Document QkmDwdra20ZbxDZOZeO6xbRz4

Denver Clinic Medical Centers, RC. Celebrating 30years...1956-1986 Corporate Offices 701 East Colfax Avenue Denver, Colorado 80203 (303) 831-7171 March 3, 1987 Thomas W. Henderson, Esquire Henderson & Goldberg, P.C. 1030 Fifth Avenue Pittsburgh, PA 15219 / 5- u i U \,<s C i Dear Mr. Henderson: Thank you for referring Ralph Evans to me for evaluation. I interviewed and examined him on February-26, 1987. ' Based upon these findings it is my opinion that Mr. Evans does have porphyria. The most probable cause of his porphyria is his extensive past exposure to polychlorinated biphenyls. In addition,' he has a number of other disorders. These are, hypertension with high triglyceride levels, some pulmonary restrictive disease, carpal tunnel syndrome, myofascial syndrome, nerve and muscle damage, and ow grade liver disease characteristic of PCB exposure. Mr. Evans is also diabetic. The blood sugar of 191 is not a favorable prognostic sign. At the time of his examination, Mr. Evans demonstrated evidence of prophyria cutanea^ tarda manifested by sun sensitivity, and elevated uroporphyrins, coproporphyrins, and porphobilinogen. His past history clearly revealed that he had chloracne. He currently has residual comedones, and other changes associated with this disorder. Based upon my review of his work history, it is my opinion that Mr. Evans' prophyria was more probably than not caused by and aggravated by his exposure to PCBs. His liver disease is associated with this abnormality. Although diabetics do develop neuropathy, the type of neuropathy which I presently see -in-Mr^Evans is not characteristic .of diabetic peripheral neuropathy."" In addition^ he has evidence of CNS'disease and neurasthenic syndrome which do not occur in diabetes. In my opinion, PCBs caused or contributed significantly to this nervous system disorder. I trust this information will be helpful to you. Daniel T. Teitelbaum, M.D Central: 701 E. Colfax, Denver 83203*831-7171 East: 9450 E. Mississippi. Denver80231 *751-1241 North: 84th & Zuni, Suite 225, Denver 80221 429-1529 West: Denver Wesi Office Park, Bldg, 52, Golden 80401 279-7525 Aurora: 15101 E. Mill, Suite 140, Aurora80014 *696-7525 Littleton: 1900 W. Littleton Blvd., Littleton 80120 797-6700 Tiffany Plaza: 7400 East Hampden, Denver 80231 770-3200 See reverse for professional staff listing 00111 WATER_PCB-SD0000032546 RE: Ralph Evans BY: Dr. Daniel Teitelbaum DATE: March 3, 1987 MEDICAL DICTATION Chief complaint: Mr. Evans is a 44 year old white male who presented with a chief complaint of memory loss, liver disease, central nervous system problems, diabetes, and pain in his bones and joints. The patient states that he had been in the National Guard for many years and had worked at various activities including teletypist, fire detection, and some other clerical type tasks, but he did no auto maintenance, garage work or any other chemical contact activities. He served intermittently in the National Guard until 1969. He received a high school equivalency certificate from the National Guard. He worked for a period of time as a cook, which he enjoyed very much. He was unable to find additional work in this area, so in 1965 he went to work for Westinghouse in the F-30 area. He worked there until 1981. Later, he worked in the fill and solder area as an operator. He worked in the oil processing area for 6 or 7 years. He worked at the hot end as a leak test operator. Mr. Evans indicted that out of every 30 transformers that went through the leak test areas, 3 or 4 leaked. The average leak rate was approximately 10%. He was heavily exposed to PCBs from these leaks for approximately 12 years. The exposure took place daily. He states that when he worked in that area he was covered with PCBs, his shoes were soaked with PCBs. There were no showers available. He had to wear his clothes home when they were fully saturated with PCBs. Following this work as a leak * test operator, he went to work in the zinc spray area. This involved work with galvinizing materials. He states that he worked "in a hole in the ground". He used zinc spray and was frequently covered with this material. Following a period in the zinc spray area he went to work in oil processing. In that area he took new, raw oil and added various additives to the oil. In particular, a clay like material and a sugar like material were added. He did this work while the material was in a steam jacket. It was hot en ough so that it would scald you if it it got on your skin. He stated that he processed 15 to 16 thousand gallons of oil per day. He was constantly breathing in fumes off the top of the oil and he would frequently get soaked because he had no protective clothing. He stated that he had to get new shoes every two months because the oil simply consumed his shoes. He wore ordinary work pants, and shoes. In 1980, he and other workers in the plant began to wear safety clothing. He states that he wouldhave to go into the ovens 3 to 4 times a year. This activity was done in order to clean the oven. His clothing and skin would get completely soaked with PCBs. Following these episodes he would have a rash and his skin would break out whenever he would get the oil on him. 00112 WATER PCB-SD0000032547 Ralph Evans Medical Dictation 3/3/87 Page - 2 - Beginning in about 1966, the patient states that he had many beta-strep infections. His children and wife did not have the same problem. In the early days, his children were in the hospital several times because of pneumonia. He stated that he had to go to the'doctor repeatedly because of esophageal stenosis which was dilated in the 1970's. Commencing in about 1970, the patient stated that he had many different types of nerve problems. In 1970, he had a carpal tunnel syndrome diagnosed. He also developed lower extremity problems. The greatest problem was tingling which made him feel as though his feet were about to go to sleep. He began to have strength and motion problems in the latter part of the 1970's. He noted that he would drop things while at work. He then noted that he began to lose visual acuity as well. He stated that he could only sit in one place for approximately 1 hour, but then his back would begin to hurt and he became very uncomfortable. Family hi story: There was no past history of nervous system disease in' the family. His mother is 68, she has a bad heart and diabetes, and had a kidney removed. His father died at age 72 of a lung cancer. He was said to be a heavy smoker. He has one son who has been worked up for porphyria and was found to be negative. Social history: ' The patient states that he, himself is a non-smoker. He also denies any alcohol consumption at the present time. He states that it has been several years since he last had any alcohol. The patient states that he has gained 26 pounds since October of 1986. He also states that when he got married his weight was 165 pounds. Most of the time he worked at Westinghouse, his weight was 210 pounds. When questioned about his occupational medical history, Mr. Evans indicated that he had a pre-employment examination but, so far as he can recall, he did not have annual medical examination, although most people who worked in the same area as he worked did have these examinations. Comment: The patient indicates that his clothing was frequently saturated with PCBs and that when his wife would wash and iron his clothing, she would have frequent exposures to the PCB materials. The fumes and smoke that came off his clothing were very irritating. His wife had two miscarriages during the period of time that he was working with PCBs. He believes that his wife was exposed to PCBs through cleaning his clothing and ironing them. His natural child had a seizure disorder early in life but is currently 00113 WATER PCB-SD0000032548 Ralph Evans Medical Dictation 3/3/87 Page - 3 - symptom free. She has had recurrent skin problems but there is no clear history of the nature of these problems. Review of systems: ' HEENT: The patient complains of memory loss and confusion. He has had poor shor term memory and forgets various tasks which he sets for himself. There is some indication that he had an MRT :Jone in 1983, which was abnormal.. The nature of the abnormality is not detailed in his written history. when questioned about this, he was uncertain about the abmormality. CT scans have been normal. Extremities: The patient has had pins and needles in his arms and legs, tingling and some pain and discomfort are as detailed in~the present illness. Chest: The patient has no significant complaints concerning his respiratory system. He does not complain of shortness of breath other than as related to his obesity. He has not had excessive phlegm or excessive sputum. GU: No comp!aints. Skin: An extensive series of problems have occurred as a result of his work at Westinghouse. He has had dermatitis which is described as dry, and itchy on his back and shoulders. He has had cysts on his shoulders and neck, and has had acne on his forehead. Detailed dermatologic evaluation will be done, Mr. Evans indicated that he has been told he has diabetes, and has been treated with oral anti-diabetic agent, Diabeta. He has not been acidotic. Medications: Occasional Darvocet N, 100 mg.; Dyazide for weight gain and hypertention; Valium; Elavil; Atarax; and Diabeta. His medical records indicate that he has taken numerous medications at various times. The patient is allergic to sulfa drugs and had hypotension following nitroglycerin use. He states that he becomes anxious, and becomes confused when he is give either ooi M WATER_PCB-SD0000032549 Ralph Evans Medical Dictation 3/3/87 Page - 4 - morphine or talwin. This does not represent true allergy. It is a predictable toxic effect in a small number of patients. The patient has had repeated problems of balanitis. He had a circumcision, and a cytoscopy this past year. Following this surgical intervention he has had no significant problems with his urinary tract. In January of 1987, the patient was seen because of his concern of the possibility that he might have cancer as a result of his exposure to PCBs. During the course of that .wo'.'k-up, a series of porphyrin studies demonstrated elevation in the tetracarboxyporphyri n, and the octacarboxyporphyrin. In Elevation in tetracarboxyprophyrin, is often found in toxic porphyria. This would certainly fit with the known propensity of PCBs to induce porpuyria Physical Examination: Blood pressure was 150/95; pulse 72; respirations 17; and the temperature was normal. The patient was a well developed, obese white male in some distress when he was asked to move and climb up on the table. Examination of the head, ears, eyes, nose and throat was generally unremarkable. The right optic fundus was noted to be pale and waxy appearing. No hemorrhages and exidates were noted. The left fundus appeared normal. The vasculature appeared normal. The chest was clear to auscultation and percussion. Examination of the heart revealed a regular sinus rhythm. There were no thrills, rubs or murmurs noted. The abdomen was obese. There was a midline sub umbilical scar and a scar in the right and left lower quadrants. Examination of the GU system revealed a normal male. He had been recently circumcised. The extremities revealed normal muscle tone, The patient was, however, unable to raise his legs to the parallel position without assistance. Examination of arms appeared to be normal. The muscles were very tender to palpation in both the upper extremities, the back and across the shoulders. The skin was generally smooth. There were some cysts and some acne on the forehead. There was no evidence of melanoma or other skin cancer. No jaundice was noted. Neurological examination: the patient was alert and oriented times 3, and he had a normal cranial nerve examination. Motor examination revealed markedly weak lower leg musculature, particularly weak from the knees to the toes. Sensory examination revealed minimal changes with some decreased pinprick and light touch. However, properception appeared to be intact. On cerebellar examination there was 2+ dymetria on both sides. The reflexes were 2+ and equal throughout. The Babinski signs were absent. Diagnoses: 00115 WATER_PCB-SD0000032550 Ralph Evans Medical Dictation 3/3/87 Page - 5 - 1) Toxiuc syndrome 2 to PCB with: a) Chloracne b) Hepatic porphyri a c) Myofascial syndrome d) Motor and sensory neuropathy e) Mypertriglyceridemia f) Carpal tunnel syndrome g) Neurasthenic syndrome 2) Diabetes Mel 1iItus Laboratory examination performed at the time of this examination revealed slightly elevated GGT at 76, the upper limits of normal was 71. The albumin was slightly elevated. The blood glucose was 191. The upper ljjnitjs^of normal was 115. Uric acid was 7.3. The upper normal a at Rush Presbyterian Hospital is 7.2. The SGPT was 40; the upper limits of normal is 30. The SGOT was 48; upper limits of normal is 35. / Based upon~~ttre--laboratory findings it appears that Mr. Evans does have low grade liver abnormality. Careful followup of these abnormalities is indicated. Further examination in detail of his extensive medical records will be carried out. oaj- / J > ooiiu WATER PCB-SD0000032551 Name: RALPH EVANS Date of birth: 01-31-43 I have reviewed and considered the clinical note of Dr. Daniel T. Teitelbaum. In addition, I have noted the following history from Mr. Evans. This 43 year-old man worked around PCS' s v/hile employed at Westinghouse from 1965 until 1981. He has had problems with chronic liver disease, poor memory, arthritis and his digestion. He also has recently been diagnosed with diabetes. When working with PCS1s containing oils he had many pimples and blackheads over his face and shoulders which gradually improved when he no longer was exposed. He has had several cysts removed from his shoulders and has had a pilonidal cyst excised. He has had burning of the skin on exposure to sunlight over the past few years and occasionally gets small blisters along the lateral aspects of his fingers. He has recently been told he has acute intermittent porphyria but he does not describe episodes of hypotension and syncopv after exposure to barbituates or other medications. He has a number of surgical procedures without problems with the medications given prior to surgery. Examination reveals a 2 cm scar on the left posterior neck, a 1 cm epidermal inclusion cyst on the center of his back and a 3 cm scar on his left shoulder. He has a few scattered comedones and follicular pustules on the bade and multiple punctate scars on the cheeks, preauricular area and forehead. There are two small yellow papules of sebaceous hyperplasia on the left forehead. He aiso has multiple skin tags on the neck and axillae and a small nodule on the ventral surface of the base of the penis. He does not have scars on the backs of the hands. I have examined and evaluated Mr. Evans with reference to his possible dermatologic problems. I have likewise reviewed various hospital, medical, and related records of Mr. Evans. Eased upon my examination, and various portions of the records, it is my opinion that Mr. Evans suffers from: 1. Chloracne by history with residual comedones, follicular papules on back and cysts 2. Sebaceous hyperplasia, forehead 3. Acrochordon (skin tags), neck and axilla 4. Possible porphyria cutanea tarda manifested by sun sensitivity and elevated uroporphyrins and coproporphvrins and porphobilinogen I also have considered the relevant medical and scientific literature regarding exposure to PCBs, dibenzofurans, and dibenzodioxins and certain adverse health effects associated ooi 1 WATER PCB-SD0000032552 page 2 ... with exposure to those chemicals. It is my further opinion that the following diagnoses are related to, i. e. caused or contributed, Mr. Evans' previous exposure to PCEs and/or their contaminants: 1. Chloracne by history with residual comedones, follicular papules on back and cysts 2. Possible porphyria cutanea tarda manifested by sun sensitivity and evaluated uroporphyrins and coproporphyrins and porphobilinogen These opinions are v/ithin a reasonable degree of medical probability. *' B. Smith, M.D. Professor and Chairman Department of Dermatology University of Texas Medical Branch Galveston, Texas 77550 00118 \ "V WATER PCB-SD0000032553 THE UNIVERSITY OF ROCHESTER MEDICAL CENTER 300 CRITTENDEN BOULEVARD ROCHESTER, NEW YORK 14642 AREA CODE 716 SCHOOL OF MEDICINE AND DENTISTRY SCHOOL OF NURSING STRONG MEMORIAL HOSPITAL Eric D. Caine, M.D. Associate Professor of Psychiatry and Neurology Director, Ambulatory Services Director, Neuropsychiatry Program (716) 275-3571 NEUKOPSYCHIATRIC EVALUATION NAME.: Ralph L. Evans DOB: ** 31 January 1943 Thank you for-the opportunity to evaluate Ralph L. Evans ,~~who'T"assessed on 26 February 1987. In addition to examining Mr. Evans, I reviewed and considered the clinica": note of Dr. Daniel T. Teitelbaum. I have also reviewed various hospital, medical, and other related records of Mr. Evans.' Mr. Evans underwent a comprehensive neuropsychiatric evaluation. This evaluation included administration of the Neuropsychological Symptcm Checklist (NSC), the 28-item version of the General Health Questionnaire (GHQ), the abbreviated version of the Beck Depression Inventory (BDI), the revised 90-item version of the Hopkins Symptcm Checklist (SCL-90-R), and a seni-structured interview usirg the Schedule for Affective Disorders and Schizophrenia - Lifetime Version (SADS-L), with the Global Assessnent Scale (GAS). The NSC is a general, qualitative (non-quantitative) symptcm inventory useful for preliminarily assessing patients with possible neurological, emotional, or intellectual dysfunction. The GHQ is used typically in medical, non psychiatric settings to establish the presence of clinically prominent enotional distress. The BDI is used to establish the overall severity of depressive mental symptans, which can be grouped as mild, moderate, or severe. The SCL-90-R is used in a variety of clinical settings, most often for , defining problems in patients having behavioral or enotional symptans. Fran data gathered using the SADS-L interview, it is possible to develop a standardized, rigorous lifetime psychiatric diagnosis,-where--applicable. --The ----- GAS is useful for establishing the overall level of current disease severity -- and functional impairment due to psychopathology. ....--------------------- --- , -- Mr. Evans was also evaluated with an array of standardized neuro psychological tests to assess his intellectual functioning. These tests included assessnents of orientation, attention/concentration, verbal and nonverbal memory, visuospatial abilities, language/reasoning, and motor/ "Executive" functions. . Based upon my examination, including the tests that I have indicated, as well as Mr. Evans's records and Dr. Teitelbaum's evaluation, it is my opinion that Mr. Evans suffers from a neurasthenic syndrome, associated with neuropsychological impairments indicativeof mild to moderate central nervous systen damage. - ooi i:) v. WATER PCB-SD0000032554 Ralph L. Evans 26 February 1987 Page 2 I have also considered the relevant medical and scientific literature regarding exposures to PCBs, dibenzofurans, and dibenzodioxins, and adverse health effects associated with the exposure to those chemicals. It is my opinion that the above condition is related to, i.e., caused or contributed to, his previous exposure to PCB's and/or their contaminants. This opinion is within a reasonable degree of medical certainty. If you have any questions, please feel free to call me. 0012 U WATER PCB-SD0000032555 RUSH I'RESIJYTERIAN ST. LUKE'S MEDICAL ('ENTER doomMi.n west congress parkway. Chicago. Illinois DEPARTMENT OF NEUROLOGICAL SCIENCES 19 March 1987 Thomas W. Henderson, Esquire Henderson & Goldberg, P.C. 1030 Fifth Avenue Pittsburgh, PA 15219 . . __ ........... ................... RE: Ralph Evans Dear Mr. Henderson: ,' I have reviewed and considered the clinical note of Dr. Daniel T. Teitelbaum. I have examined and evaluated Mr. Evans with reference to his possible neuro logic problems. I have likewise reviewed various hospital, medical, and related records of Mr. Evans which were supplied by your office. I also obtained a history at the time of the neurologic examination which I performed. Based upon my history and examination and supported by various portions of the records, it is my opinion that Mr. Evans suffers from: 1. Postural tremor and terminal intention tremor (action tremor); 2. Pressure sensitive peripheral neuropathy; - 3. Neurasthenic syndrome. . ` I also have considered the relevant medical and scientific literature regarding exposure to PCBs, dibenzofurans, and dibenzodioxins and certain adverse health effects associated with exposure to those chemicals. It is my further opinion that Mr. Evans's previous exposure to PCBs ^and/or thei ^contaminants' caused 'oi---- ~~ contributed to all of the above diagnoses. These opinions are within a reasonable degree of medical probability. Mr. Evans also has probable transient ischemic attacks. The relationship of these to toxic exposure is unclear. Sincerely, Harold l. Klawans, M.D. Professor, Neurology & Pharmacology /gi 1725 W. Harrison, Suite 915, Chicago, Illinois 60612, (312) 942-5936 00121 WATER PCB-SD0000032556 HARRIS BUSCH, M.D., PH.D. PROFESSOR ANDCHAIRMAN DEPARTMENT OF PHARMACOLOGY BAYLOR COLLEGE OF MEDICINE TEL. 17131 790-1457 1200 MOURSUND AVENUE HOUSTON. TEXAS 77030 EXAMINATION Dr. Harris Busch Dr. Frank Smith EVANS, Ralph March 23, 1987 Mr. Evans is 44 years of age and has multiple medical complaints including various skin afflictions and a past history of "porphyria?" apparently diagnosed in 1985. He also had some kind of "liver disease" at that time. The patient has had several abdominal procedures including a cholecystectomy and a laparotomy, resection of scar tissue and an appendectomy at that time. He also had another laparotomy in 1981 for lysis of adhesions. Mr. Evans has a chronic pain syndrome with syncope on occasion. For some reason, he eats six meals a day. He has pain in the right side when he lies down. The pain is less when he is on his right side. Because he has pain in other areas as well, he uses Demerol. He concludes his life is "pure hell". He has insomnia which makes him even worse. One problem is that his "feet are on fire" which he says is associated with a form of sensory neuropathy. On physical examination, Mr. Evans was found to be obese weighing 262 pounds and had a blood pressure of 210/130, respiratory rate is 10 per minute and regular. There is no adenopathy. Lung fields were clear to auscultation and percussion. There is no rub, murmur or gallop on cardiac examination. The liver is a normal size and there is no ascites although the abdomen is somewhat protuberant. There is no splenomegaly or ascites. He has mild findings of peripheral neuritis on examination. A urine sample was sent for examination considering the possible diagnosis of porphyria made two years ago; our labora tory results show normal urinary porphrine. A CBC shows no abnormality and his SMA-13 discloses an SGPT of 46 which is very modestly elevated. The remainder of his liver function tests are normal. The blood sugar at the time of his SMA-13 was 233 and suggests that his previous diagnosis of diabetes is well founded. Preliminary Diagnosis 1. Diabetes mellitus 2. Obesity 3. Mild peripheral neuritis, associated with diabetes 4. Factitious disorder (?) 00122 WATER PCB-SD0000032557 Tape Transcription Cecil Scott, et al vs Monsanto Company, et al Evans, Ralph L. WM 4 4 3-24-1987 HP! : Mr. Evans is a 44 year old married white male who has been on disability retirement from Westinghouse since 1981. He also draws social security disability. He entered the lawsuit in 1984 or '85 (he "thinks" 1985), having found out about the potential toxicity of PCBs from a City Council meeting in Bloomington, Indiana. Pt has a long list of medical complaints, all allegedly beginning after he began work at Westinghouse in 1965. These include: Skin: 1. 2. 3. 4. 5. Scaly dermatitis of back, chest and shoulders since 1965 Cysts on shoulders and neck Acne on forehead Lesions behind ears and in hair Mascular rash and itchy sensation on back and chest Neuropsychological: Headaches', since 1 965, almost constant at present and over the past 4-5 years. They are nonloca 1ized, dull, constant, beginning in the nuchal area and radiating bilaterally over both temporal areas to the frontalis. He takes Rufen (ibuprophen) or Darvocet, the latter up to 4-6/day. "Silent seizures" during 1983-1984 described as TIAs. Unpredictably the pt would become unconscious, remain so 3-4 minutes, often falling at the beginning of a seizure. For this he was often hospitalized, recovery requiring a variable period, from a short time up to several days. He remembers once having to "learn to walk all over again following a seizure." Pt complains of "pins and needles" syndrome, both arms and legs, since the 1970s. His feet burn, "like walking on a bed of coals, especially over the last 3 years or so." He has been stumbling and falling since 1981. The pt complains of worsening memory since the late 1970s. Recent memory is significantly worse than past memory. In addition, he reports increased irritability and anxiety over the past 10 years or so. 00J2.i WATER PCB-SD0000032558 ENT: Eyes and hearing both "going down" rapidly. He can tell the difference almost from month to month. Tongue, "lots of sores," associated he believes with his esophageal problems. G! : Esophagus: ' Reported "blistered" in the 1970s. He received multiple examinations and multiple dilatations. Finally the doctors decided on a cho1ecystectomy hoping that it wou1d help, but there was no relief. He still suffers frequent nausea, heart burn, and vomiting. Sometimes just sme11ing spicy foods will induce nausea with resultant vomiting. Hepatic: Pt reports that "acute intermit tent toxic porphyria" was diagnosed in October, 1985 at the Mayo Clinic and received a confirmatory diagnosis in November, 1985 from the Smith, Kline Laboratory in California. He is on a special diet, which includes 6 meals a day. He tires easily because of his 1iver disease. Chronic diarrhea, watery, since the 1970s; at one time, bloody. Diagnosed at Bloomington, Indiana Hospital as diverticulitis, treated with Maalox and IVs. He reports presently suffering from constant unchanging abdominal pain, particularly over the hepatic area. Respiratory: Pt complains of shortness of breath and wheezing. Cardiac: At some unspecified time in the past his EKG showed that he. had suffered a "silent heart attack," but other doctors said that this was not established. Pt did not mention hypertension during formal evaluation, but during the evening session reported that he had to return quickly to Bloomington for his "special diet" because his blood pressure was 210/120. GU: Pt has had decreased sex desire over the past 4 Sexual intercourse now occurs every 1-2 months. think about it, I just can't do it." years or "I can so. Report s that he had an infection of his bladder and penis whi ch was corrected surgica1ly in November, 1 986 at the Bloomington Hospital. The surgeon found varicose veins of the bladder with an at tendant infection. Since his operation this complaint has been resolved. (Pt was diagnosed as diabetic in 1986 . For this he takes Diabeta 250 mg bid.) 00124 WATER PCB-SD0000032559 Muscu1oske1e t a 1: Pt complains of constant "skeletal pain." He has had carpal tunne1 and ulna tunne1 syndrome, both arms, both treated surgically. Arthritis diagnosed 6 years ago at Mayo Clinic. They "report ed that my spine had grown together." For thi8 combination of complaints the pt currently is on the following medications: Darvoce t, 4-6/day Valium, 10 mg bid Elavil, 7 5 mg ha for sleep only Atarax, 2-3 per month, for upset stomach Dibet a, 2 5 0 mg bid Demerol, rxd for arthritic pain but pt doesn't take it. "I j u81 1ive without it." Dyzide, amount and frequency unknown Significantly, this patient states that he has had 27 surgical procedures during the 20 year period 1 966-1986. reported, "I know.that's a lot, but they always found something wrong." He Past Psych. Hx: Pt was evaluated in the 1970s because of his stomach prob1ems, in Indianapo 1 is . The psychiatrist saw him for only 15-20 minutes and made no recommendations. In 1986 Dr. Joel Griffeth, Bloomington, saw him for 14 visits, in an attempt to find a reason for his constant pain. He was tried on various medications and nothing worked. He and the psychiatrist agreed mutually to discontinue therapy because of lack of progress. Psychosocial Hx: Pt was born in Indianapolis. His family consisted of father, mother, and 10 children. He describes his childhood as "good." His father was an interior decorator who moved the family frequently, living in Diboll, Texas; Paragould, Arkansas, London, Kentucky; and finally from 4th grade onward, in Bloomington, Indiana. Despite this itinerancy, he report s a close-knit family who enj oyed hunting, fishing, coon hunting, and a family devotion to work. They cut wood t oge ther with a crosscut saw , they piayed together, they enjoyed each other. They were faithful to the Baptist Church. Despite this proclaimed closeness and intrafami1ial serenity, the pt is vague about his siblings, stating "I think it's 4 girls and 5 boys," and later "I'm probably just about in the middle." He doesn't know where some of his siblings are but at other times states that "we keep in touch, we write to each other . " 00125 WATER PCB-SD0000032560 Pt qui t schoo 1 at age 16, in the 8 th grade. He then worked at various jobs in and around Bloomington, much of it at Indiana University. He worked in the greenhouse and at other university jobs. At age 21 or 22 ("I can' t remember") , he j oined the Na tiona1 Guard, serving for 6 months a t Ft. Knox and Ft. Sill, and then finished his 6 . year enlistment in the reserve. He was most enthusiastic when describing his experiences in the military. "I 1 oved it." He was honorably discharged as a corporal . Pt started dating a t age 16, and a t 2 3 he married. Hi s wife, now 46, is a part-time merchandising assistant at J C Penney's. She is described as quite obese, but a good wife. "We run our marriage fifty-fifty." There are 2 children, an 18 year old adopted son and a 15 year old natural son, both doing well. From 1965-1981 the pt worked for Westinghouse in Bloomington. It was here that he alleges his association with PCBs, from breathing "Innerteen." He was p1aced on disability in 1981. Pt has been arrest ed once, a t age 16 or 17, for "running moonshine." He reportedly served no time, however. "They t ook me to jail , took my whiskey, and let me go." Pt is also an ordained Baptist minister. He was ordained at age 39, and had 3 churches in the southern Indiana area. But 2 years ago he had to give up preaching because of his worsening memory. Pt now spends his time "just walking around, or watching TV." He is an avid fan of TV car races, baseball games, and would like to attend baseball games but he "can't sit up that long." He formerly liked fishing but had to give that up because of his physical condition. He likes to cook if his wife will "get everything ready." Habits: Pt denies ever having used tobacco, drugs, and uses alcohol only to the extent of "1 beer per year." MS Exam: Pt is an obese white male who walks with a limp and uses a cane. He entered the interview situation without hesitation, and was cooperative throughout. In fact, it occurred to one at times that he actually enj oyed relating his di f ficulties in a smi1ingly resigned fashion. There was no abnormality in body language, no aberrant demeanor from a psychological standpoint. Speech was normal in rate and clarity. He gave his hi story in a 1ogica1 coherent fashion. In mood he was almost jovial; there was no sign of depression. Affect was congruent with mood. Thought processes were entirely within norma 1 1 imits. There 0012G WATER PCB-SD0000032561 was no disrup tion, t angent i a 1ity, circums t antia 1ity , paranoid ideation, or abnormality of association. His thought content was significantly preoccupied with worry about the future, about family security, his inabi1ity to be a good father and a good husband. Orientation was normal. His memory and reca11 essentia 1ly within normal limits when tested formally. That is, he could remember exquisite details about his i1lness and about his early chiIdhood and about his present living situation, but a 1legedly could remember no dates at all. There was no sign of con fusion. He was able to reca11 it ems given to him after momentary hesitation. There was no attention deficit. Concre t enes s was absent: he interpreted proverbs quite abs t ract 1 y . Judgment and insight were within normal 1imit s. Impression: This pt, who alleges significant difficulty in every system of the body, evidences no overt depression and no significant anxiety. There is no thought disorder. There' is no acceptable evidence for any memory disturbance. Patients of this type, who present with studied resignation in the face of such an overwhelming picture of disability in virtually every system of the body usually are extremely angry, passive-aggressive individuals who attempt to compensate for their feelings of isolation and aloneness by denying their feelings and manifest them as somatizat i ons . Conmonly there is a great deal of contradiction, as in this case: hypertension and diabetes, on the one hand, and obesity on the other. Factitious disorder needs to be ruled out. 0012 WATER PCB-SD0000032562 i.:' ;o i i'u30 SPEC IHEN DATE WLLpDAY/DAY OF STAY hue 23HAR87 MQH 1 1532HRS HEHATOLQSY >:r.rcRErrsr - - - - - - - c.ECilC- -.'ii.l. PROFILE -- 1. 5- 11.0 k/UL UDC A. AO- 8.00 It/UL RPC 1A 0- i- n ' T1 HGP AL M- j L 1 {. HCT 82.0 100 0 FL ncv 27.0- 3A.0 PG Rl'H 32. 0- 36 0 7 ncHC ------- ELQ0D SHEAR PERCENT 0IFF - 35- o5 <. L'j " 13 {.1 SEGS LYMPHS o- 10 7 R0N0 o- 5 l. EOS o- 1 7. PASO - - - - - - - - - ol::::- ; ft; r.! nilRPHdt3SY -- PLT ESTIMATE 9.7 5.30 1A.5 A2.3 79. 9L 27. A SA. 2 63 26 8 2 1 ADEQUATE ,w/ 'oooo. iuvi -ns: sex n age 4i m PRINTED: 2AHAR8? 07:02 ( * = VALUE OUTSIDE REFERENCE RANGE I = RESULT CORRECTION HEKATQL0GY ^ Methcsixst _ (nnnn)itm?30-A 7082 EVANS RALPH L SLBA PAGE 1 The Methodist Hospital Department ol Pathology Houston, Texas 77030 Cumulative Pathology Report ' .- r., . - jDan ^ 00128 WATER PCB-SD0000032563 * . V j* '1 ^ 1/ HL' tAtUR -LA.'A " HQiJS rQrt 770 ;:0 .* ix SPECIttEH DATE UEEkOflY/DAY DF STAY TIME REFERErtCE RANGE TEST -- ELECTRULYTE/PRQFILE CHEMISTRIES - 8- 24 MG/DL DUN 0.5- 1.5 MG/DL creatinine 65- 110 MG/DL GLUCOSE 4.0- 9.0 MG/DL URIC ACID 8.7- 10.7 MG/DL CALCIUM 2.5- 4.5 MG/DL PHOSPHORUS 6.0- 3.4 G/DL TOTAL PROTEIN 3.5- 5.1 MG/DL ALDUMIN 0.2- 1.2 MG/DL TOTAL BILIRUBIN 30- 115 U/L ALK PHOS 3- 40 U/L ALT (SGPT) 5- 35 U/L AST (SGQT) 75- 200 U/L LD 23MAR87 HON 1 1532HRS CHEMISTRY 17 1.2 233H 5.4 10.0 3.1 7.6 4.6 0.4 66 46H 33 162 E y A .x. i Rsl--: l <0Oi)O>lO9i93O-6-7082 SEX M AGE 44 YRS PRINTED: 25MAR87 07:14 n = VALUE DU IS IDE REFERENCE RANGE I = RESULT CORRECTION CHEMISTRY ^ /Methodist -- ------------ ---------- ----------- ---------- ------ -- -- - -(0000)1091930-6 7082 Th Melhodlat Deparlmanl ol Pathology Houston, Texas 77030 Hospital .. ' Cumulative Pathology Report i EUANS RALPH L SLDA PAGE 1 00129 WATER PCB-SD0000032564 OHf PAYIOH i'-U 'A H 011 vj 1 UN ?7O'J0 FX SPECIMEN DATE UEEKOAY/DAY Of STAY TIME 23HAR87 HON 1 1532HRS HEMATOLOGY REFERENCE RANGE TEST ------- PLOOD CELL PROFILE ............ - A. 5" .11.0 R/UL UPC 4. AO- 6.00 M/UL RPC 1A.0- 18.0 G7DL HGP Al. 0- 51.0 7 HCT 82.0- 100.0 FL HCV 27.0- 3A.0 PG MCH 32.0- 36.0 7 MCHC - PLOOD SMEAR PERCENT DIFF --- 35- 65 7 SEGS 25- A 5 7 o- 10 7 o- 5 7 o- 1 7 LYMPHS MONO EOS PASO - PLOOD SMEAR MORPHOLOGY -- PLT ESTIMATE 9.7 5.30 1A.5 A2.3 79. 9L 27. A 3A. 2 63 26 8 2 1 AOE0UATE <0000/10919:0-6-7082 SEX M AGE 44 YRS PRINTED: 25NAR87 07:14 * = UALUE OUTSIDE REFERENCE RANGE I = RESULT CORRECTION HEMATOLOGY Metha&vst ---- --------------------------------------- --...... ........ (0000)1091930-6 7082 The Mtlhodlst Hospital Department ol Pathology Houston, Texas 77030 ^ Cumulative Patho' -v Report EVANS RALPH L SLDA PACE . 2 00130 WATER PCB-SD0000032565 i. . n . i k ,i t\ r, l ^ QHE BAYLOR PLAZrt HOUSTON 77030 TX SPECIMEN DATE WEEKDAY/DAY OF STAY HUE 23HAR87 HON 1 1532HRS 25HAR87 NED 3 1539HRS CHEHISTRY REFERENCE RANGE TEST - ELECTRQLYTE/PRQFILE CHEMISTRIES - 8- 2A HG/DL BUN 0.5- 1.5 HC/DL CREATININE 65- 110 HC/DL GLUCOSE A.O- 9.0 MC/DL URIC ACID 8.7- 10.7 HC/DL CALCIUM 2.5- A.5 MC/DL PHOSPHORUS 6.0- 8.A G/DL TOTAL PROTEIN 3.5- 5.1 HC/DL ALBUMIN 0.2- 1.2 HC/DL TOTAL BILIRUBIN 30- 115 U/L ALK PHDS 5- AO U/L ALT (SCPT) 5- 35 U/L AST (SCOT) 75- 200 U/L LD 17 1.2 233H 5.A 10.0 3.1 7.6 A. 6 0. A 66 A6H 33 162 SPECIAL CHEMISTRY REFERENCE RANGE TEST - PORPHYRIN (CARBOXYPORPHYRIK) FRACTIONATION, URINE -- PORPHYRIN INTRP+) BELQH -- HEAVY METAL/TOXICOLOCY .......... DATE STARTED*> 23HAR87 TIME STARTED*> 1600 DATE STOPPED*> 2AHAR87 TIME STOPPED*) 1600 ---------- PORPHYRINS - 0.0- 2.0 MG/2AH PORPHOBILINOGEN*> 0.6 EUfthS RALPH L <0000)1091930-6-7082 SEX N AGE AA YRS PRINTED: 28HAR87 06:18 f - FOOTNOTES > PERFORMED AT REFERENCE LABORATORY SMITH KLINE BIOSCIENCE LAB 25MAR87 1539 PORPHYRIN IHTRP SEE INTERPRETIVE DATA AT END OF REPORT x = VALUE OUTSIDE REFERENCE RANGE I RESULT CORRECTION CHEMISTRY /Methodist "---- ----" ......... ....... ...... . .. 0)000)1091930-6 7082 Department ol Pathology Melhodlsl Houston. Texas 77030 Hospital Cumulative Patholc Report EVANS RALPH L SLBA PAGE 1 00131 WATER PCB-SD0000032566 V K . I f Xrl.XX C.trtKJ ONE BAYLOR PLAZA HOUSTON 77030 TX SPEC IMEH DATE 23NAR87 ^ WEEKDAY/OftY OF STAY HUH 1 TIflE 1532HRS HEMATOLOGY REFERENCE RANGE TEST ........ BLOOD CELL PROFILE 4.5- 11.0 K/UL UBC 4.40- 6.00 H/UL RBC 14.0- 18.0 G7DL HGB 41.0- 51.0 7. HCT 82.0- 100.0 FL HCV 27.0- 34.0 PC HCH 32.0- 36.0 7 NCHC - BLOOD SHEAR PERCENT DIFF - 35- 65 7 SEGS 25- 45 7. LYMPHS 0- 10 7 MONO 0- 5 7 EOS 0- 1 7 BASQ -- BLOOD SHEAR MORPHOLOGY -- PLT ESTIMATE 9.7 5.30 14.5 42.3 79. 9L 27.4 34.2 63 26 8 2 1 ADEQUATE EVAN3 RALPH i_ <0000)1091930-6-7082 SEX N AGE 44 YSS PRINTED: 28HAR87 06:18 = VALUE OUTSIDE REFERENCE RANGE I = RESULT CORRECTION HEMATOLOGY . yfiethcfflist The Methodist HospiUI 70000)1091930-6 7082 Department ol Pathology Houston, Texas 77030 Cumulative Pathology n ^oort EVANS RALPH L SLBA PAGE 2 00132 ; ` T .... , ....... ^nma ilailuA Denhst WATER PCB-SD0000032567 BEN COOPER, M.D., P.A. NEUROLOGICAL CONSULTATION 6560 FANNIN, SUITE 1426 HOUSTON. TEXAS 77030 (71 3) 797-1 1 80 April 1, 1987 RE: RALPH L. EVANS TO WHOM IT MAY CONCERN: Mr. Evans was examined on March 24, 1987. A detailed history was taken and a neurological examination was carried out. The neurological examination revealed a right handed man with a large frontal boss. His cranial nerve examination was entirely within normal limits. The motor system revealed normal development with large musculature. His strength was normal throughout as was his tone, co-ordination and reflexes. In examining his sensation, I found he had a diminution in appreciation of pin prick to the mid -forearm in his upper extremities and to the lower third of his legs. Joint position sense and vibration sense was normal throughout. * The neurological examination man in this man revealed the findings of a sensory neuro-pathy. The cause for this neuropathy is not apparent from the neurological examination. This gentleman has had a host of illnesses including diabetes and porphyria which could be a factor in his pheripheral neuropathy. He has in addition, had bilateral ulnar nerve and bilateral carpal tunnel releases which is a rather unusual combination of operations. I was unable to demonstrate weakness in muscles innervated by either nerves. To my knowledge no tests of P.C.B. have been made in this gentleman. Thank you for a 1 lowing me to share in Mr. Evans care. Sincerely BC: jb Ben Cooper, M.D oo m WATER PCB-SD0000032568 6560 FANNIN, SUITE 1 426 HOUSTON, TEXAS 77030 DOB: 1-31-43 ^ AGE: 44 3-24-87 IOV BEN COOPER, M.D., P.A. Neurological consultation 0S0O FANNIN, SUITE 1420 HOUSTON. TEXAS 77030 TELEPHONE 17 1 3) 707' 11 80 EVANS, RALPH L. (713) 797-1 180 l ) ^or^V\fvc\ - HwwiaVW^. He<^lcA o{ Vmmvl - djkx^h aV>: a) VlkA ~ Laaj \>*l5JjiA-*-^ -- 0"^-AAA, i) ~ W1 ^ VWUATM^vAijjuU^ XWAAu\^-\0 . iy uJaww amawm, cluh^v-l. UWto iVwi Va iMTio ^Wwsmaa^^aa. WaUanvaam V ^xxjjSM^b- ** HuhuukIU lpv^fc iWvwUHAV^ i'mMa. ^ A Va3uO noAjA u^V v?) W* wjwA s uio. -\) jGwsSjua^i^waa^ Vj3t. VAlO W 00134 WATER_PCB-SD0000032569 'J XSJ^tA '^AfceVMA^W - wyjf- ^JLCAlAl AjlAW* Aj^KU ^d&^a. AjAmWa4 . ) \ ^ww Amo ^waa. im u) Mjl-^\ Vltoee\/^*&@U44 W*H Wbl- a.3^V20. ') VuLVtUM. JWJUAA v*. VjSjuUUaA - VfeA cWjMAX cd>Wt v ^mwAMVWN djxx 'M'UJ^ib- ^ i) ^cmw4 "3. ojaw, \ % ^ S' AWMaXuJ^ Cl- . V5 I4 QJUtVtfl& /tMV 't4Xfl4 AkifpC a^4j *5 Vv - cduw. -. a^odTO aUwIuSaa -Win KifljA kjtiAk^'^^O- fM44-/*V`J*W v - c^sQajuI ttAAjni- AKtaAc^joM^ *>\ ^M. 'flMi- Ut'A VA ^crtW A/^JftbV \M4VUAN4 VJ^\AV \\i ^uwiwA bO'fcs-MAMt GtA- W&\ Vo^a-^M M^j^lvvaaaijm!/m*XJ$ucb./vai^' ^(lijesM^iSeAc*^^. 00135 WATER_PCB-SD0000032570  BEN COOPER, M.D., P.A. NEUROLOGICAL CONSULTATION 6580 FANNIN. SUITE 1.428 HOUSTON. TEXAS 77030 TELEPHONE (7131 797-1 I 80 6560 FANNIN. SUITE 1 426 HOUSTON. TEXAS 77030 PAGE TWO 3-24-87 AGE: 44 EVANS, RALPH L. 'At (a i.oT- R. (71 3) 797-1 1 80 h<*vfci.v! ^ ^<^X(Avyv. \0 AW IsV > /iAAAitt-Wbb. Klukj^COHTAUA^JLo ^ V-**- p XU c<-uUtiU . AcA lUiLf %AA\)4i)w4 - ^UOUU, a 4 . D Cc(aAjm ' --" ^yt ~ ^MMc udr Wj w V>i4%Mju oa cm vmXx AmuA Vo WE**- V(^U^) vu (fe^u. AAwm ^ V^CO - Am. wj. A^ W &&&*. W <Xb ^^AM^\CU*A . WjU\|a\*AjuA tt^WUWAV iUfMXWy ^MAMi M Wa^LUMi MA /{tUAAl )'i^h UtflAA. ktjfrbbU| 10* 0013U WATER_PCB-SD0000032571 V>-AUUyA oiu). fcxMjJA. uA <MAJ* - 1^CjaX/r^A3 diM 0* KM ^JlUVtJ CSuVo^Ct ^w uM). VIaowwi a* ok\. W aW ^ l<'o,u^ V\ Vm - YVlAAiAr u\,Vd^^/^^4- NW/C^m u>edU, Sl-l> AH^cWa . A wmwuAm^o ax^ Voa MbtAdW MaimV Vj mu- -v ***Mirf - Am- Ajl^Ql ^ii VAiW \XaWx> <MVam* V >*>eM \^juM Ve Wut jdsw^OpA ^>,HW ^QAk k>SsrUc^eufti; (Ve'fc Q4S2/<wrtuA ak VailMLiUb^di^iL Usdstota. , w^WwMA Vu Uie/yusj. k*SUu/&4 iw, OuJUX W- wh 'rVY^Mum^4l WauM , Ujl uxh lu Uti ^MkA \M Ol^Mm Wf*-\0U d^uh\M 0013V WATER_PCB-SD0000032572 BEN COOPER, M.D., P.A. Neurological consultation 0300 FANNIN. SUITE I 420 HOUSTON. TEXAS 77030 Telephone (71 3) 797-t 180 6560 FANNIN. SUITE 1426 HOUSTON, TEXAS 77030 it AfcJUfi W Amm Wufci oWaaV VO (71 3) 797-1 1 80 aUazmajL t ^poMAMiiiT- W Vjlw W, ti. oulA inl 7,-L\ Ntoiuk- , U-^ \KM_ \jl>P cjAM/W^A- \^l VomA'' iUaa.& .U _____ Vjva^wv. - ViU.V c5uw\aWGmJwJ C\A\ VjU-UAA, VA\ ^ V* K^i2JU>fO ^IMAAa. ^VjoJA- ^JlvWl ^iA^' 'fc* W<U4 V) v / Vi&64 OA \i fry vir w, y ^ e"p^ -- <*> 0 D 13d WATER_PCB-SD0000032573 Wt^t /yvvuaJLu ' vW)<sm^ aInu_ '. ^ Jj cNefc. '. ^ sicXUnA,v/ \\) V /Yta4^eQMt\ 'V V-t> Uvjwa/'Ij^^u Ijua T.n^ 1 xJ^A^aW*-' ^ ^|v\o. i v\^ A^wrt^-\ - 00139 WATER_PCB-SD0000032574