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Rita Cain v. Michael J. Astrue

December 21, 2011


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


Michael T. Mason, United States Magistrate Judge:

Rita Cain ("Cain" or "claimant") has brought a motion for summary judgment [19] seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying her claim for Disability Insurance Benefits ("DIB") under the Social Security Act ("Act"), 42 U.S.C. §§ 416(i) and 423(d). The Commissioner has filed a response [24] asking the court to uphold the decision of the Administrative Law Judge ("ALJ"). We have jurisdiction to hear this matter pursuant to 42 U.S.C. §405(g). For the reasons set forth below, claimant's motion for summary judgment [19] is granted.


A. Procedural History

Cain filed her application for DIB on June 5, 2008, alleging an onset date of July 27, 2006 due to chronic obstructive pulmonary disease ("COPD"), obesity, osteoarthritic left knee, and high blood pressure. (R. 170.) Cain's application was denied initially on August 28, 2008, and again on November 20, 2008 after a timely request for reconsideration. (R. 49-50.) Cain then requested a hearing, which was held on December 8, 2009 before ALJ Curt Marceille. (R. 32-48.)

On December 18, 2009, ALJ Marceille issued a written decision denying Cain's request for benefits. (R. 9-20.) On February 2, 2010, Cain filed a request for review of the ALJ's decision. (R. 4.) The Appeals Council denied that request on August 25, 2010, at which time the ALJ'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 Evidence

Cain was admitted to Community Hospital in Munster, Indiana on July 27, 2006.

(R. 232.) Admission records reveal that Cain complained of shortness of breath and felt that her throat was closing. (Id.) In his physical examination notes, Dr. Waddah Ahdab, M.D. ("Dr. Ahdab") noted that Cain was "a very heavy smoker, smoking 4-5 packs per day." (R. 236.) Cain received an Echocardiogram test ("EKG"), which revealed mild concentric left ventricular hypertrophy and trace mitral regurgitation. (R. 227.) A chest CT showed "interstitial and micronodular infiltrate of the middle lobe" which may "represent an infectious infiltrate." (R. 254.)

Cain's condition improved with treatment and, after spending two days at Community Hospital, she was released on July 29, 2006 in stable condition. (R. 231.) Upon discharge, Dr. Ahdab diagnosed pneumonia, COPD, congestive heart failure, mild diabetes, hypertension, obesity, and hyperlipidemia. (Id.) Dr. Ahdab instructed Cain to follow up in 3-5 days, and noted that she was to resume activity "as tolerated." (Id.) On August 22, 2006, Cain returned to Community Hospital for a follow up chest CT scan.

(R. 262.) Radiologist Dr. Wassim Atassi found "interval resolution of hazy air space disease within the right middle lobe," but noted that "currently the lungs are clear." (Id.)

Records reveal that Cain returned to see Dr. Ahdab several times throughout 2008 and 2009. Specifically, Dr. Ahdab saw Cain on May 28, 2008, August 27, 2008, November 24, 2008, February 24, 2009, June 1, 2009, and September 1, 2009.(R. 267-268, 299-304, 310-319.) In his treatment notes, Dr. Ahdab noted that Cain's lungs were clear bilaterally and that she was "doing well" and "o.k." throughout 2008 and 2009. (R. 310-319.)At the August 27, 2008, appointment, Cain and Dr. Ahdab both signed an application for a disability license plate on the grounds of permanently restricted mobility "due to a pulmonary or cardiovascular disability, arthritic condition, orthopedic condition or neurological impairment." (R. 301-302.) Cain eventually received those plates. (R. 222.)

On July 19, 2008, Dr. ChukwuEmeka Ezike, M.D. ("Dr. Ezike") performed an internal medicine consultative examination for the Bureau of Disability Determination Services. (R. 273-277.) Cain complained of shortness of breath, dyspnea with mild exertion, and pain in the left knee with prolonged walking. (R. 273.) Specifically, Cain reported that she could walk only half a block because of shortness of breath, but had no difficulty standing or sitting, and could lift fifteen pounds. (R. 274.) As for activities of daily living, Cain told Dr. Ezike that she can vacuum her home a little bit at a time and needs assistance with shopping. (Id.) Dr. Ezike's physical examination revealed that claimant was 5'2.5", weighed 251 pounds, and was markedly obese, but not in acute distress. (R. 274.) Dr. Ezike observed that Cain had normal range of motion in her knees with crepitation in the left knee, but found no knee tenderness. (R. 275.) Dr. Ezike further observed that Cain was unable to squat completely without support. (Id.) According to Dr. Ezike, Cain was able to get on and off the exam table with no difficulty, could walk greater than 50 feet without support, had a non-antalgic gait without the use of assistive devices and was able to perform toe/heel walk. (Id.) Dr. Ezike also noted that Cain had normal range of motion in her shoulders, elbows, wrists, hips, ankles, cervical and lumbar spine, and had no lumbar or paralumbar tenderness. (Id.) Grip strength and her ability to grasp and manipulate objects were normal. (Id.)

With respect to Cain's lungs, Dr. Ezike noted that there was "good air entry bilaterally with mild diffuse wheezes," but "no rales or crackles." (R. 274.) Cain also received a pulmonary function test, which revealed a moderate restriction in breathing with no significant improvement after medication. (R. 281.) Following his examination, Dr. Ezike assessed COPD, obesity, left knee degenerative joint disease, hypertension and diabetes. (R. 275--276.)

On August 26, 2008, state agency reviewing physician Dr. Richard Bilinsky ("Dr. Bilinsky") assessed Cain's Physical Residual Functional Capacity ("RFC"). (R. 288-294.) Dr. Bilinsky determined that Cain could occasionally lift and/or carry 20 pounds, frequently lift and/or carry 10 pounds, and could sit, stand, or walk for six hours each in an eight hour workday. (Id.) Dr. Bilinsky also found that, as a result of Cain's left knee degenerative joint disease, her postural limitations included never climbing ladders, ropes or scaffolds and only occasionally climbing ramps or stairs, balancing, stooping, kneeling, crouching, and crawling. (R. 290.) Dr. Bilinsky further determined that Cain had several environmental limitations due to her COPD diagnosis, which included avoiding concentrated exposure to extreme cold, extreme heat, fumes, odors, dusts, gases, and poor ventilation. (R. 292.) Cain had no manipulative, visual or communicative limitations. (R. 291-292.) In closing, Dr. Bilinksy noted that Cain's statements were credible and consistent with the objective medical findings and the limitations indicated in the RFC assessment. (R. 295.) On November 17, 2008, Dr. Virgilio Pilapil affirmed Dr. Bilinsky's initial RFC determination, and noted that Cain was "partially credible." (R. 305--307.)

C. Daily Living Questionnaires

In her written responses to the Social Security Administration's questions regarding "activities of daily living," Cain stated that she lives with her husband. (R. 186.) She explained that she spends her days preparing meals, reading, watching television, doing crossword puzzles, doing laundry, feeding her dog, watering flowers and taking her medications including testing her blood sugar three times a day. (R. 186-192.) According to Cain, her illnesses affect her ability to lift, squat, bend, ...

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