Clendenin v. Commissioner of Social Security
Filing
34
MEMORANDUM AND ORDER, The Commissioner's final decision denying Jacob Clendenin's application for social security disability benefits is AFFIRMED. The Clerk of Court is directed to enter judgment in favor of defendant. Signed by Judge J. Phil Gilbert on 6/26/2017. (jdh)
IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ILLINOIS
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JACOB W. CLENDENIN,
Plaintiff,
vs.
NANCY A. BERRYHILL,
Acting Commissioner of Social Security,
Defendant.1
Case No. 16-cv-00601-JPG-CJP
MEMORANDUM and ORDER
In accordance with 42 U.S.C. § 405(g), plaintiff Jacob Clendenin (plaintiff), represented
by counsel, seeks judicial review of the final agency decision denying his application for
Supplemental Security Income (SSI) pursuant to 42 U.S.C. § 423.
Procedural History
Plaintiff initially applied for benefits in June 2011, alleging disability beginning on April
10, 2005. An evidentiary hearing was held before Administrative Law Judge (ALJ) Stuart T.
Janney, who issued an unfavorable decision on April 17, 2013. (Tr. 20-28). The Appeals
Council denied review, and plaintiff filed a timely complaint with this Court, which reversed and
remanded the ALJ’s decision on June 19, 2015. (Tr. 443-62). The Appeals Council issued an
order remanding this case to ALJ Janney, and an additional hearing was held on December 14,
2015. (Tr. 466, 289). ALJ Janney issued another unfavorable decision on February 3, 2016.
(Tr. 289-301). Plaintiff exhausted his administrative remedies and filed a timely complaint in
this Court on June 2, 2016.
1
Nancy A. Berryhill is now the Acting Commissioner of Social Security. See, Casey v. Berryhill, 853 F.3d 322 (7th
Cir. 2017). She is automatically substituted as defendant in this case. See Fed. R. Civ. P. 25(d); 42 U.S.C. § 405(g).
1
Issues Raised by Plaintiff
Plaintiff raises the following points:
1. The ALJ erred in failing to identify the evidentiary basis of his assessment of plaintiff’s
RFC.
2. The ALJ erred in evaluating the limiting effects of plaintiff’s headaches.
3. The ALJ erred by violating the law of the case doctrine.
Applicable Legal Standards
To qualify for SSI and/or DIB, a claimant must be disabled within the meaning of the
applicable statutes.2 For these purposes, “disabled” means the “inability to engage in any
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 12 months.” 42 U.S.C. § 423(d)(1)(A).
A “physical or mental impairment” is an impairment resulting from anatomical,
physiological, or psychological abnormalities which are demonstrable by medically acceptable
clinical and laboratory diagnostic techniques. 42 U.S.C. § 423(d)(3). “Substantial gainful
activity” is work activity that involves doing significant physical or mental activities, and that is
done for pay or profit. 20 C.F.R. § 404.1572.
Social Security regulations set forth a sequential five-step inquiry to determine whether a
claimant is disabled. The Seventh Circuit Court of Appeals has explained this process as
follows:
2
The statutes and regulations pertaining to Disability Insurance Benefits (DIB) are found at 42 U.S.C. § 423, et seq.,
and 20 C.F.R. pt. 404. The statutes and regulations pertaining to SSI are found at 42 U.S.C. §§ 1382 and 1382c, et
seq., and 20 C.F.R. pt. 416. As is relevant to this case, the DIB and SSI statutes are identical. Furthermore, 20 C.F.R.
§ 416.925 detailing medical considerations relevant to an SSI claim, relies on 20 C.F.R. Pt. 404, Subpt. P, the DIB
regulations. Most citations herein are to the DIB regulations out of convenience.
2
The first step considers whether the applicant is engaging in substantial gainful
activity. The second step evaluates whether an alleged physical or mental
impairment is severe, medically determinable, and meets a durational
requirement. The third step compares the impairment to a list of impairments that
are considered conclusively disabling. If the impairment meets or equals one of
the listed impairments, then the applicant is considered disabled; if the
impairment does not meet or equal a listed impairment, then the evaluation
continues. The fourth step assesses an applicant's residual functional capacity
(RFC) and ability to engage in past relevant work. If an applicant can engage in
past relevant work, he is not disabled. The fifth step assesses the applicant's RFC,
as well as his age, education, and work experience to determine whether the
applicant can engage in other work. If the applicant can engage in other work, he
is not disabled.
Weatherbee v. Astrue, 649 F.3d 565, 568-569 (7th Cir. 2011).
Stated another way, it must be determined: (1) whether the claimant is presently
unemployed; (2) whether the claimant has an impairment or combination of impairments that is
serious; (3) whether the impairments meet or equal one of the listed impairments acknowledged
to be conclusively disabling; (4) whether the claimant can perform past relevant work; and (5)
whether the claimant is capable of performing any work within the economy, given his or her
age, education and work experience. 20 C.F.R. § 404.1520; Simila v. Astrue, 573 F.3d 503, 512513 (7th Cir. 2009); Schroeter v. Sullivan, 977 F.2d 391, 393 (7th Cir. 1992).
If the answer at steps one and two is “yes,” the claimant will automatically be found
disabled if he or she suffers from a listed impairment, determined at step three. If the claimant
does not have a listed impairment at step three, and cannot perform his or her past work (step
four), the burden shifts to the Commissioner at step five to show that the claimant can perform
some other job. Rhoderick v. Heckler, 737 F.2d 714, 715 (7th Cir. 1984). See also Zurawski v.
Halter, 245 F.3d 881, 886 (7th Cir. 2001) (Under the five-step evaluation, an “affirmative
answer leads either to the next step, or, on Steps 3 and 5, to a finding that the claimant is
disabled. . . . If a claimant reaches step 5, the burden shifts to the ALJ to establish that the
3
claimant is capable of performing work in the national economy.”).
This Court reviews the Commissioner’s decision to ensure that the decision is supported
by substantial evidence and that no mistakes of law were made. It is important to recognize that
the scope of review is limited. “The findings of the Commissioner of Social Security as to any
fact, if supported by substantial evidence, shall be conclusive . . . .” 42 U.S.C. § 405(g). Thus,
this Court must determine not whether plaintiff was, in fact, disabled at the relevant time, but
whether the ALJ’s findings were supported by substantial evidence and whether any errors of
law were made. See, Books v. Chater, 91 F.3d 972, 977-78 (7th Cir. 1996) (citing Diaz v.
Chater, 55 F.3d 300, 306 (7th Cir. 1995)). This Court uses the Supreme Court’s definition of
substantial evidence, i.e., “such relevant evidence as a reasonable mind might accept as adequate
to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971).
In reviewing for “substantial evidence,” the entire administrative record is taken into
consideration, but this Court does not reweigh evidence, resolve conflicts, decide questions of
credibility, or substitute its own judgment for that of the ALJ. Brewer v. Chater, 103 F.3d 1384,
1390 (7th Cir. 1997); Moore v. Colvin, 743 F.3d 1118, 1121 (7th Cir. 2014). However, while
judicial review is deferential, it is not abject; this Court does not act as a rubber stamp for the
Commissioner. See, Parker v. Astrue, 597 F.3d 920, 921 (7th Cir. 2010), and cases cited therein.
The Decision of the ALJ
ALJ Janney followed the five-step analytical framework described above. He determined
that plaintiff had not been engaged in substantial gainful activity since his application date. He
further found that plaintiff had the severe impairments of Chiari malformation, syringomyelia,
hypertension, level III obesity, tremors, and headaches. (Tr. 291).
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ALJ Janney held that plaintiff had the RFC to perform light work with physical
limitations. Based on the testimony of a vocational expert (VE), the ALJ found that plaintiff
could perform jobs that existed in significant numbers in the national economy and was
therefore, not disabled. (Tr. 292-301).
The Evidentiary Record
The Court has reviewed and considered the entire evidentiary record in formulating this
Memorandum and Order. The following summary of the record is directed to the points raised
by plaintiff.
1.
Agency Forms.
The Court previously summarized plaintiff’s disability and function reports during its
initial review of plaintiff’s claim. (Tr. 448-452). In sum, plaintiff alleged the following physical
and mental conditions limited his ability to work: Chiari malformation of the brain,
syringomyelia, chronic headaches, numbness in feet, severe back pain, back and shoulder
spasms, chronic insomnia, dizziness, and vertigo. (Tr. 145).
In 2011, plaintiff reported that he was prescribed Flexeril, Neurontin, Ultram, Vicodin,
and a TENS unit. He stated that the syringomyelia and Chiari malformation caused chronic
insomnia and migraines. He described chronic pain that prevented him from lifting much
weight, inhibited his ability to concentrate, and restricted him to standing, sitting, and walking
for thirty minutes. He also experienced uncontrollable back spasms. Plaintiff claimed he
suffered from depression as well. (Tr. 148-158).
2.
Evidentiary Hearing.
ALJ Janney presided over the initial evidentiary hearing in March 2013. (Tr. 450-452).
A subsequent hearing following remand was held on December 14, 2015.
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Plaintiff was
represented by counsel. (Tr. 209).
Plaintiff held a valid driver’s license, which was reinstated on March 28, 2014. He drove
approximately once per month to visit his fiancée, who lived twenty minutes away. (Tr. 315-16).
Driving made plaintiff fatigued and uncomfortable. (Tr. 329-30).
At the hearing, plaintiff weighed approximately 275 pounds and was five foot, eleven
inches tall. He lost about eighty pounds over the previous year. The weight loss alleviated some
of his lower back pain, but had not “really made much of a difference.” (Tr. 329-30).
Plaintiff lived with his mother, grandmother, and brother. He occasionally helped his
grandmother prepare meals and enjoyed cooking but was unable to cook as often as he would
have liked. (Tr. 318-19).
Since obtaining a medical card three years prior, plaintiff was not prevented from
receiving any treatments, consultations, medications, or therapy due to an inability to afford a
copay or deductible. (Tr. 320).
Plaintiff had not worked anywhere since the last hearing. He did submit job applications
in order to remain eligible for SNAP benefits.3 Potential employers never contacted plaintiff.
(Tr. 321). He did not believe he would have been able to perform any of these jobs eight hours
per day, five days per week, due to his anxiety, depression, pain, and fatigue. (Tr. 361).
Dr. Schward4 was plaintiff’s neurologist and Dr. Natasha Youngblood was his primary
care physician. Dr. Fox was plaintiff’s initial primary care physician but she discharged plaintiff
after a nurse failed to note that plaintiff was taking Tramadol, and it appeared on plaintiff’s drug
test. Dr. Fox prescribed the Tramadol. Plaintiff unsuccessfully attempted to contact Dr. Fox to
3
SNAP stands for supplemental nutrition assistance program. United States v. Odeh, 832 F.3d 764, 766 (7th Cir.
201).
4
This is a phonetic spelling because there are no records from this doctor. “Dr. Trebetti,” who plaintiff refers to
later in this section, is also spelled phonetically for the same reason.
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offer an explanation. (Tr. 322-24). Plaintiff saw a neurologist, Dr. Trebetti, one time before
treating with Dr. Schward. Plaintiff stopped seeing Dr. Trebetti because he did not like his
bedside manner and though he was dismissive. Dr. Trebetti suggest plaintiff stop taking all of
his medications. Similarly, plaintiff’s primary care doctor suggested plaintiff stop taking Norco
due to the possibility of developing a tolerance and kidney issues.5 Plaintiff followed through
with his primary care physician’s suggestion, but his pain increased significantly. Plaintiff had
presented to Dr. Schward four times. During those examinations, Dr. Schward took images of
plaintiff’s back and head. The doctor recommended pain management via medication. (Tr. 32528).
Plaintiff was prescribed Flexeril for muscle spasms, Tramadol and Neurontin for nerve
pain, a beta-blockers for headaches, and Amitriptyline to help with sleeping and depression. He
also underwent injection therapy around 2006 and tried physical therapy and a TENS unit.
Plaintiff’s medications caused changes in vision, fatigue, dizziness, and problems balancing. He
experienced these side effects daily. Plaintiff reported these symptoms to his doctors. (Tr. 329341).
Plaintiff had “searing” and decreased sensation in his upper back, sensitivity to
temperature, and frequent grinding with nerve pain in his left shoulder. The burning and pain
made sleep difficult, so plaintiff always felt exhausted. (Tr. 332). He found himself falling
asleep throughout the day. His depression and anxiety also contributed to his sleeping problems.
(Tr. 357-59). He also developed neuropathy in his fingers and toes, most prominent in his big
toes.
Plaintiff reported minor numbness and tingling five years before.
The neuropathy
increased over the previous year and at the hearing plaintiff experienced almost complete
numbness in his toes. Plaintiff told his doctors about the neuropathy and underwent deep
5
It is unclear from the record which primary care physician plaintiff was referring to here.
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injections for it. Plaintiff also had nerve pain in his shoulder and spine. (Tr. 334-37).
Plaintiff’s depression and anxiety had become “troubling” over the previous year and a
half. Plaintiff thought about harming himself in the past. (Tr. 358). He had not treated with
anyone for these conditions, Dr. Youngblood had not referred him to anyone, and plaintiff had
not requested a referral for treatment. (Tr. 338-39). He had panic attacks as frequently as three
times per week and had trouble finding motivation. These attacks persisted for about forty-five
minutes. (Tr. 353). They made his tremors worse and made it difficult to breathe. (Tr. 358). He
sweated immensely and experienced nausea and vomiting during the attacks. Plaintiff also got
tearful throughout the week because of his inability to do things. (Tr. 364). Plaintiff took
Bupropion, which was an antidepressant and anti-anxiety medication. (Tr. 340).
Plaintiff no longer experienced cluster headaches after he began taking beta-blockers in
January or February of that year, but he did continue to have severe headaches on a regular basis.
(Tr. 341). He also had smaller headaches he described as short bursts of pain, lasting anywhere
from thirty seconds to twenty minutes. These occurred weekly. The smaller headaches made it
very difficult for plaintiff to focus. (Tr. 342). The cluster headaches lasted about one to two
minutes and required plaintiff to lay down the rest of the day. (Tr. 342-43). The longer
headaches lasted about an hour and brought on sensitivity to light and motion. (Tr. 343).
Plaintiff could not go outside without sunglasses, watch television, or look at a computer while
having a severe headache. Sounds such as semi-trucks and tornado sirens bothered him as well
but he could sometimes tolerate listening to music. (Tr. 344). The headaches could be triggered
by stress, pain, fatigue, or dehydration. (Tr. 345).
Aside from the food stamps, plaintiff had no other source of income. (Tr. 335-56).
Plaintiff could only do a few dishes and cook simple meals because of his back pain. He could
8
not do laundry, sweep, dust, or mop. He sometimes went grocery shopping with his brother, but
he had issues with crowds. Plaintiff had difficulty with collar buttons, tying his tie, and putting
in contacts due to his neuropathy. He also had difficulty shaving. He could only be on his feet
for approximately forty minutes at a time, lift less than a gallon of milk, and sit for about fortyfive minutes. (Tr. 347-52).
To pass the time, plaintiff read, listened to music, played computer games, and watched
foreign films. He played computer games about once a month. There were times when he had to
stop playing because he did not feel well. He lacked motivation to play the concertina and
guitar, which he used to play often. He could play the concertina about forty-five minutes while
lying down. Plaintiff had not built anything for about a year because the small details were
difficult to navigate. (Tr. 349-361).
When plaintiff attended John A. Logan College,6 he was permitted to sit in the back of
the class so he could stand without being disruptive and was given more time to get from class to
class. He also had access to faculty elevators and note takers. (Tr. 355).
Plaintiff’s condition had gotten worse since the previous hearing. His lower back pain
was better and the headaches were gone, but his depression and anxiety were very bad and the
pain in his shoulder was far worse. His neuropathy also worsened. (Tr. 366).
Ms. Stambaugh, a VE, also testified. The ALJ posed several hypothetical questions
regarding a person who could perform light work with various restrictions. The VE testified
there were jobs in the national and local economy that such a person could perform. (Tr. 36872).
3.
Medical Records
In addition to the medical records already summarized in the Court’s previous order, the
6
The transcript incorrectly refers to John A. Logan College as “Don and Logan College.”
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following records were submitted after remand.
In May 2008, plaintiff treated with Dr. Jodi Fox for back pain, numbness, and tingling.
He also complained of some numbness in his shoulder. She recommended an MRI of his
thoracic spine and head. In September 2008, plaintiff reported headaches and parethesias in his
upper left extremity. Dr. Fox noted a diagnosis of Chiari I malformation with thoracic syrinx.
She recommended an MRI of his head, neck, and spine. (Tr. 603-05).
In August 2012, Dr. Joseph Fonn from Midwest Neurosurgeons reviewed an MRI of
plaintiff’s thoracic spine and stated the image showed no changes in plaintiff’s syrinx or Chiari
malformation, which measured at 2mm. A physical examination was “normal” and plaintiff was
instructed to return in two years for a follow-up. (Tr. 602).
Plaintiff treated with Dr. Fox several times in 2013 and 2014. Throughout treatment, he
reported back symptoms, intermittent tremors in his right hand, cluster headaches, which
eventually improved with beta-blockers, and left shoulder pain. Dr. Fox diagnosed plaintiff with
syringomyelia and syringobulbia, benign essential hypertension, and tremors. She prescribed
plaintiff hydrocodone, Flexeril, atenolol, gabapentin, and tramadol. On March 14, 2014, Dr. Fox
wrote to plaintiff stating she would no longer treat him due to the inability “to maintain a
satisfactory physician-patient relationship.” (Tr. 576-591).
Plaintiff then presented to Dr. Fonn on June 23, 2014 and requested that he take over
plaintiff’s medications. Dr. Fonn refused, pending a review of plaintiff’s medical records. (Tr.
601). In July 2014, plaintiff reported an increase in loss of sensation in his left shoulder and
numbness and burning in his back. He also complained of cluster headaches. Dr. Fonn reviewed
an MRI of the brain and cervical and thoracic spine from March 15, 2014, and stated that there
was no change in plaintiff’s syrinx or Chiari malformation compared to an MRI from August
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2012. Plaintiff’s Chiari malformation measured 2mm. (Tr. 599). Dr. Fonn ultimately refused to
refill plaintiff’s medications and recommended a course of physical/aquatic therapy. (Tr. 598).
In August 2011, plaintiff had a physical consultative examination with Dr. Adrian
Feinerman. (Tr. 253–58). He noted that plaintiff was able to ambulate fifty feet without
assistance and had normal muscle strength throughout. (Tr. 256). Plaintiff's fine and gross
manipulation were normal and he was oriented to person, place and time. (Tr. 256–57). His
diagnostic impressions were Chiari malformation of the brain and syringomyelia. (Tr. 257).
4.
State Agency Consultant RFC Assessments.
In September 2011, state agency physician Lenore Gonzalez completed an assessment of
plaintiff's physical RFC capabilities. (Tr. 264–70). She reviewed plaintiff's records but did not
examine plaintiff. She felt plaintiff could occasionally lift fifty pounds, frequently lift twentyfive pounds, and stand, walk, and sit for about six hours in an eight hour workday. (Tr. 264).
Dr. Gonzalez opined that due to plaintiff's history of vertigo, he should only occasionally climb
ramps and stairs, never climb ladders, ropes, or scaffolds, and avoid hazards such as machinery
and heights. (Tr. 265–67).
5.
Dr. Freeman’s Opinion.
In March 2013, neurologist Dr. Julian Freeman performed a records review at the request
of plaintiff's attorney. (Tr. 211–14). Dr. Freeman's diagnoses were Chiari malformation at the
base of the brain and upper cervical spine, thoracic cord syringomyelia, morbid obesity, and
cluster headaches that may actually be migraine headaches. (Tr. 212). Dr. Freeman opined that
plaintiff's thoracic syrinx would have several immediate and consequential limitations. He stated
that plaintiff would have intense pain that would be difficult to suppress and would require very
frequent changes in posture. The thoracic syrinx would also disrupt sleep and would cause a
11
marked impairment in higher cognitive thought, slow responses, and instability of mood and
personality. (Tr. 213).
Dr. Freeman stated that plaintiff's headaches would also impose functional limitations.
Dr. Freeman opined that the headaches were independent of the syrinx or the Chiari
malformation and most likely stemmed from a motor vehicle accident. Dr. Freeman stated
migraines would cause impairments of speech, memory, and cognitive function, and the cluster
headaches would cause pain and personality changes. (Tr. 213).
Dr. Freeman's RFC assessment was that plaintiff could walk and stand for about two
hours and sit for about six hours with incessant shifts in posture and position during a typical
work day.
Additionally, plaintiff could lift, carry, push, or pull about twenty pounds
occasionally and ten pounds frequently with minimal overhead reach. (Tr. 213). Plaintiff would
need postural changes of all types with no substantial twisting motion of the spine, and no
exposure to more than minimal levels of vibration. (Tr. 213–14). Dr. Freeman stated that
plaintiff would have prolonged interruption of all work activities at least once a week for several
hours due to his headaches. Plaintiff's mental activities should be limited to simple tasks with
limited memory and pace of mental or physical activities due to his sleep deprivation. Dr.
Freeman noted that plaintiff would have imprecise and slow spatial organization and
arrangement of work objects, tools, and work tasks. (Tr. 214).
Analysis
The Court first notes that the ALJ held the record open for submission of medical
records, but plaintiff did not submit records of Dr. Schward, Dr. Youngblood, or Dr. Trebetti.
The first issue addressed is whether the ALJ provided a sufficient evidentiary basis for
his RFC assessment.
12
Three physicians offered an opinion on plaintiff’s physical limitations and each reached a
different conclusion. The ALJ found that each opinion was lacking in some sense and did not
wholly adopt any of them. Now, plaintiff asserts that the ALJ created an “evidentiary deficit” by
rejecting the assessments and impermissibly substituted his own lay opinion for that of a medical
expert by crafting his own RFC.
Plaintiff cites Suide v. Astrue, 371 F.App’x. 684 (7th Cir. 2010) in support of his
“evidentiary deficit” argument. However, in Suide, the ALJ erred in not discussing significant
medical evidence in the record. The ALJ does not commit this error here and “the ALJ is not
required to rely entirely on a particular physician’s opinion or choose between the opinions [of]
any of the claimant’s physicians.” Schmidt v. Astrue, 496 F.3d 833, 845 (7th Cir. 2007). The
regulations vest the ALJ with authority to determine the plaintiff’s RFC by weighing the
evidence in the record. 20 C.F.R. § 404.1527. However, an ALJ must not “play doctor” by
either rejecting or drawing medical conclusions without relying on medical evidence. See Dixon,
270 F.3d 1171, 1177-78 (7th Cir. 2001); Green v. Colvin, 204 F.3d 780, 782 (7th Cir. 2000).
Here, the ALJ thoroughly considered the medical record along with plaintiff’s subjective
complaints and hearing testimony. He weighed the evidence but did not (with one exception,
discussed infra) impermissibly interpret medical evidence as a layperson.
Plaintiff also contends that the ALJ erred by not explaining how the evidence supported
each specific restriction. However, the ALJ must only build a logical bridge that connects the
evidence and the conclusions. The ALJ, here, explained,
[i]n limiting the claimant to light work, the residual functional
capacity assessment takes into consideration, the combined effect
of the claimant’s obesity and tremors . . . some credence is given to
the claimant’s complaint of pain in determining his exertional
capability.
In determining the claimant’s manipulative
capabilities, the assessment considered the claimant’s Chiari
13
malformation, syringomyelia, and complaints of shoulder
problems. The limits on climbing and working around hazards
give consideration to the claimant’s complaints of balance
problems.
(Tr. 299). This explanation, along with the ALJ’s discussion of the evidence, permits this Court
to traverse the logical bridge.
Plaintiff next contends that the ALJ improperly assessed plaintiff’s subjective complaints.
Credibility determinations will only be disturbed if they are “patently wrong,” Simila v. Astrue,
573 F.3d 503, 517 (7th Cir. 2009), which is a “high burden” Turner v. Astrue, 390 F.App’x. 581,
587 (7th Cir. 2010).
The ALJ provided a sufficient basis for the credibility determination. He noted the lack
of objective evidence supporting plaintiff’s claim in the form of unremarkable MRIs and
negative examinations, Dr. Fonn’s refusal to refill plaintiff’s pain medications, and plaintiff’s
own testimony that his conditions improved. (Tr. 296-97).
Plaintiff also alleges the ALJ specifically erred in addressing plaintiff’s complaints of
headaches. The record is ultimately unclear regarding plaintiff’s symptoms and the treatment he
is receiving for headaches. Plaintiff testified that his cluster headaches were resolved with betablockers and Dr. Fox’s records from 2014 state the same. However, he testified that he still
experiences smaller headaches, along with severe headaches. He also testified that he receives
treatment for headaches from Dr. Youngblood, his current primary care physician, but plaintiff
did not submit any of Dr. Youngblood’s records.
The ALJ determined these complaints were not entirely credible because plaintiff had
“not been prescribed and does not take medications designed for the treatment of migraine
headaches.” (Tr. 298). The ALJ provided a sufficient basis for his credibility determination that
took into account plaintiff’s medications, treatment, and other objective evidence. Thus, the
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credibility determination was not patently wrong and will be upheld.
Next, plaintiff asserts that the ALJ failed to consider the aggregate effects of his obesity
and failed to explain how the RFC assessment accounted for plaintiff’s obesity. The regulations
require an ALJ to assess the impact of obesity in combination with other impairments. SSR 021p. However, any error in addressing the effects of a plaintiff’s obesity is subject to harmless
error analysis. Prochaska v. Barnhart, 454 F.3d 731, 736-37 (7th Cir. 2006).
The ALJ determined that plaintiff’s obesity constituted a severe impairment, he noted
plaintiff’s weight and body mass index in his opinion, and then he opined that obesity would
reduce plaintiff’s ability to carry and lift. (Tr. 291-98). Moreover, the ALJ relied on medical
evidence from physicians who included plaintiff’s height and weight in their records in
formulating plaintiff’s RFC. See Prochaska, 454 F.3d at 738 (upholding the ALJ’s decision
where, although he did not explicitly address the plaintiff’s obesity, he predicated his decision
upon physician opinions and medical reports noting the plaintiff’s height and weight).
Additionally, any error is harmless because plaintiff failed to articulate how his obesity
affected his function or exacerbated his symptoms. Skarbek v. Barnhart, 390 F.3d 500, 504 (7th
Cir. 2004) (The plaintiff “[did] not specify how his obesity further impaired his ability to
work.”); Mueller v. Colvin, 524 F.App’x. 282, 287 (7th Cir. 2013) (“[A]ny error in failing to
mention obesity is harmless if the claimant did not explain to the ALJ how her obesity
aggravated her condition and rendered her disabled.”); Hisle v. Astrue, 258 F.App’x. 33, 37 (7th
Cir. 2007) (“But the claimant must articulate how her obesity limits her functioning and
exacerbates her impairments.”). Thus, the ALJ did not err in considering plaintiff’s obesity.
Plaintiff next contends that the ALJ erred in dismissing Dr. Freeman’s assessment. In
evaluating the weight to afford a physician’s opinion, an ALJ will consider the examining
15
relationship, the treatment relationship, supportability and consistency of the opinion, and the
physician’s specialization. 20 C.F.R. § 404.1527. The ALJ, here, noted that Dr. Freeman
conducted a records review. He also explained that the doctor’s opinions were extreme in light
of other evidence in the record and unsupported.
These are legitimate reasons under the
regulations for rejecting a physician’s opinions and the ALJ’s decision will be upheld as long he
“minimally articulates” his reasoning. Schmidt v. Astrue, 496 F.3d 833, 842 (7th Cir. 2007)
The ALJ also stated that Dr. Freeman’s restrictions were consistent with an individual
with a cervical spine condition, which is an opinion beyond the expertise of a layperson.
However, a remand on this point would not result in a different outcome, so the error was
harmless.
Finally, plaintiff asserts that the ALJ violated the law of the case doctrine, which, among
other things, requires an ALJ to conform further proceedings on remand to the principles set
forth in the appellate court’s opinion, absent a compelling reason for departure. Wilder v. Apfel,
153 F.3d 799, 803 (7th Cir. 1998). Plaintiff argues that the ALJ violated the doctrine because he
did not analyze plaintiff’s activities of daily living (ADLs). During the initial review by this
Court, we held that the ALJ incorrectly equated ADLs to an ability to maintain full-time
employment and further opined that “[t]he ALJ’s reliance on [plaintiff’s] daily activities without
further explanation is inadequate.” (Tr. 457). On remand, the ALJ mentioned plaintiff’s ADLs,
but did not lean on them as his primary basis for finding plaintiff not disabled. The ALJ
mentioned some of plaintiff’s ADLs in support of his adverse credibility determination and
explained his reasoning. For example, he stated, “[T]he claimant’s testimony that he plays
musical instruments such as the concertina tends to indicate that he does have functional
manipulative abilities.” The ALJ is not required to mention every piece of evidence, Craft, 539
16
F.3d at 674, and the ALJ otherwise complied with the doctrine.
Conclusion
The Commissioner’s final decision denying Jacob Clendenin’s application for social
security disability benefits is AFFIRMED.
The Clerk of Court is directed to enter judgment in favor of defendant.
IT IS SO ORDERED.
DATED: 6/26/2017
s/J. Phil Gilbert
J. PHIL GILBERT
U.S. DISTRICT JUDGE
17
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