United States District Court, N.D. Indiana, South Bend Division
OPINION AND ORDER
JON E. DEGUILIO, District Judge.
On October 7, 2013, Plaintiff Angela Clark filed a complaint in this Court, seeking review of the final decision of the Defendant Commissioner of Social Security ("Commissioner"). [DE 1.] The matter is fully briefed and ripe for decision. For the reasons stated below, the Court REMANDS this matter to the Commissioner for further proceedings.
I. Procedural History
Ms. Clark filed an application for disability insurance benefits and supplemental security income in September 2007. (R. 224-29.) Her applications were denied in January 2008 and again on reconsideration in March 2008. (R. 106-07.) A hearing was held before Administrative Law Judge Sherry Thompson on April 1, 2010 (R. 85-105), after which she issued an unfavorable decision. (R. 111-18.) The Appeals Council granted a request for review and remanded Ms. Clark's claim for further evaluation of a medical source statement. (R. 123-25.)
After remand, the case was assigned to Administrative Law Judge Melody Paige. She conducted a hearing on February 22, 2012. (R. 41-84.) On March 9, 2012, ALJ Paige issued a decision, again denying both claims. (R. 29-40.) The Appeals Council denied a request to review the second decision on August 14, 2013, making the ALJ's decision the final decision of the Commissioner. (R. 7-9.) This suit followed.
Ms. Clark was born on November 19, 1982, and was 29 years old on the date the ALJ rendered her decision. (R. 224.) Ms. Clark graduated from high school, and began attending college part-time in 2006. (R. 56-57.) Her past employment includes work as a group home worker, a home health care worker, and a part-time receptionist. (R. 66-69.) Ms. Clark alleges a disability onset date of September 10, 2007 (R. 224), and claims disability based on physical impairments.
A. Medical Evidence
Ms. Clark claims, and the ALJ found, that she suffers from Postural Orthostatic Tachycardia Syndrome ("POTS"), hypertension, and obesity. (R. 31-32.) POTS is a fairly rare condition that is classified as a form of Inappropriate Sinus Tachycardia by the National Institute of Neurological Disorders and Stroke. (R. 15.) POTS is characterized by "a rapid increase in heartbeat of more than 30 beats per minute, or a heart rate that exceeds 120 beats per minute, within 10 minutes of rising." NINDS Postural Tachycardia Syndrome Information Page, National Institute of Neurological Disorders and Stroke, http://www.ninds.nih.gov/disorders/postural_tachycardia_syndrome/postural_tachycardia_syndrome.htm (last visited Feb. 6, 2015).
Medical records of Ms. Clark's physical impairments date to late 2005, though she has reported similar symptoms since childhood. (R. 381; 523-24.) On December 11, 2005, Ms. Clark received an electrocardiography test ("EKG") at Portage Community Hospital. The EKG indicated a minor sinus arrhythmia, with the rest of the EKG within normal limits. (R. 524.)
On January 27, 2006, Ms. Clark saw Gary Brigham, M.D., a cardiologist at Cardiac Care Associates, for evaluation of tachycardia and recurrent episodes of near syncope. (R. 390). Dr. Brigham's notes from the consultation reference previous Holter monitor and echocardiogram tests, conducted when Ms. Clark was 16 or 17 years old, which showed normal results. (Id. ) A physical examination revealed a drop in blood pressure from 112/62 to 94/60 when standing. (Id. ) Ms. Clark underwent 24-hours of monitoring using a Holter monitor, which indicated substantially increased heartbeat during times of normal activity, as well as an increase in heart rate of 40 beats per minute while standing and ambulating. (R. 392.) Dr. Brigham's summary of the monitoring states, in part, "the patient has a tendency towards a sinus tachycardia during minimal activity." (Id. ) Dr. Brigham ordered an Echo-Doppler Report, which appeared normal. (R. 393.) Ms. Clark also underwent a tilt table test. (R. 470.)
On February 9, 2006, Dr. Brigham conducted a stress test, which was eventually halted because of fatigue. (R. 391.) Ms. Clark achieved a peak heart rate of 167 beats per minute and a total work load of 8.4 mets. Dr. Brigham's summary indicated that Ms. Clark showed "excessive resting tachycardia" and became symptomatic when her heart rate exceeded 160 beats per minute. (Id. ) Later that month, Ms. Clark was prescribed medication to attempt to regulate her presyncope and tachycardia. (R. 403.) Throughout 2006 and 2007, adjustments were made to prescription dosages and a variety of medications were prescribed. (R. 396-402.)
On March 27, 2007, Ms. Clark was admitted to the emergency department at St. Anthony Medical Center for lightheadedness, elevated blood pressure, shortness of breath, heart palpitations, and irregular heart rate. (R. 460-75.) An EKG was performed and revealed normal sinus rhythm and no evidence of ischemia or dysrhythmia. (R. 471.) Ms. Clark was released with instructions to lower the dosage of her current medication and follow-up with her primary care physician. (Id. )
Ms. Clark's condition proved resistant to medication. On November 19, 2007, Dr. Brigham wrote a letter to Indiana Medicaid, in which he indicated that the medications used to affect Ms. Clark's condition had been poorly tolerated or ineffective. (R. 492.) Dr. Brigham confirmed Ms. Clark's diagnosis of POTS and reported that Ms. Clark's recurrent episodes of disabling presyncope had progressed "to the point where she is now unable to effectively work." (Id. ) Dr. Brigham indicated that Ms. Clark's condition left her with limited functionality and noted that there was no expected date of improvement because Ms. Clark had already been through almost all of the usual medications, without seeing improvement. (Id. )
On July 1, 2008, Ms. Clark presented to the emergency room at Saint Anthony Medical Center. (R. 505.) The Emergency Department Note states that Ms. Clark was driving home when her heart started to race and she started to feel lightheaded, shaky, and weak. Ms. Clark believed she was going to pass out. (Id. ) An ambulance was called and Ms. Clark was taken to the hospital where an EKG was conducted. Ms. Clark's EKG showed a sinus rhythm with a rate of 82 and no ischemic changes. (R. 506.) Ms. Clark was released with a plan to follow up with Dr. Brigham. (Id. )
On October 28, 2008, Ms. Clark underwent another stress test performed by Dr. Brigham. (R. 552.) Upon standing on the treadmill, Ms. Clark's heart rate went to 115 beats per minute. (Id. ) Ms. Clark achieved a peak heart rate of 180 beats per minute "at which point she became very symptomatic and required discontinuation of exercise." (Id. ) The report states in summary that Ms. Clark had an "[a]bnormal treadmill study demonstrating a resting sinus tachycardia with a pronounced exacerbation during low level exercise" as well as "severely diminished functional capacity." (Id. )
In a Medical Source Statement dated on October 30, 2008, Dr. Brigham opined that Ms. Clark was limited to lifting less than ten pounds even occasionally, as well as less than two hours standing or walking in an eight-hour workday. (R. 500-503.) He opined no limitations on sitting. (R. 501.) Dr. Brigham wrote that Ms. Clark "has severe functional limitations that are exertional in nature. These were documented by treadmill testing. She is unable to lift or carry things for any period of time due to recurrent tachycardia and near syncope." (Id. ) At some point before July 2009, Dr. Brigham updated the assessment, writing "[b]ased upon her most recent assessment, I believe she is limited to walking < 1="" hour."="" (r.="">
On November 1, 2011, Dr. Brigham wrote a letter in support of Ms. Clark's Social Security Disability Appeal. (R. 555.) Dr. Brigham wrote that Ms. Clark's "has had no significant change in overall functional status [since 2008] despite tapering doses of medication and attempts at new medications." (Id. ) He further wrote: "Her control of her arrhythmias with this medication has been marginal at best. I don't anticipate that this is due to any reversible cause and it continues to significantly limit her and result in recurrent periods of near syncope. Mrs. Clark's arrhythmias have been documented extensively including during ambulatory monitoring as well as during provocative stress testing. I anticipate continuing Mrs. Clark on her current medications and don't expect any significant change in overall functional status over the next several years." (Id. )
B. Hearing Testimony
At the 2012 hearing, testimony was heard from Ms. Clark and Vocational Expert ("VE") Lee Knutson; Ms. Clark was represented at the hearing by her attorney, Rick Gikas. (R. 47.)
1. Ms. Clark's Testimony
Ms. Clark testified that she is single and lives by herself in a duplex home. (R. 56.) She has a driver's license and is able to drive. (Id. ) She graduated from high school and has attended college classes part-time since 2006 at Indiana University Northwest. (R. 56-57.) She takes approximately nine credits per semester and hopes to earn a Bachelors of Fine Arts, focusing in photography. (R. 57.) Following graduation, she hopes to have some kind of job in photography, "taking pictures or working kind of on a freelance." (Id. ) She attends school two days a week. (R. 58.) Ms. Clark estimated that she had missed five class days in the four-to-five weeks immediately preceding the hearing, as well as eight or nine class days in the prior semester. (R. 70.) The reason for missing the classes was that she was "too dizzy, or lightheaded or my heart is going too fast" and she is not able to get out of bed. (Id. ) On some days that she attends classes, she lays down in between classes in order to prepare for the next class. (R. 71-72.)
At the time of the hearing, Ms. Clark was not employed. (R. 53.) She stated that she had not been employed since 2007, when her cardiologist suggested that she not work anymore. (Id. ) Prior to that time, she had worked full-time for a few years, in a variety of positions. (Id. ) Her previous positions included being a part-time receptionist with a real estate company, working in the office of a home health care company, and working as a direct care professional in a group home with mentally handicapped adults. (R. 67.)
Ms. Clark testified that she has "good days and bad days." (R. 57.) Even on good days, it takes her "a little while to get out of bed" because she has to "get up slow." (R. 58.) She explained that if she gets up quickly, her "blood pressure can drop, [and] heart rate can race or go [too] low." (Id. ) She testified that "it's quite a process just to get up and get ready." (Id. ) On school days, she has an hour-and-a-half break to relax between classes. On bad days, she said "there's not much activity at all. It's either I'm in bed or I'm laying on the couch. There's not, there's not much I do at all if it's a bad day." (Id. ) When questioned by counsel, Ms. Clark estimated that she has three "bad days" in a typical week. (R. 69.)
Ms. Clark explained that she does not always take her medicine because she builds up a tolerance to the medicine. (R. 62.) To combat this, she starts on lower doses, which she increases over time. When the dosage is maxed out, she has "to go off the medicine and be off of it for at least three months" before she can begin taking it again. ...