United States District Court, C.D. Illinois, Springfield Division
JERRY L. EALEY, SR., Plaintiff,
CAROLYN W. COLVIN, Commissioner, Social Security Administration, Defendant.
MYERSCOUGH, UNITED STATES DISTRICT JUDGE
before this Court are cross-motions for summary judgment (d/e
15, 19), the Report and Recommendation of United States
Magistrate Judge Tom Schanzle-Haskins (d/e 23), and
Plaintiff's Objections to the Report and Recommendation
careful review of the record and the pleadings, the Court
OVERRULES the Plaintiff's Objections because the
ALJ's decision is supported by substantial evidence.
Accordingly, the Court ACCEPTS and ADOPTS the Report and
Recommendation (d/e 16). The Commissioner's Motion for
Summary Affirmance (d/e 19) is GRANTED. The Plaintiff's
Motion for Summary Judgment (d/e 15) is DENIED. This decision
of the Commissioner is AFFIRMED.
Jerry L. Ealey, Sr. was born on May 18, 1959. He has a high
school education and previously worked as a plant operator.
Plaintiff alleges that he became disabled on December 1,
2011. R. 14, 58-60, 67. He suffers from diabetes, obesity,
degenerative disc disease, status post cervical spine
surgery, and depression. R. 16-17.
January 31, 2011, Plaintiff saw orthopedic surgeon Dr.
Stephen Pineda because of pain in Plaintiff's neck and
shoulders. An MRI reviewed by Dr. Pineda showed that
Plaintiff had degenerative changes in his cervical spine at
¶ 4-5, C5-6, C6-7, and to a lesser degree C3-4. Dr.
Pineda stated that these changes had caused spinal stenosis.
Dr. Pineda recommended surgery, but Plaintiff did not undergo
the surgery at that time. R. 384.
February 7, 2011, Plaintiff saw chiropractor Dr. John L.
Kain, complaining of neck and arm pain, his left hand going
to sleep, headaches, and trouble lifting his right arm. Dr.
Kain found that Plaintiff's range of motion in the
cervical, thoracic, and lumbar spine was moderately
restricted by pain. Dr. Kain also noted moderate spasm and
tenderness on palpitation of the cervical and thoracic spine.
A leg drop test was positive for lower back pain, and a
foraminal compression test was positive for neck pain.
However, strength in all extremities was 5/5. Dr. Kain
assessed cervicobrachial syndrome with myospasm and lumbar
facet syndrome. Dr. Kain also stated that a June 25, 2010 MRI
showed severe spinal stenosis with cord compression at ¶
4-5-6-7. R. 406. Plaintiff saw Dr. Kain again on August 12,
2011. Dr. Kain confirmed his prior assessments but added that
straight leg tests were negative. R. 408.
November 7, 2011, Plaintiff saw Dr. David Hoelzer for an
endocrine follow-up. Dr. Hoelzer stated that Plaintiff had
diabetic peripheral neuropathy and diabetic retinopathy.
Plaintiff reported stable numbness in his feet and toes and
stable vision. Dr. Hoelzer assessed Type 2 diabetes with
slowly improving control. Dr. Hoelzer continued
Plaintiff's insulin medication, discussed diet and
exercise with Plaintiff, and advised Plaintiff to report the
results of his home glucose readings. R. 360-62.
same date, Plaintiff saw Dr. Pineda, complaining of neck and
shoulder pain. Dr. Pineda stated that an EMG study was
descriptive of right radiculopathy and right carpal tunnel
syndrome. Plaintiff denied numbness issues and, upon
examination, Dr. Pineda found that Plaintiff's
“deltoid, biceps, triceps, wrist flexors and extensors,
finger flexors and extensors, and everything fires
well.” R. 364. Dr. Pineda found that Plaintiff did not
require immediate surgery.
January 25, 2012, Plaintiff saw his primary care physician,
Dr. Dennis Yap, for a follow-up on an emergency room visit
for swelling in Plaintiff's leg. Plaintiff appeared
disheveled and in moderate pain. His Body Mass. Index was
35.7 and he walked with a left leg limp. Dr. Yap assessed
cellulitis of the left leg. Dr. Yap refilled Plaintiff's
prescription for clindamycin and advised Plaintiff to keep
his leg elevated, to wear thigh high compression stockings,
and to stop smoking. R. 428-29.
March 8, 2012, Plaintiff saw Dr. Hoelzer. Plaintiff reported
glucose readings in the mid to upper 100s and numbness in his
feet and toes but no significant pain. Plaintiff reported no
change in his diabetic retinopathy. Upon examination, Dr.
Hoelzer found a cyst in Plaintiff's skin over his left
Achilles tendon. However Plaintiff had no peripheral edema or
lesions. Plaintiff had mildly diminished sensation in his
toes. Plaintiff's A1c reading of his blood glucose level
was 7.8%. Dr. Hoelzer noted that the reading had slowly
decreased over time. Dr. Hoelzer assessed Type 2 diabetes
mellitus with gradually improving control. R. 357-59.
April 3, 2012, Plaintiff had an MRI of his left ankle. The
MRI showed marked advanced diffuse tendinopathy and swelling
in the left Achilles tendon, as well as a partial tear in the
posterior fibers of the tendon. R. 401-02.
April 10, 2012, Plaintiff saw podiatrist Dr. Timothy Graham,
for a follow-up on his ankle. Plaintiff reported a pain level
of 5/10. Dr. Graham noted mild decrease in range of motion of
the left ankle and prescribed a walking boot to be used
whenever Plaintiff walked. R. 613-14.
20, 2012, Plaintiff saw Dr. Yap for vertigo. Dr. Yap found
mild fatigue, dizziness, headaches, and vertigo. Dr. Yap
advised Plaintiff to control his sugar tightly and
recommended weight loss, a low-calorie diet, and daily
exercise. R. 436.
22, 2012, Plaintiff saw Dr. Graham and reported no pain in
his left Achilles tendon. Dr. Graham found considerable
improvement but observed a mild decrease in range of motion.
28, 2012, state agency physician Dr. David Bitzer prepared a
Physical Residual Functional Capacity Assessment. Dr. Bitzer
opined that Plaintiff could: (1) occasionally lift twenty
pounds and frequently lift 10 pounds; (2) stand and/or walk
for six hours in an eight-hour workday and sit for more than
six hours in an eight-hour workday; and (3) frequently climb
ladders, ropes, and scaffolds. Dr. Bitzer found no other
functional limitations. R. 71-72.
12, 2012, Plaintiff saw Nurse Practitioner Pamela Brodt in
Dr. Hoelzer's office. Plaintiff reported not taking
insulin due to cost, missing most of his NovoLog doses
regardless of whether he had insulin, and blood sugar
readings in the 200s. Plaintiff's A1c was 11%. Brodt
stated that Plaintiff had peripheral neuropathy with
decreased sensation in both big toes but that Plaintiff had
no edema and retained movement in all extremities. Brodt
found decreased sensation to fine monofilament touch in both
big toes. Brodt also found that Plaintiff had a normal mood
and affect. Brodt assessed diabetes mellitus poorly
controlled and advised Plaintiff to report home glucose
readings. R. 491-93.
September 11, 2012, Plaintiff saw Dr. Hoelzer. Plaintiff had
not reported any blood sugar readings since his last visit,
but the readings in his monitor for the prior 60 days
averaged 161. Plaintiff reported a tendency toward
“easy fatigability.” Dr. Hoelzer assessed
peripheral neuropathy with chronic numbness in his feet and
toes, but he assessed no significant neuropathic pain or
focal weakness. On examination, Dr. Hoelzer found diminished
sensation in the toes. Dr. Hoelzer assessed poorly controlled
Type 2 diabetes mellitus. R. 488-90.
September 21, 2012, Plaintiff saw Dr. Yap for back pain and
depression. Plaintiff reported arthralgia, back pain, joint
stiffness, bilateral leg pain, myalgia, and depression with
feelings of sadness and stress but no difficulty
concentrating, no sleep disturbance, and no suicidal
thoughts. On examination, Dr. Yap found normal range of
motion, strength, and tone. Dr. Yap assessed depression,
neuropathic pain, and pitting edema. Dr. Yap prescribed
Prozac for the depression. R. 509-12.
October 5, 2012, Plaintiff saw Dr. Yap. Plaintiff's BMI
was 35.3. Plaintiff reported that his depression was getting
better. Dr. Yap found paresthesia in both lower extremities,
and pain with range of motion in Plaintiff's back. Dr.
Yap also found depression and sadness but no anxiety, sleep
disturbance, or suicidal thoughts. Dr. Yap continued
Plaintiff's Prozac prescription. R. 506-08.
November 12, 2012, Plaintiff saw state agency psychologist
Dr. Delores Trello for a mental status examination. Dr.
Trello found that Plaintiff had a normal affect; he was
oriented; and his immediate; recent; and remote memory was
intact. Plaintiff reported that he bathed himself, sometimes
cooked, did laundry, drove around town, and went grocery
shopping with his wife. Dr. Trello assessed depression,
anxious mood associated with chronic pain and medical
conditions, and adjustment disorder with depressed, anxious
mood. Dr. Trello assigned a Global Assessment of Functioning
(GAF) score of 50, indicating serious impairment in
vocational functioning. R. 534-37.
November 13, 2012, Plaintiff saw Dr. Kain. Plaintiff reported
lower back pain, bilateral buttock burning pain, and
stiffness. Dr. Kain assessed lumbar facet syndrome with
myospasm. R. 556.
November 24, 2012, state agency psychologist Dr. David Voss
prepared a Psychiatric Review Technique assessment of
Plaintiff. Dr. Voss opined that Plaintiff's mental
impairments caused mild restrictions on activity of daily
living, mild restrictions on social functioning, mild
difficulties in maintaining concentration, persistence, or
pace, and no repeated periods of decompensation. Dr. Voss
noted that the mental-status examination showed memory and
concentration within normal limits. As a result, Dr. Voss
opined that Plaintiff's mental impairments were
non-severe. R. 80-81.
November 27, 2012, state agency physician Calixto Aquino
prepared a Physical Residual Functional Capacity Assessment.
Dr. Aquino's opinion on Plaintiffs residual functional
capacity was identical to that of Dr. Bitzer's previous
assessment. R. 82-84.
December 14, 2012, Plaintiff underwent a cervical MRI ordered
by Dr. Pineda. Radiologist Dr. Joseph Baima found that
“osseous structures are normal in alignment and signal
characteristics. The cord is normal in position and signal
characteristics.” However, Dr. Baima stated that
Plaintiff had severe canal and bilateral foraminal stenosis
from C4-5 through C6-7 with moderate canal and severe
bilateral foraminal stenosis at ¶ 3-4. R. 703. On
December 17, 2012, based on the same MRI, Dr. Pineda found
multilevel cervical spondylosis with probable osteophyte disc
complex at ¶ 4-5-6-7. Dr. Pineda stated that there was
both anterior and posterior decompression. Plaintiff reported
some pain and burning into his upper extremity. Dr. Pineda
recommended surgery on Plaintiff's cervical spine and
ordered another x-ray. The x-ray showed mild to moderate disc
space narrowing at ¶ 4-5-6-7. R. 723.
January 4, 2013, Plaintiff saw Dr. Yap for a preoperative
examination. Plaintiff complained of back pain, joint
stiffness, myalgia, anxiety, depression, and sadness.
Plaintiff denied crying spells, feelings of stress, sleep
disturbance, or suicidal thoughts. R. 725. On examination,
Plaintiff's BMI was 35.1. Plaintiff had full range of
motion in his neck and normal range of motion in other
joints, normal strength, and normal tone. Plaintiff had
appropriate affect, normal speech, and grossly normal memory.
January 10, 2013, Dr. Pineda performed anterior surgery on
Plaintiff's cervical spine, and on January 31, 2012, Dr.
Pineda performed posterior surgery on Plaintiff's
cervical spine. R. 584, 684-87, 708. On February 18, 2013,
Plaintiff reported pain of 0/10 to Dr. Pineda. Dr. Pineda
removed Plaintiff's stitches and told Plaintiff to
“limit his lifting to 10 pounds or so.” R.
February 21, 2013, a cervical x-ray showed a posterior
cervical fusion from C3-4-5-6-7 without evidence of hardware