Dent v. Colvin

Filing 34

MEMORANDUM Opinion and Order Signed by the Honorable Sheila M. Finnegan on 9/5/2014: Plaintiff's Motion for Summary Judgment 18 is granted, and Defendant's Motion for Summary Judgment 28 is denied. Pursuant to sentence four of 42 U.S .C. § 405(g), the ALJ's decision is reversed, and this case is remanded to the Social Security Administration for further proceedings. Civil case terminated. [For further details see memorandum opinion and order.] Mailed notice. (is, )

IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ILLINOIS
EASTERN DIVISION
DIANE DENT,
Plaintiff,
v.
CAROLYN W. COLVIN, Acting
Commissioner of Social Security,
Defendant.

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No. 13 C 4452
Magistrate Judge Finnegan

MEMORANDUM OPINION AND ORDER
Plaintiff Diane Dent seeks to overturn the final decision of the Commissioner of
Social Security (“Commissioner”) denying her application for Disability Insurance
Benefits (“DIB”) under Title II of the Social Security Act. 42 U.S.C. §§ 423(d), 1381a.
The parties consented to the jurisdiction of the United States Magistrate Judge pursuant
to 28 U.S.C. § 636(c), and filed cross-motions for summary judgment. After careful
review of the record, the Court now grants Plaintiff’s motion, denies the Commissioner’s
motion, and remands this case for further proceedings.
PROCEDURAL HISTORY
Plaintiff filed her initial application for DIB on November 30, 2009, alleging that
she became disabled on July 25, 2009, due to rheumatoid arthritis, high blood pressure,
and vitamin D deficiency. (R. 167-68; 192). The Social Security Administration (“SSA”)
denied Plaintiff’s claims initially on March 17, 2010, and upon reconsideration on August
18, 2010. (R. 105). After Plaintiff’s timely request, Administrative Law Judge (“ALJ”)
Marlene R. Abrams held an August 2, 2011 hearing in this matter. (R. 19; 36). Plaintiff,

who appeared with counsel, testified at the hearing, as did Randall L. Harding, a
vocational expert (“VE”), and Dr. Sheldon Slodki, a medical expert (“ME”). (R. 36-103).
Several months after the hearing, on March 29, 2012, the ALJ found Plaintiff is
not disabled because she is capable of performing light work, including her past
relevant work as a medical records clerk and as an inventory control clerk. (R. 19-31).
On April 24, 2012, Plaintiff requested review of the ALJ’s decision, and on April 19,
2013, the appeal was denied. (R. 6-10; 15). Plaintiff now seeks judicial review of the
ALJ’s decision, which stands as the final decision of the Commissioner.
In support of her request for remand, Plaintiff argues that the ALJ erred: (1) by
finding that her impairments or combination of impairments do not meet or medically
equal Listing 14.09 for inflammatory arthritis; (2) in analyzing the medical opinions of her
treating internist, Dr. Irene Aluen,1 DDS consulting physician Dr. George Andrews, and
the ME, Dr. Sheldon Slodki; (3) by improperly determining her residual functional
capacity (“RFC”); and (4) in making a flawed credibility assessment.
FACTUAL BACKGROUND
Plaintiff was born on February 18, 1955, and was 56 years old at the time of the
hearing in this matter. (R. 43-44). Plaintiff lives in an apartment with her daughter, sonin-law, and seventeen-year-old grandson. (R. 65-66). She earned a GED and also
received certificates in medical records and word processing at a training school. (R.
44-45). Plaintiff worked as a word processing operator for nine years, as a medical
records clerk for about three years, and then as an inventory clerk dealing with airplane
parts beginning in September 2006.

(R 46-53; 193).

She was laid off from the

1
The record indicates that the internist’s full name is Dr. Irene Aluen Metzner, but the
parties refer to her as “Dr. Aluen,” and thus so shall the Court.

2

inventory clerk job on April 17, 2009, due to a downturn in the economy. (R 46-53;
193).
Shortly after being laid off, Plaintiff began receiving unemployment benefits,
which lasted until mid-2010. (R. 21; 46-47). While she received those benefits, Plaintiff
applied for jobs in customer service and attended some interviews for inventory clerk
jobs, but did not obtain employment. (R. 46-47). In late July 2009, Plaintiff began
experiencing pain, soreness, stiffness, and swelling in her hands and ankles, and was
eventually diagnosed with arthritis (R. 53-54; 86).
A.

Medical History
1.

2009

The first available medical records are from Plaintiff’s August 20, 2009
emergency room visit at Loyola Hospital, a couple of weeks after the date Plaintiff
allegedly became disabled. (R. 264-72). Plaintiff complained of severe pain in her
ankles and hands for a couple of days, and reported experiencing similar pain a couple
of weeks prior. (R. 266). She also indicated that she had needed assistance walking
because of the pain. (R. 267.). On examination, Plaintiff displayed erythema (redness
of the skin), mild warmth and swelling in the left ankle. (Id.). The attending physician
ordered a metabolic panel and other labs, but found nothing concerning. (R. 267-271).
Plaintiff was injected with a pain killer to relieve her immediate pain, and was
discharged from the emergency room the next day with orders to take Naprosyn for
pain. (R. 266; 272). At discharge, Plaintiff denied pain or discomfort, and ambulated
with a normal gait. (R. 266).

3

A week later, on August 27, 2009, Plaintiff visited another emergency room at
Stroger Hospital. (R. 430-33). She told the attending physician, Dr. David Levine, that
the Naprosyn she had been given helped her pain, but she still experienced wrist and
ankle pain that were worse with activity and in the morning. (Id.). Dr. Levine found
Plaintiff had a full range of motion and normal strength in both her ankles, although
there was some redness in her left ankle and tenderness in the right. (R. 430). Dr.
Levine also noted decreased strength and range of motion in the left wrist, and ordered
left wrist and left ankle x-rays. (R. 430, 433). The x-rays are not in the record, but Dr.
Levine’s notes described the wrist x-ray as “unremarkable,” and his note regarding the
ankle x-ray is illegible.

(R. 433).

Dr. Levine diagnosed Plaintiff with polyarthritis,

recommended she be discharged, prescribed ibuprofen for pain, and referred her for a
follow-up at the Stronger Musculoskeletal Clinic. (R. 431, 433).
A few weeks later, on September 10, 2009, Plaintiff returned to the emergency
room at Loyola Hospital, complaining of neck and cervical spine pain. (R. 253-63). She
was asked about her arthritis, and denied any hand pain. (Id.). She also had no
redness, swelling or deformities, and had a full range of motion and strength in all
extremities. (Id.). Plaintiff had a CT scan of the head and neck which showed a small
amount of mild inflammation in the back of the neck. (R. 255; 261). Plaintiff was given
some morphine for pain, and refused any more diagnostic procedures or treatments,
stating that her pain was resolved with the morphine. (Id.). She told the emergency
room attending physician that she “felt much better,” and she thought her pain was
probably caused by having “slept wrong.” (Id.). Plaintiff was then discharged, and was

4

encouraged to establish a primary care physician rather than continue being treated at
emergency rooms. (Id.).
About a month later, on October 13, 2009, Plaintiff began seeing Dr. Aluen at
Logan Square Health Center, to establish primary care. (R. 331-35). Plaintiff described
her ankle and wrist pain history to Dr. Aluen, and complained at that time of pain and
stiffness in the hands and ankles that was worse in the mornings and lasted all day. (R.
331). Plaintiff stated her pain was then at a 2 on a scale of 1 to 10, 10 being the worst.
(R 335). She was also wearing a wrist brace that she said relieved her pain. (Id.).
Plaintiff also complained of fatigue. (R. 398).
Dr. Aluen found no redness in any of Plaintiff’s joints, but found synovitis
(inflammation of the synovial membrane)2 in her distal interphalangeal joints, proximal
interphalangeal joints,3 wrists, and ankles. (Id.). The doctor also noted that Plaintiff had
significantly elevated blood pressure. (R. 333). Dr. Aluen also wrote that Plaintiff’s wrist
and ankle x-rays from August 2009 were “unremarkable.” (Id.). Based on her findings,
the doctor diagnosed Plaintiff with polyarthralgia (pain in several joints) and indicated a
preliminary diagnosis of rheumatoid arthritis.

(Id.).

She prescribed Prednisone for

Plaintiff’s inflammation, Tylenol #3 for pain, and a blood-pressure medication. (Id.). Dr.

2
“Synovial membrane” refers to the “connective-tissue membrane that lines the cavity of a
joint and produces the synovial fluid.” http://www.thefreedictionary.com/synovial+membrane (all
websites in this opinion were last visited September 2, 2014).
3 “Distal interphalangeal joints” refers to “the synovial joints between the middle and distal
phalanges
of
the
fingers
and
of
the
toes.”
http://medicaldictionary.thefreedictionary.com/distal+interphalangeal+joints. “Proximal interphalangeal joints”
refers to “the synovial joints between the proximal and middle phalanges of the fingers and of
the toes.”
http://medical-dictionary.thefreedictionary.com/proximal+interphalangeal+joints.
“Phalanges” refers to “the bones of the fingers and toes.”
http://medicaldictionary.thefreedictionary.com/phalanges.

5

Aluen also referred Plaintiff to Stroger for various lab work, and a follow-up that the
doctor later rescheduled. (Id.).
Dr. Aluen reviewed the results of Plaintiff’s lab work on October 27, 2009, and
noted they showed Plaintiff had mild pancytopenia, and an elevated rheumatoid factor.4
(R. 398-404). Dr. Aluen then called Dr. John Case, a rheumatologist at Stroger, and
discussed Plaintiff’s conditions with him. (Id.). The doctors determined Plaintiff’s joint
pain suggested a rheumatologic condition, but her pancytopenia and fatigue could also
be due to a hematological, or blood-related, malignancy. (Id.). The doctors scheduled
Plaintiff for additional lab work and follow-ups. (Id.).
After the lab work was completed, Plaintiff met with Dr. Aluen on November 13,
2009. (R. 328; 395-97). Plaintiff told Dr. Aluen that the Prednisone did not help her
pain, so she stopped taking it. (R. 328). Plaintiff also said that she could not afford to
purchase her blood pressure medication. (Id.). Upon evaluation, Plaintiff presented the
same synovitis issues as before, and now had swelling in the sternoclavicular joint.5
(Id.). Dr. Aluen also noted that Plaintiff’s autoimmune panel was negative and her other
lab results were normal, except she had a rheumatoid factor of 61. (Id.). Dr. Aluen
recommended additional labs to further investigate Plaintiff’s pancytopenia.

(Id.).

Those lab results showed Plaintiff had iron deficiency anemia. (R. 389-93). Dr. Aluen
then recommended Plaintiff have additional testing at the emergency room so that her
physicians could determine whether the anemia was related to her arthritis.

(Id.).

4
“Pancytopenia” refers to a “reduction in the number of red blood cells, white blood cells,
and platelets.” http://medical-dictionary.thefreedictionary.com/pancytopenia.
5
“Sternoclavicular joint” refers to “the synovial articulation between the medial end of the
clavicle and the manubrium of the sternum and cartilage of the first rib.” http://medicaldictionary.thefreedictionary.com/sternoclavicular+joint.

6

Plaintiff declined to go to the emergency room, and also did not show up for an initial
consultation scheduled with Dr. Case around this time, for reasons not explained by the
record. (R. 387-88; 425).
Plaintiff did show up for her scheduled appointment at the Musculoskeletal Clinic
at Stroger, on November 25, 2009. (R. 429). She met with Dr. Steven A. Clar, a
physical medicine specialist. (R. 428). Plaintiff explained her medical history, and Dr.
Clar reviewed Plaintiff’s August 2009 x-rays. (Id.). The doctor found Plaintiff’s left ankle
x-ray showed mild soft tissue swelling, but his physical examination revealed no
swelling in her joints. (Id.). He also observed Plaintiff was using a splint for her wrist,
and told her to avoid using it.

(Id.).

Dr. Clar diagnosed Plaintiff with polyarticular

arthritis, and found she “likely” had rheumatoid arthritis since she met 3 of the 7 criteria,
or 4 of 7 when taking into account her history of swelling. (Id). The doctor referred
Plaintiff for x-rays of both hands, gave her a handout on paraffin wax treatments,
recommended ibuprofen for pain, and asked her to return in two months. (Id.).
Plaintiff had the hand x-rays done at Stroger after meeting with Dr. Clar. (R. 28889; 384-86). The x-rays showed mild joint space narrowing in the distal interphalangeal
joints bilaterally, with minimal productive changes and normal carpal alignment as well
as mid-carpal joints.6 (R. 288). The radiologist’s impression was osteoarthritis, with no
evidence of inflammatory arthropathy. (Id.). It does not appear, however, that Plaintiff
ever returned to the Musculoskeletal Clinic, or that Dr. Clar ever reviewed these x-rays,
and the record reveals no explanation for the reasons why. A few days after her visit to

6
“Carpal” refers to the carpus, or wrist, and its related bones.
dictionary.thefreedictionary.com/carpal.

7

http://medical-

the Musculoskeletal Clinic, on November 30, 2009, Plaintiff applied for DIB with the
SSA. (R. 167-68).
2.

2010

Plaintiff’s next treatment records are from January 27, 2010, when she first met
in person with Dr. Case. (R. 425-27). Plaintiff told Dr. Case that she had pain even
when taking Tylenol #3, but that paraffin wax treatments with occasional ibuprofen
controlled her pain. (R. 426-27). Plaintiff further complained that her “main issue” was
the limitations in her daily functioning caused by the pain in her hands. (R. 427). Dr.
Case examined Plaintiff and found she had swelling and tenderness in her finger joints,
wrists and ankles; a decreased range of motion in the fingers, wrists and ankles, grip
strength of 4 out of 5; and she was unable to fully flex her interphalangeal joints. (Id.).
The doctor also reviewed Plaintiff’s medical records, including her hand x-rays from
August and November 2009. (R. 426). Dr. Case found that Plaintiff’s hand x-rays
showed she likely had osteoarthritis, but her left ankle x-ray was normal. (Id.). Dr.
Case’s initial impression was “presumed rheumatoid arthritis,” as well as pancytopenia
and iron deficiency.

(R. 426-27).

The doctor recommended Plaintiff continue the

paraffin wax treatments, try Prednisone again and begin taking Plaquanil for her pain
and swelling. (R. 427). Dr. Case also recommended Plaintiff have her labs done, and
that she return in March. (R. 378-80; 427).
On February 2, 2010, a few days after meeting with Dr. Case, Plaintiff had a
follow-up with Dr. Aluen.

(R. 325-27).

Plaintiff said her joint pain was somewhat

improved, and Dr. Aluen found she had tenderness in her hand and ankle joints, but no

8

longer had effusion.7 (Id.). Dr. Aluen also referred Plaintiff for a CT scan related to
kidney issues, but Plaintiff’s sister accidently cancelled the appointment. (R. 367; 37677).
A few days later, on February 4, 2010, Plaintiff developed a skin infection in her
right elbow and arm, for which she received treatment at Saints Mary and Elizabeth
Medical Center. (R. 292-309). On February 9, 2010, Plaintiff followed-up with Dr. Aluen
on the skin infection, and that doctor noted that Plaintiff no longer had any visible
redness and swelling in her right arm, and the infection was “resolving.” (R. 319).
Plaintiff told the doctor she had been prescribed antibiotics, but she could not afford
them. (Id.). Dr. Aluen encouraged Plaintiff to apply for Medicaid, as she could “not
imagine [Plaintiff] would not qualify for” the benefits because “her symptoms are severe
and disabling.” (Id.)
Shortly thereafter, on February 16, 2010, Dr. Aluen filled out an “Arthritis
Residual Functional Capacity Questionnaire” in support of Plaintiff’s DIB claim. (R. 442444). In the form, Dr. Aluen explained that she had seen Plaintiff five times since
October 2009 as her primary care provider. (Id.). The doctor wrote that Plaintiff had
been diagnosed with inflammatory arthritis, anemia, high blood pressure, and potentially
rheumatoid arthritis, for which she was seeing a rheumatologist.

(Id.).

Under

prognosis, Dr. Aluen wrote that it was unclear at this point whether Plaintiff actually had
rheumatoid arthritis or whether the condition would respond to drugs. (Id.). Dr. Aluen
explained that Plaintiff’s symptoms included generalized joint pain, a reduced range of
motion at “all limb points,” and tenderness. (R. 442).

7
“Effusion” refers to “[t]he escape of fluid from the blood vessels or lymphatics into the
tissues or a cavity.” http://medical-dictionary.thefreedictionary.com/effusion.

9

In regards to Plaintiff’s capabilities, Dr. Aluen wrote that Plaintiff could walk two
city blocks slowly without rest or pain, and could sit for at least six hours in an eight-hour
work day, including for more than two hours at a time before needing a break. (R. 443).
On the other hand, the doctor wrote that Plaintiff could only stand for about 15 minutes
at a time and for less than two hours total in a work day. (Id.). Dr. Aluen also opined
that Plaintiff required a job in which she could sit or stand at will because “[i]f she gets
tired from standing, she must be allowed to sit down.” Id. Dr. Aluen also wrote that
Plaintiff could only occasionally lift up to ten pounds, and has significant limitations in
doing repetitive reaching, handling or fingering because of joint pain limiting her
movements. (R. 444). The doctor also expected Plaintiff to be absent from work about
two days per month “in a good month,” and wrote that “her illness may flare and require
more frequent absence.” (Id.).
A couple of weeks later, on March 2, 2010, Plaintiff had a follow-up with Dr.
Case. (R. 424). Plaintiff reported that she was taking her medications, and still had
stiffness and pain from the hands that was “shooting” up her arms, but her pain had
improved considerably (going from a 10 out of 10, to a 4 out of 10) and she was feeling
“much better.” (Id.). Dr. Case also noted Plaintiff had decreased finger stiffness. (Id.).
He recommended Plaintiff return in May, and also visit the Stroger Hematologic Clinic
due to signs of leukopenia, or a low white blood cell count, in her recent lab work
results. (Id.).
Shortly thereafter, on March 15, 2010, Dr. George Andrews completed a physical
RFC assessment for DDS related to Plaintiff's DIB claim. (R. 310-317). Dr. Andrews
found Plaintiff could occasionally lift up to 20 pounds, frequently lift up to 10 pounds,

10

and stand, walk or sit for about 6 hours in an 8 hour work day. (Id.). Due to evidence of
minor swelling in her lower extremities, Dr. Andrews limited Plaintiff to occasionally
climbing ladders, ropes or scaffolds, and occasional kneeling and crawling. (Id.). Dr.
Andrews found no evidence to support any other limitations.

(Id.).

The doctor

specifically noted that Plaintiff’s November 2009 x-rays of the hands showed only mild
joint space narrowing and no evidence of inflammatory arthropathy, and that her
September 2009 examination at the Loyola Hospital emergency room showed she had
normal strength in all extremities and a full range of motion in all joints. (R. 317).
Shortly after Dr. Andrews’ completed his report, on March 17, 2010, Plaintiff’s DIB claim
was denied by the SSA. (R. 105).
On Dr. Case’s referral, Plaintiff saw Dr. Rubenstein, a hematologist at the Stroger
Hematologic Clinic, on April 21, 2010. (R. 420). Plaintiff’s examination was normal, but
Dr. Rubenstein was concerned that Plaintiff’s lab work showed her leukopenia had
worsened while she was taking medications for her rheumatoid arthritis. (Id.). The
hematologist suggested that Plaintiff’s physicians consider alternative treatments for her
arthritis. (Id.). He scheduled Plaintiff for a follow-up in May, but she missed it. (Id.).
Plaintiff met with Dr. Case on May 5, 2010, complaining of worsening pain and a
decreased range of motion in the hands and wrists, as well as morning stiffness. (R.
437.).

Plaintiff also reported compliance with her medications.

(Id.).

Dr. Case’s

examination showed Plaintiff had a limited range of motion in her fingers and was
unable to make a fist; her left wrist was tender to palpation; she had pain with active and
passive motion in the right wrist; and she had decreased muscle strength in the wrists.
(Id.). On the other hand, her elbow, shoulder, knees and ankles were normal, and she

11

had no swelling or erythema (redness) in the fingers or wrists. (Id.). In response to Dr.
Rubenstein’s theory that Plaintiff’s medications were affecting Plaintiff’s anemia, Dr.
Case had her discontinue taking Plaquenil, prescribed Methotrexate and folic acid, and
lowered her dosage of Prednisone. (Id.).
On June 2, 2010, Plaintiff followed-up with Dr. Case. (R. 439). She stated that
she had stopped taking the Methotrexate and folic acid after one week because it upset
her gastrointestinal tract. (Id.). She also continued to complain of finger stiffness and
wrist pain and stiffness. (Id.). Dr. Case noted Plaintiff had mild tenderness to palpation
in the wrists and hands, but no swelling. (Id.). Dr. Case adjusted Plaintiff’s medications
and asked her to return for a follow-up in a month. (ld.). Plaintiff then returned on July
7, 2010, complaining of continued pain and stiffness that was somewhat relieved with
exercises and aspirin. (R. 463). Upon examination, Plaintiff’s wrists showed pain with
range of motion testing, but no swelling or pain on palpation. (Id.). Plaintiff’s hands also
showed no swelling or deformities and she had normal strength. (Id.). Dr. Case wrote
that Plaintiff’s polyarthritis was atypical, and still thought it was “possibly” rheumatoid
arthritis. (Id.). The doctor also considered, but “doubt[ed],” that Plaintiff had Felty’s
syndrome, but suggested she return to the Hematologic Clinic for further analysis.8
(Id.).
On Dr. Case’s recommendation, Plaintiff went for her overdue follow-up at the
Hematologic Clinic on July 2, 2010. (R. 462). She met with a new doctor, Dr. Telfer,
8
“Felty’s syndrome” is “a syndrome of splenomegaly with chronic rheumatoid arthritis and
leukopenia; there are usually pigmented spots on the skin of the lower extremities, and
sometimes there is other evidence of hypersplenism such as anemia or thrombocytopenia.”
http://medical-dictionary.thefreedictionary.com/Felty%27s+syndrome. “Splenomegaly” refers to
“abnormal enlargement of the spleen.”
http://www.thefreedictionary.com/splenomegaly.
“Thrombocytopenia” is “a blood disease characterized by an abnormally low number of platelets
in the bloodstream.” http://medical-dictionary.thefreedictionary.com/thrombocytopenia.

12

and complained of stress, the inability to “move well,” and stated that she hoped to
return to work. (Id.). Dr. Telfer noted Plaintiff had mild leukopenia that could potentially
be caused by her medications, or possibly another condition, such as Felty’s syndrome.
(Id.). He recommended she have a complete blood count test and return in one month.
(Id.).
Plaintiff had a follow-up with Dr. Aluen a few days later, on July 13, 2010. At that
time, Plaintiff admitted to not refilling one of her blood-pressure medications since
November 2009, and her high blood pressure reading showed it was unlikely she had
taken that medication. (R. 469). Plaintiff also reported generalized joint tenderness,
and Dr. Aluen found she had pain with range of motion testing in her upper and lower
extremity joints, but no effusion or erythema (redness). (Id.). Dr. Aluen noted Plaintiff
had a low white blood cell count according to her recent lab results. (Id.).
Plaintiff’s DIB claim was denied on reconsideration on August 18, 2010. (R.
105). In follow ups with at the Hematologic Clinic in September and October 2010,
Plaintiff had no new complaints, but had not yet undergone the complete blood count
test that Dr. Telfer had recommended. (R. 460-61). She finally had the testing done in
mid-September and scheduled a follow up for October. (R. 465-66).
A couple of weeks later, on September 29, 2010, Plaintiff saw Dr. Case for a
regular follow-up. (R. 459). She reported experiencing pain at a rate of 5 out of 10,
morning stiffness in the hands that lasted a half day, and arm stiffness that lasted all
day. (Id.). Upon examination, her range of motion in the hands, wrists and ankles was
normal, although she had some tenderness in the ankles and pain in the hand joints.
(Id.).

To determine whether Plaintiff’s leukopenia was improving, Dr. Case

13

recommended that she have her lab work redone before her next visit, set for
November. (Id.).
On October 13, 2010, Plaintiff returned to the Hematologic Clinic with the
complete blood count test results, and met with a new doctor, Dr. Catchatourian. (R.
458). Plaintiff had no swelling in the joints, but did display some “purple discoloration” in
the ankles and tenderness on palpitation. (Id.). Dr. Catchatourian’s impression was
mild thrombocytopenia and mild leukopenia, that was probably due to Plaintiff’s
medications. (Id.). The doctor determined there was no need to have Plaintiff undergo
any further testing at that time, and instead instructed Plaintiff to return in six months
with new lab work results. (Id.).
In November and December 2010, Plaintiff visited Dr. Aluen for routine checkups. (R. 448-50; 500-502). At this time, Plaintiff had some fatigue and joint pain, as
well as synovitis at the wrists, but stated her joint pain was improved. (R. 500-02). Dr.
Aluen made an appointment for Plaintiff to have a colonoscopy, and noted she had tried
to refer Plaintiff previously for this procedure three times.

(R. 502).

There is no

explanation in the record for why Plaintiff required four referrals for this procedure. Dr.
Aluen also noted Plaintiff was experiencing postmenopausal bleeding, and scheduled
her for an endometrial biopsy to investigate. (R. 448-49; 502). After Plaintiff initially
missed the appointment for the biopsy due to confusion regarding the date, she
underwent the procedure, which showed her bleeding was benign and was not the
cause of her anemia. (R. 476; 482; 488; 502).

14

3.

2011

Plaintiff’s first records in 2011 are from a follow-up with Dr. Case on April 15,
2011.

(R. 493-96).

Dr. Case noted that Plaintiff had missed her November 2010

appointment, and he had not seen her since September 2010.

(Id.).

There is no

explanation in the record for the gap in treatment. Plaintiff complained of pain in the
wrists going up to her elbows and through her hands, and also in her ankles. (Id.). She
also complained of stiffness for 6 to 7 hours in the morning, and that her hands lacked
both dexterity and strength. (Id.). Dr. Case observed Plaintiff had some joint pain and
tenderness during her musculoskeletal examination, a decreased range of motion in the
wrist, fingers and shoulder, and the inability to squeeze her fingers. (Id.). Nevertheless,
Plaintiff was able to clasp her hands, and had no swelling in any joints. (Id.). Dr. Case
also noted that the pharmaceutical records showed Plaintiff was not likely as compliant
with her medications as she reported. (R. 493; 496).
Dr. Case noted that the Hematologic Clinic had determined that Plaintiff’s low
white blood cell count was due to her arthritis medications. (R. 495; 502). But, since
Plaintiff did not have timely lab work done, the doctor could not evaluate whether the
medication use was causing her hematological issues. (R. 495). Dr. Case also noted
that Plaintiff showed some symptomology of rheumatoid arthritis, but it was “mild and
apparently inactive today.” (R. 494-96). Overall, Dr. Case felt that Plaintiff’s diagnosis
was unclear, and it was particularly complicated by her not-fully explained leukopenia
and cytopenia. (R. 494-95). The doctor recommended Plaintiff undergo hand x-rays
and updated lab work, follow-up with the Hematologic Clinic, and return in mid-June.

15

(R. 496). Dr. Case also wrote that he did not feel Plaintiff “is disabled at this time
pending x-rays or a hematological disease.” (Id.).
After having some problems with the Hematologic Clinic declining to schedule an
appointment for her, Plaintiff was finally able to follow-up at that clinic on May 4, 2011.
(R. 479; 495). At that time, it appears she met with a new doctor, whose name is not
legible in the record. (R. 479). Plaintiff was in no acute distress and denied fatigue.
(Id.). The doctor noted that Plaintiff’s recent lab results were within normal limits, and
the hematologic disorders seen on previous lab reports was mild and likely caused by
her medications. (Id.).
A few days later, on May 13, 2011, Plaintiff saw Dr. Aluen, seeking help with a
Medicaid form. (R. 481-82). Plaintiff told Dr. Aluen that she can usually walk for about
10 minutes without stopping, but stated that on some days when her disease flares up,
she “gets tired.” (Id.). Plaintiff described pain in her upper and lower extremities, but
Dr. Aluen found no synovitis. (Id.). Dr. Aluen noted that a diagnosis of inflammatory
arthropathy was questionable at that time. (Id.).
On June 15, 2011, Plaintiff went for her scheduled follow-up with Dr. Case. (R.
484-87). She complained of pain in her wrists that traveled up to her elbows, pain in her
ankles, and morning stiffness that lasted throughout the day. (Id.). She also stated she
was not sure which medications she was taking. (Id.). The doctor thought it likely that
Plaintiff was non-compliant with her medications based on her statements and the
pharmaceutical records he had. (Id.). Upon examination, Dr. Case found Plaintiff had
normal strength, no swelling, deformities, or synovitis, and a normal range of motion in
the ankles, despite some pain. (Id.). The doctor was unable to assess Plaintiff’s range

16

of motion in her hands and wrists due to pain; Plaintiff stated her pain was about a 2 or
3 out of 10. (Id.). Dr. Case also reviewed Plaintiff’s recent x-rays, finding that they
showed narrowing of the distal interphalangeal joints and proximal interphalangeal joints
(these x-rays are not in the record). (Id.). However, the doctor determined Plaintiff’s
arthritis was “improved” and there was “no evidence of acute arthritis.” (Id.). Plaintiff’s
pancytopenia also appeared to be improving. (Id.). Dr. Case’s medical notes from this
visit were the most recent notes in the record.
B.

Testimony/Reports
1.

Plaintiff’s Function Reports and Testimony

Plaintiff provided function reports dated February 22, 2010 and July 15, 2010,
related to her DIB claim. (R. 199-209; 229-237). In her February 22, 2010 report, she
stated she was unable to use her hands for two hours upon waking, but was then able
to bathe, dress, prepare quick meals, and do light chores. (R. 199-209). She bathes
with a stool, and, when cooking, required help with holding pans and pots and opening
jars. (Id.). Plaintiff generally spent her time resting and napping, doing light chores,
watching television, and doing her recommended exercises and treatments, including
daily paraffin bath treatments.

(Id.).

She has trouble writing checks and handling

money, because of difficulty using her hands to write and grasp coins. (R. 202-03).
Although Plaintiff can walk for a block or two before needing to rest, she only
leaves the home for necessary tasks, such as doctor’s appointments or bi-weekly, light
shopping trips. (R. 204). She also noted that she sometimes uses a cane, but stated it
was not prescribed by any doctor. (R. 205). Plaintiff’s July 15, 2010 report describes
similar activities, except she stated that she stopped using her cane because it was

17

hurting her wrists when leaning on the cane. (R. 235). Notably, the handwriting on the
reports differs from page to page, including that some sections are in all capital letters
while others are not. (R. 199-209; 229-237). It is not clear if each page was written by
the same person, or which, if any, portions were written by Plaintiff.
At the hearing, Plaintiff testified that her arthritis affects her in both hands, both
ankles, and her shoulder, causing pain, swelling and stiffness. (R. 53-54). She claimed
her arthritis had progressively worsened in the year before the hearing.

(R. 54).

Plaintiff also has a vitamin D deficiency and high blood pressure, both of which are
controlled with medication. (R. 55-56). Plaintiff’s doctors told her that her white blood
cell count was unusual, and she is anemic, which she believes she treats with vitamins.
(R. 57-58). The chronic nature of her illness also makes her depressed. (R. 57-60).
When asked why she could not work, Plaintiff stated that when she tries to use
her hands, her fingers, particularly in her right hand, become stiff, swollen, painful and
do not work right. (R. 60). The pain radiates to her wrists, creating knots and nodules.
(R. 61). As a result, she is not able to push or pull things with her hands, and has
trouble grasping. (R. 63-64). Paraffin wax and warm water treatments help, but she
cannot afford the wax. (R. 61-62). She also uses (and was wearing at the hearing) a
wrist brace to “stabilize” her right hand, and it helps a little. (R. 64-65). She admitted
the brace was not prescribed by her doctors. (Id.). When asked, Plaintiff testified that
her main limitations are the stiffness and pain in the wrists and hands, and “not so much
the feet.” (R. 75).
Plaintiff also testified regarding her activities of daily living, including that she
bathes and grooms herself, cooks light meals, and does light cleaning such as

18

sweeping. (R. 66-67). Plaintiff’s daughter helps her wash and style her hair and helps
her get out of the tub. (R. 68-70, 76). Plaintiff also uses her arms to manipulate
objects, such as drinking glasses and brooms for sweeping, rather than her hands. (R.
66-67; 80-82). She also uses a Styrofoam device to help her hold her toothbrush, and
brushes by moving her head rather than her wrist. (R. 66-67, 80-82).
Plaintiff further testified that walking causes her feet to swell, and she can only
walk a couple of blocks. (R. 68-69). Plaintiff first said she could stand for a couple of
hours before needing to sit, and can sit for about a couple of hours before becoming
stiff, but equivocated when questioned by her attorney, and said she had not “put
[herself] to the test.” (R. 68-69; 79-80). She changed positions due to discomfort during
the hearing. (R. 79-80). Plaintiff also said that she has a computer, but she only uses it
for emailing, and her daughter helps her with the emails. (R. 45).
Regarding her unemployment compensation, Plaintiff testified that she applied
for it right after being laid off on April 17, 2009, and stopped receiving it when it ran out
in mid-2010.

(R. 46).

The ALJ asked Plaintiff about her certification to the state

unemployment agency during this time that she was willing and able to look for work.
(R. 46-47). Plaintiff explained that she applied for inventory clerk jobs and customer
service jobs that she thought she could do. (Id.). But when she went to interviews for
the inventory clerk jobs, she was limping, and was not hired. (R. 47). She specifically
avoided applying for medical record clerk jobs because they involved tasks she could
not do. (R. 47-48).

19

2.

ME Testimony

The ME, Dr. Slodki, testified that he reviewed the entire record and heard
Plaintiff’s testimony. (R. 86). He stated that Plaintiff was treated by a rheumatologist
under a diagnosis of rheumatoid arthritis.

(Id.).

The ME opined that Plaintiff had

arthritis in the wrists, hands, ankles and possibly the elbows. (R. 86-87). The ME noted
that the record contained evidence of thrombocytopenia, mild leukopenia and anemia,
and that pancytopenia is a feature of rheumatoid arthritis, but found that her conditions
were not severe enough to meet any listing. (R. 87).
The ME also discussed that Plaintiff’s main difficulty appeared to be with fine and
gross manipulation, but the medical records did not substantiate that she met a listing
based on limitations in manipulations, nor did the records substantiate the severity of
symptoms she testified about. (R. 89-91). Plaintiff’s testimony described progressively
worsening symptoms that were significantly severe, and if she was credible, she was
reduced to “less than sedentary” abilities. (Id.).
When questioned by Plaintiff’s attorney, the ME confirmed that Plaintiff’s arthritis
could cause the severity of the symptoms that she testified about, that the record
showed findings of arthritis in the hands, and that the disease could have “flares, with
increases and decreases.” (R. 93). Regarding Plaintiff’s treatment history, the ME
stated that her physicians had decreased some of her treatment due to side effects, and
generally her treatment has remained the same over time. (R. 91-92). The ME noted
that Plaintiff’s prescribed levels of medication were “not very high.” (R. 92).

20

3.

VE Testimony

The VE testified that Plaintiff had worked as a word processor at the sedentary
level, as a medical records clerk at the sedentary level (although the Dictionary of
Occupational Titles (“DOT”) listed the job as light work), and as an inventory control
clerk at the light into the medium level (the DOT listed that job as medium). (R. 95-96).
All of the jobs were semi-skilled. (Id.). The VE testified that a hypothetical person who
could perform light work, of Plaintiff’s age, education and work experience, with
limitations to occasionally climbing ladders, ropes, scaffolds and kneeling and crawling,
would be capable of Plaintiff’s past work as a word processor and medical records clerk.
(R. 96). The person would also be capable of Plaintiff’s past work as an inventory
control clerk, if performed at the light level. (Id.).
If the person were limited to never crawling, kneeling, climbing ropes or scaffolds;
occasionally stooping, crouching, and climbing ramps or stairs; avoiding exposure to
environmental pollutants, moving machinery and unprotected heights; and only frequent
gross and fine manipulations, they would be capable of the work of a medical records
clerk. (R. 97). They would also be capable of Plaintiff’s past work as an inventory clerk
if performed at the light level, but not as performed in the national economy. (Id.). If the
person was reduced to occasional gross and fine manipulations, the person would not
be able to perform any of Plaintiff’s past work. (R. 97).
C.

ALJ’s Decision
In the ALJ’s subsequent March 29, 2012 decision, she wrote that Plaintiff

suffered from a severe impairment, rheumatoid arthritis, and the following non-severe
impairments: hypertension, depression, anemia, leukopenia, and tuberculosis (R. 21-

21

22). The ALJ found that the Plaintiff’s impairments, or a combination thereof, do not
meet or medically equal any of the listed impairments in 20 C.F.R. Part 404, Subpart P,
Appendix 1. (R. 22; 30). The ALJ further determined that Plaintiff was capable of light
work and frequent fine and gross manipulations, but should never climb ladders, ropes,
or scaffolds, crawl or kneel, and could only occasionally climb ramps and stairs, stoop
and crouch.

(R. 22).

The ALJ also found that Plaintiff must avoid exposure to

environmental pollutants, moving machinery, and unprotected heights. (Id.). Relying on
the VE’s testimony, the ALJ determined that Plaintiff was able to perform her past
relevant work as a medical records clerk and as an inventory control clerk. (R. 31).
DISCUSSION
A.

Standard of Review
Judicial review of the ALJ’s decision, which constitutes the Commissioner’s final

decision, is authorized by Section 405(g) of the Social Security Act. See 42 U.S.C. §
405(g). That decision will be upheld “so long as it is supported by ‘substantial evidence’
and the ALJ built an ‘accurate and logical bridge’ between the evidence and her
conclusion. Thomas v. Colvin, 745 F.3d 802, 806 (7th Cir. 2014) (quoting Simila v.
Astrue, 573 F.3d 503, 513 (7th Cir. 2009)). An ALJ need not mention every piece of
evidence in her decision, as long as she does not ignore an entire line of evidence that
is contrary to her conclusion. Id. (citing Arnett v. Astrue, 676 F.3d 586, 592 (7th Cir.
2012)). Although the Court will not reweigh the evidence or substitute its judgment for
that of the ALJ, a decision that “lacks adequate discussion of the issues will be
remanded.” Moore v. Colvin, 743 F.3d 1118, 1121 (7th Cir. 2014); see also id. (the

22

ALJ's articulated reasoning must be sufficient to allow the reviewing court to assess the
validity of the agency's findings and afford a claimant meaningful judicial review).
B.

Five-Step Inquiry
To qualify for DIB under Title II of the Social Security Act, a claimant must

establish that she suffers from a “disability” as defined by the Act and regulations.
Infusino v. Colvin, 12 CV 3852, 2014 WL 266205, at *7 (N.D. Ill. Jan. 23, 2014); Gravina
v. Astrue, 10-CV-6753, 2012 WL 3006470, at *3 (N.D. Ill. July 23, 2012). A person is
disabled if she is unable to perform Aany substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be expected to result
in death or which has lasted or can be expected to last for a continuous period of not
less than twelve months.

42 U.S.C. § 423 (d)(1)(A); see also Infusino, 2014 WL

266205, at *7; Gravina, 2012 WL 3006470, at *3.
In determining whether a claimant suffers from a disability, the ALJ conducts a
standard five-step inquiry: (1) Is the claimant presently unemployed?

(2) Is the

claimant’s impairment severe? (3) Does the impairment meet or equal one of a list of
specific impairments enumerated in the regulations?

(4) Is the claimant unable to

perform her former occupation? and (5) Is the claimant unable to perform any other
work? See 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4); see also Simila, 573 F.3d at
512-13 (citing Clifford v. Apfel, 227 F.3d 863, 868 (7th Cir. 2000)).
C.

Listing 14.09(B)
Plaintiff first argues that the ALJ should have found at Step 3 that her

impairments or combination of impairments met or medically equaled Listing 14.09B.

23

(Doc. 18, at 2-8; Doc. 33, at 13-14). Listing 14.09B relates to persons with inflammatory
arthritis which results in the following conditions:
Inflammation or deformity in one or more major peripheral joints9 with:
1.

Involvement of two or more organs/body systems with one of the
organs/body systems involved to at least a moderate level of
severity; and

2.

At least two of the constitutional symptoms or signs (severe fatigue,
fever, malaise, or involuntary weight loss).

20 C.F.R. Pt. 404, Subpt. P, Appendix I, § 14.09B. The Listings identify and describe
impairments that the SSA considers severe enough to prevent an individual from doing
any gainful activity, regardless of age, education, or work experience. 20 C.F.R. §
404.1525(a). Thus, if a claimant's impairment matches or is medically equal to a listed
impairment, the claimant is presumed disabled. Sullivan v. Zebley, 493 U.S. 521, 525
(1990) (citing 20 C.F.R. § 416.920(d)). The claimant bears “the burden to present
medical findings that match or equal in severity all the criteria specified by a listing.”
Knox v. Astrue, 327 F. App’x 652, 655 (citing Zebley, 493 U.S. at 531; Ribaudo v.
Barnhart, 458 F.3d 580, 583 (2006)). “In considering whether a claimant's condition
meets or equals a listed impairment, an ALJ must discuss the listing by name and offer
more than a perfunctory analysis of the listing.” Barnett v. Barnhart, 381 F.3d 664, 668
(7th Cir. 2004) (citations omitted).
In this case, the ALJ found that Plaintiff did not have any impairment or
combination of impairments that met or medically equaled any listing, including Listing
14.09, and specifically subpart B of that listing. (R. 22). In support, the ALJ wrote that
“no treating or examining physician has identified findings equivalent in severity to the
9
The “major peripheral joints” are the hip, knee, shoulder, elbow, wrist-hand, and anklefoot. 20 C.F.R. Part 404 Subpart P Appx 1 (Listings) § 1.00(F).

24

criteria of any listed impairment,” and based on the record, the ALJ found “no reason to
conclude otherwise.” (Id.). Although the ALJ did not set forth her supporting analysis of
the record at Step 3, she did so at Step 4. (R. 22-31). In the ALJ’s detailed discussion
of the record, she noted that Plaintiff suffered from various impairments, including mild
leukopenia, anemia and arthritis, but Plaintiff’s arthritis, the most limiting of her
conditions, was not as severe as Plaintiff claimed. (R. 22-31). The ALJ also discussed
the ME’s testimony, and stated that she gave great weight to the ME’s opinion that
Plaintiff’s impairments did not meet or equal any listing. (R. 30-31).
Plaintiff argues that the ALJ erred in analyzing whether she met a listing by
mischaracterizing evidence, performing a “perfunctory” analysis, and, in particular, by
failing to properly assess whether her impairments met or equaled the requirements of
Listing 14.09B. (Doc. 18, at 3-8). Plaintiff claims the record shows that her impairments
met that listing’s requirements, including because her arthritis affected her
musculoskeletal system to “at least a moderate level of severity,” and affected her
hematological and endocrine systems.

(Id.).

As explained below, the ALJ’s

assessment was sufficient, logical, and supported by substantial evidence.
Regarding the effects of Plaintiff’s arthritis on her musculoskeletal system,
Plaintiff cites a handful of items from the record, including excerpts from her x-rays and
some of her physicians’ examination findings. (Id. at 4-5). Plaintiff acknowledges that
the ALJ considered this evidence and found it supported finding she had some
functional capacity limitations. (Id. at 5). Nevertheless, Plaintiff argues that the ALJ
failed to sufficiently explain why the record did not demonstrate that Plaintiff’s
musculoskeletal system was not involved to a least a moderate level of severity. (Id.).

25

Contrary to Plaintiff’s argument, the ALJ developed an “accurate and logical
bridge” from the evidence to the conclusion that Plaintiff’s arthritis did not involve any of
her body systems, including her musculoskeletal system, to a moderate level of
severity.

(R. 22).

The ALJ explained that there was “limited objective medical

evidence” supporting Plaintiff claims regarding the severity of her arthritis symptoms.
(R. 28). The ALJ noted that Plaintiff’s August 2009 left wrist x-ray was described as
“unremarkable,” her August 2009 ankle x-ray showed only “mild” soft tissue swelling,
and her November 2009 hand x-rays showed only “mild joint space narrowing” and no
inflammatory arthropathy. (R. 24-25.).
The ALJ also found that although Plaintiff’s physicians periodically observed that
she exhibited various symptoms of arthritis, her physicians described her symptoms in
mild terms. (R. 27-28.). In particular, both her treating internist, Dr. Aluen, and her
treating rheumatologist, Dr. Case, did not find any signs of swelling, heat, redness or
inflammation in her joints in their examinations during the four months prior to the
hearing.

(Id.).

Dr. Case also described Plaintiff’s arthritis as “mild,” “inactive,

“improved” and “not acute” in the most recent medical records. (Id.). The ALJ also
discussed the supportive testimony of the ME, including his observations that Plaintiff’s
arthritis had been treated and controlled with relatively low dosages of medications over
time, suggesting that her symptoms “are not particularly serious.” (R. 29-31). When
reviewing the ALJ’s decision as a whole, her conclusion that Plaintiff’s impairments did
not meet or equal the requirements of any listing is sufficiently explained, and supported
by substantial evidence in the record.

26

Plaintiff raises several arguments against the ALJ’s reasoning, none of which
have any merit. She first argues that the ALJ “mischaracterized the medical evidence
offered by” Drs. Aluen and Case, undermining the ALJ’s determination. (Doc. 18, at 3).
In support, Plaintiff argues that the ALJ ignored Dr. Aluen’s February 9, 2010 remark
that Plaintiff would likely qualify for Medicaid because “her symptoms are severe and
disabling.” (Id. at 4 (citing R. 319)). But the ALJ did not ignore Dr. Aluen’s February 9,
2010 notes; instead, the ALJ accurately described them as recounting a visit concerning
a follow-up on a skin infection issue. (R. 26). Also, this statement from the notes
appears to be nothing more than an off-hand remark regarding the doctor’s thoughts on
whether Plaintiff should apply for Medicaid. There is no evidence that the ALJ ignored
or mischaracterized this evidence, or any other notes by Dr. Aluen.
Regarding Dr. Case, Plaintiff argues that the rheumatologist found her arthritis
caused her significant functional limitations, citing in particular findings of reduced ability
to use her hands and fingers in his January 2010 and April 2011 examinations. (Doc.
18, at 3; 5). Plaintiff’s argument that the ALJ ignored or mischaracterized this evidence,
or any other notes by Dr. Case, is also incorrect.

Instead, the ALJ accurately

summarized Dr. Case’s notes in her decision, including that doctor’s January 2010
findings that Plaintiff’s grip strength was only mildly reduced to 4 out of 5, and April 2011
conclusion that her arthritis was “mild and apparently inactive.” (R. 25; 27).
Plaintiff also argues that the ALJ erred by relying on the ME’s testimony that
Plaintiff’s impairments did not meet or equal any listing without “conduct[ing] any
analysis of her own.” (Doc. 18, at 7-8). As explained above, the ALJ did not rely
exclusively on the ME’s opinion that Plaintiff’s impairments did not meet any listing.

27

Rather, the ALJ also justified her conclusion by giving her own analysis of the record,
which was supported by substantial evidence. And Plaintiff argues that the ALJ erred in
according great weight to the ME’s opinion that her impairments did not meet any
listing, because the ME’s testimony focused on Listing 14.09A, and the ME failed to
consider Listing 14.09B.

(Doc. 18, at 7).

However, the ME’s testimony shows he

considered Plaintiff’s arthritis in multiple locations, and considered her other
impairments and symptoms, including her hematological conditions, when determining
whether her impairments met Listing 14.09.

(R. 86-87; 89-93).

Although the ME

testified more extensively on the requirements of subsection A of that listing, it is clear
he did so because her complaints focused on her limitations in fine and gross
manipulations. (R. 89-90). The record does not support Plaintiff’s argument that the
ME only considered Listing 14.09A, or that the ALJ erred in taking the ME’s testimony
into account.
Finally, Plaintiff argues that the ALJ erred by not discussing whether her
hematological conditions and her constitutional symptoms, in combination with the
effect of her arthritis on her musculoskeletal system, met the requirements of Listing
14.09B. (Doc. 18, at 5-8). Plaintiff fails to recognize that she must meet “all of the
specified medical criteria” in a listing to qualify as presumptively disabled. Zebley, 493
U.S. at 530. Once the ALJ properly determined that Plaintiff’s arthritis did not involve
any of body systems to at least a moderate degree of severity, she could not meet
Listing 14.09B, regardless of her hematological conditions or other symptoms. Plaintiff
admits she only argues that her arthritis involved her musculoskeletal system to at least
a moderate degree of severity, as opposed to any of her other systems or organs.

28

(Doc. 33, at 14). As a result, Plaintiff’s argument that the ALJ was required to discuss
whether she met the other requirements of Listing 14.09B also fails.
For the foregoing reasons, the ALJ’s Step 3 finding was sufficiently explained,
supported by substantial evidence, and does not require reversal.
D.

Medical Opinions
1.

Dr. Aluen

Plaintiff next argues that the ALJ erred in declining to give controlling weight to
the February 16, 2010 opinion of her treating physician, Dr. Aluen, and in failing to
explain what weight the ALJ gave to that opinion. (Doc. 18, at 8-11, Doc. 33, at 8-10).
A treating source opinion is entitled to controlling weight if it is “well-supported by
medically acceptable clinical and laboratory diagnostic techniques and is not
inconsistent with the other substantial evidence” in the record.

20 C.F.R. §

404.1527(c)(2); see Scott v. Astrue, 647 F.3d 734, 739 (7th Cir. 2011); Campbell v.
Astrue, 627 F.3d 299, 306 (7th Cir. 2010).

An ALJ must offer “good reasons” for

discounting a treating physician’s opinion, Scott, 647 F.3d at 739, and then determine
what weight to give it considering (1) the length of the treatment relationship and
frequency of examination, (2) the nature and extent of the treatment relationship, (3) the
degree to which the opinion is supported by medical signs and laboratory findings, (4)
the consistency of the opinion with the record as a whole, and (5) whether the opinion
was from a specialist, and (6) other factors brought to the attention of the ALJ. 20
C.F.R. § 404.1527(c)(2)-(6). See, e.g., Simila, 573 F.3d at 515.
In this case, the ALJ explained her reasons for declining to give controlling
weight to Dr. Aluen’s February 16, 2010 opinion in detail, and her reasoning showed a

29

consideration of the factors required by the regulations. The ALJ began by describing
the opinion, including that it was set forth in an attorney-generated questionnaire. (R.
29). The ALJ noted that Dr. Aluen indicated Plaintiff could only stand or walk for 2
hours or less in an 8 hour workday; had significant limitations in handling and fingering
due to joint pain; had to be permitted to shift positions at will; and would likely be absent
from work for two days or more per month. (Id.). The ALJ then explained that although
Dr. Aluen had a treating relationship with the Plaintiff, at the time this opinion was
rendered, the treatment history was “quite brief.” (Id.). The ALJ also found that the
opinion was “generally not supported” by Dr. Aluen’s own treatment notes. (Id.).
The ALJ also discounted the weight of Dr. Aluen’s opinion because she was an
internist, rather than the treating specialist for Plaintiff’s arthritis, and some of the
doctor’s assessments fell outside of her area of expertise. (R. 29-30). The ALJ gave
more weight to the assessments of Plaintiff’s treating rheumatologist, Dr. Case,
regarding her arthritis.

(R. 28; 29-30).

The ALJ also found that Dr. Aluen relied

“heavily” and “uncritically” on Plaintiff’s subjective reports of symptoms and limitations,
and that the doctor’s opinion substantially departed from the rest of the medical
evidence in the record. (R. 30). The ALJ further noted that Dr. Aluen may have been
motivated, due to sympathy or other reasons, to express an opinion that assisted
Plaintiff, and that the disparity between the opinion and the other medical evidence
supported that inference here. (Id.). The ALJ concluded by stating that Dr. Aluen’s
opinion could not be given controlling weight because, for the reasons she discussed, it
was not well-supported by, or consistent with, the record. (Id.).

30

Plaintiff argues that the ALJ’s reasons for discounting Dr. Aluen’s opinion were
not “good reasons.” (Doc. 18, at 9-11). First, she argues that the ALJ improperly
discounted Dr. Aluen’s opinion because it was given at the request of her counsel, and
because it was on a check box form. (Id. at 9). But the ALJ’s decision does not indicate
that she discounted Dr. Aluen’s opinion because it was given in a check-box form, or
because was requested by counsel. Instead, the ALJ merely described the opinion as
being set forth in an attorney-generated functional capacity questionnaire, which was an
accurate description. (R. 29). As a result, this argument fails.
Second, Plaintiff argues that the ALJ incorrectly found that Dr. Aluen relied
heavily on Plaintiff’s subjective complaints, because the doctor actually relied upon
objective medical findings. (Doc. 18, at 10; Doc. 33, at 9).

In support, Plaintiff cites

some of Dr. Aluen’s treatment notes and excerpts from other medical records that she
claims were available for the doctor’s review. (Id.). Although Plaintiff admits that the
ALJ examined these records and found that Dr. Aluen’s opinion was not generally
supported by them, Plaintiff argues that the ALJ did not sufficiently explain the basis for
her conclusion. (Doc. 18, at 11; see also Doc. 33, at 9 (citing Zurawski v. Halter, 245
F.3d 881, 889) (ALJ erred by only discussing evidence that favored the denial of
benefits, and for not explaining why that evidence outweighed the evidence that
supported the claimant)).
Unlike the ALJ in Zurawski, the ALJ in this case did not “ignore an entire line of
evidence that is contrary to her findings,” such as treating physicians’ records, or MRIs.
Zurawski, 245 F. 3d at 888. Instead, the ALJ accurately summarized the portions of the
record that Plaintiff claims supported Dr. Aluen’s opinion, and compared it to the

31

evidence that did not, including from Dr. Aluen’s own notes. (R. 25-26). As a result, the
ALJ’s decision reflects a consideration of the record as a whole.
Moreover, the portions of the record that Plaintiff cites in support of her argument
do not undermine the supportability of the ALJ’s conclusion. For example, Plaintiff cites
Dr. Aluen’s October and November 2009 findings of synovitis in her ankles, wrists and
finger joints, and notes discussing Plaintiff’s x-rays, as evidence that the ALJ did not
properly assess. (Doc. 18, at 10; Doc. 33, at 9). But the ALJ acknowledged these
portions of Dr. Aluen’s notes, and also discussed that Dr. Aluen described the x-rays as
“unremarkable,” found no redness in any of Plaintiff’s joints, and recommended only
Tylenol #3 when Plaintiff complained of a pain level of 2 out of 10. (R. 25). Plaintiff also
cites the emergency room records from February 4, 2010, documenting redness and
swelling in Plaintiff’s arm and elbow joint, as supportive evidence of Dr. Aluen’s opinion.
(Doc. 33, at 9). As the ALJ correctly found, this evidence only related to a minor skin
infection that Dr. Aluen found was resolving as of February 9, 2010. (R. 26). Plaintiff
cites no evidence in support of her argument that was not sufficiently addressed by the
ALJ’s decision.
Third, Plaintiff argues that the ALJ erred when she conjectured that Dr. Aluen
may have been motivated to give an opinion that helped Plaintiff due to sympathy, or
some reason other than an “honest, accurate assessment” of Plaintiff’s condition. (Doc.
18, at 10-11; Doc. 33, at 9). Relying on Micus v. Bowen, 979 F.2d 602 (7th Cir. 1992),
she argues that the ALJ’s “speculation” was reversible error. (Id.). But the Micus court
acknowledged that an ALJ may consider a treating physician’s possible bias for her
patient in certain instances, such as when a treating physician’s opinion differs from the

32

opinions of other physicians who “may not share” that bias. 979 F.2d at 607-08. In
cases involving “dueling doctors,” it is “up to the ALJ to decide which doctor to believe . .
. subject only to the requirement that the ALJ’s decision be supported by substantial
evidence.” Id. at 608 (citing Stevens v. Heckler, 766 F.2d 284, 289 (7th Cir. 1985)).
Here, the ALJ surmised that potential bias might explain the significant contrast
between Dr. Aluen’s opinion and the rest of the record, including the opinions and
findings of Plaintiff’s treating rheumatologist, Dr. Case. (R. 30). The Court finds nothing
inappropriate in the ALJ’s reasoning here.
Next, Plaintiff argues that the ALJ should not have discounted the weight of Dr.
Aluen’s opinion due to the briefness of the relationship at the time it was given, because
the relationship was sufficiently developed for Dr. Aluen to give a reliable opinion. (Doc.
18, at 9-10; Doc. 33, at 8).

She further argues that the nature of the treatment

relationship, not its length, is determinative, relying on Schisler v. Bowen, 851 F.2d 43,
45 (2d Cir. 1988).

Plaintiff fails to recognize that the regulations instruct ALJs to

consider both the length of the treating relationship, and the nature of the relationship,
when evaluating a treating source’s opinion. 20 C.F.R. §§ 404.1527(c)(2)(i), (ii). The
regulations do not provide that either factor should “trump” the other.
Schisler also does not hold that the nature of the treating relationship is more
important than the length, as a rule. Rather, the Schisler court merely held that the
regulations (then in draft form) were not meant to impose any rigid, mechanical rule
requiring “a legally fixed period of time” for the formation of a physician-patient
relationship. 854 F.2d at 45. The ALJ did not apply any rigid or arbitrary rule here;
instead, the ALJ noted that Dr. Aluen had a treating relationship with Plaintiff, but that it

33

had only existed for about four months at the time she gave her opinion. (R. 29). The
ALJ discussed the nature of the treatment relationship up to that point in the decision as
well, including the doctor’s examinations of Plaintiff; the doctor’s evaluation of diagnostic
testing; that the doctor was waiting on a “work up” to further evaluate Plaintiff’s
condition; and the treatments the doctor prescribed. (R. 25-26). Dr. Aluen herself noted
that when she gave the opinion, she had only seen Plaintiff five times; certain
consultations with specialists and a work-up were still in progress; and it was not clear
yet what Plaintiff’s condition was or whether it would respond to medication. (R. 442).
Based on the foregoing, the ALJ adequately considered the length and nature of
Plaintiff’s treating relationship with Dr. Aluen, and her findings are supported by the
record.
Plaintiff next argues that the ALJ “improperly discounted” Dr. Aluen’s opinion on
the basis of her specialization as an internist. (Doc. 18, at 10; Doc. 33, at 8-9). She
specifically argues that Dr. Aluen was “competent” enough to evaluate the effects of
Plaintiff’s arthritis. (Id.). She further argues that Dr. Aluen’s opinion was consistent with
the opinion of her treating rheumatologist, Dr. Case, and cites a statement from Dr.
Case’s April 15, 2011 treatment notes that Plaintiff did not have “usage of her hands.”
(Id.). This argument is factually incorrect; as the ALJ pointed out, although Plaintiff
complained to Dr. Case of problems with usage of her hands, including a lack of
dexterity and strength, at her April 15, 2011 follow-up, Dr. Case found her arthritis was
“mild” and “apparently inactive” that day. (R. 27). Rather than supporting Dr. Aluen’s
opinion, Dr. Case explicitly wrote that he did not think Plaintiff was disabled, as the ALJ
correctly noted. (R. 496).

34

Also, as the Commissioner argues, the regulations permit the ALJ to “give more
weight to the opinion of a specialist about medical issues related to his or her area of
specialty.” 20 C.F.R. § 404.1527(c)(5). Here, the ALJ noted that Dr. Aluen’s opinion
“rest[ed] at least in part on an assessment of an impairment outside the doctor’s area of
expertise,” and conflicted with the opinion of the relevant specialist, the rheumatologist
Dr. Case.

(R. 30).

Thus, it appears the ALJ properly considered Dr. Aluen’s

specialization as one of the factors in evaluating the doctor’s opinion.
Finally, Plaintiff argues that, even if the ALJ gave valid, well-supported reasons
for not attributing controlling weight to Dr. Aluen’s opinion, the ALJ still committed
reversible error if she did not state the exact weight given to the opinion. (Doc. 18, at
11; Doc. 33, at 9). Here, the ALJ explained that Dr. Aluen’s opinion was due less than
controlling weight after properly analyzing the checklist of factors in the regulations.
This is sufficient; the ALJ is not required to “state precisely how much weight—beyond
‘not controlling’—[s]he places on” the opinion. Manley v. Barnhart, 154 F. App’x 532,
536-37 (7th Cir. 2005); see also Spraggs v. Colvin, 11 C 1026, 2014 WL 2118823, at
*11 (N.D. Ill. May 21, 2014) (“The Seventh Circuit has expressly held that an ALJ may
simply state he is giving a controlling physician's opinion ‘less than controlling’ or ‘not
controlling’ weight so long as the ALJ explains why she is doing so.”) (quoting Manley,
154 F. App’x at 536); Elder v. Astrue, 529 F.3d 408, 412 (7th Cir. 2008) (upholding
ALJ’s decision to “decline[] to afford ‘substantial weight’” to treating physician’s opinion
since the ALJ minimally articulated his reasons after considering the regulatory factors).
For these reasons, the ALJ did not err in according Dr. Aluen’s February 16,
2010 opinion less than controlling weight. Rather, when read as a whole, the ALJ’s

35

decision sets forth a logical bridge from the evidence to her conclusion that is supported
by the record. See Molnar v. Astrue, 395 F. App'x 282, 287 (7th Cir. 2010) (“We review
the ALJ's opinion as a whole to give it the most sensible reading. . . .”) (citing Rice v.
Barnhart, 384 F.3d 363, 369 (7th Cir. 2004); Shramek v. Apfel, 226 F.3d 809, 811 (7th
Cir. 2000)).
2.

ME Dr. Slodki

Plaintiff also argues that the ALJ erred in according “great weight” to the opinion
of the ME, Dr. Slodki, that her subjective allegations were not supported by the record.
(Doc. 18, at 11-12; Doc. 33, at 10).

An ALJ may “give substantial weight to the

testimony of a medical advisor even though the advisor has not examined the claimant
personally,” so long as that determination is supported by substantial evidence.
DeFrancesco v. Bowen, 867 F.2d 1040, 1043 (7th Cir. 1989) (citing Cummins v.
Schweiker, 670 F.2d 81, 84 (7th Cir. 1982)); see also Ketelboeter v. Astrue, 550 F.3d
620, 624-25 (upholding ALJ’s decision to place more weight on testimony of the nonexamining medical experts than the treating physicians because substantial evidence
supported the ALJ’s decision).
Plaintiff argues that the ALJ ignored certain evidence in the record that
contradicted Dr. Slodki’s opinion. (Doc. 18, at 12; Doc. 33, at 10). She specifically cites
Plaintiff’s August 27, 2009 emergency room records discussing her decreased range of
motion and strength in the left wrist, and Dr. Case’s January 27, 2010 notes stating she
was unable to fully flex her fingers and had a decreased range of motion in her wrists
and ankles. (Id.). Rather than ignoring this evidence, the ALJ expressly discussed both
of these records, including most of the findings Plaintiff focuses on. (R. 24-25). As the

36

ALJ noted, Plaintiff’s physicians described the x-rays taken of Plaintiff’s left wrist in
response to her decreased range of motion and strength as “unremarkable.” (R. 25-26).
And, although Plaintiff described some limitations in January 2010, Dr. Case also noted
her grip strength was only mildly reduced and her pain was controlled with paraffin wax
and ibuprofen. (R. 25). The ALJ’s decision reflects a consideration of the entire record,
including the evidence Plaintiff cites, in determining to accord great weight to Dr.
Slodki’s opinion, and her decision is supported by substantial evidence.
3.

DDS Examiner Dr. Andrews

Plaintiff argues that the ALJ erred in failing to apply the regulatory factors when
determining to adopt a portion, and reject a portion, of DDS examiner Dr. Andrews’
March 15, 2010 opinion. (Doc. 18, at 13-14; Doc. 33, at 10). ALJs are required to
evaluate the opinions of state agency physicians based on the relevant factors
described in the regulations, including the physician’s expertise in the SSA’s rules and
regulations, the supporting explanation for the opinion, and the other evidence in the
record. See 20 C.F.R. § 404.1527(e)(2). Furthermore, ALJs must “explain the weight
given to the opinions [of state agency physicians] in their decisions.”

McKinzey v.

Astrue, 641 F.3d 884, 891 (7th Cir. 2011) (quoting S.S.R. 96-6p, 1996 WL 374180, at
*1).
Here, the ALJ’s explanation of her evaluation of Dr. Andrews’ opinion consists of
one sentence. (R. 30). The sentence states that the ALJ “generally agree[s] with the
exertional level Dr. Andrews presented, but find[s] that subsequent records support that
the claimant is further restricted” in certain respects, which the ALJ then lists. (Id.). The

37

Court agrees with Plaintiff that this explanation for the weight accorded to Dr. Andrews’
opinion is insufficient and requires reversal.
The Commissioner notes that state agency consultants are “highly qualified
physicians” and “experts in Social Security disability regulations,” and that the ALJ could
have determined to adopt Dr. Andrews’ opinion in its entirety, rather than just in part.
(Doc. 29, at 8-9 (citing 20 C.F.R. § 404.1527(e)(2)(i))).

But this argument fails to

address whether the ALJ sufficiently explained her decision so that a reviewing court
could determine if she complied with the regulations and whether her conclusion is
supported by substantial evidence. The Commissioner also noted that the ALJ at least
explained that she considered the record and determined that Plaintiff was more limited
than Dr. Andrews found.

(Id.).

Since consistency with the record is one of the

regulatory factors for evaluating medical opinions, the Commissioner argues that the
ALJ properly evaluated the opinion according to the regulations, and did not err. (Id.
(citing 20 C.F.R. § 404.1527(c)(4))).
As Plaintiff points out, this argument fails to address the lack of explanation in the
decision regarding why the ALJ found the record supported certain additional limitations
for Plaintiff, but not others. (Doc. 18, at 15; Doc. 33, at 10). Also, the ALJ’s statement
that “subsequent records” supported finding her more limited than Dr. Andrews opined
in March 2010 appears to contradict her other findings that Plaintiff’s 2011 records
showed improvement in her condition. (R. 28). Finally, as Plaintiff argues, these logical
gaps in the ALJ’s analysis of Dr. Andrews’ opinion also affected the supportability of the
ALJ’s RFC determination, and this case requires reversal to address those issues, as
discussed further below.

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E.

RFC
Based on some of the reasons discussed above, as well as certain other

reasons, Plaintiff argues that the ALJ erred in determining her residual functional
capacity (“RFC”). (Doc. 18, at 14-17). “Residual functional capacity” is defined as “the
most [the claimant] can still do despite [her] limitations.” 20 C.F.R. §§ 404.1545(a),
416.945(a). “When determining the RFC, the ALJ must consider all medically
determinable impairments, . . . even those that are not considered ‘severe.’” Craft v.
Astrue, 539 F.3d 668, 676 (7th Cir. 2008). “[T]he responsibility for the RFC assessment
belongs to the ALJ, not a physician, [but] an ALJ cannot construct his own RFC finding
without a proper medical ground and must explain how he has reached his
conclusions.” Amey v. Astrue, No. 09 C 2712, 2012 WL 366522, at *13 (N.D. Ill. Feb. 2,
2012) (citations omitted). See also 20 C.F.R. §§ 404.1527(e)(2), 416.927(e)(2). First,
Plaintiff argues that the ALJ erred in rejecting the RFC determination set forth by Dr.
Aluen in her February 16, 2010 opinion. (Doc. 18, at 14). For the reasons set forth
above, the ALJ did not err in declining to accord controlling weight to any part of Dr.
Aluen’s opinion, including that doctor’s RFC determination.
Plaintiff also argues that the ALJ failed to consider her hematologic conditions, in
combination with her other impairments, when determining her RFC. (Doc. 18, at 14,
16-17; Doc. 33, at 10-11, 13). She specifically argues the ALJ ignored evidence of the
symptoms caused by her hematologic conditions, including fatigue, lethargy, malaise,
stiffness, hair loss, and iron deficiency. (Id.). The decision shows the ALJ did not
ignore this evidence; it contains numerous references to Plaintiff’s complaints of
stiffness in various body parts and joints, soreness, drowsiness, body aches, lethargy,

39

and fatigue, including several of the statements she claims the ALJ overlooked. (R. 2327).

The ALJ also noted Plaintiff’s diagnoses of anemia and leukopenia, and her

treatment with the Stroger Hematologic Clinic. (R. 24; 26-27). Plaintiff is correct that
the ALJ finding that Plaintiff’s postmenopausal bleeding caused her anemia lacks
support; the record shows Plaintiff’s doctors thought the bleeding was benign and not
the cause of her anemia. (Doc. 18, at 16-17; see also R. 22; 476; 482; 488). Although
the ALJ made a minor factual error regarding the cause of Plaintiff’s anemia, the
decision shows she still considered the fact that Plaintiff had the condition when
determining the RFC.

Thus, Plaintiff has not shown that the ALJ ignored her

hematological conditions, or the symptoms she alleges were caused by those
conditions.
Plaintiff further argues that, to the extent the ALJ considered the evidence related
to her hematological conditions, the ALJ erred by failing to include any limitations
caused by those conditions in the RFC. (Doc. 33, at 10-11, 13). But Plaintiff does not
identify any limitations that the ALJ failed to include in the RFC. Nothing in the record,
including the excerpts Plaintiff cites, suggests that the ALJ overlooked any functional
limitations caused by these conditions.
Plaintiff’s argument that the ALJ erred in “construct[ing] a ‘middle ground’ RFC”
by making her own independent medical determination of Plaintiff’s limitations, has
some merit. (Doc. 18, at 14-16). As Plaintiff argues, two aspects of the ALJ’s RFC
determination appear to lack sufficient explanation and support. First, the ALJ rejected
the physical RFCs in the record concerning Plaintiff’s use of her hands: Dr. Aluen’s
opinion that she had significant manipulative limitations, and Dr. Andrews’ opinion that

40

she had no manipulative limitations. (R. 29; 30). The ALJ then “constructed a ‘middle
ground’” and determined that Plaintiff could frequently perform fine and gross
manipulations. Bailey v. Barnhart, 473 F. Supp. 2d 822, 838 (N.D. Ill. 2006). The ALJ
gives no explanation of the evidence supporting this finding, other than to comment that
“subsequent records” after Dr. Andrews’ March 15, 2010 opinion support it. (R. 30).
As noted above, this explanation appears to contradict the ALJ’s other findings
that Plaintiff’s most recent medical records showed improvement in, particularly, her
arthritis. (R. 28). And, as Plaintiff argues, this brief explanation suggests that the ALJ
made her own independent medical evaluation regarding the degree of Plaintiff’s
impairments, based on some, unspecified, portions of the record. As a result, it appears
the ALJ “impermissibly played doctor” here, requiring reversal of the RFC determination.
Bailey, 473 F. Supp. 2d at 839 (citing Rohan v. Chater, 98 F.3d 966, 970 (7th Cir.
1996)).
The Commissioner argues that the ALJ was not required to rely on or choose any
particular medical opinion in determining the RFC, and thus did not err by “craft[ing] an
RFC assessment based on the entirety of the record.”

(Doc. 29, at 9-10).

The

Commissioner cites Schmidt v. Astrue, 496 F.3d 833 (7th Cir. 2007) and Diaz v.
Charter, 55 F.3d 300 (7th Cir. 1995), in support, but those cases are distinguishable
from this case. In Diaz, the ALJ supported the RFC determination by relying on both
opinion evidence and non-medical evidence, and the Seventh Circuit rejected an
argument that the ALJ should have relied solely on physicians’ opinions when
determining a claimant’s RFC. 55 F.3d at 306-07, n.2. And in Schmidt, the ALJ did not
err in determining the claimant’s RFC by weighing physicians’ opinions along with the

41

testimony and other evidence, rather than adopting an RFC that was determined by any
single physician. 496 F.3d at 845.
In this case, the ALJ does not explain what evidence from the record supported
her RFC finding.

Thus, it appears the ALJ developed her own opinion regarding

Plaintiff’s manipulative limitations, which she cannot do. See Suide v. Astrue, 371 Fed.
App’x. 684, 690 (7th Cir. 2010) (ALJ cannot user her own lay opinion to “fill evidentiary
gaps in the record”) (citing Blakes v. Barnhart, 331 F.3d 565, 570 (7th Cir. 2003)). On
remand, the ALJ must articulate sufficient support for her RFC determination, including
regarding Plaintiff’s manipulative limitations.
Second, as Plaintiff argues, the ALJ’s explanation regarding her finding that
Plaintiff could lift or carry 20 pounds occasionally and 10 pounds frequently, and could
stand, walk or sit for up to 6 hours in an 8 hour workday, is also lacking. (Doc. 18, at
14-15). The ALJ states that she made this finding because she “generally agree[d] with
the exertional level Dr. Andrews presented,” but, as discussed above, fails to explain
why she thought the record supported Dr. Andrews’ finding in this respect, but not the
doctor’s other findings.

(R. 30).

The ALJ merely states that “subsequent records

support that the claimant is further restricted,” but does not explain why, for example,
those records support a finding of greater restrictions in climbing stairs than Dr.
Andrews found, but not in standing or walking. (Id.). On remand, if the ALJ chooses to
rely on Dr. Andrews’ opinion for determining any portion of Plaintiff’s RFC, she must
explain why, consistent with the requirements of the SSA’s rulings and regulations.

42

F.

Credibility
Plaintiff also argues that the ALJ erred in finding that her testimony was “not

credible” to the extent it was “inconsistent with, and not supported by, the objective
medical record as discussed.” (Doc. 18, at 17-22; Doc. 33, at 2-7). In assessing a
claimant’s credibility, an ALJ must first determine whether the claimant’s symptoms are
supported by medical evidence. See SSR 96-7p, 1996 WL 374186, at *2 (July 2, 1996);
Arnold v. Barnhart, 473 F.3d 816, 822 (7th Cir. 2007). If not, SSR 96-7p requires the
ALJ to consider “the entire case record, including the objective medical evidence, the
individual’s own statements about symptoms, statements and other information
provided by treating or examining physicians or psychologists and other persons about
the symptoms and how they affect the individual, and other relevant evidence in the
case record.” Arnold, 473 F.3d at 822. See also 20 C.F.R. § 404.1529; Carradine v.
Barnhart, 360 F.3d 751, 775 (7th Cir. 2004). An ALJ’s credibility determination must
contain specific reasons for the credibility finding that are supported by evidence in the
record, but the credibility determination will normally be reversed only if “patently
wrong.” Craft, 539 F.3d at 678; Schreiber v. Colvin, 519 F. App’x 951, 960 (7th Cir.
2013).

Although, as the Commissioner notes, the ALJ gave many reasons for

discrediting Plaintiff’s testimony, a number of them are concerning.
The ALJ found that Plaintiff did not take her prescribed medications as required,
and cited several instances of non-compliance in the record.

(R. 28).

As Plaintiff

argues, however, it is not clear that the ALJ considered her reasons for non-compliance,
including her statements in the record that certain medications did not help her pain,
had unpleasant side effects, or were too expensive to purchase. (Doc. 18, at 20). ALJs

43

must not “draw any inferences about an individual's symptoms and their functional
effects from a failure to seek or pursue regular medical treatment without first
considering any explanations that the individual may provide.” Roddy v. Astrue, 705
F.3d 631, 638 (7th Cir. 2013) (citations omitted). The ALJ did note that the ME testified
that some of Plaintiff’s medications were decreased due to side effects. (R. 30). But
the ALJ did not discuss the impact of this testimony on her finding. The Commissioner
also notes that the ALJ cited a couple of instances in the record where Plaintiff gave no
explanation for failing to refill her medications. But the ALJ did not ask Plaintiff whether
she had any reason for failing to purchase her medications in those instances, before
drawing a negative inference based on them. This lack of discussion concerning the
reasons for Plaintiff’s non-compliance undermines the ALJ’s credibility determination.
The ALJ also discounts Plaintiff’s credibility because of a “reduced frequency of
treatment in 2011” and states that this reduced treatment suggests Plaintiff did not
require or avail herself of “treatment one would expect for a totally disabled individual.”
(R. 28). In support, the ALJ cites Plaintiff’s failure to follow up with Dr. Case between
late September 2010 and mid-April 2011. (Id.). The ALJ also cites several instances
when Plaintiff missed appointments, including appointments for her endometrial biopsy,
colonoscopy, and CT scan. (Id.). However, as with Plaintiff’s non-compliance with her
medications, the ALJ must not draw a negative inference based on these missed
appointments or failures to follow-up with her physicians without considering any
reasons for these issues. See Shauger v. Astrue, 675 F.3d 690, 696 (7th Cir. 2012)
(“Although a history of sporadic treatment or the failure to follow a treatment plan can
undermine a claimant's credibility, an ALJ must first explore the claimant's reasons for

44

the lack of medical care before drawing a negative inference.”) (citing S.S.R. 96–7p,
1996 WL 374186, at *7; Moss v. Astrue, 555 F.3d 556, 562 (7th Cir. 2009); Craft, 539
F.3d at 679).
The record contains explanations for several of the instances in missed
treatments that the ALJ cited, including that Plaintiff’s sister accidentally cancelled her
CT scan appointment, and that she was confused about the date regarding her
endometrial biopsy. (R. 367; 502). Both appointments were rescheduled and properly
attended. (R. 255; 261; 488). The ALJ did not discuss any of these explanations, or
ask Plaintiff about her other missed appointments.

Some of Plaintiff’s follow-up

appointments, including a few that the ALJ described Plaintiff as missing, were actually
cancelled and rescheduled by her doctors, not Plaintiff. (R. 333; 398; 495). As a result,
this finding must also be re-visited by the ALJ should she choose to rely upon it on
remand.
The ALJ also noted several “discrepancies” in the record that she thought were
indicative of symptom exaggeration, but some of these findings were problematic. (R.
28-29). For example, the ALJ stated that there was a discrepancy between Plaintiff’s
testimony that she could walk about two blocks when her arthritis in the feet and ankles
flares up, and her May 2011 statement to Dr. Aluen that she could walk for about 10
minutes without stopping. (R. 29). But, Plaintiff’s statement to Dr. Aluen regarding her
ability to walk for 10 minutes related to her ability to walk when feeling well. (R. 481).
She stated to Dr. Aluen, and other physicians, that “flare ups” sometimes affected her
ability to walk, including by causing her to walk “slowly” or by limiting her to walking

45

about two blocks before needing to rest. (R. 267; 443; 481). There does not appear to
be support for finding a discrepancy here.
The ALJ also noted that Plaintiff described stiffness and pain in her wrists, but
apparently handwrote her function reports. (R. 29). But the ALJ never asked Plaintiff
whether she wrote the reports herself, whether she had assistance, or whether she had
problems writing those reports. Variations in the handwriting on the reports from page
to page suggest Plaintiff may have had help or worked on them over several days. (R.
199-209; 229-237). As a result, this finding also lacks support in the record.
Finally, the ALJ noted that Plaintiff’s affirmation of her ability to work to the state
unemployment authorities, while alleging that she cannot work during the same period
of time to the SSA, undermines her credibility. (R. 29). Plaintiff argues that she was
only able to work at a sedentary or part-time level, which would have allowed her to be
eligible for unemployment benefits and DIB benefits. (Doc. 18, at 21-22). An ALJ may
“consider any representations [the claimant] has made to state authorities and
prospective employers that he can work” when evaluating credibility. Knox v. Astrue,
327 F. App'x 652, 656 (7th Cir. 2009) (citing Schmidt v. Barnhart, 395 F.3d 737, 746
(7th Cir. 2005)). This could include evidence that a claimant applied for more strenuous
positions than other potential jobs, or told prospective employers that he was capable of
certain job duties. Id. Although the ALJ asked Plaintiff about what kinds of jobs she
applied for, the ALJ did not discuss Plaintiff’s answers, or her job applications, in the
decision. If the ALJ chooses to rely on this factor in evaluating Plaintiff’s credibility on
remand, the ALJ should more explicitly discuss these issues.

46

CONCLUSION
For the reasons stated above, Plaintiff’s Motion for Summary Judgment (Doc. 18)
is granted, and Defendant’s Motion for Summary Judgment (Doc. 28) is denied.
Pursuant to sentence four of 42 U.S.C. § 405(g), the ALJ’s decision is reversed, and
this case is remanded to the Social Security Administration for further proceedings
consistent with this opinion.
ENTER:

Dated: September 5, 2014

_____________________________
SHEILA FINNEGAN
United States Magistrate Judge

47