Patient Case: C.Y.

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 exposure to grain dust . 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.

Patient case C.Y.

C.Y. is a 38 year old man who presents with dyspnea. Over the past two months he has noted worsening dyspnea on exertion. He has had cough associated with the dyspnea which is non-productive. He finds that he can no longer run in the morning when he walks his dog around the neighborhood. He helped a friend move from one apartment to another last weekend and found that he got winded much sooner than his friend did. He has never had similar symptoms. He smoked for about five years from age 16 to age 22 but has not smoked since. He denies any childhood history of asthma or allergy. Two years ago he was off work for two months with low back pain which was treated conservatively.

Patient script C.Y.

You are a 38 year old man who has been having shortness of breath for the last couple of months. You never feel bad except when you exert yourself, then you get winded much quicker than usual. You sometimes get a hacking cough when you are already winded and then you have to stop for a few minutes to catch your breath. This has happened a couple of times when you try to run with your dog after walking her around the block in the mornings. You helped a friend move from one apartment to another last weekend and found that you got winded much sooner than your friend did. You have never had similar symptoms.

You smoked for about five years from age 16 to twenty two but have not smoked since. You do not drink alcohol, even when you tend bar. You deny any childhood history of asthma or allergy. Two years ago you were off work for two months with low back pain which was treated with rest and then physical therapy.

Home: You live with your wife and a three year old daughter in a relatively new garden apartment in the city. You have undertaken no new renovations around the apartment. The dog is six years old and you don't think you have any increased symptoms when you are around her or brush her.

Community: There are no sources of pollution in the neighborhood that you are aware of.

Work: You work as a longshoreman and have done so on and off for fifteen years. You were laid off for an extended period of time after your back problem, which happened during a car trip on a vacation to relatives in Michigan. When you have been laid off from your primary job on the docks you work as a cab driver and tend bar. You sometimes tend bar on the weekends for your cousin.

During the first decade of your career with the longshoreman's union you primarily helped load and unload containers at the Dundalk Marine Terminal. After your back problem kept you away from work for so many days, you lost your spot on your gang. You now have a spot on a gang working regularly at the Consolidated Grain loading piers in South Baltimore. You started there about a year and a half ago. It has been much busier this year. You started out doing a wide variety of tasks around the grain elevators, hauling hoses, cleaning up spills, setting rat traps, doing repairs etc. This year you have been spending more time on deck and in the holds of the ships guiding the hoses that carry wheat into the ship's holds. You sometimes have to walk around on top of the grain to guarantee that the hold is evenly loaded. You use a safety line whenever you do this and have a buddy watching you. The loading is quite dusty and you always wear a respirator when you do it. The respirator has a dust filter and was fitted to your face by the safety supervisor. It is off only after the flow of grain stops and you take a breather on deck.

You are pleased that your back has rarely given you any problems, despite the strenuous nature of pulling the large diameter hose around. You have been more short of breath when climbing ladders and stairs over the last few months.

If asked, you are not aware of co-workers with respiratory problems. You have not been told of any hazard associated with the grain, but you have regular safety meetings about fall hazards, electrical safety, and procedures on shipboard and around rail cars.

MOSH script for Consolidated Grain elevators:

You are not aware of any prior complaints. You can discuss procedures and jurisdictional issues (if any) with the students. You may also provide advice and guidance on researching the patient's problem.

MDE script for Consolidated Grain

You have no prior occupational disease reports for this company. You are aware of reports of respiratory problems from grain dust. You can alert the students they might look into this and suggest getting some articles from the library. You remember reading case reports about grain dust problems in Canada. You recall that in many cases individuals with this sort of a problem will need to change jobs, and may ask the students what will happen to a young person who needs to change careers. You can provide any other general advice to the students you wish.

Arthur Semolina, Safety Manager at Consolidated Grain

You are not aware of any one who has developed pulmonary complaints as a result of their work at the grain piers. The work of loading is extremely dusty and all workers are required to use respirators. You have had two or three co-workers in the past who have had to move to less dusty work after they developed "emphysema". These were older men who had been cigarette smokers.

On reflection, you wonder if the person the doctor is concerned about is also getting emphysema or some sort of lung problem. Being able to move to a less dusty assignment might depend on an employee's seniority, so you can't guarantee that such an arrangement can be made.

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.