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Enuenwosu v. Berryhill

United States District Court, N.D. Illinois, Eastern Division

June 21, 2017

NDIDI A. ENUENWOSU, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1] Defendant.

          MEMORANDUM OPINION AND ORDER [2]

          Sidney I. Schenkier United States Magistrate Judge.

         Plaintiff, 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.

         I.

         Mr. 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).

         II.

         Mr. 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).

         Plaintiff 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).

         A 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).

         An 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. 370).

         On 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[3] and Klonopin[4] (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, 701, 706).

         On June 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.).

         On 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. 109-10).

         State 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).

         On 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. 710-712).

         Dr. 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 exhibiting ...


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