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FEDERAL REMAND: ALJ Failed to Provide Notice of New Medical Evidence to Plaintiff's Representative (Federal Case 1, p. 2)

Disabilities: Arthritis, Diabetes, and Hypertension

Report & Recommendation on Plaintiff's Motion for Summary Judgement
Federal Magistrate Judge: Frank J. Lynch, Jr.
United States District Court: Eleventh Circut, Southern District of Florida

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3. The medical record begins in April 2004 with the notes of Dr. Hamilton who had been caring for the Plaintiff's hypertension and diabetes. At that time he was overweight and was taking medication for his conditions, and he had no other physical complaints. However, in July of that year, the Plaintiff saw Dr. Ellowitz for complaints of migratory joint pain which he had had intermittently for a year. At the time of examination he complained of right ankle and wrist pain. Upon physical examination he had a mildly swollen but severely tender right wrist with a decreased range of motion. However hand functioning remained intact. In the Plaintiff's right knee he had mild swelling and a guarded range of motion, but the knee was stable. X-rays of the affected joints were normal. The doctor diagnosed migratory arthritis.

4. The Plaintiff returned a couple of weeks later with complaints of continued right hand pain and swelling that interfered with lifting, carrying, and writing activities. The physical examination was normal, and blood tests were negative. Dr. Ellowitz diagnosed tendonitis. He recommended a brace and therapy for the Plaintiff's hand and anti-inflammatory medication.

5. The Plaintiff saw Dr. Ellowitz a few months later, in early September, with persistent right wrist pain and a painful left knee that swelled after use and interfered with work activities. Upon examination the Plaintiff's right wrist was swollen and was somewhat painful with movement. His left knee was tender with minimal swelling. The doctor diagnosed slowly improving tendonitis in the Plaintiff's right wrist for which he again recommended therapy. (The Plaintiff had yet to attend.) He also diagnosed left knee derangement.

6. An MRI taken of the Plaintiff's left knee revealed substantial injury. Abnormalities included a complex meniscus tear, various other tears, and a range of milder ligament strain, degeneration, and effusion. There was also the possibility of a small loose body in the knee. The Plaintiff did not return to Dr. Ellowitz thereafter, and he pursued no further joint or knee treatment.

7. Around this time the focus of treatment turned to the Plaintiff's diabetes. In September 2004 the Plaintiff's blood sugar was so high that Dr. Hamilton's staff advised him to go to the hospital. In August 2005 the Plaintiff switched care to the 7th Avenue Clinic. He had run out of medication, and his hypertension and diabetes were uncontrolled. The Plaintiff also complained of ankle and left knee pain over the prior several weeks. That December and again in March 2006 the clinic described the Plaintiff's hypertension and diabetes as uncontrolled and his medication use as non-compliant. However the Plaintiff reported no further pain complaints.

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