Patient Case: J.L.

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 exposures to hard metals. 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.

J.L. Patient History

J.L. is an 18 year old woman who presents to the emergency room with severe dyspnea. She has been extremely short of breath for the past six hours and is audibly wheezing. After initiation of therapy with bronchodilators. she is able to provide a more complete history.

She was in generally good health until about eight weeks ago when she noted a non-productive cough which was severe and interfered with sleep. She was seen by her family physician who prescribed antibiotics and bed rest. She was better in about 24 hours, but about two weeks ago began to have a non-productive cough again. This time she found herself becoming short of breath with the cough and a week ago went to see her doctor again. He prescribed amoxicilin and an expectorant and she spent a day and a half in bed before recovering, but has felt generally well for the last three days.

This morning she awoke feeling well, but began to cough again in mid morning and has been getting more and more dyspneic since that time. Her cough is productive of only scant phlegm and she denies fever or chills. She does not recall a fever with either of the two previous episodes.

Script for Patient J.L.

You are a non-smoker. You do not drink alcohol or coffee. You have never used illicit drugs.

Home Environment: You live in a row house in Highlandtown with your mother and father, two younger brothers and an older sister. Your mother is not employed outside the home. Your father works as a truck driver for a freight hauling company. Your older sister works at K-Mart as a cashier; your brothers are in school. There are no pets, no recent repairs or painting in the house, no new household chemicals or cleaners.

Community: Your neighborhood is surrounded by industrial plants on all sides. In the summertime there is occasional problems with odors from some of these facilities. Five blocks from your house is the Lombard Street landfill where there have been problems with gas explosions and fires. There is a relatively busy street two blocks from your house which carries traffic from the port. There are no industrial operations within three blocks on any side of your house.

You have city water and sewerage. Heat is an oil fired burner with forced air which was checked before use last season. It is not currently in use as it is May.

Occupational History: You began working about 10 weeks ago at a tool supply and manufacturing company. Your previous jobs were in restaurants in the neighborhood where you worked as a helper in the kitchen.

On this new job you grind drilling bits which are made of "hard metal" or "carbide." You do not know what the exact composition of the metal is, but it is hard enough to be used to drill steel and other metals.

Your employer sells drilling bits and parts for drills, but also recycles drilling bits which have become dulled by use. This job involves taking drilling bits which have been sorted by size and grinding them with a Carborundum grinding wheels. You work at a bench which is equipped with an exhaust hood. Using a magnifying glass, you grind off burrs in order to restore the sharpness of the drilling bits. After the drilling bits are ground, they are cleaned with a solvent and repackaged.

The work is occasionally dusty and, in particular, when grinding the larger drilling bits, a significant amount of dust is created which is not captured by the ventilating system. Your co-workers occasionally use disposable dust respirators, but you have not used these.

You had been doing the grinding task at the time of your first illness. Subsequently, you were assigned to a job cleaning and sorting incoming drilling bits. This involved dipping the bits in a solvent bath and sorting them by size. You occasionally felt a little lightheaded around the solvent bath, but had no problems with shortness of breath or cough while doing this. You returned to the grinding job about two days prior to your second episode of illness. After that illness you were off work for several days and then had a long weekend. This morning you returned to work for the first time in over a week. After you had been grinding for a matter of an hour, you began to cough rather severely and had to leave work early around noontime. You continued to cough and wheeze since that time until you became so short of breath that your family made you come to the emergency room.

You are not aware of other co-workers who have had problems on this job, but feel that you do not know many of your co-workers well.

Employer for the T.C.B. Supply Company

You are the employer of J.L. Your company grinds drilling bits which are made of "hard metal," a tungsten carbide alloy with a significant amount of cobalt. Your company has installed ventilation on all of the grinding booths to reduce dust exposures and respirators are made available to individuals who request them. You are willing to admit that the dust captured by the local ventilation is not 100% and that there is occasionally dust which settles on the work table. Employees should be cleaning this up with a vacuum, but frequently fail to do so.

No smoking, eating or drinking is permitted in the area where the drilling bits are being ground. You are not aware of anyone who has become ill in your work place previously. You do not have material safety data sheets available for the solvents or the drilling bits.

Script for MOSH re. T.C.B. Supply Company

You have never inspected the T.C.B. Supply Company. You are aware of the hazards of "hard metal" and that exposure to grinding tungsten carbide tools parts can cause both occupational asthma and a chronic pneumoconiosis. You have not received any previous complaints about this work place.

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.