Gray v. Berryhill

CourtDistrict Court, N.D. Illinois
DecidedOctober 30, 2018
Docket1:17-cv-01185
StatusUnknown

This text of Gray v. Berryhill (Gray v. Berryhill) 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
Gray v. Berryhill, (N.D. Ill. 2018).

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

LINDA M. GRAY ) ) No. 17 CV 1185 Claimant, ) ) v. ) ) Magistrate Judge Michael T. Mason NANCY A. BERRYHILL, Acting ) Commissioner of the U.S. Social ) Security Administration, ) ) Defendant. ) )

MEMORANDUM OPINION AND ORDER Plaintiff Linda M. Gray (“Claimant”) filed a motion for summary judgment seeking reversal of the final decision of the Commissioner of Social Security (“Commissioner”), denying her claim for disability benefits. The Commissioner has filed a cross-motion asking the Court to uphold the decision of the Administrative Law Judge (“ALJ”). For the reasons set forth below, Claimant’s motion for summary judgment (Dkt. 17) is granted and the Commissioner’s motion for summary judgment (Dkt. 24) is denied. I. Background A. Procedural History Claimant filed her application for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI) on May 1, 2013, alleging that her disability began on November 4, 2012. (R. 176-85.) Claimant’s applications were denied initially and on reconsideration. (R. 85-86, 111-12.) She requested a hearing before an ALJ, which was held on November 2, 2015. (R. 30-65.) On December 7, 2015, the ALJ issued a written decision finding that Claimant was not disabled. (R. 12-29.) On December 13, 2016, her request for review by the Appeals Council was denied, making the ALJ’s decision the final decision of the Commissioner. (R. 1-7.) This action followed. Claimant filed an amended complaint on March 23, 2018, in which she states that she filed a second application for DIB and was found disabled with an onset date of

December 14, 2016. (Dkt. 30 at 3.) Claimant requested that the Court look at the closed period of April 13, 2014 through December 13, 2016. (Id.) B. Relevant Medical Evidence 1. Examining and Treating Sources Claimant had multiple x-rays completed in July of 2014, showing mild degenerative changes and mild disc space narrowing of the lumbar spine, multilevel degenerative changes and disc space narrowing of the cervical spine with end plate osteophytes, and mild degenerative change with moderate joint effusion of the left knee. (R. 390-93.) In September of 2014, she was examined and found to have radicular pain and positive straight leg raises on her right side both elevated and supine, as well as

reflex loss. (R. 579-81.) In December of 2014, she had more imaging done, where she was found to have multifactorial, multilevel degenerative changes, neural foraminal stenosis, and disc bulging with minimal bilateral facet joint arthropathy. (R. 403.) In January of 2015, more imaging was done of her knees. (R. 558.) Her right knee showed moderate tricompartment degenerative changes with narrowing of the compartments and patellofemoral joint space, osteophytes in all three compartments, and enthesophytes identified. (Id.) Her left knee showed moderate tricompartment degenerative changes with narrowing of the compartments and patellofemoral joint space, and evidence of osteophytes in all three compartments. (Id.) In July of 2015, Claimant was diagnosed with bilateral lower extremity radiculopathy, and more imaging showed significant loss of disc height, mild three level degenerative disc disease with diffuse disc bulging, and mild facet arthropathy. (R. 552.) In September of 2015, imaging showed disc herniation with spinal stenosis, disc degeneration and herniation,

and right upper and lower extremity radiculopathy. (R. 539-40.) 2. Consultative Examiner Dr. Fauzia A. Rana, M.D., completed a consultative examination on July 16, 2013. (R. 363.) Dr. Rana noted that Claimant was cooperative, had no difficulty in breathing, and had no difficulty in any movement. (R. 364.) In examining her upper extremities, Dr. Rana noted no evidence of redness, warmth, thickening, or effusion of any joint. (R. 365.) Claimant had fist and grip strength of 4/5 on the right hand and 5/5 on the left hand. (Id.) She had no difficulty in performing manipulations with either hand, and had full range of motion in the shoulder, elbow, and wrist joints. (Id.) Dr. Rana also noted normal muscle strength with no cyanosis, clubbing, or edema. (Id.)

In examining her lower extremities, Dr. Rana noted that her ankles, knees, and hips had full range of motion. (R. 365.) Claimant’s straight leg raising test was accomplished on the right and left to 90 degrees in both sitting and supine positions. (Id.) Dr. Rana again noted normal muscle strength with no cyanosis, clubbing, or edema. (Id.) Furthermore, Claimant had no difficulties in any of the performance areas except in hopping on one leg. (Id.) Claimant used a cane in the examination. (Id.) She walked with a slow gait without limping or staggering and could walk more than 50 feet without the cane. (Id.) Her motor power was 4-5/5 on the right side and 5/5 on the left side. (Id.) Dr. Rana stated that Claimant had slight residual right-sided weakness with possible degenerative arthritis. (R. 366.) Dr. Rana opined that Claimant could sit, stand, walk, lift, carry, speak and hear without difficulty. (Id.) 3. Agency Physicians Dr. Charles Kenney, M.D., completed an RFC Assessment Form based on

Claimant’s medical records on August 19, 2013. (R. 65-74.) He opined that Claimant could occasionally lift twenty pounds and frequently lift ten pounds. (R. 70.) He further opined that Claimant could stand or walk for about six hours in an eight hour work day, and she could sit for about six hours in an eight hour work day. (R. 71.) Dr. Kenney opined that Claimant would be limited to occasionally climbing ramps/stairs, climbing ladders/ropes/scaffolds, balancing, stooping, kneeling, crouching, and crawling. (Id.) Dr. Kenney also found Claimant to be partially credible, noting 4-5/5 strength on the right side, 5/5 strength on the left side with full range of motion in all joints. (R. 72.) Based on the CE exam, Dr. Kenney opined that Claimant could walk 50 feet without her cane. (Id.)

On reconsideration, Dr. Vidya Madala, M.D., affirmed Dr. Kenney’s assessment with very little discussion. (R. 87-98.) C. Claimant’s Testimony Claimant’s hearing occurred on November 2, 2015. Claimant appeared at the hearing represented by her attorney. Claimant amended her alleged onset date to April 2014 at this hearing. (R. 15, 60-62.) At the hearing, Claimant testified that she lives with her sisters, aged 54 and 58. (R. 34.) Claimant testified that there are four stairs going into the front of the house and three stairs going into the side of the house. (Id.) In order to do laundry, Claimant had to go down approximately ten stairs into the basement. (Id.) Claimant testified that she has not driven since shortly after her stroke in 2012, and she has been told that she should no longer drive due to numbness in her foot. (R. 36.) Claimant testified that she only completed two years of college, and she received a certificate for business machines in high school. (R. 37.) She stated that

she stopped smoking in 2010, and she occasionally has a glass of wine. (R. 38.) Claimant also testified that she was terminated from her job with the United States Postal Service in 2006 due to attendance. (R. 47.) Claimant stated that this was due to her mother having a stroke. (Id.) She stated that she was unable to work now due to numbness in her right thigh and foot, falling, and tingling in her head. (Id.) She attended physical therapy after her stroke but could not afford further treatment because she did not have insurance. (R. 48.) She stated she was given home exercises to do, but they did not improve her numbness. (Id.) Claimant stated that she could only stand for five to ten minutes before pain forces her to lay down or take pain pills. (Id.) She testified that she could walk a block but would have to stop due to her right foot. (R.

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Bluebook (online)
Gray v. Berryhill, Counsel Stack Legal Research, https://law.counselstack.com/opinion/gray-v-berryhill-ilnd-2018.