United States District Court, N.D. Illinois, Eastern Division
JONDA R. HILL, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER 
I. SCHENKIER MAGISTRATE JUDGE
Jonda R. Hill ("Mr. Hill"), has filed a motion for
summary judgment seeking reversal or remand of the final
decision of the Acting Commissioner of Social Security
("Commissioner") denying Mr. Hill's application
for Disability Insurance Benefits ("DIB") and
Supplemental Security Income Benefits ("SSI") (doc.
#11: Opening Brief ("PL's Mem.")). The
Commissioner filed a response seeking affirmance of the
decision denying benefits (doc. #18: Def.'s Mot. for
Summary J.; doc. # 19: Def.'s Mem. in Support of the
Commissioner's Decision ("Defi's Mem.")).
Mr. Hill also filed a reply (doc. # 20: PL's Reply to
Def.'s Mem. in Support of the Commissioner's Decision
("PL's Reply")). For the following reasons, we
grant Mr. Hill's motion for summary judgment and deny the
Commissioner's motion to affirm.
Hill applied for DIB and SSI benefits on June 13, 2013,
alleging he became disabled on February 8, 2013 (R. 19,
82-83, 89) due to sarcoidosis (growth of inflammatory cells
in different body parts - most commonly lungs) and a heart
condition ("walls too thick") (R. 82). His date
last insured was March 31, 2016 (R. 82). Mr. Hill's
claims were denied initially on October 9, 2013, and upon
reconsideration on May 27, 2014 (R. 19, 87, 94, 106, 118).
Upon timely request, a hearing was held before an
Administrative Law Judge ("ALJ") on February 1,
2016 (R. 19, 37). The ALJ issued a decision on March 31,
2016, finding that Mr. Hill was not disabled (R. 16-36). The
Appeals Council then denied Mr. Hill's request for
review, making the ALJ's ruling the final decision of the
Commissioner (R. 1-6). See 20 C.F.R. §§
404.981, 416.1481; Loveless v. Colvin, 810 F.3d 502,
506 (7th Cir. 2016).
Hill was born on October 7, 1961, and was 51 years old at his
onset date (R. 82). On February 8, 2013, Mr. Hill was
admitted to Stroger Hospital complaining of shortness of
breath and chest pain (R. 902). While in the hospital, he was
examined by pulmonologist, Patricia Macias, M.D., who found
his symptoms consistent with sarcoidosis (R. 949). He was in
fact diagnosed with granulomatous lung disease after a
bronchoscopy performed found granulomas suggestive of
sarcoidosis, and he was started on prednisone (medication
providing relief for inflamed areas of the body) (R. 902).
Mr. Hill also reported left hand numbness/paresthesias and
was evaluated for a left axillary mass (R. 902, 914). On
February 14, 2013, he was discharged from the hospital with
instructions to follow up with various doctors (R. 902).
27, 2013, Mr. Hill underwent surgery to remove the left
axillary mass (R. 382-385). The following day during a
cardiology consult, Mr. Hill reported to the doctor a
"decreased exercise tolerance" and only being able
to walk a block and a half before experiencing difficulty
breathing (R. 347). On July 3, 2013, at a follow-up
appointment with his pulmonologist, Dr. Macias, he was
diagnosed with sarcoidosis and complained of difficulty
breathing (R. 426-27). On July 29, Mr. Hill attended his
physical therapy evaluation wherein he reported pain lifting
his arm but also noted diminished swelling in his left arm
(R. 435). The report noted a "precaution" of a
five-pound lifting restriction by Mr. Hill's surgeon,
Stefan Szczerba, M.D., but also stated that "upgrades
should be clarified with Dr. Marcus" who assisted Dr.
Szczerba with the surgery to remove the left axillary mass
(Id.). On August 1, the precautions were lifted (R.
October 2, 2013, Mr. Hill was seen by Dr. Macias and reported
his symptoms were getting worse, his shortness of breath did
not improve, he felt more fatigued, and he had more headaches
on his right side and memory loss (R. 555). Dr. Macias
remarked that Mr. Hill's lungs were clear to auscultation
and he had a normal range of motion, no swelling or deformity
and a normal gait (R. 557). She continued him on the same
medications but added Flonase and cetirizine for headaches
(R. 558). Later in October, Mr. Hill saw his primary care
physician, Titilayo Abiona, M.D., who noted that Mr. Hill had
mild shortness of breath but also that he "smokes
cigarettes" (R. 588). Upon examination, Mr. Hill's
lungs were clear to auscultation and movements of his left
shoulder improved (R. 591).
October 3, 2013, a medical consultant for the Disability
Determination services opined based on the record that Mr.
Hill could occasional lift or carry 20 pounds and frequently
lift or carry 10 pounds, stand or walk six hours in a work
day, sit six hours in a work day and perform unlimited
pushing or pulling within the weight limitations (R. 85, 92).
The consultant opined that Mr. Hill had the RFC to perform
his past relevant work as a banquet manager (R. 87, 94).
Macias, Mr. Hill's pulmonologist, filled out a
Sarcoidosis Residual Functional Capacity Questionnaire on
November 6, 2013 and listed the frequency and length of
contact as two months; however, the records indicate Dr.
Macias had been treating Mr. Hill for nine months at that
time (R. 445-47, 949). She diagnosed Mr. Hill with
sarcoidosis and identified his symptoms as shortness of
breath, chest tightness, fatigue and coughing (R. 445). Dr.
Macias opined that Mr. Hill could tolerate moderate work
stress and described his prognosis as "fair"
(Id.). Dr. Macias noted that Mr. Hill could sit for
more than two hours at a time before needing to get up, that
he could stand for two hours at one time and that in an
8-hour work day he could stand or walk for two hours but
could sit for eight hours (R. 446). Dr. Macias also indicated
that Mr. Hill would need to take unscheduled breaks four
times in an eight-hour day (every two hours) for 10 minutes
to sit quietly (Id.) She opined that Mr. Hill could
frequently lift and carry 10 pounds, rarely 20 pounds and
never 50 pounds (Id.). Further, Mr. Hill could
rarely stoop, crouch/squat or climb ladders, occasionally
climb stairs and frequently twist (Id.). Finally,
Dr. Macias opined that Mr. Hill's impairments would cause
good and bad days and that on average he would be absent
about four days per month from work as a result of his
impairments (R. 447).
Hill saw Dr. Macias again on February 5, 2014 and reported
pain and numbness in his hands and feet, and headaches with
visual changes (R. 573). Mr. Hill's lungs continued to be
clear to auscultation, and his range of motion was normal
with no swelling or deformity (R. 575). Dr. Macias reported
that from a pulmonary view point, Mr. Hill was stable and was
to continue with the same medications (R. 578). Mr. Hill also
reported numbness in his hands and feet to Dr. Abiona on
February 14, 2014, and some pain at the sight of the surgical
incision (R. 568). In addition to other medications to manage
his sarcoidosis, Mr. Hill was prescribed gabapentin for pain
and referred for a rheumatology consultation (R. 571).
February 25, 2014, Mr. Hill was examined by rheumatologist,
Indira S. Hadley, M.D. Mr. Hill reported pain with sitting
and walking, pain in his feet, and tingling in his right leg
and right lateral foot with a "pins and needles
sensation" (R. 661-62). Dr. Hadley continued the
gabapentin prescription and noted a decreased pinprick
sensation over right lateral foot and left midfoot (R. 664,
666). In Dr. Hadley's March 21, 2014 report, it was noted
Mr. Hill's MRI of the brain was negative for sarcoidosis
Hill next underwent a needle electromyography
("EMG") of the lower and upper limbs on May 13,
2014 with Simon Zimnowodzki, M.D. (R. 991-92). The upper
limbs test showed right and left chronic C7 denervation and
radiculopathy (R. 992). On June 9, 2014, a cervical spine
x-ray was performed on Mr. Hill with "mild
osteoarthritis seen, between C4 and C5, C5-C6, C6-C7 with
intervertebral disc space narrowing and spur formation"
(R. 996). The x-ray also showed a "mild nan-owing of
intervertebral foramen seen from C4-C7" (Id.).
Also on June 9, Mr. Hill was examined by Dr. Abiona and he
again complained of numbness in his hands and feet and
headaches (R. 998). In that report, an EMG showed possible
radiculopathy and an MRI of Mr. Hill's brain showed
nonspecific gliosis but was otherwise unremarkable (R.
September 22, 2014, Mr. Hill was seen by a pulmonologist,
Richard Lenhardt, M.D., and reported respiratory symptoms
"when lying flat" (R. 1018). Dr. Lenhardt examined
Mr. Hill and opined that Mr. Hill's sarcoidosis of the
lungs had "improved markedly since last year" (R.
1020). Soon thereafter, Mr. Hill visited Dr. Abiona on
October 3, 2014, who noted that the MRI of Mr. Hill's
spine showed cervical spondylosis and multilevel degenerative
disc disease (R. 744, 1022, 1027-28).
October 6, 2014, Mr. Hill presented to neurologist, Michael
A. Kelly, M.D., with neuropathy (nerve damage) and
complaining of headaches (R. 1030). Dr. Kelly's
impressions were that Mr. Hill had headaches with a normal
neurology examination and normal MRI to his head (R. 1035).
Dr. Kelly opined that the headaches may be cervicogenic given
the degenerative disc disease that was seen on Mr. Hill's
cervical MRI (Id.). Transformed (increase in
frequency) migraine was noted as a possibility but was not
expected to be daily (Id.) Dr. Kelly's suggested
treatment was lifestyle changes such as sufficient sleep,
regular meals and stress reduction and he also prescribed
amitriptyline (antidepressant and pain management) for
headaches and the numbness in Mr. Hill's hands and feet
reconsideration on May 23, 2014, the medical consultant added
limitations to the RFC after reviewing Dr. Macias'
November 2013 "Sarcoidosis Residual Capacity
Questionnaire" (R. 101, 113). The consultant gave Dr.
Macias' opinion "great weight" but not
"controlling weight" because the limitations were
not totally supported by the evidence in the file (R. 102,
114). The medical consultant opined that Mr. Hill could
occasionally lift or carry 20 pounds and frequently lift or
carry 10 pounds; he could stand or walk six hours in a
workday; sit six hours in a workday; was limited in the left
upper extremity in pushing and pulling; could occasionally
climb ramps, stairs, ladders, ropes and scaffolds; was
unlimited in balancing and stooping; and could frequently
kneel, crouch and crawl (R. 103, 115). Additionally, Mr. Hill
was limited in reaching in front, laterally or overhead on
his left extremity but was unlimited in handling, fingering
and feeling (R. 104, 116). Mr. Hill also had environmental
limitations due to his sarcoidosis (Id.). The
consultant opined that Mr. Hill's past relevant work was
"expedited, " however; he could sustain a
"light" work capability (R. 106, 118).
January 5, 2015 physical, Mr. Hill denied headaches,
psychiatric disease or a history of depression (R. 762). He
also denied shortness of breath and numbness and tingling (R.
763). Chest x-rays on January 27, 2015 showed "some
slight prominence of the hilar structures and mild
interstitial changes in the upper lobes consistent with old
sarcoid" but no acute infiltrates (substance denser than
air) (R. 792). Also in January, Mr. Hill reported at a
pulmonary visit that he was breathing well and had no recent
emergency room visits (R. 846). In a pulmonary function
report dated May 28, 2015, the testing showed borderline
restrictive ventilatory defect (reduction in total lung
capacity) but normal diffusion capacity (transport of gas
into and out of the blood) (R. 803).
rheumatology appointment with Dr. Hadley on February 17,
2015, Mr. Hill complained of pain in his hands and forearm
and had intermittent left hand swelling for a month (R. 861).
Mr. Hill also stated there was "improvement in
neuropathy symptoms in hands and foot" (Id.).
Furthermore, he had no shortness of breath but did have joint
pain (R. 862). Upon examination, Mr. Hill's lungs were
clear to auscultation and he had a normal range of motion,
normal strength and no tenderness; however, he was positive
for soft tissue swelling of his left hand and forearm that
was "pitting in nature" (pressure-induced
indentation) (R. 864). Mr. Hill had full range of motion of
his shoulders, elbows, wrists and knees but was tender in 18
out of 18 fibromyalgia points (Id.).
Hill underwent a lumbar spine MR1 on June 28, 2015, which
showed "multilevel degenerative disc disease and
degenerative facet arthropathy" (R. 793-94). In Dr.
Hadley's June 30, 2015 report, she noted that the MRI
showed "L4-L5 disc bulge and ? [sic] nerve compression
of L5" (R. 1067). Dr. Hadley noted that Mr. Hill was
seen in the pain clinic for an upcoming epidural injection
(R. 1067). Dr. Hadley increased his gabapentin dose to ease
Mr. Hill's pain, and he was issued a lumbar corsette (R.
October 22, 2015, x-rays of Mr. Hill's left shoulder
showed "no acute changes" and no significant
osteoarthritis (R. 1073). In December 2015, Mr. Hill reported
worsening of his breathing with increased walking and the
winter weather (R. 1119). Mr. Hill's lungs were clear to
auscultation and his respirations were non-labored at a
January 12, 2016 examination (R. 1126). Mr. Hill had body