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Maxwell v. Berryhill

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

September 21, 2017

MARY C. MAXWELL, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of the U.S. Social Security Administration, Defendant.



         Claimant Mary Maxwell (“Claimant”) brings this action seeking judicial review of the final decision of the Commissioner of Social Security (“Commissioner”), denying Claimant's request for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under §§ 404, 416(i), and 423(d) of the Social Security Act (the “SSA”). The parties have filed a cross-motions for summary judgment [17, 24]. 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 [17] is denied, and the Commissioner's cross-motion [24] is granted.

         I. BACKGROUND

         A. Procedural History

         On May 24, 2012, Claimant filed a Title II DIB application and a Title XVI SSI application, alleging a disability onset date of December 31, 2000. (R. 281-90.) Her claim was denied initially on September 19, 2012, and again upon reconsideration August 20, 2014. (R. 135-38.) After both denials, Claimant filed a hearing request on August 28, 2014, pursuant to 20 C.F.R. § 404.929 et seq. (R. 173.) A hearing was held on November 5, 2015, before an Administrative Law Judge (“ALJ”).[1] (R. 234.) Claimant appeared along with her representative. (R. 47-99.) A Vocational Expert (“VE”) was also present and offered testimony. (Id.) On December 4, 2015, the ALJ issued an unfavorable written decision denying Claimant's claims for DIB and SSI. (R. 18-46.) Claimant then requested review by the Appeals Council. (R. 7-10.) On April 11, 2016, the Appeals Council denied her request for review, at which time the ALJ's decision became the final decision of the Commissioner. (R. 1-6.); Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). Claimant subsequently filed this action in the District Court.

         B. Medical Evidence

         Claimant was born on February 20, 1970 and was forty-five years old at the time the ALJ issued her decision. (R. 52.) She seeks DIB and SSI for disabling conditions stemming from bipolar disorder, partial vertebra removal, a shattered kneecap, and chronic migraines. (R. 313.)

         1. Treating Physicians

         We note at the outset that claimant's records reference several injuries and conditions that are not detailed in the administrative record, including a fractured pelvis and vertebra injury as a result of an automobile accident in 1991, (R. 59, 1067), a history of cervical cancer, (R. 746, 914), a stroke in early 2014, (R. 717, 855), and hypertension, (R. 732). In addition, much of the administrative record reflects sporadic emergency room visits and hospitalizations, rather than consistent care from primary care physicians.

         Claimant was taken to Elgin Mental Health Center in May of 2000 for depression and suicidal thoughts; she explained that she had lost her job and was struggling to cope with her mother's death. (R. 553-54.) She was treated there for one month and then released with a diagnosis including bipolar disorder. (R. 529, 532.)

         Subsequently, in February of 2001, Claimant voluntarily admitted herself to another psychiatric care facility where she again expressed suicidal ideation. (R. 487.) Claimant reported a history of bipolar disorder; however, her doctor noted that “she did not give clear-cut symptoms or show signs of symptomatology” of bipolar disorder (R. 488.). It was also noted that her presentation was much more consistent with substance abuse. (Id.) While Claimant did admit to a history of cocaine, marijuana, and alcohol use, she reported that she had recently stopped using those substances. (Id.) Her records indicated that her thought process was “clear, logical and coherent with no disorganization or delusions.” (Id.) Claimant's memory was intact and aside from showing signs of chemical dependency, she had no other active medical problems. (Id.) She was discharged from care five weeks later. (R. 487.)

         Claimant was admitted to Alexian Brothers Medical Center in September of 2008 following an incident where she consumed alcohol and attempted to commit suicide by overdosing on 100 Tylenol P.M. pills. (R. 576, 578.) Her doctors performed a gastric lavage, and subsequently transferred her to psychiatric care at Alexian Brothers Behavioral Health for an alcohol detox and management of her psychiatric issues. (R. 576.)

         Claimant next presented for medical care in May of 2009 at Advocate Condell Medical Center (“Advocate”) due to pain and swelling in her left knee. (R. 622.) A magnetic resonance imaging (“MRI”) from the same month revealed she had large knee joint effusion. (R. 624.) Her left knee was subsequently injured in September of 2009 when she fell down five steps. (R. 610-16.) An x-ray of her knee revealed mild hypertrophic and degenerative changes, but there was no fracture. (R. 621.)

         Two months later, Claimant injured her left knee again when it “gave out” beneath her. (R. 600-05.) Her doctor recommended that she ice and elevate her knee, in addition to following-up with her orthopedist. (R. 605.)

         In March 2010, Claimant slipped and fell on ice, aggravating her existing knee pain. (R. 648.) Once again, an x-ray of her left knee revealed mild hypertrophic changes, and she was diagnosed with a knee sprain on an old meniscal tear. (R. 650, 657.)

         Claimant returned to Advocate two months later in May of 2010, where she complained that she had re-injured her left knee following another fall. (R. 626.) Once again, her doctors obtained x-rays of her left knee, which showed knee joint effusion, as well as advanced osteoarthritic changes in the knee. (R. 634.) She was advised to take pain medications (including Norco and Aleve) and follow-up with her treating physician. (R. 630.)

         After a gap in treatment, Claimant returned for care and treatment of her left knee in August of 2013, after she fell out of bed. (R. 829-31.) She was instructed to continue to take Norco and follow up with her orthopedist. (Id.) Beginning in late December of 2013, Claimant started a treatment relationship with Dr. Timothy Froderman, M.D., which lasted through June 2014. (R. 707-19.) Dr. Froderman typically assessed Claimant with generalized anxiety disorder, lower back pain, cervical cancer, and benign hypertension; however, in terms of treatment, he primarily refilled her medical prescriptions. (Id.)

         On February 5, 2014, Claimant presented to the hospital and was admitted for inpatient care after three episodes of syncope (temporary loss of consciousness), while she was incarcerated. (R. 743-47.) It was noted that she had recently learned she had cervical cancer and felt depressed. (R. 747.) She reported abdominal pain, dizziness, depression and back pain. (Id.)

         On June 21, 2014, Claimant was admitted to Advocate after experiencing several episodes of “unresponsiveness” where she would stand still and stare. (R. 807.) She explained to Dr. Mark Trelka, M.D., that she had no memory of the episodes and would come out of them after two to four minutes. (R. 807-08.) Although Claimant admitted to using cocaine four days before her most recent episode, she stated that they were not associated with any drug use; however, her toxicology screen was positive for opiates and benzodiazepines. (R. 808-10.) Dr. Trelka opined that her condition may be due to complex partial seizures and advised her to avoid dangerous machinery and climbing ladders for at least six months. (R. 808-09.)

         In connection to her seizures, Claimant underwent an CT scan of her cervical spine, which revealed mild degenerative arthritic changes at ¶ 6-C7 with central canal narrowing, (R. 768), and a CT scan of her abdomen and pelvis which revealed grade 2 spondylolisthesis at ¶ 5-S1. (R. 768-70.) A magnetic resonance angiography (“MRA”), and MRI of her head and neck were all within normal limits. (R. 813, 826.)

         Next, Claimant presented to the emergency room on August 12, 2014 complaining of back pain, due to no specific incident. (R. 892-95.) Upon examination, she demonstrated normal strength but had painful and limited range of motion in her lumbar spine. (R. 880.) She was diagnosed with chronic back pain and discharged with pain medications. (R. 894, 880.) By ...

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