Simpson v. Berryhill

CourtDistrict Court, N.D. Illinois
DecidedMay 16, 2018
Docket1:17-cv-02299
StatusUnknown

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

Opinion

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

TERRY SIMPSON, ) ) Plaintiff, ) ) No. 17-cv-2299 v. ) ) Magistrate Judge Susan E. Cox NANCY A. BERRYHILL, Deputy ) Commissioner for Operations for the Social ) Security Administration, ) ) Defendant. )

MEMORANDUM OPINION AND ORDER Plaintiff Terry Simpson (“Plaintiff”) appeals the decision of the Commissioner of the Social Security Administration (“Commissioner”) denying his disability insurance benefits (“DIB”) under Title II and Title XVI of the Social Security Act. The Parties have filed cross motions for summary judgment. For the reasons detailed below, the Commissioner’s Motion for Summary Judgment (dkt. 17) is granted and Plaintiff’s motion (dkt. 12) is denied. I. Background a. Procedural History and Plaintiff’s Background1 On November 14, 2012, Plaintiff applied for Title II disability insurance benefits and Title XVI supplemental security income, alleging disability since June 15, 2007. (Administrative Record (“R.”) 272-84). Plaintiff’s claim was denied initially and again at the reconsideration stage. (R. 135-144; 1-6). Plaintiff timely requested an administrative hearing, which was held on March 31, 2015 before Administrative Law Judge (“ALJ”) Michael G Logan. (R. 148; 52-100). Plaintiff was represented by counsel, and both a Medical Expert (“ME”) and a Vocational Expert (“VE”) testified during the hearing. (R. 52-100). On September 25, 2015, the ALJ issued a written decision denying Plaintiff

1 With respect to Plaintiff’s background and medical history, the Court finds the ALJ’s recitation of these facts to be disability benefits and supplemental security income. (R. 17-37). On January 19, 2017, the Appeals Council denied Plaintiff’s appeal, and the ALJ’s decision became the final decision of the Commissioner. (R. 1-6). Plaintiff filed the instant action on March 27, 2017. (Dkt. 1). The record contains no medical evidence prior to 2011. Plaintiff was 55 years old at the onset date of disability, and did not complete high school (he has no more than a ninth grade education). (R. 55, 57, 665). He last worked in 2005, as a box loader and machine operator and repairer. (R. 58). Plaintiff first filed his application for benefits on November 14, 2012. Shortly thereafter, on November 30, 2012, he sought treatment at Cook County’s Near South facility (“Near South”) alleging a myriad of physical disorders but no mental health symptoms aside from a diagnosis of alcoholism. (R. 415). Plaintiff next was seen on January 7, 2013 for back and arthritis pain, where he reported a past

diagnosis of hypertension but noted that he had been off hypertension medication for a year. (R. 438, 440). He was started on medication for his elevated blood pressure on that occasion and his reports of the prior diagnosis. (R. 20). He was referred for imaging based on complaints of knee pain and back pain but results were normal. (R. 20, 441). Notably, there is no suggestion of mental health complaints or substance abuse at this time, nor is there any suggestion of abnormal mental health observations. (R. 415, 438-441). Although there is no work up for asthma, Plaintiff’s reports of a prior asthma diagnosis are credited and he is prescribed an inhaler (R. 415, 440). Plaintiff appeared for a consultative internal medicine examination on January 10, 2013 with Liana Palacci, D.O. of Disability Determination Services (“DDS”) (R. 421-25). At this time, Plaintiff admitted to use of beer and whiskey, and alleged that he quit use of marijuana and cocaine in 2012. (R. 421). He acknowledged being in rehab for substance abuse in the 1990’s. Id. Plaintiff claimed he was diagnosed with asthma and COPD in the 1980’s, yet also reported smoking 2½ packs of cigarettes per day for the prior 40 years. (R. 421-22). He reported low back pain since the age of 13 with numbness

and weakness in the right leg. (R. 422). He reported a stroke in 2001 with left sided hemiparesis and reported attending of physical rehabilitation for several months. Id. He also alleged experiencing a “mild heart attack” in 1982 with chest pain for the prior 3 months. Id. On examination, Plaintiff’s blood pressure was not remarkable. Id. Lungs were clear. Id. His grip strength was 4+/5, and Dr. Palacci noted that this was due to poor effort on Plaintiff’s part. (R. 423). He presented with some reduced range of motion but had negative straight leg raise testing, no loss of sensation, and full 5/5 strength. (R. 423-24). On mental status examination, Plaintiff was alert and oriented. (R. 424). He had normal affect, knew who the President was, and could perform simple arithmetic. Id. Dr. Palacci’s clinical impressions were that Plaintiff had well-controlled asthma and COPD; complaints of low back pain; history of stroke with no residual weakness; and history of coronary artery disease with complaints of chest pain that appear atypical. Id. On March 12, 2013, Plaintiff appeared at Near South for a prescription medication follow-up.

(R. 460-63). Plaintiff had good grip strength on examination despite alleging numbness, and there were no diagnostic findings supportive of neuropathy. Id. Plaintiff reported chronic hand numbness that comes and goes and has been present for several months. (R. 479). Plaintiff’s allegations of arm and hand numbness were considered to possibly be related to neuropathy from long-term alcoholism or a Vitamin B deficiency. (R. 461, 480). On April 24, 2013, Plaintiff went to the Provident Hospital outpatient clinic asking for a psychiatric referral. (R. 475-78). He claimed that he “sometimes hears voices” and that he was on medication (presumably psychiatric medication) a long time ago. (R. 475). He reported “jumping muscles” in his arms and occasional dizziness. Id. He also reported use of hypertension medication. Id. Although Plaintiff complained about his knees, back, and cervical spine, imaging studies from around that time of the cervical spine and knees were normal (R. 436-37, 478). The Plaintiff was given a psychiatric referral at his request and advised to return in one to two months. (R. 476, 478). On July 5, 2013, Plaintiff returned to Near South for a prescription refill and also complained of

right shoulder pain. (R. 482-84). It was noted that imaging studies (CT and x-ray) taken within the prior 5-6 months were normal. Id. Examination did not show any significant deficit and grip strength was largely unimpacted. (R. 483-84). At his July 9, 2013 follow-up, Plaintiff again complained of right upper extremity deficit, some chest pain, and instances of his legs giving out, all without objective confirmation. (R. 485-491). He was started on medication for neuropathic pain. (R. 487, 490). At this time, he also reported visual hallucinations at night/seeing dead people; he conversed with them, but they were not threatening or disturbing. (R. 487). He stated that sometimes he feels held down to his bed. Id. He further reported some non-threatening auditory hallucinations during the day. Id. Despite the fact Plaintiff claimed not to be using alcohol at this time, his doctor opined, relative to Plaintiff’s allegations of anxiety and hallucinations, that Plaintiff’s alcohol use was likely worsening. (R. 487, 491). There was no mention of drug use. (R. 485-491). Despite his contentions of no current alcohol use, alcoholism remained an active diagnosis and Plaintiff was advised to quit. (R. 490).

On July 29, 2013, Plaintiff appeared before psychiatrist Regina Hall-Ngorima (“Dr. Ngorima”) for a new patient evaluation. (R. 661-66). Dr. Ngorima noted that Plaintiff’s last psychiatric visit was 10 years ago. (R. 662, 664). Plaintiff’s living situation was somewhat tenuous: he reported he had lost his apartment last year and that he had been living with his daughter for the prior two weeks. (R. 662, 665).

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Simpson v. Berryhill, Counsel Stack Legal Research, https://law.counselstack.com/opinion/simpson-v-berryhill-ilnd-2018.