MES snilJTiONS we"! we Alan F. Barker. MD Date: February 2, 2016 Pulinonnlogist kevin Albert Referring Party: s, Depurtmentorlabor/Seattl m: Referred by: charclene McGill Claim ti: Alan F, Barker, MD, completed an independent evaluation on Kevin Albeit on Febnttiry 2, 2016, for the above-referenced claim The opinions expressed in this report are those of the examiner Mr Albert was also informed that the examination was for evaluative purposes only, intended to address specific injuries or conditions as outlined by the us. Depanment ofLabor/Seanle, and was not intended as a general examination, Mr Albert was asked at the time ofthc examination not to engage in any physical maneuvers beyond peisoiial limits, or those which could cause harm or injury Reason for Consultation Cough, shortness of breath; possible asthma; possibly related to work at a water waste treatment facility, Pugel Sound Naval Yard Identifying [ni'onnalion Mr. Albert is a 48--year--old male who currently works as a supervisor for injured workers at the Puget Sound Naval Yard, _he elnimant was arairto good historian being uncertain of some dates. He had many complaints and interrupted several times wanting to be certain that I understood about the various exposures that he had in his workplace reviewed medical reports and the chest imaging studies. The claimant subsequently brougit me a folder that contained a few of the medical reports, and also some e-mails for which he was copied, regarding some potential exposures, as well as MSD sheets regarding some or the chemicals and solutions used in his workplaee, He has seen at least 17 diil'erent medical care providers including physiclms and Ms related to this problem including occupational positions at the University ofWas-hington. Problem number one is shortness of breath/cough, In approximately 2009, Mt Albert developed coughing and was diagnosed with bronchitis, This was during the wintertime, and the persisted for several months At least one time he had violent counting accompanied by blood. streaked phlegm, He was seen several times by physicians and prescribed Perles, possibly metered--dose inhaler, and perhaps an antibiotic There was partial relief, but the cough recurred, mainly during the wintertime over the next two to three years, in mm, the cough Page 2 of r) RE Kevall-iert 21715030531 Claimd 146073813 Dan: Febrtniryz 2 '6 oecurrett dnil ufien was Violent sometimes accompanied by chest pain, There was no fever or chills. There vi 5 occmional wheeling He said iiccitsioiidlly he: had blood-streaked phlegm liltd urgent care visits for this problem Sometimes he was treated with Cumbivenl dntL'or albutcml. There were other times when he was not (mailed, There was a partial rclicfi bul Ihc coughing ieeurred. The coughing hes continued on an almost daily hilsls, worse in the morning than in the evening He said the eonghing was considerably worsc when he was tlireetly Involved in the wastewalor cleaning process He has bad no fever or chills cecumpanying these episodes tasked him about triggers and he says dust, molds found in buildings, and sometimes coltt nir He has had repeated urgent care eyer the past couple of years. sometiincs treated inhaler and oflen treated prettnisone in the urgent care setting and for several days meiwards In the past, he has been treated With several aerosol steroid preparations and Monlelukasi Currently. he is on an Adiair Diskus one pufftWice daily since October 2015, He uses olbnteiol to 7 times per day and no Combiyeni. lnsked him about Spirlva and he says he was on that medication sometime in the past and was stopped for rcnsons There is no history uftubcrculosis In 201 I, he had pneumonia, but via: not liospiliili/cd. He was treated wltli antibiot and he says the persisted for weeks, but disappeated He has a se ~onal history ofliny fever manifested by watering ofhis eyes and runny nose, most notably [0 scotch broom II is usually treated with a deeongestant. He has not had allergy testing There is no histoiyot'ecycma He denies history of asthma He has 21 past history of hennbuin and buming worse in the past couple ofmonths There is relicfwilh Tums He has been prescribed Prilosec in the past because it has been thought thai be may have had a Contribution ofiefluxt He is not that medication because it was nt'no help A dingiosis ot'vocal eerd dysfunction has been raised He saw omlaryngology in September 2015 and note: indicate normal vocal cord molion some cn1hcma ofthe true and false cords In order to siimiilalc AbllOnllal vocal cord muliun he was exposed to the odor of solution of alcohol He had gagging and no exaxninaxiou could be performed. He denies any msh. ui-itation, or ninny nose at work ct Vladical Histoiw /Revicw of Svstems MES (mm) (2531-55 2999 on) "Jug" 5 mm Page 3 ol 0 RE Kevinillhen MEN 21715030531 Claim; 146073815 Date February 27 2015 was rendered and he was treated an "anublouc." He denies diabetes, seizure; he denies hcpliljlis bill has had abnormal liver tests but those are not he has [lad an test that has been negative Surgeries: At a oung age he had a repair ol'laoerauon ofhis right thumb, ls years ago he had a rotator and in 2014 lie had an with pustupemlwe frequent d)spuca and chest pain Family Farlier is79 and has diabetes, mother is 78 and well and has a diagnosis lhavo already discussed 131-11) and his two siblings, Revmw of stems: he denies urinary tract infection and stones, There is no history of arthritis, He denies slnus . Then: is no hismry of cinema He has been hntlicred for several) 01: with red and dark blood in his sluul. He has been 552" an Urgent Care on A couple of 0:0 lul'lS with stahle hemaloerit Diagnosis ofliemonhoids and proctitis has hem made based on He slates he had an upper GI, but 1 do not know the results Endoscopy several years ago was unremarkable. lashed alioiit his weighl, said his highest was 220 pounds approximater two vears ago Reports in multiple notes mentions "anxiely, depression, and I did n01 explore. Socioeconomic IIistorv llahilar He was born in Cannoolioui where he lived for lg months, followed by 10 years in Boflxell, Washington and he has lived in olher areas of Washington Fur the past 15 years he lives in Seebeck, Washington. He lives in a one storey house Vulh oontral and electrie heal He says he has a siove and he does not use "very much" because it bothers his Pets - l\\0 dogs and two cats that are mainly outside Education: Educational background, highest level is one and a half years, ioealional institute taking cuinpuler drafiing Work history; For six years he was an electrician, mainly working in a residential selling. 11is Job was mainly and he states he did no Between 2002 and 2004, he was in cleanmg up hazardous waste forshipyards and between 200410 2006 he did same Job pan time From 2005 to 2009, he was in maintenance in lhe treatment of Illduslrlal warer waste Between 2009 and 201 i, he was a supervisor but also pan-time worker involved in cleaning industrial water waste, Since late 2013 he has been a supervisor ror iinured workeis at the Puget Sound Naval! Yard. He works in an old building and there are areas of mold that he thinks induces coughing When he was treating wastew aler, he would wear a l'yvek suit 1310300111 mimosa WABXAIUX 1860153 6959 (mini) . 1253,7554"? rm; *1 Fag: 4 or; m; Kol Alb MES: Clam fr Dole om- clot mhher hools gloves on chemicals usedr splash nnu gogglos The notes rnonhonod llral mspu'alor) was nvmlablc, Mr smles he never used pmlecllon Servlce' [\onc. Several nolos rnonnoned lhal the aslownlor system ls a aimed-loop s}stem nillr ohomlcals added al vauolls umcs Ml Alben slates 11ml \che leaks during sworn parllculaxl) an. lug zlm, The chelmcals' ussd ln lhe cleanmg include shlorino, \'al'lous solos nod chromic llud The sold alarms high chlonns levels \wuld g0 parlrcularly l" 2013 when cough was at us worsl He also stated ventilation was inadequate. 1 how no l'here are no notes lo lhallhoro was an or h: was exposed Orhsr uclivll). hc has enjoyed and Ila says he has nol humng Forth: pasl 10 cars He go rnosl recently ln .lnno 2015 llo does some yard work Including rnonlng durmg Lhe He used to ohop wood, bul ho nor done any recemly because orlho cough goes lo tho granary slore and has no oormng gl'ocerlcs I asked obonl olhu' nonver ho cnjuys watching 1V He does porromr aummubile repalr lncludmg orl and spark plugs. and lmuhleshuulmg, particultu lhe as he based on his rernolo nucupmioll as an slcumclan llo nol slan whether he my clemch durng the aulornolnlo rcpalr He does no pdmling or wood work EON lnlaul, and fund: belugrl \vllh \l'v 2'3 Nose Thurs rs no mlnoss, n0 and no polws soon lhroor Then: is no BVudnlc or redness mice ls nal lronrso There an: no nodes I could see a MES Masons 54) 25275959 (mum) . (253) 75572999 (ml ler'," 3 Page 5 of9 RE 21715030531 Cla a -- Date February 2, 2016 Chest: There is no fist percussion tenderness. [heat breath sounds symmetrical, lhear no crackles, no wheezing. He does have cougt with deep breathing on a couple of occasions. I hear a transient pleural rub at the right basc. l-leart has a regular without a murmur. I do not hear a pericardial rub. Abdomen is sofi. The liver is felt below the right costal margin with deep inspiration, but is not enlarged by percussion. There is no palpable spleen. hrtrernitres: No clubbing. cyanosis, or edema. He has multiple clear 24 millimeterpapules ovcr his forehead and on the right side ofhls neck. To me these look like fibrofolliculomas. Neuro is not done. thomtugx Data A recent chest x-ray showed a good inspiration, normal heart size and no infiltrates. It is a nomtal film. A chest CT from 2013 is remarkable for approximately 10 to 12 true of variable size mainly in the lower half of the chest. There may be one or two in the right upper lobe The are in both lungs. There is no evidence uffibrosis. brollchieclasis, or consolidation A repeat chest CT from November 2014 shows no cvidenoe of a pneumothorax. Although difficult to be certalrt I see no evidence of a new or enlargement of the noted in 2013, They appear stable. There are no other new findings spirnmetry today required many efforts, but met ATS criteria The FVC was 5.72 or 107% and the is 4.48 or 111% These are normal. The DLCO is 36.0 or 1 l4%, this is also nonnal reviewed accompanying pulmonary function provided in the medical record. On January 29, 20l4, the FVC is 5 04 liters and the is 4.57 liters. These are better than the current study, but within the variahility of dnTerent study dates and timeThcy are normal. The difiusion on that day is 36.7, also normal and essentially unchanged. There was another study dated June 24, 2014, FVC o.l, FEVI 4.2, and the DLCO was 37.5. These are also normal and unchanged compamd to the earlier study and similar tn the current ones. There is a methachollne bronchoprovocation on June 10, 2015. The baseline sprrornetry is normal and unchanged compared to tho current values. He rcceived two low doscs of methacholinc up to 0.25 milligrams per millimeter. The repons states that he had coughing and gagging and could not complete the study making this a nondiagnostic study. To be diagnostic one would have to complete dosing at a higher level and produce acceptable [see no recent bloat! studies such as CBC with a difl'crentjal. In the medical report there is llsted pulmonary function although 1 cannot verify the values as the actual tests are not available. These date back to approximately 2006, The highest FVC is o. 52, when it says he made maximal efiort without difiiculty Other values are lower and in the range that have been noted rttla south 315" street Sultc no, Federal Way, WA 98003 (806) 253-6959 (maul) (75315572999 Page 5 of9 RE Kevin Al'btzn claim a -- 1n the past three yam. The best is on lhal same date in 2008 when it was 5.01116". Other values are much closer to the ones reported in the past three years including the one from today Conclusions Diagnoses 1. No respiratory diagnosis can be made, The medical chart mentions concern about "bronchitis," and reactive airway disease, or asthma. He has that might be concerning for asthma, but objective evaluations including my own are not confirmatory. virtually every physical examination ofzhe chest, including today mentions no respiratory limitation and no evidence or wheezing. Idid find one physical examination (5/6/2014) out of many that mentioned mild wheezing. Multiple pulmonary function studies dating back almost 9 years are entirely normal A diagnosis ofaslhma cannot be rendered. His background suggestive of hay fever might put him at risk. Regarding his work, he undoubtedly has had exposure to chemicals that have strong odors that would be noticed. It is possible that coughing has occasionally exacerbated by exposure to these odor causing chemicals, but there is no impairment nor damage. Most or these chemicals would usually cause or nasal irritation or skin lesions, none ofwhich have been described or noted on any physical exarnination. Overall, the work exposure plays no role in this man 2. Blfl-Hngg-Dube he has cutaneous manifestations and in the lung. The main impairment in BHD is pneumothorax that can be recurrent He has never had a pneumothornx, His of cough and are not usual ones unless there is some degree ofimpairrnent, IIis pulmonary function including ditrusion has been normal on multiple occasions. Comment and Management I mentioned that I had not had a chance to review the extensive reports and chest imaging studies. Stated my report would probably be available in 2 to 3 weeks for his physician and probably himself. Answer: to specific questions from the claim manager: 1. Please provide all current diagnoses concerning Mr. Albert's pulmonary conditions. List the objective findings that support them. 'ihc diagnoses regarding Mr. Albert's pulmonary conditions were started in my and the objective findings discussed in detail. He does not have a diagnosis of asthma, reactive airway disease, or reactive airway dysfunction (RADS), RADS requires usually an intense or massive exposure to anoxious or toxic iirme with overwhelming There is often a subsequent abnormal physical examination, (x66)253-6959 (mun) (253)75572999 (fix) 21715030531 Date lrelrruaryz 2016 sotflifll'x'us Poge7oi9 RE Kevin Albert claim is Midst: 21715030531 Daw Fcbl'uary 2, 2015 pulmonary function, and ofien hronehoprovoeation. The claimant did not have any overwhelming exposure, it is possible that some oflh: leaks could be considered but most importantly he has no objective findings including normal physical examinations, and pulmonary function. lie does not have RADS. Please pmvide your unequivocal opinion whether the diagnosed condition(s) are related to the employment activities. Please provide medical rationale for your opinions He has no respiratory diagnosis, so there is no relationship to his employment or work activities, Please revim definitions helow: b. Direct Causation is shown when the injury of factors of employment, through a natural and unhroken sequence result in the condition claimed. occurs if a pre-existing condition is worsened, either temporarily or permanently, by an injury arising in the course of employment 1) Temporary aggravation hrvolves a limited period otnredicirl treatment and/or disability. alter which the employee returns to his or her previous physical status. 2) Permanent aggravation occurs when a condition will persist indefinitely due to the oithc work related injury or when a condition is materially worsened such that it will not revert to its previous level of severity. Acceleration occurs when an employment related injury or illness may hasten the development oian underlying condition, and acceleration is said to occur when the oldlnary course onlre disease does not account for the speed with which a condition develops. Precipitation is a latent condition which would not have manirested hut for the employment is said to have lieen hy iactors oicmployrnent. Based on the above definitions, please answer the 3. Are the diagnosed condition(s) medicauy connected to the work injury by direct cause, aggravation, precipitation or acceleration? He has no respiratory diagnosis and there is no relationship to work exposures iriosoon onion . (mi assesses (fax) Fag: 3 of9 RE Kevin Albert Clalnl '1 -- 4. MES 1' 21715030531 Date. February 2, 2015 "aggravation is indicated. it should he explained if this is temporary or permanent There is no midence ofaggravation He has no impairment. By the AMA Guidelines, he has no a. It temporary, when did such aggravation reuse or when may it be exported to cease? h. It permanent, what material change has oeonrred to alter the course or the underlying disease? Please give detailed reasoning for your conclusions. Pleuse provide your prognosis and recommendnfiuns tor medical treatment it indicated, and deserihe the type, duration. frequency and expected results His prognosis is excellent, He is taldng inhaled corticosteroid and a long-acting beta agnnist. Ido not sec any indication forthose medications. He could continue the as needed alhuterol, although I am not sure that is necessary, lie is currently not working in the water treatment facility and the notes indicate no plans to roam to that area. Does the claimant continue to sulter residuals ore worh injury or has it resolved? Give your medical reasons {or the opinion expressed. He has suffered no residual damages There is no diagnosis. Does the claimant require work restrietinns due to a work related condition? If so. please complete the attached Farm owc1>5h No work related restrictions are required in his current duties. lfhe would return to any work in the treatment plant, the previous protections should be used and he most certainly should use respiratory protection. "ugly" 1 Page 9 am RE Kevin Albert 21715030531 ciann: -- Date Thank you far the opportunin assist you inlh: evaluation ufthis case. Ifyou have any queslions or concerns, please {so} fine to Contact MES. Sincerely, Alan Baker, M.D. Pulmonologist Diciaied. reviewed, and opinion verified. ,i'fliws lolflsoudinemsum. sininssn,ngmiwuwamna (35925175959 (mill!) [25375572999