United States District Court, N.D. Illinois, Eastern Division
DELVARNOIS B. Plaintiff,
ANDREW SAUL, Commissioner of Social Security, Defendant
MEMORANDUM OPINION AND ORDER 
I. SCHENKIER United States Magistrate Judge.
Delvarnois B., moves for summary judgment seeking reversal
and remand of the final decision of defendant, the
Commissioner of Social Security ("Commissioner"),
denying his applications for disability insurance benefits
("DIB") and supplemental security income
("SSI") (doc. # 19; doc. # 20: Pl's Summ. J.
Mem.). The Commissioner has filed a cross motion for summary
judgment asking us to affirm his decision (doc. # 29; doc. #
30: Def.'s Summ. J. Mem.), and Mr. B. has filed a reply
(doc. #31: Pl's Reply). For the following reasons, we
grant Mr. B.'s motion, deny the Commissioner's
motion, and remand the case for further proceedings.
29, 2014, Mr. B. applied for DIB and SSI, alleging disability
beginning on April 15, 2014 due to an esophageal tear and
GERD (R. 83, 88, 93-94, 119, 123, 178, 180,
198). The Social Security Administration
("SSA") denied Mr. B.'s applications at the
initial and reconsideration stages of review, after which Mr.
B. requested a hearing before an Administrative Law Judge
("ALJ") (R. 93-94, 109-15, 119-25). On January 11,
2017, the ALJ held a hearing at which Mr. B. and a vocational
expert ("VE") testified (R. 46-82). On April 7,
2017, the ALJ issued a decision denying Mr. B.'s DIB and
SSI claims (R. 23-43). The Appeals Council denied Mr.
B.'s request for review, making the ALJ's decision
the final word of the Commissioner (R. 1-6). See Varga v.
Colvin, 794 F.3d 809, 813 (7th Cir. 2015); 20 C.F.R.
§§ 404.981, 416.1481.
was born on November 25, 1958 (R. 178). He completed one year
of college, and from the late 1990s through 2002, he worked
as a book packer and sorter, a punch press operator, and a
spray booth technician/operator (R. 55, 199, 205, 207-09). In
2004, he began working at a nursing home, where he worked as
an activity aide, a security person, and a smoking monitor
until January 15, 2014, when he was laid off (R. 62-68,
198-99, 205-06). This is the last time Mr. B. worked (R. 62,
Mr. B. does not allege that he stopped working because of his
conditions, he alleges that by April 15, 2014, his conditions
had become severe enough to keep him from working (R. 198).
On that date, Mr. B. presented to the emergency room after
vomiting several times and complaining of chest and upper
abdominal pain (R. 282, 286). He was found to have a lower
esophageal rupture, and he underwent surgery (R. 281-83,
286). Mr. B. remained in the hospital until May 8, 2014 (R.
August 2014, Mr. B. visited his primary care provider,
Nasreen Shah, M.D., complaining of shortness of breath (R.
30, 60, 847-56, 865). Dr. Shah diagnosed Mr. B. with GERD,
shortness of breath, and dyspnea on exertion
("DOE") (R. 865). Mr. B. saw Dr. Shah again two
weeks later for a follow-up appointment, where Mr. B. also
complained of pain in his left wrist (R. 856-61). In
September 2014, Mr. B. underwent an echocardiogram and, a few
days later, a myocardial perfusion imaging ("MPI")
test (R. 920-22, 925-30). Mr. B. thereafter followed up with
Dr. Shah on October 14, 2014 (R. 869-71). Dr. Shah identified
chronic, systolic congestive heart failure as a primary
diagnosis, and she referred Mr. B. to cardiology (R. 871). At
a December 2014 follow-up visit (after Mr. B. had been seen
by a cardiologist), Dr. Shah repeated her congestive heart
failure diagnosis and further identified essential
hypertension as a primary diagnosis (R. 872-75). She also
noted Mr. B.'s left wrist pain (R. 875).
February 2015, Dr. Shah completed a cardiac residual
functional capacity ("RFC") questionnaire (R.
885-87). Dr. Shah diagnosed Mr. B. with Class II congestive
heart failure and identified the following symptoms:
difficulty breathing, shortness of breath, fatigue,
dizziness, some memory loss, and some recurring headaches (R.
885). Dr. Shah opined that Mr. B. could lift and carry less
than 10 pounds occasionally; he could sit for about four
hours and stand/walk for less than two hours in an eight-hour
workday; and he needed to use a cane while occasionally
standing and walking (R. 886). Dr. Shah also believed that
Mr. B.'s impairments would likely produce good days and
bad days, and she estimated that Mr. B. would likely be
absent from work about three days per month because of his
impairments or treatment (R. 887).
same month (February 2015), Mr. B. presented to Harish
Patlolla, M.D., who worked at the same medical clinic as Dr.
Shah (R. 875-77). Mr. B. complained of left wrist pain, and
on examination, Dr. Patlolla observed wrist tenosynovitis (R.
876-77). He referred Mr. B. to occupational therapy and
ordered an x-ray of Mr. B.'s left wrist (R. 877). An
x-ray of Mr. B.'s left wrist taken the following week
revealed marked joint space narrowing and subchondral
sclerosis (bone hardening) compatible with severe
degenerative change (R. 889). Mr. B. saw Dr. Shah in April
2015 to find out the results of the left wrist x-ray, but the
corresponding medical notes do not reflect what was discussed
about these results (R. 1152-63).
returned to Dr. Shah in July 2015 for a follow-up visit,
where he specifically complained of DOE when he used the
stairs (R. 1173-76). The next month, Mr. B. presented to
cardiologist Jose Daniel Benatar, M.D., complaining of DOE
and hypertension (R. 1188-90). Dr. Benatar noted that, for
the past year, Mr. B. had experienced DOE after walking a
block or going up one flight of stairs, but he believed that
it was unlikely that Mr. B.'s DOE had a cardiac etiology
(R. 1188-89). Nonetheless, Dr. Benatar identified congestive
heart failure as one of Mr. B.'s "active
problems" (R. 1188, 1190). Dr. Benatar also reported
that Mr. B. recently had some memory problems and that he
forgets to take his medications regularly (R. 1188). The
following week, Mr. B. saw Dr. Shah to follow up on a recent
blood test, which was found to be within normal limits (R.
followed up with Dr. Benatar in January 2016 (R. 1034-40).
Dr. Benatar again noted that Mr. B.'s DOE was likely not
cardiac-related; rather, he believed it could be
pulmonary-related, as Mr. B. had a history of smoking (R.
1035). Dr. Benatar removed congestive heart failure from the
list of Mr. B.'s active problems (R. 1034, 1040).
also presented to Dr. Shah in January 2016, seeking a
referral for foot and hand x-rays (R. 1052-56). Dr. Shah
assessed Mr. B. as suffering from unspecified lateral chronic
foot and hand pain and planned for Mr. B. to have x-rays
taken (R. 1055). The x-rays of Mr. B.'s feet showed
bilateral pes planus; degenerative changes in the feet, right
significantly greater than left; and mild right hallux valgus
(R. 1062, 1211-12). Mr. B.'s hand x-rays showed an old
boxer's fracture in his right hand (R. 1062).
returned to see Dr. Shah in February 2016 regarding his
chronic left shoulder pain, left wrist pain, bilateral foot
pain, and heartburn (R. 1062). Dr. Shah assessed Mr. B. as
having neuropathic pain and bilateral shoulder and foot pain
(R. 1056, 1063). She ordered an x-ray for Mr. B.'s left
shoulder and electromyography (EMG) for his neuropathic pain,
and she referred Mr. B. to ...