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Hopson v. Colvin

United States District Court, Northern District of Illinois, Eastern Division

December 5, 2014

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.


SHEILA FINNEGAN, United States Magistrate Judge.

Plaintiff Jessie Hopson seeks to overturn the final decision of the Commissioner of Social Security (“Commissioner” or “Defendant”) denying her application for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act. 42 U.S.C. §§ 416, 423(d). The parties consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c), and filed cross-motions for summary judgment. After careful review of the record, the Court now grants the Commissioner’s motion, denies Plaintiff’s motion, and affirms the decision to deny disability benefits.


Plaintiff, a 53 year-old high school graduate with one year of college education, alleges she has been disabled since December 22, 2010, due to Carpal-Tunnel Syndrome, diverticulitis, skin lupus, and arthritis. (R. 109-11). After working full time for about 14 years, including 10 years as a line worker/assembler, she was laid off in December 2010 due to lack of work. (R. 74-76, 80-81, 89).

A. Medical and Procedural History Prior to the ALJ’s Decision

1. Treatments Prior to Plaintiff’s Application for Benefits

In Plaintiff’s earliest medical records from June 2010, Plaintiff complained of dull, moderate body and back pain while being treated for a throat infection, and was told to take Tylenol or Advil for her pain. (R. 319-23). A few months later, on August 26, 2010, Plaintiff was hospitalized for abdominal issues, which were eventually diagnosed as acute diverticulitis. (R. 299-300). While hospitalized, Plaintiff complained of joint pain, and the attending physician, Dr. Chaden Sbai, assessed her with “the possibility of lupus.” (R. 293). Dr. Sbai prescribed Norco for Plaintiff’s pain and ordered testing, but the results are not in the record. (Id.).

2. Plaintiff’s Application for Benefits and Subsequent Medical History

On December 26, 2010, Plaintiff, who was then 49 years old, applied for disability benefits. (R. 109-11). A few days later, on January 4, 2011, Plaintiff sought treatment from an orthopedic surgeon, Dr. Robert Markus, for what she described as longstanding pain in her hands and knees. (R. 254). Dr. Markus wrote that Plaintiff had documentation showing bilateral knee arthritis, including a June 2010 MRI of her left knee (which is not in the record), and that she reported having surgery in the right hand to treat Carpal-Tunnel Syndrome in 2009. (Id.). The surgeon also examined Plaintiff and found no abnormal results, except for some signs of finger locking in her right ring finger. (Id.). He also noted that Plaintiff’s height was 5’4” and weight was 172 pounds, giving her a body mass index (“BMI”) of 29.5. (Id.).

Dr. Markus administered cortisone injections in Plaintiff’s finger and knees, prescribed wrist splints, Vitamin B6 and Meloxicam for her arthritis-related pain, and recommended an EMG. (Id.). The EMG is not in the record, but Dr. Markus’ January 18, 2011 notes state that the EMG showed “very mild bilateral median neuropathy.” (R. 253). Dr. Markus recommended Plaintiff follow up as needed, but she did not visit him again. (Id.).

On March 9, 2011, Plaintiff submitted a function report to the Social Security Administration (“SSA”) in support of her disability claim. (R. 183-192). In that report, Plaintiff complained of pain “all day every day, ” particularly in the stomach, knees and hands. (R. 183-84). She reported that she can cook, including quick meals using the oven or microwave, and that she does laundry, but cannot stand for cooking or doing laundry for more than 10 or 15 minutes. (R. 185).

Plaintiff also reported going outside alone once a week and going to church regularly. (R. 186-87). However, her daughter does her shopping for her, because she cannot walk or stand for a long time. (R. 184, 186). She explained that she could walk for about a block, but then needed to stop and rest for about 15 or 20 minutes. (R. 188). In the section of the report asking Plaintiff to check a box to indicate if she used crutches, a cane, a walker, or a wheel chair, she checked no boxes. (R. 189). She did check boxes indicating she uses a brace and glasses, and wrote that those devices had been prescribed by doctors. (Id.).

On May 4, 2011, Plaintiff underwent a right knee x-ray (which is not in the record) and had a BDDS consultative examination by Dr. Liana G. Palacci, an internist, for the purposes of evaluating her disability claim. (R. 257-62). Plaintiff told Dr. Palacci that she had, among other issues, joint pains in the feet and knees, with creaking and swelling in the knees. (R. 258-59). She also told Dr. Palacci that she had been using a non- prescribed walker for balance and pain relief, and that she needed it to ambulate less than 50 feet. (Id.). She used the device during the examination. (Id.). Plaintiff also reported wearing her prescribed wrist splints at night, and was still taking Meloxicam. (Id.).

Dr. Palacci reviewed Plaintiff’s medical records from Dr. Markus and her right knee x-ray, and examined her. (R. 258; 260-61). Dr. Palacci measured Plaintiff’s height as 5’5” and weight as 185 pounds at the time, making her obese. (R. 259). Dr. Palacci also found Plaintiff exhibited signs of lupus in the scalp; difficulty with heel and toe standing and squats; an antalgic gait; a reduced range of motion in the knees (120/150 flexion in the left and 70/150 flexion in the right); 4 strength in the right leg; and 5/5 strength in the left leg. (R. 260-61). The doctor also wrote that Plaintiff’s right knee x-ray showed mild osteoarthritis. (Id.).

On May 19, 2011, Dr. Francis Vincent, a BDDS consulting physician, prepared a residual functional capacity assessment of Plaintiff, and determined that she is capable of light work, with limited use of the upper extremities. (R. 101-04). Due to Plaintiff’s knee issues, Dr. Vincent limited Plaintiff to the occasional climbing of ramps, stairs, ladders, ropes and scaffolds, and occasional crouching, kneeling and crawling. (Id.). To account for Plaintiff’s lupus, Dr. Vincent recommended she limit her exposure to concentrated heat and sun. (R. 104). The doctor’s analysis of the evidence includes a discussion of Dr. Markus’s notes and Dr. Palacci’s notes, as well as other evidence. (R. 101). Dr. Vincent specifically noted that Plaintiff had a BMI of 30.8 at the time of Dr. Palacci’s examination. (Id.).

On June 14, 2011, Plaintiff underwent foot, knee and hip x-rays, apparently after complaining of pain at a hospital (the referral is not in the record, and the x-rays list the referring doctor as “unassigned MD”). (R. 335-37). The foot x-rays showed mild to moderate bunions, and the hip x-ray showed mild degenerative changes in the hip and lower back joints. (R. 335-36). The knee x-rays showed moderate to marked narrowing of the patellofemoral joint spaces, marked narrowing of the medial and lateral knee joint compartments, and osteoarthritic spurs.[1] (R. 337). A few days after these x-rays were taken, on June 17, 2010, the SSA denied Plaintiff’s disability claim. (R. 107).

3. Plaintiff’s Post-Denial Medical History and Claim Reconsideration

Plaintiff visited an emergency room on June 17, 2011 at the Oak Forest Hospital due to, among other issues, severe aching pain in the knees and heels. (R. 280-81). She reported to the emergency room physician that she was still taking her arthritis medication. (Id.). She was referred for ankle and foot x-rays, which she underwent on June 20, 2011. (R. 266-69). Those x-rays showed a “slightly decreased” plantar arch in the left foot and degenerative changes in the mid-foot and hind-foot in both feet. (Id.). The radiologist described Plaintiff’s degenerative changes in the right foot as “early.” (Id.).

On July 19, 2011, Plaintiff filed for reconsideration of the denial of her disability claim. (R. 108). A few weeks later, on August 31, 2011, BDDS consulting physician Dr. James Hinchen prepared a residual functional capacity assessment pursuant to the reconsideration of Plaintiff’s claim. (R. 287-89). Dr. Hinchen affirmed Dr. Vincent’s May 19, 2011 findings. (R. 287-89). On September 1, 2011, the SSA again denied Plaintiff’s disability claim. (R. 108).

4. Plaintiff’s Request for a Hearing and Subsequent Medical History

On September 27, 2011, Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”) to review her disability claim. (R. 123). A few days later, on October 11, 2011, Plaintiff had wrist x-rays done, which produced “normal” results. (R. 338).

On November 16, 2011, Dr. Mayuri Dasari, a geriatric medicine specialist, filled-out a physical residual functional capacity questionnaire form for Plaintiff. (R. 339-341). Dr. Dasari wrote that she treated Plaintiff for degenerative joint disease on three occasions since August 2011, but there are no notes concerning such treatments in the record. (R. 339). Dr. Dasari found that Plaintiff suffers from chronic pain and a limited range of motion in the joints, as well as ...

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