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Dunteman v. Berryhill

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

October 24, 2017

DAVID LENARD DUNTEMAN, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION AND ORDER

          MICHAEL T. MASON, UNITED STATES MAGISTRATE JUDGE

         Claimant David Lenard Dunteman (“Claimant”) brings this motion seeking review of the final decision of the Commissioner of Social Security (“Commissioner”). The Commissioner denied Claimant's claim for disability insurance benefits under Sections 216(i) and 223(d) of the Social Security Act (“SSA”). 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 seeking review [17] is denied and the Commissioner's cross-motion for summary judgment [22] is granted.

         I. BACKGROUND

         A. Procedural History

         Claimant filed an application for disability insurance benefits on May 10, 2013 for disability allegedly beginning on March 1, 2009 with a date last insured of December 31, 2012. (R. 32, 174-75.) He alleges that he has been severely disabled due to atrial fibrillation, peripheral neuropathy, obesity, depression, anxiety, and alcohol abuse. (R. 15.) His application was initially denied on July 15, 2013, and again upon reconsideration on November 7, 2013. (R. 109-12; 115-17.) Claimant filed a timely request for a hearing on December 10, 2013. (R. 119-20.) On June 30, 2014, Claimant appeared with counsel before ALJ Lorenzo Level. (R. 27-80.) On October 31, 2014, the ALJ issued a decision denying Claimant's disability claim. (R. 13-22.) Claimant filed a timely request for review, and on December 10, 2013, the Appeals Council denied Claimant's request for review, which made the ALJ's decision the final decision of the Commissioner. (R. 1-9); Zurawski v. Halter, 245 F.3d. 881, 883 (7th Cir. 2001). Claimant subsequently filed this action in the District Court.

         B. Medical Evidence

         1. Treating Physicians

         a. Physical Treatment

         Claimant presented to the emergency room at Adventist LaGrange Memorial Hospital (“LaGrange Hospital”) on September 5, 2008, after suffering a fall the day before that resulted in knee pain and bilateral foot neuropathy. (R. 334.) X-rays indicated fractures of the second and third metatarsal bases in his left foot. (R. 334-36.) Claimant was prescribed Vicodin and discharged home. (R. 332.) On September 10, 2008, Claimant was seen by Dr. Steven Mash at M & M Orthopaedics, who recommended a consultation for Claimant's neuropathy. (R. 453.)

         Claimant had a follow-up visit with Dr. Mash on October 6, 2008, at which time the doctor commented that Claimant had neuropathy from the ankles downward. (R. 452.) Dr. Scott Robertson at the Family Medical Group of LaGrange authored a progress note on February 20, 2009, stating that Claimant was unable to leave his house due to his severe depression and was considering disability because he could not work. (R. 395.) Dr. Robertson noted “he clearly cannot work as of now.” (R. 396.) On March 3, 2009, Dr. Robertson's office documented that Claimant called to report that he was depressed. (R. 393.)

         On February 2, 2010, Dr. Robertson noted that that Claimant was looking for a job and taking care of his mother. (R. 389.) Claimant's depression was the same, but Tegretol helped. (Id.) Dr. Robertson's office received a call from a pharmacy on September 10, 2011, after Claimant told the pharmacist that he was experiencing chest pains because he did not have his medication. (R. 388.) The pharmacist was informed that Claimant had not been to the office since February 2010; he authorized a few tablets and instructed Claimant to make an appointment with Dr. Robertson. (Id.) Claimant presented for a follow up with Dr. Robertson on September 20, 2011 and reported experiencing atrial fibrillation about once a month. (R. 386.) Dr. Robertson noted that Claimant could not afford a cardiologist and ordered lab work. (R. 387.)

         Claimant was informed on September 23, 2011 that he needed to lose weight and abstain from drinking. (R. 385.) Claimant presented to Dr. Robertson on November 23, 2011 with a regular heart rate and rhythm. (R. 383.) It was recommended that Claimant see Dr. Meechai Tessalee, a cardiologist. (R. 384.)

         On February 8, 2012, Claimant underwent a transthoracic echocardiogram examination at Suburban Cardiologists, which identified mild concentric left ventricular hypertrophy, a mildly dilated left atrium, trace mitral regurgitation, and mild tricuspid regurgitation. (R. 353.) A stress echocardiogram examination on February 15, 2012 found a severely reduced exercise capacity for Claimant's age, but also found normal resting wall motion and no stress-induced wall motion abnormality. (R. 355.)

         Claimant was referred to Dr. Alex Chicos, whom he saw on April 24, 2012. (R. 344.) Dr. Chicos reported that Claimant had episodes of paroxysmal atrial fibrillation every two weeks, including one episode that lasted four days. (R. 344.) Claimant also informed Dr. Chicos that he was unable to find work despite his experience as an accountant. (Id.) Due to Claimant's financial limitations, among other considerations, Dr. Chicos believed that “a pill in the pocket approach would be an excellent approach for him” and decided that flecainide was the best option. (Id.)

         On July 23, 2012, Claimant went to LaGrange Hospital complaining of a racing heart and palpitations. (R. 306.) He was found to have rapid atrial fibrillation, which resolved and he was discharged that same day. (R. 309.) Claimant was in sinus rhythm during a follow-up appointment with Dr. Tessalee on August 3, 2012. (R. 341.)

         Claimant presented to Dr. Robertson's office on September 20, 2012, complaining of rib pain from a fall ten days before. (R. 381.) He was prescribed Vicodin for the pain. (R. 382.) On October 12, 2012, he sought a refill for the Vicodin, and it was noted that he should not have needed the medication for that long. (R. 377.)

         On March 26, 2013, Dr. Robertson reported that Claimant appeared well, was not in distress, still presented with depression, and was on Prozac. (R. 371-72.) On May 30, 2013, and again on July 2, 2013, Claimant stated he was “more depressed because of his neuropathy” and reported “throbbing pain in all his body and increased neuropathy.” (R. 468, 470.) During a March 7, 2014, appointment with Dr. Daniel Miller at Loyola University Medical Center, it was noted that Claimant had “probable alcohol induced peripheral neuropathy.” (R. 618.) He was prescribed diabetic shoes and custom molded multi-density insoles. (Id.)

         On April 8, 2014, Claimant had a consultation with Dr. Khaled A. Dajani at the cardiovascular clinic at Loyola “to establish care for atrial fibrillation, ” which Claimant was diagnosed with ten years prior. (R. 622.) Dr. Dajani stated that Claimant was in sinus rhythm and recommended continued use of current medications. (R. 622, 625.)

         b. Mental Health Treatment

         From March 17, 2009 to May 4, 2010, Claimant attended multiple sessions with Associates in Professional Counseling, usually attending one or two sessions per month.[1] (R. 281-97.) The discussions typically addressed Claimant's mood, his addiction, and concerns over his mother's health. (R. 286-297.) During his first session on March 17, 2009, Claimant stated that he felt depressed for the past four years, drank too much, and was unable to get motivated to seek work. (R. 284-85.) His symptoms were hopelessness, sadness, withdrawal, anger, and weight gain. (Id.)

         During his September 1, 2009 session, Claimant expressed an inability to focus on work. (R. 291.) On November 3, 2009, his therapist noted that he appeared more in control, but was still depressed and had a lack of energy and focus. (R. 293.) On January 15, 2010, it was noted that Claimant was determined to do better in his coping efforts with his mom, who entered hospice the following month. (R. 295.) By the time of his final session on May 4, 2010, Claimant was withdrawing from his friends and expressed that he was stuck in a negative pattern. (R. 297.)

         From March to July of 2013, Claimant attended regular psychiatric sessions with Dr. Ghassan Aldura. (R. 465-79.) At his initial appointment, Claimant reported that he had been unable to work for the past five years, that he was broke, and that he took care of his mother for the past 13 years until her death in October of 2010. (R. 476.) Claimant stated that he could not function and did not shower or leave the house. (Id.)

         Claimant attended individual and group counseling through Pillars from April 23, 2013 through March 27, 2014. (R. 505-19.) He initially presented with a cooperative but helpless attitude and appeared unkempt. (R. 519, 523.) He expressed an interest in reintegrating himself into the world so that he could work. (R. 519.) He had stopped drinking in November 2012. (R. 530, 533.) He was diagnosed with major depressive disorder, severe without psychotic features and alcohol dependence, with physiological dependence, early full remission, and given a GAF score of 32. (R. 538.)

         2. Agency Consultants

         Dr. Vidya Madala completed a Disability Determination Explanation on July 12, 2013. (R. 88-96.) She determined Claimant has severe cases of cardiac dysrhythmias, essential hypertension, affective disorders, anxiety disorders, and a non-severe fracture. (R. 92.) His primary diagnosis was for ...


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