MEMORANDUM-DECISION AND ORDER
On June 4, 2004, Plaintiff David W. Seaton ("Plaintiff"), filed an application for Disability Insurance Benefits ("DIB") under the Social Security Act ("the Act"). In that application, Plaintiff asserts that he has been disabled since approximately November 1, 2003. The Commissioner of Social Security ("the Commissioner") denied Claimant benefits for lack of disability.
Plaintiff now seeks judicial review of the Commissioner's decision pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). Compl. (Dkt. No. 1). Both parties have moved for judgment on the pleadings. For reasons that follow, this case is remanded for further proceedings.
Plaintiff was born November 25, 1955, and was 48 years old at the alleged onset date of his disability.R. 47, 56.*fn1 He has a ninth grade education and never received a GED. R. 64, 262. For 24 years, from 1979 to 2003, Plaintiff worked as a utility operator at a chocolate factory. R. 60, 262. In that position, he was required to hang sacks of powdered milk weighing approximately 2000 lbs. R. 60, 262. Plaintiff has a history of tobacco and alcohol use. R. 127, 134-36, 223.
Plaintiff testified that he first began to experience numbness in his legs during a long car ride that he took in November 2003. The numbness dissipated once he got out of the car. R. 263. Prior to this incident, Plaintiff experienced shortness of breath and pain in the back. R. 170, 168. On August 13, 2003 and August 22, 2003, Plaintiff went to see Dr. Jayakumar Thotambilu, who noted Plaintiff suffered from hypertension, but that his blood pressure had come under control with medication. Dr. Thotambilu noted Plaintiff's back pain, for which he prescribed Paxil and Xanax, and arranged for an MRI and x-rays. R. 169. Following the MRI, Dr. Thotambilu again noted that Plaintiff was in a lot of pain from his back and found "MRI of the lumbosacral spine series three view for fracture or subluxation . . . [and] no significant disc bulge or herniation . . . [or] significant effacement of the thecal sac." R. 168. The doctor noted that Plaintiff displayed "L5-S1 central disc protrusion . . . marked degradation images through the upper thoracic spine . . . mild disc bulges at the [lower thoracic spines; and m]ild degenerative disc disease. No significant canal stenosis is appreciated." R. 168. He prescribed Flexeril and physical therapy. R. 168.
Plaintiff, continuing to suffer from back and buttock pain despite months of treatment by Dr. Christiana, a chiropractor, R. 99-119, went to see Dr. Karen Beckman, M.D. on December 29, 2003.
R. 223-24. Plaintiff told Dr. Beckman that he was having difficulty sleeping, but denied that he was suffering from shortness of breath or chest pain. Dr. Beckman diagnosed Plaintiff as suffering from "[b]ack pain and neurological symptoms with increased reflexes" after noting that "[t]here is some tenderness at his lower spine and across his SI joints bilaterally . . . Sensation is intact throughout. Strength is intact throughout. Gait is within normal limits." R. 223-24. She referred Plaintiff to a neurologist and surgeon. R. 224.
On February 24, 2004, Plaintiff, complaining of "heaviness, stiffness, and difficulty with his gait and balance[,] . . . burning in his legs . . . [and] neck stiffness" went for a neurological consultation conducted by Hassan Shukri, M.D. Dr. Shukri assessed Plaintiff as suffering from "weakness in his right upper and lower extremities with sustained clonus" the etiology of which "could be either cervical or thoracic myelopathy either due to herniated disc or spondylosis." R. 121-23. Dr. Shukri noted that Plaintiff had decreased sensation to pinprick and recommended an MRI. He speculated that Plaintiff "could have some lumbar spinal stenosis with some radiculopathy." R. 123. Following the MRI, which revealed a herniated disc, Dr. Shukri referred Plaintiff for a neurosurgical consultation. R. 120.
Dr. David Eng, M.D., Ph.D. conducted that consultation on April 7, 2004. R. 125. Eng's evaluation found that Plaintiff's pinprick, light touch, vibratory, and position sense were intact; gait was unsteady; no straight leg raising; clonus present in both lower extremities and Hoffmann sign in both upper extremities. Responding to Plaintiff's complaints of neck and right arm pain, hand and leg numbness, and stiffness in the legs, Dr. Eng found Plaintiff "clearly has signs of myelopathy" resulting from a C5-C6 cervical stenosis; he opined that surgery warranted. R. 126-27.
Plaintiff saw Dr. Thotambilu again on May 26, 2004, complaining of chest pressure. Dr. Thotambilu diagnosed Plaintiff as having multiple coronary risk factors and hypertension, but found that his medication had kept his blood pressure under control. The doctor increased Plaintiff's Paxil prescription and arranged for him to undergo a Persantine Cardiolite stress test. R. 166.
On July 1, 2004, Plaintiff saw Kalyani Ganesh, M.D. for a consultative orthopedic examination. R. 129-32. Diagnosing Plaintiff with myelopathy and herniated disc with foraminal narrowing, Dr. Ganesh found that Plaintiff did not appear to be in acute distress and had a normal gait, was able to rise from a chair without difficulty; his hand and finger dexterity appeared intact and his grip strength was 5/5 bilaterally. R. 130. Plaintiff's cervical spine had full flexion and rotary movements with no cervical pain or spasm and no trigger points. R. 131. Plaintiff complained of pulling sensation in the thoracic spine and presented some reduced range of movement in his shoulder. Dr. Ganesh found a full range of movement in Plaintiff's elbows, forearms, wrists, hips knees and ankles bilaterally, and no joint inflamation, effusion, instability, or muscle atrophy. He displayed hypersensitivity to pinprick in his lower extremities. His strength was deemed 4/5. R. 131. Dr. Ganesh opined that Plaintiff had no gross limitation as to sitting, standing, or using his upper extremities, but a moderate degree of limitation in walking, climbing, lifting, carrying, pushing, pulling, or repetitively using his upper extremities. R. 131.
Also, on July 1, 2004, Plaintiff saw psychologist Kristen Barry, Ph.D. for a consultative psychiatric evaluation. R. 133-37. Barry noted that Plaintiff had no history of psychiatric hospitalizations or outpatient psychiatric treatment or counseling; Plaintiff was not taking any medications because they made him sick. R. 133. Claimant complained of poor sleep, decreased appetite, and depressed mood, though not so depressed as to be suicidal. Barry found Plaintiff's prognosis from the psychological standpoint to be fair, and diagnosed him as suffering adjustment disorder with depressed mood. Barry opined that Plaintiff is able to follow and understand simple directions and that he is able to maintain attention and concentration. She recommended medical follow-up and continued use of psychiatric medications. R. 136.
On July 23, 2004, before undergoing his stress test, Plaintiff, experiencing less shortness of breath but significant pain in his neck, returned to Dr. Thotambilu. Dr. Thotambilu again recommended the stress test and noted that Dr. Eng was considering the possibility of surgical intervention to Plaintiff's fifth cervical vertebrae. Plaintiff returned to Dr. Thotambilu on August 14, 2004, again complaining of back and chest pain, and shortness of breath. Dr. Thotambilu found Plaintiff's stress test positive for "periinfarct schemia," and he therefore strongly recommended a cardiac catheterization. R. 91. That catheterization was performed August 19, 2004 and revealed insignificant coronary artery disease and normal left ventricular functioning.
On September 13, 2004, Dr. Seok, a state agency medical consultant, reviewed Plaintiff's file, and found that no significant limitation existed with regard to Plaintiff's cardiac condition. Dr. Seok proposed that Plaintiff's charts indicate he has a residual functional capacity of light with further limitations of pushing or pulling objects over 20 pounds. R. 171. Dr. Seok opined Plaintiff could stand or walk for up to 6 hours in an 8 hour day, and/or sit for the same duration. R. 171.
On September 23, 2004, Plaintiff received another residual functional capacity assessment, completed by C. Zelno, DA. R. 173-78. Zelno found Plaintiff could occasionally lift or carry 20 pounds, frequently lift or carry 10 pounds, stand or walk about 6 hours in an 8 hour day, sit about 6 hours in an 8 hour day, and exhibited limited ability to push or pull in the upper extremities; based on this, Plaintiff was deemed able to do light work. R. 174-75.
On September 24, 2004, Ed Kamin, Ph.D., a non-examining psychologist, provided Plaintiff with a mental residual functional capacity assessment in which Plaintiff was deemed to have "the ability to maintain attention and concentration for an 8 hour work day[,] . . . make simple work related decisions . . . [and] follow simple directions . . . . His ability to maintain a normal work day without interruption from psychological symptoms is only moderately limited . . . [as is] his ability to get along with others." R. 94. Dr. Kamin determined that Plaintiff suffered only mild restrictions in activities of daily living, mild difficulties in maintaining social functioning, moderate difficulties on maintaining concentration, persistence, or pace, and no episodes of deterioration. R. 179-92.
In May 2005, after Plaintiff's application for benefits was denied by the SSA, but prior to his hearing before an administrative law judge, Plaintiff received a physical medical source statement from Dr. Shukri. Dr. Shukri noted that Plaintiff is capable of low stress jobs, but could sit or stand less than 2 hours in an 8 hour day at intervals of no longer than 30-45 minutes at a time; rarely lift or carry objects weighing 10 pounds; never look down or turn his head right or left; occasionally hold his head in a static position; and never twist, stoop, crouch, or climb ladders or stairs. R. 227-31.
Plaintiff was hospitalized on May 12, 2005. Dr. Francis Arce, M.D. diagnosed Plaintiff as suffering from acute pancreatitis, new onset type II diabetes, chronic obstructive pulmonary disease, hypertension, hyperlipidiemia, renal insufficiency, ...