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Griffith v. Berryhill

United States District Court, C.D. Illinois, Springfield Division

July 22, 2019

NANCY BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff 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 REMANDED.


         Griffith 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.

         On 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.

         On 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. 1178.

         On April 21, 2014, Griffith underwent an exercise nuclear stress test.[1]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.

         On July 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.

         On July 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.

         On 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.

         On 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.

         On 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.

         On 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.

         On December 12, 2014, Griffith completed a form entitled Pain Questionnaire.[2] 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.

         On May 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. 149-51.

         On May 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.

         On 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. 1428-29.

         On 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.

         On 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.

         On May 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.

         On May 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 ...

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