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Charles M. v. Saul

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

January 15, 2020

CHARLES M., Plaintiff,
ANDREW SAUL, Commissioner of Social Security, Defendant.


          Jeffrey Cummings, United States Magistrate Judge

         Claimant Charles M. (“Claimant”)[1] brings a motion for summary judgment to reverse the final decision of the Commissioner of Social Security (“Commissioner”) that denied Claimant's application for a period of disability and Supplemental Security Income (“SSI”) under the Social Security Act. 42 U.S.C. §§ 416(i), 402(e), and 423. The Commissioner has brought a cross-motion for summary judgment seeking to uphold the Social Security Agency's (“SSA”) decision finding that Claimant is not disabled. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). This Court has jurisdiction to hear this matter pursuant to 42 U.S.C. §§ 405(g) and 138(c)(3). For the reasons stated below, Claimant's motion for summary judgment [17] is granted and the Commissioner's cross-motion for summary judgment [24] is denied.

         I. BACKGROUND

         A. Procedural History

         On December 18, 2014, Claimant filed a disability application alleging an onset date of June 10, 2010. His claim was denied initially and upon reconsideration. On October 25, 2017, an Administrative Law Judge (“ALJ”) issued a written decision denying benefits to Claimant. After the Appeals Council denied review, the ALJ's decision became the Commissioner's final decision. 20 C.F.R. § 404.985(d); see also Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). Claimant subsequently filed this action on October 16, 2018.

         B. Medical Evidence

         1. Evidence from Claimant's Treatment History

         Claimant was a 62-year old attorney at the time of the ALJ's decision. Claimant alleges that he began experiencing disabling symptoms as of June 10, 2010 that included numbness extending from his upper abdomen to his feet. He also experienced impairments in his ability to control his bladder and bowels. (R. 760). Claimant saw his treating physician Dr. Scott Schieber on July 13, 2013 for his condition. (R. 519). Dr. Schieber referred him to specialists who diagnosed an arachnoid cyst at the T2-T3 level of the thoracic spine.[2] On August 27, 2013, neurologist Dr. Charles Cybulski carried out a T2-T4 laminectomy to treat Claimant's condition.[3] (R. 699-700). Dr. Cybulski noted improvement in Claimant's condition over the following months: he was able to mow his lawn as of October 25, 2013 and played golf at least once by January 9, 2014. (R. 839-40).

         One of the symptoms that had accompanied the arachnoid cyst was spasticity in Claimant's legs. (R. 760). Dr. Cybulski noted that his gait was “markedly spastic” and that Claimant was unable to walk with any degree of stability prior to surgery. (R. 838). By May 14, 2014, Claimant still displayed spasticity and was prescribed the anti-spasmatic medications diazepam (Valium) and Baclofen to help with his symptoms. (R. 760-61). Claimant complained of drowsiness that resulted from the medications. (R. 760).

         Claimant also experienced problems with his hands. An x-ray taken on September 17, 2014 of the left hand showed persistent flexion of the second and fifth fingers; mild to moderate degenerative changes in the fourth finger; and moderate degenerative changes in the first metacarpophalangeal joint. (R. 794). He was diagnosed with Dupuytren's disease, which involves a thickening of the fascia beneath the skin in the palms and fingers that pulls the fingers inwards. Claimant underwent a subtotal palmar fasciectomy on his small finger on October 2, 2014 with a release of the proximal interphalangeal joint and a subtotal palmar fasciectomy of the left ring finger. (R. 799). A second operation was done on January 29, 2015. (R. 796). A post-operative x-ray on February 3, 2015 showed an improved expansion of the fifth finger but an unchanged severe degenerative alteration of the first carpometacarpal joint. (R. 781).

         2. Evidence From Treating and Consulting Physicians

         On March 30, 2015, Dr. Dinesh Jain examined Claimant at the request of the SSA. Claimant told Dr. Jain that his gait and balance had improved since his spine surgery but he still experienced some imbalance. Dupuytren's contractions also created problems in using a keyboard. Dr. Jain's physical exam showed contractions in both little fingers and in the left ring finger and thumb. Claimant demonstrated a normal gait and could get on and off the exam table without difficulty. He was able to tandem walk, walk on his toes and heels, squat, and hop on one leg. Dr. Jain noted that Claimant continued to have some pain in the upper thoracic region after his surgery and - despite the normal gait stated earlier - concluded that Claimant showed “some limitation of gait.” He diagnosed a decrease in Claimant's focus and short-term memory and found that Claimant could sit for two to three hours, stand for one hour, walk four to six blocks, and lift or carry up to 40 pounds. (R. 732-34).

         On March 31, 2015, psychologist Dr. Edward Klutcharch interviewed Claimant for the SSA. Claimant told Dr. Klutcharch that he could no longer work as an attorney due to problems in walking and retaining information. Dr. Klutcharch found that he was oriented to place and time; had an appropriate demeanor; and was properly dressed. No perceptual distortions or delusional thinking were noted. Dr. Klutcharch diagnosed Claimant with a major depressive disorder of moderate intensity and assigned a current GAF score of 48.[4] (R. 736-39).

         Treating physician Dr. David Chen issued a report on Claimant's condition on January 20, 2016. Dr. Chen stated that Claimant suffered from incomplete paraplegia following the surgery on his arachnoid cyst. Claimant suffers from lower extremity weakness, impaired balance, and spasticity. He cannot stand or walk for six hours a day. In addition, Dr. Chen stated that the side effects of the medications that Claimant took to control spasticity would affect his attention and concentration. Combined with his neurological deficits, that could require Claimant to miss work “on occasion.” (R. 478-82).

         Treating physician Dr. Schieber also met with Claimant on May 5, 2017 for the first time in over three-and-one-half years. He noted “a dramatic decline in functional status” for Claimant since he last saw him in July 2013. Dr. Schieber noted that Claimant had problems in walking due to balance issues and that he needed to take prescription pain medication daily to control his pain. Dr. Schieber found numbness and decreased sensation around the cervical thoracic region and hyperreflexic lower extremities. Like Dr. Jain, Dr. Schieber stated that Claimant could only walk for four blocks without severe pain. He can sit or stand for no more than 20 minutes at one time and can sit, stand, or walk for no more than two hours in an eight-hour day. Periods of rest would be necessary after walking for 60 minutes. Claimant could only lift or carry less than 10 pounds frequently and 20 pounds occasionally. Claimant would not experience “good days” and “bad days” and would need to be off work more than four days each month. (R. 1044-46).

         3. Evidence From State-Agency Experts

         On May 16, 2015, non-examining psychologist Dr. Lionel Hudspeth issued a report finding that claimant suffered from a non-severe affective disorder. Dr. Hudspeth assessed no restrictions in Claimant's ability to carry out activities of daily living (“ADLs”) and mild limitations in his capacity for social functioning and in maintaining concentration, persistence, or pace. (R. 267). Dr. David Biscardi disagreed with that assessment on reconsideration by finding mild restrictions in all three of Claimant's functional areas. (R. 284).

         4. Evidence From Claimant's Testimony

         Claimant appeared at the July 20, 2017 hearing and gave testimony to the ALJ about his condition. He stated that he first sought medical treatment for his thoracic numbness after he had difficulty with his balance, gait, and bowel control. (R. 236). Claimant stated that the loss of his bowel control began in June 2010 and progressed to the point where he lost control once every other day. (R. 237). Surgery for the thoracic cyst in August 2013 helped with his bowel problems but Claimant still had difficulty with balance after the operation. That included continuous spasticity with his legs as he lay in bed at night. Claimant was referred to Dr. Chen at the Chicago Rehabilitation Institute and was started on a protocol of drugs that included diazepam and Baclofen. (R. 241). Claimant stated that before starting those medications he fell down stairs frequently but now has greater control over his balance. He also takes four Norco tablets each day for pain. (R. 243-44). These medications cause side effects like drowsiness that cause Claimant to fall asleep while he is reading or watching TV. (R. 246).

         Claimant told the ALJ that he can stand for only 15 minutes and could walk for four blocks. He can lift up to 35 pounds but not on a regular basis. Claimant stated that after his hand surgery he had difficulty with fine manipulation like using zippers and buttons and would have problems typing on a keyboard. (R. 345-46). The medications also make it difficult for Claimant to concentrate. He described diminished concentration, slurred speech, and difficulty in typing to be the biggest barriers to his employment as a real estate attorney. (R. 249). Claimant told the ALJ that he still had an active bar membership and that he had done some legal work after his alleged onset date in June 2010. He described the scope of his legal work as very limited. Claimant helped his stepdaughter in a child custody matter, handled a contract issue for a friend, and ...

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