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Cluesman v. Berryhill

United States District Court, S.D. Indiana, Terre Haute Division

January 27, 2017

KATHLEEN A. CLUESMAN, Plaintiff,
v.
NANCY A. BERRYHILL Acting Commissioner of the Social Security Administration, [1] Defendant.

          ENTRY ON JUDICIAL REVIEW

          McKINNEY, JUDGE.

         Plaintiff Kathleen Cluesman requests judicial review of the final decision of Defendant Nancy A. Berryhill, Acting Commissioner of the Social Security Administration (the “Commissioner”), who denied her application for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. § 423(d).

         I. BACKGROUND

         A. PROCEDURAL HISTORY

         Cluesman applied for DIB on April 10, 2013. R. at 16. She first alleged disability beginning on October 9, 2011, but later amended the onset date to July 9, 2013. Id. On May 5, 2015, Cluesman, with counsel, presented for a hearing in front of an Administrative Law Judge (“ALJ”), in which she testified about her alleged disability. R.at 32-71. The ALJ denied Cluesman's claim, finding that she was not disabled at any point from the alleged onset date through the date of the ALJ's June 1, 2015 decision. R. at 16, 26. The Appeals Council denied Cluesman's request for review of the ALJ's decision, which renders it the Commissioner's final administrative decision for purposes of judicial review. 20 C.F.R. § 404.981.

         B. RELEVANT MEDICAL EVIDENCE

         On March 27, 2013, Cluesman saw Dr. Chua, her primary care doctor, for the first time. R. at 250. Cluesman complained of headaches and arthritis in both ankles. Id. She also complained of pain in both hands and feet, as well as carpal tunnel syndrome in her right hand. Id. She reported that she was falling asleep while driving. Id. Upon exam, Cluesman had tenderness in her hands, feet, knees, and ankles with a positive Phelan's test (a test for carpal tunnel syndrome) and Tinel's sign (a test for irritated nerves) on the right, but an otherwise normal neurological exam. R. at 251. Dr. Chua diagnosed Cluesman with uncontrolled diabetes, benign hypertension, and ankle and knee pain. R. at 252. He ordered a blood test. R. at 252-59.

         In May 2013, consulting physician Dr. Robert Burkle examined Cluesman. R. at 268-71. An EKG from that day suggested impaired left ventricle relaxation, but Cluesman's ventricle systolic function was normal. R. at 264-65. Upon exam, Cluesman's ankles were very tender to the touch, and she had reduced range of motion in several joints and some reduced strength in her hands, shoulder, hips, ankles, and knees. R. at 268-70. She also complained that she was unsteady and her feet hurt when she bent forward eighty degrees. R. at 270. But she could make a full fist, pick up small objects without difficulty, had normal reflexes, walked with a normal gait and no assistive device, walked on her tiptoes and heels, and stood on one leg. R. at 270-71. She also had a negative straight-leg-raise test. R. at 271.

         In June 2013, state agency reviewing physician Dr. Corcoran opined that Cluesman could perform sedentary work; never climb ladders, ropes, or scaffolds; and occasionally perform all other postural movements. R. at 74-76. The following month, Dr. Sands reviewed the medical evidence and affirmed the opinion as written. R. at 87.

         On June 12, 2013, Cluesman saw Dr. Chua with complaints of feet, hand, ankle, and knee pain, and she reported that she was dropping things with her right hand. R. at 277. She had not gone to the emergency room or seen any other doctors. Id. Upon exam, Cluesman had tenderness in her hands, knees, ankles, and one part of her foot with positive Tinel's sign and Phalen's tests, but an otherwise normal exam. R. at 278.

         On July 8, 2013, Dr. Chua completed a questionnaire, in which he opined that Cluesman could continuously lift or carry up to ten pounds but never lift or carry any more than this weight; could stand or walk for twenty minutes at a time for a total of one hour each; could sit for eight hours at one time without interruption but for six hours total in an eight hour work day; required a cane to walk; could walk forty feet without a cane; could never reach overhead or finger; could occasionally reach otherwise, handle, feel, or push/pull; could never use foot controls; could never perform any postural movements; could never work around most environmental conditions; and could not walk one block at a reasonable pace on uneven surfaces, travel without a companion, or sort, handle or use paper files. R. at 303-08.

         One day later, on July 9, 2013, Cluesman saw Dr. Chua with complaints of pain and burning in both hands, difficulty closing her hands at times, and pain in her knees, ankles, and feet. R. at 274. She reported that she was using a cane and always traveled with her husband, due to a reportedly unsteady gait. Id. Dr. Chua observed Cluesman had tenderness in her lower back, hands, knees, and ankles, with limited range of motion in her ankles. R. at 275. Dr. Chua diagnosed Cluesman with diabetes with neurology manifestation, benign hypertension, arthritis of the hand, and ankle, knee, and foot pain. R. at 276. He ordered multiple x-rays and prescribed Gabapentin (commonly prescribed for neuropathic pain) and Celebrex (a non-steroid anti-inflammatory). R. at 277.

         In August 2013, Cluesman saw Dr. Chua and she was wearing a brace. R. at 348. Upon exam, she had tenderness and spasms in her lower back and tenderness in her ankles and feet. R. at 349. Dr. Chua prescribed Tizanidine (a muscle relaxant) in place of Flexeril. R. at 350.

         Four months later, in November 2013, Cluesman reported that the Tizanidine helped with the pain. R. at 345. She reported still having back pain and wondered if a back brace would help. Id. Upon exam, Cluesman had tenderness in her lower back and ankles. R. at 346. Dr. Chua prescribed a back brace. R. at 297-98.

         Five months later, in March 2014, Cluesman reported that she had arthritis achiness in both feet. R. at 302, 342. She also complained of lower back pain, right knee pain, and burning in both hands. R. at 342. Upon exam, she had tenderness in her lower back, knees, ankles, and feet. R. at 343.

         The following month, in April 2014, Dr. Chua completed an Arthritis Medical Source Statement, in which he gave Cluesman a fair prognosis and identified the following symptoms: knee, ankle, foot, and hand pain; an ability to sit for about fifteen minutes before needing to stand or move; an ability to stand ten minutes at a time; and lower back pain. R. at 210. Dr. Chua characterized Cluesman's pain as severe and sharp. Id. For objective signs, Dr. Chua noted that Cluesman had reduced range of motion in her ankles, tenderness at various points, and reduced grip strength in her hands. Id. He opined that Cluesman could walk one block without rest or pain; could sit for fifteen minutes at a time and stand for ten minutes at a time; with no indication as to how many hours total in a day Cluesman could sit or stand; required several unscheduled breaks for fifteen minutes at a time; needed to elevate her legs, with no indication as to how high; required a cane, could rarely ...


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