# United States Court of Appeals

For the Seventh Circuit Chicago, Illinois 60604

Argued November 13, 2019 Decided November 26, 2019

Before

WILLIAM J. BAUER, Circuit Judge

MICHAEL B. BRENNAN, Circuit Judge

MICHAEL Y. SCUDDER, Circuit Judge

No. 19-1399

PATRICK J. DUNN, Plaintiff-Appellant

,

v

.

ANDREW M. SAUL

, Commissioner of Social Security, Defendant-Appellee

. Appeal from the United States District
Court for the Northern District of Illinois, Eastern Division.

No. 17-cv-8068

J effrey T. Gilbert,

M agistrate Judge

.

O R D E R

Patrick Dunn seeks Social Security disabilit y benefits, claiming that he became disabled from memory loss in September 2012 at age 58. Before 2012, he worked at various jobs, including as a bank manager and in retail sales. But his employment records show that he struggled with memo ry loss and headaches that impeded his job performance until he could no longer wo rk. An administrative law judge denied Dunn’s application for disability benefits on the ground that his cognitive limitations were not “severe,” and the district court affi rmed. We cannot conclude that substantial evidence supports the ALJ’s decision. Foremo st, the ALJ altogether failed to consider NONPRECEDENTIAL DISPOSITION
To be cited onl y in accordance with Fed. R. A pp . P. 32.1No. 19-1399 Page 2

Dunn’s employment records and did not expl ain why he rejected testimony about how Dunn’s memory struggles affected his daily activities and social interactions.

I

Dunn attributes the start of his cognitive decline to a traumatic head injury he experienced in 1990, when he fell down a flight of stairs. He sustained a head contusion and concussion, and a physician diagnose d him with “post-concussion syndrome” shortly after. Dunn did not receive further brain evaluation or treatment until April 2014, when he injured his head again. A CT scan of his brain revealed “[a]bnormal density ... involving the inferior aspect of the right frontal lobe as described likely [result] of remote trauma” and “show[ed] evid ence of old traumatic injury ... consistent with [Dunn’s] history of remote head trau ma.” Treating physicians diagnosed him with
a forehead abrasion and head contusion.

Later that month, Dunn applied for disab ility benefits, claiming that he had not been able to work since 2012. Dr. Glen Wurglitz, a state-retained physician, performed a psychological exam. Dunn told Dr. Wurglitz that he suffered from chronic headaches and worsening memory problems. He explaine d that he tried to manage his headaches with non-prescription pain medicine, but th en had to stop working in 2012 because of worsening memory loss. At home, Dunn could manage only light housework. Dr. Wurglitz nonetheless concluded that Du nn could “readily concentrate on a task until it is finished,” had no problems expressing himself, and had “excellent” short-term memory. The agency denied his application for disability benefits, and Dunn requested a hearing before an ALJ.

Before the hearing, Dunn sought an evalua tion and treatment from a neurologist, Dr. Zoran Grujic, for progressive cognitiv e decline. Dr. Grujic examined Dunn and found that he had encoding and retrieval difficulties. He diagnosed Dunn with “mild cognitive impairment,” chronic daily headaches, and a history of traumatic brain injury. He also opined that “[a]ging on top of an old brain injury may account for the progressive nature of [Dunn’s] symptoms” and ordered a brain MRI, which revealed “right frontal encephalomalacia.” (Encephaloma lacia is an abnormal softness or loss of brain tissue after a head injury.) After revi ewing the MRI results, Dr. Grujic confirmed his diagnosis of “mild cognitive impairment .” He added that Dunn’s low vitamin B12 level and insomnia might have contributed to his cognitive difficulties.

At the hearing before the ALJ, Dunn te stified that he suffered from memory shortfalls at home and work. He explained, for example, that he destroyed several potsNo. 19-1399 Page 3

and pans because he would forget that he was cooking and burn the bottoms. His daughter had to call him daily to remind him to take his medications and to eat. He also often forgot where he was going, so much so that he missed appointments. At work, his memory problems caused his performance to gradually deteriorate until he was fired from his job at Harris Bank in 2005. Be tween 2005 and 2012, Dunn worked other jobs but struggled to maintain long-term employ ment because he could not remember his schedule. He was disciplined repeatedly because his forgetfulness continued to interfere with his job performance. Ev entually, in 2012, he stopped working.

To corroborate his testimony about memory deficits, Dunn submitted his employment records from 2010 to 2012—the last two years of his employment history, when he worked as a retail sales supervisor at Bon-Ton. The records show tardiness and absenteeism for which Dunn received 30 reprim ands in 18 months, as well as failures to follow instructions and complete tasks. So, t oo, do the records trace a decline in work performance, culminating in a rating of “unacceptable” performance in 2012.

Two other witnesses testified at the ALJ hearing. Dunn’s daughter explained that he moved in with her because he was strugg ling to live on his own. Although she had hoped Dunn would be able to care for her child ren, he often lost their clothes, forgot to bathe them and change their diapers, and missed their medical appointments. She also confirmed Dunn’s account that he forgot to eat and take his medicine without daily reminders, and that, unless she took him to medical appointments, he missed them. A vocational expert opined that a person with Dunn’s asserted limitations and record of absenteeism and tardiness would be unemployable.

Applying the five-step analysis mandated by agency regulations for assessing disability, see 20 C.F.R. § 404.1520, the ALJ determined that Dunn was not disabled. Dunn’s application failed at step two, wh ere the ALJ found that Dunn’s cognitive impairment was not “severe.” After characterizing Dunn’s testimony about the intensity, persistence, and limiting effects of his symptoms as “not entirely consistent” with the record, the ALJ rated him in the fo ur functional areas for assessing the severity
of a mental disorder. See 20 C.F.R. § 404.1520a. The ALJ found that Dunn had (1) “no limitation” in the area of daily living becaus e he could bathe, dress, make meals, and care for his grandchildren; (2) “no limitation” in the area of social functioning because he enjoyed activities with family and frie nds and had no history of depression or suicidal ideation; (3) “mild limitations” in the area of concentration, persistence, or pace because he had excellent short-term memory, could readily concentrate on a task until completion, and was able to manage his ow n money; and (4) no decompensation. ToNo. 19-1399 Page 4

reach this assessment, the ALJ gave “great wei ght” to Dr. Grujic’s diagnosis of a mild cognitive impairment because he was a tr eating physician and his diagnosis was consistent with the record. The ALJ gave only “some weight” to Dr. Wurglitz’s
assessment because he did not see the full medical record and only “some weight” to Dunn’s daughter’s testimony because she was not a medical professional.

Dunn sought review of the ALJ’s decision in district court, where a magistrate judge presided by consent. He argued that the ALJ failed to properly assess his employment records, his medical evidence, and his testimony about his symptoms. The district court affirmed the ALJ’s denial of his disability benefits.

II

We will vacate a decision to deny disab ility benefits if it is not supported by substantial evidence or if the ALJ did not adequately discuss the issues and evidence
involved in the claim. See Meuser v. Colvin, 838 F.3d 905, 910 (7th Cir. 2016); Jelinek v. Astrue, 662 F.3d 805, 811 (7th Cir. 2011); Villano v. Astrue, 556 F.3d 558, 562 (7th Cir. 2008).

Dunn first contends that, in finding that he did not have a “severe” cognitive impairment, the ALJ impermissibly disregarded his employment records from Bon-Ton. We agree. These records span almost two years, show chronic tardiness, absenteeism, and incomplete work, and support Dunn’s test imony that his failing memory inhibited his ability to continue working. Yet the AL J did not mention them. Although under no obligation to address every piece of evidence in the record, see Villano, 556 F.3d at 562, an ALJ may not ignore an entire line of evidence contrary to his ruling. See Meuser, 838 F.3d at 912. The ALJ here was free to consider Dunn’s employment records and expressly decide that they deserved little wei ght, but to disregard them completely was impermissible. Because the records appe ar to confirm Dunn’s testimony that his cognitive decline rendered his ability to work “unacceptable,” the ALJ needed to at least
address and evaluate them. See, e.g.

, Villano, 556 F.3d at 563; Meuser, 838 F.3d at 912.

The Commissioner urges that no la w required the ALJ to discuss these employment records, and that the ALJ could no t have used them to infer that cognitive impairments caused Dunn’s workplace prob lems. But the regulations require the agency to consider an applicant’s employme nt records in assessing the severity of a claimant’s mental impairment. See 20 C.F.R. Part 404, Subpart P, App. 1, § 12.00(C) (explaining that the Administration evaluate s evidence from work and work-related programs in assessing the severity of ment al impairments). Ruling SSR 16-3p likewiseNo. 19-1399 Page 5

requires an ALJ to consider “the entire case record, including ... information provided by medical sources and other persons ; and any other relevant eviden ce in the individual’s case
record ” in determining the severity of an im pairment. SSR 16-3p, 2016 WL 1119029, at *4 (Mar. 16, 2016) (emphasis added); see also 20 C.F.R. § 404.1529(a) (explaining that the agency considers both “objective medical ev idence and other evidence” in evaluating whether an impairment affects activities of daily living and the ability to work). Even more, Dr. Grujic noted that Dunn’s impa irments “affected his work.” From this statement, the ALJ could have inferred that Dunn’s “unacceptable” work record resulted from his memory loss. On this ev idence, the ALJ was not free to deny Dunn’s application for benefits without addressing the information in and takeaways available
from his work records.

Dunn also argues that, in assessing his fun ctional limitations as required by the Social Security regulations, the ALJ erred by ignoring any evidence contrary to his decision. Here, too, we agree with Dunn. The functional assessment insufficiently
addressed three areas. First , in concluding that Dunn had “no limitation” in the area of daily living, the ALJ did not explain why he rejected the testimony from both Dunn and his daughter that Dunn missed medical appoin tments, forgot about pots and pans on a burning stove, and overlooked household chores, meals, and daily medications. Second

, in finding that Dunn had “no limitation” in the area of social fun ctioning, the ALJ did not assess his daughter’s testimony that Du nn had no friends and could not adequately
care for her children. Third , in ruling that Dunn had only “m ild limitation” in the area of concentration, persistence, and pace, the ALJ did not address whether Dunn’s employment records confirmed his testimony that his cognitive decline rendered his work unacceptable.

To be sure, the ALJ acknowledged th at Dunn’s “statements concerning the intensity, persistence, and limiting effect s” of his symptoms were “not entirely
consistent” with other evidence in the reco rd. But we discourage the use of boilerplate without a more thorough explanation of wh ich evidence is inconsistent with the applicant’s testimony and why. See Pepper v. Colvin, 712 F.3d 351, 367–68 (7th Cir. 2013). Likewise, under the agency’s own policy st atements, an ALJ cannot simply say that “statements about the individual’s symptoms are (or are not) supported or consistent” with the record. SSR 16-3p, 2016 WL 1119029, at *9. Here the ALJ did not explain which aspects of Dunn’s testimony he rejected and why. Moreover, the ALJ‘s explanation that he discounted the daughter’s testimony because she was not a medical professional does not adequately explain his decision to give little weight to her testimony. HerNo. 19-1399 Page 6

observations that Dunn forgot his meals, medicine, appointments, and caregiving duties concern daily living and did not require a professional degree.

One more aspect of the ALJ’s decision warranted further elaboration. In determining whether an impair ment is severe, the agency uses five terms to describe functional limitations: “none, mild , moderate, marked, and extreme.” See 20 C.F.R. § 404.1520a(c)(4). Recall that Dr. Grujic had also used the term “mild” in diagnosing Dunn’s cognitive impairment. But “mild” in that context means something different. Dr. Grujic relied on the Diagnostic and Statistical Manual of Mental Disorders, which classifies “neurocognitive disorder due to t raumatic brain injury” wi th only two ratings, “mild” or “major.” Neurocognitive Disorders, DSM-V (2013). Even in its “mild” form, the disorder causes “reduced cognitive efficien cy, difficulty concentrating, and lessened ability to perform usual activities.” Id. Furthermore, Dunn’s underlying traumatic brain injury was not rated but may have caus ed additional functional limitations. Id. The ALJ omitted any explanation of how Dr. Grujic’s terminology connected to the agency’s definitions in Dunn’s case, as the regulations require. See 20 C.F.R. § 404.1527(d)(2).

In combination, these errors warrant re manding for further proceedings. The ALJ omitted any mention of Dunn’s employment records and cited only the portions of his and his daughter’s testimony that downplayed his daily impediments. According to the vocational expert, someone with Dunn’s asserted impairments is unemployable. Because the ALJ did not address or weigh this evidence, Dunn’s disability benefits application merits reconsideration.

We therefore VACATE the judgment an d REMAND to the agency for further proceedings.