Patient Case: H.N.

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 general and reproductive health problems associated with occupational solvent 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.

H.N. Patient History

H.N. is a 33 year old woman who presents to your office because of complaints of discomfort in her hands.

Over the past month the patient has had frequent paresthesias in her hands which sometimes persist for 5-10 minutes. She complains that they "feel like they are falling asleep," but the symptom is largely confined to the tips of the fingers. At times it bothers her more than others and she notes that she has been having some difficulty with tasks around the house. She recalls losing her grip on dishes that she has been drying She has also been feeling tired and rundown a lot of the time recently and, occasionally, feels dizzy and lightheaded during the day.

This week she has been having problems with vomiting. She has had 5-6 different episodes. At other times she finds herself ravenously hungry. She has not had any abdominal pain. Her bowel movements have been normal.

Physical Examination: Unremarkable. Strength and sensation in her upper and lower extremities seems grossly intact on examination.

Script for Patient H.N.

You are a 33 year old young woman. Other items of history which you can provide if asked include: Your last menstrual period was seven weeks ago. Usually your periods are regular. You have also noted some tenderness of your breasts. You have never previously been pregnant. You live alone in an apartment in Catonsville. You have a regular boyfriend for the past six months. You have been using condoms for contraception.

If asked, you may also admit that you are concerned that you might be pregnant, your periods have generally been quite regular and this is the longest you have been late since you were a teenager.

Home Environment: Your apartment is heated by an electric heat pump. You are on city water and sewerage. You have one cat and there have been no recent repairs in the house. You have not recently changed any cleaning products. You have not done any unusual cleaning or renovation work around the house recently.

Environment: The garden apartment complex is in a wooded area. You are not aware of any environmental problems in the general area.

Occupational History: You have been working for the past year at a company which prints T-shirts by a screen printing process. Your job as a screen printer involves setting the screens (which hold the printing pattern) in place and inking them with a squeegee roller. You rotate the printing heads to print with different colors. At present, you are using a machine that can use up to eight different colors and screens; most jobs involve 3-4 colors.

Between jobs, you remove the screens and clean them in a room adjacent to the general work area. In this room there is a small ventilating fan mounted on an outer wall. The screens are cleaned in a sink which is attached to a drum of a solvent known as "varsol." You use a sprayer to spray solvent onto the screens. The sink drains back into another drum. The fresh solvent is brought and taken away by a company called Safety-Clean.

In addition to a number of different inks and the screen cleaning solvent, you also use a spray on the pallet where you place the shirts to be printed. This helps "tack" the shirts down to the pallet so they are not lifted off when the printing press lifts off after contact. It is a mildly sticky substance which has to be renewed after every dozen shirts or so and is provided in a spray can.

In addition, you use a "blasting" solution to remove spots both from shirts which are smudged and from you own clothing, if ink gets on them. For cleaning ink from your press, you use a small squeeze bottle of the safety clean "varsol. "

You have been concerned that some of the problems you are having may be related to the chemicals that you are using at work. You work in a large room where four other presses are in operation. There are a total of about a dozen employees. On very busy days the room seems to fill with fumes and vapor and several of your co-workers have complained of lightheadedness at these times. One other co-worker has been complaining of a numbness or a tingling feeling in her hands, but has not yet seen a doctor.

You recently had a training session on working safely with chemicals. You are confused about much of what was said. The training was provided by an outside person who you had not previously met and who stuck around for only 10 minutes after showing you a video. The consultant left a folder with material safety data sheets on the chemicals that are used and you could go and get them and copy them, you think. You want to do this later in the afternoon when the boss has gone home because you are a little worried about appearing too inquisitive.

Employer at the Happy Shirt Printing Company

Inquiries really need to be dealt with by Mr. Jones, the manager, but unfortunately he is not in. You will be happy to take a number and get back to anyone making inquiries.

Don't cooperate easily, wait until the students are insistent. THEN:

If asked about MSDSs for the chemicals, or pressed for further information, or reminded that under hazard communication you need to give MSDSs in response to requests, you can provide the Material Safety Data Sheets for "spotting fluid" which the workers call "blasting" fluid and for the "tacking fluid".

MOSH Script on the Happy Shirt Printing Company

You have no records on any previous inspections of this workplace. You can explain options the physician and worker may have if they want MOSH's help. Emphasize issues of hazard communication, tell them that if the employer must provide the employee or an inquiring physician with MSDSs. Indicate an immediate willingness to intervene if there is a failure to comply with right to know in a medical situation like this. Send the students to (or back to) the employer to be insistent.

MDE Script on the Happy Shirt Printing Company

You are not aware of anything about this company. Suggest looking up information on solvents, since these are often problems at screen printing operations. Emphasize issues of hazard communication, tell them that if the employer must provide the employee or an inquiring physician with MSDSs. Indicate an immediate willingness to intervene if there is a failure to comply with right to know in a medical situation like this. Send the students to (or back to) the employer to be insistent. Offer to help them contact MOSH if needs be.

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.