Delvarnois B. v. Saul

          MEMORANDUM OPINION AND ORDER ^[2]

          SIDNEY I. SCHENKIER United States Magistrate Judge.

         Plaintiff, 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.

         I.

         On May 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).^[3] 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.

         II.

         Mr. B. 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, 190, 198).

         Although 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. 286-87).

         In 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).^[4] 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).

         In 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).

         The 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).

         Mr. B. 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. 1198-1201).

         Mr. B. 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).

         Mr. B. 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).^[5] Mr. B.'s hand x-rays showed an old boxer's fracture in his right hand (R. 1062).

         Mr. B. 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 ...