United States District Court, N.D. Illinois, Eastern Division
OPINION AND ORDER
L. Ellis United States District Judge.
Arcelia B. seeks to reverse the final decision of the
Commissioner of Social Security Administration denying her
application for disability insurance benefits
(“DIB”) under Title II of the Social Security
Act, 42 U.S.C. §§ 416(i), 423(d), and supplemental
security income (“SSI”) under Title XVI of the
Social Security Act, 42 U.S.C. § 1381(a). In addition to
Arcelia B.'s appeal of the decision denying her
application for benefits, the Commissioner has filed a motion
for summary judgment, asking the Court to uphold the
decision. Because the Administrative Law Judge
(“ALJ”) supported Arcelia B.'s residual
functional capacity (“RFC”) determination with
substantial evidence and properly assessed her subjective
statements about her symptoms, the Court affirms the
Arcelia B.'s initial claim for DIB and SSI, she stated
that her rheumatoid arthritis and pacemaker implant prevented
her from working beginning on September 26, 2014. AR 67. In
2007, she had a myocardial infraction and received a
defibrillator. AR 357. In March 2011, a physician diagnosed
her with rheumatoid arthritis. AR 418.
B. started seeing Dr. Syed Rizvi, a rheumatologist, on March
27, 2014, with complaints of joint pain. Id. In
Arcelia B.'s physical examination results, Dr. Rizvi
wrote that her cervical spine had a full range of motion; she
had complete handgrip and swelling and tenderness on her left
third proximal interphalangeal (“PIP”) joint; the
flexion of both of her wrists was limited to 20 degrees and
their extension to 30 degrees; her right elbow had a flexion
contracture of 20 degrees; and her wrists, elbows, and
shoulders were within normal limits. AR 419. Concerning
Arcelia B.'s lower limbs, Dr. Rizvi noted that she had a
full range of motion in her hips and knees. Id.
Additionally, he wrote that Arcelia B.'s right ankle had
mild swelling, and both of her ankles had tenderness and pain
in their flexion, extension, and eversion. Id. To
address her symptoms, Dr. Rizvi prescribed meloxicam and
prednisone. AR 418. On April 15, Arcelia B. complained to Dr.
Rizvi of experiencing pain in her ankles when at rest or when
performing a physical activity. AR 413. In response, Dr.
Rizvi added methotrexate sodium and sulfasalazine to her
prescriptions and increased the dosage of prednisone. AR 417.
Dr. Rizvi assessed that Arcelia B.'s rheumatoid arthritis
was worsening, but her physical examination results remained
the same from her previous appointment. Id.
4, Arcelia B. complained to Dr. Rizvi of pain in both wrists,
her left foot, and both ankles, describing the pain as
constant and at its worst early in the morning. AR 410. She
also reported that the increased dosage of prednisone made
her eyes swell. Id. Dr. Rizvi decreased the dosage
of prednisone and increased the dosage of the methotrexate
sodium instead. AR 411. Arcelia B.'s physical examination
results remained the same from her previous appointments. AR
412. On July 18, Arcelia B. went to the emergency room for
back and chest pain. AR 352. Her electrocardiogram and chest
x-ray showed no abnormalities, and a physician discharged her
the following day. AR 354. On September 10, Arcelia B.
presented to Dr. Rizvi with complaints of constant, aching
pain, reaching ten on a ten-point scale. AR 407. Dr. Rizvi
found the same results for Arcelia B.'s physical
examination and increased the dosage of methotrexate sodium.
AR 409. On December 9, Arcelia B. reported to the emergency
room complaining of arm and hand numbness and neck pain. AR
489. The next day, she saw Dr. Rizvi, reporting wrist, right
knee, and ankle swelling. AR 572. Dr. Rizvi found the same
results for Arcelia B.'s physical examination. AR 573. He
again increased the dosage of methotrexate sodium and also
prescribed Xeljanz. AR 574. On December 24, Arcelia B. saw
her primary care physician, Dr. Elsa Valero. AR 539. During
that visit, Arcelia B. indicated she could no longer work
because of hand numbness and weakness. Id. Dr.
Valero noted that, although Arcelia B. reported muscle
weakness and joint pain, she did not report muscle aches or
back pain. AR 540. Dr. Valero prescribed diclofenac potassium
for neck pain. AR 542.
February 4, 2015, Arcelia B. complained to Dr. Rizvi of pain
in her neck, hands, right knee, and ankles. AR 567. She also
reported that Xeljanz caused her dizziness and nausea. AR
570. Her physical examination results remained the same.
Id. Dr. Rizvi again increased the methotrexate
sodium dosage. Id. On April 7, Dr. Rizvi again
recorded the same physical examination results, with Arcelia
B. indicating she had swelling in her wrists and right knee
and experienced ankle stiffness. AR 562, 566. Dr. Rizvi
increased Arcelia B.'s sulfasalazine dosage. AR 566. On
July 7, Dr. Rizvi increased the dosage of sulfasalazine and
prednisone, even though Arcelia B.'s physical examination
results remained the same. AR 648. On October 6, Arcelia B.
complained to Dr. Rizvi that the pain in her neck and back
increased with stress and weather changes. AR 639. Dr. Rizvi
noted slight changes to Arcelia B.'s physical examination
results, recording swelling and tenderness of right ulnar
prominence, painful wrist movements, and mild swelling and
tenderness of the left ankle. AR 643. Arcelia B.'s
physical examination results did not change between her
October 6 and December 5 appointments. AR 638.
report of Arcelia B.'s June 7, 2016, visit, Dr. Rizvi
removed the record of painful wrist movements and increased
the methotrexate sodium dosage. AR 629. Dr. Rizvi added back
an observation that Arcelia B. had limited range of motion in
her left wrist due to pain during her September 6
appointment, in addition to noting bilateral knee pain with
pre-patellar pressure. AR 623. On December 6, 2016, Arcelia
B. reported to Dr. Rizvi that the pain in her neck, lower
back, left wrist, right knee, and left ankle sometimes left
her bedridden for a few days. AR 616. Her physical
examination results remained unchanged from her previous
appointment. AR 618.
2015, Arcelia B. saw Dr. Valero because she had been feeling
depressed. AR 328-29. Dr. Valero prescribed Paxil and Xanax.
Id. Arcelia B. saw Dr. Valero again in September
2016 for depression, and Dr. Valero referred her for therapy
and increased her Paxil dosage. AR 606, 609. Arcelia B.
followed up with a therapist, who diagnosed her with major
depressive disorder, recurrent episode, moderate. AR 595. She
participated in individual therapy sessions to manage her
symptoms. AR 596.
B. was born in 1975, and was forty-one years old at the time
of the ALJ's decision. AR 67, 14. She has a high school
education. AR 264. From 2005 to September 2014, she worked as
a cook in a cafeteria, taking orders, handling transactions,
taking inventory, cleaning the cafeteria, and washing dishes.
AR 255-56. She also lifted boxes of chicken and vegetables
and carried them five to ten feet throughout the day.
Id. The heaviest weight she lifted was twenty
pounds. Id. For one-third to two-thirds of a given
workday, she lifted less than ten pounds. Id.
Disability Claim and Hearing History
October 1, 2014, Arcelia B. filed for DIB and SSI, alleging
that she became disabled on September 26, 2014. AR 252. The
agency denied her claims on December 17, 2014, and again on
reconsideration on May 12, 2015. AR 72, 92. Arcelia B.
requested a hearing, which occurred on November 16, 2016, and
at which she had counsel and an interpreter. AR 38. Arcelia
B. and Edward J. Pagella, a vocational expert, testified at
the hearing. AR 20.
Arcelia B.'s Limitations and Activities
to the hearing, in a function report completed in November
2014, Arcelia B. indicated she needed help with most
household tasks and that her sister helped her take care of
her son. AR 276-77. She complained that pain interfered with
her ability to undertake most activities as well. AR 276-83.
In another report completed in April 2015, she emphasized
that her hands, wrists, feet, and right knee were always
swollen, making it difficult for her to walk and use her