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Davis v. Berryhill

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

October 23, 2017

NANCY A BERRYHILL, Acting Commissioner of Social Security, Defendant.


          Michael T. Mason, United States Magistrate Judge

         Claimant Jeffrey Davis ("Claimant") brings this motion for summary judgment seeking judicial review of the final decision of the Acting Commissioner of Social Security ("Commissioner"). The Commissioner denied Claimant's claim for disability insurance benefits under Section 1614(a)(3)(A) of the Social Security Act (the "Act"). 42 U.S.C. § 1383(c). The Commissioner filed a cross-motion for summary judgment, requesting 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). For the reasons set forth below, Claimant's motion for summary judgment [18] is granted and the Commissioner's cross-motion for summary judgment [22] is denied.

         I. BACKGROUND

         A. Procedural History

         Claimant filed an application for a period of disability and supplemental security income on August 26, 2012. (R. 15.) Claimant alleges that he become disabled on May 1, 2010, but later amended the onset date to September 4, 2012 due to degenerative joint disease and obesity. (R. 15, 335.) His application was initially denied on October 23, 2012, and again on March 15, 2013, after a timely request for reconsideration. (R. 15.) On April 26, 2013, Claimant filed his request for a hearing. (Id.) On January 14, 2015, he testified before the ALJ Karen Sayon. (R. 24.) On March 16, 2015, the ALJ issued a decision denying Claimant's application for supplemental security income. (R. 15-24.) On May 19, 2015, Claimant requested review by the Appeals Council. (R. 335.) On June 15, 2016, the Appeals Council denied Claimant's request for review, at which time the ALJ's decision became the final decision of the Commissioner. (R. 4.); Zurawski v. Halter, 245 F.3d. 881, 883 (7th Cir. 2001); 20 C.F.R. § 404.955, 404.981. Claimant subsequently filed this action in the District Court.

         B. Medical Evidence

         1. Dr. Ngu, Internal Medicine

         On April 8, 2011, Dr. Lawrence Ngu saw Claimant for the first time. (R. 380.) At this appointment, Dr. Ngu completed Claimant's annual exam. (R. 349.) During this exam, Claimant stated his symptoms included joint pain, joint stiffness, and joint swelling. (Id.) Claimant did not complain about muscle cramps, joint redness, or joint warmth. (Id.) Dr. Ngu's physical exam of Claimant found his musculoskeletal to have a “normal range of motion, normal strength, no tenderness, no swelling, and normal gait.” (R. 350.) After his examination, Dr. Ngu diagnosed Claimant with “probable degenerative joint disease / osteoarthrosis.” (R. 350.)

         Claimant again saw Dr. Ngu on June 1, 2011 for a follow-up appointment. (R. 347.) At this meeting, Dr. Ngu's treatment notes described Claimant as stable and reported no new complaints. (R.347-48.) Dr. Ngu reported that Claimant had a normal range of motion, normal strength, no tenderness, and no swelling. (R. 379.) On January 17, 2012, Claimant attended a follow-up appointment with Dr. Ngu and reported no new complaints, but stated he was still experiencing pain. (R. 375.)

         On February 11, 2013, Claimant again visited Dr. Ngu. (R.360.) During this visit, Dr. Ngu increased Claimant's Tramadol prescription for pain and removed Claimant's previous prescription for Ibuprofen 800. (R. 361.) Dr. Ngu also informed Claimant to continue to take his Ranitidine as prescribed. (Id.) Dr. Ngu's report noted that Claimant was not in pain at the time. (R. 368.) Also at this appointment, Dr. Ngu completed a residual functional capacity (“RFC”) questionnaire on behalf of the Claimant. (R. 382.) On the questionnaire, Dr. Ngu stated he had seen Claimant every three to six months for the last year and that he diagnosed Claimant with osteoarthritis. (Id.) Dr. Ngu noted that Claimant's symptoms “frequently” interfered with his attention and the concentration required to perform simple work-related tasks. (Id.) Dr. Ngu also stated Claimant could walk two city blocks without rest or significant pain. (Id.) Dr. Ngu noted Claimant can use his hands, fingers, and arms twenty-five percent of the time during an eight-hour work day. (R. 383.) On May 7, 2013, Claimant attended a follow-up appointment with Dr. Ngu to have his medications renewed. (R. 365.)

         2. Aunt Martha's Health Center

         In 2013, Claimant began seeing Dr. Anna Pacis at Aunt Martha's Health Center (“Aunt Martha's.”). (R. 452.) On September 17, 2013, Claimant attended an appointment at Aunt Martha's to obtain a “functional capacity evaluation” so he could apply for disability. (R. 386, 400.) These appointment notes described Claimant's pain as zero. (R. 401.) On October 21, 2013, Claimant again sought treatment for pain at Aunt Martha's. (R. 396.) Later, in 2014, a physician at Aunt Martha's prescribed Claimant a cane. (R. 419.)

         A May 2014 x-ray of Claimant's knee found: “Bilateral knees appear relatively symmetric. The medial and lateral compartment joint space intact. No significant degenerative changes.” (R. 426.) An Aunt Martha's visit report from May 4, 2014, noted Claimant's pain as a three on a scale of ten. (R. 430.) A report dated May 27, 2014 described Claimant's pain as a five on a scale of ten. (R. 432.)

         In July of 2014, Claimant began physical therapy. (R. 420.) At Claimant's first appointment, he informed physical therapist Amber Kline that “he bikes daily.” (R. 479.) Claimant also told her that his pain rated as an eight on a scale of ten, he does not drive, and he was not working. (Id.) Ms. Kline's report noted that Claimant displayed impaired gait and the ability to ascend-descend steps. (R. 480.) Ms. Kline's report also stated that he would benefit from physical therapy twice a week for six weeks “to improve gross function and mobility and to decrease risk of fall due to knee instability…” (Id.) In addition, on July 19, 2014, Claimant reported his pain as a four on a scale of ten. (R. 437.) On January 7, 2015, Claimant went to Aunt Martha's complaining of ongoing knee pain at a five on a scale of ten. (R. 452.)

         3. Dr. Sompalli Chandrasekh, Orthopedic Specialist

         In October of 2014, Claimant began seeing orthopedic surgeon, Dr. Sompalli Chandrasekh, at St. Anthony's Hospital for his chronic knee pain. (439, 452.) At his October 10, 2017 appointment, Dr. Chandrasekh diagnosed Claimant with “osteoarthrosis local prim lower leg: 715.16 B/L knee.” (R. 440.) To treat Claimant's pain, Dr. Chandrasekh gave Claimant a Lidocaine injection in his right knee, advised that he should have his knees x-rayed, and scheduled him for a reevaluation the following week. (Id.) Claimant's x-ray results revealed that the bones and joints in his left and right knees were normal. (R. 442-43.) Both Claimant's left and right knees were “unremarkable.” (Id.) At Claimant's follow-up appointment, on October 17, 2014, Claimant reported the Lidocaine injection “helped him significantly with the pain.” (R. 445.) During this appointment, Claimant described the pain in his left knee as an eight on a scale of ten and worse with movement. (Id.) To assist with the pain, Dr. Chandrasekh gave Claimant another Lidocaine injection in his left knee. (R. 446.)

         On January 16, 2015, Dr. Chandrasekh provided his medical opinion regarding Claimant's physical capacity for work. (R. 478.) Dr. Chandrasekh stated Claimant could not lift and carry ten pounds for up to two-thirds of an eight-hour work day. (Id.) Dr. Chandrasekh wrote Claimant could not lift or carry heavier items because of his “severe...arthritis…” (Id.) Dr. Chandrasekh also noted Claimant could stand or walk for thirty to forty-five minutes without a break. (Id.) If Claimant was permitted to take breaks, Dr. Chandrasekh stated he could work for two hours in an eight-hour work day due to severe right and left arthritis. (Id.)

         4. ...

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