Madera v. Saul

CourtDistrict Court, N.D. Illinois
DecidedJanuary 17, 2020
Docket1:18-cv-07074
StatusUnknown

This text of Madera v. Saul (Madera 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
Madera v. Saul, (N.D. Ill. 2020).

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION SHANNON M.,1 ) ) Plaintiff, ) No. 18 C 7074 ) v. ) Magistrate Judge Jeffrey Cole ) ANDREW SAUL, Commissioner of ) Social Security, ) ) Defendant. ) MEMORANDUM OPINION AND ORDER INTRODUCTION Shannon M. applied for Supplemental Security Income (“SSI”) under Title XVI of the Social Security Act (“Act”), 42 U.S.C. §§ 1381a, 1382c, in January of 2015. (Administrative Record (R. 171-77). She claimed that she became disabled as of December 30, 2011 (R. 171), due to a number of complaints, including: fibromyalgia, myalgia myosis, hypothyroidism, GERD, hiatal “heredia [sic],” anemia, asthma, allergies, insomnia, bipolar disorder, anxiety, and “arthritis – everywhere.” (R. 212). Her claim was denied at every level: initial, reconsideration, administrative law judge (ALJ), and appeals council. It is the ALJ’s decision, from September 8, 2017, 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 October 22, 2017, and the parties consented to the jurisdiction of a Magistrate Judge pursuant to 28 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. 1 U.S.C. § 636(c) on December 7, 2018. [Dkt. # 10]. The case was then reassigned to me after it was fully briefed, several months later, on August 22, 2019. [Dkt. #25]. Plaintiff asks the court to reverse and remand the Commissioner’s decision, while the Commissioner seeks an order affirming the decision.

I. FACTUAL BACKGROUND A. Plaintiff was born on June 16, 1975, and so was just 36 years old when she claims she became unable to work ever again, and 42 at the time of the ALJ’s decision. She worked only sporadically prior to that. She didn’t work at all from age 21 through 25, age 29 through 34, or age 39 on. (R. 191-92). She used heroin regularly from age 35 through 39. (R. 560-61,708,720). In

terms of whether she continues to use heroin or not, she’s a completely unreliable historian. She’s told her doctors her last use was in the fall of 2014, but she clearly continued to use the drug in early 2015 and the fall of 2015. (R. 464, 631). And at least one of her doctors indicated she continued using heroin into 2017. (R. 699, 704). In terms of medical evidence, the record is large, spanning almost 400 pages. (R. 340-737). But, as is also usually the case, very little of it is significant in determining whether plaintiff can work or is disabled. Indeed, the plaintiff only points to about 20 pages of that evidence as supporting her claim for SSI. [Dkt. #20, at 11-15]. The medical record shows that plaintiff has, and has been

treated for, fibromyalgia since at least 2013. (R. 521). But over the course of the medical record, findings are generally benign, and the examinations are normal. For example, at the first examination plaintiff points to in her brief in January 2013 [Dkt. # 20, at 2], plaintiff reported that 2 she was feeling well. (R. 505). Her treating physician, Dr. Adrian, noted no tenderness anywhere upon examination, no neurological symptoms, and no symptoms in plaintiff’s extremities. (R. 506). In April 2013, Dr. Adrian again reported normal findings – no swelling, redness, or tenderness. (R. 521). The record goes on like this, with the vast majority of clinical findings reported as normal,

without limitations, without tenderness, etc. (R. 340-42, 509-510, 513, 516, 518-19, 521, 525-26, 529-30, 533, 536, 539, 543-44, 547, 549-50, 624, 626-29, 631, 636-37, 640, 648-49, 711, 715-16, 721). There are a few exceptions, of course, as few people feel great every day. But there is nothing significant enough to suggest disability. On March 29, 2010, plaintiff complained of back pain over the prior 5 days, although there was no tenderness upon examination. (R. 518-19). On May 1, 2013, Dr. Adrian noted moderate ankle tenderness, but normal strength, range of motion, and no swelling.

(R. 526). On June 5, 2013, Dr. Adrian noted lower abdomen tenderness. (R. 536). Plaintiff reported constipation, heartburn and abdominal pain on July 17, 2013. (R. 543). On March 26, 2014, Dr. Adrian noted inflammation where plaintiff had last injected heroin. (R. 516). On May 1, 2014, there was tenderness from bruising on plaintiff’s shoulder. (R. 530). Dr. Adrian reported tenderness to palpation along the cervical, thoracic, and lumbar spine, the clavicle, upper legs, and ankles on August 19, 2015. (R. 443). On July 12, 2016, there was moderate tenderness and decreased grip strength and range of motion in plaintiff’s hands. (R. 640). There was tenderness along plaintiff’s spine on December 14, 2016, and February 3, 2017, but range of motion and all other findings were

normal. (R. 654, 716, 721).2 2 Fibromyalgia is difficult to diagnose, and even more difficult for an ALJ to deal with in assessing a disability claim. Doctors formerly used certain trigger or tender points, nine pairs of locations throughout (continued...) 3 Treatment records regarding plaintiff’s mental status aren’t much different, although they are fewer and farther between. Plaintiff went to the ER on October 28, 2014, after cutting her left forearm with scissors in response to an argument with her husband. (R. 357-58). She was transferred for psychiatric treatment (R. 581-82), where she was assessed with a GAF score of 45-50

upon admission and diagnosed with major depression before discharge on October 31st. (R. 584- 85). There is no record of any further treatment until a year later in October 2015 (R. 440, 569), when she was admitted for symptoms of depression. (R. 569). Group therapy and counseling were offered at that time, but there is no record of plaintiff continuing with counseling. (R. 569). On November 25, 2015, Dr. Stanley Tomczyk noted that plaintiff was going to 12-step meetings, 3-4 times a week. (R. 628). Dr. Tomczyk prescribed Adderil for depression on December 23, 2015. (R. 626). Dr. Gaonkar, a psychiatrist, reported on April 4, 2017, that he had seen plaintiff every

month since November 2015, but after November 15, 2015, there appear to be no notes of his treatment, and plaintiff does not direct the court to any. (R. 699); [Dkt. 320, at 2-8]. The single note

2(...continued) the body where palpation produced pain. https://www.mayoclinic.org/diseases-conditions/fibromyalgia/ in-depth/fibromyalgia-symptoms/art-20045401. Some of the tender points mentioned in Dr. Adrian’s records were among those associated with fibromyalgia, and some, like those along the ankles and thoracic and lumbar spine, were not. https://www.mayoclinic.org/tender-points/img-20007586. Under the former diagnostic technique, the “rule of thumb [was] that the patient must have at least 11" tender points. Sarchet v. Chater, 78 F.3d 305, 306 (7th Cir. 1996). Clearly, plaintiff never demonstrated that many at any examination. More recently, doctors have looked for somewhat vaguer criteria: widespread pain lasting at least three months; presence of other symptoms such as fatigue, waking up tired and trouble thinking; no other underlying condition that might be causing the symptoms.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Richardson v. Perales
402 U.S. 389 (Supreme Court, 1971)
Davis v. Alaska
415 U.S. 308 (Supreme Court, 1974)
United States v. Abel
469 U.S. 45 (Supreme Court, 1984)
Bowen v. Yuckert
482 U.S. 137 (Supreme Court, 1987)
United States v. 5443 Suffield Terrace, Skokie, Ill.
607 F.3d 504 (Seventh Circuit, 2010)
Larson v. Astrue
615 F.3d 744 (Seventh Circuit, 2010)
Barbara Castile v. Michael Astrue
617 F.3d 923 (Seventh Circuit, 2010)
Punzio v. Astrue
630 F.3d 704 (Seventh Circuit, 2011)
United States v. Vasquez
635 F.3d 889 (Seventh Circuit, 2011)
United States v. Archer
671 F.3d 149 (Second Circuit, 2011)
Jelinek v. Astrue
662 F.3d 805 (Seventh Circuit, 2011)
Anthony Tyus v. Urban Search Management
102 F.3d 256 (Seventh Circuit, 1997)

Cite This Page — Counsel Stack

Bluebook (online)
Madera v. Saul, Counsel Stack Legal Research, https://law.counselstack.com/opinion/madera-v-saul-ilnd-2020.