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Hardin v. Berryhill

United States District Court, E.D. Missouri, Northern Division

March 11, 2019

SONNY R. HARDIN, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         This action is before the court for judicial review of the final decision of the defendant Commissioner of Social Security denying the application of plaintiff Sonny R. Hardin for disability insurance benefits under Title II of the Social Security Act (Act), 42 U.S.C. §§ 401-434, and Supplemental Security Income (SSI) under Title XVI of the Act, 42 U.S.C. §§ 1381-1385. The parties have consented to the exercise of plenary authority by the undersigned United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, the final decision of the Commissioner is reversed and remanded.

         I. BACKGROUND

         Plaintiff was born in 1964 and was 50 years old at the time of his hearing. He filed his applications for disability insurance benefits and for SSI on August 9, 2016 and September 30, 2014, respectively. (Tr. 192-98, 163-68.) He alleged that he became disabled on August 15, 2014, due to heart disease, HIV/AIDS, “no immune system, ” high blood pressure, pain, fatigue, and weight loss. (Tr. 163-68, 203.) His application was denied, and he requested a hearing before an Administrative Law Judge (ALJ). (Tr. 91-98.)

         On February 1, 2017, following a hearing, an ALJ issued a decision finding that plaintiff was not disabled under the Act. (Tr. 20-27.) The Appeals Council denied his request for review. (Tr. 1-6.) Thus, the decision of the ALJ stands as the final decision of the Commissioner.


         The following is a summary of plaintiff's medical and other history relevant to this appeal.

         Plaintiff was diagnosed with HIV in 1998. He was admitted to University Hospital in Columbia, Missouri, from September 9-12, 2014, with fever and chills due to complications from HIV that went untreated for two years. Plaintiff had shortness of breath, dyspnea on exertion, chest pain aggravated by activity, dehydration, dry mouth, lightheadedness, dizziness, diarrhea, decreased urine output, blurry vision, abdominal bloating, back pain, abdominal pain and cough. He was alert, in no acute distress, had regular cardiac rate and rhythm, and clear lungs. He had normal musculoskeletal range of motion, no tenderness, and no swelling. Plaintiff had been receiving Highly Active Antiretroviral Therapy (HAART) until two years earlier when he was hospitalized for severe bodily burns, placed in a coma, and provided multiple skin grafts. He was unable to afford HAART after discharge for reasons concerning insurance coverage. He had a history of drug use and had last used methamphetamine one week earlier. He was a cigarette smoker for 41 years.

         He was diagnosed with febrile neutropenia from HIV. He had pancytopenia, a condition marked by a reduction in the number of red and white blood cells, as well as platelets. A CT scan showed left axillary lymphadenopathy, a disease of the lymph nodes, that was concerning for Kaposi sarcoma. A biopsy and complete lymphoma work-up were performed. Upon discharge on September 12, 2014, plaintiff was improved, had no restrictions, and could resume normal activities as tolerated. (Tr. 251-88, 320.)

         Plaintiff was admitted to the University Hospital from September 22-24, 2014 for a dog bite and subsequent infection. He was administered IV antibiotics in light of his immune status. Plaintiff was compliant with HAART and other medications but continued to have weight loss and diarrhea in addition to extreme pain near the biopsy site and numbness in his shoulder. He denied any fevers, chills, vomiting, or diarrhea. He had no neurological deficits. He had intact range of motion of the right hand with no obvious joint swelling. (Tr. 314-36.)

         On September 30, 2014, plaintiff was seen for follow-up for the dog bite due to concerns with infection and HIV-positive status. Notes indicated there were no concerns regarding further healing. (Tr. 353-55.)

         On October 3, 2014, plaintiff was seen for follow-up. Swelling in his lymph nodes had increased and was now associated with numbness. His CD4 count or T-cell test, used to determine the status of a person's immune system, was 10. His viral load test, used to determine the level of HIV in the body, was approximately 75, 000. His diarrhea was resolving. He had no musculoskeletal swelling or gross restricted range of motion. (Tr. 346-48.)

         On November 7, 2014, plaintiff was seen at the University of Missouri Specialty Clinic for follow-up. Swelling in the left axilla had decreased but numbness was still present. He was gaining weight and was taking prescribed medications. (Tr. 341-45).

         On May 12, 2015, plaintiff was seen at the infectious disease clinic for HIV follow-up and a swollen lymph node. He was taking Atripia, for HIV, and Dapsone, an anti-infective used to treat skin conditions. His last CD4 cell count was 90. He had issues with scratching. He was having some compliance issues with medications. (Tr. 356-57.)

         On June 5, 2015, plaintiff was seen at Missouri Orthopedic Institute for painful warts on his left foot for the past 2 years. Notes indicate he was immunosuppressive with HIV and AIDS, as well as hepatitis and heart problems. His pain was rated 8 out of 10, and ...

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