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Rochelle Tolbert v. Michael J. Astrue

April 13, 2012

ROCHELLE TOLBERT, 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:

Plaintiff, Rochelle Tolbert ("Tolbert" or "claimant"), has filed a motion for summary judgment [26] seeking judicial review of the final decision of the Commissioner of the Social Security ("Commissioner") denying her application for disability insurance benefits ("DIB") and supplemental security income ("SSI") under the Social Security Act, 42 U.S.C. §§ 416(i), 423(d), and 1382c(a). In his response [41], the Commissioner asks the Court to uphold the decision of the Administrative Law Judge. This Court has jurisdiction to hear this matter pursuant to 42 U.S.C. §§ 405(g) and 1383(c). For the reasons set forth below, claimant's motion for summary judgment is granted in part and denied in part.

I. BACKGROUND

A. Procedural History

Tolbert filed her applications for DIB and SSI on May 8, 2006, alleging disability beginning April 1, 2005. (R. 135-142.) Her claims were denied initially on August 17, 2006, (R. 77-80), and upon reconsideration on January 18, 2007. (R. 82-87.) A preliminary hearing was held on March 18, 2009 before Administrate Law Judge ("ALJ")

Percival Harmon, at which time ALJ Harmon determined that he needed to obtain Tolbert's recent medical records from Rush University Medical Hospital ("Rush"). (R. 48-61.) Tolbert also waived her right to counsel at that time. (R. 52-53, 110.) ALJ Harmon held a second hearing on June 10, 2009, during which he heard testimony from Tolbert and vocational expert Glee Ann L. Kehr. (R. 11-45.) ALJ Harmon kept the record open after the hearing because he still had not received the records from Rush.

(R. 44.)

On August 31, 2009, ALJ Harmon issued a written decision denying Tolbert's applications for benefits. (R. 66-76.) Tolbert filed a timely request for review of that decision. (R. 131-133.) On July 14, 2010, the Appeals Council denied that request. (R. 6-8.) Then, on October 14, 2010, the Appeals Council set aside that denial to consider additional information. (R. 1-5.) But, after reviewing the additional information, the Appeals Council ultimately denied Tolbert's request for review. (Id.) As a result, ALJ Harmon's decision became the final decision of the Commissioner. Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). This action followed.

B. Medical Evidence

1. Treating Physicians

a. Harrison Medical Center

Records reveal that Tolbert was under the care of Dr. Mohammad Ahmed at Harrison Medical Center ("Harrison") from May 24, 2005 through March 6, 2007. (R. 228-245, 261-271, 372-382.) As a general matter, at every visit, Tolbert's height was noted as 5'7" and her weight was noted as "350" or "350." (See, e.g., R. 232-245.) "Weight reduction" was always noted in the "education & [follow-up]" portion of the medical records. (Id.) She also consistently complained of frequent urination and constipation. (Id.) Her mental status was always documented as "normal," with "no anxiety." (Id.)

On May 24, 2005, Tolbert complained of a cold, sore throat, numbness in her right hand, swelling of her left legs, and severe headaches and dizziness for the previous four days. (R. 245.) She also complained of polyuria and nocturia, but denied shortness of breath, dysuria, or discharge. (Id.) At the time, she was taking only thyroid medication, and hypothyroidism was noted in the section for "past medical Hx." (Id.)

Dr. Ahmed's physical exam revealed an enlarged thyroid, "some rhonchi, distant wheezing," congestion, obesity, swollen hands, and edema in the lower extremities. (Id.) He assessed an upper respiratory infection, rhinitis, headache, dizziness, polyuria, nocturia, hypertension, and pedal edema. (Id.) Dr. Ahmed prescribed Amoxicillin, Synthroid, Claritin, Amibid, Tylenol, Plendil, and Lozol. (Id.)

Tolbert returned to Harrison on June 23, 2005 with the same complaints as at the previous appointment. (R. 244.) Dr. Ahmed again noted swollen hands and edema. (Id.) His assessment was essentially the same, although he included hypothyroidism, and the respiratory infection had cleared up. (Id.) Tolbert reported feeling better on July 23, 2005, but continued to complain of swelling in her legs, polyuria, and nocturia.

(R. 243.) The results of the physical exam were, for the most part, unremarkable, and Dr. Ahmed's diagnoses remained the same. (Id.)

From August 22, 2005 through March 30, 2006, Tolbert saw Dr. Ahmed for "family planning," among other things. (R. 235-241.) On August 2, 2005, August 22, 2005, September 24, 2005, and October 24, 2005, Tolbert complained of lower abdominal pain and backache. (R. 239-242.) On those dates, Dr. Ahmed continued to note edema in the lower extremities and "some rhonchi, distant wheezing" of the lungs. (Id.) He continued to assess pedal edema, hypertension, and hypothyroidism. (Id.) A family history of diabetes was also noted. (Id.)

By January 3, 2006, Tolbert's headaches and dizziness had returned and she still suffered from backaches, although her dizziness and backaches had improved by February 1, 2006. (R. 237-238.) On March 2, 2006, Tolbert suffered from nausea, vomiting, abdominal pain, headaches, and recent episodes of palpitation. (R. 236.) On March 30, 2006, Tolbert complained of swelling in both legs and continuing headaches.

(R. 235.) On April 29, 2006, she complained of pain in her knee joints, along with numbness and tingling in her fingers. (R. 234.)

As of May 9, 2006, Tolbert continued to suffer from severe pain in both knee joints, as well as swelling of both knees and ankle areas. (R. 233.) Dr. Ahmed assessed arthralgia, obesity, arthritis, and pedal edema, and prescribed Volteran. (Id.) On June 5, 2006, Tolbert reported that the pain in her joints had improved with the Volteran, but she continued to complain of swelling of her legs, right foot and ankle, as well as numbness and tingling in her fingers. (R. 232.) Tolbert had similar complaints on July 17, 2006, and explained that she experienced "knee joints pain and shortness of breath with a little walk." (R. 268.) An examination of her lungs revealed no rhonchi and no wheezing. (Id.) Dr. Ahmed noted "moderate obesity" at the July 17 appointment and every appointment thereafter. (R. 268-271, 372-374.)

On August 23, 2006, along with the pain and swelling of her knees and legs, Tolbert reported a severe backache. (R. 269.) She also experienced shortness of breath while sleeping at night. (Id.) She voiced similar concerns on October 3, 2006, November 1, 2006, and November 29, 2006. (R. 270-271, 382.)

In a letter dated November 30, 2006, Dr. Ahmed stated that Tolbert had been under his care for hypertension, arthritis, chronic backache, moderate obesity, sleep apnea, and hypothyroidism. (R. 264.) In Dr. Ahmed's "best opinion," because of these problems, Tolbert's "physical routine is restricted" and she "will not be able to do routine work." (Id.)

On March 6, 2007, Tolbert complained of palpitations and "feeling very hot and cold, but sweating." (R. 372.) She had pain in her right shoulder, both legs, and knees. (Id.) She continued to voice concerns of knee pain, and shortness of breath on April 11, 2007 and July 16, 2007. (R. 373-374.) Dr. Ahmed continued to assess backache, arthralgia, hypertension, and hyper/hypothyroidism and continued to prescribe Tylenol, Synthroid, Plendil, Volteran, Ecotrin, Folic Acid, and Vitamin C. (Id.)

b. Rush University Medical Center

Records reveal that Tolbert presented to the Rush emergency room on June 20, 2007 complaining of left, lower back pain. (R. 358-360.) More specifically, Tolbert reported that she had suffered from left lower back pain intermittently for the past year, which had worsened over the prior two days. (R. 358.) A history of hypertension and hypothyroidism was noted. (Id.) A physical exam in the emergency room revealed primarily normal results apart from "paraspinal tenderness," and "low back tenderness with bilateral straight leg rise." (R. 359.) The final diagnosis was a low back strain and Tolbert was discharged the same day with a prescription for Motrin and Valium. (R. 360.)

Following her emergency room visit, Tolbert continued receiving care from various physicians at Rush University Internists. At her first appointment on July 5, 2007, she reported that her back pain had gotten "better," but she still experienced some pain. (R. 293.) The physical examination by Dr. Ruby Pouw revealed primarily normal results other than extreme obesity. (Id.) Dr. Pouw assessed chronic lower back pain, morbid obesity, ...


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