Module 4: Cases in Occupational Medicine

CASE 2: A retired signmaker

A 72 year old man is found on admission to hospital with a suspected myocardial infarction (heart attack), to have a highly abnormal x-ray, shown here below. (Clicking on one of the marked rectangular areas on the x-ray will provide a magnified view).

On the right, there is a sausage like mass in the upper zone, with loss of volume (the transverse fissure is pulled up) and blunting of the right costophrenic angle. On the left there is a mixture of ill-defined nodules and linear opacities of varying size in mid and upper zones. The are a few typical small rounded opacities on both sides.

Question #1:

What is the differential diagnosis of irregular large opacities in the upper lobes on chest x-ray?

(See the answer)

Following discharge, he is referred for assessment of his lungs. On review, his main complaints are breathlessness and fatigue on effort, enough to interfere with his activity. He also has stable angina on treatment. There is no productive cough, progressive loss of weight, loss of appetite, night sweats nor haemoptysis. Examination reveals an elevated blood pressure, no cardiac failure, and normal breath sounds with variable crackles and expiratory wheeze at the bases, left more than right. The spiromety is shown in the table below.

Question #2:

What does this show?

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On occupational history, his only job has been with a sign making company in Cape Town for 40 years. He does not recall ever having had tuberculosis. He last smoked 40 years previously, about 5 per day for a period of 4 years. He retired 8 years previously when the company changed hands.

Question #3:

What other questions would you ask?

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Question #4:

Does this information help with the differential diagnosis?

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You make the diagnosis. An obstacle to submitting a claim under COIDA is that the company is closed.

Question #5:

How would you proceed to try to get the patient some compensation?

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Question #6:

The manager states in the letter that precautions were taken including provision of regular milk rations. What is the relevance of this?

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Question #7:

He is awarded 20 percent disablement by the Commissioner. He asks you if this is reasonable? What is your opinion?

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Question #8:

What is the next step?

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Course: The Commissioner offered to reconsider the percentage disablement if the claimant withdrew his objection, which was done. Duration of case thus far: 2 years.