United States District Court, N.D. Illinois, Eastern Division
MARY L. PRATT, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER
DANIEL G. MARTIN, Magistrate Judge.
Plaintiff Mary L. Pratt (Pratt) seeks judicial review of a final decision of the Acting Commissioner of Social Security (Commissioner) denying her application for supplemental security income (SSI). The parties have consented to the jurisdiction of the undersigned United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). Because the administrative law judge's decision is not supported by substantial evidence, the denial of benefits is reversed and this case is remanded for further proceedings consistent with this opinion.
Pratt applied for SSI on December 17, 2009, alleging she became totally disabled on December 1, 2007 because of asthma, arthritis in both knees, obesity, depression, and anemia (R. 169-71). She later amended her onset date to December 17, 2009. (R. 47). Pratt was born on July 31, 1967 and suffers from arthritis, back pain, asthma, hypertension, and morbid obesity. (R. 49). Pratt completed high school. (R. 49, 181). Pratt does not drive and has past work experience as a bagger at a grocery store, cashier, and babysitter. (R. 49, 50-52). Pratt last worked in 2009 as an after-school babysitter. (R. 52). Pratt's SSI application was denied at the initial and reconsideration levels. (R. 97-103, 107-110, 515-22, 530-40).
A. Medical Evidence
Dr. Harvey I. Friedson, Psy.D., evaluated Pratt on April 3, 2010 for approximately one hour. (R. 436-40). Pratt presented as "very cooperative" and alert with "somewhat of a sad quality." (R. 436, 438). As to Pratt's mood and affect, Dr. Friedson noted that "there was some range of affect, though she does appear depressed." (R. 438). Pratt's speech was relevant and coherent. Id . Dr. Friedson found no evidence of psychotic or schizophrenic process. Id . Dr. Friedson noted that Pratt was "quite heavy" and her breathing "may be somewhat labored." (R. 439). Dr. Friedson found that Pratt has "somewhat of a sad, subdued quality." Id . He diagnosed Pratt with depressive disorder. (R. 440).
On April 3, 2010 Pratt underwent a consultative examination with Norbert De Biase, M.D. (R. 490-99). Dr. De Biase reviewed the medical information sent by the Bureau of Disability Determination Services and spent thirty-five minutes with Pratt obtaining her history and performing the consultative examination. (R. 490). Pratt reported having daily pain in her back and knees "for a short time." Id . Pratt also complained of daily pain in her shoulders. Id . Pratt described the pain in her back as radiating down both legs and being worse in the morning. Id . She stated the pain in her joints is throbbing in nature. Id . Pratt also stated that she could sit for an hour and stand for a half an hour. Id . Pratt's pain is alleviated when she lays down and is worse with movement. Id. at 490-91. On physical examination, Pratt weighed 373.4 lbs. (R. 491). Her respiratory rate was 18 and unlabored. Id . Dr. De Biase found Pratt to be awake, alert, oriented, no acute distress, obese, and a fair to good historian. Id . Dr. De Biase noted that Pratt was able to walk 50 feet without the use of an assistive device, but that her gait was abnormal with wobbling. (R. 492, 495). Dr. De Biase wrote that Pratt had mild difficulty performing toe, heel, squat and tandem gait, and getting on and off the examination table. (R. 492). Straight leg raising was negative. (R. 492, 495).
Dr. De Biase found tenderness in both shoulders, both knees, and lower back, but Pratt's range of motion was free, full, and painless in all joints except for the lumbosacral spine, both hips and both knees. (R. 492). Pratt had a reduced range of motion in her lumbar spine-flexion to 50/90 degrees and extension/left and right lateral bending to 15/25 degrees. (R. 497). Pratt also had a reduced range of motion in her hips, exhibiting flexion of 80/100 degrees, extension of 10/30 degrees, abduction of 30/40 degrees, and adduction of 10/20 degrees. (R. 498). Dr. De Biase noted knee flexion of 100/150 degrees. Id . On neurologic examination, Dr. De Biase found Pratt's strength, sensation and deep tendon reflexes were symmetric and within normal limits throughout. Id . Pratt's motor strength was 5/5 throughout and cerebellar testing was negative. Id . Dr. De Biase diagnosed back pain, arthritis, asthma, depression, anemia, and morbid obesity. (R. 493).
A lumbar spine x-ray taken on April 3, 2010 revealed "mild degenerative arthritic change" with "bony hypertrophy noted along the iliac crests." (R. 489). An x-ray of Pratt's left knee on the same day revealed mild degenerative changes. (R. 500). On April 16, 2010, Pratt underwent a spirometry test, which is used to assess lung function. The spirometer results showed premed testing of a "moderate restriction" and postmed testing of a "mild restriction." (R. 485).
On April 12, 2010, Pratt saw Dr. Chukwudozie Ezeokoli in connection with a follow-up for an overnight hospital admission due to a food allergic reaction on March 27, 2010. (R. 546-58, 567-80). Under the heading "Problem List, " Dr. Ezeokoli listed allergic reaction to food, asthma, hypertension, osteoarthritis in knees, and overweight. (R. 546). Dr. Ezeokoli noted that Pratt's chest was clear and she was not wheezing. Id . Pratt weighed 377 pounds. Id . Dr. Ezeokoli advised Pratt to lose weight and recommended a bariatric procedure. (R. 547). Dr. Ezeokoli recommended that Pratt continue using her asthma and hypertension medications and carry around an EpiPen and Benadryl for her allergies. Id.
On April 27, 2010, Lionel Hudspeth, Psy.D., prepared a Psychiatric Review Technique. Dr. Hudspeth diagnosed Pratt with a depressive disorder but found that her impairments were "not severe." (R. 501, 504). Dr. Hudspeth concluded that Pratt had mild restriction of activities of daily living, mild difficulties in maintaining social functioning, mild difficulties in maintaining concentration, persistence, or pace, and no episodes of decompensation. (R. 511). Dr. Hudspeth found Pratt's allegations about her symptoms "partially credible" given her history. (R. 513).
On April 28, 2010, Dr. James Madison, a non-examining state agency physician, reviewed Pratt's medical records and assessed her RFC. (R. 515-22). Dr. Madison concluded that Pratt could occasionally lift and/or carry 20 pounds and frequently lift and/or carry 10 pounds. (R. 516). He also found that Pratt could sit, stand, or walk for about six hours in an eight-hour workday and push or pull for an unlimited period. Id . Dr. Madison noted that Pratt should only occasionally balance and should avoid concentrated exposure to extreme cold and pulmonary irritants. (R. 517, 519). Dr. Madison found that Pratt showed no manipulative, visual, or communicative limitations. (R. 518-19). Dr. Madison determined that Pratt's statements regarding her symptoms appeared to be "partially credible." (R. 522).
On August 30, 2010, Dr. Marion Panepinto, another non-examining state agency physician, completed a Physical Residual Functional Capacity Assessment of Pratt and found more significant limitations. (R. 530-37). In his assessment, Dr. Panepinto concluded that Pratt could occasionally lift 10 pounds; frequently lift less than 10 pounds; stand or walk at least two hours in an eight-hour workday; sit about six hours in an eight-hour workday; and had an unlimited ability to push and pull. (R. 531). Dr. Panepinto found that Pratt could occasionally climb ramps and stairs, balance, stoop, kneel, crouch, and crawl. (R. 532). Dr. Panepinto determined that Pratt should never climb ladders, ropes, or scaffolds. Id . Dr. Panepinto identified no manipulative, visual, or communicative limitations for Pratt. (R. 533-34). Dr. Panepinto noted that Pratt should avoid concentrated exposure to extreme cold, pulmonary irritants, and hazzards like machinery or heights. (R. 534). Dr. Panepinto found Pratt's allegations concerning her symptoms to be "partially credible" in light of her history of degenerative joint disease of the knees and degenerative disc disease of the lumbar spine as well as asthma but concluded that her allegations were "not to the severity alleged." (R. 537).
At a follow-up appointment with Dr. Ezeokoli on September 15, 2010, Pratt complained of pain in her knees and hips. (R. 549). Dr. Ezeokoli noted that x-rays of her knees showed arthritis. Id . Dr. Ezeokoli wrote that a musculoskeletal examination was normal. Id . Dr. Ezeokoli further noted that Pratt weighed 372 pounds and was not wheezing. Id . Dr. Ezeokoli again advised Pratt to lose weight and to return to the clinic in three months. (R. 550). Dr. Ezeokoli recommended that Pratt continue with the same regime of medications. Id
On September 28, 2010, Dr. Ezeokoli completed a Physical Residual Functional Capacity Questionnaire for Pratt. (R. 541-45). Dr. Ezeokoli noted that Pratt has been diagnosed with asthma, osteoarthritis of both knees, high blood pressure, and as overweight and her conditions are chronic. (R. 541). Dr. Ezeokoli reported that Pratt suffers from the following symptoms: shortness of breath on exertion, bilateral knee pain with walking, wheezing, and facial swelling. Id . He described Pratt as having limited ambulation with sharp, constant pain in both knees at a 7-9 out of 10, not relieved by pain medications. Id . Dr. Ezeokoli noted clinical findings of shortness of breath, knee swelling and tenderness, and wheezing. Id . He reported that Pratt was not a malingerer and found that her impairments were reasonably consistent with the symptoms and functional limitations he described. (R. 542).
Dr. Ezeokoli concluded that Pratt was incapable of even "low stress" jobs given her constant pain. Id . Dr. Ezeokoli opined that Pratt could walk 1 to 2 city blocks without rest or severe pain, sit 45 minutes at a time, stand 20 minutes at a time, stand or walk less than 2 hours in an eight-hour workday, and sit about 2 hours in an eight-hour workday. (R. 542-43). Dr. Ezeokoli concluded that Pratt would need to take unscheduled breaks every 20 to 45 minutes during an eight hour workday and the breaks would need to be 15-20 minutes long. (R. 543). He reported that Pratt could occasionally lift less than 10 pounds and rarely lift 10 pounds. Id . Dr. Ezeokoli found that Pratt should rarely twist, stoop (bend), or climb stairs and never crouch/squat or climb ladders. (R. 544). Dr. Ezeokoli concluded that Pratt would likely miss work about four days a month because her impairments produced "good days and bad days." Id.
On June 29, 2011, Pratt went to Provident Hospital's emergency room complaining of knee pain, mostly in her joints for two months, which was exacerbated by movement and weight-bearing walking and relieved by rest. (R. 635). Pratt rated her pain as 8 on a 10-point scale upon activity. (R. 649, 659). Pratt reported that she received no relief from non-steroidal anti-inflammatory drugs. (R. 635). An x-ray taken of Pratt's knees that same day showed joint space narrowing of the left knee. (R. 644-45). The emergency room physician diagnosed degenerative joint disease of the knees with osteophytes noted on the x-ray. (R. 637). The physician prescribed naproxen and ketorolac for the pain. (R. 638, 639). Pratt was directed to follow-up with the orthopedic clinic within 1 to 2 days. (R. 638).
On July 20, 2011, Pratt had another follow-up appointment with Dr. Ezeokoli. (R. 660-62). Dr. Ezeokoli noted that Pratt was recently seen in the emergency room for knee pain. Dr. Ezeokoli also noted that Pratt had gained 30 pounds since her last visit and weighed 402 pounds. (R. 661). Dr. Ezeolkoli indicated that x-rays of Pratt's knees showed osteoarthritis of the knees bilaterally. Id . He recommended that Pratt follow-up with the orthopedic clinic and that she would likely need steroid injections. (R. 662). Dr. Ezeolkoli ...