United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
SHEILA FINNEGAN United States Magistrate Judge
Plaintiff Robin Anthony Moran seeks to overturn the final decision of the Commissioner of Social Security (“Commissioner” or “Defendant”) denying his application for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act. 42 U.S.C. §§ 416, 423(d). The parties consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c), and filed cross-motions for summary judgment. After careful review of the record, the Court now grants Defendant’s motion, denies Plaintiff’s motion, and affirms the denial of benefits.
Plaintiff applied for DIB on May 26, 2011, alleging that he became disabled on or about November 25, 2010 due to heart disease (for which he had a triple-bypass surgery, valve replacement, and a defibrillator implant) and hypertension. (R. 15-16; 42; 135). He also alleges that he experiences dizziness, a racing heart, being “out of wind, ” stress, and depression, all of which limit his ability to work. (R. 135; 165). The Social Security Administration denied his application initially on August 25, 2011, and again upon reconsideration on October 24, 2011. (R. 42-43). Plaintiff filed a timely request for hearing and appeared before Administrative Law Judge Lovert F. Bassett (the “ALJ”) on August 15, 2012. (R. 13). The ALJ heard testimony from Plaintiff, who was represented by counsel, and medical expert Ashok Jilhewar, M.D. (the “ME”). Shortly thereafter, on September 20, 2012, the ALJ found that Plaintiff can perform the full range of sedentary work, and thus he is not disabled since there are a significant number of jobs in the national economy that he can do. (R. 47-56).
In support of his request for remand, Plaintiff argues that the ALJ erred by (1) failing to fully address whether his impairments met or medically equaled Listing 4.02 for disability due to chronic heart failure; (2) failing to provide a narrative discussion of his functional capabilities, consider his impairments in combination, and assess him with any mental limitations in determining his residual functional capacity (“RFC”); (3) failing to sufficiently explain and provide supporting evidence for his credibility finding; and (4) improperly applying the medical-vocational grids (“grids”) at Step Five to find him not disabled. As discussed below, the Court finds that the ALJ’s decision is supported by substantial evidence and there is no basis for remanding the case.
Plaintiff is currently 49 years old, and was 46 years old at the time of the ALJ’s decision. (R. 42). He lives with his mother and teenaged son. (R. 17; 174). He is a high school graduate who worked from 1992 until 2000 as a laborer doing site maintenance at a mall. (R. 16; 140). He then worked for several years at various jobs, including as an asphalt paving truck driver, cement truck driver, and machine operator. (Id.). He was laid off from his last position in May 2008, and has not worked since. (R. 135). He alleges that his health has prevented him from performing the jobs he used to do after undergoing heart surgeries in late November and early December 2010. (R. 15-17; 140).
A. Medical History
1. November 2010 through December 2010
Plaintiff’s earliest medical records are from his November 25, 2010 to December 18, 2010 hospitalization, during which he underwent his heart surgeries. (R. 219-242). He had felt fatigued for about a month prior to this hospitalization, and suffered severe attacks of shortness of breath and coughing for about three or four days at the end of that month, which caused his family to bring him to the emergency room at Sherman Hospital. (R. 237). Plaintiff was admitted on November 25, 2010 and immediately underwent a chest x-ray, which revealed signs of congestive heart failure. (R. 238). He was then seen by cardiologist Syed Hasan, M.D., who prescribed IV fluids to stabilize his condition and recommended he undergo an echocardiograph that same day. (Id.). The echocardiograph revealed severe aortic valve stenosis with severe regurgitation; ejection fraction of about 25% in the left ventricle of the heart, which the cardiologist considered poor; and moderate pulmonary hypertension. These findings were then confirmed with a cardiac catheterization test. Upon evaluating these diagnostic testing results, Dr. Hasan concluded Plaintiff would likely need an aortic valve replacement, so he asked a heart surgeon at Sherman, Joong H. Choh, M.D., to consult. (R. 238-39).
The next day, on November 26, 2010, Dr. Choh interviewed and examined Plaintiff, as well as reviewed the results from the tests ordered by Dr. Hasan. (R. 237-42). Plaintiff explained to the heart surgeon that he knew he had a heart problem for many years, as he was told when applying for the Marines that he had a heart murmur and possible issues with his heart valves. (R. 237). Also, a few years prior to this hospitalization, a different doctor told him that he had a heart valve disorder. (Id.). Plaintiff also told Dr. Choh that he had been smoking a half a pack to a pack of cigarettes per day all his life and drank a couple of beers daily, but he had not been smoking in the past month. (R. 239).
Upon examination, Plaintiff appeared fatigued, showed shortness of breath when resting and exerting himself, had a cough with frothy mucus, and had a loud heart murmur. (R. 239-40). The heart surgeon also noted that Plaintiff’s lung sounds were clear, his examination was otherwise unremarkable, and at about 178 pounds and 6 feet tall, his weight was normal. (Id.). Dr. Choh determined Plaintiff’s heart failure episode was improving while he was in the hospital, but concluded that his “main problem is severe aortic valve pathology” that had been ongoing for many years and had “developed into a state of cardiomyopathy and congestive heart failure[.]” (R. 240-41). Although there was a high risk of complications or death from the surgery due to Plaintiff’s condition, Dr. Choh recommended aortic valve replacement as soon as possible because his prognosis was “rather dismal” without the surgery. (R. 241-42).
On December 1, 2010, Dr. Choh operated on Plaintiff’s heart, performing several surgical procedures, including an aortic valve replacement; a triple coronary bypass; the insertion of an intra-aortic balloon pump to help the heart pump blood during Plaintiff’s recovery; and the insertion of various tubes and wires. (R. 229-36). Plaintiff was then transferred to the cardiac unit for observation, with “fairly stable” vital signs. (R. 236). At first, he had “a difficult postoperative course” in the hospital, with complications including “runs of ventricular tachycardia.” (R. 219). On December 8, 2010, he required an electric shock to correct his abnormal heart rhythm. (Id.).
About a week later, on December 14, 2010, the surgeon implanted a defibrillator in Plaintiff’s heart to treat his tachycardia, and he had no complications from that surgery. (R. 219-20). He did, however, complain of feeling anxious before and after the surgery, and was treated with some sedatives by Dr. Hasan. (R. 313). By December 18, 2010, Plaintiff had generally recovered from the surgeries, with no complaints other than some discomfort in the area of his surgical incisions, and was accordingly discharged from Sherman that day. (Id.).
2. January 2011 – June 2011
On January 5, 2011, Plaintiff saw his heart surgeon, Dr. Choh, for a follow-up on his post-operative condition. (R. 229-30). Dr. Choh wrote that Plaintiff was “doing well” and was maintaining an “excellent general condition” including “ambulating well without any shortness of breath.” (R. 229). His incisions were all well-healed, lungs were clear, and heart sounds were regular. (Id.). He was taking pain medications, potassium, and Coumadin, a blood thinner, and was undergoing regular International Normalized Ratio (“INR”) testing to monitor the effects of the Coumadin. (R. 229-30). Although Plaintiff’s medications required some adjustments based on his recent INR testing results, he was instructed to continue them and the surgeon found he had reached a “satisfactory therapeutic range.” (R. 230). Dr. Choh recommended a follow-up in six to eight weeks. (R. 230).
A couple of weeks later, on January 20, 2011, Plaintiff also followed up with his cardiologist at Sherman, Dr. Hasan. (R. 537). He reported doing well with no complaints, and the cardiologist noted no abnormalities in his examination. (Id.). Dr. Hasan wrote in his treatment notes that Plaintiff’s condition, including his cardiomyopathy, was “stable” and he recommended a follow-up in three months. (Id.). A few days later, on February 1, 2011, Plaintiff also saw his internist at Sherman, Edwin B. Soriano, M.D. (R. 260, 262-63). He reported that he was “generally feel[ing] better since his heart surgery” and the internist noted no examination abnormalities other than a “slight murmur” in his heart and anemia that was “likely from post op [sic] recovery.” (Id.).
On February 13, 2011, Plaintiff was in a car accident, and although he was not injured, he felt “extremely emotionally upset and angry.” (R. 283). He took a Xanax to try and calm down, but had persistent anxiety and stress the rest of the day. (R. 280). Due to his anxiety and his concern that his heart could be affected, he went to the emergency room at Sherman the next day, February 14, 2011. (Id.). His initial blood tests in the emergency room showed a troponin leak, and so he was admitted for further care. (Id.).
The day after Plaintiff was admitted, on February 15, 2011, he was examined by Dr. Soriano, who found he was no longer in any acute distress and that his anxiety was caused by “a stressor event.” (R. 280-82). The internist also noted Plaintiff had high blood pressure that required medications, and recommended Plaintiff continue his other medications and have a consultation with Dr. Hasan. (R. 282). Dr. Hasan saw Plaintiff that same day, and noted he had been doing well prior to the accident. (R. 283). The cardiologist also noted Plaintiff was “somewhat” short of breath after the accident, but “this was apparently due to hyperventilating from the anxiety.” (Id.). Plaintiff denied any problems and said he felt “very well physically” but was “very emotionally upset after this accident.” (Id.). Dr. Hasan found no abnormalities in Plaintiff’s examination and noted that his lab results were normal except for “mildly elevated” troponin levels. (R. 284-85). The cardiologist assessed Plaintiff with an anxiety attack but stated he did “not believe that his current symptoms represent any sort of heart failure or true angina.”(R. 285).
Regarding the troponin leak, Dr. Hasan thought it was likely explained by a blockage in one of the grafts performed in the triple bypass surgery. (Id.). He concluded that “currently there is nothing mechanically that can be done for him, but fortunately he is otherwise asymptomatic.” (R. 286). Dr. Hasan recommended an echocardiograph, but discharged Plaintiff from the hospital and requested that he come back for a follow-up in one or two weeks. (Id.). Plaintiff’s February 16, 2011 echocardiograph was normal and “without evidence of insufficiency” in his aortic valve, but did show his “[o]verall ejection fraction [was] diminished at 45%.” (R. 287-88).
On February 22, 2011, Plaintiff went for his follow-up with Dr. Hasan, but was instead seen by a colleague, cardiologist Pradeep M. Maheshwari, M.D. (R. 517). Plaintiff denied any symptoms or problems, and stated that he felt better. (Id.). Upon examination, Dr. Maheshwari found Plaintiff’s defibrillator was functioning normally and he had no arrhythmia events, his lungs were clear, and he had no edema. (Id.). The cardiologist recommended a follow-up in about three months. (Id.).
At a March 3, 2011 follow-up with Dr. Soriano, Plaintiff reported generally feeling well, except for some leg pain near his surgical scars where veins were taken for use in his bypass surgery. (R. 259). The doctor recommended ibuprofen and a cold compress. (Id.). Some weeks later, on April 21, 2011, Plaintiff had a follow-up with Dr. Hasan, who found he had no symptoms from his conditions. (R. 536). His pulse was normal, respirations were normal and unlabored, breathing was clear, heart rhythm was normal, and heart sounds were normal, other than a heart murmur. Plaintiff also reported feeling like he was “doing remarkably well.” (R. 477). The cardiologist did note that Plaintiff now weighed 206 pounds, giving him a BMI of 28, in the overweight range. (Id.). Overall, he found Plaintiff’s cardiomyopathy manifested no heart failure symptoms, he had no reoccurrences of tachycardia, and his blood pressure medication was decreased due to good results. (Id.). The cardiologist recommended Plaintiff continue his current medications and return in three months. (Id.).
On May 11, 2011, Plaintiff had a follow-up with Dr. Soriano, and reported he generally felt well other than some occasional heartburn. (Id.). The internist recommended Plaintiff avoid triggering foods and prescribed Prevacid, as well as recommended exercise due to signs of high cholesterol in his recent laboratory results. (Id.). A couple of weeks later, on May 26, 2011, Plaintiff applied for disability benefits. (R. 42).
3. July 2011 through August 2011
On July 28, 2011, Plaintiff had a follow-up with Dr. Soriano, with complaints of soreness near his defibrillator site and near his sternal surgical wound. (R. 475). He also complained he was easily fatigued, and very anxious and emotional such that he needed “frequent reassurance about his condition.” (Id.). On the other hand, he denied chest discomfort suggestive of any blood flow problems, angina, shortness of breath, palpitations, stroke-like symptoms, symptoms of valvular heart disease, or any other problems. (Id.). Dr. Soriano also found Plaintiff’s examination was normal, his wounds were healed, his mood was appropriate, but he was still overweight. (R. 476). The internist prescribed Xanax for Plaintiff’s feelings of anxiousness but did not yet add an anxiety diagnosis to his file, and told him to follow-up with Drs. Hasan and Maheshwari. (Id.).
On August 9, 2011, Plaintiff had a consultative examination by Roopa Karri, M.D., to evaluate his disability claim. (R. 480-83). Dr. Karri reviewed Plaintiff’s records, interviewed him, and conducted an examination. (R. 480). Plaintiff stated he had a history of hypertension and hyperlipidemia, and discussed his hospitalization and surgeries in November and December 2010. (Id.). He said he still gets shortness of breath despite the surgeries. (Id.). He also stated that he has chest wall pain near his left nipple, his feet hurt and swell occasionally, and his hands go numb occasionally at night. (R. 480-82). Dr. Karri noted Plaintiff was taking various medications including for high blood pressure, high cholesterol, and blood thinning, and that he cried and became emotional when discussing his condition. (R. 481). She further noted upon examination that Plaintiff’s blood pressure was just above normal; he was anxious; he weighed 215 pounds; he had something protruding that seemed like a wire from his sternal sutures where his surgical incision was made; and his range of motion in the left shoulder was slightly reduced. (R. 481-82). He was otherwise normal, including that his lungs were clear; he had normal strength; he could ambulate without support; his mental status was alert and oriented with a good memory and ability to do calculations; and his effort and cooperation were excellent. (Id.). Dr. Karri’s impression was a history of hypertension and hyperlipidemia that were “under control, ” a history of aortic valve replacement and current use of a blood thinner, and a history of triple bypass surgery and defibrillator implantation with current left chest wall pain. (R. 483).
Consulting psychologist David Voss, Ph.D., prepared a Psychiatric Review Technique for evaluating Plaintiff’s disability claim, dated August 20, 2011. (R. 492-505). Dr. Voss found Plaintiff had no medically determinable mental impairment based on his review of the record, including Dr. Karri’s consultative examination report and Plaintiff’s disability reports. (Id.). He noted that although Plaintiff was anxious and cried during Dr. Karri’s examination, he attributed his limitations to physical rather than mental impairments. (R. 504). Dr. Voss also noted that there were no medical statements or opinions in the record from a treating mental health professional. (Id.).
Consulting physician Calixto Aquino, M.D., prepared a Physical Residual Functional Capacity Assessment for evaluating Plaintiff’s disability claim, dated August 23, 2011. (R. 506-13). Dr. Aquino found Plaintiff capable of light work, but only occasional climbing of ladders, ropes and scaffolds. (R. 507-08). Dr. Aquino explained that his finding was based on Plaintiff’s records showing a denial of post-surgery symptoms except for some pain near his defibrillator, and the most current examination showing some chest wall pain, above-normal blood pressure, and something protruding from his chest. (R. 507). The doctor further explained that although Plaintiff complains of shortness of breath, he had no current signs of lung complications, and there was no objective evidence of any musculoskeletal complaints. (R. 508, 511). On the other hand, the doctor determined that Plaintiff’s impairments could cause ...