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Nicholas G. v. Saul

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

August 28, 2019

NICHOLAS G., Plaintiff,
ANDREW SAUL, Commissioner of Social Security, [1] Defendant.



         Claimant Nicholas G. (“Claimant”) brings a motion for summary judgment to reverse the final decision of the Commissioner of Social Security that denied Claimant's claim for Disability Insurance Benefits. The Commissioner brings a cross-motion for summary judgment seeking to uphold his decision to deny benefits. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. §636(c). For the reasons stated below, Claimant's motion for summary judgment to reverse the final decision of the Commissioner [Dckt. #13] is denied, and the Commissioner's motion for summary judgment [Dckt. #20] is granted.

         I. BACKGROUND

         A. Procedural History

         On March 12, 2012, Claimant (then 53-years old) filed a Title II Disability Insurance Benefits (“DIBs”) application alleging a disability onset date of December 22, 2011. (R. 12, 43.) His claim was denied initially, upon reconsideration, and following a hearing held by Administrative Law Judge (“ALJ”) Roxanne Kelsey. (R. 9-20.) Claimant requested review by the Appeals Council. (R. 7-8.) On June 24, 2014, the Appeals Council denied his request for review, at which time the ALJ's decision became the final decision of the Commissioner. (R. 1-3); Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). Claimant subsequently filed a complaint in the District Court. (R. 380.) Then Magistrate Judge Rowland issued a decision reversing the ALJ's decision on June 10, 2016. (R. 384-98.) On remand, ALJ Kelsey held another hearing and again denied Claimant's application on January 30, 2017. (R. 317-29.) Claimant's request for review by the Appeals Council was denied on September 29, 2017. (R. 303.) Claimant subsequently filed a complaint in this Court.

         B. Medical Evidence In The Administrative Record

         The administrative record contains the following medical evidence that bears on Claimant's claim for DIBs:

         1. Evidence from Treating Sources

         Claimant presented to Tamika Hobson, PA-C, at Personal Physicians on December 28, 2011 complaining of nervousness and insomnia. (R. 201.) PA Hobson attributed this to his recent unemployment and denial of disability. (Id.) On February 2, 2012, Claimant saw Dr. Jain Shishir at Personal Physicians for his asthma. (R. 203.) Claimant had been seeing Dr. Shishir quarterly for treatment for his asthma since 2009. (R. 174-217, 233-251.) Claimant was prescribed Singulair and an Advair Diskus inhaler. (R. 203.) At an October 2010 appointment, the asthma was noted to not limit his activities. (R. 192.) In January 2011, Dr. Shishir documented that the asthma symptoms were rare. (R. 194.) In September 2011, dyspnea and wheezing were reported to be monthly or less and coughing was weekly or less. (R. 199.) At the February 2012 appointment, Dr. Shishir noted that the symptoms were well controlled with medicine and assessed the chronic asthma as mildly persistent and stable on his current medication dosage. (R. 203.) Claimant's lungs were clear to auscultation and percussion. (Id.)

         On June 25, 2012, Claimant was seen as an outpatient by Dr. Rafiq Muhammad. (R. 292-95.) Claimant's chief complaints were that he needed a primary care physician, that he had lower back problems, was stressed, had no job, and slept poorly. (R. 292.) Claimant's diagnoses upon discharge were hypertension (“HTN”), asthma (unspecified), low back pain, gastroesophageal reflux disease (“GERD”), and allergic rhinitis. (R. 294.) His lungs were reported to be clear to auscultation, and his asthma was documented as stable. (R. 293-94.) Claimant was again seen by Dr. Muhammad for a routine visit on September 14, 2012. (R. 282-90.) While the medical records from that outpatient visit reference a June 2012 exam of the lumbar spine that found mild scoliosis of the lumbar spine with concavity toward Claimant's right side and small, thin spurs noted at ¶ 5 and L2, Claimant's lower back pain was documented to be mildly improved. (R. 289.) Claimant's lungs were again reported to be clear to auscultation and asthma was stable. (R. 287, 289.)

         Dr. Muhammad completed a medical questionnaire on February 8, 2013. (R. 297-98.) He reported treating Claimant since April 18, 2012. (R. 297.) Dr. Muhammad noted Claimant's HTN, asthma, allergic rhinitis, GERD, and low back pain (which was identified as moderate in severity). (Id.) Dr. Muhammad further stated that Claimant had difficulty bending and lifting heavy objects and would not be capable of performing a full-time job. (R. 297-98.)

         Dr. Muhammad saw Claimant for routine outpatient follow-up visits on February 14, 2014, July 14, 2014, October 20, 2014, May 22, 2015, October 23, 2015 (R. 637-78.) During those visits, Dr. Muhammad consistently documented that Claimant's lungs were clear to auscultation, that there were no neurologic focal deficits, and that his asthma was stable. (Id.) Claimant's treatment plan was maintained throughout the course of the visits. (Id.) However, in April of 2015, Claimant presented to the emergency room at Advocate Christ Hospital complaining of shortness of breath that had been present for ten weeks. (R. 553, 572.) Claimant was treated with a nebulizer and given steroids and an inhaler on discharge. (R. 561, 573, 584.)

         Dr. Muhammad completed another medical questionnaire on September 26, 2016, this time stating that he had been treating Claimant since May 16, 2014. (R. 550-51.) Dr. Muhammad opined that Claimant had the following diagnoses: low back pain (moderate severity), neck pain (moderate severity), asthma, and hypertension. (R. 550.) The lower back pain was said to radiate to the left lower extremities, but there was no radiation of the neck pain. (Id.) Dr. Muhammad further documented that Claimant's functional limitations due to his medical conditions were that he had difficulty bending, twisting, lifting, and pulling heavy objects as well as difficulty moving his neck from side-to-side. (Id.) Dr. Muhammad noted that Claimant had not worked since December 2011. (R. 551.)

         2. Evidence from Agency Consultants

         Dr. Charles Kenny completed a physical residual functional capacity assessment on May 14, 2012. (R. 253-60.) Asthma was identified as the primary diagnosis, with chronic fatigue listed as another alleged impairment. (R. 253.) Dr. Kenny opined that Claimant should avoid concentrated exposure to extreme heat, extreme cold, humidity, and pulmonary irritants to prevent the exacerbation of asthma. (R. 257.) According to Dr. Kenny, Claimant's statements regarding his limitations were consistent with the objective medical findings and credible. (R. 258.) Dr. Gotway affirmed Dr. Kenny's findings on August 10, 2012, noting that “[t]he additional records received at the reconsideration level did not indicate any worsening of the [C]laimant[']s conditions and no new conditions or complaints.” (R. 261-63.)

         On October 30, 2012, Dr. Patrice Solomon completed a Psychiatric Review based on Claimant's anxiety disorder. (R. 267-77.) Dr. Solomon opined that Claimant had a medically determinable impairment that did not satisfy the diagnostic criteria of an anxiety disorder. (R. 271.) With respect to Claimant's functional limitations, Dr. Solomon documented that Claimant had no limitations in activities of daily living, and mild limitations in maintaining social functioning and maintaining concentration, persistence, and pace. (R. 275.) There was insufficient evidence of any repeated episodes of decompensation. (Id.)

         C. Evidence from Claimant's Testimony

         During a hearing on November 8, 2016, Claimant testified that he has not worked since December 22, 2011 because of his numerous problems, specifically noting his arthritis in his neck and back and lethargy as a result of his asthma. (R. 342.) He reported that he did not have problems seeking medical treatment, but that he has had problems falling after being treated, specifically noting a time that he fell after coughing and trying to open a door. (Id.) Claimant testified that his doctor told him it was a result of his asthma. (Id.)

         Claimant then discussed his December 2015 hospitalization, stating that he went because his lungs felt full and he could not breathe. (R. 343.) He was put on a nebulizer breathing machine, given two doses of medication, and eventually discharged with a new medication. (R. 343-44.) When asked if he has had problems since then, Claimant responded that he always has problems, but not so severe as to warrant going to the hospital. (Id.) Claimant uses a nebulizer about three times a week when he feels very suffocated in his chest. (Id.) His doctor has advised him to continue taking his medications and that there is nothing else to be done. (R. 344-45.)

         Claimant reported being unable to help with chores except possibly “light” tasks. (R. 345.) He explained that chores like mopping are heavy and make him “tired in [his] chest.” (Id.) Claimant then testified that he can stand for about an hour, walk very slowly for four blocks, lift 18-20 pounds, and cannot sit or lay down for a long time because of the pain in his back. (R. 346.)

         Upon questioning by his attorney, Claimant explained that he has pain in his neck and lower back and gets headaches when he coughs a lot. (R. 347.) He stated that it hurts to bend at his waist, and he has to sit on the floor in the shower in order to wash his feet. (Id.) His doctor told him to continue with his medications and do arm and bending exercises. (Id.) Fumes or odors affect Claimants asthma and cause problems breathing. (R. 347-48.)

         Claimant further testified that he continues to have problems with anxiety. (R. 348.) He explained that three-to-four nights a week he wakes up coughing and cannot fall back to sleep for a couple of hours. (R. 348-49.) On those days, Claimant needs to take a nap in order to feel better. (R. 349.) Claimant testified that ...

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