Patient Case: C.R.

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 health problems associated with occupational chromium and asbestos exposure. 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.

C.R. Patient History

C.R. is a sixty two year old man who presents to your office with a two day history of hemoptysis. He denies chest pain. The cough began about five days ago with a runny nose. Three days ago he began to have a sensation of being feverish, and the cough became productive of greenish sputum. Yesterday, the sputum became blood streaked and frankly bloody last night. On examination there are no rales, no ronchi, no wheezing. Nasal mucosa appears normal but there is a small perforation of the nasal septum.

The chest x-ray shows a patchy infiltrate in the right middle lobe and a fullness in the right hilum.

C.R. Patient script

You are a 62 year old man with a bad cold with a nagging cough for the past five days. When it began you had a runny nose for the first day, but this as since cleared up. On the third day you began coughing up some greenish sputum. Yesterday this became blood streaked and by last night there seemed to be mostly blood in what you were bringing up. You have never had anything like this before. You have had no chest pain. Your weight has been stable. You had hypertension diagnosed fifteen years ago and have been on medications with reasonably good control ever since.

You live at home with your wife, who is in fair health and has had hypertension and diabetes and some problems with ulcers on her legs. You smoked one pack of cigarettes per day from age twenty to age forty, but have not smoked since. You drink two beers a day on average, but rarely drink other alcoholic beverages.

Home: You live in a detached house in a residential neighborhood in Baltimore County. You have aluminum siding on the house, and have not repainted inside for about ten years. The house is heated by an oil furnace and hot water baseboard heaters. If you are specifically asked: There is some insulation on the pipes in the basement and on the furnace that as been there since you bought the house thirty years ago.

Community: There are no industrial plants near your home. The nearest commercial area is about one mile away. There is a landfill about five blocks away, which was closed about six years ago, in part because of community complaints about odors, you believe.

Work: You work for the Baltimore County school system as a maintenance supervisor. Your responsibilities are principally for carpentry, electrical, painting, and minor plumbing at two elementary schools. You rarely have to work in the boiler rooms, because there is a stationary engineer and an assistant who take responsibility for the heating plant. You work from 7:30 am to 4:00 pm and only occasionally have to do overtime.

If asked, you can admit that you have worked for the county only ten years, since the plant where you were working before was closed.( see below)

Last summer you spent two weeks at a school in the Eastern part of the county which had been closed for removal of asbestos. Along with other county employees you moved furniture out of the way of crews from an asbestos removal company who then sealed off large areas of the school. They subsequently removed asbestos that had been sprayed on the steel beams above the dropped ceiling at the time of the school's construction. After they were finished with the entire school and air measurements were done by the county's asbestos coordinator, you and the county employees spent two weeks doing cosmetic repairs, painting, and furniture moving.

If asked about protection, or about your opinion of this as a risk you can report the following. At the time, some younger employees complained that they should have had respiratory protection during the initial furniture moving phase, but you think this was unnecessary because exposures then were probably trivial. You discussed this with the asbestos coordinator who concurred that exposures were measurable, but just barely, in only a few parts of the school. Moreover you recall jobs removing asbestos without any protection when you were working in industry prior to taking the job with the county ten years ago.

This illness is the first time in five years you have had to call in sick, and you are eager to get back to work.

Prior jobs: ** (if no one asks about prior jobs point this out at the end of the role play) After high school you started working at the United Chemical company in Hawkins point. At this plant you held a variety of jobs, starting out as a laborer, then as an operator in the "liquor" department, and finally as a maintenance worker and supervisor. You had completed thirty years there at the time the plant finally closed completely and you were laid off. The plant manufactured chromate pigments and some other chromium based chemicals. The process involved roasting chromite ore in a huge rotating kiln and then extracting the chromate with strong acid to make a "liquor" that was further reacted to produce dry compounds. Express some ignorance of the chemical steps involved, saying that you always found it confusing. Much of the "dry" part of the plant was quite dusty when you started there, and the bright yellow and red dust got into everything, staining the buildings, clothing etc. Spills in the "wet" part of the plant also dried to create dust if not cleaned up promptly.

The fumes from hot processes and the dust were very irritating and you developed the small perforation you have in your nasal septum after three years on the job.

In recent years the company took great pains to reduce dust and fume exposure, requiring respirator use, using dedicated "house keeping" crews, and trying to keep the chemicals in less dusty forms. Fifteen years ago the company opened a new plant in South Carolina with newer equipment and began phasing out operations at the plant here. Some of the younger workers took jobs there and moved their families, but others like you stayed in the area when the plant here closed and sought new jobs.

While you were still a laborer you worked cleaning up after the pipe fitters whenever they repaired and recovered pipe. You had what may have been several months of intense exposure to asbestos dust during the first five years you worked at the plant. You didn't know it was harmful, and took no precautions. During the late 1970's the plant instituted strict asbestos handling rules to minimize exposure. By this time you were no longer involved directly.

You stay in touch with some of your former co-workers through a United retirees club which meets monthly at the Steelworkers Hall in Dundalk. The meeting keeps the aging member up to date on who has died, raises money for a scholarship fund (now mostly for grandchildren) and has a drawing for a modest door prize each time. You are bothered by how many of your contemporaries are dying of lung cancer and other cancers, and you are glad you quit smoking when you did.

MOSH script for United Chemical

You are vaguely familiar with the history of the plant which is now closed for ten years. You think that there was a lot of MOSH activity at the plant related to chromates and concern about their carcinogenic potential. The files are all in storage and it will take a while to retrieve.

MDE script for United Chemical

You have no records of investigations or reports at this plant. You may discuss the carcinogenic potential of chromates and point the students to better sources.

MDE script for Baltimore county Schools asbestos removal

You have worked with the school system providing advice in the past. The asbestos coordinator has been knowledgeable and responsible as far as you know. You were aware of the asbestos removal projects at the elementary schools in the eastern part of the county. These were not in response to any real problems, although there were some slightly high readings in one of the schools after some maintenance work which disturbed the dropped ceilings. As far as you know the removals are part of a strategic plan to eventually do removal at all the schools. The worst situations were all dealt with a few years ago. You may want to discuss the case the students are discussing with you, particularly if they haven't thought about issues of latency. Point out that an exposure to asbestos last year is unlikely to be the cause of a lung cancer this year.

Thomas Jones, President United Chemical retirees club

You worked with C.R. for thirty years at United Chemical. you recall the plant as always dusty, hot, and unpleasant. You are, however, proud of how you and your co-workers put up with difficult conditions, and the good living you made for yourselves and your families.

You are the president of a United retirees club which meets monthly at the Steelworkers Hall in Dundalk. The meeting keeps the aging member up to date on who has died, raises money for a scholarship fund (now mostly for grandchildren) and has a drawing for a modest door prize each time. You are bothered by how many of your contemporaries are dying of lung cancer and other cancers, and you are glad you quit smoking when you did.

You have been keeping tabs on the causes of death as best you can from obituaries and discussions with the bereaved families. You think that lung cancer is far and away the most common cause of death after heart attack. You discussed this with your own physician, who pointed out that lung cancer is the most common fatal cancer in men, and that many of your co-workers were probably smokers. You recall that many men seemed to die of this cancer at a young age, even while you were still working.

You have heard through a friend, that C.R. had been seeing a doctor. You know you can't ask about confidential medical information from a doctor, but you heard that the problem was a "spot" on his lung. You wonder how C.R. and his wife will be able to manage if he can't work. Is he going to be able to get some kind of disability?? You heard that his wife has some sort of problems with her health as well. You think she hasn't worked outside the home in years.

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

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