United States District Court, N.D. Illinois, Eastern Division
SYLVESTER A. CALLAHAN, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
SHEILA FINNEGAN, Magistrate Judge.
Plaintiff Sylvester A. Callahan seeks to overturn the final decision of the Commissioner of Social Security ("Commissioner" or "Defendant") denying his application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act. 42 U.S.C. §§ 416, 423(d), 1381a. The parties consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c), and after careful review of the record, the Court now remands the case for further proceedings.
Plaintiff applied for DIB and SSI on August 27, 2009, alleging in both applications that he became disabled on August 27, 2008 due to lupus, fibromyalgia and depression. (R. 139, 142, 149). The Social Security Administration denied the applications initially on October 7, 2009, and again upon reconsideration on March 24, 2010. (R. 82-96). Plaintiff filed a timely request for hearing and appeared before Administrative Law Judge Robert T. Karmgard (the "ALJ") on November 16, 2010. (R. 30). The ALJ heard testimony from Plaintiff, who was represented by counsel, as well as from vocational expert William M. Newman. Shortly thereafter, on March 25, 2011, the ALJ found that Plaintiff is not disabled because there are a significant number of light and sedentary jobs he can perform. (R. 16-23). The Appeals Council denied Plaintiff's request for review, (R. 5-8), and Plaintiff now seeks judicial review of the ALJ's decision, which stands as the final decision of the Commissioner.
In support of his request for remand, Plaintiff argues that the ALJ (1) made a flawed credibility determination; (2) provided no basis for the residual functional capacity ("RFC") assessment for light and sedentary work; and (3) failed to properly evaluate whether he met Listing 14.02. Plaintiff also claims that the Appeals Council erred in concluding that new evidence he submitted after the administrative hearing did not warrant reversal. As discussed below, the Court agrees that the ALJ's credibility finding is patently wrong, and that the case must be remanded for further consideration of this issue.
Plaintiff was born on September 5, 1969, and was 41 years old at the time of the ALJ's decision. (R. 139). He completed high school and spent approximately 17 years doing shipping and receiving work for the ULINE company. (R. 45, 150). Most recently, Plaintiff worked for two years as a loader at Walmart, but he had to quit on August 27, 2008 due to constant pain. (R. 43).
A. Medical History
On August 28, 2008, Plaintiff started seeing Gerald Gamalski, M.D., of Deerpath Physicians Group ("Deerpath") for joint pain in the fingers, elbows, shoulders, knees and ankles, and significant swelling in the hands. Dr. Gamalski thought Plaintiff could have a rheumatologic problem such as rheumatoid arthritis or systemic lupus erythematosus ("SLE"), and he ordered a series of related tests and prescribed the steroid prednisone. (R. 235-37). At a follow-up visit on September 5, 2008, Plaintiff still had "quite a bit of pain" in his joints but the swelling had "much improved" and he was feeling "better overall." (R. 233). Dr. Gamalski noted that the testing had confirmed the presence of a rheumatologic or autoimmune process and ordered an SLE panel for further evaluation. He also increased the dosage of prednisone and referred Plaintiff to a rheumatologist. (R. 234).
A week later, on September 12, 2008, Plaintiff saw Chinyoung Park, M.D., of Park Rheumatology. He complained of insomnia, morning stiffness, fatigue, stress, photosensitivity, weight loss and chest pain, and Dr. Park observed that Plaintiff had tenderness in the shoulders; swelling and tenderness in the right wrist; left elbow contracture; and synovial (joint lining) thickening in both hands. Dr. Park administered a steroid injection in Plaintiff's right wrist, prescribed Plaquenil (a drug for lupus/autoimmune diseases), and instructed him to return in one month. (R. 243-44).
Plaintiff next had a follow-up visit with Dr. Gamalski on October 10, 2008. Overall, he was "greatly improved" with reduced pain and swelling in many joints, but he still complained of "quite a bit of pain" in the right ankle, right shoulder and right elbow. Dr. Gamalski diagnosed SLE, and prescribed Norco for pain. (R. 231-32). When Plaintiff saw Dr. Park the following week on October 17, 2008, he continued to exhibit elbow contracture with mild synovial thickening, and his toes were "pulled up on the right due to exterior tendon contractures." Dr. Park diagnosed SLE and fibromyalgia, prescribed Elavil (a mood stabilizer), and encouraged Plaintiff to do some swimming exercises. He also noted that Plaintiff's "[s]ubjective complaints of pain [were] disproportional to the exam." (R. 249-50).
Over the next two years, Plaintiff was hospitalized three times due to chest pain and once because of a severe headache. While at Vista Medical Center East ("Vista Medical") between December 22 and 24, 2008, Plaintiff was diagnosed with pleural effusion (excess fluid around the lungs) and cardiomegaly (an enlarged heart). (R. 221, 227). During a second admission to Vista Medical from July 31 to August 2, 2009, he was diagnosed with acute cephalgia (headache), possibly secondary to a migraine, and noncompliance with his lupus medications. (R. 315). Plaintiff applied for disability benefits later that same month on August 27, 2009. Shortly thereafter, on October 6, 2009, Barry Free, M.D., found that Plaintiff is not disabled from lupus, noting that during his August 2009 hospital stay, he exhibited "a completely unremarkable" review of symptoms with no fever, chills, weight loss, sore throat, coughing, sputum production, chest pains, palpitations, abdominal pains, nausea, vomiting, or weakness in the arms and legs. (R. 332).
Plaintiff's third hospitalization from March 7 to 13, 2010 was for acute shortness of breath and right lower chest wall pain lasting two days. (R. 349). At the time of discharge he was in stable condition with a diagnosis of lupus exacerbation, lupus arthritis, polyserositis, pleural effusion, right-sided chest pain, and paroxysmal atrial fibrillation. (R. 347). On March 23, 2010, less than two weeks after Plaintiff's release from the hospital, Francis Vincent, M.D., affirmed Dr. Free's finding of no disability. (R. 338).
The final hospitalization at Vista Medical was from October 3 to 5, 2010, again due to chest pain with productive cough lasting several weeks. (R. 379). An echocardiogram showed mildly dilated left atrium and small pericardial effusion, but a chest CT scan revealed no evidence of acute cardiopulmonary process. (R. 388, 392). Plaintiff was discharged with medication. (R. 379). Thereafter, on December 21, 2010, Plaintiff had a physical therapy evaluation at Vista Medical showing decreased range of motion in the elbows hips and ankles; 3-/5 strength in the hips and hamstrings; ...