United States District Court, S.D. Indiana, Indianapolis Division
JAMES B. GRAHAM, Plaintiff,
CAROLYN W. COLVIN Acting Commissioner of the Social Security Administration, Defendant.
ENTRY ON JUDICIAL REVIEW
J. McKINNEY, JUDGE
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.
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,
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.
October 9, 2015, Graham filed the instant appeal pursuant to
42 U.S.C. §§ 405(g) & 1383(c)(3).
AGE, EDUCATION, WORK HISTORY & GRAHAM'S PERCEPTION OF
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.
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.
stated that, since approximately June 2013, he quit drinking
alcohol entirely. R. at 54.
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.
testified that since November 2011,  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.
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.
RELEVANT MEDICAL EVIDENCE
Treatment Records - Physical Impairments
had right and left SFA recanalization and stenting in
November 2011 due to claudication and bilateral peripheral
artery disease. R. at 375-416.
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.
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.
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.
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.
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.
Treatment Records - Mental Impairments
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. R. at 305.
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.
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
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.
Social Security Administration ...