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Spaulding v. Berryhill

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

September 7, 2017

NANCY A BERRYHILL, Acting Commissioner of Social Security, Defendant.


          Michael T. Mason, United States Magistrate Judge.

         Claimant Dawn M. Spaulding (“Spaulding” or “Claimant”) brings this motion for summary judgment seeking judicial review of the final decision of the Acting Commissioner of Social Security (“Commissioner”). The Commissioner denied Spaulding's claim for disability insurance benefits under Sections 216(i) and 223(d) of the Social Security Act (the “Act”). The Commissioner filed a cross-motion for summary judgment, requesting that this Court uphold the decision of the Administrative Law Judge (“ALJ”). This Court has jurisdiction to hear this matter 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 cross-motion for summary judgment is granted.

         I. BACKGROUND

         A. Procedural History

         Claimant filed an application for a period of disability and disability insurance benefits on August 29, 2012. (R. 19.) Claimant alleges that she has been disabled since June 30, 2011 due to Lyme Disease, with meningitis and encephalitis, recurrent arrhythmias, asthma/allergies, peripheral neuropathy to include bilateral foot pain, neck and shoulder pain, depression, anxiety, and a cognitive disorder. (R. 152, 71-72, 465.) Her application was initially denied on November 2, 2012, and again on May 16, 2013, after a timely request for reconsideration. (R. 71-72.) On June 11, 2013, Claimant requested a hearing regarding her disability application. (R. 95.) On August 21, 2014, she testified before ALJ Cynthia M. Bretthauer. (R. 35.) On October 7, 2014, the ALJ issued a decision denying Claimant's disability claim. (R. 19-30.) On August 20, 2015, Claimant requested review by the Appeals Council. (R. 4.) On April 15, 2016, the Appeals Council denied Claimant's request for review, at which time the ALJ's decision became the final decision of the Commissioner. (R. 1-3.); Zurawski v. Halter, 245 F.3d. 881, 883 (7th Cir. 2001); 20 C.F.R. § 404.955, 404.981. Claimant subsequently filed this action in the District Court.

         B. Medical Evidence

         Sometime between June 11-12, 2011, a tick bit Claimant in Wisconsin. (R. 454.) Over the next several days, while visiting Mexico, Claimant began experiencing fevers, headaches, bilateral leg pain, generalized fatigue, and she noted a rash on her anterior thigh. (Id.) She sought medical attention, but had a negative reaction to the prescribed medication. (Id.) Subsequently, she returned to the United States where her symptoms worsened. (Id.) She experienced sudden right side facial paralysis. (R. 247.) Claimant sought treatment from her primary care physician, Dr. Ann Garcelon. (Id.) Dr. Garcelon administered a lumbar puncture and thereafter admitted Claimant to Mercy Medical Center in Chicago on July 13, 2011. (R. 246.)

         Once admitted, Mercy Medical Center diagnosed Claimant with Bell's Palsy and Lyme Disease Meningitis. (Id.) The center prescribed Claimant with intravenous antibiotics and discharged her on July 15, 2011. (R. 285-287.) After completion of the antibiotics, Claimant's symptoms of fatigue, cognitive problems, and foot pain continued. (R. 320.)

         1. Dr. Jeffrey Kramer, Neurological Specialist

         As a result of persistent symptoms, Claimant began regular medical visits with neurologist Dr. Jeffrey Kramer. (R. 355-60.) These visits occurred from October 2011 through June 2012. (Id.) While some of Dr. Kramer's records are illegible, he clearly recommended that Claimant undergo a Magnetic Resonance Imaging test (“MRI”) of her head and an Electroencephalogram test (“EEG”) of her brain as well as treatment at the Rehabilitation Institute of Chicago (“RIC”). (R. 355.)

         Based on Dr. Kramer's recommendation, on October 18, 2011, Claimant underwent an MRI and an EEG. (R. 320.) These test results were evaluated by Dr. Kramer and specialists at the Columbia University Medical Center, Lyme and Tick-Borne Diseases Evaluation Service. (Id.)

         2. Columbia University Medical Center, Lyme and Tick-Borne Diseases

         On November 30, 2011, Claimant saw Dr. David Hardesty of the Columbia University Medical Center, Lyme and Tick-Borne Diseases Evaluation Service. (Id.) During this appointment, Dr. Hardesty reviewed Claimant's MRI results and EEG results. (R. 320-54.) He then performed a series of neurological tests and he took Claimant's blood for evaluation. (R. 320.) First, Dr. Hardesty informed Claimant that her MRI results showed “multiple subcentimeter ectatic perivascular spaces randomly distributed about both BG/thalami and brainstem. Strabismus noted.” (Id.) Next, Dr. Hardesty told Claimant her EEG results were “mildly abnormal, with 4-5 Hz low voltage underlying normal background 9-10 Hz, read to occasionally be more isolated to left temporal region.” (Id.)

         Dr. Hardesty then conducted neurological testing on Claimant. (R. 321.) The results of Claimant's neurological testing are captured in Dr. Hardesty's report, dated February 14, 2012. (R. 330.) The report characterized Claimant's intellectual capacity as at least high average. (Id.) The report detailed Claimant's gross motor speed and fine motor control as intact, but noted Claimant's reaction times were relatively slowed. (Id.) Dr. Hardesty's report further identified Claimant's greatest difficulties as her inattention and slowed response times. (R. 330-31.) In the report, Dr. Hardesty stated, “though [Claimant] is able to compensate for some of this slowing, performance varied across tasks as she struggled to maintain focus.” (R. 331.)

         On February 6, 2012, Dr. Hardesty followed up with Claimant to report that all of her blood test results were essentially normal. (R. 324.) Based on Claimant's test results, Dr. Hardesty concluded that Claimant's Lyme Disease could be the cause of her persistent fatigue and cognitive difficulties, but it was unlikely. (R. 321, 324.) Instead, Dr. Hardesty suggested that Claimant's cognitive difficulties likely stemmed from fatigue and depression. (R. 324.) Dr. Hardesty recommended Claimant seek therapy and psychiatric evaluation as needed, begin taking low dose Ritalin with cessation of caffeine, participate in cognitive training/rehabilitation, as well as fatigue management through diet, exercise, and elimination of other possible medical causes. (R. 325.)

         3. Rehabilitation Institute of Chicago

         In late 2012, Claimant began treatment at the RIC. (R. 410.) On August 29, 2012, Dr. David Ripley, Director of the Brain Trauma Unit at the RIC, assessed Claimant. (R. 420, 465.) After this evaluation, Dr. Ripley referred Claimant to the physical therapy, speech therapy and vocational rehabilitation programs within the RIC. (R. 420.) Dr. Ripley also provided Claimant with a prescription for Ritalin to help with fatigue, attention, and memory. (Id.)

         On September 10, 2012, RIC staff evaluated Claimant's speech language pathology. (R. 413.) Claimant's chief complaint was her difficulty with language formation, attention/concentration, organization and planning, and cognitive fatigue. (R. 414.) During the examination, Claimant stated that her primary goal was returning to work. (R. 413.) Claimant also stated her current responsibilities included household financial management, home management of her three properties, planning social events, and taking Spanish classes online. (R. 447.) The RIC approved Claimant to participate in the outpatient speech language pathology therapy program. (R. 416.)

         On September 18, 2012, the RIC assessed Claimant for outpatient vocational rehabilitation therapy (often referred to as occupational therapy in the record) to assist Claimant with returning to work. (R. 417.) The RIC accepted Claimant into this program. (R. 443.)

         On October 10, 2012, Claimant saw Dr. Ripley for a follow up appointment. (R. 423.) During this appointment, Claimant stated that the Ritalin had been somewhat effective, but had not completely alleviated her symptoms. (Id.) Dr. Ripley prescribed Claimant Ritalin for “breakthrough fatigue.” (R. 425.) Dr. Ripley also informed Claimant that she needed to conserve her energy throughout the day and that her fatigue may be a long-term problem. (Id.)

         On October 12, 2012, Claimant underwent a physical therapy examination at the RIC. (R. 410.) This evaluation, performed by Physical Therapist (“PT”) Anne Hooker, stated Claimant was not a good candidate for skilled physical therapy because she could complete all functional tasks independently. (R. 411.)

         On July 29, 2013, Dr. Zachery McCormick of the RIC evaluated Claimant's physical therapy progress regarding her neck, shoulder, and foot pain as well as her general fatigue. (R. 514.) Dr. McCormick's review of Claimant's medical records indicated that as of December 12, 2012, Claimant was frustrated with the results of her neurophysical testing and no longer believed she could return to any type of work at Deloitte Consulting, her former employer. (R. 535.) Dr. McCormick's also noted that as of November 15, 2012, Claimant demonstrated mild residual cognitive impairment likely caused by Lyme Disease. (R. 536.) The records stated that Claimant meets the diagnostic criteria for Adjustment Disorder with Mixed Anxiety and Depressed Mood. (Id.) Based on his assessment and review of Claimant's records, Dr. McCormick recommended that Claimant complete a work trial to determine what environmental modifications, such as a quiet solitary work place, would be necessary in order for Claimant to be able to function at work. (Id.) Claimant declined to participate. (Id.) It was also noted at this appointment that Claimant had an upcoming five-week trip to her home in Mexico planned. (Id.)

         On August 14, 2013, Claimant participated in occupational therapy where she continued to work on body mechanics, pacing, pain management, posture, and sensory deficit management. (R. 540-43.) During this appointment, the PT advised Claimant to attend occupational therapy one to two times per week for three to four weeks. (R. 543.)

         On August 15, 2013, RIC PT Hannah Nilles reevaluated Claimant to assess Claimant's neck, shoulder, and foot pain as well as her general fatigue. (R. 515.) Claimant described pain intensity as a seven on a scale of zero to eight. (Id.) Claimant stated that her pain affected her ability to complete daily living activities, and also affected her concentration, emotions, mobility, motivation, sleep, and work. (Id.) Claimant also stated that pain increased while sitting, standing, and walking. (Id.) The PT report stated that Claimant's posture issues likely contributed to her pain and she would benefit from continued physical therapy. (R. 518.) The PT recommended physical therapy one to two times per week for three to four weeks. (R. 519.)

         On August 21, 2013, the RIC reevaluated Claimant's physical therapy progress. (R. 545.) Claimant reported completing all assigned at home exercises, but did not ...

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