United States District Court, C.D. Illinois, Springfield Division
JODY I. DELONJAY, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
SCHANZLE-HASKINS, U.S. MAGISTRATE JUDGE
Jody I. Delonjay appeals from the denial of her application
for Social Security Disability Insurance Benefits (Disability
Benefits) under Title II of the Social Security Act. 42
U.S.C. §§ 416(i) and 423. This appeal is brought
pursuant to 42 U.S.C. § 405(g). Delonjay filed a Motion
for Summary Judgment (d/e 11). The Defendant Commissioner
filed a Motion for Summary Affirmance (d/e 14). The parties
consented to proceed before this Court. Consent to the
Exercise of Jurisdiction by a United States Magistrate Judge
and Reference Order entered January 19, 2018 (d/e 17).
For the reasons set forth below, the decision of the
Commissioner is affirmed.
was born on June 12, 1962. She completed high school.
Delonjay filed her application for Disability Benefits on
October 12, 2012. She has not engaged in substantial gainful
activity since August 11, 2012. Delonjay previously conducted
door-to-door interviews for government surveys. She testified
that she last worked on August 12, 2012. She suffers from
history of concussion and right comminuted humerus fracture,
degenerative disc disease of the cervical spine with history
of fusion, depression, anxiety, and borderline personality
disorder. She also suffers from headaches, a history of right
shoulder replacement, and past substance abuse. Certified
Transcript of Proceedings before the Social Security
Administration (d/e 7) (R.), 35-38, 54, 64, 65, 303,
30, 2012, Delonjay saw her primary care physician Dr. Herbert
E. Childress, D.O., for treatment and management of right
shoulder pain and cervical pain. She was status post
comminuted fracture of her right humerus and status post
cervical fusion with internal hardware fixation devices. R.
297. On examination, Dr. Childress noted reduced range of
motion of the cervical spine and reduced range of motion in
the right shoulder secondary to internal hardware fixation
device and previous fracture. Delonjay reported that she had
no history of drug misuse, and she exercised five or more
times per week. Dr. Childress assessed chronic intractable
pain from cervical radiculitis, discogenic disease, and
status post fracture right humerus. R. 297-98. Dr.
Childress' records of this visit did not mention memory
August 1, 2012, Delonjay went to the emergency room with
right foot pain. She was assessed with bunions. R. 281, 398,
423-24. Delonjay did not report any problems with memory
October 4, 2012, Delonjay saw Dr. Childress to discuss
getting on disability. R. 293-95. Dr. Childress noted
Delonjay's subjective history as follows:
of Present Illness
SUBJECTIVE: Patient reports here today with ongoing treatment
and management of her cervical radiculitis, her migrainous
cephalgia and her other multitude of medical problems which
includes a comminuted fracture right humerus with
arthroplasty for a total joint replacement. She cannot focus,
cannot concentrate based on her chronic pain management and
this makes her dire need of a consideration for a different
occupation and/or no occupation as she has been through a
multitude of surgical surgeries, right humeral surgeries,
chronic intractable pain and medication management for same.
R. 293. On examination, Dr. Childress found reduced range of
motion of the right shoulder, surgical scarification from
shoulder surgery and cervical spine surgery. Dr. Childress
noted, “We referred her to decompression and fusion and
she has had some relief but adhesive radiculopathy has
encompassed her with reoccurring chronic pain.” R. 293.
Dr. Childress assessed cervical radiculitis secondary to
degenerative discogenic disease as well as adhesive
radiculopathy, and recurring right shoulder pain secondary to
arthroplasty and comminuted fracture right humerus. Dr.
Childress opined, “She needs to not be participating in
physical activity associated with occupation. I would
consider her 100% incapacitated.” R. 293. Dr. Childress
also noted “no reported history of drug misuse, ”
and “Exercises 5 or more days/wk.” R. 294.
Childress prescribed hydrocodone-acetaminophen (Norco),
baclofen, butalbital-acetaminophen-caffeine (Fioricet),
lorazepam (Ativan), and promethazine. R. 294-95. Dr.
Childress did not order any tests, such as x-rays, MRIs, or
EMG/nerve conduction studies, and did not recommend physical
therapy or other treatment to address Delonjay's
about October 31, 2012, Delonjay completed a Social Security
Administration Disability Report-Adult form. R.
201-11. Delonjay reported that she suffered from
degenerative disk disease, status post cervical surgery,
right shoulder replacement, eosinophilia, migraines,
recurrent kidney stones, chronic pain, depression, anxiety,
and PTSD. R. 202.
December 30, 2012, Delonjay's husband Jeffrey S. Delonjay
completed a Function Report-Adult-Third Party form. R.
212-19. Jeffrey Delonjay reported that Delonjay could not
keep a daily routine due to pain. He stated that she did not
feel good more than two to three days in a row. He said that
she did not take care of anyone else. He said that she had no
normal sleep routine, sometimes too much sleep, sometimes not
enough. He said Delonjay could dress and bathe herself, but
she had trouble bending and he had to remind her sometimes to
take a bath. He helped shave her underarms. She could feed
herself. R. 213. Jeffrey Delonjay said that Delonjay needed
reminders to take medicine. R. 214.
Delonjay said that Delonjay prepared meals daily. She made
sandwiches, soup, and frozen pizza; and prepared full meals
two to three times a week. Jeffrey Delonjay said Delonjay did
household cleaning and laundry two to three times a week. She
had no consistent cleaning routine. He said she had good days
and bad days. R. 214.
she got out of the house shopping three times a week. She
both drove and rode in cars. Shopping usually took 30
minutes. R. 215. He said she was with her grandchildren two
to three days a week. R. 216. Jeffrey Delonjay said Delonjay
had a short temper. R. 217.
Delonjay opined that Delonjay could lift 10 pounds, stand 10
to 15 minutes, and walk two blocks. He said she needed a
10-minute rest after walking two blocks. He said she could
pay attention for five to 10 minutes. He said she did not
finish what she started. He said her ability to follow
written and spoken instructions depended on how she felt at
the time. R. 217. He said she could get along with authority
figures. She could not handle stress or changes in her
routine well. R. 217.
January 2, 2013, Delonjay saw Dr. Childress. R. 286-88. Dr.
Childress noted that Delonjay reported that she exercised
five or more days a week and had no history of drug misuses.
February 27, 2013, psychologist Dr. Frank Froman, Ed.D.,
conducted a consultative mental examination of Delonjay. R.
303-07. Delonjay's appearance and presentation was
unremarkable. She had a good ability to relate, her speech
was normal, and she made good eye contact. R. 304.
reported that she had a history of drug abuse, including
cocaine, alcohol, and methamphetamine. She reported that in
August 2012 she was in inpatient drug rehabilitation
treatment for 49 days. She said she went into treatment to
see if she could live without Norco. R. 303-04.
reported to Dr. Froman that she had a driver's license,
smoked one pack of cigarettes a day, and socialized modestly.
She reported that she cleaned house and took care of her
grandchildren. She said that she loved her grandchildren. She
said that her grandchildren made her happy. She said she
could perform her own self-care, but some days she hurt too
much to do such care. She said she could do chores, but
sometimes, “'particularly if my kidneys act up, it
hurts too much to do them.'” R. 304.
reported to Dr. Froman that she was frequently depressed and
anxious. She reported that she suffered from PTSD due to her
mother's abusive treatment of her as a child. She
reported, “‘I have fugue episodes.'”
Dr. Froman stated:
Unfortunately, there is no psychological documentation of
this. What we have in her record is a medical note about
shoulder and cervical root compression injuries. One would
need to look back on her psychiatric background in order to
document these problems that she alleges.
R. 305. Dr. Froman diagnosed nicotine dependence, continued
marijuana use, history of alcohol and cocaine abuse in full
remission, mood disorder not otherwise specific, allegations
of fugue states, and borderline personality disorder. Dr.
Froman assigned a Global Assessment of Functioning (GAF)
score of 55. R. 305.
Froman opined that Delonjay could perform one or two-step
assemblies at a competitive rate, she could relate to others,
and she could understand oral and written instructions. Dr.
Froman expressed concern about the allegations of Fugue
states, but offered no opinion on the allegations because no
historical documentation existed in the records provided. R.
March 11, 2013, Delonjay saw Dr. Childress for medication
refills and back pain after a recent fall. R. 328-30.
Delonjay reported that she had headaches that were controlled
with Fioricet. Dr. Childress asked about the frequency of her
use of Fioricet and rebound headaches. Delonjay said she
“takes it under advisement.” Delonjay also
reported that she was under Dr. Froman's care for
depressed mood. R. 328.
examination, Dr. Childress found that Delonjay had
“intermittent tension cephalgia secondary to stressors
of life.” Dr. Childress noted reduced range of motion
in lumbar spine. He stated that “previous radiographs
confirm her degenerative discogenic disease.” R. 328.
Dr. Childress noted that Delonjay had surgery on her right
arm for right humerus fracture on January 29, 2007. Dr.
Childress renewed her medications. R. 328.
next day, on March 12, 2013, state agency physician Dr.
Joseph Kozma, M.D., performed a consultative examination of
Delonjay. R. 310-15. Delonjay reported to Dr. Kozma that she
had right shoulder replacement surgery and had decreased
range of motion in her right shoulder. She reported that her
memory was poor. She reported that she had “difficulty
with spatial orientation although she does not get
lost.” She reported having migraine headaches. She
reported that the headaches “are not very frequent and
she takes some Fioricet for that.” She reported
“some type of post traumatic syndrome” caused by
her mother when she was younger. She reported that she had
chronic anxiety. She reported that she had panic attacks
three times a month. She said she had shortness of breath
during the panic attacks. R. 310.
reported that she had kidney stones removed in 2009, right
shoulder replacement surgery in 2008, and surgery on her neck
in 2007. Delonjay reported that she was bipolar. R. 311. She
said she had migraine headaches once or twice a month. R.
examination, Dr. Kozma found that Delonjay had normal range
of motion in her cervical spine. She had no tenderness in her
cervical spine and her neck muscles had normal tone without
rigidity. R. 312. Her upper extremities had normal strength.
Her left shoulder had normal range of motion. Her right
shoulder had limited range of motion in forward elevation,
backward elevation, and abduction. Delonjay had normal
internal and external rotation, and adduction of the right
shoulder. She had normal dexterity and normal grip strength.
R. 313. Delonjay's lower back showed no tenderness and
Kozma's neurological examination showed deep tendon
reflexes of 3 in the lower extremities and 4 in the upper
extremities; normal sensory examination; normal cranial nerve
examination; no abnormal reflexes; and normal equilibrium. R.
Kozma's functional examination showed that Delonjay had
normal heel and toe walking, and squatting. She had a normal
gait and no postural instability. She could bend forward with
her leg straight and reach within an inch of the floor. Her
lumbar spine flexion was 95 degrees; rotation of her upper
pelvis was 45 degrees in both directions, lateral tilt was 25
degrees in both directions, and extension was 10 degrees. Her
straight leg raising was 85 degrees for the right leg and 90
degrees for the left. R. 314.
Kozma observed that Delonjay was oriented in all spheres and
seemed to have a stable emotional state. Delonjay's
intellectual functions were intact, and her thought content
and communication were proper to the occasion. R. 313.
DISCUSSION: Ms. Delonjay is a right handed individual who has
no difficulty using her hands and fingers for gross and fine
manipulations. Her grip strength is good, so is her finger
She is complaining of generalized aches and pains but she
emphasizes that her main problem, really, is emotional. She
has bipolar disorder. She also has significant changes in her
She is depressed. This is a lifelong condition for her and
she is not suicidal.
She has some days when she cannot remember things and she has
nightmares and she attributes that to mistreatment that she
experienced when she was very young and her mother was the
person causing the problems.
She has a history of kidney stones in the past but she has no
She has a great deal of anxieties. She has panic attacks. She
had three (3) to four (4) of them during the past months. It
used to be much more frequent.
Her right shoulder replacement is working satisfactory. The
range of motion is determined by the hardware.
She has a condition that she was told but she does not know
what it is and she simply says it is called eosinophilia but
no further information is found.
A review of some of the medical records indicate that she has
chronic cervical radiculitis and her pain in the right
shoulder is considered to be intractable. She is taking
narcotic pain medications.
It seems that her medications are quite adequate. Reduction
of the range of motion of the right shoulder is noted in one
of the medical records.
This examination and interview required 38 minutes to
complete and is considered reliable. If you need additional
information or desire clarification, please contact me at
IMPRESSION: Chronic pain in the right
History of arthroplasty of the right
Decreased range of motion of the right
Pain in the cervical spine.
Defective memory (needs assistance).