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Murphy v. Colvin

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

October 5, 2016

CAROLYN W. COLVIN, Acting Commissioner of the U.S. Social Security Administration, Defendant.



         Claimant Patricia Murphy (“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 her concurrent application for Social Security Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (“the Act”) and Supplemental Security Insurance (“SSI”) under Title XVI of the Act. See 42 U.S.C. § 423; 20 C.F.R. § 416.110. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow, Claimant's motion for reversal or remand is granted and the Commissioner's motion for summary judgment is denied. The case is remanded to the SSA for proceedings consistent with this opinion.


         I. Procedural History

         Claimant filed a concurrent DIB and SSI application on August 8, 2011 alleging an onset date of January 1, 2011 due to anxiety, high blood pressure, leg and back problems, as well as agoraphobia. (R. 324, 341.) The applications were denied initially on September 7, 2011 and upon reconsideration on February 8, 2012. (R. 164-67.) After both denials, Claimant filed a hearing request, which was scheduled on October 22, 2013 before an Administrative Law Judge (“ALJ”). (R. 48-105, 188-89.) The hearing was continued to February 11, 2014 for further testimony from Claimant. (R. 106-63.) Claimant appeared for both hearings along with her representative. (Id.) A Vocational Expert (“VE”) was also present to offer testimony. (Id.) On June 27, 2014, the ALJ issued a written opinion finding that Claimant was not disabled and denying her DIB and SSI applications. (R. 16-40.) Claimant sought review by the Appeals Council, which was denied on September 18, 2015. (R. 1-3.)

         II. Medical Evidence

         On April 18, 2009, Claimant was treated at the Norwegian American Hospital for chest tightness and pain. (R. 429.) An exam of the chest showed “no acute infiltrates” and “mild blunting of right costophrenic angle.” (R. 438.) She was diagnosed with anxiety and discharged in good condition. (R. 440.)

         Records reveal that Claimant is a patient of Mount Sinai Hospital (“Mount Sinai”) and has been receiving regular treatment for complaints of dizziness and abdominal pain. Claimant had a CT scan of her pelvis and abdomen on June 23, 2008, which revealed normal results. (R. 456.) On January 14, 2009, after a complaint of dizziness, Claimant underwent a cranial scan, which showed “no evidence of extracranial or vertebral artery occlusive disease.” (R. 476.) On March 10, 2009, Dr. Joseph Rosman noted “she [was] doing well, ” but planned to conduct a pulmonary function test. (R. 747.) On April 9, 2009, Claimant returned to Mount Sinai with complaints of chest pain. A CT scan revealed normal results with “no evidence of pulmonary emboli.” (R. 496.) A chest scan on the same day showed “grossly normal” results. (R. 497.) On August 30, 2010, Claimant returned to Mount Sinai due to chest pains and dizziness. (R. 575.) She received a CT scan of the brain, which was normal. (R. 528.) An MRI of her brain showed no abnormalities. (R. 530.) She was discharged home on September 2, 2010 with a diagnosis of dizziness and hypertension. (R. 576, 708.)

         On October 27, 2013, Claimant was admitted to Mount Sinai due to abdominal pain that woke her from her sleep. (R. 1348.) A CT scan of her abdomen and pelvis were unremarkable. (Id.) The medical staff noted that her pain was likely caused by constipation. (R. 1358.) She reported to hospital staff that she remained anxious due to her relationship with her estranged husband. (R. 1331.) She was referred to the psychiatry department for evaluation. (Id.) She was advised to continue Zoloft for her anxiety and depression. (R. 1346.) She was discharged from the hospital on October 30, 2013. (R. 1345-46.)

         Claimant has also been treated at Lawndale Christian Health Center (“LCHC”) since 2009. (R. 752-53.) On February 23, 2009, she was diagnosed with shingles and hypertension and prescribed medication as treatment. (R. 749-50.) On April 22, 2009, the attending physician noted that Claimant's dizziness may be due to her high dosage of medication and advised her to stop taking Benazepril and Lopressor. (R. 742.) On June 23, 2009, she reported to LCHC due to crying spells and was diagnosed with depression. (R. 735.) She was prescribed Lexapro. (R. 736.)

         On October 26, 2010, Claimant was admitted to the emergency room at LCHC after complaints of dizziness. (R. 701.) The attending physician opined that her dizziness may be due to an ear infection. (R. 702.) During a follow-up appointment on November 19, 2010, Claimant stated that she was feeling better and that her dizziness had improved. (R. 698.) On December 22, 2010, Claimant completed a survey and noted that she frequently felt nervous, could not control her worries, had trouble relaxing, and feared that something awful may happen. (R. 783.) She commented that she was often bothered by stomach and back pains, pain in the arms, legs, and joints, chest pains, headaches, and dizziness. (Id.) The attending physician noted that her symptoms were likely due to anxiety, depression, and stress. (R. 786.)

         On August 12, 2011, Claimant called LCHC to ask for a letter “for SS disability stating she has panic attacks.” (R. 1017.) On May 10, 2012, Claimant completed another survey with largely the same answers regarding her mental and physical well-being. (R. 1181-82.) She was diagnosed with Post-Traumatic Stress Disorder (“PTSD”) due to past experiences in her life including her sister's death in 2008. (R. 1141.) On August 13, 2012, the attending physician noted that her condition was stable and that she has good days and bad days. (R. 1196.) She had been compliant with her Zoloft. (Id.) A record from September 11, 2012 reveals that Claimant “continues to get out of the house more and engage in enjoyable activities.” (R. 1205.) However, she had experienced recent stress due to harassment from her estranged husband. (Id.) On December 15, 2012, Claimant was able to independently leave her apartment and pick up her medications. (R. 1213.) But on May 7, 2013, Claimant reported living in isolation once again and had discontinued all social activities, including going to church. (R. 1080.) Claimant continued to visit LCHC through January 29, 2014 and treatment notes indicated that her condition fluctuated. (R. 1087, 1104, 1292, 1297, 1312.)

         On January 21, 2011, Dr. Nathan Wagner completed a formal mental status examination for the Bureau of Disability Determination Services (“DDS”). (R. 580-87.) Dr. Wagner's diagnostic impression was that Claimant had panic disorders with agoraphobia and depressive disorder. (R. 585.) Claimant had several crying spells during the evaluation, but was able to “pull herself together after several minutes.” (R. 583.) She was able to interact appropriately throughout the evaluation. (Id.) On the same day, Dr. Norbert De Biase of DDS completed an internal medicine consultative examination. (R. 588-96.) His clinical impression was that Claimant had high blood pressure, vertigo, chest pain, anxiety, and depression. (R. 591.) However, the examination returned mostly normal results as she had normal dexterity, normal range of motion, and no physical limitations. (R. 93-97.)

         On August 23, 2011, Dr. Marion Panepinto completed a physical Residual Functional Capacity (“RFC”) assessment for hypertension and vertigo. (R. 964-71.) Dr. Panepinto found Claimant did not have any exertional, manipulative, visual, or communicative limitations, but found Claimant should only occasionally climb stairs and balance, and should avoid hazardous machinery. (R. 965, 968.) Dr. Panepinto found Claimant's allegations regarding her physical limitations to be partially credible based upon the medical evidence. (R. 971.)

         On September 1, 2011, Dr. Elizabeth Kuester completed a mental RFC assessment and a Psychiatric Review Technique Form (“PRTF”), evaluating Claimant under listing 12.04 for affective disorders and 12.06 for anxiety-related disorders. (R. 972-889.) Dr. Kuester noted that Claimant was impaired by depression, a persistent irrational fear of a specific object, activity, or situation, as well as recurrent severe panic attacks “manifested by sudden unpredictable onset of intense apprehension, fear, or terror.” (R. 975, 977.) With regard to Claimant's functional limitations, Dr. Kuester found that Claimant was mildly limited in activities of daily living and maintaining concentration, persistence, and pace. (R. 982.) Claimant would be moderately limited in certain areas of understanding and memory and sustained concentration and persistence. (R. 986-87.) Specifically, Dr. Kuester noted that Claimant would be moderately limited in the ability to carry out detailed instructions and maintain attention and concentration for extended periods. (R. 986.) She would also be moderately limited in the ability to complete a normal workday, interact appropriately with the general public, accept instructions and respond appropriately to criticism, travel to unfamiliar places, and set realistic goals. (R. 987.) Dr. Kuester concluded, after reviewing the overall medical evidence, that Claimant could learn and perform simple, routine tasks adequately with ordinary instruction and supervision, but that she should not be required to interact extensively or deal with the public. (R. 988.) She would be able to relate with supervisors and coworkers to a minimal and superficial extent. (Id.)

         On June 7, 2012, a physician completed another mental RFC statement.[1] (R. 1066-69.) It was noted that it was “most likely” the case that Claimant's conditions had prevented her from working since December 2010. (R. 1066.) Claimant's prognosis was “poor.” (Id.) The physician found that Claimant would be precluded from performing activities within a schedule, working in coordination with others, completing workday tasks, interacting appropriately with the public, accepting instructions, interacting with coworkers, responding to changes in the work setting, traveling to unfamiliar places, and maintaining socially acceptable behavior for 15 percent or more of a typical workday. (R. 1067-68.) The physician also opined that Claimant would be precluded from performing more than 30 percent of an eight-hour workday, would be absent from work or unable to continue a workday for five days or more, and could not efficiently perform a full-time job. (R. 1068.) The physician concluded that based on her conditions, Claimant would be unable to obtain and retain full-time work in a competitive work environment. (R. 1069.)

         III. Claimant's Testimony

         Claimant was present at the hearing on October 22, 2013 and testified before the ALJ. (R. 48.) At the time of the hearing, Claimant was married with four adult children. (R. 55.) She does not work and relies on her children to provide for her. (R. 56.) Claimant testified that she last worked in June 2009 as a Child Development Assistant for a social service non-profit organization. (R. 59-60.) She performed administrative duties until she was laid off. (R. 62.) Claimant explained that she believed she became disabled on January 1, 2011, but not because of a specific event or hospitalization. (R. 63.) She testified that she is unable to work because she is afraid of being outside. (R. 68.) She further stated that she has felt scared since 2009. (Id.)

         With regard to physical impairments, Claimant testified that she sometimes cannot walk because she has trouble moving her arms and legs. (R. 69.) Claimant can walk about thirty feet independently. (R. 94-95.) She also has pain in her neck and shoulders, ...

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