Cruz v. Astrue

746 F. Supp. 2d 978, 2010 U.S. Dist. LEXIS 102852, 2010 WL 3862530
CourtDistrict Court, N.D. Indiana
DecidedSeptember 27, 2010
Docket3:09-cv-00262
StatusPublished
Cited by3 cases

This text of 746 F. Supp. 2d 978 (Cruz v. Astrue) is published on Counsel Stack Legal Research, covering District Court, N.D. Indiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Cruz v. Astrue, 746 F. Supp. 2d 978, 2010 U.S. Dist. LEXIS 102852, 2010 WL 3862530 (N.D. Ind. 2010).

Opinion

OPINION AND ORDER

PAUL R. CHERRY, United States Magistrate Judge.

This matter is before the Court on a Complaint [DE 1], filed by Plaintiff Ralph Cruz on August 27, 2009, and Plaintiffs Memorandum in Support of His Motion for Summary Judgment [DE 19], filed by Plaintiff on April 2, 2010. Plaintiff requests that the January 16, 2009, decision of the Administrative Law Judge to deny him disability insurance benefits be reversed or, alternatively, remanded for further proceedings. For the following reasons, the Court grants the request and remands for further proceedings.

PROCEDURAL BACKGROUND

On March 8, 2007, Plaintiff filed an application for Supplemental Security Income, and filed an application for Disability Insurance Benefits on August 7, 2007, alleging a disability onset date of January 18, 2006. Plaintiffs applications were denied initially and upon reconsideration.

A hearing was held on October 6, 2008, before Administrative Law Judge (“ALJ”) John E. Meyer, at which Plaintiff, his attorney Thomas Scully, Medical Expert James McKenna, and Vocational Expert (“VE”) Grace Gianforte appeared. On January 16, 2009, the ALJ issued a decision denying Plaintiffs applications. Plaintiff filed a Request for Review and the Appeals Council denied this request on July 20, 2009, leaving the ALJ’s decision the final decision of the Commissioner.

*980 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).

FACTS

A. Background

Plaintiff, born in 1962, was 43 years old on the date of his alleged onset of disability, and 46 years old on the date of the ALJ’s decision. He had a ninth grade education, past work experience as an order puller at K-Mart from October 2005 through January 2006, and prior work as an assembler, a janitor, and in a hybrid position as a grinder, crane operator and spray painter.

B. Medical Evidence

In February 2002, Plaintiff was seen in the emergency room at St. Catherine Hospital for complaints of low back pain after he fell shoveling snow. He was assessed with acute back strain and discharged with prescriptions for Motrin, Skelaxin (a muscle relaxer), and Vicodin. In March 2003, an MRI of Plaintiffs lumbar spine showed degenerative disc disease from Ll-2 through L5-S1, diffuse disc bulges at L2-3 through L5-S1, and a herniation at L3-4 with possible compression of the left L4 nerve root and mild to moderate spinal stenosis.

In June 2005, Plaintiff was seen in St. Catherine’s emergency room for complaints of worsening back pain over the prior two to three weeks, with some numbness and tingling in his legs. He was discharged with prescriptions for Vicodin and Flexeril, and instructed not to engage in heavy lifting.

On January 10, 2006, Plaintiff returned to the emergency room at St. Catherine’s with complaints of low back pain that began the day before. Plaintiff reported his pain as moderate to severe, but, on examination, it was noted that he was only in mild distress. Straight leg raising was positive on the right, and Plaintiff exhibited muscle spasm and range of motion limitations in his lumbar region. He was discharged with prescriptions for Motrin, Flexeril, and Vicodin, and instructions not to work for four days or engage in lifting. On January 13, 2006, Plaintiff returned to St. Catherine’s. It was noted that he was ambulating, but required a cane. X-rays of his lumbar spine showed no obvious fractures.

On January 18, 2006, Plaintiff saw Dr. Joseph Spott. Plaintiff told Dr. Spott that he injured his back while pulling patio furniture out of a box a this job at K-Mart. Dr. Spott noted that despite Plaintiffs prescriptions for pain medications and a muscle relaxer, he still complained of tenderness in his lower back. On examination, Plaintiff exhibited some muscle spasm in his lumbar spine, range of motion limitations secondary as a result of the spasm neurological testing was normal, and his legs were stable with range of motion. He also had paresthesias from his buttocks to his bilateral knees. Dr. Spott assessed Plaintiff with lumbar sprain, recommended physical therapy, and indicated that Plaintiff could return to work if he lifted no more than five pounds.

Plaintiff started physical therapy on January 19, 2006. He described his pain as “hot-burning” and rated it as an eight on a scale of zero to ten. After one session, Plaintiff stated that he felt much better and rated his pain as a four on a scale of zero to ten. Despite missing his January 26, 2006, appointment, on January 30, 2006, Plaintiff stated that he felt better *981 and had been performing his exercises. Plaintiff reported continued improvement at his next two appointments in early February 2006, but missed his appointment on February 6, 2006. Plaintiff again reported progress on February 8, 2006, but missed his final three appointments.

On October 13, 2006, Plaintiff was seen in the emergency room at St. Margaret Mercy hospital for an abscess on his left thigh. On examination, it was noted that he was in no acute distress.

On October 26, 2006, Plaintiff underwent a consultative physical examination with Dr. Kanayo Odeluga. Plaintiff complained of lower back pain, joint pains, and blood in his stool. He stated that his back pain had been present for over a year and described it as unbearable on the day of the examination and severe the day before. He also claimed that he experienced tingling, burning, and numbness in his arms, legs, face, and hands. Plaintiff told Dr. Odeluga that he was in a car accident over three weeks prior. He also reported an unspecified work injury and a serious head injury. He claimed that he formerly used alcohol, but no more than one to two drinks per day, and he reported formerly using illegal drugs. On examination, Dr. Odeluga observed that Plaintiff was cooperative and in no painful distress, his lumbar range of motion was slightly limited; straight leg raise testing was negative; his strength was normal; his gait was slow and short, but without an assistive device; neurological testing was normal; he exhibited mild difficulty squatting and walking on toes, but had no difficulty tandem walking or getting on and off the examination table.

On December 3, 2006, Plaintiff returned to St. Margaret’s emergency room and saw Dr. Chittaranjan Patel for treatment of an abscess on his right thigh. On examination, Plaintiff was in mild distress secondary to pain. Dr. Patel diagnosed Plaintiff with cellulitis. Plaintiff was able to walk with a cane. Dr. Patel instructed him to stop smoking.

In February 2007 Plaintiff returned to the emergency room at St. Margaret’s with complaints of rectal pain and bleeding which was attributed to a ruptured hemorrhoid. Plaintiffs physical examination was otherwise normal.

On April 18, 2007, state agency reviewing physician Dr. J.V.

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Cite This Page — Counsel Stack

Bluebook (online)
746 F. Supp. 2d 978, 2010 U.S. Dist. LEXIS 102852, 2010 WL 3862530, Counsel Stack Legal Research, https://law.counselstack.com/opinion/cruz-v-astrue-innd-2010.