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Holmes v. Berryhill

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

November 29, 2017

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


          Young B. Kim, Magistrate Judge.

         Harriet Holmes filed applications for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) alleging that she is disabled by degenerative arthritis, bronchitis, difficulty walking after surgery on her toes, and problems breathing while walking. After the Commissioner of the Social Security Administration denied her applications, Holmes filed this suit seeking judicial review. See 42 U.S.C. § 405(g). Before the court are the parties' cross-motions for summary judgment. For the following reasons, Holmes's motion is denied, and the government's is granted:

         Procedural History

         Holmes filed her DIB and SSI applications on March 31, 2014, alleging a disability onset date of October 15, 2013. (Administrative Record (“A.R.”) 15.) After her claims were denied initially and upon reconsideration, (id. at 87-120), Holmes sought and was granted a hearing before an Administrative Law Judge (“ALJ”), (id. at 31-84). The ALJ issued his decision on July 25, 2016, denying Holmes's applications. (Id. at 15-25.) When the Appeals Council denied Holmes's request for review, the ALJ's denial of benefits became the final decision of the Commissioner. See Minnick v. Colvin, 775 F.3d 929, 935 (7th Cir. 2015). Holmes filed this suit seeking judicial review of the Commissioner's decision, (R. 1); see 42 U.S.C. § 405(g), and the parties consented to this court's jurisdiction, (R. 9); see 28 U.S.C. § 636(c).


         At her May 2016 administrative hearing before the ALJ, Holmes, represented by counsel, submitted both documentary and testimonial evidence in support of her claims.

         A. Medical Evidence

         The medical evidence of record shows that Holmes receives primary care treatment through the Midtown Medical Center where she is seen by Dr. Syed Husain. Holmes saw Dr. Husain once or twice a month between August 2014 and April 2016, primarily for management of her ongoing low-back and hip pain. (A.R. 403-63.)

         On January 10, 2014, Holmes underwent x-rays of her lumbosacral spine, pelvis, and bilateral hips. (Id. at 343-44.) The lumbosacral x-rays revealed no acute fracture and only mild degenerative facet disease and mild degenerative disk disease. (Id. at 344.) The pelvic and hip x-rays indicated that the pelvic ring was intact, the sacroiliac joints were unremarkable, there was pseudo-articulation between the right transverse process of L5 vertebra and the sacrum, and that there were calcifications in the right and left pelvis. (Id. at 343.) Views of the hips were unremarkable, demonstrating no acute fracture or dislocation and that the hip joints were preserved. (Id.)

         On September 3, 2014, Holmes underwent an internal medicine consultative examination performed by Dr. Liana Palacci. (Id. at 356-59.) Holmes reported a past medical history of low-back pain since approximately November 2013. (Id. at 357.) She denied any history of trauma. (Id.) She indicated that she had x-rays of her back and was diagnosed with arthritis. (Id.) Holmes told Dr. Palacci that her pain radiated into the right buttock and leg, but she denied having numbness or weakness. (Id.) She stated that walking and standing exacerbated her pain and that sitting alleviated her discomfort. (Id.) Holmes also indicated that she had been using a non-prescribed cane for balance since February 2014 and that she needed the cane in order to walk more than 50 feet. (Id.)

         Other than noting that Holmes had a mildly antalgic gait, Dr. Palacci reported that the physical examination was otherwise unremarkable. (Id. at 358.) She found that Holmes's grip strength was normal, that she could make fists and oppose fingers, that her range of motion of the shoulders, elbows, wrists, hips, knees, and ankles were normal, and that her reflexes were present, equal, and symmetric. (Id.) Her strength was 5/5 in the upper and lower extremities. (Id.) Holmes was able to heel-and-toe stand, perform knee squats, and walk 50 feet without the use of any assistive devices. (Id.) The range of motion of her cervical and lumbar spine were normal and her straight leg raise test was negative. (Id.) The mental status examination was also normal. (Id.)

         Following Holmes's consultative examination, non-examining agency consultant Dr. Charles Kenney reviewed her records and opined that Holmes retains the capacity to lift up to 20 pounds occasionally and up to 10 pounds frequently, and can sit, stand, or walk for approximately six hours in an eight-hour workday. (Id. at 99.) He further opined that Holmes could occasionally climb ramps, stairs, ladders, ropes, or scaffolds, balance, stoop, kneel, crouch, and crawl. (Id. at 99-100.)

         On January 21, 2015, another non-examining agency consultant, Dr. Bernard Stevens, reviewed Holmes's records. Dr. Stevens noted that Holmes had not alleged worsening symptoms or limitations at the reconsideration level and affirmed Dr. Kenney's assessment of Holmes's exertional limitations. (Id. at 99, 106, 108.) However, Dr. Stevens assessed less restrictive postural limitations than Dr. Kenney. (Id. at 99-100, 109.) He opined that Holmes would be limited to occasionally climbing ladders, ropes, or scaffolds, and frequent climbing of ramps or stairs, stooping, kneeling, crouching, and crawling. Dr. Stevens found no limitations with regard to balancing. (Id. at 109.)

         Meanwhile, Dr. Husain's 2014 and 2015 treatment records typically show Holmes reporting either low-back pain or hip pain made worse with ambulation and prolonged standing. (Id. at 403-41.) Musculoskeletal findings upon physical examination revealed either low-back tenderness or hip or bilateral hip tenderness. (Id.) Overall, the notes reflect various diagnoses such as low-back pain, hip pain, joint stiffness, pain in the joint involving the lower leg, and pain in the joint involving the pelvic region and thigh. (Id.) In January 2015 Holmes began reporting myalgias and lower extremity pain and tightness, for which Dr. Husain prescribed Flexeril. (Id. at 412-15.) Then in June 2015, Holmes began reporting lower extremity neuropathic pain. (Id. at 423.) The records also reflect prescriptions for a walker and a shower bench for mobility assistance. (Id. at 418, 427.)

         In May 2015 Holmes reported to Dr. Husain that she had been “feeling more depressed recently.” (Id. at 421.) Dr. Husain noted that Holmes cried during the interview but that she had not followed up with a previous psychiatric referral. (Id.) Dr. Husain assessed depression and provided a new referral to a psychiatrist. (Id. at 421-22.)

         On September 1, 2015, Dr. Husain completed a physical Medical Source Statement. (Id. at 366-71.) He noted diagnoses of degenerative arthritis, hip pain, and depression. (Id. at 366.) He indicated a satisfactory prognosis and reported that treatment had consisted of physical therapy and oral pain medication. (Id.) He noted, among other things, Holmes's bilateral hip pain, borderline diabetes mellitus, lower back tenderness, and bilateral hip tenderness. (Id.) Dr. Husain opined that Holmes's pain, symptoms, or medication side effects are frequently severe enough to interfere with her attention and concentration, and that she is incapable of tolerating even low-stress jobs. (Id. at 367.) He further opined that Holmes's symptoms prevent her from maintaining the persistence and pace to engage in competitive employment. (Id.) He indicated that she is incapable of functioning on a part-time basis, and that her symptoms have a moderate impact on her ability to perform activities of daily living. (Id. at 368.)

         According to Dr. Husain, in an eight-hour day Holmes could sit, stand, and walk less than two hours each. (Id. at 371.) He wrote that she would have to shift positions from sitting to standing or walking every 30 minutes, (id. at 370), but that she could sit continuously for 60 minutes, (id. at 369). Further, Holmes would need to elevate her legs or feet to 90 degrees. (Id. at 370.) According to Dr. Husain, if Holmes had a sedentary job her legs should be elevated 100% of the workday. (Id.) He also opined that Holmes requires the use of an assistive device and is unable to ambulate effectively ...

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