                        NONPRECEDENTIAL DISPOSITION
                To be cited only in accordance with Fed. R. App. P. 32.1




               United States Court of Appeals
                                For the Seventh Circuit
                                Chicago, Illinois 60604

                              Argued November 17, 2015
                              Decided December 7, 2015

                                          Before

                           JOEL M. FLAUM, Circuit Judge

                           FRANK H. EASTERBROOK, Circuit Judge

                           DAVID F. HAMILTON, Circuit Judge

No. 15-1254

DEBORAH SLAYTON,                               Appeal from the United States District Court
    Plaintiff-Appellant,                       for the Western District of Wisconsin.

      v.                                       No. 14-cv-117-bbc

CAROLYN W. COLVIN,                             Barbara B. Crabb,
Acting Commissioner of Social Security,        Judge.
      Defendant-Appellee.

                                       ORDER

       Deborah Slayton applied for Disability Insurance Benefits and Supplemental
Security Income claiming disability from several impairments. An administrative law
judge denied benefits (a decision upheld by the district court). The ALJ found that
Slayton was exaggerating the extent of her symptoms and concluded that, in fact, she is
able to perform unskilled, light work with certain restrictions. Because the ALJ’s
credibility assessment is not patently wrong and is supported by substantial evidence,
we uphold the denial of benefits.
No. 15-1254                                                                         Page 2

        Slayton applied for benefits in April 2011 alleging an onset date in May 2009. Her
date last insured was in September 2009. Slayton identified four impairments affecting
her ability to work: hepatitis C; chronic obstructive pulmonary disease; arthritis, causing
pain in her shoulders, knees, and elbows; and pain of unspecified origin in her lower
back, hip, and tailbone. Before her onset date she had worked sporadically at several
jobs, including cleaning and laundry services. The Social Security Administration denied
Slayton’s application initially in August 2011 and again on reconsideration in May 2012.
Her hearing before the ALJ was in July 2013.

       Slayton’s back pain had begun in 2001. An occupational medical specialist who
examined Slayton at that time saw nothing in the results of an MRI explaining the
amount of pain she reported. The physician noted “a lot of psychological overlay and
overreaction to her pain level.” 1 She cleared Slayton to return to work but imposed a
few days’ restrictions on lifting and bending. The record contains no evidence about
what, if any, medical care Slayton sought between this evaluation in 2001 and her next
general checkup in 2010.

       At that routine checkup in October 2010, Slayton told a nurse practitioner that she
was experiencing joint paint, but the provider concluded that Slayton was not in acute
distress and did not find any neurologic or musculoskeletal abnormality. Then in
February 2011, two months before Slayton applied for benefits, she switched providers.
Dr. Robert Nogler, her new personal physician, performed an initial exam and
diagnosed degenerative joint disease and a history of “asthma/chronic obstructive
pulmonary disease.” He prescribed an anti-inflammatory drug and an inhaler.

       Although Slayton had not complained about symptoms indicative of hepatitis C,
Dr. Nogler referred her to a hematologist because routine blood work had shown an
abnormality. Slayton then disclosed to the specialist that she had been diagnosed with
hepatitis C in the 1980s but never treated. Lab tests in March 2011 confirmed hepatitis C.
Since that time Slayton has not been treated for the condition because her low platelet




      1
         Psychological overlay, sometimes called functional overlay, refers to subjective
experiences of pain that cannot be explained by diagnostic findings. See, e.g., Ron
Lechnyr, Ph.D, D.S.W. & Henry H. Holmes, M.D., Taxonomy of Pain Patient Behavior,
PRACTICAL PAIN MANAGEMENT, December 28, 2011, http://www.practicalpain
management.com/treatments/psychological/taxonomy-pain-patient-behavior; Functional
Overlay, MOSBY’S MEDICAL DICTIONARY (8th ed. 2009).
No. 15-1254                                                                         Page 3

count would worsen the side effects of medication intended to forestall liver cirrhosis. 2
Her condition was monitored, though, and in March 2012, September 2012, and
May 2013 she reported generalized fatigue but no other symptoms. Lab tests in
May 2013 showed “evidence of cirrhosis,” but Slayton’s gastroenterologist simply
recommended imaging twice yearly to monitor the situation.

       In June 2011 a specialist in physical medicine and rehabilitation, Dr. Eric Carlsen,
performed a “Social Security Consultative Exam” at the request of the state agency. He
concluded that Slayton probably suffers from osteoarthritis of the knees 3 and lumbar
spondylosis. 4 He noted “functional overlay on exam, which might be related to pain or
anxiety.” He found that her gait was normal, that she had diffuse giveaway weakness 5
but displayed “4/5” muscle strength 6 “with coaxing,” and that she could reach overhead



       2 Slayton has been advised to take Telaprevir, should her platelet count allow it,
to “reduce and prevent cirrhosis-related complications.” See E. Ogawa, et al.,
Telaprevir-Based Triple Therapy for Chronic Hepatitis C Patients With Advanced Fibrosis,
ALIMENT PHARMACOL THER., 2013, at 1076–85, http://www.medscape.com/
viewarticle/812834.

       Osteoarthritis occurs when protective cartilage on the ends of bones wears
       3

down over time. Osteoarthritis, STEDMAN’S MEDICAL DISCTIONARY 1282 (27th ed. 2000).

       4
        Lumbar spondylosis is not a clinical diagnosis but a general term used to
describe any manner of spine degeneration or arthritis. See Spondylosis: What It Actually
Means, SPINE-HEALTH, http://www.spine-health.com/conditions/lower-back-pain/
spondylosis-what-it-actually-means (visited November 25, 2015).

       5
         “Giveaway weakness” may be a sign of exaggeration of pain. See Simila v.
Astrue, 573 F.3d 503, 508 (7th Cir. 2009) (citing MURIEL D. LEZAK ET AL.,
NEUROPSYCHOLOGICAL ASSESSMENT 326 (4th ed. 2004) (“Neurological examiners
repeatedly noted give-away weakness (poor effort on strength testing) indicating that
[the patient] was actively preserving a disability status.”)).

       6 The Medical Research Council grades muscle strength on a scale of 0 (no
movement) to 5 (contracting normally against full resistance). Grade 4 indicates that
muscle strength is reduced but muscle contraction can still move the joint against
resistance. See Medical Research Council Scale for Muscle Strength, MEDICAL CRITERIA,
No. 15-1254                                                                        Page 4

and do fine finger movements. He acknowledged that Slayton might be unable to
perform heavy manual labor or engage in frequent bending, squatting, or stooping. A
second state-agency consultant reviewed Slayton’s medical records in August 2011 and
opined that she could do light work with some restrictions and could perform her past
relevant work at a laundry.

       The SSA denied benefits soon after receiving these opinions. From then on
Slayton reported worsening back pain. In October 2011 she consulted another new
physician, rheumatologist Marlon Navarro, and reported a “constant, 8 out of 10
intensity dull ache” that had lasted a week. Dr. Navarro observed that Slayton’s gait and
her range of motion in the lumbar area were normal, and he noted that the etiology of
her back pain was unclear. He prescribed a gel for her lower back. Slayton returned to
Navarro later complaining that the pain had not improved; he ordered an X-ray but
found nothing significant.

       In 2012, while her request for reconsideration was pending, Slayton began
seeking treatment for hip and tailbone pain. In March of that year she returned to
Dr. Navarro reporting pain in her hips that had persisted for 30 years, and pain in her
tailbone that she reported experiencing for the previous 2 years. Navarro reviewed an
MRI of Slayton’s pelvis and found some trochanteric bursitis. 7 An MRI and an X-ray of
the lumbar spine showed some joint degeneration, while X-rays of the pelvis were
negative. Navarro injected a steroid into her hips, recommended a donut cushion, and
referred Slayton to a pain clinic. The pain clinic performed a ganglion impar block, 8 and
Slayton reported a 50% improvement in her pain.

        A second state-agency physician reviewed Slayton’s medical records in May 2012
and opined that she could perform her past work or other light work with some
restrictions. That same month the SSA denied reconsideration of its initial decision.

http://www.medicalcriteria.com/site/en/criteria/64-neurology/238-neuromrc.html
(visited November 25, 2015).

      7  Trochanteric bursitis is inflammation of the fluid-filled sac near the hip joint.
See Trochanteric Bursitis, CLEVELAND CLINIC, https://my.clevelandclinic.org/health/
diseases_conditions/hic_Bursitis/hic_Trochanteric_Bursitis (visited November 25, 2015).

      8
         A ganglion impar block is an injection in the tailbone to block nerve endings
that cause pain. See Ganglion Impar Sympathetic Nerve Blocks, MEDSCAPE, http://
emedicine.medscape.com/article/309486-treatment#d11 (visited November 25, 2015).
No. 15-1254                                                                        Page 5

       Afterward, Slayton’s complaints of pain and associated treatment expanded
further in scope. Days later she returned to Dr. Navarro complaining of severe knee
pain, and he injected a steroid into both knees. Then in September 2012 she returned to
Dr. Carlsen, whose role had shifted from consultant for the state agency to treating
physician. Slayton reported pain and numbness in her right arm, but Carlsen could not
find evidence of a problem. Also that month Slayton returned to Navarro complaining of
pain in her neck and shoulders and numbness in her hands. He could not explain these
symptoms and ordered an MRI of Slayton’s spine, which showed two small disc
protrusions but no sign of spinal canal degeneration or other abnormality. Navarro
recommended an analgesic cream and visits to a physical therapist or pain clinic.

        Elbow pain was next. Slayton complained of chronic elbow pain in an April 2013
visit to Dr. Carlsen, who suspected only “medial epicondylitis,” known as “golfer’s
elbow” or “suitcase elbow.” 9 Carlsen also observed “functional overlay” possibly linked
to “pain, anxiety, or desire for acknowledgment of disability.” He noted in the file that
Slayton had arrived wearing unnecessary arm braces and that she might be entering “a
downward spiral of chronic pain syndrome.” Another MRI and X-ray were normal, and
Carlsen simply recommended ice and anti-inflammatories for Slayton’s elbows.

        Slayton continued to report severe shoulder and knee pain in the months leading
to her hearing before the ALJ. An MRI in May 2013 identified severe acromioclavicular
arthritis 10 in both shoulders. Slayton was referred to orthopedic surgeon Glen Rudolph,
who treated her pain with injections in both shoulders. Tests in June 2013 showed a
meniscus tear in Slayton’s right knee, which required arthroscopic surgery. After that


      9
         Medial epicondylitis is strain of the muscles from elbow to wrist caused by
repetitive or excessively forceful movement such as swinging a golf club or carrying a
heavy suitcase. Ceasing the activity that caused the strain and ice or anti-inflammatories
are common treatments. See Medial Epicondylitis (Golfer's and Baseball Elbow), JOHNS
HOPKINS MEDICINE, www.hopkinsmedicine.org/healthlibrary/conditions/orthopaedic_
disorders/medial_epicondylitis_golfers_and_baseball_elbow_85,P00928/ (visited
November 25, 2015).

      10
          Acromioclavicular arthritis results when the cartilage between the two bones in
the shoulder wears away. See Acromioclavicular (AC) Joint Problems, JOHNS HOPKINS
MEDICINE, http://www.hopkinsmedicine.org/healthlibrary/conditions/orthopaedic_
disorders/acromioclavicular_ac_joint_problems_22,AcromioclavicularJointProblems/
(visited November 25, 2015).
No. 15-1254                                                                        Page 6

surgery Dr. Navarro concluded that Slayton was healing well and showing stability in
all other joints. He did not recommend further treatment.

        At the hearing before the ALJ in July 2013, Slayton recounted experiencing
debilitating pain. She explained that pain in her tailbone radiates up her back and is
lessened only briefly with injections. This pain, as well as knee pain, she continued,
prevents her from sitting or standing continuously for more than ten minutes. Slayton
said she could walk only about 75 feet because of her knees and shortness of breath,
though without someone around to assist she normally does not walk at all. She also
asserted that frequently she must lie down for 30 to 45 minutes and estimated that she
would need to lie down for 3 out of 8 working hours. Her back pain is so intense, Slayton
said, that lifting much at all is difficult and some days she cannot even pour a glass of
milk. And neither can she reach forward to grasp objects because her shoulder pain
(which radiates to her hands) is so severe that her hands cramp and go numb. Slayton
testified that, although she was recovering well from surgery on her right knee, she
anticipated needing surgery on the other knee and both shoulders.

      Slayton’s husband and son submitted letters. Her husband described helping
wash her hair and back because lifting her arms is painful. He also said that Slayton
must use a scooter when shopping.

       A vocational expert testified that Slayton could perform her past work in a
laundry or other jobs with the limitations identified by the ALJ. He acknowledged that
two or more absences a month would not be tolerated and that no competitive
employment would be available to Slayton if her impairments cause her to be off-task for
three out of eight hours during the workday.

       The ALJ applied the familiar 5-step analysis in finding that Slayton was not
disabled. See 20 C.F.R. §§ 404.1520(a), 416.920(a). At Step 1 the ALJ determined that
Slayton had not engaged in substantial gainful activity since her alleged onset date. At
Step 2 the ALJ identified Slayton’s severe impairments as hepatitis C, chronic obstructive
pulmonary disease, knee pain, low back pain, tailbone pain, osteoarthritis in both
shoulders, and reduced bone mass. At Step 3 the ALJ concluded that these impairments,
individually or in combination, do not satisfy a listing for presumptive disability.
Slayton does not dispute any of these conclusions.

       At Step 4, in assessing Slayton’s residual functional capacity, the ALJ rejected
Slayton’s account of disabling limitations. Though acknowledging that Slayton’s
testimony could evidence a greater impairment than suggested by medical evidence, the
No. 15-1254                                                                            Page 7

ALJ concluded that her account was “only very minimally credible.” Apart from the
absence of corroborating medical findings, the ALJ noted that Slayton’s doctors
occasionally had commented that her pain seemed disproportionate to their objective
findings. And, the ALJ added, Dr. Carlsen and Dr. Navarro had settled on conservative
pain treatment that appeared successful. Slayton’s testimony was further undercut, the
ALJ reasoned, since she had not told medical providers about some of the symptoms she
mentioned when testifying, like shortness of breath and difficulty walking. He gave little
weight to the letters from Slayton’s husband and son, and noted that Slayton, who was
54 when she applied for benefits, had only a minimal work history in the 7 years before
her alleged onset. The ALJ gave significant weight to the opinion of Dr. Carlsen, the
state-agency consultant turned treating physician, because he had examined Slayton and
was experienced in evaluating medical impairment under the regulations. The ALJ also
gave weight to the other state-agency medical consultants but limited Slayton’s residual
functional capacity even more than they thought necessary.

       The ALJ concluded at Step 4 that Slayton still could perform her past work with
the limitations he specified. In the alternative, the ALJ concluded at Step 5 that Slayton
could also work at other jobs.

       The Appeals Council denied review, making the ALJ’s decision the final word of
the Commissioner. See Scrogham v. Colvin, 765 F.3d 685, 695 (7th Cir. 2014). In this court
Slayton challenges the ALJ’s credibility finding. In determining credibility an ALJ must
consider factors imposed by regulation, see 20 C.F.R. § 404.1529(c), and must support his
credibility finding with evidence in the record, see Villano v. Astrue, 556 F.3d 558, 562
(7th Cir. 2009). If the ALJ satisfies these criteria, his credibility determination is reviewed
with deference and will stand unless “patently wrong.” Curvin v. Colvin, 778 F.3d 645,
651 (7th Cir. 2015); Pepper v. Colvin, 712 F.3d 351, 367 (7th Cir. 2013); Jones v. Astrue,
623 F.3d 1155, 1160 (7th Cir. 2010).

       Slayton argues that the ALJ relied solely—and thus incorrectly—on the lack of
objective medical evidence to discount her report of disabling pain. She cites to decisions
recognizing that an ALJ may not deny benefits simply because the objective medical
evidence falls short of explaining the claimant’s reported pain. See Hall v. Colvin, 778 F.3d
688, 691 (7th Cir. 2015); Pierce v. Colvin, 739 F.3d 1046, 1049–50 (7th Cir. 2014).

      But the ALJ relied on more than the lack of medical evidence to conclude that
Slayton’s reports of her limitations due to pain are “only very minimally credible.” The
ALJ acknowledged that “symptoms can sometimes suggest a greater level of severity of
impairment than can be shown by the objective medical evidence alone” and recited the
No. 15-1254                                                                          Page 8

statutory factors other than medical evidence which must be considered. See 20 C.F.R.
§ 415.929(c). The ALJ also noted Slayton’s testimony regarding her pain and work
limitations and considered the correspondence from her husband and son. The ALJ
ultimately concluded, though, that Slayton’s allegations of limitations due to severe pain
were not credible for several reasons: doctors had thought her reports of pain were
disproportionate to exam findings, her pain appeared to respond to conservative
treatment, she had never mentioned some of her symptoms to doctors, and her work
history was sporadic before her alleged onset date. These reasons are sufficient to
support the ALJ’s finding that Slayton’s allegations regarding her pain were not fully
credible. See Schmidt v. Astrue, 496 F.3d 833, 843–44 (7th Cir. 2007) (upholding credibility
decision concerning claimant’s subjective complaints of pain when ALJ considered
testimony, normal examination findings, and daily activities in addition to objective
medical tests); Sienkiewicz v. Barnhart, 409 F.3d 798, 803–04 (7th Cir. 2005) (upholding
credibility decision when ALJ considered conservative treatment, failure to report
certain symptoms to doctors, and inconsistency of reports of extreme pain with
examiner’s findings in addition to lack of objective medical test findings); Schmidt v.
Barnhart, 395 F.3d 737, 746–47 (7th Cir. 2005) (upholding credibility decision when ALJ
considered treatment, daily activity, and work history in addition to lack of objective
medical evidence).

       Slayton next argues that the ALJ erred in his credibility finding by misstating or
ignoring parts of the medical record. She cites to a slew of medical records that she
believes the ALJ mischaracterized or failed to consider. These include mild changes in
her lungs, a physician’s progress note mentioning her history of hepatitis C and chronic
obstructive pulmonary disease, a physical therapy note indicating decreased shoulder
strength and stability, the prescription of an electrical nerve stimulation unit, X-rays of
her shoulders showing moderate degenerative changes, an MRI of her neck showing
small protrusions, an MRI of her left shoulder and referral for left shoulder surgery, and
treatment notes documenting her reports of fatigue and severe pain in her neck,
shoulders, elbows, and legs. As Slayton notes, an ALJ does not need to discuss every
piece of evidence in the record, although neither may the ALJ analyze only the evidence
supporting his ultimate conclusion while ignoring the evidence that undermines it.
Moore v. Colvin, 743 F.3d 1118, 1123 (7th Cir. 2014); Terry v. Astrue, 580 F.3d 471, 477
(7th Cir. 2009); Myles v. Astrue, 582 F.3d 672, 678 (7th Cir. 2009).

       First, two of the medical records that Slayton faults the ALJ for overlooking were
not before the ALJ when he issued his decision in September 2013. Those records—the
results of an MRI of Slayton’s left shoulder and the referral for left shoulder
No. 15-1254                                                                             Page 9

surgery—were submitted later to the Appeals Council, which included them in the
administrative record but also decided that this new evidence did not warrant review of
the ALJ’s decision. Medical records that were not available to the ALJ cannot be used to
determine the correctness of the ALJ’s decision. See 42 U.S.C. § 405(g); Stepp v. Colvin,
795 F.3d 711, 721 n.2 (7th Cir. 2015); Rice v. Barnhart, 384 F.3d 363, 366 n.2 (7th Cir. 2004);
Eads v. Sec'y of Dept. of Health & Human Servs., 983 F.2d 815, 817 (7th Cir. 1993). And
Slayton has not argued—either in the district court or this court—for a remand to
consider this new evidence, see Stepp, 795 F.3d at 721–26, so she has waived that
contention.

       As for the records that were before the ALJ, Slayton’s appellate claim fails because
the ALJ properly considered the record as a whole and did not neglect to address any
evidence undermining his credibility finding. Contrary to Slayton’s assertions, the ALJ
did consider the X-rays of Slayton’s shoulders and knees and MRIs of her neck and
spine. The ALJ also considered many of the notes she characterizes as ignored, but he
focused on the physicians’ examination findings rather than dwell on Slayton’s
self-reports of pain documented in those notes. Although the ALJ did not specifically
analyze how Slayton’s hepatitis C diagnosis affects her ability to work (other than noting
her complaints of fatigue), that is because nothing in the record suggests that Slayton
manifested any symptoms of hepatitis C which would limit her functioning. The ALJ
summarized the significant medical findings in the record as related to Slayton’s
functional limitations, and no doctor ever opined that she had greater limitations than
what the ALJ found.

      In sum, because the ALJ did not ignore any line of evidence and substantial
evidence supports his decision, we uphold it.

                                                                                 AFFIRMED.
