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Andrews v. Colvin

United States District Court, N.D. Illinois, Eastern Division

September 15, 2016

BOBBY E. ANDREWS, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.


          Michael T. Mason United States Magistrate Judge.

         Claimant Bobby Andrews (“Claimant”) seeks judicial review under 42 U.S.C. §405(g) of a final decision of Defendant Commissioner of the Social Security Administration (“SSA”) denying his claim for Social Security Supplemental Security Income (“SSI”) benefits under Title XVI of the Social Security Act (“the Act”). 42 U.S.C. §1382a(a)(3)(A). The parties have consented to the jurisdiction of a United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). Claimant asks that the court reverse the decision of the Commissioner (Dkt. 18), and the Commissioner asks that the decision be affirmed. (Dkt. 22, 23.) For the reasons that follow, Claimant's motion is granted and the Commissioner's motion is denied. This case is remanded to the SSA for further proceedings consistent with this opinion.

         I. BACKGROUND

         A. Procedural History

         Claimant applied for SSI on May 16, 2012, alleging that he had been disabled since January 31, 2008, due to short-term memory loss, seizures, and alcoholism. (R. 197-203, 232.) His application was denied initially and on reconsideration (R. 68-89), and he filed a request for an administrative hearing. (R. 131-33.) On July 17, 2014, an administrative law judge (“ALJ”) convened a hearing at which Claimant testified and was represented by counsel. (R. 33-67.) In addition, Cheryl Hoiseth testified as a vocational expert (“VE”). (R. 56-67.) On August 28, 2014, the ALJ denied the Claimant's application for SSI, finding that he was not disabled because he was capable of performing his past relevant work as a custodian/institutional cleaner, as well as other jobs that exist in significant numbers in the national economy. (R. 15-27.) This became the final decision of the Commissioner when the Appeals Council denied the Claimant's request for review on July 2, 2015. (R. 1-3.) See 20 C.F.R. §§404.955; 404.981. That decision is now before the court for review under 42 U.S.C. §405(g).

         B. Factual Background

         Claimant was born on June 18, 1966 (R. 197), making him 48 years old on the date of the ALJ's decision. He has a ninth-grade education, taking special education classes throughout his schooling and can “write a little bit, but . . . can't read.” (R. 43.) Claimant has a limited work history. He was a school custodian from 2005 to 2008, and prior to that, worked sporadically as a laborer through a temp agency. (R. 216-17, 238-40.) He also briefly held a custodial job for three or four months in 2014, until he had a seizure at work. (R. 45.) Claimant is single and lives with his older sister. (R. 42)

         C. The Medical Record

         The medical record begins with the Claimant presenting to the emergency room on June 12, 2012, after experiencing a seizure. (R. 341.) He said he had been binge drinking and was off Dilantin, a medicine used to treat seizures. (R. 342.) The admission note indicates he was stressed and anxious. (Id.) Lab results confirmed his alcohol level was 0.19. (R. 351.) A month later, Claimant was back after suffering another seizure. (R. 392.) The event had lasted 3-4 minutes, according to a family member, and Claimant had bitten his tongue. (Id.) Examination confirmed abrasion and bite marks. (R. 393.) Claimant reported he had not taken Dilantin in a year and drank a six pack of beer a day. (R. 392.) Lab tests showed his Dilantin level was less than 0.8 - the therapeutic range is 10.0 to 20.0. (R. 393, 401.) A CT brain scan revealed no evidence of acute inter-cranial process. (R. 398.)

         Claimant began seeing Dr. Tais Crawford at Cook County Hospital Clinic for treatment in December of 2012. (R. 423.) On January 9, 2013, the doctor confirmed diagnoses of epilepsy, unspecified, and alcohol abuse, and ordered a prescription for phenytoin (or Dilantin). (R. 495.) She ordered lab work and instructed Claimant to return in six months. (R. 497-98.)

         The state disability agency arranged consultative physical and psychological exams for Claimant on January 19, 2013. (R. 411-14, 416-19.) At the physical exam, Dr. Lopez observed Claimant to be alert and oriented. (R. 414.) Claimant had a normal gait, normal range of motion in his spine and all extremities. (R. 413.) Motor strength and grip strength were both normal. (Id.) Reflexes and sensation were normal as well. (R. 414.) Dr. Lopez reported Claimant's affect was normal, his memory was intact, and there was no sign of depression or anxiety. (Id.)

         Dr. Michael Stone performed the consultative psychological exam. (R. 416.) Claimant denied abusing alcohol at that time and said he was attending AA meetings. (Id.) He said his cousin helped him with things like filling out forms. (Id.) Dr. Stone reported that Claimant's affect was depressed and anxious; his mood was dysthymic and dysphoric. (R. 417.) Thought content was positive for depression and anxiety, but there was no suicidal ideation. (Id.) Dr. Stone noted that Claimant had difficulty maintaining a consistent level of attention and concentration during the examination. (Id.) There was evidence of impaired memory: Claimant could recall three objects immediately and after one minute, but not after three or five minutes. (R. 418.) He was able to identify the President but not the Mayor. (Id.) He could identify four large cities in the United States, but not the past four Presidents. (Id.) Even simple mathematical calculations were somewhat difficult for Claimant. (Id.) He didn't grasp that a hat and a shirt were both clothing, or that an apple and a banana were both fruit. (Id.) He didn't understand the meaning of common proverbs. (Id.)

         Dr. Stone concluded that Claimant suffered from depressive disorder and generalized anxiety disorder, in addition to memory problems, a seizure disorder and a history of alcohol abuse. Claimant's prognosis was guarded. (R. 419.) Dr. Stone didn't feel he would be capable of managing his own funds if he were granted benefits. (Id.)

         In February 2013, state agency physicians reviewed the file and the results of the consultative exams in order to assess Claimant's residual functional capacity (“RFC”) assessment, among other things. (R. 76-88.) As related to his mental health, Dr. Terry Travis determined that Claimant's depression and anxiety amounted to severe impairments. (R. 81.) In his view, Claimant suffered from moderate limitations in activities of daily living, social functioning, and concentration, persistence and pace. (Id.)

         Claimant returned to the County Hospital Clinic in May 2013 for a refill of his medication and lab tests. (R. 480.) He saw Dr. Crawford for a follow-up on his seizure disorder on August 12, 2013. (R. 458.) He reported that he had passed out on July 29, 2013. (Id.) Dr. Crawford noted he had been compliant with his medications. (Id.) Lab tests showed elevated levels of glucose, cholesterol, and triglycerides. (R. 459.) Claimant reported he suffered from intermittent headaches. (R. 460.) Dr. Crawford increased Claimant's Dilantin dosage. (R. 461.)

         On October 25, 2013, Claimant had another appointment with Dr. Crawford for a check-up and a refill of his prescription. (R. 450.) He denied feeling depressed or hopeless over the previous two weeks. (R. 451.) Dr. Crawford completed a Seizures Medical Source Statement for Claimant's attorney on October 31, 2013. (R. 423-26.) She indicated Claimant suffered from convulsive seizures and had hyperlipidemia. (R. 423.) He had no warning of his seizures and lost consciousness and bit his tongue during episodes, which occurred twice a week. (R. 423, 424.) Claimant described them as headaches accompanied by tremors. (R. 423.) Dr. Crawford felt Claimant was capable of low stress work. (R. 424.) Exertion could bring on a seizure; he should not lift more than ten to twenty pounds occasionally. (R. 424-25.) They resulted in loss of vision focus and light-headedness. (R. 425.) Dr. Crawford reported Claimant was compliant with taking medication, but missed dosages on July 29, 2013. (Id.) She added that Claimant had poor self-esteem, short attention span, and memory problems. (R. 426.)

         Claimant had additional lab tests done on October 31, and November 13, 2013. (R. 436-37, 441.) On March 10, 2014, during another visit with Dr. Crawford, Claimant complained of dizziness and giddiness. (R. 432.) Claimant told the doctor he had been off alcohol for a few months. (R. 502.) Liver function tests were abnormal. (R. 432.) Dr. Crawford noted Claimant had been adherent to his medication regimen and increased his Dilantin dosage. (R. 502, 505.) Lab work showed that his cholesterol and triglycerides levels were elevated. (R. 503.) His last EEG in December 2013 was normal. (R. 432.) Claimant denied being hopeless or depressed over the previous two weeks. (R. 504.)

         D. The Administrative Hearing

         1. Claimant's Testimony

         At his administrative hearing, Claimant testified that he began having seizures when he was a child, and that they worsened with age. (R. 50.) The last job he held for an extended period of time was as a custodian at a school. (R. 44.) He said he had to leave that job in 2008 because he had a couple of seizures and fell and hurt his back. (Id.) He worked briefly as a janitor early in 2014 but, again, that job ended when he had a seizure while at work. (R. 44-45.) He had hoped to keep that job indefinitely; he had been briefly homeless just before that. (R. 51.)

         Now, on a typical day, he did very little: “[b]asically just get up and sit outside.” (R. 45.) When he couldn't sit outside, he would stay in and watch TV. (R. 47.) He was able to shower and dress himself, but he didn't cook. (R. 46.) His sister took care of that. (Id.) She also did the grocery shopping, but he sometimes went with ...

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