United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
MICHAEL T. MASON, United States Magistrate Judge
Teresa Hernandez ("Claimant") has brought a motion
for summary judgment (Dkt. 10) seeking judicial review of the
final decision of the Commissioner of Social Security (the
"Commissioner"). The Commissioner denied
Claimant's request for Disability Insurance Benefits
("DIB") under the Social Security Act, 42 U.S.C.
§§416(i) & 423(d). The Commissioner has
responded to the motion (Dkt. 19), asking the Court to uphold
the decision of the Administrative Law Judge (the
"ALJ"). This Court has jurisdiction to hear this
case pursuant to 42 U.S.C. § 405(g). For the reasons set
forth below, Claimant's motion for summary judgment is
denied and the Commissioner's request for summary
judgment is granted.
filed her application for DIB on September 23, 2011, alleging
disability beginning July 11, 2011 due to lupus and related
fatigue. (R. 165, 196-97.) Her claim was denied initially in
January 2012, and again upon reconsideration in July 2012.
(R. 158-65, 167-70.) Claimant filed a timely request for a
hearing. (R. 172-73.) On June 19, 2013, Claimant appeared
with counsel and testified at a hearing before ALJ Robert
Senander. (R. 126-51.) A vocational expert also provided
testimony. On November 14, 2013, the ALJ issued a written
decision denying Claimant's application for benefits. (R.
25-31.) Claimant submitted a timely request for a review by
the Appeals Council, which was denied on February 26, 2015.
(R. 1-8, 17.) At that point, the ALJ's decision became
the final decision of the Commissioner. Zurawski v.
Halter, 245 F.3d 881, 883 (7th Cir. 2001). Claimant
filed this action and the parties consented to the
jurisdiction of this Court pursuant to 28 U.S.C. §
medical records indicate that Claimant was diagnosed with
systemic lupus erythematous ("SLE") and lupus
nephritis (or inflammation of the kidneys) as early as 2007.
(R. 294, 315.) Records from Loyola Family Practice Center
reveal that Claimant was experiencing high levels of protein
in her urine (or proteinuria) in March 2010 and was taking a
higher dose of prednisone (20 mg) as a result. (R. 294, 298.)
The increased prednisone led to poor sleep and constant
fatigue. (R. 293.) It was noted that past treatment with
mycophenolate mofetil ("MMF") was not successful.
(R. 294.) By April 20, 2010, Claimant's levels and
symptoms had resolved, and her doctors planned to taper her
prednisone dosage back to 5 mg. (Id.) Her blood
pressure was well-controlled with lisiniprol. (Id.)
appears Claimant was primarily treated by rheumatologist Dr.
Daniel Hirsen at DJH Rheumatology, whose treatment records
date back to June 2010. (R. 314.) By that point, Claimant was
taking only 10 mg of prednisone and Dr. Hirsen commented on
the recent flare up. (Id.) Her muscles were noted as
strong the next month, though she complained of occasional
myalgia (or muscle pain) and recent chest pain. (R. 313.)
March 2011, Claimant's prednisone dosage had been tapered
back down to 5 mg. (R. 311.) She continued to complain of
some muscle pain and fatigue at her next few visits. (R.
309-10.) She reported her fatigue had increased in July 2011,
and she was still experiencing widespread muscle pain. (R.
308.) Tenderness in her hands was also noted. (Id.)
It appears she was also started on methotrexate
("MTX"). (Id.) Her pain had not improved
the following month. (R. 307.)
point it appears that Dr. Hirsen referred claimant to
Nephrology Associates for assessment. (R. 313.) There, Dr.
Matthew Andersen described claimant's proteinuria as
moderate in severity, but stable as of September 12, 2011.
(R. 365.) At that visit, Claimant complained of occasional
numbness in her face for the previous month and
"debilitating fatigue." (Id.) Dr. Andersen
noted that Claimant seemed to be doing well based on lab
reports, but that she was reporting a number of symptoms
likely related to her SLE. (R. 366.) Dr. Andersen was hopeful
that over time she would see more relief from her plaquenil
(or hydroxychloroquine) medication, and he continued her on 5
mg of prednisone and lisinopril. (Id.) A few days
later, Claimant complained to Dr. Hirsen that she was tired
from the MTX, so he decreased her dosage. (R. 306.) Her
muscles were again noted as strong. (Id.) On October
25, 2011, Claimant reported she was still tired, but not in
pain (R. 305.) Dr. Hirsen discontinued her prescription for
January 27, 2012, Claimant complained to Dr. Hirsen that her
muscle pain had increased since she stopped taking MTX. (R.
351.) She was experiencing minor joint pain the following
month. (R. 350.) By early April 2012, Claimant had been
started on MMF again and was doing "fairly well"
according to notes from Dr. Andersen (R. 367.) Her lab
reports showed progress, and she was ordered to continue
taking lisinopril, MMF, and prednisone. (R. 368.) Around that
same time, Claimant told Dr. Hirsen that her joint and muscle
pain were better, and that she was only experiencing some
dizziness as a side effect of one of her medications. (R.
349.) She reported neck pain in June 2012 and minor pain in
her forearms in mid-September 2012. (R. 363-64.)
presented to the ER at MacNeal Hospital on September 25,
2012, complaining of a headache and neck pain. (R. 382.) She
admitted to sleeping in an uncomfortable position the
previous night, but also reported band-like headaches and
recent life stressors. (Id.) She explained that she
was feeling chronically weak and fatigued. (Id.) She
denied dizziness at the time, but otherwise reported some
dizziness upon sudden head movements. (Id.)
physical exam revealed unremarkable results, apart from some
tenderness to palpation in the neck region. (R. 383.) A CT
scan was essentially normal. (R. 379, 389.) Claimant was
diagnosed with a cervical sprain or strain, and was
discharged the same day with directions to take hydrocodone
and ibuprofen as needed. (R. 379-80.)
returned to see Dr. Andersen on November 2, 2012. (R. 374.)
She was no longer taking MMF and was feeling "well
overall, " but "tired rather often."
(Id.) Her creatinine level was stable, though her
labs were showing some proteinuria. (Id.) Dr.
Andersen noted, however, that her proteinuria had improved
overall from a few years prior. (Id.) He considered
increasing her lisiniprol, but was concerned it may cause
additional fatigue. (Id.) She was directed to
continue on the same medication regime and to follow-up in
six months. (R. 374-75.)
reported minor forearm pain to Dr. Hirsen on February 1,
2013. (R. 376.) A bone density test performed on ...