MODULE 7: PSYCHOSOCIAL ISSUES AND OTHER MISCELLANEOUS TOPICS IN OCCUPATIONAL AND ENVIRONMENTAL HEALTH
SECTION 7: SHIFTWORK AND HOURS OF WORK:
A Case Study
 

CASE STUDY:

Here are some notes a doctor at the WorkHealth Clinic for Occupational Diseases at Groote Schuur Hospital made about a client.
Assume you are the client's doctor...
(The real patient has consented to his particulars being used in teaching).

Visit #1:

Mr Zain Kara is a 42 year old mail handler (a postal sorter). He works the night-shift at the mail depot in Goodwood, Cape Town. He has been in the same job for 6 years, and is currently also the health and safety committee chairperson.

He presented to the clinic with the following current symptoms:
indigestion, heartburn, slight cough, insomnia, loss of weight, malaise. These symptoms started some 6 months after starting to work there, but have worsened of late. He has consulted many doctors over the years with the same symptoms, but his symptoms remain.

Medical history:

He has been a smoker for the past 20 years. He smokes 15 daily if at work, and 5 cigarettes daily if not. He does not drink alcohol. He had an appendicectomy in 1996 or 1997. Medication: sleeping tablets from a GP, but has now developed tolerance to these.

Social:

His wife and 3 children are all well. He does not think that they feel that his health has suffered due to his job. He lives in a brick house, with electricity and tapped water. There are 3 bedrooms. They have no pets.

Exposure:

His work hours are 17h00 to 05h00, 3 nights a week. There is no day-shift. When off shift, he wakes at 12h45, eats at 13h00 and 20h00. When on shift, he wakes at 14h00, eats 'lunch' at 21h00 and at 24h00 His work: He sorts 14 700 articles per shift. Describing his work, he says he has to sort 42 bins of mail a night. The articles come to him along a chute type conveyor belt, and he receives and sorts them into appropriate pigeon-holes. If the articles are heavy, or he is running behind, he has to stand. Otherwise he does his job seated.

Effects:

His main problems are sleeplessness and heartburn. He has had indigestion pain in the lower abdomen for 2 weeks now. This is not associated with bowel actions. He has no nausea, no blood in the stool, nor a change in his stool appearance, nor in stool habit. His sexual functioning is currently normal, although it did go through a bad patch recently, with a decrease in his libido and erectile stiffness.

Examination:

He looks well, and strikes one as either tired or mildly depressed. He is articulate, and gets animated when discussing the chronicity and intractability of his problems.

General features: He had no jaundice, pallor, clubbing, cyanosis, oedema, lymphadenopathy nor thyromegaly.
Temperature = 35.2, Pulse = 75 regular, Blood pressure = 135/95.
Other positive findings:
Slight tenderness in the epigastric area, a localised area of tenderness suprapubically, musculo-skeletal tenderness in his R thumb, and R shoulder-girdle muscles.

Question #1:
  1. Are there any additional features about Mr Kara that you would like to find out? Maybe the doctor missed these or omitted to document them.
  2. Does this client suffer any health effects of shiftwork? List these.
  3. What hazards is he exposed to at work? Think about all categories of hazard.
  4. How many hours does he work per week? What is the legal limit, and which law prescribes working hours?
  5. What is your medical assessment of your client?
  6. Outline a plan of management for this client.

(See the answers to the above.)

Visit #2 - 1 month later:

He tells the doctor that he has been diagnosed by a medical specialist as having peptic ulcer disease. He had a barium swallow which made the diagnosis. He is feeling very much better. He has been off work for 3 weeks and is returning to work the following week. He no longer has stomach ache, and is on Lanzor, one daily before lunch.

Note: Lanzor (lansoprazole) is a specific proton pump inhibitor of gastric parietal cells.

On examination, he is looking remarkably better. He is not depressed. There is no abdominal tenderness at all.

Question #2:
  1. Is there any information the doctor omitted to gather?
  2. What is your diagnosis now?
  3. What is your management?
  4. What do you tell your client?
  5. Are any health effects of shiftwork scheduled as occupational diseases?

(See the answers to the above.)

Visit #3 - 7 weeks after the previous visit:

He tells the doctor that he is stable. He has successfully returned to work, and has had no more symptoms. He is going to see the specialist for his second follow-up visit in 2 days. On being asked about his working conditions, he complains again about the lighting and heating, and that management do not listen to them as workers, nor to the H&S committee. On prompting, he says that his family are taking strain, and that his impotence has returned. He starts crying.

Question #3:
  1. What is your management plan now?

(See the answers to the above.)