Document vBEk443YRy7pnMrQ05zZ85LLY

' 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 '.^*-/ " .w 7`"t Dear Mr. Henderson: ._ Thank you for referring Montgomery Toon to me for evaluation. interviewed and examined him on February 27, 1987. I Based upon this examination, it is clear that Mr. Toon had a very significant exposure to PCBs during the course of his work at the Westinghouse Company. As a result of Mr. Toon's exposure to PCBs and to their breakdown products at high temperature, he developed reactive airway dysfunction syndrome,'l- characterized by a y.Tsistent and unremitting asthmatic diathesis. In, i spite of vigorous therapy, his asthma has not been adequately controlled. ~ Mr. Toon has been taking steroids in large amounts to treat this reactive airways dysfunction syndrome. Steroids in large doses over a long period of time are a disease unto themselves. Thus, treatment of Mr. Toon's PCB induced respiratory disease has now led to alterations in Mr. Toon's skin, his glucose metabolism, his general state of well being, his opthalmic function, and his peripheral nervous system. He now has evidence of a myofascial syndrome, of possible skin cancer, of chloracne, of immune system changes. He may have continuiung evidence of a thyroid disorder in the form of proptosis. All of these systems are now seriously affected by both the underlying PCB exposure, and the steroid treatment which has been superimposed on that problem. ` In my opinion, the patient cannot survive without the use of steroids. Under these conditions it is likely that he will be virtually crippled because of the'original PCB exposure, "and^the multiple problems' which have followed treatment for that disorder. ';r -.... A complicating question has been raised concerning possible scleroderma. It is my understanding that his recent dermatologic evaluation did not support that diagnosis. He does have, however, chloracne by history, and several other skin changes characteristic both of cortico-steroid exposure and his previous PCB exposures. . Central: 701 E. Colfax, Denver80203 *831-7171 East:9450 E. Mississippi, Denver 80231 *751-1241 North: 84th & Zuni, Suite225, Denver 80221*429-1529 West: Denver Wesl Office Park, Bldg. 52, Golden 80401 279-7525 Aurora: 15101 E. Iliff, Suite 140, Aurora 80014 -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 00203 HARTOLDMONOQ21781 Montgomery Toon Page - 2 There is laboratory evidence of slightly elevated porphyrins. In the 1 ight of the abnormal red cel 1 metabolism which may be present in seriously steroid dependent individuals, this finding may be another manifestation of steroid dependency. In my opinion, Mr. Toon has serious respiratory disease as a result of his PCB exposure. In addition he has disorders of his central and peripheral nervous systems, he has a cataract, and his ski-rv is damaged as a result of PCB work at Westinghouse Company. I trust this information will be helpful to you. Daniel T. Teitelbaum, M.D 00210 HARTOLDMON0021782 RE: Montgomery Toon BY: Dr. Daniel Teitelbaum DATE: March 3, 1987 MEDICAL DICTATION Chief complaint: ' Mr. Toon is a 40 year old white male who has had extensive exposure to PCB fluids while working at the Westinghouse Corporation between 1967 and 1982. He has been totally disabled because of respiratory disease since 1982. The patient states that in his early life he worked on his family farm. He used very little in the way of chemicals and no spraying was done. 'l He went to work for Westinghouse (. . p. as a clerk in the PCB areas. He, frequently did walkabouts and delivered materials to the PCB using floors*.' Later, he did time study work. He spent approximately 60% of his time in the PCB areas. In this process, PCB containing capacitors were filled with transformer oil so that the paper would be impregnated. Following his work in the time study area, he went to inventory control. He was specifically responsible for all of the activities involving the use of PCBs. Ht, himself did not handle the PCBs. His office was across from the area in which PCBs were used. He kept the PCB inventory. Mr. Toon's clothes and shoes frequently got wet with PCBs. He would have to crawl under ovens and everywhere in the area, and was often completely soaked with PCBs. He states that in the particular area which he worked sawdust was spread on the floors to absorb cooked PCBs all the time. At this time Mr. Toon is having severe nightmares. In addition, he is having very severe respiratory problems which began in 1973. At that time his personality changed. He began to cough all the time, and gasp for air. He developed a great deal of phlegm, and coughed up so much of the yellow to dark phlegm that it hurt. The patient stated that at that time the area around his desk was used for welding and that this was a hot use. There were frequently steaming and boiling PCBs. He states that the smell of the boiling PCBs was slightly sweet which suggests the presence of phosgene. He states that in the area in which he worked, the restrooms had steam pipe heating which came from the capacitor area, and on occasion, there was so much PCB smoke in the restroom, that you could not see your way through. His respiratory disease became so serious that he required hospitalization at National Jewish Hospital, in Denver. At the present time he is taking Alupent, Intal, Proventil, Aerobid, Albuteral, Synthroid, Nasalide, Os-Cal, Carafate, and Prednisone 20 mg. per day. he has taken prednisone at this level for four to five years, at no less than 15 to 20 mg. per day. He also takes Theodur 700 mg. twice a day. He states that he is one of a pair 00211 HARTOLDMON0021783 Montgomery Toon Medical Dictation 3/3/87 Page - 2 - of twins, and that his twin brother has no asthma. He denies any asthma in the family. The patient has had very substantial problems with his skin. He has had blackheads, inflammatory papules, and cysts, as-documented in his history. In addition, he has had a distinct change in the color of his skin. A brief look at the patient reveals obvious steroid induced changes with thinning of the skin, flushed skin, somewhat protuberant eyes, and overall ill general appearance. The patient states that at the presnt moment the biggest problem is chest and back pain which is extremely ; ./ere. He has multiple nodules on his arms. He has terrible difficulty breathing, and he has continuous joint ' aching. He retired on disability in 1982 at age 36 because of severe| respiratory problems. His hobbies include occasional work with stained glass. He may solder using 60/40 lead solder.He did one piece in 1986, and 2 pieces in 1987. He takes noalcohol. He states that he probably had one glass in the last 20 years, and he has never smoked. Family history: Both parents are -alive. His father had a heart attack in at age 60. He has an uncle who has lung cancer. He has a 43 year old identical twin brother who has a hiatus hernia but is otherwise well. He has two children, one of whom has epstaxis on occasion, but is otherwise well. Physical Examination: Blood pressure was 120/30; pulse 72; respirations 17; and the temperature was 97.3. The patient was a well developed, well nourished very tremulous white male with pop eyes, and obvious steroid changes. His skin revealed multiple petichia, some of which were confluent. There was a lesion on the right arm which was soft, but of some concern. There were also several lesions on the shoulders which required dermatologic evaluation. The face was extremely florid. The head, ears, eyes, nose and throat was generally unremarkable, other than the protuberance of the eyes. The right fundus was well seen, the left fundus is obscured by a cataract. There was mild laziness of the right eye on lateral gaze, no stigmatose was detected. The ears, nose and throat were normal The thyroid was normal. The chest showed a scar on the right chest under the nipple. There was increased AP diameter. There were multiple musical rales in all lung fields, which did not clear on coughing. Examination of the heart revealed a regular sinus rhythm. There were no thrills, rubs or murmurs noted. The abdomen was unremarkable. No liver, spleen or kidney enlargement was noted. 00212 HARTOLDMONOQ21784 Montgomery Toon Medical Dictation 3/3/87 Page - 3 - Examination of the GU system revealed a normal male. Rectal examination was not done. Neurological examination revealed the patient was alert and oriented. He was extremely anxious and tremulous. Cranial nerves appeared to be intact. There was marked bilateral optic protuberance but no lid lag. Sensory examination was abnormal with decreased pinprick and light touch. Motor examination was normal but appeared to be*extremely weak for the age. His vibratory sense, proppioception. Cerebellar findings were normal. No lymph nodes were noted to be enlarged. Diagnoses: 1) Toxic Syndrome 2 to PCB with: a) Reactive airways dysfunction b) Occupational asthma c) Peripheral and central neuropathy d) Chi or acne e) R/0 skin cancer f) Immune system dysfunction g) Steroid dependency 2 to 1 h) Porphyrin elevation 2) S.P. Thyroid reaction with residual proptoses and exopthalmia 3) R/0 Scleroderma . ti ~ /Is 00218 HARTOLDMON0021785 / Name: MONTGOMERY TOON Date of birth: 06/15/46 I have reviewed and considered the clinical note of Dr. Daniel T. Teitelbaum. In addition, I have noted the following history from Mr. Toon. This 40 year-old man worked for many years for Westinghouse. Part of this time he was exposed to oils containing PCB's. He had little acne as a youth but during the time he was exposed to oils he developed numerous blackheads and pimples on the face and upper trunk and on the scrotum. He has three or four cysts excised from his back. He' states that he has developed increased hair on his back in the last ten to fifteen years. He also says that his skin has a more yellowish appearance. His skin is fragile and tears and bruises easily. He has had discoloration over the shins for the past ten to fifteen years. Since the early 70' s he has been on corticosteroids systemically for chronic lung disease. In addition, he has had problems with headaches, vertigo, memory loss and muscle weakness. Examination reveals a 1 x 1 cm slightly scaly red circular plaque on the anterior aspect of the left shoulder. There are several areas on the back with thick darker hairs. T' ,e is a 3 x 3 mm dark black papule with irregular border on the posterior aspect of the right shoulder. He has prominent follicles on the scrotum and slight dryness of the legs with well demarcated atrophic slightly hyperpigmented patches over both shins. I have examined and evaluated Mr. Toon with reference to his possible dermatologic problems. I have likewise reviewed various hospital,'medical, and related records of Mr. Toon. Based upon my examination and various portions of the records, it is my opinion that Mr. Toon suffers from: ' 1. - 2. " 3. 4. 5. 6. Chloracne by history Superficial basal cell carcinoma, left shoulder, proven by biopsy by Dr. Roy Knowles Junctional nevus (rule out superficial spreading melanoma), right shoulder Hyperpigmentation, legs Hirsutism, back, probably second airy to corticosteroids Increased skin fragility, secondary to corticosteroids Eiopsv of nevus of shoulder recommended. I also have considered the relevant medical and scientific literature regarding exposure to PCBs, dibenzofurans, and dibenzoaioxins and certain adverse health effects associated with exposure to those chemicals. It is my further opinion -V 00214 HARTOLDMON0021786 I page that the following diagnoses are related to, i.e. caused or contributed, Mr. Toon's previous exposure to PCBs and/or their contaminants: - " -- . - 1. Chloracne by history 2. Superficial basal cell carcinoma left shoulder, proven by biopsy by Dr. Roy Knowles. 3. Hyperpigmentation, legs 4. Hirsutism, back, probably secondary to corticosteroids 5. Increased skin fragility, secondary to corticosteroids These opinions are v;ithin a reasonable degree of medical probability. Edphr B-; Smith, M.D. Profess'.i and Chairman Department of Dermatology University of Texas Medical Center Galves'K'-'i, Texas 77550 V 0021s HARTOLDMONOQ21787 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 NSUKOPSYCHIATRIC EVALUATION NAFE: Montgomery L. Toon DC: 15 June 1946 Thank you for the opportunity to evaluate Montgomery L. Toon, who I assessed on 27 February 1987.__In addition to examining Mr. Toon,. I_.reviewed..and________ considered the clinical note of Dr. DanieT~T. Teitelbaum.~'Thave also '' reviewed various hospital, medical, and other related records of Mr. Toon. Mr. Toon underwent a comprehensive neuropsychiatric evaluation. This . evaluation included administration of the Neuropsychological Symptom Checklist (NSC), the 28-item version of the General Health Questionnaire (GHQ), the T. . abbreviated version of the Beck Depression Inventory (BDI), the revised i 90-itan version of the Hopkins Symptom Checklist (SCL-90-R), and a ~ semi-structured interview using the Schedule for Affective Disorders and Schizophrenia - Lifetime Version (SADS-L), with the Global Assessment Scale (GAS) . The NSC is a general, qualitative (non-quantitative) symptom 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 emotional distress. The BDI is used to establish the overall severity of depressive mental symptoms, 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 emotional symptoms. From 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. Toon was also evaluated with an array of standardized neuro psychological tests to assess his intellectual functioning. These tests included assessments of orientation, attention/concentration, verbal and nonverbal memory, visuospatial abilities, larguage/reasoning, and motor/ "Executive" functions. Based upon my examination, including the tests that I have indicated, as well as Mr. Toon's records and Dr. Teitelbaum's evaluation, it is my opinion that Mr. Toon suffers from a major depressive disorder associated with severe suicidal ideation, as well as neuropsychological impairment indicative of mild to moderate central nervous system damage. 0021b HARTOLDMON0021788 Montgomery L. Toon 27 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 conditions are 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. Eric D. Caine, M.D 20 March 1987 0021V HARTOLDMON0021789 HrsiI-l'HKSHVTF'.lUAN-ST. LUKE'S MEDICAL CENTER mr,:i wxsr co\<;iu:.ss i^hkway, nn< ago. n.uxois <mm DEPARTMENT OF NEUROLOGICAL SCIENCES 19 March 1987 Thomas W. Henderson, Esquire Henderson & Goldberg, P.C. 1030 Fifth Avenue Pittsburgh, PA 15219 . ,,_ *' RE: Montgomery Toon Dear Mr. Henderson: I have reviewed and considered the clinical report of Dr. Daniel . Teitelbaum. I have examined and evaluated Mr. Toon with reference to his possible neuro- ;i logic problems. I have likewise reviewed various hospital, medir'.l, and '. related records which were supplied to me. _ - *J Based upon my history and examination and supported by various portions of the records, it is my opinion that Mr. Toon suffers from: 1. Postural tremor and terminal intention tremor (action tremor); * 2. Action dystonia; 3. Peripheral.neuropathy. 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 further opinion that Mr. Toon's previous exposure to PCBs and/or their contaminants caused or contributed to all of the above diagnoses. These opinions are within a reasonable degree of medical probability. Since--1w Harold t. Klawans, M.D. Professor, Neurology & Pharmacology /gi 1725 W. Harrison, Suite 915, Chicago, Illinois 60612, (312) 942-5936 00211* HARTOLDMON0021790 HARRIS BUSCH. M.D., PH.D. PROFESSOR ANDCHAIRMAN DEPARTMENTOF PHARMACOLOGY BAYI-OR COLLEGE OF MEDICINE TEL 17131790-4457 1200 MOUHSUND AVENUE HOUSTON.TEXAS 77030 EXAMINATION Dr. Harris Busch Dr. Frank Smith TOON, Montgomery March 23, 1987 Mr. Toon is 41 years of age and his major complaint is that of chronic asthma. He has been hospitali zed in the Emergency Room multiple times for exacerbations of his asthmatic condition. His asthma has been evaluated in Denver at the National Jewish Hospital and he has multiple allergies to dust, molds, etc. His asthma is now steroid dependent and he takes Alupent and TheoDuru as well to maintain his pulmonary status. On physical examination, Mr. Toon is found to be a 41 year old male who appears his stated age. He seems slightly dyspneic at rest and coughs frequently during the examination. There.As no adenopathy noted. The accessory muscles of respiration are active during normal respiration. The cardiac examination does not disclose any rubs, murmurs, or gallops. The pulmonary second sound is louder than the aortic second sound indicative of some degree of chronic cor pulmonale. The liver is a normal size and there is no splenomegaly or ascites. Mr. Toon suffers from chronic respiratory insufficiency due to atopic asthma. His elevated white count of 13,200 probably reflects his chronic steroid management of asthma as does his low lymphocyte count which is 2%. - A review of skin testing indicated that Mr. Toon has serious allergies to dusts, molds, corn (4+) and feathers and possibly to chicken. The tests were done by Dr. Spencer in Bloomington at the request of Dr. Ray in the late 1970's or 1980. For the last nine years, he has lived in a new house and has not used electronic air filters or other devices to prevent development of asthma. The only item he remembered in the list of substances to which he was allergic are feathers. It is not clear why more precautions have not been taken in his new home or with respect to his diet. We had scheduled a visit to Dr. Redman, with the potential for immunotherapy. Mr. Toon was unable to remain for further studies because of other appointments at the Jewish Hospital of Denver, where he was urged to have a review of skin testing. Preliminary Diagnosis 1. Asthma, chronic, poorly controlled 2. Chronic asthmatic bronchitis with cor pulmonale 00219 HARTOLDMONOQ21791  ' -- __ TPEC iALN DATE NEEl'OAY/DAY OF STAY 11 RE TEFERE-C >. "ANOE TEST ELECTRlil V fE/ PROFILE CHEMISTRIES - 8- 24 MG/DL bun 0.5- 3.5 JIG/OL CREATININE 65- 110 MG/DL GLUCOSE 1 0 9.0 MG/DL URIC AGIO K 7- ID 7 MG/DL CALCIUM 2 J- L it MG/DL PHOSPHORUS 6 l! f) 3 G/OL TOTAL PROTEIN J 5- 7 i MG/DL ALBUM IH 0 2- 1.2 MG/DL TOTAL BILIRUBIN 30- J10 U/L ALK PH05 5- At) U/L ALT <SGPT> 5- 3r> U/L AST (SCOT) 75- 200 U/L to 28J1AR87 flQN 1 1003HRS CHEMISTRY 11 1.1 89 6.9 10.2 1.9L 6.0 4.5 0.4 81 33 20 181 - <0000)i09l8l?-3-709: SEX ACE 40 YSS PRINTED: 24A8R87 07:03 < -- UALUE OUTS [OE REFERENCE RANGE ^ kESULi correction CHEMISTRY ^ /Methcsiist ____ _ _ _ _ _ _ _ _ ------------ --.. 10000)1091817-5 7082 Th Methodist Hospital Department of Pathology Houston. Texas 77030 Cumulative Patho? Report , TOON HQHTSQftERY L UHKK PA6E 00220 y^rrr- -- HARTOLDMON0021792 1 p n. i . - M(i U >0 ^ SPEC[m:.3 DATE wLEkOpy/oftv or stay TIME 23MAR87 non i 10G3HRS HEI1ATDLQGY REFERENCE: SANSF. TEST ........ ClUUD CELL PROFILE 4. O- 11 0 K/UL HOC A. AO- A.UU M/UL RCC 13 0- 18.0 G/9L H8B 41.0- 51. >! /. HCT 02 n- 100.0 f'L MCI' 27.0 .13 0 PG MCH 32.0- 36 0 7. ncnc 150- 400 K/UL PLATELET - 6L00D SHEAR PERCENT DIFF - 5- A 5 7 SEGS 25- 13 2 LYMPHS n- .10 7. MONO o- 5 7 EOS -- 8LU0D SMEAR MORPHOLOGY -- PLT ESTIMATE 13. 2H 5.35 16.4 48.3 90.3 30. 7 33.9 234 92H 2L 3 3 ADEQUATE SEX ft AGE 40 YRS PRINTED: 24HAR8? 07:03 * = IIALUE OUTSIDE REFERENCE RANGE * RESULT CORRECTION HEMATOLOGY ^ yWethcslist _,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0000)1091817-5 7082 Th Methodist Hospital Depaitmenl ol Pathology Houston, Texas 77030 Cumulative Pathology ^oort TOON MONTGOMERY t UHKH PAGE 2 00221 HARTOLDMON0021793 r.. :*1 f rOGN, MONTGOMERY L 1 O'D l1! 7'li ..M t TH, i RHNK finWORD MD 1WM I il U vn:wo> Of! O', LOTGRGL Si:' X : OOP: ROOM >*; EXttM LWE: M 06-13-1SAG S/7 op 03--G 3 ti / fJRDl R #: A 1030 I I'lrRL: ,-j i'.OM : Thei ! is c-oma right chess 1 wa 1 l deformity and (.hare? is & 1 so corns i ' 1 tiiia i i.,.: rih deformity, H.-ari si us is within normal limits. 1. i is.1 unrjc free of ir, f i. 11 va t ion s i j ual i fi Mi.-, right mid chest. There i a small cdlcifi f l t I> / m /Methcsltst The Melhodlil HoeplUI Oenartmenl of Radiology 656b Kinnin Houslon Texas 77030 [ iii<SBSH5!35&. 00222 HARTOLDMON0021794