United States District Court, N.D. Illinois, Eastern Division
GREGORY A. WASHINGTON, Plaintiff,
MICHAEL J. ASTRUE, Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER
SUSAN E. COX, Magistrate Judge.
Plaintiff Gregory Washington seeks judicial review of the final decision of the Commissioner of the Social Security Administration ("Commissioner") denying his application for Disability Insurance Benefits and Supplemental Insurance Income (collectively herein, "disability benefits") under the Social Security Act ("Act"). Mr. Washington seeks reversal of the Commissioner's final decision and a remand for an award of benefits, or in the alternative, reversal of the Commissioner's final decision and remand for additional proceedings. For the reasons set forth below, Mr. Washington's motion to reverse the Commissioner's final decision is granted [dkt. 25].
I. PROCEDURAL HISTORY
Mr. Washington filed an application for disability benefits on October 20, 2005, alleging he became disabled on February 15, 2004. On August 31, 2007, after a hearing was held, Administrative Law Judge Marin Dougherty denied Mr. Washington's claims, stating Mr. Washington was not disabled because he could perform a significant number of jobs in the national economy. Mr. Washington filed a timely appeal, and on July 28, 2008, the Appeals Council denied his request for review. Mr. Washington sought judicial review in the U.S. District Court for the Northern District of Illinois.
On July 10, 2009, pursuant to a stipulation of the parties to remand, District Court Judge Blanche M. Manning entered an order remanding the matter back to the Commissioner. On remand, the Commissioner was directed to re-evaluate Mr. Washington's residual functional capacity ("RFC"), the impact of his mental impairment, the combination of his impairments, re-assess his credibility, and obtain testimony from a vocational expert ("VE") based on Mr. Washington's revised assessment.
On September 18, 2009, the Appeals Council, in turn issued, an order remanding Mr. Washington's case to Administrative Law Judge Daniel Dadabo ("ALJ"). Pursuant to that order, Mr. Washington appeared and testified, along with two medical experts and one VE, at a hearing on February 18, 2011. On March 11, 2011, the ALJ issued a decision finding that Mr. Washington was not disabled because he could perform a number of jobs in the national economy. The Appeals Council declined to exercise jurisdiction, leaving the ALJ's decision as the final decision of the Commissioner. Mr. Washington filed a complaint in this Court seeking judicial review of the final decision of the Commissioner.
At the time of the hearing, Mr. Washington was fifty years old and lived with mother and aunt. His most recent work consisted of maintenance and janitorial services position in a condominium complex. Prior to this position, Mr. Washington found jobs as a driver, custodian, dishwasher, and janitor through temporary employment services, as well as various positions with the City of Evanston's Park District.
Since at least 2004 Mr. Washington has been treated for a wide variety of medical conditions including: anemia, fatigue, obesity, dyspnea, pneumonia, chronic bronchitis, hypertension, type II diabetes,  diabetic retinopathy,  glaucoma, cataracts, diabetic neuropathy,  diabetic nephropathy,  difficulty bending, and edema. Furthermore, Mr. Washington has been diagnosed with borderline intellectual functioning and a learning disability.
A. Mr. Washington's Physical Health Records
Mr. Washington's medical records are extensive and therefore only the relevant portions are discussed below.
The records show that prior to 2004, Mr. Washington had issues with gallstones, was hospitalized for pneumonia, edema, and hypertension, and complained of left shoulder pain. In September of 2004, Bhupinder Singh, M.D. reported that Mr. Washington was limited to occasionally lifting no more than 20 pounds, could frequently lift up to ten pounds, and had full ability to perform physical activities of daily living. At this time and through 2005, a physician at St. Francis Community Health Center prescribed Mr. Washington Zestroetic, Lipitor, ASA, Glucovance, Allupernt, Prednisone, and Zithremax.
In March of 2005, Mr. Washington visited James H. McClure, M.D. for his diabetes. Dr. McClure prescribed the following medications for the following problems: Ecotrine for blood clotting; Glyburide for diabetes; Lipitor for cholesterol; and Lisinpril for blood pressure. In May of 2005, Mr. Washington visited Frank Rubin, M.D. at Evanston Eyes to receive vision testing.
Mr. Washington went to see Aaron B. Weinberg, M.D. on August 26 and September 20, 2005 to receive vision exams. Records note that the reason for the visit was that he had experienced loss in vision, although it is unclear which eye was tested. Mr. Washington visited Evanston Health Clinic on October 3, 2005 for a check-up and to receive medication. According to his "Disability Report - Adult - Form SSA-3368, " Mr. Washington indicated that he had seen two doctors as an outpatient at Cook County Hospital for examinations due to loss of vision in September and October of 2005.
After complaining of eye trouble during visits at St. Francis and Cook County Hospitals, Mr. Washington went to see Doctors at the University of Illinois UIC Eye Center. He was seen as a patient from October 27, 2005 to September 12, 2006, by Norman Blair, M.D. On October 27, 2005, Dr. Blair diagnosed Mr. Washington with diabetic retinopathy with traction retinal detachment and vitreous hemorrhage and immature cataract in both eyes. Dr. Blair noted that Mr. Washington had been suffering from substantial vitreous hemorrhage in the right eye for at least three months. Mr. Washington had 20/40 vision in his left eye and testing showed retinal detachment in his right eye.
On February 3, 2006, Mr. Washington had surgery on his right eye. In March of 2006, Mr. Washington had an ultrasound done and was being treated for glaucoma. On June 6, 2006, Mr. Washington received care from Benedito Carneiro, M.D. and Kelly Tan, M.D. for his diabetes and high blood pressure. On September 4, 2006, Mr. Washington was admitted to the hospital for pneumonia.
On May 20, 2007, a magnetic resonance imagining ("MRI") scan was performed to evaluate complaints of gait instability. On June 5, 2007, Mr. Washington's vision was tested and he had no visual complaints. The visual acuity in his left eye was 20/30 with hand movement in his right eye. On June 11, 2007, Mr. Washington's visual acuity in his left eye was 20/40 with hand movement in his right eye.
From 2007 to 2008 Mr. Washington continued his treatment for diabetic retinopathy, cholesterol, anemia, type II diabetes, obstructive sleep apnea, and gait training. In October of 2007, Dr. Tan suggested physical therapy for gait training and recommended he walk for 30 to 45 minutes per day.47 In March of 2008, Mr. Washington had surgery on his left eye to repair a detached retina. In November of 2008, Mr. Washington visited Evanston Hospital complaining of foot pain, and was diagnosed with plantar fascial fibromatosis and hallux limitus. He was directed to wear over-the-counter orthotics, do calf stretches, and heel lifts.
In January of 2008, Mr. Washington was diagnosed with chronic kidney disease. In June of 2008, Mr. Washington received treatment for a chronic wound on his left leg as well as for edema on his lower legs. Treatment included leg elevation, wearing a support stocking, and skin care.
In 2009, Mr. Washington continued to be treated at Evanston Hospital for diabetes and chronic kidney disease. On April 15, 2009, Mr. Washington noted that he felt well, did not have chest pain or shortness of breath, and was walking more. On January 4, 2010, Mr. Washington had surgery for the glaucoma in his right eye.
On December 23, 2010, Mr. Washington was admitted to emergency care at Northshore University Health System for flu-like symptoms and pneumonia. The records from his hospital stay indicate that Mr. Washington suffered from stage III chronic kidney disease, hypertension, shortness of breath, diabetes, obstructive sleep apnea, high cholesterol, anemia, and diabetic retinopathy.
On June 14, 2010, Mr. Washington was seen by Jonathan G. Lippitz, M.D. at Northshore University Health Systems as a walk-in for shoulder pain. Mr. Washington reported that he had hurt his shoulder helping someone move one month earlier.
On November 15, 2010, Roopa K. Karri, M.D. performed a consultative exam on Mr. Washington for the Bureau of Disability Determination Services. Dr. Karri noted that Mr. Washington could not see at all out of his right eye and that his visual acuity in his left eye was 20/70. In addition, Dr. Karri wrote that Mr. Washington had poor depth perception due to his right eye blindness and very poor vision in his left eye. Dr. Karri measured Mr. Washington's edema at 1 and observed that Mr. Washington could walk fifty feet without support. His grip strength was normal, as was his range of motion of his shoulders, elbows, and wrists.
Regarding Mr. Washington's neurological response, Dr. Karri noted that he had "sustained, audible and understandable speech" and that the strength in his upper and lower limbs was 5/5. Dr. Karri determined that Mr. Washington could lift twenty-one to fifty pounds frequently and fifty-one to one hundred pounds occasionally. Mr. Washington could carry eleven to twenty pounds frequently and twenty-one to fifty pounds occasionally. Dr. Karri opined that Mr. Washington could sit uninterrupted for eight hours, stand uninterrupted for one hour, and walk uninterrupted for one hour. In an eight hour period, Dr. Karri concluded that Mr. Washington could sit for eight hours or stand for four hours and walk for four hours.
Dr. Karri found that Mr. Washington could continuously reach with both hands, perform handling, pushing and pulling, and frequently perform fingering and feeling. Dr. Karri did note that Mr. Washington had occasional tingling in his hands.
In regards to the operation of foot controls, Dr. Karri concluded that Mr. Washington could operate them on a frequent basis with both of his feet, but he had occasional tingling. In regard to postural activities, Dr. Karri found that Mr. Washington could not climb ladders, scaffolds, or perform activities that required him to balance. Mr. Washington could occasionally climb stairs and ramps, stoop, kneel, crouch, and crawl.
Dr. Karri stated that Mr. Washington had "diabetic retinopathy with laser surgeries on both eyes causing blindness in right eye and poor vision in left eye." Given Mr. Washington's visual impairment, Dr. Karri opined that he was unable to read very small print, ordinary newspaper or book print, and was unable to view a computer screen. Despite this conclusion, she believed that he was able to avoid ordinary hazards in the workplace and could determine differences in shape and color of small objects.
In regard to environmental limitations, Dr. Karri concluded that Mr. Washington could never tolerate exposure to unprotected heights, moving mechanical parts, or operating a motor vehicle. She found that he could occasionally tolerate exposure to dust, odors, fumes and pulmonary irritants, extreme cold and extreme heat. He could frequently tolerate exposure to loud noise and vibrations.
Physically, Dr. Karri found Mr. Washington able to shop, travel without a companion for assistance, ambulate without assistance, walk a block, use public transportation, climb a few steps with handrail assistance, prepare a simple meal and feed himself, and care for his personal hygiene. She found him not capable of sorting or handling paper files due to his poor vision.
Subsequent to Dr. Karri's evaluation, on November 19, 2010, Mr. Washington was examined by Felix Chau, M.D. an ophthalmologist with the City of Evanston. Dr. Chau stated that Mr. Washington was not capable of full-time employment due to poor vision in the right eye and difficulty with reading in his left eye.
B. Mr. Washington's Mental Health Records
A psychological assessment of Mr. Washington was performed on May 20, 2010 by Dr. Mark B. Langgut, Ph.D., a licensed clinical psychologist. Dr. Langgut observed that Mr. Washington had a "friendly, immature, and regressed presentation. He was cooperative and responded adequately...He was oriented to time, place, and person." Mr. Washington informed Dr. Langgut that he received special education services while in school.
Additionally, Mr. Washington explained his issues with substance abuse, noting his arrest in 1993 for driving while intoxicated. Mr. Washington admitted to occasionally drinking alcohol at the present time, to using marijuana from age fifteen to forty-two, and stated that he occasionally smoked cigarettes. Under "social functioning, " Dr. Langgut noted that Mr. Washington stated he "sleeps adequately well" and during the day he "watches TV, exercises, and walks." He stated he "helps neighborhood children get on the bus.'" Regarding his mental status, Dr. Langgut stated Mr. Washington was "irritable but cooperative...presented with mild depression, ranking at two on a one-to-ten scale with one indicating minimal sadness and ten being indicative of the most extreme depression." Dr. Langgut wrote that Mr. Washington "needs external structure. His anxiety appeared within normal limits...Mr. Washington's emotional presentation appeared within normal limits, while by report it is variable...no behavioral abnormalities were observed."
Dr. Langgut found Mr. Washington to have "variable memory skills" as well as "limited computational skills." He stated that Mr. Washington "may have significant difficulty with forming generalizations and understanding concepts, and he may become frustrated when faced with these types of tasks." After administering standardized tests, Dr. Langgut concluded that Mr. Washington had a Full Scale IQ score of 67, which indicated that he was "functioning in the mentally deficient or extremely low range."
Dr. Langgut filled out the "Medical Source Statement of Ability To Do Work-Related Activities (Mental)" and indicated that Mr. Washington had the "ability to understand, remember and carry out instructions..." Dr. Langgut further indicated that Mr. Washington had a mild restriction in his ability to understand, remember, and carry out simple instructions; a moderate restriction in his ability to make judgments for simple work-related decisions; and marked restrictions in understanding, remembering, and carrying out complex instructions, and the ability to make judgments for complex work-related decisions.
Further, Dr. Langgut believed that Mr. Washington's ability to interact appropriately with supervisors, co-workers, and the public was affected by his impairment. Dr. Langgut indicated that Mr. Washington had mild restrictions in interacting with the public; moderate restrictions interacting with supervisors and co-workers; and marked restrictions in responding to usual work situations and changes in a routine work setting. Dr. Langgut did not note any additional impairments, but did mention Mr. Washington's history of alcohol abuse and self-reported denial of current or recent abuse of alcohol or cannabis.
Joan F. Hakimi, Psy.D., also a licensed clinical psychologist, performed a second psychological examination of Mr. Washington for the Bureau of Determination Services on November 15, 2010. Dr. Hakimi determined that Mr. Washington had fair general knowledge, poor judgment and problem solving, and that his capacity for abstract thinking varied. In her report, Dr. Hakimi wrote that Mr. Washington's mental status was "alert and [he was] oriented to time, place and person, " and that "[h]e understood the purpose of the evaluation and was fully attentive." Regarding Mr. Washington's thought content, Dr. Hakimi concluded that he had "logical and sequential" thought processes and that he maintained his attention and concentration during the evaluation. Under the heading "Attention and Concentration, " Dr. Hakimi noted that Mr. Washington was able to say the months of the year forward and backward "with no difficulty."
Dr. Hakimi's review and assessment also considered that Mr. Washington had diabetes that went untreated for twenty years and that it was the cause of his difficulties with his eyesight, heart, and kidneys. She found no evidence of a formal thought disorder or a mood disorder. Dr. Hakimi believed that the results of her exam were "an accurate reflection of ...