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Vanprooyen v. Colvin

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

August 25, 2016

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


          Young B. Kim Magistrate Judge

         Melissa Vanprooyen seeks Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) based on her claim that she is unable to work because of a combination of medical problems including seizures, fibromyalgia, short-term memory loss, anxiety, attention deficit hyperactivity disorder (“ADHD”) and post-traumatic stress disorder (“PTSD”). After the Commissioner of the Social Security Administration denied her applications, Vanprooyen filed this lawsuit seeking judicial review. See 42 U.S.C. § 405(g). Before the court are the parties' cross-motions for summary judgment. For the following reasons, Vanprooyen's motion is denied, the government's is granted, and the Commissioner's final decision is affirmed:


         Vanprooyen filed her DIB and SSI applications in February 2012 claiming a disability onset date of March 15, 2010. (Administrative Record (“A.R.”) 200-12.) After her claims were denied initially and upon reconsideration, (id. at 122-23, 150- 51), Vanprooyen sought and was granted a hearing before an administrative law judge (“ALJ”). That hearing took place on April 29, 2013. (Id. at 54-95.) On May 30, 2013, the ALJ issued a decision concluding that Vanprooyen is not disabled and therefore not entitled to DIB or SSI. (Id. at 32.) When the Appeals Council declined review, (id. at 1-6), the ALJ's decision became the final decision of the Commissioner, see Schomas v. Colvin, 732 F.3d 702, 707 (7th Cir. 2013). Vanprooyen filed this lawsuit seeking judicial review of the Commissioner's final decision, (R. 1); see also 42 U.S.C. § 405(g), and the parties consented to this court's jurisdiction, (R. 8); see also 28 U.S.C. § 636(c).


         In March 2010 Vanprooyen was 27 years old and working as a waitress when she fell down a flight of stairs and suffered a brain injury. In pursuing disability benefits Vanprooyen initially identified her disability onset date as the day of that injury, but when the ALJ pointed out at her hearing that she continued to work as a waitress until October 2011, Vanprooyen amended her onset date to October 1, 2011. (A.R. 94.) At the hearing Vanprooyen presented medical records, her own testimony, and the testimony of her fiancé, James Ribar, in support of her claim that symptoms related to her brain injury, fibromyalgia, anxiety, PTSD, and ADHD prevent her from engaging in full-time work.

         A. Medical Evidence

         Vanprooyen's medical records reflect that starting in 2009 she was receiving treatment from internal medicine specialist Dr. Dorothy Jones for headaches and fibromyalgia. (A.R. 365, 376, 382.) At the time she was also seeing a psychiatrist who prescribed medications to treat her anxiety, depression, and ADHD. (Id. at 516-17.)

         On March 15, 2010, Vanprooyen was admitted to the hospital after falling down a flight of stairs and suffering a head injury. (Id. at 354-55.) CT scans showed that she had a traumatic hemorrhage and contusion in her brain's left hemisphere. (Id. at 320-21, 327.) She also underwent an electroencephalogram to rule out epileptiform activity, which showed results consistent with mild diffuse encephalopathy. (Id. at 343-44.) Vanprooyen was discharged six days after her admission with prescriptions for pain and anticonvulsant medications and with instructions to resume activity as tolerated. (Id. at 354-55.) She was also given a form signed by a neurosurgeon stating that she was able to return to work. (Id. at 311.) At her follow-up appointment a month after her fall, Dr. Nassir Mansour wrote that her general physical exam was normal and that she had made a “very good recovery.” (Id. at 353.) Dr. Mansour noted that Vanprooyen was “very keen to go back to her job where she works as a waitress” and wrote that there was no reason why she could not return to work. (Id.)

         On April 22, 2010, Vanprooyen was admitted to the hospital again after she experienced a grand mal seizure at home and again in the emergency room. (Id. at 403, 441.) Dr. Jones noted that she had been taken off of her seizure medications and that one of her pain medications may have lowered her seizure threshold. (Id. at 443.) The day after her hospital admission Vanprooyen had a consultation regarding her seizure disorder with Dr. Engin Yilmaz. (Id. at 394.) He noted that Vanprooyen had been stabilized but that she would need to be on antiepileptic medications for at least two years. (Id. at 399, 401.) He also noted that Vanprooyen was working at a Chili's restaurant and wrote that he “would not allow her to work more than 8 hours” and that she shouldn't drive, climb heights, or use machines. (Id. at 401.) A few days after her two seizures Dr. Jones prescribed medication for headaches and provided Vanprooyen with a work-release form stating that she could return to work on April 28, 2010, with no restrictions. (Id. at 366, 368.)

         Dr. Yilmaz saw Vanprooyen twice more in 2010 and once in January 2011. In May 2010 Dr. Yilmaz observed that Vanprooyen walked with a normal gait, had normal speech, and displayed appropriate attention. (Id. at 397.) In December 2010 he noted that Vanprooyen had stopped taking her anticonvulsant medications because they made her drowsy and now was complaining about increased insomnia and anxiety. (Id. at 395.) Vanprooyen suffered a seizure in his office. (Id.) Dr. Yilmaz wrote that she was not compliant with her medications and that he had a long discussion with her about the importance of antiepileptic compliance. (Id.) Dr. Yilmaz also wrote “I have limited her working hours to six hours per day, ” and that she should follow up in two months. (Id. at 396.) In January 2011 Vanprooyen reported to Dr. Yilmaz that since she restarted her antiepileptic medication she had not had any lethargy or gait instability. (Id. at 391.)

         Vanprooyen was next hospitalized when she gave birth in October 2011. Her physician noted that she had not had a seizure in close to a year but that she was lucky in that respect because she had gone to a doctor other than Dr. Yilmaz, and the new doctor changed her epilepsy medications. (Id. at 448.) The doctor observed that Vanprooyen had normal coordination and sensation and a normal gait, and noted that she promised to restart her anticonvulsant medications. (Id.)

         Eight days after giving birth Vanprooyen went to an emergency room and reported that she had been having pain from the waist down for four days and that she was experiencing low-back pain at a level of seven out of ten on the pain scale. (Id. at 415.) The doctor noted that her pain was likely related to fibromyalgia and that she was asking for pain medication. ( 418.) He observed a normal lower extremity exam with normal range of motion, and noted that upon discharge Vanprooyen was in good condition. (Id. at 49.)

         In 2011 Vanprooyen received psychiatric treatment from Dr. Harlan Alexander at a youth services center. Dr. Alexander prescribed Vanprooyen Xanax for her anxiety. (Id. at 513-14.) She reported to Dr. Alexander that she had trouble sleeping, endured headaches, and needed to keep logs to remember to do things. (Id. at 511.) She reported that she had trouble sustaining memories and that only Xanax made her feel good. (Id. at 510.) Throughout this time, Dr. Alexander marked categories on the “mental status” form of his note showing that she was generally functioning in the normal range. (Id. at 509-14.)

         In late 2011 Vanprooyen switched to seeing Dr. Paul Carter for her psychiatric issues. From that time through April 2013 Dr. Carter noted that Vanprooyen reported anxiety, insomnia, and a poor attention span but checked boxes in the mental status portion of the form indicating generally normal responses. (Id. at 506-07, 509, 667-70, 673, 681.) Vanprooyen declined antidepressants but Dr. Carter prescribed her Xanax, Methadone, and Trazodone. (Id. at 506, 673.) In October 2012 Dr. Carter filled out a medical source statement in support of Vanprooyen's disability benefits applications in which he wrote that her “ability to maintain focus, mental organization and memory is impaired.” (Id. at 641.) Dr. Carter rated her abilities as fair or poor in every sub-category listed for understanding, remembering, and carrying out instructions, wrote that she needs assistance for organization and transportation, and stated that she has difficulty comprehending written language. (Id. at 642.) In response to the question, “what medical/clinical findings support this assessment, ” Dr. ...

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