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Larry Sydnor v. Michael J. Astrue

August 13, 2012


The opinion of the court was delivered by: Judge Robert M. Dow, Jr.


This matter is before the Court on a motion for summary judgment [15], filed by Plaintiff Larry Sydnor, seeking judicial review of a decision of Defendant Michael J. Astrue, Commissioner of the Social Security Administration, denying Sydnor's application for disability insurance benefits ("DIB"). Plaintiff asks the Court to reverse the decision of the Administrative Law Judge denying him benefits or, alternatively, remand for further proceedings. Defendant filed a memorandum in support of the Commissioner's decision. For the following reasons, the Court grants Plaintiff's motion for summary judgment [15] and remands this matter for further proceedings consistent with this opinion.

I. Procedural Background

On February 20, 2007, Plaintiff applied for disability insurance benefits without the assistance of counsel, alleging an onset date of September 15, 2004.*fn1 See Administrative Record ("R") at 138.*fn2 Plaintiff's application was denied both initially and upon reconsideration. Plaintiff timely requested a hearing. On April July 29, 2009, Plaintiff, his attorney, his wife, a medical expert, and a vocational expert appeared and testified at a hearing before an Administrative Law Judge ("ALJ"). R. at 24. In a decision dated November 16, 2009, the ALJ denied Plaintiff's application and made the following findings:

1. The claimant last met the insured status requirements of the Social Security Act on March 31, 2008.

2. The claimant did not engage in substantial gainful activity during the period from his alleged onset date of September 15, 2004 through his date last insured of March 31, 2008 (20 CFR 404.1571 et seq.). 3. Through the date last insured, the claimant had the following severe impairments: diabetes mellitus, history of coronary artery disease (CAD)/cardiomyopathy, degenerative disc disease/degenerative joint disease of the lumbar spine, and osteoarthritis of the hands ((20 CFR 404.1520(c)).

4. Through the date last insured, the claimant did not have an impairment or combination of impairments that met or medically equaled one of the listed impairment in 20 CFR Part 404, Subpart P, Appendix 1.

5. After careful consideration of the entire record, I find that, through the date last insured, the claimant had the residual functional capacity to perform the full range of light work, frequent fingering and handling objects, no climbing ladders, ropes, or scaffolds, and occasional climbing ramps and stairs, balancing, stooping, kneeling, crouching, or crawling. The claimant must avoid all exposure to heights and moving machinery.

6. Through the date last insured, the claimant was capable of performing past relevant work as a security guard. This work did not require the performance of work-related activities precluded by the claimant's residual functional capacity (20 CFR 404.1565).

7. The claimant was not under a disability, as defined in the Social Security Act, at any time from September 15, 2004, the alleged onset date, through March 31, 2008, the date last insured (20 CFR 404.1520(f) and 404.1520(g)).

R. at 16-22.

Plaintiff sought review of the ALJ's decision and the Appeals Council denied his request, leaving the ALJ's decision as the final decision of the Commissioner. Plaintiff now seeks judicial review of the final decision of the Commissioner of Social Security. This Court has jurisdiction pursuant to 42 U.S.C. § 405(g).

II. Facts

A. Background

Plaintiff, born on April 10, 1955, was fifty-two years old at the time that he applied for DIB. R. at 387. Mr. Sydnor has a long work history. For approximately 25 years, Mr. Sydnor was a warehouse clerk at a cleaning company, rising to the level of working supervisor. Mr. Sydnor was last employed in September of 2004 by Continental Security at an assisted living home. His responsibilities included helping the residents with their packages, making sure they got to their cars safely, and patrolling the grounds. Mr. Sydnor earned slightly under $8,685.00 in 2004.

B. Medical Evidence

The medical evidence in this case documents longstanding diabetes with neuropathy and cardiac problems and other problems such as arthritis, lumbosacral spine problems, knee pain, elbow pain, hand pain, muscle atrophy, and depression. Beginning in October 2004, Dr. Kaihua Lai diagnosed Plaintiff with acute epididymitis, type-I diabetes, hyperlipidemia, and diabetic nephropathy. R. at 398. Plaintiff was prescribed Cipro. In January 2005, Sydnor reported pain to the left elbow area when doing pushups and heavy weight lifting. R. at 395-96. Then, in August 2005, Sydnor's physical exam revealed slight tachycardia and premature atrial contractions but was otherwise normal. R. at 382.

With respect to Mr. Sydnor's diabetes and neuropathy, the medical records indicate that he has been a diabetic since 1998. R. at 424. The medical records document that beginning in 2005, Mr. Sydnor struggled with high levels of glucose, hemoglobin, trigylcerides, and cholesterol. R. at 418, 420, 421. In February 2006, Plaintiff reported to Dr. Lai that he was working as a babysitter and "feeling well except for the low back pain." R. at 377. Dr. Lai noted that Mr. Sydnor suffered from low back pain and spasms and made an assessment of diabetic neuropathy. R. at 599, 601. The physical examination showed mild tenderness to the left side paraspinal muscle area, but otherwise was normal. R. at 377. Later that month, Plaintiff presented to the emergency room, where he was diagnosed with pneumonia with pleural effusion on the left side, non-insulin dependent diabetes mellitus, reactive airway disease, hypertension, and mild anemia. R. at 255. He also had a cough, fever, and hypotension from sepsis. R. at 255. Mr. Sydnor's sepsis was treated with both chest tubes and aggressive antibiotic treatment in theintensive care unit. R. at 255.

In March 2006, Plaintiff saw Dr. Lai for a follow-up for his pneumonia. R. at 374. Dr. Lai recommended a chest x-ray and that Plaintiff follow-up with Dr. Arnold Bolisay for his diabetes. R. at 374. She also stressed diet and exercise. R. at 374. Later that month, Plaintiff saw Dr. Robert Markus and complained of left-sided mid-back pain. R. at 371. Dr. Markus noted some atelectasis in the left lower lung and elevation of the left hemidiaphragm. R. at 371. He recommended that Plaintiff follow-up with his primary care physician. R. at 371.

In May 2006, Plaintiff saw Dr. Bolisay for a recheck of his diabetes. R. at 368. He was diagnosed with Type II diabetes uncontrolled with non-compliance, hypertension controlled with medication, and hyperlipidemia on Lipitor daily. R. at 368. In August 2006, Dr. Bolisay noted that Plaintiff recently started exercising. R. at 365. Then, in December of 2006, Dr. Bolisay indicated in his notes that "Mr. Sydnor complains of bilateral hand weakness to the point where he can't open a jar." R. at 582. In January 2007, Plaintiff's physical examination was normal.

R. at 361. Plaintiff's Glucophage dosage was increased. R. at 361.

On June 6, 2007, the Administration's consulting physician, Dr. Stanley Rabinowitz, examined Mr. Syndor and completed a Disability Examination Report. R. at 423-27. Dr. Rabinowitz found that range of motion testing in all the joints and spine was normal, except for the lumbar spine. R. at 426. Straight-leg raising was negative. R. at 426. Plaintiff had mild interossei atrophy of the thumb area and moderate difficulty squatting, but otherwise Dr. Rabinowitz's concluded that the examination of the extremities was normal. R. at 426. Plaintiff had decreased pinprick and light touch in a stocking distribution and reflex testing revealed absent ankle reflexes. R. at 426. Plaintiff had full motor strength in both the upper and lower extremities, there was no evidence of atrophy, and his gait was intact. R. at 426. Plaintiff was diagnosed with history of spontaneous pneumothorax, status post chest tube insertion with resolution; type II adult onset insulin dependent diabetes mellitus, poorly controlled on therapy with peripheral neuropathy and microscopic albuminuria secondary to nephropathy; and probable degenerative joint disease. R. at 427.

In addition to diabetic neuropathy, medical records confirm that Sydnor suffered from degenerative joint disease, which causes pain to his foot, knee, arm, and elbow. R. at 424, 427, 444, 491, 492, 543. In August 2007, Dr. Lai's progress notes reflect that Syndor presented with left upper arm pain and right knee pain for more than six months with no improvement. R. at 444. Dr. Lai ordered a radiology exam, which revealed early degenerative changes involving the left elbow, including a small spur. R. at 492. Dr. Lai also noted loose bodies within the right knee joint space and possible joint effusion. R. at 446, 492. On exam, Plaintiff had muscle tenderness over the triceps and slight tenderness over medial superior distal femur area. R. at 444. The cardiopulmonary exam was normal, Plaintiff had normal range of motion in the elbow joint and shoulder joints, muscle strength was normal, and right ...

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