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Brett C. v. Saul

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

November 8, 2019

Brett C., Plaintiff,
Andrew Saul, Commissioner of Social Security, Defendant.



         Plaintiff is seeking Social Security disability benefits based on limitations from a stroke occurring in the fall of 2014. He was then 49 years old. His main limitations are speech difficulties and right-sided weakness. An administrative law judge (“ALJ”) found that plaintiff was not disabled largely because his condition gradually improved over time such that he was able to do part-time work and other activities consistent with the ALJ's findings. In this appeal, plaintiff argues that the ALJ should have developed the record in various ways. As explained below, the Court is not persuaded by this argument.


         The medical narrative begins on November 1, 2014, when plaintiff went to a hospital in Florida presenting with speech problems or, in the medical parlance, expressive dysphasia.[2]Doctors concluded that plaintiff had a stroke at some point. Over the next several weeks, tests and procedures were performed. On November 13, 2014, Dr. Jacques Morcos performed a bypass procedure to address the problems from the stroke. On November 19, 2014, plaintiff was discharged from the hospital. He was provided a rolling walker and advised to participate in occupational therapy. According to plaintiff's later testimony, this therapy took place over the next three to four months. However, the therapy records were not made a part of the administrative record for reasons that are not known.

         On January 29, 2015, while still in Florida, plaintiff saw neurologist Dr. Nils Mueller-Kronast as a follow-up to his hospital treatment. This would be plaintiff's only visit with this doctor. Dr. Mueller-Kronast observed that plaintiff weighed 285 pounds; that he could walk independently with a limp but he did not need a cane; that he had a 4/5 weakness in his right shoulder with some difficulty and a possible frozen shoulder; and that his coordination was intact with a degree of weakness. R. 343. Dr. Mueller-Kronast told plaintiff that he needed to lose weight, which was described in the notes as a “drastic risk factor modification.” Id. Dr. Mueller-Kronast concluded as follows:

Clinically [plaintiff] is significantly improved, but still has nonfluent speech and especially proximal right upper extremity weakness. He is independently ambulating. In the meantime, he has undergone smoking cessation.

R. 342.

         The following week, plaintiff filed for disability benefits under both Title II and XVI.

         On March 16, 2015, Dr. Mueller-Kronast wrote a one-paragraph letter supporting plaintiff's disability applications. The letter states as follows:

This letter serves to certify that Mr. [C] is completely and totally disabled. He suffered a debilitating stroke and as a result is completely unable to obtain or participate in any type of gainful employment. He still suffers from residual cognitive impairment as well as non-fluent speech and upper extremity weakness. Please feel free to contact my office with any questions or if I can be of further assistance.

R. 345.

         On July 14, 2015, plaintiff was seen by consultative examiner Dr. K.P. Ramchandani who examined plaintiff for 30 minutes and then prepared a report. Ex. 4F. Set forth below are two screenshots from the report, which summarize some of the key observations:

PHYSICAL EXAMINATION: Reveals him to be alert, obese, in no acute physical distress. Pulse: 84/min. Rhythm: regular. Resp: 12min. BP: 110/70. Height: 69". Weight: 268 pounds. His gait is normal, unassisted. He is able to walk on heels and toes. He is able to squat and get up without support. He is able to get on and off the examination table without assistance. He is able to dress and undress without assistance. He is right-handed. Grip is 4/5 on the right and 5/5 on the left. He is able to make a fist, pick up objects, open and close the door, oppose the thumb to fingers and flip pages.
CNS EXAMINATION: Speech is slightly slurred and searching for words. He is able to recall current and past presidents. He knew the meaning of don't cry over spilled milk and the grass is greener on the other side offence. He is able to do serial seven's. He is alert, oriented to time, place and person. He is well dressed and answers questions appropriately with proper eye contact. His ability to relate is normal. From observation claimant is capable of handling funds in his own interest. Cranial nerves are intact. He is able to hear and understand conversational voice without difficulty. Motor system: Power is 5/5 in the lower extremities and left upper extremity. Power at the right shoulder is 3, at the right elbow 4/5 and at the right wrist 4/5, no wasting. Tone is slightly increased in the right upper extremity. Reflexes are brisk on the right, and 2 on the left. Plantars equivocal bilaterally. Sensory system: No. deficit to touch and pin prick in all four extremities.

R. 351.

         On July 27, 2015, Dr. Lenore Gonzalez, a state agency physician, made a residual functional capacity (“RFC”) assessment. See Exs. 3A, 4A. Dr. Gonzalez reviewed both Dr. Ramchandani's report, as well as Dr. Mueller-Kronast's treatment notes and opinion letter. Dr. Gonzalez opined that plaintiff could occasionally lift or carry 20 pounds, could frequently lift or carry 10 pounds, and could sit, walk, or stand six hours in an eight-hour day. On November 30, 2015, Dr. Dimitri Teague, another agency doctor, reached the same conclusions. Exs. 7A, 8A.

         On March 29, 2016, plaintiff established care with FHN Family Healthcare Center. At the initial visit with a nurse practitioner, plaintiff explained that he was seeking a DOT physical and stated that most of his problems with his right side were “gone” and that he did not have any deficits other than a few issues with his left eye. R. 403. He ...

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