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Bradley v. Colvin

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

October 11, 2016

RICKEY BRADLEY, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of the U.S. Social Security Administration, Defendant.

          MEMORANDUM OPINION AND ORDER [1]

          SIDNEY I. SCHENKIER Magistrate Judge.

         Plaintiff Rickey Bradley has filed a motion seeking reversal of the final decision of the Commissioner of Social Security ("Commissioner") denying his application for disability insurance benefits ("DIB") under Sections 216(i) and 223(d) of the Social Security Act (doc. # 9). The Commissioner has filed her own motion seeking affirmance of the decision denying benefits (doc. # 11). For the following reasons, Mr, Bradley's motion is denied and the Commissioner's motion is granted.

         I.

         Mr. Bradley applied for benefits on April 12, 2012, alleging he became disabled on November 26, 2011 due to the effects of a stroke and hypertension (R. 42, 52, 156-62). His date last insured is December 31, 2016 (R. 176). The application was denied initially on August 24, 2012, and upon reconsideration on December 5, 2012 (R. 42-70, 91-95, 98-101). Mr. Bradley, represented by counsel, appeared and testified before administrative law judge ("ALJ") Patrick Nagle on March 20, 2014 (R. 13-41). Vocational expert ("VE") Karen Schneider also testified (R. 31-39). On April 4, 2014, the ALJ issued a decision finding that Mr. Bradley was not disabled and denying his claim for benefits (R. 74-90). The Appeals Council denied Mr. Bradley's request for review on July 16, 2015, making the ALJ's decision the final decision of the Commissioner (R. 1-6). See Shauger v. Astrue, 675 F.3d 690, 695 (7th Cir. 2012).

         II.

         We begin with a summary of the administrative record. Part A reviews Mr. Bradley's medical history, Part B reviews the hearing testimony, and Part C summarizes the ALJ's opinion.

         A.

         Mr. Bradley was born on June 24, 1961 and was 52 years old at the time of the hearing (R. 178). Mr. Bradley completed high school and one year of college (R. 182). Mr. Bradley's past work includes working as a crane operator and a machine operator.

         On March 27, 2010, Mr. Bradley visited the emergency room at the University of Chicago Medical Center, complaining of acute onset left-sided weakness (R. 281). Mr. Bradley's symptoms included focal weakness, loss of sensation, loss of balance, and speech change (R. 279). The emergency room physician diagnosed Mr. Bradley with a "likely stroke" (R, 280). During his hospitalization, Mr. Bradley was put on prescription medications for uncontrolled hypertension (R. 268). On April 5, 2010, while Mr. Bradley was still in the hospital, a lower extremity Doppler examination was performed which showed an acute deep vein thrombosis ("DVT") (R. 351, 353). An inferior vena cava ("IVC") filter was placed on April 5, 2010 (R. 351).

         On April 6, 2010, Mr. Bradley was transferred to Schwab Rehabilitation Hospital ("Schwab") for comprehensive rehabilitation, including physical therapy, occupational therapy, speech therapy, and psychological counseling (R 268). On April 11, 2010, Mr. Bradley was transferred to Mercy Hospital for further workup due to acute renal failure (R. 348). Mr. Bradley's renal function improved with IV hydration (Id.). On April 14, 2010, a bilateral DVT was found (R. 345). Mr. Bradley underwent a thrombectomy and thrombolysis on April 26 and 27, 2010 at the University of Chicago Medical Center (Id.). Because of his history of DVTs and clotting around the IVC filter, Mr. Bradley was placed on life-long anticoagulation therapy (R. 645). On April 30, 2010, Mr. Bradley was transferred back to Schwab and was finally discharged to return home on May 21, 2010 (R. 343).

         Between July 12, 2010 and October 4, 2012, Mr. Bradley visited internist Angela Weingarten. M.D. and her colleagues at the University of Chicago Medical Center's Primary Care Group Clinic, including Dr. Catherine Glunz, thirteen times for follow-ups on his multiple medical problems, including history of stroke, hypertension, extensive DVTs, and hyperlipidemia (R. 295-301, 319-27, 330-35, 642-48, 656-659). On July 12, 2010, Mr. Bradley saw Dr. Weingarten for the first time. Dr. Weingarten wrote that Mr. Bradley reported that he was doing well and was regaining his strength (R. 342). Mr. Bradley had no specific complaints (Id.). Dr. Weingarten noted that Mr. Bradley required a cane to walk (R. 343). Mr. Bradley's sensation on the left was slightly decreased as compared to the right, and his upper extremity had slightly decreased sensation compared to his left lower extremity (Id.). Mr. Bradley's strength was also slightly decreased on the left as compared to the right in both upper and lower extremities (Id.). Dr. Weingarten was concerned about Mr. Bradley's blood pressure and doubled his blood pressure medication dosage (R. 343-44). Dr. Weingarten directed Mr. Bradley to follow-up in one month to confirm that his hypertension was under control (R. 344).

         On August 6, 2010, during a follow-up visit with Dr. Gioia Herring at Schwab, Mr. Bradley reported that he had been doing fairly well since his discharge from his inpatient rehabilitation stay (R. 272). Mr. Bradley also stated that he completed his outpatient therapies, including physical therapy, occupational therapy, and speech therapy (Id.). Mr. Bradley was ambulating with a cane (Id.). Dr. Herring noted that Mr. Bradley's primary care physician, Dr. Benitez, released him to return to work on September 1, 2010 at a reduced schedule with work restrictions (Id.). A manual muscle test of Mr. Bradley's upper extremities revealed essentially 5/5 strength except for his hand grasp on the left side which was -5 (R. 273). A manual muscle test of the lower extremities revealed strength to be 5/5 on the right lower extremity and -5/5 on the left (Id.). Mr. Bradley's ambulation with an assistive device showed a decreased heel-to-toe gait pattern and decreased knee flexion with his gait (Id.). Dr. Herring determined that Mr. Bradley was doing fairly well and directed him to follow-up in six months for a recheck (Id. at 273).

         On August 26, 2010, Mr. Bradley visited Dr. Kenneth J. Lee at the University of Chicago Medical Center's Neurology Clinic (R. 335-38). Dr. Lee noted that Mr. Bradley was doing very well since his discharge from rehabilitation (R. 336). Dr. Lee wrote that Mr. Bradley had very good mobility, used a cane sporadically, and had been able to use his left arm very well (Id.). Upon examination, Mr. Bradley had 5/5 strength in the right upper and lower extremities (R. 337). On the left side, Mr. Bradley had a mild pronator drift on the upper extremity but was 5/5 strength in the deltoids and triceps and 5-/5 in the biceps, wrist extensor, and wrist flexors (Id.). On the left lower extremities, Mr. Bradley had 5/5 strength in the hip extensor, hip flexors, dorsiflexors, and the plantar flexores and 5-/5 in the knee extensor and knee flexores (Id.). Mr. Bradley had a mildly unsteady and a slightly spastic gait with increased spasticity on the left side (R. 337). Mr. Bradley was able to do plantar flexion (Id.). Dr. Lee prescribed Tizanidine 2 mg as needed for Mr. Bradley's spasticity (Id.).

         At his third visit with Dr. Weingarten on September 8, 2010, Mr. Bradley had 5/5 strength on his right side and 4/5 strength in his left upper and lower extremities (R. 334). Dr. Weingarten referred Mr. Bradley for a physical therapy evaluation and treatment for his increased spasticity (Id.). At his next appointment with Dr. Weingarten on October 19, 2010, Mr. Bradley reported that he was feeling much better and his arm was less stiff and uncomfortable since he began physical therapy (R. 330-31). Dr. Weingarten noted that she wrote a letter to Mr. Bradley's employer explaining that he was unable to lift weight above five to seven pounds and was unable to stand for extended periods of time without sitting (R. 331).

         On January 6, 2011, Mr. Bradley returned to the University of Chicago Medical Center's Neurology Clinic for a follow-up appointment with Dr. Lee (R. 327-30), Dr. Lee noted that since Mr. Bradley's last visit in August 2010, he had been doing very well (R. 327). Mr. Bradley reported that he was on Tizanidine 2 mg and doing exercises at home (Id.). As a result, the spasticity and throbbing pain in Mr. Bradley's left arm and leg had improved greatly (Id.). Mr. Bradley had 5/5 strength in the right upper and lower extremities (R. 328). He had approximately 5-/5 strength in his left upper and lower extremities (Id.). Mr. Bradley had a spastic stance as well as a spastic gait (Id.). Dr. Lee directed Mr. Bradley to continue to exercise and take Tizanidine as needed (R. 329). Dr. Lee noted that Mr. Bradley was doing well neurologically and did not need to schedule another neurology clinic visit (Id.).

         At his February 15, 2011 appointment with Dr. Weingarten, Mr. Bradley reported that he was not back to his baseline from before his stroke, but his spasticity was not bothering him nearly as much and he was doing better (R. 325). Dr. Weingarten wrote that she was not comfortable releasing Mr. Bradley to return to work without a functional capacity test (Id.). On March 14, 2011, Mr. Bradley visited with Dr. Weingarten and reported that he completed his functional capacity testing and planned to return to work on March 16, 2011 (R. 322). Mr. Bradley reported that his weakness and spasticity had improved (R. 323). Mr. Bradley was given a return to work note (R. 324).

         On July 1, 2011, Mr. Bradley returned to Dr. Weingarten and reported a burning sensation in his left hand and foot (R. 320). Mr. Bradley stated that the pain was "really bothering him while at work" (Id.). Dr. Weingarten prescribed Gabapentin 100 mg 3 times daily for his paresthesias (R. 321). Dr. Weingarten also gave Mr. Bradley a referral for further workup due to his persistent hypertension (Id.).

         On August 16, 2011, Mr. Bradley saw Colleen Flynn, M.D. at the University of Chicago Medical Center's Endocrinology Center for a hypertension consultation at Dr. Weingarten's request (R. 317-19). Mr. Bradley reported that he had been on medications for his hypertension for approximately five years, but his blood pressure has never been well controlled (R. 318). Mr. Bradley stated that he experienced left leg swelling at the end of his workday (Id.). Dr. Flynn noted that Mr. Bradley had a gait with a slight limp favoring his left leg and 5/5 strength on both sides upper and lower extremities (R. 318-19). Regarding Mr. Bradley's high blood pressure, Dr. Flynn added chlorthalidone 25 mg daily, nifedipine 120 mg XL every evening, bisoprolol 20 mg every evening, and Edarbi 80 mg daily and stopped his hydralazine, amlodipine and metoprolol (R. 319). Mr. Bradley saw Dr. Flynn again on September 27, 2011 for hypertension management and she adjusted his high blood pressure medications (R. 315-17).

         On September 29, 2011, Mr. Bradley saw Jennifer McDonnell, M.D. at the University of Chicago Medical Center's Medicine and Pediatrics Clinic (R. 312-15). Mr. Bradley reported difficulty with his work conditions (R. 312-313). Mr. Bradley explained that he stood all day as he drove a silo and stacked cut metal bars which weighed approximately thirty to forty-five pounds (R. 313). Mr. Bradley stated that standing all day exacerbated his numbness and tingling and his left leg swelled by the end of the day (Id.). Mr. Bradley reported that he was independent in his activities of daily living and instrumental activities of daily living (R. 314).[2] Mr. Bradley had 5/5 strength in his right upper extremities and 4/5 strength in his left upper extremities (Id.). In his lower extremities, he had 5/5 strength on the right and 4/5 strength in his quadriceps and calf muscle on the left (Id.). Mr. Bradley's sensation was intact bilaterally but Mr. Bradley reported a subjective feeling of numbness in his arm and leg on the left side as well as a lot of tingling and burning (Id.). Dr. McDonnell concluded that Mr. Bradley's job was exacerbating his symptoms of neuropathy and leg swelling (R. 314). She stated that he would do better in a job where he was not on his feet all day and not lifting heaving objects (Id.). Dr. McDonnel added: "I think ideally it would be nice if the patient could retain ... a different job in the same company as the patient is still functional in his IADLs and ADLs and would be able to do other things, such as his old job of driving as a crane operator" (Id.).

         Mr. Bradley visited Dr. Lee on November 18, 2011 at the University of Chicago Medical Center's Neurology Clinic for new symptoms of head pressure (R. 301-04). Upon examination, Mr. Bradley had 5/5 strength in the right upper and lower extremity (R. 303). On the left upper extremity, Mr. Bradley had 5/-5 in his arm flexion as well as his wrist extension (Id.). Mr. Bradley had 5/5 strength in his left arm flexors (Id.). Mr. Bradley had increased tone in his left upper and lower extremities with some mild spasticity (Id.). Mr. Bradley had a mildly spastic gait but was able to ambulate without assistance (Id.). Dr. Lee wrote that Mr. Bradley's post-stroke symptoms had been stable and he was doing well in terms of his rehabilitation on his left side (R. 303). Dr. Lee was not concerned about Mr. Bradley's new symptoms of head pressure and recommended Tylenol and ice packs to relieve pressure (Id.).

         On December 19, 2011, Mr. Bradley reported to Dr. Weingarten that he did not think he could continue performing such a physically demanding job at his employer (R. 299). Mr. Bradley stated that he was working in the "shop" and he was required to stand all day and lift heavy loads (Id.). He said that after work he was in an incredible amount of pain and had left lower extremity swelling (Id.). Dr. Weingarten wrote a letter to Mr. Bradley's employer requesting accommodations (R. 299-300). By his next appointment on January 10, 2012, Mr. Bradley had stopped working and was receiving temporary disability (R. 297-98). Mr. Bradley reported that his left arm pain had gotten a little better since he stopped working, but had not completely subsided (Id.). At his March 6, 2012 appointment with Dr. Weingarten, Mr. Bradley stated that he still had neuropathic pain and numbness and tingling in his left hand and foot, but he felt better than when he was working (R. 295). At his May 22, 2012 appointment, Dr. Weingarten noted that Mr. Bradley's blood pressure continued to be elevated and she deferred to Dr. Bakris in the Endocrinology Clinic for the best way to manage Mr. Bradley's blood pressure (R. 658). Dr. Weingarten noted that Mr. Bradley's cholesterol levels had improved and he was close to reaching his target for a reduced cholesterol level (R. 658-59).

         Mr. Bradley returned to the University of Chicago Medical Center's Endocrinology Clinic for a hypertension management follow-up appointment on April 19, 2012 (R. 290-91). Mr. Bradley reported that he was measuring his blood pressure at home using a wrist cuff, watching the sodium in his diet, and exercising by weight lifting (R. 290). Mr. Bradley stated that his morning blood pressure range was between 160-180/95 and that he used less than 20 pounds of upper body weights (Id.). On physical examination, Mr. Bradley's blood pressure sitting was 102/70 with a pulse of 68 and standing was 120/60 with a pulse of 60 (Id.). Dr. Flynn noted that Mr. Bradley's goal blood pressure was less than 130/80 with a resting heart rate of less than 80 (R. 290-91). Dr. Flynn directed Mr. Bradley to continue his bisoprolol 20 mg and chlorthalidone 25 mg every morning, add amilordie 10 mg every morning and nifedipine XL 90 mg in the evening, continue his low-sodium diet, get adequate sleep, get a new blood pressure machine with an arm cuff, check his blood pressure in the morning before taking his medication, and follow up with his primary care doctor (R. 291).

         On May 10, 2012, Mr. Bradley visited Dr. Weingarten for a hypertension follow-up exam (R. 291-94). Mr. Bradley reported that his blood pressure at home had been running in the 120s/80s and he continued to be active and watch his salt intake (R. 292). Dr. Weingarten noted that Mr. Bradley continued to complain of numbness, pain, and weakness (Id.). Mr. Bradley also reported that he continued to have burning neuropathy in his hands and feet on the left side of his body as well as weakness and spasticity on that side (R. 293). Mr. Bradley stated that he was not taking his Gabapentin even though it was recommended at his last appointment that he increase his Gabapentin to three times a day for paresthesia (R. 292). Mr. Bradley stated that instead he "just deals with the pain" (Id.). Upon examination, Mr. Bradley's blood pressure was 140/85 and his pulse was 80 (R. 293). Dr. Weingarten observed that Mr. Bradley had numbness on the left side of his face with a slight facial droop on that side (Id.). Mr. Bradley's blood pressure was elevated (R. 293). Dr. Weingarten noted Mr. Bradley's follow-up appointment with Dr. Bakris on April 17, 2012 and deferred to him on the best way to manage Mr. Bradley's blood pressure (Id.).

         On June 7, 2012, Mr. Bradley and his fiancee, Charlene Golden, completed a function report for the Bureau of Disability Determination Services ("DDS") (R. 189-97). Mr. Bradley reported left-sided weakness since his stroke (R. 189). Mr. Bradley described his daily activities as getting up, bathing, getting help with breakfast, exercising, laying down, getting back up, getting ready for dinner, watching TV, and going to bed (R. 190). Mr. Bradley reported no problem with personal care except he cannot button his shirt, washes with one hand, and sits down to wash his feet (Id.). Mr. Bradley wrote that he can do laundry but cannot iron, do household repairs, or mow the lawn (R. 191). He stated that he goes outside two to three times a week and does not drive because of left-side weakness (R. 192). Mr, Bradley shops for food and personal items once a month and goes to the doctor once or twice a week (R. at 192-93). Mr. Bradley wrote that he can walk two or three blocks before having to stop and rest a few minutes, can sit for two hours without having to get up to stand or walk, needs to take a rest period during the day, has difficulty reaching overhead or above waist level on his left side, and does not handle stress or change in routine well (R. 194-95, 198-99). Mr. Bradley reported that he has used a cane, brace, and splint on a daily basis since his stroke (R. 195).

         On August 8, 2012, Dr. Rochelle Hawkins conducted a consultative examination of Mr. Bradley for DDS (R. 666-74). Mr. Bradley described left sided weakness and paresthesia and a burning sensation in his left arm and bottom of his foot since his stroke (R. 666). Mr. Bradley stated that he was unable to exercise much because of pain (Id.). Dr. Hawkins noted that there was no limitation of motion of shoulder, elbow, or wrist joints (R. 667). Mr. Bradley's fist and grip strength was 5/5 on the right and 4/5 on the left (R. 667-68). Mr. Bradley was able to perform manipulations with either hand without difficulty (R. 668). Mr. Bradley had muscle strength of 5/5 on the right and 4/5 on the left in his upper and lower extremities (Id.). A straight leg raising test was accomplished on the right and was 90 degrees on the left (Id.). There was normal sensation to pin prick and touch over both arms and legs but Mr. Bradley complained of burning sensation in his left hand and foot (Id.). Dr. Hawkins noted that Mr. Bradley walked with a limp favoring his left side (Id.). Mr. Bradley had a cane but was able to walk 50 feet without it (Id.). Mr. Bradley had mild difficulty walking on his toes and heels and squatting and arising and moderate difficulty hopping on one leg (Id.). Dr. Hawkins concluded that Mr. Bradley could sit, speak, or hear without difficulty but has "some difficulty in prolonged standing, walking, lifting and carrying due to left sided weakness and burning sensation in left hand and food" (R. 669).

         On August 23, 2012, Dr. Charles Wabner completed a physical Residual Functional Capacity ("RFC") assessment of Mr. Bradley (R. 46-48). Dr. Wabner opined that Mr. Bradley could occasionally lift and carry 20 pounds and frequently lift and carry 10 pounds; stand, walk and/or sit for a total of six hours in an eight-hour workday; push and/or pull unlimited; occasionally climb ramps or stairs, balance, stoop, kneel, crouch, or crawl; never climb ladders, ropes, or scaffolds; should avoid moderate exposure to extreme cold and heat; and should avoid concentrated exposure to hazardous machinery (Id.). Dr. Calixto F. Aquino, Jr. affirmed Dr. Wabner's ...


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