1

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ILLINOIS

WESTERN DIVISION

Nicole P., )

 )

Plaintiff, )

 ) Case No. 3:20-cv-50245

v. )

 ) Magistrate Judge Lisa A. Jensen

Kilolo Kijakazi, )

Acting Commissioner of Social Security,1

 )

 )

Defendant. )

MEMORANDUM OPINION AND ORDER

Plaintiff Nicole P. brings this action under 42 U.S.C. § 405(g) seeking a remand of the 

decision denying her disability insurance benefits.

2 For the reasons set forth below, the 

Commissioner’s decision is reversed, and this case is remanded.

I. Background

In September 2013, Plaintiff filed an application for disability insurance benefits alleging 

a disability beginning on August 2, 2010, because of degenerative disc disease, facet joint disease, 

disc bulge, back injury, anxiety, arthritis, spinal stenosis, and nasal disease. R. 142, 236. Plaintiff

last worked as a caretaker for individuals with disabilities. However, in August 2009 Plaintiff 

suffered a work-related injury to her lower back. Plaintiff continued working, but she was injured 

again in June 2010. On August 2, 2010, Plaintiff stopped working because of her impairments.

Although Plaintiff sought treatment for her back, she continues to complain of disabling pain.

1 Kilolo Kijakazi has been substituted for Andrew Marshall Saul. Fed. R. Civ. P. 25(d).

2 The parties have consented to the jurisdiction of a United States Magistrate Judge for all proceedings 

pursuant to 28 U.S.C. § 636(c).

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Following a hearing, an administrative law judge (“ALJ”) issued a decision in 

October 2016, finding that Plaintiff was not disabled. R. 18-28. Plaintiff subsequently challenged 

the ALJ’s decision in the district court. In October 2018, pursuant to the parties’ agreed motion, 

the case was remanded for a new decision. R. 868. The remand order directed the ALJ to reevaluate 

Plaintiff’s sleep and mental impairments, the medical opinions, and Plaintiff’s subjective 

statements.

Following remand, in August 2019, Plaintiff testified at another hearing before the same 

ALJ that issued the first decision. Plaintiff’s testimony focused on her back pain, sleep issues, and 

mental health issues. In March 2020, the ALJ issued a second decision again finding that Plaintiff 

was not disabled. R. 789-801. The ALJ found that Plaintiff had the following severe impairments:

lumbar fact arthropathy, depression, parasomnia, hypersomnia, sleep-related eating disorder, sleep 

apnea, and obesity. The ALJ determined that through Plaintiff’s date last insured, namely 

December 31, 2014, her impairments did not meet or medically equal a listed impairment. The 

ALJ concluded that Plaintiff had the residual functional capacity (“RFC”) to perform light work 

with certain restrictions. Plaintiff was 35 years old on her date last insured.

Plaintiff appeals the ALJ’s decision arguing that the ALJ erred in analyzing the testifying 

medical expert’s opinions, her father’s statement, and the RFC. Therefore, this Court will focus on 

the evidence relevant to the ALJ’s evaluation of these issues in the discussion below.

II. Standard of Review

A reviewing court may enter judgment “affirming, modifying, or reversing the decision of 

the [Commissioner], with or without remanding the cause for a rehearing.” 42 U.S.C. § 405(g). If 

supported by substantial evidence, the Commissioner’s factual findings are conclusive. Id.

Substantial evidence consists of “such relevant evidence as a reasonable mind might accept as 

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adequate to support a conclusion.” Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019). Accordingly, 

the reviewing court is not to “reweigh evidence, resolve conflicts, decide questions of credibility, 

or substitute [its] judgment for that of the Commissioner.” Burmester v. Berryhill, 920 F.3d 507, 

510 (7th Cir. 2019).

However, the Seventh Circuit has emphasized that review is not merely a rubber stamp. 

Scott v. Barnhart, 297 F.3d 589, 593 (7th Cir. 2002) (a “mere scintilla” is not substantial evidence). 

A reviewing court must conduct a critical review of the evidence before affirming the 

Commissioner’s decision. Eichstadt v. Astrue, 534 F.3d 663, 665 (7th Cir. 2008). Even when 

adequate record evidence exists to support the Commissioner’s decision, the decision will not be 

affirmed if the Commissioner does not build an accurate and logical bridge from the evidence to 

the conclusion. Berger v. Astrue, 516 F.3d 539, 544 (7th Cir. 2008). Moreover, federal courts 

cannot build a logical bridge on behalf of the ALJ. See Mason v. Colvin, No. 13 C 2993, 2014 WL 

5475480, at *5-7 (N.D. Ill. Oct. 29, 2014).

III. Discussion

Plaintiff argues that remand is required because the ALJ: (1) improperly rejected the 

testifying medical expert’s opinions; (2) improperly rejected her father’s statement; and (3) 

determined an RFC that was unsupported by substantial evidence.

A. Medication Side Effects

Plaintiff argues that the ALJ improperly adopted the testimony of the medical expert that 

testified at the first hearing, Dr. Ronald Semerdjian, over the testimony of the expert that testified 

at the second hearing, Dr. Alvin Stein. Although both experts testified that Plaintiff’s impairments

did not meet or equal a listed impairment, Plaintiff takes issue with the ALJ’s rejection of Dr. 

Stein’s additional testimony that the side effects of Plaintiff’s current medications would prevent 

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her from working a full-time job. For the reasons stated below, this Court finds that a remand is 

required.

At the first administrative hearing in October 2015, the ALJ called Dr. Semerdjian, a 

medical expert board certified in internal medicine and pulmonary disease, to testify about 

Plaintiff’s physical impairments. Dr. Semerdjian testified that Plaintiff’s impairments did not meet 

or equal a listed impairment; however, her chronic pain caused functional limitations that limited 

her to light work with certain restrictions. R. 72-73.

At the second administrative hearing in August 2019, the ALJ called a new medical expert, 

Dr. Stein, who was board certified in internal medicine and medical oncology. Dr. Stein testified 

that although Plaintiff’s physical impairments did not meet or equal a listed impairment, the six 

medications Plaintiff was currently taking for her pain and mental health issues caused side effects 

that would prevent her from working a full-time job. R. 842-48. Dr. Stein identified the following 

medications Plaintiff was taking at the time of the hearing: gabapentin, bupropion (an 

antidepressant), Celexa (an antidepressant), alprazolam (Xanax), cyclobenzaprine (a muscle 

relaxant), and hydrocodone with Tylenol (Norco). R. 842. Dr. Stein admitted that, other than 

hydrocodone, he did not know which medications Plaintiff was taking between August 2010 and 

December 2014. R. 842, 849.

Dr. Stein opined that Plaintiff’s medications “are definitely causing neurocognitive effects, 

memory problems, drowsiness, confusion and she is on six central nervous system acting drugs, 

any one of which can cause fatigue, tiredness, drowsiness.” R. 842. Dr. Stein based his opinion on 

his experience with patients taking a combination of the six medications and Plaintiff’s testimony 

at the hearing. R. 851. Dr. Stein found that Plaintiff sounded sedated at the hearing and referenced 

her slurred speech and slow thought process. R. 846. Dr. Stein further opined that aside from the 

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side effects caused by Plaintiff’s medications, she would be able to perform light work with certain 

restrictions. R. 846.

In evaluating this opinion evidence, the ALJ gave great weight to Dr. Semerdjian’s opinion

because:

it is based on a review on the entirety of the record. He had the opportunity to listen 

to the claimant’s testimony, as well as observe her. As a medical expert who is 

experienced in providing testimony for disability hearings, he also has a familiarity 

with the regulations that allows her [sic] to offer insight into the various ways an

impairment might restrict an individual’s ability to function. Finally, the medical 

expert’s testimony is consistent with the medical evidence of record.

R. 798. The ALJ gave little weight to Dr. Stein’s opinion that Plaintiff would not be able to sustain 

full-time employment for three main reasons:

First, Dr. Stein specializes in internal medicine, and is, therefore, not able to provide 

accurate testimony on the claimant’s mental health impairments. Second, Dr. 

Stein’s observations of the claimant at the August 2019 hearing do not apply to her 

ability to function prior to the date-last-insured of December 31, 2014. Dr. Stein 

noted that there was no evidence prior to December 31, 2014 of the claimant 

complaining of the side effects he felt would render her disabled, i.e., medication

induced sedation. Finally, Dr. Stein admitted that he based that opinion on the 

claimant’s current presentation at the August 2019 hearing where he heard the 

claimant’s “slowing words” when she testified. When questioned what mental 

health medications and narcotics claimant took prior to the date-last-insured, he 

testified that he did not know and that he was basing his opinion on the claimant’s 

presentation at the August 2019 hearing, which, as noted, is nearly five years after

the date-last-insured.

R. 798.

The Commissioner argues that the ALJ provided sufficient reasons for discounting Dr. 

Stein’s opinion and properly considered the impact of medication side effects. This Court 

disagrees.

The ALJ largely discounted Dr. Stein’s opinion as irrelevant because the period of 

disability at issue was between August 2010 and December 2014, and Dr. Stein based his opinion 

on Plaintiff’s testimony at the August 2019 hearing and the medications she was taking at that 

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time. Yet, the ALJ made no attempt to determine if Plaintiff was or was not on these or similar 

medications during the relevant period based on a review of the record. This is not a case where 

there was no evidence in the record to determine what medications Plaintiff was taking. The 

medical records show that Plaintiff had consistently been taking Norco, Xanax, and Celexa, along 

with other pain medication, muscle relaxers, and antidepressants, throughout the relevant period. 

See, e.g., R. 384, 393, 444, 495, 500, 511, 538, 692, 698, 716. Additionally, at the August 2019 

hearing Plaintiff testified that she had been taking medication for her anxiety and depression, 

including Xanax, since 2010. R. 826-27. At the first hearing in October 2015, Plaintiff also 

testified that she had been taking Norco, Celexa, and Xanax since 2010. R. 48-49.

Moreover, although Dr. Stein testified that the combination of medications increases the 

likelihood that Plaintiff would suffer from medication side effects, any one medication could cause 

the side effects he described. R. 856. Dr. Stein also testified that Plaintiff was taking Norco for at 

least 10 years. R. 842. However, the ALJ did not address this portion of Dr. Stein’s testimony or 

otherwise indicate that she did or not did not believe that Plaintiff was taking Norco during the 

relevant period.

The ALJ also discounted Dr. Stein’s opinion because he specialized in internal medicine

and therefore was “not able to provide accurate testimony on the claimant’s mental health 

impairments.” The fact that Dr. Stein was an internist is not enough to discount his opinion

completely. A medical source’s specialty is just one factor to consider when evaluating the 

opinion. See 20 C.F.R. § 404.1527(c)(5).

3 Even considering this factor, Dr. Stein’s testimony 

3 The Social Security Administration has modified how they evaluate medical opinions. However, the new 

regulations apply only to disability applications filed on or after March 27, 2017. Compare 20 C.F.R. § 

404.1527 (“For claims filed (see § 404.614) before March 27, 2017, the rules in this section apply.”) with

20 C.F.R. § 404.1520c (“For claims filed (see § 404.614) on or after March 27, 2017, the rules in this 

section apply.”). Plaintiff’s application in this case was filed in 2013. Accordingly, this Court will reference 

20 C.F.R. § 404.1527.

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focused on the side effects of Plaintiff’s pain and mental health medications, and only briefly 

addressed Plaintiff’s mental health issues. However, the focus of Dr. Stein’s testimony was that 

Plaintiff’s “major impairments which keep her from being able to work are the drugs which she’s 

taking.” R. 842, 846. Dr. Stein testified that he based his testimony on his experience with patients 

taking a similar combination of Plaintiff’s medications. R. 851. Again, the ALJ did not explain 

why Dr. Stein’s experience would not qualify him to discuss the impact of Plaintiff’s medications.

If the ALJ found Dr. Stein unqualified because he was an internist, she should have summoned a 

qualified medical expert.

As Plaintiff points out, there is no medical opinion in the record that conflicts with Dr. 

Stein’s testimony regarding the functional impact of Plaintiff’s medications. Dr. Semerdjian, 

whose opinion the ALJ afforded great weight, did not consider the impact Plaintiff’s medications 

would have on her RFC. Dr. Semerdjian testified only that he did not recall any specific references 

to the side effects of Plaintiff’s medications in the record. R. 77.

Nevertheless, the Commissioner relies on this lack of evidence in Plaintiff’s medical 

records to assert that “plaintiff’s claim that medication side effects were not properly considered 

must fail.” Defendant’s Response at 7, Dkt. 25. However, the ALJ’s brief reference to the lack of 

evidence in the medical records fails to address Dr. Stein’s testimony that the lack of such evidence 

was not unusual because Plaintiff’s treaters were likely concerned with her back pain and may not 

have spoken with her enough to get a sense of her neurocognitive impairment or side effects from 

other drugs she was taking. R. 851. While Plaintiff’s failure to report side effects to her treaters 

would have been a factor for the ALJ to consider in evaluating whether Plaintiff’s alleged 

symptoms are consistent with the record, the ALJ made no attempt to analyze this evidence. See

20 C.F.R. § 404.1529(c)(3)(iv) (requiring the ALJ to consider “[t]he type, dosage, effectiveness, 

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and side effects of any medication”); see also SSR 16-3p, 2016 WL 1119029. The ALJ also failed 

to evaluate, or even mention, other evidence in the record that Plaintiff experienced side effects 

from her medications. See 20 C.F.R. § 404.1527(c)(3) (stating that in assigning weight to an 

opinion, the ALJ must consider consistency “with the record as a whole”). This evidence included 

Plaintiff’s statements in her disability reports, Plaintiff’s testimony at the first and second 

administrative hearing, and Plaintiff’s father’s statement. See R. 60, 257, 275, 291, 305, 309, 820, 

827, 835-36. Although the ALJ generally discounted Plaintiff’s and her father’s statements as 

inconsistent with the record, the ALJ did not address medication side effects.

The ALJ had a duty to develop a fair and complete record regarding the functional impact 

of Plaintiff’s medications and could not just ignore evidence in the record suggesting that Plaintiff 

suffered from side effects of her medications without explanation. See Yurt v. Colvin, 758 F.3d 

850, 859 (7th Cir. 2014) (explaining that the Seventh Circuit has “repeatedly forbidden” ALJs 

from cherry-picking only the medical evidence that supports their conclusions.”); Dunn v. Saul, 

794 Fed. App’x 519, 522 (7th Cir. 2019) (“Although under no obligation to address every piece of 

evidence in the record, an ALJ may not ignore an entire line of evidence contrary to his ruling.”) 

(internal citation omitted). If the ALJ considered the impact of medication side effects and found 

it unsupported, she should have said as much in her decision instead of omitting any discussion of 

side effects when considering Dr. Stein’s opinion and Plaintiff’s RFC. Accordingly, a remand is 

required for the ALJ to properly consider the impact that medication side effects would have on 

Plaintiff’s RFC. On remand, the ALJ should call a qualified medical expert who can review the 

medical record and opine about the combined effect of Plaintiff’s various medications on her 

ability to work. See Martinez v. Astrue, 630 F.3d 693, 697-98 (7th Cir. 2011) (faulting the ALJ for 

not considering the interaction of the claimant’s physical and mental problems because “[e]ven if 

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each problem assessed separately were less serious than the evidence indicates, the combination 

of them might well be totally disabling”).

B. Father’s Statement

Plaintiff also argues that the ALJ improperly evaluated the statement of her father. In 

September 2014, Plaintiff’s father submitted a third-party function report wherein he stated that 

Plaintiff’s pain, sleep issues, and depression limited her ability to complete activities of daily 

living. R. 296-305. Plaintiff’s father also filled out the section of the form relating to Plaintiff’s 

functional limitations and specified that Plaintiff’s conditions limited her ability to lift, squat, bend, 

stand, reach, walk, sit, kneel, climb stairs, remember, complete tasks, and concentrate. R. 302.

The ALJ afforded little weight to the statement of Plaintiff’s father for the following 

reasons:

First, since Mr. [P.] is not medically trained to make exacting observations as to

dates, frequencies, types and degrees of medical signs and symptoms, or of the 

frequency or intensity of unusual moods or mannerisms, the accuracy of her [sic] 

observations is questionable. Moreover, by virtue of his relationship as the 

claimant’s father, his statements cannot be considered the observations of a 

disinterested third party witness whose opinion would not tend to be colored by 

affection for the claimant and a natural tendency to agree with the symptoms and 

limitations the claimant alleges. Most importantly, significant weight cannot be 

given to this opinion because it, like the claimant’s allegations, is simply not 

consistent with the preponderance of the opinions and observations by medical 

doctors in this case.

R. 799.

As Plaintiff points out, the regulations allow an ALJ to consider statements from third 

parties, including family members. See 20 C.F.R. § 404.1529(a), (c)(3); 

20 C.F.R. § 404.1545(a)(3); SSR 16-3p, 2016 WL 1119029, at *7. Plaintiff argues, however, that 

the ALJ improperly discounted her father’s statement because he was not medically trained and 

was not a disinterested third party. The Commissioner’s only argument in response is that nothing 

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prohibits the ALJ from considering these factors. Defendant’s Response at 15, Dkt. 25. The 

Commissioner then makes the conclusory argument that because the ALJ found that Plaintiff’s 

father’s statement was not consistent with the medical opinions, the ALJ did not err in giving little 

weight to his statement.

The fact that Plaintiff’s father was not medically trained to “make exacting observations” 

of Plaintiff’s impairments by itself is not a proper basis to discount his statement. See Dunn, 794 

Fed. App’x at 523 (“[T]he ALJ’s explanation that he discounted the daughter’s testimony because 

she was not a medical professional does not adequately explain his decision to give little weight 

to her testimony.”); Sylvia C. v. Saul, No. 19 C 0624, 2020 WL 1189290, at *8 (N.D. Ill. Mar. 12, 

2020) (“The regulations permit testimony from ‘other persons’ such as family members without 

requiring them to have medical training.”) (citation omitted). Between 2013 and 2014, Plaintiff 

was living with her father. R. 42, 445, 829-30. Accordingly, at the time Plaintiff’s father submitted 

his statement in September 2014, he would have been very familiar with Plaintiff’s functional 

limitations. Additionally, while Plaintiff’s father is not a disinterested third-party, his familial

relationship with Plaintiff alone is not a valid reason to discount the symptoms and limitations he 

outlined in his statement. See Sylvia C., 2020 WL 1189290, at *8 (“It would be both unfair and 

inefficient for the SSA to seek this type of third-party evidence and then automatically discount it 

based on the claimant’s relationship with the third parties from whom the evidence is sought.”).

The ALJ also discounted the statement from Plaintiff’s father because it was “not consistent 

with the preponderance of the opinions and observations by medical doctors in this case.”

Although consistency with the medical opinions in the record is a valid basis to evaluate a thirdparty statement, the ALJ failed to explain any inconsistency. See Garcia v. Colvin, 741 F.3d 758, 

761 (7th Cir. 2013) (holding the ALJ erred in discounting testimony based on a familial 

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relationship without explaining what part of the testimony is credible and what is not). An ALJ 

cannot simply say that “statements about the individual’s symptoms are (or are not) supported [by] 

or consistent” with the record. SSR 16-3p, 2016 WL 1119029, at *9. There were several medical 

opinions provided in this case. Without further explanation from the ALJ, this Court cannot trace 

the path of the ALJ’s reasoning for discounting Plaintiff’s father’s statement. Accordingly, upon 

remand the ALJ should identify which statements from Plaintiff’s father she did or did not find 

consistent with the evidence or medical opinions in the record.

C. RFC

Lastly, Plaintiff argues that the ALJ’s RFC determination is not based on substantial 

evidence because the ALJ failed to properly analyze the statements from Dr. Stein, Plaintiff, and 

Plaintiff’s father. Specifically, Plaintiff argues that the ALJ failed to account for the side effects of 

her medications and her need to frequently shift positions, take breaks, and lie down to reduce her 

pain. Because the Court is remanding for the ALJ to properly evaluate the opinion from Dr. Stein, 

the impact of any side effects from Plaintiff’s medications, and the statements from Plaintiff’s 

father, the ALJ will be required to reassess the RFC determination. Accordingly, this Court will 

not address Plaintiff’s specific arguments relating to the RFC. However, on remand, the ALJ 

should fully account for and explain the reasons for including or not including limitations in the 

RFC relating to the side effects of Plaintiff’s medications and her need to frequently shift positions, 

take breaks, and lie down to reduce her pain based on a thorough evaluation of the evidence in the 

record and Plaintiff’s subjective symptoms.

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IV. Conclusion

For the foregoing reasons, Plaintiff’s motion for summary judgment is granted, and the 

Commissioner’s motion is denied. The decision of the Commissioner is reversed, and the case is 

remanded for further proceeding consistent with this opinion.

Date: August 2, 2021 By: ______________________

Lisa A. Jensen

United States Magistrate Judge

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