Kem v. Berryhill

352 F. Supp. 3d 101
CourtDistrict Court, District of Columbia
DecidedDecember 11, 2018
DocketCIVIL ACTION NO. 16-40172-TSH
StatusPublished
Cited by3 cases

This text of 352 F. Supp. 3d 101 (Kem v. Berryhill) is published on Counsel Stack Legal Research, covering District Court, District of Columbia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Kem v. Berryhill, 352 F. Supp. 3d 101 (D.D.C. 2018).

Opinion

On March 11, 2014, Dr. Cruz wrote that Plaintiff "has symptoms of depression and anxiety due to her work." (AR 425). On March 27, 2014, Courtney Petter, LMHC, completed a Psychiatric Disorder Form. (AR 485-487). Ms. Petter concluded that Plaintiff's Global Assessment of Functioning ("GAF") score was 56,1 she was oriented to three spheres, and there were no concentration and attention deficits (AR 485). Further, Ms. Petter diagnosed Plaintiff with major depressive disorder. Id.

On March 28, 2014, Dr. Cruz saw Plaintiff, who complained that she was continuing to have memory problems. He noted she was "working in housekeeping" though recently, she slipped and fell on her right side. (AR 491). Dr. Cruz also recommended that Plaintiff speak with a neurologist about her memory loss and headaches. (AR 492). Dr. Cruz opined that Plaintiff's "memory loss can be due to her depression/anxiety. This can also be due to the Topamax medication. However, we cannot stop this medication because of his or her seizure." (AR 494).

During the summer of 2014, Plaintiff began treating with Margot Pagan, MA. In her initial assessment, Ms. Pagan assigned Plaintiff a GAF score of 56 and noted Plaintiff suffered from anxiety and depression. (AR 532-42). Plaintiff continued treating with Ms. Pagan through July 2015. During that time, Ms. Pagan Ms. Pagan noted Plaintiff was "extremely challenged by symptoms of depression" (AR 805) and found no significant changes in Plaintiff's mood/affect, thought process/orientation, behavior/functioning, or medical conditions. (AR 790-827, 848-860).

On July 28, 2014, Plaintiff again presented to UMass Memorial Medical Center. Dr. Butler noted that Plaintiff had a few beers the night before and then had intentionally taken more than 10 Baclofen in a suicide attempt. (AR 576). Her suicide risk assessment tools noted severe depression, preoccupation with hopelessness, despair, feelings of worthlessness, and continued suicidal thoughts. Id. On assessment, Plaintiff was anxious, crying, and depressed. Id. In addition, Dr. Butler found Plaintiff to be a low suicide risk. (AR 570). The same day, Plaintiff was seen by Michael Lebeaux, a therapist affiliated with Community Health Link, and he assigned her a GAF score of 50.2 (AR 645).

On August 5, 2014, Plaintiff treated with Ronald Gobeil, DO. (AR 564). Plaintiff reported being depressed and anxious. Dr. Gobeil reported that Plaintiff was dysphoric over her job situation and hesitant to find a new job, maybe because she feared *106a similar situation as her last job where she had problems with a co-worker. (AR 564). Two days later, Plaintiff again treated with Dr. Cruz. Plaintiff informed Dr. Cruz about her suicide attempt and Dr. Cruz noted that she presented with depression. (AR 549).

On October 21, 2014, Plaintiff was treated at the neurology clinic and reported that she had a seizure the previous weekend. Plaintiff reported "deep depression" and that Topamax was worsening he memory problems. On examination, Drs. Chu and Ramirez found that Plaintiff denied suicidal ideation, she was alert and oriented to three spheres, her upper extremity strength was rated as five out of five, her lower extremity strength was four plus out of five, and her sensation, gait, cerebellar function, and coordination were normal. (AR 565, 567). Further, Dr. Chu concluded that Plaintiff's seizures were uncontrolled and therefore ordered an extended EEG and increased her dosage of carbamazine. (AR 568). On October 26, 2014, Plaintiff was again treated at the UMass Memorial Medical Center and reported that she had a seizure. The EMT reported, however, that it appeared that she had a panic attack. (AR 785).

On June 3, 2015, John Fleming, LMHC, RN, noted that Plaintiff reported experiencing increased stress, resulting in increased anxiety and depression (AR 649). Nurse Fleming then found Plaintiff was oriented to four spheres, she was not experiencing any delusions or hallucinations, her though process was linear, she was easily engaged with a tearful affect at times, and she had passive suicidal ideation with no intent. (AR 651). Further, Nurse Fleming assigned Plaintiff a GAF score of 55. (AR 657).

Plaintiff continued to receive treatment from Island Counseling Center through July 2015. (AR 680-691). During that period, Dr. Gobeil noted that Plaintiff was anxious, depressed, and dysphoric. Id.

From June 11, 2015 to July 17, 2015, Plaintiff participated in an outpatient day program. (AR 692-717). Notes from the program reflect Plaintiff being observed as "upset" and "really depressed." (AR 690; 694). Dr. Nesr, a psychiatrist, diagnosed Plaintiff with PTSD, depression, and anxiety. (AR 706). In addition, she was assigned a GAF score of 45. (AR 710).

On June 16, 2015, Plaintiff presented to the ER for facial numbness. (AR 740). It was noted that due to her ongoing seizures, "all seizure precautions apply for 6 months from the date of the last seizure." (AR 741). The same day, Plaintiff had a CT scan of her head that revealed no acute abnormalities and was unchanged from the prior scan in January 2014. (AR 747). The next day, Plaintiff treated with Dr. Gobeil. She appeared anxious and depressed. (AR 62). On June 30, 2015, Plaintiff reported intense anxiety to Ms. Pagan. On July 22, 2015, Plaintiff reported to Ms. Pagan that she was feeling better after a three-day hospitalization. (AR 858).

On July 14, 2015, Plaintiff again presented to UMass memorial Medical Center complaining of suicidal thoughts, stating that she did not want to live and wanted to take pills. (AR 762). On examination, the attending provider found Plaintiff alert and oriented to three spheres, her affect was anxious, she was crying, and her speech was normal. (AR 763, 767). The same day, Ms. Pagan submitted a Mental Medical Source Statement. (AR 661-666). Ms. Pagan noted that she had been treating Plaintiff biweekly since June 20, 2014 and wrote that Plaintiff had "severe symptoms of depression according to a major depression inventory (7/14/15) severe symptoms of anxiety according to the Hamilton [A]nxiety [S]cale." Further, Ms. Pagan noted Plaintiff's "severe difficulties"

*107recovering and need for long-term continued care to overcome her symptomology. (AR 661). According to Dr. Pagan, Plaintiff would be unable to complete a normal workday and workweek without interruptions form her symptom's accept instructions and respond appropriately to criticism, respond properly to changes in routine work setting, deal with normal work stress, be aware of normal hazards, and take appropriate precautions. She found Plaintiff would be off task 25% of the day and absent six days or more a month due to her mental health symptoms. (AR 666).

Similarly, on July 16, 2015, Dr. Gobeil completed a Mental Medical Source Statement.

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Bluebook (online)
352 F. Supp. 3d 101, Counsel Stack Legal Research, https://law.counselstack.com/opinion/kem-v-berryhill-dcd-2018.