James Fishel is a 56-year-old maintenance worker who has worked for the same company for 32 years, spending most of his time installing and removing insulation from buildings. He saw his physician with complaints of becoming increasingly short of breath over the past year, particularly when he is exerting himself. He notes that "just getting enough air in" is exhausting. A chest X-ray revealed a "shaggy" (i.e. blurred) heart border and a hazy appearance of the lungs. Pulmonary function testing.