KRIS JOYCE D. TREAZISE, Employee/Appellant, v. UNITED HOSP., SELF-INSURED/GALLAGHER BASSETT SERVS., Employer-Insurer, and ALLINA HOME OXYGEN AND MED. EQUIP., Intervenor.
WORKERS= COMPENSATION COURT OF APPEALS
NOVEMBER 10, 2003
CAUSATION- SUBSTANTIAL CONTRIBUTING CAUSE - AGGRAVATION. Where the employee=s exposure to roses at work triggered an aggravation of the employee=s pre-existing asthma condition and necessitated more extensive steroid treatment than she had received in the past, which in turn led to an elevation of the employee=s blood sugar level and a related diagnosis of diabetes mellitus Type II, and where the employee=s condition and need for treatment for both conditions continued at the time of the hearing, the compensation judge=s findings that the employee had sustained only a temporary aggravation of an underlying asthmatic condition and a diabetic condition that ended as of September 12, 2001, were not supported by substantial evidence of record and we accordingly reverse both findings. We remand this matter in part for reconsideration of the duration of the temporary aggravation of the employee=s asthmatic condition. We reverse the finding that the steroid medication did not cause or accelerate the employee=s diabetes, and hold that the employer and insurer remain liable for treatment of the employee=s diabetic condition.
Reversed and remanded in part.
Determined by Rykken, J., Wilson, J., and Pederson, J.
Compensation Judge: Gary P. Mesna
Attorneys: Patrick W. Kelly, Patrick W. Kelly & Associates, Woodbury, MN, for Appellant. Douglas J. Brown, Brown & Carlson, Minneapolis, MN, for Respondents.
MIRIAM P. RYKKEN, Judge
The employee appeals from the compensation judge=s findings that the employee sustained a temporary aggravation of an underlying asthma condition and a temporary aggravation of a diabetic condition as a result of a work injury on July 11, 2001. Concluding that there is not substantial evidence to support the compensation judge=s findings, we reverse and remand in part.
Ms. Kris Treazise, the employee, has worked as a licensed practical nurse (LPN) for Allina Health System, D/B/A United Hospital, the employer, since January 6, 1997. On July 11, 2001, while working in the Birth Center, the employee was exposed to numerous cut roses at her nursing job; there were four vases, with a dozen roses in each, in the unit=s central nurses= station where the employee sat frequently during her shift. Two of her four patient rooms that evening also contained rose bouquets. The employee testified that she had worked for less than one hour when she began to notice an onset of symptoms which included itchy and watery eyes, stuffiness, coughing, sneezing and difficulty inhaling, which worsened throughout her shift.
The employee has a history of allergies and an asthmatic condition. At age nine or ten the employee was tested for allergies, and was found to be allergic to dust, mold, grass, trees, walnuts, flowers, dust mites, and roses. At that age, she received allergy injections two to three times per week, tapering off over approximately one year. The employee did not treat again for allergy symptoms until 1995, when she was 29 years old. She sought treatment with Dr. Jill Linse, who later diagnosed her with asthma. The employee continued to treat with Dr. Linse through at least August 19, 1998, reporting, at various times, acute shortness of breath, significant respiratory distress and wheezing. During that period of time, the employee was prescribed Azmacort inhaler, Albuterol inhaler, prednisone, and Depo Medrol. Prior to July 11, 2001, cold air, excessive coughing, excessive dust and pollen could all trigger an asthma event. The employee testified that in the two or three years prior to her 2001 work exposure, she typically noted a flare-up of asthma symptoms during July and August.
On July 11, 2001, after experiencing asthma symptoms at work after the exposure to roses, the employee treated herself with an Albuterol inhaler. However, that inhaler provided no relief and the employee=s symptoms progressed to the point where she felt as if she was Asucking in butter.@ The employee testified that she could not catch her breath and felt as if there was a band around her chest.
On July 15, 2001, the employee sought treatment at an urgent care center for severe respiratory symptoms, and was prescribed an antibiotic medication as well as respiratory medications. The employee treated for a few days at home with medication, under the care of her family doctor, Dr. Thomas Ferry. On July 19, 2001, due to the employee=s worsened symptoms, Dr. Ferry admitted the employee to the hospital in order to commence IV Solu-Medrol treatment for her condition which he diagnosed as status asthmaticus. The employee remained hospitalized until July 25, 2001, and was treated with intravenous antibiotics and IV Solu-Medrol, which is a form of prednisone. During her hospitalization, the employee became ill when her kidneys nearly stopped functioning. Testing of her blood sugar level showed extremely high blood sugar. The employee was diagnosed with diabetes and was placed on insulin treatment. This was the first time that the employee had been diagnosed and treated for diabetes; the employee testified that her blood sugar level had been tested earlier in 2001, with normal results, although there is no reference in her medical records in evidence documenting any earlier testing results. The employee has continued to take insulin for her diabetic condition through the date of hearing.
At Dr. Ferry=s referral, the employee was examined by Dr. James Quaday, Pulmonary and Critical Care Associates, while she was hospitalized in July 2001, and she received periodic treatment from both Drs. Quaday and Ferry thereafter. Dr. Quaday confirmed the diagnosis of status asthmaticus. By September 2001, Dr. Ferry released the employee to return to work, but restricted her from working near flowers. The employee returned to work on a part-time basis in August 2001, and full-time on September 19, 2001, although she has worked less than full-time hours during most pay periods thereafter due to her symptoms. In September 2001, she still noted symptoms of wheezing and difficulty breathing even while using Albuterol and nebulizers. Her diabetic symptoms also continued at that time, and included a blood sugar level which was uncontrolled and she often became nauseated, shaky, sweaty, very lethargic and tired with a low energy level.
The employee=s medical records reflect that various regimens of medication were prescribed for her asthma condition, and also reflect the effect of prescribed steroids on the employee=s blood sugar levels and her corresponding attempts to limit steroid intake to maintain a consistent blood sugar level. Her records also reflect periodic flare-ups of her respiratory symptoms. For example, Dr. Quaday examined the employee on September 12, 2001, and recommended that she continue her steroid medication even though she informed the doctor that she did not want to increase her steroid dosage because of its effect on her diabetes. The employee was seen in the emergency room on November 10, 2001, for asthma symptoms and was re-hospitalized on December 5-6, 2001, after a non-work-related exposure to flowers.
On March 1, 2002, the employee again consulted Dr. Ferry for her diabetes and asthma. According to a Medical Certification Form signed by Dr. Ferry on that date, he diagnosed the employee as having severe brittle asthma with an onset of July 11, 2001. He stated that the employee Awill have periodic severe asthma attacks requiring physician visits or off work.@ He responded Ayes@ to the question on the form as to whether it will be necessary for the employee to work only intermittently or to work on a less-than-full schedule as a result of this condition, and he stated AProbably lasting lifetime.@
On April 4, 2002, at the request of the self-insured employer, the employee was examined by Dr. Paul Johnson, a specialist in internal medicine and pulmonary diseases. Dr. Johnson diagnosed chronic asthma which is steroid dependent, tobacco dependence, exogenous obesity, a recent onset of diabetes mellitus secondary to the employee=s obesity and steroid medication, and chronic depression, in addition to other medical conditions. He concluded that the employee became steroid dependent for her asthma condition sometime in 1997. Dr. Johnson concluded that the employee=s exposure to roses on July 11, 2001, was not a substantial contributing cause of her asthma condition but that it was a temporary aggravating factor of her underlying asthmatic condition. He concluded that the employee had reached MMI from her asthma condition in August of 2001 and again at the time of his examination in April 2002, basing those opinions on her pulmonary function tests that Awere essentially normal on those two occasions.@
On May 8, 2002, the employee was examined for her asthma by Dr. Quaday=s nurse practitioner, reporting shortness of breath, difficulty breathing and concerns about her elevated blood sugar level due to her prescribed prednisone. On May 9, 2002, the employee spoke to Dr. Quaday by telephone, reporting respiratory difficulties. Dr. Quaday called the 911 emergency response line on behalf of the employee, stating in his chart note that the employee Adid not sound like she should be driving to the emergency room.@ She was examined at the emergency room, and was again hospitalized from May 20-24, 2002, for treatment of her asthma. While hospitalized, she underwent an endocrinology consultation with Dr. James Wiberg who stated that the employee Ahas steroid-induced diabetes but almost surely has underlying insulin-resistant syndrome.@ He recommended long-term insulin in order to provide maximum flexibility in coordinating the employee=s insulin intake with varying levels of prednisone intake.
Following this hospitalization, the employee again consulted Dr. Quaday. According to his last chart note contained in the record, dated September 17, 2002, Dr. Quaday prescribed ongoing respiratory medication but did not re-start prednisone treatment. His chart note reflects that the employee reported Athings have been going a little bit better@ for her, that she was back at work full time, and that her diabetes was better-controlled. He advised the employee to follow up with him on an as-needed basis, and recommended that she continue to treat on a regular basis with her primary treating physician, Dr. Ferry.
On October 14, 2002, the employee consulted Dr. Ferry for her ongoing asthma and diabetes symptoms as well as depression which she related to her need to cope with diabetes. Dr. Ferry=s chart notes indicate that he discussed the chronic nature of diabetes and asthma with the employee, and stressed the importance of continuing treatment. His chart note states that he would try to minimize the employee=s use of steroids as they caused her blood sugar level to elevate which caused her to feel much worse, but that steroids may be required as opposed to nebulizer medication, in spite of the resulting side effects. On November 21, 2002, the employee reported worsening respiratory symptoms and Dr. Ferry again prescribed a regimen of prednisone.
On December 3, 2002, Dr. Quaday issued a report, stating, in part, that
It is my opinion that the exposure to roses on July 11, 2001 exacerbated a pre-existing condition, namely her asthma. It caused significant problems because we had to increase the steroids and she has never really been able to wean completely off. I think that the increase in steroids did lead to increase in weight gain and exacerbation of her Type II diabetes. The weight and the steroids both contribute to the diabetes. She does have some life style issues of the intermittent smoking and was not always completely compliant with continuing the steroids but that was also a problem because of her depression. . . . The problems of the obesity, diabetes and depression are all exacerbated by the steroids. It was very difficult to control her asthma following the exposure to roses on July 11, 2001. Prior to that exposure she had steroids but not of the dosages required following the exposure. I think she did get back to her base line or close to it by December of 2001. However, then had another exacerbation, which was probably secondary to a different exposure. I think she has reach[ed] maxim[um] medical improvement as of the time I saw her in September, she was doing better, and peak flows were in the green zone meaning that she had better control of her asthma. . . . The fact that it takes steroids to keep her well, would give her a permanent partial disability rating of 38% [permanent partial disability of the whole body] . . . based on the last pulmonary function testing that I have from my office records.
The employee also consulted an endocrinologist, Dr. Harold Katz, between May and November 2002. In his report of December 26, 2002, Dr. Katz responded to questions posed by the employee=s attorney, diagnosing the employee as having ADiabetes Mellitus Type II currently being treated with oral anti-diabetic agents and insulin.@ Dr. Katz also stated, in response to a question on whether the employee=s injury on July 11, 2001, has contributed to her diabetic condition, that
I would state that the prednisone that she is requiring for management of her asthmatic condition firmly accelerated the onset of diabetes mellitus type II. . . . In addition, I certainly believe that the prednisone is aggravating her diabetic condition currently, in that it is making it much harder to achieve adequate control of the blood sugar.
Dr. Katz concluded that over time the employee may be able to achieve good blood sugar control with proper insulin dosage. However, he concluded that the employee had not yet reached maximum medical improvement (MMI) from her diabetic and hypertensive condition, and diagnosed the employee as having a 15 percent permanent partial disability as a whole due to her diabetes mellitus Type II.
Dr. Johnson diagnosed the employee as having Arecent onset diabetes mellitus, secondary to her exogenous obesity, as well as her current steroid medication requirement.@ However, when asked whether the employee=s diabetic condition was a consequential condition resulting from her exposure to roses in July 2001, Dr. Johnson testified that the employee=s diabetes was not a direct consequence of her exposure to roses on July 11, 2001. He stated that
It=s not a simple cause and effect. I mean, she does have diabetes mellitus but it=s multifactorial in terms of its genesis, not the least of which is her broad significant problem with exogenous obesity. That is probably the major underlying cause for her diabetes mellitus.
Certainly the use of corticosteroid medications to manage an acute asthma attack may make her diabetes mellitus on a temporary basis more problematic, but I don=t view it as an underlying causative factor that roses exposure caused diabetes. She had an underlying susceptibility inherent maybe because of familial reasons and certainly because of her obesity.
On October 3, 2001, the employee filed a claim petition alleging that she had sustained a work injury on July 11, 2001, in the nature of status asthmaticus and a consequential diabetes disorder, claiming entitlement to temporary partial and temporary total disability benefits and payment of medical expenses. The employer and insurer denied primary liability for the claimed injuries. A hearing was held on January 22, 2003. In his Findings and Order served and filed on February 11, 2003, the compensation judge found that the employee sustained a temporary aggravation of an underlying asthma condition and a temporary aggravation of a diabetic condition as a result of her work injury on July 11, 2001, and that the temporary aggravations lasted until September 12, 2001. The employee appeals.
STANDARD OF REVIEW
On appeal, the Workers' Compensation Court of Appeals must determine whether "the findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted." Minn. Stat. ' 176.421, subd. 1 (1992). Substantial evidence supports the findings if, in the context of the entire record, "they are supported by evidence that a reasonable mind might accept as adequate." Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, findings of fact should not be disturbed, even though the reviewing court might disagree with them, "unless they are clearly erroneous in the sense that they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole.@ Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).
The compensation judge found that the employee=s exposure to roses at work on July 11, 2001, caused a temporary aggravation of her pre-existing asthma condition which lasted only until September 12, 2001. The employee argues that the compensation judge=s finding that the exposure at work caused only a temporary aggravation of her asthma is not supported by substantial evidence. The employee=s arguments are two-fold. She argues that the compensation judge erroneously interpreted Dr. Quaday=s opinion as being supportive of a finding of a temporary aggravation, and that the compensation judge failed to address the permanent nature of the employee=s aggravated asthma condition.
The compensation judge relied on Dr. Quaday=s opinion in determining that the employee=s temporary aggravation had lasted only until September 2001. In his memorandum, the compensation judge concluded that
While Dr. Quaday did not specifically state that the asthma exacerbation from the rose exposure was only temporary in nature, he did state that she got back to her baseline or close to it by December 2001. Nevertheless, the court finds that the temporary aggravation lasted only until September 12, the date that Dr. Quaday felt that she had reached maximum medical improvement from the exacerbation and the date that he released her to work full time. Her spirometry testing was good and her reduced her Prednisone to 5 mg. per day. She did not need to see Dr. Quaday again until December 7, 2001, after another exposure to roses outside of work. (Emphasis added.)
In his report of December 3, 2002, the report to which the compensation judge evidently referred, and which we previously cited, Dr. Quaday stated that AI think she has reach[ed] maxim[um] medical improvement as of the time that I saw her in September. . .@ (emphasis added) but did not specify in his report whether he meant September 2001 or 2002. The employee=s medical records show that the employee saw Dr. Quaday during September of 2001 and September of 2002. Based on our review of the employee=s medical records and Dr. Quaday=s specific references to the pulmonary function testing performed on the employee in September 2001 and September 2002, we conclude that Dr. Quaday=s reference was to September 2002. In his report of December 3, 2002, when rendering his opinion on when the employee reached maximum medical improvement for her asthma condition, Dr. Quaday refers to a time when Aaccording to the guidelines regarding her asthma, she would be class 10 with an FEV1 [forced expiratory volume] less than 70% but greater than or equal to 60% of predicted.@ In September 2001, the employee=s FEV1 was 71% of predicted, while in September 2002 it was 67% of predicted. Based on those results, it is apparent that Dr. Quaday was referring to September 2002 when he wrote that Ashe has reach[ed] maxim[um] medical improvement as of the time that I saw her in September.@
The compensation judge linked the duration of the employee=s temporary aggravation of her asthma condition to the date that he believed Dr. Quaday determined as the date when the employee reached maximum medical improvement---September 12, 2001. Since Dr. Quaday did not find that the employee had reached MMI on September 12, 2001, we conclude that the compensation judge=s determination that the duration of the employee=s work-related aggravation ceased on September 12, 2001, is not substantiated by the evidence of record and is clearly erroneous, and we reverse that finding. We remand for reconsideration of whether the work-related aggravation of the employee=s asthma condition was temporary or permanent, and if temporary, when the aggravation ended.
The compensation judge also found that the steroid medications given to control the employee=s asthma did not cause or accelerate the employee=s diabetes but were an aggravating factor for her diabetes from July 11, 2001, to September 12, 2001. In his memorandum he outlined his basis for that conclusion, stating that
As far as the diabetes, there appears to be little question that the steroid medication that was given for the asthma was an aggravating factor. The court is persuaded that the Prednisone, especially the higher initial doses, made it more difficult to control the employee=s blood sugar. But the fact that the steroid medication made it more difficult to control blood sugar, does not necessarily make it a causative factor for the underlying diabetic condition. The court is simply not persuaded that the steroid medication that was given for the temporary asthma aggravation was a substantial precipitating, accelerating, or aggravating cause of the underlying diabetic condition. It is more than likely that the employee would have developed diabetes eventually, considering her risk factors of obesity and family history. The mere fact that the diabetes was first discovered when she was in the hospital for the temporary asthma aggravation does not compel the conclusion that the steroid medication caused or accelerated the development of the diabetic condition. The timing may have been merely coincidental.
Injuries are compensable if the employment is a substantial contributing factor not only to the cause of the condition but also to the aggravation or acceleration of a pre-existing condition. Wallace v. Hanson Silo Co., 305 Minn. 395, 235 N.W.2d 363, 28 W.C.D. 79 (1975). In Salmon v. Wheelbrator Frye, 409 N.W.2d 495, 497-98, 40 W.C.D. 117, 122 (Minn. 1987), the supreme court held that A[i]t is not necessary . . . for the employee to show that the work-related injury was the sole cause of the disability. It is only necessary to show that the injury was a legal cause, that is, an appreciable or substantial contributing cause.@ (Cites omitted). In addition, an employer is not only liable for disability resulting from a work-related injury, but also for any injury resulting from treatment for the work injury. Smith v. Fenske=s Suburban Sanitation, 266 N.W.2d 892, 30 W.C.D. 411 (Minn. 1978). In Laurent v. Sterling, Inc., slip. op. (W.C.C.A. Mar. 9, 1994), this court stated that A. . .if in the course of reasonable and necessary treatment of an admitted injury, an employee is further disabled as a result of such treatment, he is then entitled to benefits based on the additional disability as well,@ provided the employee proves the causal relationship between the treatment and the additional injury or disability.
The employee was first diagnosed with diabetes while hospitalized in July 2001 after being treated with steroids for her asthma condition. When discharged, she was diagnosed with Ahyperglycemia secondary to steroid administration@ and her later hospital records refer to steroid-induced diabetes or hyperglycemia. Each of the employee=s treating and consulting physicians recognized the aggravating effect of the employee=s prescribed steroids on her diabetic condition and her ability to control the level of her blood sugar. Dr. Katz, endocrinologist, opined that the employee=s use of steroid medication for management of her asthmatic condition firmly accelerated the onset of diabetes mellitus Type II. Dr. Quaday, pulmonary specialist, concluded that the employee=s increased use of steroids, required to treat her asthma, led to her increase in weight gain and exacerbation of her diabetic condition, and that the Aweight and the steroids both contribute to the diabetes.@ Dr. Johnson, pulmonary specialist, termed the employee=s diabetes mellitus as being Amultifactorial in terms of its genesis,@ and referred to the employee=s weight and familial history as the major underlying causes for the diabetes. However, although he did not directly attribute the employee=s diabetic condition to her exposure to roses, Dr. Johnson testified that Athe use of corticosteroid medications to manage an acute asthma attack may make her diabetes mellitus on a temporary basis more problematic.@ No doctor has stated that the employee has reached MMI from her diabetes.
The compensation judge stated that it was Amore than likely@ that the employee would have developed diabetes eventually. However, whether the employee eventually may have developed diabetes is irrelevant to an analysis of whether the employee=s steroid treatment is a substantial contributing factor in the development of her diabetes. The fact that a condition did not become symptomatic until after a work injury may support a finding that a work injury aggravated or accelerated a pre-existing condition. Lundberg v. Bemidji Ambulance Serv., slip op. (W.C.C.A. May 22, 1998); see also Wallace, 305 Minn. 395, 235 N.W.2d 363, 28 W.C.D. 79. In Vanda v. Minn. Mining and Mfg. Co., 300 Minn. 515, 218 N.W.2d 458, 27 W.C.D. 379 (1974), the Minnesota Supreme Court held that:
* * * The longstanding rule, applied by this court in numerous cases, is that when the usual tasks ordinary to an employee=s work substantially aggravate, accelerate, or combine with a pre-existing disease or latent condition to produce a disability, the entire disability is compensable, no apportionment being made on the basis of relative causal contribution of the pre-existing condition and the work activities.
The record clearly indicates that steroid medication provided during the employee=s hospitalization in July 2001 made her blood sugar difficult to control, that is, that the steroids prescribed for treatment of the employee=s asthma triggered or Aprecipitated@ her diabetes or accelerated its development. That factor by itself establishes a causal relationship between the employee=s asthma and the development of her diabetes, regardless of whether the employee=s continued need for steroids is work-related or not. The compensation judge=s conclusion that Athe timing may have been merely coincidental,@ and his related findings, are not supported by substantial evidence in the record and misstate the law. In other words, that the employee=s aggravation of her asthma is temporary in nature does not negate the causal connection between the employee=s asthma and her ongoing diabetic condition.
There is no evidence in the record that the employee had been diagnosed with diabetes or treated for any diabetic condition before her hospitalization for the July 11, 2001, work exposure. The medical records indicate that the employee gained weight from use of steroids, and all the doctors refer to weight as contributing to the development of diabetes. In addition, all the doctors concluded that the steroid medications, taken to treat the employee=s asthma, aggravated her diabetes. For those reasons, we reverse the compensation judge=s findings that the steroid medication did not accelerate the employee=s diabetes and that there was only a temporary aggravation of the employee=s diabetes. The employer and insurer therefore remain liable for treatment of the employee=s diabetic condition.
Concurring in part and dissenting in part
WILLIAM R. PEDERSON, Judge
I concur in the majority=s reversal of the compensation judge=s finding on the duration of the employee=s work-related aggravation of her asthma condition. Dr. Quaday=s opinions, relied upon by the judge, do not support the conclusion that the aggravation ended on September 12, 2001, or that the aggravation was necessarily temporary.
I would, however, affirm the judge=s determination that the steroid medication necessary to treat the employee=s asthma condition temporarily aggravated an underlying diabetes condition. Because the judge identified the temporary period of both aggravations as ending by September 12, 2001, I would remand to the judge the issue of the duration of the employee=s diabetes aggravation.
It is clear from his memorandum that the judge carefully considered the issue of whether the steroid medication necessary to treat the employee=s asthma was a substantial precipitating, accelerating, or aggravating cause of the employee=s diabetic condition. I acknowledge that there is substantial evidence in the record that would have supported such a determination, had that been the conclusion of the judge. But there is also substantial evidence in the record to support the decision of the compensation judge, that the employee=s steroid treatment made her diabetes condition more problematic only on a temporary basis, reliant as that decision is on the expert medical opinion of Dr. Paul Johnson. I agree with the compensation judge that A[t]he mere fact that the diabetes was first discovered when [the employee] was in the hospital for [her] . . . asthma aggravation does not compel the conclusion that the steroid medication caused or accelerated the development of the diabetic condition. The timing may have been merely coincidental.@ Concluding that the judge=s finding of a temporary aggravation is adequately supported by Dr. Johnson=s testimony and report, I would affirm. Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985); Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 37 W.C.D. 235 (Minn. 1984).
Status asthmaticus is defined as Aa particularly severe episode of asthma that does not respond adequately to ordinary therapeutic measures and may require hospitalization.@ Dorland=s Illustrated Medical Dictionary, 29th Ed., 2000, p. 1696.
The employee testified, and her medical records note, that her paternal grandmother had been diagnosed with diabetes.
Spirometry is defined as Athe measurement of the breathing capacity of the lungs, such as in pulmonary function tests.@ Dorland=s Illustrated Medical Dictionary, 29th Ed., 2000, p. 1680..