Hoskin v. Berryhill

CourtDistrict Court, N.D. Illinois
DecidedMarch 21, 2019
Docket1:17-cv-06909
StatusUnknown

This text of Hoskin v. Berryhill (Hoskin v. Berryhill) is published on Counsel Stack Legal Research, covering District Court, N.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Hoskin v. Berryhill, (N.D. Ill. 2019).

Opinion

UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

REGIS H.,1 ) ) No. 17 CV 6909 Plaintiff, ) ) v. ) Magistrate Judge Young B. Kim ) NANCY BERRYHILL, Acting ) Commissioner, Social Security ) Administration, ) ) March 21, 2019 Defendant. )

MEMORANDUM OPINION and ORDER

Regis H. (“Regis”) seeks Supplemental Security Income (“SSI”) based on his claim that the combination of congestive heart failure, hypertension, sleep apnea, chest pain, lower extremity edema, water retention, alcohol addiction, and morbid obesity prevents him from being able to perform full-time work. After the Commissioner of Social Security denied his application, Regis filed this lawsuit seeking judicial review of the Commissioner’s decision. See 42 U.S.C. § 405(g). Before the court are the parties’ cross-motions for summary judgement. For the following reasons, Regis’s motion is denied and the government’s is granted: Procedural History Regis filed his SSI application in November 2013, alleging a disability onset date of August 31, 2010. (Administrative Record (“A.R.”) at 216-21.) After his

1 In accordance with Internal Operating Procedure 22, this court uses only the first name and last initial of Plaintiff in this opinion to protect his privacy to the extent possible. application was denied initially and upon reconsideration, (id. at 73-92), Regis sought and was granted a hearing before an administrative law judge (“ALJ”), (id. at 133- 44), which took place in June 2016, (id. at 22-72). Regis appeared at the hearing with

his attorney. (Id. at 179, 201.) Thereafter, on November 8, 2016, the ALJ issued a decision concluding that Regis was not disabled and therefore not entitled to SSI. (Id. at 96-108.) When the Appeals Council denied Regis’s request for review, (id. at 1-6), the ALJ’s denial of benefits became the final decision of the Commissioner, see Minnick v. Colvin, 775 F.3d 929, 935 (7th Cir. 2015). Regis timely filed this lawsuit seeking judicial review of the Commissioner’s final decision, see 42 U.S.C. § 405(g);

(R. 1), and the parties have consented to this court’s jurisdiction, see 28 U.S.C. § 636(c); (R. 9). Background Regis was 37 years old when he applied for SSI, and he asserts that his symptoms became disabling when he was 34. He has limited education and limited work history. Although Regis testified that he worked as a barber for three years, (A.R. 32), the record shows that he reported income only in 2008, (id. at 32, 236).

According to Regis, he stopped working because of numbness and pain in his hands. (Id. at 33-34.) He presented documentary and testimonial evidence in support of his application at his hearing. A. Medical Evidence

The treatment record begins on July 2, 2013, when Regis presented to the hospital with complaints of chest pain and pressure after being non-compliant with his medication. (A.R. 384.) He reported feeling a sudden onset of chest pressure that resolved after he took his mother’s prescription medication. (Id.) He was admitted into the hospital for overnight observation. (Id. at 383.) During his hospitalization,

he underwent a stress echocardiogram, which did not reveal any abnormalities. (Id. at 409-10.) Regis was discharged the following day with a diagnosis of chest pain, hypertension, morbid obesity, and alcohol addiction. (Id. at 388.) He was instructed to follow up with Advanced Practice Nurse Ruth Shah and to bring with him his medications to the follow-up visit. (Id.) A little over a week later, on July 12, 2013, Regis met with Nurse Shah. (Id. at 689.) Regis brought in his prescriptions but had

not filled them because they cost too much. (Id.) Nurse Shah counseled him on low- cost alternatives and the importance of taking his medications. (Id.) Regis was advised to follow up with his primary care doctor. (Id.) On August 29, 2013, Regis met with Dr. Bassem Ibrahim. (Id. at 691.) Regis complained of daytime somnolence and bilateral leg swelling. (Id.) Dr. Ibrahim thought that Regis’s drowsiness was the result of sleep apnea and ordered a sleep study. (Id. at 693.) He also thought that the swelling could be caused by sleep apnea.

(Id.) Regis’s body mass index (“BMI”) was 63. (Id.) On December 14, 2013, Regis reported to an emergency room with difficulty breathing. (Id. at 339.) Regis complained of shortness of breath, chest tightness, cough, and abdominal swelling. (Id.) He was admitted into the intensive care unit and tested positive for influenza, which was found to be the cause of his shortness of breath and cough. (Id. at 342, 344, 354.) Regis was discharged on December 17, 2013, with a diagnosis of dyspnea, tachypnea, and upper respiratory infection. (Id. at 360.) On December 26, 2013, Regis once again reported to the hospital complaining

of chest pain and shortness of breath. (Id. at 453.) An electrocardiogram revealed “isolated ST elevation.” (Id.) A physical examination revealed wheezing, irregular heart rhythm, and bilateral 1+ edema. (Id. at 455.) Regis was admitted for atrial fibrillation (“AFib”) with rapid ventricular rate and for a non-ST-elevation myocardial infarction.2 (Id. at 459.) His treating physicians considered performing a cardioversion but eventually decided against the procedure because Regis was

considered high risk and because his AFib was under control with medication. (Id. at 462, 466, 486, 545-46, 550, 706.) On January 6, 2014, Regis was discharged with a diagnosis of AFib. (Id. at 553-54.) He was advised to follow up with a Coumadin Clinic. (Id. at 555.) On April 8, 2014, Regis met with Dr. Abina Goncalves, who has treated Regis during the relevant period. (Id. at 741-44, 747-68, 795-800, 888-930.) Dr. Goncalves noted that Regis reported a history of hypertension, chronic heart failure, AFib, and

thigh pain.3 (Id. at 742.) Associated symptoms of his heart failure included lower

2 AFib is a medical condition characterized by an irregular heartbeat that causes the lower chambers of the heart to beat too quickly. See https://www.webmd.com/heart- disease/atrial-fibrillation/afib-rapid-response#1 (last visited on March 14, 2019).

3 According to Regis, he was diagnosed with chronic heart failure at Stroger hospital in 2010. (Id. at 344, 457.) Although the agency sent a request for records asking for his treatment notes, the hospital responded that it had no treatment notes concerning Regis. (Id. at 445-48.) extremity swelling. (Id.) On exam, his BMI was 57, (id. at 743), and there was trace edema in his lower extremities, (id. at 744). On May 6, 2014, Regis was diagnosed with diabetes and started on Metformin. (Id. at 748-50.)

On June 13, 2014, Regis followed up with Dr. Goncalves. (Id. at 754-55.) He reported blood in his stool and was referred to the ER for further evaluation. (Id.) That same day Regis presented to the ER where it was noted his INR level was subtherapeutic. (Id. at 729-40.) He was then discharged from the hospital in stable condition. (Id. at 734.) On July 3, 2014, Regis followed up with Dr. Goncalves and trace edema was again noted in his lower extremities. (Id. at 756-58.)

On December 12, 2014, Regis was again sent to the ER by Dr. Goncalves because he ran out of medication. (Id. at 769, 795.) Dr. Goncalves noted that Regis was in poor compliance with his medications and recommended that he be admitted into the hospital. (Id. at 778.) Regis presented to the ER and appeared in no acute distress. (Id.

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