United States District Court, N.D. Illinois, Eastern Division
JEFFREY P. DAVIS Plaintiff,
NANCY A BERRYHILL, Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER
Michael T. Mason, United States Magistrate Judge
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  is granted and the Commissioner's
cross-motion for summary judgment  is denied.
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
Dr. Ngu, Internal Medicine
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.)
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.
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.)
Aunt Martha's Health Center
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.)
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.)
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.
Dr. Sompalli Chandrasekh, Orthopedic Specialist
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.)
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.)