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Parker v. Saul

United States District Court, N.D. California

September 18, 2019

ANDREW M. SAUL, Defendant.




         Plaintiff Antonia Antoinette Parker seeks review of the final decision of Defendant Andrew M. Saul, Commissioner of Social Security (“the Commissioner”), denying her applications for disability insurance benefits and Supplemental Security Income benefits under Titles II and XVI of the Social Security Act. The parties have filed cross motions for summary judgment pursuant to Civil Local Rule 16-5. For the reasons stated below, the Court GRANTS Parker’s Motion for Summary Judgment, DENIES the Commissioner’s Motion for Summary Judgment, REVERSES the decision of the Commissioner and REMANDS the case to the Social Security Administration for award of benefits.[1]

         1. II. BACKGROUND

         A. Factual Background

         Education and Employment Background

         Parker was born on April 23, 1964. Administrative Record (“AR”) at 1172. She graduated from high school in 1982 and then joined the Army, where she worked as a secretary for two years. Id. at 1175. After she left the Army, she worked in customer service. Id. Parker completed cosmetology school in 1990. Id. at 380. Parker received her cosmetology license in 2001 and held various cosmetology jobs in New York. Id. at 1175. In 2008, she worked twenty hours a week as a spa attendant for six months. Id. at 381. In 2015, Parker worked 10 hours a week as a house monitor at Casa de Maria for a month. See Id . at 73-74. Parker stopped working in this position because she “was always tired” and “did not have the energy” to do the work. Id. at 74.

         Parker’s Medical History

         Parker alleges that she is unable to work because of both physical and mental impairments as well as side effects from medication. See Id . at 77. She was diagnosed with polycystic liver and kidney disease in 1998. Id. at 1404. In addition, she fell down a flight of stairs in 2008, sustaining spinal injuries and fracturing her clavicle and her “T5 and T6 spinous processes.” Id. She began having “nerve blocks” every three months after this accident. Id.

         Parker also has a history of physical and sexual abuse. Id. at 945. When she was a child, her grandparents stripped her naked and whipped her. Id. She was also raped in 2011, which she reported to the police. Id. Parker is also a victim of domestic violence and suffered both physical and emotional abuse when she lived with her ex-husband. Id. As a result of her history of trauma, Parker suffers from panic attacks and nightmares. Id. at 1317. She also suffers from major depression and anxiety disorder and experiences confusion and other side effects of her medications. Id. at 77, 1089.

         Parker takes Morphine three times a day to manage her pain, which she says makes her drowsy. Id. at 79, 1174. She also takes Xanax for anxiety, Cymbalta for depression and to give her energy, Seroquel “for [her] mood and sleeping, ” and Prozac for her mood as well. Id. at 1173-74. Parker sees multiple doctors for treatment of her impairments. See Id . The Court summarizes Parker’s relevant medical treatment below.

         a. Parker’s Polycystic Kidney Disease

         Parker was diagnosed with polycystic kidney disease in 1998 after feeling “excruciating pain” in her back and stomach. Id. at 1404. Between 1998 and 2000, she had four surgeries to drain cysts on her liver and kidneys. Id.

         Between 2000 and 2009, Parker was treated for abdominal pain from her kidney cysts at Alta Bates Summit Medical, in Oakland, California. Id. at 1278-1308. Philip Rich, M.D., conducted a transabdominal ultrasound on August 14, 2000 and found “[p]olycystic disease of the kidneys and liver.” Id. at 1308. Parker went to the Emergency Department at Alta Bates Summit on December 15, 2008 complaining of constant abdominal pain she had been experiencing for approximately two weeks. Id. at 1286. She was treated by Ben Bonnes, M.D., who attributed Parker’s pain to “ovarian cyst” and “bacterial vaginitis.” Id. at 1290. On January 22, 2009, Patrick Perkins, M.D., took a CT of Parker’s abdomen and found that:

The liver exhibits multiple hypodensities which are all well defined and of various size from moderate to tiny. These are seen throughout the liver. The kidneys are enlarged by multiple cysts of varying size with a degree of parenchymal replacement less than usually seen with classic polycystic disease.

Id. at 1278.

         On March 27, 2013, Clifford Wong, M.D., evaluated Parker for renal insufficiency at St. Rose Hospital. Id. at 944. Dr. Wong diagnosed her with renal insufficiency with reported polycystic kidney disease, given a “very strong family history” and “suspect[ed] autosomal dominant polycystic kidney disease.” Id. at 945–6.

         Parker was also referred by her primary care physician to Varun Chawla, M.D., a nephrologist at Chabot Nephrology Medical Group. Id. at 741. Her first appointment with Dr. Chawla was on October 24, 2013. Id. Parker continued to see him through September 2015. Id. at 1194–1240. Parker reported to Dr. Chawla that she had flank pain, “mostly right side, severe.” Id. at 741. Dr. Chawla confirmed Parker’s diagnosis of polycystic kidney disease when he examined her on October 24, 2013. Id. at 745. He further added that she suffers from “excruciating flank pain, ” the cause of which he suspected was a “cyst bleed causing acute pain.” Id. at 746. Dr. Chawla also diagnosed Parker with chronic atrial fibrillation, anxiety and hypertension. Id. He recommended Vicodin for severe pain and Tylenol for mild to moderate pain. Id. However, he also noted that “no specific treatment has been proven to prevent or delay progression of autosomal dominant polycystic kidney disease.” Id. Parker saw Dr. Chawla for a follow-up on November 14, 2013. Id. at 738. Dr. Chawla confirmed the same diagnoses, adding anemia and hypertension, and asked Parker to follow up in three to four months. Id. at 739. Parker saw Dr. Chawla again on March 28, 2014 for flank pain. Id. at 1205–07. He prescribed Percocet for severe pain. Id. at 1207. Dr. Chawla saw Parker again on July 1, 2014 and noted the same diagnoses. Id. at 1210. However, when he treated her on February 18, 2015, Dr. Chawla also diagnosed Parker with “[a]cute renal failure syndrome, ” based on lab results showing that her creatinine had “jumped from baseline 1.0-1.2 to 1.6” and noted that “this could be [acute kidney injury] versus progression of [polycystic kidney disease].” Id. at 1212. He ordered a re-check in one to two weeks. Id. At a follow-up appointment on March 18, 2015, Dr. Chawla again diagnosed Parker with acute renal failure syndrome noting that on recheck her creatinine remained high at 1.5. Id. at 1228. He also diagnosed Parker with polycystic kidney disease and “chronic kidney disease, stage three.” Id. At Parker’s follow-up appointment on June 12, 2015, Dr. Chawla listed Parker’s diagnoses as “[p]olycystic kidney disease, adult type, ” “[c]hronic kidney disease, stage 3, ” “[e]ssential hypertension, ” “[a]nxiety, ” “[a]nemia, ” and “[a]cute renal failure syndrome.” Id. at 1230. He prescribed Venofer by IV weekly for three weeks in his care plan to address Parker’s anemia. Id. Parker returned on July 17, 2015 and Dr. Chawla listed the same diagnoses as the previous visit. Id. at 1234. He referred Parker to a pain management specialist. He also prescribed Percocet for “severe pain.” Id. Dr. Chawla saw Parker again on September 1, 2015, and confirmed all previous diagnoses except for acute renal failure syndrome, which was no longer listed. Id. at 1239.

         b. Parker’s Chronic Back Pain

         i. Alta Bates Summit

         Parker went to Alta Bates Summit Medical Center emergency department on July 1, 2009 after she was hit by a car. Id. at 555. Stephan D. Chin, M.D., treated Parker and took x-rays of her spine. Id. at 556–558. Dr. Chin concluded that Parker fractured her “distal right clavicle” but did not fracture her spine. Id. at 558. He instructed her to ice her clavicle and wear a sling until better. Id. at 559. Dr. Chin prescribed Ibuprofen, Vicodin, and Flexeril. Id. Parker went back to the emergency room on July 11, 2009, complaining of persistent back pain, and the attending doctor, Dr. Klemenson-Chau, ordered a CT of Parker’s spine. Id. at 546. Based on the CT and a reevaluation of Parker’s back x-ray, Dr. Klemenson-Chau concluded that Parker did have a fracture of “T5 involving the spinous process, ” and “[f]racture of T6 involving the spinous process.” Id. at 546. Dr. Klemenson-Chau instructed Parker to wear a fiberglass splint. Id. at 547. Khalil Zahra, M.D., also consulted and confirmed “[a]cute fracture of the spinous process of T5, T6, and possibly T7.” Id. at 543.

         ii. Washington Hospital and Dr. Banh

         Parker sought treatment for chronic back pain exacerbated by a fall on July 16, 2009 at the Washington Hospital emergency room. Id. at 670. Mohamed Nazari, M.D., her attending physician, diagnosed Parker with a back sprain but also noted “pain syndrome: chronic” and prescribed Vicodin. Id. at 674. On August 19, 2009, Parker returned to the Alta Bates emergency department and was evaluated by Ronn Berrol, M.D., who noted, “[r]eview of old records show a CT that did indeed show a spinus [sic] process [fracture] last month, [i]t appears well healed.” Id. at 540. Parker went back to the Washington Hospital emergency department on August 29, 2009, seeking treatment for thoracic back pain, reporting that the symptoms began two months earlier. Id. at 658. David Orenburg, M.D., the attending physician, prescribed Norco for “acute back pain.” Id. On September 22, 2009, Dr. Banh at Mission Peaks Orthopedics to whom Parker was referred by her primary care physician, evaluated Parker’s back pain. Id. at 565. Parker reported that the pain in her back increased to nine out of ten. Id. Dr. Banh noted under assessments, “thoracic spine fracture, ” “right distal clavicle fracture, ” “right radial head fracture” and “right thoracic strain.” Id. at 566. Dr. Banh recommended “conservative” treatment of the thoracic fracture and referred Parker to a surgeon to consider surgery regarding her elbow fracture. Id.

         On January 9, 2011, Parker returned to Washington Hospital emergency department seeking treatment for back pain, “right flank” and vomiting. Id. at 627. Leonard Popky, M.D., the attending physician, prescribed Vicodin and gave Parker “a lot of Zofran by IV.” Id. Parker returned to Washington Hospital emergency department two weeks later on January 22, 2011, again seeking treatment for chronic back pain and vomiting. Id. Dr. Nazari, the attending physician, prescribed Vicodin and set up a Zofran IV again. Id. at 615. Parker went to the Washington Hospital emergency department on February 22, 2011 after suffering an assault which exacerbated her back pain. Id. at 579. However, Dr. Halimi, the attending physician, found no “evidence of spine trauma.” Id. at 580. He prescribed Flexitril. Id. at 576.

         iii. St. Rose

         Between July and November 2013, Parker went to St. Rose emergency department multiple times for treatment of her chronic back pain. Id. at 791–932. On August 17, 2013, Parker went to the St. Rose emergency department after falling down a flight of concrete stairs. Id. at 931. Tan Nguyen, M.D., noted her back pain but found no fracture of Parker’s thoracic spine. Id. at 932. Dr. Nguyen administered Morphine and Zofran intravenously and gave Parker Vicodin and Clonidine. Id. at 933. Parker returned a week later, with continuing back pain. Id. at 911. Attending physician, Dimpi Kalira, M.D., noted no fracture of the thoracic spine, but ordered Morphine and Zofran and prescribed Norco for treatment of severe pain. Id. at 920. On November 4, 2013, Parker went back to St. Rose emergency department, complaining of constant right flank pain that had lasted more than four months and had worsened in the last few days, reaching a level of eight out of ten. Id. at 836. Dr. Nguyen administered Morphine and Zofran and prescribed Norco. Id. at 838, 843. Further, she notes “you have back pain, which is likely related to your polycystic kidney disease.” Parker returned to the St. Rose emergency department two weeks later, on November 18, 2013, complaining of continued abdominal and back pain, and attending physician, Alia Kim, M.D., gave her Morphine again. Id. at 817, 821.

         Parker went to the St. Rose emergency department on December 2, 2013 for lightheadedness “[a]ssociated with chest pain, [a]ssociated with tremors, dizziness.” Id. at 806. Parker’s triage notes indicate “patient here for chest pain and severe headache . . . was doing errands when chest pain happened with diaphoresis.” Id. at 810. Parker was inpatient from December 2, 2013 to December 6, 2013 and her attending physician is listed as Prasad Ghimire, M.D. Id. at 747. When Parker was first admitted on December 2, 2013, Zarah Napuli, RN, noted that Parker’s speech was slurred, and she was “complaining of severe headache.” Id. at 811. David Wei, M.D., ordered a CT scan “[without] [c]ontrast” and Michael Faer, M.D., a radiation oncologist, read the results, noting “[n]o acute findings” and “[n]o signs of intracranial hemorrhage, hematoma, hydrocephalus, acute infarct, large mass, mass effect, or fracture.” Id. at 784, 808–809. Dr. Wei also ordered a chest x-ray using a portable x-ray machine to determine the cause of Parker’s chest pain. Id. at 808. Dr. Faer conducted the exam and found “[r]educed lung volumes with elevation of the hemidiaphragms compressing the lung bases, accentuating the cardiovascular mediastinal size and producing bibasilar decreased acration.” Id. at 780. Dr. Faer also found “vascular crowing and compressional atelectasis.” Id. Dr. Faer recommended “repeat[ing] evaluation in full inspiration for clarification” as to what was causing the basilar areas of decreased aeration. Id. Dr. Wei performed an EKG and found “[heart rate] 52, ” “sinus [bradycardic].” Id. at 808. Dr. Wei ordered a CT of Parker’s chest, abdomen and pelvis as well. Id. at 782. Dr. Faer read the results and found “[n]o evidence for aortic aneurysm nor dissection” and “[n]o signs of central pulmonary embolism.” Id. at 783. Dr. Faer also noted “[b]ilateral layering pleural effusions/compressional atelectasis, small.” Id. At the end of the day, Dr. Ghimire, Parker’s attending physician, summarized the results from her tests. Id. at 750. In addition to the above findings, Dr. Ghimire included “[h]ypertension, ” “[a]nemia, ” “[h]ypokalemia, ” and “[g]astrointestinal bleeding by history.” Id. He made a further note to “[c]heck occult blood and GI workup.” Id. Dr. Ghimire noted “[r]ecent CT is negative for any bleeding and headache improved at the moment.” Id.

         On December 3, 2013, Dr. Ghimire requested a consultation by Bhupinder Bhandari, M.D., for Parker’s [a]nemia, anterior abdominal discomfort, nausea and vomiting.” Id. at 751. Based on his evaluation of Parker, Dr. Bhandari recommended “[u]pper GI endoscopy” and “colonoscopy” if endoscopy is “nonrevealing.” Id. at 752.

         On December 4, 2013, Dr. Bhandari performed the upper GI endoscopy “with biopsy.” Id. at 761. The test revealed “mild gastritis, ” but otherwise findings were normal. Id. On the same day, Dr. Kumar assessed Parker for chest pain at the request of Dr. Ghimire. Id. at 759. He noted that “[c]hest pain appears atypical” and planned to “check an echocardiogram” and “check stress thallium test for coronary ischemia.” Id. at 760. On the same day, December 4, 2013, Qi Che, M.D., ordered an MR Angiogram of Parker’s head “without contrast.” Id. at 790. Dr. Faer read the test and noted “[n]o acutely significant MRA abnormality detected. Specifically, no signs of intracranial aneurysm or stenosis seen.” Id. Later that night, Vasiliki Economou, M.D., performed an EEG and found “[n]ormal electroencephalogram without evidence of any epileptiform abnormalities.” Id. at 805. Dr. Ghimire addressed the negative findings in his discharge notes, commenting that Parker’s severe headache was likely a “tension headache or possible migraine.” Id. at 748. On December 5, 2013, Dr. Khetrapal ordered an MRI of Parker’s brain and brain stem, which Dr. Faer read, finding “[n]o signs of intracranial hemorrhage, hematoma, hydrocephalus, acute infarct, large mass, mass effect, or fracture.” Id. at 793. On the same day, Shankar Prasad Ghimire, M.D., also ordered an MRI of Parker’s lumbar spine. Id. at 791. Dr. Faer performed the MRI and noted “[n]o acutely significant MRI abnormality detected.” Id. at 791–92.

         On December 6, 2013, Dr. Bhandari performed a colonoscopy on Parker. Id. at 763. He diagnosed her with “[c]olonic diverticulosis” and “internal hemorrhoids.” Id. Dr. Bhandari recommended “consideration for small bowel capsule endoscopy as an outpatient.” Id.

         Parker was discharged on December 6, 2013. In his discharge notes, Dr. Ghimire described the tests that had been performed while Parker was inpatient, and their results, and stated that Parker’s “[m]edication has been adjusted and [she] needs to follow up closely with [her] primary care doctor.” AR at 748. He further stated:

[P]atient discharged home with following medications; clonidine 0.3mg one table p.o. three times a day, hydralazine 25 mg p.o three times a day, Protonix 40mg twice a day, sucralfate 1 gram twice a day, Colace 250 mg once a day, aspirin 162 mg once a day, Zocor 20mg once a day, and continue Seroquel, Prozac as before and Xanax 1mg three times a day as needed, Percocet 5/325 mg one tablet every four hours as needed for moderate-to-severe pain and Dilaudid 2 mg p.o. every six hours as needed for severe pain and advised to follow up with primary care doctor and will be referred to pain specialist for further management of chronic pain including headache and all these plan[s] explained to the patient.

Id. at 748.

         iv. Dr. Khetrapal

         Dr. Rabin Khetrapal, of Fremont Primary Care, treated Parker from November 27, 2013 to May 7, 2014. Id. at 1107, 1110. Progress notes have been provided for examinations on November 27, 2013, December 11, 2013, February 7, 2014, April 23, 2014 and May 7, 2014. Id. at 1101-1106. In addition, Dr. Khetrapal completed a Medical Opinion re: Ability to do Work- Related Activities (Physical) form on May 7, 2014. Id. at 1107-1110. In that form, he states that Parker can lift or carry no more than 10 pounds occasionally and can stand and walk less than two hours in an eight-hour day due to pain. Id. at 1108. He opines that Parker must alternate between, sitting, standing and walking frequently to alleviate her discomfort, stating that she can sit no more than 10 minutes without changing position, stand no more than 5 minutes without changing position, and must walk around every ten minutes for at least 5 minutes. Id. He states that Parker must be able to shift at will and needs to lie down at unpredictable intervals. Id. He states that she can never stoop, kneel or climb stairs or ladders and can rarely crouch or crawl. Id. at 1109. He states that Parker’s pain and other symptoms interferes with her attention and concentration constantly and that she would need to be absent more than three times a month due to her symptoms. Id. at 1109-1110.

         v. Dr. Narra

         Parker was referred for pain treatment to Kishore Narra, M.D., a physiatrist, by her primary care physician, Dr. Khetrapal. Id. at 1143. Dr. Narra treated Parker between December 2013 and June 2014. Id. at 1143–71. Parker first saw Dr. Narra on December 10, 2013 for a pain evaluation. Id. at 1166. Dr. Narra diagnosed Parker with “chronic pain syndrome, lumbago, and polycystic kidney disease.” Id. at 1168. Dr. Narra recommended obtaining an x-ray of Parker’s spine. Id. On December 31, 2013, Robert Huberman, M.D., took x-rays of Parker’s thoracolumbar spine, finding “[s]pine alignment is unremarkable” and “minimal scoliosis.” Id. at 1170. Parker saw Dr. Narra on the same day because she felt increased pain in her feet and hips. Id. at 1164. She reported that the Norco was not helping and that she could not walk because of the pain. Id. Dr. Narra diagnosed Parker with lumbago, chronic pain syndrome, and lesion of ulnar nerve, for which he prescribed methadone. Id. at 1165. On January 9, 2014, Parker saw Dr. Narra again because the night before she had “swelling in [her] whole body” and difficulty walking. Id. at 1161–63. Dr. Narra added diagnoses of “hypertension” and “hyperlipidemia” but kept the treatment the same. Id. When Parker saw Dr. Narra for a follow-up on February 28th, 2014, she said it “feels like someone is stabbing [me] in the legs.” Id. at 1158. Dr. Narra continued treatment with methadone. Id. at 1159. At an appointment on March 27, 2014, Dr. Narra diagnosed chronic pain syndrome and paresthesia of the feet. Id. at 1156. He discontinued the methadone because Parker told him it was “making her sleepy all the time” and instead prescribed Percocet. Id. at 1155–57. On April 23, 2014, Dr. Narra conducted a nerve conduction study and EMG, which showed “prolonged distal onset latency” of the left tibial motor nerve, but “all remaining nerves within normal limits.” Id. at 1149–54. On May 23, 2014, when Parker saw Dr. Narra for a one month follow-up, he prescribed 30 mg. MS Contin once daily for her chronic pain. Id. at 1147. At an appointment on July 18, 2014, Dr. Narra adjusted Parker’s MS Contin prescription to 15 mg. twice a day. Id. at 1143, 1145.

         vi. Dr. Rasheed

         Parker saw Sabiha Rasheed, M.D., at Tricity Rheumatology between March 11, 2014 and November 5, 2015. Id. at 1259–65. Parker first sought treatment from Dr. Rasheed for low back, hip, knee and foot pain on March 11, 2014. Id. at 1265. Dr. Rasheed noted that Parker had a history of back pain due to osteoarthritis. Id. Dr. Rasheed also diagnosed Parker with trochantric bursitis and recommended application of ice and Tylenol for pain. Id. In addition, treatment records from Dr. Rasheed reflect diagnoses of lumbosacral spondylosis and thoracic spondylosis without myelopathy. Id. at 1261, 1413-1414.

         Treatment notes from March 11, 2014 reflect that Dr. Rasheed ordered x-rays to evaluate Parker for osteoarthritis. Id. at 12654. On April 2, 2014, Dr. Robert Huberman at NorCal Imaging took x-rays of Parker’s hips, thoracic spine, knees, hands, wrists, and feet. Id. at 1267-72. Dr. Huberman reported “mild midthoracic disc changes, ” “mild scoliosis, ” but “no other findings evident.” Id. at 1268. Each of the other x-rays showed “[n]o significant joint related abnormality” and normal “bone architecture findings.” Id. at 1267, 1269–72. Parker saw Dr. Rasheed again on April 2, 2014 for a follow-up. Id. at 1264. Dr. Rasheed diagnosed Parker with osteoarthritis of the thoracic and lumbar spine but noted “x-rays of the hands, knees, feet and hips: normal.” Id. She changed nothing in her treatment plan. Id. Dr. Rasheed saw Parker again on May 8, 2014, September 9, 2014, September 28, 2015, November 5, 2015, July 26, 2016 and October 25, 2016. Id. at 1259–62, 1412-1417.

         Treatment notes from July 26, 2016 reflect that Dr. Rasheed ordered an MRI of Parker’s lumbar spine because Parker was experiencing “radicular pain in the lower extremities.” Id. at 1415. She also ordered x-rays of Parker’s bilateral hips and noted, “consider steroid injection if [hip] pain persists.” Id. On October 25, 2016, an MRI of Parker’s lumber spine was performed. Id. at 1416. According to the report, the alignment of the lumbar spine was normal and there was no abnormal bone marrow edema, though the MRI showed polycystic kidney disease. Id. The report also revealed a “[s]mall posterior disc protrusion at ¶ 5-S1 with no significant neural impingement.” Id. In treatment notes from Parker’s October 25, 2016 visit to Dr. Rasheed, Dr. Rasheed observed that Parker was experiencing hip pain and lower back pain. Id. at 1417. She wrote that Parker had tenderness at the “trochanter of the right hip, ” that her thoracic spine was “tender with paraspinal muscle spasm” and that the lumber spine was “tender at ¶ 5S1, SLRT at 60 degrees, no sensory/motor deficit.” Id.

         On October 25, 2016, Dr. Rasheed completed a Residual Functional Capacity Questionnaire (“RFC Questionnaire”) and on October 26, 2016 she completed a form entitled Medical Opinion re: Ability to do Work-Related Activities (Physical) (“Medical Opinion form”). AR 40-46. In the RFC Questionnaire, Dr. Rasheed lists the following diagnoses: 1) “osteoarthritis of lumbar and thoracic spine”; 2) “Myalgia – lower back sciatica”; and 3) “Hip bursitis.” AR 40. She found that Parker had the following physical limitations: lifting and carrying less than 10 pounds; standing less than 2 hours in an 8 hour workday; walking less than 2 hours in an 8 hour workday; sitting less than 2 hours in an 8 hour workday; limited ability to push or pull as to both upper and lower extremities; and no climbing, balancing, stooping, kneeling, crouching or crawling. AR 40-41. In the Medical Opinion form, Dr. Rasheed wrote that Parker was “unable to walk at this time due to pain in midback, low back and hips.” Id. at 45.[2]

         vii. Dr. Khalsa

         In February of 2014, Parker was referred to Prabhjot Khalsa, M.D., at Fremont Neurology Medical Associates, by her primary care physician, Dr. Khetrapal. Id. at 999. Dr. Khalsa examined Parker on February 11, 2014 for “lower extremity pain and weakness.” Id. In his assessment, he listed “[p]ain in limb, ” “[g]ait impairment “[paresthesias and numbness, ” “[w]eakness of muscles, ” and “[f]amily history of cerebral aneurysm.” Id. at 1000. Dr. Khalsa ordered an MRI of Parker’s lumbosacral and cervical spine. Id. At a subsequent appointment on February 20, 2014, Dr. Khalsa summarized the results of the MRI as follows:

MRI of the cervical spine revealed C3-4, C4-5, C5-6, and C6-7 disc desiccation with mild canal stenosis and some right-sided neural foraminal stenosis at C5-6. MRI scan of the thoracic spine has revealed mild wedging along the superior end plate of T5, along with T6-7 left posterior lateral disc protrusion. Additionally, there was evidence of bilateral pleural effusions and extensive lesions identified within the right lung and/or within the hepatic parenchyma. MRI scan of the lumbar spine reveals L1-2 and L3-4, L5-S1 disc desiccation, L4-5 disc bulge, with moderate foraminal narrowing. Extensive bilateral renal cysts were demonstrated.

Id. at 1004. Dr. Khalsa recommended that Parker follow up with her primary care physician for “further evaluation and management of pleural effusions, lung/hepatic lesions, and bilateral renal cysts.” Id. At the February 20, 2014 appointment Dr. Khalsa also conducted electrodiagnostic studies to attempt to determine the “underlying neuropathology” of her “ongoing pain syndrome.” Id. at 1002-1003. He was unable to find “evidence of radiculopathy, plexopathy, or other peripheral neuropathic process” and recommended that Parker obtain a rheumatology evaluation. Id. at 1004.

         Parker’s Mental Health Treatment

         a. Treatment Providers

         i. Dr. Kumar

         Pradeep Kumar, M.D., a psychiatrist at Pathways to Wellness, treated Parker from November 2013 to April 2014. Id. at 1078-93. In his initial evaluation on November 20, 2013, he described Parker’s history as follows:

This 49-year-old Afro-American female who is treated for depression and anxiety while at primary care for years. She was on Prozac 40 mg a day for four years, Wellbutrin 150 mg for four years and Xanax 0.25 mg three times a day. The patient felt current medication is not working because she has no motivation in her life. Her symptoms include chronic fatigue, depression, anhedonia, paranoid thought. People are watching her or they are doing something wrong and messing her life. She is also complaining about confusion, irritable mood, poor sleep, fatigue for few years. The patient denies auditory or visual hallucinations. Denies obsessive thoughts.

Id. at 1089. In the comments from Dr. Kumar’s mental status examination for the same visit, on November 20, 2013, Dr. Kumar writes that Parker was “very well dressed, ” “cooperative, ” that her speech was “normal rate and rhythm, ” that she had “good eye contact” and no suicidal ideation, movement disorder or hallucination” and that her mood was “irritable and depressed, ” her affect was “restrictive” and that she has “delusions, ” namely, that she is “very paranoid about the people around her.” Id. at 1091. He rated Parker’s functional limitations as follows: mild restrictions of activities of daily living; moderate difficulties in maintaining social functioning/relationships; moderate difficulties in maintaining concentration, persistence of place; and moderate “episodes of decomposition and increased symptoms, each of extended duration.” Id. at 1092. In his supporting comments he wrote, “patient has significant irritable mood. She is fatigue[d] most of the time, unable to concentrate, unable to finish her job.” Id. He diagnosed Parker with Major Depressive Disorder, severe, and Generalized Anxiety Disorder. Id. Dr. Kumar increased Parker’s Prozac dose to 60 mg. a day, discontinued her Wellbutrin prescription, prescribed 100mg. of Seroquel at night, and increased her Xanax prescription from .25mg. three times a day to .50 mg. three times a day. Id. at 1092.

         When Parker returned for a follow-up on December 18, 2013, Dr. Kumar noted “[t]he patient states she is doing very well on current medications, ” and that Parker “is sleeping well after many, many months.” Id. at 1086. The following month, on January 22, 2014, however, Parker still felt depressed and anxious, and reported that she was having difficulty concentrating. Id. at 1084–85. Dr. Kumar did not change Parker’s prescriptions of Xanax, Prozac, and Seroquel at this appointment. Id. At Parker’s next visit, on February 19, 2014, Parker complained of “more anxiety. . . depression” and “poor concentration.” Id. at 1002. Dr. Kumar doubled her Seroquel dose “to decrease her depression and anxiety” but did not change her Xanax and Prozac prescriptions. Id. at 1082. Parker returned for a follow-up visit on March 19, 2014, complaining that she was having significant concentration and focus problems. Id. at 1080. Dr. Kumar added “possible ADHD” to her diagnoses and prescribed Strattera. Id. at 1081. On April 21, 2014, Parker told Dr. Kumar that her concentration had improved but that she was “still feeling depressed.” Id. at 1072. He noted that Parker had “significant anhedonia, ” had “no motivation, ” and was “feeling fatigue[d].” Id. at 1078.

         ii. Dr. Hiawatha Harris

         Hiawatha Harris, M.D., another psychiatrist at Pathways to Wellness, treated Parker in 2015. Id. at 1245–57. Dr. Harris evaluated Parker on July 21, 2015 and diagnosed her with Bipolar Affective Disorder and General Anxiety Disorder. Id. at 1249. Dr. Harris noted that Parker was “trying to go back to school.” Id. at 1249. On August 13, 2015, Dr. Harris saw Parker again and confirmed the same diagnoses. Id. at 1247. Parker told Dr. Harris, “I’m not doing good today.” Id. Dr. Harris prescribed Abilify, Cymbalta, Hydroxyzine, Alprazolam and Venlafaxine. Id. at 1244. On September 15, 2015, ...

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