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Yashimura Washington v. Carolyn W. Colvin

May 7, 2013


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


Michael T. Mason, United States Magistrate Judge:

Claimant Yashimura Washington ("Washington" or "claimant") has brought a motion for summary judgment [20] seeking judicial review of the final decision of the Commissioner of Social Security (the "Commissioner"). The Commissioner denied Washington's claim for Supplemental Security Income ("SSI") under the Social Security Act (the "Act"), 42 U.S.C. § 1382c(a)(3)(A). The Commissioner has filed a cross-motion for summary judgment [24] and memorandum in support thereof [25] asking the court to uphold its prior decision. The court has jurisdiction to hear this matter pursuant to 42 U.S.C. § 1383(c)(3). For the reasons set forth below, Washington's motion for summary judgment is granted in so much as Washington seeks a remand to the Social Security Administration (the "SSA"). The Commissioner's motion is denied.


A. Procedural History

Washington applied for SSI on September 9, 2009, alleging disability beginning on May 2, 2009 due to morbid obesity, asthma, hypertension, nerve damage in both legs, back pain, and migraines.*fn2 (R. 164-69.) Her application was denied initially on December 28, 2009, and upon reconsideration on June 11, 2010. (R. 103-07, 121-24.) Washington then filed a timely request for a hearing. (R. 125-26.) On May 19, 2011, Washington appeared with counsel at a hearing before Administrative Law Judge ("ALJ") Judith S. Goodie. (R. 46-97.) Both Washington and vocational expert ("VE") Thomas F. Dunleavy testified at the hearing.

On August 24, 2011, ALJ Goodie issued a written decision finding that Washington was not disabled under the Act. (R. 27-40.) Washington filed a timely request for review with the Appeals Council, which was denied on April 20, 2012. (R. 15-17, 23-25.) As a result, ALJ Goodie's decision became the final decision of the Commissioner. This action followed.

B. Medical Evidence

1. Treating Physicians

At the time she applied for benefits, Washington was twenty-seven years old. She stands six feet two inches tall and weighs approximately 430 pounds. Medical records reveal she has received treatment for various conditions, including morbid obesity, migraines, shortness of breath, and palpitations.

On August 23, 2009, Washington was transported by ambulance to the emergency department of Stroger Cook County Hospital ("Cook County") complaining of a severe right-sided headache, as well as numbness in her right arm, sensitivity to light, and nausea.*fn3 (R. 254, 261.) Washington denied vomiting, visual or speech disturbances, motor weakness, and gait instability. (Id.) Washington reported using marijuana daily over the last three months, up to five times a day. (R. 261, 264.) X-rays of the cervical spine, limited to evaluation through C6, showed no evidence of fracture, subluxation, or other acute bony injury. (R. 268.) Her CT scan was normal. (R. 278.)

The examining resident physician, Dr. Atish Mathur, commented on Washington's known history of asthma and her morbid obesity. (R. 261-62.) Dr. Mathur assessed possible migraine or pseudotumor cerebri, well-controlled asthma (with albuterol inhaler), and hypertension. (R. 262.) The attending physician, Dr. Daryl Woods, commented on Washington's decreased hand grip and her right-side numbness. (R. 266.) In addition to the assessments by Dr. Mathur, Dr. Woods assessed "RUE numbness and weakness" and noted "clinical findings consistent with C7 cervical radiculopathy possibly from cervical rib or disc disease." (Id.) He also documented her body mass index as 51.5. (Id.) Washington was discharged in stable condition on August 24, 2009 and was advised to follow-up with Dr. Mathur. (R. 270-71.) She was prescribed acetaminophen-hydrocodone, zolmitriptan, hydrochlorothiazide, and potassium chloride. (R. 271.) She was also advised to lose weight. (R. 266.)

It appears that Washington saw Dr. Emanuel Diaz on September 8, 2009 at the Jorge Prieto Family Health Center ("Prieto Health Center") for management of migraines, hypertension, asthma, possible sleep apnea, and low back pain. (R. 381-82.) Washington complained of right arm numbness and explained that she was undergoing family stressors that caused insomnia. (R. 381.) Dr. Diaz reviewed the lab results from Washington's recent stay at Cook County and assessed controlled hypertension, among other things. (Id.) He commented that Washington's "body aches and pain could be due to anxiety and stressors." (R. 382.)

Washington saw a Dr. Martinez at the Prieto Health Center on September 22, 2009. (R. 379.) Dr. Martinez listed generalized anxiety disorder with panic attacks as his diagnosis and also noted obesity. (Id.)

On September 29, 2009, Washington presented to the emergency department of Mount Sinai Medical Center complaining of shortness of breath, palpitations, and associated dizziness, which had started a week prior. (R. 284.) Among other things, Washington described a history of chronic lower back pain, as well as a history of seizures per a diagnosis at Cook County. (Id.)

A physical examination revealed tenderness in the lower back area and distant breath sounds due to obesity. (R. 285.) A limited chest x-ray showed no evidence of acute cardiopulmonary abnormality. (R. 281.) There was no evidence of pulmonary emboli. (R. 294.) Though Washington's initial EKG showed normal sinus rhythm, repeat testing showed sinus arrhythmia with occasional and consecutive premature ventricular complexes and fusion complexes. (R. 286, 303, 307.) A severely limited echocardiogram revealed that the left ventricle appeared to be normal. (R. 304.)

Washington was discharged on October 1, 2009 with diagnoses of aberrant supraventricular tachycardia, asthma, hypertension, and migraine headaches. (R. 284.) She was prescribed hydrochlorothiazide, potassium chloride, albuterol, tylenol, and magnesium oxide. (R. 286-87.) A sleep study for possible sleep apnea and a low salt diet were advised. (R. 286, 312.) Washington was directed to follow up with Dr. Mathur and a cardiologist. (R. 286, 309.)

On October 6, 2009, Washington followed up with Dr. Mathur as directed. (R. 325-27.) A physical examination revealed primarily unremarkable results. (R. 325.) Dr. Mathur again assessed hypertension, migraines, and obesity. (R. 326.)

Washington returned to the Prieto Health Center on October 30, 2009, at which time she was again diagnosed with generalized anxiety disorder with panic attacks by Dr. Martinez. (R. 371-72.) She was advised to continue with therapy.*fn4 (R. 371.)

On February 2, 2010, Washington returned to see Dr. Mathur, complaining of intermittent right arm numbness with and without migraine attacks. (R. 355.) She also complained of lightheadedness, mostly on walking, sitting up suddenly, or bending over. (Id.) Her migraines were improving and she had no complaints of visual disturbances or gastric symptoms. (Id.) Dr. Mathur noted possible vertigo and commented that Washington's migraines were "well-controlled" with her medication. (R. 356.) Although her blood pressure was high at the appointment, this was attributed to the fact that she had been without her medication for a week. (Id.) Dr. Mathur ordered an EMG to assess her right arm numbness. (Id.) On April 7, 2010, a clinical neurological examination revealed a positive Tinel sign on Washington's right wrist. (R. 360.) The EMG, conducted that same day, showed "evidence of a median mononeuropathy at the right wrist." (Id.)

Washington returned to the Prieto Health Center on October 5, 2010. (R. 370.) At that appointment, Washington appears to have complained that she suffers from migraines two days a week and explained that she seeks relief by decreasing noise and sleeping in a dark room. (Id.) Among other things, the examining physician assessed migraines, anxiety, stable hypertension, and insomnia. (Id.) A similar assessment was made on December 2, 2010, at which time it was also noted that her migraines had mildly improved. (R. 369.) Carpal tunnel syndrome was also noted on that date and wrist splints were recommended.*fn5 (Id.) A progress note from January 7, 2011 is, for the most part, illegible. (R. 389.)

2. Agency Consultants

On December 7, 2009, Washington underwent a consultative exam with Dr. Sarada Deshpande of Chicago Consulting Physicians. (R. 328-36.) At that time, Washington explained that she suffered from "pretty bad migraine headaches" about twice a week, which last a couple of hours. (R. 329.) The headaches are mostly on the right side and she rated them an eleven on a ten-point scale. (Id.) She described associated nausea, but no vomiting. (Id.) According to Washington, medication does not alleviate her headaches. (Id.) Washington also stated that she has suffered from severe pain in both legs since she was diagnosed with toxic shock syndrome at age fifteen. (Id.) She gets minor relief from ibuprofen. (Id.) She denied the use of a cane. (Id.) She claimed she experiences shortness of breath after walking for two blocks. (Id.)

Washington further explained that she suffers from intermittent back pain, which she rated an eight on a ten-point scale. (R. 329.) Her back pain worsens upon standing and walking. (Id.) Additionally, Washington said that she suffers from left knee pain as a result of a car accident in her childhood. (Id.) This too worsens with walking and in cold weather. (Id.) Washington claimed that both her back pain and left knee pain are alleviated "a little" with medication. (Id.) Washington also reported numbness in her right arm, which causes her to lose feeling in her fingertips. (Id.) Washington denied illicit drug use. (Id.)

On physical examination, Washington weighed 430.8 pounds and had a blood pressure of 130/80. (R. 329.) Dr. Deshpande described her general appearance as "a morbidly obese female in no apparent distress." (Id.) He noted that Washington displayed "a waddling gait with a mild limp on the left knee." (R. 330.) She could walk over fifty feet without assistance. (Id.) Washington had mild difficulty getting on and off the exam table, moderate difficulty doing certain special maneuvers, and severe difficulty squatting. (R. 330, 332.) Straight leg testing was negative. (R. 332.) Range of motion in her cervical spine, shoulders, elbows, and wrists was normal. (R. 330, 333-34.) Lumbar spine flexion was 60/90 degrees and painful. (R. 330, 334.) Right knee flexion was 90/150 degrees ...

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