Delonjay v. Commissioner of Social Security
OPINION Entered by Magistrate Judge Tom Schanzle-Haskins on 04/13/2018. SEE WRITTEN OPINION. IT IS ORDERED that the Defendant Commissioner's Motion for Summary Affirmance (d/e 14 ) is ALLOWED; Plaintiff Jody Delonjay's Motion for Summary Judgment (d/e 11 ) is DENIED; and the decision of the Commissioner is AFFIRMED. All pending motions are denied as moot. THIS CASE IS CLOSED. (DM, ilcd)
Friday, 13 April, 2018 11:44:36 AM
Clerk, U.S. District Court, ILCD
IN THE UNITED STATES DISTRICT COURT
FOR THE CENTRAL DISTRICT OF ILLINOIS, SPRINGFIELD DIVISION
JODY I. DELONJAY,
NANCY A. BERRYHILL,
Acting Commissioner of
TOM SCHANZLE-HASKINS, U.S. MAGISTRATE JUDGE:
Plaintiff Jody I. Delonjay appeals from the denial of her application for
Social Security Disability Insurance Benefits (Disability Benefits) under Title
II of the Social Security Act. 42 U.S.C. §§ 416(i) and 423. This appeal is
brought pursuant to 42 U.S.C. § 405(g). Delonjay filed a Motion for
Summary Judgment (d/e 11). The Defendant Commissioner filed a Motion
for Summary Affirmance (d/e 14). The parties consented to proceed before
this Court. Consent to the Exercise of Jurisdiction by a United States
Magistrate Judge and Reference Order entered January 19, 2018 (d/e 17).
For the reasons set forth below, the decision of the Commissioner is
Page 1 of 43
STATEMENT OF FACTS
Delonjay was born on June 12, 1962. She completed high school.
Delonjay filed her application for Disability Benefits on October 12, 2012.
She has not engaged in substantial gainful activity since August 11, 2012.
Delonjay previously conducted door-to-door interviews for government
surveys. She testified that she last worked on August 12, 2012. She
suffers from history of concussion and right comminuted humerus fracture,
degenerative disc disease of the cervical spine with history of fusion,
depression, anxiety, and borderline personality disorder. She also suffers
from headaches, a history of right shoulder replacement, and past
substance abuse. Certified Transcript of Proceedings before the Social
Security Administration (d/e 7) (R.), 35-38, 54, 64, 65, 303, 310.
On July 30, 2012, Delonjay saw her primary care physician Dr.
Herbert E. Childress, D.O., for treatment and management of right shoulder
pain and cervical pain. She was status post comminuted fracture of her
right humerus and status post cervical fusion with internal hardware fixation
devices. R. 297. On examination, Dr. Childress noted reduced range of
motion of the cervical spine and reduced range of motion in the right
shoulder secondary to internal hardware fixation device and previous
fracture. Delonjay reported that she had no history of drug misuse, and
Page 2 of 43
she exercised five or more times per week. Dr. Childress assessed chronic
intractable pain from cervical radiculitis, discogenic disease, and status
post fracture right humerus. R. 297-98. Dr. Childress’ records of this visit
did not mention memory loss.
On August 1, 2012, Delonjay went to the emergency room with right
foot pain. She was assessed with bunions. R. 281, 398, 423-24. Delonjay
did not report any problems with memory loss.
On October 4, 2012, Delonjay saw Dr. Childress to discuss getting on
disability. R. 293-95. Dr. Childress noted Delonjay’s subjective history as
History of Present Illness
SUBJECTIVE: Patient reports here today with ongoing
treatment and management of her cervical radiculitis, her
migrainous cephalgia and her other multitude of medical
problems which includes a comminuted fracture right humerus
with arthroplasty for a total joint replacement. She cannot focus,
cannot concentrate based on her chronic pain management
and this makes her dire need of a consideration for a different
occupation and/or no occupation as she has been through a
multitude of surgical surgeries, right humeral surgeries, chronic
intractable pain and medication management for same.
R. 293. On examination, Dr. Childress found reduced range of motion of
the right shoulder, surgical scarification from shoulder surgery and cervical
spine surgery. Dr. Childress noted, “We referred her to decompression and
fusion and she has had some relief but adhesive radiculopathy has
Page 3 of 43
encompassed her with reoccurring chronic pain.” R. 293. Dr. Childress
assessed cervical radiculitis secondary to degenerative discogenic disease
as well as adhesive radiculopathy, and recurring right shoulder pain
secondary to arthroplasty and comminuted fracture right humerus. Dr.
Childress opined, “She needs to not be participating in physical activity
associated with occupation. I would consider her 100% incapacitated.” R.
293. Dr. Childress also noted “no reported history of drug misuse,” and
“Exercises 5 or more days/wk.” R. 294.
Dr. Childress prescribed hydrocodone-acetaminophen (Norco),
baclofen, butalbital-acetaminophen-caffeine (Fioricet), lorazepam (Ativan),
and promethazine. R. 294-95. Dr. Childress did not order any tests, such
as x-rays, MRIs, or EMG/nerve conduction studies, and did not recommend
physical therapy or other treatment to address Delonjay’s condition.
On or about October 31, 2012, Delonjay completed a Social Security
Administration Disability Report—Adult form. R. 201-11.1 Delonjay
reported that she suffered from degenerative disk disease, status post
cervical surgery, right shoulder replacement, eosinophilia, migraines,
recurrent kidney stones, chronic pain, depression, anxiety, and PTSD. R.
For date of the report, see R. 228 (listing 10/31/2012 as date of Disability Report).
Page 4 of 43
On December 30, 2012, Delonjay’s husband Jeffrey S. Delonjay
completed a Function Report—Adult—Third Party form. R. 212-19. Jeffrey
Delonjay reported that Delonjay could not keep a daily routine due to pain.
He stated that she did not feel good more than two to three days in a row.
He said that she did not take care of anyone else. He said that she had no
normal sleep routine, sometimes too much sleep, sometimes not enough.
He said Delonjay could dress and bathe herself, but she had trouble
bending and he had to remind her sometimes to take a bath. He helped
shave her underarms. She could feed herself. R. 213. Jeffrey Delonjay
said that Delonjay needed reminders to take medicine. R. 214.
Jeffrey Delonjay said that Delonjay prepared meals daily. She made
sandwiches, soup, and frozen pizza; and prepared full meals two to three
times a week. Jeffrey Delonjay said Delonjay did household cleaning and
laundry two to three times a week. She had no consistent cleaning routine.
He said she had good days and bad days. R. 214.
He said she got out of the house shopping three times a week. She
both drove and rode in cars. Shopping usually took 30 minutes. R. 215.
He said she was with her grandchildren two to three days a week. R. 216.
Jeffrey Delonjay said Delonjay had a short temper. R. 217.
Page 5 of 43
Jeffrey Delonjay opined that Delonjay could lift 10 pounds, stand 10
to 15 minutes, and walk two blocks. He said she needed a 10-minute rest
after walking two blocks. He said she could pay attention for five to 10
minutes. He said she did not finish what she started. He said her ability to
follow written and spoken instructions depended on how she felt at the
time. R. 217. He said she could get along with authority figures. She
could not handle stress or changes in her routine well. R. 217.
On January 2, 2013, Delonjay saw Dr. Childress. R. 286-88. Dr.
Childress noted that Delonjay reported that she exercised five or more days
a week and had no history of drug misuses. R. 288.
On February 27, 2013, psychologist Dr. Frank Froman, Ed.D.,
conducted a consultative mental examination of Delonjay. R. 303-07.
Delonjay’s appearance and presentation was unremarkable. She had a
good ability to relate, her speech was normal, and she made good eye
contact. R. 304.
Delonjay reported that she had a history of drug abuse, including
cocaine, alcohol, and methamphetamine. She reported that in August
2012 she was in inpatient drug rehabilitation treatment for 49 days. She
said she went into treatment to see if she could live without Norco. R. 30304.
Page 6 of 43
Delonjay reported to Dr. Froman that she had a driver’s license,
smoked one pack of cigarettes a day, and socialized modestly. She
reported that she cleaned house and took care of her grandchildren. She
said that she loved her grandchildren. She said that her grandchildren
made her happy. She said she could perform her own self-care, but some
days she hurt too much to do such care. She said she could do chores, but
sometimes, “’particularly if my kidneys act up, it hurts too much to do
them.’” R. 304.
Delonjay reported to Dr. Froman that she was frequently depressed
and anxious. She reported that she suffered from PTSD due to her
mother’s abusive treatment of her as a child. She reported, “‘I have fugue
episodes.’” Dr. Froman stated:
Unfortunately, there is no psychological documentation of this.
What we have in her record is a medical note about shoulder
and cervical root compression injuries. One would need to look
back on her psychiatric background in order to document these
problems that she alleges.
R. 305. Dr. Froman diagnosed nicotine dependence, continued marijuana
use, history of alcohol and cocaine abuse in full remission, mood disorder
not otherwise specific, allegations of fugue states, and borderline
Page 7 of 43
personality disorder. Dr. Froman assigned a Global Assessment of
Functioning (GAF) score of 55. R. 305.2
Dr. Froman opined that Delonjay could perform one or two-step
assemblies at a competitive rate, she could relate to others, and she could
understand oral and written instructions. Dr. Froman expressed concern
about the allegations of Fugue states, but offered no opinion on the
allegations because no historical documentation existed in the records
provided. R. 305.
On March 11, 2013, Delonjay saw Dr. Childress for medication refills
and back pain after a recent fall. R. 328-30. Delonjay reported that she
had headaches that were controlled with Fioricet. Dr. Childress asked
about the frequency of her use of Fioricet and rebound headaches.
Delonjay said she “takes it under advisement.” Delonjay also reported that
she was under Dr. Froman’s care for depressed mood. R. 328.
On examination, Dr. Childress found that Delonjay had “intermittent
tension cephalgia secondary to stressors of life.” Dr. Childress noted
reduced range of motion in lumbar spine. He stated that “previous
radiographs confirm her degenerative discogenic disease.” R. 328. Dr.
A GAF score of 55 indicates moderate symptoms or functional difficulties. Diagnostic and Statistical
Manual of Mental Disorders (4th ed., Text Revision) (DSM-IV-TR), at 34. The American Psychiatric
Association no longer recommends using GAF scores. Diagnostic and Statistical Manual of Mental
Disorders (5th ed. 2013) (DSM-5), at 16.
Page 8 of 43
Childress noted that Delonjay had surgery on her right arm for right
humerus fracture on January 29, 2007. Dr. Childress renewed her
medications. R. 328.
The next day, on March 12, 2013, state agency physician Dr. Joseph
Kozma, M.D., performed a consultative examination of Delonjay. R. 31015. Delonjay reported to Dr. Kozma that she had right shoulder
replacement surgery and had decreased range of motion in her right
shoulder. She reported that her memory was poor. She reported that she
had “difficulty with spatial orientation although she does not get lost.” She
reported having migraine headaches. She reported that the headaches
“are not very frequent and she takes some Fioricet for that.” She reported
“some type of post traumatic syndrome” caused by her mother when she
was younger. She reported that she had chronic anxiety. She reported
that she had panic attacks three times a month. She said she had
shortness of breath during the panic attacks. R. 310.
Delonjay reported that she had kidney stones removed in 2009, right
shoulder replacement surgery in 2008, and surgery on her neck in 2007.
Delonjay reported that she was bipolar. R. 311. She said she had
migraine headaches once or twice a month. R. 311.
Page 9 of 43
On examination, Dr. Kozma found that Delonjay had normal range of
motion in her cervical spine. She had no tenderness in her cervical spine
and her neck muscles had normal tone without rigidity. R. 312. Her upper
extremities had normal strength. Her left shoulder had normal range of
motion. Her right shoulder had limited range of motion in forward elevation,
backward elevation, and abduction. Delonjay had normal internal and
external rotation, and adduction of the right shoulder. She had normal
dexterity and normal grip strength. R. 313. Delonjay’s lower back showed
no tenderness and normal tone.
Dr. Kozma’s neurological examination showed deep tendon reflexes
of 3+ in the lower extremities and 4+ in the upper extremities; normal
sensory examination; normal cranial nerve examination; no abnormal
reflexes; and normal equilibrium. R. 313.
Dr. Kozma’s functional examination showed that Delonjay had normal
heel and toe walking, and squatting. She had a normal gait and no
postural instability. She could bend forward with her leg straight and reach
within an inch of the floor. Her lumbar spine flexion was 95 degrees;
rotation of her upper pelvis was 45 degrees in both directions, lateral tilt
was 25 degrees in both directions, and extension was 10 degrees. Her
Page 10 of 43
straight leg raising was 85 degrees for the right leg and 90 degrees for the
left. R. 314.
Dr. Kozma observed that Delonjay was oriented in all spheres and
seemed to have a stable emotional state. Delonjay’s intellectual functions
were intact, and her thought content and communication were proper to the
occasion. R. 313.
Dr. Kozma concluded:
DISCUSSION: Ms. Delonjay is a right handed individual who
has no difficulty using her hands and fingers for gross and fine
manipulations. Her grip strength is good, so is her finger
She is complaining of generalized aches and pains but she
emphasizes that her main problem, really, is emotional. She
has bipolar disorder. She also has significant changes in her
She is depressed. This is a lifelong condition for her and she is
She has some days when she cannot remember things and she
has nightmares and she attributes that to mistreatment that she
experienced when she was very young and her mother was the
person causing the problems.
She has a history of kidney stones in the past but she has no
She has a great deal of anxieties. She has panic attacks. She
had three (3) to four (4) of them during the past months. It used
to be much more frequent.
Page 11 of 43
Her right shoulder replacement is working satisfactory. The
range of motion is determined by the hardware.
She has a condition that she was told but she does not know
what it is and she simply says it is called eosinophilia but no
further information is found.
A review of some of the medical records indicate that she has
chronic cervical radiculitis and her pain in the right shoulder is
considered to be intractable. She is taking narcotic pain
It seems that her medications are quite adequate. Reduction of
the range of motion of the right shoulder is noted in one of the
This examination and interview required 38 minutes to
complete and is considered reliable. If you need additional
information or desire clarification, please contact me at your
IMPRESSION: Chronic pain in the right shoulder.
History of arthroplasty of the right shoulder.
Decreased range of motion of the right shoulder.
Pain in the cervical spine.
Defective memory (needs assistance).
Possible chronic pain syndrome.
History of migraine headaches.
R. 314-15 (emphasis in the original).
On April 24, 2013, Dr. Richard Lee Smith, M.D., prepared a Physical
Residual Functional Capacity Assessment of Delonjay. R. 95-97. Dr.
Smith opined that Delonjay could occasionally lift 50 pounds, frequently lift
25 pounds, stand and/or walk six hours in an eight-hour workday, and sit
Page 12 of 43
six hours in an eight-hour workday. He opined that Delonjay was limited in
reaching overhead with her right hand. Dr. Smith said that the shoulder
replacement decreased her range of motion, “particularly abduction of only
90º.” R. 96.
On May 14, 2013, psychologist Dr. Joseph Mehr, Ph.D., completed a
Psychiatric Review Technique. R. 93-95. Dr. Mehr opined that Delonjay
had an affective disorder, personality disorder, and substance addiction
disorder. He opined that Delonjay’s mental disorders caused mild
restrictions on activities of daily living, mild difficulties in maintaining social
functioning, and mild difficulties in maintaining concentration, persistence or
pace. Dr. Mehr opined that Delonjay had no episodes of decompensation
of extended duration. R. 94. Dr. Mehr noted as one of his additional
explanations, “FOFAE NON-SEVERE.” R. 94. Dr. Mehr recited Dr.
Froman’s findings. R. 94. The acronym “FOFAE” means Findings of Fact
and Analysis of Evidence. See e.g., Nerland v. Berryhill, 2017 WL 345461,
at *3 (D. Kan. August 8, 2017).
On or about May 24, 2013, Delonjay completed a Social Security
Administration Disability Report—Adult form. R. 228-33. See Disability
Report—Field Office form, R. 234-35. Delonjay reported that she was
having more memory problems, more nerve pain in her arms, legs,
Page 13 of 43
buttocks, and feet. She reported that the changes in her condition began
on May 1, 2013. Delonjay said she had no new limitations as a result of
her impairments. R. 288.
On June 20, 2013, Delonjay saw Dr. Sharon Harris M.D. Delonjay
reported diffuse constant myalgias. She reported problems with short-term
memory. On examination, Dr. Harris found no proximal muscle weakness.
Dr. Harris was unable to determine a unifying diagnosis for her symptoms.
She posited that Delonjay’s status post menopause may be a reason for
some of her symptoms. Dr. Harris recommended stopping smoking,
exercising, and eating a healthy diet. R. 326. Delonjay reported to Dr.
Harris that she had no history of drug use and that she exercised five or
more days per week. R. 325.
On August 20, 2013, Delonjay saw Dr. Childress. Delonjay reported
memory loss spanning a few days. R. 376-77. On August 22, 2013,
Delonjay underwent an MRI of her brain because of indications of amnesia
and headaches. The MRI was normal with no significant findings. R. 356,
On September 6, 2013, psychologist Dr. Linda Lanier, Ph.D.,
prepared a Psychiatric Review Technique for Delonjay. R. 105-07. Dr.
Lanier repeated verbatim with Dr. Mehr’s opinions in all material respects.
Page 14 of 43
On September 9, 2013, Dr. Vidya Madala, M.D., prepared a Physical
Residual Capacity Assessment. R. 107-09. Dr. Madala repeated verbatim
Dr. Smith’s opinions in all material respects.
In September 2013, Delonjay completed a Social Security Disability
Report Appeal form. R. 236-42.3 Delonjay reported that her memory
episodes were worse, her constant nerve pain was worse, and her cervical
pain was worse. She stated that the changes in her condition occurred on
September 15, 2013. R. 236.
On September 30, 2013, Delonjay saw Dr. Julie Viehmann, D.O., for
an annual gynecologic examination and pap smear. On examination, Dr.
Viehmann noted no costovertebral angle tenderness and a normal
musculoskeletal examination. R. 339.
On October 11, 2013, Delonjay saw Dr. Childress. Dr. Childress
noted “point tenderness at cervical regions, C5, C6, C7 radiant to the right
arm with radicular pain.” Dr. Childress said, “Cephalgia is circumstantial
beginning at the base of the occiput and circumferentially surrounding her
head.” R. 369. Dr. Childress added Soma to her medications and reduced
The form is undated; however, the form states her condition changed in the past on September 15, 2013
(R. 236), and she had an appointment scheduled in the future on September 27, 2013 (R. 237). Based
on this information, the Court concludes that Delonjay completed the form between those two dates.
Page 15 of 43
the dosage of Norco and Fioricet. Dr. Childress stated that he was
concerned about rebound headaches. R. 369.
On October 29, 2013, Delonjay’s sister, Alice Hall, completed a form
statement about Delonjay. R. 246-48. Hall stated that Delonjay usually felt
bad, but her symptoms were unpredictable day-to-day. Hall stated that
Delonjay complained about pain in her extremities, primarily in her legs,
almost every time she saw Delonjay. R. 246. Hall said she never
observed Delonjay use a cane or other device to walk. Hall opined that
Delonjay could only walk across a room before she had to sit down for a
few minutes. She said Delonjay was usually lying down when Hall saw her.
Hall opined that Delonjay could not lift anything heavy. Hall said Delonjay
could bathe herself, but had a hard time showering when she was in pain.
She said Delonjay could wash dishes when she could stand long enough.
Hall said Delonjay was stressed because she could not do things she used
to do. R. 247. Hall reported that Delonjay had problems with her memory.
Hall said Delonjay had periods when she could not remember things she
said or did. R. 248.
On the same day, October 29, 2013, another sister of Delonjay, Ivy
Benedict, completed a form statement about Delonjay. R. 250-52.
Benedict said that Delonjay had memory problems, daily headaches,
Page 16 of 43
fevers, and daily leg pain. Benedict said that Delonjay could not sit or lie
down for “periods lasting any amount of time.” Benedict said she spent
much of her time lying down, but could not get comfortable while doing so.
Benedict described her pain as severe. R. 250. Benedict said that
Delonjay did not use a cane or other assistive device to walk. Benedict
opined that Delonjay could only walk very short distances before sitting or
lying down. Benedict opined that Delonjay could sit for an hour before
standing or lying down. Benedict said Delonjay could not lift much weight.
Benedict said Delonjay could take care of herself, but took a long time and
rested while caring for herself. Benedict said she did household cleaning
slowly. R. 251.
Benedict said Delonjay seemed stressed on a daily basis. Benedict
said Delonjay was stressed because of her memory losses, pain, and
fevers. Benedict said Delonjay was upset whenever she visited Delonjay
because Delonjay forgot things and because she was physically unable to
carry out plans. R. 252.
On November 8, 2013, Delonjay saw ophthalmologist Dr. Abram
Geisendorfer, M.D. She reported to Dr. Geisendorfer that she exercised
five or more days per week and she had no history of drug misuse. Dr.
Page 17 of 43
Geisendorfer performed a procedure on her eyes to correct anatomically
narrow angles. R. 368.
On December 18, 2013, Delonjay saw Dr. Gary Carpenter, M.D., for
headaches, sinus pressure, and an allergy evaluation. R. 362-66.
Delonjay reported that she had headaches since a motor vehicle accident
in 1987. She reported that the headaches were becoming more severe
and frequent. She reported that the headaches were occurring daily. She
reported that she had seen multiple neurologists and underwent multiple
scans. Dr. Carpenter noted that the August 22, 2013 MRI was normal. Dr.
Carpenter stated that Delonjay fractured her right shoulder falling down
some stairs in 2008. He stated that she had cervical neck surgery on C4,
C5, and C6 in January 2006. R. 362-63. Dr. Carpenter said, “She is
disabled due to chronic pain and memory problems. She lost her job in
August 2012 because of pain and memory problems.” R. 363. Dr.
Carpenter gave Delonjay a sample of Spiriva and ordered a sleep study.
R. 365. On December 23, 2013, Delonjay saw Dr. Human Farah, M.D.,
who conducted a sleep study. R. 348-49. Dr. Farah found no significant
sleep disorder. R. 349.
On January 13, 2014, Delonjay saw Dr. Carpenter. Dr. Carpenter
said that Delonjay experienced post-concussion headaches. Dr. Carpenter
Page 18 of 43
noted that the sleep study he ordered was normal. Dr. Carpenter stated
that Delonjay had a history of headaches after a motor vehicle accident in
1987. She reported she had seen multiple neurologists and underwent
multiple scans. Dr. Carpenter noted that the August 22, 2013 MRI was
normal. Dr. Carpenter stated that Delonjay fractured her right shoulder
falling down some stairs in 2008. He stated that she had cervical neck
surgery on C4, C5, and C6 in January 2006. R. 357-58. Dr. Carpenter
said, “She is disabled due to chronic pain and memory problems. She lost
her job in August 2012 because of pain and memory problems.” R. 358.
Dr. Carpenter stopped her prescription for Spiriva, but renewed her other
medications. R. 360.
On February 10, 2014, Delonjay saw Dr. Childress. R. 389-91. Dr.
Childress noted Delonjay’s subjective history as follows:
History of Present Illness
SUBJECTIVE: Patient reports here today status post cervical
decompression and fusion. She has a multitude of medical
problems that extends back a considerable period of time. I
have taken care of her for a decade or better and this has been
ongoing difficulty for her. She has attempted to resume her
previous work related activity but based on the chronicity of her
medical problems she has been overwhelmed with these and
we shall delineate them as same.
Page 19 of 43
On examination, Dr. Childress noted crepitance to flexion, extension,
and rotation of the cervical spine; reduced range of motion in the right
shoulder; and reduced grip strength bilaterally with right worse than left
“based on radiculopathy from her cervical discogenic disease and fusion
with what I believe to be adhesive induced radiculitis.” R. 389. Dr.
Childress noted limited range of motion in the lumbar spine:
There is reduced range of motion of the lumbar spine to forward
bending, backward bending, side bending and this raises
question whether the cervical discogenic disease has given her
lumbar radiculopathy and reduced functioning or indeed does
she have lumbar disease that is compatible with cervical
R. 389. Dr. Childress found radiculopathy in her extremities:
Neurological finds her to be with radiculopathy to the lower
extremities bilaterally. There is radiculopathy to the right and
left upper extremities, right worse than left, but there has been
previous fractured humerus of the right shoulder and proximal
R. 389. Dr. Childress also found headaches and memory deprivation:
There is memory deprivation secondary to falling down a flight
of stairs approximately 13-14 stairs where she was rendered
unconscious and received a severe concussion as well as the
fractured right humerus at the same time. There are chronic
recurring daily headaches that I believe are migrainous in
nature from her previous closed head trauma. Neurological
finds her to be with memory disturbance, radiculopathy, chronic
recurrent daily headaches and certain memory disturbance
associated with previous head trauma.
R. 389. Dr. Childress assessed:
Page 20 of 43
1. Cervical degenerative disk disease.
2. Cervical radiculopathy.
3. Fractured right humerus.
4. Concussion from previous blunt head trauma.
5. Post concussion syndrome from memory deprivation.
6. Chronic daily recurring headaches from previous head trauma.
Dr. Childress stated his plan for her condition:
PLAN: Continue her medical management as is. There is no
way she can return to work. She has a multitude of problems.
She cannot remember. Her pain medication is impairing in
itself. It is my belief that she is 100% physically and mentally
incapacitated to carry out the complicated work that she
previously does. I consider her 100% incapacitated.
R. 389-90. Dr. Childress renewed her prescriptions. R. 390-91.
On November 11, 2014, Delonjay saw Dr. Childress for flank pain,
muscle pain, and headache. Delonjay reported that she had been throwing
up for five days the prior week. Delonjay reported that her daily headaches
were worsening and she felt muscle pain all over. Dr. Childress noted right
upper quadrant pain, epigastric discomfort, and nausea. Dr. Childress
refilled her prescription for hydrocodone and gave her a sample of Nexium.
On November 28, 2014, Delonjay saw Dr. Childress for a recheck.
Delonjay said the “purple pill” helped somewhat but she wanted something
Page 21 of 43
else. Delonjay also had “disability paperwork that she needs to be filled
out.” Dr. Childress prescribed Dexilant instead of Nexium. R. 431-32.
On December 29, 2014, Delonjay saw Dr. David Arndt, D.O., for
upper right quadrant pain. Delonjay denied any backache or shoulder
ache. On examination, Delonjay’s CVA was nontender. Dr. Arndt ordered
an ultrasound of her gallbladder. After review of the results, Dr. Arndt
recommended a surgical consult. R. 434.
On January 5, 2015, Delonjay saw Medical Assistant Sherrie Hayes
to review results of the ultrasound of her gallbladder. R. 435-36. On
examination Hayes noted that Delonjay had normal range of motion. R.
On January 28, 2015, Delonjay saw physician’s assistant Jaclyn
Thobaben, PA-C. Delonjay reported epigastric abdominal pain with acute
attacks after eating. Her medical history noted new daily persistent
headache since December 18, 2013. A review of symptoms stated that
Delonjay was negative for headaches. On examination, Delonjay’s gait
was normal, and her mood, memory, and affect were all normal. R. 414-17.
On January 29, 2015, Delonjay was admitted to Blessing Hospital in
Quincy, Illinois, for cholecystitis. She saw Dr. Timothy Scott Smith, D.O.
Delonjay reported upper right quadrant pain. In a review of her systems,
Page 22 of 43
she said she had occasional headaches. On examination, Delonjay had
good grip strength and sensation was intact. R. 401. Delonjay discussed
options with Dr. Smith and decided to undergo a surgical cholecystectomy
to remove her gallbladder. R. 402.
On February 20, 2015, Delonjay saw Dr. Childress for diarrhea and
vomiting. Delonjay also reported that her legs and hips hurt all the time.
Dr. Childress assessed cervical radiculitis and irritable bowel syndrome. R.
On March 20, 2015, Delonjay saw Dr. Childress for medication refill.
On examination, Delonjay had normal range of motion and normal reflexes.
Dr. Childress assessed chronic retractable (sic) neck pain. He refilled her
prescription. She also wanted him to complete some AFLAC paperwork.
On April 14, 2015, Delonjay saw Dr. Ernest Wallace, M.D., for
symptoms of a urinary tract infection, vomiting, and diarrhea. On
examination, she had no costovertebral angle pain and “[a] little bit of low
back pain.” Dr. Wallace assessed a urinary tract infection and resolved
viral gastroenteritis. R. 454.
On August 4, 2015, Dr. Childress completed a form entitled Medical
Source Statement of Ability to do Work-Related Activities (Physical). R.
Page 23 of 43
481-84. Dr. Childress opined that Delonjay could occasionally lift 20
pounds and frequently lift 10 pounds, stand and walk three hours in an
eight-hour workday, and sit about two hours in an eight-hour workday. He
opined that Delonjay needed to change sitting positions every 15 minutes
and change standing positions every 15 minutes; and needed to walk
around for 10 minutes about six times during an eight-hour workday. Dr.
Childress opined that Delonjay needed to shift positions at will and needed
to lie down every two hours during an eight-hour workday. Dr. Childress
stated that these limitations were due to medical findings of “Frequency of
pain Rx use for ADL activity.” R. 481. The acronym “ADL” means activities
of daily living.
Dr. Childress opined that Delonjay could occasionally twist, stoop,
bend, crouch, and climb stairs, but could never climb ladders. R. 482. Dr.
Childress stated that these limitations were due to medical findings of “®
arm and shoulder discomfort from Fx. Vertigo post head injury.” R. 482.
Dr. Childress opined that Delonjay could occasionally reach and push/pull;
and frequently handle, finger, and feel with her hands and fingers. Dr.
Childress stated that these limitations were due to medical findings of
“Previous Fx and head injury.” R. 482.
Page 24 of 43
Dr. Childress opined that Delonjay should avoid concentrated
exposure to perfumes; moderate exposure to extreme cold, extreme heat,
high humidity, soldering fluxes, and solvents/cleaners; and all exposure to
fumes, odors, dusts, gases, and chemicals. R. 483. Dr. Childress stated
that the medical findings that supported these limitations were, “Rx use and
headache frequency as well as previous Fx ® arm.” R. 483. Dr. Childress
opined that Delonjay would miss 4 days of work per month due to her
impairments or for treatment. R. 483. Dr. Childress opined that Delonjay
would need to be off-task 25% or more of the time and she would need
unscheduled breaks during the workday. He opined that she would need
unscheduled breaks due to muscle weakness; pain/paresthesias,
numbness; adverse effects of medication; and cephalgia. R. 484.
THE EVIDENTIARY HEARING
On August 5, 2015, the Administrative Law Judge (ALJ) conducted
an evidentiary hearing. R. 60-88. Delonjay appeared with her counsel.
Vocational expert Dr. Roxane Minkus, Ph.D., also appeared at the hearing
by telephone. R. 62, 78-79.
Delonjay gave the first testimony. She said she lived with her
husband. She and her husband had grown children who did not live with
them. She last worked on August 12, 2012. Delonjay said that her
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“memory was really lapsing.” In her last employment she interviewed
people for a drug study. She said she re-interviewed the same person
because of her memory lapse. She said she was not fired, “No, I quit more
or less because I knew that I wasn’t up to doing the job correct. It was an
important job.” R. 66.
Delonjay indicated that she broke her right humerus on January 27,
2008. She said that six months later, she underwent right shoulder
replacement surgery. R. 66.
Delonjay testified that she experienced daily migraine headaches.
She stated that the headaches lasted an average of four to six hours. She
said she would lie down, shut off all noise and all light, and take her
medication Fioricet (Fiorinal in the transcript). R. 68.
Delonjay indicated that she had a neck fusion surgery in 2007, a year
before she broke her humerus. She said the pain affected her work as a
researcher. She testified she was still able to do the job, but not her best.
She stated that her supervisors started writing her up. R. 68-69.
Delonjay described her neck pain. She testified the pain was “like
inflammation that just gets out of control.” She said she could not turn her
neck to the right or left because of the pain. She stated that she could not
move her head up or down because of the surgery. She indicated she had
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nerve pain shooting down her arms. R. 69. The pain radiated into her
fingers. She said nothing alleviated the pain. R. 69-70.
Delonjay testified that she had muscle pain in her legs daily. She
described the pain as “a deep throbbing pain.” Her pain medication,
hydrocodone, allowed her to cope with the pain, but the pain did not go
away. She indicated hot baths helped with the pain. She took hot baths
three to four times a day. She stayed in the tub for about 15 minutes each
time. R. 70-71.
Delonjay said that nothing else helped with the pain. She testified,
“Laying down doesn’t help because it just makes you feel it worse. I will
get up and walk, pace the floor so that I feel that instead of laying down and
feeling the pain.” R. 71.
Delonjay tried inpatient drug rehabilitation when she quit her job. She
That was like when I quit my job I had to - - my husband was
not understanding the pain and he thought I was addicted to
pain pills, and I needed to find out if I was or I need -- I was
very confused so I did go to rehab in California.
R. 71. She was in inpatient rehabilitation treatment for 47 days. She said,
“The result was that they had me on more medication when I came home
than I was on when I went there.” T. 72.
Page 27 of 43
Delonjay testified that she also had a concussion in an automobile
accident many years ago. She had memory problems for three months
after the auto accident. She indicated she later dove into three feet of
water and hit her head again. She said the memory problems came back
then. She testified she then fell down a flight of stairs and hit her head and
broke her shoulder. She was unconscious after that fall. She stated that
her memory has not gotten better since that fall. R. 72-73.
Delonjay testified that the MRI of her brain was normal. She said her
doctor compared her to a football player who suffered concussions,
“[T]hey’re fine for a while and then suddenly they’re having like sort of
compared to dementia, and they relate that back to the trauma their head
injuries had during the football.” R. 73.
Delonjay said that during the day she changed positions and took hot
baths to alleviate the pain. She said that no position alleviated the pain
completely. R. 76.
Delonjay testified that she could lift a gallon of milk to pour a drink,
but could not carry it around. She said she could not bend, stoop, or squat
because her legs were too weak. She indicated that she did some light
housework. She washed dishes about twice a week. R. 77. Delonjay said
Page 28 of 43
that her husband helped her dress and bathe. He shampooed her hair. He
helped her put on her clothes. R. 78.
She stated she could concentrate for 20 to 30 minutes. She said she
had trouble driving because sitting in her car made her legs hurt worse.
Her husband usually drove her. She stated that her husband did the
shopping, but she accompanied him sometimes. R. 78.
Dr. Minkus then testified. The ALJ asked Minkus the following
Let's assume an individual closely approaching advanced age
50 but under 55, 12th grade education, and the past relevant
work history is doing government surveys for both the Census
Bureau and private companies that were contracting with the
government . . .
Okay. All right. Well, let's say 20 pounds occasionally, 10
pounds frequently; standing and walking a total of six hours in
eight, sitting total of six hours in eight; the posturals, balancing,
kneeling, crouching, crawling, stooping, ramps, and stairs
would all be occasional; no ladders, ropes, or scaffolds.
I'm going to say no overhead tasks, so there's no
reaching overhead but handling, fingering, feeling, pushing,
pulling, and reaching in directions -- other directions just not
overhead, those can all be frequent; and then simple routine
So starting with that, are there any occupations that such
a person could do?
R. 80-81. Dr. Minkus opined that such a person could work as a subassembler electrical equipment, with 32,000 such jobs nationally, and
Page 29 of 43
1,000 in Illinois; a bench assembler with 70,000 such jobs nationally, and
2,600 in Illinois; a product assembler with 65,000 such jobs nationally, and
2,600 in Illinois. R. 82. Dr. Minkus opined that such a person could not
perform any of these jobs if the person were limited to occasional reaching,
handling, and fingering. R. 83.
Dr. Minkus testified that a person could not work if she were
consistently absent from work three days a month. She also opined that a
person could not work if she was off-task 20 percent or more of the time
during the workday. R. 85-86. The hearing concluded.
THE DECISION OF THE ALJ
The ALJ issued his decision on November 3, 2015. The ALJ followed
the five-step analysis set forth in Social Security Administration Regulations
(Analysis). 20 C.F.R. §§ 404.1520, 416.920. Step 1 requires that the
claimant not be currently engaged in substantial gainful activity. 20 C.F.R.
§§ 404.1520(b), 416.920(b). If true, Step 2 requires the claimant to have a
severe impairment. 20 C.F.R. §§ 404.1520(c), 416.920(c). If true, Step 3
requires a determination of whether the claimant is so severely impaired
that he is disabled regardless of his age, education and work experience.
20 C.F.R. §§ 404.1520(d), 416.920(d). To meet this requirement at Step 3,
the claimant's condition must meet or be equal to the criteria of one of the
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impairments specified in 20 C.F.R. Part 404 Subpart P, Appendix 1
(Listing). 20 C.F.R. §§ 404.1520(d), 416.920(d). If the claimant is not so
severely impaired, the ALJ proceeds to Step 4 of the Analysis.
Step 4 requires the claimant not to be able to return to the claimant’s
prior work considering age, education, work experience, and Residual
Functional Capacity (RFC). 20 C.F.R. §§ 404.1520(e) and (f), 416.920(e)
and (f). If the claimant cannot return to his or her prior work, then Step 5
requires a determination of whether the claimant is disabled considering his
RFC, age, education, and past work experience. 20 C.F.R. §§
404.1520(g), 404.1560(c), 416.920(g), 416.960(c). The claimant has the
burden of presenting evidence and proving the issues on the first four
steps. The Commissioner has the burden on the last step; the
Commissioner must show that, considering the listed factors, the claimant
can perform some type of gainful employment that exists in the national
economy. 20 C.F.R. §§ 404.1512, 404.1560(c); Weatherbee v. Astrue, 649
F.3d 565, 569 (7th Cir. 2011); Briscoe ex rel. Taylor v. Barnhart, 425 F.3d
345, 352 (7th Cir. 2005).
The ALJ found that Delonjay met her burden at Steps 1 and 2. She
had not engaged in substantial gainful activity since August 11, 2012, and
she suffered from severe impairments of history of concussion, history of
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right comminuted humerus fracture, degenerative disc disease of the
cervical spine with history of fusion surgery, anxiety, and borderline
personality disorder. R. 35.
As part of Step 2 of the Analysis, the ALJ found that Delonjay’s
headaches were not severe. The ALJ noted that Dr. Childress diagnosed
daily migraine headaches in February 2014. The ALJ did not find that
evidence persuasive in light of other evidence in the record. The ALJ cited:
the record of her March 11, 2013 visit with Dr. Childress in which he said
she had intermittent tension headaches rather than migraine headaches;
the MRI of her brain that showed normal results; the January 13, 2014
office visit with Dr. Carpenter in which she reported that her headaches
were better with montelukast (Singulair); the March 11, 2013, office visit
with Dr. Childress in which she reported that the headaches were
controlled with Fioricet; the January 28, 2015 office visit with physician’s
assistant Thobaben in which she was negative for headaches on
examination; and the January 29, 2015, office visit with Dr. Scott Smith in
which Delonjay reported that she had occasional headaches. R. 36.
The ALJ also found at Step 2 that Delonjay’s nausea and other
abdominal problems were not severe. The ALJ cited the medical evidence
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that her condition was addressed when she had cholecystectomy surgery.
At Step 3, the ALJ determined that none of Delonjay’s impairments or
combination of impairments met or medically equaled any Listing. R. 3840.
At Step 4, the ALJ found that Delonjay had the following RFC:
After careful consideration of the entire record, the
undersigned finds that the claimant has the residual functional
capacity to perform a range of light work as defined in 20 CFR
404.1567(b). She can lift 20 pounds occasionally and 10
pounds frequently. She can stand and walk a total of 6 hours in
8 and sit a total of 6 hours in 8. She can never climb ladders,
ropes or scaffolds. She can occasionally balance, kneel,
crouch, crawl, stoop and climb ramps and stairs. She cannot
reach overhead, but she can frequently reach in other
directions. She can frequently handle, finger, feel, push and
pull. The claimant can perform simple routine tasks.
R. 41. The ALJ relied on the consultative examinations of Drs. Kozma and
Froman; the opinions of Drs. Madala and Lanier; the numerous references
in the record that Delonjay exercised five or more days per week; Dr.
Harris’ recommendation on June 20, 2013, to exercise more; the medical
examinations in which she had normal strength and normal range of
motion; the records from Dr. Arndt that she had no CVA pain and a little low
back pain, and other medical records that showed no CVA pain; the MRI of
her brain that was normal; and the lack of x-rays, scans, nerve conduction
Page 33 of 43
studies, or other tests to confirm the severity of her condition. R. 41-54.
The ALJ also relied on the fact that Delonjay engaged in substantial gainful
activity after her 2007 and 2008 surgeries. R. 51.
The ALJ gave only limited weight to Dr. Childress’ opinions. The ALJ
stated that Dr. Childress’ opinions were based on Delonjay’s subjective
complaints because “very little objective medical evidence” existed to
support the opinions. The ALJ found that “Dr. Childress also appears to be
actively attempting to assist the claimant in her requests for help with her
application for benefits, despite the lack of objective evidence in the file.”
R. 50. The ALJ also relied on the fact that Delonjay had not been referred
to a specialist for her neck, back, or shoulder since the alleged onset date.
The ALJ found Dr. Childress’ first two opinions on October 4, 2012,
and February 10, 2014, that she was 100% incapacitated were “too general
and vague to be given much weight.” R. 51. The ALJ also said the two
were inconsistent with the third opinion on August 4, 2014, because Dr.
Childress opined that she “could do work that lies between the light and
sedentary exertional levels.” R. 51. The ALJ accepted Dr. Childress’
opinion in the Medical Source Statement that Delonjay could lift 20 pounds
occasionally and 10 pounds frequently, but rejected the rest. The ALJ
Page 34 of 43
rejected the opinions primarily because of the lack of x-rays, imaging, or
electro diagnostic studies to support the opinion; and a lack of observations
from other doctors to support the opinions. R. 51.
The ALJ considered Dr. Froman’s GAF score of 55. The ALJ
erroneously said he considered “each of the GAF scores,” but Dr. Froman
is the only doctor who assigned a score. Drs. Mehr and Lanier repeated
Froman’s score in their Psychiatric Review Techniques forms. R. 94, 106.
The ALJ gave the GAF score limited weight because of its subjective
limitations and because one score is of a person’s condition at a given
moment. R. 52-53.
The ALJ also considered the statements of Delonjay’s husband and
sisters, but gave them little weight because the opinions were lay opinions
that were not supported by the other evidence in the file. The ALJ,
however, noted that Jeffrey Delonjay’s statements that Delonjay cleaned,
cooked, did laundry, went shopping three to four times a week, visited
grandchildren, drove, and watched television were inconsistent with
Delonjay’s claims about the severity of her symptoms. R. 53.
After determining Delonjay’s RFC, the ALJ found at Step 4 that a
person with her RFC could not perform her prior work because none
involved only simple routine tasks. R. 54.
Page 35 of 43
At Step 5, the ALJ found that Delonjay could perform a significant
number of jobs in the national economy. The ALJ relied on the RFC
determination; the Medical-Vocational Guidelines, 20 C.F.R. Part 404,
Subpart P, Appendix 2; and the opinions of Dr. Minkus that such a person
could perform the sub-assembler, electrical equipment job, the bench
assembler, and production assembler job. R. 54-55. The ALJ concluded
that Delonjay was not disabled.
Delonjay appealed. On November 4, 2016, the Appeals Council
denied Delonjay’s request for review. The decision of the ALJ then
became the final decision of the Defendant Commissioner. R. 9. Delonjay
then filed this action for judicial review.
This Court reviews the Decision of the Commissioner to determine
whether it is supported by substantial evidence. Substantial evidence is
“such relevant evidence as a reasonable mind might accept as adequate”
to support the decision. Richardson v. Perales, 402 U.S. 389, 401 (1971).
This Court must accept the findings if they are supported by substantial
evidence, and may not substitute its judgment or reweigh the evidence.
Jens v. Barnhart, 347 F.3d 209, 212 (7th Cir. 2003); Delgado v. Bowen, 782
F.2d 79, 82 (7th Cir. 1986). This Court will not review the ALJ’s evaluation
Page 36 of 43
of statements regarding the intensity, persistence, and limiting effect of
symptoms unless the evaluation is patently wrong and lacks any
explanation or support in the record. See Pepper v. Colvin, 712 F.3d 351,
367 (7th Cir. 2014); Elder v. Astrue, 529 F.3d 408, 413-14 (7th Cir. 2008);
SSR 16-3p, 2016 WL 1119029, at *1 (2016) (The Social Security
Administration no longer uses the term credibility in the evaluation of
statements regarding symptoms). The ALJ must articulate at least
minimally his analysis of all relevant evidence. Herron v. Shalala, 19 F.3d
329, 333 (7th Cir. 1994). The ALJ must “build an accurate and logical
bridge from the evidence to his conclusion.” Clifford v. Apfel, 227 F.3d 863,
872 (7th Cir. 2000).
The ALJ’s decision was supported by substantial evidence. The
RFC determination was supported by the consultative examinations of Drs.
Kozma and Froman; by the opinions of Drs. Smith, Madala, Mehr, and
Lanier; and by the medical records that showed normal range of motion
except for her right shoulder, no CVA pain, limited low back pain,
occasional headaches controlled by medication, regular exercise five or
more days per week; and normal results of an MRI of her brain.
The ALJ’s decision not to credit Dr. Childress’ opinion was supported
by the conflicting evidence from Drs. Kozma, Arndt, Scott Smith, and
Page 37 of 43
Harris; and the lack of x-rays, MRIs or other imaging, EMG/nerve
conduction studies, or other medical tests or studies that would support his
opinion. The RFC determination and Dr. Minkus’ opinions supported the
ALJ’s conclusion at Step 5 that Delonjay could perform a significant
number of jobs in the national economy. Substantial evidence supported
Delonjay argues that the ALJ’s RFC determination was not fully
grounded in the evidence. The Court disagrees. The decision was fully
grounded in the examinations of Drs. Kozma and Froman; the records from
Drs. Harris, Scott Smith, Arndt; some of the medical records from office
visits with Dr. Childress; the opinions of Drs. Smith, Madala, Mehr, and
Lanier; and the repeated medical notes that she exercised five or more
days per week.
Delonjay argues that the ALJ made up the RFC first and then
selected credited evidence that supported it. The Court again disagrees. A
fair reading of the decision shows that the ALJ relied on the consultative
examinations, the lack of consistency between Dr. Childress’ examination
records and the records of the other treating and examining physicians and
health professionals, and the paucity of objective imaging or electro
diagnostic testing evidence. The ALJ discounted Dr. Childress’ opinions
Page 38 of 43
because his opinions were inconsistent with findings by other physicians
during examinations and because significant objective test results did not
exist in the record.
Delonjay cites Murphy v. Colvin, 759 F.3d 811 (7th Cir. 2014) to
support her claim that the ALJ did not ground his RFC determination in the
evidence. The ALJ in Murphy failed to build a logical bridge from the
evidence to his conclusion. Id. at 819. The ALJ built such a bridge here.
The findings of Dr. Kozma, combined with the treatment notes of Drs.
Harris, Arndt, Scott Smith and physician’s assistant Thobaben; and the
opinions of Drs. Smith, Mehr, Madala, and Lanier supported the RFC
determination. The Murphy case does not apply. The RFC determination
was supported by substantial evidence.
Delonjay argues that the ALJ did not rely on Dr. Froman’s opinion.
The Court disagrees. Dr. Froman opined that Delonjay could “perform one
or two step assemblies at a competitive rate.” R. 305. The ALJ found that
Delonjay had the RFC to perform “simple routine tasks.” Delonjay argues
that these two characterizations of Delonjay’s function abilities are
inconsistent. She cites the Department of Labor’s Dictionary of
Occupational Titles (DOT) to support this argument. The DOT categorizes
different aspects of jobs. One aspect is reasoning ability. The simplest
Page 39 of 43
level of reasoning ability in the DOT, R1, involves, in relevant part, the
ability to “apply commonsense understanding to carry out simple one- or
two-step instructions.” The next higher level of reasoning, R2, involves the
ability to “apply commonsense understanding to carry out detailed but
uninvolved written or oral instructions.” DOT, Appendix C, § III General
Education Development, 02 Reasoning Level Development and 01
Reasoning Level Development, available at
viewed February 6, 2018. Delonjay argues that Dr. Froman’s opinion
limited Delonjay to jobs with an R1 reasoning level, but the ALJ’s RFC
determination improperly included jobs with R2 reasoning. The
representative jobs cited by Dr. Minkus had a reasoning level of R2.
The Commissioner correctly points out that Dr. Froman did not opine
that Delonjay was limited to jobs with simple one- or two-step instructions.
He opined that she could perform simple one- or two-step assemblies.
Commissioner’s Memorandum in Support of Motion for Summary
Affirmance (d/e 15), at 9. The DOT reasoning categories (R1, R2, etc)
describe the type of instructions a person must understand to perform a
job, not the functional steps a person must follow to perform the job. The
Commissioner also points out that the bench assembler job cited by Dr.
Page 40 of 43
Minkus (a/k/a assembler, small products I), DOT No. 706.684-022, has a
reasoning level of R2, but often involves assembling one or two specific
parts. The ALJ’s RFC finding of an ability to perform simple, routine tasks
is consistent with Dr. Froman’s opinions.
Delonjay argues that the ALJ erred in not crediting Dr. Childress’
opinions. The Court disagrees. The ALJ must give the opinions of a
treating physician controlling weight if the opinions are supported by
objective evidence and are not inconsistent with other evidence in the
record. 20 C.F.R. § 404.1527(d)(2); Bauer v. Astrue, 532 F.3d 606, 608
(7th Cir. 2008).4 The ALJ found that Dr. Childress’ opinions were largely not
supported by objective evidence in the file and were inconsistent with other
medical evidence in the file. The ALJ found that the opinions were
inconsistent with the findings of Dr. Kozma; and the treatment notes from
Drs. Arndt, Scott Smith, Harris. The ALJ also found that Dr. Childress’
opinions were not well supported by any x-rays, MRIs or other imaging,
EMG/nerve conduction studies, or other objective medical tests or studies
that would support his opinion.
The Commissioner recently amended the regulations regarding the interpretations of medical evidence.
The amendments apply prospectively to claims filed on or after March 27, 2017. Revisions to Rule
Regarding the Evaluation of Medical Evidence, 82 Fed. Reg. 5844-01, at 5844-45 (January 18, 2017). As
such, the amendments do not apply here.
Page 41 of 43
Delonjay notes that the ALJ incorrectly stated that Dr. Childress’
August 4, 2015 opinions indicated that Delonjay could perform work at an
exertional level between light and sedentary work. Delonjay is correct on
this point. This statement does not appear in the August 4, 2017 medical
source statement of Dr. Childress. The ALJ, however, did not just rely on
this observation in assessing Dr. Childress’ opinions. As discussed above,
the assessment of Dr. Childress’ opinions was inconsistent with the
medical treatment and examination notes by Drs. Kozma, Harris, Arndt,
Scott Smith; and the opinions of Drs. Smith, Mehr, Madala, and Lanier. Dr.
Childress’ opinions were not supported by imaging, EMG/nerve conduction
studies, or other tests. The ALJ’s decision not to credit most of Dr.
Childress’ opinions was supported by substantial evidence.
Delonjay argues that the ALJ erred in the consideration of her
headaches. Delonjay argues that the ALJ failed to consider her headaches
in the formulation of the RFC. As discussed above, the ALJ adequately
addressed her impairments, including her headaches in his opinion. The
ALJ is not required to address each piece of evidence. See Murphy, 759
F.3d at 817-18. There was no error.
Delonjay also argues that the ALJ erroneously found that she had
both tension headaches and migraine headaches. Delonjay is mistaken.
Page 42 of 43
The ALJ only recited Dr. Childress’ diagnoses. Dr. Childress diagnosed
tension headaches on March 11, 2013, and later diagnosed migraine
headaches on February 10, 2014. The ALJ did not err in characterizing
these pieces of evidence.
Delonjay argues that the ALJ failed to consider her nausea
adequately. The ALJ treated the nausea appropriately. The ALJ recited
the evidence that indicated she had significant problems with nausea
associated with problems with her gallbladder. The ALJ then concluded
that she was status post cholecystectomy. R. 36. The ALJ clearly found
that the problem was no longer severe after the surgery. Delonjay cites no
evidence to the contrary. The treatment of Delonjay’s nausea was not
THEREFORE, IT IS ORDERED that the Defendant Commissioner’s
Motion for Summary Affirmance (d/e 14) is ALLOWED; Plaintiff Jody
Delonjay’s Motion for Summary Judgment (d/e 11) is DENIED; and the
decision of the Commissioner is AFFIRMED. All pending motions are
denied as moot. THIS CASE IS CLOSED.
ENTER: April 13, 2018
s/ Tom Schanzle-Haskins
UNITED STATES MAGISTRATE JUDGE
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