December 13, 2012


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


Ms. Sally Mae White seeks judicial review of a final decision of the Commissioner of the Social Security Administration ("SSA") denying her application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act ("Act"). Ms. White filed a Motion for Summary Judgment, seeking a judgment reversing or remanding the Commissioner's final decision [dkt. 19]. For the reasons set forth below, Ms. White's motion is granted and her case is remanded to the SSA for further proceedings.


On April 4, 2007, Ms. White applied for disability insurance benefits and supplemental security income claiming that a combination of impairments, including knee pain, foot cramps, high blood pressure, and depression, prevented her from working.*fn1 The Commissioner denied Ms. White's applications initially on May 30, 2007, and upon reconsideration on August 31, 2007.*fn2 Ms. White subsequently requested a hearing with an Administrative Law Judge ("ALJ").*fn3

A hearing took place in front of ALJ John Kraybill on March 11, 2009.*fn4 Following the hearing, the ALJ issued a decision denying benefits, concluding that Ms. White was not disabled within the meaning of the Act at any time after her application was filed.*fn5 The Appeals Council denied review, making the ALJ's decision the final decision of the Commissioner.*fn6 Ms. White filed this action on November 11, 2011.


This section is a brief review of the facts in the medical record that the ALJ reviewed at Ms. White's hearing and considered when rendering his decision. These facts provide a summary of Ms. White's medical history and the reasons she applied for disability. We begin with her personal history and continue with an overview of her short medical record from before her application for disability. Next, we discuss her application and her medical history following her application until her ALJ hearing. We then summarize the ALJ hearing testimony and the ALJ's decision.

A. Ms. White's Personal Background

Ms. White was born on June 15, 1958, making her 50 years old on the date the ALJ issued his final decision.*fn7 She is five feet, seven inches tall and weighed 198 pounds on the date of her application.*fn8 Ms. White graduated from high school in 1976.*fn9 Two years later, she got a job working as a copy operator at the accounting firm Ernst and Young.*fn10 She had her first and only child in 1980, a son who she raised on her own.*fn11 Ms. White left Ernst and Young in 1993, after which she held a number of different jobs. She worked on an assembly line at ABC NACO National Casting from 1994-2000.*fn12 She also worked as a cook at Preferred Meal Systems from 2003-2005.*fn13 Her most recent job was as a housekeeper at Sunrise Senior Living Services from August 2006 to February 2007.*fn14 Ms. White married in 2000.*fn15 In 2002, Ms. White suffered two separate hardships when her younger sister passed away and she lost her apartment.*fn16 In 2004, Ms. White's husband left her.*fn17 That same year, her son's first child died of pneumonia at sixteen months of age.*fn18 At the time of her application, Ms. White had no income and no resources and she received food stamps.*fn19

B. Pre-Application Medical History

We begin our review of Ms. White's relevant past medical history starting in 2002 and ending with her application in April 2007. In 2002, Ms. White started to suffer from major depressive disorder. There are no corresponding medical records to document this 2002 diagnosis. However, in 2007, Ms. White's treating psychiatrist, Adedapo Williams, M.D., conducted a medical assessment of her ability to do work related activities based on her mental impairments.*fn20 In his assessment, Dr. Williams noted she had suffered from major depressive disorder since February 2002.*fn21 This is corroborated by another record from a visit to Dr. Williams in February 2007, wherein he noted that Ms. White alleged she suffered from depression all her life, but it got worse in 2002 when her sister died and she lost her apartment.*fn22

The bulk of Ms. White's medical records are from 2006-2009. In June 2006, Ms. White went to Fantus Health Clinic complaining of bilateral knee pain and intermittent swelling.*fn23

Examination of her knees was essentially normal, and she was advised to take Motrin for 10 days.*fn24 She was next seen in January 2007 for depressive symptoms after having lost her job at Sunrise Senior Living Center.*fn25 At this visit, Ms. White complained of stress, appetite change, sleep deprivation, and muscle pains.*fn26 She also said she had knee pain for "many years" made worse by the weather.*fn27

Additionally, she described grief over her dead grandson.*fn28

She was diagnosed with osteoarthritis of bilateral knees and was referred to the Fantus psychiatric clinic for treatment of her symptoms of depression.*fn29

The following month, Ms. White went to the Fantus psychiatric clinic and met with her treating psychiatrist, Dr. Williams, for the first time. During this visit, Ms. White complained of insomnia, decreased appetite, and feelings of worthlessness, helplessness, guilt, and hopelessness.*fn30 Dr. Williams diagnosed Ms. White with major depressive disorder and prescribed her two antidepressant medications.*fn31 Finding herself unresponsive to medication, Ms. White returned to Dr. Williams in March 2007 alleging nothing had changed.*fn32 After a mental status examination ("MSE"), Dr. Williams noted that she was tearful and dysphoric.*fn33 He assessed her with poor response to her medication and adjusted it.*fn34 That same month at an annual female examination, Ms. White reported feeling depressed and was assessed with reactive depression due to the death of her grandson.*fn35

C. Application for Disability

Ms. White applied for disability benefits and supplemental security income on April 4, 2007, complaining of right foot cramps, depression, stress, and high blood pressure.*fn36 In her application, Ms. White alleged her disabilities first began to interfere with her work on January 1, 2007.*fn37 She was unable to carry the mop and bucket necessary for her cleaning position at the Sunrise Senior Center, and her pain prevented her from working fast enough.*fn38 Ms. White indicated that she stopped working altogether on February 14, 2007. She alleged that she is unable to do even simple jobs because her right foot cramps so severely that she is forced to sit down.*fn39 She also reported that she cries every day.*fn40 The SSA representative who filled out the disability report observed that she had no trouble sitting, standing, or walking.*fn41

Following her application, Ms. White underwent an internal medicine consultative examination for the bureau of disability determination services in May 2007.*fn42 The evaluation was conducted by Peter Biale, M.D., who assessed her with painful knees, a painful right foot, and psychiatric problems.*fn43 Dr. Biale's examination of her right foot and ankle did not reveal any gross abnormality.*fn44 Dr. Biale also concluded that Ms. White's "painful knees" had no limitations.*fn45 The range of motion testing of her back and joints were also within normal limits.*fn46

Also in May 2007 as part of her application, Ms. White underwent a psychiatric evaluation by Harley G. Rubens, M.D., a consultant for the bureau of disability determination services.*fn47 Dr. Rubens diagnosed her with a dysthymic disorder and an adjustment disorder, with mixed anxiety and depression.*fn48 During this evaluation, Ms. White described daily activities that included doing some light cleaning, microwave cooking, laundry, going grocery shopping with her mother, watching television, reading the Bible, and going to church every Sunday.*fn49 She alleged cyclic feelings of sadness and depression, but said she was able to continue to focus and function.*fn50 Dr. Rubens wrote that she described adjustment anxiety and depression because of finances; losses of loved ones including a grandchild and a failed marriage; and anxiety about her future and the pain she experienced in her knees.*fn51 Ms. White was given a Global Assessment of Functioning ("GAF") Scale (DSM- IV Axis V) score of 65, indicative of someone with mild symptoms but functioning pretty well.*fn52

D. Period Between Ms. White's Application and Her ALJ Hearing

In May 2007, Ms. White went to the emergency room at Stroger Hospital complaining of knee stiffness and pain with sitting and standing.*fn53 The x-ray revealed arthritis and she was again diagnosed with depression and degenerative joint pain in both knees.*fn54 In June 2007, Ms. White returned to the Stroger Hospital emergency room for pain in her right foot, but the x-ray taken during that visit was within normal limits.*fn55

During a psychiatric visit to Dr. Williams in June 2007, Ms. White voiced symptoms of poor sleep, tiredness, general anxiety, paranoia, arthritis pain, and feeling hopeless and helpless.*fn56 Dr. Williams noted she still had poor response to her medications and subsequently adjusted them.*fn57 Ms. White returned to Dr. Williams the following month with complaints of having crying spells and suicidal ideas with no plan or intent.*fn58 Ms. White also complained of poor sleep and poor appetite.*fn59 Despite these complaints, Dr. Williams' progress notes from that visit indicated Ms. White's MSE was "essentially unremarkable."*fn60

On July 30, 2007, Dr. Williams completed a medical assessment of Ms. White's condition and ability to do work-related activities based on mental impairments.*fn61 He opined that Ms. White had a "moderate" limitation due to tiredness, poor concentration, and low stress tolerance.*fn62 Dr. Williams also indicated that Ms. White was moderately limited in the ability to understand, remember and carry out short and simple instructions, maintain attention and concentration for extended periods, and she was markedly limited with detailed instructions.*fn63

Dr. Williams also determined Ms. White was markedly limited in sustaining an ordinary routine without special supervision; markedly limited in maintaining regular attendance or performing activities within a schedule; and markedly limited in all areas of social interaction and adaptation.*fn64 Dr. Williams further assessed the plaintiff with marked limitations in completing a normal workweek without interruptions from psychologically based symptoms.*fn65

In October 2007, Ms. White again sought treatment, and Stroger Hospital records included complaints of right foot pain and the x-rays revealed degenerative joint disease.*fn66

During this visit, Ms. White said her medications were still not helping her mood and she was referred to Dr. Williams for a medication adjustment.*fn67 Dr. Williams saw her again for a follow-up on February 6, 2008, when she presented with no psychotic symptoms or suicidal ideation.*fn68 However, he did assess her with "pain syndrome."*fn69 On February 18, 2008, when seen at Stroger for lab results, Ms. White denied any symptoms from her history of depression.*fn70
Additional records dated May 13, 2008, show Ms. White "feels better" but still experienced occasional crying spells, isolated herself, and felt uncomfortable in social situations.*fn71 The assessment indicated she was "improving."*fn72 Six days later, she returned to Stroger for follow-up for her foot problem and also complained of depression.*fn73 She was referred for a psychiatric appointment with Dr. Williams.*fn74 Based on the note from her medical visit to Stroger, the appointment with Dr. Williams was scheduled for May 29, 2008.*fn75 However, there is no record to confirm whether that visit actually took place. On September 19, 2008, Ms. White went to Stroger hospital complaining of left foot pain.*fn76 An x-ray of her foot was taken that revealed a very small plantar spur.*fn77 This the last medical record in Ms. White's file.

D. The March 11, 2009 Hearing

Ms. White appeared and testified at a hearing held on March 11, 2009, in Chicago, Illinois, before ALJ John Kraybill.*fn78 Her attorney, Stephen Jackson, was also present.*fn79 Also appearing and testifying were Mark I. Oberlander, Ph.D., an impartial medical ...

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