United States District Court, C.D. Illinois, Springfield Division
THELMA I. McGRAW, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
SCHANZLE-HASKINS UNITED STATES MAGISTRATE JUDGE
Thelma I. McGraw 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). McGraw filed a Motion
for Summary Judgment titled Brief in Support of Motion for
Summary Judgment (d/e 14). The Defendant Commissioner filed a
Motion for Summary Judgment entitled Motion for Summary
Affirmance (d/e 15). McGraw filed a Reply (d/e 17) to
Defendant's Motion for Summary Judgment. 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 2, 2018 (d/e 13).
For the reasons set forth below, the Commissioner's
Motion for Summary Judgment is ALLOWED, McGraw's Motion
for Summary Judgment is DENIED, and the decision of the
Commissioner is AFFIRMED.
was born on September 3, 1951. She secured a GED and took
some college courses. She previously worked as a
coordinator/receptionist-secretary. She alleged that she
became disabled on June 1, 2012 (Onset Date). She qualified
for Disability Benefits through December 31, 2015 (Date Last
Insured). McGraw suffers from status post breast cancer
surgery and treatment, status post shoulder surgery and hip
surgery, left knee arthritis, diabetes, obesity, asthma,
gastroesophageal reflux disease (GERD), and vision
impairments. Certified Copy of Transcript of Proceedings
before the Social Security Administration (d/e 11) (R.),
at 22, 24-25, 59, 61-62, 227.
2002, McGraw underwent right hip replacement surgery. R. 72.
She also underwent shoulder replacement surgery on each
shoulder, one in 2004 and the other in 2007. R. 71; see
e.g., R. 490. She continued working until April 2010.
She retired at that time to take care of her husband. She has
not worked thereafter. R. 80, 227, 234.
March 13, 2011, McGraw underwent a chest x-ray due to a cough
and congestion. The x-ray showed some scarring in the left
mid lung, but no acute pulmonary abnormalities, and no other
abnormalities. R. 354.
January 24, 2012, McGraw saw Dr. Venu Reddy, M.D., for a
follow-up examination after a pulmonary function test (PFT),
methacholine challenge, sleep study, and chest x-ray. R.
577-79. McGraw reported that she was not able to sleep well.
She reported severe insomnia. The PFT and methacholine
challenge were normal. The sleep study showed no evidence of
obstructive sleep apnea. On examination, McGraw's lungs
were clear bilaterally to auscultation. Dr. Reddy assessed
cough with unclear etiology, no evidence of sleep apnea, and
moderate to morbid obesity. R. 578.
20, 2012, McGraw underwent a mammogram, which identified
lumps in her right breast. Subsequent biopsies established
that she had breast cancer. Later in June 2012, McGraw
underwent a lumpectomy, and then a right modified radical
mastectomy and a prophylactic left mastectomy. R. 472.
August 31, 2012, McGraw saw Dr. Mark Khil, M.D., for
evaluation and consideration for radiation therapy. R. 473.
McGraw reported that she had no headaches, dizziness, blurry
vision, or episodes of seizures or strokes. She reported a
history of insomnia. On examination, McGraw was 5 feet 3
½ inches tall and weighed 288 pounds. Dr. Khil
recommended chemotherapy followed by radiation. McGraw had
already seen Dr. Christian El-Khoury, M.D., to schedule the
chemotherapy. McGraw agreed to Dr. Khil's planned
radiation therapy. R. 475.
November 20 2012, McGraw saw nurse practitioner Lisa
Kauffman, CNP, for a follow-up visit during chemotherapy.
McGraw was receiving six cycles chemotherapy treatment every
21 days. McGraw reported that she was feeling better, but had
moderate fatigue. Her chest x-ray taken November 14, 2012,
was clear. McGraw reported numbness in her toes. On
examination, her lungs were clear to auscultation. Her blood
sugar was 178. Kauffman assessed breast carcinoma and
fatigue. R. 387-88.
December 5, 2012, McGraw saw Dr. El-Khoury for a follow-up
during her chemotherapy treatments. McGraw's toes hurt
“without much neuropathy.” The toes were slightly
red and swollen. On examination, McGraw's lungs were
clear. Dr. El-Khoury noted that McGraw would receive her last
chemotherapy treatment on December 20, 2012. R. 391.
January 30, 2013, McGraw saw Dr. Raymond P. Smith, M.D. Dr.
Smith stated that McGraw received her last chemotherapy
treatment on January 9, 2013. On examination, McGraw's
lungs were clear with no rales, rhonchi, or wheezes. Her
blood sugar was 168. McGraw reported that she had her best
night's sleep in months. Dr. Smith stated that she would
continue the recovery from chemotherapy phase of her
treatment. R. 402.
March 12, 2013, McGraw saw Dr. El Khoury for a follow-up.
McGraw was undergoing physical therapy for lymphedema. McGraw
reported not having much pain. She reported some pain in the
left popliteal area. She also had grade I neuropathy, which was
improving. Her fatigue was also better. R. 408. Dr. El Khoury
planned a “Doppler” to see if she had a popliteal
cyst. R. 409.
therapy followed the chemotherapy. On April 3, 2013, McGraw
completed the radiation therapy. R. 477.
April 29, 2013, McGraw saw Dr. Christopher Wagoner for a
three-month diabetes check. R. 523-26. McGraw's A1c was
“fantastic at 6.0.”McGraw denied having blurry
vision. R. 523. On examination, McGraw had normal breath
sounds. She had a normal gait, no joint swelling, normal
movement in all extremities, no joint instability, and normal
muscle strength and tone. McGraw's feet were swollen. Her
toes appeared normal. R. 526. Dr. Wagoner noted that
McGraw's asthma was controlled. He adjusted her insulin
dosage. R. 526.
2, 2013, McGraw saw Dr. Khil for a post-radiation treatment
follow-up. McGraw was stable and otherwise unremarkable. Dr.
Khil scheduled McGraw for a follow-up appointment in six
months. R. 480.
about May 8, 2013, McGraw completed a Function Report- Adult
form. R. 264-71. She reported that she lived in a house
with family. She said she required “lots of
rest.” R. 264. She said that in a usual day, she
showered and dressed, prepared meals for herself and her
husband, did simple housework and laundry, drove to
laundromat, grocery, and “many” doctors'
appointments for herself and her husband. R. 265. She said
she could not do “heavy housework, yard work, drive as
much as needed. Carry things heavy.” She said she had
problems sleeping. R. 265.
said she prepared simple meals because she could not stand
for long periods. She said she washed dishes and performed
“simple cleaning, ” laundry, and cooking. She
said her sons and brothers did the “heavy work, ”
yardwork, and carrying for her. R. 266. She said she could
not do yardwork because she felt weak, she tired easily, and
she often did not feel well. R. 267. She went grocery
shopping three times a week so she could buy a “little
bit at a time” because she could not carry much. R.
267. She rode scooters while in grocery stores. R. 270. She
was able to pay her bills, handle her own funds. R. 267.
said her hobby was researching genealogies. She used a
computer to conduct this research. She did not use the
computer more than three times a week because she tired
easily. She talked to friends and relatives on the phone and
went to church regularly. R. 268-69.
opined that she could not lift more than 10 pounds; she could
walk 50 feet before she needed to rest 10 to 30 minutes; she
could pay attention one to three hours; she finished what she
started unless she was tired; she could follow instructions
and get along with authority figures; and she could handle
stress and changes in routine. R. 269-70.
August 26, 2013, McGraw saw Dr. Christopher Wagoner, M.D.,
for a diabetes check. R. 501-05. Her blood sugar logs ranged
from 141 to 377 with an average reading of 233. McGraw
reported that she was fatigued; but she had no shortness of
breath, no wheezing, and no cough. She reported joint pain
and muscle aches; but no joint swelling, stiffness, muscle
weakness, or loss of strength. She had no headaches, no
numbness, no tingling. R. 501. On examination, she had clear
breath sounds bilaterally, a normal gait, normal movement of
all extremities, no joint swelling, no joint instability, and
normal muscle strength and tone. Dr. Wagoner assessed stress
and prescribed amitriptyline to reduce stress and help McGraw
sleep. R. 505.
same day August 26, 2013, McGraw saw state agency physician
Dr. Joseph Kozma, M.D., for a consultative examination. R.
482-87. McGraw reported that she last worked in April of
2009. She reported that she had diabetes and her last A1c was
7.2. She reported she had diarrhea after every meal. She said
she was not able to walk a block. She said she was unstable
when she walked. She did not use a cane or crutches. R. 482.
She reported that she had migraines occasionally. She said
her diabetes was poorly controlled. She said she had diabetic
neuropathy in her legs. R. 483.
examination by Dr. Kozma, McGraw was 63 inches tall and
weighed 272 pounds. McGraw's visual acuity was 20/20 with
correction. McGraw's lungs were clear to percussion and
auscultation. McGraw had normal strength in her extremities.
McGraw had decreased range of motion in her shoulders. She
had normal grip strength and normal finger dexterity. Sensory
examination and reflexes were normal. R. 484-85.
could heel walk and toe walk. She could squat ¾ of the
way. Straight leg raising was 50 degrees bilaterally. She had
a normal gait. Dr. Kozma observed no instability in her
walking. McGraw could use her hands for both fine and gross
manipulations. R. 485-86.
Kozma stated that McGraw “has a rather strong emotional
attachment to her various symptoms. She is rather convinced
that they are quite incapacitating.” R. 486. Her
medical records indicated that her hypertension and diabetes
were not well controlled. R. 486.
August 28, 2013, state agency physician Dr. B. Rock Oh, M.D.,
prepared a Physical Residual Functional Capacity Assessment
of McGraw. Dr. Oh opined that McGraw could occasionally lift
20 pounds and frequently lift 10 pounds; could stand and/or
walk six hours in an eight-hour workday; could sit six hours
in an eight-hour workday; could frequently climb stairs and
ramps; could occasionally climb ladders, ropes, and
scaffolds; and was limited in reaching overhead with her
right arm. Dr. Oh opined that McGraw had no other functional
limitations due to her impairments. R. 93-95
September 9, 2013, McGraw saw Dr. Wagoner for a two-week
checkup after starting protonix for GERD. R. 489-93 On
examination, McGraw's lungs had clear bilateral breath
sounds and no cough. McGraw had a normal gait, no joint
swelling, normal movement of all extremities, no joint
instability, muscle strength and tone were normal. R. 492.
Dr. Wagoner assessed essential hypertension, depression,
GERD, and insomnia. R. 493.
February 18, 2014, McGraw completed another Function
Report-Adult form. R. 287-95. She reported that she lived
alone in her house. She said that she could not sleep for up
to five days at a time. She did not sleep well even when she
went to sleep. She said she had no stamina. She said she
carried groceries “in stages” or she used a
children's toy wagon to carry them. She said she did not
have much strength. R. 287.
said that she shopped only for necessities. She also went to
the laundromat and visited her husband at the nursing home
where he resided. He husband had dementia. She said she could
not drive for more than 45 minutes. She said her insomnia has
gotten worse since the last report. R. 288.
reported that she prepared her own meals. She prepared
“quick simple things” because she could not stand
for long periods. She no longer prepared big family meals.
She did laundry, dishes, and light vacuuming with breaks. R.
289. She did no yardwork. R. 290. She drove to the nursing
home daily to see her husband. She shopped only when
necessary. She could pay her bills and manage her funds. R.
described her hobbies as “Reading, genealogies, TV,
grandkids.” She sat in a wheelchair when she went
anywhere with her grandchildren. She visited with others
during the day, which included eating with them and going to
movies with them. She went regularly to church, the nursing
home, and the pharmacy. R. 291.
opined that the farthest distance she could walk was
“to the car.” She then had to rest 10 to 15
minutes. She had no problems paying attention. She finished
what she started “unless I fall asleep.” She
could follow instructions and get along with authority
figures. She tried to handle stress, but “when it is
too much I cry.” She could handle changes in routine.
February 24, 2014, McGraw's aunt Marva Hurst completed a
Function Report-Adult-Third Party form. R. 299-306. Hurst
said that she spent two to five hours with McGraw daily.
Hurst said they ate together, watched television, and went
shopping. She said McGraw could not stand or walk very long
before her knee gave out. She said McGraw could not carry
much and had a difficult time catching her breath. Hurst said
McGraw spent her days going to the doctor, the pharmacy, the
laundromat, the nursing home, and visiting her. R. 299.
said McGraw had trouble sleeping. Hurst said McGraw had
difficulty bending to dress and wash herself. R. 300. Hurst
said that McGraw prepared her own meals, but did not take
much time doing so. Hurst said McGraw did her own laundry and
“basic housework.” Hurst said McGraw needed help
carrying laundry to and from the laundromat. R. 301. She said
McGraw's sons did the yardwork. She said McGraw used a
motorized grocery cart to shop for groceries. She said McGraw
could pay her bills and manager her funds. R. 302.
said that McGraw visited her husband daily. She said McGraw
also visited friends and family, including Hurst. McGraw also
went to church. McGraw had someone accompany her when she
drove out of town. R. 303.
opined that McGraw could lift a maximum of 10 pounds; McGraw
could not squat or bend; could not stand for long; and could
walk 50 feet before needing to rest for 10-15 minutes. Hurst
said McGraw could pay attention, follow instructions, get
along with authority figures, handle stress, and handle
changes in circumstances. R. 304-05.
March 26, 2014, state agency physician Dr. Michael Nenaber,
M.D., prepared a Physical Residual Functional Capacity
Assessment of McGraw. R. 103-05. Dr. Nenaber's assessment
was identical to Dr. Oh's assessment in August 2013.
September 19, 2014, McGraw saw ophthalmologist Dr. Robert
Weller, M.D., for a diabetic eye examination. R. 703-05.
McGraw's visual acuity was 20/30 in the right and 20/20
in the left. R. 703. Dr. Weller diagnosed senile cataracts in
both eyes and non-exudative senile macular degeneration of
the retina in the right eye. R. 703.
November 7, 2014, McGraw saw Dr. Wagoner for a three-month
diabetes check. R. 758-63. McGraw's A1c was 6.0, no
change from previous check. McGraw reported headaches in the
evenings sometimes. The headaches resolved
“quickly/spontaneously.” R. 758. On examination,
McGraw had clear bilateral breath sounds, normal gait, no
joint swelling or joint instability, normal movement of all
extremities, normal muscle strength and tone, and full range
of motion in the extremities. R. 762. Dr. Wagoner adjusted
McGraw's diabetes medication. R. 762.
February 9, 2015, McGraw saw Dr. Wagoner for a three-month
diabetes check. R. 850-54. McGraw reported her blood sugar
was running 120-130, and she was having headaches and
fatigue. R. 850. On examination, McGraw had normal breath
sounds bilaterally, normal gait, no joint swelling, normal
movement in all extremities, no joint instability, normal
muscle strength and tone, and full range of motion in her
extremities. McGraw's feet and toes were not swollen.
McGraw had normal tactile sensation with monofilament
testing, normal position sense, and normal vibratory
sensation bilaterally. R. 853-54. Dr. Wagoner assessed
diabetes mellitus type II, controlled. R. 854.
April 15, 2015, McGraw saw ophthalmologist and retina
specialist Dr. Kevin Blinder, M.D. McGraw's vision was
20/50-2 in the right eye and 20/20 in the left. McGraw had
cataracts in both eyes and sub-retinal fluid in the right
eye. Her retinas were attached in both eyes. She had no
leakage of fluid out of either eye. Dr. Blinder assessed
cataracts in both eyes, right worse than left; and possible
central serous chorioretinopathy. Dr. Blinder recommended
removing the right cataract. R. 901.
April 28, 2015, McGraw saw ophthalmologist Dr. Robert Weller,
M.D., for a pre-operative visit. R. 875. On May 12, 2015, Dr.
Weller performed the surgical removal of McGraw's
cataract in her right eye. R. 996.
3, 2015, McGraw saw Dr. Blinder. McGraw's visual acuity
was 20/50-1 in the right eye and 20/40 in the left. Dr.
Blinder found sub-retinal fluid in the right eye, but none in
the left. Dr. Blinder's impression was possibly central
serous chorioretinopathy and pseudophakia in the right eye
and cataract in the left. Dr. Blinder treated her right eye with
an injection. R. 909. The injection consent form stated that
the diagnosis was age-related macular degeneration. R. 911.
22, 2015, McGraw saw Dr. Blinder. McGraw's visual acuity
was 20/50 in the right eye and 20/40-2 in the left. Dr.
Blinder's examination showed pseudophakia in the right
eye and a cataract in the left. Dr. Blinder's impression
was probable occult choroidal neovascularization of the right
eye versus central serous chorioretinopathy. On July 22, 2018,
Dr. Blinder again treated her right eye with an injection. R.
31, 2015, McGraw saw podiatrist Dr. Duane Hanzel, D.P.M., for
thickened and discolored toenails, and a routine clinic
follow-up of diabetic feet. R. 836-40. On examination, McGraw
had abnormal dorsalis pendis pulse and abnormal capillary
refill. She had normal response to light touch and
normal response to monofilament testing. R. 839. Dr. Hanzel
assessed peripheral neuropathy and debrided her toenails. R.
September 3, 2015, McGraw saw Dr. Blinder. McGraw's
visual acuity was 20/50 in the right eye and 20/30 in the
left. Examination showed pseudophakia in the right eye and
cataract in the left. Dr. Blinder's impression was
central serous chorioretinopathy in the right eye, possibly
choroidal neovascularization; pseudophakia in the right eye;
and cataract in the left. McGraw agreed to undergo a laser
treatment in her right eye in the near future. R. 924.
September 29, 2015, McGraw saw Br. Blinder. McGraw reported
that her vision was out of focus in both eyes at night. R.
929. McGraw's visual acuity was ...