United States District Court, N.D. Illinois, Eastern Division
SHIRLEY J. WILLIAMS, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER
DANIEL G. MARTIN, Magistrate Judge.
Plaintiff Shirley J. Williams (Williams) seeks judicial review of a final decision of the Acting Commissioner of Social Security (Commissioner) denying her application for disability insurance benefits (DIB) and 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.
Williams protectively applied for DIB and SSI on November 12, 2008, alleging she became totally disabled on August 25, 2007 because of vertigo. (R. 127, 185-95). Williams was born on August 13, 1956 and suffers from a hernia, hypertension, vertigo, carpel tunnel syndrome, obesity, and bilateral knee osteoarthritis. (R. 43). Williams received an associate's degree in general studies from Harold Washington College in 2000. (R. 47). Williams has a driver's license but has not driven since 2008. (R. 49-50). Williams has past work experience as a records clerk, delivery driver, babysitter, and home health caregiver. (R. 51-54, 56). Williams' applications were denied at the initial and reconsideration levels. (R. 110-17, 124-31, 147-48, 360-62).
A. Medical Evidence
On February 5, 2007, Williams visited the Michael Reese Hospital emergency room for vertigo. (R. 313-320). A CT scan of her brain taken that day was normal. (R. 321). Williams was prescribed Meclizine. (R. 314). On July 26, 2007, Dr. John C. Farmer prepared a Disability Statement in which he certified that Williams had been under his care for a hernia and "was totally incapacitated from July 26, 2007 to indefinite." (R. 374). Dr. Farmer further stated that as of July 26, 2007, Williams had sufficiently recovered to return to work with the following limitations: unable to lift 20 pounds or greater and unable to push/pull 165 pounds or greater. Id . On July 3, 2008, Williams was seen at a Cook County Clinic for a check-up. (R. 378-81). Williams complained of dizziness in the mornings. (R. 378). Williams was 5'4" tall and weighed 189 pounds. Id . Her BMI was 32. The doctor found that Williams' symptoms were consistent with benign paroxysmal positional vertigo and refilled her Meclizine prescription. (R. 381).
Dr. Roopa K. Karri, M.D., evaluated Williams on January 23, 2009 for approximately 42 minutes. (R. 336-39). Williams complained of knee pain. (R. 337). On physical examination, Dr. Karri noted that Williams was obese. (R. 337). Her BMI was 33.3. (R. 356). Williams had no trouble getting on and off the examining table. (R. 338). Dr. Karri determined that Williams could walk 50 feet without support, had normal grip strength, and had a normal range of motion of the shoulders, elbows, wrists, hips, ankles, lumbar and cervical spine. Id . Williams could tandem gait and her gait was non-antalgic without the use of assistive devices. Williams had a reduced range of motion in her knees, exhibiting flexion to 130 degrees and normal extension. Id . Dr. Karri found that Williams had tenderness in her knees with her left knee worse than her right. Id . Dr. Karri's impressions were: (1) history of vertigo with tinnitus and mild hearing impairment associated with nausea which comes and goes in spurts and etiology is unclear; (2) bilateral knee osteoarthritis with mildly decreased range of motion; and (3) obesity. (R. 339).
On February 5, 2009, Dr. Frank Jimenez, a non-examining state agency physician, reviewed Williams' medical records and assessed her RFC. (R. 349-56). Dr. Jimenez concluded that Williams could occasionally lift and/or carry 50 pounds and frequently lift and/or carry 25 pounds. (R. 350). He also found that Williams could sit, stand, and/or walk for about six hours in an eight-hour workday and push or pull for an unlimited period. Id . Dr. Jimenez noted that Williams could frequently climb, balance, stoop, kneel, crouch, and crawl despite her history of vertigo and bilateral knee pain. (R. 351). Dr. Jimenez found that Williams showed no manipulative, visual, or communicative limitations. (R. 352-53). Dr. Jimenez determined that Williams should avoid concentrated exposure to hazards like machinery and heights due to her history of vertigo. (R. 353). Dr. Jimenez concluded that Williams' statements "regarding vertigo are partially credible, " but the extent of the limitations described by her "exceeds that supported by the objective medical findings." (R. 356).
A right knee x-ray on March 25, 2009 revealed "marked narrowing of patellofemoral joint space as well as the medial knee joint compartment. Moderate to marked narrowing of the lateral knee joint compartment. Small superior and interior patellar spurs. Tiny osteoarthritic spurs. No lytic or osteoblastic bony lesions." (R. 358-59).
In July 2010, Williams was seen at the Cook County Englewood Clinic ("Englewood Clinic") for a Meclizine refill and vertigo follow-up. (R. 364). Williams complained of carpel tunnel symptoms and symptoms of vertigo. Id . Williams had elevated blood pressure but refused medication. She wanted to try a low salt diet and weight loss to control her blood pressure. Id . The doctor diagnosed carpel tunnel syndrome and recommended a splint and non-steroidal anti-inflammatory drugs followed by, if needed, a steroid injection. Id.
On September 23, 2010, Williams visited the Englewood Clinic again. (R. 365). Williams' blood pressure was elevated at 142/92, but she denied symptoms related to hypertension. Id . Williams agreed to start blood pressure medication. Williams also complained of a four-week history of left hand pain at a level of 9 out of 10 with no current pain. Id . At a routine checkup on November 22, 2010, Williams complained of carpal tunnel symptoms in her left wrist but reported no current pain. (R. 401). Williams weighed 182 pounds and had a BMI of 31. Id . The doctor advised Williams to continue using the splint for her carpal tunnel symptoms. Id.
On June 27, 2011, Williams saw Dr. Debbie Donelson at the Englewood Clinic. (R. 399-400). Williams reported that she had been using her splint and exercising which was "helping the carpal tunnel on her left wrist." (R. 399). Dr. Donelson diagnosed osteoarthrosis, localized and primarily involving the lower leg, and hypertension. (R. 400). Williams requested a medication refill and injections in both knees. (R. 399). Dr. Donelson scheduled bilateral knee injections for August 10, 2011. (R. 400).
B. Plaintiff's Testimony
At the administrative hearing before the ALJ on November 2, 2010, Williams stated that she is right-handed and suffers from daily pain and constant burning in her left hand. (R. 64-66). Williams explained that the wrist split helps because it keeps her from moving her hand in certain ways. (R. 65). Williams wears her splint during the day but sometimes takes it off because her left hand still hurts and burns with the split on. Id . She testified that her doctor also gave her a prescription for ibuprofen but did not refer her ...