United States District Court, N.D. Indiana, Hammond Division
DONNA G. MRSKOS, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of the Social Security Administration, Defendant.
OPINION AND ORDER
PAUL R. CHERRY, Magistrate Judge.
This matter is before the Court on a Complaint [DE 1], filed by Plaintiff Donna G. Mrskos on July 5, 2012, and a Plaintiff's Brief in Support of Reversing the Decision of the Commissioner of Social Security [DE 16], filed on December 10, 2012. Plaintiff requests that the December 17, 2010 decision of the Administrative Law Judge denying her claims for disability insurance benefits be reversed or remanded for further proceedings. On March 19, 2013, the Commissioner filed a response, and Plaintiff filed a reply on April 1, 2013. For the following reasons, the Court grants Plaintiff's request for remand.
On October 14, 2008, Plaintiff filed an application for disability insurance benefits, alleging an onset date of November 16, 2007. The application was denied initially on February 27, 2009, and upon reconsideration on May 1, 2009. Plaintiff timely requested a hearing, which was held on November 1, 2010, before Administrative Law Judge ("ALJ") Sherry Thompson. In appearance were Plaintiff, her attorney Thomas J. Scully III, and vocational expert Thomas F. Dunleavy. The ALJ issued a written decision denying benefits on December 17, 2010, making the following findings:
1. The claimant meets the insured status requirements of the Social Security Act through December 31, 2013.
2. The claimant has not engaged in substantial gainful activity since November 16, 2007, the alleged onset date (20 CFR 404.1571 et seq. ).
3. The claimant has the following severe impairments: atrial fibrillation and obesity (20 CFR 404.1520(c)).
4. The claimant does not have an impairment or combination of impairments that meets or medically equals one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525, 404.1526).
5. After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform medium work as defined in 20 CFR 404.1567(c) except the claimant can occasionally climb ramps and stairs; never climb ladders, ropes, and scaffolds; can frequently balance, stoop, kneel, crouch and crawl; and must avoid moderate exposure to extreme heat.
6. The claimant is capable of performing past relevant work as a clerical worker/secretary. This work does not require the performance of workrelated activities precluded by the claimant's residual functional capacity (20 CFR 404.1565).
7. The claimant has not been under a disability, as defined in the Social Security Act, from November 16, 2007, through the date of this decision (20 CFR 404.1520(f)).
On May 15, 2012, the Appeals Council denied Plaintiff's request for review, leaving the ALJ's decision the final decision of the Commissioner. See 20 C.F.R. §§ 404.981, 416.1481. On July 5, 2012, Plaintiff filed this civil action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) for review of the Agency's decision.
The parties filed forms of consent to have this case assigned to a United States Magistrate Judge to conduct all further proceedings and to order the entry of a final judgment in this case. Therefore, this Court has jurisdiction to decide this case pursuant to 28 U.S.C. § 636(c) and 42 U.S.C. § 405(g).
A. Medical Background
Plaintiff was fifty-nine years old on the date of the ALJ's decision. She has a history of atrial fibrillation as early as July 2000 and was treated with ultrasound ablation in 2000. She did well but then began experiencing persistent atrial fibrillation in October 2006.
Prior to the onset date, an April 11, 2005 spirometry test revealed mildly reduced functional residual capacity, "probably obesity related." (AR 342).
On May 3, 2007, an echocardiogram showed a nondilated left ventricle with mild to moderate hypokinesis affecting the anterior wall and septum more so than the remainder of the ventricle; the ejection fraction was around 40%; there was moderate left atrial enlargement; and no significant valvular abnormalities were noted.
On May 9, 2007, Plaintiff underwent cardioversion. An electrocardiogram showed rapid atrial fibrillation with some nonspecific ST changes. The impression was recurrent persistent atrial fibrillation, post pulmonary vein isolation as well as "moderate systolic dysfunction-new. Possibly new to rate related systolic dysfunction." (AR 553). The cardioversion was not successful as her atrial fibrillations immediately returned.
On July 20, 2007, Plaintiff underwent another cardioversion. Sinus rhythm was restored.
However, Plaintiff continued to have persistent atrial fibrillation. On November 15, 2007, Plaintiff underwent another ablation procedure. After this surgery, Plaintiff had a hematoma adjacent to the right femoral vein that had been accessed. Medication and observation were prescribed.
In a treatment note dated November 25, 2007, it was noted that Plaintiff had a history of tachycardia induced cardiomyopathy.
On December 10, 2007, the follow-up visit note indicates a "history of obesity." (AR 237). Plaintiff denied chest pain, dizziness, and/or dyspnea. She reported occasional fast skipped beats for several beats that would then subside. The doctor diagnosed paroxysmal atrial fibrillation status post ultrasound ablation in 2000, morbid obesity, and persistent atrial fibrillation.
On December 20, 2007, the treatment notes report that Plaintiff remained in sinus since the November ablation. The doctor also noted that since the May 3, 2007 echocardiogram showed an ejection fraction of 40%, her LV function had returned to normal. She was also diagnosed with hypertension with diastolic dysfunction.
At a February 11, 2008 check up, Plaintiff denied chest pain, dyspnea, palpitations, and/or dizziness. The diagnoses were again paroxysmal atrial fibrillation status post ultrasound ablation in 2000, morbid obesity, and persistent atrial fibrillation.
A June 9, 2008 progress note report indicates that Plaintiff denied palpitations, chest pain, dyspnea, or dizziness. Plaintiff's exercise tolerance was 6 minutes once a month on the treadmill. Her "active lifestyle" included walking around her yard. (AR 231). Plaintiff was given the same diagnoses of paroxysmal atrial fibrillation status post ultrasound ablation in 2000, morbid obesity, and persistent atrial fibrillation.
In a June 29, 2008 progress note report, Dr. Wilber wrote that he had seen and examined Plaintiff, that Plaintiff remained in sinus with no medications, and that Plaintiff "feels well and has returned to an active lifestyle." (AR 231). Dr. Wilber again noted that Plaintiff's LV function had returned to normal and that she had hypertension with diastolic dysfunction. Dr. Wilber commented that she had an "[e]xcellent outcome from ablation." Id.
A September 2, 2008 echocardiogram showed that Plaintiff was in atrial flutter at a rate of 166. Her medication was then increased. On September 5, 2008, Plaintiff underwent cardioversion, which returned her to sinus rhythm.
On January 27, 2009, J. Sands, M.D. reviewed the medical records and completed a Physical Residual Functional Capacity Assessment for the Disability Determination Bureau. Dr. Sands listed Plaintiff's primary diagnosis as atrial fibrillation and her secondary diagnosis as obesity. Dr. Sands opined that Plaintiff could perform a range of medium work with some postural and environmental limitations. In the explanation section for the postural limitations, Dr. Sands wrote: "57 yr old female w/hx of atrial fibrillation. underwent cardioversion on 5/9/2007, 7/20/2007, and 9/5/2008. 12/17/08 notes show no recurrence of atrial fibrillation. 9/5/08 echo states normal aortic valve with normal doppler and nondialated left ventricle. bmi 38.3." (AR 749). In assessing the severity of Plaintiff's symptoms, Dr. Sands wrote:
Careful consideration has been given to the clmt's statements regarding alleged symptoms and their effect on functioning. The clmt's [medically determinable impairments ] could reasonably be expected to produce the alleged symptoms, and the allegations are not inconsistent with the objective findings on record. The credibility of these statements is further supported by the general consistency of the clmt's description of her symptoms within progress notes and ...