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Aitmus R. v. Saul

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

October 4, 2019

AITMUS R., Plaintiff,
ANDREW M. SAUL, Commissioner of Social Security, [1] Defendant.



         On May 29, 2012, the claimant, Aitmus R. ("Plaintiff), [3] filed applications for supplemental security income ("SSI") and Disability Insurance Income ("DIB"), alleging that he became disabled on December 31, 2008. (R. 294-301.) Plaintiff initially pursued his claims pro se, and after a hearing on September 16, 2014 (R. 79-114), the Administrative Law Judge ("ALJ") issued an opinion on June 19, 2015 denying his claims (R. 119-39). On October 13, 2016, the Appeals Council remanded Plaintiffs case back to the ALJ to obtain additional evidence on Plaintiffs impairments and to further consider Plaintiffs maximum residual functional capacity ("RFC"). (R. 140-42.) On remand, Plaintiff submitted additional evidence and received a second hearing before the ALJ, this time represented by counsel. (R. 44-78.) On July 19, 2017, the ALJ issued a partially favorable decision: he found that Plaintiff could perform a limited range of sedentary work and thus was not disabled since his alleged onset date, but that on May 30, 2017, on his 50th birthday, Plaintiff became disabled. (R. 15-43.) On July 5, 2018, the Appeals Council denied Plaintiffs request for review of the ALJ's July 2017 decision (R. 1), making it the final decision of the Commissioner. Jozefyk v. Berryhill, 923 F.3d 492, 496 (7th Cir. 2019).

         On January 8, 2019, Plaintiff, represented by counsel, filed a motion seeking reversal or remand of the Commissioner's decision denying her applications for benefits. (D.E. 17.) The Commissioner has filed a cross-motion for summary judgment asking the Court to affirm the decision. (D.E. 25.) For the following reasons, the Court grants Plaintiffs motion for remand and denies the Commissioner's motion to affirm.

         I. The Record

         Plaintiff begins his review of the evidence on April 21, 2009, when he presented to the emergency room ("ER") with complaints of headache and chest pain. (D.E. 18: Pl.'s Mem. at 1, citing R. 588.).[4] Plaintiff was discharged the next day with diagnoses of atypical chest pain (ruled out heart attack), hypertensive urgency, morbid obesity, polysubstance abuse and obstructive sleep apnea. (R. 588.) The physician noted Plaintiffs headache was likely secondary to uncontrolled hypertension (high blood pressure) as Plaintiff had been "fairly noncompliant" in taking his medications. (Id.) The physician also noted that Plaintiff was noncompliant with wearing his CPAP (continuous positive airway pressure) machine for his sleep apnea.[5] (Id.)

         Between 2009 and 2012, Plaintiff received medical care while he was incarcerated in Indiana on drug-related crimes. He took medication for hypertension and high cholesterol, and he was granted a request for a bottom bunk. (See R. 707, 755.) He made repeated requests for stronger pain medication - such as Tylenol # 3 (Tylenol with Codeine) and Neurontin (for nerve pain) -for pain in his knees, legs, feet, hands, neck and back (R. 676-731), which he received until he was "cut off because he was "caught hoarding medication" in January 2010 (R. 661, 752-54, 759-60, 770.) Plaintiff had occasional chest pain and shortness of breath, and a chest x-ray in March 2010 showed evidence of pulmonary hypertension[6] and edema (swelling caused by excess fluid). (R. 1163-68, 1178.) In 2010 and 2011, several medical notes indicated Plaintiff had difficulty ambulating due to knee problems or shortness of breath. (R. 891-96, 1164, 1172-75.) In February 2012, Plaintiff weighed 415 pounds and had a body mass index ("BMI") of 54.75. (R. 867-70.)

         On August 3, 2012, Teofilo Bautista, M.D., conducted a state agency consultative examination. (R. 991.) He noted that Plaintiff walked with a cane and limped. (R. 992.) Plaintiff refused range-of-motion testing on his back and refused to walk without a cane due to pain. (R. 992-93.) Plaintiffs range of motion in his knees, feet, wrists, neck and left shoulder was limited due to pain, and he had swelling in both ankles and feet and numbness in his fingertips and toes. (Id.) Further, he could not button or zip with his left hand and had bilateral wheezing in his lungs. (Id.) An x-ray on August 21, 2012, showed mild degenerative changes in Plaintiffs knees. (R. 1001.) On August 22, 2012, a state agency consultant issued a physical RFC opinion finding Plaintiff could perform light work with environmental and postural limitations. (R. 1008-12.) This opinion was affirmed on reconsideration. (R. 1039.)

         On August 6, 2012, Roger Parks, Psy.D., performed a state agency consultative psychological examination. (R. 995.) Plaintiff reported having suicidal thoughts and hearing voices commanding him to harm himself or others. (R. 996.) Plaintiff stated that he lived with his uncle, who did all the chores. (R. 997.) Dr. Parks found Plaintiffs mood was depressed, his affect was very constricted and he had difficulty concentrating. (R. 996-97.) He diagnosed Plaintiff with major depressive disorder with psychotic features and a Global Assessment of Functioning ("GAF") score of 50.[7] (Id.) On August 28, 2012, a state agency consultant issued a mental RFC opinion finding Plaintiff had moderate restriction in activities of daily living ("ADLs"), mild difficulties in maintaining social functioning, and mild difficulties in maintaining concentration, persistence or pace. (R. 1026.) The opinion found Plaintiff was moderately limited in the ability to understand, remember and carry out detailed instructions, but that he could "understand, remember and carry out unskilled and semi-skilled tasks[J ... attend to task for sufficient periods of time to complete tasks [and] . . . manage the stress involved with such work." (R. 1030-32.) This opinion was affirmed on reconsideration (R. 1040.)

         On February 11, 2013, Plaintiff was admitted to the ER with complaints of chest pain and dizziness. (R. 1318-19.) A chest x-ray revealed his heart was moderately enlarged but testing showed myocardial injury was unlikely. (R. 1340, 1347, 1352.) Plaintiff was discharged on February 13, 2013 with a diagnosis of atypical chest pain but readmitted the same day due to suicidal thoughts. (R. 1257.) He was assessed an initial GAF score of 45-50, but he showed improvement with medication and therapy and was discharged on February 15, 2013 with a diagnosis of major depressive disorder in partial remission. (R. 1575.)

         In October 2013, Plaintiff was hypertensive when he went to the ER complaining of chest pain; his EKG was normal except for some atrial enlargement. (R. 1049-55.) Plaintiff reported not having his hypertension medication for more than a year and taking his mother's medication. (R. 1055-56.) He had swelling in his lower extremities but normal range of motion. (R. 1056.) Plaintiff was discharged the same day in good condition: his blood pressure had improved and he was ambulating without assistance with a steady gait. (R. 1050.)

         On January 8, 2014, Plaintiff was admitted to the hospital after claiming to have had a stroke two days prior with left-sided weakness and facial numbness. (R. 1064, 1069.) Testing for a stroke was negative; however, Plaintiff reported having a "history" of strokes.[8] (R. 1064-67.) Plaintiff also complained of chest pain and foot pain, and he used a wheelchair and ambulated only very short distances with a cane. (R. 1064-66.) He had been noncompliant with his medications, and his blood pressure was "out of control." (R. 1067, 1069.) Upon examination, his physician found that Plaintiffs reliability was poor and that he put forth very little effort. (R. 1064, 1071.) On January 10, 2014, the physician concluded that Plaintiff was at "baseline function" and did not need inpatient rehabilitation. (R. 1065.)

         On April 29 and 30, 2014, Plaintiff had intake examinations at the Indiana Department of Corrections after he was again incarcerated for drug-related crimes. He reported having a seizure the prior week, and regularly hearing his sister's voice telling him to hurt himself or others. (R. 1124-31). He was given a GAF score of 60. (R. 1129.)

         On June 22, 2014, Plaintiff was taken to the ER reporting left-side paralysis and left-eye blindness for the previous few days. (R. 1221.) The physician noted he had "some mild left facial droop" and weakness, his left pupil was unresponsive to light, and he had decreased strength in his left lower and upper extremity. (R. 1224-25.) However, an extensive workup was negative for an acute or old CVA (cerebrovascular accident or stroke).[9] (R. 1226.) Plaintiff reported having had two prior strokes, but the doctor did not see evidence of this in the medical history and noted Plaintiff "really was not consistent with his information at all and story was changing." (R. 1229.) The doctor also questioned whether Plaintiff put full effort into testing his upper and lower extremity strength. (R. 1230-31.) Plaintiff was discharged on June 23, 2014. (R. 1227.)

         Plaintiff was still in jail when he appeared telephonically and pro se at his first hearing before an ALJ on September 16, 2014. (R. 81, 83.) He testified that he could stand only two to three minutes before needing to sit due to back pain and shortness of breath, and he could only sit about 20 to 30 minutes before he had to lay down due to pain. (R. 92-93.) In addition, he sleeps sitting up because of his sleep apnea. (R. 101-02.) Plaintiff also testified that he was blind in his left eye, had no feeling in his fingers and toes and had suffered several strokes. (R. 93-95.)

         On October 9, 2015, Plaintiff sought treatment after falling and hurting his left shoulder. (R. 1463.) He reported having several falls since leaving jail two months before. (Id.) On October 17, 2015, Plaintiff was back in the ER after falling twice when his knee gave out. (R. 1558.) In addition to pain in his knees, right ankle, left shoulder and head, Plaintiff reported numbness in his hands and feet. (Id.) A CT scan of his cervical spine (neck) revealed "severe central spinal canal narrowing with spinal cord compression at C3-C4 level" and "multilevel degenerative changes with diffuse disc bulge." (R. 1561.) Later that month, Plaintiff underwent cervical spine fusion surgery. (R. 1503.) There are no hospital reports from the surgery in the record; however, the record shows that Plaintiff received post-surgery inpatient treatment from HCR Manor Care from October 30 through December 10, 2015. (R. 1484-85, 1504-40.)

         From January 2016 through February 2017, Plaintiff saw Mithila Janakiram, M.D., approximately once a month to receive treatment and medication for diabetes, hypertension, hyperlipidemia, depression and coronary arteriosclerosis (hardening of the heart arteries) (R. 1264-99.) Although the medical reports generally indicated that Plaintiff was ambulating normally, in June 2016, Dr. Janakiram noted Plaintiff had chronic back pain and used a cane (R. 1282-83), and in October 2016, Plaintiff was in "acute distress," wheezing and short of breath, and ambulating with a walker. (R. 1270-76.) In December 2016, Plaintiff was again having difficulty breathing, and he had an episode of atrial flutter (an arrhythmia, or heart rhythm disorder). (R. 1268-71.)

         On January 10, 2017, Plaintiff went to the ER complaining of severe shortness of breath and sharp chest pain; an EKG showed atrial flutter and a chest x-ray showed moderate pulmonary vascular congestion (accumulation of fluid in lungs), but he does not appear to have been admitted. (R. 1563-69.) However, on January 17, 2017, Plaintiff returned to the hospital via ambulance with shortness of breath, acute pulmonary edema (excess fluid in lungs) and atrial flutter with rapid ventricular rate. (R. 1410, 1421.) On admission, Plaintiff was diagnosed with heart failure and respiratory failure secondary to chronic obstructive pulmonary disease (R. 1419.) He was discharged on January 28, 2017, with additional diagnoses of left atrial and left ventricular thrombus (blood clot), seizure disorder (he had an acute seizure while in the hospital), Type 2 diabetes mellitus, atrial flutter, obesity hypoventilation syndrome, [10] obstructive sleep apnea and dyslipidemia (abnormal amount of lipids in the blood). (R. 1419-20.) The physician also noted Plaintiff had an overall problem with compliance with medications. (R. 1414, 1419.)

         At a follow-up visit in February 2017, Dr. Janakiram noted Plaintiff could not "walk really well" and continued to have shortness of breath. (R. 1267-68.) In March 2017, he had weakness and increased fatigue with standing ...

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