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Arroyo v. Colvin

United States District Court, N.D. Illinois, Eastern Division

July 18, 2014

CAROLYN W. COLVIN, Acting Commissioner of Social Security, [1] Defendant.


MICHAEL T. MASON, Magistrate Judge.

Claimant Patricia Arroyo ("Arroyo" or "claimant") brings this motion for summary judgment seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner"). The Commissioner denied Arroyo's claim for Disability Insurance Benefits under Sections 216 and 223 of the Social Security Act (the "Act"), 42 U.S.C. §§ 416(I) and 423(d), and her claim for Supplemental Security Income under Section 1614(a)(3)(A) of the Act, 42 U.S.C. § 1382a(a)(3)(A). The Commissioner filed a cross-motion for summary judgment, requesting that this Court uphold the decision of the Administrative Law Judge ("ALJ"). This Court has jurisdiction pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). For the reasons set forth below, claimant's motion for summary judgment is denied, and the Commissioner's cross-motion for summary judgment is granted.


A. Procedural History

On February 22, 2010, claimant filed an application for a period of disability, Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") due to a fractured disc and severe back pain. (R. 192, 199, 219). The Social Security Administration initially denied her claims on May 12, 2010, and upon reconsideration on August 4, 2010. (R. 105-08, 120.) Arroyo filed a timely request for a hearing, and on April 19, 2011, she appeared before ALJ Helen Cropper. (R. 39.) On August 11, 2011, the ALJ issued a written decision denying Arroyo's request for benefits. (R. 14-33.) Arroyo filed a timely request for review, and on September 18, 2012, the Appeals Council denied this request, which made the ALJ's decision the final decision of the Commissioner. (R. 1); McKinzey v. Astrue, 641 F.3d 884, 889 (7th Cir. 2011); 20 C.F.R. § 416.1481. Arroyo subsequently filed this action.

B. Medical Evidence

1. Su Salud Medical Center and MacNeal Hospital

Prior to her alleged onset date, Arroyo was treated for several ailments at Su Salud Medical Center and MacNeal Hospital. At Su Salud, she was under the care of Dr. Sylvia Juarez. Claimant was initially treated at Su Salud for headaches and abdominal pain. (R. 400-20.) As part of her treatment for abdominal pain, claimant underwent a CT scan in April 2009 that disclosed a small ventral hernia, or bulging of the abdominal wall. (R. 466.) On February 20, 2009, Arroyo underwent a sleep study at MacNeal Hospital. (R. 332-33.) The results of this study showed no abnormalities. ( Id. ) Arroyo was diagnosed with unspecified hypersomnia and snoring. (R. 356.)

On April 15, 2009, Arroyo visited the emergency room at MacNeal, where a CT of the abdomen and pelvis was performed. (R. 343.) This test revealed a punctate density within the left lung base that appeared noncalcified. ( Id. ) It also revealed that pelvic structures were within normal limits, there was no evidence of appendicitis, and there was a small ventral hernia just above the umbilicus. ( Id. ) Arroyo saw Dr. Juarez on November 18, 2009, complaining of pelvic pain, headaches, vomiting, and a rash. (R. 421.) Dr. Juarez diagnosed sciatica and morbid obesity and prescribed naproxen. ( Id. ) On January 20, 2010, Arroyo had an MRI of the lumbar spine. (R. 345.) The radiology report noted that she had suffered from pelvic pain for six years. ( Id. ) The MRI revealed a small but broad-based central disc protrusion resulting in effacement of the anterior thecal sac at L4-5. ( Id. ) There was no malalignment of the lumbar spine and the vertebral body heights were well-maintained. ( Id. ) There was no spinal canal stenosis and the neural foramina were "grossly patent bilaterally." ( Id. )

On February 4, 2010, Arroyo visited Dr. Juarez again and complained of headaches, dizziness, blurred vision and vomiting. (R. 420.) Dr. Juarez diagnosed claimant with cervical radiculopathy, a herniated disc and obesity. ( Id. ) She also noted that Arroyo's reflexes were positive and her strength was 3.5/5. ( Id. ) She referred Arroyo to a pain clinic and ordered an MRI, which showed a "subtle central disc bulge" that caused some narrowing of the spinal canal. (R. 344-46, 420.)

Claimant visited the emergency room at MacNeal again on February 10, 2010, complaining of frequent urination. (R. 349.) The report states that she had no other complaints. ( Id. ) She was diagnosed with a urinary tract infection, and she was prescribed medication. (R. 350.)

On February 15, 2010, the date of alleged onset of disability, claimant saw Dr. Juarez for a headache, neck pain, wrist pain, and lower back pain. (R. 423.) Dr. Juarez again referred her to a pain clinic, as well as a bariatric clinic, neurologist, and ear, nose, and throat specialist. ( Id. ) Dr. Juarez noted that Arroyo's strength was 3/5, she had a herniated disc at L5, she was obese and had cervical radiculopathy. ( Id. ) Claimant went to Su Salud on February 18, 2010 complaining of immense pain, and she was promptly sent to the emergency room by ambulance. (R. 422.)

On March 17, 2010, Dr. Juarez filled out a medical questionnaire listing claimant's conditions as severe low back pain, herniated lumbar disc, and radiculopathy, with weakness in the lower extremities. (R. 605.) In this form, Dr. Juarez noted that Arroyo was unable to sit, stand, or lie down for a long period of time, and that she used a cane to walk. ( Id. ) Dr. Juarez also noted that claimant continued to need assistance with activities of daily living. ( Id. ) Dr. Juarez described claimant's prognosis as poor. (R. 605-06.) She opined that claimant was not able to work a full-time job because she was in constant pain, unable to maintain concentration, and unable to sit or stand for more than fifteen minutes. (R. 606.)

On April 15, 2010, Arroyo again complained to Dr. Juarez of severe back pain. (R. 425.) Claimant informed Dr. Juarez that she was only using Advil to manage her increasing back pain. ( Id. ) She reported that the pain is radiating to her leg and she is unable to sit. ( Id. ) Dr. Juarez noted that the examination of Arroyo was positive for tenderness and weakness, and she also indicated a decrease in sensation. ( Id. ) Dr. Juarez advised claimant to follow up at the pain clinic at Loyola and she wrote her a prescription for Norco. ( Id. )

On April 22, 2010, Arroyo had a chest exam, which showed normal results with no evidence of chest disease. (R. 340.) On May 7, 2010, Arroyo complained of abdominal pain, radiating back pain and a heavy feeling in her right leg. (R. 426.) She also told Dr. Juarez that she had difficulty sitting or standing up, and that she was not obtaining relief from the Norco she was prescribed. ( Id. ) (In fact, it appears that she never filled this prescription. (R. 305-07.)) She reiterated the same complaints at a subsequent appointment on May 21, 2010. (R. 428.)

Claimant saw Dr. Juarez again on June 22, 2010 and reported headaches and dizziness, as well as numbness in both legs. (R. 607.) Dr. Juarez prescribed medication for what she diagnosed as a migraine headache, but again this prescription was apparently never filled. (R. 305-07, 607.) She noted that Arroyo's pain was a 9/10 and her back pain continued to radiate down her right leg, causing numbness. (R. 607.)

On July 16, 2010, claimant saw Dr. Juarez, again complaining of headaches, nausea, and abdominal pain and tenderness. (R. 608.) She also noted fatigue and poor appetite. ( Id. ) With regard to her back, she reported some improvement as a result of epideral steroid injections. ( Id. ) Dr. Juarez noted that Arroyo was taking Norco for her pain (although again, it appears the prescription was not filled). ( Id. ) She also prescribed Zantac for acid reflux disease and Imitrex for migraines, although neither prescription was filled. (R. 305-07)

On August 13, 2010, claimant reported to Dr. Juarez that the headaches she had experienced had worsened in the past two months. (R. 609.) She also reported abdominal bloating, back pain, and episodes of incontinence. ( Id. ) Medications listed in Dr. Juarez's notes from this appointment included Cyclobenzaprine, Imitrex, Zantac, and Tylenol/Advil. ( Id. ) Arroyo also told Dr. Juarez that she was not benefitting from physical therapy. ( Id. ) Dr. Juarez ordered a pelvic ultrasound. ( Id. )

On August 27, 2010, claimant again reported to Dr. Juarez that her headaches were worsening, making it difficult for her to sleep. (R. 610.) Dr. Juarez's notes refer to Arroyo's cane, her obesity and her back pain. ( Id. ) On September 14, 2010, claimant complained to Dr. Juarez that she had a sore throat, cough and difficulty swallowing. (R. 611.) On September 15, 2010, claimant went to the emergency room complaining of cough, congestion, and associated chest pain, and was wheezing when examined. (R. 519-20.) Arroyo had no other complaints at this visit. (R. 520.) She was diagnosed with acute bronchitis and given prescriptions for an antibiotic, immunosuppressant, expectorant, and inhaler (none of which appear to have been filled). ( Id.; R. 305-07.)

Claimant went to see Dr. Juarez again on November 12, 2010 and complained of headaches, back pain, nausea, and shortness of breath. (R. 613.) She claimed to have recently run out of two prescriptions (Cyclobenzaprine and Gabapentin) that she apparently had never previously filled. (R. 305-07, 613.) Dr. Juarez ordered a chest x-ray and cardiac tests and prescribed Imitrex, and more Cyclobenzaprine and Gabapentin; these prescriptions were actually filled. ( Id. )

Claimant saw Dr. Juarez on December 10, 2010, complaining of back pain and abdominal pain. (R. 615.) Dr. Juarez noted increased sensation with continued weakness in the right leg. ( Id. ) She again prescribed Cyclobenzaprine and Gabapentin and told claimant to follow up with the pain clinic. ( Id. )

Claimant visited Dr. Juarez on February 4, 2011, complaining of headaches, nausea, vomiting, abdominal and neck pain, and night sweats. (R. 617.) She reported an inability to do housework or sit or stand for any significant length of time due to continued pain. ( Id. ) She required assistance with daily activities such as getting dressed, bathing, and grooming. ( Id. ) Dr. Juarez noted that Arroyo has had four epideral steroid injections but continues to have pain and cannot sit or stand for more than five or ten minutes. ( Id. ) Dr. Juarez again prescribed Cyclobenzaprine, Gabapentin, Zantac, and Imitrex. ( Id. )

On March 17, 2011, claimant visited Dr. Juarez again and reported that she was taking Gabapentin and Norco for her symptoms, which had not improved, despite a recent steroid injection. (R. 618.) She told Dr. Juarez that she still walked with a cane and had difficulty sitting for longer than five minutes, and that she was having trouble sleeping. ( Id. ) Dr. Juarez wrote new prescriptions for Gabapentin and Norco. ( Id. )

On January, 27, 2012, Dr. Juarez filled out a second medical questionnaire about Arroyo's condition. (R. 719.) She noted that Arroyo had been diagnosed with a herniated lumbar disc with severe radicularity pain with a supporting MRI showing L4-5 broad disc bulge. ( Id. ) She also noted that Arroyo suffered from major depression. ( Id. ) She described Arroyo's symptoms as severe pain associated with numbness in the lower extremities and weakness, stiffness and spasm of back and leg muscles. ( Id. ) She further noted that Arroyo needs a cane to walk and support for standing, she is unable to lift, push or pull greater than five pounds, and she is unable to stoop, sit, stand or lay down for prolonged periods due to her pain. ( Id. ) She stated that Arroyo's prognosis was poor and she opined that ...

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