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Ronald T. White v. Michael J. Astrue

November 7, 2011


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


Michael T. Mason, United States Magistrate Judge:

Plaintiff, Ronald T. White ("White" or "claimant"), has filed a motion for summary judgment [14] seeking judicial review of the final decision of the Commissioner of the Social Security Administration ("Commissioner") denying his claim for benefits under the Social Security Act, 42 U.S.C. §§ 416(i), 423(d) and 1382c(a)(3)(A). In response, the Commissioner filed a cross-motion for summary judgment [23] asking the Court to affirm the decision of the Commissioner. We have 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 is granted, the Commissioner's motion for summary judgment is denied, and this case is remanded for further proceedings consistent with this Opinion.


A. Procedural History

On March 30, 2006, White filed applications for period of disability, disability insurance benefits ("DIB") and supplemental security income ("SSI"), alleging an onset date of December 9, 2000. (R. 124-27, 133.) For purposes of White's DIB application, his date last insured was March 31, 2001. (R. 17.) The Social Security Administration ("SSA") denied White's claims initially on May10, 2006 (R. 67-76), and again upon reconsideration on August 1, 2006. (R. 85-92.) Thereafter, claimant filed a timely request for a hearing. (R. 94-95.) On December 13, 2007, claimant appeared with counsel at a hearing before Administrative Law Judge Denise McDuffie Martin ("ALJ" or "ALJ Martin"). (R. 29.) At claimant's request, the record was held open after the hearing so additional evidence could be submitted. (R. 62.)

On November 26, 2008, ALJ Martin issued a decision denying White's request for benefits. (R. 12-28.) White filed a timely request for review of ALJ Martin's decision.

(R. 10.) The Appeals Council denied that request on August 25, 2009, and ALJ Martin's decision became the final decision of the Commissioner. (R. 1-3); Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). This action followed.

B. Medical History

White saw a number of different medical professionals for various reasons during his incarceration at Dixon Correctional Center ("Dixon") from May 25, 2001 through March 31, 2006. Medical progress notes from August 2001 reveal hypertension and corresponding headaches and dizziness. (R.190-93.) Other handwritten progress notes dated May 2001 through March 2006 include a number of references to hypertension and asthma. (R. 248, 252-263.)

As for specific treatment, on September 26, 2001, White was seen in the psychiatric clinic by a staff psychiatrist, at which time he reported that he had adjusted to new blood pressure medication. (R. 185.) As a result, his headaches had improved.

(Id.) White also indicated he was benefitting from his group therapy sessions. (Id.) He reported an improvement in mood, appetite, energy, motivation and sleep, and denied hopelessness, anhedonia, or homicidal or suicidal ideations. (Id.)White did report a learning disability and complained of low test scores in his classes. (Id.) The staff psychiatrist noted that White had an "appropriate and related" affect and "logical and sequential thought" processes. (Id.) He saw no signs of tardive dyskinesia.(Id.) The psychiatrist diagnosed major depressive disorder, polysubstance abuse and "learning disability per self-report." (Id.) White was directed to continue with Sinequan for mood systems. (Id.) At an individual therapy session on March 6, 2002, White complained of feelings of depression. (R. 187.) Dysthmia was indicated as the Axis I diagnosis. (Id.)

On February 24, 2004, claimant visited the orthopedic clinic complaining of "pain at the anterior superior iliac spine of the right hip." (R. 188.) During that appointment, White explained that he was shot in the right hip in either 1982 or 1983, and the bullet remained lodged in that region. (Id.) On occasion, the pain caused his right knee to buckle. (Id.) Examination showed the patient walking with a normal gait. (Id.) There was full flexion, extension, and rotation of the right hip without any pain, although there was "tenderness on palpation at the right anterior superior iliac spine region of the right hip." (Id.) The left hip had full active range of motion without pain.(Id.) Both lower extremities had good circulation and sensation. (Id.)

White underwent a routine physical examination on December 16, 2005. (R. 249-251.) That exam revealed a history of asthma, hypertension and diabetes, all of which were controlled. (R. 249.) Among other things, the physician assessed obesity and recommended a low fat diet. (R. 254.)

Notes from an individual therapy session on June 22, 2004 reveal an increase in depressive symptoms. (R. 186.) The Axis I diagnosis was documented as chronic PTSD. (Id.)Individual therapy notes from February 13, 2006 indicate that White suffers from PTSD and dysthymia. (R. 245.) At that therapy session, White "continued to identify and challenge cognitive distortions." (Id.) He appeared alert and his thought content was good. (Id.)

On March 15, 2006, Dixon's SSA liaison and a Dixon health care professional completed the "Prescreening Information Checklist" for the SSA. (R. 148-149.) To their knowledge, White did not suffer from any medical conditions, physical or mental, that prohibited him from performing his work duties while incarcerated, or restricted his normal activities. (Id.) The form explicitly indicates that the information provided "will be used by SSA to determine priority of processing and not final eligibility." (Id.)

As a condition of White's release from Dixon in March 2006, he was required to undergo substance abuse counseling and outpatient mental health counseling, "due to his history of polysubstance [abuse] and mental health issues." (R. 230.)White apparently did not participate in the substance abuse program at Dixon. (Id.)

Immediately followinghis release, White underwent a number of consultative examinations.On April 17, 2006, Dr. Helena Radomska of Chicago Consulting Physicians conducted a psychiatric evaluation. (R. 267-271.) Dr. Radomska noted that White walked with a cane, "although there was no abnormality of his gait." (R. 267.)White reported that he suffered a major trauma at the age of nine when he witnessed his father cut his mother's throat. (Id.) The incident always plays over in his mind. (Id.)On occasion, White has nightmares and flashbacks. (R. 268.)He also explained that he sometimes sees a finger pointing at him and hears voices "telling him he is not good." (Id.)White reported that he is taking medication for depression, which helps him 75% of the time, but makes him groggy during the day. (R. 267.) White complained of problems with comprehension, as well as variance in mood. (R. 268.) He denied suicidal or homicidal ideation, panic attacks and obsessive compulsive symptoms. (Id.)As for daily activities, White told Dr. Radomska that he does not have a set schedule, but mainly stays at home and sometimes goes to bed. (Id.) White admitted to abusing heroin and crack/cocaine for 20 years before going to prison. (R. 269.) He denied daily use of alcohol. (R. 268.)

Dr. Radomska reported White's mood as dysphoric with mood congruent affect.

(R. 269.) She diagnosed major depression with psychotic features, currently partially treated with medication; a history of polysubstance abuse and dependence, currently in remission from cocaine and heroin; a possible history of PTSD; hypertension; asthma; and a bullet lodged in his right hip. (R. 270.) As for stressors, Dr. Radomska reported that White was still depressed, hearing voices and having trouble adjusting to life after prison. (Id.) White's Global Assessment of Functioning ("GAF") at the time was 50.*fn1


Also on April 17, 2006, claimant underwent an internal medicine examination with Dr. Dominic Gaziano of Chicago Consulting Physicians. (R. 281-287.) White complained of asthma, high blood pressure and pain in his right hip. (R. 281.) According to White, his asthma is elicited by dust, pollen and smoke, and he is short of breath every day. (Id.) White reported compliance with his blood pressure medication.

(R. 282.) He complained of occasional right leg weakness and stated that he can walk a block and a half without a cane. (Id.)

Dr. Gaziano reported that White could walk fifty feet without assistance, but noted that he ambulated with short steps. (R. 282.) Toe walk was normal, but claimant was unable to heel walk. (Id.) Claimant was able to squat one-fourth of the way to the floor. (Id.) White had limited range of motion of the lumbosacral spine to 80 degrees of flexion and 20 degrees of extension. (Id.) Flexion and extension were not associated with pain. (R. 282-283.) White had decreased range of motion of his right hip to 100 degrees of flexion and 20 degrees of abduction. (R. 283.) Both flexion and extension were associated with pain. (Id.) Grip strength and dexterity were normal. (Id.) Bilateral hip flexors strength was -4/5; bilateral knee flexion/extension was the same. (Id.) Straight leg raising was negative. (R. 286.) An x-ray from his visit revealed a "bullet in the soft tissues adjacent to the superolateral aspect of the right ilium with multiple fragments probably embedded in the ilium and a post-traumatic exostosis from the superolateral margin." (R. 274.) The radiologist indicated that there may be very slight central narrowing of the hip joint. (Id.) A pulmonary function test showed mild restrictions both pre and post bronchodilation. (R. 275.)

Based on his examination, Dr. Gaziano assessed a history of asthma, hypertension and gun shot wound. (R. 283.) He found that claimant had difficulty ambulating for longer than one and a half blocks, but no history of lower extremity weakness. (Id.)

Claimant saw Dr. Gaziano again on May 1, 2006 for another evaluation in connection with his application for state public aid. (R. 218-232.) During that evaluation, White complained of insomnia, difficulty concentrating, and shortness of breath, with occasional chest pains. (R. 231.) White admitted to smoking half a pack of cigarettes a day, but denied alcohol or illicit drug use. (Id.) Dr. Gaziano diagnosed hypertension, asthma, PTSD and major depression. (R. 219.) Dr. Gaziano further reported a negative straight leg raising test and again noted that White could walk fifty feet without assistance. (R. 223.) White could squat half way to the floor. (Id.) White exhibited normal range of motion in the hips, knees, ankles, ...

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