United States District Court, E.D. Missouri, Southeastern Division
MEMORANDUM AND ORDER
W. SIPPEL UNITED STATES DISTRICT JUDGE.
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.
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.
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.
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
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.
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.
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.
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
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.
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.
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
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.
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.
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.
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.
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.
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 ...