# Hays v. Commissioner of Social Security

> District Court, S.D. Illinois · March 31, 2023

URL: https://www.frixlaw.com/law-library/cases/10646007

## Case

- **Court:** District Court, S.D. Illinois
- **Decided:** March 31, 2023
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

- No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases.
- Full citator and citing cases: https://www.frixlaw.com/law-library/cases/10646007

## How later opinions describe it (automated extraction)

- noting, while the plaintiff claimed testing rendered prior medical opinions stale, the results of that testing, as interpreted by the plaintiff’s physicians and not the ALJ, did not reveal a worsening condition that required resubmission to a medical expert
- finding the ALJ failed to explain why the evidence did not require nonexertional limitations in an RFC

## Opinion text

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ILLINOIS

THOMAS H.,1 )
)
Plaintiff, )
)
vs. ) Case No. 3:21-cv-1479-DWD
)
COMMISSIONER OF SOCIAL )
SECURITY, )
)
Defendant. )

MEMORANDUM & ORDER
DUGAN, District Judge:
Pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), Plaintiff seeks judicial review of the
final agency decision of Defendant, which denied Plaintiff’s applications for Disability
Insurance Benefits (“DIBs”) and Supplemental Security Income (“SSI”). For the reasons
explained below, the Court AFFIRMS the final agency decision of Defendant.
I. Procedural History2
Plaintiff filed applications for DIBs and SSI on September 26, 2019, alleging a
disability onset date of June 1, 2018. (Doc. 13-5, pg. 14). On March 5, 2020, Defendant
issued Notices of Disapproved Claims. (Doc. 13-4, pgs. 2-11). Plaintiff requested, but was
ultimately denied, reconsideration. (Doc. 13-4, pgs. 12-13, 17-22). Plaintiff then filed a
Request for Hearing. (Doc. 13-4, pg. 23). After that hearing was held before an
Administrative Law Judge (“ALJ”) on April 27, 2021, an Unfavorable Decision was issued

1Plaintiff’s full name will not be used in this Memorandum & Order due to privacy concerns.
See Fed. R. Civ. P. 5.2(c) and the Advisory Committee Notes thereto.
2Plaintiff does not include the correct dates in this section of his brief.
to Plaintiff on May 6, 2021. (Doc. 13-2, pgs. 13-35). Plaintiff’s Request for Review by the
Appeals Council was denied on October 5, 2021. (Doc. 13-2, pgs. 2-7) As a result, Plaintiff

exhausted his administrative remedies, and the ALJ’s decision is final and ripe for review.
II. The Evidentiary Record
Plaintiff was born on August 29, 1980, so he was 37 years old on the alleged
disability onset date. (Doc. 13-2, pgs. 30, 44). He did not graduate from high school and
does not have his GED. (Doc. 13-2, pg. 30). The alleged disability stems from diabetes,
arthritis in the knees, hand cramps, hypertension, vision problems, high cholesterol,

depression and anxiety, back pain, and neuropathy of the feet. (Doc. 13-3, pgs. 2, 5).
A. Treatment and Prior Administrative Medical Findings
Plaintiff’s primary care physician is Dr. Mahvish Zahoor, M.D. Between July 19,
2018, and January 28, 2021, Plaintiff presented to Dr. Zahoor on ten occasions, usually for
a follow-up visit related to his diabetes and hypertension. (Doc. 13-7, pgs. 65, 85, 98, 144-

45, 166-67, 260). During that time, Plaintiff’s weight fluctuated between a low of 244 lbs
(BMI of 33.09) on July 19, 2018, and a high of 269 lbs and 9.6 oz (BMI of 37.08) on January
28, 2021. (Doc. 13-7, pgs. 66, 262). Plaintiff’s blood pressure also varied during those visits,
reaching a high of 130/80 on July 19, 2018, and June 21, 2019, and a low of 124/60 on
February 21, 2019. (Doc. 13-7, pgs. 66, 82, 99). On his last treatment date with Dr. Zahoor,

January 28, 2021, Plaintiff’s blood pressure was down to 126/74. (Doc. 13-7, pg. 262).
Plaintiff was consistently assessed by Dr. Zahoor as having Type 2 diabetes
mellitus without complication or long-term use of insulin, hypertension, unspecified
hyperlipidemia, and other diabetic neurological complications. (Doc. 13-7, pgs. 67, 71, 87,
97, 100, 147). Dr. Zahoor also assessed Plaintiff as having neuropathy and, on certain
occasions, noted Plaintiff’s knee and foot pain. (Doc. 13-7, pgs. 77, 87, 100, 145, 167).

On certain visits with Dr. Zahoor, Plaintiff was also assessed as having anxiety,
shortness of breath, insomnia, depression, dizziness, and headache. (Doc. 13-7, pgs. 75,
77, 79, 81, 83, 87, 100, 169). In a treatment note from November 29, 2018, Dr. Zahoor stated:
Pt reports he has been under a lot of stress lately and only gets about 4 hours
a [sic] sleep a night. Pt reports his stress stems from being behind on bills,
only just now finding a job after being unemployed for months, and family
obligations. Pt has never been on anxiety medications before. He reports he
has dealt with depression since he was 15 yos, but has not been treated with
antidepressants.

(Doc. 13-7, pg. 73).
Plaintiff reported that he used marijuana and was compliant with his medications
of Hydrochlorothiazide, Lisinopril, Lofibra, Glipizide, Sitagliptin, Pioglitazone, and
Atorvastatin. (Doc. 13-7, pgs. 73, 87). Dr. Zahoor also prescribed Plaintiff Lexapro and
Trazodone, which were reported as not strong enough. (Doc. 13-7, pg. 75). Plaintiff later
received Januvia, Gabapentin, and Wellbutrin. (Doc. 13-7, pg. 87). Gabapentin was
reported as not helpful to Plaintiff’s pain. (Doc. 13-7, pg. 167). However, Plaintiff’s anxiety
and depression were responding to and helped by Wellbutrin. (Doc. 13-7, pg. 167).
Plaintiff presented to Marion Eye Center on November 14, 2018, and March 7,
2019, for “existing condition, diabetes.” (Doc. 13-7, pgs. 10, 13). Plaintiff was noted as
having high blood pressure. (Doc. 13-7, pgs. 10, 13). On each date, he reported no
noticeable changes to visual acuity and “[s]everity [wa]s described as stable.” (Doc. 13-7,
pgs. 10, 13). Plaintiff had hypermetropia, regular astigmatism, refractive amblyopia, and
Type 2 diabetes mellitus without complications. (Doc. 13-7, pgs. 11, 13-14). With glasses,
Plaintiff had a visual acuity of 20/40. (Doc. 13-7, pgs. 11, 14).

On January 3, 2020, Dr. Jonathan Thomas-Stagg, Ph.D., completed a mental status
examination of Plaintiff. (Doc. 13-7, pg. 118). Dr. Thomas-Stagg considered Plaintiff’s
statements regarding his symptoms and level of functioning. (Doc. 13-7, pgs. 118-120). In
terms of clinical observations, Dr. Thomas-Stagg noted as follows:
The claimant was of average height and somewhat overweight…He was
quite fidgety. The claimant related adequately well with the examiner. The
claimant interrupted the examiner at times, most likely out of anxiety. The
claimant was alert and oriented to person, place, and time. The claimant’s
mood appeared to be anxious. The claimant’s affect was within normal
limits in terms of range, intensity, and congruency. The claimant’s speech
was within normal limits in terms of rate, articulation, and prosody. The
claimant was able to produce sustained, audible, and understandable
speech. The claimant’s content and process of thinking was within normal
limits. There were no noticeable problems with gait, or evidence of fine-
motor control difficulties. The claimant was able to walk without the
assistance of an ambulatory device, and able to bear his own weight. The
claimant’s insight and judgment were fair for his age. The claimant’s
reliability as an informant was good.

(Doc. 13-7, pg. 120).
Further, Plaintiff answered various questions and completed an inference task, the
serial sevens task, and paper-and-pencil tasks. (Doc. 13-7, pgs. 120-21). Given his age and
education, Plaintiff performed within the expected range. (Doc. 13-7, pg. 121). He was
diagnosed, by history, with depression and anxiety. (Doc. 13-7, pg. 121). Dr. Thomas-
Stagg found: Plaintiff “was cooperative and responsive during the examination…. MSE
results were within the expected range. He reported physical and health related problems
including diabetes, neuropathy, and back pain, as well as a history of depression and
anxiety…. [He] appears capable of managing his own funds.” (Doc. 13-7, pg. 121).

On January 14, 2020, Plaintiff was examined by an internist, Dr. Raymond Leung,
M.D. (Doc. 13-7, pgs. 127-130). At that time, Plaintiff was 260 lbs and had a blood pressure
of 132/83. (Doc. 13-7, pgs. 128, 130). Dr. Leung observed, with a BMI of 38.4, Plaintiff was
obese. (Docs. 13-3, pg. 11; 13-7, pg. 128). Plaintiff was alert, oriented, cooperative, and had
an intact memory and normal affect, dress, and hygiene. (Doc. 13-7, pg. 128). Dr. Leung
believed Plaintiff could manage funds in his own interest. (Doc. 13-7, pg. 128). Further,

with glasses, Plaintiff’s visual acuity was identified as 20/70. (Doc. 13-7, pg. 130).
Dr. Leung noted Plaintiff had a mild limp, but he could walk unassisted for 50 feet.
(Doc. 13-7, pg. 129). He could also tandem walk and hop, heel walk, toe walk, and squat.
(Doc. 13-7, pg. 129). There was decreased range of motion in his lumbar spine, but no
muscle atrophy or spasms. (Doc. 13-7, pg. 129). An x-ray of the lumbar spine showed no

acute fracture, dislocation, destructive process, or spondylolysis or spondylolisthesis.
(Doc. 13-7, pg. 132). There were diffuse spondylotic changes, but vertebral body heights
and intervertebral disc spaces were unremarkable, pedicles and paraspinal soft tissue
structures were normal, prevertebral soft tissue structures were unremarkable, and facet
joints were normal. (Doc. 13-7, pg. 132). Straightening of the lumbar spine was secondary

to muscle spasms or pain, and there was severe constipation. (Doc. 13-7, pg. 132).
Moreover, an x-ray of Plaintiff’s thoracic spine indicated no acute fracture,
dislocation, destructive process, or spondylolisthesis. (Doc. 13-7, pg. 133). There was
thoracic spondylosis and disc degeneration, but vertebral body heights were well-
maintained, pedicles and paraspinal soft tissue structures were normal, and prevertebral
soft tissue structures appeared unremarkable. (Doc. 13-7, pg. 133).

An x-ray of the right knee found mild soft tissue swelling but no acute fracture,
dislocation, destructive process, significant osteoarthrosis, osseous erosive changes, or
joint effusion. (Doc. 13-7, pg. 131). Plaintiff also had full range of motion in the knees.
(Doc. 13-7, pg. 130). Further, Plaintiff’s pinch, arm, and grip strength was 5/5, and he
could oppose the thumb to finger in each hand. (Doc. 13-7, pg. 129).
Plaintiff’s feet showed signs of neuropathy. (Doc. 13-7, pg. 130). He had a

decreased sensation to pinprick, but the sensation to light touch was intact. (Doc. 13-7,
pg. 129). Plaintiff had mild decreased vibratory sensation in his feet. (Doc. 13-7, pg. 129).
Plaintiff’s proprioception in the toes was normal and his cranial nerves were intact. (Doc.
13-7, pg. 129). Plaintiff’s extremities displayed good distal pulses, and he had no lower
extremity peripheral edema, ulcerative lesions, or varicosities. (Doc. 13-7, pg. 129).

Drs. Frank Mikell, M.D., and M.W. DiFonso, PsyD, rendered initial administrative
medical findings in February 2020. (Doc. 13-3, pgs. 2-12). The impairments related to
Plaintiff’s back, diabetes, loss of vision, neuropathy, and hypertension were severe. (Doc.
13-3, pg. 5). Plaintiff’s anxiety and obsessive-compulsive disorders were nonsevere. (Doc.
13-3, pg. 5). Dr. DiFonso found Plaintiff had mild limitations in the ability to:

(1) understand, remember, or apply information; (2) interact with others; (3) concentrate,
persist, or maintain pace; and (4) adapt or manage oneself. (Doc. 13-3, pg. 6).
Dr. Mikell noted Plaintiff’s symptoms were pain and limitations in understanding,
remembering, concentrating, persisting, interacting socially, and adapting. (Doc. 13-3, pg.
7). Dr. Mikell concluded Plaintiff’s statements about the intensity, persistence, and
limiting effects of those symptoms were not substantiated by the objective medical

evidence. (Doc. 13-3, pgs. 7-8). The longitudinal treatment records were most informative
in assessing the consistency of the statements. (Doc. 13-3, pg. 8). Dr. Mikell found Plaintiff
was “partially consistent,” as there was evidence supporting medically determinable
impairments but he was “not as disabled as originally claimed.” (Doc. 13-3, pg. 8).
In terms of a Residual Functional Capacity (“RFC”), Dr. Mikell found Plaintiff
could occasionally lift and/or carry 20 pounds, climb ramps and stairs, stoop, kneel,

crouch, and crawl. (Doc. 13-3, pgs. 8-9). Dr. Mikell also found Plaintiff could frequently
lift and/or carry 10 pounds, but he could never climb ladders, ropes, or scaffolds. (Doc.
13-3, pgs. 8-9). Dr. Mikell believed Plaintiff could stand and/or walk with normal breaks
for a total of approximately 6 hours in a workday. (Doc. 13-3, pg. 8). With normal breaks,
Plaintiff could also sit for about 6 hours in a workday. (Doc. 13-3, pg. 8). Plaintiff’s ability

to push and/or pull with his lower extremities was limited. (Doc. 13-3, pg. 8).
Dr. Mikell also found Plaintiff had visual, but not manipulative, limitations. (Doc.
13-3, pg. 9). He had limited near acuity, far acuity, and depth perception. (Doc. 13-3, pg.
9). With glasses, Plaintiff had a visual acuity of 20/70 in each eye. (Doc. 13-3, pg. 9).
Therefore, Dr. Mikell opined that Plaintiff could perform a wide variety of tasks,

including working with large and small objects. (Doc. 13-3, pg. 10). Plaintiff could have
difficulty working in precise detail and viewing small objects. (Doc. 13-3, pg. 10). Plaintiff
was not limited to unskilled work and, based on his RFC, he could perform certain light
work. (Doc. 13-3, pgs. 11-12). Ultimately, Plaintiff was “not disabled.” (Doc. 13-3, pg. 12).
In September 2020, in response to a request for activities of daily living, Plaintiff
reported that his knees were “in severe pain,” sometimes causing him to collapse. (Doc.

13-3, pg. 31). Plaintiff’s back and knee pain was constant. (Doc. 13-3, pg. 31). He also
experienced sharp needle pains in his feet, as well as arm pain that affected the use of his
hands. (Doc. 13-3, pg. 31). Plaintiff struggled to sleep due to the pain. (Doc. 13-3, pg. 31).
Plaintiff cared for his children, managed his personal care, and fixed simple meals. (Doc.
13-3, pg. 31). Plaintiff’s children “mostly do the chores” due to his pain. (Doc. 13-3, pg.
31). Plaintiff still drove, shopped, and managed his money. (Doc. 13-3, pg. 31). Plaintiff

occasionally visited a friend’s house; otherwise, he left the house for appointments and
to shop. (Doc. 13-3, pg. 31). Plaintiff could lift 20 lbs, but anything heavier caused pain.
(Doc. 13-3, pg. 31). Plaintiff could stand “for a few minutes” but was “immediately in
pain.” (Doc. 13-3, pg. 31). Plaintiff could walk less than a block, but he did not use an
assistive device. (Doc. 13-3, pg. 31). To manage his pain, Plaintiff alternated between

standing and sitting. (Doc. 13-3, pg. 31). Plaintiff had trouble squatting, bending,
reaching, kneeling, climbing stairs, and using his hands. (Doc. 13-3, pg. 31). He struggled
to concentrate, manage stress and change, and get along with others. (Doc. 13-3, pg. 31).
Plaintiff could follow instructions, and he had a visual acuity of 20/40. (Doc. 13-3, pg. 31).
Plaintiff was referred to an orthopedist by Dr. Zahoor. (Doc. 13-7, pg. 170). Plaintiff

presented to Dr. Angela Freehill, M.D., of the Orthopaedic Center of Southern Illinois on
October 2, 2020. (Doc. 13-7, pg. 183). Dr. Freehill noted Plaintiff had knee pain “for years”
and could not find relief. (Doc. 13-7, pg. 183). Dr. Freehill also noted Plaintiff’s
uncontrolled diabetes and low back pain. (Doc. 13-7, pg. 183). On the date of service,
Plaintiff’s pain was a 6 or 8 out of 10. (Doc. 13-7, pg. 183). That pain was “sharp, dull,
throbbing, aching, stabbing, burning, [and] constant.” (Doc. 13-7, pg. 183). Other

symptoms involved Plaintiff’s knees popping, grinding, locking, catching, and giving
way. (Doc. 13-7, pg. 183). Standing, walking, lifting, exercising, twisting, bending, lying
in bed, squatting, kneeling, climbing stairs, sitting, pushing, and pulling exacerbated
those symptoms. (Doc. 13-7, pg. 183). Plaintiff was 250 lbs, resulting in a BMI of 33.9.
(Doc. 13-7, pg. 183). Upon examination, Dr. Freehill noted as follows:
Examination of patient’s bilateral knees shows…no joint effusion. He is
tender at the medial and lateral facets of the patella bilaterally. He lacks full
active extension 15 degrees bilaterally and he has flexion 120 degrees. I can
passively extended [sic] to full extension bilaterally, but he has extreme pain
in the posterior hamstrings and the low back when I do this. He has no
radicular symptoms when I do this.

(Doc. 13-7, pgs. 183).
Dr. Freehill obtained x-rays of Plaintiff’s knees, noting “completely normal x-rays
of the knees with no evidence of osteoarthritis, patellar tilt or patellar subluxation. His
joint spaces are entirely preserved. These are 100% normal knee x-rays.” (Doc. 13-7, pg.
184). Dr. Freehill also obtained an x-ray of the pelvis, noting Plaintiff has “significant
bilateral acetabular dysplasia with 50% of uncoverage of bilateral femoral heads. He has
minimal arthritis changes.” (Doc. 13-7, pg. 184). Finally, Dr. Freehill obtained an x-ray of
Plaintiff’s lumbar spine, noting “[t]hese are essentially normal with a normal flexion and
extension and no evidence of degenerative disc disease.” (Doc. 13-7, pg. 184). Plaintiff
was assessed as having “bilateral knee pain secondary to patellofemoral pain syndrome,
tight hamstrings[,] and chronic low back pain.” (Doc. 13-7, pg. 184). Dr. Freehill noted a
component of bilateral hip dysplasia, which caused external rotation of the femurs and
malalignment syndrome. (Doc. 13-7, pg. 184). Plaintiff was recommended for physical

therapy, referred to an endocrinologist, prescribed Meloxicam and Tramadol for his pain,
and recommended for MRIs of the lumbar spine and left hip. (Doc. 13-7, pg. 184).
On October 14, 2020, Plaintiff presented to SSM Health St. Mary’s in Centralia for
physical therapy. (Doc. 13-7, pgs. 194-95). At the time of the visit, Plaintiff’s pain in the
hips and knees was a 7 out of 10. (Doc. 13-7, pg. 197). At worst, Plaintiff’s pain was a 9
out of 10 and, at best, it was a 4 out of 10. (Doc. 13-7, pg. 197). Plaintiff’s pain was

aggravated by physical activity, twisting, turning, and lifting. (Doc. 13-7, pg. 197). He
obtained relief by frequently changing position. (Doc. 13-7, pg. 197). Plaintiff noted “he
feels stressed out and overwhelmed more recently than before.” (Doc. 13-7, pg. 197).
Plaintiff’s posture was “deconditioned,” and he stood “with severe B hip ER.” (Doc. 13-
7, pg. 197). Plaintiff had antalgic gait with decreased knee and hip flexion. (Doc. 13-7, pg.

197). He was tender to palpitation to “B hip and lumbar muscles.” (Doc. 13-7, pg. 197).
Plaintiff’s joints were “decreased through spine and B hips.” (Doc. 13-7, pg. 197). Plaintiff
presented with signs and symptoms of congenital hip dysplasia. (Doc. 13-7, pg. 198).
Physical therapy was recommended 2-3 times a week for 8 weeks. (Doc. 13-7, pg. 198).
Plaintiff presented for physical therapy on October 22 and 23, 2020, at which time

he had generalized pain at a 6 out of 10. (Doc. 13-7, pgs. 233, 245). Plaintiff had a “fair”
tolerance of that pain during treatment. (Doc. 13-7, pg. 233). He “performed exercises well
with…cues to stay on task, focus, participate, and push himself.” (Doc. 13-7, pg. 246).
In late-October 2020, on reconsideration of the initial administrative medical
findings rendered in February 2020, Drs. Douglas Chang, M.D., Jerda M. Riley, M.D., and

Richard J. Hamersma, Ph.D., rendered administrative medical findings related to
Plaintiff. (Doc. 13-3, pgs. 26-42). Dr. Riley found Plaintiff’s visual condition was
nonsevere, imposing not more than a minimal impact on functioning. (Doc. 13-3, pgs. 34).
It was noted that Plaintiff did not return to his treating eye doctor with visual complaints.
(Doc. 13-3, pgs. 34, 39). Dr. Hamersma found Plaintiff’s anxiety and obsessive-compulsive
disorders, as well as depressive, bipolar, and related disorders, were nonsevere. (Doc. 13-

3, pg. 35). He found the “paragraph B” criteria were the same as in the initial
administrative medical findings. (Doc. 13-3, pg. 35). Plaintiff’s dysfunction in major joints,
diabetes mellitus, peripheral neuropathy, and hypertension were noted as severe. (Doc.
13-3, pg. 35). In a symptom evaluation, Dr. Chang found Plaintiff “remain[ed] partially
credible. Extent of limitations alleged [wa]s not fully supported by the evidence.” (Doc.

13-3, pg. 37). Dr. Chang found Plaintiff’s RFC was substantially the same as in the initial
administrative medical findings, except Dr. Chang found Plaintiff could stand and/or
walk for only 2 hours in a workday with normal breaks. (Doc. 13-3, pg. 38). Plaintiff was
not limited to unskilled work but, based on his RFC, he could perform only sedentary
work. (Doc. 13-3, pg. 41). Accordingly, Plaintiff was “not disabled.” (Doc. 13-3, pg. 42).

Plaintiff continued physical therapy in October and November 2020. On October
28, 2020, Plaintiff indicated he continued to have back and knee pain, described as a 6 out
of 10 in his back and 5 out of 10 in his knees. (Doc. 13-7, pg. 314). Plaintiff did not believe
physical therapy helped. (Doc. 13-7, pg. 314). On November 2, 2020, Plaintiff reported
that he had some pain in his back and knees. (Doc. 13-7, pg. 311). Pain in the right knee
was a 7 out of 10 and pain in the left knee was a 5 out of 10. (Doc. 13-7, pg. 311). Despite

some pain, Plaintiff tolerated the treatment well. (Doc. 13-7, pg. 312). The next day,
November 3, 2020, Plaintiff noted constant pain in his knees and back. (Doc. 13-7, pg.
308). Plaintiff’s pain in the right knee was an 8 out of 10, pain in the left knee was a 6 out
of 10, and pain in the hips was a 6 out of 10. (Doc. 13-7, pg. 308). Despite some pain in his
knees, Plaintiff fairly tolerated the treatment. (Doc. 13-7, pg. 309).
On November 17, 2020, Plaintiff reported his right knee was buckling and popping

occasionally, which was painful. (Doc. 13-7, pg. 305). Plaintiff’s pain was rated as an 8 out
of 10. (Doc. 13-7, pg. 305). Despite the pain, he tolerated treatment well. (Doc. 13-7, pg.
306). Plaintiff’s response to treatment was “positive.” (Doc. 13-7, pg. 306). On November
25, 2020, Plaintiff “report[ed] no change[] but maybe worsening pain since starting
therapy.” (Doc. 13-7, pg. 300). Plaintiff’s pain had never been in his hips, but now that

pain was consistent with his knee and back pain. (Doc. 13-7, pg. 300). Plaintiff could sit
or stand for 10 to 20 minutes before needing to “do the opposite to get [the] pain to
decrease.” (Doc. 13-7, pg. 300). Plaintiff’s knee and back pain was an 8 out of 10. (Doc. 13-
7, pg. 300). During the prior week, Plaintiff’s pain, at best, was a 5 out of 10 and, at worst,
was a 10 out of 10. (Doc. 13-7, pg. 300). Plaintiff’s gait was unchanged. (Doc. 13-7, pg.

300). The records note he “attended 9 sessions of physical therapy in 6 weeks,” despite a
referral for 2-3 times a week for 8 weeks. (Doc. 13-7, pg. 300). Plaintiff canceled most visits
due to lack of money for fuel. (Doc. 13-7, pg. 300). Plaintiff improved his lower extremity
strength. (Doc. 13-7, pg. 300). However, he was “unchanged according to subjective.”
(Doc. 13-7, pg. 300). Plaintiff’s progress was “poor.” (Doc. 13-7, pg. 303).

On December 1, 2020, Plaintiff returned to Dr. Freehill at the Orthopaedic Center
of Southern Illinois. (Doc. 13-7, pg. 284). Plaintiff weighed 250 lbs, resulting in a BMI of
33.9. (Doc. 13-7, pg. 284). Dr. Freehill noted Plaintiff had knee pain secondary to
patellofemoral pain syndrome, tight hamstrings, and chronic low back pain. (Doc. 13-7,
pg. 284). Plaintiff also had malalignment syndrome due to severe external rotation of his
hips. (Doc. 13-7, pg. 284). At the time of the visit, Plaintiff had tenderness at the

patellofemoral joint and numbness and tingling in the ulnar three fingers, the latter of
which was “possibly related to his uncontrolled diabetes.” (Doc. 13-7, pg. 284). Plaintiff’s
pain was a 6 or 7 out of 10 in both his knees and back. (Doc. 13-7, pg. 284). He was not
experiencing hip pain. (Doc. 13-7, pg. 284). Dr. Freehill indicated an MRI of the lumbar
spine was ordered but denied by insurance. (Doc. 13-7, pg. 284). Further, she instructed

Plaintiff to obtain a referral for an endocrinologist for his uncontrolled diabetes, but
Plaintiff had not done so. (Doc. 13-7, pg. 284). X-rays of Plaintiff’s pelvis indicated he had
bilateral acetabular dysplasia with greater than 40% of bilateral femoral heads uncovered.
(Doc. 13-7, pg. 284). X-rays of Plaintiff’s lumbar spine were normal and did not show
degenerative disc disease. (Doc. 13-7, pg. 284). Plaintiff was assessed as having lower

extremity pain and chronic low back pain, and he failed conservative treatment by
physical therapy and anti-inflammatories. (Doc. 13-7, pg. 284). Dr. Freehill opined that
Plaintiff “likely [has] a herniated disc or some lumbar spinal canal stenosis[,] which is not
evident on x-ray.” (Doc. 13-7, pg. 284). She recommended a referral to an endocrinologist
for management of uncontrolled diabetes, an MRI of the lumbar spine, and an EMG nerve
conduction study of the right upper extremity. (Doc. 13-7, pg. 284).

On March 2, 2021, Plaintiff again presented to Dr. Freehill at the Orthopaedic
Center of Southern Illinois for a follow-up to an MRI. (Doc. 13-7, pg. 281). Plaintiff
weighed 255 lbs, resulting in a BMI of 34.6. (Doc. 13-7, pg. 281). Dr. Freehill noted Plaintiff
had knee pain secondary to patellofemoral pain syndrome, tight hamstrings, and chronic
low back pain. (Doc. 13-7, pg. 281). Plaintiff also had malalignment syndrome due to
severe external rotation of his hips. (Doc. 13-7, pg. 281). Dr. Freehill noted she requested

an endocrinologist referral, but that it was still not completed. (Doc. 13-7, pg. 281).
Further, a nerve conduction study of the right upper extremity was ordered, but Plaintiff
missed the appointment. (Doc. 13-7, pg. 281). Plaintiff’s knee pain was a 6 or 7 out of 10
and his back pain was an 8 out of 10. (Doc. 13-7, pg. 281). Plaintiff was tender at the
patellofemoral joints and the midline of the back. (Doc. 13-7, pg. 281). An MRI showed

no obvious herniated disc, but Plaintiff had foraminal narrowing at the L3-L4 and L4-L5
levels due to short pedicles and bulging discs. (Doc. 13-7, pg. 281). Plaintiff was assessed
as having knee pain and malalignment syndrome, as well as chronic low back pain due
to mild canal stenosis and foraminal narrowing. (Doc. 13-7, pg. 281). Plaintiff was referred
to pain management. (Doc. 13-7, pg. 281). Dr. Freehill still believed an endocrinologist

was necessary in order to manage Plaintiff’s diabetes. (Doc. 13-7, pg. 281).
Plaintiff returned to the Orthopaedic Center of Southern Illinois, complaining of
low back pain, on March 11, 2021. (Doc. 13-7, pg. 277). He indicated physical therapy
worsened the low back pain, and over-the-counter medication had not helped. (Doc. 13-
7, pg. 277). Plaintiff reported that the pain did not radiate to the legs, and he did not have
any numbness or tingling. (Doc. 13-7, pg. 277). The pain was a 6 to 10 out of 10, depending

on Plaintiff’s activity. (Doc. 13-7, pg. 277). The pain was sharp, dull, stabbing, burning,
throbbing, and constant. (Doc. 13-7, pg. 277). Plaintiff reported numbness, tingling,
popping, grinding, weakness, locking, catching, giving way, and instability. (Doc. 13-7,
pg. 277). Bending, walking, standing, sitting, and lying down worsened the pain. (Doc.
13-7, pg. 277). Plaintiff was 250 lbs, resulting in a BMI of 33.9. (Doc. 13-7, pg. 277).
Psychologically, Plaintiff showed “mild pain magnification behavior,” but was

otherwise pleasant and oriented to time, place, and person. (Doc. 13-7, pg. 277).
Neurologically, no weakness was noted. (Doc. 13-7, pg. 277). Relating to the lumbar spine,
Plaintiff had tenderness with palpitation. (Doc. 13-7, pg. 277). He had forward flexion to
the floor with an increase in back pain, a lumbar extension to 15 degrees with a significant
increase of axial back pain, and a negative hyperextension test bilaterally with back pain.

(Doc. 13-7, pg. 277). X-rays were conducted of the lumbar spine and pelvis. (Doc. 13-7,
pg. 278). Disc heights were fairly well maintained and there was normal lumbar lordosis,
mild facet arthritis, and no evidence of fracture. (Doc. 13-7, pg. 278). It was noted that an
MRI of the lumbar spine was conducted on December 11, 2020, which revealed as follows:
There is mild right L3-4 neural foraminal narrowing with congenitally
shortened pedicles. There is mild L5-S1 bulging disc asymmetric to the right
with congenitally shortened pedicles. There is no evidence of fracture or
significant disc herniation or bulge. There is facet arthritis throughout the
lumbar spine. The disc heights are fairly well maintained.

(Doc. 13-7, pg. 278).
Plaintiff was assessed as having low back pain with facet arthritis. (Doc. 13-7, pg.
278). Surgical intervention was not necessary. (Doc. 13-7, pg. 278).

On April 8, 2021, Dr. Sajjan Nemani, M.D., completed a Report of Nerve
Conduction Study and EMG. (Doc. 13-7, pg. 295). The Report supported a diagnosis for
moderate ulnar neuropathy at the elbow with “[n]o denervation changes but mild to
moderate decreased recruitment…in ulnar innervated muscles in forearm or hand.”
(Doc. 13-7, pg. 285). The report also supported a diagnosis for mild right carpal tunnel
syndrome, “suggestive of conduction slowing[] [but] [n]o denervation changes…in

Abductor Pollicis Brevis.” (Doc. 13-7, pg. 295). Finally, there was a possibility of mild
diffuse sensory polyneuropathy of axonal type, as seen with diabetes. (Doc. 13-7, pg. 295).
B. The Administrative Hearing
A hearing was held by an ALJ on April 27, 2021. (Doc. 13-2, pg. 36).3 Plaintiff
testified that he did not have a sudden traumatic injury; rather, his chronic conditions

worsened over time. (Doc. 13-2, pg. 46). Plaintiff complained of his back, right arm, knees,
and feet. (Doc. 13-2, pgs. 58-59). Plaintiff’s back had “always been an issue,” but he only
recently realized something was “severely wrong.” (Doc. 13-2, pg. 46). Plaintiff’s back
was in “constant pain” and “way worse than it ever was.” (Doc. 13-2, pgs. 58-59). Plaintiff
stated there are times when it is difficult for him to “even get up and do anything.” (Doc.

13-2, pg. 59). His back locks up and gets really tight. (Doc. 13-2, pg. 59). Plaintiff indicated
sometimes he cannot bend over due to his back pain. (Doc. 13-2, pg. 59). The back pain

3At the start of the hearing, Plaintiff’s attorney indicated the record was complete, such that he
was not aware of any additional evidence relating to the disability issue. (Doc. 13-2, pgs. 40, 79).
also makes it difficult to sit up and sit down. (Doc. 13-2, pg. 59). Plaintiff also noted, when
cooking, he cannot stand for too long because his back gets tight. (Doc. 13-2, pg. 59).

Plaintiff rated his back pain as an 8 out of 10, which is typical. (Doc. 13-2, pg. 60). “Trying
to do anything,” such as going to the kitchen to cook, going up or down stairs, walking
around a store, or sitting too long, worsens the back pain. (Doc. 13-2, pg. 60). Usually,
Plaintiff can sit for around 30 minutes before the back pain requires him to stand. (Doc.
13-2, pg. 60). Marijuana has helped Plaintiff manage the back pain. (Doc. 13-2, pg. 71).
Plaintiff also testified that his knees are in “constant pain” and “just keep getting

worse,” such that it is difficult “to do anything that I need to do.” (Doc. 13-2, pgs. 58-59).
The knee pain, which takes his breath away when going up stairs, is a burning sensation.
(Doc. 13-2, pg. 61). Plaintiff’s knees also begin to hurt when sitting. (Doc. 13-2, pg. 61). At
the hearing, Plaintiff’s knee pain was an 8 or 9 out of 10. (Doc. 13-2, pg. 61). To manage
the knee pain, Plaintiff must alternate between sitting and standing. (Doc. 13-2, pg. 61).

With respect to his right arm, Plaintiff testified, “[i]f I try to use it to do anything[,]
it starts to tighten up.” (Doc. 13-2, pg. 62). Plaintiff’s “whole hand will just lock” for 5 to
10 minutes. (Doc. 13-2, pg. 62). When this happens, Plaintiff can pick up a gallon of water,
but he cannot open a jar. (Doc. 13-2, pg. 62). He would not last an hour if he had to pick
up a gallon of water every five minutes. (Doc. 13-2, pg. 63).

In relation to his feet, Plaintiff testified to “constant, sharp[,] needle pains that feel
like [his feet are] on fire.” (Doc. 13-2, pg. 63). There are times when Plaintiff must “stop
doing everything just to pull [his] foot off the floor…to hold it there until it stops.” (Doc.
13-2, pg. 62). Sometimes, the pain prevents Plaintiff from standing. (Doc. 13-2, pg. 63). On
a good day, the pain occurs ten times. (Doc. 13-2, pg. 63). On a bad day, which occurs a
couple of times a week, the pain occurs about 20 times. (Doc. 13-2, pg. 63). Plaintiff

testified that the pain may last 1 to 2 minutes or 5 to 10 minutes. (Doc. 13-2, pgs. 63-64).
Plaintiff spends his time at home, not doing much. (Doc. 13-2, pg. 66). If he can,
Plaintiff tries to wake up and clean. (Doc. 13-2, pg. 66). Plaintiff has three children living
in the home. (Doc. 13-2, pg. 65). Plaintiff cooks for his children. (Doc. 13-2, pg. 66).
However, they help clean because Plaintiff cannot do much. (Doc. 13-2, pg. 66). They also
help fix meals, wash dishes, do laundry, and shop. (Doc. 13-2, pgs. 66-67). Sometimes

Plaintiff takes a chair into the kitchen so he can sit while cooking. (Doc. 13-2, pg. 66).
Plaintiff does not engage in hobbies or social activities due to his anxiety. (Doc. 13-
2, pg. 67). Over the past few years, Plaintiff feels anxious around a lot of people, requiring
him to walk off to be alone. (Doc. 13-2, pg. 67). Further, Plaintiff wears glasses, which
“[k]ind of” allow him to see well enough to do everyday activities. (Doc. 13-2, pg. 72).

Plaintiff noted “[t]hey can only correct my vision to 20/40.” (Doc. 13-2, pg. 72). In order
to read, Plaintiff must hold the material “[j]ust inches from [his] face.” (Doc. 13-2, pg. 72).
The ALJ received testimony from a Vocational Expert (“VE”). (Doc. 13-2, pgs. 41,
73-80). The ALJ engaged the VE in various hypotheticals. (Doc. 13-2, pgs. 75-79). The VE
assumed a younger individual with a limited education who could not engage in his past

work. (Doc. 13-2, pg. 75). The individual could perform unskilled, sedentary work,
occasionally requiring pushing and pulling with the bilateral lower extremities, climbing
ramps and stairs, stooping, kneeling, crouching, and crawling. (Doc. 13-2, pgs. 75, 77).
The individual could not climb ladders, ropes, or scaffolds and was to avoid concentrated
exposure to certain environmental elements and hazards. (Doc. 13-2, pgs. 75-76). The
individual could work with large and small objects but, with very small objects, such as

needles or those with small print, the individual needed to hold the object six inches from
his eyes. (Doc. 13-2, pg. 76). The individual could frequently reach, handle, and perform
fine finger manipulation with the right upper extremity. (Doc. 13-2, pg. 77). The VE
opined that this individual could perform the work of a cuff folder (10,000 jobs in the
national economy), table worker (16,000 jobs in the national economy), and circuit board
assembler (21,000 jobs in the national economy). (Doc. 13-2, pg. 77).

III. Legal Standards
To qualify for DIBs or SSI, a claimant must be disabled. To assess an alleged
disability, the ALJ employs a “five-step sequential evaluation process.” See 20 C.F.R.
§§ 404.1520(a)(1), (2), (4); 416.920(a)(1), (4). The ALJ inquires into whether: (1) the claimant
is doing substantial gainful activity; (2) the claimant has a severe medically determinable

physical or mental impairment that meets certain duration requirements or a
combination of impairments that is severe and meets the duration requirements; (3) the
claimant has an impairment that meets or equals one of the impairments listed in the
regulations and satisfies the duration requirements; (4) in view of the claimant’s RFC and
past relevant work, he or she can perform past relevant work; and (5) in view of the

claimant’s RFC, age, education, and work experience, he or she can adjust to other work.4

4At step 3, most mental impairment listings require at least two “marked” limitations or one
“extreme” limitation under the “paragraph B” criteria, which include: (1) understanding, remembering,
or applying information; (2) interacting with others; (3) concentrating, persisting, or maintaining pace;
and (4) adapting or managing oneself. See Thompson v. Saul, 470 F. Supp. 3d 909, 912 (E.D. Wisc. 2020).
See 20 C.F.R. §§ 404.1520(a)(4), (b), (c), (d), (e), (f), (g); 416.920(a)(4), (b), (c), (d), (e), (f), (g);
Young v. Barnhart, 362 F.3d 995, 1000 (7th Cir. 2004).

If the claimant is doing substantial gainful activity under step 1, does not have an
impairment or combination of impairments as described at step 2, can perform past
relevant work under step 4, or can adjust to other work under step 5, then the claimant is
not disabled. See 20 C.F.R. §§ 404.1520(a)(4)(i),(ii), (iv), (v); 416.920(a)(4)(i), (ii), (iv), (v). If
the claimant has an impairment that meets the requirements of step 3 or is incapable of
adjusting to other work under step 5, then he or she is disabled. See 20 C.F.R.

§§ 404.1520(a)(4)(iii), (v); 416.920(a)(4)(iii), (v). The claimant has the burden of proof at
steps 1 to 4. See Mandrell v. Kijakazi, 25 F.4th 514, 516 (7th Cir. 2022). At step 5, the burden
of proof shifts to the Commissioner of Social Security to show that the claimant can adjust
to other work existing in “a significant number of jobs…in the national economy.”
See Young, 362 F.3d at 1000; accord Brace v. Saul, 970 F.3d 818, 820 (7th Cir. 2020).

A claimant’s impairments and related symptoms may cause physical and mental
limitations that affect the ability to work. See 20 C.F.R. §§ 404.1545(a)(1); 416.945(a)(1). The
RFC at steps 4 and 5 assesses the most a claimant can do at work, despite the limitations.
See 20 C.F.R. §§ 404.1545(a)(1); 416.945(a)(1); accord SSR 96-8p, 1996 WL 374184, *2; Clifford
v. Apfel, 227 F.3d 863, 872-73 n. 7 (7th Cir. 2000). In this way, an RFC is an assessment of

the ability to perform sustained work-related physical and mental activities in a work
setting on a regular and continuing basis, i.e., for eight hours a day and five days a week
or an equivalent schedule. See Tenhove v. Colvin, 97 F. Supp. 2d 557, 568 (E.D. Wisc. 2013);
SSR 96-8p, 1996 WL 374184, *2; accord Moore v. Colvin, 743 F.3d 1118, 1121 (7th Cir. 2014).
An RFC must be based on all the relevant medical and other evidence of record. See 20
C.F.R. §§ 404.1545(a)(3); 416.945(a)(3); SSR 96-8p, 1996 WL 374184, *2-3, 5.

When completing an RFC, the ALJ considers all impairments, including nonsevere
impairments, and the claimant’s ability to meet physical, mental, sensory, and other
requirements of work.5 6 See 20 C.F.R. §§ 404.1545(a)(2), (4); 416.945(a)(2), (4); see also
Alesia v. Astrue, 789 F. Supp. 2d 921, 933 (N.D. Ill. 2011) (“[T]he ALJ must consider the
combined effect of all impairments, ‘even those that would not be considered severe in
isolation.’ “). After identifying the claimant’s functional limitations and assessing his or

her work abilities on a function-by-function basis, the RFC may be expressed by
exertional category, i.e., “sedentary.”7 See Tenhove, 97 F. Supp. 2d at 569; accord Lechner v.
Barnhart, 321 F. Supp. 2d 1015, 1036 (E.D. Wisc. 2004); SSR 96-8p, 1996 WL 374184, *3. To
do a full range of work in an exertional category, the claimant must be able to perform
substantially all of the functions at that level. See SSR 96-8p, 1996 WL 374184, *5-6.

IV. The ALJ’s Decision
The ALJ assessed the alleged disability under the five-step sequential evaluation

5“An impairment or combination of impairments is not severe if it does not significantly limit
[the] physical or mental ability to do basic work activities.” 20 C.F.R. §§ 404.1522(a); 416.922(a).
6A limited ability to perform physical demands of work activity, such as sitting, standing,
walking, lifting, carrying, pushing, pulling, reaching, handling, stooping, or crouching may reduce the
ability to do “other work” at step 5. See 20 C.F.R. §§ 404.1545(b); 416.945(b); see also SSR 96-8p, 1996 WL
374184, *5-6. A limited ability to do certain mental activities, such as understand, remember, carry out
instructions, and respond appropriately to supervision, co-workers, and work pressures, may reduce the
ability to do “other work” at step 5. See 20 C.F.R. §§ 404.1545(c); 416.945(c). Other impairments affecting
work abilities include, among other things, impairments of vision. See 20 C.F.R. §§ 404.1545(d); 416.945(d).
7Sedentary work involves “lifting no more than 10 pounds at a time and occasionally lifting or
carrying articles like docket files, ledgers, and small tools.” 20 C.F.R. §§ 404.1567(a); 416.967(a). A
sedentary job involves sitting but often has a certain amount of walking and standing necessary to its
related duties. See 20 C.F.R. §§ 404.1567(a); 416.967(a). Jobs are sedentary if walking and standing are
required occasionally, and other sedentary criteria are satisfied. See 20 C.F.R. §§ 404.1567(a); 416.967(a).
process. At step one, Plaintiff had not engaged in substantial gainful activity since the
alleged disability onset date. (Doc. 13-2, pg. 18). At step 2, Plaintiff had the following

severe limitations in the ability to perform basic work activities: (1) lumbar and thoracic
spine degenerative disc disease; (2) bilateral knee malalignment syndrome; (3) bilateral
acetabular dysplasia; (4) hypermetropia, astigmatism, and amblyopia; (5) hypertension;
(6) neuropathy of the feet; (7) right upper extremity carpal tunnel and ulnar neuropathy;
(8) type 2 diabetes mellitus; and (9) level two obesity. (Doc. 13-2, pg. 19).
The ALJ noted, at step 2, there was evidence of Plaintiff contending with other

nonsevere impairments. (Doc. 13-2, pg. 19). For example, in relation to Plaintiff’s
medically determinable mental impairments of generalized anxiety disorder with panic
attacks, which were considered singly and in combination, the ALJ found those mental
impairments were nonsevere because they did not cause more than minimal limitations
in Plaintiff’s ability to perform basic mental work activities. (Doc. 13-2, pgs. 19, 28).

To arrive at this finding, the ALJ considered the “paragraph B” criteria.
See Thompson, 470 F. Supp. 3d at 912. (Doc. 13-2, pg. 19). At the first “paragraph B”
criterion, the ALJ reasoned, while Plaintiff reported conditions affecting his
concentration, completion of tasks, understanding, and ability to follow spoken
instructions, Plaintiff could follow written instructions and he performed within the

expected range on the consultative mental status examination. (Doc. 13-2, pg. 19). Plaintiff
was also alert and oriented to person, place, and time. (Doc. 13-2, pg. 19). He had an intact
memory and could recall three items, complete a brief inference task and the “serial
sevens” task, and perform other basic mathematical calculations. (Doc. 13-2, pgs. 19-20).
Further, Plaintiff’s daily activities did not indicate more than minimal limitations, as he
did not need reminders to take medication or conduct personal care and he prepared

simple meals, washed dishes, did laundry with his son, drove a car, paid bills, maintained
bank accounts, and shopped for groceries. (Doc. 13-2, pg. 20). Despite a slight deficit, the
ALJ found a functional limitation of not more than minimal or mild. (Doc. 13-2, pg. 20).
At the second “paragraph B” criterion, the ALJ noted Plaintiff’s claim that it was
difficult to get along with family, friends, and neighbors. (Doc. 13-2, pg. 20). However,
Plaintiff lives with his girlfriend and three young children. (Doc. 13-2, pg. 20). He takes

care of his children by waking them up for school, cooking their meals, doing laundry
with his son, and attending doctors’ appointments. (Doc. 13-2, pg. 20). The ALJ noted that
Plaintiff’s ability to get along with authority figures is dependent upon his level of
physical pain, depression, and anxiety. (Doc. 13-2, pg. 20). But he has never been fired
due to an inability to get along with others. (Doc. 13-2, pg. 20). Further, according to

treatment records, Plaintiff took medication that helped the symptoms of depression and
anxiety. (Doc. 13-2, pg. 20). While he appeared anxious at the consultative mental status
examination, the affect was within the normal limits of range, intensity, and congruency.
(Doc. 13-2, pg. 20). Plaintiff could independently, appropriately, and effectively interact
with others on a sustained basis, as there was no evidence of fights, evictions, fear of

strangers, isolation, or social avoidance. (Doc. 13-2, pg. 20). The evidence did not support
a finding of more than a slight deficit and mild limitation in this area. (Doc. 13-2, pg. 20).
At the third “paragraph B” criterion, the ALJ noted Plaintiff reported conditions
affecting his ability to concentrate and complete tasks. (Doc. 13-2, pg. 20). Plaintiff could
pay attention, depending on the task, but had difficulties understanding and following
spoken instructions. (Doc. 13-2, pg. 20). However, the ALJ noted Plaintiff could follow

written instructions and, as previously mentioned, his performance on the consultative
mental status examination was within the expected range. (Doc. 13-2, pg. 20). In addition
to the results discussed above with respect to the first “paragraph B” criterion, the ALJ
noted that Plaintiff’s insight and judgment were fair, rate of speech was normal, and he
had no noticeable problems with gait or fine-motor control. (Doc. 13-2, pgs. 19-20). The
ALJ found there was no evidence that Plaintiff needed extra supervision, assistance, or

unreasonable rest time or disruptions. (Doc. 13-2, pgs. 20-21). As such, the ALJ found only
a slight deficit and not more than a mild limitation in this area. (Doc. 13-2, pgs. 20-21).
At the fourth “paragraph B” criterion, the ALJ noted Plaintiff reported not
handling stress well. (Doc. 13-2, pg. 21). Similarly, his ability to tolerate change depended
on the extent of the changes. (Doc. 13-2, pg. 21). Plaintiff reported not bathing for days

due to depression, but he otherwise adapted and managed. (Doc. 13-2, pg. 21). The ALJ
found Plaintiff could mostly manage day-to-day schedules. (Doc. 13-2, pg. 21). Further,
Plaintiff took care of his personal needs, such as grooming, money management, grocery
shopping, cooking simple meals, and driving a car. (Doc. 13-2, pg. 21). Usually, he
finishes what he starts. (Doc. 13-2, pg. 21). The ALJ found Plaintiff can do these things

despite his physical and mental conditions. (Doc. 13-2, pg. 21). Therefore, the ALJ found
the evidence supported a slight deficit and not more than a minimal limitation in this
area. (Doc. 13-2, pg. 21). Since Plaintiff’s medically determinable mental impairments
caused no more than mild limitations under the “paragraph B” criteria and the evidence
did not indicate there was more than minimal limitations on the ability to do basic work
activities, the ALJ found the mental impairments were nonsevere. (Doc. 13-2, pg. 21).

Returning to step three, the ALJ found Plaintiff did not have an impairment or
combination of impairments that met or medically equaled the severity of one of the
impairments listed in the regulations. (Doc. 13-2, pg. 21). Before proceeding to step 4, the
ALJ found Plaintiff had an RFC to perform sedentary work, with the exception of the
occasional ability to push and pull with the bilateral lower extremities. (Doc. 13-2, pg. 22).
Plaintiff could also occasionally climb ramps and stairs, but could never climb ladders,

ropes, or scaffolds. (Doc. 13-2, pgs. 22-23). Plaintiff could occasionally stoop, kneel,
crouch, and crawl. (Doc. 13-2, pg. 23). Plaintiff could work with large or small objects, but
when working with very small objects he required the ability to hold the object as close
as six inches from his eyes. (Doc. 13-2, pg. 23). Plaintiff could frequently reach, handle,
and perform fine finger manipulation with the right upper extremity. (Doc. 13-2, pg. 23).

The ALJ elaborated on its process for considering Plaintiff’s symptoms, including
his pain, in the RFC. See 20 C.F.R. §§ 404.1529; 416.929; (Doc. 13-2, pg. 23). The ALJ
described Plaintiff’s household activities, typical day, and the reported effects of his
conditions, including his pain. (Doc. 13-2, pgs. 23-24). The ALJ then found Plaintiff’s
medically determinable impairments could reasonably be expected to cause his

symptoms. (Doc. 13-2, pg. 24). However, Plaintiff’s statements concerning the intensity,
persistence, and limiting effects of his reported symptoms were inconsistent with the
medical and other evidence of record, which “detract[ed] from the subjective
allegations.” (Doc. 13-2, pg. 24). That is, the evidence generally did not support Plaintiff’s
alleged loss of functioning. (Doc. 13-2, pg. 24). His allegations were greater than expected
in view of the objective clinical evidence and treatment notes. (Doc. 13-2, pg. 24).

For example, the ALJ found the objective signs, diagnostic imaging, and laboratory
findings supported type 2 diabetes mellitus, degenerative disc disease, and neuropathy,
but the evidence did not support Plaintiff’s alleged degree of limitation. (Doc. 13-2, pg.
24). Similarly, x-rays, an MRI, and other examinations showed lumbar and thoracic
degenerative change, reduced leg strength, and decreased sensation in both feet. (Doc.
13-2, pg. 24). Plaintiff walked with an antalgic gait and reported that Gabapentin did not

assist with the pain. (Doc. 13-2, pg. 24). An eye examination demonstrated a visual acuity
of, at best, 20/40 with glasses. (Doc. 13-2, pg. 24). Despite these things, the ALJ noted
Plaintiff did not use an assistive walking device, he could ambulate for 50 feet, he
obtained relief from marijuana, and he drove a vehicle. (Doc. 13-2, pg. 24). While the
combined effects of obesity and chronic physical impairments affected his functional

abilities, Plaintiff’s daily living activities also showed he could perform light exertional
work and there was no objective examination findings supporting a greater functional
limitation. (Doc. 13-2, pg. 27). The symptoms of depression and anxiety were nonsevere
and caused minimal limitations. (Doc. 13-2, pg. 24). Overall, the evidence of physical and
mental conditions suggested Plaintiff could perform light work. (Doc. 13-2, pgs. 24-28).

Further, the ALJ emphasized it “fully considered the medical opinions and prior
administrative medical findings.” (Doc. 13-2, pg. 28). The ALJ discussed its consideration
of the State agency medical consultants, including Drs. Mikell and Chang for Plaintiff’s
physical condition and Drs. DiFonso and Hamersma for Plaintiff’s mental condition.
(Doc. 13-2, pgs. 28-29). The ALJ found Dr. Mikell’s initial prior administrative medical
finding was more persuasive than that of Dr. Chang at reconsideration, as Dr. Mikell

accounted for the “difficulty with prolonged visual work or very fine vision.” (Doc. 13-2,
pgs. 28-29). The ALJ found Dr. Mikell’s finding was “consistent with the claimant’s
limited near and far acuity and depth perception bilaterally, which corrects with glasses
to only 20/70.” (Doc. 13-2, pgs. 28-29). Dr. Chang “removed the visual limitations, but
retained the remaining limitations.” (Doc. 13-2, pg. 28). As such, Drs. Mikell and Chang’s
prior administrative medical findings were “partially persuasive.” (Doc. 13-2, pg. 29).

The ALJ reasoned that Plaintiff was found to have orthopedic impairments,
neuropathy in his feet, and obesity, which supported a conclusion that Plaintiff could
function more easily seated than while standing and walking. (Doc. 13-2, pg. 29). The
record evidence did not support a conclusion that Plaintiff could not perform sedentary
work. (Doc. 13-2, pg. 29). Likewise, Plaintiff’s allegation that, after minimal use, his right

hand locked, was unsupported. (Doc. 13-2, pg. 29). Plaintiff’s pinch, arm, and grip
strength remained normal, and he could oppose his thumb to each finger despite carpal
tunnel syndrome. (Doc. 13-2, pg. 29). Therefore, the manipulative limitations did not
support a greater limitation than that stated in the RFC. (Doc. 13-2, pg. 29).
With respect to Drs. DiFonso and Hamersma, whose prior administrative medical

findings related to Plaintiff’s mental condition, the ALJ noted each doctor found
Plaintiff’s mental impairments caused mild limitations under the “paragraph B” criteria.
(Doc. 13-2, pg. 29). Therefore, Plaintiff’s mental impairments were nonsevere. (Doc. 13-2,
pg. 29). Each prior administrative medical finding was persuasive, consistent with the
unremarkable mental status examinations, and supported by the evidence that
medication improved Plaintiff’s symptoms. (Doc. 13-2, pg. 29). The ALJ emphasized that

its RFC assessment was supported by the entire record. (Doc. 13-2, pg. 29).
At step four, the ALJ found Plaintiff was unable to perform any past relevant work.
(Doc. 13-2, pg. 29). At step five, the ALJ noted that Plaintiff’s ability to perform all or
substantially all of the requirements of sedentary work was impeded by additional
limitations. (Doc. 13-2, pg. 30). Therefore, to determine the extent to which those
limitations eroded the unskilled sedentary occupational base, the ALJ relied upon its

questioning of the VE about jobs existing in the national economy for an individual like
Plaintiff. (Doc. 13-2, pgs. 30-31). The ALJ noted that such an individual would be able to
perform the requirements of representative occupations, such as cuff folder (a sedentary,
unskilled occupation with 10,000 jobs in the national economy), table worker (a
sedentary, unskilled occupation with 16,000 jobs in the national economy), and printed

circuit board assembler (a sedentary, unskilled occupation with 21,000 jobs in the national
economy). (Doc. 13-2, pg. 31). Thus, the ALJ concluded Plaintiff could successfully adjust
to other work, existing in significant numbers, in the national economy. (Doc. 13-2, pg.
31). Accordingly, a finding of “not disabled” was appropriate. (Doc. 13-2, pg. 31).
For these reasons, the ALJ concluded Plaintiff was not disabled from June 1, 2018,

through May 6, 2021, which was the date of its decision. (Doc. 13-2, pgs. 17, 31). As a
result, Defendant denied Plaintiff’s applications for DIBs and SSI. (Doc. 13-2, pg. 31).
V. Analysis
The Court’s review of the ALJ’s decision is “extremely limited” and “very
deferential.” See 42 U.S.C. § 405(g); Jarnutowski v. Kijakazi, 48 F.4th 769, 773 (7th Cir. 2022)
(quoting Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008)). Findings of fact, supported by

substantial evidence, are conclusive. See 42 U.S.C. § 405(g); accord Clifford, 227 F.3d at 869.
The Court will reverse the ALJ’s decision only if the findings of fact were not supported
by substantial evidence or the ALJ applied the wrong legal standard. See Clifford, 227 F.3d
at 869; accord Martin v. Saul, 950 F.3d 369, 373 (7th Cir. 2020). “Substantial evidence means
‘such relevant evidence as a reasonable mind might accept as adequate to support a
conclusion.’ ” See Clifford, 227 F.3d at 869 (quoting Richardson v. Perales, 402 U.S. 389, 401

(1971)); accord Jarnutowski, 48 F.4th at 773. If reasonable minds could differ about the
alleged disability and the ALJ’s decision is supported by substantial evidence, the Court
will affirm the denial of claims. See Jarnutowski, 48 F.4th at 773 (quoting Elder, 529 F.3d at
413). The Court reviews the entire record, but does not reweigh the evidence, resolve
conflicts, decide credibility, or substitute its judgment for that of the ALJ. See Clifford, 227

F.3d at 869; accord Lopez ex rel. Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003). However,
an ALJ must build a logical bridge between the evidence and the conclusions.
See Jarnutowski, 48 F.4th at 773 (quoting Butler v. Kijakazi, 4 F.4th 498, 501 (7th Cir. 2021)).
Now, Plaintiff presents three main arguments for the Court’s consideration in this
case. Each argument is addressed separately below.

A. The RFC Assessment
First, Plaintiff argues the ALJ’s RFC assessment was not supported by substantial
evidence. (Doc. 21, pgs. 2-4). Plaintiff states, while the ALJ’s decision summarizes some
medical evidence, it fails to explain how that evidence supports the RFC assessment.
(Doc. 21, pg. 3). Specifically, Plaintiff asserts that, in addition to analyzing his depression
and anxiety, the ALJ was required to consider the effect of mild mental limitations, alone

and coupled with physical impairments, on the ability to work. (Doc. 21, pg. 3). Plaintiff
notes the ALJ did not include any mental limitations in his RFC. (Doc. 21, pg. 3).
“While a mild…limitation in an area of mental functioning does not necessarily
prevent an individual from securing gainful employment, [citation], the ALJ must still
affirmatively evaluate the effect such mild limitations have on the claimant’s RFC.” See
Simon–Leveque v. Colvin, 229 F. Supp. 3d 778, 783 (N.D. Ill. 2017) (citing Sawyer v. Colvin,

512 Fed. Appx. 603, 611 (7th Cir. 2013)) (Emphasis in original). The Court FINDS the ALJ
did that here, and Plaintiff’s assertions to the contrary mischaracterize the ALJ’s decision.
Here, the ALJ noted Plaintiff’s nonsevere impairments, including the medically
determinable mental impairments of generalized anxiety disorder with panic attacks.
(Doc. 13-2, pg. 19). The mental impairments, which were considered singly and in

combination, were nonsevere because they did not cause more than minimal limitations
in the ability to perform basic mental work activities. (Doc. 13-2, pgs. 19, 28). The ALJ
explained, in painstaking detail, how he arrived at this finding under the “paragraph B”
criteria. See Thompson, 470 F. Supp. 3d at 912. (Doc. 13-2, pgs. 19-21). Further, the ALJ
explained all medically determinable impairments, including those that were nonsevere,

were considered in the RFC. (Doc. 13-2, pgs. 19, 24-29). The RFC “assessment reflect[ed]
the degree of limitation…in the ‘paragraph B’ mental function analysis.” (Doc. 13-2, pgs.
21, 24-29). The Court has summarized the ALJ’s explanations and its consideration of the
evidence above, and it will not repeat itself here. (Doc. 13-2, pgs. 19-21). However, the
Court emphasizes that this case is not like Craft v. Astrue, where “the RFC was for
‘unskilled’ work, which by itself d[id] not provide any information about…mental

condition or abilities.” See 539 F.3d 668, 677 (7th Cir. 2008) (Emphasis added.). Here, the
RFC was for “unskilled” work but, again, the ALJ discussed the ways in which Plaintiff
could “understand, carry out, and remember simple instructions; respond appropriately
to supervision, coworkers, and usual work situations; and deal with changes in a routine
work setting.” See id. (citing 20 C.F.R. § 404.1545(c); SSR 85-15); (Doc. 13-2, pgs. 19-21).
Therefore, the Court FINDS the ALJ adequately discussed its RFC assessment,

including the effect of all Plaintiff’s mental limitations, and the support for that RFC in
the evidence. See Pepper v. Colvin, 712 F.3d 351, 362 (7th Cir. 2013) (holding the ALJ’s
discussion of the RFC was adequate, despite the plaintiff’s argument that “the ALJ
‘merely summarized some of the medical evidence without assessment or discussion
specifying how the medical and other evidence supported his conclusions,’ ” where, inter

alia, the ALJ provided a lengthy discussion of the medical records and plaintiff’s
testimony on the alleged impairments before concluding each impairment supported the
light work limitation), compare Simon–Leveque, 229 F. Supp. 3d at 783 (finding the ALJ
failed to explain why the evidence did not require nonexertional limitations in an RFC).
For these reasons, the Court CONCLUDES the ALJ’s RFC assessment was based

on substantial evidence and not an erroneous legal standard.
B. The Medical Opinions of Record
Second, Plaintiff argues the ALJ improperly considered the medical opinions of
record. (Doc. 21, pgs. 4-9). Plaintiff argues, in relation to each doctor’s prior
administrative medical findings, the ALJ failed to address the supportability and
consistency factors. (Doc. 21, pg. 7). Plaintiff also notes perceived inconsistencies in the

ALJ’s conclusions related to the prior administrative medical findings of Drs. Mikell and
Chang, as well as the fact that the ALJ did not evaluate Dr. Riley’s opinion at all. (Doc.
21, pgs. 5-6). Finally, Plaintiff alleges “new” evidence, obtained after the initial and
reconsideration decisions, would have impacted the doctors’ prior administrative
medical findings.8 (Doc. 21, pgs. 6-7). Plaintiff takes issue with the ALJ’s evaluation of
that evidence, allegedly without a review by a physician. (Doc. 21, pgs. 7-8).

Now, when medical sources provide prior administrative medical findings, an
ALJ must consider each of those findings together with certain enumerated factors. See
20 C.F.R. §§ 404.1520c(a), (b), (c); 416.920c(a), (b), (c). The most important factors for
evaluating the persuasiveness of prior administrative medical findings are supportability
and consistency. See id. §§ 404.1520c(a), (b)(2), (c)(1)-(2); 416.920c(a), (b)(2), (c)(1)-(2).

Therefore, at a minimum, an ALJ must explain its consideration of those two factors.9
See Christina S. v. Comm’r of Soc. Sec., No. 21-261, 2023 WL 2553928, *3 (N.D. Ind. March
17, 2023) (quoting 20 C.F.R. § 404.1520c(b)(2)). The failure to adequately discuss these
factors requires a remand. See id. (quoting Willis v. Acting Comm’r of Soc. Sec., No. 21-178,

8As best the Court can glean from his brief, Plaintiff is specifically referring, in part, to the
medical records from December 1, 2020 (x-rays assessed by Dr. Freehill at the Orthopaedic Center of
Southern Illinois), December 11, 2020 (MRI that was subsequently assessed by Dr. Freehill and Jamie
Smith, MSN, FNP, of the Orthopaedic Center of Southern Illinois), and April 8, 2021 (Report of Nerve
Conduction Study and EMG by Dr. Nemani). (Docs. 21, pg. 6; 13-7, pgs. 278, 284, 295).
9The more relevant the objective medical evidence and supporting explanations presented by a
medical source are to support his or her medical opinions, the more persuasive the medical opinions will
be. See 20 C.F.R. §§ 404.1520c(c)(1); 416.920c(c)(1). The more consistent medical opinions are with the
evidence from other medical sources and nonmedical sources in the claim, the more persuasive the
medical opinions will be. See 20 C.F.R. §§ 404.1520c(c)(2); 416.920c(c)(2).
2022 WL 2384031, *3 (N.D. Ind. July 1, 2022)). Although the ALJ “need only ‘minimally
articulate’ ” its reasoning when assessing a medical opinion, the ALJ ”must still consider

the regulatory factors and build a ‘logical bridge’ from the evidence to his conclusion.”
See id. (quoting Taylor v. Kijakazi, No. 22-32, 2023 WL 334601, *3 (N.D. Ind. Jan. 20, 2023)).
Here, before addressing the prior administrative medical findings, the ALJ
extensively detailed all of the evidence. (Doc. 13-2, pgs. 23-28). Then, with respect to Drs.
Mikell and Chang, the ALJ found each doctor’s prior administrative medical findings to
be “partially persuasive.” (Doc. 13-2, pg. 29). With respect to Plaintiff’s vision, which was

the only differing limitation between the two doctors, Dr. Mikell’s initial findings were
“more persuasive” than those of Dr. Chang on reconsideration. (Doc. 13-2, pg. 28). Dr.
Mikell’s findings were “consistent with the claimant’s limited near and far acuity and
depth perception bilaterally, which corrects with glasses to only 20/70.” (Doc. 13-2, pgs.
28-29). Further, Plaintiff’s orthopedic impairments, neuropathy in his feet, and obesity,

“support[ed] a conclusion that the claimant could function more easily seated than while
standing and walking.” (Doc. 13-2, pg. 29). The record did not show Plaintiff was unable
to perform sedentary work. (Doc. 13-2, pg. 29). To the extent there was an inconsistency
between Drs. Mikell and Chang, based on differing opinions as to Plaintiff’s ability to
stand and/or walk in a workday, the ALJ clearly found the evidence supported sedentary

work. (Docs. 13-2, pg. 29; 13-3, pgs. 8, 38). Finally, in view of Plaintiff’s pinch, arm, and
grip strength, and his ability to oppose his thumb to each finger despite carpal tunnel
syndrome, the record did not support hand locking after minimal use. (Doc. 13-2, pg. 29).
Relating to Drs. DiFonso and Hamersma, the ALJ found each doctor’s prior
administrative medical findings were “persuasive.” (Doc. 13-2, pg. 29). Each doctor found
Plaintiff’s mental impairments caused mild limitations under the “paragraph B” criteria

and, thus, were nonsevere. (Doc. 13-2, pg. 29). The prior administrative medical findings
were noted as “most consistent” with the unremarkable mental status examination and
supported by the evidence of improved symptoms with medication. (Doc. 13-2, pg. 29).
Therefore, the Court FINDS the ALJ adequately discussed the supportability and
consistency factors in relation to the prior administrative medical findings of Drs. Mikell,
Chang, DiFonso, and Hamersma. See Willis, No. 21-178, 2022 WL 2384031, *3 (the ALJ’s

“general statements” about the consistency of medical opinions, when compared to the
evidence, were “not enough,” where “the ALJ simply provided her end result…without
giving any indication of which specific evidence she considered in coming to those conclusions)
(Emphasis added.). The Court recognizes, though, the ALJ failed to mention, let alone
apply the regulatory factors to, Dr. Riley’s prior administrative medical findings, relating

only to Plaintiff’s vision. However, the Court FINDS this error was harmless. Dr. Riley
believed the visual impairment was nonsevere and had a minimal impact on functioning.
(Doc. 13-3, pg. 34). This stands in contrast to Dr. Mikell’s prior administrative medical
findings, which were more limiting and found to be “consistent with the claimant’s
limited near and far acuity and depth perception bilaterally.” (Doc. 13-2, pg. 28-29; 13-3,

pgs. 9-10). As such, the Court is “convinced that the ALJ would reach the same result on
remand.” See Lambert v. Berryhill, 896 F.3d 768, 776 (7th Cir. 2018) (citing McKinzey v.
Astrue, 641 F.3d 884, 892 (7th Cir. 2011)); see also Schomas v. Colvin, 732 F.3d 702, 707-08
(7th Cir. 2013) (stating, in response to argument that the ALJ’s silence as to the controlling
weight of one assessment over another, was the “kind of error [that] is subject to
harmless-error review, and we will not remand a case to the ALJ for further explanation

if we can predict with great confidence that the result on remand would be the same.”).
Next, the Court notes the “new” evidence noted by Plaintiff was not actually
“new” evidence, as that term is defined in the case law. See Schmidt v. Barnhart, 395 F.3d
737, 742 (7th Cir. 2005) (“Evidence is ‘new’ if it was ‘not in existence or available to the
claimant at the time of the administrative proceeding.’ [Citation].”). All of the noted
evidence was in existence and available to Plaintiff as of the hearing date, April 27, 2021.

Nevertheless, the Court understands Plaintiff’s point that additional evidence was
received by Plaintiff subsequent to the administrative medical findings of Drs. Mikell,
DiFonso, Chang, Riley, and Hamersma. (Doc. 21, pgs. 6-7). When this is the case, an ALJ
may rely on a reviewing physician’s assessment unless the subsequent evidence,
containing new and significant medical diagnoses, changed the picture so much that it

could reasonably change the reviewing physician’s opinion. See Massaglia v. Saul, 805 Fed.
Appx. 406, 410 (7th Cir. 2020) (quoting Stage v. Colvin, 812 F.3d 1121, 1125 (7th Cir. 2016));
accord Marilyn C. v. Kijakazi, No. 20-1816, 2023 WL 1862988, *13 (N.D. Ill. Feb. 9, 2023).
Here, the ALJ summarized and considered all of the evidence noted by Plaintiff
before assessing the prior administrative medical findings. (Doc. 13-2, pgs. 25, 27).

Further, the ALJ did not “play doctor,” by interpreting the medical evidence on its own.
See McHenry v. Berryhill, 911 F.3d 866, 871 (7th Cir. 2018) (quoting Goins v. Colvin, 764 F.3d
677, 680 (7th Cir. 2014)). To the contrary, in its discussion of the evidence, the ALJ relied
on the assessments contained in the records of Plaintiff’s treating physicians. (Docs. 13-2,
pgs. 25, 27). For example, the x-rays obtained on December 1, 2020, were assessed by Dr.
Freehill, who stated “I personally reviewed these x-rays and these are my findings.” (Doc.

13-7, pg. 285). The MRI obtained on December 11, 2020, was reviewed by both Jamie
Smith, MSN, FNP, and Dr. Freehill, who again noted “I personally reviewed these x-rays
and these are my findings.” (Docs. 13-7, pgs. 278, 281). The Report of Nerve Conduction
Study and EMG of Dr. Nemani included a summary and supported diagnoses. (Doc. 13-
7, pg. 295). For these reasons, the Court FINDS the ALJ did not err in its consideration of
or reliance on the prior administrative medical findings after discussing all of the record

evidence. See Marilyn C., No. 20-1816, 2023 WL 1862988, *13 (the ALJ did not commit
reversible error by relying on the state-agency physicians’ opinions, despite later
evidence that the plaintiff’s vision worsened before improving and stabilizing, where
“the ALJ carefully considered the evidence [that] the state-agency physicians did not
review and [then] reasonably concluded that the physicians’ assessments [we]re

consistent with the record as a whole.”); Durham v. Kijakazi, 53 F.4th 1089, 1096 (7th Cir.
2022) (noting, while the plaintiff claimed testing rendered prior medical opinions stale,
the results of that testing, as interpreted by the plaintiff’s physicians and not the ALJ, did
not reveal a worsening condition that required resubmission to a medical expert).
For these reasons, the Court CONCLUDES that the ALJ did not err in its

consideration of the medical opinions of record.
C. Plaintiff’s Subjective Complaints of Pain
Third, Plaintiff argues the ALJ improperly considered his subjective complaints of
pain. (Doc. 21, pgs. 9-12). Plaintiff notes the ALJ never found his severe impairments were
not reasonably expected to produce pain and the medical records note his complaints of
pain. Further, the ALJ concluded Plaintiff performed light exertional work around the

house but did not explain how that work was inconsistent with the complaints of pain.
(Doc. 21, pg. 11). Plaintiff argues the ALJ dismissed his subjective complaints of pain and
made findings that were not supported by substantial evidence. (Doc. 21, pgs. 10-12).
The Court may overturn a credibility finding only if it was “patently wrong.” See
Pepper, 712 F.3d at 367 (quoting Craft, 539 F.3d at 678). But an ALJ must “adequately
explain his credibility finding by discussing specific reasons supported by the record.”

See id. at 367 (citing Terry v. Astrue, 580 F.3d 471, 477 (7th Cir. 2009)). Factors relied upon
by the ALJ in this analysis, which must be based on “the entire case record,” include the
claimant’s daily activities, level of pain or symptoms, precipitating and aggravating
factors, medication, treatment and measures of relief, and other limitations. See Villano v.
Astrue, 556 F.3d 558, 562 (7th Cir. 2009); Simon–Leveque, 229 F. Supp. 3d at 790-91; 20 C.F.R.

§§ 404.1529(c)(3); 416.929(c)(3). Statements of pain or other symptoms are considered, but
they are not conclusive of a disability. See 42 U.S.C. § 423(d)(5)(A); 20 C.F.R.
§§ 404.1529(a); 416.929(a). However, a claimant’s testimony about pain and limitations
may not be discredited solely because there is no objective medical evidence supporting
the testimony. See Villano, 556 F.3d at 562 (citing 20 C.F.R. § 404.1529(c); S.S.R. 96-7p;

Johnson v. Barnhart, 449 F.3d 804, 806 (7th Cir. 2006); Clifford, 227 F.3d at 871-72).
Here, in its RFC assessment, the ALJ summarized its process for considering
Plaintiff’s symptoms, including pain. (Doc. 13-2, pg. 23). The ALJ also summarized, in
detail, Plaintiff’s reported effects of conditions, activities of daily living, hearing
testimony, diagnostic imaging, laboratory findings, treatment records and assessments,
diagnoses, attempts at treatment through physical therapy, prescriptions, and

aggravating factors. (Doc. 13-2, pgs. 23-27). All along the way, the ALJ detailed his
subjective complaints of pain. (Doc. 13-2, pgs. 23-27). However, after this thorough
review of the record, the ALJ found Plaintiff’s statements about his symptoms were “not
entirely consistent” with the evidence. (Doc. 13-2, pg. 24). Those statements did not
support Plaintiff’s alleged loss of functioning, as his allegations were “greater than
expected in light of the objective clinical evidence and treatment notes.” (Doc. 13-2, pg.

24). The inconsistencies “detract[ed] from [his] subjective allegations.” (Doc. 13-2, pg. 24).
Critically, the ALJ provided examples of these inconsistencies. (Doc. 13-2, pgs. 24-
25). Despite the record evidencing certain impairments, Plaintiff did not require the use
of an assistive device to walk, he could ambulate for 50 feet, marijuana helped with his
pain, and he could drive. (Doc. 13-2, pg. 24). Further, Plaintiff’s activities of daily living,

which have been discussed extensively in this Memorandum & Order, demonstrated he
could and did “perform light exertional level work.” See Pepper, 712 F.3d at 369 (“The ALJ
concluded that, taken together, the amount of daily activities [the plaintiff] performed,
the level of exertion necessary to engage in those types of activities, and the numerous
notations in [the plaintiff’s] medical records regarding her ability to engage in activities

of daily living undermined [her] credibility when describing her subjective complaints of
pain and disability,” which were “exactly the type of factors the ALJ was required to
consider”). (Doc. 13-2, pg. 27). Also, there was “no objective exam findings to support [a]
greater functional limitation.” (Doc. 13-2, pg. 27). Therefore, the Court FINDS the ALJ
adequately explained its credibility finding, which was not “patently wrong” under the
factors articulated in the regulations and case law. See Pepper, 712 F.3d at 368 (holding the
ALJ sufficiently justified its credibility finding, where, despite some “boilerplate,” the
AL] discussed the plaintiff's testimony in conjunction with the RFC statement, noted the
plaintiff's physical abilities fell within the light work category, described the plaintiff's
testimony on her daily activities and the exacerbation of pain and symptoms from sitting
or standing for extended periods of time or engaging in excessive bending, and discussed
the plaintiff's testimony that medication was somewhat effective).
Therefore, the Court CONCLUDES the ALJ properly considered Plaintiff's
subjective complaints of pain and rendered findings supported by substantial evidence.
VI. Conclusion
For these reasons, the Court AFFIRMS the final agency decision of Defendant. The
Clerk of the Court is DIRECTED to enter judgment for Defendant and against Plaintiff.
SO ORDERED.
Dated: March 31, 2023.

DAVID W. DUGAN
United States District Judge

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10646007. Public record. Not legal advice.