CONSULTATION
The above-captioned patient was examined by me on this date for the purpose of making an impartial determination regarding his ability to work and regarding the possible industrial origin of his disability. I have reviewed some, but not all, of his medical records from the factory and have also examined documents shown to me by him.
He states that in 1979, he began to notice gradual onset of chronic tiredness and lack of normal pep and energy. He states that his wife was aware of this before he was. He took frequent naps and lacked sufficient pep for normal activities. Later, he began to experience episodes of pressure or pain in the midchest, particularly at night, lasting minutes to hours. These were not triggered by exertion or eating, nor were they associated with dyspnea or diaphoresis. The pain did not radiate. He had very little cough, but did occasionally note wheezing in his chest.
His private physician evaluated him thoroughly but was unable to document any abnormality except mild hypertension for which Inderal was prescribed. He was evaluated at an environmental health clinic, and according to their report, a copy of which the subject showed me, he demonstrated bronchial hyperreactivity to toluene diisocyanate (TDI) as manifested by reduction in forced vital capacity (FVC) and 1-second forced expiratory volume (FEV-1). He also demonstrated bronchospasm in response to a methacholine challenge. Radioallergosorbent test (RAST) was negative for IgE antibody to TDI.
A diagnosis of bronchial asthma with TDI sensitivity was made and Theo-Dur and Alupent were started, with some relief of symptoms. Returned to work at the factory with the approval of his physician and with restrictions on exposure to TDI, asbestos, carbon black, and other noxious inhalants, and although he experienced no symptoms while at work, he had chest pain and dyspnea that night severe enough to require medical consultation. He is presently taking Theo-Dur, Alupent, Bronkometer, Vanceril, and Aldoril. He denies any history of asthma or wheezing before 1979. He smoked 1 package of cigarettes daily from 1967 to 1980.
On physical examination, the subject is a normally developed and somewhat overweight white male appearing older than the stated age of 41 years. He is alert, normally oriented, in good spirits, and cooperative. He is eupneic at rest, both sitting and supine. His skin shows a “farmer’s tan” of moderate intensity on the face, neck, and arms, and scanty acneiform eruption of the trunk. The skin is pale, warm, and dry without cyanosis, striae, vascular lesions, or scars.
The head shows no gross deformity or lesions. Scalp hair is normally distributed and gray. The eyes are grossly normal, and the extraocular muscles are intact. The pupils react to light. The ocular fundi examined without mydriatic show no vascular changes or exudates. The right ear is normal. The left ear has a large central perforation of the tympanic membrane without inflammation or exudate. The mouth and pharynx appear healthy. The lower teeth are worn, and there is an upper partial denture in place. The thyroid and cervical lymph glands are not palpable. Carotid pulsations are full and equal, and neck veins are not distended.
The heart is regular at 100 without murmurs, clicks, S3 or S4, or clinical evidence of cardiomegaly. A2 is equal to P2 in intensity. The thorax is symmetrical without increase in anteroposterior diameter, and respiratory excursions are full and symmetrical without accessory respiratory muscle activity. Bronchovesicular breath sounds are heard over both upper lung lobes on auscultation, and there are a few coarse sibilant expiratory rhonchi over the right middle lobe, not clearing with coughing. The percussion note is normal throughout the chest.
The abdomen is slightly protuberant. No masses, organomegaly, abnormal tenderness, or surgical scars are noted. The extremities show grossly normal strength and mobility without tremor, edema, or clubbing. Pedal pulses cannot be detected at this examination. Cranial and spinal nerves are grossly intact. Deep tendon reflexes are elicited with difficulty but are symmetrical. Orientation, memory, judgment, and associations are unimpaired, and affect is appropriate.
Posteroanterior and left lateral chest radiographs taken today are not in full inspiration but show no abnormalities. There is no cardiomegaly, and the lungs are free of infiltrates, fibrosis, calcifications, or space-occupying lesions. The pleural margins are clear. Pulmonary function studies done on this date show an FVC of 2.4 liters (48% of predicted), FEV-1 of 1.8 liters (48% of predicted), and FEV-1/FVC of 0.78 (101% of predicted). Assuming maximal effort by the examinee, these studies show significant restrictive and obstructive abnormalities.
In summary, the examinee has mild exogenous obesity, a chronic perforation of the left tympanic membrane, and adult-onset reactive airways disease with demonstrated hyperreactivity to isocyanate vapor. It is doubtful that the last-mentioned diagnosis adequately explains the full range of his symptoms. There can be little doubt that he is abnormally sensitive to the irritant and bronchospastic effects of isocyanate. It is not clear, however, what role his exposure to TDI played in the genesis of his pulmonary disease. He continues to have bronchospastic symptoms, although he has not been near the factory for a year and a half. This implies a chronic asthmatic diathesis not dependent on exposure to isocyanate vapor. (It is known that in a small number of isocyanate reactors, a period of exposure to isocyanate may be followed by bronchiolitis with longstanding and progressive reduction in small airway caliber despite avoidance of any further exposure.) Again, his FVC is only about half of what would be predicted for a man of his height and age. This is hard to reconcile with the normal chest films, which show neither reduction in thoracic volume nor destruction or infiltration of pulmonary parenchyma.
A clearer picture of his condition might be obtained by doing FEF25-75, blood gases, and ventilatory and perfusion lung scans. The scans have apparently been done in the past but with equivocal results. On the basis of information available to me, I cannot say that this man’s present symptoms definitely are or definitely are not due to TDI exposure. I would not consider the subject disabled for gainful employment.
FOOTNOTE
Line 30 (Page 1). The dictation error ventilatory was changed to vital.
Line 31 (Page 1). Ordinarily, a hyphen is not used to connect a letter and numeral; however, a hyphen was inserted in FEV-1 to avoid the numeral 1 being misread as the letter L.
Line 41 (Page 2). Alternative. The metric measurement liter is abbreviated L or l.
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