United States District Court, C.D. Illinois, Rock Island Division
MARK A. MATHEWS, Plaintiff,
CAROLYN W. COLVIN, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.
JONATHAN E. HAWLEY, Magistrate Judge.
The Plaintiff, Mark Mathews, filed his application for disability insurance and Supplemental Security Income benefits on September 12, 2011, alleging that he became disabled on August 19, 2011. At each stage of the review process, his claim for benefits was denied. Having exhausted all of his administrative remedies, he now asks this Court to reverse the Defendant Commissioner's denial of his claim for benefits. For the reasons set forth herein, this Court reverses the Commissioner's denial of benefits, and therefore GRANTS the Plaintiff's Motion for Summary Judgment (D. 13) and DENIES the Defendant's Motion for Summary Affirmance (D. 16).
The issue before the Court is whether the ALJ erred when she failed to order a consultative examination related to the Plaintiff's impairment of his left hand, wrist, and forearm (referred collectively herein as Mathews's "arm") and, in light of that alleged failure, whether the ALJ's RFC and conclusion that the Plaintiff is not disabled is supported by substantial evidence. Because the inquiry before the Court is solely related to the arm impairment, the Court will not discuss medical evidence related to other impairments, except where necessary for completeness's sake. Although there is a great deal of medical evidence in the record concerning Mathews's other impairments, there is very little concerning his arm impairment. Whether there was still enough in this record for the ALJ to properly determine Mathews's RFC is the central question before the Court.
Mathews's problems with his arm began on August 17, 2011, when his girlfriend stabbed him with a butcher knife in his left forearm (his dominant one), resulting in extensive tendon injury. His hospital intake record notes:
Of the left posterior forearm and the extensor compartment is a laceration of 6 cm that violates the muscles and tendons. He does have range of motion in both the extensor and flexor motions although this is painful and his extensor range is somewhat limited. There is numbness and tingling to the last 3 digits of the left upper extremity although grip strength is intact.
(D. 11-1 at ECF p. 153). His girlfriend also stabbed him in the chest with a pair of scissors several times, but he claims no impairment due to these injuries. He underwent surgery the next day to repair the damage, but he re-injured his hand later in the month while picking up a pair of jeans. Upon reexamination, he showed decreased range of motion of the fingers and left hand, precipitating another surgery to again repair his injuries.
Mathews's orthopedic surgeon, Dr. Aric Eckhardt, produced a record one month later, on September 28, 2011, which indicated that Mathews had one out of five (1/5) muscle strength in his fingers, hands, wrist, and forearm of the left upper extremity, and forearm atrophy. He concluded that Mathews would have severe difficulty performing all tested manipulative abilities with his left hand. (D. 11-2 at ECF p. 18-22).
On December 9, 2011, agency physician, Dr. Francis Vincent, completed a "Physical Residual Functional Capacity Assessment." It does not appear as if Dr. Vincent examined Mathews, but rather reviewed the medical evidence, including Dr. Eckhardt's report. He noted the findings made by Dr. Eckhardt. He also found that Mathews's statements were considered credible as consistent with medical evidence in the record, which indicated limitations with fine manipulation and grip in his left hand. (D. 11-2 at ECF p. 97). He concluded that Mathews was "[l]imited to occasional" reaching, handling, fingering, and feeling with the left hand. (D. 11-2 at ECF p. 93).
The medical record is silent regarding Mathews left arm impairment for over a year and a half until, in July of 2013, he was examined by Dr. Hassan Haji Abdiraham. Dr. Abdiraham noted that Mathews stated he sustained injuries to his hand from a butcher knife, and "[a]pparently he had surgery on this left hand on August 17, 2011 then a revision surgery 3 weeks after." (D. 11-3 at ECF p. 38). He went on to note:
He states he is fighting disability case and would like to be referred to orthopedics. He says he has some pain in the hand and weakness in strength. Denies paresthesia. Surprisingly he has not seen anyone since 8/2011 when he had his surgery.
(D. 11-3 at ECF p. 39). Regarding Dr. Vincent's own examination, in contrast to his report of what Mathews told him, the sum total of his findings with regard Mathews's musculoskeletal findings were: "Comments: he has scar on left forearm. he has good grips bilat. full distal pulses bilat. no gross sensory loss. no deformity seen" (bad grammar in original). (D. 11-3 at ECF p. 40). Although Mathews requested a referral to an orthopedist, he was never seen by one; nor was a consultative examination ever ordered.
Although there is a great deal of medical evidence regarding Mathews's other impairments, the evidence discussed above is the entirety of the medical ...