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Joyce H. v. Saul

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

January 14, 2020

NINA JOYCE H., Plaintiff,
ANDREW M. SAUL, Commissioner of Social Security, [1] Defendant.



         Plaintiff, Nina Joyce H., [3] has moved to remand the Commissioner's decision denying her application for Disability Insurance Benefits ("DIB") (D.E. 15), and the Commissioner has moved to affirm. (D.E. 22.) The matter is now fully briefed. Because substantial evidence supports the ALJ's decision, the Court denies Plaintiffs motion and grants the Commissioner's motion.

         I. Procedural History

         Plaintiff initially filed for DIB on July 24, 2012, at age 42, alleging an onset date of disability of October 9, 2011, which was later amended to July 10, 2012. (R. 193, 730.) Plaintiffs date last insured ("DLI") was September 2016. (R. 708, 916, 924.) On December 23, 2014, the Administrative Law Judge ("ALJ") denied her application for benefits, and Plaintiff ultimately appealed to the U.S. District Court. On June 8, 2017, upon the parties' agreement, the District Court entered an order reversing the Commissioner's decision and remanding it for further administrative proceedings.[4] After remand, the ALJ held a second hearing and issued a second opinion denying Plaintiffs claim for benefits. The Appeals Council did not assume jurisdiction, making the ALJ's decision the final decision of the Commissioner. See 20 C.F.R. § 404.984(a) ("when a case is remanded by a Federal court for further consideration, the decision of the administrative law judge will become the final decision of the Commissioner after remand . . . unless the Appeals Council assumes jurisdiction of the case.")

         II. Administrative Record

         Plaintiff developed right arm and shoulder pain after she was a in a car accident in 2010. (R. 325-36.) In November 2011, March 2012 and July 2012, she received steroid injections for pain in her right shoulder (R. 323-24), and in August 2012, Plaintiff told her primary care physician, William Crevier, M.D., that she had no pain. (R. 321-22.) Plaintiff also took multiple medications for hypothyroidism (underactive thyroid) and asthma (chronic lung disease that inflames and narrows the airways). (R. 325-26.) On August 15, 2012, Plaintiff saw a mental health therapist, Latrice Richards, at the Sadie Waterford Assessment and Therapy Center. Plaintiffs mental status examination was normal except for some agitated motor activity. (R. 380.) She was diagnosed with dysthymic (persistent depressive) disorder and assigned a Global Assessment of Functioning ("GAF") score of 51-60.[5] (R. 381.)

         On August 20, 2012, Plaintiff filled out a function report for the Social Security Administration. She wrote that she was tired all the time and had chronic shoulder pain; she could wash dishes, clean the bathroom and prepare simple meals, but it took her a long time and she could only lift five pounds and walk two feet at a time. (R. 268-70, 273.) She babysat for her grandchild twice a week, cared for her dog and shopped for groceries with her son (R. 270-71). Plaintiff also reported that she got angry easily and had bad mood swings. (R. 273-74.) Her mother filled out a function report that was mostly consistent with Plaintiffs. (R. 243-50.)

         On October 16, 2012, Michael Stone, Psy.D., examined Plaintiff for the Disability Determination Services ("DDS"). (R. 484.) Plaintiff was cooperative during her mental status examination, but her behavior was tense and irritable, her affect and mood appeared depressed, and although her thought process was logical and she had adequate judgment, she "exhibited problems maintaining a consistent level of attention and concentration throughout the evaluation." (R. 485, 487.) Dr. Stone assessed her with depression "secondary to medical problems." (R. 487.)

         On October 17, 2012, a non-examining state agency consultant opined Plaintiff had mild restriction in her activities of daily living ("ADLs"), mild difficulties in maintaining social functioning, and moderate difficulties in maintaining concentration, persistence or pace. (R. 88.) Physically, another non-examining agency consultant opined that she could do light work and stand, walk or sit up to six hours in an eight-hour day, with limited overhead reaching. (R. 91-92.)

         On November 27, 2012, Plaintiff had a psychiatric evaluation at Sadie Waterford. (R. 489.) Her mood was listed as euthymic (normal, stable), but also depressed and angry, and her behavior was noted to be appropriate, but also hostile and defensive. (R. 493.) Plaintiffs diagnoses were listed as mild recurrent depression, generalized anxiety disorder and post-traumatic stress disorder ("PTSD") from past abuse. (R. 493, 495.) Her GAF was assessed at 45, [6] and her medications were listed as bupropion (an antidepressant) and clonazepam (a sedative used to treat anxiety). (R. 490.) On August 15, 2013, Ms. Richards found Plaintiffs presentation was normal, her mental functioning was intact and her GAF range was 51 to 60. (R. 640-41.) Her diagnosis was listed as dysthymic disorder, and she was still taking bupropion and clonazepam. (Id.)

         Plaintiff also was treated at Chandra Diagnostic Cardiology for asthma and chronic obstructive pulmonary disease ("COPD");[7] she smoked every day and was frequently advised to quit. (See, e. g., R. 55 9.) Between May and November 2013, Plaintiff often complained of shortness of breath upon exertion and some coughing and wheezing, which was worse when she was congested. (R. 570-72, 578-80, 585.) However, her lungs were clear without abnormality. (R. 567-69.) On November 26, 2013, Plaintiff had swelling, pain and cramping in her leg, which cardiology notes indicated could have been a sign of claudication (pain caused by too little blood flow). (R. 565-66.) Plaintiff also complained of daytime fatigue (id.), but at a February 2014 cardiology visit, she reported having less fatigue with nightly CPAP use (continuous positive airway pressure machine, used to treat sleep apnea). (R. 556.) She continued to have signs of claudication, usually after exertion, but cardiology notes indicated no further intervention was needed. (R. 553-55.)

         In February 2014, Plaintiff told Dr. Crevier that she had sharp pain and spasms in her neck (R. 550-51), and in May 2014, she complained of joint aches, back pain and breathing trouble. (R. 546-47.) In July 2014, Plaintiff reported that she did not have any pain. (R. 1013.) She continued taking multiple medications for asthma and hypothyroidism, as well as clonazepam and bupropion.

         On July 23, 2014, at her first hearing before the ALJ, Plaintiff testified that she was often achy, irritable, angry or sad, she had trouble concentrating, and it was hard for her to get along with people. (R. 57.) In addition, because of her asthma and shortness of breath, it took her a long time to shower and dress herself, and she used her inhaler multiple times a day when she did household chores. (R. 60, 62, 70.) Plaintiffs husband did the laundry and grocery shopping because her shortness of breath made it too hard for her. (R. 70-71.)

         In October 2014, Plaintiff complained to Dr. Crevier of shortness of breath upon exertion. Her medications remained the same except she was no longer taking bupropion. (R. 1017-18.) In December 2014, she reported pain in her thumbs, and Dr. Crevier added a prescription for Medrol, a steroid to treat inflammation. (R. 1024-26.) In January 2015, Plaintiff also complained of some chest pain and tremors in her right arm. (R. 1035-37.) In June 2015, she went to the emergency room with shortness of breath but was discharged two hours later after treatment. (R. 1112.)

         On June 24, 2015, Plaintiff met with mental health therapist Deborah Bump and psychologist Nathanial Isaac, PsyD. Plaintiff told Ms. Bump that for the past week she had become angry and verbally aggressive at the slightest provocation. (R. 1090-91.) Her speech was slightly pressured, but she had normal rate of thoughts and intact judgment and insight. (Id.) In July 2015, Dr. Isaac assessed Plaintiff with a GAF of 50 and prescribed clonazepam, hydroxyzine for anxiety, and Lamictal (an anticonvulsant, also used to treat bipolar disorder). (R. 1092-96, 1101.)

         Between June and October 2015, Plaintiff complained to her cardiologist and Dr. Crevier of tiredness, wheezing, chest pain and neck and shoulder pain. (R. 1086, 1590-92.) Testing showed no electrophysiological evidence of neuropathy or radiculopathy in her neck or shoulder. (R. 1255, 1259). In November 2015, Plaintiff went to physical therapy for right arm pain and numbness. (R. 1139, 1178-79.) By December 2015, she reported progress with physical therapy; she did not have neck pain, she had much less numbness in her right arm and hand, and she had better cervical range of motion and overall function. (R. 1182-83.) Plaintiff again complained of neck and right shoulder pain in June 2016 and March 2017. (R. 1353, 1355.)

         On August 2, 2016, Plaintiff reported worsening shortness of breath (R. 1594), and on October 11, 2016, her new primary care physician, Jerome Buster, M.D., noted her asthma was very poorly controlled; she reported multiple nighttime and daytime asthma symptoms. (R. 1461.) On November 22, 2016, cardiology noted Plaintiff had continued shortness of breath and fatigue but indicated that her COPD was controlled. (R. 1596.)

         On February 9, 2017, Plaintiff presented to licensed clinical professional counselor Beryl Armstrong with a depressed mood; she reported being angry all the time and feeling as if her family was falling apart. (R. 1439.) Her mental examination was otherwise normal. (R. 1440.) On February 21, 2017, Plaintiff told psychiatric nurse practitioner Yvette Johnson that she was depressed, anxious, and had trouble sleeping and eating. (R. 1433.) Her mental status examination was normal except for her depressed mood. (R. 1436-37.) In May 2017, Plaintiff presented to Ms. Armstrong with a melancholy mood; she complained of worsening depression and anxiety, which she attributed to intense pain in her right foot and marital problems. (R. 1475-76.)

         III. Evidentiary Hearing

         On February 14, 2018, at her second hearing before the ALJ, Plaintiff testified that she could not raise her right hand because it hurt to hold her arm overhead or straight out. (R. 685.) She described having tremors and numbness in her right hand that made it difficult to hold a pen and dress herself; however, she could type on a computer and wash dishes for 10 to 30 minutes. (R. 685, 689-92.) Physical therapy alleviated her pain, but the pain returned when therapy ended. (R. 692.) Plaintiff testified she could stand for 15 minutes and walk for 10 minutes; she said she was prescribed a cane after a 2017 accident, but she did not bring it to the ...

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