Working Impression - Case Study Example

?As a doctor, one should first identify the possible causes of the symptoms, based on the initial information provided. From this set, a primary working impression, which is the most probable cause among the list, is chosen. The investigation then initially centers on proving the working impression. If the working impression holds after confirmatory test/s, then it will hold to be the diagnosis, and the future steps will be dedicated onto eradicating the sources and treating the symptoms accordingly. However, if the PWI turns out not to be the diagnosis, then the differentials will then be tested, so that the primary root of the chief complaint be identified. Treatment will thus be planned based on the definitive diagnosis. Working Impression In coming up with our primary impression, we should look into the information we have for any pertinent data. In summary, we have four female employees of a food distribution warehouse facility who complain of dizziness. They conduct blister packing in an area with a 40°F temperature, and two railroad car lines and gas-powered forklifts nearby. The facility also has a special seal that insulates in the cold temperature needed for storage. There was no noticeable odor, nor there mention of a ventilating system for the area. Because multiple cases (four) have been reported in the facility, we consider this as an occupational health issue. Because of the nature of their work, the only possible factors that might have caused dizziness are inhalation of toxic fumes, exposure to chemicals from the food products, and the cold temperature (40°F). Because there are no reports of food poisoning caused by the products of the facility, then we can rule out the second factor. In considering the presence of toxic fumes, we must take note that the suspected inhalant must be odorless and colorless. In addition, the special insulating system in the warehouse might have been contributing in keeping the toxic fumes in the facility. A possible source of such fumes must be established, and the symptoms observed in our case should be explained by its presence. With these qualifications, we take carbon monoxide (CO) poisoning as our primary working impression. CO is an odorless, colorless gas that may come from the incomplete burning of organic substances such as gasoline, kerosene, oil, propane coal or wood (Canadian Centre for Occupational Health and Safety, 2008; WorkSafe Victoria, 2008). In our case, CO may have been emitted by the car and forklift exhaust and possibly, a kerosene-powered heater, although the presence of such equipment must first be verified. CO gas interferes with the oxygenation of red blood cells and subsequently of tissues such as the brain, causing dizziness. Other symptoms include chest pains, headache, fatigue, dizziness, drowsiness or nausea. Prolonged exposure may result to weakness, vomiting, confusion, loss of consciousness, coma, and death (Canadian Centre for Occupational Health and Safety, 2008). Differential Diagnoses It is important to consider other causes of the incidents, as the PWI might not be the root cause, or there are environmental conditions that may cause harm to the employees. Low oxygen levels In preserving food products, it is important to have a room wherein oxygen levels can be kept at a low level (1% to 2%) to prevent the growth of aerobic microorganisms that compromise the quality of food products. This room is referred to as a controlled atmosphere (CA) room. Inhalation of this highly deoxygenated atmosphere from CA room has detrimental consequences to employees, who need oxygen levels of 19.5% to 23.5% to survive. In fact, inhaling a single breath of this highly deoxygenated atmosphere will result to instantaneous loss of consciousness, with consequent brain and health injuries. Employees who work near a CA room are thus susceptible to health risks (WorkSafe Victoria, 2008). If a CA room is present in the warehouse, then this diagnosis is highly likely. Ammonia The cooling condition exposes the employees to many factors. One of them is ammonia, a colorless gas with a sharp, pungent odor. It is one of the chemicals used in refrigeration, and possibly, it is present at low levels or is released intermittently as no malodorous fumes were noticed during the initial investigation. At such levels, it can cause coughing, wheezing, shortness of breath, laryngitis, headaches, fever, nausea, vomiting, pink frothy phlegm, chest pain, asthma, rapid pulse and hypertension. On the other hand, exposure to high concentrations of ammonia results to burning of the eyes, skin, throat and lungs (US National Library of Medicine, 2011). The presence or absence of these symptoms, as well as sources of ammonia, must thus be elicited. Cold stress Low temperature also cause health issues to the employees of a cold storage facility. It produces shivering, vasoconstriction, increased oxygen consumption and pulse rate, tachypnea, hypertension, and elevated cardiac output (WorkSafe Victoria, 2008). To rule this out, ample protective clothing and equipment must be present in the work stations. Steps on Identifying the Source 1. Interview the patients and other employees First, we should ask for the presence of symptoms mentioned above either at present or previously. For each symptom, the onset (Before or after working for the warehouse?), timing (At work? While at home? During the day? At night?), as well as precipitating factors and palliative measures should be elicited. 2. Investigation of work area Aside from getting information from the employees, the work station should be searched for clues as well, by looking for health risks and corresponding protective measures. The air and food products should be checked any harmful or contaminating chemicals, such as ammonia and CO. Presence of anhydrous ammonia refrigeration systems and gas-operated machines should be noted. Presence of established protective measures such as appropriate clothing, ventilation and sensor should be looked at as well. 3. Definitive testing by checking of chemicals and gases in blood Finally, the findings of the chemical levels in the atmosphere should be comparable with the levels of chemical in blood. For example, if there is poor oxygenation of the atmosphere, then blood oxygen levels should be low as well. If CO poisoning has been established, then CO levels in the work station should be high. Recommendations Despite not yet knowing the cause of the symptoms among the four employees, it is important to remove risks and maintain protection at all times. To remove the risk of CO poisoning, gas-powered machines such as cars, forklifts and heaters should be converted to their electrical counterparts. If not, then it should be run in a room with ample ventilation. As well, a gas sensor with audio and visual alarms should be installed to determine whether the concentrations of gases are in safe amounts. Oxygen should be kept at a level safe for the employees, which is 19.5% to 23.5%. On the other hand, the CO atmospheric concentration should be lower or equal to 30 parts per million (ppm) (Canadian Centre for Occupational Health and Safety, 2011; WorkSafe Victoria, 2008). If anhydrous ammonia refrigerating system is being used, protective measures should be taken. This includes having an enclosed, well-ventilated area to house the equipment, a material safety data sheet (MSDS) specific for ammonia, informed authorities on the presence of the dangerous substance, maintenance and emergency systems, signs around the facility indicating the presence of the chemical, and proper information of the employees regarding the presence of ammonia. Changing the refrigerating system might be suggested as well. In addition, a complete, durable protective gear with appropriate level of insulation and fastening should be ensured to prevent cold stress (WorkSafe Victoria, 2008). References Canadian Centre for Occupational Health and Safety (2008). Exposing the Dangers of Carbon Monoxide. Health and Safety Report. 6(1). US National Library of Medicine (27 October 2011). Ammonia. Retrieved from http://toxtown.nlm.nih.gov/text_version/chemicals.php?id=2 WorkSafe Victoria. (2008) A Handbook for Workplaces: Safe Operation of Cold Storage Facilities. 1st ed. 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