PazCaballero v. Saul

CourtDistrict Court, N.D. Illinois
DecidedMay 16, 2022
Docket1:20-cv-06490
StatusUnknown

This text of PazCaballero v. Saul (PazCaballero 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
PazCaballero v. Saul, (N.D. Ill. 2022).

Opinion

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION ROSA MARIA PAZCABALLERO,

Plaintiff, No. 20 C 06490

v. Judge Thomas M. Durkin

KILOLO KIJAKAZI, Acting Commissioner of Social Security,1

Defendant.

MEMORANDUM OPINION AND ORDER Rosa Maria PazCaballero brought this action under 42 U.S.C. § 405(g) for judicial review of the final decision of the Commissioner of Social Security denying her claim for disability insurance benefits. The parties filed cross-motions for summary judgment. Dkt. 12; Dkt. 17. For the following reasons, PazCaballero’s motion is denied and the Commissioner’s motion is granted. Background I. Procedural History PazCaballero filed a Title II application for a period of disability and disability insurance benefits on October 10, 2017, alleging disability beginning June 16, 2016. R. 17.2 The claim was denied on January 2, 2018, and again upon administrative

1 Kilolo Kijakazi became the Acting Commissioner of Social Security on July 9, 2021, and is automatically substituted as the defendant under Fed. R. Civ. P. 25(d). 2 References to the Administrative Record (Dkt. 11) are cited as “R. #.” reconsideration on June 20, 2018. R. 17. PazCaballero then timely filed a written request for a hearing before an Administrative Law Judge. R. 17. She appeared and testified at the hearing on August 13, 2019. R. 17. The hearing was continued to allow

for collection of outstanding medical records and to provide PazCaballero an opportunity to obtain legal representation for the supplemental hearing. R. 17. PazCaballero appeared and testified at the supplemental hearing on December 10, 2019. R. 17. The ALJ issued a decision denying benefits on February 26, 2020. R. 17-33. PazCaballero sought review in the Appeals Council, which denied her request on

September 3, 2020. R. 1. PazCaballero timely filed for review in this Court on November 1, 2020. II. Factual Background A. Medical Record Evidence As noted by the ALJ, PazCaballero has a history of medical issues centered on her right ankle, originating from a May 2008 fracture that required surgery with hardware placement. R. 20, 26. She thereafter underwent multiple procedures on the

ankle to remove the retained hardware. R. 123-24. She was prescribed physical therapy and mobility assistance, beginning with a wheelchair and progressing to use of a cam walker and eventually a cane. R. 124. On May 11, 2010, PazCaballero was awarded a closed period of Social Security disability benefits for the period of May 30, 2008 to August 4, 2009. R. 123. In April 2016, PazCaballero presented with pain, swelling, and instability in her right ankle and leg. R. 597. She underwent an MRI that revealed postoperative changes and several ailments, including osteoarthritis. R. 595-96. PazCaballero

underwent surgery on June 16, 2016 (the alleged disability onset date) to repair structural damage in the ankle. R. 601. She followed with physical therapy for several months, and post-operative notes indicate gradual improvement in her condition and mobility. R. 637. For example, by October 2016, she was noted as walking with a cane support and had improved strength through her ankle and foot with mild edema. R. 637. Treatment notes indicated that she needed to extend her time off work until

January 2017 because her employer would not allow use of a knee roller at work. R. 637. PazCaballero was discharged from physical therapy in March 2017, with her treating physician Dr. Lim noting that she had reached the maximum benefit from therapy and demonstrated independence with a home exercise plan. R. 1237-38. The discharge summary noted improvements in range of motion, strength, gait, and weight bearing but noted continuing difficulties with ascending/descending stairs,

standing more than 30 minutes, and walking on uneven surfaces. R. 1237. Her therapy notes also indicate some pain and discomfort in her left ankle. R. 1240, 2066. PazCaballero has reported symptoms of fibromyalgia, including stiffness, numbness, and pain. R. 2165, 2179, 2206. She is under the care of a rheumatologist, R. 1072, and treats these symptoms with medical marijuana, R. 2165, 2179. She also has a diagnosis of complex regional pain syndrome. R. 1072, 2193. A July 2019 MRI of her cervical spine showed mild-moderate arthritic changes at multiple levels. R. 1069. PazCaballero’s BMI during the alleged disability period consistently placed her in the obese range. R. 1071, 2036, 2172. She underwent a gastric sleeve procedure

prior to the alleged disability onset date which resulted in substantial weight loss, but continued to experience pain in her right ankle thereafter. R. 1071-72. PazCaballero underwent a psychological consultative examination in December 2017 in which she reported feeling depressed and experiencing mood swings that began two years prior. R. 1037-40. The examining physician noted that she appeared to be in some emotional distress but saw no indication of psychosis or

suicidal ideation. R. 1038. She was noted to be “fairly independent and self-sufficient with all activities of daily living.” R. 1038. PazCaballero was diagnosed with major depressive disorder. R. 40. PazCaballero then underwent a mental health consultation in January 2018, in which she was diagnosed with post-traumatic stress disorder and moderate major depressive disorder. R. 977-82. Her symptoms included sadness, crying easily, irritability, anhedonia, poor concentration and sleep, and occasional auditory

hallucinations. R. 977. By May 2018, she reported improvements in her depression and anxiety with treatment. R. 988. She underwent a second mental health consultation at the end of May and was diagnosed with bipolar disorder, type II, and anxiety. R. 1061-65. PazCaballero treated her mental health symptoms with counseling from March 2018 to December 2019, during which she reported symptoms including depression and anxiety. R. 2072-157. She was intermittently noted to have poor concentration and racing thoughts. R. 2129, 2146. She continued to partake in activities with her children and was receiving social support from her husband and

friends. R. 2089, 2098, 2129, 2131. PazCaballero reported increasing forgetfulness during a July 2019 neurology visit, but her mental status examination was normal, and the neurologist suggested her memory loss was likely due to stress and impaired sleep. B. Medical Opinion Evidence PazCaballero’s treating therapist, Christine Burback, completed two Mental

Residual Functional Capacity Statements in November 2019. Burback opined that PazCaballero would continue to experience mental symptoms that would cause her to be “off-task” at least 15 to 30% of the workday and would likely be absent more than 6 days per month. R. 2056-58. Dr. Myrna Patricio, one of PazCaballero’s long-term treating primary care physicians, opined that her pain and stress would frequently be severe enough to interfere with her ability to perform simple work tasks. R. 2066. Her assessment

suggested PazCaballero would need to lie down during the day as a result of pain and could not sit, stand, or walk more than 30 minutes at a time. R. 2067-68. She opined that PazCaballero would be unable to obtain and retain employment in a competitive work environment because of her impairments. R. 2069, 2071. C. Hearing Testimony At the initial and continued hearings before the ALJ, PazCaballero first testified about her employment history. R. 47-54. She testified that she was presently

unable to work full time because of her physical and mental disabilities, citing depression and PTSD. R. 54.

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