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Borgo v. Berryhill

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

July 25, 2017

ROGER S. BORGO, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security[1] Defendant.


          MICHAEL T. MASON, United States Magistrate Judge:

         Claimant Roger S. Borgo (“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 disability insurance benefits under §§ 416(i) and 423(d) of the Social Security Act (the “SSA”). The Commissioner filed a cross-motion for summary judgment [19], requesting that this Court uphold the decision of the Commissioner. This Court has jurisdiction to hear this matter pursuant to 42 U.S.C. § 405(g). For the reasons set forth below, Claimant's motion for summary judgment is granted, and the Commissioner's cross-motion is denied.

         I. BACKGROUND

         A. Procedural History

         On April 27, 2012, Claimant filed an application for a period of disability and Disability Insurance Benefits (“DIB”), alleging an onset of disability of March 29, 2007. (R. 18.) His date last insured was March 31, 2013. (R. 19.) The Social Security Administration initially denied his claim on July 13, 2012, and upon reconsideration on March 18, 2013. (R. 18.) Claimant filed a timely request for a hearing on April 22, 2013. (Id.) On June 2, 2014, Claimant appeared with counsel before Administrative Law Judge (“the ALJ”) David R. Bruce. (R. 18, 29.) On September 10, 2014, the ALJ issued a written decision denying Claimant's request for benefits. (R. 18-28.) Claimant filed a timely request for review; and the Appeals Council denied this request on December 11, 2015, which made the ALJ's decision the final decision of the Commissioner. (R. 1-3, 7-8); 20 C.F.R. § 416.1481; Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). Claimant subsequently filed this action in the District Court.

         B. Medical Evidence

         Claimant seeks DIB for disabling conditions stemming from sarcoidosis, asthma, chronic diarrhea, allergic rhinitis, disorders of lipoid metabolism, mild cardiomegaly, kyphosis of the thoracic spine, and a thyroid disorder. (R. 21.)

         1. Treating Physicians

         Claimant's medical records date back to April of 2007, when he was treated at Loyola University Medical Center (“Loyola”). (R. 254.) Claimant was seen in the emergency room on April 3, 2007, at which time the physician noted that he had multiple bruises and swelling on his lower legs. (Id.) Claimant informed the physician that he was seen by an immediate care center four days previously and was told that he had spots on his lung. (Id.) Claimant also told the physician that he had been feeling fatigued and had experienced intermittent diarrhea and shortness of breath over the past year. (R. 254, 257.) The physician performed a chest radiograph on Claimant and determined that he had a possible nodule on his lung as well as multiple enlarged lymph nodes. (R. 262-63.) He was discharged the same day. (R. 258.)

         Claimant returned to Loyola on April 10, 2007, and was seen by Dr. Michael Gill. (R. 269.) He informed Dr. Gill that he was in good health until the end of March. (R. 267.) Dr. Gill noted his suspicions that Claimant might have sarcoidosis rather than a neoplastic process. (Id.) At an initial pulmonary consultation on April 11, 2007, Claimant said that he had not felt like himself for the past year, but that his problems have increased over the past few weeks. (R. 272.) The physician agreed that Claimant had dyspnea and mediastinal lymphadenopathy, and stated that he suspected Lofgren's syndrome due to Claimant's sarcoidosis. (R. 274.) Claimant was started on Prednisone. (Id.)

         On May 23, 2007, Claimant returned to Loyola for a pulmonary follow-up regarding his sarcoidosis. (R. 277.) He informed Dr. Daniel Dilling that he felt better overall, had more energy, and that the diarrhea had improved. (Id.) Claimant's bruising was gone, and he appeared better since starting the Prednisone. (Id.)

         Claimant went to the Loyola emergency room on June 4, 2007, complaining of difficulty breathing, increased pain on the right side of his face, blisters on the tongue and chin, and neck swelling. (R. 283-84.) He had an otolaryngology consultation, and the consult assessed an “apparent zoster of right V3 distribution.” (R. 287-88.) Claimant was discharged the same day. (R. 289.) On July 11, 2007, Claimant returned to Loyola for a pulmonary consultation. (R. 291.) Dr. Dilling noted that Claimant's trigeminal zoster had improved and that Claimant's chest x-ray showed a vast improvement in his adenopathy as compared with April 2007. (R. 291-92.) Dr. Dilling also documented that Claimant's symptoms had improved, but he was still breathless, experiencing depressive symptoms, and had diarrhea. (Id.) Dr. Dilling further commented that Claimant's symptoms, the zoster, and depression created reason to suspect Claimant was not tolerating therapy. (R. 294.) Dr. Dilling recommended a tapering off of Prednisone over three weeks. (Id.)

         On August 28, 2007, Claimant saw Dr. Gill at Loyola. (R. 298.) Dr. Gill noted that the Prednisone had been tapered off about a month ago and that the sarcoidosis has responded well, but that Claimant complained of other symptoms such as diarrhea, fatigue, and joint pain. (Id.) Claimant was next seen by Dr. Gill on September 11, 2007. (R. 303.) According to Dr. Gill, Claimant continued to be fatigued and experienced the same symptoms he did when he first presented with erythema nodosum and the pulmonary sarcoidosis was identified. (Id.) Dr. Gill reported being suspicious of the extra-pulmonary sarcoid symptoms and wondered if a low dose of Prednisone would clear up the symptoms. (R. 304.) Dr. Gill documented that Claimant had a pulmonary appointment the following week, and if his conditions worsened, he would recommend going back on Prednisone. (Id.)

         On October 15, 2007, Claimant saw Dr. Dilling for a pulmonary consultation, and Dr. Dilling reported that Claimant's energy was better, but not normal. (R. 306.) Additionally, Dr. Dilling noted that Claimant's lungs were “grossly clear.” (R. 307.) Claimant was next seen by Loyola medical staff on September 23, 2008. (R. 312.) During that visit, the treating physician noted that Claimant has become more fatigued over the past six months and had increased joint and eye pain. (Id.) The physician observed that Claimant acted depressed and admitted to depression because of his health issues. (Id.) Claimant was prescribed Lexapro for his symptoms. (R. 314.)

         The next visit in Claimant's records was on September 28, 2012, when Claimant was seen by Dr. Titilayo Abiona at Oak Forest Hospital. (R. 342.) Claimant informed Dr. Abiona that he was experiencing pain of the lower left quadrant as well as chronic lower back pain and bilateral lower extremity pain. (Id.) Additionally, Claimant informed Dr. Abiona that he experienced a tightening of his chest and pain when he cut his lawn and was experiencing diarrhea. (Id.) He reported taking Tylenol or Aspirin for relief. (Id.) A creatinine kinase was ordered, and a colonoscopy was scheduled for December 12, 2012. (R. 344.)

         On October 2, 2012, Claimant was again seen by Dr. Abiona at Oak Forest Hospital. (R. 333.) A chest exam revealed kyphosis of the thoracic spine. (Id.) Dr. Abiona also stated that Claimant possibly had an enlarged liver with a fatty infiltration, as well as a mild cardiomegaly and mild peripheral pulmonary congestion, and he recommended a follow-up and clinical evaluation. (Id.) Additionally, a one-cm size soft tissue nodule was noted on a chest x-ray, and further evaluation with a CT scan of the chest was advised. (Id.) A Doppler Arterial study of Claimant's legs was performed on October 10, 2012, and the study returned normal results. (R. 434.) Claimant was seen for a follow-up visit with Dr. Abiona on November 30, 2012. (R. 336.) Dr. Abiona noted that Claimant was experiencing stomach pain and diarrhea. (Id.) Upon discharge, the plan was to have a pulmonology consultation and a colonoscopy. (R. 340.)

         Claimant was again seen at Oak Forest Hospital on January 24, 2013, at which time the treating physician again noted that Claimant possibly had an enlarged liver with a fatty infiltration. (R. 329.) Claimant had a January 30, 2013 pulmonary outpatient visit with Dr. Patricia Macias and reported that he self-discontinued his Prednisone in 2007 because of side effects and that he had not been on any medications since then. (R. 346.) Claimant informed Dr. Macias that his respiratory symptoms never improved and that he had generalized pain and sinus problems. (Id.) He also reported that he lost his medical insurance. (Id.) Dr. Macias prescribed several medications, including Prednisone, and recommended pulmonary rehabilitation. (R. 348.)

         On March 27, 2013, Claimant had a follow-up visit with Dr. Macias. (R. 420.) He explained that the steroids he was on were not working and that he had been experiencing severe chest pain. (Id.) Claimant's wife expressed her disagreement about the test results and medications, but Dr. Macias reassured her and asked her to allow Claimant to take the medications as prescribed. (Id.) A CT scan was ordered. (Id.)

         Claimant saw Dr. Abiona on April 12, 2013, and informed him that he had been experiencing fatigue, chest pain, low back pain, and that he wanted his kidneys evaluated. (R. 408.) Dr. Abiona stated that Claimant had undergone numerous tests, including a colonoscopy, all with normal results, but that Claimant and his wife were not satisfied with those tests. (Id.) Dr. Abiona was also informed that Claimant had not been using the medications that he was prescribed. (Id.) A lumbar spine Comp AP showed early osteoarthritis, but no acute changes or fracture. (R. 396.)

         On April 17, 2013, Claimant saw Dr. Macias for a pulmonary outpatient visit. (R. 416.) Dr. Macias noted that the CT of his chest was normal. (Id.) She also documented that Claimant was uninterested in going to physical therapy to improve his pain and that he felt he should be resting instead of working in physical therapy. (Id.) Notably, Dr. Macias stated that she found it “very difficult to believe that all the symptoms [Claimant] has are secondary to sarcoidosis. . . since he is not improving with the appropriate therapy and all the testings are normal.” (Id.) She opined that Claimant might benefit from anxiety therapy. (Id.)

         Claimant saw the Lung Heath Educator in Oak Forest on April 17, 2013, and demonstrated improved spacer technique post-encounter. (R. 414.) On April 30, 2013, Claimant had a CT scan, which showed no abnormalities of the lungs, no enlargement of the liver, and was overall a normal CT of the abdomen and pelvis. (R. 405.) Claimant saw Dr. Abiona on May 1, 2013 and had continued complaints of shortness of breath, fatigue, and occasion left-sided chest pain. (R. 401.) He was instructed to follow up in four months. (R. 407.)

         On July 17, 2013, Claimant presented for a pulmonary follow-up visit with Dr. Macias and completed a ventilation scan with normal perfusion. (R. 392.) Dr. Macias noted that although Claimant was referred to pulmonary rehabilitation, he declined to continue with therapy. (Id.) She, again, stated that Claimant's symptoms were out of proportion to the physical findings and that he was not responding to any treatment. (R. 393.) Dr. Macias questioned whether Claimant had a component of ...

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