United States District Court, N.D. Indiana, Fort Wayne Division
KIRK W. STEPHENS, 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 Supplemental Security Income ("SSI") to Plaintiff, Kirk W. Stephens ("Stephens"). For the reasons set forth below, the Commissioner of Social Security's final decision is REVERSED and this case is REMANDED for proceedings consistent with this opinion pursuant to sentence four of 42 U.S.C. section 405(g).
On May 22, 2008, Stephens applied for SSI under Title XVI of the Social Security Act, 42 U.S.C. § 1381 et seq. This application was denied initially on July 15, 2008. Stephens filed a new application for SSI on March 31, 2010, alleging disability beginning January 5, 2007. This claim was denied initially on July 17, 2010, and upon reconsideration on November 10, 2010. In response, Stephens filed a written request for a hearing on January 7, 2011.
On September 16, 2011, Stephens appeared with counsel before Administrative Law Judge ("ALJ") Yvonne K. Stam ("Stam") in Fort Wayne, Indiana. Stephens testified at the hearing, as did Robert S. Barkhaus, Ph.D., a vocational expert ("VE"). On October 24, 2011, the ALJ issued a decision finding Stephens not disabled. (Tr. 16-24).
Stephens requested that the Appeals Council review the ALJ's decision, and this request was denied. As a result of the denial, ALJ Stam's decision became the Commissioner's final decision. See 20 C.F.R. § 422.210(a). Stephens has initiated the instant action for judicial review of the Commissioner's final decision pursuant to 42 U.S.C. section 405(g).
Stephens was born on May 23, 1957, and was 49 years old at the date of the alleged disability onset, and 54 at the time of the ALJ's decision. He has a ninth grade education. Stephens' past relevant work experience includes work as a taxi dispatcher and security officer.
Plaintiff initially alleged that he suffered from the following medical conditions: type 2 diabetes, hypertension, stage three chronic kidney disease, heart disease, back injury, asthma, and arthritis. (Tr. 72, 187). He later alleged that he also suffered from morbid obesity, COPD, thoracic degenerative disc disease, lumbar spondylosis, edema in the feet and lower legs, urinary and fecal incontinence, sleep apnea, and side effects from his medications. The medical evidence can be summarized as follows:
Stephens was diagnosed with Type 2 diabetes and hypertension at least as early as August of 2004. (Tr. 228-29). He received regular treatment for these conditions for several years. (Tr. 228-40).
Dr. Kinzi Stevenson examined Stephens on June 28, 2008, after Stephens filed his first application for benefits, at the request of the state disability determination agency. (Tr. 241-44). Stephens reported to Dr. Stevenson that he had been diagnosed with diabetes about ten years earlier and hypertension ten to twelve years earlier. (Tr. 241). Dr. Stephenson found Stephens "positive for vision loss, glasses, vertigo, epistaxis, pneumonia, wheezing, murmur, chest pain, edema, palpitations, and hernia." (Tr. 242). Dr. Stephenson found that Stephens "ambulates normally" and was able to get on and off the exam table and chair without trouble. (Tr. 242). He also found that Stephens had 5/5 handgrip strength and motor strength of 5/5 in upper and lower extremities bilaterally. (Tr. 243). According to Dr. Stevenson:
The patient was very cooperative and did seem to put forth good effort during the exam. I could not appreciate any limitations in sitting, lifting, carrying, seeing, hearing or speaking. There appears to be very mild neuropathy present, however he still appears able to walk long distances and on uneven terrain. The patient does not use any assistive device for ambulation.... The patient complains of chest pain and it is suggestive of angina.
In June of 2009, Dr. Steven Orlow performed a left heart catheterization. (Tr. 249-52). He found mild to moderate coronary artery disease and recommended medical management. (Tr. 249).
Also in June of 2009, Stephens saw Dr. Mark Meier, M.D. (Tr. 328-29). Stephens reported "a constellation of symptoms which include fatigue and shortness of breath" as well as chest discomfort. (Tr. 328). Dr. Meier's impression was:
1. Exertional chest discomfort with dyspnea, concerning for unstable angina.
2. Multiple risk factors including diabetes, hypertension, obesity, history of tobacco use, and dyslipidemia.
3. Chronic renal insufficiency, creatinine 1.5.
(Tr. 329). Dr. Meier indicated Stephens needed a cardiac catheterizaiton and nonselective renal angiogram. (Tr. 329). He prescribed nitroglycein and directed him to see a dietician for consultation regarding diet and weight loss. (Tr. 329).
On July 28, 2009, Stephens was seen by Hector Perez, M.D. at the vascular medicine clinic. (Tr. 326-27). Dr. Perez calculated Stephens' BMI at 41. (Tr. 326). Dr. Perez' impressions were:
1. Hypertension, suboptimally controlled.
2. Dyspnea on exertion associated with chest tightness.
3. Known nonobstrutive coronary artery disease with a 60% circumflex lesion.
5. Stage III chronic kidney disease.
6. History of tobacco abuse, currently abstaining.
A nuclear cardiology exam was performed in May of 2010 due to coronary artery disease, dyspnea on exertion, and chest pain. (Tr. 411-12). The study revealed normal myocardial perfusion and function without regional variation and a normal stress ECG response. (Tr. 411).
In June of 2010, Stephens was seen by David Ringel, D.O., for a Disability Determination Examination. (Tr. 412-15). Stephens reported that he had been diagnosed as having heart disease with a 65% blockage. (Tr. 412). Stephens' hypertension was "well controlled" at the time. (Tr. 412). He reported arthritis in both knees, right ankle, shoulders, and mildly in his hands. (Tr. 412). According to the report, Stephens could dress and make meals, but could only stand for five to six minutes and a total of less than thirty minutes over an eight hour period. (Tr. 412). Stephens could only lift up to fifteen pounds and could only drive a car for up to an hour. (Tr. 412). He is able to do household chores and grocery shopping, but he needs "slight adjustments and some assistance." (Tr. 413).
Dr. Ringel found Stephens to have a slightly impaired gait, and that he moaned as he pulled himself out of his chair. (Tr. 413). Stephens had edema of the feet and lower legs. (Tr. 413). Stephens' grip strength was 4/5 on his right hand, and 3/5 on his left hand. (Tr. 413). He has full range of motion with his cervical spine, but has restrictions in his lumbar spine, and he is only able to do a partial squat with pain. (Tr. 413). Dr. Ringel attributed most of Stephens' physical symptoms to his back injury. (Tr. 415). He also noted that Stephens walked with a slight limp but did not need an assistance device. (Tr. 415). Furthermore, he found that Stephens suffered from "some loss of find motor control of both hands." (Tr. 415).
X-rays of Stephens left hand and wrist showed moderate to advanced degenerative changes in June of 2010. (Tr. 432, 434-35). An x-ray of Stephens' lumbar spine from July of 2010 showed degenerative disc changes from T10-T11 through L1-L2, but no change since a previous x-ray. (Tr. 418, 430-31). X-rays of Stephens' knees showed a small patellar spur or osteophyte on the right knee but were otherwise normal. (Tr. 429).
On July 6, 2010, Stephens saw Dr. Sanjay Jain in the pulmonary and sleep-disorders clinic. (Tr. 444-46). He diagnosed moderately severe COPD, probable concomitant sleep apnea, obesity, hypertension, diabetes mellitus, chronic kidney disease, and allergic rhinitis. (Tr. 445). He recommended a sleep study; that study confirmed obstructive sleep apnea. (Tr. 445, 454-81).
Also in July of 2010, Dr. Sands completed a physical residual functional capacity assessment for Stephens. (Tr 420-27). Dr. Sands believed Stephens could lift 20 pounds occasionally and 10 pounds frequently, stand and sit about 6 hours in an 8-hour workday, and was unlimited in his ability to push and/or pull. (Tr. 421). Dr. Sands recommended that Stephens be limited to occasional climbing, balancing, stooping, kneeling, crouching, and crawling. (Tr. 422).
On August 24, 2010, Stephens was seen by Dr. Shantunu Kulkarni, DO. (Tr. 490-91). Dr. Kulkarni's impression was thoracic degenerative disc disease, lumbar pain, and lumbar spondylosis. (Tr. 491). He recommended a lumbar facet steroid joint ...