Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Dean v. Berryhill

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

July 27, 2018

DELORIS DEAN, Claimant,
v.
NANCY A. BERRYHILL, Acting Commissioner of the U.S. Social Security Administration, Defendant.

          MEMORANDUM OPINION AND ORDER

          HONORABLE MICHAEL T. MASON UNITED STATES MAGISTRATE JUDGE

         Plaintiff Deloris Dean (“Claimant”) filed a motion for summary judgment seeking reversal of the final decision of the Commissioner of Social Security (“Commissioner”), denying her claim for disability benefits. The Commissioner has filed a cross-motion asking the Court to uphold the decision of the Administrative Law Judge (“ALJ”). For the reasons set forth below, Claimant's motion for summary judgment (Dkt. 17) is granted and the Commissioner's motion for summary judgment (Dkt. 21) is denied.

         I. Background

         A. Procedural History

         Claimant filed her applications for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) on November 5, 2012 due to two strokes, obstructive sleep apnea, diabetes and hypertension. (R. 231.) Claimant's applications were denied initially and on reconsideration. (R. 134, 145.) Claimant requested a hearing before an ALJ, which was held on December 17, 2014. (R. 35-83.) On April 13, 2015, the ALJ issued a written decision finding that Claimant was not disabled. (R. 17-34.) On July 26, 2016, Claimant's request for review by the Appeals Council was denied, making the ALJ's decision the final decision of the Commissioner. (R. 1-6.) This action followed.

         B. Relevant Medical Evidence

         1. Treating Physicians

         Evidence before the ALJ dates back to October of 2012. (R. 384.) Claimant claims she suffered a stroke in 2012. (R. 54.) A discharge report from St. James Hospital shows that she was admitted with complaints of right arm and facial weakness and numbness, and she was diagnosed with a transient ischemic attack with a rule out of cerebrovascular accident. (R. 392.) She was also diagnosed with diabetes mellitus, dyslipidemia, a urinary tract infection, an anxiety disorder, and substance abuse. (Id.)

         There are no treatment notes, doctor visits, or hospital visits in the record between October of 2012 and November of 2013 that relate to Claimant's ambulatory limitations. Claimant underwent a physical therapy assessment with Dr. John Williams, PT, in November of 2013. Claimant was recommended skilled physical therapy to address deficits in balance, gait, and endurance during this assessment. (R. 541.) She presented to the assessment with pain, and she demonstrated reduced balance, gait deficits, significant muscle weakness, decreased range of motion and flexibility, and reduced endurance. (Id.) Dr. Williams gave Claimant a short term goal of an ability to ambulate 300 feet with a rolling walker and noted that Claimant had a mild/moderate left antalgic gait pattern while using her walker, and that without her assistive device, she had an increased hip sway while ambulating. (R. 543.) Physical therapy reports from January of 2014 show that Claimant was using her cane. (R. 843.)

         2. Agency Physicians

         In March of 2013, Claimant underwent a consultative examination for the Bureau of Disability Determination Services with Dr. Albert Osei. (R. 488.) During that exam, the adjudicator noted that Claimant had mild difficulties getting on and off the exam table and mild difficulties getting up from the sitting position. (R. 491.) Dr. Osei also noted that Claimant could walk greater than 50 feet both with using a walker and without the walker; however, without the walker, she had mild dragging of her left foot and less swinging of her left arm. (R. 429.) She was able to perform toe, heel and tandem walk with marked unsteadiness and could squat with holding, but she was unable to hop on either leg. (Id.) This information was reviewed by physician Vidya Madala, M.D., also in March of 2013. Dr. Madala noted that Claimant walked with a walker, but that she was capable of walking with mild difficulties without any assistive device. (R. 91.) Dr. Madala asserted that Claimant was unable to walk for long without pain and needed the use of a walker or a cane. (R. 92.)

         In November of 2013, Claimant attended an internal medicine consultative examination for the Bureau of Disability Determination Services with Dr. Charles Carlton. (R. 516.) At this exam, Claimant stated she suffered another stroke in August of 2013. (R. 517.) There are no records from the hospital from the time period in which the stroke allegedly occurred. While at the hospital, Claimant reports to have received physical therapy, but that she was experiencing balance problems and was given a prescription for additional physical therapy on an outpatient basis. (Id.) Claimant also claims that she was prescribed a walker during her hospitalization for the stroke in August of 2013 to help with balance. (Id.) Dr. Carlton once again noted that Claimant was able to walk greater than 50 feet without an assistive device, but that she displayed some unsteadiness on her feet while attempting to toe walk, heel walk, squat, and tandem walk. (R. 518.) He also noted a mild degree of difficulty in performance without the use of an assistive device. (R. 521.) The reviewing physician on consideration, Dr. Julio Pardo, M.D., opined in January of 2014 that Claimant needs a walker or cane, noting mild difficulties in walking when not using any assistive device. (R. 112.)

         C. Claimant's Testimony

         Claimant appeared at the hearing represented by her attorney and offered the following testimony. At the time of the hearing, Claimant was 54 years old and living with her sister, mother, and father. (R. 53, 63.) Claimant began using a walker after her stroke in 2012. (R. 71.) After her stroke in 2013, she again was using a walker and a cane. (R. 46.) She started using the cane while in physical therapy, and she was told at the hospital to use the cane to avoid falls. (R. 71.) She stated that she uses the cane because she has trouble with balance and is a fall risk, so the cane helps her to get around. (R. 51.) Claimant also indicated that she has fallen down the stairs due to her struggle with balance. (R. 58.) She stated that she cannot walk long distances, so she uses a ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.