United States District Court, N.D. Indiana, South Bend Division
RANDY E. WATKINS, JR., Plaintiff,
CAROLYN W. COLVIN, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.
OPINION AND ORDER
RUDY LOZANO, District Judge.
This matter is before the Court for review of the Commissioner of Social Security's decision denying Disability Insurance Benefits to Plaintiff, Randy E. Watkins, Jr. For the reasons set forth below, the Commissioner of Social Security's final decision is REVERSED and this case is REMANDED to the Social Security Administration for further proceedings consistent with this opinion pursuant to sentence four of 42 U.S.C. section 405(g).
In July of 2009, Randy E. Watkins, Jr. ("Watkins" or "claimant") applied for Social Security Disability Insurance Benefits ("DIB") under Title II of the Social Security Act, 42 U.S.C. section 401 et seq. The application indicated that Watkins' disability began on February 7, 2009.
The Social Security Administration denied Watkins' initial applications for benefits and also denied his claims on reconsideration. On December 15, 2010, Watkins appeared with Mr. Jeff Bares,  a non-attorney representative, at an administrative hearing before Administrative Law Judge Romona Scales ("ALJ Scales"). Testimony was provided by the claimant and Thomas A. Gusloff (a vocational expert or "VE"). On April 29, 2011, ALJ Scales denied the claimant's DIB claim, finding that Watkins had not been under a disability as defined in the Social Security Act.
The claimant requested that the Appeals Council review the ALJ's decision and the request was denied. Accordingly, the ALJ's decision became the Commissioner's final decision. See 20 C.F.R. § 422.210(a)(2005). The claimant has initiated the instant action for judicial review of the Commissioner's final decision pursuant to 42 U.S.C. § 405(g) and 1383(c).
Watkins was born on July 18, 1970. (Tr. 67). Watkins completed high school. (Tr. 44). He alleges the following impairments:congestive heart failure, enlarged heart, high blood pressure, anxiety/panic disorder, kidney stones, history of angioplasty, chest pain, fatigue, and dizziness caused by his medications. (Tr. 170).
His past relevant work includes work as a fast food cook, retail department manager, stock clerk, and service station manager. (Tr. 29, 44). He worked as a cook at Denny's for approximately 4 years. (Tr. 47). Watkins then worked at Meijer for several years. He held various positions there, including working in the gas station, the furniture department, and the shipping and receiving department. (Tr. 45-46). His last position at Meijer was as a shift manager. (Tr. 45-46). Watkins last worked regularly at IHOP as a chef manager. (Tr. 45). This job ended in February of 2008. (Tr. 44). In early 2009, he worked briefly at a bakery. (Tr. 44).
Watkins testified that he can not work because of high blood pressure and heart problems. (Tr. 48). He claims his medications cause fatigue. (Tr. 48). He further testified that he has chest pain that radiates all the time, at various levels. (Tr. 49). He suffers shortness of breath. (Tr. 49). His heart function has improved with treatment. (Tr. 50). He testified that he has panic attacks two or three times a week, but his doctor took him off his anxiety medication because he was concerned about weight gain. (Tr. 50-51). He reports that he sometimes falls without any warning, and that Dr. Burns thinks there is some weakness in his legs but he did not know what it was from. (Tr. 53). These falls were occurring at least once per week. (Tr. 54). He admits that he has not been treated by a psychologist or psychiatrist for anxiety or panic disorder. (Tr. 55). Watkins believes that he can be on his feet only ten minutes at a time due to chest pain and his legs giving out. (Tr. 55). He can sit no more than 45-minutes before needing to lie down, and he spends most of his day lying down. (Tr. 55).
The medical evidence of record is adequately summarized by the claimant's counsel and, in a nutshell, is as follows:
On May 9, 2009, Watkins went to the emergency room with chest discomfort, shortness of breath, dizziness, and weakness and numbness in his left arm. (Tr. 296). At the time of his admission he suffered uncontrolled hypertension. (Tr. 294). Laboratory tests revealed he had an elevated creatinine kinase ("CK") level (1, 258 iU/L). (Tr. 298). Watkins received numerous medications: aspirin, "nitro-paste", Lisinopril, Prilosec, and Atenolol. (Tr. 294-95). A stress test showed a left ventricular ejection fraction ("EF") of 32 percent. (Tr. 294). After seven minutes, the exercise portion of the stress test was terminated due to "dyspnea on exertion and lower extremity discomfort." (Tr. 302). At the point the exercise portion was terminated, Watkins had achieved a total of 5.7 METS. (Tr. 302). The stress test documented a "hypertensive blood pressure response, " occasional premature ventricular contractions ("PVCs") and pronounced ST-T wave depressions during exercise. (Tr. 302, 468). A left heart catherization documented an EF of 25-30 percent and severe global hypokinesis. (Tr. 304-05). After being stabilized, Watkins was diagnosed with:
1. Atypical chest pain probably secondary to gastroesophegeal reflux disease.
2. Severe left ventricular systolic dysfunction with left ventricular ejection fraction of 25 to 30 percent.
3. Mild nonobstructive coronary artery disease.
6. History of renal calculi.
Watkins was discharged on May 12, 2009, but he returned to the emergency room the next day with complaints of heart palpitations, shortness of breath, and anxiety. (Tr. 305). Watkins was given Ativan for anxiety. An EKG showed sinus tachycardia and ST segment abnormalities that were "more pronounced" than previous studies. (Tr. 385). A 24-hour Holter Monitor Study was ordered. (Tr. 382). The study revealed nine premature ventricular contractions and five premature atrial contractions. (Tr. 336). During the study Watkins reported "several episodes of fatigue, feeling stressed, lightheaded, and heart fluttering" although these events did not correlate to the aforementioned premature contractions. (Tr. 336).
On May 18, 2009, Watkins' CK level was measured as 1264 iU/L. (Tr. 372). On May 19, 2009, Watkins met with a therapist at HealthLink and was diagnosed with an anxiety disorder. (Tr. 483). Watkins received instructions on coping with anxiety attacks. (Tr. 483).
Watkins received regular cardiac care with Dr. Dali beginning in June of 2009. On June 3, 2009, he saw Dr. Dali and reported no chest pain, shortness of breath, heart palpitations, or leg swelling. (Tr. 455). He did have elevated blood pressure. (Tr. 455-56). Dr. Dali wrote that "I suspect the hypertension is causing patient's cardiomyopathy." (Tr. 454-456). Dr. Dali assigned Watkins a functional classification of II-III on the New York Heart Association ("NYHA") functional classification system. (Tr. 454-56).
On June 11, 2009, Watkins' CK level was again elevated (1409 iU/L). (Tr. 460). When Watkins saw Dr. Dali on June 15, 2009, he reported experiencing dizziness. (Tr. 449). After examination, Dr. Dali's impressions were as follows:
1. Dilated cardiomyopathy with moderately reduced left ventricular ejection fraction, EF of 30 to 35%. The patient is Functional Classification II.
2. Chronic increase in CPK of [sic] musculoskeletal in nature, unknown etiology with muscle aches. Patient would like to have the [sic] set for muscle bx.
3. Hypertension recently diagnosed. I suspect the hypertension is causing patient's cardiomyopathy.
4. Tinnitus, possibly secondary to aspirin.
6. History of social tobacco use.
8. Orthostatic hypotension.
(Tr. 451). Dr. Dali explained the addictive nature of Ativan to Watkins and prescribed Remeron for anxiety instead. (Tr. 449-451).
In August, Watkins saw Dr. Dali and complained of almost constant right upper quadrant pain in his abdomen. (Tr. 444). Dr. Dali observed tenderness in the area and opined that it was likely secondary to costochondritis. (Tr. 446). Dr. Dali believed Watkins needed a muscle biopsy to determine the cause of his diffuse muscle pain. (Tr. 446).
In September of 2009, Watkins saw Dr. Heather Gillespie, a rheumatologist. (Tr. 718-20). He complained of chest pain extending into his shoulder and indicated that Darvocet did not relieve his symptoms. (Tr. 718). He reported that he had chest pain regularly for the past five months. (Tr. 718). He also reported weakness in his upper extremities and shortness of breath with exertion. (Tr. 718). Dr. Gillespie noted longstanding elevated CK levels and documented tenderness to palpation along the third, fourth, and fifth costochondral junctions bilaterally and in the left shoulder. (Tr. 720). Dr. Gillespie thought Watkins may be suffering from "congenital myopathy that has some sort of cardiac impact." (Tr. 720). She noted that "[w]ith the symptoms in his chest, it is hard to ignore that his overall ejection fraction and cardiac function is not normal." (Tr. 720).
In October of 2009, Watkins' CK level was again elevated (1162 iU/L). (Tr. 637). Dr. Gillespie injected Kenelog into Watkins' third and fourth costochondral junction on October 26, 2009, in an attempt to reduce his pain. (Tr. 640).
Watkins met with Dr. John Heroldt for a consultative psychological examination on October 13, 2009. (Tr. 593-95). Watkins complained of recurring panic attacks with shortness of breath, lightheadedness, chest tightness, loss of control, and loss of interest. (Tr. 593). He indicated that during a panic attack he feels like he is in a tunnel. (Tr. 593). Dr. Heroldt noted that Watkins "presented with flat affect with some overt anxiety noted by sweaty palms." (Tr. 593). Dr. Heroldt diagnosed panic disorder without agoraphobia and adjustment disorder with depressed mood. (Tr. 595). Dr. Heroldt assigned a GAF of 55. Dr. Heroldt felt that Watkins was not capable of handling his own funds at that time. (Tr. 595).
On October 14, 2009, Dr. J. Gange, a medical consultant, reviewed the evidence of record and completed a Psychiatric Review Technique form. (Tr. 601-14). Dr. Gange assessed moderate limitations in Watkins' ability to maintain social functioning and concentration, persistence, or pace. (Tr. 611). He then completed a mental RFC assessment and concluded that Watkins would be moderately limited in his ability to set realistic goals or make plans independently of others, interact appropriately with the general public, complete a normal workday and work without interruptions from psychologically based symptoms. (Tr. 597-98). He also believed Watkins would be moderately limited in his ability to perform at a consistent pace without an unreasonable number and length of rest periods and understand, remember, and carry out detailed instructions. (Tr. 597-98). Dr. Gange noted the following:
While [claimant] did exhibit some objective signs to support his allegations, the severity of limitations alleged exceeds the objective findings (partially credible). [Claimant] drove himself to the MSE and was able to interact appropriately. Although he may ...