Dunka v. Saul

CourtDistrict Court, N.D. Illinois
DecidedMay 25, 2021
Docket1:20-cv-02827
StatusUnknown

This text of Dunka v. Saul (Dunka v. Saul) is published on Counsel Stack Legal Research, covering District Court, N.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Dunka v. Saul, (N.D. Ill. 2021).

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION JOSEPH D.,1 ) ) Plaintiff, ) No. 20 C 2827 ) v. ) Magistrate Judge Jeffrey Cole ) ANDREW SAUL, Commissioner of ) Social Security, ) ) Defendant. ) MEMORANDUM OPINION AND ORDER Plaintiff applied for Disability Insurance Benefits under Title II of the Social Security Act, 42 U.S.C. §§416(i), 423, in June of 2019. (Administrative Record (R.) 21-14). He claimed that he became disabled as of February 15, 2019, due to over two dozen impairments, including depression, asthma, migraines, arthritis in his hands, ankles, and back, bulging discs in his back, and neuropathy in both legs. (R. 211, 245). He is also obese, with a BMI of 35.9 to 37. (R. 16, 245). Over the next year or so, plaintiff’s application was denied at every level of administrative review: initial, reconsideration, administrative law judge (ALJ), and appeals council. It is the ALJ’s decision that is before the court for review. See 20 C.F.R. §§404.955; 404.981. Plaintiff filed suit under 42 U.S.C. § 405(g) on April 24, 2020. The parties consented to my jurisdiction pursuant to 28 U.S.C. § 636(c) on May 14, 2020. [Dkt. #6]. Plaintiff asks the court to remand the Commissioner’s decision, while the Commissioner seeks an order affirming the decision. 1 Northern District of Illinois Internal Operating Procedure 22 prohibits listing the full name of the Social Security applicant in an Opinion. Therefore, the plaintiff shall be listed using only their first name and the first initial of their last name. I. A. Plaintiff was born on November 11, 1970, and so was over 49 years old at the time of the ALJ’s decision on February 6, 2020. (R. 211, 10-28). He served for 20 years in the military from

1995 through 2015, and moved from job to job for a few years after that. (R. 236-38, 254-60). He was rendered unconscious in an explosion while serving in Afghanistan back in 2009-10. (R. 80, 596). Since then, he has endured headaches, tinnitis, and vertigo. The incident also left him with a cognitive disorder and memory loss. (R. 597-98). His was discharged in 2015 with a 100% permanent and total disability rating. (R. 227). Obviously, given injuries as serious as that, the medical record in this case is massive, over 2000 pages long. (R. 334-2375). But, as is usually the case, very little of it is relevant to plaintiff’s

disability claim. The plaintiff directs the court to 28 pages of psychiatric medical evidence and 27 pages of physical medical evidence. [Dkt. #16, at 2-5]. Thus, we can dispense with an extended summary of the entire medical record and focus on that evidence plaintiff singles out as supporting his claim On June 22, 2015, plaintiff underwent a psychological evaluation at the Veterans Administration (VA) Hospital. (1119-1129). During the examination, plaintiff had significant difficulty providing straightforward responses, and his mood was noted to be generally anxious and depressed. (R. 1128). His affect was observed to be flat to irritable. (R. 1128). Plaintiff reported

difficulty with memory and concentration. (R. 1129). Diagnosis was persistent depressive disorder, mild. (R. 1129-30). The examiner found plaintiff to have an occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform tasks. (R. 1131). 2 After that, the picture got a bit brighter. In March 2016, plaintiff underwent a neurological evaluation at the VA for headaches, dizziness, memory loss, and depression. (R. 592-595). Plaintiff reported mild memory loss, tinnitis, insomnia, daily headaches. (R. 597-98). Judgment, orientation, and social interaction were normal. (R. 596). Headaches were the main problem affecting his ability

to work. (R. 599). The neurologist attributed Plaintiff’s headaches and dizzy spells to his traumatic brain injury in 2009, and his memory problems and depression to his PTSD or ADHD or bipolar disorder. (R. 599-600). In January, February, March, May, and July 2019, mental status examinations conducted during regular treatment visits at the VA Hospital revealed consistently normal affect and no mood disturbances. (R. 349, 507, 514, 517, 714). In April 2019, plaintiff denied any depression or anxiety. (R. 342). At the beginning of the session, he was guarded and upset, but behavior was then noted to

be normal. Attention and concentration were intact; insight was good, and judgment was intact. (R. 343). He was noted to be stable on medication. (R. 343). In June, he again denied any depressive symptoms and reported that the medication was working. He was working and denied any problems with regard to that. (R. 728). Mental status examination was normal, including attention and concentration. (R. 729). Plaintiff also has a history of back and joint pain. In January of 2018, x-rays of his left hand revealed mild joint space narrowing and osteophyte formation. (R. 1614). In August 2018, plaintiff was diagnosed with chronic pain syndrome, pain in the right shoulder, and pain in the hip,

unspecified. (R. 1673). His medications list included oxycodone, celecoxib, omeprazole, and lisiniprol. (R. 1672). Hip x-rays at that time showed mild osteophytic changes and joint space narrowing. (R. 1612). In September 2018, several months before he became unable to work, he was 3 noted to have general, bilateral limited mobility. (R.1666). In November 2018, an MRI of his lumbar spine revealed mild degenerative arthritis of the facet joints at L3-4 and L4-5. (R. 375). In December 2018, plaintiff’s orthopedic surgeon noted some improvement in plaintiff’s pain, and recommended he continue with medication management. R. 2359.

In February 2019, treatment notes indicate plaintiff was complaining of general body pain, although he experienced some relief with weekly acupuncture treatments. (R. 1643). The doctor noted plaintiff’s mobility was limited. (R. 1644). The following month, he was noted to be suffering from chronic pain syndrome. (R. 1635). But, treatment notes at that time indicate mobility was not limited. (R. 1641). In May, July, August, and September 2019, however, plaintiff’s general bilateral mobility was again noted to be limited. (R. 1616, 1621, 1624, 1631). Right knee x-rays in July 2019 demonstrated that the reconstructive surgery was aligned well, with moderate joint space loss and

effusion. (R. 1621). In August 2018, x-rays of plaintiff’s right shoulder revealed moderate right glenohumeral arthritic changes and stable periarticular changes of the acromioclavicular joint. (R. 1613). Left shoulder x-rays at that time revealed moderate arthritis of the glenohumeral and acromioclavicular joints. (R. 1611). Lower back x-rays were essentially normal aside from mild arthritic changes at L3-L5. (R. 1608). Plaintiff had injections in both shoulders in September 2018. (R. 780, 782). Examination at that time revealed mild tenderness in both shoulders. (R. 781). On July16, 2019, plaintiff underwent a consultative internal medicine examination with Dr.

Jorge Aliaga arranged by the Bureau of Disability Determination Services. (R. 737-742). The doctor observed plaintiff to be “in a depressed mood” but had a “good attitude and demeanor.” (R. 739). Upper extremities had full range of motion throughout. (R. 740). In the lower extremities there was 4 limited range of motion in the left hip and right knee. (R. 740). There was no joint swelling or tenderness. (R. 740).

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Dunka v. Saul, Counsel Stack Legal Research, https://law.counselstack.com/opinion/dunka-v-saul-ilnd-2021.