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Dickson v. Commissioner of Social Security

February 27, 2008


The opinion of the court was delivered by: Norman A. Mordue, Chief U.S. District Judge



Plaintiff David Dickson brings the above-captioned action pursuant to 42 U.S.C. § 405(g) and 1383(c)(3) of the Social Security Act, seeking review of the Commissioner of Social Security's decision to deny his applications for disability insurance benefits ("DIB") and supplemental security income ("SSI"). The Court, having considered plaintiff's contentions and the entire administrative record, finds that the ALJ erred in finding that plaintiff was not disabled. Accordingly, the decision must be reversed and remanded.


Plaintiff was born in 1957; at the time of the administrative hearing held in this matter on June 3, 2003, plaintiff was forty-six years old. Administrative Transcript at pp. 48, 263.*fn1

Plaintiff is single and has no children. AT 263. He lives in his mother's house with his mother and brothers. Id.

Plaintiff completed one year of college. AT 70, 264. He previously worked as an assistant manager at a fast food restaurant and as a manger of Cumberland Farms. AT 265. He also performed data entry on a seasonal basis apparently for approximately seven years. AT 65, 268.

Plaintiff alleges that he is disabled due to sarcoidosis,*fn2 a damaged disc, migraine headaches, arthritis, asthma, and seizures. AT 16, 64, 81. He also claims that he suffers from auditory hallucinations. AT 270-71. He claims that he became unable to work due to these conditions on July 24, 2001. AT 48.

A. Physical Condition

From February 16, 1996 to June 28, 1999, plaintiff was treated for, inter alia, low back pain by Arvinder Singh, M.D. and Abraham Rivera, M.D., pain management specialists.*fn3 AT 100-21. He was diagnosed as suffering from posterior joint syndrome of the lumbar spine and treated with, inter alia, medications, hydrotherapy, and radio frequency denervation. Id.

As of October 19, 1999, plaintiff was treating with Nathan Mitkoff, M.D. AT 125. Plaintiff complained of, inter alia, shoulder pain, right arm pain, shortness of breath, pain on his left side, seizures, and syncopal. AT 127, 191, 195-200. Dr. Mitkoff diagnosed plaintiff as suffering from, inter alia, sarcoidosis, seizures, pain, and osteoporosis. AT 126-29, 196-200. He prescribed numerous medications, such as Prednisone.*fn4 AT 201-05.

On December 10, 2001, plaintiff underwent an orthopedic examination at the request of the agency by Amelita Balagtas, M.D. AT 154-56. During the examination, plaintiff's abilities to perform forward flexion and straight leg raising were limited by lower back pain. AT 155. An x-ray of plaintiff's lumbar sacral spine revealed that the disc space at L5-S1 was "severely narrowed," and showed "mild degenerative 'lipping.'" AT 157. Dr. Balagtas diagnosed plaintiff as suffering from lower back pain and concluded that plaintiff would have "some limitations" in performing bending, lifting, prolonged sitting, and prolonged standing. AT 156.

On February 6, 2002, plaintiff underwent an internist examination at the request of the agency by Jogendra Chhabra, M.D. AT 171-79. During the examination, plaintiff's lumbar spine showed a limited range-of-motion, but there was no spasm or point tenderness. AT 174. Straight leg raising was positive bilaterally. Id. Results of pulmonary function testing showed a "mild restriction." AT 175, 176. Dr. Chhabra concluded that plaintiff has no limitations with personal grooming, speech, vision, hearing, or with the use of his upper extremities for fine and gross motor activities. AT 175. Dr. Chhabra found "mild" limitations performing household activities, and "moderate" limitations with exertional activities, such as walking distances, climbing stairs, lifting, and bending. Id. Dr. Chhabra also opined that due to plaintiff's history of seizures, plaintiff "needs to avoid situations like water bodies, heights, and machinery, and maybe driving." Id.

In the interim, on February 28, 2003, plaintiff saw Natalia E. Veselova, M.D., a rheumatologist. AT 218-20. Dr. Veselova opined that "the main issue" for plaintiff appears to be pain management rather than management of his sarcoidosis. AT 219. She recommended that plaintiff see Dr. Singh, taper his dosage of Prednisone, and continue taking Plaquenil.*fn5 Id.

Plaintiff returned one month later on March 28, 2003. AT 221-22. Dr. Veselova noted that plaintiff complained of "generalized achiness" and discomfort in his knees without significant swelling. AT 221. Dr. Veselova found that plaintiff was in no apparent distress. Id. She recommended that plaintiff start taking a small dose of Methotrexate.*fn6 AT 221. X-rays taken of plaintiff's chest, right knee, right shoulder, and scapula on April 2, 2003 were negative. AT 223-27.

The record also contains a Physical Residual Functional Capacity ("RFC") Assessment form, which appears to have been completed by a non-physician disability analyst, "R. Friedlander." AT 180-87. In the form, it is indicated that plaintiff could lift and carry twenty pounds occasionally; lift and carry ten pounds frequently; and stand, walk, or sit about six hours in an eight-hour workday. AT 181. It was also indicated that plaintiff had unlimited abilities to push and pull; occasional postural limitations; should avoid concentrated exposure to fumes, odors, dusts, gases, poor ventilation, etc; and should avoid all exposure to hazards. AT 181-84.

B. Mental Condition

On May 13, 2002, plaintiff's treating physician, Dr. Mitkoff, noted that plaintiff experienced auditory hallucinations. AT 200. Dr. Mitkoff noted that past medications had failed plaintiff and that the hallucinations were likely due to steroids, which he should try to taper. Id. Dr. Mitkoff referred plaintiff to "Pinnacle Psych." Id.

On June 12, 2002, Dr. Mitkoff noted that plaintiff was hospitalized "for several days when he was seen [at] Pinnacle Psych." AT 198. Dr. Mitkoff noted that plaintiff stated that "the voices were commanding him [and] he must obey." Id. It was also noted that plaintiff's dosage of Prednisone was reduced, which helped control the voices; however plaintiff complained of experiencing "aches all over." Id.

On August 5, 2002, Dr. Mitkoff noted that the auditory hallucinations "are not more prevalent" and there was "no steroid psychosis." AT 196. However, on September 23, 2002, Dr. Mitkoff noted that plaintiff experienced increased auditory hallucinations, which caused him to run from a security guard, resulting in a ticket from the police. Id. Dr. Mitkoff noted that plaintiff "is seeing Psych" and that the dosage of Prednisone had been reduced, which decreased the voices to "manageable levels." Id.

The record reflects that as of October 29, 2002, plaintiff was treating with Dr. Alarcon at Pinnacle Behavioral Health.*fn7 AT 229-33; see AT 246. After adjusting plaintiff's medications, plaintiff's auditory hallucinations "decrease[d] substantially;" however visual hallucinations increased. AT 232. Plaintiff was diagnosed as suffering from psychotic disorder with hallucinations due to Prednisone. AT 230-33.

Dr. Veselova noted on February 28, 2003 that plaintiff claimed that he was unable to reduce his dosage of Prednisone because he experiences a "flare," which he defined as aches, and because "the voices in his head become louder." AT 218. She stated that sarcoidosis generally responds to smaller doses of ...

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