Washington v. Astrue

• Decision Date: 15 May 2008
• Docket Number: Civil Action No. 1:07-CV-1908-AJB.
• Parties: Shonna M. WASHINGTON, Plaintiff, v. Michael J. ASTRUE, Commissioner of Social Security Administration, Defendant.
• Court: U.S. District Court — Northern District of Georgia

Page 1287

558 F.Supp.2d 1287

Shonna M. WASHINGTON, Plaintiff, v. Michael J. ASTRUE, Commissioner of Social Security Administration, Defendant.

Civil Action No. 1:07-CV-1908-AJB.

United States District Court, N.D. Georgia, Atlanta Division.

May 15, 2008.

Shonna M. Washington, Marietta, GA, pro se.

Melaine A. Williams, Office of United States Attorney, Atlanta, GA, for Defendant.

ORDER AND MEMORANDUM OPINION¹

ALAN J. BAVERMAN, United States Magistrate Judge.

Plaintiff Shonna Washington ("Plaintiff), proceeding pro se (without an attorney), brought this action pursuant to sections 205(g) and 1631(c)(3) of the Social Security Act, 42 U.S.C. §§ 405(g), 1383(c)(3), to obtain`judicial review of the final decision of the Commissioner of the Social Security Administration ("the Commissioner") denying her application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") Benefits under the Social Security Act ("the Act").² For the reasons stated below, the Court REVERSES AND REMANDS for further proceedings consistent with this Order and Opinion.

I. PROCEDURAL HISTORY

Plaintiff filed an application for DIB on June 4, 2003, alleging disability commencing on June 4, 2003. [Record (hereinafter "R") 47-49]. She also filed an application for SSI on May 26, 2004, alleging the same disability onset date. [R53-55]. Plaintiff's SSI and DIB applications were denied initially and on reconsideration. [See R18-22, 30-31]. Plaintiff then requested a hearing before an Administrative Law Judge ("ALJ"). [See R17A, 32]. An evidentiary hearing was held on June 14, 2006. [R325-39]. The ALJ issued a decision on January 3, 2007, denying Plaintiff's claims on the grounds that she had not been under a "disability" at any time through the date of the decision. [R8-17]. Plaintiff sought review by the Appeals Council and on May 25, 2007, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner. [R4-6].

Proceeding pro se, Plaintiff then filed an action in this Court on July 23, 2007, seeking review of the Commissioner's decision. Shonna M. Washington v. Commissioner of Social Security, Civil Action File No. 1:07-cv-1908. [Doc. 2]. The answer and transcript were filed on January 24, 2008. [Docs. 7-8]. A supplement to the transcript was filed on April 30, 2008. [Doc. 16]. The matter is now before the Court upon the administrative record, the parties' pleadings, and the parties' briefs, and is accordingly ripe for review pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3).

II. STATEMENT OF FACTS

A. Plaintiff's Representations in Social Security Administration Forms

In a May 15, 2003, disability report, Plaintiff complained that the following conditions limited her ability to work: (1) valvular heart disease; (2) hypertension; and (3) iron deficiency. These conditions caused constant dizziness, chest pain, fatigue, and swelling feet. [R57].

In a June 19, 2003, pain report, Plaintiff indicated that she had aching and crushing pain in her chest two times per hour and constant pain in her upper back. She indicated that her chest pain caused her to hold her breath and forced her to take small breaths. [R79]. Plaintiff also had pain, which lasted all day long, in her right knee, lower legs and tenderness on the bottom of her feet. [R81]. She also had pain in her upper abdomen two times per day after eating. [R83]. She would get dizzy, light headed, and fatigued. [R85].

In a May 20, 2004, disability report appeal, Plaintiff reported that since her last report, she had the following new problems: palpitations, fatigue, constant break out of hives all over her body, and joint pain. [R92]. Plaintiff's problems from shortness of breath, chronic joint pain, hand swelling, and hives affected her ability to walk. [R96].

B. Medical Record

Plaintiff went to Med-Com Health Services on February 19, 2002, complaining of palpitations, chest pain, and dizziness. [R117, 119]. Her blood pressure was 140/90, and a physical exam revealed even and unlabored respiration. [R117]. Her judgment and insight were within normal limits and she was alert and oriented. Plaintiff was given the following assessment: palpitations, anemia, and fatigue. [R118]. Notes from a doctor's examination are largely illegible, but appear to indicate that Plaintiff needed a cardio consultation. [R119], On February 22, 2002, Plaintiff had an echocardiogram (an exam that uses ultrasound to create a moving picture of the heart),³ which revealed: (1) normal left ventricular dimensions and systolic function (2) trace tricuspid valve regurgitation (the backflow of blood across the tricuspid valve separating the right ventricle from the right atrium); and (3) no pericardial effusion (increased fluid in the pericardial sac that can cause circulatory problems from compression of the heart). [R129, 260].

Plaintiff returned to Med-Com Health Services on March 20, 2002, complaining of heart palpitations. She also complained of headaches and dizziness. Plaintiff's respiration was even and unlabored. [R113]. Her judgment and insight were within normal limits, and she was alert and oriented. Plaintiff was given the following assessment: palpitations, anemia, and fatigue. [R114]. Plaintiff again went to MedCom Health Services on April 30, 2002, where she complained of headaches and nausea. Her blood pressure was 118/72, and her breathing was even and unlabored. [Rill]. Plaintiff was alert and oriented. [R113]. She had some tenderness of the central spine with some spasms. [R112]. The assessment indicated that Plaintiff had headaches and anemia. [Id.].

Plaintiff was seen at Med-Com Health Services on May 9, 2002, where she complained of chronic headaches. Her blood pressure was 134/80. Her respiration was even and unlabored. Plaintiff had a normal MRI on May 6. She also had tight braids, but her head was not throbbing. [R109]. Plaintiff was assessed with headaches and told to diet, exercise, and take Alleve. [R110].

On May 6, 2002, Plaintiff had an MRI of the brain and a MRA (imaging of blood vessels) of the brain because of a history of chronic headaches. Both exams came back normal. [R187].

Plaintiff was seen on May 16, 2002, for a medical consultation by an unidentified doctor. The medical note indicated that Plaintiff was seen for evaluation of her palpitations, heart murmur, and valvular insufficiency. The note also indicated that Plaintiff had been seen for the past few months with a combination of palpitation, chest heaviness, occasional dizziness, and shortness of breath. Plaintiff's tests indicated some mild arrhythmias and a leaky valve. A physical examination revealed that: Plaintiff's blood pressure was 150/90; she had clear lungs; and she had a grade I/VI apical systolic murmur.⁴ [R104]. An EKG showed nonspecific ST alterations. Plaintiff was assessed with the following: atypical chest pain, dizziness and dyspnea (difficult or labored respiration); hypertension, possible mitral insufficiency; migraine headaches; and anemia. [R104, 263].

Plaintiff went to Med-Com Health Services on August 27, 2002, where she complained of palpitations, chest pain, nausea, and abdominal pain. Her blood pressure was 154/92. Her respiration was even and unlabored. [R107]. Her gait was smooth and coordinated, and she was alert and oriented with normal insight and judgment. Plaintiff was assessed with hypertension, palpitations, headaches, nausea, and anemia. [R108].

On February 3, 2003, Plaintiff went to the Southern Jersey Family Medical Centers, Inc., ("SJFMC"), because she was out of her hypertension medications. The notes also indicated that Plaintiff complained of occasional shortness of breath on exertion, but she denied palpitations or chest pain. The doctor gave the following impression: (1) hypertension; (2) anemia; and (3) shortness of breath probably due to anemia or valve disease. [R291].

Plaintiff went to the SJFMC on February 20, 2003, where she was assessed with hypertension and a history of valvular heart disease. [R301]. Plaintiff returned to the SJFMC on February 28 where she was diagnosed with stable hypertension, valvular heart disease, and iron deficiency anemia. [R300]. Plaintiff had a treadmill stress echocardiogram on March 8, 2003. The results were normal. [R181].

Plaintiff went to the SJFMC on March 12, 2003, where she was diagnosed with hypertension, valvular heart disease, and anemia. [R299]. Two days later, Plaintiff had an x-ray of her pelvis. This x-ray revealed a small cyst-like fluid collection. The report indicated that it might indicate a uterine cyst, a remote hemorrhage, or a cystic degeneration of a fibroid. Also, the report indicated that a very early pregnancy may be present. [R175]. Plaintiff then went to the SJFMC on March 26, 2003, where she was diagnosed with controlled hypertension, anemia, and valvular heart disease. [R298].

Plaintiff was seen on April 25, 2003, at the SJFMC. She complained of swelling in the legs. Plaintiff did not exhibit shortness of breath or palpitation. The medical notes indicated that Plaintiff had a history of hypertension and anemia. [R307].

On May 15, 2003, Plaintiff went to the SJFMC where she was diagnosed with hypertension, anemia, and valvular heart disease. [R296]. On May 16, 2003, Plaintiff had x-rays of her right lower leg and chest. Plaintiff complained of leg pain three inches below her patella, but the x-ray of her right lower leg was negative. Also, x-rays of Plaintiff's chest were normal, but it was noted that there was a suggestion of rotatory scoliosis of the lumbar spine. [R152].

On May 18, 2003, Plaintiff was admitted to the Atlantic City Medical Center because of abdominal pain, pain of the left shoulder, and shortness of breath. [R133, 139]. She was discharged on May 24, 2003. [R1331. An ultra sound of the upper abdomen on May 18, 2003, was normal. [R168]. A CAT scan of the abdomen showed a large amount of ascites ...