United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
SIDNEY I. SCHENKIER, Magistrate Judge.
Plaintiff Courtney Ludwig has filed a motion seeking reversal and remand of the final determination of the Commissioner of Social Security ("Commissioner") denying her application for benefits under Title II of the Social Security Act (doc. #14). The Commissioner has filed a memorandum in response, requesting that the Court affirm that determination (doc. #23). For the reasons below, the Court grants Ms. Ludwig's motion.
Ms. Ludwig submitted her application for disability insurance benefits on January 7, 2009, claiming she became unable to work due to disability as of the alleged onset date of July 13, 2007 (R. 191-92). Her application was denied on February 23, 2009, and upon reconsideration on August 19, 2009 (R. 87, 92). Ms. Ludwig was then granted a hearing before an Administrative Law Judge ("ALJ"), which was held on September 15, 2010 (R. 29). A supplemental hearing was held on March 8, 2011 (R. 63). On June 6, 2011, the ALJ issued a written decision finding that Ms. Ludwig was not disabled (R. 11-22). On August 2, 2012, the Appeals Council denied Ms. Ludwig's request for review (R. 1-5), making the ALJ's ruling the final decision of the Commissioner. See Shauger v. Astrue, 675 F.3d 690, 695 (7th Cir. 2012). On August 28, 2012, Ms. Ludwig filed her complaint in this Court seeking review.
We begin with a summary of the administrative record. We discuss Ms. Ludwig's general background and her medical record in Part A, the testimony from the first hearing in Part B, later submitted evidence in Part C, testimony from the second hearing in Part D, and the ALJ's written opinion in Part E.
On March 4, 2003, Ms. Ludwig - then 26 years old - suffered a sudden cardiac arrest while tending bar at her parents' tavern (R. 566). Paramedics shocked her nine times in the field, and she was still unconscious when she arrived at the emergency room ( Id. ). Ms. Ludwig likely experienced a period of anoxic encephalopathy (loss of oxygen to the brain) during the cardiac event (R. 551). After her condition stabilized several days later, she was implanted with an ICD ("implantable cardioverter defibrillator") (R. 547). For several years, Ms. Ludwig continued to work multiple jobs as a waitress or bartender (R. 254-55). She last worked full-time in 2007 (R. 209). Ms. Ludwig continued to work part-time in 2008 for friends who accommodated her health issues, and the job did not have a set schedule (R. 46). She has not worked since then.
In August 2006, Ms. Ludwig began treatment with cardiologist Mary Gordon. Ms. Ludwig reported chest pain, fatigue, and hair loss to Dr. Gordon, who prescribed nitroglycerin and ordered a coronary arteriogram (an imaging test to see inside arteries) (R. 592-95). The examination revealed a moderately reduced "ejection fraction" but otherwise normal coronary arteries (R. 591). At that time, Ms. Ludwig was taking atenolol and Norvasc (for blood pressure and chest pain), Topamax (to help prevent migraine headaches), Midrin (for migraine pain), Xanax (for anxiety), and nitroglycerin (for chest pain) (R. 594). Throughout 2007, Ms. Ludwig reported chest pain at some of her office visits with Dr. Gordon, but not others. At her March 2007 appointment, Ms. Ludwig reported chest discomfort and fatigue, and Dr. Gordon opined that Ms. Ludwig had a coronary spasm (R. 698).
Ms. Ludwig got married on July 13, 2007, her alleged onset date (R. 41). After returning from a honeymoon to Germany, she reported to Dr. Gordon on July 30, 2007, that she was feeling "great, " and had no complaints of chest pain or any other health issues (R. 691-92). However, she complained of chest pain at her August 10, 2007 visit with Dr. Gordon despite having had a normal echocardiogram; nevertheless, Ms. Ludwig was looking forward to a year-long road trip with her husband (R. 688). She had a follow-up appointment with Dr. Gordon in December 2007 at which she denied any chest pain (R. 684), but on January 13, 2008, she went to the emergency department after having a flutter and pain in her chest (R. 641-42).
Ms. Ludwig next saw Dr. Gordon in August 2008 (R. 676). Dr. Gordon reported that "[f]rom a heart standpoint, she has been feeling well, " but Ms. Ludwig continued to have chest pain which had remained constant over the years (R. 677). Ms. Ludwig also complained of "chronic, almost daily headaches, " and she reported being too tired to work or exercise ( Id. ). At that appointment, Dr. Gordon substituted propranolol for atenolol and added a prescription for amitriptyline (an anti-depressant) ( Id. ). At an appointment in September 2008, another doctor at the same clinic noted that Ms. Ludwig had ceased taking her migraine medication and that migraines were "not voiced as an active problem" (R. 671). In October 2008, however, she told Dr. Gordon that she "continued to have headaches" and fatigue, though she denied having chest pain at that appointment (R. 666). That month, she also had a transesophageal echocardiogram which showed moderate mitral valve prolapse and mild mitral regurgitation (R. 625).
In August 2008, Ms. Ludwig requested an evaluation by a rheumatologist, Dr. Alan Jacobson, who found no evidence of inflammatory arthritis and insufficient evidence to diagnose fibromyalgia because Ms. Ludwig had only slight tenderness and no swelling (R. 683). Ms. Ludwig also had an appointment with an internal medicine physician, Karen Burgner, M.D., in October 2008, at which she reported experiencing chest pain and headaches (R. 662). Ms. Ludwig stated that she had smoked about a pack of cigarettes per day since she was 18 years old, and she was not interested in quitting at that time (R. 663). Ms. Ludwig also reported binge drinking five to six drinks about every two months ( Id. ).
Charles Kenney, M.D., a state agency physician, completed a Physical Residual Functional Capacity ("RFC") Assessment in February 2009 based on the medical record (R. 752). He found Ms. Ludwig's reports of her symptoms "partially credible;" while he agreed that her condition may cause fatigue, he found that her allegations of chest pain were not consistent with the medical evidence, which showed that her cardiac function had been relatively asymptomatic since the defibrillator was implanted ( Id. ). Dr. Kenney further stated that no medical findings supported Ms. Ludwig's allegations of arthritis and joint problems ( Id. ). The assessment indicated that Ms. Ludwig was capable of light work with no other functional limitations (R. 748-52). That same month, Dr. Carl Hermsmeyer, Ph.D., completed a psychiatric review technique based on Ms. Ludwig's medical records and found no medically determinable mental impairment (R. 733).
In April 2009, Ms. Ludwig told Dr. Gordon that she was not working, sleeping up to 14 hours a day, and experiencing "continuous" chest pain (R. 761). Dr. Gordon also noted a "gradual worsening" in Ms. Ludwig's concentration and cognitive function ( Id. ). However, at a mental status evaluation for the Bureau of Disability Determination Services ("DDS") in July 2009, the assessing psychologist, David NieKamp, Psy.D., found that she had "severe" anxiety but generally unimpaired cognitive function (R. 814).
A state agency medical consultant, Keith Burton, Ph.D., completed a Mental RFC Assessment for Ms. Ludwig in August 2009. After reviewing the medical evidence, Dr. Burton found that Ms. Ludwig's cognitive functions were "intact, " and she had no difficulties in maintaining social functioning, mild restriction in her activities of daily living, and no episodes of decompensation of extended duration (R. 825-27). As a result of her anxiety, however, the consultant concluded that Ms. Ludwig had moderate difficulties in maintaining concentration, persistence, or pace (R. 825, 829-30). Nevertheless, Dr. Burton found that overall, Ms. Ludwig had the mental capacity to engage in basic work activities, follow one- or two-step instructions, and do so within the concentration, persistence, and pace required for competitive work (R. 831).
On October 21, 2009, Dr. Gordon wrote a letter stating that Ms. Ludwig suffered from chronic fatigue, chest pain, and significant memory difficulties following her heart attack (R. 891). She wrote that Ms. Ludwig is taking multiple medications and receives the "best medical therapy possible, " but that she continues to experience fatigue and chest pain to the point that she is unable to be substantially employed ( Id. ). In addition, Dr. Gordon stated that Ms. Ludwig suffers from disabling migraine headaches on a monthly basis, lasting as long as three to four days, but Ms. Ludwig cannot take certain preventive medications due to her underlying heart disease ( Id. ).
Ms. Ludwig next went to the emergency department with severe chest pain and confusion in February 2010, and at her follow-up with Dr. Gordon a few days later, she stated that she continued to have chest pain, fatigue, and difficulty sleeping (R. 884). Dr. Gordon changed her dose of Novarsc and started her on prednisone and trazodone (R. 884-85). When Ms. Ludwig saw Dr. Gordon again in April 2010 and reported no improvement, Dr. Gordon referred her to another cardiologist, Dr. Edward Lipman, for a full electrophysiology study (R. 872). Dr. Lipman performed a "cardiac ablation" ...