Patient Case: R.P.

University of Maryland - School of Medicine
Baltimore, Maryland

Instructor(s): Keogh, James P.; Gordon, Janie
Subject area: Health / Medicine
Department: Occupational and Environmental Medicine
Level: Undergraduate Medical
Learning objective: Develop Group Skills, Develop Individual Skills, Provide Information
Teaching style: Group Activity, In-class Activity

Please note that the copyright for this course project is retained by the instructor.

This case is presented to medical students at the University of Maryland School of Medicine. Developed by the University of Maryland's Occupational Health Project, this case focuses on adult lead poisoning associated with occupational exposures in foundry work. It teaches students to:
- Describe how exposures at home, in the community and at work influence health.
- Derive the elements of an occupational and environmental history.
- Develop an approach to assessing the work relatedness of an illness.
- Identify chemical exposures and find existing toxicological information.
- Learn how to gather more information from employers, co workers, and unions.
- Learn the capabilities and limitations of existing public health and regulatory agencies.
- Practice problem solving skills needed in caring for patients with environmental illnesses.

This case is also included in the video The Doctor Never Asked Me. This 15 minute video produced at the University of Maryland School of Medicine documents the cases of five patients with occupational illnesses or injuries.

R.P. Patient History

R.P. is a 32 year old man who presents complaining of abdominal pain and leg and back pain which has been getting worse over the past six months. He has seen you on two previous occasions. The first time for leg pain which was worse at night and was not clearly related to exertion and had not been associated with trauma. X-rays of the hip and knee were normal. You began the patient on anti-inflammatory medicines with some relief. Two months later he had seen you for abdominal pain. An extensive work-up, including tests for fecal occult blood, barium enema and upper GI were all unrevealing. You prescribed an anti-spasmodic and the patient reported some relief at his most recent visit a month ago.

At today's visit he has a new concern; he notes a decrease in libido. He has not told you about this previously, but it dates back about two months. He was prompted to make the appointment after an argument with his girlfriend about his loss of interest in sex. He is able to have erections on occasion, but he complains of a general loss of interest and a decrease in his "sex drive."

Review of Systems: He complains that he is still having aches and pains in his arms and legs as well as occasional abdominal pain. He is having constipation. He discontinued the anti-spasmodic because of this, but the constipation persists.

Script for Patient R.P.

Occupational and Environmental History: You are 32 years old and live at home with your mother and one brother. You have never been married. You have had a five year relationship with your present girlfriend. This is the first time you have had serious problems in this relationship.

You smoke one pack per day of cigarettes since age 15. You recently have been considering quitting. You used to drink beer on the weekends, but stopped this entirely when the abdominal pain started.

Home Environment: You live in a detached house in northwest Baltimore. You and your brother repainted the house with latex paint about two years ago. There have been no major repairs since then. The outside of the house has aluminum siding. You are on city water and sewerage. You are not aware of any environmental problems in the neighborhood.

Occupational History: You are working at a foundry called ABC Iron for the past four years. The first year you worked as a "charge man. " This involved loading scrap metal including pipes and radiators and broken up parts of bathtubs into a charging furnace which melted them down. Molten metal was subsequently poured into a mold to make iron parts for railroad equipment. Principally, the plant makes iron brake shoes for freight cars and freight locomotives.

After the first year as the charging furnace, you moved to a job where you were shoveling sand into a machine which made molds. You were not involved with any other chemicals in that area. For the past 4-5 months you have worked in the "melting department" where you help tip a ladle which pours molten iron into the various molds.

Occasionally while working in this area you have to "skim" the top of the ladle removing contaminants that float on the surface of the molten iron. These are dropped on the floor and, subsequently, you shovel and broom these up into 55 gallon drums which are removed to a yard and subsequently disposed of.

For the past year the company has been providing coveralls which are laundered by the company at work. You have not had any medical surveillance testing at the plant. Respirator use is not required on your job, but respirators are available for workers in the dustier operations of shaking out.

Script for Mr. Jones. Safety Manager for ABC Co. On Patient R.P.

Your company manufacturers iron parts for railroad equipment. The principal product at this plant is brake shoes for railroad engines and freight cars.

Molds are made of sand and a thermo-setting resin. These molds are made by an automated mold-making machine. The iron is prepared by melting scrap iron from various sources in a cupola furnace. Coke, pig iron and limestone are also added at times. Molten iron is tapped out of the bottom of the cupola into ladles and then transferred from ladles into the molds.

After the cupola has been drained of molten metal, slag, which has floated to the top, is drained off and disposed of. Last year, during an OSHA inspection, air sampling was taken during this process which revealed rather high levels of lead in the air. Since that time you have been providing protective clothing and respirators for workers involved in tapping out the furnace and in handling the slag. Occasionally, there is some slag on the top of the ladles full of molten iron. This is skimmed off with a long handled rake-like tool.

After the molten metal has hardened, parts are knocked out of the molds and excess sand is shaken off of them. This is an operation which produces a good deal of dust and noise and has been the major area of your concern for safety. Respirators are used during dusty operations involved in knock-out and shake-out where there is some exposure to silica.

Script for MOSH on ABC Iron

Last year there was a routine inspection which brought attention to fumes from the furnace area of the plant. Subsequent air sampling was taken during this process which revealed rather high levels of lead in the air (160 mcg/cubic meter) adjacent to the furnace. Samples in other areas of the plant were below the action level of 30 mcg/cubic meter. MOSH required that protective clothing and respirators be provided to workers involved in tapping out the furnace. The company was given a longer period of time to come up with plans for engineering controls to reduce levels of lead in air. Because air levels for other jobs were below the action level the company resisted providing similar protection for other workers in the plant, despite MOSH advice to do so. The need to keep work surfaces clear of dust and to avoid dry sweeping was emphasized as well. A follow-up inspection has not yet taken place.

Script for MDE on ABC Iron

You have had no previous knowledge of this employer. Please advise the students on how they might pursue the work up of the patient.

This document was last modified on 06/14/2000 03:07:57 PM

This resource was acquired by CEEM (Consortium for Environmental Education in Medicine), a program of Second Nature, under the auspices of a NIEHS grant to gather and disseminate environmental health educational resources over the internet in order to help medical and allied health sciences faculty identify, locate and use resources for incorporating environment and health perspectives into their curricula. CEEM has authorized the use of these materials on this website for archival purposes. Please note that the copyright for this material is retained by the instructor and/or contributing institution.