United States District Court, N.D. Illinois, Eastern Division
RUBEN D. REYES, Plaintiff,
CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER
plaintiff, Ruben D. Reyes, seeks review of the final decision
of the Commissioner of the Social Security Administration
denying his application for Disability Insurance Benefits
under Title II of the Social Security Act, 42 U.S.C. §
423(d)(2). Mr. Reyes asks the court to reverse and remand the
Commissioner's decision, while the Commissioner seeks an
order affirming the decision in his motion for summary
Reyes applied for Disability Insurance Benefits on April 9,
2013, alleging that he had been disabled since March 22,
2013, when he was shot in the right shoulder by an unknown
shooter (R. 55-56). His claim was denied initially and on
reconsideration (R. 55, 63). Mr. Reyes filed a written
request for a hearing on February 3, 2014 (R. 86).
convened a hearing on June 27, 2014, at which Mr. Reyes
waived his right to representation by counsel (R. 39, 41-42).
After some brief questioning, the ALJ continued the hearing
to request further medical records. (R. 52-53). At the second
hearing on April 7, 2015, Mr. Reyes appeared and testified
and was represented by counsel (R. 1090). Dr. Ashok G.
Jilhewar, MD, testified as the medical expert, Dr. Allen
Heinemann, PhD, testified as the psychological expert, and
Lee O. Knutson testified as the Vocational Expert
(“VE”) (R. 1092).
15, 2015, the ALJ found that Mr. Reyes was not disabled and
denied his application for Disability Insurance Benefits
because, although Mr. Reyes could no longer perform his past
medium work, he could still perform a limited range of light
work (R. 9-38). The ALJ's decision became the
Commissioner's final decision on September 4, 2015, when
the Appeals Council denied Mr. Reyes' request for review
(R. 1-6). See 20 C.F.R. §§ 404.955. Mr. Reyes
appealed the decision to the United States District Court for
the Northern District of Illinois under 42 U.S.C. §
405(g), claiming that the ALJ improperly evaluated his
credibility and rejected the opinions of his treating and
Reyes was born on June 6, 1975, making him 37 years old when
he filed his application (R. 30). He has at least a high
school equivalent education and can communicate in English
(R. 30). According to his Work History Report, Mr. Reyes was
a tow truck driver for Shell Gas Station from July 2002 to
May 2003 (R. 169). He was then a self-employed mechanic from
2006 to 2007 (R. 169). Finally, he was an intern at Lygase
from July 2009 to December 2012 (R. 169). As a tow truck
driver, Mr. Reyes noted that he had to lift and carry
wheel-lift equipment, ranging from about twenty to
twenty-five pounds (R. 170). As a mechanic he replaced car
parts, lifting anywhere from twenty to fifty pounds (R. 171).
Finally, as an intern for Lygase he lifted and set-up
equipment, lifting less than ten pounds frequently and fifty
pounds occasionally (R. 172).
record is 1157 pages long and in no particular order. It is
not organized chronologically, and multiple pages of the
record are duplicated throughout.
March 22, 2013, Mr. Reyes was shot in his dominant, right
shoulder while riding in the backseat of a car (R. 275). As a
result of the accident, Mr. Reyes claims to suffer from both
physical and mental impairments. Following the accident, the
fire department took Mr. Reyes to the emergency department at
Advocate Lutheran General Hospital (R. 261). He was seen
immediately upon arrival (R. 261, 263, 264). He complained of
right shoulder pain (R. 264). The radiology was unremarkable
except for the bullet, and all of his vitals were stable (R.
266, 264). The doctor also found marijuana in his system (R.
296). He was discharged the same day, with no follow-up
instructions (R. 238).
April 9, 2013, Mr. Reyes returned to Advocate Lutheran
General Hospital, complaining of pain in his right shoulder
due to a fall (R. 236). Mr. Reyes' grip strength was
normal, and he had normal strength and range of motion in his
right wrist and hand, normal range of motion in his right
elbow with pain radiating to his right upper arm and
shoulder, and minimal range of motion in his right shoulder
due to pain (R. 237). Mr. Reyes cried from pain during this
exam (R. 237). The ultimate diagnosis was contusion of the
upper extremity (R. 237).
24, 2013, the Bureau of Disability Determination Services
arranged a Consultative Examination for Mr. Reyes with Dr.
Roopa Karri (R. 326). Dr. Karri spent forty- two minutes with
Mr. Reyes, reviewing his records and information (R. 325).
Dr. Karri found that his grip strength was 3/5 in both hands,
and that he had moderate difficulty squeezing the blood
pressure pump with his right hand (R. 327). His strength was
4/5 in his right upper limb (R. 327). However, he could
button, zip, tie shoelaces, make fists, and oppose fingers
(R. 327). During this examination, he could walk fifty feet
without support (R. 327). Dr. Karri reported no signs of
depression, agitation, irritability, or anxiety (R. 327).
September 16, 2013, Mr. Reyes returned to Advocate Lutheran
General Hospital, complaining of hand pain and numbness (R.
377). At this time, doctors attempted to remove the bullet
from Mr. Reyes' shoulder but were unsuccessful because
the bullet was located so close to nerve cells that a
neurosurgeon would have to remove it (R. 327).
Reyes began seeing Dr. Patel, his primary care doctor, on
November 14, 2013 (R. 394). At this time, Dr. Patel diagnosed
Mr. Reyes with anxiety and shoulder pain (R. 405). Mr. Reyes
continued to see Dr. Patel from November 2013 through May
2015 and repeatedly complained of pain to his right shoulder
(R. 404, 414-415, 422, 429, 434, 446, 951, 957, 962, 970,
973). On the whole, Mr. Reyes saw Dr. Patel monthly for two
years (R. 848).
March 27, 2015, after two years of treating Mr. Reyes on a
monthly basis, Dr. Patel completed a Physical Medical Source
Statement (R. 848). He diagnosed Mr. Reyes with anxiety and
chronic pain, noting that his symptoms were anxiety,
insomnia, and chronic, severe right shoulder pain (R. 848).
Dr. Patel opined that his physical conditions were affected
by his depression and anxiety (R. 849). He concluded that in
an eight-hour workday Mr. Reyes could stand and walk for less
than two hours, sit for about two hours, and never lift or
carry anything ten pounds or heavier (R. 850). He could only
sit or stand for an hour at a time before changing positions.
(R. 850). He could only rarely bend, crouch, squat, and climb
ladders and could occasionally twist and climb stairs (R.
850). He had “significant limitations” in
reaching, handling, and fingering (R. 850). He could use his
right hand 10% of the workday, his right fingers 40% of the
workday, and he could reach in front of his body 10% of the
day (R. 850). He was unable reach overhead with his right arm
(R. 850). Dr. Patel also estimated that Mr. Reyes would
likely be “off task” 10% of the day, and that he
was only capable of “low stress” work, likely
missing approximately one day per month (R. 851). Dr. Patel
noted that Mr. Reyes' right shoulder tests were normal
November 26, 2013, Mr. Reyes visited neurosurgeon, Dr. Shaun
O'Leary, for a treatment consultation (R. 510). Dr.
O'Leary reported that Mr. Reyes had some mild weakness
and pain in his right arm (R. 511). Dr. O'Leary found
that Mr. Reyes could move all of his extremities with 5/5
strength except the right upper extremity which was limited
by pain and only had 4 strength (R. 512). Dr. O'Leary
suggested the possibility that Mr. Reyes suffered from
Complex Regional Pain Syndrome (CRPS), which could require a
spinal cord stimulator to treat the pain (R. 512). Dr.
O'Leary also discussed the possibility of another surgery
to remove the bullet from Mr. Reyes' shoulder, warning
him that the pain might continue after the surgery (R. 512).
In the pre-operative report Dr. Seitz, a plastic surgeon who
assisted Dr. O'Leary with the surgery, admitted that
removing the bullet could worsen Mr. Reyes' pain (R.
29, 2014, Dr. Seitz and Dr. O'Leary removed the bullet
(R. 555, 559). After the surgery, Mr. Reyes continued to
complain to Dr. Patel of shoulder pain (R. 404, 414-15, 422,
429, 434, 446, 951, 957, 962, 970, 973).
September 30, 2014, Mr. Reyes attended a physical therapy
evaluation at Presence Holy Family (R. 1023). He appeared to
have decreased shoulder range of motion, decreased strength,
and pain in his right shoulder (R. 1025). Mr. Reyes was
supposed to begin physical therapy multiple times per week,
but there is no record of additional physical therapy
sessions (R. 1028-29).
Reyes met with an orthopedic surgeon, Dr. Nicholas Frisch, on
February 16, 2015, complaining of constant, significant pain
radiating from his shoulder to his elbow (R. 852, 854). He
also reported tingling in his right shoulder area (R. 854).
At this time both the X-Rays and the range of motion tests
were mostly normal (R. 854). Dr. Frisch speculated that much
of Mr. Reyes' pain could have come from trauma to his
trapezius muscle during his first unsuccessful surgery (R.
855). He also stated that he was “not extremely
optimistic” that further surgical intervention would
significantly improve Mr. Reyes' symptoms (R. 855).
October 22, 2013, Mr. Reyes returned to the emergency
department of Advocate Lutheran General Hospital, complaining
of depression and suicidal thoughts (R. 626). He was
diagnosed with anxiety and chronic shoulder pain (R. 626).
During his psychological assessment conducted on October 23,
2013, Mr. Reyes' heart was pounding heart, and he
experienced chest tightness, and suffered from the feeling of
impending doom (R. 837). The report also stated that he was
hyper-vigilant and hesitant to go to sleep at night (R. 837).
He reported that he slept poorly and frequently woke up
during the night due to nightmares about the shooting (R.
837). He was also noted to have exaggerated startle response
(R. 837). He was diagnosed with generalized anxiety disorder
and post-traumatic stress disorder (PTSD) (R. 646).
October 23, 2013, Mr. Reyes requested referrals for
outpatient therapists because he had just recently applied
for CountyCare Insurance (R. 645). He was directed to ask
Advocate Lutheran General Hospital for a referral (R. 645).
November 27, 2013, the Social Security Administration
arranged for Mr. Reyes to have a psychological consultative
examination with Dr. Norton B. Knopf (R. 384). Mr. Knopf
spent a total of 1.5 hours with Mr. Reyes before writing his
report (R. 384). During their time together, Mr. Reyes
complained of major anxiety and the existence of panic
attacks (R. 385). He did not cook or do chores and required
help from his family to conduct activities of daily living
(R. 387). He also reported experiencing trouble sleeping,
seeing dark shadows, and hearing sharp noises like gunshots
(R. 386-87). Finally, Mr. Reyes explained that he was trying
to see a psychiatrist but kept getting denied for insurance
reasons (R. 387).
Knopf observed overt signs of distress during the interview,
including tearfulness as Mr. Reyes described his lack of
returned calls from hospitals due to his medical insurance
situation (R. 385). He said that Mr. Reyes seemed scared and
nervous, and reported daily bouts of anxiety, although he did
not exhibit any signs of anxiety during the interview itself
(R. 385-86). Dr. Knopf noted that there were indications of
the presence of delusions, and Mr. Reyes admitted to having
compulsions and obsessive thoughts (R. 386). Dr. Knopf
concluded that Mr. Reyes was reliable during the interview
and seemed trustworthy (R. 388). Dr. Knopf's diagnostic
impressions were that Mr. Reyes suffered from generalized
anxiety disorder, major depressive disorder, PTSD, and
moderate cannabis use disorder (R. 389).
February 25, 2015 to March 31, 2015, Mr. Reyes had weekly
psychological assessments with Alyssa Naimon, a clinical
intern at Presence St. Mary's (R. 859). She observed that
he had a depressed mood, flat affect, and hypomanic speech
(R. 865). He reported frequent thoughts of suicide, lack of
friends, difficulty leaving the house, difficulty falling
asleep, observance of shadows resembling the reaper, the
frequent occurrence of angry outbursts at family members, and
hearing gunshots and occasional screams (R. 865-68). He told
her that he could barely remember what life was like before
he was shot (R. 868). Mr. Reyes reported feeling a lot of
anxiety when he went to the emergency room in October 2013
because the waiting area was crowded with what he believed to
be potentially dangerous people (R. 866). During a few of his
visits Mr. Reyes reported that he was too scared to attend a
wedding or take his son to the toy store for his birthday (R.
April 28, 2015, Dr. Ahmadi, a psychiatrist at Presence St.
Mary's hospital, completed a Mental Medical Source
Statement for Mr. Reyes (R. 1040). He diagnosed Mr. Reyes
with PTSD, bipolar disorder, and related disorder due to a
medical condition (R. 1040). He reported findings of motor
agitation with sad/irritable mood, constricted affect with
increased intensity, slow speech, hopelessness, helplessness,
anhedonia, circumstantial thought process, and a cognitive
deficit on attention (R. 1040). He concluded that Mr. Reyes
was not mentally fit to work, but that he had a high chance
of recovery and reduced symptoms with intense psychotherapy
and medical management (R. 1040). He reported that Mr. Reyes
had no ability to carry out short and simple instructions,
maintain attention for two-hour segments, maintain regular
attendance and be punctual, complete a normal workday or
workweek without interruptions from psychologically based
symptoms, get along with co-workers without distracting them,
respond appropriately to changes in a routine work setting,
or deal with normal work stress (R. 1042). He expected that
Mr. Reyes would be absent from work more than four days per
month (R. 1044).
Administrative Hearing Testimony
April 7, 2015, Mr. Reyes had his second hearing with the ALJ
(R. 1090). Mr. Reyes testified that he was living with his
mother and his grandmother in his grandmother's
(R. 1119). Mr. Reyes complained of both physical and mental
impairments (R. 1096-128). He reported that he had been in
constant pain and had problems with his arm even when he was
sitting down, requiring him to sit a certain way to avoid
pain (R. 1108, 1127). He was able to write for awhile, but
then his arm would begin to hurt (R. 1108). He was able to
dress, feed, and bathe himself, but he was still unable to
assist his grandmother with household chores like cooking,
cleaning, and laundry (R. 1119). Picking up dishes and scrubbing
pots, he reported, hurt his shoulder (R. 1122). Before his
mother arrived to help his grandmother, he testified that he
mostly only made sure that his grandmother took her medicine
and looked after her (R. 1119). On occasion he accompanied
her to the grocery store, but when he did he frequently felt
like he was having a panic attack (R. 1119).
with the pain, Mr. Reyes went through roughly a bottle of
Toradol every month and occasionally took hot baths (R. 1113,
1125). He sometimes received medications ...