United States District Court, M.D. Pennsylvania
REPORT AND RECOMMENDATION
JOSEPH F. SAPORITO, Jr., Magistrate Judge.
This is an action brought under 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking judicial review of the partially favorable decision of the Commissioner, in which Eduardo Torres was awarded Title XVI benefits beginning April 25, 2011, and was denied benefits under Title II and Title XVI of the Social Security Act for the period between October 30, 2009 and April 24, 2011. Jurisdiction is conferred upon this Court pursuant to 42 U.S.C. § 42 U.S.C. §§ 405(g) and 1383(c)(3), and this matter has been referred to the undersigned Magistrate Judge for the preparation of a report and recommended disposition pursuant to the provisions of 28 U.S.C. § 636(b) and Rule 72(b) of the Federal Rules of Civil Procedure.
For the reasons stated herein, we recommend that the final decision of the Commissioner of Social Security be VACATED and this case be REMANDED for further proceedings consistent with this report.
I. BACKGROUND AND PROCEDURAL HISTORY
On February 16, 2007, Torres was admitted into intensive care after he presented to the Pocono Medical Center emergency department with complaints of upper abdominal pain, chills, hematemesis (vomiting blood) and melena (tarry feces associated with upper GI bleeding). (Admin Tr. 216). Torres received a blood transfusion on February 17, 2007, and was transferred to St. Luke's Hospital. (Admin Tr. 223). At St. Luke's Hospital, a CT scan revealed evidence suggesting the presence of varices, and Torres was diagnosed with bleeding in his stomach and esophagus, alcoholic liver disease, cirrhosis, and alcohol abuse. (Admin Tr. 435, 444, 453). Torres was discharged from St. Luke's Hospital on February 23, 2007. (Admin Tr. 436). However, three days later he returned to the Pocono Medical Center with complaints of pain in his lower back and right shoulder. (Admin Tr. 228). Torres was diagnosed with back and shoulder pain, and was discharged. (Admin Tr. 234).
On June 12, 2007, Torres was admitted to the Elmhurst Hospital emergency room due to an overdose of Lorazepam combined with alcohol consumption. (Admin Tr. 125). Torres later admitted that he ingested the Lorazepam because he felt depressed and hopeless. (Admin Tr. 138). Torres was transferred to the psychiatric ward for treatment, and was discharged on June 19, 2007. (Admin Tr. 178).
On September 11, 2007, Torres presented to the Pocono Medical Center emergency department with complaints of vomiting and diffuse abdominal pain. (Admin Tr. 235). Torres was diagnosed with abdominal pain with the secondary diagnoses of cirrhosis and vomiting, and was discharged. (Admin Tr. 244).
On November 15, 2007, Torres returned to the Pocono Medical Center emergency department with complaints of hematemesis. (Admin Tr. 246). An endoscopy revealed a few grade three varices in the esophagus and cardia. Id. Blood was also found in Torres' stomach. He was admitted to intensive care, where four ligation bands were applied to control the bleeding. Id. On November 20, 2007, Torres was released from the hospital in stable condition with the discharge diagnoses of delirium tremens, portal hypertension, cirrhosis secondary to alcohol abuse, and hepatic encephalopathy. Id.
The record does not document any medical treatment from December 2007 to June 2009.
From June 2009 through December 2010, Torres was incarcerated at SCI-Waymart for credit card theft and possession of stolen property. A June 2009 check-box physical examination was mostly normal, and a mental health evaluation confirmed that no mental health services were required. (Admin Tr. 254-57). On March 4, 2010, blood work revealed a low A/G ratio, high bilirubin, high alkaline phosphatase levels, high aspartate aminotransferase (AST) levels, high gamma-glutamyl-transpeptidase levels (G-GTP), high mean corpuscular volume (MCV), and a low platelet count. (Admin Tr. 268-69). On April 20, 2010, blood work revealed that Torres had a high level of ammonia in his blood. (Admin Tr. 267). On August 27, 2010, blood work revealed a low A/G ratio, high alkaline phosphatase levels, high AST levels, and high G-GTP levels. (Admin Tr. 261). On May 18, 2010, trace amounts of ketones and a small amount of bilirubin were detected in a urinalysis study. (Admin Tr. 265). On August 28, 2010, Torres' platelet count was low. (Admin Tr. 262). On December 20, 2010, in a medical release summary, it was noted that Torres suffered from cirrhosis, heptospenomegaly, a history of ascites, and questionable positive lab results for Hepatitis C. (Admin Tr. 253). It was also noted that Torres had no employment limitations. Id. However, the signature on this document is illegible, and the precise medical credentials of the individual who conducted this evaluation are unknown.
Upon his release, Torres protectively filed applications for benefits under Title II and Title XVI of the Social Security Act alleging disability due to cirrhosis, anemia, gastro-intestinal bleeding, and gastric varies beginning on October 30, 2009.
An abdominal ultrasound performed on February 12, 2011, revealed that Torres' liver was of normal size, but had diffusely coarsened parenchymal echotexture and nodular contours consistent with cirrhosis.
On April 13, 2011, Torres underwent a esophagogastroduodenoscopy. (Admin Tr. 399). This study revealed the impression of esophageal and cardia varices. Id.
In order to fully evaluate Torres' claims, the Social Security Administration commissioned a consultative examination of Torres' physical impairments by nontreating internist, Dr. Sethuraman Muthiah. (Admin Tr. 280-88). Dr. Muthiah reported the impression of cirrhosis of the liver, hypertension, and history of duodenal ulcer. Dr. Muthiah also assessed that, regarding work-related physical activities, Torres could: lift up to twenty pounds and carry up to fifteen pounds frequently; stand and walk up to two hours per eight-hour workday; sit between three and four hours per eight-hour workday; and, occasionally bend, kneel, stoop, crouch, balance, and climb. Dr. Muthiah also recommended that Torres work in an environment where he would not be exposed to heights, moving ...