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Catrina C. v. Commissioner of Social Security

United States District Court, C.D. Illinois, Rock Island Division

August 5, 2019

CATRINA C., Plaintiff,



         Now before the Court is the Plaintiff's Motion for Summary Judgment (Doc. 12), the Defendant's Motion for Summary Affirmance (Doc. 17), and the Plaintiff's Reply (Doc. 19). This matter has been referred for a report and recommendation. The Motions are fully briefed, and for the reasons stated herein, the Court recommends the Plaintiff's Motion for Summary Judgment be denied and the Defendant's Motion for Summary Affirmance be granted.[1]


         Catrina C. filed an application for disability insurance benefits (DIB) on April 15, 2014 and alleged disability beginning on December 22, 2012. Her claim was denied initially on October 15, 2014 and upon reconsideration on June 2, 2015. Catrina filed a request for hearing concerning her application for DIB. A hearing was held before the Honorable John M. Wood (ALJ) on August 9, 2016. At that hearing, Catrina was represented by an attorney and a vocational expert (VE) testified. Following the hearing, Catrina's claim was denied on April 14, 2017. Her request for review by the Appeals Council was denied on October 25, 2017, making the ALJ's Decision the final decision of the Commissioner. Catrina filed the instant civil action seeking review of the ALJ's Decision on July 19, 2018.


         At her August 2016 hearing, Catrina was 40 years old and lived with her seven-year-old daughter and boyfriend in a home in Monmouth, Illinois. She alleged the following conditions limited her ability to work: rheumatoid arthritis (RA) with nodules; fibromyalgia; degenerated and herniated discs; irritable bowel syndrome; polycystic ovarian syndrome; bone spurs on front of spine; poly inflammatory arthritis; memory problems; fatigue; and bone spur and cyst on right heel. AR 251.

         Catrina testified that she was able to get up and down the stairs in her home “most days, ”and she “sometimes” drove. AR 83, 84. As for the last time she worked, Catrina worked as a companion to a disabled woman. The job entailed washing a few dishes for the woman, turning her pillow over for her, doing some light dusting, and sometimes having to physically re-adjust the woman. Catrina did not believe she could do that job at present (at the time of the hearing) because she could not physically help the woman adjust anymore. She testified she was otherwise too tired to work a full day, even if the job were simple and Catrina could stand when she wanted, sit when she wanted, and lift no more than five or 10 pounds. She also said another reason she would be unable to work was because there were days she did not drive due to experiencing a flare and because of pain she had. When she did not have flare ups, Catrina was able to do household tasks such as cooking, laundry, dishes, and cleaning. She mentioned she had help with the laundry and did not carry the laundry baskets and did not vacuum because she could not push and pull it. She cooked “most weeks, ” did the dishes when she was “able to, ” and usually had help when she grocery shopped. AR 86, 87.

         As for her flare ups, Catrina said they came and went, but she “usually” had them most days, and some had lasted an afternoon while some had lasted for three weeks. AR 87. She left her home to take her daughter to and from school which, that year, entailed a three-block drive. Every few months she visited her father who lived an hour away. In the summer, if “up for it, ” Catrina liked to go fishing which involved standing on a bridge, and she was “sometimes” able to reel the fish in herself. AR 88, 89. As of the summer of the hearing, Catrina was able to go fishing twice. She said she was no longer able to go to church because she was falling asleep in church. She went to see her boyfriend's family every couple of months, and the friends Catrina still had she talked to on the phone or via text message. She testified she used to read but could not stay focused long enough to do so anymore. The last book she read was right after the new year. She attended parent-teacher conferences and music concerts at her daughter's school.

         Catrina's attorney then questioned her. Catrina explained her pain flares to be caused by her RA and that they felt like hot concrete had been poured into her joints “all over.” AR 92. Catrina stated that she had headaches “[a]lmost daily, ” and they were made worse by stress, being too tired, and too much noise. AR 93. Catrina elaborated regarding her daily naps that they lasted anywhere from a half hour to two hours, and she usually took two per day. Catrina testified that her daughter helped her with cleaning the house and laundry, her daughter's cousin took her daughter to church, and friends dropped her daughter off at school. She could push a grocery cart if it was not too full.

         Upon her attorney pointing out that Catrina used a walker, Catrina explained the walker was prescribed because she was having problems with her balance. She said she would “get so far and then [she had] to stop and sit down.” AR 94. Also upon her attorney pointing it out, Catrina explained she had a brace on her right leg due to a fractured heel and torn Achilles tendon. She stated it was not yet fully healed so the doctor had her wear the brace to try to keep her foot “lined up.” AR 94. Catrina confirmed that she noticed a difference in her memory since the onset of her disability and currently used reminders for her medications, necessary groceries and household items, and events like registration day at her daughter's school. She was “sometimes” able to use a keyboard when she was not “flaring” in her hands and wrists. AR 96.

         The VE was next questioned.


         The ALJ determined Catrina had the following severe impairments: RA; polycystic ovarian syndrome; fibromyalgia; obesity; degenerative changes of the cervical spine; degenerative disc disease and osteoarthritis lumbosacral spine; and right Achilles tendinitis. AR 24. The ALJ made the following residual functional capacity (RFC) finding in his Decision:

[T]he claimant had the [RFC] to perform sedentary work as defined in 20 CFR 404.1567(a) except no climbing ladders, ropes or scaffolds; no crawling or kneeling; other postural functions occasionally; occasional pushing/pulling with the upper and lower extremities; occasional overhead reaching; other manipulative functions frequently; must avoid hazards; no appreciable exposure to vibrations; must avoid concentrated exposure to extreme temperatures; and owing to chronic physical pain and side effects from medication, a limitation to the performance of simple and repetitive tasks involving little or no change in work routine and only occasional interactions with the public, coworkers and supervisors.

AR 25-26. The ALJ discussed Catrina's July 2014 Function Report in which Catrina reported, among other things, difficulty staying focused on tasks, had extreme fatigue, had to take naps, could not lift over 10 pounds though some days even two or three pounds was too painful, she could not stay in one position for too long, walking was difficult for her, had flares that limited her movement, used a heating pad and took pain medications, walked unbalanced due to back pain, and needed to change positions and rest often. The ALJ noted that Catrina made similar complaints of pain symptoms and functional limitations in her hearing testimony and would not repeat them in his Decision for the sake of economy.

         The ALJ also considered Catrina's daily activities which included driving, doing dishes, light cleaning, laundry, cooking, grocery shopping, caring for her seven-year-old daughter, and occasionally fishing. The ALJ concluded such activities were “not limited to the extent one would expect, given the complaints of disabling symptoms and limitations.” AR 27. The ALJ next concluded, regarding Catrina's alleged RA, fibromyalgia, obesity, degenerative changes of the cervical spine, and degenerative disc disease and osteoarthritis lumbosacral spine, the “longitudinal medical evidence of does [sic] not show diagnostic findings that correlate to pain symptoms or objectively determinable functional limitations that prevented the claimant from engaging in all substantial gainful activity.” Id.

         The ALJ discussed Catrina's August 2014 internal medicine consultative examination and her complaints of generalized joint and body pains, pain flares, fatigue, difficulty with focusing and concentrating, and lapses of memory. Findings on examination at that time revealed she was unable to toe/heel walk, tandem walk, squat or hop on her right leg, had full grip strength and normal grasping and manipulation of both hands, had 16 of 18 fibromyalgia tender points, and had limited range of motion of the lumbar spine, the right ankle, and left shoulder. She could walk 50 feet at that time, but did have a “mildly-antalgic” gait “with the use of a non-prescribed cane for confidence.” AR 27, citing AR 507.

         The ALJ also discussed Catrina's treating rheumatologist Vaugh Hanna, M.D.'s treatment notes dated November 2014, February 2015, April 2016, and October 2016. The ALJ cited Dr. Hanna's November 2014 objective examination during which Catrina demonstrated “moderate pain behaviors, ” exhibited tenderness of the MCP and PCP joints, reduced fist closure, and pain with limited active ranges of motion of parts of her body. At her February 2015 appointment, Catrina alleged 8.5/10 pain, malaise/fatigue, and continued use of a cane or walker at times. She again showed “moderate pain behaviors.” AR 28, citing 532. Dr. Hanna again noted “moderate pain behaviors” in April 2016, that Catrina ambulated using a cane and was wearing a boot cast, and she had no significant swelling or synovitis of peripheral joints but did have tenderness of certain identified muscles with a limited active range of motion of her lumbar spine with pain. The ALJ noted Dr. Hanna's treatment plan consisted of weaning Catrina off Prednisone, refilling Tylenol 3, a return visit in six months, laboratory testing ordered, physical therapy as needed, and podiatry and pain clinic follow-ups as recommended. Dr. Hanna's October 2016 treatment notes indicated “moderate pain behaviors, ” no edema or swelling, tenderness of the MCP and PCP joints, mild osteoarthritis changes of the hand, pain with limited active range of motion of the wrists and shoulders, tenderness of certain identified muscles, and limited active range of motion with pain.

         The ALJ also detailed the results of a May 2015 lumbar spine x-ray (mild to moderate spondylosis of the lumbosacral spine) and a May 2015 cervical spine x-ray (moderate degenerative changes of the lower cervical spine and grade 1 retrolisthesis of C5 on C6). The ALJ detailed the results of Catrina's pulmonary function testing in September 2015 which were normal and at the lower limits of normal. Catrina presented to the emergency room in December 2015 for back pain that started the previous day and became worse as it went down her left leg. While she alleged 8/10 pain and a frequent occurrence of episodic pain, she did not appear in acute distress, exhibited no numbness or neurological abnormality, and straight leg raises were negative. The ALJ also quoted the results of a February 2016 lumbar spine MRI and a February 2016 cervical spine MRI.

         The ALJ additionally discussed Catrina's right Achilles tendinitis and stated, “the record reveals a gap in treatment for the allegedly disabling symptoms with the longitudinal record not showing this impairment causes greater functional limitations than those found within this decision.” AR 29. The ALJ noted Catrina's history of Achilles tendon repair in June 2014, results of MRIs and x-rays, and that Catrina started to use a right boot case and used a cane, walker, or scooter as needed. The ALJ concluded, “The medical evidence of record does not document this impairment has resulted in a lasting inability to ambulate effectively.” Id.

         The ALJ turned to the opinion evidence and explained the State Agency physicians' RFC conclusions supported a “not disabled” finding and deserved “some weight” where there existed “a number of other reasons to reach similar conclusions (as explained throughout [the] decision).” AR 30. The ALJ detailed treating Dr. Hanna's April 8, 2014 Arthritis Medical Source Statement which limited Catrina to walking 1-2 city blocks without rest, she could sit no longer than one hour at a time before needing to get up, and she could stand for 20 minutes at one time before needing to sit down or walk around. Dr. Hanna opined Catrina was limited to standing/walking about two hours total in an eight-hour work day, sitting about four hours total in an eight-hour work day with the need for a job to allow shifting positions at will from sitting, standing, or walking, she needed unscheduled breaks every two hours for five minutes, she was limited to lifting and carrying less than 10 pounds occasionally and 20 pounds rarely, and she was limited to no climbing ladders, occasionally climbing stairs, and rarely twisting, stooping/bending, and crouching/squatting. Dr. Hanna further opined Catrina would be off task where her symptoms were likely severe enough to ...

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