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McGuire v. Berryhill

United States District Court, E.D. Wisconsin

March 19, 2018

RANDY L. McGUIRE Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration Defendant.



         Plaintiff Randy McGuire applied for social security disability insurance benefits, alleging that he became disabled as of August 28, 2011 due to polycystic kidney disease (“PKD”). Because plaintiff's “insured status” ended on September 30, 2011, he had to establish disability prior to that date. The Administrative Law Judge (“ALJ”) assigned to the case concluded that during the relevant time plaintiff retained the ability to perform a range of medium work, allowing him to do a number of jobs in the economy.

         In this action for judicial review, plaintiff argues that the ALJ provided an insufficient explanation for rejecting the opinion of his treating physician, who found plaintiff disabled during the relevant time. I agree that the ALJ's one-sentence rejection of the treating source report cannot be upheld and thus remand for further proceedings.

         I. BACKGROUND

         A. Medical Evidence

         On August 28, 2011, plaintiff went to the emergency room following a syncopal episode. (Tr. at 294.) Doctors suspected cardiac arrhythmia or vasovagal syncope, possibly due to dehydration. (Tr. at 295.) They treated plaintiff with IV fluids and released him. (Tr. at 295-96.)

         Plaintiff returned to the ER on September 1, 2011, complaining of left-side flank pain of ten days' duration, which significantly worsened that day. (Tr. at 297.) Doctors provided IV pain medications and obtained a CT scan, which revealed numerous bilateral renal cysts with two hemorrhagic cysts on the left side. Plaintiff was admitted (Tr. at 298), and on September 2 consulted with Dr. Logan Elangovan, a nephrologist, who diagnosed PKD based on plaintiff's presentation and the imaging. Plaintiff was discharged on oral pain medications, with close follow up as an out-patient. (Tr. at 283, 285, 291-92, 306.)

         Plaintiff was admitted to the hospital yet again on September 4, 2011, for confusional episodes. (Tr. at 301, 308.) Doctors ordered a brain CT and echocardiogram, which were normal. (Tr. at 303, 309, 326). Plaintiff discharged on September 6, with a diagnosis of syncope, probably related to pain medication and hypoxia. (Tr. at 311-12.)

         On September 16, 2011, plaintiff saw Dr. James Chapman, a primary care physician. (Tr. at 333.) He reported still having some pain, with over-the-counter medications not providing enough benefit. Dr. Chapman prescribed hydrocodone. Plaintiff was to follow up with urology and nephrology. (Tr. at 335.)

         On September 28, 2011, plaintiff saw Dr. Brian Butler, urologist, who recommended a repeat CT scan in two months to check for resolution of the hemorrhagic cysts. He further recommended continued aggressive management of plaintiff's blood pressure and preservation of renal function long-term. (Tr. at 458.)

         On October 3, 2011, plaintiff followed up with Dr. Elangovan, who noted “pain control adequate.” (Tr. at 281.) On December 21, Dr. Butler noted, “Looks well, feels well. He is now complaining of intermittent left flank pain[.]” (Tr. at 323, 474.) A CT scan taken on that date revealed interval growth of one cyst but no definite enhancement. “Otherwise, stable polycystic disease[.]” (Tr. at 317-18.) On January 5, 2012, Dr. Butler noted, “He's clinically asymptotic at this time.” (Tr. at 459.) He recommended a follow up CT in three to six months. (Tr. at 459.)

         On January 23, 2012, plaintiff told Dr. Elangovan that he still had left sided flank pain, especially with activity. (Tr. at 279.) On March 23, plaintiff advised Dr. Chapman that he was still having some intermittent pain issues. (Tr. at 345.) Dr. Chapman stressed the importance of following up with his specialists. “However, his symptoms have gradually improved. He apparently had stopped working as a truck driver because of concerns about the cyst. I told him I thought it would be safe for him to return to work but did ask him to verify this with his specialists.” (Tr. at 346.)

         Plaintiff returned to Dr. Chapman on April 23, 2012, reporting a prominent lump in his mid upper abdomen, otherwise asymptomatic. He used Vicodin as needed for pain, although less than he initially required. (Tr. at 358.) Plaintiff underwent a repeat CT scan on May 2, which revealed stable left renal cyst without evidence of enhancement and no acute findings. (Tr. at 385-86, 469-70.)

         On August 18, 2012, plaintiff followed up with Dr. Elangovan, reporting significant pain in the kidney area from simple activities like driving a truck, sitting, and walking fast. (Tr. at 264, 289.) On March 23, 2013, he reported continued significant pain related to PKD. (Tr. at 267, 286.) On March 26, he told Dr. Chapman that he still had left sided pain from the large cyst. He used Vicodin sparingly for this pain. (Tr. at 365.)

         A repeat CT scan on May 1, 2013, revealed no interval change in the numerous cysts. (Tr. at 390, 466-67.) On May 10, plaintiff followed up with Dr. Butler, who noted: “He is truly asymptomatic. CT shows no evidence for changes in his cysts over time.” (Tr. at 457.) He was to follow up in two years. (Tr. at 457.)

         On September 21, 2013, plaintiff saw Dr. Elangovan, reporting significant flank pain, which limited his lifestyle. He was not even able to stretch to reach above his head. (Tr. at 478.) Dr. Elangovan contacted Dr. Butler about aspirating the ...

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