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Davenport v. Berryhill

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

May 15, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security [1] , Defendant.


          Susan E. Cox Magistrate Judge.

         Plaintiff Louise Davenport (“Plaintiff”) appeals the decision of the Commissioner of Social Security (“Defendant, ” or the “Commissioner”) to deny her application for disability benefits. Plaintiff has filed a Motion for Summary Judgment. [Dkt. 34.] For the following reasons, Plaintiff's motion is denied [dkt. 34] and the Administrative Law Judge's decision is affirmed.


         I. Background

         A. Procedural History

         Plaintiff, who filed other unsuccessful applications for disability benefits in the past, applied for Disability Insurance Benefits (“DIB”) under Title II and Supplemental Security Income (“SSI”) under Title XVI of the Social Security Act on May 2, 2012. (R. 225, 232, 247.) After her claim was denied initially and upon reconsideration, Plaintiff requested and received a hearing before an Administrative Law Judge (“ALJ”), at which she appeared without counsel. (R. 76.) The ALJ advised Plaintiff of her right to counsel and continued the hearing. (R. 108-110.) At her continued hearing date of March 13, 2014, Plaintiff again appeared, waived her right to counsel, and testified before the ALJ. A vocational expert (“VE”) also testified. (R. 40-75.)

         On May 29, 2014, the ALJ issued a denial of Plaintiff's claim, finding that Plaintiff was able to perform her past work as a secretary or, in the alternative, other work, and that she was not disabled as defined by the Social Security Act. (R. 34.) The Appeals Council then denied Plaintiff's request for review, leaving the ALJ's decision as the final decision of the Commissioner and reviewable by this Court under 42 U.S.C. § 405(g). See Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005).

         A. Plaintiff's Medical History

         Plaintiff, who is homeless, has a bachelor's degree and last worked in 1999 as a secretary at a bank. (R. 47, 49, 252.) Medical records from 2001 and earlier indicate that Plaintiff at various times reported back pain, chest congestion, shortness of breath, leg pain, fatigue, headaches, and dizziness. (R. 519-523, 530- 31.) She tested positive for mild cardiomegaly (enlarged heart) and hypertension, which was treated with hydrochlorothiazide. (R. 521-523.) In August 2002, she visited the emergency room because of problems with her eye. (R. 537.) She continued to experience hypertension, though she was not taking any medications at that time. (Id.) At a February 2003 medical appointment, Plaintiff complained of excessive urination, excessive thirst, some dizziness and nausea, shortness of breath on exertion, and leg swelling. (R. 517.) She mentioned that she had been diagnosed with congestive heart failure. (Id.) She was prescribed two medications for high blood pressure. (Id.)

         The file also contains some medical evidence from 2004 through 2010. Although these dates fall outside the period under consideration for the purposes of Plaintiff's claims of disability before 2003 and after 2012, [2] a summary of the medical evidence is included here in order to draw a full picture of Plaintiff's conditions. In January 2004, she presented to the emergency room with chest pain and reported that she had congestive heart failure. (R. 349.) However, the emergency room physician doubted her report because she acknowledged that she had not undergone an echocardiogram or other testing to establish that diagnosis. Plaintiff stated that she had been diagnosed solely based on swelling in her legs and refused to undergo cardiac testing. (Id.) A chest X-ray revealed she had bronchitis. (R. 359.) In April 2004, she was admitted to the hospital with chest pains and edema in her feet and legs. (R. 368-377.) A chest X-ray suggested early interstitial pneumonia. (R. 382.) In June 2004, a stress test electrocardiogram revealed a subnormal exercise tolerance but no symptoms suggestive of ischemia (reduced blood flow to the heart). (R. 365.)

         Plaintiff returned to the hospital in August 2005 with chest pain and left eye pain. (R. 389.) A chest X-ray indicated some pulmonary scarring but no evidence of congestive heart failure. (R. 395.) Follow-up eye care notes from 2005 through 2012 are difficult to read, but do confirm the presences of uveitic glaucoma in the left eye and blepharitis (recurring inflammation of the eyelid) in the right. (R. 478, 480-483, 485, 491.) The glaucoma since has caused blindness in her left eye. (R. 445, 485, referencing “NLP, ” or “no light perception, ” in the left eye.) She retains vision in her right eye but continues to experience irritation from blepharitis, which is treated with eye drops. (R. 445, 483, 485.)

         In September 2007, Plaintiff again sought treatment for chest pain and shortness of breath. (R. 400-01.) Treatments notes indicate she was given education regarding non-cardiac chest pain and a prescription for blood pressure medication. (Id.) In December 2007, she went to the emergency room reporting abdominal pain and discomfort when urinating, and was released with prescriptions for blood pressure medications and pantoprazole, a medication used to reduce stomach acid. (R. 403.) April 2008 treatment notes indicate that she had swelling in both legs and was given prescriptions for two blood pressure medications. (R. 408-09.)

         In addition to care for her eye ailments, high blood pressure, and chest pain, Plaintiff received foot care throughout 2009. (R. 436-37, 439, 443-44.) Her podiatric records and a record of a diabetes education session describe her as a diabetes patient, though there is no record of her actual diagnosis in her file. (R. 438, 442.) A June 2009 record from a diabetes program indicates that the doctor was unsure whether Plaintiff had diabetes, that her A1C was normal, and that the program would recheck her fasting blood sugar. (R. 441.) In July 2009, Plaintiff's fasting blood sugar tested at 122, and the doctor noted that she had prediabetes.[3] (R. 438.)

         Plaintiff has also received treatment for arthritis. In January 2010, she had experienced wrist pain, but recounted “significant improvement” while being treated with methotrexate. (R. 470.) Still, she experienced stiffness for about ten minutes in the morning. (Id.) She also reported feeling weak, with daytime sleepiness, while taking methotrexate. (Id.) In May 2010, she described pain in numerous joints, and stiffness in the morning in the first hour after she wakes up. (R. 433.) She also recounted that she experienced some swelling, and shortness of breath after walking six to seven blocks in the morning or two to three blocks later in the day. (Id.) Notes from July 2011 characterize her arthritis as “well-controlled.” Her pain had improved and she had no complaints, although mild tenderness in her joints persisted. (R. 484.) In October 2011, she had run out of medications and was again experiencing “mild” rheumatoid anthric symptoms. (R. 458.)

         In a written function report dated June 8, 2012, Plaintiff attested to extreme fatigue; pain and numbness in the upper extremities and upper back; shortness of breath on exertion; left eye blindness; a right eye that gets stuck shut and requires frequent flushing; itching attacks; pain in the knees, hips, ankles and lower back after sitting for a while; and frequent headaches and dizziness. (R. 260-61.) She wrote that she had extreme fatigue and fell asleep during the day. (R. 260, 262.) She indicated that her impairments caused her some trouble dressing, bathing, and doing her hair. (R. 262.) She estimated that she could lift ten pounds and could walk one to two blocks before needing to rest due to pain in her legs. (R. 266-67.) She reported stiffness after sitting for about 15 minutes and shortness of breath when climbing stairs. (R. 267.)

         On August 2, 2012, reviewing physician Calixto Aquino, M.D. reviewed Plaintiff's file, including medical records from several sources, and determined that there was insufficient evidence in the file to support a claim of disability. (R. 123- 25.) Dr. Aquino noted that an exam had been arranged with a consulting internist in order to assess any limitations in Plaintiff's motor abilities due to her rheumatoid arthritis, but that Plaintiff had refused to attend the exam. (R. 123-24.) A second state agency medical consultant, Dr. James Madison, later reviewed Plaintiff's file and concurred with Dr. Aquino's assessment. (R. 131-34.)

         On her first hearing date on December 12, 2013, Plaintiff explained that she had not undergone a scheduled consultative exam because she believed that the evidence in her file was already sufficient to establish disability. (R. 82-85.) The ALJ indicated that he needed more evidence to make a determination and agreed to order X-rays of her right shoulder and elbow and to reschedule her consultative exam. (R. 104-106.) He warned her that a failure to undergo the exam would limit the arguments available to her and would affect his decision. (R. 83-85, 98-99, 106.) The ALJ then explained to Plaintiff her right to counsel and postponed the hearing in order to give her time to seek representation. (R. 108-10.)

         At her second hearing date on March 23, 2014, Plaintiff again appeared without counsel, waiving her right to representation. (R. 40, 45, 216.) She had not undergone a consultative examination. She testified that, when walking, she frequently had to stop due to shortness of breath, and she also had pain in her legs and hips. (R. 50-51, 63.) She observed, “everybody walks faster than I do.” (Id.) She stated that she had recently gone to the arthritis clinic with pain and swelling in her hands, and that the arthritis also caused pain in her elbows and shoulders. (R. 52, 55-56.) She had trouble lifting her arms to do her hair. (R. 65.) Sometimes, her neck was stiff as well, and she had sciatic pain going from her back to her leg. (R. 57.) She was taking Methotrexate for arthritis and Diovan for hypertension. (R. 53- 54.) She sometimes felt dizzy but did not know why. (R. 54.) She frequently fell asleep during the day, and would get thrown out of places for falling asleep. (R. 64- 65.) She also stated that her shortness of breath was a result of congestive heart failure. (R. 66.)

         A vocational expert (“VE”) also testified. She described Plaintiff's past work as a secretary as light work. (R. 68.) The ALJ then asked whether Plaintiff's past job could be performed by a person who could work at a light exertional level but who lacked peripheral acuity on the left side; could not climb ladders, ropes, or scaffolds; could frequently but not constantly stoop; could only occasionally crouch, kneel, or reach overhead; could never crawl; must avoid concentrated exposure to the cold ...

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