Domain – Occupational and environmental medicine (case)

Mercy is a 32-year-old factory worker who presents with a chronic eruption on both hands and daily rhinosinusitis. She has worked for three years for a food manufacturing company mixing ingredients, including soy protein concentrates with flour, sugar and salt.

The process results in aerosolisation/dust particles in the air. She is provided with a hairnet, but no other protective equipment. Within 30 minutes of this activity her eyes become pruritic and watery, and she gets itchy papules on the dorsum of the hands and neck. Her medical history includes seasonal asthma and allergic rhinitis in the spring that is usually managed with salbutamol. Last year, following a thunderstorm asthma public health warning, Mercy had an asthma attack and presented to the emergency department where she received treatment overnight, before being discharged home the next morning.

Communication and consultation skills

What aspects of the history are important to ask about?

• Detailed description of symptoms (onset, duration, frequency, and severity).
• Occupational history (specific job duties, duration of exposure, use of protective equipment).
• Timing of symptoms in relation to work and non-work periods.
• History of atopic diseases (asthma, eczema, allergic rhinitis).
• Previous treatments and their effectiveness.
• Environmental factors at work (ventilation, use of air filtration).
• Impact of symptoms on daily activities and quality of life.
• Any recent changes in work environment or procedures.
• History of similar symptoms in coworkers.

Clinical information gathering and interpretation

What further information would you like to know about the relationship between Mercy’s symptoms and her work?What would you look for when examining Mercy’s skin? Which areas of skin are of particular interest? What other examination is important? Think of the respiratory tract and other mucocutaneous surfaces, such as the eyes and nose.

To better understand the relationship between Mercy’s symptoms and her work, the following additional information would be useful:

1. Detailed Occupational History:
   • Specific Tasks: More details about her specific tasks and the duration of each task.
   • Exposure: Information on the frequency and duration of her exposure to the allergenic substances.
   • Protective Measures: Details about any other protective measures in place, besides the hairnet.
2. Symptom Pattern:
   • Timing: The onset of symptoms in relation to her work schedule (e.g., do symptoms improve on weekends or holidays?).
   • Triggers: Identification of any specific triggers at the workplace, such as certain ingredients or specific processes that exacerbate her symptoms.
3. Workplace Environment:
   • Ventilation: Information about the ventilation system and any dust control measures in place.
   • Cleaning Practices: Details about the frequency and methods of cleaning the workplace to reduce allergen buildup.
4. Previous Episodes:
   • Past Incidents: Any previous episodes of similar symptoms and their management.
   • Co-Workers: Whether any co-workers have experienced similar symptoms.

Examination of Mercy’s Skin

When examining Mercy’s skin, the following aspects and areas should be given particular attention:

1. Visual Inspection:
   • Erythema: Look for areas of redness or inflammation.
   • Papules and Vesicles: Check for the presence of itchy papules or vesicles on the dorsum of the hands, neck, and other exposed areas.
   • Dryness and Scaling: Examine for signs of dryness, scaling, or lichenification, which could indicate chronic dermatitis.
2. Areas of Particular Interest:
   • Hands and Forearms: These are primary areas of exposure, especially the dorsum of the hands.
   • Neck: Another area mentioned with symptoms.
   • Face and Eyelids: Given her complaint of pruritic and watery eyes, examining the periorbital region is crucial.
   • Other Exposed Areas: Any other skin areas that might be exposed during her work activities.

Additional Examination

1. Respiratory Tract Examination:
   • Lungs: Auscultate for wheezes, which might indicate reactive airway disease or asthma.
   • Nasal Mucosa: Inspect the nasal mucosa for signs of allergic rhinitis, such as pale, boggy mucosa or nasal polyps.
   • Sinuses: Palpate the sinuses for tenderness, which could indicate sinusitis.
2. Ocular Examination:
   • Conjunctiva: Check for redness, swelling, or discharge, which are signs of allergic conjunctivitis.
   • Lids and Periorbital Area: Look for signs of dermatitis or edema.
3. Other Mucocutaneous Surfaces:
   • Oral Mucosa: Inspect for signs of angioedema or other allergic reactions.
   • Ears: Check the external auditory canal for signs of dermatitis or other allergic reactions.

Making a diagnosis, decision making and reasoning

What diagnoses are you considering? Are there allergy tests that can be done in the general practice setting? What additional investigations would you order? What additional diagnoses would you consider if Mercy worked as a hairdresser? Or a stone mason?

Potential Diagnoses

1. Occupational Allergic Contact Dermatitis:
   • Likely due to repeated exposure to allergens such as soy protein concentrates or other food ingredients.
2. Occupational Asthma:
   • Triggered by inhalation of aerosolized particles, given her history of asthma and the exacerbation of symptoms in the workplace.
3. Allergic Rhinitis and Conjunctivitis:
   • Due to exposure to airborne allergens at work.

Allergy Tests in General Practice

In the general practice setting, the following allergy tests can be performed:

1. Skin Prick Testing:
   • Useful for identifying immediate hypersensitivity reactions to specific allergens.
2. Patch Testing:
   • Helps diagnose contact dermatitis by identifying allergens that cause delayed hypersensitivity reactions.
3. Specific IgE Blood Tests (RAST or ImmunoCAP):
   • Measures specific IgE antibodies to various allergens, useful when skin tests are contraindicated or impractical.

Additional Investigations

1. Spirometry:
   • To assess lung function and confirm the diagnosis of occupational asthma.
2. Peak Expiratory Flow (PEF) Monitoring:
   • Conducted over several weeks to identify any patterns related to workplace exposure.
3. Nasal Endoscopy:
   • To evaluate the nasal passages and sinuses for signs of chronic rhinosinusitis.
4. Complete Blood Count (CBC):
   • To check for eosinophilia, which can be associated with allergic conditions.
5. Workplace Environmental Assessment:
   • Referral to an occupational health specialist to evaluate the workplace environment and exposure levels.

Additional Diagnoses in Other Occupations

1. Hairdresser:
   • Allergic Contact Dermatitis:Due to exposure to hair dyes, shampoos, and other hair care products.
   • Irritant Contact Dermatitis:From frequent hand washing and exposure to various hairdressing chemicals.
   • Occupational Asthma: Triggered by inhaling hair spray or other aerosolized products.
2. Stone Mason:
   • Silicosis:Due to inhalation of silica dust from cutting or grinding stone.
   • Occupational Asthma:Triggered by inhaling stone dust or other particulates.
   • Contact Dermatitis:From exposure to cement or other materials used in masonry.

Clinical management and therapeutic reasoning

If Mercy’s initial RAST testing is positive for soybean, how would you manage her symptoms? What general measures could Mercy adopt in the workplace that may help alleviate her symptoms?How might your management be different if her condition related to a psychological condition or bullying at work?

If Mercy’s initial RAST testing is positive for soybean, how would you manage her symptoms?

• Avoidance of soybean exposure at work.
• Use of personal protective equipment (gloves, masks, protective clothing).
• Medications: Antihistamines, topical corticosteroids for skin, inhaled corticosteroids, and bronchodilators for asthma.
• Referral to an occupational health specialist for workplace assessment and modifications.

What general measures could Mercy adopt in the workplace that may help alleviate her symptoms?

• Mercy’s symptoms suggest an allergic reaction to the aerosolized particles in her workplace. The following measures could help alleviate her symptoms:
• Personal Protective Equipment (PPE):
  • Respiratory Protection: Recommend that Mercy use a high-quality particulate respirator mask (e.g., N95 or P2 mask) to filter out airborne particles.
  • Eye Protection: Encourage the use of safety goggles or glasses to protect her eyes from irritants.
  • Skin Protection: Suggest wearing gloves and long-sleeved clothing to minimize skin exposure to allergens.
• Workplace Modifications:
  • Ventilation: Advocate for improved ventilation systems in the workplace to reduce the concentration of airborne particles.
  • Dust Control: Suggest implementing dust control measures, such as local exhaust ventilation or using wet methods to reduce dust generation.
  • Job Rotation: Consider discussing with her employer the possibility of rotating her duties to reduce her exposure time to allergens.
• Workplace Hygiene:
  • Hand Hygiene: Emphasize the importance of regular hand washing to remove allergens from her skin.
  • Changing Rooms: Recommend having a dedicated changing area to avoid bringing allergens home on her clothes.
• Medical Management:
  • Allergy Medications: Advise the use of antihistamines for her allergic symptoms and topical corticosteroids for her skin eruptions.
  • Asthma Management: Ensure she has an updated asthma action plan and access to inhalers (e.g., salbutamol for acute relief and possibly a corticosteroid inhaler for maintenance).
• Occupational Health Referral:
  • Assessment: Recommend an assessment by an occupational health specialist to evaluate her work environment and suggest further modifications.
  • Allergy Testing: Consider referral for allergy testing to identify specific allergens and tailor her management plan.

How might your management be different if her condition related to a psychological condition or bullying at work?

• If Mercy’s condition were related to psychological issues or bullying at work, the approach would differ significantly:
• Psychological Support:
  • Counseling: Refer Mercy to a psychologist or counselor for support in managing stress, anxiety, or other psychological impacts.
  • Employee Assistance Program (EAP): Encourage her to utilize any available EAP services for confidential counseling and support.
• Workplace Intervention:
  • HR Involvement: Suggest she discuss the issue with her HR department to address the bullying or psychological stress.
  • Workplace Mediation: Recommend mediation services to resolve conflicts or bullying incidents.
• Legal and Advocacy Support:
  • Fair Work Commission: Inform her about the Fair Work Commission, which provides resources and support for workplace bullying complaints.
  • Unions: If she is a union member, advise her to seek assistance from her union for support and advocacy.
• Medical Management:
  • Mental Health Plan: Develop a mental health treatment plan, which may include therapy and medication if needed.
  • Regular Follow-up: Schedule regular follow-ups to monitor her mental health and workplace situation.

Preventive and population health 

How would you describe the possible diagnoses to Mercy and their implications for her current work activities? What instructions would you give to the employer about restrictions and occupational health and safety precautions in the workplace? Climate change has been associated with increased risk of thunderstorm asthma due to the release of aeroallergens with warmer temperatures and rising frequency of more severe thunderstorms. What is another example of how climate change is increasing environmental health risks? How could Mercy’s asthma management be changed to reduce the carbon emissions associated with the asthma management?

Describing Possible Diagnoses to Mercy

1. Occupational Allergic Contact Dermatitis:

• Explanation: “Mercy, your skin reactions on your hands and neck are likely due to an allergic reaction to substances you are exposed to at work. This is known as occupational allergic contact dermatitis.”
• Implications: “You might need to avoid direct contact with certain ingredients or use protective gear to prevent exposure.”

2. Occupational Asthma:

• Explanation: “The respiratory symptoms you experience, including rhinosinusitis and asthma exacerbations, could be related to inhaling airborne particles at your workplace. This condition is called occupational asthma.”
• Implications: “It’s important to identify the specific triggers and find ways to minimize your exposure to them.”

3. Allergic Rhinitis and Conjunctivitis:

• Explanation: “Your itchy, watery eyes and nasal congestion are symptoms of allergic rhinitis and conjunctivitis, likely caused by allergens present in your work environment.”
• Implications: “Using protective equipment and reducing your exposure to these allergens can help manage these symptoms.”

Instructions to the Employer

1. Personal Protective Equipment (PPE):

• Provide high-quality particulate respirator masks (N95 or P2) to filter airborne particles.
• Ensure safety goggles or glasses are available to protect the eyes.
• Supply gloves and long-sleeved clothing to reduce skin contact with allergens.

2. Workplace Modifications:

• Improve ventilation systems to reduce the concentration of airborne particles.
• Implement dust control measures, such as local exhaust ventilation or wet methods to minimize dust production.
• Rotate job duties to reduce prolonged exposure to allergens.

3. Workplace Hygiene:

• Regular cleaning to reduce allergen buildup.
• Ensure that employees have access to handwashing facilities and are encouraged to wash hands regularly.
• Provide a designated changing area to prevent allergens from being taken home.

4. Occupational Health Assessment:

• Arrange for an occupational health assessment to evaluate the workplace and suggest further modifications.

Climate Change and Environmental Health Risks

Example: Increased Heat-Related Illnesses

• Climate change leads to more frequent and severe heatwaves, which increase the risk of heat-related illnesses such as heat exhaustion and heat stroke. Vulnerable populations, such as the elderly, children, and those with preexisting health conditions, are particularly at risk.

Reducing Carbon Emissions in Asthma Management

1. Use of Eco-Friendly Inhalers:

• Transition from metered-dose inhalers (MDIs), which contain hydrofluorocarbons (HFCs), to dry powder inhalers (DPIs) or soft mist inhalers (SMIs), which have a lower carbon footprint.

2. Proper Inhaler Use and Education:

• Educate Mercy on the correct use of inhalers to ensure efficacy and reduce waste.
• Ensure regular medication reviews to optimize her asthma management and avoid overuse of reliever inhalers.

3. Promote Non-Pharmacological Management:

• Encourage the use of non-pharmacological measures such as breathing exercises and physical activity to improve overall respiratory health.

4. Waste Reduction:

• Implement a recycling program for inhalers, where available, to reduce environmental impact.

Professionalism

Outline the relevant documentation that would be required if this were to be completed as a workers compensation claim.
General practice systems and regulatory requirement What treatment and rehabilitation measures do you need to consider when certifying a patient’s level of fitness for work? How do you assess response to treatment and ability to conduct occupational activities?

Documentation Required for a Workers Compensation Claim in QLD

1. WorkCover Queensland Medical Certificate:
   • This is the initial certificate required to start a claim. It includes:
     • Patient details.
     • Details of the injury or illness.
     • Date of injury or onset of symptoms.
     • How the injury or illness is work-related.
     • Initial treatment provided and a recommended treatment plan.
     • Certification of the patient’s capacity for work (full capacity, capacity for selected duties, or no capacity).
2. Worker’s Compensation Claim Form:
   • Completed by Mercy and may require the GP’s assistance.
   • Includes personal information, employment details, and the specifics of the injury or illness.
3. Employer’s Report:
   • The employer must complete an Employer Incident Report to document the injury or illness and the circumstances surrounding it.
4. Progress Medical Certificates:
   • Regularly updated certificates from the GP, providing updates on Mercy’s condition, treatment progress, and any changes in work capacity or restrictions.
5. Specialist Reports:
   • If Mercy is referred to specialists (e.g., dermatologists or respiratory physicians), their detailed reports and treatment recommendations should be included.
6. Occupational Health and Safety Reports:
   • Any reports from occupational health assessments or workplace environmental evaluations.

General Practice Systems and Regulatory Requirements

1. Accurate Record-Keeping:
   • Detailed medical records must be maintained, documenting all consultations, treatments, and communications related to Mercy’s condition.
   • Use the practice’s electronic health record (EHR) system to document all relevant information.
2. Compliance with WorkCover Queensland Regulations:
   • Ensure adherence to the guidelines and requirements set by WorkCover Queensland.
   • Follow all procedural requirements for filing claims and providing medical certificates.
3. Effective Communication:
   • Maintain clear and timely communication with Mercy, her employer, WorkCover Queensland, and any involved specialists or therapists.
   • Provide regular updates and respond promptly to any requests for additional information or documentation.

Treatment and Rehabilitation Measures

1. Medical Treatment:
   • Prescribe medications for allergic symptoms and asthma.
   • Provide topical treatments for dermatitis and consider referrals to dermatologists or other specialists as needed.
2. Workplace Health and Safety Measures:
   • Recommend specific modifications in the workplace to reduce exposure to allergens.
   • Advise on the use of personal protective equipment (PPE).
3. Rehabilitation Programs:
   • Refer Mercy to occupational therapy or physiotherapy to manage symptoms and maintain functionality.
   • Recommend ergonomic adjustments in her workplace.

Certifying a Patient’s Level of Fitness for Work

1. Physical and Mental Health Assessment:
   • Evaluate Mercy’s physical symptoms, including skin condition and respiratory function.
   • Consider psychological factors, such as workplace stress or anxiety.
2. Functional Capacity Evaluation (FCE):
   • Conduct or refer for an FCE to assess Mercy’s ability to perform work-related tasks.
3. Developing a Return-to-Work Plan:
   • Create a structured, graduated return-to-work plan outlining specific duties and hours, taking into account her medical condition and any necessary accommodations.

Assessing Response to Treatment and Ability to Conduct Occupational Activities

1. Regular Follow-Up Appointments:
   • Schedule regular follow-ups to monitor Mercy’s progress and response to treatment.
   • Adjust treatment plans based on her symptoms and recovery.
2. Objective Measures:
   • Use spirometry and other diagnostic tests to assess respiratory function.
   • Perform skin examinations to evaluate the severity of dermatitis.
3. Patient Feedback:
   • Obtain feedback from Mercy regarding her symptoms, work-related triggers, and overall well-being.
4. Workplace Assessments:
   • Collaborate with occupational health specialists to conduct workplace assessments and ensure a safe working environment.
5. Communication with Employer:
   • Provide the employer with regular updates on Mercy’s condition and any necessary work restrictions or accommodations.
   • Ensure the employer is implementing recommended workplace modifications and providing necessary protective equipment.

Climate Change and Environmental Health Risks

Example: Increased Heat-Related Illnesses:

• Climate change is leading to more frequent and severe heatwaves, increasing the risk of heat-related illnesses like heat exhaustion and heat stroke. Vulnerable populations, including the elderly, children, and those with preexisting health conditions, are particularly at risk.

Reducing Carbon Emissions in Asthma Management

1. Use of Eco-Friendly Inhalers:
   • Transition from metered-dose inhalers (MDIs), which contain hydrofluorocarbons (HFCs), to dry powder inhalers (DPIs) or soft mist inhalers (SMIs), which have a lower carbon footprint.
2. Proper Inhaler Use and Education:
   • Educate Mercy on the correct use of inhalers to ensure efficacy and reduce waste.
   • Ensure regular medication reviews to optimize her asthma management and avoid overuse of reliever inhalers.
3. Promote Non-Pharmacological Management:
   • Encourage the use of non-pharmacological measures such as breathing exercises and physical activity to improve overall respiratory health.
4. Waste Reduction:
   • Implement a recycling program for inhalers, where available, to reduce environmental impact.

Procedural skills

Where would you refer Mercy for skin prick testing? Can you describe the procedure and interpretation of this test?

In Queensland, Mercy can be referred to an allergist or an immunologist for skin prick testing. These specialists can be found in private clinics, hospital outpatient departments, or specialized allergy centers. Here are a few referral options:

1. Allergy and Immunology Clinics:
   • Many cities have dedicated clinics specializing in allergy and immunology. Examples include Allergy Medical Group, Queensland Allergy Services, or similar local providers.
2. Hospital Outpatient Departments:
   • Major hospitals often have outpatient allergy and immunology services. Examples include the Royal Brisbane and Women’s Hospital or the Princess Alexandra Hospital.
3. Private Specialist Practices:
   • Allergists and immunologists in private practice can provide skin prick testing. Referrals can be made to specific specialists known for their expertise in occupational allergies.

Procedure for Skin Prick Testing

1. Preparation:

• Mercy should stop taking antihistamines at least 48-72 hours before the test, as these can interfere with the results.
• The skin is usually tested on the forearm or the back.

2. Procedure:

• Cleaning the Skin: The area to be tested is cleaned with alcohol.
• Application of Allergens: Small drops of various allergens (including common occupational allergens like soy protein, flour, etc.) are placed on the skin.
• Pricking the Skin: A small, sterile lancet is used to prick the skin through each drop, allowing a small amount of the allergen to enter the skin. This does not cause bleeding.
• Control Tests: A positive control (histamine) and a negative control (saline or glycerin) are also included to compare reactions.

3. Waiting Period:

• The patient waits for about 15-20 minutes for reactions to develop.

4. Reading the Results:

• The allergist examines the skin for reactions. A positive reaction usually manifests as a raised, red, itchy bump (wheal) surrounded by a small area of redness (flare).
• The size of the wheal and flare is measured in millimeters.

Interpretation of Results

1. Positive Reaction:

• A positive reaction indicates that Mercy is likely allergic to the substance tested. The size of the wheal (typically larger than 3 mm) compared to the negative control determines the significance of the reaction.

2. Negative Reaction:

• A negative reaction indicates that Mercy is not allergic to the substance tested, or the reaction is not strong enough to be clinically significant.

3. Control Reactions:

• The positive control (histamine) should produce a significant reaction, confirming that Mercy’s skin is capable of reacting.
• The negative control should not produce a reaction, confirming that any reactions to allergens are specific.

Managing uncertainty

What timeframe would you consider for Mercy to return to work? What capacity will she have to conduct her duties when she returns?
Identifying and managing the significantly ill patient How would you diagnose anaphylaxis? When would it be appropriate to ‘stand down’ a worker? Who can you refer a patient to in this scenario?

Timeframe for Mercy’s Return to Work and Capacity

Timeframe for Return to Work: The timeframe for Mercy’s return to work depends on several factors, including her response to treatment, the implementation of workplace modifications, and her overall health status. A typical approach might include:

1. Immediate Short-Term Absence:
   • Initially, Mercy may need a few days to a week off work to start treatment, undergo allergy testing, and allow for any necessary modifications to be made at her workplace.
2. Gradual Return to Work:
   • 1-2 Weeks: If her symptoms are under control and appropriate workplace modifications (such as PPE and improved ventilation) are in place, she could start returning to work on a part-time basis.
   • 2-4 Weeks: Monitor her closely. If she remains symptom-free or her symptoms are manageable, gradually increase her hours and duties as tolerated.

Capacity to Conduct Duties: When Mercy returns to work, her capacity will be influenced by her allergic reactions and asthma management. Her duties should initially be modified to reduce exposure to allergens:

1. Light Duties:
   • Assign tasks with minimal exposure to allergens (e.g., administrative duties or tasks away from the mixing area).
   • Ensure she uses appropriate PPE (e.g., N95 masks, gloves, goggles).
2. Regular Monitoring:
   • Regular check-ins to assess her symptoms and make further adjustments as needed.
3. Long-Term Adjustments:
   • If her symptoms persist despite precautions, consider long-term changes to her duties or work environment.

Diagnosing Anaphylaxis

Signs and Symptoms of Anaphylaxis: Anaphylaxis is a severe, life-threatening allergic reaction that can occur rapidly. Key signs and symptoms include:

1. Skin:
   • Urticaria (hives), flushing, itching.
   • Angioedema (swelling of the face, lips, tongue, throat).
2. Respiratory:
   • Difficulty breathing, wheezing, stridor.
   • Tightness in the throat or chest.
3. Cardiovascular:
   • Hypotension, fainting, dizziness.
   • Tachycardia or bradycardia.
4. Gastrointestinal:
   • Nausea, vomiting, diarrhea, abdominal pain.
5. Neurological:
   • Anxiety, confusion, a sense of impending doom.

Diagnosis: Anaphylaxis is diagnosed based on clinical presentation. It usually involves:

• Acute onset of symptoms (minutes to hours) with involvement of the skin/mucosa and either respiratory compromise or hypotension.
• Exposure to a known allergen and the rapid development of symptoms.

Appropriate Time to ‘Stand Down’ a Worker

Stand Down Criteria:

• A worker should be stood down if they are experiencing acute symptoms that pose a health risk to themselves or others, such as severe allergic reactions or poorly controlled asthma.
• If the work environment cannot be modified to ensure their safety.
• If their condition significantly impairs their ability to perform essential job functions safely.

Referrals for Mercy

Specialists for Referral:

1. Allergist/Immunologist:
   • For comprehensive allergy testing (e.g., skin prick testing) and long-term allergy management.
2. Respiratory Physician:
   • For specialized management of asthma, especially if her condition is difficult to control.
3. Occupational Health Specialist:
   • To assess the workplace, recommend modifications, and provide guidance on safe return-to-work practices.
4. Dermatologist:
   • For managing occupational dermatitis if skin symptoms are severe or persistent.
5. Psychologist/Counselor:
   • If there are psychological factors, such as anxiety or stress related to her condition or work environment.