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Shear v. Saul

United States District Court, E.D. Missouri, Southeastern Division

September 30, 2019

ANDREW M. SAUL, Commissioner Social Security Administration Defendant.



         Plaintiff Catherine Shear brings this action pursuant to 42 U.S.C. §§ 405(g) seeking judicial review of the Commissioner's decision denying her application for supplemental security income under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381 et seq. Because the Commissioner's final decision is supported by substantial evidence on the record as a whole, I will affirm the decision of the Commissioner.


         On March 27, 2014, Plaintiff Catherine Shear went to the Community Counseling Center. An intake note revealed restless motor behavior and anxious mood. Shear was diagnosed with Bipolar II Disorder. She was treated “regularly” until November 21, 2014.

         On November 21, 2014, Shear was in a motor vehicle accident in which she was seriously injured. She sustained multiple fractures including to her right distal clavicle, right proximal humerus, left supra condylar humerus, left sacral ala, left acetabular, left superior and inferior pubic rami, right subtrochanteric femur, left femoral neck, right open pilon, left tibial plateau, and several vertebrae. In addition to her fractures Shear sustained other injuries including a scalp laceration, a subdural hemorrhage, a subarachnoid hemorrhage, multiple rib fractures, and a pulmonary laceration. Shear was in the hospital from November 21, 2014 through December 31, 2014. She underwent multiple surgeries when she was hospitalized to repair her fractures and injuries including the removal of her spleen and part of her left lung.

         Shear was transferred to a rehabilitation facility until February 24, 2015. She had been prescribed Celexa and Seroquel to help her mental state and to come to terms what had happened to her. On March 10, 2015, Shear saw Dr. Scott Kaar regarding the extremely limited motion Shear had in her right shoulder. On March 16, 2015, Dr. Kaar performed surgery on the right shoulder.

         On April 3, 2015, Shear was seen at the Community Counseling Center by Dr. Fred Gaskin, M.D. for the first time after her accident. Dr. Gaskin noted that Shear was alert, oriented, had “ok” speech, and an appropriate affect. Her mood was neither manic nor depressed. DE. Gaskin continued to prescribe Seroquel and Celexa.

         On April 14, 2015, Shear returned to the hospital for a follow up orthopedic examination with Dr. Joanie M. Columbia. Shear reported that she was doing well and was able to walk 20 feet without an assistive device. She did not require pain medications any longer and took Tylenol as needed. Her left hip was “popping.” Her right humerus continued to be subluxed and additional surgery was planned.

         On April 21, 2015, Shear met with her mental health counselor Walter Major for individual therapy. Major observed that Shear was in a friendly mood, cooperative, and talkative. She had a matching mood and affect. Shear had logical, sequential, and connected thoughts, and she was properly oriented. She exhibited appropriate motor activity.

         On May 19, 2015, Shear returned to see Dr. Kaar about her right shoulder. Dr. Kaar observed Shear to be alert, oriented, and pleasant to speak with. She walked with a normal gait, and she had good neck range of motion in all directions. Shear had no problems with her left shoulder. He right shoulder was neurovascularly intact with some proximal tenderness to palpation. Her shoulder had restricted passive and active range of motion to 90 degrees of elevation. She had somewhat reduced (4/5) abduction strength. On June 15, 2015, Dr. Kaar performed another surgery on Shear's right shoulder. This surgery resulted in improved alignment but the inferior subluxation of the humerus remained, possibly related to joint effusion.

         On June 9, 2015, state agency psychologist James Morgan Ph.D. reviewed the evidence in Shear's file in connection with her SSI application. He concluded that Shear was moderately limited in her ability to carry out detailed instructions and maintain attention and concentration for extended periods. He assessed Shear as having moderate difficulties in maintaining concentration, persistence or pace.

         On July 24, 2015, Shear returned to the Community Counseling Center and reported to Dr. Gaskin that she was doing “pretty good.” She stated that she felt down because she could not ride her horses yet. On September 18, 2015, Shear reported to Dr. Gaskin at the Community Counseling Center that she was starting to be a happy person again. She started riding horses again. She said it hurt because she was not used to it. Shear had a slow deliberate gait but could walk without a cane. On November 6, 2015, Shear saw Dr. Gaskin again and reported doing “pretty good” and that she was happy. She rode a horse for the second time for two hours since her accident and was “sore.” He noted that her judgment was “still an issue” apparently based on her alcohol use and rushing into relationships with boys. On January 8, 2016, she returned to Dr. Gaskin and stated that she had experience some romantic “drama” regarding boyfriends. She said that she was irritabile but was sleeping well. Her prescription for Seroquel was refilled.

         On April 1, 2016, Shear returned to Dr. Gaskin and reported that the Seroquel made her feel like a zombie and she stopped taking it two weeks before her visit. She said her plan to get a house with friends did not work out and she was “back with her mom.” She said her boyfriend of the past month was not a good driver and made her anxious. That's why she prefers to drive. Dr. Gaskin asked about her drug and alcohol use. Shear stated that she had stopped smoking pot but had used alcohol recently. Dr. Gaskin asked Shear whether her mother limited Shear's use of drugs and alcohol. Shear replied, “I usually just leave when I want to. I just do what I want to.” Dr. Gaskin noted the case manager noted that Shear was more stable when she lived with her mom. Shear stated that if someone tried to put her in a residential place she would “kill herself.”

         On January 31, 2017, subsequent x-rays showed her fractures were healing but she had some residual deformities in her left hip and her right ankle revealed progressive bridging callus across the distal syndesmosis.

         On February 15, 2017, Shear had a pain management consultation with Dr. Vivek Manchanda. She complained of pain all over the worst of which was in her right shoulder and ankle. She said her pain was a 7 on a scale of 10. Manchanda diagnosed pain in her right shoulder, right ankle and joints of the right foot and chronic pain syndrome.

         In early 2017, Shear filled out a social security questionnaire regarding her present medications. She recorded that the was taking Keppra and Vimpat to prevent seizures and Voltaren (a non-steroidal anti-inflammatory medication) for pain beginning in December 2016.

         On February 23, 2017, x-rays of Shear's left hip revealed sclerosis and mild deformity in the left femoral neck from a healed fracture. She told Dr. John T. Watson that she was back to her usual activities including horseback riding. Shear complained of pain in the left hip and the screws placed in the left hip were removed the next day by Dr. Watson.

         On March 15, 2017, Shear returned to Dr. Manchanda for pain management. She said her pain was a 6 on a scale of 10. She was taking hydrocodone for pain. On April 19, 2017, Shear returned to pain management and rated her pain as a 5 on a scale of 10. Her right shoulder and left hip were the most painful. Her right shoulder and right ankle were examined and showed a decrease range of motion and tenderness to palpitation. She continued to have swelling in her right ankle. Her hydrocodone was refilled.

         On June 21, 2017, Shear reported to Dr. Manchanda that her pain was worse lately and was aggravated by walking, standing, and weather changes. Shear saw Dr. Manchanda in follow up visits on August 16, 2017 and September 20, 2017. She reported her pain as a 9 on a scale of 10. An examination revealed decreased range of motion in all planes of her right shoulder and right ankle with mild swelling of the right ankle. Her left knee had swelling and tenderness to palpitation. Her left hip and lumbar paraspinal muscles were tender. She was diagnosed with pain in her right shoulder, right ankle, joints of the ...

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