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JONES v. BARNHART

January 7, 2005.

ROBERT L. JONES, Plaintiff,
v.
JO ANNE B. BARNHART, Commissioner of Social Security, Defendant.



The opinion of the court was delivered by: MORTON DENLOW, Magistrate Judge

MEMORANDUM OPINION AND ORDER

This case comes before this Court on the parties' cross-motions for summary judgment. Plaintiff Robert L. Jones ("Claimant") challenges the decision of Defendant Jo Anne B. Barnhart, Commissioner of Social Security ("Commissioner"), claiming that her denial of his Social Security Disability Insurance Benefits ("DIB") and Social Security Insurance payments ("SSI") should be reversed or remanded because the decision contains errors of law and is not supported by substantial evidence. For the reasons stated below, Claimant's motion for summary judgment is granted and the Commissioner's motion for summary judgment is denied. The case is remanded to the Commissioner for further proceedings.

  I. PROCEDURAL HISTORY

  Claimant filed an application for DIB and SSI on November 27, 2000, alleging that he had been disabled since May 18, 1999, due to a right wrist injury. R. 17, 30. On February 6, 2001, the Social Security Administration determined that Claimant was disabled from May 18, 1999, through September 7, 2000, but not thereafter, and awarded Claimant benefits for that closed period. R. 17, 32-34. Claimant's request for reconsideration of this determination was denied, and he requested an administrative hearing. R. 17, 35-46. On November 7, 2002, an administrative law judge ("ALJ") conducted a hearing at which Claimant, represented by counsel, appeared and testified. R. 268-89. In addition, Timothy Bodsoniski testified as a vocational expert ("VE"). R. 289-301. In a decision dated December 10, 2002, the ALJ found that Claimant was not disabled after September 7, 2000, because he had regained the ability to perform jobs that existed in significant numbers in the local economy R. 14-29. This became the final decision of the Commissioner when the Appeals Council denied Claimant's request for review of the decision on December 10, 2003. R. 5-8. Claimant then filed this action for review of the decision pursuant to 42 U.S.C. § 405(g). The parties have consented to this Court's jurisdiction to decide this case pursuant to 28 U.S.C. § 636(c)(1).

  II. BACKGROUND FACTS

  Claimant was forty-six years old at the time of the administrative hearing. R. 30, 271. He has an eighth-grade education, and has difficulty reading and writing. R. 98, 276, 285. He is right-handed. R. 285. From 1994 until he injured his wrist in May of 1999, Claimant worked as a temporary laborer, a job that required mostly heavy lifting. R. 80, 290. Prior to that, Claimant held jobs as a leather tanner from 1976 to 1993, as a security guard from 1985 to 1987, and as a housekeeper from 1991 to 1993. R. 80-83. After he injured his wrist, he was unable to perform the lifting his temporary labor job required. He also claims that he suffers from a heart condition that causes him chest pain and shortness of breath.

  A. MEDICAL EVIDENCE

  1. Wrist Injury and Treatment

  Claimant's primary medical complaint is a loss of function in his right wrist. He injured the wrist in a work-related automobile accident on May 18, 1999. R. 145, 172, 270. He was treated at Rush Presbyterian Occupational Health Center, where he was diagnosed with a sprain of the right wrist, given a splint and Naprosyn, and was advised to begin occupational therapy. R. 172. On October 9, 1999, Claimant went to see Dr. John Ruder, who recommended an arthrogram. R. 172. The study revealed a scapholunate ligament*fn1 tear. R. 172.

  On October 30, 1999, Claimant sought treatment for wrist pain in the outpatient department of Norwegian American Hospital. R. 145. Upon examination, Dr. Mohammed Sirajullah determined that Claimant needed a scapholunate fusion, but he asked Claimant to seek additional opinions due to the complicated nature of Claimant's injury and unlikelihood of a completely satisfactory solution. R. 146. On January 4, 2000, Dr. Sirajullah performed a scapholunate fusion and placed a cast on Claimant's arm, but the operation did not result in the healing of the wrist. R. 135-143. Following the procedure, the range of motion in Claimant's wrist was limited: dorsiflexion and palmar flexion were 10 degrees; radial and ulnar deviation were 10 degrees and 15 degrees, respectively. R. 135.

  On April 13, 2000, Dr. Sirajullah advised Claimant to undergo a course of physical therapy. R. 135. When Dr. Sirajullah saw Claimant again on May 4, 2000, Claimant had been drinking heavily and admitted that he had gone to only three physical therapy appointments. R. 135. Dr. Sirajullah last saw Claimant on May 23, 2000, at which time Claimant continued to express dissatisfaction with the function of his wrist. R. 135. An x-ray examination showed no changes to the wrist, and there was no bony union at the site of the attempted fusion. R. 135.

  On June 21, 2000, Claimant went back to see Dr. Ruder. Upon examination, Dr. Ruder felt that Claimant had a static scapholunate disassociation without sign of fusion of the scapholunate articulation. R. 173. A week later, Claimant saw Dr. Daniel Nagle, who confirmed Dr. Ruder's opinion and diagnosed Claimant with scapholunate disassociation and possible triangular fibrocartilage tear. R. 174. Dr. Nagle noted arthritic changes, and felt a CT scan was needed, as well as possible arthroscopy. R. 174.

  On July 26, 2000, Dr. Nagle performed the arthroscopy. Claimant tolerated the procedure well, and awoke from anesthesia "without difficulty." R. 149, 153. The arthroscopy demonstrated diffuse posttraumatic arthritic changes to his right wrist and grade IV chondromalacia.*fn2 R. 167. Dr. Nagle recommended that Claimant engage in no "heavy activity" and perform gentle wrist range of motion exercises. R. 167. In a follow-up visit, Claimant informed Dr. Nagle that his pain along the ulnar side of the wrist was gone, and he was able to do "a little work on his car" the day after surgery. R. 167.

  Claimant's relief was short-lived, however, and he returned to see Dr. Nagle on August 8, 2000, complaining of pain in his wrist. R. 166. Dr. Nagle suggested that Claimant use a splint and consider undergoing a panarthrodesis operation.*fn3 R. 166. Claimant demurred, but returned to see Dr. Nagle again on September 7, 2000, because of discomfort in his wrist. R. 163. Dr. Nagle informed Claimant that without further surgery, Claimant had likely reached his maximum medical improvement. R. 163. Claimant informed Dr. Nagle that he was afraid of surgery and would rather simply try to return to work. R. 163. As such, Dr. Nagle recommended a functional evaluation to determine Claimant's work restrictions. R. 163. While the evaluation was scheduled for September 29, 2000, the record fails to indicate that Claimant kept the appointment. R. 165. It would appear that Claimant has not sought further treatment for his wrist since that time.

  2. Chest Pain

  Claimant has also been treated for complaints of chest pain. On April 12, 2001, Claimant was admitted to Norwegian American Hospital for chest pain. Claimant admitted to having used cocaine, which was confirmed in testing. R. 192, 195. The attending physician, Dr. Farida Ahmed, found diffuse perfusion abnormalities in all three major coronary arteries, left ventricular dilation, decreased ejection fraction, and severe wall motion abnormalities. R. 189. An EKG performed on April 13, 2001, by Dr. Raghu Ramadurai was characterized as abnormal with sinus rhythm, occasional premature atrial contractions, and left ventricular hypertrophy with ST-wave abnormalities. R. 191. Dr. Ahmed's principal final diagnosis was cardiomyopathy, with atypical chest pain, cocaine abuse, and hypertension. R. 188-89.

  On December 13, 2001, Claimant was again admitted to Norwegian American Hospital for chest pain. R. 236-38. Claimant was diagnosed with palpitation, chest pain, and cocaine abuse. Claimant returned on May 22, 2002, again complaining of chest pain, which was, again, apparently associated with cocaine abuse. R. 255.

  3. Consultative Examination

  On July 17, 2001, Dr. Martin Beermann performed a consultative examination of Claimant at the request of the state disability agency, in connection with Claimant's application for disability benefits. R. 211-227. Claimant informed Dr. Beermann that he was able to dress and groom himself independently, take his boys to school and fix them meals, and do light household work such as sweeping, making the beds, cooking, and light dusting. R. 212. Upon examination of Claimant's wrist, Dr. Beermann found that it was difficult to determine whether the joint had fused, but flexion and extension, although limited to 30 degrees out of 60 degrees, had improved from Claimant's previous examination. R. 213-14. Grip strength in Claimant's right hand was 4 on a scale of 5. R. 213. Dr. ...


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