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Carrasco v. Colvin

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

May 26, 2015

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


SHEILA FINNEGAN, Magistrate Judge.

Plaintiff Madelyn Carrasco 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 affirms the Commissioner's decision.


On April 27, 2011, Plaintiff (at age 59) applied for DIB, alleging that she has been disabled since November 8, 2010 due to arthritis, lupus, diabetes, hepatitis C and a heart condition. (R. 153, 156). On July 9, 2011, Plaintiff indicated in a Function Report, among other things, that she was also suffering from fibromyalgia. (R. 162). The Social Security Administration denied Plaintiff's application initially on September 12, 2011, and again upon reconsideration on December 15, 2011. (R. 39-40). She then filed a timely request for hearing and appeared before Administrative Law Judge David Skidmore (the "ALJ") on October 9, 2012. (R. 17-37). The ALJ heard testimony from Plaintiff, who was represented by counsel, and from vocational expert Jill Radke (the "VE"). Shortly thereafter, on November 2, 2012, the ALJ found that Plaintiff is not disabled because she is capable of performing her past light duty work as a security guard. (R. 44-53). The Appeals Council denied Plaintiff's request for review, (R. 1-6), and she now seeks judicial review of the ALJ's decision, which stands as the final decision of the Commissioner.

In support of her request for reversal or remand of the ALJ's decision, Plaintiff first argues that the ALJ erred in evaluating her credibility because he used "meaningless boilerplate" language, "drew inferences against [her] without laying the proper foundation to do so[, ]" and failed to discuss some of her medication side effects. (Doc. 13, at 4-12; Doc. 22, at 1-3). She also argues that he erred when determining her residual functional capacity ("RFC") by failing to consider the combined effects of all of her impairments, and particularly her bunions, fibromyalgia, and obesity. (Doc. 13, at 12-16; Doc. 22, at 4-9). As discussed below, the Court finds no merit to these arguments.


Plaintiff was 61 years old and living alone in her home at the time of the ALJ's decision. (R. 21, 24). She had completed high school and earned some college credits, worked as a CTA bus driver for many years, and then worked most recently for Chicago Public Schools as a security guard in a high school for 20 years. (R. 21, 25, 157). She stopped working on November 8, 2010 because her security guard job required her to "just keep walking, keep being mobile" and she felt she could no longer perform those duties due to pain and swelling in her knees, and pain in her ankles and feet. (R. 25-26).

A. Medical History

1. 2010

Plaintiff's earliest medical records from February 2010 show she was diagnosed with high cholesterol, osteoarthritis, coronary artery disease (treated with a stent), hypertension, and hepatitis C. (R. 335). She was admitted to the emergency room at Rush University Medical Center on February 10, 2010 because of chest pain and heart palpitations. (R. 207-15). Since her physical exam and stress test were normal, she was quickly discharged with instructions to follow up with her regular physician. ( Id. ). On February 16, 2010, Plaintiff followed-up with her family practitioner at Rush, Dr. Miguel Salas. (R. 339). She reported being asymptomatic at that time, and her physical exam was normal. (R. 339-41). However, Dr. Salas found that Plaintiff had high blood pressure, high cholesterol, and was obese (weighing 188 pounds at 5'4" in height), so he prescribed blood pressure and cholesterol medications, and recommended daily exercise and diet changes. (R. 341-42).

At a March 2010 follow-up with Dr. Salas to go over lab work results, Plaintiff's cholesterol and blood pressure had not improved, but she refused additional medications. (R. 353). She was reminded to improve her diet and to exercise. ( Id. ). Dr. Salas also diagnosed Plaintiff with Type II diabetes, but found she was "completely asymptomatic." (R. 348, 352-53). Dr. Salas noted at an April 2010 follow-up that Plaintiff had lost weight (down to 182 pounds) and she was still "completely asymptomatic." (R. 361, 363). A few months later, at a July 2010 appointment with Dr. Salas, Plaintiff complained of moderate lower back pain that sometimes radiated to her left thigh. (R. 372). It was dull, and was relieved by rest or NSAIDs. ( Id. ). Her physical examination was again normal, including a normal gait, a full range of motion, normal strength, and no redness, swelling or warmth in the joints. (R. 373). Dr. Salas recommended ibuprofen as needed, physical therapy, and exercise. (R. 375).

On October 12, 2010, Plaintiff again visited Dr. Salas, complaining of generalized joint pain, a cyst on her left foot, and pain in her foot joints. (R. 392). Plaintiff said her pain was mostly controlled with Motrin, but her foot issues also limited her ability to walk for long periods of time. (R. 386). Dr. Salas noted that Plaintiff had a bunion on the right foot and calluses on her feet, and she reported previous foot surgeries. (R. 386, 389). Her physical examination was normal, including her gait, strength, range of motion, and muscle tone, and her joints had no redness, warmth or swelling. (R. 387, 389, 393). Plaintiff was recommended to increase her ibuprofen to relieve her joint pain and increase her blood pressure medication, but she declined the increased blood pressure medication, stating she instead planned to exercise more once her feet felt better. (R. 390). Dr. Salas also recommended Plaintiff keep up her physical activity, and referred her to a podiatrist for her foot issues. (R. 395). The record does not show that Plaintiff visited any podiatrist at this time.

On November 8, 2010, Plaintiff stopped working. The next day, she visited Dr. Joel Augustin, an internist at Rush, complaining of several days of pain in the tailbone, left hip, left knee, left ankle, and chest pain. (R. 410). She sought a referral to an orthopedic specialist. ( Id. ). Dr. Augustin's examination revealed tenderness of Plaintiff's lumbar spine and coccyx area and mild tenderness in the chest, but no redness, warmth, swelling or tenderness in her joints, a full range of motion, and a negative straight leg raise test. (R. 411). The internist recommended x-rays and told Plaintiff he could not refer her to an orthopedic specialist without performing any imaging studies. (R. 411, 414). Plaintiff's November 9, 2010 knee x-rays showed "scattered mild to moderate drain with marginal osteophyte formation" in the left knee, consistent with osteoarthritis. (R. 450). Her lumbar spine x-ray showed some minimal decrease in disk height at L5, small anterior osteophytes in the lower spine, and joint inflammation at the L5-S1 level. (R. 461-62). A pelvic x-ray showed Plaintiff's coccyx was unremarkable, but she had mild degenerative narrowing in the SI joints and moderate degenerative narrowing in the joint between the two pubic bones. (R. 463).

About a week later, on November 16, 2010, Plaintiff visited Dr. Salas, complaining of "a lot" of joint pain, particularly in the right shoulder, knees and lumbar spine. (R. 418, 423). She was also crying in the doctor's office due to "personal issues and body aches" and said her pain was keeping her from sleeping and working. ( Id. ). Other than joint tenderness, her physical exam was normal, including a full range of motion, full motor strength, and no redness, warmth or swelling in the joints. (R. 424). The doctor also noted Plaintiff had lost some weight (she was then at 180 pounds). ( Id. ). Dr. Salas noted that Plaintiff was not progressing in her physical therapy at home, and recommended more physical activity. (R. 425). He prescribed Tramadol and Lidocaine patches for her pain. (R. 425). The doctor also noted that Plaintiff's diabetes was controlled with her diet. (R. 216).

A few days later, on November 23, 2010, Plaintiff returned to Dr. Salas' office to have disability forms completed, stating she "wants to retire and then have enough time to improve her symptoms" and she was "requesting FMLA to do so." (R. 436). Plaintiff complained of intense joint pain and pain all over her body, stated her job was too demanding, and said she had been crying due to pain and feeling like her "disease" was "consuming her life." ( Id. ). Her physical exam was normal except for generalized joint tenderness and "mild deformity" of the knees. (R. 438). Dr. Salas recommended Plaintiff use more Tylenol and again recommended physical therapy. (R. 439). The doctor also wrote Plaintiff a note stating she would be released to work on November 29, 2010. (R. 440).

On December 5, 2010, Plaintiff followed-up with Dr. Salas to discuss her FMLA forms, and stated she was feeling better. (R. 448). She also reported that she wanted to "retire sooner rather than later." (R. 450). Upon examination, Plaintiff displayed some mild tenderness in her joints, particularly the knees, but her exam was otherwise normal. ( Id. ). Dr. Salas recommended continued physical activity and Tylenol for pain, and noted that Plaintiff refused "ortho intervention." ( Id. ).

Plaintiff visited Dr. Salas again on December 30, 2010 for help with more FLMA forms. (R. 460). The doctor noted that before Plaintiff came in, he and she spoke on the phone, and he suggested she could return to work with pain medication and physical therapy. ( Id. ). Plaintiff "refused completely the idea to return to work" because she felt she was unable to work in her condition. ( Id. ). Once again, her physical examination at this time was normal, including a normal walk, full range of motion and full motor strength, except for some joint and lumbar spine tenderness and some mild knee swelling. (R. 461). Her weight was also down to 177 pounds. ( Id. ). Dr. Salas also reviewed Plaintiff's November 2010 x-rays and believed they potentially showed facet syndrome.[1] (R. 463). The doctor recommended Plaintiff get a second opinion, including for the possibility of fibromyalgia, and in case Plaintiff sought to refrain from working after January 29, 2011, the date through which he extended her disability leave. ( Id. ). The doctor also recommended an orthopedic examination and bone loss medication, both of which Plaintiff refused. ( Id. ). Finally, the doctor referred Plaintiff to a rehabilitation specialist. ( Id. ).

2. 2011

Plaintiff followed-up with Dr. Salas on January 27, 2011, and told the doctor that she did not go to the rehabilitation specialist he recommended because she did not have the money to pay for it, and because "they do not deal with diagnosis [sic] like fibromyalgia." (R. 220). Dr. Salas told Plaintiff he needed the opinions of specialists to support her claim that she was "100% not capable to work anymore" since his prior analysis had been based "mainly on [Plaintiff's] statements" and he now needed a "scientific opinion." ( Id. ). He requested she see a rehabilitation medicine specialist, a rheumatologist, and a podiatrist before he could agree to support extending her disability leave again. ( Id. ).

A few days later, on February 1, 2011, Plaintiff followed-up again with Dr. Salas so that he could complete forms to extend her disability leave. (R. 227). Plaintiff also told the doctor that all her joints were sore and "she decided not to work anymore." ( Id. ). The doctor noted that after months of not following his recommendations, Plaintiff had now made appointments with a podiatrist, a rheumatologist, and a rehabilitation specialist, and was going to start physical therapy. ( Id. ). The doctor further wrote that his physical examination results thus far only allowed him to diagnose Plaintiff with "incipient Osteoarthritis not at the point for permanent disability" but he would consider the other specialists' forthcoming opinions. ( Id. ). The doctor extended Plaintiff's leave until February 15, 2011 in the meantime. ( Id. ).

On February 16, 2011, Plaintiff returned to Dr. Salas to have forms completed for another FMLA leave extension. (R. 237). Her physical exam was normal, but the doctor was concerned that her blood pressure was high despite her statements that she was medication compliant and was dieting. (R. 238-42). Notably, when Plaintiff told Dr. Salas she was taking all of her medications (including Tramadol), she did not state she was suffering any side effects. ( Id. ). The doctor recommended additional diet changes and exercise, including moderate jogging 3 to 5 days a week. ( Id. ).

A couple of weeks later, on February 24, 2011, Plaintiff returned to see Dr. Salas for another extension of her disability leave. (R. 249). She had finally seen the rehabilitation specialist, Dr. Merrie Viscarra, who according to Dr. Salas' notes, had diagnosed Plaintiff with chronic generalized pain and recommended physical therapy (the record contains no notes from Dr. Viscarra herself). ( Id. ). Plaintiff's physical exam by Dr. Salas at this time was normal, but he extended her disability leave until March 9, 2011 so that he could evaluate further assessments by Dr. Viscarra and the other specialists. (R. 250-51).

Plaintiff followed-up with Dr. Salas on March 22, 2011, reporting that she recently had lab work done and visited Dr. Antoine Sreih, a rheumatologist, and Dr. Allan Shoelson, a podiatrist. (R. 259). There are no notes or reports from these specialists' consultations at this time in the record, but Dr. Salas recorded some information in his notes that he learned from Dr. Sreih. Specifically, he noted that Dr. Sreih recommended Plaintiff be off work until April 11, 2011 so that she could start new medications for her generalized joint pain. (R. 263). Dr. Salas also added a provisional diagnosis of lupus to Plaintiff's file based on Dr. Sreih's findings (which are not detailed in Dr. Salas' notes), discontinued her ibuprofen, and noted she was starting Plaquenil on Dr. Sreih's recommendation. (R. 262). Dr. Salas also found that Plaintiff's cholesterol had improved and her diabetes was controlled, with no episodes of hypoglycemia or other symptoms or complications. ( Id. ). Plaintiff reported that she was walking for 30 minutes a day, 3-5 times per week. (R. 263). Her exam at this time was normal, except for joint tenderness and pain during her range of motion testing. (R. 260). The doctor also noted that Plaintiff's weight was down to 175 pounds and her BMI was lower. (R. 258-59). However, her blood pressure was still high. (R. 262).

On April 1, 2011, Plaintiff visited Dr. Steven Rothschild, a geriatric medicine specialist, complaining of low back, left knee and left foot pain, and seeking to have disability forms completed. (R. 270). She told him that Dr. Shoelson, her podiatrist, had given her injections which had reduced her foot pain, and that her physical therapy was "helping somewhat." (R. 271). She also said she became lightheaded on Plaquenil so she stopped taking it, but reported no other medication side effects. ( Id. ). Plaintiff also told Dr. Rothschild that she cannot work as a security guard because she cannot be on her feet all day, and that she was considering applying for permanent disability benefits. ( Id. ).

Dr. Rothschild noted that Plaintiff had been seeing Dr. Salas and that her "[w]ork-up [was] mostly non-contributory" and "concerns have been raised regarding somatization disorder or factitious disorder-Dr. Salas has observed patient walking briskly through parking lot here, although in severe pain in clinic."[2] (R. 271). The doctor further wrote that Plaintiff was moving slowly but without difficulty in his office. (R. 272). He concluded that he agreed with Dr. Salas' recommendations to continue Plaintiff's physical therapy and medication while awaiting further information from her specialists. ( Id. ). Dr. Rothschild also extended her disability until April 22, 2011. ( Id. ).

A week later, on April 8, 2011, Plaintiff returned to visit Dr. Rothschild in tears, stating that her employer interpreted Dr. Salas' paperwork as indicating she could immediately return to work. (R. 279). She also stated that she could not tolerate Plaquenil because of palpitations, and Dr. Rothschild noted that at her last visit she mentioned lightheadedness from that medication, not palpitations. ( Id. ). She reported no side effects from her other medications. The doctor also noted Plaintiff complained of pain in the neck, low back, hips, ankles, feet and shoulders, but she had no red, inflamed joints or swelling, and she reported her Lidocaine patches and physical therapy had been helping "a lot." ( Id. ). Plaintiff further reported being able to walk to the store near her house, walk or stand for 30 minutes without sitting down, and the physical therapist noted Plaintiff could stand for up to 60 minutes. ( Id. ). Dr. Rothschild examined Plaintiff and noted she could walk well, was able to pull her shirt on and use both her upper extremities with adequate range of motion (despite her complaints of pain and limitations with her right shoulder), and she was otherwise normal except for some complaints of pain in the hips. (R. 281).

Dr. Rothschild concluded that Plaintiff had been given various diagnoses, including possible lupus, had somewhat inconsistent examinations "with improved function when she is unaware of being observed[, ]" and had a "significant emotional overlay aggravating her condition." (R. 281). He was unsure whether her behavior was volitional or the result of stress. ( Id. ). The doctor gave Plaintiff a letter for her employer indicating she was on medical leave through April 22, 2011 on the advice of several of her doctors, and recommended she contact Dr. Sreih to change her medication. (R. 281-82). He also noted Plaintiff's high blood pressure might require increased medications, but Plaintiff raised concerns regarding costs. (R. 281). The doctor further advised Plaintiff to continue dieting and losing weight, including to avoid potential hepatitis C complications from having a "fatty liver." ( Id. ).

Plaintiff followed-up with Dr. Rothschild on April 22, 2011 to have her disability leave extension forms completed, and review lab work results. (R. 290-91). Plaintiff reported that she had visited Dr. Sreih, who recommended she try Plaquenil again at a decreased dosage because it was a very effective medication, and she agreed to this plan. (R. 291). Plaintiff also reported having an injection in her ankle that made the pain there somewhat better, and said she was continuing to attend physical therapy twice a week. ( Id. ). According to Dr. Rothschild's notes, Plaintiff's hepatologist, Dr. Dhillon, was concerned about her liver and recommended hepatitis vaccinations and continuation of her disability leave to allow for medication adjustment, liver monitoring, and "aggressive" physical therapy. (R. 291, 296). Dr. Dhillon's notes from this consultation are not in the record. Dr. Rothschild extended Plaintiff's disability leave for eight more weeks, and noted that she was developing "better endurance, albeit very gradually, with continued pain." (R. 296). Plaintiff applied for disability benefits through the Social Security Administration a few days later, on April 27, 2011. (R. 153, 156).

Plaintiff scheduled appointments with Drs. Shoelson, Dhillon and Rothschild in late May and early June 2011, but there are no notes or reports concerning those visits in the record. (R. 302). On June 2, 2011, Dr. Viscarra filled-out a Physical Residual Functional Capacity Questionnaire form in support of Plaintiff's disability claim. (R. 304-08). Dr. Viscarra wrote that she had seen Plaintiff once a month for the previous four months, and thought her prognosis was "good." (R. 304). The doctor further indicated Plaintiff's pain was made worse with movement, walking, and prolonged sitting and standing; that she could walk up to two blocks without severe pain; that she could sit or stand for up to 20 minutes before needing a break; and that she could sit, stand or walk for less than 2 hours in an 8 hour workday. (R. 304-06). In the section of the report asking what treatments Plaintiff was undergoing and whether she was suffering any side effects, Dr. Viscarra wrote that Plaintiff was attending physical therapy and taking Tramadol and ibuprofen, and listed no medication side effects. (R. 304). There are no treatment notes or reports from Dr. Viscarra in the record to support her questionnaire form responses.

On July 12, 2011, Plaintiff visited Dr. Augustin, complaining of leg and coccyx pain, and seeking medication. (R. 473). The doctor also noted Plaintiff's weight was at 176 pounds. (R. 476). Plaintiff's straight leg test was negative and the doctor was unsure of her degree of pain, so he offered to refer Plaintiff to a pain clinic. ...

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