Medical Report - CPP Disability Benefits

Medical Report for Canada Pension Plan Disability Benefits Date of Report: 1 November 2024 Patient Information: Name: Smith, John Michael Date of Birth: 15 March 1970 Address: 123 Maple Street, Anytown, AB T1X 2Y3 Health Card Number: 1234-567-890 Reporting Physician: Name: Dr. Eleanor Vance Specialty: Family Medicine Address: 456 Oak Avenue, Anytown, AB T1X 2Y4 Telephone Number: (555) 123-4567 Fax Number: (555) 123-4568 Medical History Relevant to Disability: 1. Primary Medical Condition Causing Disability: Chronic Low Back Pain with Radiculopathy (L5-S1 nerve root compression secondary to disc herniation). 2. Date of Onset of Primary Condition: Approximately 10 May 2020 3. Diagnoses (including ICD-10 codes): - M51.26: Other intervertebral disc displacement, lumbosacral region, with radiculopathy - G54.1: Lesions of lumbosacral roots and plexuses - M54.5: Low back pain 4. Relevant Past Medical History: - Hypertension (managed with ramipril) - Type 2 Diabetes Mellitus (managed with metformin and diet) - Previous appendectomy (1995) 5. Current Medications (including dosage and frequency): - Gabapentin 300mg three times daily - Tramadol 50mg as needed for severe pain (max 4 doses/day) - Ramipril 5mg once daily - Metformin 500mg twice daily - Naproxen 500mg twice daily (discontinued due to GI upset) 6. Allergies: Penicillin (rash) 7. Relevant Surgical History: - Lumbar microdiscectomy (L5-S1) on 15 January 2021 (partial relief, but pain recurred and worsened). 8. Other Medical Conditions: - Mild osteoarthritis in knees (not currently disabling) Functional Limitations (Impact on Daily Living and Work Activities): 1. Limitations in activities of daily living (ADLs): - Difficulty with prolonged standing (more than 15 minutes). - Limited ability to lift objects over 5 kg. - Problems with bending, twisting, and reaching overhead. - Requires frequent position changes and breaks when sitting for more than 30 minutes. - Struggles with getting dressed, particularly putting on socks and shoes due to back stiffness and pain. 2. Limitations in occupational activities: - Unable to perform previous occupation as a warehouse worker due to heavy lifting, bending, and prolonged standing requirements. - Difficulty with light manual tasks requiring fine motor skills or repetitive movements due to pain exacerbation. - Reduced concentration and fatigue due to chronic pain, affecting ability to perform desk-based tasks for extended periods. 3. Prognosis and Rehabilitation Efforts: - Prognosis for significant improvement in back pain and functional limitations is guarded. Despite conservative management (physiotherapy, medication) and surgical intervention, chronic pain and radicular symptoms persist. - Patient has undergone extensive physiotherapy (2 courses, 6 months each) without sustained benefit. - Participated in a chronic pain management program (6 weeks) focusing on coping strategies and activity pacing, with limited long-term impact on functional capacity. - Ongoing pain specialist consultations provide medication management, but no further surgical or interventional options are currently recommended. 4. Expected Duration of Disability: - The patient's condition is considered chronic and unlikely to improve sufficiently for competitive employment. Disability is expected to be long-term/permanent. 5. Treatment Plan (current and proposed): - Continue current medication regimen (Gabapentin, Tramadol, Ramipril, Metformin). - Ongoing monitoring by pain specialist and family physician. - Referral to occupational therapist for assessment of assistive devices and home modifications. - Psychological support for chronic pain management and mood disturbance. 6. Physician's Opinion on Patient's Ability to Work (including any restrictions/accommodations): - Mr. Smith is currently unable to perform his pre-disability occupation. He is also significantly limited in performing light or sedentary work due to the need for frequent position changes, inability to sit/stand for prolonged periods, and impact of pain/medication on concentration. - Restrictions include: no lifting over 2-3 kg, no prolonged sitting or standing (max 30 minutes without a break), no repetitive bending, twisting, or prolonged reaching, and need for flexible work environment with option for frequent rest breaks. - Accommodations would include: ergonomic workstation, ability to alternate between sitting and standing, frequent breaks, and reduced work hours if attempting modified duties. Even with these accommodations, sustained competitive employment is highly unlikely given the severity and chronicity of his symptoms. 7. Impact on Social and Leisure Activities: - Significant reduction in social outings due to pain and fatigue. - Unable to participate in previous hobbies such as gardening, hiking, and playing with grandchildren. - Experiences social isolation and increased dependence on family members. Supporting Documentation (e.g., reports from specialists, imaging results): - MRI Lumbar Spine Report (dated 10 June 2020): L5-S1 disc herniation with impingement on right S1 nerve root. - MRI Lumbar Spine Report (dated 20 December 2021): Post-surgical changes, persistent disc bulge at L5-S1 with evidence of scar tissue formation and ongoing nerve root irritation. - Physiotherapy discharge summaries (dated March 2021 and October 2022) detailing limited progress. - Pain Specialist Consultation Reports (various dates). Additional Comments: Mr. Smith presents as genuinely distressed by his inability to work and participate in family activities. His chronic pain has significantly impacted his quality of life and mental well-being, leading to symptoms of depression. He has been compliant with all recommended treatments. Based on the objective medical evidence and functional limitations, he meets the criteria for severe and prolonged disability.