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Gonzalez v. Berryhill

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

February 10, 2017

ORFALINDA C. GONZALEZ, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of the U.S. Social Security Administration[1], Defendant.

          MEMORANDUM OPINION AND ORDER

          HON. MARIA VALDEZ United States Magistrate Judge

         This action was brought under 42 U.S.C. § 405(g) to review the final decision of the Commissioner of the Social Security Administration (the “Administration”) denying Plaintiff Orfalinda C. Gonzalez's (“Plaintiff”) claim for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (the “Act”). The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow, Plaintiff's Motion for Summary Judgment [Doc. No. 9] is granted, and the Commissioner's Cross-Motion for Summary Judgment [Doc. No. 14] is denied.

         BACKGROUND

         I. Procedural History

         Plaintiff filed an application for DIB On July 18, 2011, alleging a disability onset date of October 29, 2008 due to urinary incontinence and Crohn's disease. (R.145; 171.) Her claim was denied initially on October 26, 2011 and then upon reconsideration. (R. 106-107.) On November 19, 2012, Plaintiff appeared before Administrative Law Judge (“ALJ”) Lee Lewin. (R. 30-105.) She testified at the hearing and was represented by counsel. (R. 32.) Medical Expert (“ME”) Sheldon J. Slodki M.D. and Vocational Expert (“VE”) Ruben Luna also testified. (R. 82-104.) On March 25, 2013, the ALJ issued a written opinion finding Plaintiff not disabled under the Act. (R. 16-25.) The Appeals Council denied her request for review, leaving the ALJ's decision as the final decision of the Commissioner and therefore reviewable by the District Court under 42 U.S.C. § 405(g). See Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005); Herron v. Shalala, 19 F.3d 329, 332 (7th Cir. 1994). (R. 1-5.)

         II. Medical Testimony

         The Plaintiff's relevant medical history is as follows. At the time of the hearing, Plaintiff was 53 years old, had worked as a machine feeder and box maker, and had attained a high school education. (R. 37, 96-97.) In October 2008 Plaintiff consulted with urologist Anthony M. Grimaldi, D.O. regarding urinary incontinence. (R. 229, 235-250.) Later that month, Plaintiff underwent surgery consisting of a laparoscopic-assisted vaginal hysterectomy and anterior colporrhapy[2] in conjunction with a vaginal sub-urethral sling. (Id.) In a follow-up exam in November 2008, she indicated that her incontinence was improved. (R. 229.) Her doctor recommended that she refrain from heavy lifting and never lift more than ten pounds, as this might compromise the integrity of the urethral sling. (Id.)

         Plaintiff also has been treated for Crohn's disease under the care of gasteroenterologist Kevin J. Dolehide, M.D. seeing him approximately every three months since 2006. (R. 364, 369, 470-471.) Colonoscopies performed in March 2009 and June 2011 revealed diverticulosis, gastritis, and hemorrhoids. (R. 362-363, 366-368.)

         In July 2011, Dr. Dolehide completed a Gastrointestinal Disorders Impairment Questionnaire indicating that Plaintiff experienced pain, fatigue, loss of appetite, and abdominal pain and cramping due to Crohn's disease, diverticulosis, and infectious colitis. (R. 369-371.) Dr. Dolehide opined that Plaintiff's primary symptoms were severe enough to constantly interfere with her attention and concentration. (R. 371-372.) Her symptoms were exacerbated by stress. (Id.) In an eight-hour workday, Dr. Dolehide opined that Plaintiff can occasionally lift and carry up to twenty pounds but can only sit for two hours and stand/walk up to an hour total. (R. 372-373.) He recommended that she not sit continuously in a work setting due to her urge to go the bathroom. (R. 372.) Dr. Dolehide further stated that Plaintiff requires ready access to a restroom two to three times a day for approximately thirty minutes each time, often on an urgent basis. (R. 373-374.) Dr. Dolehide estimated that, on average, Plaintiff would be absent from work more than three times a month. (R. 373.) He indicated that his findings were supported by laboratory and diagnostic tests, including the June 2011 colonoscopy, he opined that Plaintiff is not a malingerer, and described her prognosis as “chronic disorder, lifetime illness.” (R. 366-369, 372.)

         Dr. Dolehide also submitted a hand-written report to the Administration in September 2011. (R. 361.) In this report, Dr. Dolehide noted that he had been treating Plaintiff since 2006 for her Crohn's disease. (Id.) He reported that medications decreased Plaintiff's abdominal pain, but the illness had caused her “to change her lifestyle drastically due to fear of going out in public and not having access to a bathroom, ” given that she “often has to use the bathroom several times in a short time frame.” (Id.) He concluded that Plaintiff's disease was a “lifelong illness” and that she could not work full-time. (Id.)

         In a letter dated November 5, 2012, Dr. Dolehide indicated that Plaintiff is “completely disabled” and “incapable of performing full time work.” (R. 470.) His letter described Plaintiff's symptoms of chronic abdominal pain, change and loss of appetite, fatigue, and stress, to be factors that would continue to affect her daily life. (Id.) He heightened her ten-pound lifting limitations set after her October 2008 surgery to twenty-pounds, and reiterated her need to constantly access the restroom. (R. 229, 470.) Dr. Dolehide concluded by echoing his opinion from his July 2011 letter stating that Plaintiff's symptoms continue to be severe enough to constantly interfere with her attention and concentration, and that her impairments and limitations would cause her to miss more than three days of work each month. (R. 470.)

         Plaintiff began seeing urogynecologist Denise Elser, M.D. in March 2011. (R. 345.) After initial testing and two follow up exams, Dr. Elser diagnosed Plaintiff with “prolapse of vaginal vault after hysterectomy.” (R. 335.) She assisted in Plaintiff's second surgery, a repair of the prolapse, on June 13, 2011. (R. 359-360.)

         In October 2011, medical consultant Ernst Bone, M.D. reviewed Plaintiff's medical file and completed a Physical Residual Functioning Capacity (“RFC”) Assessment, reporting evidence of diverticulosis, internal hemorrhoids, and Crohn's disease. (R. 375-382.) Dr. Bone found no significant limitations that would prevent Plaintiff from performing substantial gainful activity (“SGA”). (Id.) Dr. Bone's assessment was affirmed by another medical consultant, Charles Wabner, M.D., in March 2012. (R. 383-385.)

         On November 19, 2012, Plaintiff testified before the ALJ that she was terminated from her job after undergoing her first surgery in October 2008. (R. 49-50.) She stated that she was unable to return to work because of “the way she feels.” (R. 54.) She specifically reported experiencing “a lot of discomfort” in the form of abdominal and lower back pain, which began to occur after her second surgery in July 2011. (R. 54-58.) Plaintiff revealed feeling like she had to move her bowels, without success, which would occur two to three times per day for thirty minutes. (R. 68-70.) She pointed out she could not lift more than a gallon of milk, and that her lifting restriction presented an obstacle to finding a job. (R. 54.)

         In addition, Plaintiff revealed that despite medication, her Crohn's disease caused her stomach to be upset and she continued to experience constipation. (R. 61.) Plaintiff also testified to taking Metamucil for her constipation, which she said “sometimes” helped. (R. 61-62.) She testified she had not seen Dr. Dolehide in months, but saw him when she felt something was wrong. (R. 61, 74.) Plaintiff indicated she had urinary incontinence. (R. 79.) She mentioned that if she drank coffee or tea, she went to the bathroom more than five times per day. (Id.) Plaintiff further indicated that she experienced leakage five times a day or more. (R. 79-81.) Finally, Plaintiff indicated that her depression prevented her from working because she did not feel like doing anything, or getting out of bed. (R. 64, 70.) She testified that she was taking medication, which helped somewhat, and saw her psychologist on an as-needed basis. (R. 65-66.)

         With respect to her mobility, Plaintiff reported that she might be able to walk a mile, and would take breaks by sitting “for a little while.” (R. 71.) Plaintiff estimated being able to walk for twenty minutes at a time, and to sit for ten minutes or less. (R. 72-73.) She further testified she could stand for only five minutes due to pain. (R. 73.)

         In describing her daily activities, Plaintiff acknowledged that she could shower and dress herself, complete household chores, do little loads of laundry, wash dishes, and sometimes make the bed. (R. 39.) She cooked breakfast, and she cooked dinner approximately twice a week. (Id.) She drove when she needed to, approximately once a week, to go to medical appointments or to the store. (R. 38.) She was able to ride in a car for approximately one hour to her family's campground, a location she visited approximately three times in 2012. (R. 45-46.) Her husband made stops along the way to the campground “just to get out for a little bit.” (Id.) At the campground, Plaintiff reported doing nothing more than sitting around the trailer and the fire. (R. 47.) She did not disclose the duration of her sitting down. (Id.) Finally, Plaintiff testified that she watched news on television for less than an hour, and read the newspaper. (R. 42-43.) She did not report any difficulties doing either activity. (Id.) She did, however, testify that she gets “depressed a lot” and that her depression makes her feel like she does not want to do anything. (R. 64.) She reported taking medication for her depression and receiving counseling about two to three times a month. (R. 65-66.)

         The ALJ then asked the VE whether a hypothetical person with the same age, education, and work history as Plaintiff, and a residual functional capacity (“RFC”) limiting her to unskilled light exertional work with frequent climbing of ramps and stairs; the occasional climbing of ladders, ropes, or scaffolds; and occasional crouching, and crawling, could perform Plaintiff's past work. (R. 97.) The VE indicated three light jobs that Plaintiff could perform, which included cafeteria attendant; a shipping, receiving, and routing clerk; and a packager. (R. 97-99.) The VE further testified that an individual with Plaintiff's restrictions could also perform three sedentary jobs, such as bench hand assembly, credit checker, and order clerk. (R. 99-100.) However, when asked whether any of these jobs would remain available to Plaintiff if she missed more than three days of work per month for unexcused absences, the VE reported no jobs in the national economy that allow three or more ...


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