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Grabill v. Commissioner of Social Security

United States District Court, C.D. Illinois, Springfield Division

September 19, 2017

EVA M. GRABILL, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          OPINION

          TOM SCHANZLE-HASKINS, U.S. MAGISTRATE JUDGE:

         Plaintiff Eva M. Grabill appeals from the Defendant Commissioner of Social Security's final decision on her application for Social Security Disability Insurance Benefits (DIB) under Title II of the Social Security Act and Supplemental Security Income Disability Benefits (SSI) under Title XVI of the Social Security Act. 42 U.S.C. §§ 416(i), 423, 1381a, and 1382c (collectively Disability Benefits). This appeal is brought pursuant to 42 U.S.C. §§ 405(g) and 1383(c). Grabill has filed a Brief in Support of Motion for Summary Judgment (d/e 12), and Defendant Commissioner has filed a Motion for Summary Affirmance (d/e 15). The parties consented, pursuant to 28 U.S.C. § 636(c), to proceed before this Court. Consent to the Exercise of Jurisdiction by a United States Magistrate and Reference Order entered May 4, 2016 (d/e 8). For the reasons set forth below, this Court recommends that the decision of the Commissioner be AFFIRMED.

         STATEMENT OF FACTS

         Grabill was born on September 15, 1959. She secured her GED in 1993. Grabill previously worked as a secretarial assistant and a telemarketer. She last worked on January 15, 2012. Grabill suffers from degenerative disc disease, facet arthritis, status post cervical spinal surgery, bilateral chronic venous insufficiency the lower extremities, chronic obstructive pulmonary disease (COPD), and obesity. Grabill last met the requirements for insured status for DIB on December 31, 2013 (Date Last Insured). Certified Transcript of Proceedings before the Social Security Administration (d/e 10) (R.), at 14, 36, 37, 170, 193. A claimant will be entitled to DIB only if she was disabled before her Date Last Insured. 42 U.S.C. §§ 423(a)(1)(A), (c)(1); 20 C.F.R. § 404.131; Briscoe ex rel. Taylor v. Barnhart, 425 F.3d 345, 348 (7th Cir. 2005); Stevenson v. Chater, 105 F.3d 1151, 1154 (7th Cir.1997).

         On February 17, 2012, Grabill saw Dr. Taylor Moore, O.D., for lower back pain. Grabill weighed 193 pounds and had a Body Mass. Index (BMI) of 36.91. On examination, Grabill had bilateral SI joint tenderness, and negative straight-leg testing. The remainder of her examination was normal. Dr. Moore stated that Grabill could not take NSAID[1] pain relievers because of a previous nephrectomy.[2] Dr. Moore prescribed Tramadol. R. 371-72.

         On March 1, 2012, Grabill saw Dr. Moore again for lower back pain. Grabill reported that she has had chronic back pain for five years. She reported that the pain had gradually gotten worse. According to Grabill, the pain was moderate to severe and worse when walking long distances. She said the pain occasionally radiated to her legs bilaterally. Dr. Moore's examination of Grabill was normal. Dr. Moore ordered x-rays and prescribed muscle relaxants and NSAIDs. R. 368-70.

         On March 2, 2012, x-rays of Grabill showed degenerative disc disease of the lumbar spine. R. 358. On March 16, 2012, x-rays of Grabill showed degenerative disc disease of the cervical spine. R. 359.

         On March 16, 2012, Grabill saw Dr. Moore. Grabill reported trouble sleeping due to back pain. At this time, Grabill was 5 feet 1.25 inches tall and weighed 191 pounds, for a BMI of 35.6. She reported that cyclobenzaprine improved her sleep. Dr. Moore reviewed the x-rays and recommended physical therapy. R. 365-66. Grabill underwent four weeks of physical therapy, three sessions per week. R. 393-420.

         On June 13, 2012, Grabill saw Dr. Moore. Dr. Moore noted a positive Hoffmann's sign on the left upper extremity.[3] Dr. Moore assessed cervical radiculopathy and neck pain. R. 360.

         On June 28, 2012, Grabill completed a Function Report-Adult form. R. 212-19. Grabill stated that she could not stand for long periods of time and could not lift more than five pounds without severe pain and losing feeling in her hands. She stated that when she woke up, she took her medications and performed exercises learned from physical therapy. She lived with her family. She reported that she prepared the food for the family, but later stated that friends helped her with cooking and cleaning. She said she could not sleep because of the pain. She took care of herself, but had trouble dressing and getting in and out of the bath tub. She indicated she had to sit down from time to time while she cooked. She washed dishes, but had to sit down while washing them. She did not do any yardwork because such activities caused pain in her back and neck. She went shopping once a month for food and household needs. She sewed, but was unable to sew every day like she did in the past. She spent time daily with friends and attended church regularly. She said she could walk one block before she had to rest for five to ten minutes. R. 212-19.

         On August 27, 2012, state agency physician Dr. C.A. Gotway, M.D., completed a Residual Functional Capacity Assessment of Grabill. Dr. Gotway opined that Grabill could lift 20 pounds occasionally and 10 pounds frequently, stand and/or walk six hours in an eight-hour workday, and sit six hours in an eight-hour workday; and should avoid concentrated exposure to extreme heat, cold, humidity, fumes, odors, dusts, gases, and poor ventilation. Dr. Gotway opined that Grabill had no other physical limitations on her functional capacity. R. 67-69, 92-93.

         On September 17, 2012, Grabill saw Dr. Moore. Dr. Moore noted that Grabill's neck pain was better, but she had worsening intermittent paresthesias[4] of the upper extremities. On examination, Grabill's motor exam was normal and her pulmonary exam was normal. R. 424.

         On November 6, 2012, Grabill underwent an anterior cervical discectomy and fusion with allograft. On November 16, 2012, Grabill saw Dr. Moore. Grabill reported some neck pain and severe muscle spasms after the surgery. Grabill reported that the paresthesias improved after the surgery. Grabill had an apneic episode under anesthesia. Grabill also reported chronic fatigue. Dr. Moore ordered a sleep study. R. 421. The sleep study showed COPD and sleep apnea. R. 433.

         On December 1, 2012, Grabill completed another Function Report-Adult form. R. 243-53. She lived with her family. She said others helped her with housework and cooking. She reported that she took more time to care for herself and dress herself. She said she helped prepare some meals, but could not prepare all meals by herself. She stated that she did “light household work” but the work took “all day” because she had to rest often. She shopped for food once a month. She said she could not draw or sew anymore because her hands “would lock up.” She reported that she spent time with others daily and went to church weekly. She opined that she could lift no more than five pounds, walk a block before she needed to rest for ten minutes. R. 243-48.

         On December 21, 2012, Grabill underwent a pulmonary function test. Grabill had an FEV1 of 1.44 liters, 60% of predicted; FVC of 2.06 liters, 72% of predicted.[5] Bronchodilator therapy showed significant improvement. Grabill's FEV1 improved to 1.58 liters and her FVC improved to 2.43 liters. The test showed moderate obstruction with significant change post-bronchodilator therapy. R. 460.

         On January 3, 2013, x-rays showed stable, satisfactory alignment and appearance of Grabill's surgical fusion of C4-5 and C5-6. R. 461. Grabill underwent another course of physical therapy. R. 439-56.

         On January 22, 2013, state agency physician Dr. Richard Smith, M.D., completed a Physical Residual Functional Capacity Assessment of Grabill. Dr. Smith agreed with Dr. Gotway's opinions in his August 2012 assessment. R. 92-93, 101-02.

         On March 12, 2013, Grabill saw Dr. Moore. Grabill complained of continuing neck pain and, in addition, lower extremity pain. Grabill reported that she had begun having headaches. She reported that the therapy helped her. On examination, Grabill had increased swelling and redness in her lower extremities, but she could ambulate without assistive devices and she could fully bear her weight on both legs. Grabill's motor and pulmonary examinations were normal. Dr. Moore continued Grabill's medications and recommended continuing to perform the exercises from physical therapy. R. 435.

         On April 12, 2013, Grabill saw Dr. Moore. Grabill reported left ankle pain and cramps in her lower extremities at night. Grabill had been wearing compression stockings. The stockings improved the swelling in her legs. At this visit, Grabill weight 232 pounds 4 ounces and had a BMI of 43.29. Grabill's pulmonary examination was normal. R. 499-500. An ex-ray of the ankle showed soft tissue swelling, but was otherwise negative. R. 466. Dr. Moore told Grabill to continue wearing compression stockings. R. 499.

         On May 30, 2013, Grabill saw Dr. Moore for headaches. Grabill reported that she had been having headaches since the neck surgery. Grabill reported, “The headaches were debilitating, and pretty much every morning.” R. 496. Dr. Moore prescribed nortriptyline and strongly advised Grabill to increase her activity, decrease caffeine intake and avoid MSG. Dr. Moore also told Grabill to stop taking ibuprofen due to stomach upset. R. 496.

         On August 26, 2013, Grabill saw Dr. Anne Degreve, D.O., complaining of numbness and tingling in her arms bilaterally when she leaned on her elbows. She did not have any loss of grip strength and the numbness did not awaken her at night. She had intact sensation to light touch and pinprick. Her pulmonary examination was normal. Dr. Degreve recommended consultation with an orthopedic surgeon. R. 492.

         On October 17, 2013, physiatrist Dr. Maria Espejo, M.D., examined Grabill and performed a nerve conduction/EMG study on her upper extremities. On examination, Grabill could ambulate within normal limits, she had normal muscle bulk and tone in her upper extremities, normal sensory and reflex tests in the upper extremities, and negative Hoffmann's, Spurling's, and Phalen's tests bilaterally.[6] The nerve conduction/EMG study showed results were normal. R. 464-65.

         On November 22, 2013, Grabill saw Dr. Degreve for chronic back pain. Grabill reported that the pain started at her neck surgery incision and radiated down her back. Grabill reported that the pain made her eyes water. She said that she had tried muscle relaxers, amitriptyline, flexeril, NSAIDs, and Tylenol, and nothing helped. Grabill reported that the pain limited her daily activity. Grabill had no weakness no decreased range of motion, and no decreased sensation. Grabill also could ambulate. R. 490. On examination, Dr. Degreve found full range of motion in all extremities, intact sensation, and negative straight leg testing. Dr. Degreve noted, “Pain out of proportion of exam. Multiple tender points bilat.” R. 491. Dr. Degreve changed Grabill's medication to Lyrica and prescribed additional physical therapy. R. 490.

         On February 3, 2014, Grabill saw Dr. Degreve for back pain. Grabill was having problems getting her insurance to approve the prescription for Lyrica. Dr. Degreve prescribed gabapentin, and told Grabill to increase her activities of daily living as she was able. R. 487. On examination, Grabill had a normal gait and did not use assistive devices to ambulate. Grabill's sensory exam and motor examination were normal.

         On March 19, 2014, Grabill saw Dr. Degreve complaining of low back pain when walking, and also swelling feet. The back pain was worse after walking and first thing in the morning. Grabill reported that her strength was fine. On examination, Dr. Degreve ordered x-rays of Grabill's lumbar spine. R. 483. The x-rays showed minimal ...


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