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Sheila R. Brown v. Michael J. Astrue Commissioner of Social Security

December 19, 2012

SHEILA R. BROWN PLAINTIFF,
v.
MICHAEL J. ASTRUE COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Magistrate Judge Daniel G. Martin

MEMORANDUM OPINION AND ORDER

Plaintiff Sheila Brown ("Plaintiff" or "Brown") seeks judicial review of a final decision of Defendant Michael J. Astrue, the Commissioner of Social Security ("Commissioner"). The Commissioner denied Plaintiff's application for Disability Insurance Benefits ("DIB") and Supplemental Security Income benefits ("SSI") under Title II of the Social Security Act, and Brown filed a motion for summary judgment. The parties have consented to have this Court conduct any and all proceedings in this case, including an entry of final judgment. 28 U.S.C. § 636(e); N.D. Ill. R. 73.1(c). For the reasons stated below, Plaintiff's motion is granted.

I. Legal Standard

A. The Social Security Administration Standard

In order to qualify for DIB, a claimant must demonstrate that he is disabled. An individual does so by showing that he cannot "engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 4243(d)(1)(A). Gainful activity is defined as "the kind of work usually done for pay or profit, whether or not a profit is realized." 20 C.F.R. § 404.1572(b).

The Social Security Administration ("SSA") applies a five-step analysis to disability claims. See 20 C.F.R. § 404.1520. The SSA first considers whether the claimant has engaged in substantial gainful activity during the claimed period of disability. 20 C.F.R. § 404.1520(a)(4)(i). It then determines at Step 2 whether the claimant's physical or mental impairment is severe and meets the twelve-month durational requirement noted above. 20 C.F.R. § 404.1520(a)(4)(ii). At Step 3, the SSA compares the impairment (or combination of impairments) found at Step 2 to a list of impairments identified in the regulations ("the Listings"). The specific criteria that must be met to satisfy a Listing are described in Appendix 1 of the regulations. See 20 C.F.R. Pt. 404, Subpt. P, App. 1. If the claimant's impairments meet or "medically equal" a Listing, the individual is considered to be disabled, and the analysis concludes; if a Listing is not met, the analysis proceeds to Step 4. 20 C.F.R. § 404.1520(a)(4)(iii).

Before addressing the fourth step, the SSA must assess a claimant's residual functional capacity ("RFC"), which defines his exertional and non-exertional capacity to work. The SSA then determines at the fourth step whether the claimant is able to engage in any of his past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). If the claimant can do so, he is not disabled. Id. If the claimant cannot undertake past work, the SSA proceeds to Step 5 to determine whether a substantial number of jobs exist that the claimant can perform in light of his RFC, age, education, and work experience. An individual is not disabled if he can do work that is available under this standard. 20 C.F.R. § 404.1520(a)(4)(v).

B. Standard of Review

A claimant who is found to be "not disabled" may challenge the Commissioner's final decision in federal court. Judicial review of an ALJ's decision is governed by 42 U.S.C. § 405(g), which provides that "[t]he findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive." 42 U.S.C. § 405(g). Substantial evidence is "such evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). A court reviews the entire record, but it does not displace the ALJ's judgment by reweighing the facts or by making independent credibility determinations. Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008).

Instead, the court looks at whether the ALJ articulated an "accurate and logical bridge" from the evidence to her conclusions. Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008). This requirement is designed to allow a reviewing court to "assess the validity of the agency's ultimate findings and afford a claimant meaningful judicial review." Scott v. Barnhart, 297 F.3d 589, 595 (7th Cir. 2002). Thus, even if reasonable minds could differ as to whether the claimant is disabled, courts will affirm a decision if the ALJ's opinion is adequately explained and supported by substantial evidence. Elder, 529 F.3d at 413 (citation omitted).

II. Background Facts

Brown has been treated for a variety of physical and mental conditions, including bi-lateral knee pain, restrictions in the use of her shoulders, cervical spine pain, diabetes, a skin disorder, alcohol abuse, and depression. The ALJ's decision only concerns Plaintiff's neck pain, shoulder limitations, and depression. The Court limits its consideration to those portions of the record related to these conditions.

A. Brown's Physical History

Brown began experiencing neck pain as early as 2005, when a MRI was ordered to evaluate her condition. The results of that study are not part of the record, but notes from the Hennepin County Medical Clinic ("HCMC") in April 2008 indicate that the MRI showed cervical stenosis and a bulging of the cervical discs at multiple levels. (R. 332). The notes also state that Brown had previously been treated at HCMC's pain clinic, where she had been prescribed the pain medications Vicodin and morphine to control her discomfort. (R. 331-32, 676).

A second MRI in the spring of 2008 showed a loss of the normal inward curvature in Brown's neck and mild disc narrowing at C2-C3, C3-C4, C4-C5, and C5-C6. (R. 669). Brown followed up on this study with neurosurgeon Dr. Walter Galicich at the HCMC clinic for both neck and shoulder pain. Dr. Galicich did not find any significant shoulder pathology, but he reconfirmed the results of the recent MRI study of Brown's cervical spine. (R. 675-76).

As Dr. Galicich's notes suggest, Brown was experiencing pain in her right shoulder, together with some limitations in her range of motion. On July 14, 2008, she underwent a MRI of the right shoulder to determine the cause of these complaints. The radiology report indicated that she had suffered a tear to the supraspinatus tendon of her right shoulder, together with a narrowing of the subacromial space that impinged on the supraspinatus. (R. 703). Brown sought help for this diagnosis by meeting with orthopedic surgeon Dr. Jonathan Haas on September 23, 2008. Dr. Hass noted that she had been experiencing pain and some weakness in both shoulders for about one year. (R. 302). He determined that Brown suffered from a significant intrasubstance tear over fifty percent of her right supraspinatus tendon and a mild narrowing of the humeral cartilage. (R. 302-03). Dr. Haas treated her with a subacromial injection and referred Brown to physical therapy. (R. 303).

By this point, Brown had received several recommendations from her physicians for physical therapy. She complied with them by meeting with therapist Hegel Brandes on June 23, 2008. At her initial evaluation, Brown complained of shoulder pain at a level of nine out of ten and neck pain at seven out of ten. (R. 670). Brown completed sixteen therapy sessions but felt unable to continue with the final stages of treatment due to worsening symptoms of her depression. (R. 320).

Nevertheless, she met her goals of reaching overhead with reduced pain and was released with a home exercise program. (Id.). Brown resumed treatment for her pain by undergoing treatments with chiropractor Dr. Timothy Hammer from March 23, 2009 through July 2010. (R. 538-619). Dr. Hammer did not note any significant improvement in her symptoms. By November 2009, Brown was "in [an] extreme amount of pain" that she rated at nine out of ten. (R. 611). The pain was at eight out of ten at the final visit in July 2010. (R. 617).

Brown returned to her neurosurgeon on December 29, 2009 to see if surgery was a possibility for her continuing pain. Dr. Galicich noted that she was no longer experiencing significant pain radiation through her arms and had a good range of motion in the cervical spine. (R. 736). Absent any signs of a radiculopathy or a myelopathy, Dr. Galicich concluded that an occipital nerve block was more appropriate than surgery. (Id.). Brown had already received a bupivacaine injection at HCMC on September 6, 2010, which she found had relieved her pain temporarily. (R. 711).

Brown was also administered a variety of prescription pain medications throughout her treatment to help control her discomfort. The full scope of her pharmacological treatment is not entirely clear from the record, but Brown appears to have been prescribed Vicodin and morphine at HCMC's pain clinic prior to April 2008. (R. 331-32, 673). A SSA disability report cites a daunting list of medications Brown was taking on or around October 2008 for pain and insomnia, including carisoprodol (Soma), midazolam, morphine sulfate beads, morphine, trazadone, and Vicodin. (R. 210). These were in addition to the other medications prescribed for her skin irritations and depression.

Brown's treatment professionals continued to prescribe a variety of pain medications and muscle relaxants, including Vicodin, morphine, Soma, oral cortisone, and nerve injections. (R. 210,400, 625). The combination of these medications varied, but the last treatment records of July 2010 show that Brown's physicians were still prescribing Vicodin as well as gagapentin for pain. (R. 418, 724).

B. Brown's Mental Health History

In addition to her physical impairments, Brown began treatment for depression at least as early as June 2008. Nurse practitioner Melissa McClellan noted that Brown felt depressed and had become increasingly forgetful. (R. 297). By September 2008, Brown was taking the antidepressant medications Prozac and trazodone, which helped both with her depression and insomnia. (R. 310). Despite this improvement, nurse McClellan continued to be concerned about Brown's reports of increased memory loss. Brown claimed, for example, that she would walk into her kitchen for a glass of water only to forget what she was seeking. (R. 310).

1. Dr. Mark Schuler

Brown's memory losses led another nurse practitioner, Katherin Lund, to refer her to psychologist Dr. Mark Schuler in October 2008 for an evaluation of her cognitive functions. He described Brown as depressed and noted that a long struggle with alcohol addiction, which was currently under control, may have masked "a background mild depression that is of a longstanding nature." (R. 280). Dr. Schuler's evaluation primarily involved a battery of cognitive tests to assess Brown's overall functioning. The Wechsler Adult Intelligence Scale-III test indicated that Brown's overall IQ was a "borderline" low normal score of 74. (R. 278). Dr. Schuler concluded from this and other tests that Brown's memory problems were likely the result of her relatively low level of intellectual functioning.

(R. 279-80). He concluded that she had a major recurring depressive disorder, reading disorder, and borderline ...


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