United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
MICHAEL T. MASON, Magistrate Judge.
Claimant, Margaret A. Fitzpatrick ("Claimant" or "Fitzpatrick"), brings this motion for summary judgment  seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner"). The Commissioner denied Fitzpatrick's claim for disability insurance benefits under Sections 216(i) and 223(d) of the Social Security Act ("SSA"), 42 U.S.C. §§ 216(i) and 223(d). The Commissioner filed a cross-motion for summary judgment , asking the Court to affirm her decision. This Court has jurisdiction to hear this matter pursuant to 42 U.S.C. § 405(g). For the reasons set forth below, Fitzpatrick's motion for summary judgment  is granted, and the Commissioner's motion for summary judgment  is denied. The case is remanded for further proceedings consistent with this opinion.
A. Procedural History
Fitzpatrick filed an application for disability insurance benefits on December 1, 2009, alleging a disability onset date of June 20, 2009. (R. 18.) Claimant alleged she was disabled as a result of diabetes mellitus, hypertension, obesity, lumbar degenerative disc disease ("DDD"), osteoarthritis ("OA") of the bilateral knees, coronary artery disease ("CAD"), and sleep apnea. (R. 20.) Her application was initially denied on March 4, 2010 and again on June 3, 2010 after a timely request for reconsideration. (R. 56, 57.) Thereafter, on July 2, 2010, Fitzpatrick requested a hearing, which was held on June 27, 2011 before Administrative Law Judge Karen Sayon ("ALJ" or "ALJ Sayon"). (R. 18, 25, 30.) On July 12, 2011, ALJ Sayon issued a written decision denying Fitzpatrick's request for benefits. (R. 18-25.) Fitzpatrick filed a timely request for review, which the Appeals Council denied on November 16, 2012. (R. 1-6.) The ALJ's decision denying benefits was adopted as the final decision by the Commissioner. See Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). Fitzpatrick subsequently filed this action in the District Court.
B. Medical Evidence
On May 17, 2006, Fitzpatrick underwent a Myocardial Perfusion Scan and a Stress Cardiolite at Advocate Christ Medical Center. (R. 247-48.) These tests revealed an "apparent anterolateral defect" and "mild nondiagnostic EKG changes at peak stress." ( Id. ) On May 24, 2006, Fitzpatrick had a cardiac status evaluation. (R. 233.) During this evaluation, Claimant complained of "feeling more fatigued and tired recently." ( Id. ) Claimant also reported that on some days she could walk "about one to two blocks without any chest pain, " and that she had quit smoking one month prior to the visit. ( Id. ) The evaluator noted that "patient's recent 2-D echocardiography was relatively unremarkable; however, the patient's Cardiolite stress test revealed a possible anterolateral defect of the anterolateral wall..." and noted that "attenuation needs to be considered also." ( Id. )
In June of 2006, Fitzpatrick had three cardiac procedures at Advocate Christ Medical Center. (R. 246.) They included a selective coronary angiography, left ventricular angiography, and an angioseal administration. ( Id. ) The procedures were completed without any complications and the following observations were noted by cardiologist Sunitha R. Avula, M.D. ("Dr. Avula"): "minimal luminal irregularities of the right coronary artery in the range of 10% to 20% but no critical stenosis, tortuous coronary arteriography, and preserved left ventricular systolic function." ( Id. )
On September 6, 2006, Nasser Zakieh, M.D. ("Dr. Zakieh") saw Fitzpatrick for a follow up and to review her sleep study. (R. 245.) Dr. Zakieh noted that during her last visit, Fitzpatrick's "apnea hypopnea index" was 6.4 with a minimum oxygen saturation of 72%. ( Id. ) He also noted that Fitzpatrick may need oxygen supplementation and that she may suffer from chronic obstructive pulmonary disease due to her history of heavy smoking. ( Id. ) Dr. Zakieh recommended that Fitzpatrick lose weight and participate in a continuous positive airway pressure titration sleep study. ( Id. )
Fitzpatrick's blood tests from June 2, 2008, indicated that she had a suboptimal glycemic control level of 12.3%. (R. 258.) Fitzpatrick had additional blood tests on April 15, 2009, which indicated that she again had a suboptimal glycemic control level of 14.7%. (R. 278.) Another blood test in January of 2010 indicated her glycemic control was 13%. (R. 275).
On May 28, 2009, Dr. Francis Jamilla, performed a pulmonary function test on Fitzpatrick to evaluate her shortness of breath. (R. 255.) Spirometry testing suggested a low FVC, a normal FEV-1, and a supranormal FEV-1/FVC ratio. ( Id. )
On January 4, 2010, Claimant visited Dr. Avula for a follow-up appointment, and to have her disability forms signed. (R. 271.) During this visit, Fitzpatrick reported knee and back pain, walking restrictions, smoking one pack of cigarettes a day and that she "didn't go back for her CPAP, " machine to treat her sleep apnea. ( Id. ) Claimant also reported dyspnea with exertion, but the physician noted that Fitzpatrick did not have chest pain or palpitations. ( Id. )
On January 26, 2010, Fitzpatrick again visited Advocate Christ Medical Center and complained of pain in her hip, back, and knee, and of her inability to stand for long periods of time. (R. 269.) She further explained that she took Ibuprofen and Tylenol to help alleviate this pain. ( Id. ) Fitzpatrick also stated that she needed her scooter to travel long distances. (R. 270.) During this visit, Dr. Avula ordered x-rays of Fitzpatrick's back, hips and knees. (R. 281-83.) Dr. Avula's review of Fitzpatrick's back x-ray revealed "lumbar spondylosis with facet arthritis" and "degeneration of the L5-S1 disc." (R. 281.) Dr. Avula noted that Fitzpatrick's hip x-ray indicated that there were vascular calcifications, "no significant bony or soft tissue pathology, " and "inferior lumbar spondylosis." (R. 282.) Dr. Avula's review of Fitzpatrick's knee x-rays also revealed vascular calcifications with a finding of "osteoarthritic changes in the knees greater on the right." (R. 283.) The main point of this visit was "to have disability forms signed." (R. 269.)
On February 17, 2010, Dr. Mahesh Shah conducted an independent medical evaluation at the request of the Bureau of Disability Determination Services for the State of Illinois. (R. 299-302.) Dr. Shah noted that Claimant did not seem to suffer from acute distress and walked into the office without an assistive device. (R. 300.) Dr. Shah also noted that Claimant's hips and knees revealed mild tenderness without any swelling or deformity. (R. 301.) He also noted Claimant's lumbar range of motion: flexion was seventy degrees, extension was ten degrees, and straight leg raising was thirty degrees bilaterally. ( Id. ) From these observations, Dr. Shah concluded that Claimant had a full range of motion. ( Id. ) Additionally, he noted that Claimant's gait was normal but slow, that Claimant was able to heel-walk and toe-walk with some discomfort, and that Claimant was able to partially squat. ( Id. ) Dr. Shah concluded that Fitzpatrick was suffering from arthritis in the lumbar spine, hips, and knees, from high blood pressure and diabetes, which are medically controlled, and from heart disease, which was previously treated with an angioplasty with stenting. (R. 302.) Lastly, Dr. Shah noted that Claimant was mildly obese, which could exacerbate her medical problems. ( Id. )
On March 3, 2010, Dr. Charles Kenney, an independent medical consultant, issued a Physical Residual Functional Capacity Assessment ("RFC"). (R. 290-97.) Dr. Kenney found that Claimant could stand and walk for up to six hours in an eight hour workday and sit for a total of six hours in an eight hour workday, and he recommended that she avoid concentrated exposure to fumes and odors. (R. 291, 294.) He stated that Fitzpatrick's "exam in its entirety was within normal limits." (R. 292.) Dr. Kenney's conclusions were based on Claimant's medical records; he did not examine her personally. (R. 291.)
Fitzpatrick visited Oak Forest Hospital on April 22, 2010, for hyperglycemia, hypertension, and to refill her prescription medications. (R. 329.) Claimant reported her pain as zero. (R. 326.) Her hyperglycemia was reported at 720.29 and her hypertension at 401.29. (R 329.) Fitzpatrick visited Oak Forest Hospital again on August 28, 2010 to refill a prescription. (R. 355.) Claimant reported her pain as one out of ten, and complained of having achy arms for the past year. (R. 353, 355.)
On May 26, 2010, Dr. Young-Ja Kim, a medical consultant, affirmed Dr. Kenney's RFC issued on March 3, 2010. (R. 305.) Dr. Kim noted "claimant indicates no worsening of impairments, no new limitations, no new allegations, ...