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Arcelia B. v. Saul

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

July 30, 2019

ARCELIA B., Plaintiff,
v.
ANDREW SAUL, Commissioner of Social Security Administration, [1] Defendant.

          OPINION AND ORDER

          Sara L. Ellis United States District Judge.

         Plaintiff 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 ALJ's decision.

         BACKGROUND

         I. Medical History

         In 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.

         Arcelia 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.

         On June 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.

         On 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.

         In the 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.

         In June 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.

         II. Employment History

         Arcelia 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.

         III. Disability Claim and Hearing History

         On 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.

         A. Arcelia B.'s Limitations and Activities

         Prior 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 hands ...


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