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Hill v. Berryhill

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

May 24, 2018

JONDA R. HILL, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security,[1] Defendant.

          MEMORANDUM OPINION AND ORDER [2]

          SIDNEY I. SCHENKIER MAGISTRATE JUDGE

         Plaintiff, 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.

         I.

         Mr. 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).

         II.

         A.

         Mr. 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).

         On June 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. 439).

         On 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).

         On 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).

         Dr. 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).

         Mr. 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).

         On 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 (R. 666-67).

         Mr. 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. 1002-03).

         On 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).

         On 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 (Id.).

         On 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).

         At a 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).

         At a 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.).

         Mr. 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. 1013, 1067).

         On 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 ...


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