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Joseph M. v. Saul

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

December 19, 2019

JOSEPH M. Plaintiff,
v.
ANDREW SAUL, Commissioner of Social Security, [1] Defendant.

          MEMORANDUM OPINION AND ORDER [2]

          SIDNEY I. SCHENKIER UNITED STATES MAGISTRATE JUDGE.

         Plaintiff, Joseph M., moves for summary judgment seeking reversal or remand of the final decision of defendant, the Commissioner of Social Security ("Commissioner"), denying his applications for disability insurance benefits ("DIB") and supplemental security income ("SSI") (doc. # 17: Pl.'s Summ. J. Mot; doc. # 18: Pl.'s Summ. J. Mem.). The Commissioner has filed a cross motion for summary judgment asking us to affirm his decision (doc. # 28: Def.'s Summ. J. Mot.; doc. # 29: Def.'s Summ. J. Mem.), and Mr. M. has filed a reply (doc. #31: Pl.'s Reply). For the following reasons, we deny Mr. M.'s motion, grant the Commissioner's motion, and affirm the Commissioner's decision.

         I.

         On November 17, 2014, Mr. M. applied for DIB and SSI, alleging disability beginning on January 21, 2013 due to a meniscus tear in his right knee, high blood pressure, and vision problems (R. 76, 86, 96-97, 124-25, 130, 135, 255). The Social Security Administration ("SSA") denied Mr. M.'s applications at the initial and reconsideration stages of review, after which Mr. M. requested a hearing before an Administrative Law Judge ("ALJ") (R. 96-97, 124-35, 142-46, 148-49). On July 26, 2017, the ALJ held a hearing at which Mr. M., represented by counsel, and a vocational expert ("VE") testified (R. 39-75). On November 16, 2017, the ALJ issued a decision denying Mr. M.'s DIB and SSI claims (R. 17-38). The Appeals Council denied Mr. M.'s request for review, making the ALJ's decision the final word of the Commissioner (R. 1-5). See Varga v. Colvin, 794 F.3d 809, 813 (7th Cir. 2015); 20 C.F.R. §§ 404.981, 416.1481.

         II.

         Mr. M. was born on November 11, 1954 (R. 204).[3] He obtained his GED in 1979 and served in the National Guard (R. 46-47, 50-51, 256). He has worked as a home healthcare provider, an electrician, and, most recently, a truck driver (R. 257).

         It appears that Mr. M. worked steadily (for the most part) as a truck driver from 2007 through January 2013 (R. 52-53, 231-32, 257, 299).[4] On January 21, 2013, Mr. M. suffered a work-related injury to his right knee and stopped working (R. 248, 257; see R. 61-62 (testimony from Mr. M. that he originally injured his right knee while working in 2013); R. 486 (May 30, 2015 consultative examination report that Mr. M. "stated that he had right knee joint pain from injury at work about two years ago")). He remained unemployed until May 2014, when he went back to work as a truck driver for a different company (R. 232, 238, 248, 257). Mr. M.'s return to work was short-lived, as he was laid off a month later (R. 238, 241, 248). Mr. M. tried again to work as a truck driver in August 2014, but he was laid off from this job in September 2014 because "he was too slow" and could not keep up (Id.). After not working in 2015, Mr. M. worked as a truck driver again from early 2016 through September or October of that year, when he stopped working for good (see R. 45-47, 54-55, 221, 233-34).

         A.

         Mr. M. asserts that his conditions (right-knee meniscus tear, high blood pressure, and vision problems) became severe enough to keep him from working on January 21, 2013 (R. 255). On that date, which is also the date Mr. M. suffered his work-related right-knee injury, Mr. M. had an x-ray taken of his right knee (R. 248, 364). The x-ray indicated mild degenerative change and no fracture or effusion (R. 364). The following month, an MRI showed a meniscus tear, Assuring of cartilage, and mild edema in a knee fat pad (R. 363).

         In September 2013, Mr. M. presented to Titilayo Abiona, M.D., complaining of headaches and dizziness (R. 426, 435-36). He reported occasional chest tightness, although he was not experiencing any at the time of the visit (R. 436). Dr. Albiona requested a cardiac stress test, which Mr. M. underwent in November 2013 (R. 453-54). During the stress test, Mr. M. experienced no chest pain, but the test had to be stopped due to Mr. M.'s fatigue (R. 454). The impressions from the stress test were a normal stress EKG, negative for ischemia; hypertensive blood pressure response to exercise; and below-average exercise capacity for age (Id.).

         In December 2013, Mr. M. presented to Lorena Monterubianesi, M.D., to establish a primary care physician relationship (R. 455-56; see also R. 498 (July 2015 note reporting that Mr. M. identified Dr. Monterubianesi as his primary physician)). A review of Mr. M.'s musculoskeletal system was negative, but he was diagnosed with uncontrolled hypertension (R. 456, 458). At the time, Mr. M. was taking two medications, metoprolol tartrate and amlodipine, which are used to treat hypertension (R. 457).[5] Dr. Monterubianesi reinforced the need for Mr. M. to maintain a low sodium diet and to take his medications (R. 458).

         Mr. M. followed up with Dr. Monterubianesi in June 2014 (R. 459-63). Mr. M.'s musculoskeletal system review was once again negative (R. 460). Dr. Monterubianesi noted that Mr. M. had been out of his medications for the past two weeks, and she reinforced her advice about medication compliance (R. 460, 462).

         After undergoing some diagnostic tests in December 2014 (R. 467-74), Mr. M. followed up with Dr. Monterubianesi again in January 2015 (R. 475-76). Although Mr. M. had a lump on his right wrist, a review of Mr. M.'s musculoskeletal system was otherwise negative (R. 476, 478). In addition to noting Mr. M.'s hypertension and wrist lump, Dr. Monterubianesi noted that Mr. M. had experienced two episodes of vasovagal syncope in 2014 (R. 479).[6] Mr. M. showed up without taking his medications and, like his last visit, he had run out of his medications two weeks before (R. 476, 479). Dr. Monterubianesi changed Mr. M.'s blood pressure medications to losartan and hydrochlorothiazide and advised Mr. M. to take his medications and return the next week (R. 479).

         On January 11, 2015, Mr. M. was admitted to the emergency room after he became dizzy and lightheaded and passed out for a couple seconds (R. 259, 373, 376-77). Mr. M. reported that this had happened in the past, but he did not report any concerning symptoms (R. 381). Mr. M. also denied joint pain and, upon physical examination, exhibited good range of motion in his musculoskeletal system (R. 379). The emergency room records note that after being admitted, Mr. M. was "continuously ambulating the hallways and even went outside to make a phone call," where he was pacing while talking on his cell phone (R. 376, 381). Mr. M. was discharged a few hours after his admission to the emergency room (R. 373, 381).

         Mr. M. followed up with Dr. Monterubianesi in March 2015 and, again, in April 2015 (R. 591-98). At the March visit, Mr. M. had been out of his medications for two weeks and had stopped taking losartan and hydrochlorothiazide due to his belief that these medications caused his past syncope episodes (R. 593, 595, 597). Instead, he was taking clonidine, another medication for hypertension, for which Dr. Monterubianesi upped the dosage (R. 597).[7] Dr. Monterubianesi reinforced medication compliance; nevertheless, Mr. M. showed up for his April visit again being out of medications for two weeks (R. 591, 597). Dr. Monterubianesi again reinforced medication compliance (R. 593). Other than the lump on his right wrist, review of Mr. M.'s musculoskeletal system was negative at each visit (R. 591, 593, 595, 597).

         On May 30, 2015, Mr. M. presented to Albert Osei, M.D., for an internal medicine consultative examination (R. 486-94). Dr. Osei identified Mr. M.'s chief complaints (i.e., what allegedly caused Mr. M.'s disability) as knee pain and hypertension (R. 486). Mr. M. told Dr. Osei "that he had right knee joint pain from [an] injury at work about two years ago," that he experienced pain daily, and that, for the past two years, he had used a cane that was given to him when he had his right knee x-rayed in January 2013 (Id.)[8]According to Mr. M., he had also undergone a few sessions of physical therapy and surgery had been recommended; however, surgery "was not done because the company went into bankruptcy" (Id.). Mr. M. also told Dr. Osei that he could only walk "one half blocks," stand for 20 minutes, and sit for one hour (Id.). Mr. M. further reported that his hypertension had been controlled for the most part with clonidine, which he was currently taking, and that he did not experience syncope episodes on standing while taking clonidine, whereas he did with other antihypertensive medications he previously took (R. 486-87).

         Upon physical examination, Dr. Osei noted that Mr. M. could get on and off the examination table and get up from a seated position with no difficulty (R. 488). Range of motion was normal in Mr. M.'s spine, although it was reduced in his right knee joint due to pain (R. 489). Mr. M. could walk more than 50 feet using a cane; without the cane, he could still walk more than 50 feet, but he did so at a slow to moderate pace and with a limp (Id.). Mr. M. could perform toe/heel/tandem walk with moderate difficulty, could only partially squat because of right-knee pain, and was able to stand on either leg unsupported, although he could not hop on either leg (Id.). Dr. Osei's impressions were a right knee injury and pain, with an MRI finding of a torn meniscus; uncontrolled hypertension; and obesity (R. 490).

         In June 2015, non-examining state agency consultant Prasad Kareti, M.D., reviewed Mr. M.'s medical evidence, including Dr. Osei's examination, at the initial stage of SSA review (R. 76-97). Dr. Kareti opined that Mr. M. could lift and/or carry 50 pounds occasionally and 25 pounds frequently; stand, walk, or sit for about six hours in an eight-hour workday; and occasionally kneel, crouch, crawl, and climb ramps, stairs, ladders, ropes, or scaffolds (R. 81-83, 91-93). Dr. Kareti also opined that although Mr. M. had severe loss of central visual acuity, he did not experience any corresponding visual limitations (R. 80, 83, 90-91, 93).

         On July 1, 2015, Mr. M. went to the emergency room complaining of chest pain (R. 317, 495-96, 498). He denied any muscle pain and, upon examination, did not exhibit any back tenderness (R. 500). Mr. M. also admitted that he had missed a few doses of clonidine, and he was educated for medication compliance (R. 504, 508). Mr. M. was admitted overnight and discharged the next day (R. 495, 497). Two weeks later, Mr. M. saw Pankaj Jain, M.D., at Pulmonary and Sleep Associates for assessment of a lung nodule that had been shown by imaging during Mr. M.'s July 1-2 emergency room stay (R. 496, 501-02, 504, 548-50). Dr. Jain identified "back ache" as one of Mr. M.'s ongoing medical problems (R. 550).

         On August 10, 2015, Mr. M. presented to Dr. Monterubianesi for a follow-up visit (R. 587-90). Mr. M. had been out of his hypertension medication (clonidine) for the past two weeks, and Dr. Monterubianesi, once again, reinforced medication compliance (R. 587, 589). At this visit, Mr. M. complained of intermittent lower back pain on his right side that had begun two years ago and which he rated as an eight out often for pain (R. 587 ("today c.o lbp off and on, started 2 years ago, no radiated, it is on the right side, 8/10")). He also complained of right-knee pain and requested a knee brace (Id.). Dr. Monterubianesi's review of Mr. M.'s musculoskeletal system noted bilateral knee crepitus, lower back pain, and muscles tender to palpation (R. 589). Dr. Monterubianesi diagnosed Mr. M. with chronic lower back pain and, presumably referring to Mr. M.'s right knee, joint pain (Id.).

         The same day, Mr. M. underwent a series of x-rays for his reports of back and right knee pain (R. 571-76, 589). The knee x-ray showed mild degenerative joint disease ("DJD") in the medial compartment of the right knee (R. 571). The x-rays of Mr. M.'s spine showed a normal thoracic spine but DJD of the facet joints and mild degenerative disc disease ("DDD") in the lumbosacral region (R. 573, 575).

         Mr. M. saw Dr. Jain again in September 2015 (R. 554-56). Dr. Jain again identified "back ache" as one of Mr. M.'s ongoing medical problems (R. 556). The following month, Mr. M. returned to see Dr. Monterubianesi (R. 582-86). At this October 2015 follow-up visit, Mr. M. still complained of intermittent right-side lower back pain (R. 582). As was the case at Mr. M.'s last visit (in August 2015), Dr. Monterubianesi's review of Mr. M.'s musculoskeletal system noted bilateral knee crepitus, lower back pain, and muscles tender to palpation (R. 584). Dr. Monterubianesi also repeated her diagnosis of chronic lower back pain and joint pain and she listed, for the first time, chronic lower back pain as a problem (compare R. 583-85, with R. 588-89). Furthermore, Dr. Monterubianesi noted that Mr. M. could walk up to three blocks and that he walks with a cane (R. 582, 584). The notes from this visit indicate that Dr. Monterubianesi intended to or did refer Mr. M. to physical therapy for his lower back pain (R. 584). Dr. Monterubianesi prescribed Mr. M. tramadol (a pain reliever) and also increased the dosage of Mr. M.'s clonidine prescription (R. 584-85).

         On November 5, 2015, Mr. M. underwent a CT scan of his lumber spine (R. 579-80). The scan showed moderately severe to severe DJD of the facet joints throughout the lumbar spine with disc bulging at various levels, but no foraminal narrowing (R. 579).

         The same month, non-examining state agency consultants Jerda Riley, M.D., and Anne Prosperi, D.O., evaluated Mr. M.'s medical evidence at the reconsideration stage of SSA review (R. 98-125). Dr. Riley evaluated the evidence regarding Mr. M.'s visual abilities and determined that Mr. M.'s loss of central visual acuity was not severe (R. 104-05, 117-18). Dr. Prosperi evaluated the evidence regarding Mr. M.'s other physical abilities and came to the same conclusion about Mr. M.'s functional limitations as the consultant who reviewed Mr. M.'s evidence at the initial stage of SSA review, Dr. Kareti (compare R. 106-08, 119-21, with R. 81-83, 91-93).

         In January 2016, Mr. M. visited the emergency room after hurting his wrist while climbing into a truck (R. 608-09). Review of his musculoskeletal system was positive for arthralgias, but, upon physical examination, Mr. M. moved all extremities equally and had full range of motion in all extremities (R. 611-12). It was also noted that, upon discharge, Mr. M. ambulated with a slow, steady gait (R. 610).

         A little more than six months later, in July 2016, Mr. M. was at the emergency room again, this time with chest pain (R. 618-20). The attending physician noted that Mr. M. had run out of his blood pressure medication (clonidine) two weeks before (R. 620, 628, 630). Mr. M. denied back pain, and he was noted to have "[g]ood range of motion in all major joints" with "[n]o tenderness to palpation . . . noted" (R. 621-22). According to the emergency room records, the discharging physician suspected that his symptoms were related to uncontrolled hypertension (R. 628). It was further noted that Mr. M. was only taking clonidine daily, which is not appropriate, and that his poor compliance also made clonidine more difficult to use (Id.).[[9]] As a result, Mr. M.'s blood pressure medication was changed from clonidine to Procardia (Id.).

         Mr. M. saw Dr. Monterubianesi again in March 2017 (R. 659-65). The visit record noted that Mr. M. complained of right knee pain and said that his knee "sometimes gives [out] when [he] tries to walk" (R. 661). Upon examination, Mr. M. exhibited right knee crepitus with a mild decreased extension, and he was diagnosed with chronic knee pain (R. 663-64). Although chronic lower back pain was also diagnosed, Mr. M.'s musculoskeletal review was negative and he exhibited normal range of motion and no tenderness upon examination outside of his right knee (R. 661, 663-64). Dr. Monterubianesi further noted that Mr. M. had missed physical therapy in the past and that he was walking unassisted, although he would need a cane for stability (R. 665). Mr. M.'s hypertension was also uncontrolled, and he reported that he had no blood pressure medications other than clonidine, and that he had run out months ago (R. 661, 664). Dr. Monterubianesi continued Mr. M. on clonidine and had him resume taking losartan and hydrochlorothiazide (R. 664). Dr. Monterubianesi also had Mr. M. continue to take tramadol (R. 661, 665).

         Less than a month later, on April 5, 2017, Mr. M. was admitted to the emergency room after experiencing two short-lived episodes of chest pain (R. 670-73). He reported that he was compliant with his medications, which included Cozaar (a brand name for losartan) and Procardia, although his discharge summary noted that "[i]t is not clear that he has been taking" his hypertension medications (R. 673, 680). The discharge summary also noted Mr. M.'s report that "[h]e has not taken some medicines in the past because of the 'side effects'" (R. 680). Review of his musculoskeletal system was negative for back pain, joint pain, or muscle pain and showed normal range of motion (R. 673, 675, 686-87). When Mr. M. went to the bathroom the night of his admission, his gait was observed to be steady, and the notes do not refer to any use of a cane by Mr. M. (R. 679). Mr. M. was discharged two days after he was admitted (R. 670).

         B.

         As already noted, the ALJ held a hearing where Mr. M., represented by counsel, testified. When the ALJ asked Mr. M. why he stopped driving trucks in 2016, Mr. M. replied that back pain and fainting episodes (preceded by overheating) prevented him from working (R. 54-55). Mr. M. testified that his back pain is about an eight or nine out often (R. 55-56). He was not prescribed physical therapy for his back, but he was prescribed pain medication (R. 55-57). The pain medication sometimes helped to reduce his back pain to about a five out often, although Mr. M. indicated that he took three or four more pills than prescribed to achieve this level of relief (Id.). When asked whether this pain medication caused any side effects, Mr. M. testified that he did not know (Id.). Mr. M. was also prescribed a back brace, but the brace "somehow [went] missing" (R. 57). Mr. M. further testified that he did not know the cause of his overheating and fainting episodes, but that his doctors told him they resulted from Mr. M. eating at truck stops and getting food poisoning (R. 57-58).

         Upon questioning from his attorney, Mr. M. also identified his right knee as a source of pain (R. 61-62). The pain comes "[e]very now and then" and can reach the level of a seven or eight out often (R. 63). He was prescribed medication that sometimes helps to alleviate his knee pain (R. 63-64). Mr. M. is supposed to take the medication once every time he needs it, but sometimes he takes the medication twice because of the pain, even though he does not "like taking too many pills" (R. 63). His knee also sometimes "gives out" when he tries to walk (R. 62). Mr. M. testified that he was prescribed physical therapy and given a cane when he hurt his right knee in January 2013 (R. 57, 61-62, 218, 248). Mr. M. had a cane with him at the hearing and testified that he had been using it ever since it was given to him (R. 61).

         Mr. M. testified that he can stand for, at most, 30 minutes, and he sometimes has difficulty sitting (R. 61). During the day, he walks around for a little bit, and then he will sit down for a while (R. 58). He has trouble showering and getting dressed (R. 58-59). He does not clean, do laundry, or work outside (R. 59). If Mr. M. goes grocery shopping, he goes with someone (Id.). Mr. M. is sometimes compliant with taking all his medications (and sometimes not), and he indicated that he sometimes overmedicates (R. 56-58, 63).

         A VE also testified at the hearing. The VE testified that an individual who could perform medium work; frequently climb ramps and stairs, balance, stoop, kneel, crouch, and crawl; occasionally climb ladders, ropes, or scaffolds; and occasionally work at unprotected heights and around moving mechanical parts could perform Mr. M.'s past work as a truck driver "per the DOT and as typically performed" (R. 66-67).[10] The VE further testified that an individual with these capabilities could perform work as a packager, order picker, or machine feeder (R. 67-68).

         III.

         In denying Mr. M.'s claims, the ALJ followed the familiar five-step process for assessing disability. See 20 C.F.R. §§ 404.1520(a), 416.920(a). As an initial matter, the ALJ determined that Mr. M.'s date last insured was September 30, 2020 (R. 22). Then, at Step One, the ALJ determined that Mr. M. had not engaged in substantial gainful activity since his alleged disability onset date, January 21, 2013 (R. 22-23).[11] At Step Two, the ALJ determined that Mr. M. suffered from the following severe impairments: osteoarthritis, degenerative disc disease in the lumbar spine, obesity, and hypertension with chest pain (R. 23). At Step Three, the ALJ determined that none of Mr. M.'s impairments, individually or in combination, met or equaled a listed impairment (Id.).

         Between Steps Three and Four, the ALJ evaluated Mr. M.'s residual functional capacity ("RFC"). See 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The ALJ concluded that Mr. M. retains the RFC to perform medium work as defined in 20 C.F.R. §§ 404.1567(c) and 416.967(c) except that he can frequently climb ramps and stairs, balance, stoop, kneel, crouch, and crawl; occasionally climb ladders, ropes, and scaffolds; and occasionally work at unprotected heights and around moving mechanical parts (R. 23-24).[12] At Step Four, the ALJ found that Mr. M. could perform his past relevant work as a truck driver (R. 31-32). The ALJ also proceeded to Step Five and found, in the alternative, that Mr. M. could perform other ...


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