United States District Court, Northern District of Illinois, Eastern Division
JAN W. BUDZ, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security,  Defendant.
MEMORANDUM OPINION AND ORDER
HON. MARIA VALDEZ, United States Magistrate Judge.
This action was brought under 42 U.S.C. § 405(g) to review the final decision of the Commissioner of Social Security denying Plaintiff Jan W. Budz’s claims for Disability Insurance Benefits and Supplemental Security Income. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow, Plaintiff’s motion for summary judgment [Doc. No. 18] is denied, and the Commissioner’s cross-motion for summary judgment [Doc. No. 23] is granted.
I. PROCEDURAL HISTORY
On May 9, 2008, Budz filed a claim for Disability Insurance Benefits and on July 16, 2008, he filed another application for Supplemental Security Income benefits, alleging disability since May 15, 2005. The claims were denied initially on January 12, 2009 and upon reconsideration on April 30, 2009, after which he timely requested a hearing before an Administrative Law Judge (“ALJ”), which was held on July 7, 2010. Claimant personally appeared and testified at the hearing and was represented by counsel. Vocational expert Ed Pagella also testified.
On September 27, 2010, the ALJ denied Budz’s claims for both Disability Insurance Benefits and Supplemental Security Income and found him not disabled under the Social Security Act. The Social Security Administration Appeals Council then denied Claimant’s request for review on February 28, 2012, leaving the ALJ’s decision as the final decision of the Commissioner and, therefore, reviewable by the District Court under 42 U.S.C. § 405(g). See Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005).
II. FACTUAL BACKGROUND
Budz was born on October 7, 1956 in Poland and as of June 30, 2009, his date last insured, he was fifty-two years old. He has a limited eighth-grade education and past relevant work as a machine mechanic. At the time of the hearing, he was living with his elderly mother. Budz claimed disability due to ataxia (poor motor coordination), leg weakness, and pain.
B. Medical Evidence
Budz saw Dr. Peter Biale, M.D. at the SSA’s request on September 22, 2008. Budz reported difficulty walking and an unsteady gait that had been getting progressively worse. A recent CT scan performed at Stroger Hospital showed atrophy of the cerebellum. Dr. Biale noted that Budz walked with an unsteady, wide gait, and while he could bear his own weight, he experienced tremors in both legs. The tremors caused him difficulty in getting on and off the examination table. Dr. Biale further reported that Budz could not squat or do a heel walk or toe walk without losing balance immediately. Deep tendon reflexes (“DTRs”) were hyperreflexive in Plaintiff’s legs, and motor strength in both legs was recorded as 4/5. Cerebellar testing was found to be abnormal, with Romberg positive 4, and finger-to-nose and heel-to-shin both abnormal.
Dr. Charles Wabner, M.D., a non-examining state agency review completed a Residual Functional Capacity (“RFC”) form on January 7, 2009. He concluded that Budz could perform work at the medium exertional level without any postural or environmental limitations.
On March 13, 2009, Budz went to the Stroger Hospital emergency room, complaining of slowly progressive bilateral leg pain. He also stated that he experienced leg cramps at night and could walk only two blocks as a result of leg pain. The examining physician noted an ataxic gait and anaxic finger-to-nose presentation, and a negative Romberg test. He was diagnosed with ataxia of unknown etiology.
An MRI of Budz’s brain taken on August 25, 2009 showed moderate atrophy, considered advanced for his age, and mild small vessel ischemic changes. The MRI also revealed “multiple small old infarcts in the pons bilaterally.” (R. 291.) A September 2009 EMG was normal.
Plaintiff began seeing Dr. Serge Pierre-Louis at the Cook County Health neurology clinic in April 2009, when Budz reported that he experienced progressive leg pain, decreased balance, and leg weakness for three years, and tingling in his feet for two to three months. He admitted to being a heavy drinker in his twenties and thirties but stated that his use of alcohol had decreased over the last five years. Budz’s DTRs were slightly increased, and there was positive horizontal nystagmus on examination. His gait was noted to be spastic with mild ataxia, and the Romberg test was positive. The physician’s impression was of probable cerebellar dysfunction. Notes from July 14, 2009 show positive horizontal ...