United States District Court, W.D. Wisconsin
OPINION AND ORDER
BARBARA B. CRABB District Judge.
John Francis Tobin is seeking review of a final decision by
defendant Nancy A. Berryhill, Acting Commissioner of Social
Security, denying his claim for disability insurance benefits
and supplemental security income under the Social Security
Act. 42 U.S.C. § 405(g). Dkt. #8. Plaintiff seeks remand
of that decision, arguing that the administrative law judge
who decided the case erred in failing to develop the record
with respect to plaintiff's atrial fibrillation and did
not rely on a physician's opinion when assessing
plaintiff's residual functional capacity with respect to
that condition. Dkt. #9.
reasons explained below, I am remanding this case so the
administrative law judge can consider whether the present
record is sufficient to allow him to draw a conclusion about
the effect of plaintiff's atrial fibrillation on his
ability to work and to explain his findings with respect to
plaintiff's residual functional capacity.
following facts are drawn from the administrative record
Relevant Medical History
John Tobin was admitted to the hospital on July 9, 2013,
after he had had shortness of breath and a high heart rate
for five days. Dr. Rick Klein, plaintiff's primary
physician, noted that plaintiff had acute renal failure,
atrial fibrillation with rapid ventricular response,
cardiogenic shock, respiratory shock, respiratory failure,
severe tricuspid regurgitation and fatty liver disease.
Plaintiff had to be resuscitated three times on July 9, and
he remained on a ventilator until July 15, 2013.
Plaintiff's conditions improved with medication,
dialysis, oxygen treatment and other measures, but he
continued to experience weakness and trouble walking and
climbing stairs. Dr. Klein noted that many of plaintiff's
conditions were secondary to severe alcohol abuse and that
plaintiff had reported drinking 24 beers a day for 15 years.
AR 325-28. Plaintiff was released from the hospital on July
August 8, 2013, nurse practitioner Jenny Prinsen evaluated
plaintiff for the heart failure clinic. She noted that he had
alcoholic cardiomyopathy that was rated class II and
“ACC stage C” on the New York Heart Association
scale and that he had normal sinus rhythm. AR 514-15. On
October 28, 2013, cardiologist Dr. Monique Freund noted
inconsistent reports regarding plaintiff's continued use
of alcohol and whether he was wearing a life vest. (This is
not identified in the record, but it appears to be a wearable
defibrillator.) AR 564. Freund reviewed plaintiff's
recent transthoracic echocardiogram, which revealed that his
left ventricle ejection fraction had “significantly
increased” from 10 to 45 percent and that he had mild
right ventricle enlargement and dysfunction. AR 565 and 575.
On March 14, 2014, Dr. Klein wrote a letter stating that
plaintiff was unable to care for his five-year old child
before or after school because of his health. AR 620.
March 28, 2014, Prinsen reported that when she saw plaintiff
in February 2014, he had weakness and dizziness and reported
falling four or five times. AR 621. Plaintiff experienced an
episode of paroxysmal atrial fibrillation on February 27,
2014. Dr. Klein and Dr. Freund reduced his digoxin dosage,
which improved his symptoms somewhat. Id. Prinsen
questioned whether plaintiff would have the energy and
strength to return to work at that time. Id. On
September 22, 2014, Prinsen noted that plaintiff's
heartbeat was irregular, and an electrocardiogram confirmed
atrial fibrillation. AR 640. An October 6, 2014
echocardiogran revealed that plaintiff's left ventricle
ejection fraction was mildly reduced at 42%. Id. On
October 20, 2014, plaintiff told Prinsen that his fatigue and
dizziness seemed worse after the atrial fibrillation and that
he would like to try to convert it again. Id.
Prinsen planned a hospitalization on October 27, 2014 for
sotalol initiation and a cardioversion for October 28 or 29.
AR 641. She noted that scheduling the procedure required
working around plaintiff's work schedule. Id.
plaintiff did successfully convert into sinus bradycardia in
October, Prinsen noted that he went back into atrial
fibrillation in November 2014. AR 628-32. After examining
plaintiff on November 20, 2014, Dr. Freddy Del-Carpio Munoz
recommended atrial fibrillation catheter ablation and started
plaintiff on Amiodarone. On December 22, 2014, plaintiff told
Prinsen that he did not have chest discomfort or shortness of
breath and was walking a mile and a half every day but that
he felt dizzy after taking his morning medications and felt
palpitations that he thought were atrial fibrillation. AR
underwent catheter ablation for atrial fibrillation on
January 7, 2015 and then developed recurrent atypical atrial
flutter and fibrillation. Dr. Del-Carpio Munoz noted that
plaintiff developed symptoms similar to those he had had
during his atrial fibrillation. Cardioversion was not
performed because plaintiff self-converted. AR 624-27.
applied for benefits on August 7, 2013, alleging that he
became disabled when he was hospitalized on July 9, 2013. AR
20 and 23. His claims were denied initially on November 20,
2013, and upon reconsideration on March 24, 2014, and he
filed a written request for hearing on April 3, 2014. AR 20.
His last insured date under the Social Security Act was
December 31, 2014. AR 21.
Law Judge Thomas Springer held an administrative hearing on
April 22, 2015, at which plaintiff testified that his
medications made him feel tired, out of breath, nauseated and
dizzy for three or four hours after he took his pills in the
morning. AR 65-66, 76-77. He testified that these symptoms
prevented him from working more than four hours a day handing
out samples at Walmart. Id ...