United States District Court, N.D. Illinois, Eastern Division
NDIDI A. ENUENWOSU, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security,  Defendant.
MEMORANDUM OPINION AND ORDER 
I. Schenkier United States Magistrate Judge.
Ndidi Enuenwosu, seeks reversal and remand of the final
decision of the Commissioner of Social Security
("Commissioner") denying his application for
Disability Insurance Benefits ("'DIB") (doc. #
11). The Commissioner has filed a cross-motion asking the
Court to affirm the decision (doc. # 19). For the reasons set
forth below, we grant Mr. Enuenwosu's motion to remand
and deny the Commissioner's motion to affirm.
Enuenwosu applied for benefits on September 19, 2012,
alleging he became disabled on March 3, 2010 (R. 83-84).
After his claim was denied initially and upon
reconsideration, he received a hearing before an
Administrative Law Judge ("ALJ) on November 6, 2013 (R.
96, 114, 151). On April 1, 2014, the ALJ issued a written
opinion finding Mr. Enuenwosu was not disabled from March 3,
2010 through the date of the decision (R. 36-52). The Appeals
Council upheld the ALJ's determination, making it the
final opinion of the Commissioner (R. 18-21). See 20
C.F.R. § 404.981; Shauger v. Astrue, 675 F.3d
690, 695 (7th Cir. 2012).
Enuenwosu was born on January 13, 1965 (R. 214). He lives
with his wife and three children ages 6. 9, and 15, and has
two master's degrees (R. 61-62). Mr. Enuenwosu went to
the emergency room on March 3, 2010, following an assault
when he was working as a Department of Children and Family
Services ("DCFS") caseworker, during which he was
struck in the head multiple times with an unknown object (R.
347). He was given an x-ray and CT scan and diagnosed with an
orbital (blow out) fracture (R. 344-47).
was evaluated by a physician's assistant, Thad L. Cuasay,
under the supervision of Jon Christofersen, M.D., on March 4,
2010 (R. 519-22). He received four follow- up evaluations
with Mr. Cuasay between March 8, 2010 and June 21, 2010, and
was diagnosed with head contusions with left orbital fracture
and left nasal fracture, post-concussion syndrome, cervical
herniated disk C6-C7, neck and trapezius strains,
post-traumatic stress disorder C'PTSD"), bilateral
knee contusions and bilateral upper extremity paresthesia (R.
519-22, 524-28, 529-33, 574-78, 582-86).
neurologist, Padmaja Gutti, evaluated Mr. Enuenwosu on April
29, 2010 for ongoing headaches, dizziness and difficulties
with concentration, opining that his symptoms were due to
post-concussion syndrome (R. 569-72). Mr. Enuenwosu had five
follow-up appointments with Dr. Gutti between May 26, 2010
and July 12, 2011, at which time Dr. Gutti indicated that
Plaintiff had "mild improvement" in his symptoms of
post-concussion syndrome (R. 579-81, 588-97).
orthopedist, Tariq Iftikhar, diagnosed Mr. Enuenwosu with
cervical spine strain, possible neuropraxia of the bilateral
median nerve, and contusion of the right hand on June 11,
2010 (R. 724-25). On an Occupational Disability Medical
Report dated May 2, 2011, Dr. Iftikhar diagnosed contusion of
the right knee with bursitis, cervical strain with herniated
disc, contusion of the right hand, and orbital fracture (R.
386). Dr. Iftikhar also opined on an Authorization for
Disability Leave and Return to Work form dated May 25, 2011,
that Mr. Enuenwosu had moderate limitations in functional
capacity including limitations in lifting and climbing (R.
March 19, 2012, Mr. Enuenwosu was evaluated by a
psychiatrist, Jeremy Brown (R. 603-06). Plaintiff reported
depressive symptoms as well as flashbacks, avoidance
behavior, fearfulness and hypervigilance related to the
attack (R. 605). Dr. Brown diagnosed PTSD and prescribed
Zoloft and Klonopin (R. 606). Mr. Enuenwosu had a
psychiatric evaluation with psychiatrist, Ramon
Alvarez-Leonardo, M.D., on June 20, 2012 (R. 614-18). On that
same day, Dr. Alvarez-Leonardo completed an
"Authorization for Disability Leave and Return to
Work" form indicating that "[patient] continues to
have severe [symptoms] of PTSD and major depression, "
and that "'his prognosis is guarded" (R.
506-07). Records indicate that Plaintiff saw Dr.
Alvarez-Leonardo for psychiatric evaluations and medication
management seven more times between June 20, 2012 and January
14, 2014 (R. 614, 619, 631, 646, 703, 811, 844). Plaintiff
also had ten psychotherapy sessions with Patricia Rosenmann,
LCPC, between August 13, 2012 and March 15, 2013 for
treatment of PTSD (R. 622, 634, 636, 638, 640, 642, 644, 698,
12, 2012, Dr. Iftikhar filled out a second Authorization for
Disability Leave and Return to Work form, opining that Mr.
Enuenwosu had severe limitations in functional capacity
including limitations in lifting, climbing and bending
(432-33). Tapas Dasgupta, M.D., a specialist in physical
medicine and rehabilitation and pain management, offered a
medical source statement on August 22, 2012, noting that he
had treated Mr. Enuenwosu monthly from April 25, 2012 to
August 22, 2012 (R. 672-673). Dr. Dasgupta diagnosed cervical
and lumbar strain, cervical radiculopathy and PTSD (R. 672).
He opined that Mr. Enuenwosu had limitations in standing and
lifting, as well as, psychological limitations and assessed a
class 2 or medium manual activity ability (R. 673). Dr.
Dasgupta concluded that Mr. Enuenwosu was temporarily
disabled and indicated that it was not yet determined when he
could return to work (Id.).
December 17, 2012, Mary Sandra Story, Psy.D., completed a
Mental Residual Functional Capacity ("RFC")
Assessment for the state agency (R. 92-93). Dr. Story
indicated that Mr. Enuenwosu had moderate difficulties in
maintaining attention and concentration for extended periods;
moderate limitations in his ability to work in coordination
with or in proximity to others without being distracted by
them; moderate limitations in his ability to interact
appropriately with the general public; moderate limitations
in his ability to accept instructions and respond
appropriately to criticism from supervisors; and moderate
limitations in his ability to get along with coworkers or
peers without distracting them or exhibiting behavioral
extremes (Id.) She concluded, "[claimant's
ability to sustain attention and focus may be mildly limited
on varying basis due to PTSD symptoms; however, he retains
sufficient comprehension, persistence, pace and concentration
to engage in multiple level stepped tasks" (R. 93). This
mental RFC determination was affirmed by state agency
psychologist, Lionel Hudspeth, Psy.D., on April 9, 2013 (R.
agency consultant, Philip Galle, M.D., completed a Physical
RFC Assessment on December 17, 2012, opining that Plaintiff
could occasionally lift and/or carry 50 pounds; could
frequently lift and/or carry 25 pounds, could stand and/or
walk about six hours in an eight-hour workday and could sit
with normal breaks for about six hours in an eight hour
workday (R. 91 J. Dr. Galle also concluded that Plaintiff
could frequently climb ramps and stairs, balance, stoop,
kneel and crawl but could only occasionally climb ladders,
ropes or scaffolds (Id.). Vidya Madala, M.D.,
affirmed this physical RFC on April 10, 2013 (R. 107-09).
March 20, 2013, Dr. Iftikhar filled out a medical source
statement diagnosing Mr. Enuenwosu with cervical strain and
disc herniation and opining that Mr. Enuenwosu could stand or
walk for six to eight hours, and could sit or stand for six
hours, alternating positions every 15 to 30 minutes (R.
Alvarez-Leonardo completed a second "Authorization for
Disability Leave and Return to Work'" form on August
21, 2013, indicating that Mr. Enuenwosu had continued issues
with sleep, anhedonia, crying spells, nightmares,
hypervigilance, avoidance, guardedness and feelings of
worthlessness, hopelessness and helplessness (R. 796). On
November 4, 2013, Dr. Alvarez-Leonardo completed a
Psychiatric/Psychological Impairment Questionnaire (R. 822).
He diagnosed PTSD, chronic and major depressive disorder, and
indicated that Mr. Enuenwosu was prescribed Zoloft 150mg and
Klonopin .5mg, with no side effects at these doses (R. 822,
827). Dr. Alvarez-Leonardo assessed moderate limitations in
Mr. Enuenwosu's ability to carry out simple one-to-two
step instructions or detailed instructions, to sustain
concentration and persistence, to work in coordination with
or proximity to others without being distracted by them, to
make simple work related decisions, and to complete a normal
workweek without interruptions from psychologically based
symptoms (R. 825-27). He further concluded that Mr. Enuenwosu
had marked limitations in his ability to interact
appropriately with the general public, to respond
appropriately to criticism from supervisors, to get along
with coworkers or peers without distracting them or