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Case 1.

Re: Mrs Jane Duncan. Mrs Duncan has had problems with her breathing and her sinuses since March this year.

This may have started two and a half years ago, 6-8 months after starting her job at a dry cleaners. The original symptoms started with an upper respiratory tract infection, but did not clear up. Originally, it was triggered by exposure to chemicals at work, but it became more persistent and occurred at home.

This went on for several months, and she began to experience pains in her chest and back. She also coughed at night. The cough was productive at night. She also began to experience hayfever symptoms for the first time, with perennial symptoms of sneezing, nasal itch, occasional rhinorrhoea and excessive lacrimation.

At the start of this year, things seemed to get worse, with increasing wheeze and shortness of breath. She made a number of visits to her GP, who prescribed flixotide without much improvement. She was also prescribed a number of treatments of antibiotics, also without much improvement.

She has remained at work, and is still working. From the moment that she arrives at work, she experiences tightness in her chest. Within 2 hours of starting work, with wheezing and cough. On some days, the symptoms are worse than others. The dry-cleaning machine is in operation for 8 hours a day. She thinks that there is significant exposure when the door is opened to unload it. There is also exposure when she is hanging the clothes up, when folding overalls and when ironing clothes. The factory is open plan, and connected to the shop. Ventilation is natural, with a “garage door” that is opened, with windows providing the remainder. There are roof vents, but they do not work. The chemicals used include perchloroethylene, and other agents used to “spot clean” garments. She does not have any material safety data sheets.

More recently she has been reacting to strong odours including perfumes and household cleaners.

Apart from the respiratory symptoms she has had menorrhagia. She has also recently had symptoms of dysphagia, to liquids as well as solids. She experiences heartburn most of the day, and has epigastric pain. Past occupational history. Has worked in the retail trade, and in a number of catering job. No bakery work. Di work in photographic processing 17 years ago for 2 months. No exposure to chemicals in any previous jobs. At present. She was at work all day yesterday, and was “quite puffed” on walking up the flight of stairs to the consultation. She frequently gets short of breath, and has limited exercise tolerance. Her ability to do housework is quite limited. Family history Nil of note, no FH of asthma. Investigations Serial peak flows, appended. She is on the waiting list for gastroscopy. Treatment. She is on flixotide and ventolin. Losec. Codeine for the chest pain. Laratine for hayfever. Psychosocial. Quite dispirited at present, not getting much enjoyment out of life. Low mood, and has a sense of frustration about not being able to do the things that she usually does. Her energy is poor. Concentration is however good, as is her memory. Past medical history. Up to two years ago she had good health. Ovarian cyst removed 1994, which for some years was suspected to be malignant. More recently, she has learned that this was in fact not so. No history of atopy or eczema. Social She was previously been playing social softball, but has to give this up last year. She was also coaching, but she cannot do this now. She has two children, and a stepdaughter. Recently re-marrried. Ex smoker. Systems. CNS. Occasional headaches which are frontal, can be unpredictable in onset and last for 2-3 hours. No blackouts fits or syncope. Has dizziness and unsteadiness which seem to be more common at work. RS. Cough and wheeze as described. This can be brought on by exertion. CVS. Has chest pain with coughing, but not on physical exertion. Gastrointestinal. Heartburn and dyspepsia as above, bowels regular, and had black stools last week. Urinary. NAD Locomotor. No joint pains. Psychological As above On examination. Looks quite well and gives a lucid clear history.

Height 1.66m, weight 85.4 Kg.

BP 130/86

P108, occasional ectopic (has been investigated)

Chest: good expansion, breath sounds vesicular, inspiratory and expiratory wheeze throughout lung fields.

Respiratory function (01015-P2) Respiratory function.jpg

Questions. 1. What are your initial impressions about provisional diagnoses? 2. What would you plan to do next? 3. Are there any additional tests that you would perform?