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Wright v. Berryhill

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

February 16, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security[1] Defendant.


          Michael T. Mason, United States Magistrate Judge

         Claimant Jeffrey L. Wright (“Claimant”) brings this motion for summary judgment [12] seeking judicial review of the final decision of the Commissioner of Social Security (“Commissioner”). The Commissioner denied Claimant's claim for Social Security Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) under §§§ 416(i), 423(d) and 1614(a)(3)(A) of the Social Security Act (the “SSA”). The Commissioner filed a cross-motion for summary judgment [22], asking that this Court uphold the decision of the Administrative Law Judge (“ALJ”). This Court has jurisdiction to hear this matter pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). For the reasons set forth below, the Claimant's motion for summary judgment is granted and the Commissioner's cross-motion is denied.

         I. BACKGROUND

         A. Procedural History

         Claimant filed applications for DIB and SSI on August 4, 2011, alleging an onset date of December 21, 2010. (R. 135, 137.) Both the DIB and SSI claims were denied initially on November 10, 2011, and upon reconsideration on March 9, 2012. (R. 143, 151.) Claimant filed a written request for a hearing on March 13, 2012 pursuant to 20 C.F.R. § 404.929 et seq. (R. 156-57.) Claimant appeared and testified at a hearing held on August 8, 2012 before an ALJ. (R. 92-133.)

         After the initial hearing, the ALJ allowed Claimant's attorney to supplement the record with additional information. (R. 133.) After the supplemental information was provided, the ALJ requested another hearing on September 21, 2012. (R. 84.) Claimant did not appear or testify at this hearing because he was in the hospital. (R. 86.) The ALJ heard supplemental testimony from the impartial medical expert (“ME”) and continued the hearing. (R. 90.) On February 8, 2013, Claimant appeared for his continued hearing along with his attorney and testified. (R. 49-83.) A Vocational Expert (“VE”) and ME were also present to offer testimony. (Id.) On June 28, 2013, the ALJ issued a written determination finding Claimant not disabled and denying his DIB application. (R. 19.) Thereafter, Claimant requested review by the Appeals Council. (R. 16.) The Appeals Council denied the request for review on August 18, 2014. (R. 1-3.) The ALJ's April 25, 2013 decision became the final decision of the Commissioner. 20 C.F.R. § 416.1481; Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). Subsequently, Claimant filed this action in the District Court.

         B. Medical Evidence

         1. Treating Physicians

         Claimant had a history of coronary heart disease and, in 2009, had a stent placed in the left anterior descending artery.[2] (R. 384.) On May 9, 2010, Claimant presented to LaGrange Memorial Hospital with atypical chest pain. (R. 477.) He had negative cardiac enzymes, a negative EKG, and an abnormal dobutamine stress echo. (Id.) Upon discharge “compliance with all meds and smoking cessation were stressed.” (Id.) On October 25, 2010, Claimant had a cardiac catheterization, which showed a patent stent and nonobstructive coronary artery disease. (R. 384-85.) On November 18, 2010, Claimant presented to LaGrange Hospital with left arm pain, where he was treated and discharged two days later. (R. 670-71.)

         On December 20, 2010, Claimant was admitted to the LaGrange Memorial Hospital for on-going chest pressure and shortness of breath. (R. 384.) Doctors conducted another catheterization because of Claimant's “history and progression of symptoms.” (R. 384.) The catheterization showed nonobstructive coronary artery disease. (Id.) Claimant's blood pressure was also reported to have risen significantly. (Id.) It was noted that Claimant had chronic kidney disease and a history of diverticulosis. (Id.) He was released on December 21, 2010, and, again, instructed to stop smoking. (R. 385, 393.)

         Claimant returned to the emergency room the following day. (R. 415.) He presented with pain in the right middle thigh. (R. 416.) A CT scan showed iliopsoas muscle hematoma, and an ultrasound showed evidence of a pseudoaneurysm in the right common femoral artery. (R. 414, 425.) Claimant underwent a thrombin injection and a profunda femoris repair.[3] (R. 414.) He was discharged on December 24, 2010, and his physicians requested he follow up in 10 days with Drs. Walsh and Lambert and Dr. Ansari, his primary care physician, as needed. (Id.)

         Claimant returned to the emergency room on December 28, 2010 alleging right thigh pain and possible wound infection from the thrombin injection. (R. 458-59.) He was treated for an iliopsoas hematoma on the right with cellulitis, and was discharged three days later with instructions to continue medication. (R. 456-57.)

         On January 4, 2011, Claimant went to his vascular surgeon and complained of pain and swelling near the wound area. (R. 546.) He was admitted to the hospital and was treated for the infection and related pain. (Id.) Two days later he was in stable condition and discharged with instructions to continue antibiotics. (R. 546-47.)

         Claimant returned to the hospital again on January 17, 2011, citing right thigh pain. (R. 599.) His pain was thought to be paresthesia due to neuropathy. (Id.) A CT suggested acute sigmoid diverticulitis. (R. 619.) An EMG was recommended for two weeks after his January 20, 2011 discharge. (R. 599.) Claimant, however, returned to the hospital on January 29, 2011, complaining of right groin pain that caused his leg to “give way.” (R. 665.) He reported that Dilaudid helped with the pain. (Id.)

         On February 7, 2011, Claimant presented to LaGrange Hospital with right lower extremity pain and difficulty walking. (R. 708.) It was noted that he had a BMI of greater than 40, which is considered obese. (R. 709.) He was given Neurotonin and Dilaudid, which improved the pain, and discharged three days later. (R. 708-09.)

         Claimant returned to the emergency room on March 28, 2011, complaining of abdominal pain in the right lower quadrant and suprapubic region. (R. 750.) A CT showed a known hernia with some pelvic adipose tissue. (Id.) An MRI of the brain and c-spine were recommended, but due to his size it needed to be ordered as an outpatient test. (R. 751.) His complex regional pain syndrome was discussed, but his pain appeared to stabilize and he was discharged the following day. (Id.)

         Claimant was next admitted to LaGrange Memorial Hospital from April 1, 2011 to April 18, 2011 for rectal bleeding. (R. 778.) He was severely anemic when he arrived in the emergency room due to the blood loss. (Id.) He continued to have recurrent red blood per the rectum, and a colonoscopy revealed diverticulitis. (Id.) A total abdominal colectomy and ileorectostomy were performed on April 9, 2011. (Id.) It was noted that he had “[a]cute renal failure on chronic kidney disease, stage III.” (R. 779.) He was cleared for discharge with home healthcare and told to follow up with Dr. Ansari. (Id.)

         Clinical notes indicate that Claimant was seen on May 19, 2011 with complaints of pain in his right leg and neck.[4] (R. 836.) He was said to be in chronic pain and requested Vicodin. (Id.)

         On September 7, 2011, Claimant presented at LaGrange Memorial Hospital with complaints of black stool. (R. 906.) He underwent an EGD that revealed a duodenal ulcer, and there was no evidence of bleeding in the stomach. (Id., R. 933.) He was discharged three days later. (R. 906.) Claimant returned to the emergency room with groin pain on September 25, 2011. (R. 850.) He had dysphagia of unclear etiology. (Id.) An MRI showed mild to moderate foraminal narrowing, to be managed with pain medication. (R. 851.) The attending physician documented complex regional pain syndrome (“CRPS”) secondary to mild degenerative joint disease of the spine. (R. 850.) Claimant was discharged after eight days and told to follow up with Dr. Ansari in one week. (R. 851.)

         Claimant presented to Palos Community Hospital on October 7, 2011 with chest pain and hypertension. (R. 1013.) He stated that the pain began when he was driving his cab, and that it felt similar to his heart attack two years prior. (Id.) Diagnostic findings were all normal. (Id.)

         On November 10, 2011, Claimant presented to LaGrange Hospital with left arm pain after falling while walking. (R. 1116.) There was no evidence of fracture or dislocation and minimal degenerative changes. (R. 1117.) He was given pain medication and discharged the same day. (R. 1114.)

         On December 14, 2011, Claimant returned to LaGrange Hospital with complaints of left arm pain for the past three days. (R. 1021.) His test results were normal. (R. 1017.) The cardiologist recommended pain treatment for his left arm pain using morphine and cycling serial cardiac biomarkers. (R. 1022.)

         On March 7, 2012, Claimant went to Holy Cross Hospital with complaints of chest pain, and he was transferred to LaGrange Hospital due to his history of treatment there. (R. 1121.) A stress test showed reversible ischemic changes, and the physician recommended an angiogram. (Id.) A cardiac catheterization showed no significant coronary artery disease, and the chest pain was noted to have resolved. (R. 1122.) The physician documented that Claimant had chronic pain and prescribed Norco upon discharge two days later. (Id.)

         On May 12, 2012, Claimant was taken by ambulance to MacNeal Hospital with complaints of pain and tingling radiating down his left arm. (R. 1041, 1049.) A cardiac catheterization and coronary angiogram showed nonobstructive coronary artery disease. (R. 1043.) His arm pain was thought to be possible early brachial plexus neuralgia, root disease, or a developing zoster rash (shingles.) (R. 1047.)

         On June 20, 2012, Claimant presented to LaGrange Memorial Hospital with a two-day history of worsening abdominal pain located over the left lower quadrant and intermittent blood in his stool. (R. 1086.) He was found to have an anal fissure. (R. 1163.) During his stay, he was sent to the ICU when there was a concern of a stroke due to left upper extremity and left lower extremity weakness. (R. 1165.) He was discharged on June 22, 2012. (Id.)

         On August 7, 2012, Claimant was seen by his primary physician, Dr. Nasreen Ansari. (R. 998, 1196.) Dr. Ansari completed a physical residual functional capacity questionnaire (”RFC”), where she noted that Claimant suffered from neuropathy, coronary artery disease, chronic kidney disease, hypertension, and duodenal ulcers, among other things. (Id.) Dr. Ansari characterized Claimant's pain as “daily constant pain in the back/leg/arm.” (Id.) Dr. Ansari further documented that Claimant's pain would be a constant interference with his ability to be attentive and concentrate on even simple work tasks. (R. 999.) It was also Dr. Ansari's opinion that Claimant was incapable of walking any city blocks without significant pain, and that Claimant would likely be absent more than four days of work per month due to his conditions. (R. 999, 1001.)

         On November 14, 2012, Claimant presented to the emergency room at Hinsdale Hospital with intractable back pain. (R. 1197.) The physician noted that Claimant had numerous presentations for this in the past. (Id.) The CT was negative, and the diagnosis was musculoskeletal back pain. (R. 1197; 1211.) The physician advised follow up with his primary care ...

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