Parker v. Commissioner of Social Security

Filing 27

MEMORANDUM AND OPINION. The Commissioner's final decision denying plaintiff's application for social security disability benefits is AFFIRMED.The Clerk of Court is directed to enter judgment in favor of Defendant. Signed by Magistrate Judge Clifford J. Proud on 11/2/2018. (jmt)

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ILLINOIS
NICOLE A. P. 1

)
)
)
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)
)
)
)
)
)

Plaintiff,
vs.
COMMISSIONER OF SOCIAL
SECURITY,
Defendant.

Case No. 18-cv-0001-CJP 2

MEMORANDUM and ORDER
In accordance with 42 U.S.C. § 405(g), plaintiff Nicole A. P. (Plaintiff) seeks
judicial review of the final agency decision denying her application for Supplemental
Security Income (“SSI”) pursuant to 42 U.S.C. § 423.
Procedural History
Plaintiff applied for SSI on October 9, 2014, alleging a disability onset date
of July 15, 2011. (Tr. 151). Plaintiff’s application was denied at the initial level,
and again upon reconsideration.

(Tr. 48-70).

She requested an evidentiary

hearing, which Administrative Law Judge (“ALJ”) Raymond Souza conducted on
September 13, 2016. (Tr. 34-47). ALJ Souza reached an unfavorable decision on
November 28, 2016. (Tr. 18-29). The Appeals Council denied Plaintiff’s request
for review, rendering the ALJ’s decision the final agency decision.

1

(Tr. 1-3).

The Court will not use plaintiff’s full name in this Memorandum and Order in order to protect her
privacy. See FED. R. CIV. P. 5.2(c) and the Advisory Committee Notes thereto.
2
This case was assigned to the undersigned for final disposition upon consent of the parties
pursuant to 28 U.S.C. § 636(c). See Doc. 20.

Page 1 of 27

Plaintiff exhausted her administrative remedies and filed a timely Complaint in this
Court. (Doc. 1).
Applicable Legal Standards
To qualify for SSI or disability insurance benefits, a claimant must be
disabled within the meaning of the applicable statutes. 3

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:
The first step considers whether the applicant is engaging in
substantial gainful activity. The second step evaluates whether an
3

The statutes and regulations pertaining to 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.

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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, 512-513
(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

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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 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,

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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 ALJ’s Decision
ALJ Souza found Plaintiff had not engaged in substantial gainful activity since
September 23, 2014, the application date.

She had severe impairments of

degenerative disc disease and gastroesophageal reflux disease (“GERD”). None of
her impairments or combination of impairments met or equaled a Listing. (Tr. 20).
Plaintiff had the RFC to perform sedentary work, with several additional
limitations. (Tr. 21). Plaintiff was unable to perform any past relevant work but
other jobs existed in significant numbers in the national economy that Plaintiff
could perform.

(Tr. 27-28).

The ALJ ultimately determined Plaintiff was not

disabled. (Tr. 29).
The Evidentiary Record
The following summary is directed at Plaintiff’s arguments.
1. Agency Forms
In her agency forms, Plaintiff alleged the following conditions limited her
ability to work: narrow bones in her spine, hernia surgery, degenerative disc
disease, bad knees, not liking public interaction, GERD, and sickness from the air
quality. (Tr. 169). Plaintiff previously worked as a hair dresser and for a temporary
agency. (Tr. 171). She stated her right side went numb when she sat for too long
and she would lose the ability to use her right leg. She could hardly walk and had
to drag her leg. She could walk for about five minutes before needing to rest for
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ten minutes. She could not stand for long, either, because she would lose her
balance.

She had trouble bending, using stairs, and squatting.

She could

concentrate for twenty minutes. Plaintiff tossed and turned all night due to hip
pain. She could not use her dominant hand to open things when she cooked. It
was difficult for her to bend and she could not lift. Back pain made it difficult for
her to drive long distances. On an average day, she got her children ready for school
and tried to walk around periodically throughout the day. She cooked and cleaned
for her children. Plaintiff was able to grocery shop. She enjoyed reading but
bending her head pulled on her back, so she was limited in her ability to read for
long periods. (Tr. 177-82).
2. Evidentiary Hearing
Plaintiff appeared at an evidentiary hearing on September 13, 2016, at which
she was represented by counsel. Plaintiff’s attorney stated he had reviewed the
record and did not object to the evidence. ALJ Souza admitted the exhibits into
evidence and asked, “Anything further?” to which counsel replied, “I don’t believe
so, Judge.” (Tr. 37).
Plaintiff testified her impairments were related to her back, neck, knees, and
arms. She also had GERD. Plaintiff experienced a “pins and needles” sensation in
her arms and sometimes had no strength in them. Her hands bruised easily.
Plaintiff received injections in her neck, which offered temporary relief. She had
difficulty sleeping because her hips felt like they were going to “pop.” (Tr. 38-42).

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3. Medical Records
Plaintiff presented to Dr. Bradley on August 9, 2013 for low back pain and
left knee pain. She received injections prior to her visit, which did not help much
with back pain.

The injections did resolve her radiculopathy.

Her biggest

complaint was of lateral knee pain. On exam, Plaintiff had some pain to palpation
along the lateral joint line. Her range of motion was from 0 to 135 degrees with
excellent stability to varus and valgus stress. She did not open up approximately
1-1/2 centimeters to varus stressing but a good end point was noted. She had
normal anterior and posterior drawer. McMurray created some very mild lateralsided joint line pain, as did reverse McMurray, but no mechanical symptomatology
was noted. Plaintiff had 5/5 strength in her quads, hamstrings, ankles, plantar
flexors, dorsiflexors and extensor hallucis longus. Her sensation was intact distally.
Multiple radiographs of Plaintiff’s bilateral knees showed very mild degenerative
disease of the lateral compartment with some loss of joint space. No particular
osteophytes or subchondral sclerosis were noted. Dr. Bradley noted Plaintiff had
early degenerative disease in her knee, but not a significant amount. She had a
slightly valgus knee.

Dr. Bradley administered an intra-articular cortocsteroid

injection in her left knee without complication. (Tr. 243).
Plaintiff presented to Dr. Miguel Granger on March 18, 2014 for a checkup
and complained of knee, hip, and back pain. On exam, Plaintiff demonstrated low
back and knee pain with range of motion. Dr. Granger assessed Plaintiff with

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hypertensions, osteoarthritis, and GERD. He referred Plaintiff to Dr. Bradley for
x-rays. (Tr. 246-47).
Plaintiff saw Dr. Bradley on May 27, 2014 and complained of pain in her low
back that radiated down her left leg. She also experienced some numbness in the
lateral aspect of her leg and foot. Throughout the previous two weeks, her low back
pain increased and she had radiculopathy-type symptoms. She said she had very
minimal pain relief from the Medrol Dosepak she recently received from the
emergency room. She was stretching and exercising at home. An examination of
her low back revealed no erythema, redness, or warmth. Her flexion was to 70
degrees, her extension was to 10 degrees on the lateral side, and bending was 10
degrees in each direction. The bilateral lower extremities showed she had some
weakness in her quads, rated at 4+/5 compared to the contralateral right quad.
Otherwise, she had 5/5 strength throughout the entire left lower extremity. Plaintiff
reported some decreased sensation along the lateral aspect of her lower leg and
foot. Her plantar sensation was completely intact. She had 1+ patellar tendon,
Achilles’ tendon reflexes bilaterally, normal Babinski reflexes bilaterally, and no
sustained clonus bilaterally. Dr. Bradley opined Plaintiff had some degenerative
disc disease in her back, in combination with some symptoms of radiculopathy.
She

failed

nonoperative

treatment,

including

activity

modification,

inflammatories, home exercises programs, and Medrol Dosepak.

anti-

Dr. Bradley

recommended an MRI scan to look for disc herniation with foraminal stenosis or

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compression of the nerve root.

He referred Plaintiff to pain management and

instructed her to follow up as needed. (Tr. 242).
Plaintiff followed up with Dr. Granger on July 29, 2014. He prescribed
Plaintiff tramadol and norco for osteoarthritis pain and referred her to a pain clinic.
(Tr. 248-49).
Plaintiff followed up with Dr. Bradley on July 25, 2014. She reported her
back pain was getting worse.

An MRI scan from June 4, 2014 showed some

degenerative disc disease at L4-5, resulting in some mild to moderate bilateral
lateral foraminal stenosis. A physical examination remained completely unchanged
from her prior exam. There was some facet hypertrophy throughout the entire
lumbar spine.

Dr. Bradley provided Plaintiff with a prescription for pain

management and prescribed her tizanidine and “a very small amount of narcotic
medication to get her through.” He noted that no follow-up was necessary. (Tr.
241).
Plaintiff saw Dr. Kristina Naseer at Dr. Granger’s office on September 3, 2014
and complained of right low back pain and left-sided neck pain. She previously
had injections for low back pain, which helped with the pain. Her pain was in her
left upper shoulder blade and right leg. The pain was present for about two years
with gradual onset in her back that travelled to her hips and down to her knee. Her
average pain was 10/10. Plaintiff described it as burning, aching, severe, constant,
and worsening. She described associated weakness and numbness as well. The
pain worsened when Plaintiff rolled in bed, exercised, drove, sat, moved from sitting

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to standing, laid down, with weather changes, walking, stress, and fatigue. Pain
medication offered relief. On exam, Plaintiff was slow to go from sitting to standing.
She ambulated with a normal gait. Plaintiff had difficulty with heel and toe standing
secondary to balance. Her range of motion was good, overall. She had exacerbated
pain with forward flexion.

Strength, sensation, and reflexes were otherwise

unremarkable. A straight leg raise test produced axial back pain. She had some
localized tenderness present along her right scapula region with good range of
motion, overall, of her upper extremities and with her cervical spine. Dr. Naseer
assessed Plaintiff with lumbar degenerative disk disease and lumbar spondylosis.
She administered a right sided lumbar epidural injection and ordered an MRI of
Plaintiff’s cervical spine. Plaintiff was to follow up for reevaluation in two weeks.
(Tr. 265-66).
Plaintiff presented to Southern Illinois Healthcare Foundation on October 28,
2014 and demonstrated lower back pain on range of motion. (Tr. 252).
Plaintiff received bilateral L4 lumbar transforaminal epidural injections on
September 22, 2014 and October 31, 2014. (Tr. 261, 263).
Plaintiff saw Dr. Naseer on November 17, 2014 and complained of mid and
low back pain. She had undergone a total of three epidural injections with very
little benefit. Her pain was primarily in her low back and traveled down towards
her hips. She also reported upper back pain. Tramadol helped a little bit but not
significantly. Her pain score during the visit was 7/10. Plaintiff ambulated with a
normal gait. She demonstrated pain with extension, palpable tenderness across

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her lumbar facets, and pain with facet loading. A straight leg raise test was negative.
Strength, sensation, and reflexes were unremarkable. She had multiple areas of
muscle spasms and muscle knots present across her cervical trapezius and
paraspinous muscles bilaterally. Dr. Granger assessed Plaintiff with myofascial
pain, lumbar facet arthropathy, and lumbar spondylosis. He suggested lumbar
facet blocks and physical therapy and prescribed her Norco for pain to take as
needed. (Tr. 259-60).
Plaintiff attended three physical therapy sessions from November 25, 2014
through December 15, 2014. At her last visit, Plaintiff reported neck pain that she
rated at a 5/10 and low back pain she rated at an 8/10. She reported her back had
been feeling a little better. (Tr. 270-72).
Plaintiff received bilateral L4-5 and L5-S1 lumbar intraarticular facet join
injections on December 5, 2014 and December 18, 2014. (Tr. 255, 257).
On February 17, 2015 and March 4, 2015, Plaintiff underwent right L2, L3,
L4, and L5 lumbar medial branch radiofrequency denervation. (Tr. 276-77, 27879).
Plaintiff followed up with Dr. Naseer on March 19, 2015. She was doing well
following the radiofrequency denervation. Her pain was at a 2/10 and she had
minimal pain across the left scapular region.

Otherwise, her pain was much

improved. She had increased her activity and decreased her medication. She was
currently taking Norco and amitriptyline. On exam, Plaintiff had good range of
motion with very minimal tenderness present to palpation across her cervical

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paraspinous muscles and across her lumbar facets. Dr. Naseer assessed Plaintiff
with cervical myofascial pain and lumbar facet arthropathy. Dr. Naseer instructed
Plaintiff to follow up as needed. She refilled Plaintiff’s Norco “one more time” and
started Plaintiff on Flexeril and topical cream. (Tr. 280).
Plaintiff followed up with Dr. Granger on May 14, 2015. On exam, she
demonstrated low back pain with range of motion and decreased range of motion.
Dr. Granger prescribed her hydrocodone for lumbar radiculopathy. (Tr. 305-07).
State agency consultant Dr. Adrian Feinerman examined Plaintiff on July 7,
2015. Plaintiff reported low back pain that was present for the previous five years
and due to degenerative disc disease. The pain radiated to both lower extremities.
She also had knee pain secondary to her back problems and pain in her left
shoulder and upper extremity. Plaintiff said she could walk one block, stand for
10 minutes, and sit for 10 minutes. She was able to squat, bend, and perform fine
and gross manipulations without difficulty.

Plaintiff was taking gabapentin,

cyclobenzaprine, amitriptyline, and hydrocodone. On exam, there was no anatomic
abnormality of any extremity and no evidence of redness, warmth, thickening or
effusion of any joint, and no limitation of motion of any joint. Her grip strength was
strong and equal bilaterally. There was no anatomic deformity of the cervical,
thoracic, or lumbar spine and no limitation of motion of any spinal segment. She
ambulated to 50 feet normally without any assistive device.

Plaintiff’s muscle

strength was normal throughout, she had no spasm or atrophy, and her fine and

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gross manipulation were normal. Dr. Feinerman assessed Plaintiff with lumbar
disc disease and hypertension. (Tr. 282-91).
Plaintiff presented to the emergency room on July 29, 2015 with complaints
of neck pain on the right side that she rated at a 10/10. An x-ray of Plaintiff’s pelvis
was unremarkable. A CT of her cervical spine showed mild loss of the normal
cervical lordosis.

Plaintiff was diagnosed with cervical radiculopathy and

prescribed Ultram and Baclofen. (Tr. 317-23).
Plaintiff presented to Dr. Granger on August 12, 2015.
demonstrated low back and neck pain with range of motion.

On exam she
Dr. Granger

prescribed Plaintiff hydrocodone for her lumbar radiculopathy. (Tr. 302-04).
Plaintiff saw Dr. Naseer on August 26, 2015 with complaints of neck and hip
pain. She was diagnosed with myofascial pain and received cervical and lumbar
trigger point injections. (Tr. 335).
An MRI of Plaintiff’s cervical spine from October 9, 2015 demonstrated a tiny
spinal cord syrinx at C6-C7, measuring six millimeters in length; minimal
degenerative changes with physiologic annular bulging at C4-5 and C6-7; a small
right perineural cyst at C6-7, measuring seven millimeters; and empty sella and
borderline sellar enlargement, measuring 14 millimeters. (Tr. 337-38).
An MRI of Plaintiff’s cervical spine from November 10, 2015 showed a stable
small syrinx at C66-7 with no surrounding abnormal enhancement or causative
mass lesion, which may have been a developmental variant, and a stable right

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perineural nerve root sheath cyst at C6-7 with no abnormal enhancement that
occupied approximately 50% of the diameter of the right foramen. (Tr. 339).
Plaintiff followed up with Dr. Granger on November 12, 2015.
demonstrated low back and neck pain with range of motion on exam.

She
He

prescribed hydrocodone and tramadol for osteoarthritis. (Tr. 298-300).
Plaintiff went to the emergency room on November 25, 2015 with complaints
of right knee and back pain after slipping and falling on a loose rug the previous
day. She demonstrated normal range of motion on exam. An x-ray of her right
knee showed early medial compartment osteoarthritis but no fracture or joint
effusion. An x-ray of her lumbosacral spine showed no fracture, subluxation, or
bone destructive process. Her interspaces appeared within normal limits and her
sacroiliac joints were normal. She was diagnosed with a right knee strain with
lower back pain. Plaintiff was instructed to rest, ice, and elevate her knee, apply
warm heat to her back, keep moving, and follow up with her primary care
physician. (Tr. 341-49).
Plaintiff received a left C7-T1 cervical interlaminar epidural steroid injection
on December 16, 2015. (Tr. 351).
Plaintiff saw Dr. Granger on January 21, 2016.

She had a right knee

abrasion and demonstrated pain with range of motion of the bilateral knees. Dr.
Granger refilled Plaintiff’s medications, including gabapentin for osteoarthritis,
sertraline for anxiety, and hydrocodone and tramadol for lumbar radiculopathy.
He also referred Plaintiff to a neurologist for her radiculopathy. (Tr. 294-97).

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Plaintiff presented to Dr. Muddasani Reddy on February 22, 2016 with
complaints of pain in her lower and upper back. The lower back pain had been
present for five years and the upper back pain had been present for two years. She
experienced some pain radiation down to the right arm. Her low back pain radiated
down to the right leg. A spine x-ray revealed syrinx of six millimeter in length at the
C6-C7 level. A lumbosacral spine x-ray showed degenerative disc disease centered
on L4-L5, which resulted in bilateral lateral disc space narrowing effecting
descending nerve roots and bilateral mild foraminal stenosis.

There was no

evidence of canal stenosis. There was bilateral facet arthropathy at L3-L4, L4-L5,
and L5-S1 with bilateral facet effusions at L4-L5. There was no suspicious bone
lesion and no cord signal abnormalities were identified. A straight leg raising test
was around 70 degrees bilaterally. Dr. Reddy assessed Plaintiff with severe back
pain, probably related to degenerative joint disease and neck pain with radiation to
the right upper extremity. In light of the C6-C7 syrinx, Dr. Reddy recommended
Plaintiff see a neurosurgeon. He instructed her to continue to treat with pain
medication and seek continued follow up care with a pain clinic. (Tr. 308-11).
Plaintiff underwent a right L2, L3, L4, L5, and S1 lumbar medial branch
radiofrequency denervation on March 8, 2016. (Tr. 354).
Plaintiff presented to the emergency room on March 26, 2016 with
complaints of back pain, which had persisted for months.

On exam, she

demonstrated normal range of motion and 5/5 strength of the upper and lower
bilateral extremities.

She was nontender in the extremities.

Page 15 of 27

Her thoracic

paraspinous muscles were tender to palpation. She was diagnosed with chronic
back pain and prescribed Flexeril and hydrocodone. (Tr. 398-401).
On April 19, 2016, Plaintiff underwent bilateral C6 and C7 cervical medial
branch blocks. (Tr. 451).
Plaintiff saw Dr. Jeroen Coppens on May 31, 2016 for back pain. She was
diagnosed with chronic back pain and instructed to obtain an MRI and follow up
with the results. (Tr. 374-75).
Plaintiff followed up with Dr. Granger on June 9, 2016.

He prescribed

hydrocodone and Voltaren for osteoarthritis and referred her to a neurologist for
lumbar radiculopathy. On exam, she had low back pain with range of motion. (Tr.
415-18).
Plaintiff consulted neurologist Dr. Juan Carlos Escandon on July 29, 2016.
On exam, she had a normal gait with a negative Romberg and Pull test. She had
significant head forward posturing, four fingers on both sides. She had multiple
areas of muscle tenderness to deep palpation, including in the suboccipital region,
cervical, paraspinals, and trapezius, in the upper thoracic para spinal with
exquisite tenderness, in the arms just below shoulder and below the elbows in the
dorsal aspect, and in the distal phalanx of the fingers. Dr. Escandon wrote that
Plaintiff suffered from pain and parasthesias in multiple areas of her body that did
not represent a particular dermatomal distribution or peripheral neuropathy.
There were no objective abnormalities on her neurological exam.

The

abnormalities were on the musculoskeletal exam. In addition to the head forward

Page 16 of 27

syndrome, which may have explained the pain in her left scapular region, she had
multiple tender points. On a review of symptoms, she enforced intermittent local
swelling in the right foot as well as fatigue and active anxiety. Dr. Escandon opined
that Plaintiff’s problems were more in the rheumatological area.

He was

“particularly suspicious of fibromyalgia. . .” Dr. Escandon recommended Plaintiff
obtain a rheumatological evaluation, participate in physical therapy for the head
forward syndrome, and continue pain management. Dr. Escandon wrote to Dr.
Granger that Plaintiff was “clearly in distress” and her complaints were “real.” (Tr.
383-87).
Plaintiff presented to Dr. Michael Prim on July 26, 2016 with complaints of
intermittent hand weakness and numbness, as well as a burning sensation in her
thigh and left foot. Dr. Prim assessed Plaintiff with mild degenerative disc disease
and peripheral neuropathy. He reviewed an MRI of Plaintiff’s lumbar spine and
noted it was “without significant pathology that explains patients symptoms.” Dr.
Prim referred Plaintiff to a neurologist.

Dr. Coppens reviewed Dr. Prim’s

assessment and added that Plaintiff would not benefit from surgery. (Tr. 390-93).
Plaintiff underwent a left C5, C6, and C7 cervical medial branch
radiofrequency denervation on August 17, 2016. (Tr. 446).
Plaintiff saw Dr. Granger on August 22, 2016 for a follow up. He prescribed
Plaintiff hydrocodone and ranitidine for osteoarthritis and referred her to a
rheumatologist. He also prescribed Plaintiff baclofen and tramadol for lumbar
radiculopathy and referred her to a neurologist. (Tr. 412-14).

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4. State-Agency Consultant RFC Assessments
State-agency consultant Dr. Julio Pardo conducted an RFC assessment of
Plaintiff on January 26, 2015. He opined Plaintiff could occasionally lift and/or
carry 20 pounds; frequently lift and/or carry 10 pounds; stand and/or walk for a a
total of six hours in an eight-hour workday; sit for a total of six hours in an eighthour workday; and was limited n her ability to push and/or pull with the bilateral
upper extremities. Plaintiff could occasionally climb ladders, ropes, and scaffolds;
climb ramps/stairs; kneel; stoop; crawl; and crouch. She could frequently balance.
Plaintiff was limited in her ability to reach overhead with both arms. Plaintiff
should avoid concentrated exposure to extreme cold and heat, vibration, and
hazards. (Tr. 53-55).
Dr. David Mack conducted an RFC assessment of Plaintiff on July 24, 2015
and concurred with Dr. Pardo’s opinion. (Tr. 66-68).
Analysis
Plaintiff argues the ALJ erroneously omitted and mischaracterized medical
evidence that is crucial to the disability determination.
An ALJ has a duty to evaluate the record fairly. Golembiewski v. Barnhart,
322 F.3d 912, 917 (7th Cir. 2003). Although an ALJ need not mention every piece
of evidence in the record, he must articulate a “logical bridge” between the evidence
and his conclusions and cannot ignore an entire line of evidence contrary to his
ruling. Terry v. Astrue, 580 F.3d 471, 475-77 (7th Cir. 2009). On review, the
Court does not “nitpick the ALJ’s opinion for inconsistencies or contradictions,”
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but rather, “give[s] it a commonsensical reading.” Jones v. Astrue, 623 F.3d 1155,
1160 (7th Cir. 2010).
Plaintiff first takes issue with the ALJ’s deference to a medical record from
July 26, 2016. On that date, Plaintiff saw Dr. Prim, who reviewed an MRI of
Plaintiff’s lumbar spine and opined that it did not demonstrate a “significant
pathology” that explained Plaintiff’s symptoms. (Tr. 392). The ALJ highlighted this
in his decision, noting, “The opinion that the lumbar spine MRI is without
significant pathology that explains the claimant’s symptoms is given considerable
deference in finding that the claimant is limited as stated above but does not have
disabling symptoms and limitations.” (Tr. 25). Plaintiff contests this line of the
ALJ’s reasoning because the ALJ allegedly failed to recognize contrary evidence.
Namely, Plaintiff points to a letter from Dr. Escandon to Dr. Granger following a
neurological examination. The letter reads, “Includ[ed] are recommendations that
I hope you implement [as] she clearly is in distress. . . I do feel her complaint[s] are
real.” (Tr. 383). According to Plaintiff, “The ALJ failed or refused to recognize that
Dr. Escandon believed Plaintiff’s reports of pain and limitations, irrespective of the
cause.” (Doc. 16, p. 4).
Despite Plaintiff’s contentions, the ALJ did acknowledge that Dr. Escandon
validated Plaintiff’s complaints of pain. The ALJ wrote, “Based on exam findings,
[Dr. Escandon] concluded that the claimant suffers from pain . . . “ (Tr. 25). The
ALJ did not did commit an error in this part of his decision.

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Plaintiff also argues the ALJ failed to accurately summarize Plaintiff’s visit to
the emergency room on March 26, 2016. The ALJ stated,
The claimant presented to the emergency department (ER) on March
26, 2016 for complaints of chronic back pain and being out of her
Hydrocodone . . . Exam showed normal range of motion in all
extremities, 5/5 strength in the upper and lower extremities bilaterally,
normal pulses.
(Tr. 24).
According to Plaintiff, she “actually presented to the ER secondary to a panic
attack brought on by severe pain.” (Doc. 16, p. 5). She argues the ALJ committed
error by not recognizing this detail.
Plaintiff’s argument is unconvincing because the medical record does not
state that severe pain induced Plaintiff’s panic attack. Instead, the document reads,
39-year-old female presents with back pain. Patient has a history of
chronic back pain. States she has been dealing with this pain for
months. States that earlier today she became very overwhelmed
couldn’t breathe her heart was racing and she became nauseous. Her
family called an ambulance states she has never had a panic attack
before now currently denying shortness of breath, chest pain, fever,
headache, feelings of anxiety.
(Tr. 398).
Plaintiff cannot fault the ALJ for failing to draw an inference from the medical
record to determine the source of a panic attack. In fact, ALJs may not “draw
medical conclusions themselves about a claimant without relying on medical
evidence.” Back v. Barnhart, 63 F. App’x 254, 259 (7th Cir. 2003). The ALJ did
not erroneously interpret Plaintiff’s emergency room visit from March 2016.

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Plaintiff seems to generally critique the ALJ’s evaluation of her complaints of
pain.

Social Security Ruling 96-7p provides that an ALJ should consider the

following factors when evaluating subjective complaints: the claimant’s daily
activities; the location, duration, frequency, and intensity of the pain; precipitating
and aggravating factors; the type, dosage, effectiveness, and side effects of
medication; treatment, other than medication; and other measures used to relieve
pain. The ALJ, here, complied with this Ruling. ALJ Souza mentioned Plaintiff’s
testimony about the limiting effects of her pain. The ALJ noted Plaintiff could not
use her hands when she had pain and had to rest for 20 minutes after performing
only five to 10 minutes of activity. (Tr. 22). The ALJ also noted Plaintiff’s claims
that she could only walk one block, stand for ten minutes, and sit for ten minutes.
(Tr. 26). The ALJ also identified the location of Plaintiff’s pain as her back, arms,
and hips.

(Id.).

Additionally, the ALJ pointed out Plaintiff’s use of pain

medications, stating Plaintiff was prescribed Tramadol, Hydrocodone, Flexeril, and
“narcotic pain medication.” (Tr. 24). The ALJ indicated that activity exacerbated
Plaintiff’s pain, and that medication and injections offered temporary relief. (Tr.
22). Finally, the ALJ acknowledged other treatments Plaintiff utilized to alleviate
her pain, including injections and nerve ablation. (Tr. 22-25).
In sum, Plaintiff has failed to demonstrate that the ALJ cherry-picked from
the record or omitted a line of evidence contrary to the disability determination.
The ALJ’s analysis of the record related to Plaintiff’s complaints of pain was not
erroneous.

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Plaintiff also criticizes the ALJ for ignoring objective medical evidence that
supported Plaintiff’s subjective complaints. Specifically, the ALJ mentioned Dr.
Naseer’s observation that Plaintiff “was able to go from a sitting to standing
position.” (Tr. 23). Plaintiff criticizes the ALJ for not acknowledging that Dr.
Nasser noted Plaintiff was slow to go from a sitting to standing position. Plaintiff
does not explain how this “error” is relevant to the disability determination or how
it altered the ALJ’s logic. (Tr. 21). Again, the Court does not nitpick the ALJ’s
decision on review. Jones v. Astrue, 623 F.3d 1155, 1160 (7th Cir. 2010).
Plaintiff also asserts the ALJ’s decision was erroneous because “although the
ALJ recognized that Dr. Escandon confirmed significant head forward posturing,
the ALJ failed to consider the remainder of Dr. Escandon’s sentence, which
confirms that the head forward syndrome, ‘may help to explain the pain in the left
scapular region.’” (Doc. 16, p. 4) (internal citations omitted). But the ALJ did
recognize this portion of Dr. Escandon’s record. ALJ Souza wrote, “In addition to
the head forward posturing syndrome that may help to explain the pain in the left
scapular region. . .” (Tr. 25). There was no error here.
Additionally, the Plaintiff says the ALJ failed to cite to Dr. Granger’s note
from March 8, 2016, in which “it appears that Dr. Granger observed tenderness to
palpation (TTP) in the extremities.” (Doc. 16, p. 5). Plaintiff argues that “it appears”
that Dr. Granger made this finding because the record she cites to in her argument
is a largely illegible handwritten record. (Tr. 455). Even if the ALJ did fail to
identify a TTP finding, it was not reversible error. The ALJ noted elsewhere in his

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opinion that Plaintiff demonstrated TTP of the extremities on exam, (Tr. 24-25),
and, therefore, he did not ignore an entire line of evidence contrary to his ruling.
Plaintiff also asserts the ALJ erroneously opined that Plaintiff demonstrated
“only somewhat decreased” range of motion of the lumbar spine at a doctor’s
appointment on May 27, 2014. On that day, Plaintiff’s flexion was to 70 degrees,
her extension was to 10 degrees on the lateral side, and bending was 10 degrees in
each direction. (Tr. 242). Plaintiff maintains the reduction in the range of motion
of the lumbar spine was ”significant” because extension and lateral side bending
were to 10 degrees out of 30 degrees, which is a 66% reduction in the ability to
extend the spine and side-bend. (Doc. 16, pp. 4-5).
Plaintiff has not explained how this error altered the ALJ’s determination.
The ALJ, through the vocational expert, identified jobs Plaintiff could perform that
do not require any stooping or crouching. 4 (Cosmetologist, DOT #332.271-010;
Assembler, DOT #700.684-014).

Thus, any error in the ALJ’s description of

Plaintiff’s range of motion from May 2014 and her ability to bend would not alter
the disability determination.
In sum, Plaintiff has failed to show the ALJ committed reversible error in
evaluating the medical record. Although there were portions of the record that
corroborated Plaintiff’s complaints of pain, the ALJ acknowledged them and
weighed the evidence as he saw fit. Unless Plaintiff can show the ALJ’s decision
was illogical or based on an unfair or incomplete review of the record, the Court

4

Social Security Ruling 83-10 uses “stooping” and “crouching” to describe different types of bending.

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must uphold the disability determination. Plaintiff has not met this burden and the
Court cannot reweigh the evidence. Terry v. Astrue, 580 F.3d 471, 476 (7th Cir.
2009).
Plaintiff also argues the ALJ erred at Step 2 of the disability determination.
“The Step 2 determination is a de minimis screening for groundless claims. . . .”
O’Connor-Spinner v. Colvin, 832 F.3d 690, 697 (7th Cir. 2016) (internal quotations
and citations omitted). “As long as the ALJ determines that the claimant has one
severe impairment, the ALJ will proceed to the remaining steps of the evaluation
process. . . .” Castile v. Astrue, 617 F.3d 923, 926-27 (7th Cir. 2010) (internal
quotations and citations omitted). In sum, if the ALJ finds at least one severe
impairment, continues on with the analysis, and considers the combined effect of
all impairments, any error at Step 2 is harmless. Arnett v. Astrue, 676 F.3d 586,
591 (7th Cir. 2012).
Here, the ALJ found Plaintiff had severe impairments of degenerative disc
disease and GERD. (Tr. 20). Plaintiff argues the ALJ’s decision must be reversed
and remanded because the ALJ did not specify whether Plaintiff had degenerative
disk disease in the cervical spine, the lumbar spine, or both, and failed to consider
the combined effects of those impairments.

As already stated, any error in

designating an impairment as severe is harmless as long as the ALJ continues to
Step 3. Thus, the only issue here is whether the ALJ considered the combined
effects of Plaintiff’s impairments, both severe and non-severe.

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Plaintiff regurgitates medical records documenting treatment of her cervical
spine and lumbar spine and asserts the ALJ failed to support the RFC. However,
Plaintiff does not point out any evidence the ALJ did not address. ALJ Souza
thoroughly documented Plaintiff’s issues with her lumbar and cervical spine. He
included in his discussion of the evidence the MRIs showing degenerative disc
disease of the cervical spine and lumbar spine, Plaintiff’s subjective complaints,
and the treatments Plaintiff underwent for those issues, such as injections. The
ALJ’s decision demonstrated that he considered the combined effects of Plaintiff’s
impairments when crafting the RFC.

Moreover, ALJ Souza relied on RFC

assessments from state-agency consultants to craft the RFC.

Plaintiff has not

proffered any contrary evidence suggesting she had a more restrictive RFC. The
ALJ’s finding, to this end, was not erroneous.
Finally, Plaintiff contends the ALJ did not fully and fairly develop the record
related to her arm pain. “[T]he ALJ in a Social Security hearing has a duty to
develop a full and fair record.” Nelms v. Astrue, 553 F.3d 1093, 1098 (7th Cir.
2009).

The Seventh Circuit has considered a number of factors to determine

whether the record is “full and fair:”
(1) whether the ALJ obtained all of the claimant’s medical and
treatment records; (2) whether the ALJ elicited detailed testimony
from the claimant at the hearing (probing into relevant areas, including
medical evidence on the record, medications, pain, daily activities, the
nature of all physical and mental limitations, etc.); and (3) whether the
ALJ heard testimony from examining or treating physicians.
Ferguson v. Barnhart, 67 F. App’x 360, 367 (7th Cir. 2003). When a claimant is
represented by counsel, the ALJ is “entitled to assume” that she is making her
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“strongest case for benefits.” Wilkins v. Barnhart, 69 F. App’x 775, 781 (7th Cir.
2003) (internal quotations and citations omitted).
Here, ALJ Souza asked Plaintiff’s counsel whether he reviewed the record.
Counsel stated he had no objection to the evidence and there was nothing further
to submit. (Tr. 37). Additionally, Plaintiff testified she had issues with her arms
and the ALJ continued to probe her for more information:
Q: Okay. What happened to your arms?
A: They have the sensation of pins and needles and sometimes they just –
strength just leaves them. Like the other day when – you probably see it, a
slight – my knuckle bruised. . .
(Tr. 38).
The ALJ met his duty to develop a full and fair record by questioning Plaintiff
about her arm and hand issues and ensuring the record was complete.
Nonetheless, Plaintiff does not contend there is any additional evidence that would
warrant a more restrictive RFC. “Mere conjecture or speculation that additional
evidence might have been obtained in the case is insufficient to warrant a remand.”
Nelms v. Astrue, 553 F.3d 1093, 1098 (7th Cir. 2009).

Plaintiff’s conclusory

allegation that the ALJ failed to develop the record is not enough for remand.
The bulk of Plaintiff’s arguments disputes the ALJ’s interpretation of the
evidence. Without more, the Court must affirm the ALJ’s decision, as it cannot
reweigh evidence or substitute its own judgment for that of the ALJ’s. Terry v.

Page 26 of 27

Astrue, 580 F.3d 471, 476 (7th Cir. 2009). Substantial evidence supports the ALJ’s
disability determination.
Conclusion
The Commissioner’s final decision denying plaintiff’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.
DATE: November 2, 2018.

s/ Clifford J. Proud
CLIFFORD J. PROUD
U.S. MAGISTRATE JUDGE

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