United States District Court, N.D. Illinois, Eastern Division
[Copyrighted Material Omitted]
For Bryan Colson, Plaintiff: Austin Joseph McGreal, LEAD ATTORNEY, Kelie C Schneider, Daley Disability Law, Chicago, IL.
For Carolyn W. Colvin, Acting Commissioner of Social Security, Defendant: Eric S Pruitt, LEAD ATTORNEY, AUSA-SSA, United States Attorney's Office (NDIL), Chicago, IL.
MEMORANDUM OPINION AND ORDER
Young B. Kim, United States Magistrate Judge.
Bryan Colson claims that he is entitled to Supplemental Security Income (" SSI" )
because he is disabled by a combination of back and other bodily pain, hypertension, borderline intellectual functioning, and depression. After the Appeals Council declined to review the Administrative Law Judge's (" ALJ" ) decision denying him benefits, Colson filed this suit seeking judicial review. See 42 U.S.C. § 405(g). Before the court are the parties' cross-motions for summary judgment. For the following reasons, Colson's motion for summary judgment is granted and the government's motion is denied:
Colson applied for SSI on June 21, 2010, claiming that he became disabled on January 1, 2007. (Administrative Record (" A.R." ) 123-26.) Colson's claim was denied initially and on reconsideration. (Id. at 69-70, 83-85.) Thereafter, Colson requested and was granted a hearing before an ALJ, which took place on October 28, 2011. (Id. at 38, 87-88, 90-98.) On December 16, 2011, the ALJ issued a decision concluding that Colson is not entitled to SSI. (Id. at 24-33.) The Appeals Council declined review on February 15, 2013, (id. at 1-5), thereby rendering the ALJ's decision as the final decision of the Commissioner of Social Security Administration, s ee Schomas v. Colvin, 732 F.3d 702, 707 (7th Cir. 2013). Colson then filed this action seeking judicial review of the Commissioner's decision. See 42 U.S.C. § 405(g). The parties consented to this court's jurisdiction. See 28 U.S.C. § 636(c); (R. 7).
Colson alleges that he has been unable to work since January 2007 as a result of back pain, hypertension, and other ailments. (A.R. 123-26, 141-47.) Colson was 48 years old at the time of his alleged disability onset date. (Id. at 123.) He became homeless in 2007 and has been impoverished since that time. (Id. at 232-35.) Colson is a high school graduate, but he had to repeat several grades and has a full-scale IQ of 76. (Id. at 61, 232, 241.) At his hearing before an ALJ, Colson supplied documentary and testimonial evidence in support of his claim.
A. Medical Records
Colson's medical records show that he has suffered from a number of physical ailments, including back, shoulder, and wrist pain and hypertension. With respect to his back pain, Colson sustained a back injury in 1994 while lifting heavy boxes at Cook County Hospital, where he worked in the shipping and receiving department from 1981 to 1996. (A.R. 57, 237, 296.) Colson underwent physical therapy and lumbar surgery in 1994. (Id. at 296.) After his back surgery, Colson continued to experience " severe and persistent" back pain. (Id. at 232.) He returned to work but transitioned to a more sedentary position and worked as a pill counter at the pharmacy. (Id. at 238.) This new position required him to sit for the duration of his eight-hour shift, which " exacerbated his back pain." (Id.) As a result, Colson quit and subsequently was unable to maintain steady employment. (Id.) For example, in 2000, Colson worked briefly at a dollar store but was fired after injuring his back while emptying trash. (Id. at 58, 238.) Colson said he " felt something snap" and was taken by ambulance to the emergency room. (Id. at 238.) In recent medical records, Colson was diagnosed with sciatica and nerve damage in his lower back. (See id. at 331.) Colson has complained of back pain that radiates down from his back to his legs, particularly when he walks more than two or three blocks, climbs stairs, or sits for extended periods. ( Id. at 232-33.)
Colson also has pain in his left shoulder and wrist, which he claims precludes him from carrying anything in his left hand. (Id. at 233.) Colson has described the shoulder pain as a " 'terrible,' cramping
pain." (Id.) Furthermore, Colson has suffered from hypertension since 1983. (Id. at 296.) Colson has been hospitalized twice for hypertension, including most recently in 2009. (Id.) Colson has been prescribed a number of medications for his hypertension, (see, e.g., id. at 207, 221, 268, 307), although he has not taken them consistently because of his indigency, (id. at 56, 268).
Colson did not supply any medical records pre-dating 2009. Medical records from 2009 to 2010 show that Colson sought treatment for, and has a history of, back and other bodily pain and hypertension. For example, in May 2009, Colson was treated at West Suburban Medical Center (" WSMC" ) for cardiac issues, headache, dizziness, and blurred vision. (Id. at 206-11.) The treating physicians ordered a number of tests, including an EKG and head and chest CT scans. (Id. at 211-19.) Those tests showed the following: " [s]light hyperinflation" of Colson's heart, (id. at 216); no evidence of " acute infarct, intracranial hemorrhage or mass lesion" in Colson's head, (id. at 218); and a " small hypodense area bordering the occipital horn of the left lateral ventricle," (id.). Colson also visited WSMC on December 20, 2010, after he fell and injured his back, left hip, shoulder, and neck. (Id. at 346.) The treating physician noted that Colson had a " strong gait" but was " hunch[ed] over a littl[e]." (Id.)
Additionally, Colson saw Dr. Thomas Staff of PCC Austin Family Health Center in October and November 2010. (Id. at 304-11, 323-27.) Colson complained of left shoulder pain, lower back pain, headaches, left arm and leg weakness, hypertension, cardiac issues, and a ganglion cyst in his left wrist. (Id. at 304, 305, 307, 311, 325, 326.) During those visits, Dr. Staff noted that Colson needed to be evaluated for a possible stroke, (id. at 307, 326), and that Colson had a " limp" gait and station, (id. at 306, 310, 325). As a result, in October 2010 Colson underwent scans of his chest and head. (Id. at 276-77.) The chest image showed " [n]o evidence of any acute cardiopulmonary process." (Id. at 276.) The head scan showed " no evidence of acute infarct, intracranial hemorrhage or mass lesion." (Id. at 277.) But there was " very slight hypodensity in the periventricular white matter" and " a minute lacune at the basal ganglia on the right." (Id.)
Colson visited Dr. David Freedman of the University of Illinois Medical Center at Chicago on July 9 and July 30, 2010. (Id. at 268-72.) Dr. Freedman's July 9, 2010 progress notes are faint and largely illegible, but it is clear that Colson visited Dr. Freedman on July 9th and complained of back pain, explained his medications, and related his social history. (Id. at 270-72.) Dr. Freedman diagnosed Colson with hypertension, left lower back pain, headaches, and " [l]eft shoulder pain which appears to be rotator cuff tendinitis." (Id. at 268-72.)
Drs. Staff and Freedman completed residual functional capacity (" RFC" ) questionnaires for Colson on November 19, 2010, and July 30, 2011, respectively. (Id.
at 328-35.) In the questionnaires, Colson's diagnoses are listed as: " (1) sciatica [on the left side of his] lower back L4-5 with nerve damage[,] (2) hypertension[, and] (3) rotator cuff tendinitis [on the left] shoulder," (id. at 331; see also 328), as well as " weakness on [left] side [with history of] lacunar infarct/CVA," (id. at 328). Dr. Freedman also noted the following limitations: Colson had decreased range of motion along with weakness and decreased sensation in his left leg; left leg pain; left shoulder pain; and decreased range of motion in his left shoulder. (Id. at 331.) Straight-leg testing showed decreased strength, and knee flexor extensions showed decreased sensation in the left lateral leg. (Id.) According to Drs. Staff and Freedman, Colson's general prognosis was " fair" to " poor." (Id. at 328, 331.) Based upon their examinations, they separately concluded that Colson was functionally limited in the following ways:
1. can walk one to two blocks without resting or experiencing severe pain;
2. can sit for 30 to 45 minutes at one time;
3. can stand for 30 minutes at one time;
4. can sit and stand/walk for fewer than two hours in an eight-hour work day, (id. at 333; but see id. at 329 (stating that Colson can sit for at least six hours and stand/walk for ...