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Graham v. Colvin

United States District Court, S.D. Indiana, Indianapolis Division

November 22, 2016

JAMES B. GRAHAM, Plaintiff,
v.
CAROLYN W. COLVIN Acting Commissioner of the Social Security Administration, Defendant.

          ENTRY ON JUDICIAL REVIEW

          LARRY J. McKINNEY, JUDGE

         Plaintiff James B. Graham requests judicial review of the final decision of Defendant Carolyn W. Colvin, Acting Commissioner of Social Security (the “Commissioner”), which denied Graham's applications for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) benefits under titles II and XVI of the Social Security Act, 42 U.S.C. §§ 416, 423, & 1382c. Graham contends that the Administrative Law Judge (“ALJ”) failed to properly consider his left leg wound with respect to his residual functional capacity when the ALJ deemed the wound non-severe. Graham further alleges that the ALJ did not adequately account for Graham's social limitations in determining his residual functional capacity. For the reasons set forth below, the Commissioner's decision is AFFIRMED.

         I. BACKGROUND

         A. PROCEDURAL HISTORY

         On July 24, 2012, Graham filed applications for DIB and SSI, alleging disability beginning July 15, 2008. R. at 184-91. Graham alleges disability due to symptoms associated with personality disorder with avoidant and paranoid features, dysthymic disorder, generalized anxiety disorder, lumbar degenerative disease, left leg peripheral neuropathy, bilateral peripheral artery disease, and a left leg non-healing wound. R. 277, 281. Graham's applications were initially denied and upon reconsideration, at which point he requested a hearing before an ALJ. R. at 115-22, 126-43.

         The hearing before the ALJ took place on February 26, 2014, at which Graham, who was represented by counsel, and a vocational expert testified. R. at 42-68. On May 23, 2014, the ALJ issued a decision finding Graham was not disabled. R. at 19-41. The Appeals Council denied Graham's request for review, making the ALJ's determination the final decision of the Commissioner. R. at 5-10; 20 C.F.R. §§ 404.955, 404.981, 416.1455, & 416.1481.

         On October 9, 2015, Graham filed the instant appeal pursuant to 42 U.S.C. §§ 405(g) & 1383(c)(3).

         B. AGE, EDUCATION, WORK HISTORY & GRAHAM'S PERCEPTION OF HIS IMPAIRMENTS[1]

         Graham was fifty-one years old at the time of the alleged onset date of July 15, 2008. Graham has a GED and has past relevant work as an auto mechanic. R. at 48. Graham testified at the hearing that the primary reason he was not able to work was due to depression. Id. He described the severity of his depression as an eight out of ten and testified that it was the same in 2008. R. at 48-49. Since 2010, Graham has taken medication to relieve his depression, which has resulted in some improvement. R. at 49-50. Graham testified that his depression medications affect his memory and causes his mind to wander. R. at 51. He also stated that he was seeing a medical doctor every two months, but had never received mental health therapy with a counselor or therapist. R. at 50.

         Graham indicated that, because of the depression, he does not set goals or look forward to or feel anything. R. at 52. He also stated that he does not “do crowds” and has difficulty trusting people he is not acquainted with. Id. Graham stated that he gets uncomfortable when six or seven people are around him. Id. Graham admitted that he has had prior altercations with strangers, but none have resulted in physical “blows” since high school. R. at 53. He also testified that he has had trouble with authority in the past, which has resulted in the loss of many jobs. R. at 53-54.

         Graham stated that, since approximately June 2013, he quit drinking alcohol entirely. R. at 54.

         Graham further testified about problems he had with his left leg, following a surgery in 2013. R. at 57. On the day of the hearing, Graham was wearing a wound vac to assist with circulation. R. at 55. He received various treatments for the leg in addition to antibiotics, including debriding. Id. Graham initially had an operation on the leg, which resulted in an infection. R. at 56. He was assigned a wound specialist, who he had seen every two weeks since receiving the wound, but had not seen her in “about a month.” Id. Graham also received a visiting nurse three times a week in order to change the bandage, take vitals, and ensure that the wound did not become infected. Id.

         Graham testified that since November 2011, [2] when he had his first surgery on his right leg - which is not at issue in this case - that standing for twenty minutes “is pushing it” but that he can sit without affect, except for his foot falling asleep. R. at 57-58. Prior to November 2011, he could stand for “[p]robably 20 minutes or so.” Id. Graham also testified that, before his most recent surgery he would only be able to lift approximately twenty pounds because of his legs and because he is not as strong as he used to be. R. at 60-61.

         Graham testified that his pain was a five out of ten with medications. R. at 58-59. He claimed that moving increases his pain. R. at 59. Graham stated that the current wound problem resulted from his last surgery. Id. He indicated that, prior to the surgery, his foot would fall asleep for long periods or his whole leg would fall asleep if he laid down, which forced him to sleep upright in a chair. Id. Graham stated that following the surgery, his leg was swollen and twice as large. R. at 60. He also testified that he has had stints placed in both of his legs, and multiple operations performed on his left leg. Id.

         C. RELEVANT MEDICAL EVIDENCE

         1. Treatment Records - Physical Impairments

         Graham had right and left SFA recanalization and stenting in November 2011 due to claudication and bilateral peripheral artery disease. R. at 375-416.

         On January 30, 2013, Graham underwent a CT angiogram after a Doppler report showed a decrease in ABI (ankle brachial index), which was reduced to 0.19 on the left. R. at 506. Findings showed status post stenting of the entire left SFA with complete occlusion throughout the stented portion and progressive mild to moderate multifocal stenosis of the popliteal artery, reconstitution of the distal SFA above the knee with essentially three-vessel runoff to the left foot, status post stenting of the entire right SFA which is widely patent with three-vessel runoff to the right foot, and a stable indeterminate 1.5 cm left adrenal nodule. R. at 507.

         From March 29, to April 1, 2013, due to the occlusion, Graham was admitted to the VA clinic and underwent a surgical bypass graft. R. at 73, 539. He was then referred to physical therapy for evaluation and treatment of his strength and mobility. R. at 555. Graham was able to perform functional mobility at a moderate independent level with a front wheeled walker and had a slow gait secondary to pain. R. at 556. He was not assigned to continue physical therapy and was discharged with a front wheeled walker for ambulation. Id. The following month it was noted that his ABI had improved to 0.81 on the right and 0.66 on the left, and he was noted to have trifurcation disease by pressures only with mild distal ischemia at rest. R. at 568. On June 4, 2013, Graham presented with left lower extremity edema and the incision made in the prior surgery remained open in his groin. R. at 565.

         On August 20, 2013, Graham was admitted for wound healing difficulty in the left leg. R. at 706. Blood flow in the left leg was diminished. Id. The graft was opened up and resulted in improved blood flow. Id. Graham was released from the hospital on August 24, 2013. Id.

         On December 11, 2013, approximately nine months after the original surgery, Graham was again hospitalized for a chronic non-healing incision of the left leg and swelling. R. at 1018-19. Graham stated that he had had the chronic left total leg edema since March 2013. R. at 1018. An EMG was performed which revealed the left tibial and peroneal motor nerves were nonresponsive, a great deal of edema was present distally in the left lower extremity from the site of the open wound, and the right peroneal motor nerve was very low in amplitude and slowed in conduction velocity. R. at 1034. Graham's leg was very taught and swollen, with limited bending at the knee and mobility limitation, and a great deal of pain. R. at 1035, 1071. Graham stated that his pain is worse in the supine position or when elevating it. R. 1075.

         In January 2014, Graham underwent surgical debridement of the wound. R. at 1125. Graham indicated that he did not believe that the wound was getting any worse. Id. On February 7, 2014, the home care nurse stated that she observed that the wound was no longer infected as of February 7, 2014. R. at 1126.

         2. Treatment Records - Mental Impairments

         Graham was seen for an initial psychiatric evaluation with Dr. Mary Weber on June 30, 2012. R. at 300. Regarding medication, Graham had started on Celexa but it made him jittery and caused nightmares. Id. He was then switched to Zoloft which caused other negative side effects but did help him to feel “on an even keel.” R. at 301. It was noted that he has been diagnosed with a delusional system as well as paranoid personality disorder and felt that Risperdal had helped him feel more at ease. Id. He experienced periods of difficulty sleeping, but Trazodone helps his sleep some. Id. He reported a chronic feeling of emptiness and detachment from others, and had a hard time feeling emotion. Id. Graham turned to alcohol to “let it all go and relax.” Id. Graham reports that short term memory loss had been an issue which he thinks might be related to medication side effects. Id. Graham also mentioned chronic interpersonal conflicts in the workplace leading to many jobs over the years. R. at 303. Graham was diagnosed with dysthymia, alcohol abuse, nicotine and caffeine dependence, paranoid personality disorder, and assigned a GAF of 55.[3] R. at 305.

         Graham sought treatment for mental impairment at the Indianapolis VA clinic throughout 2012 and 2013, as well as in January 2014. See generally R. at 434-642, 978-1113.

         In a follow-up examination with Dr. Weber on June 18, 2013, Graham reported being “on a nice even keel” and that he was sleeping approximately seven hours per night. R. at 572. He was noted make better eye contact, to have soft speech, to have a slightly brighter affect, a depressed mood, better judgment, poor insight, and to maybe be a little more conversant. R. at 573. Graham's GAF score was a 58. R. at 572.

         Graham's last psychiatric visit to Dr. Weber occurred on January 10, 2014. R. at 1071. His last review took place on June 18, 2014. R. at 1070. Dr. Weber noted that Graham was “doing quite well” from a mood standpoint and that his depression and anxiety were well managed. Id. Graham indicated that he was sleeping better and woke up feeling rested. R. at 1072. Dr. Weber gave Graham an improved GAF score of 60. R. at 1070.

         3. Social Security Administration ...


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