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Warnock v. Berryhill

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

April 19, 2017

JOHN WARNOCK, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1] Defendant.

          ORDER

          Susan E. Cox U.S Magistrate Judge.

         Plaintiff John Warnock (“Plaintiff”) appeals the decision of the Commissioner of Social Security (“Defendant, ” or the “Commissioner”) to deny his application for disability benefits. The parties have filed cross-motions for summary judgment. For the following reasons, Plaintiff's motion is granted [dkt. 10], the Commissioner's motion is denied [dkt. 15], and the ALJ's decision is reversed and remanded for further proceedings consistent with this opinion.

         STATEMENT

         I. Procedural History

         On September 17, 2012, Plaintiff protectively filed an application for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (the “Act”). (R. 151.) Plaintiff's alleged disability onset date was May 1, 2012. (R. 74.) His initial application was denied on December 20, 2012 and again at the reconsideration stage on March 22, 2013. (R. 73- 89.) Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”) on April 8, 2013, which was held on January 14, 2014. (R. 107-108, 31-70.) Plaintiff appeared at the hearing with his attorney. (R. 33.) Vocational Expert (“VE”) Aimee Mowery was also present and offered testimony. (R. 33.) On November 14, 2014, the ALJ issued a written decision denying Plaintiff's application for DIB. (R. 13-25.) The Appeals Council (“AC”) denied review on February 1, 2016, thereby rendering the ALJ's decision as the final decision of the agency. (R. 1-3); Herron v. Shalala, 19 F.3d 329, 332 (7th Cir. 1994).

         II. Factual Background

         A. Medical and Medical Opinion Evidence

         The medical records indicate that Plaintiff suffers from degenerative disc disease, carpel tunnel syndrome, diabetes, and emphysema/COPD. (See R. 16.) Additionally, Plaintiff's medical history includes a right ankle fracture in 2006; Plaintiff reported to his treating physician Dr. Gilbert Egezeke, M.D., as late as 2012 that he experienced “severe pain in both ankles.” On March 3, 2014, Plaintiff reported to Dr. Egezeke that he suffered from “body pain all the time in the legs, arms, joints.”[2] Plaintiff further testified that his feet and ankles “hurt from the time I get out of bed . . . [t]hey hurt all night long, all day long.” (R. 42.)

         Plaintiff also has a history of pneumonia, in addition to emphysema/COPD. In September 2013, he was hospitalized for over two weeks with severe pneumonia that was caused by legionella. (R. 359-362.) Following his discharge from the hospital, Plaintiff was on oxygen for several months, through his hearing before the ALJ. (R. 51, 393.) Shortly after the hearing, Plaintiffs stopped using oxygen and reported feeling better. (R. 438.)

         Plaintiff's back began bothering him in November 2006, and MRIs show disc bulges at ¶ 5-6, foraminal narrowing at ¶ 5-6 and C6-7, left lateral disc herniation at ¶ 4-5, and an annulus tear. (R. 407-431.) Plaintiff had lumbar epidural injections in August 2008. (R. 422.) Plaintiff also attempted to treat his back problems with physical therapy, but chose to discontinue the therapy after it exacerbated his symptoms. (R. 54.) Throughout the following several years, Plaintiff would complain to Dr. Egezeke about pain in his back and shoulder relating to his spinal condition. (See, e.g., R. 257 (“nerve pain in the left shoulder with some weakness…back hurts”), 345 (“constant pain in the shoulder, arms and neck with occasional tingling in the arms”), 435 (“complaints of body pain all the time in the legs, arms, joints”). Plaintiff did not want to take pain medications, but eventually relented approximately 5-6 months before his hearing, and was taking oxycodone for his back and shoulder pain at the time of his hearing before the ALJ. (R. 55, 257.)

         Plaintiff testified that he had carpal tunnel syndrome in both hands (worse in his right hand), and that it caused his hands to cramp any time he was performing an activity that required fine motor skills. (R. 39-40.) Dr. Egezeke referred Plaintiff for diagnostic testing in May 2013, which showed that Plaintiff had bilateral median entrapment neuropathy at both wrists compatible with bilateral carpal tunnel syndrome, and bilateral mild ulnar neuropathy at the wrists. (R. 341-343.) At the time of the hearing, Plaintiff was taking Gabapentin for the nerve pain in his shoulders and wrists. (R. 55.)

         Regarding Plaintiff's diabetes, he testified that he had his diabetes under control, with the exception of one fainting episode that occurred 8-10 weeks before the hearing. (R. 44.) He stated that he had to check his blood sugar between two and four times every day, but did not claim that the diabetes had any effect otherwise; the medical records corroborate Plaintiff's testimony that his blood sugar levels are under control.

         Plaintiff also had thumb surgery after a laceration from a band saw in 2010, but did not appear to have any lasting issues related to that incident. (R. 328-330.) Plaintiff also claims to have bipolar disorder and depression, but the medical records do not contain any mental health treatment, and Plaintiff testified that he has not received any such treatment. (R. 56.)

         The administrative record in this case also contains two consultative examinations (“CEs”) for the Bureau of Disability Determination Services. Both CEs were performed by Dr. Roopa Karri, M.D. The first CE took place on December 6, 2012; Dr. Karri reported that Plaintiff was able to get on and off the exam table, could walk 50 feet without support, had normal grip strength, had normal range of motion in his shoulders, elbows, wrists, hips, knees, and ankles, and had mild decreases in his range of motion in his neck and back. (R. 279-282.) The second CE occurred on June 26, 2014, following the hearing before the ALJ at Plaintiff's counsel's request; Dr. Karri reported that Plaintiff was able to get on and off the exam table, could walk 50 feet without support, had difficulty with tandem gait, had normal grip strength, had normal range of motion in his shoulders, elbows, wrists, hips, and knees, had mild decreases in his range of motion in his neck, back, and ankles, and had tenderness in his feet and ankles. (R. 441-446.) Dr. Karri opined that Plaintiff could: a) ...


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