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Jimmie Lee Thomas v. Michael J. Astrue

May 25, 2011

JIMMIE LEE THOMAS, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Magistrate Judge Michael T. Mason

MEMORANDUM OPINION AND ORDER

Michael T. Mason, United States Magistrate Judge:

Claimant Jimmie Lee Thomas ("Thomas" or "Claimant") brings this motion for summary judgment [21] seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner"). The Commissioner denied Thomas' claim for disability insurance benefits under Sections 216 and 223 of the Social Security Act (the "SSA"), 42 U.S.C. §§ 416(I) and 423(d), and his claim for supplemental security income under Section 1614(a)(3)(A) of the SSA, 42 U.S.C. § 1382a(a)(3)(A). The Commissioner filed a cross-motion for summary judgment [29], requesting that this Court uphold the decision of the Administrative Law Judge ("ALJ"). This Court has jurisdiction to hear this matter pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). For the reasons set forth below, Claimant's motion for summary judgment [21] is granted and the Commissioner's cross-motion for summary judgment [29] is denied.

I. BACKGROUND

A. Procedural History

On March 2, 2005, Thomas filed applications for period of disability, Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"), alleging an onset of disability of March 3, 2005. (R. 14, 45). His date last insured was December 31, 2006. (R. 47). The Social Security Administration initially denied his claims on April 27, 2005, and upon reconsideration on July 15, 2005. (R. 45). Thomas filed a timely request for a hearing on August 4, 2005. (Id.). On February 19, 2008, Thomas appeared with counsel before Administrative Law Judge ("ALJ") E. James Gildea. (R.

13). On August 7, 2008, ALJ Gildea issued a written decision denying Thomas' request for benefits. (R. 45-53). Thomas filed a timely Request for Review, and on January 23, 2009, the Appeals Council denied this request, which made the ALJ's decision the final decision of the Commissioner. (R. 1-3); Estok v. Apfel, 152 F.3d 636, 637 (7th Cir. 1998); 20 C.F.R. § 416.1481. Thomas subsequently filed this action in the District Court.

B. Medical Evidence

Claimant seeks DIB and SSI for disabling conditions stemming from liver disease, kidney disease, rheumatoid arthritis, gout, and high blood pressure (hypertension). (R. 29, 50-51,119).

1. Cook County Hospital

Thomas' medical records date back to April of 1997, when he was treated at Cook County Hospital. Although several of these records are illegible, it appears that Thomas was treated in the Trauma Unit on April 12, 1997. (R. 223-225). Thomas then had a follow up visit on April 24, 1997, and the treating physician noted that Thomas suffered from alcohol abuse, peptic ulcer disease ("PUD"), blunt facial trauma, and gastrointestinal bleeding. (R. 217). On March 12, 1998, Thomas was again treated at Cook County Hospital. The treating physician again noted Thomas' alcohol abuse, blunt facial trauma, PUD and gastrointestinal bleeding. (R. 215). On April 20, 1998, Thomas was treated for a cough and fever, and at this visit, he was diagnosed with alcoholic hepatitis, hypertension and PUD. (R. 211).

Thomas returned to Cook County Hospital on March 19, 1999 for a refill of his medications. (R. 212-214). The treating physician noted that Thomas suffered from abdominal pain due to a fatty liver, alcoholic liver disease, PUD and hypertension. (Id.). These notes also indicate that Thomas reported that he had not been consuming as much alcohol as he had in the past. (Id.).

A progress report dated October 22, 1999 notes that Thomas had been recently released from the hospital for nose bleeding but there were no signs of bleeding ulcers.

(R. 210). This report also notes that Thomas suffers from alcohol abuse, that he had his last drink two weeks ago, and that "he promises not to drink anymore." (Id.). On November 24, 1999, Thomas was treated in the emergency room, complaining of pain, headaches, dizziness and bleeding. (R. 226-28).

2. River Region Medical Center

On December 4, 2004, Thomas was treated at the River Region Medical Center in Vicksburg, Mississippi. He complained of pain and swelling in his right foot and ankle. (R. 239-240). The records indicate that Thomas' pain had been on-going for two days and that it was the result of "standing a lot at work." (R. 239). Thomas reported that the pain was moderate, exacerbated by movement, and that he was not able to find anything to relieve the pain. (Id.). Dr. Kristen Coleman reviewed an x-ray of Thomas' right ankle and saw no evidence of acute traumatic injury. (R. 242). Thomas was released with a prescription for the pain. (R. 241).

3. River Region Health System, The Street Clinic

Thomas was also treated at The Street Clinic (part of the River Region Health System) in Vicksburg, Mississippi between February, 2005 and June, 2006. On February 11, 2005, Thomas saw Dr. Robert A. Williams and complained of pain in his neck, abdomen, right hand and right leg. (R. 194-95). Dr. Williams noted that Thomas "is mildly inebriated and admits to drinking before coming in to the office this morning." (Id.). Dr. Williams ordered a CT scan of Thomas' abdomen and tests to evaluate liver function, splenic, and kidney functions. (Id.). Dr. Williams also noted that Thomas "is an apparent heavy drinker, has been for many years." (Id.). Dr. Williams stated that Thomas said he can consume "as much as a pint of Vodka a day, sometimes more." Dr. Williams wanted to address the alcohol abuse on future visits. (Id.).

A radiology report dated February 14, 2005 showed bilateral renal cysts in his kidneys and "mild diffuse low attenuation, consistent with fatty infiltration." (R. 196). On February 17, 2005, Thomas returned to Dr. Williams, complaining of swelling in his foot and hands. (R. 193). Dr. Williams noted that the "patient has been drinking." (Id.). Dr. Williams also noted "he wants disability for gout in hands and feet." (Id.).

Thomas had a follow-up appointment with Dr. Williams on March 8, 2005. Dr. Williams noted that Thomas "says that right now he is not able to work because it hurts in his head and stomach." (R. 192). Claimant told Dr. Williams that he missed an appointment with another doctor for an esophagogastroduodenoscopy ("EGD") because of his work schedule. (Id.). Thomas asked Dr. Williams for another prescription for the pain because "his sister threw his last prescription for the pain medicine away." (Id.). Dr. Williams' assessment of Thomas' lab work showed that he "has liver abnormalities, possibly cirrhosis superimposed on hepatitis C." (Id.). In order to further assess the liver problems, Dr. Williams referred him again for an EGD. (Id.). Thomas' lab work also was positive for rheumatoid arthritis. (Id.). Dr. Williams ...


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