Flores v. Massanari

19 F. App'x 393
CourtCourt of Appeals for the Seventh Circuit
DecidedSeptember 13, 2001
DocketNo. 00-4334
StatusPublished
Cited by19 cases

This text of 19 F. App'x 393 (Flores v. Massanari) is published on Counsel Stack Legal Research, covering Court of Appeals for the Seventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Flores v. Massanari, 19 F. App'x 393 (7th Cir. 2001).

Opinion

ORDER

Benedicto Flores suffers from a severe, chronic blistering skin disease known as pemphigus vulgaris. Based on that affliction and the harmful side effects caused by high-dose steroid therapy, Flores sought social security disability benefits. An administrative law judge denied benefits on the ground that Flores had the residual functional capacity to perform a limited range of light work. The Appeals Council and the district court affirmed that determination, and Flores appeals. We conclude that the ALJ failed to provide Flores with adequate reasons for the decision and disregarded evidence favorable to Flores. We therefore vacate the district court’s judgment and remand the case for further proceedings.

I.

Flores is an unskilled construction laborer with a sixth grade education. He was born in Mexico and came to United States in 1977 at the age of 25. His work in the United States has always involved heavy exertion-as a bricklayer, landscaper, and [396]*396black topper. He worked steadily from 1982-1995. Flores applied for disability insurance benefits in March 1996, alleging that he has been unable to work since December 28, 1995, when he was first hospitalized for intractable mouth and throat pain. Flores had been unable to swallow or eat because of the pain and consequently had lost 20 pounds.

During that hospital stay, a biopsy confirmed the diagnosis of pemphigus vulgar-is. Pemphigus is a relatively rare but serious skin and mucous membrane blistering disorder. The blisters usually break out in the mucous membranes of the mouth and can later spread to other parts of the body. These blisters often rupture and ulcerate. Pemphigus is caused by an immune system that produces antibodies which attack skin cells. Stedman’s Medical Dictionary 27th ed. (2000). Once a life-threatening illness with high mortality rates, pemphigus can now be controlled (but not cured) by the anti-inflammatory steroid Prednisone. The side effects of long-term Prednisone, however, can be significant, including muscle weakness, mood symptoms, diabetes, and risk of infection.

Flores has been continuously treated by two doctors since his diagnosis—Dr. John J. McGillen, an internist who specializes in infectious diseases, and Dr. Joan Guitart, a dermatologist. Dr. McGillen saw Flores approximately once a month from December 1995 until early-1998. During Flores’ initial hospitalization in December 1995, the doctor initially treated the extensive ulcers and blisters in Flores’ mouth with an “immediate aggressive high dose” of Prednisone-160 mg—and Imuran, an immunosuppressant. Nearly three weeks after his discharge, however, Flores was re-hospitalized for severe pain and inability to eat or drink. A high-dose steroid treatment was resumed, and Flores was given a morphine patient-controlled administration pump to reheve his pain. Flores’ condition improved, but Dr. McGillen remained concerned and referred Flores to a tertiary care center for additional consultation.

In January 1996 Flores proceeded to Northwestern Memorial Hospital, where he began treatment with Dr. Guitart. At Flores’ initial visit, Dr. Guitart observed that Flores had “multiple erosions” in his mouth and treated him with Prednisone. At this time Flores was also diagnosed with diabetes. Dr. Guitart’s treatment notes during the ensuing months reflect that Flores’ condition continued to improve with Prednisone; she reported that Flores had no bleeding or exudation in his mouth, and his mouth lesions were slowly healing with treatment. She tapered the Prednisone from 90 mg/day in March to 60 mg/ day in May, and she continued to reduce the Prednisone by 5 mg/week. In June Dr. Guitart recorded that Flores had no oral erosion and the pemphigus condition was “stable.” In August Dr. Guitart noted that Flores had no active lesions and Flores no longer reported feeling pain when his cheeks were touched. An October visit revealed no erosions in Flores’ mouth and Dr. Guitart discontinued the Prednisone.

The aggressive use of Prednisone, however, had triggered a host of complications, ranging from muscle pain and fatigue to an onset of diabetes that required Flores to take insulin. In response to a questionnaire by the Illinois Disability Determination Services (DDS), Dr. McGillen stated in April 1996 that “[b]ecause of the toxicity of the medication and his illness, ... Flores is really unable to work at all at the present time at any capacity,” and that “[c]onstant narcotics are required for his comfort.” Around the same time, Dr. Guitart completed a DDS form in which she noted that the Prednisone had induced [397]*397diabetes as well as “muscle wasting,” and that the oral erosions were responding only “very slowly” to treatment. In early November Dr. McGillen responded to a telephone inquiry from DDS regarding a new application for benefits that Flores had filed, and the doctor reported Flores’ complaints of muscle wasting and back problems. When asked about Flores’ current functional capacity, Dr. McGillen replied that it was “doubtful” that Flores “really could do anything in the way of employment” apart from “envelope sorting or something like that,” but the doctor held out hope that Flores’ condition would improve once the Prednisone dosage was lowered.

Instead Flores’ condition declined. In mid-November Dr. McGillen noted that open sores had returned in Flores’ mouth. Later in November Dr. Guitart confirmed that the pemphigus had flared up, and she pointed out oral ulcers on the wall of the left cheek and the left side of the tongue. She restarted Flores on 40 mg of Prednisone per day. One week later, Dr. Guitart spoke with Flores’ stepdaughter, Maria Tonkin, who told her that Flores had gone to Mexico for a two-week trip but had been complaining of insomnia and depression similar to episodes previously suffered while on Prednisone. Dr. Guitart lowered the dosage to 20 mg. In mid-December Dr. Guitart gave a telephone report to DDS and stated that pemphigus is a “very unpredictable and chronic disease.” Asked to explain how the pemphigus affected Flores’ functioning, Dr. Guitart stated that the Prednisone was contributing to a condition known as myositis: ‘When the claimant had taken steroids in the past, he had been debilitated and complained of chronic tiredness, coughing and difficulties eating and drinking. Myositis is the name for this condition of chronic weakness that he has had. His myositis had been improving, but now that he is back on Prednisone he is again complaining of aches, pains and weakness.” Updating Flores’ disease in a report she prepared the following month for Flores’ private pension disability provider, Dr. Guitart emphasized pemphigus’ seriousness and unpredictability. Though Flores’ lesions remained localized, she cautioned that “generalized lesions could occur at any time, which would predispose him to infection, sepsis, and high output cardiac failure.” To control this blistering process, Flores needed “chronic high doses” of Prednisone and Imuran. The Prednisone, however, “has caused a steroid-induced myopathy as well as chronic nonspecific arthralgia” (pain in the joints). Dr. Guitart summed up her the report by “stressing] that pemphigus vulgaris is a chronic, severe, life-threatening disorder.” Despite the reports of Drs. McGillen and Guitart, the Social Security Administration determined that Flores’ condition did not prevent him from working; early in 1997 the agency denied Flores’ request for benefits and his request for reconsideration.

In March 1997 Dr. Guitart reported that Flores was “still with oral ulcerations breaking out and pain,” and referred him for another biopsy to Dr.

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Bluebook (online)
19 F. App'x 393, Counsel Stack Legal Research, https://law.counselstack.com/opinion/flores-v-massanari-ca7-2001.