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Donaldson v. Colvin

United States District Court, W.D. Missouri, St. Joseph Division

May 7, 2015

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.


ORTRIE D. SMITH, Senior District Judge.

Pending is Plaintiff's appeal of the Commissioner of Social Security's final decision denying his application for disability benefits under Titles II and XVI. The Commissioner's decision is affirmed.


Plaintiff was born in July 1977, has a ninth grade education, and has prior work experience as an animal caretaker, stock clerk, dishwasher, fast food worker, order filler, forklift operator, satellite installer, packer, construction worker, and short order cook. His alleged onset date was amended to April 25, 2011 - the day he underwent surgery for an aortic valve replacement. R. at 38-39. He contends he became disabled on that date due to a combination of his heart condition and mental issues.


As one might expect there are a multitude of medical records related to Plaintiff's heart surgery and treatment; nonetheless, the Court's attention is called to only a few of them. The Court has examined all of the medical records indicated to be important by the parties and the ALJ; the Court has also examined some of the other medical records.

At the time of his surgery Plaintiff's ejection fraction - that is, the percentage of blood leaving his heart upon each contraction - was between twenty-five and thirty percent. R. at 1038.[1] Unsurprisingly, on May 29 - approximately one month following his heart surgery - Plaintiff reported "a little bit of chest pain, " but he had been doing well since his discharge. R. at 367. Plaintiff's ejection fraction had increased to forty percent which was noted to be an improvement. R. at 374. At some point following surgery, Plaintiff developed a bacterial infection in his heart and was advised to come to the hospital if he noted any change in his condition. To that end, on June 21 Plaintiff went to the emergency room complaining of weakness. He was examined and discharged. R. at 766-67.

On August 17, Plaintiff complained of shortness of breath "with physical exertion, " fatigue, and chest pressure. Arrangements were made for him to be seen at the cardiology clinic later that week. R. at 882. On August 19 Plaintiff saw a cardiologist and reported shortness of breath and chest pain that manifested two weeks prior and that was "aggravated by mild activity." Plaintiff's medication was adjusted. R. at 1026-27. Later that month, Plaintiff went to the emergency room where he was described as "very weak and disoriented" and complaining of "acute anxiety with shortness of breath, " feelings of "being suffocated, " and "pain in his chest consistent with angina type of discomfort." R. at 754-55. He was transferred to another hospital, where it was determined Plaintiff's symptoms were secondary to the surgery and that he was "[o]kay to discharge from cardiac standpoint." He was prescribed anti-inflammatories and discharged. R. at 723-25; see also R. at 726-29. Plaintiff's ejection fraction was between fifty and fifty-five percent. R. at 1040.

In October, Plaintiff reported that his chest pain had improved. R. at 1028-29. In December 2011 and January 2012 Plaintiff was tested to assess the effectiveness of his anticoagulant medication and reported no problems or difficulties. R. at 876. R. at 1367-68. In May 2012 a cardiologist stated Plaintiff's "fatigue and exertional dyspnea are under control. Feels better than he was last time around." 1219. Later that month Plaintiff reported dizziness, but this was determined to be related to sinus surgery Plaintiff underwent earlier that month and not to his heart. R. at 1092-93.

At some point Plaintiff stopped taking his medication. Two such occasions occurred in February and March of 2012, when Plaintiff told his doctor he forgot to pick it up. R. at 1369, 1371. In August, Plaintiff told his doctor that he had not been taking his medication for two months and thereafter he "started developing intermittent chest pain and shortness of breath." He was hospitalized and medication was administered; unsurprisingly, "[w]ith simply resuming his medications, the patient's pain and symptoms slowly subsided." R. at 1229. In October he told the doctor that his three week hiatus in medication was because he had "missed his Medicaid for a few weeks" and not because he lacked access to it. R. at 1269.[2]

In September Plaintiff went to the emergency room. He was intoxicated and complaining of chest pains and shortness of breath. He also reported his extremities were turning blue, but the examining doctor indicated this was not the case. Plaintiff was taken to another hospital. R. at 1116-17. There he was diagnosed with suffering from "[a]typical chest pain, resolved, and noncardiac in nature." R. at 1193. In October, Plaintiff again reported a shortness of breath - but he also reported failing to take his medication within the last two days. R. at 1375. Later in the month he reported chest pain, which again was found to be unrelated to his heart problems. R. at 1274, 1312. In November, Plaintiff's ejection fraction was fifty to sixty percent. R. at 1194, 1197. In January 2013, Plaintiff reported that "in the last 3 months he has not had many complications, no hospitalizations, no major problems with his anticoagtulation and no major psychiatric problems either." R. at 1315.

In addition to these (and other) records, there are three records from Dr. Joseph Bodet - the doctor Plaintiff proffers as a treating physician. This proffer is made even though Dr. Bodet saw Plaintiff on only three occasions, and on less occasions than other doctors involved in his cardiac care. On October 16, Plaintiff "denie[d] chest discomfort with exertion but describes pain when recumbent." Dr. Bodet altered Plaintiffs' medication. R. at 1030-31. On October 25, Plaintiff saw Dr. Bodet complaining of chest pain that "occurred the day after moving boards around for a friend." Plaintiff also exhibited "some exertional dyspnea." Dr. Bodet again altered Plaintiff's medication. R. at 1045-47, 1061. The final time Dr. Bodet saw Plaintiff was in January 2013. Plaintiff reported that he was "sleeping 10 hours daily and never feels rested." He denied experiencing shortness of breath, palpitations, lightheadedness or chest pain. R. at 1033. Dr. Bodet adjusted Plaintiff's medications again. R. at 1034.

After these three examinations, on March 4, 2013, Dr. Bodet completed a Medical Statement spanning slightly more than one page long. On the statement, Dr. Bodet ...

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