United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
JEFFREY COLE, District Judge.
The plaintiff, Anthony Reed, seeks review of the final decision of the Commissioner ("Commissioner") of the Social Security Administration ("Agency") denying his application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act ("Act"), 42 U.S.C. §§ 416(I), 423(d), and 1382(c). Mr. Reed asks the court to reverse and remand the Commissioner's decision, while the Commissioner seeks summary judgment affirming the decision.
Mr. Reed applied for DIB and SSI on October 27, 2009, alleging he had been disabled since October 19, 2009, due to an "ataxiacerebellar" hemorrhage, constant dizziness, short term memory loss, balance problems and a speech impairment. (Administrative Record ("R.") 143-45, 185, 189). His application was denied initially and upon reconsideration. (R.81-88, 90-96). Mr. Reed filed a timely request for hearing in pursuit of his claim on August 24, 2010. (R. 100). An administrative law judge ("ALJ") convened a hearing on April 15, 2011, at which Mr. Reed, represented by counsel, appeared and testified. (R. 37-73, 76-80). In addition, Dr. Richard Hamersma testified as a vocational expert. (R. 73-76). On June 14, 2011, the ALJ issued an unfavorable decision, denying Mr. Reed's application for DIB and SSI. (R. 23). The ALJ determined that despite Mr. Reed's severe limitations due to a cerebrovascular accident (stroke) and hypertension (R. 17), and despite his minimal functional limitations due to depression (R. 18), Mr. Reed's residual functional capacity allowed him to perform his relevant past work as it is generally performed. (R. 22-23).
The ALJ's decision became the Commissioner's final decision on June 15, 2012, when the Appeals Council denied Mr. Reed's request for review. (R. 6). See 20 C.F.R. §§ 404.955; 404.981. Mr. Reed appealed that decision to the federal district court under 42 U.S.C. § 405(g), and both parties consented to jurisdiction here pursuant to 28 U.S.C. § 636(c).
THE RECORD EVIDENCE
Mr. Reed was born on February 26, 1953, making him fifty-eight years old at the time of the ALJ's decision (R. 38). He lives with his wife, who works, his daughter, who goes to school and granddaughter, who goes to daycare. (R. 38-39). He completed high school and one year of college. (R. 39). He served in the United States Navy from 1970 to 1976 (R. 68). Immediately before his application for disability, Mr. Reed worked for 32 years as a maintenance engineer for a real estate company (Lake Meadows Apartments). (R. 190, 694). As a maintenance engineer his activities included walking and standing, carrying tools and equipment, climbing ladders, snow removal, gardening, repairing air conditioning units, electrical, leaks and making other necessary repairs. (R. 50-51, 175, 190). He also supervised at least five employees who did similar work (R. 51, 190), and was certified to do electrical and plumbing work. (R. 51). Mr. Reed held this position until October 2009 when he retired. (R. 44-46).
Mr. Reed claims he suffers disability from a cerebrovascular accident (stroke), hypertension, gout and dysthemic disorder (depression). (R. 242). He claims that the effects of his physical and mental impairments, individually and in combination, have prevented him from working since October 19, 2009. (R. 189, 242). The effects of Mr. Reed's impairments allegedly include: constant dizziness and pain, short term memory loss, problems walking and standing due to imbalance and a speech impairment. (R. 204-205, 289).
Mr. Reed's relevant medical history begins in October 2006 when he was hospitalized at Northwestern Memorial Hospital after suffering a stroke. (R. 278, 666). His hospitalization lasted about three weeks, followed by speech therapy at Mercy Hospital for approximately one month in order to learn to speak again. Id. Thereafter, he was able to return to work. (R. 278).
In January of 2009, Mr. Reed sought treatment for a gout flareup in his right big toe. The remainder of the physical exam was normal and he had no other complaints. (R. 689). Mr. Reed returned with another gout flareup on April 3, 2009. He had pain in both feet, brought on by alcohol consumption. Once again, there were no other issues, and the balance of the physical exam was normal. (R. 685). On October 8, 2009, Mr. Reed complained of becoming easily fatigued with decreased exercise endurance, as well as some imbalance. (R. 409). Reflexes and motor strength were normal. (R. 409). Neurological exam was normal. (R. 410). PSA was elevated. (R. 410).
From January 15-17, 2010, Mr. Reed was hospitalized after he experienced dizziness. (R. 245). Mr. Reed's treating physician during his hospitalization was Dr. James Fairbairn. (R. 257). On January 15, 2010, head CT scans revealed chronic infarcts of the right cerebellum and inferior right basal ganglia. (R. 276). The scans further revealed: white matter lateral of the right basal ganglia with mild associated ex vacuo dilation of the anterior horn of the right lateral ventricle; consistent with generalized atrophy, the ventricles and cortical solci were otherwise somewhat prominent; conditions consistent with chronic ischemic small vessel disease; white matter hypodensity more pronounced in the right posterior centrum semiovale (which would also be secondary to chronic ischemic small vessel disease). (R. 275-76, 344).
Physicians were able to rule out acute cerebral bleed (a new stroke) as a cause of the dizziness. (R. 245). His blood pressure was elevated at 180/130. (R. 246, 248). Blood pressure remained high even after his dizziness went away. (R. 245). On January 16, 2010, a Cardio Echo Doppler Study revealed mild left ventricular hypertrophy with normal chamber diameter and contractility; borderline right ventricular diameter with preserved contractility; mild aortic root enlargement trivial mitral; trivial to mild pulmonic; mild tricuspid valvular regurgitation; abnormal mitral inflow and tissue Doppler indicating grade one diastolic dysfunction; mild pulmonary hypertension. (R. 340-43). Gait was steady. (R. 323).
On January 22, 2010, Dr. Rochelle Hawkins examined Mr. Reed for the Bureau of Disability Determination Services. (R.278-86). Mr. Reed provided his medical history to Dr. Hawkins, which she noted did include a stroke. (R. 278). Mr. Reed complained that he got some kind of rush every time he moved his head back. This sensation was accompanied with headaches, which lasted one or two minutes before going away. Mr. Reed denied past fainting seizure, nausea, vomiting or gastrointestinal problems. (R. 278). Mr. Reed's blood pressure was 130/90 in left arm and 130/86 in the right arm. (R. 279) Dr. Hawkins noted Mr. Reed had normal speech - no difficulty finding a word or slurring. (R. 279). With regard to Mr. Reed's upper and lower extremities, Dr. Hawkins noted Mr. Reed had no anatomic abnormalities, no evidence of redness, warmth, thickening of effusion of any joint, no limitation of motion of shoulder, elbow, wrist, ankles, hips, or knees. (R. 279-80).
Mr. Reed's grip strength was strong and equal bilaterally; his ability to perform fine and gross manipulation with upper extremities was normal; his muscle strength in both upper and lower extremities was normal. (R. 279-80). With regard to Mr. Reed's mental status, Dr. Hawkins noted that Mr. Reed was mentally alert, pleasant, cooperative, coherent, well oriented to place, time and person; he had good hygiene, grooming, normal affect, ability to relate well and made good eye contact; his memory of recent and remote events was completely intact; his ability to concentrate was fair; and he seemed capable of handling his funds. (R. 280).
His uncorrected vision was 20/30 on the right, 20/40 on the left. (R. 286). Dr. Hawkins's diagnostic impression of Mr. Reed was: 1) status post stroke three years ago with no residual effects; 2) high blood pressure but stable at time of exam; 3) questionable dizziness/vertigo. (R. 281). He was able to sit, speak and hear without difficulty; he had some difficulty in prolonged standing, walking, lifting and carrying due to easy fatigue and dizziness; he was able to walk greater than fifty feet unassisted; and he did not use an assistive device. (R. 281).
On February 3, 2010, Dr. Frank Jimenez reviewed the medical evidence on behalf of the disability agency. (R. 287-89). He recommended that Mr. Reed's claim be denied because he found Mr. Reed's impairments or combination of impairments were not considered severe. (R. 287). In making this recommendation, Dr. Jimenez considered the following evidence from the consultative exam on January 22, 2010: Mr. Reed's stroke, subsequent hospitalization at Northwestern and speech therapy, Mr. Reed's blood pressure reading of 130/86 in the right arm, his heart and lung sounds, speech, range of motion in all joints examined, normal gait, normal ability to bear his own wait and normal neurological portion of the exam. (R. 289). Dr. Jimenez also concluded that given the available medical evidence, Mr. Reed's symptoms were credible. (R. 289).
Mr. Reed said he was doing well on March 4, 2010. He did request medication for a pain in his foot. (R. 413). He had a consultative psychiatric exam with Dr. Robert Neufeld on July 6, 2010. (R. 201). Dr. Neufeld found that Mr. Reed was rather thin, emotionally somewhat flat-with flat and blunted affect, but that he had good eye contact with a usually linear and relevant thought stream. (R. 302). Motor movements and speech were normal. (R. 301). Remote recall was intact; immediate recall was somewhat impaired. (R. 301). IQ appeared to be in the borderline range. (R. 301). The doctor concluded that Mr. Reed had a dysthymic disorder (mild depression) and assigned him a Global Assessment of Functioning score of 65 (R. 303), denoting "[s]ome mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, ...." http://www.gafscore.com/.
On July 26, 2010, Dr. Carl Hermsmeyer reviewed the psychological evidence on behalf of the disability agency. (R. 305). Dr. Hermsmeyer determined that Mr. Reed suffered a dysthymic disorder (depression) that mildly limited Mr. Reed's activities of daily living, maintaining social functioning, maintaining concentration, persistence or pace. (R. 305, 308, 315, 317). The next day, Dr. James Madison, also on behalf of the disability agency, concurred in the February 2010 assessment by Dr. Jimenez. (R. 319-21).
On August 9, 2010, Mr. Reed reported that he was feeling about the same, with some dizziness and fatigue. Exam was normal. (R. 412). From September 21-24, 2010, Mr. Reed was hospitalized at Mercy Medical Center for a rheumatology evaluation after a gout attack. (R. 524-25). At the time of admission, Mr. Reed complained of a burning sensation that was 10/10 severity. (R. 524). His left knee and left elbow were swollen and painful, requiring him to use a cane. (R. 524). X-rays of the left knee and elbow revealed soft tissue swelling and some moderate degenerative changes in the elbow. (R. 528). On discharge he had near full range of motion. (R. 532).
On April 14, 2011, the day before Mr. Reed's social security hearing, Dr. James Fairbairn filled out a form provided by Mr. Reed's attorney. (R. 694). Dr. Fairbairn reported that he had seen Mr. Reed every three months since October 30, 2007. (R. 694). The doctor related diagnoses of a cerebellar hemorrhage, hypertension, and depression. (R. 694, 696). As for as Mr. Reed's symptoms, Dr. Fairbairn checked off boxes indicating weakness, unstable walking, falling spells, pain, fatigue, headaches, difficulty remembering, confusion, depression, personality change, speech/communication difficulties. (R. 694). But, the doctor allowed that the ...