GEORGE L. ZALDIVAR, M.D., LTD. 3100 MACCORKLE AVE., S.E. 404 CHARLESTON, wv 25304 (304)346-1811 FAX (304) 343-3055 GEORGE L. ZALDIVAR, M.D., F.C.C.P. BOARD CERTIFIED IN PULMONARY DISEASES, INTERNAL MEDICINE AND SLEEP DISORDERS. PNEUMOCONIOSIS READER HISTORY PHYSICAL EXAMINATION NAME: Charles Caldwell 'lap Lung Claim Hobit Mining, Inc. Igg'n' Ref 02304/0441 REFERRED: Attorney Mary Rich Maloy Law firm of Jackson Kelly DATE OFEXAMINATION: 3/2/94 Examination performed with use of portable tape recorder IDENTIFICATION: Mr. Caldwell is a 63 year old, white, male. Mr. Caldwell told me he almost lost an arm in Beckley during the exercise test and that he does not want to have any sort of blood gas studies today; neither resting nor with exercise. CHIEF COMPLAINT: Shortness of breath. HISTORY on PRESENT ILLNESS: He -does not know how long he has been short of breath but he guesses it might be eight years. He is hard of hearing. He has not heard any wheezing in his lungs. He says he has been coughing for a number of years, usually in the morning and the phlegm is yellow and green. He says he doesn't feel anything dripping down the back of his throat. No swelling of his feet or ankles. PAST MEDICAL HISTORY: Medication - Ventolin inhaler and Iophen-DM as needed for cough. Allergies - none. Habits - he states he began smoking in 1944 or 1945 and that he used to smoke two to two and a half pack of cigarettes per day when he quit in 1987. In 1987 he also gave up alcohol. He states that he was "saved". He didn't quit suddenly. He slowed down to one pack a day in 1987 and quit in 1987. Surgerie - none. In' rie - none. WORK HISTORY: He worked in the mining industry for 23 or 24 years. He worked inside the mines for six or seven years and the rest of the time was in strip mining. He quit the mines in May 1993. He said it was time to retire. He says that he was a mechanic for the last 19 years of work and that he had to carry heavy wrenches and heavy equipment and climb ladders with these tools. He also had to carry oil. In the deep mines he was a conveyor belt man. fl (l Page 2 - History Physical Examination Re: Charles Caldwell Date of Examination: 3/2/94 Before working in the mines he worked on the railroad, on steamboats, and in the sawmills. PERSONAL AND SOCIAL HISTORY: He is married and has two children. FAMILY HISTORY: No family history of asthma or 'fig' A PERSONAL ILLNESSES: No personal history of heart trouble, ?11661- physema. REVIEW OF SYSTEMS: Weight has remained stable. Eyes - to read. Ears - doesn't hear as well as he used to. Mouth - no as stated. Heart - no complaints. Gastrointestinal - no complaints. Genitourinary -- no complaints. Musculoskeletal - no complaints. PHYSICAL EXAMINATION: Height 66 1/4 inches. Weight 195 pounds. In general, he is an alert, white, male in no acute distress. Blood pressure in the left arm is 190/100. Pulse 70. Respirations - 14. Eyes - pupils are equal, round, and reactive to light. Mouth - oropharynx is healthy. Neck -- no bruits heard and no masses palpitated. Heart - S-1 is equal to S-2 with no murmurs or gal- lops. Lungs - clear to auscultation with no wheezes, crackles, or rales. Abdomen - no masses or tenderness. Extremities - no edema of the legs or clubbing of the fingers. Radial and popliteal pulses are Genital and rectal examinations were not performed. IMPRESSION: History of shortness of breath. History of bronchitis. Normal examination of the lungs. History of heavy cigarette use in the past. History of mine work. %wz Emerge gcorye L. Zallfivar, 911.93., 3100 91/[acCorfle Cfiarfeston, 25304 (304) 346-1811 I t_lL_l PATIENT 1155111511: 3 55151531521111 5515117: .111 155: 53 5511: 11 15111-: 2.1 1111:7115 71115: 5 SPIRDHETRY _g if 1 5555551 ACTUAL 551-:5 211555 7551 1 1 55711.11 1-5-55 11-555 . 1115 3 57 3.1:11 . 1:31 35531:. 11 1-. *1 115' 115115-75 1.27 235 1,5 15125 1.13 7.11 3'1 1511111111: .51 1 5.1 FEF 551 1.19 35 2 11 11:51 1 2 11511111 1-:111 iwv _3'_95 LUHG 1 1 11 EEF 25~75 1.55 235 2,9 51:75.11 1-555 111-555 2 i 1511111115 15 71 115151 3.5 3.15 51 1 15 2.95 2.7 153 7.31 1.FEED - 511 2.25 2.15 153 5.5 111: 5.51 3.13 35 30 511/7151 35- 33 115 '2 .53 11515111 1-1155 111555 155 . 111111 15 111 53 1 15 1 TEST 1} -d 1; 1 5 51,; 551551 1-555 111-555 - 5 51 3 111111 111 57 1-91 1 7111515551 15 153 1 1-1 1.1 51:75.11 1-555 5-555 1' 111111 95 111 51 1111515551 15 i 111-: 5117 1111155 51 11.11:: 1.91 3.25 11.3 3.55 111 331:1 5111 1111155 1: 51: 15? DIFFUSICIH 1.71 3.51 1.1.5 15.1, 1 5511131 11155 115555 SIFFUL I 1 DL 13.1 111 11151 1-1355 115175 1 UMRE11 5.311 5.13 85 . I 511551 13.5 25.3 3115?? 17.3 .15 1 11111551 1.52 3.115 u_1 5111 1.111155 51 5.71. 3 111. 15.5 3.17 153 1115111111 1 11.5.1. - -- 55555 52.53 =5?f"?fU DIFFUSIUH 5 1 1 11511151 1-11.55 55555 3 E-E3 11.1 25.3 51. 5' 1151551 1.13 33 1 3-1; DL15111 15.7 25.3 52 -1 1151551 3.33 5.13 153 _1-5 . 51/15 2.17 . 5.25 1 5-115 115 5117 1111153 51 5111: 1U 5.31:1 5.11 5.51 15.5 2.97 55 5 DIFFUSIUH 51211151 1555 1111155 51 12.5 19 v5111-51 3.13 511551 11.3 1151551 1.57 3.13 51 51/1111 2.15 511.5 51.501135 5\ . 2111 - 11111111 11111111111112111 - - 1 1131 2 11 11c1u111. 911111 21- 11111 -- I - 1111: 2.21 3.25 112 1 11111 2.23 2.1.11 .111 - - ~11 111111 122 3.22 111 1 :1 111 25-25 1.51 2.23 51 1-, -- 1 11 111111111111c1u111. 111111 111-11 . M1113 9.19. 1111: 2.15 2.25 112 1111 1 2.32 2.211 11 1111613 1. 1. 1-11111111111; 12 21 21 WV 1 115% 2 211111 2111111 1111: 3.21 3.1-5 113 111.1 1 2.31 2.111 31 1-111 1.11 2.22 111 ,-11 11 1112.5-25 1.211 2.21 11 1111111111; 21 21 11111 1 115111 111:1111.1. 11111 211.111 1111 3.111 2.25 111 1111 1 2.11 2.211 12 2111: 1.11 1.22 21 111 25-25 1.21 2.211 1111111111 211 21 ~22 1-1 1.1 1.1 1111111 211111 2.211111 111111 111 52 IE1 1-1 1.1 1: HCTUQL FRED IPEED 111111 211 111 21 1111115111 111 11 1.1 11 111111111 2111 21-2111 11111.1 111 22 1111115111 111 PULHUHARY FUHCTIHN REPHRT 1 111111111111' 11111: n21112121 11111111: 11 111111.: 5111: 11 11111: 2.1 2.12: 2111 121131 1 SPIRUHETRY PRE DRUG PQST DRUG HEHS FREE HFRD Efflfi FUC 3.3fi 3.95 35 3.13 4 FEV.5 1.51 2.03 ?9 1.Ei 14 . FEU i 2.25 3.EE 30 2.44 111 2 2.11 2.22 22 2.12 1 -.2112 1.22 1.22 11 1.21 11 FEF 35-?5 1.35 45 3? 111 212 1.11 2.11 12 1.11 - 1 FEF SDI 1.6? 4.33 2.43 45 111 211 .15 1.11 21 .22 22 FEUIIFUC 5? ?1 ?4 TD 4 11u.s111c 12 51 21 52 1n FEUBIFUE 111111111 11 I 8 VI Laboratory Serv/'CC' . qggifi PATIENT NAME '*4-it .2 Phone: (304) 345-5215 WV Wats - -- RECORD T: -- SS -- A 63 DT: PHYSICIAN: GE FATIENT PHONE WARDILOC: SVIM 5 0 9 A I 5 TEST NARE EARECN 1.7 1.3-5.1 3 ARITEST RARE 3/02/94 NCRRALS UNITS HEMUGLOBIN 13.5 14.0-15.0 GMIDL (END OF -REPORT) REPORT: FINAL PAGE: 1 TESTS PERFORMED BY CHARLESTON AREA MEDICAL CENTER GENERAL DIVISION MEMORIAL DIVISION WOMENS AND CHILDREN 501 MORRIS STREET 3200 CORKLE AVENUE. 8 800 PENNSY r:QTr"Ihl WV 9=I"ind George L. Zaldivar, M.D., Ltd. Suite 404 3100 Maccorkle Avenue. S.E. Charleston, West Virginia 25304 304-346-181 1 George L. Zaldivar, M.D., F.C.C.P. Board Certified in Lung Diseases and Internal Medicine K-'ee :1-e in 21;: 'l L7: Name Charles Caldwell 53;; - am it *1 Age -_63 Height Weight 195.__ Sex . __male Temp. - Predicted Normals: Morris, American Review of Respiratory Diseases, 103: 57-67, l?figlgfiig?lf??i Crapo R0, Morris AH, Am. Rev. Respir. Dis. 1981; 123: 185-90. XX Equipment: Collin Ape Coll' 9L Effort: Good Fair - CommentsSPIROIVI OBSERVED PREDICTED PERCENT Forced Vital Capacity (L.) 3- 36 8'5 Forced Expired Volume in 1 sec. (L.) 2.25 2.80 80 Peak Flow 6- 27 8-22 75 Maximum Mid Expiratory Flow FEF 25-75 2-78 (FEV. 100 67% 71% Maximal Voluntary Ventilation 111 87 Single Breath CO Diff. Cap. (ml./min./mmHg.) DL (SB) 11.? 99.2 lg'? Kco 2. '30 11. 8'3 '31 Total Lung Capacity (L.) 5.81.1. 6. vc (5) 3. '39 3.9% 91 Residual Volume 2.25 2.18 103 39 _36 110 AFTER INHALATION OF BRONCHODILATORS OBSERVED CHANGE Forced Vital Capacity (L.) 3.118 +11 Forced Expired Volume 1 sec. (L.) +8 Peak Flow - PEFR 6.91.; Maximum Mid Egxpiratory Flow - FEF 25-75 '1 +39 Maximal Voluntary Ventilation 90 --T Hemoglobin 15 5 Carboxyhemoglobin Level BLOOD GASES Bar. Pressure Tech, NORMAL RESTING Arterial pH 7-34-7-45 Arterial pCOz 35-45 Arterial p02 gradient in mmHg. 5-20 Time Drawn Resting Time Analyzed 7 fig SERVICE SUPPLY co uzwa I I /'xi PRINTED IN U.S.A. Collin: REORDER CHART PAPER 22023 7. O02 HVM 83033 98033 . . 7 - -- coLL|Ns MANUFACTURED BY WARREN E. COLLINS. INC . 220 WOOD ROAD. BRAINTREEI MA. 02184 (817) 843-0610 PRINTED IN USA. 5 NI '3 88038 83083 oomm-