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Halun v. Colvin

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

August 30, 2016

LISA JOAN HALUN, Plaintiff,
v.
CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION AND ORDER

          Cole Magistrate Judge

         The plaintiff, Lisa Joan Halun, seeks review of the final decision of the Commissioner (“Commissioner”) of the Social Security Administration (“Agency”) denying her application for Disability Insurance Benefits under Title II of the Social Security Act (“Act”), 42 U.S.C. §§ 423(d)(2), and Supplemental Security Income (“SSI”) under Title XVI of the Act. 42 U.S.C. § 1382c(a)(3)(A). Ms. Halun asks the court to reverse and remand the Commissioner's decision, while the Commissioner seeks an order affirming the decision.

         I.

         BACKGROUND

         A.

         The Application Process

         Ms. Halun was born October 22, 1963 and was nearly 51 at the time of the ALJ's decision. (Administrative Record (“R.”) 199). She has a high school education (R. 244) and a long work history as a waitress, since she graduated from high school. (R. 245, 340). Her most recent full-time waitressing job ended in November or December of 2012 . (R. 243, 340). The job required her to be on her feet all day, walking for nearly the whole time, and she had to lift and carry as much as 50 pounds, and frequently carry 10 pounds. (R. 245). She claims that, due to pain in her foot, she could no longer keep up and she lost her job. (R. 41-42).

         Ms. Halun alleged that she became disabled December 12, 2012, (R. 14, 199). Her application for disability benefits was denied initially and upon reconsideration (R. 11-127), and Ms. Halun requested an administrative hearing before an Administrative Law Judge (“ALJ”). (R. 136-37). At that hearing, Ms. Halun testified and was represented by counsel, and a vocational expert, Amanda Ortman, also appeared and testified. (R. 28-68). Following the hearing, on August 26, 2014, the ALJ concluded that Ms. Halun was not disabled and not entitled to disability benefits because she remained capable of performing work that existed in significant numbers in the regional economy. (R. 9-27). That decision is now before the court for review. (R. 1-5); see 20 C.F.R. §§404.955; 404.981; 42 U.S.C. §405(g).

         B.

         The Medical Record

         The medical record in this case is sparse. Ms. Halun switched treating physicians in 2012, as her former doctor could not prescribe medication anymore. Her new doctor, Dr. Gupta, noted on April 18, 2012, that she suffered from RSD affecting her right foot. Her coordination was slow and there was swelling in her foot. She noted that, at 5'3" tall, she weighed 168 pounds. She said she had been walking a lot, working double shifts at Dave and Buster's. She filled her prescription for Norco, an opioid pain killer, and Soma, a muscle relaxant, and Ativan, an anxiety disorder medication. (R. 33).

         In September of 2012, Ms. Halun saw Dr. Gupta again, with the same complaints, but added that her back was hurting as well. She was still working at Dave and Buster's, but was looking for less strenuous work. At that time, she was taking Norco, Norvasc (blood pressure medication), Soma, Triamterene (diuretic), and Xanax (anxiety disorder). Muscle strength in her right foot was weak and sensation was decreased. (R. 331). She walked with a limp. Dr. Gupta added Cymbalta (anti-depressant) to her medication regimen. (R. 332).

         Ms. Halun returned in December. She had been terminated from her job for “too much time off and moved away.” Consequently, she had lost her insurance. Her leg pain was unchanged, and was worse with activity. (R. 328). Dr. Gupta again found weakness in her right foot. She stopped the prescription for Cymbalta and added Elavil (anti-depressant). (R. 329).

         In May 2013, Ms. Halun reported that she had weakness and pain in her left leg, but that her mood was stable on medication. She wasn't engaging in any physical activity. (R. 365). Examination revealed left leg weakness and decreased sensation. Her weight was 183 pounds. (R. 366). In September, Ms. Halun reported that she had been in California in the summer and was able to exercise in a pool. She had been doing well on her pain medications. (R. 363). Sensation in arms and legs was normal, and strength was normal in her left leg. (R. 364).

         In March 2014, Dr. Gupta reported that when she had seen Ms. Halun in May 2013, she was having problems with gait and balance, and her medications caused dizziness and sedation at times. Based on Ms. Halun's pain levels and medication side effect, Dr. Gupta thought she could not sit for more than 4 or 5 hours at a time, and could walk no more than 1 to 2 hours. (R. 368).

         The state disability agency set up a consultative physical examination for Ms. Halun with Dr. Mutena Korman in February 2013. (R. 345). Examination revealed weakness - 3/5 - in the right leg, as well as sensory loss. (R. 347). Range of motion was limited throughout the right leg - hips, knees, and ankle. (R. 348). Ms. Halun had an unsteady gait and had difficulty getting up out of a chair and getting on and off the examination table. She could not stoop or squat and could not heel/toe walk. (R. 347). Dr. Korman said he did not have sufficient medical documentation to confirm a diagnosis of RSD, and that Ms. Halun might benefit from a neurological workup. He said her symptoms may be psychosomatic and she might also benefit from psychological treatment. (R. 347).

         Ms. Halun Also had a consultative psychological examination with Psychologist Victor Rini in February 2013. Dr. Rini reported that Ms. Halun was tearful and depressed. Her judgment and memory were somewhat impaired. (R. 341). He thought she was functioning at the low average range of intellectual ability, that her memory and concentration were in the low average range, and her social functioning was below average. He diagnosed chronic depression and assigned a GAF score of 59. (R. 341).

         Dr. Dobson reviewed the medical evidence on behalf of the disability agency on March 27, 2013. He determined that she could lift/carry 20 pounds occasionally and 10 pounds frequently. (R. 104). She could stand or walk for just 2 hours total every day, and sit for about 6 hours. She had a number of postural limitations: she could never climb ladders, ropes, or scaffolds; she could occasionally climb ramps or stairs; she could occasionally balance, stoop, kneel, crouch, or crawl. (R. 105). She was limited to sedentary work. (R. 107).

         In May 2013, Ms. Halun reported that she had weakness and pain in her left leg, but that her mood was stable on medication. She wasn't engaging in any physical activity. (R. 365). Examination revealed left leg weakness and decreased sensation. Her weight was 183 pounds. (R. 366). In September, Ms. Halun reported that she had been in California in the summer and was able to exercise in a pool. She had been doing well on her pain medications. (R. 363). Sensation in arms and legs was normal, and strength was normal in her left leg. (R. 364).

         In May 2013, Dr. Gupta reported that Ms. Halun suffered from pain and weakness in her lower extremities, as well as low back pain. These symptoms were often serious enough to interfere with her concentration. Side effects from her medication included dizziness and sedation. Dr. Gupta opined that Ms. Halun could sit for 4-5 hours in a workday, stand for 1-2 hours, and walk for 1-2 hours. (R. 360). The following May, May 2014, Dr. Gupta reported that when she had seen Ms. Halun in May 2013, she was having problems with gait and balance, and her medications caused dizziness and sedation at times. He explained that his estimation of her physical capacity was not based on a physical therapy evaluation, but on Ms. Halun's pain levels and medication side effects at the time. (R. 368).

         C.

         The ...


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