United States District Court, C.D. Illinois, Springfield Division
EDWIN L. GRIFFITH, Plaintiff,
NANCY BERRYHILL, Acting Commissioner of Social Security, Defendant.
SCHANZLE-HASKINS, U.S. MAGISTRATE JUDGE
Edwin L. Griffith appeals from the denial of his application
for Social Security Disability Insurance Benefits (DIB) under
Title II and Supplemental Security Income (SSI) under Title
XVI of the Social Security Act (collectively Disability
Benefits). 42 U.S.C. §§ 416(i), 423, 1381a and
1382c. This appeal is brought pursuant to 42 U.S.C.
§§ 405(g) and 1383(c). Griffith filed a Motion for
Summary Judgment (d/e 10). The Defendant Commissioner filed a
Motion for Summary Affirmance (d/e 24). The parties have
consented to proceed before this Court pursuant to 28 U.S.C.
§ 636(c). Joint Consent to the Exercise of
Jurisdiction by a United States Magistrate Judge (d/e
7); Transfer of Case for Reassignment to Magistrate
Judge entered June 22, 2018 (d/e 9); Text Order
entered February 5, 2019. For the reasons set
forth below, the Decision of the Commissioner is REVERSED and
was born June 7, 1967. He has a GED and previously worked as
a truck driver. He is five foot ten inches tall and weighs
approximately 240 pounds. The Plaintiff lives in Bath,
Illinois with his wife. He suffers from ischemic heart
disease, status post two heart attacks; degenerative disc
disease, status post two cervical spinal fusion surgeries;
obesity; and a sleep-related breathing disorder. Griffith
stopped working any substantial gainful employment after his
second heart attack on July 2, 2014. R. 16, 86, 88, 94.
March 8, 2014, Griffith went to a local hospital with chest
pain. An EKG showed an inferior ST elevation, which indicated
that he suffered a heart attack. He was transferred to Unit
Point Health Methodist Medical Center in Peoria, Illinois
(Methodist Hospital). Griffith underwent an emergency
procedure in which a stent was placed in his right coronary
artery. The artery was 80 percent blocked. The stent reduced
the blockage to 0 percent. Griffith also had “30%
distal left main and 75% proximal circumflex disease with
moderate diffuse disease. Otherwise [the left ventricle] wall
[was] normal with ejection fraction of 60%.” R. 446.
Griffith was discharged on March 10, 2014. His discharge
diagnosis was acute inferior wall myocardial infarction,
coronary artery disease, hypertension, and hyperlipidemia. He
was scheduled to undergo cardiac rehabilitation. R. 446.
Griffith reported prior to discharge that his chest pain was
gone, but he still had pain in his back, shoulder blade,
neck, shoulders, and both arms down to his fingertips. He
also reported numbness and tingling in both arms and hands.
The doctors at Methodist Hospital concluded that
Griffith's continuing pains were chronic and unrelated to
his heart attack. R. 446-47.
March 14, 2014, Griffith saw his primary care physician Dr.
Matthew McMillin for a follow-up after his hospitalization.
Griffith complained of continuing pain in his shoulders and
arms and tingling in his hands and fingers. R. 1177. On
examination, Griffith had full range of motion and 5/5
strength with normal gait, intact sensation, and intact
reflexes. R. 1179. Griffith was cleared to return to work. R.
April 21, 2014, Griffith underwent an exercise nuclear stress
test.The test did not show evidence of ischemia.
The test showed a “mild intensity, moderate size defect
in the basal and mid inferior wall, basal and mid
inferolateral wall present on both rest and stress with
normal regional wall motion consistent with bowl attenuation
artifact.” The test also showed “Normal left
ventricular systolic function with normal regional wall
motion . . . .” Griffith had an ejection fraction of
68%. R. 658. Griffith developed sinus tachycardia during the
test. R. 660.
6, 2014, Griffith went to Mason District Hospital in Mason
County, Illinois (Mason Hospital), with chest pains. He had
an abnormal EKG which indicated a possible inferior
infarction. He was transferred to Methodist Hospital. R. 476,
479, 978-80. The record submitted to the Social Security
Administration does not contain records from Methodist
Hospital of his hospitalization in July 6, 2014. On July 11,
2014, Griffith returned to the Mason Hospital with complaints
of a rash. The emergency room records from this visit state
that Griffith was transferred on July 6, 2014 for “CAD
and angioplasty with another stent, ” and was
thereafter discharged on July 8, 2014. R. 459.
15, 2014, Griffith saw Dr. McMillin. Dr. McMillin noted that
Griffith went back to work on May 15, 2014. Griffith reported
that early June 2014 Griffith went to the emergency room with
chest pain. He reported that he was sent to Methodist
Hospital and had a repeat heart catherization and stent
placement. R. 508, 1167. Griffith reported that the
cardiologist believed his heart was stable. The Plaintiff
reported moderate back pain. R. 1168. Dr. McMillin noted,
“[H]e certainly has ongoing degenerative changes to
spine - lumbar/cervical - he is unable to work and extremely
frustrated.” R. 508, 1167.
examination, Griffith was 5 foot 10 inches and weighed 278
pounds 6.4 ounces. Griffith had normal range of motion in his
neck and decreased range of motion tenderness, swelling, pain
and muscle spasms in his cervical spine. Griffith also had
radicular symptoms in both arms. R. 509-10, 1168-69. Dr.
McMillan assessed intervertebral cervical disc disorder with
myelopathy, cervical region; coronary atherosclerosis -
primary; generalized osteoarthritis; and peripheral
neuropathy. Dr. McMillan prescribed a Kenalog-40
corticosteroid injection, tramadol, and gabapentin for pain.
R. 509, 1169.
September 25, 2014, Griffith again saw Dr. McMillan. Griffith
reported persistent pain in his shoulders, arms, and back. He
said he could not sleep more than a couple of hours because
he became so stiff, he had to get up and move. Griffith
reported that increasing his Neurontin dosage did not help
with his pain. R. 512. On examination, Griffith was 5 feet 10
inches tall and weighed 283 pounds. Dr. McMillan noted that
Griffith had normal range of motion in his neck and decreased
range of motion, tenderness, swelling, pain, and spasms in
his cervical spine, with diffuse muscular discomfort
posterior to the cervical spine with radiculopathy. Griffith
had normal neurological findings with normal reflexes and
coordination. Dr. McMillan assessed thoracic or lumbosacral
neuritis or radiculitis; intervertebral cervical disc
disorder with myelopathy, cervical region; and generalized
osteoarthrosis. McMillan gave Griffith a Kenalog-40 injection
and renewed his other medications. R. 513-14.
November 6, 2014, Griffith prepared a Social Security
Administration Function Report-Adult form. Griffith's
wife, Betsy Griffith, completed the form for Griffith. R.
369. Griffith reported that his heart, pain, back, ulcers,
and hands limited his ability to work. R. 362. Griffith said
he had no problem performing his personal care. R. 363.
Griffith said he did not do any household chores or yard
work. He said he could not walk, stand, or sit for long
periods of time. Griffith said he did not drive because of
sciatica in his right leg and problems with his grip.
Griffith reported that he could only lift less than 10
pounds, could not squat, bend, reach, stand, walk, or sit. He
said he only climbed stairs if necessary. He reported that he
could pay attention continuously and had a fair ability to
follow instructions. R. 367. He said he did not handle stress
well. He said he was “on edge, moody.” R. 368.
November 20, 2014, state agency physician Dr. Ernst Bone,
M.D. prepared a Physical Residual Functional Capacity
Assessment. R. 121-23. Dr. Bone opined that Griffith could
lift and carry 20 pounds occasionally and 10 pounds
frequently; stand and/or walk six hours in an eight-hour
workday, sit for six hours in an eight-hour workday;
occasionally climb ramps, stairs, ladders, ropes, and
scaffolding; occasionally stoop and kneel; frequently
balance, crouch and crawl; and should avoid concentrated
exposure to hazards such as machinery or heights. R. 121-23.
December 12, 2014, Griffith completed a form entitled Pain
Questionnaire. Griffith stated that he started having
pain in 1988. He said that he had pain in his back, legs,
across his shoulders, both arms and hands, chest, and
stomach. He said the pain was constant. R. 387, 391. He said
he took tramadol, fentanyl, Norco, nitroglycerin, and
Neurontin for the pain. He said he has been taking the
medication for years. He said he had a dorsal nerve
stimulator implant put in his lower back for pain in 2007. He
said the medicine did not completely relieve his pain. He
indicated the medicine caused dizziness, drowsiness, and
could cause nausea. R. 387- 88, 391. Griffith stated that he
could walk for 15 feet, stand for 10 minutes, and sit for 15
minutes. He said that he did not do chores. R. 389.
4, 2015, state agency physician Dr. Janis Byrd, M.D. prepared
two Physical Residual Functional Assessments of Griffith, one
as of January 31, 2015, and one for September 9, 2014 to the
date of the assessment. R. 146-51. Dr. Byrd opined that as of
January 31, 2015, Griffith could lift and carry 20 pounds
occasionally and 10 pounds frequently; stand and/or walk six
hours in an eight-hour workday; sit six hours in an
eight-hour workday; occasionally climb ramps, stairs,
ladders, ropes, and scaffolding; occasionally stoop;
frequently balance, kneel, crouch, and crawl; and avoid
concentrated exposure to extreme cold and hazards such as
machinery or heights. R. 146-48. Byrd opined that Griffith
had the same functional limitations for the entire period
form September 9, 2014 to the date of her assessment. R.
15, 2015, Griffith saw Dr. McMillan for a follow-up visit.
Griffith reported intermittent chest discomfort. R. 1174. Dr.
McMillan assessed the same objective findings and diagnosis
as the September 14, 2014, examination. R. 1174. Dr. McMillan
continued Griffith's prescriptions for tramadol and
fentanyl patch. R. 1175-76.
August 4, 2015, Griffith had an echocardiogram of his heart
taken. The test showed normal size and function for both
ventricles, with no sign of left ventricular hypertrophy. The
left ventricle ejection fraction was 60-65 percent. R.
January 7, 2016, Griffith saw Dr. Katherine Fitzgerald, M.D.,
to establish care. Griffith reported that he lost 70 pounds
in the last seven months without trying. He reported that he
had no appetite. He reported trouble sleeping. He said he had
sleep apnea but had stopped using his Continuous Positive
Airway Pressure (CPAP) machine. On examination, Griffith
weighed 235 pounds. The examination of Griffith's neck,
heart, chest, abdomen, and extremities was normal. His
neurological exam was normal. R. 2155. Dr. Fitzgerald
assessed anxiety, coronary artery disease of native heart
with stable angina pectoris, hypertension, and weight loss.
Dr. Fitzgerald stopped Griffith's prescriptions for
Effexor and Ativan. R. 2156.
January 25, 2016, Griffith had a CT angiography of his
abdominal aorta, pelvic arteries and bilateral lower
extremities. R. 1565-66. The tests showed no vascular
etiology to explain Griffith's complaints of lower
extremity pain. R. 1566.
2, 2016, Griffith saw Dr. Keattiyoat Wattanakit, M.D., for a
cardiological follow-up examination. Griffith reported that
he had sleep apnea but stopped using his CPAP machine. On
examination, Griffith's heart rate and rhythm were
normal, with no murmur or gallop. R. 1612. R. 1613. Dr.
Wattanakit assessed essential hypertension,
hypercholesterolemia, coronary artery disease involving
native coronary artery of native heart without angina
pectoris, sleep apnea but stopped using CPAP machine, chronic
fatigue probably related to the untreated sleep apnea,
obesity, and chronic pain syndrome. R. 1606, 1613. Dr.
Wattanakit stated that the current medical regimen was
effective and to continue his pain medications. Dr.
Wattanakit prescribed pravastatin and stated that he would
start a beta blocker when Griffith resumed using his CPAP
machine. R. 1613.
3, 2016, Griffith had a sleep study performed. R. 2064-71.
The study results showed no significant sleep related
disorders. The study indicated that Griffith's daytime
sleepiness was ...