Farrell v. Colvin, Case No: 11 C 5505

CHARLES FARRELL, Plaintiff, v. CAROLYN W. COLVIN,¹ Commissioner of Social Security, Defendant.

Case No: 11 C 5505

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

DATE: November 18, 2013

Magistrate Judge Jeffrey Cole

MEMORANDUM OPINION AND ORDER

The plaintiff, Charles Farrell, seeks review of the final decision of the Commissioner ("Commissioner") of the Social Security Administration ("Agency") denying his application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act"), 42 U.S.C. §§ 423(d)(2), and Supplemental Security Income ("SSI") under Title XVI of the Act. 42 U.S.C. § 1382c(a)(3)(A). Mr. Farrell asks the court to reverse and remand the Commissioner's decision, while the Commissioner seeks an order affirming the decision.

I.PROCEDURAL HISTORY

Mr. Farrell applied for DIB and SSI on March 14, 2008, alleging that he became disabled on April 26, 2007, due to a combination of impairments, including back pain, diabetes, drug addiction, hypertension, and depression. (Administrative Record ("R."),167-74, 212). His application was denied initially and upon reconsideration. (R. 94-98, 128-30). Mr. Farrell requested a hearing and, on September 4, 2009, appeared and testified, represented by counsel, before an ALJ. (R. 38-93). In addition, Pamela Tucker testified as a vocational expert. (R. 38). On December 18, 2009, the ALJ issued a decision finding that Mr. Farrell was not disabled because he could perform a limited range of light work that allowed him to do a significant number of jobs in the regional economy. (R. 18-31). This became the final decision of the Commissioner when the Appeals Council denied Mr. Farrell's request for review of the decision on June 14, 2011. (R. 1-6). See 20 C.F.R. §§ 404.955; 404.981. Mr. Farrell has appealed that decision to the federal district court under 42 U.S.C. § 405(g), and the parties have consented to the jurisdiction of a Magistrate Judge pursuant to 28 U.S.C. § 636(c).²

II.EVIDENCE OF RECORD

A.The Vocational Evidence

Mr. Farrell was born on October 29, 1970, making him 39 years old at the time of the ALJ's decision. (R. 222). He has an eighth-grade education. (R. 220). His work history has been that of a laborer for various employers. (R. 213). This involved lifting 100 pounds and carrying 50. (R. 213).

B.The Medical Evidence

Mr. Farrell underwent an MRI on November 13, 2006, after complaining of low back pain. (R. 343). Imaging revealed central and right L4-L5 disc herniation, left-sided disc protrusion (herniation), multilevel Smorl's nodes, and mild disc bulging in the upper lumbar region. (R. 343-44). Two days later, he injured himself at work, and went to the Provena ER on December 9, 2006, with complaints of severe pain. (R. 356). Examination revealed moderate paravertebral tenderness with spasms, and Mr. Farrell was diagnosed with lumbar spine strain, treated with Toradol pain injections, and prescribed Skelaxin - a muscle relaxant - and Motrin - an NSAID. (R. 356). Mr. Farrell had another mishap two days later - a slip and fall - and sought treatment at the Ottawa Community Hospital ER. (R. 323). He was diagnosed with acute low back strain and prescribed Vicodin - a narcotic pain reliever - and Valium - for anxiety. (R. 323).

Between December 24, 2006, and December 3, 2007, Drs. Gupta and Singla regularly examined and treated Mr. Farrell for chronic lower back pain with left leg weakening, numbness, and tingling radiating down his leg while standing, monitoring of his blood pressure and diabetes, and medication management. (R. 365-77, 392).

On March 3, 2007, Mr. Farrell had another fall, and returned to the ER, complaining of groin and leg pain. (R. 315). He was diagnosed with a left thigh strain and told not to engage in sudden leg movements. He was again prescribed Vicodin,Valium, and Ibuprofen for pain and muscle spasms. (R. 313). Mr. Farrell sought treatment for back pain again on August 5, 2007, after attempting to do construction. (R. 310). He reported numbness, tingling, and pain in his left side, spine, and coccyx which radiated into both his hips and legs; it was a constant ache at a level of 8/10. (R. 310). On October 3, 2007, Mr. Farrell was treated for groin pain again and was given Vicodin. (R. 354).

On April 11, 2008, Mr. Farrell went to see by Dr. Singla and reported that his pain was a 6/10, that he had numbness in his back and legs, and that his left leg kept "going out" on him. (R. 364). In a follow-up visit on June 17, 2008, Mr. Farrell said his leg and lower back problems persisted. (R. 451). That day, Dr. Singla filled out a physical residual functional capacity ("RFC") questionnaire from Mr. Farrell's attorney. (R. 406). He listed Plaintiff's diagnoses as chronic pain, diabetes, hypertension, and neuropathy. Prognosis was good. Symptoms were low back pain radiating to the legs. There were no overlaying problems like depression, anxiety, or somatoform disorder. (R. 406). Dr. Singla said that Mr. Farrell could walk 1-2 city blocks without rest or severe pain, could sit or stand for about 30 minutes at one time, and was capable of sitting or standing/walking for less than two hours in an eight-hour work day, leaving over four hours of the day unaccounted for. Every 30 minutes, Mr. Farrell would have to rest for fifteen minutes. (R. 407). The most Mr. Farrell could ever lift was less than ten pounds. He had no limitation in reaching, figuring, or grasping, and he had no psychological orenvironmental restrictions. On average, he would miss four days of work a month. Alcohol and/or drug abuse were not involved. (R. 408).

On July 29, 2008, Mr. Farrell had a psychological consultative examination arranged by the disability agency. William Hilger, Ph.D., noted that Mr. Farrell reported the symptoms he shared with his treating physician, Dr. Singla, but added high cholesterol, depression, anxiety, social phobia, and a past alcohol and opiate addiction. He also reported that he had been staying in his home for the last four years, isolating himself from people and suffering panic attacks. (R. 417). Dr. Hilger observed that Mr. Farrell walked very slowly with the use of a cane. (R. 410-11). Dr. Hilger also noted that he answered all questions extremely slowly and appeared to be very lethargic, tired, and depressed. Mr. Farrell said he was taking Paxil and hearing voices, having trouble sleeping, had lost weight, and had attempted suicide in the past. (R. 411-12). Mr. Farrell said that he had been drinking at least 30 beers per night on the weekends the last seven years. He had used cocaine six times in the previous year, most recently five weeks before the consultative exam. (R. 411). Upon testing, remote memory was minimal, and recent memory was poor. General knowledge was minimal -he thought there were 42 weeks in a year.

He named Texas, Florida, and Mississippi as cities. He said John Adams was the president during the Civil War. (R. 412). Ability to calculate was minimal, and conceptual and abstract reasoning were fair. Judgment was fair as well. (R. 413). Diagnosis was alcohol dependence and drug abuse, dysthmic disorder, agoraphobia withpanic attacks, and estimated borderline mental functioning. Global Assessment of Function score was 55-60. Dr. Hilger felt Mr. Farrell showed poor mental potential for work involving understanding, memory, concentration, social interaction, and adaptation. (R. 413). He thought that he might need to be retrained into more sedentary, less physically stressful, types of work. (R. 414).

On August 9, 2008, Mr. Farrell had a physical consultative examination arranged by the disability agency. Dr. Chukwu Emika Ezike noted that Mr. Farrell reported his chief complaints were back pain and neuropathy. The back pain was constant and 8/10 in severity. Mr. Farrell said he had fallen and occasionally walks with a cane. (R. 421). Mr. Farrell told the doctor he could walk less than a block, stand for no more than 3-4 at a time, and sit for no more than 5 minutes at a time. He could lift no more than 10 pounds, and could drive only short distances. He also had trouble climbing stairs. (R. 422). Mr. Farrell said he did not abuse alcohol or drugs. His medications were listed as Metformin (diabetes), Vytorin (cholesterol), Glipizide (diabetes), Lotrel (hypertension), Paxil (depression/anxiety), Lyrica (nerve pain), Prilosec (acid reflux), Suboxone (opiate addiction), Motrin (pain), and naproxen (NSAID). (R. 422). Upon examination, Mr. Farrell was able to walk 50 feet without assistance, but with a slow and antalgic gait. He could heel/toe walk with mild difficulty. Grip strength and manipulation were normal. Range of motion in the upper and lower extremities and cervical spine was normal. Lumbar range of motion was limited to 30 degrees flexion and 10 degrees extension, but there was no paraspinal tenderness and straight leg raising was negative. Sensation wasdecreased in the medial aspect of both legs. (R. 422). Mr. Farrell was oriented and had a normal affect; there was no sign of depression or anxiety. (R. 422). Dr. Ezike felt that, at 5'9" and 261 pounds, Mr. Farrell's main problem was obesity, along with lumbar disc disease, hypertension, and diabetes with neuropathy. (R. 424).

Psychologist Ronald Havens, Ph.D., reviewed the file on behalf of the agency on August 28, 2008. (R. 440-43). He found Mr. Farrell moderately limited in his ability to travel in unfamiliar places, and to understand, remember and carry out detailed instructions. (R. 440-41). He noted that Mr. Farrell had no record of psychological treatment and had never mentioned depression or any emotional problems to his treating doctors or to Dr. Ezike. Then, suddenly, at the consultative exam with Dr. Hilger, he complained of depression, agoraphobia, and panic attacks. (R. 442). As such, Dr. Havens felt Mr. Farrell's allegations of psychological impairment were not credible. (R. 442). On October 23,...