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Delonjay v. Berryhill

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

April 13, 2018

JODY I. DELONJAY, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          OPINION

          TOM SCHANZLE-HASKINS, U.S. MAGISTRATE JUDGE

         Plaintiff 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.

         STATEMENT OF FACTS

         Delonjay 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, 310.

         On July 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 loss.

         On 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 loss.

         On October 4, 2012, Delonjay saw Dr. Childress to discuss getting on disability. R. 293-95. Dr. Childress noted Delonjay's subjective history as follows:

         History 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.

         Dr. 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 condition.

         On or about October 31, 2012, Delonjay completed a Social Security Administration Disability Report-Adult form. R. 201-11.[1] 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.

         On 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.

         Jeffrey 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.

         He said 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.

         Jeffrey 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.

         On 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. R. 288.

         On 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.

         Delonjay 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.

         Delonjay 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.

         Delonjay 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.[2]

         Dr. 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. 305.

         On 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.

         On 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.

         The 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.

         Delonjay 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. 311.

         On 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 normal tone.

         Dr. 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. 313.

         Dr. 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.

         Dr. 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.

         Dr. Kozma concluded:

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 dexterity.
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 memory.
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 problem now.
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 your convenience.
IMPRESSION: Chronic pain in the right shoulder.
History of arthroplasty of the right shoulder.
Decreased range of motion of the right shoulder.
Pain in the cervical spine.
Defective memory (needs assistance).

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