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Parker v. Berryhill

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

April 4, 2017

GENERAL J. PARKER JR., Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1] Defendant.

          MEMORANDUM OPINION AND ORDER

          Michael T. Mason United States Magistrate Judge.

         Claimant General J. Parker Jr. seeks judicial review under 42 U.S.C. § 405(g) of a final decision of Defendant, the Commissioner of the Social Security Administration (“SSA”), denying his claim for Social Security Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (“the Act”) and for Supplemental Security Income (“SSI”) under Title XVI of the Act. 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 to reverse or remand the final decision of the Commissioner (Dkt. 16) is granted and the Commissioner's motion for summary judgment (Dkt. 26) is denied.

         I. BACKGROUND

         A. Procedural History

         On October 8, 2013, Claimant filed a Title II DIB application and a Title XVI SSI application, alleging a disability onset date of July 5, 2013. (R. 183-196.) His initial claim was denied on January 21, 2014 and again upon reconsideration on August 18, 2014. (R. 110, 119.) After both denials, Claimant filed a hearing request, and a hearing was held before an Administrative Law Judge (“ALJ”) on January 20, 2015. (R. 38-85, 141-42.) Claimant appeared along with his representative. A Vocational Expert (“VE”) was also present and offered testimony. On July 6, 2015, the ALJ issued a written decision denying Claimant's applications for DIB and SSI. (R. 20-32.) Claimant then requested review by the Appeals Council. (R. 13-16.) On October 5, 2015, the Appeals Council denied his request for review, at which time the ALJ's decision became the final decision of the Commissioner. (R. 1-5.); Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). This action followed.

         B. Medical Evidence

         Claimant claims he is disabled due to left wrist and ankle problems, heart issues and hypertension, and degenerative disc disease, among other problems. (R. 93.)

         1. Treating Physicians

         Claimant's first treatment of record is from Mercy Hospital St. Louis (“Mercy”) on January 6, 2012 with Bryan Menges, D.O., at which time he complained of ongoing headaches and chest pains. (R. 499.) Dr. Menges noted a history of hypertension, heart disease, asthma, and cerebrovascular disease. (R. 500.) Upon exam and further testing, Dr. Menges noted elevated blood pressure, renal insufficiency, likely secondary to hypertension, and headaches likely associated with TMJ. (R. 504.) Claimant was given pain and blood pressure medication, and discharged with instructions to follow up with his primary care physician. (Id.)

         Claimant returned to Mercy on March 15, 2012, complaining of right knee pain not associated with any recent trauma. (R. 465.) Upon examination, Mark Mason, M.D., noted Claimant's knee was positive for joint swelling, arthralgia, gait problem, and stiffness. (R. 465.) X-rays of the knee were taken, but they revealed no significant abnormalities. (R. 469-70.) There was a focal area of cortical thickening observed, which the reviewing physician opined might be related to a healed fibroma or prior trauma. (Id.) Claimant was provided with a knee immobilizer and pain medication, and then discharged. (R. 469.)

         The record is silent until July 5, 2013 when Claimant injured his left arm when a steel plate fell on his wrist at work at his construction job. (R. 55.) Following the injury, Claimant reported tenderness and limited range of motion due to pain. (R. 334.) Donn Richards, M.D., diagnosed him with a contusion of the forearm, which he treated with medication and an arm sling. (R. 335.) Imaging showed no evidence of fracture or dislocation. (R. 336.) He was cleared to return to full duty work. (R. 338.)

         A few days later, on July 12, 2013, Claimant presented to the Unity Point Health Methodist Emergency Department (“UnityPoint ED”) complaining of fever, chills, body aches, sore throat, nasal congestion, cough, nausea, abdominal pain, and continued left wrist pain. (R. 369.) He showed some minor signs of a possible viral infection upon physical exam. (R. 369-370.) Chest imaging showed some patchy infiltrate. (R. 372, 390.) Imaging of his wrist again showed no evidence of acute fracture. (R. 392.) Claimant was discharged and asked to return for a follow-up appointment a few days later. (R. 372.)

         Plaintiff presented to Andrew Zidow, M.D. for follow-up on July 15, 2013, with complaints of possible pneumonia due to fever, chills, cough, and shortness of breath. (R. 350.) He reported a history of myocardial infarction and stroke in 2011, as well as a chronic kidney condition. (Id.) After a normal physical examination, Dr. Zidow concluded that Claimant had pneumonia and hypertension. (R. 352.) Dr. Zidow also noted that Claimant was 71.5 inches (5' 9”) tall and weighed 269.2 pounds, resulting in a body mass index (“BMI”) of 37.0.[2] (R. 351.) Dr. Zidow prescribed a Z-pack and blood pressure medication, and advised Claimant to follow-up to establish routine care and better manage his blood pressure and kidney condition. (R. 352.)

         Claimant returned to see Dr. Zidow on July 25, 2013, and reported that he was still coughing and suffering episodic chest pains. (R. 346.) Claimant explained that he was treated by a cardiologist following his 2011 heart attack, but that he had not continued care following his move to Peoria. (Id.) At the time of this appointment, he was unemployed and living with friends. (Id.) Claimant also complained of residual soreness from his wrist injury. (Id.) Upon examination, Dr. Zidow found no abnormalities and noted Claimant had a normal gait. (R. 347-48.) Dr. Zidow assessed chronic kidney disease, likely secondary to hypertension, and coronary artery disease. (R. 348.) Dr. Zidow suggested various medications and follow-up testing, though Claimant was resistant to some of those suggestions. (Id.) Dr. Zidow also noted a history of noncompliance with medication. (Id.)

         At his next appointment with Dr. Zidow on August 12, 2013, Claimant reported compliance with his medications, though he was unable to start one of the medications suggested for heart disease due to price concerns. (R. 342.) A physical exam was primarily unremarkable. (R. 344.) Dr. Zidow again assessed coronary artery disease, hypertension - stage two, hyperlipidemia, and prescribed him medicine that would be on the $4 list at Walmart. (Id.) He was also referred to the cardiology department for further management. (Id.)

         Claimant presented to the UnityPoint ED on September 14, 2013, complaining of a cough, sore throat, sinus congestion, an earache, chest pain, and fatigue. (R. 381.) He reported he had been off of his medication for a while because he could not afford it. (R. 379.) David Dean, M.D., found Claimant's symptoms to be consistent with acute bronchitis and admitted him to the medical unit. (R. 382, 387.) The next day, Claimant continued to complain of upper respiratory issues including nasal congestion, sore throat, and cough. (R. 361.) While at the hospital, he developed sharp chest pain, which he described as “stabbing” that radiated to his back. (Id.) Testing showed no cardiac stress-induced ischemic changes, though an ECG revealed some abnormal results. (R. 388, 396.) The consulting cardiologist opined that the chest pain was likely secondary to viral illness as opposed to any acute coronary syndrome. (R. 360, 366.) Claimant's discharge diagnoses were chest pain (resolved), upper respiratory infection, hypertension (improving), chronic kidney disease, and coronary artery disease. (R. 359.) He was discharged on September 16, 2013, provided medication, and instructed to follow-up with Dr. Zidow. (R. 360.)

         Next, Claimant presented to HeartCare Midwest on November 27, 2013, for a consultation based on his history of chest pains and shortness of breath. (R. 414.) Marco Barzallo, M.D., reviewed Claimant's medical history including hypertension, degenerative disc disease, and myocardial infarction.[3] (R. 416.) He also noted that Claimant's BMI was 38.52. (R. 414.) Claimant complained of hip/leg pain, knee pain, and back pain upon ambulation. (R. 416.) Dr. Barzallo ultimately opined that although Claimant may have some diastolic dysfunction, his shortness of breath was likely related to his weight and deconditioning. (R. 414.) Claimant was advised to lose weight, exercise and return for a follow-up in six months. (R. 415.)

         Claimant was treated at Saint Francis Medical Center on May 16, 2014 with complaints of acute worsening pain in his left arm related to his previous injury and swelling in his right leg. (R. 429.) He denied chest pain or shortness of breath. (Id.) There was no evidence of deep venous thrombosis in the right leg. (R. 434.) He was provided with pain medication, and reminded to re-start his blood pressure medication. (R. 431, 436.) Claimant appeared to follow-up with a Dr. Rufus at Proctor Hospital the following week. (R. 525.) An upper extremity exam was unremarkable. (Id.)

         Shortly thereafter, on May 26, 2014, Claimant presented to the UnityPoint ED for recurrent moderate back pain of the lumbar spine, which was not associated with a known injury. (R. 446.) The pain was aggravated by bending, twisting, and certain positions. (Id.) He was assessed with a sprain of his lumbar region and given pain medications. (R. 448.)

         On June 6, 2014, Claimant presented for a neurology consult with Howard Liu, M.D. (R. 451.) Dr. Liu noted that Claimant had complained of weakness and tingling in his left arm since his work injury, as well as back pain. (Id.) Upon examination, Dr. Liu noted that Claimant had normal range of motion in his extremities. (R. 453.) He also noted that Claimant was 5' 11” and 284 pounds, resulting in a BMI of 39.71. (Id.) Dr. Liu ordered an EMG, referred Claimant to physical therapy, and prescribed Neurontin. (R. 454.) He also recommended regular exercise. (Id.)

         Claimant returned to see Dr. Rufus on June 25, 2014 with continued wrist pain, as well as intermittent back pain. (R. 525.) An exam of both wrists showed fairly normal range of motion, no effusion, tenderness, or deformities. (Id.) His grip and strength were reported as normal. (Id.)

         On June 30, 2014, Claimant presented for the EMG of his left wrist, which was conducted by Tony Jacob, M.D. (R. 455.) Dr. Jacob was unable to complete the test due to Claimant's pain, but it did show left ulnar neuropathy. (R. 455.) A few days later, Claimant reported to Dr. Liu that his left arm weakness had improved with therapy, but that he was still suffering from back pain. (R. 457.) Dr. Liu increased Claimant's medication and recommended further physical therapy for back pain. (R. 458.) He opted to treat Claimant with more medication and physical therapy. (Id.)

         At an appointment with Dr. Rufus in August 2014, Claimant continued to complain of intermittent back pain, but exhibited normal flexion, and no tenderness. (Id.) He explained that his back pain had worsened following a recent run-in with police. (Id.) Claimant did not appear for his next appointment the following month. (Id.)

         In November 2014, Claimant was discharged from his physical therapy sessions, which he began in June. (R. 565.) He often complained to his therapist about continued arm and back pain. (R. 546-65.) Therapy notes do indicate a “severe” problem with walking, a “negligible” ability to participate in work-related activities, and limited range of motion in his back. (R. 554, 564.) Upon discharge, the therapist commented that Claimant demonstrated only slight improvement overall, but did question whether his “sporadic” attendance may have limited his progress. (R. 565.)

         On January 8, 2015, Claimant returned to see Dr. Liu for follow-up. (R. 527.) At his appointment, Claimant reported that his left arm pain had worsened following an incident with police in August 2014 during which his arm was shut in a car door. (Id.) On examination, Claimant complained of pain in his left arm upon movement. (R. 528.) Dr. Liu recommended a different pain medication. (R. 529.) In April 2015, he ...


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