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Willie Lakes v. Michael J. Astrue

February 19, 2012


The opinion of the court was delivered by: Magistrate Judge Maria Valdez


This is an action brought under 42 U.S.C. § 405(g) to review the final decision of the Commissioner of Social Security denying plaintiff Willie Lakes's claim for Social Security Disability and Supplemental Security Income Benefits. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow, Lakes's motion for summary judgment [Doc. No. 14] is granted in part and denied in part. The Court finds that this matter should be remanded to the Commissioner for further proceedings.



Lakes originally applied for Social Security Disability and Supplemental Security Income benefits on April 10, 2003, alleging disability due to depression and pain since May 3, 2002. (R. 207-09.) The application was denied on June 18, 2003 and upon reconsideration on November 10, 2003. (R. 164-75.) Lakes filed a timely request for a hearing by an Administrative Law Judge ("ALJ"), which was held on November 30, 2005. (R. 177, 132-63.) Lakes personally appeared and testified at the hearing and was represented by counsel. (R. 135.) A vocational expert also testified at the hearing. (Id.)

On March 31, 2005, the ALJ denied Lakes's claim for benefits and found him not disabled under the Social Security Act. (R. 132-63.) After Lakes requested review of the ALJ's decision, the Social Security Administration Appeals Council remanded his claim to give further consideration to the claimant's maximum Residual Functional Capacity ("RFC") on a function-by-function basis; obtain evidence from a medical expert to clarify the nature and severity of his impairments; and obtain supplemental evidence from a vocational expert, if warranted by the expanded record. (R. 126-28.) A second hearing before the same ALJ occurred on December 2, 2008, and the ALJ again found Lakes not disabled.

(R. 35-82, 1402-83.) The Appeals Council denied Lakes's request for review of the second decision on July 22, 2011, (R. 10-14), leaving the ALJ's decision as the final decision of the Commissioner and therefore reviewable by the District Court under 42 U.S.C. § 405(g). See Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005).


A. Testimony and Medical Evidence

1. Lakes's Testimony

At the time of the second ALJ hearing, Lakes had recently turned fifty years old. (R.1414.) He had been divorced for three or four years and had one biological child. (R. 1412.) He completed school through the ninth grade; he began the tenth grade but did not finish and did not obtain a GED. (R. 1414.) In the past, Lakes had been employed as a forklift driver, a machine operator, heavy equipment operator, warehouse worker, school bus driver, and a day laborer. (R. 1417-22.) Lakes had received worker's compensation for a period of time following an on-the-job accident, and at the time of the hearing, he was on public aid. (R. 1413-14.)

Plaintiff stated that he can read and write some, but not well. (R. 1414-15.) He claimed to suffer from anxiety and depression, as well as headaches and pain in his back, shoulders, and neck. (R. 1427, 1449-51.) He stated that his ability to read is negatively affected by the anxiety and depression, which make him unable to concentrate and focus. (R. 1415.) He was hospitalized in 2004 for a suicide attempt but had not been admitted since that time. (R. 1427.)

Lakes testified that he cannot sit or stand for long periods of time, and he cannot bend over, reach, or push or pull anything. (R. 1426.) He cannot lift his left arm above his head, and the most he can lift is approximately twelve pounds; he can stand in place three to five minutes at a time, walk one block without stopping and resting, and sit comfortably for about five or ten minutes. (R. 1439-40, 1447.) He stated that he has trouble putting on shirts by himself, and he cannot wash his back or feet without the assistance of his fiancee or sister. (R. 1441, 1447-48.)

Lakes claimed that he had once been an alcoholic and drug addict, but he had not used any alcohol or hard drugs in eight or nine years prior to the hearing. (R. 1442-43.)

Plaintiff does not usually sleep through the night, and he had been awake since 2:30 or 2:45 the morning of the hearing. (R. 1443.) When he cannot sleep, he will watch television, listen to the radio, or read the Bible or a magazine. (R. 1443, 1445.) He is usually in bed by 8:00 or 8:30 at night. (R. 1443.) He does not prepare his own meals; his fiancee, sister, or parents cook for him. (R. 1443-44.) He does no housework but sometimes exercises during the day. (R. 1444.) He can no longer engage in any hobbies such as bowling, golfing, and going to the movies, but he remains active in his church. (R. 1444-45.)

2. Medical Evidence

a. Treating Physician Reports*fn1

Dr. Odeh

Dr. Odeh, an internal medicine specialist, completed a state welfare form in July 2003 after examining Lakes twice, in April and July 2003. (R. 455-58.) He noted that Lakes had back and knee pain which caused moderate limitations in his ability to stand and sit, as well as marked limitations in his ability to walk, bend, stoop, turn, push, and pull. (R. 458.) Dr. Odeh also diagnosed Plaintiff with asthma, hypertension, and depression. (R. 455.)

In another state form completed on January 27, 2004, Dr. Odeh diagnosed him with schizophrenia, depression, asthma, hypertension, and back and knee pain.

(R. 1124.) Dr. Odeh found that Lakes is significantly restricted in his ability to walk, bend, stand, stoop, sit, turn, climb, push, or pull; and mildly restricted in gross and fine manipulations and dexterity. (R. 1127.) He can lift no more than twenty pounds, with frequent lifting of up to ten pounds. (Id.) He has marked limitations in his activities of daily living and concentration, persistence, and pace; and extreme limitations in social functioning. (Id.)

Dr. Lee

Dr. Lee, a psychiatrist, completed a welfare form on August 4, 2003, after his second visit with Lakes. (R. 576-77.) He concluded that Plaintiff had moderate functional limitations in daily and social function and the ability to sustain concentration, caused by depression and substance dependence. (R. 577.)

Dr. Snyder

On October 7, 2003, Ms. Nora Guini (who has a master's degree in psychology) performed a psychological evaluation of Lakes under the supervision of Dr. Snyder, a psychologist. (R. 517-22.) As part of the evaluation, Lakes was given the Wechsler Adult Intelligence Scale - III test and obtained a Verbal IQ of 81, Performance IQ of 70, and a Full Scale IQ of 74. (R. 520.) The evaluation noted that the scores placed Lakes within the Borderline range of intelligence and rank him at the fourth percentile. (Id.)

Based upon the results of evaluation, Ms. Guini and Dr. Snyder jointly submitted a Psychiatric Review Technique Form ("PRTF") and a mental RFC form.

(R. 523-41.) The PRTF concluded that Lakes's impairments met Listing 12.04 (Affective Disorders) and equaled Listings 12.08 (Personality Disorders) and 12.09 (Substance Addition Disorders). (R. 523.)

In the RFC, Dr. Snyder found that Lakes had marked limitations in his ability to understand, remember, and carry out detailed or complex tasks or instructions; his ability to interact with co-workers or supervisors; and in his ability to sustain concentration and attention for complex tasks; and had moderate limitations in his ability to interact with the general public; to adapt to changes; or to sustain attention and concentration even for simple or repetitive tasks. (R. 535-36.)

Dr. Doshi

Dr. Doshi was one of Lakes's treating psychiatrists at Loretto Hospital. He was the attending physician at the time Lakes was admitted to the hospital in January 2004 for severe depressive disorder with suicidal ideation. (R. 698-99.) Lakes was discharged in improved condition after several days, and he continued treatment with Dr. Doshi thereafter at Loretto's outpatient mental health clinic. (R. 699-708.) A November 25, 2005 note states that Lakes was being treated for "severe and incapacitating depression with marked anxiety." (R. 689.)

In a March 21, 2007 welfare form, Dr. Doshi opined that Lakes's mental impairments markedly limited his activities of daily living, social functioning, and concentration, persistence and pace. (R. 1005.) Dr. Doshi noted that Plaintiff had one episode of decompensation of extended duration during the preceding year. (Id.)

Dr. Husain

Dr. Husain, Lakes's primary care physician, began seeing him in February 2004. (R. 954, 923-38.) On November 5, 2005, Dr. Husain concluded that Lakes was "unable to do any work" as a result of his chronic physical and mental impairments.

(R. 954.) In a November 25, 2008 impairment form, Dr. Husain opined that Plaintiff can sit, stand, and or walk for less than one hour per work day; sit for no longer than five minutes at a time; and needs five to ten minute breaks every five to ten minutes throughout the work day. (R. 1132-33.) Lakes can lift five to ten pounds occasionally and carry less than five pounds occasionally, and he has marked limitations in using either upper extremity. (R. 1133.) He could not push, pull, kneel, bend, or stoop, or work in environments that would expose him to moisture, fumes, gases, extremes of temperature, dust, or heights. (R. 1136.) Dr. Husain concluded that Plaintiff's symptoms would likely increase if he were placed in a competitive work environment and that he was incapable of even low-stress work activity. (R. 1134-35.)

A May 29, 2007 note from Dr. Husain opines that Lakes "is totally disabled without consideration of any past or present drug and/or alcohol use. Drug and/or alcohol use is not a material cause of this individual's disability." (R. 949.)

Dr. Case

Beginning in April 2004, Lakes began regularly seeing Dr. Case, a rheumatologist. (See generally R. 713-33, 738-56, 872-91.) Dr. Case diagnosed Lakes with fibromyalgia. (R. 756.) In October 2004, Dr. Case repeated the fibromyalgia diagnosis but noted that Lakes was possibly ...

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