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Hernandez v. Colvin

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

September 7, 2016

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


          MICHAEL T. MASON, United States Magistrate Judge

         Claimant 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.

         I. BACKGROUND

         A. Procedural History

         Claimant 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. § 636(c).

         B. Medical Evidence

         1. Treating Physicians

         The 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.)

         It 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.)

         By 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.)

         At some 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 MTX. (Id.)

         On 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.)

         Claimant 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.)

         A 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.)

         Claimant 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.)

         Claimant reported minor forearm pain to Dr. Hirsen on February 1, 2013. (R. 376.) A bone density test performed on ...

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