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Woodson v. Astrue

August 27, 2010

JOHN D. WOODSON, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Magistrate Judge Young B. Kim

MEMORANDUM OPINION and ORDER

Before the court is John Woodson's motion for summary judgment challenging the denial of his applications for disability insurance benefits ("DIB") and supplemental security income ("SSI") under the Social Security Act, 42 U.S.C. §§ 416(i), 423, 1381a, 1382c. Woodson claims that he is disabled by high blood pressure and hypertrophic cardiomyopathy, which cause him to experience severe chest pain, shortness of breath, and fatigue. For the following reasons, Woodson's motion is granted and this case is remanded for further proceedings consistent with this opinion:

Procedural History

Woodson applied for SSI and DIB in May 2007, claiming that his disability began on September 1, 2002. (A.R. 109, 117.) The Social Security Administration ("SSA") denied his claim initially and on reconsideration. (Id. at 57-60.) Woodson then requested, and was granted, a hearing before an administrative law judge ("ALJ"). (Id. at 21.) The ALJ determined that Woodson is not "disabled" as defined in the Social Security Act and denied his claims for DIB and SSI. (Id. at 19.) When the Appeals Council denied review, (id. at 1-3), the ALJ's decision became the final decision of the Commissioner, see Schmidt v. Astrue, 496 F.3d 833, 841 (7th Cir. 2007). Woodson then filed the current suit seeking judicial review of the ALJ's decision. See 42 U.S.C. §§ 405(g), 1383(c)(3). The parties have consented to the jurisdiction of this court. See 28 U.S.C. § 636(c).

Facts

In 1986-when he was 20 years old-Woodson suffered blunt chest trauma while serving in the United States Army at Ft. McCoy, Wisconsin. (A.R. 32, 295-97, 306-07.) He was moving artillery when a 250-pound projectile fell off of a storage rack onto his chest, damaging his sternum and causing a myocardial tear and contusion. (Id. at 295, 306-07.) He underwent cardiopulmonary bypass surgery to repair the damage. (Id. at 306.) After being discharged from the Army in 1989, he went on to work several jobs, most recently as a housekeeper in a nursing home. (Id. at 32-34, 154.) He stopped working in 2002 because, he says, he was experiencing chest pain and dizziness that rendered him disabled. (Id. at 33.) At his hearing before the ALJ in June 2008, Woodson offered both documentary and testimonial evidence to support his claims.

A. Medical Evidence

Although Woodson claims a disability onset date of September 1, 2002, the first medical evidence in the record-other than that related to the 1986 injury-is from May 2007, the month he first sought disability benefits. (A.R. 139.) On May 3, 2007, Woodson was interviewed at an SSA field office. (Id. at 135-39.) The interviewer reported that Woodson had no difficulties in sitting, standing, walking, or breathing. (Id. at 138.) The following month, Woodson was examined at the SSA's behest by consultative physician Dr. Jeffrey Ryan. (Id. at 188.) Woodson told Dr. Ryan that he had persistent pain at the site of his 1986 surgery and that he was unable to walk more than 10 steps without becoming short of breath. (Id.) Dr. Ryan reported that Woodson walked into the examination center with his arm around his sister and that he had "great discomfort even in getting around" that was "consistent throughout the examination." (Id. at 189.) Dr. Ryan said that Woodson was "significantly dyspneic"-out of breath, in layman's terms, see STEDMAN'S MEDICAL DICTIONARY 601 (28th ed. 2006)-and "unable to walk more than 15 feet unassisted." (Id.)

Dr. Ryan further noted that Woodson could not perform a toe or heel walk, tandem gait, or squat and rise. (Id.) Dr. Ryan diagnosed Woodson as having "significant severe shortness of breath with uncertain cause," noting that the most common explanation would be pulmonary or cardiac. (Id. at 190.)

Three weeks after Dr. Ryan examined Woodson, a medical consultant named Dr. Robert Patey completed a residual functional capacity assessment based on his review of Woodson's medical file. (A.R. 197-204.) Dr. Patey opined that Woodson could sit, stand, or walk for six hours in an eight-hour workday without any postural, manipulative, or environmental limitations. (Id. at 199-201.) In explaining his opinion, Dr. Patey questioned Woodson's credibility. (Id. at 204.) He said that Woodson's complaints of shortness of breath were not supported by any medical records. (Id.) He noted the contrast between Woodson's presentation to the field interviewer, who said that he had no problem walking or breathing, and Dr. Ryan's observations regarding Woodson's limitations. (Id.) Dr. Patey concluded that Woodson's complaints of chest pain "appear to be non-cardiac in nature" and "out of proportion to his history." (Id.) Dr. Patey said that the record showed that Woodson has hypertension which could warrant a functional limitation, but only to the extent that he should be restricted to lifting and carrying 50 pounds occasionally and 25 pounds frequently. (Id.)

On September 4, 2007, Woodson reported to an emergency room complaining of severe chest pain that followed his attempt to do housework. (A.R. 243.) He was hospitalized for three nights and underwent a cardiac catheterization. (Id. at 209, 211.) He was diagnosed as having untreated hypertension and "moderate to severe asymmetric hypertrophy" with "grade 1 diastolic dysfunction." (Id. at 209.) His condition was also referred to as hypertrophic cardiomyopathy. (Id. at 213.) The hospital report states that while he was hospitalized Woodson had several episodes of severe chest pain even at rest. (Id. at 240.). A cardiologist concluded that his symptoms were "most likely due to uncontrolled hypertension or due to musculoskeletal etiologies." (Id. at 252.)

Shortly after his hospitalization Woodson had a second interview at a Social Security field office, and again the interviewer found him to have no difficulties in sitting, standing, walking, or breathing. (A.R. 162.) In connection with that interview Woodson filled out a form reporting that his pain, fatigue, and weakness had all increased in the previous few months. (Id. at 165.) He reported having a limited ability to walk, no ability to climb stairs, and needing help dressing. (Id. at 168.)

The most recent treatment records are from May and June 2008. On May 14, 2008, a nurse from the Jesse Brown Veteran Administration Medical Clinic reported that Woodson complained of having chest pain after doing housework two days earlier. (A.R. 285.) He told the nurse he had not had any chest pain or shortness of breath since that episode. (Id.) Progress notes from a June follow-up appointment state that Woodson was asymptomatic (he denied having shortness of breath), but that he had not taken his medications ...


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