United States District Court, N.D. Indiana, Fort Wayne Division
OPINION AND ORDER
PHILIP P. SIMON, Chief District Judge.
Kyle Alaura appeals the Social Security Administration's determination that he is not disabled. In essence, he argues that the ALJ erred by not giving his treating physicians' opinions controlling weight, failed to derive Alaura's RFC from a hypothetical asked to the vocational expert, and improperly evaluated Alaura's credibility regarding the severity of his symptoms. Because I find that the ALJ relied on substantial evidence in making each of these findings, I AFFIRM her decision.
Readers looking for a more extensive discussion of Alaura's medical record are directed to the detailed summaries in the ALJ's decision (R. at 9-28) and in Alaura's opening brief (DE 15). Rather than reiterating those summaries, I will give a brief overview of the history of Alaura's health issues and proceedings before the Social Security Administration.
In September 2010, Alaura was attacked while leaving a bar by two assailants who hit him in the head twice with some type of blunt instrument and shattered his skull. (R. 256-257) He was taken to the Emergency Room where a CT scan revealed a depressed skull fracture with concussion. ( Id . at 258) He was then transferred to Lutheran Trauma Center for a neurosurgical/neurological consultation. ( Id .)
Once at Lutheran, Dr. Kachmann admitted Alaura and performed surgery that same night. ( Id . at 288, 295) The surgery went well, except that Alaura did have a seizure during the surgery, which Dr. Kachmann treated with the medication Keppra. ( Id . at 295) Due to his severe post-operative headaches and postconcussive syndrome, Alaura remained in the hospital until September 26, 2010 when he was discharged. ( Id . at 296, 454) At that point, according to Dr. Kachmann, Alaura was "ambulating without difficulty" ( id . at 296) with no obvious neurological deficits ( id . at 18. 454). Alaura was still being treated with Keppra for possible seizures, although he hadn't had any since the operation. ( Id. at 295-96) Two days later, Dr. Kachmann stated in a Work Status Report that Alaura "May Not Return to Work - Date of injury was 9-1-10. Off x 2 months." ( Id . at 345)
A November 1, 2010 CT scan showed a small region of missing brain matter - presumably the portion removed during surgery - but otherwise indicated "no other problems." ( Id . at 340, 285) Alaura indicated at that time that he was experiencing dizziness, numbness, irritability, and difficulty concentrating. ( Id. at 343) Dr. Kachmann found no obvious cognitive deficits. ( Id . at 454) Dr. Kachmann further noted that he wanted to see Alaura again in a month after some neuropsychological testing, and at that point, they would "decide on returning him to his job" provided had clearance from the neurologist in regards to the EEG interpretation and the neuropsychologist. ( Id . at 340-41) That subsequent EEG was normal, other than some minor indications of an old injury. ( Id . at 366)
On November 16, 2010, Dr. Kachmann stated in another Work Status Report that Alaura would not return to work until about December 20, 2010. ( Id . at 336) On December 14, 2010, Alaura saw Dr. Kachmann's partner, Dr. Banas, for a neurologic consultation requested by Dr. Kachmann. ( Id . at 368.) Alaura reported that he was experiencing excessive daytime tiredness, difficulty concentrating ("zombie-like state"), trouble falling asleep, unsteadiness and possible vertigo when he moved rapidly, fluctuating headaches, light sensitivity, and pain that increased with exertion. ( Id .) Dr. Banas also noted that Alaura had had no further seizures and lessened Alaura's dose of Keppra, which would hopefully lessen his fatigue. ( Id . at 369) He also found that Alaura was doing "reasonably well, " but that Alaura would be referred to a neurophysiologist to map any cognitive deficits. ( Id .) Dr. Banas hoped Alaura could return to full time employment within the year. ( Id .)
Dr. Kachmann then reissued and extended his previous work restriction on December 27, 2010, stating that Alaura was not to return to work until March 7, 2011. ( Id . at 328) On January 17, 2011, Alaura returned for a follow up visit with Dr. Kachmann and Physician's Assistant April Christlieb. ( Id . at 370) Christlieb indicated that Alaura had been weaned from Keppra and had had no further seizures. ( Id .) There was no redness, swelling, or drainage at his incision. ( Id .) Alaura reported continued difficulty with headaches, but denied any cognitive difficulties, vision changes, nausea, or vomiting. ( Id .) According to Christlieb, Dr. Kachmann diagnosed occipital neuralgia and arranged for Dr. Banas to administer a nerve block to treat that condition that day. ( Id .) Dr. Kachmann found that he did not need to see Alaura again, but that they (Kachmann and Christlieb) would move up his appointment for neuropsychological testing and would "go from there in regards to his returning back to work." ( Id .)
A few weeks later, Dr. Francis Goff, Ph.D., performed Alaura's neuropsychological testing. ( Id . at 375) During the test, Alaura reported some improvement - he was driving, his headaches were less frequent, he was taking no pain medications, and his positional vertigo was improving. ( Id .) Also, he was still having no seizures. ( Id. ) The nerve block had helped, but had now worn off a bit and he was still having some headaches. ( Id .) Dr. Goff found that Alaura "demonstrated borderline impaired intellectual functioning with low average delayed memory and average to low average attention span." ( Id . at 376) Alaura reported that he had filed for Social Security Disability and thought that his headaches would render him unable to work. ( Id .) Dr. Goff expressed no explicit opinion in response to that, but did find that overall, Alaura was continuing to make improvements and that he should contact Vocational Rehabilitation Services to see if job training was available. ( Id .) It does not appear that Alaura pursued this option.
A couple of weeks later, Alaura saw psychologist Neal Davidson, Ph.D., in connection with his application for disability benefits. ( Id . at 378) Dr. Davidson diagnosed Alaura with adjustment disorder with depressed mood, but found his prognosis was good. ( Id . at 384) He also found that Alaura could "understand, remember, and carry out instructions and perform tasks that are simple and concrete, " but that "[h]is frustration with physical limitations may impact his ability to complete a normal workday without minimal interference from psychologically based symptoms." ( Id .) Alaura did, however, have the "ability to interact appropriately with the public and co-workers." ( Id .)
On March 11, 2011, Alaura was examined by a State Agency physician who reported that his findings were within normal limits, except for some decreased lumbar spine motion. ( Id . at 386-89) That physician also indicated that Alaura was suffering from headaches, but not dizziness, trouble walking, nor weakness in extremities. ( Id .) Another State Agency physician later in March 2011 found that Alaura could perform work at all exertional levels, but that he could not climb ladders, ropes, or scaffolds at all; was frequently able to climb ramps and stairs, balance, stoop, kneel, crouch, and crawl; and needed to avoid concentrated exposure to noise and hazards. ( Id . at 395-98)
On March 15, 2011, Alaura saw Dr. Banas for a follow up visit. Alaura reported continued difficulty with headaches, light sensitivity, and insomnia, but stated the last nerve block had prevented his headaches for three weeks. ( Id . at 390) Dr. Banas started Alaura on Amitriptyline for the pain and administered another nerve block. ( Id .) Alaura did not return to Dr. Banas, Dr. Kachmann, or anyone in that practice. In fact, it appears that Alaura did not seek medical care again until a year later in March 2012 when he saw his primary care physician, Dr. Ted Crisman, M.D. Alaura's complaints remained largely the same - headaches, insomnia, some depression with some dizziness. ( Id . at 459) He denied having had any seizures, although the intake notes indicated that possible "absence type" seizures may be present. ( Id .) Dr. Crisman prescribed ...