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Robert Pena, Sr v. Michael J. Astrue

February 27, 2012


The opinion of the court was delivered by: Amy J. St. Eve, District Court Judge:


Plaintiff Robert Pena, Sr. seeks review of the final decision of the Commissioner of Social Security (the "Commissioner") that denied his application for disability insurance benefits under Title II of the Social Security Act (the "Act"). See 42 U.S.C. § 405(g). Before the Court is Plaintiff's motion for summary judgment. For the following reasons, the Court grants Plaintiff's motion. The final decision of the Commissioner is vacated, and this matter is remanded to the Commissioner for further proceedings consistent with this Opinion.


I. Procedural History

On July 20, 2007, Plaintiff filed an application for social security disability benefits, alleging a disability onset date of May 29, 2007. The Social Security Administration ("SSA") denied the claim initially on November 8, 2007, and again upon reconsideration on March 14, 2008. On September 30, 2009, pursuant to Plaintiff's written request, an administrative law judge ("ALJ") conducted a hearing. In a written decision dated November 6, 2009, the ALJ denied Plaintiff's application for benefits. The SSA Appeals Council thereafter denied review. On May 10, 2011, Plaintiff filed the present action against the Commissioner, seeking review of the denial of social security disability benefits. This Court has jurisdiction pursuant to 42 U.S.C. § 405(g).

II. Factual Background

The following evidence comes from the record that was before the ALJ. Plaintiff was born in 1956 and has a ninth grade education. (A.R.*fn1 at 43-44.) He has previously worked as an oiler at a machine factory, a floor cleaner, and a machine operator. (Id. at 44-46.) On or about May 30, 2007, Plaintiff was admitted to the hospital, "present[ing] with throwing up, cough, chest pains." (Id. at 348.) The next day, Plaintiff underwent a "coronary artery bypass graft and did well postoperative." (Id. at 261.) The hospital discharged Plaintiff on or about June 6, 2007, with a diagnosis of "chest pain"; "diabetes mellitus"; and "alcohol abuse." (Id.)

A. Dr. Yatin Shah, M.D. -- Treating Physician

On June 15, 2007, Dr. Yatin Shah, M.D. saw Plaintiff for a follow up visit to his hospitalization, and diagnosed him with hypertension, diabetes, and left heart failure. (Id. at 342-47.) Then, on July 20, 2007, Dr. Shah diagnosed Plaintiff with "diabetes with neurological manifestations." (Id. at 343.)

B. Dr. Muawia Martini, M.D. -- Treating Physician

On August 6, 2007, Dr. Muawia Martini, M.D. saw Plaintiff for a hospital follow up visit, and reported that Plaintiff "denies any chest pain, tightness, heaviness, or pressure. No palpitations, dizziness, or syncope." (Id. at 362.) Dr. Martini additionally reported a history of depression and congestive heart failure, among other things, and recommended cardiac rehabilitation. (Id. at 363 (further noting that Plaintiff is "[d]oing well").) On March 4, 2008, Dr. Martini again saw Plaintiff for a follow up, at which time Plaintiff complained of fatigue and dyspnea with exertion. (Id. at 449.) Dr. Martini recommended that Plaintiff engage in exercise, noting that Plaintiff "did not go through cardiac rehab because of insurance reasons." (Id. at 450.) On August 25, 2008, Dr. Martini diagnosed Plaintiff with coronary artery disease, diabetes, and history of cardiomyopathy, hypertension, history of heart failure, and arthritis. (Id. at 451.) It appears that Dr. Martini saw Plaintiff on February 23, 2009, but the record is illegible. (Id. at 453-54.)

C. Dr. ChukwuEmeka Ezike, M.D. -- SSA Consultive Examiner

In October of 2007, Dr. ChukwuEmeka Ezike, M.D. performed a consultive examination of Plaintiff at the request of the Bureau of Disability Determination Services. At that time, Plaintiff's "chief complaint" was "a history of coronary artery disease, arthritis, congestive heart failure, and neuropathy." (Id. at 376.) Dr. Ezike noted that Plaintiff experiences "occasional chest pain, which he describes as needle sticks on his chest, radiating to the neck and both upper extremities down to the fingers," in addition to "bilateral hand pain and stiffness with difficulty lifting." (Id. (further noting: "His hands get stuck when closed. He drops objects occasionally and has difficulty opening bottle tops and jars.").)

Based on an examination, Dr. Ezike's observations included the following: "trigger of the middle and ring fingers bilaterally [and] also mild medial tenderness of the right knee"; "unable to squat completely"; "diffuse tenderness of the leg bilaterally"; "able to get on and off the exam table with no difficulty [and] could walk greater than 50 feet without support"; "gait was antalgic without the use of assistive devices"; "difficulty performing toe/heel walk due to bilateral lower extremity pain"; "able to pick up a nickel with each hand [but] has difficulty with grasping due to the trigger fingers in both hands"; "mild tenderness of the PIP joint of each finger"; "difficulty with extending the fingers after flexion but was able to make fists and appose the fingers"; and "range of motion of the shoulders, elbows, [wrists, hips, knees, and ankles] was normal." (Id. at 378.)

Dr. Ezike's mental status examination showed Plaintiff to be "alert and oriented to place, time and current date," and that his "[a]ppearance, behavior and ability to relate during the examination were normal." (Id.) Dr. Ezike further observed that Plaintiff was "appropriate, polite, pleasant and cooperative. The affect was normal. There were no signs of depression, agitation, irritability or anxiety." (Id.) Dr. Ezike concluded his report with seven "impressions": coronary artery disease, status post CABG; bilateral hand arthritis; trigger fingers; diabetes mellitus; hypertension; peripheral neuropathy; and right knee pain. (Id. at 379.)

D. Dr. Francis Vincent, M.D. -- SSA Reviewing Physician; Physical Residual Functional Capacity Assessment

On November 5, 2007, Dr. Francis Vincent, M.D., a state agency reviewing physician, completed a Residual Functional Capacity Assessment ("RFC Assessment") on a pre-printed administrative form. (Id. at 381-88.) In the RFC Assessment, Dr. Vincent checked boxes corresponding to statements that Plaintiff, among other things, could "occasionally lift and/or carry" a maximum of 20 pounds; "frequently lift and/or carry" a maximum of 10 pounds; "stand and/or walk (with normal breaks)" for a total of 6 hours in an 8 hour workday; "sit (with normal breaks)" for a total of 6 hours in an 8 hour workday; and "push and/or pull (including operation of hand and/or foot controls)" for an "unlimited" amount of time, "other than as shown for lift and/or carry." (Id.) Dr. Vincent, however, did not complete numerous sections of the RFC Assessment. (See discussion infra at pages 17-19.)

E. Dr. Robert Prescott, Ph.D. -- SSA Consultive Examiner; Formal Mental Status Examination

On February 21, 2008, Dr. Robert Prescott, Ph.D., a licensed psychologist, performed a "formal mental status examination" of Plaintiff at the request of the Bureau of Disability Determination Services. (A.R. at 391.) At that time, Plaintiff stated that he was not receiving mental health treatment, nor had he in the past. (Id. at 391-92.) As to Plaintiff's level of functioning, Dr. Prescott observed that although Plaintiff "can dress himself . . . , he is unable to tie his shoes," and he performs self-care "slowly." (Id.) Additionally, Dr. Prescott observed that Plaintiff "appeared to walk with a slight limp and moved slowly [and was] a little but [sic] unsteady on his feet. He had brought his medicines in a ziplock bag which he had considerable difficulty opening up." (Id.)

Dr. Prescott noted that Plaintiff "said he has been feeling depressed for the past 2 or 3 months because he can't pay his bills. He said he cries once in awhile [and] is very irritable." (Id. at 393-94.) The doctor agreed that Plaintiff "did appear to be somewhat depressed." (Id.) Dr. Prescott further observed that Plaintiff reported being forgetful and confused at times. (Id.) Dr. Prescott concluded his report with a diagnosis of "major depression, moderate. Learning disability, NOS, per history." (Id.)

F. Dr. Norma Villanueva, M.D. -- SSA Consultive Examiner; Internal Medical Examination On February 28, 2008, Dr. Norma Villanueva, M.D., performed an "internal medicine consultative examination" at the request of the Bureau of Disability Determination Services. (Id. at 415.) Plaintiff complained of shortness of breath, chest pain that radiates to his lower back and neck, numbness of the foot and legs, tingling sensations in his foot, and pain in his fingers. (Id.) Dr. Villanueva's examination revealed decreased sensation in Plaintiff's feet and lower legs, and a "full painless range of motion in degrees of all joints. . . . Ability to grasp, finger and manipulate with each hand was entirely normal." (Id. at 416.) Dr. Villanueva concluded by noting certain "clinical impressions": "diabetes mellitus with neuropathy, on medication; hypertension, controlled on medication; coronary artery disease, status post heart bypass, possibly had myocardial infarction; arthritis of the hands, on medication; depression -- please refer to psychiatric evaluation for further information in this regard." (Id. at 416-17.)

G. Dr. Frank Norbury, M.D. -- SSA Reviewing Physician; Review of RFC

On March 13, 2008, Dr. Frank Norbury, M.D. affirmed the findings contained in the RFC Assessment that Dr. Vincent completed. (Id. at 397-98.) Dr. Norbury explained, based on a review of Plaintiff's medical file, that "[o]n reconsideration, there is found to be a decrease in sensation in both feet and lower leg. . . . Heart sounds are still normal. Claimant grip ...

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