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Hall v. Berryhill

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

February 6, 2018

JOSEPH HALL, Plaintiff,
NANCY BERRYHILL, Acting Commissioner of Social Security, Defendant.


          Michael T. Mason, United States Magistrate Judge:

         Claimant Joseph Hall (“Claimant”) seeks judicial review of a final decision of Defendant, the Commissioner of the Social Security Administration (“SSA”), denying his claim for Social Security Disability Insurance Benefits (“DIB”). The Commissioner has filed a cross-motion for summary judgment, asking that this Court uphold the decision of the Administrative Law Judge (“ALJ”). For the reasons set forth below, Claimant's request for summary judgment is granted [15] and the Commissioner's request for summary judgment [19] is denied.

         I. Background

         A. Procedural History

         On February 4, 2013, Claimant (then 65 years old) filed a Title II DIB application, alleging a disability onset date of June 26, 2012, due to a subarachnoid hemorrhage, stroke, headaches, fatigue, and dizziness. (R. 100.) Claimant's date last insured was March 31, 2013. (Id.) His application for benefits was denied initially on May 7, 2013 and again upon reconsideration on September 11, 2013. (R. 99-121.) An administrative hearing was held before an ALJ on November 14, 2014. (R. 32-98.) Claimant appeared along with his attorney. A vocational expert and medical expert were also present and offered testimony.

         On January 6, 2015, the ALJ issued a written decision denying Claimant's application for benefits. (R. 18-27.) Claimant then requested review by the Appeals Council. (R. 14.) On June 2, 2016, the Appeals Council denied his request for review, at which time the ALJ's decision became the final decision of the Commissioner. (R. 1-6); Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). This action followed.

         B. Medical History

         1. Treating Physicians

         On June 26, 2012, after complaining of a headache the day before, Claimant was found unconscious by his wife. (R. 359.) He was taken to the ER and eventually transported to the University of Illinois Hospital where it was determined that he suffered a subarachnoid hemorrhage of the brain of unknown origin, and hydrocephalus. (R. 424, 430.) Claimant was treated with Keppra for seizure prevention, and an external ventricular drain was placed for treatment of hydrocephalus. (R. 430.) While at the hospital, Claimant complained of increased headaches and confusion. (R. 397-98.) Claimant was discharged after about two weeks in the hospital and advised to follow-up with his primary care provider, Dr. Gerald Frank. (Id.) It was also recommended that Claimant undergo outpatient cognitive rehabilitation to address his mild to moderate cognitive impairments. (R. 451.)

         Shortly after his discharge, Claimant began speech therapy to address cognitive issues, such as short term memory, attention, executive functioning, and visuospatial skills. (R. 322.) At some sessions he reported problems with memory and headaches, while at other times he was “doing well” or had “no complaints.” (R. 330, 337, 339, 341, 357.) He was discharged from speech therapy in October 2012 after demonstrating significant improvement. (R. 322.) At that time, he was able to drive, but his return to work date had been extended due to the need for additional physical therapy to improve endurance. (Id.)

         Claimant also followed up with his primary care physician Dr. Frank about once a month from July 2012 through December 2012. (R. 310-18.) At each visit, Claimant complained of headaches, and at times he complained of fatigue and dizziness. (Id.) As of December 2012, Dr. Frank completed paperwork indicating that Claimant could not yet return to work due to his headaches, dizziness, and fatigue. (R. 321.)

         During the same time frame, Claimant was being treated by neurosurgeon Dr. Jonathon Citow. On September 28, 2012, Claimant complained of fatigue, mild headaches, and slow ambulation. (R. 299.) A physical exam was normal. (Id.) In contrast to Dr. Frank's opinion around this time, Dr. Citow indicated that Claimant could return to full duty work. (Id.) Dr. Citow did recommend physical therapy for gait training and prescribed Celebrex in place of Vicodin. (Id.) At that time, Claimant was also taking medication for high blood pressure and cholesterol, as well as anti-seizure medication. (Id.)

         Claimant returned to see Dr. Citow in November 2012 and reported improvement with physical therapy, but stated that further therapy was recommended. (R. 301.) He had discontinued Celebrex due to dizziness, which had since improved. (Id.) A physical exam showed a full range of motion and was otherwise normal. (Id.) In addition to headaches, Dr. Citow assessed lumbar spondylosis. (Id.) He also recommended further physical therapy. (Id.) Claimant had been discharged from physical therapy by January 2013 and reported no significant back pain. (R. 303.) His dizziness continued to improve. (Id.) A physical exam was normal and Dr. Citow advised that Claimant could continue full activities. (Id.)

         Claimant continued to see Dr. Frank throughout 2013 and 2014. (R. 311, 519-21, 529-40.) He consistently complained of headaches, fatigue, lightheadedness, and difficulties sleeping. (Id.) In July 2013, Dr. Frank referred Claimant to neurologist, Dr. Reuben Weisz. (R. 522.) Claimant told Dr. Weisz he had suffered intermittent, but daily headaches since his brain hemorrhage, which made him feel like his “head will explode.” (R. 523.) Tramadol and Ibuprofen had helped to ease his headaches. (R. 524.) Claimant said that his memory and ability to concentrate had suffered. (R. 523-24.) Upon physical examination Claimant exhibited a shuffling gait, and normal, but slow motor abilities. (R. 524.) A mental exam was within normal limits, except for “slowing.” (Id.) Dr. Weisz assessed chronic daily headaches, possible amyloid angiopathy, and possible cervical spondylosis with cervicogenic headaches. (R. 525.) The MRIs ordered by Dr. Weisz showed small vessel disease and mild to moderate degenerative disc disease of the cervical spine. (R. 511-12.) An EEG was normal. (R. 513.)

         At a follow-up in August 2013, Claimant reported that Tramadol and Ibuprofren continued to help with his headache pain. (R. 526.) The results of a physical and mental status examination remained unchanged from the previous visit. (Id.) Dr. Weisz assessed “mixed-type headaches, chronic daily, but predominantly muscle tension with cervicogenic component.” (Id.) Claimant was to continue with medication. (Id.)

         Claimant was doing better until October 2013, when his headaches worsened. (R. 559.) Dr. Weisz prescribed Fioricet, which had to be increased a few months later when his daily headaches continued. (R. 559-60.) At that time, Dr. Weisz noted limited range of motion of the cervical spine. (R. 560.) As of March 2014, Claimant still suffered daily headaches. (R. 561.) His medication dosage was increased again and in June 2014, he reported that his headaches had greatly subsided. (R. 561-62.) He was also diagnosed with obstructive sleep ...

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