KFP – Occupational and environmental medicine

Peter Whelan, aged 52, is a boilermaker who presents for review following a WorkCover claim lodged for progressive breathlessness. He has worked in the shipbuilding industry for over 30 years, primarily in confined metal fabrication areas. He recalls intermittent use of personal protective equipment, particularly during his early career.

He reports gradually worsening exertional dyspnoea over the past 12 months. He has also developed a dry cough and occasional chest tightness. He denies fever, weight loss or night sweats. He is a non-smoker. There is no history of asthma or other chronic respiratory illness.

Medications: Nil

Allergies: Nil known

Past history: Hypertension (controlled)

Social history: Lives with wife, no children at home. Recreational cyclist, but has recently stopped due to shortness of breath.

Occupational history: Long-term exposure to welding fumes, metal dust, and occasional asbestos. PPE use inconsistent, particularly prior to the 2000s.

Examination findings: Chest clear on auscultation, SpO2 96% on room air, no clubbing. Mild basal end-inspiratory crackles bilaterally. No cyanosis or oedema.

Investigations: Chest X-ray: Bilateral pleural plaques. HRCT: Interstitial thickening and honeycombing consistent with asbestosis. Spirometry: FVC 62% predicted, FEV1/FVC ratio 0.79, DLCO 52% predicted.

What is the most appropriate next step in the management of this patient? Select three (3) from the following list:

Stephanie Rowan, aged 29, presents with an acute onset of headache, nausea, and lightheadedness that began during her shift at a local restaurant. She is a kitchen hand and reports that the symptoms started around midday while working in an enclosed space near the gas stove. Several co-workers also reported feeling unwell. Stephanie describes a throbbing frontal headache and mild confusion. She denies fever, cough, or vomiting. She has no past medical history, is a non-smoker, and takes no medications.

Examination findings: Alert but mildly confused. Temperature 36.6 °C, HR 102 bpm, BP 110/70 mmHg, SpO2 99% on room air. Neurological exam is non-focal. No signs of meningism. Breath sounds are normal. Capillary refill <2 seconds. Skin appears slightly flushed. There is no neck stiffness or photophobia.

Investigations: Venous blood gas (VBG): pH 7.35, HCO3 23, pCO2 43, carboxyhaemoglobin 16% (normal <2%). ECG: Sinus tachycardia, no ST changes.

What are the most appropriate next steps in management? Select three (3) from the following list:

Amit Rajan, aged 34, presents with a three-month history of episodic wheezing, shortness of breath, and nocturnal cough. He works full-time as a spray painter in an automotive panel shop. He reports that symptoms are often worse at work, especially by the end of the week, and tend to improve slightly over the weekend or while on holiday. He denies fever, chest pain, or significant sputum production. There is no personal or family history of asthma or atopy.

Medications: Salbutamol inhaler (occasional use)

Social history: Non-smoker, lives with partner, no children. Enjoys running but has had to stop due to symptoms.

Occupational history: Daily use of isocyanate-containing paints with use of a respirator mask, although he admits it is sometimes uncomfortable and not always worn.

Examination findings: Vitals stable. Chest clear between episodes. No clubbing or cyanosis. ENT exam normal. No signs of chronic illness.

Investigations: Spirometry (performed post-shift): FEV1 75% predicted, FEV1/FVC 0.68; reversibility with bronchodilator >15%. Serial peak flow monitoring shows >20% diurnal variation with lowest values on workdays. Chest X-ray is unremarkable.

What are the most appropriate next steps in managing this patient? Select four (4) from the following list:

Linda Watkins, aged 47, is a school laboratory technician who presents with complaints of persistent headaches, fatigue, and concentration difficulties over the past three months. She reports a strong chemical odour in the science prep room that worsens when the air conditioning is off. She also mentions throat irritation and dry eyes that improve when she’s away from the workplace.

Medications: None

Allergies: None known

Past history: Well controlled hypothyroidism

Social history: Non-smoker, lives with partner and two teenage children. No recent travel. No known recreational drug use.

Occupational history: Works in an enclosed space without windows. Exposure to various solvents, cleaning agents, and formaldehyde. She states other staff have experienced similar symptoms.

Examination findings: Vital signs normal. General and neurological examination unremarkable. ENT and respiratory examination normal. No skin changes or lymphadenopathy.

Investigations: FBC, UEC, TFTs and CRP all within normal range. Urinalysis normal. Formaldehyde air sampling requested by the school is pending.

What are the most appropriate management steps for this patient? Select three (3) from the following list:

Raymond Doyle, aged 62, is a retired agricultural worker who presents with gradually progressive hearing loss and intermittent tinnitus. He worked for over 35 years on a sheep station, often using tractors, chainsaws, and firearms, with limited use of hearing protection. He reports difficulty following conversations in noisy environments and needs to increase the TV volume significantly. There is no vertigo or recent head trauma. He denies otalgia or otorrhoea.

Medications: Perindopril 5 mg daily for hypertension

Past history: Mild sensorimotor peripheral neuropathy (B12 replete), hypertension

Social history: Lives with his wife, does not smoke, occasional alcohol. No significant noise exposure outside of work.

Examination findings: Ear canals clear, tympanic membranes intact bilaterally. Weber lateralises to the right, Rinne is positive bilaterally. No cerebellar signs. Gait and cranial nerve exam normal.

Investigations: Audiometry: Bilateral high-frequency sensorineural hearing loss. Tympanometry: Normal compliance bilaterally.

What are the most appropriate management steps for this patient? Select three (3) from the following list:

Angela Thorne, aged 42, presents with an intensely itchy rash on her hands and forearms that has gradually worsened over the past six weeks. She works as a dental assistant and reports frequent handwashing and glove use during her shifts. The rash began as dry, irritated skin but is now erythematous with areas of excoriation and vesicles. She states that it is worse after work and better on weekends. She denies any new skincare products or known allergies.

Medications: None

Allergies: Nil known

Past history: Mild eczema as a child

Social history: Lives with partner, no pets, no recent travel

Examination findings: Bilateral erythematous, lichenified plaques with vesicles and excoriations on dorsal hands and wrists. No signs of infection. Nailbeds intact. No rash elsewhere. No lymphadenopathy.

Investigations: Patch testing is pending. Swabs negative for bacterial growth.

What are the most appropriate management steps at this stage? Select three (3) from the following list:

Michael Nguyen, aged 38, presents with acute onset of shortness of breath, cough, and wheeze after cleaning a poorly ventilated industrial refrigerator with a commercial bleach-based disinfectant. He reports that the symptoms began within 30 minutes of exposure and were accompanied by chest tightness and burning in the throat. He denies fever or sputum production. He has no history of asthma or other respiratory illness.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: Works as a cleaning contractor in industrial food production environments. No formal training in chemical safety provided. PPE use is variable. Reports no prior similar episodes.

Examination findings: RR 22/min, SpO2 94% on room air, scattered expiratory wheeze bilaterally. No cyanosis. Cardiovascular and other systems normal.

Investigations: Chest X-ray: No consolidation. Spirometry (post-exposure): FEV1 60% predicted, FEV1/FVC 0.65, improves by 18% with salbutamol. CRP and FBC normal. ABG not indicated at this stage.

What are the most appropriate next steps in the management of this patient? Select three (3) from the following list:

Frank Delaney, aged 59, presents with worsening fatigue, abdominal discomfort, and intermittent constipation. He has been working in battery manufacturing for over 20 years and recently returned after a 3-month break due to restructuring. He reports occasional metallic taste in his mouth, reduced appetite, and difficulty concentrating. No recent travel. No history of liver disease, malignancy, or alcohol overuse.

Medications: None

Allergies: Nil known

Past history: Hypertension, well controlled

Social history: Lives with wife, non-smoker, moderate alcohol use (6–8 standard drinks per week). No recent recreational drug use.

Occupational history: Long-standing exposure to lead dust in battery casing and smelting units. Infrequent use of PPE reported. He notes colleagues have had similar symptoms.

Examination findings: Mild pallor, bluish line along the gum margin. Abdominal tenderness over the epigastrium. No hepatosplenomegaly. Neurological exam non-focal.

Investigations: FBC: Hb 104 g/L (130–180), MCV 72 fL (80–96), Reticulocytes low. Blood lead level: 42 µg/dL (<5 normal). LFTs mildly elevated. Renal function normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Jasmine Fielding, aged 27, presents with red, painful eyes and blurred vision after completing her shift in a veterinary pathology lab. She reports that a sample tube containing formalin broke while she was handling it, splashing near her face and hands. She removed her gloves and washed her face, but did not use eye protection at the time. Over the next few hours, she developed increasing eye irritation and photophobia.

Medications: None

Allergies: Nil known

Past history: Myopia (corrected with glasses)

Occupational history: Works in laboratory processing animal tissue samples. Regular handling of formalin and other fixatives. PPE usage includes gloves and lab coat, but eye protection is inconsistently used.

Examination findings: Bilateral conjunctival injection, epiphora, and mild eyelid oedema. Fluorescein staining shows small punctate epithelial defects in both eyes. Visual acuity 6/9 bilaterally. No corneal ulceration. Pupils equal and reactive. No signs of uveitis or increased intraocular pressure.

What are the most appropriate next steps in management? Select three (3) from the following list:

Gregory Lucas, aged 45, presents with a three-month history of chronic cough, occasional wheeze, and worsening shortness of breath. He works in a stone benchtop fabrication workshop and reports frequent dry cutting of engineered stone without consistent respiratory protection. He denies a smoking history. Symptoms are worse at work and improve during weekends.

Medications: Salbutamol inhaler used intermittently

Allergies: Nil known

Past history: Nil significant

Social history: Lives with wife and two children. Non-smoker. No pets. No recent travel.

Occupational history: 10 years in engineered stone cutting, with limited use of ventilation and inconsistent PPE. Colleagues have been diagnosed with silicosis.

Examination findings: Fine inspiratory crackles at lung bases. No clubbing or cyanosis. Oxygen saturation 95% on room air. Cardiovascular and other systems normal.

Investigations: Chest X-ray: Reticulonodular infiltrates. HRCT: Patchy ground-glass opacities and early upper lobe fibrosis consistent with early silicosis. Spirometry: FEV1 78% predicted, FVC 82% predicted, DLCO 68% predicted.

What are the most appropriate next steps in management? Select four (4) from the following list:

Sarah Polanski, aged 33, presents with worsening headaches, irritability, nausea, and difficulty concentrating over the past 2 weeks. She works in a commercial printing press facility and spends most of her day in a poorly ventilated room with exposure to solvent-based inks and adhesives. Several colleagues have reported similar symptoms recently. She has no significant past medical history and denies drug or alcohol use.

Medications: None

Allergies: Nil known

Occupational history: Seven years working in printing press operations. No consistent use of respiratory PPE. Reports use of xylene, toluene, and other volatile organic compounds (VOCs).

Examination findings: Appears tired but alert. Neurological examination normal. Vitals within normal limits. No rash or lymphadenopathy.

Investigations: CBC and electrolytes normal. Liver function mildly elevated (ALT 64 U/L). Urinary hippuric acid (marker of toluene exposure) elevated. Workplace inspection pending.

What are the most appropriate next steps in the management of this patient? Select three (3) from the following list:

Aliya Noor, aged 25, presents with acute-onset itchy rash and wheezing after handling latex gloves during her shift as a hospital theatre nurse. She reports that her hands developed hives within minutes of donning the gloves, followed by throat tightness, wheezing, and dizziness. This is her third reaction in the past two months, though previous ones were milder and resolved with antihistamines. She has no known drug allergies and no history of asthma.

Medications: Nil

Allergies: None documented

Past history: Mild childhood eczema

Occupational history: Full-time scrub nurse in operating theatres, routinely handling latex gloves and other rubberised materials.

Examination findings: Vital signs stable. Wheeze on auscultation. Urticarial rash on both hands and forearms. No stridor or hypotension. Responds to salbutamol and antihistamines in ED. No further airway symptoms.

Investigations: Serum latex-specific IgE: positive. Spirometry post-event: FEV1 81% predicted, no reversibility. Skin prick testing pending.

What are the most appropriate next steps in management? Select three (3) from the following list:

David Monash, aged 61, presents for review after being diagnosed with mesothelioma on pleural biopsy. He worked for over 35 years as a plumber and reports frequent exposure to asbestos-containing pipe lagging, insulation, and roofing materials, particularly in the 1980s and 1990s. He was never provided with formal respiratory protective equipment in earlier years. His symptoms began six months ago with fatigue and chest pain, followed by worsening shortness of breath.

Medications: PRN oxycodone for pain, regular paracetamol

Allergies: Nil known

Past history: Hypertension

Social history: Ex-smoker (20 pack-years, quit 10 years ago). Lives with wife, has two adult children. Receives no home help currently.

Examination findings: Reduced breath sounds and dullness to percussion over right lower lung field. Mild finger clubbing. No peripheral oedema.

Investigations: Pleural biopsy: malignant mesothelioma. CT chest: large right-sided pleural effusion with nodular pleural thickening. Lung function: FVC 58% predicted, DLCO 48% predicted. ECOG performance status 2.

What are the most appropriate next steps in management? Select four (4) from the following list:

Leila Farouk, aged 31, presents with new-onset wheeze, chest tightness, and facial swelling that developed during her evening shift at a food processing facility. She works near the spice-mixing station and reports that the symptoms started after the introduction of a new paprika-chilli blend the week prior. She had previously been healthy with no respiratory or allergy history. She reports burning eyes and throat irritation earlier in the week but did not seek care.

Medications: Nil

Allergies: None known

Past history: Nil significant

Occupational history: 5 years in food processing. No PPE provided during spice blending. Colleagues have reported coughing and throat irritation recently.

Examination findings: Expiratory wheeze, facial erythema and swelling, throat erythema. HR 98 bpm, RR 20, SpO2 97%. No hypotension. Chest clear apart from wheeze. No rash elsewhere.

Investigations: Spirometry: FEV1 76% predicted, with 18% reversibility post-salbutamol. CXR normal. Blood eosinophils normal. Serum specific IgE to chilli extract pending.

What are the most appropriate next steps in management? Select three (3) from the following list:

James Randall, aged 29, presents with tingling and numbness in both hands, worse at night and during tool use at work. He works as an aircraft maintenance technician and spends several hours daily using vibrating tools such as grinders and pneumatic drills. Symptoms have been worsening over the past six months. He denies neck pain or trauma. No prior upper limb injuries.

Medications: None

Allergies: Nil known

Past history: Nil significant

Occupational history: 5 years in aviation maintenance. Exposed daily to hand-arm vibration. No regular ergonomic assessment conducted. No consistent use of vibration-dampening gloves.

Examination findings: Thenar muscle bulk preserved. Tinel’s and Phalen’s signs positive bilaterally. No cervical tenderness or upper motor neuron signs. Radial pulse intact bilaterally. Sensory reduction to light touch over the thumb and index fingers. Grip strength mildly reduced.

Investigations: Nerve conduction studies: bilateral median nerve conduction delay at the carpal tunnel. Cervical spine X-ray: normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Marina Estevez, aged 39, presents with chronic lower back pain that has gradually worsened over the past 12 months. She works as a disability support worker, providing personal care and patient transfers for clients in the community. She reports lifting and repositioning clients multiple times per day, often without mechanical aids due to space constraints. The pain is dull, located in the lumbar region, and exacerbated by bending and lifting. No leg weakness or bladder symptoms are reported.

Medications: Paracetamol and ibuprofen as needed

Allergies: Nil known

Past history: Nil surgical history. Non-smoker. No previous significant musculoskeletal injuries.

Occupational history: Employed full time in the community disability sector for 6 years. No formal manual handling training since induction.

Examination findings: BMI 31.5. Lumbar tenderness, reduced range of motion on flexion. Straight leg raise negative bilaterally. No neurological deficits. Gait normal.

Investigations: Lumbar spine X-ray: mild degenerative changes, no fracture. FBC, CRP, calcium: all normal. No red flags identified.

What are the most appropriate next steps in the management of this patient? Select three (3) from the following list:

Tomoko Hoshino, aged 43, presents with progressive shortness of breath, dry cough, and fatigue over the past four months. She has worked in a rural pigeon loft for 12 years, helping her family breed and race pigeons. Symptoms are worse after cleaning cages and feeding the birds. She reports occasional fevers and weight loss. She is a non-smoker and has no previous respiratory history.

Medications: None

Allergies: Nil known

Past history: Nil significant

Social history: Lives on a rural property with family. No recent travel. No pets other than pigeons.

Examination findings: Oxygen saturation 94% on room air, bilateral fine inspiratory crackles, no cyanosis or clubbing. Normal cardiovascular and neurological exam.

Investigations: Chest X-ray: diffuse reticulonodular pattern. HRCT chest: ground-glass opacities and mosaic attenuation pattern consistent with hypersensitivity pneumonitis. Spirometry: FVC 66% predicted, DLCO 54% predicted. CRP mildly elevated. ANA negative.

What are the most appropriate next steps in management? Select three (3) from the following list:

Brendan Kelly, aged 50, presents with new-onset tremor, mood swings, memory difficulty, and headaches. He works in a gold mining facility and has been involved in ore amalgamation processes that use mercury. He reports poor ventilation and inconsistent use of gloves or masks in the processing area. No alcohol or recreational drug use. Colleagues have also reported similar symptoms.

Medications: Nil

Allergies: Nil known

Past history: None of relevance

Occupational history: 10 years in mining; the past 3 years in ore processing with known mercury exposure.

Examination findings: Fine intention tremor, mild ataxia, dysarthria. No focal neurological deficits. Vitals normal. No rash or lymphadenopathy.

Investigations: Serum mercury level: 58 µg/L (>20 µg/L elevated). 24-hour urinary mercury excretion: elevated. FBC, LFTs, and renal function: normal.

What are the most appropriate next steps in the management of this patient? Select three (3) from the following list:

Patricia O’Connor, aged 46, presents with persistent sore throat, hoarseness, and throat clearing for the past three months. She is a primary school teacher and reports frequent voice strain during classroom teaching. She describes her voice as ‘tired’ by the end of each day and finds it difficult to project her voice during noisy group activities. There are no fevers, weight loss, or neck masses. She denies reflux or cough.

Medications: Nil

Allergies: Nil known

Past history: None significant

Social history: Non-smoker, moderate coffee intake. Lives with partner and two children. No relevant exposures at home.

Occupational history: Full-time teacher for over 15 years. No use of microphones or sound amplification in the classroom. Reports noisy, echoing room and frequent need to raise her voice.

Examination findings: Hoarse voice on speaking. Oropharynx clear. No cervical lymphadenopathy. Lungs and neurological exams are normal.

Investigations: Laryngoscopy by ENT: mild bilateral vocal cord nodules. No suspicious lesions. No laryngeal paralysis. Vocal cord mobility preserved.

What are the most appropriate next steps in management? Select three (3) from the following list:

Elijah Thomas, aged 41, presents with worsening skin discolouration and tightness of the fingers, as well as joint stiffness and difficulty swallowing. He works in the plastics manufacturing industry, handling industrial solvents and resins for over 15 years. His symptoms began insidiously and have progressed gradually. He also reports cold sensitivity in his hands, with fingers turning white and then blue in cold conditions. He has no known autoimmune history or family history of connective tissue disease.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: Long-term work in plastics and resin exposure, often in poorly ventilated areas. No PPE provided until recently. Reports other workers with similar symptoms.

Examination findings: Sclerodactyly, telangiectasia on face, Raynaud’s phenomenon, decreased hand grip. No digital ulcers. BP 130/85 mmHg. No synovitis or oedema. Normal cardiovascular and respiratory exams.

Investigations: ANA positive (homogeneous pattern), Anti-Scl-70 antibody positive. ESR mildly elevated. Nailfold capillaroscopy: dilated loops. Spirometry and HRCT pending.

What are the most appropriate next steps in management? Select three (3) from the following list:

Ahmed Ismail, aged 36, presents with worsening eye discomfort, foreign body sensation, and excessive tearing by the end of each workday. He is employed in a metal grinding workshop, where he often works with angle grinders and sanders. He reports that despite wearing basic safety glasses, fine metallic dust regularly irritates his eyes. Over the past two weeks, symptoms have worsened, and yesterday he removed a small speck of metal from his conjunctiva himself. He denies visual changes or systemic symptoms.

Medications: Nil

Allergies: Nil known

Past history: None significant

Occupational history: Works in a fabrication workshop. Inconsistent use of wraparound eye protection. Colleagues have had prior metal foreign body incidents. No formal workplace PPE audit conducted in the past year.

Examination findings: Mild conjunctival injection bilaterally. Visual acuity 6/6 each eye. Fluorescein staining reveals linear corneal abrasions bilaterally. No retained foreign bodies. No anterior chamber reaction. Intraocular pressures normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Daniela Russo, aged 30, presents with a 2-month history of persistent headaches, fatigue, and poor concentration. She works at a landfill site operating heavy machinery and recently moved into an older demountable office located close to a refuse sorting area. Several staff working in the same building have reported similar symptoms. She describes a musty odour in the building, and symptoms improve on days she works outdoors. No fever, visual changes, or focal neurological symptoms are reported.

Medications: Nil

Allergies: Nil known

Past history: Mild seasonal allergic rhinitis

Occupational history: Three years in environmental waste operations. Recently relocated to a demountable office suspected to have water damage and poor ventilation.

Examination findings: Vitals normal. ENT exam unremarkable. Mild bilateral periorbital puffiness. Chest clear. Neurological exam normal.

Investigations: Blood tests: CBC, electrolytes, liver and renal function all normal. CRP normal. Urinalysis unremarkable. No abnormal findings on physical exam to suggest systemic illness.

What are the most appropriate next steps in management? Select three (3) from the following list:

Simon Bradshaw, aged 54, presents with a dry cough, mild dyspnoea, and intermittent chest tightness that has developed over the past 18 months. He works in a fertiliser blending plant and reports frequent dust exposure. He describes a strong ammonia smell in the mixing shed and occasional episodes of wheezing after heavy exposure. He has no known history of asthma or allergies and is a non-smoker.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: 25 years in fertiliser handling. Limited use of respiratory PPE. No baseline spirometry available. Colleagues with similar respiratory complaints.

Examination findings: Mild end-expiratory wheeze, SpO2 96% on room air. No cyanosis or clubbing. Cardiovascular and neurological examinations unremarkable.

Investigations: Spirometry: FEV1 68% predicted, FEV1/FVC ratio 0.65, with 14% post-bronchodilator improvement. Chest X-ray: Hyperinflated lungs, no focal consolidation. Eosinophils within normal range. Peak flow diary shows diurnal variation >20% on workdays.

What are the most appropriate next steps in management? Select three (3) from the following list:

Kylie Peterson, aged 48, presents with bilateral wrist and hand pain, numbness in the fingers (particularly at night), and reduced grip strength. She has worked for 12 years as a meat packer in a refrigerated processing plant, where she repetitively cuts and wraps meat using vibrating tools and performs rapid hand movements for extended periods.

She reports that her symptoms have worsened significantly over the last six months, causing difficulty with household tasks. She denies neck pain or other joint issues. No history of inflammatory arthritis or diabetes.

Medications: Occasional ibuprofen

Allergies: Nil known

Past history: Nil significant

Occupational history: Daily exposure to repetitive wrist movements, cold environments, and hand-held vibrating equipment. No ergonomic assessment of her workstation has been done.

Examination findings: Bilateral thenar wasting, reduced grip strength, positive Tinel’s and Phalen’s signs. Normal reflexes. No cervical tenderness. No synovitis in other joints.

Investigations: Nerve conduction studies: bilateral moderate median nerve compression at the carpal tunnel. FBC, CRP, RF: normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Felicity Tran, aged 27, presents with facial flushing, palpitations, dizziness, and occasional diarrhoea occurring shortly after starting work in a seafood processing plant. She reports that the symptoms come on during shellfish handling and steam cooking shifts, especially with prawns and mussels. They began a few weeks after she started her job. She has no history of asthma, food allergies, or atopy.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: Employed for six months in seafood processing. Works in confined, steam-filled spaces without respiratory protection. Symptoms do not occur on days off.

Examination findings: Vitals normal between episodes. No urticaria or rash visible today. Chest clear. Cardiovascular and neurological exams normal.

Investigations: Serum tryptase (post-episode): mildly elevated. Skin prick testing: positive to shellfish (prawn and mussel). Spirometry normal. ECG normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Mark Reid, aged 44, presents with progressive fatigue, mild anaemia, and diffuse musculoskeletal aches. He works as a welder in a small fabrication workshop and has done so for over 20 years. He reports poor ventilation in the work area and inconsistent use of respiratory protection. He handles metal fumes daily, especially from stainless steel and galvanised metals. He has also noted a metallic taste in his mouth and mild tremor over recent months.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: Long-term welding work, exposure to metal fumes including manganese, chromium, and cadmium. No baseline biological monitoring conducted by employer.

Examination findings: Mild pallor, fine postural tremor, no focal neurological signs. Cardiovascular and respiratory exams unremarkable.

Investigations: FBC: Hb 108 g/L (normocytic), WCC and platelets normal. LFTs: mild transaminitis. Blood manganese: elevated. Renal function normal. Serum lead, cadmium: within normal limits.

What are the most appropriate next steps in management? Select three (3) from the following list:

Emily Zhao, aged 34, presents with persistent nasal congestion, sneezing, and post-nasal drip that worsens during her work shifts at a commercial bakery. She reports that symptoms improve on weekends and during holidays. She has worked in the bakery for five years and is responsible for mixing dry ingredients, including large volumes of flour and powdered additives. She has no history of asthma, eczema, or known allergies.

Medications: Occasional over-the-counter antihistamines

Allergies: Nil known

Past history: Nil significant

Occupational history: Repeated exposure to flour dust, powdered yeast, and enzymes in confined areas with limited ventilation and inconsistent use of face masks.

Examination findings: Pale, swollen nasal turbinates with clear discharge. No wheeze or respiratory distress. Throat mildly erythematous. Chest and cardiovascular exams normal.

Investigations: Skin prick testing: positive to wheat flour and fungal alpha-amylase. Spirometry: normal. Serum eosinophils mildly elevated.

What are the most appropriate next steps in management? Select three (3) from the following list:

Joseph Miles, aged 39, presents with persistent burning and numbness in his feet that has developed gradually over the past year. He works as an industrial spray painter, frequently using organic solvents such as toluene, xylene, and methyl ethyl ketone (MEK). He wears gloves but no respiratory protection. He reports occasional headaches and difficulty concentrating. No alcohol or recreational drug use.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: 15 years of spray painting in automotive and metal industries. Poor ventilation in work environment. No previous occupational health review.

Examination findings: Decreased pinprick and vibration sense in both feet. Mild ataxic gait. No upper limb abnormalities. Reflexes reduced at ankles.

Investigations: Nerve conduction studies: distal symmetric axonal polyneuropathy. B12, TSH, HbA1c: normal. Liver function: mildly elevated ALT. Blood lead: normal. Urinary hippuric acid elevated (suggesting recent toluene exposure).

What are the most appropriate next steps in management? Select three (3) from the following list:

Renee Wallace, aged 52, presents with worsening breathlessness on exertion, dry cough, and reduced exercise tolerance. She works as a textile worker in a cotton processing factory and reports many years of exposure to cotton dust in poorly ventilated areas. She describes chest tightness at the end of her shift, which improves on weekends. She has no history of asthma or smoking.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: Over 25 years in textile industry. No PPE provided historically. Recently started wearing a basic mask. Several co-workers report similar symptoms.

Examination findings: Mild end-expiratory wheeze. SpO2 96% on room air. Normal cardiovascular and neurological examination.

Investigations: Spirometry: FEV1 70% predicted, FEV1/FVC ratio 0.62, improves 15% post-bronchodilator. Chest X-ray: hyperinflated lungs, no fibrosis. Peak flow diary: diurnal variation >20% during workdays.

What are the most appropriate next steps in management? Select three (3) from the following list:

Sophie Martin, aged 32, presents with ongoing insomnia, irritability, and difficulty concentrating. She works permanent night shifts as a nurse in an aged care facility and reports that her symptoms have worsened over the last six months. She struggles to fall asleep during the day and wakes frequently. She often feels fatigued, even after what she believes is adequate rest. She uses caffeine to stay alert during her shift and occasionally uses over-the-counter sleep aids.

Medications: Occasionally takes diphenhydramine at night

Allergies: Nil known

Past history: Mild anxiety (non-medicated)

Occupational history: Has worked permanent night shifts for 4 years. Recently increased to five nights per week due to staff shortages. No rotating roster. No recent annual leave.

Examination findings: Vitals normal. Appears tired but cooperative. Mood euthymic. No signs of major depression or anxiety disorder. Neurological and cardiovascular exams normal.

Investigations: Epworth Sleepiness Scale: 15/24. Blood tests including thyroid function, FBC, B12, iron studies: all normal. PHQ-9: 4/27.

What are the most appropriate next steps in management? Select three (3) from the following list:

Geoffrey Lang, aged 47, presents with a 3-month history of persistent dry cough, dyspnoea on exertion, and fatigue. He works at a quarry site and is involved in drilling and crushing rock. He reports frequent exposure to dust clouds during blasting and loading activities. Respiratory protection is available but inconsistently used. He is a lifelong non-smoker.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: Over 20 years in quarrying. Known silica exposure. No formal occupational health surveillance performed previously.

Examination findings: Bilateral fine inspiratory crackles at lung bases. Oxygen saturation 95% on room air. Cardiovascular and other systems unremarkable.

Investigations: Chest X-ray: diffuse nodular opacities in upper lobes. HRCT chest: small rounded opacities with early coalescence consistent with chronic silicosis. Spirometry: FVC 74% predicted, FEV1/FVC ratio normal. DLCO reduced. Sputum AFB negative.

What are the most appropriate next steps in management? Select three (3) from the following list:

Linda Forrest, aged 29, presents with recurrent dermatitis affecting her hands and wrists. She works as a hairdresser and reports that her skin becomes red, itchy, and cracked after multiple client treatments, especially when using hair dyes, bleaches, and shampoos. The symptoms improve slightly on days off. She has tried moisturisers and barrier creams with limited benefit. She wears gloves, but removes them frequently due to sweating and discomfort.

Medications: Nil

Allergies: Nil known

Past history: Mild childhood eczema

Occupational history: 10 years as a hairdresser. Frequent use of hair chemicals and wet work. No formal PPE training provided.

Examination findings: Erythematous, scaly patches with some fissuring on the dorsal hands and wrists. No signs of infection. No systemic features.

Investigations: Patch testing: positive to paraphenylenediamine (PPD) and ammonium persulfate. No fungal growth on skin scrapings.

What are the most appropriate next steps in management? Select three (3) from the following list:

Ben Holloway, aged 61, presents with progressive unsteadiness, hearing loss, and persistent ringing in both ears. He retired six months ago from his long-term job as a machinery operator in a metal fabrication factory. He worked in high-noise environments for over 35 years without consistent use of hearing protection until the last decade. He denies vertigo or ear discharge. Symptoms have persisted despite retirement.

Medications: Atorvastatin, irbesartan

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Occupational history: Chronic exposure to industrial noise without early hearing protection. No prior hearing tests on record. No exposure to ototoxic agents.

Examination findings: Positive Romberg’s test. Weber test lateralises to the left. Rinne test: air conduction > bone conduction bilaterally. Gait mildly unsteady. Tympanic membranes normal bilaterally.

Investigations: Audiometry: bilateral high-frequency sensorineural hearing loss. MRI brain/IAC: normal. No vestibular schwannoma identified.

What are the most appropriate next steps in management? Select three (3) from the following list:

Tania Wells, aged 38, presents with a persistent dry cough, wheeze, and episodic chest tightness over the past eight months. She works in a commercial cleaning company and is regularly exposed to strong cleaning agents, including chlorine-based disinfectants, ammonia, and spray degreasers. She reports her symptoms worsen during and shortly after her shifts and improve on weekends and holidays.

Medications: Salbutamol inhaler used occasionally

Allergies: Nil known

Past history: Nil asthma or atopy

Occupational history: 5 years in commercial cleaning. Frequently works in poorly ventilated indoor areas. No respiratory protection provided. No baseline lung function testing ever conducted.

Examination findings: Mild expiratory wheeze. Oxygen saturation 97% on room air. No clubbing or cyanosis. No peripheral oedema.

Investigations: Spirometry: FEV1 72% predicted, FEV1/FVC ratio 0.68. Post-bronchodilator FEV1 improved by 18%. Serial peak flow diary: >20% diurnal variation on workdays. Chest X-ray: normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Robert Giles, aged 58, presents with worsening fatigue, abdominal pain, and pale stools over the past month. He works at a battery recycling plant where he is involved in dismantling lead-acid batteries. He reports poor ventilation in some areas and occasional visible dust. He has also experienced recent mood changes, memory difficulties, and reduced libido.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: 20 years in lead-acid battery dismantling. Limited use of respiratory protection until recently. No regular blood lead monitoring performed in last 5 years.

Examination findings: Mild pallor, abdominal tenderness (diffuse), slowed mental processing, normal reflexes. BP 135/85 mmHg. No jaundice. Neurological and cardiovascular systems otherwise normal.

Investigations: Blood lead level: 62 µg/dL (>20 µg/dL considered elevated). FBC: mild normocytic anaemia. Liver function: mildly elevated transaminases. Renal function: normal. Abdominal ultrasound: fatty liver, no obstruction.

What are the most appropriate next steps in management? Select three (3) from the following list:

Nathan Kaur, aged 40, presents with worsening joint stiffness, fatigue, and eye irritation. He works as a laboratory technician in a university research lab where he handles formaldehyde, glutaraldehyde, and other chemical fixatives regularly. Over the past year, he has developed sore, dry eyes and nasal congestion that improve on weekends. More recently, he has experienced diffuse joint pain and morning stiffness lasting more than 30 minutes.

Medications: Occasional ibuprofen

Allergies: Nil known

Past history: Nil significant

Occupational history: 12 years in lab-based histology work. Poor ventilation reported in the fixative storage area. No fume hoods in older sections of lab. No formal PPE fit testing completed.

Examination findings: Mild bilateral conjunctival injection. Small joint tenderness in both hands and wrists. No synovial swelling. Cardiovascular, respiratory, and neurological exams unremarkable.

Investigations: ANA negative. ESR 12 mm/hr. CRP normal. RF negative. Spirometry: normal. Visual acuity preserved. Chest X-ray: clear lung fields.

What are the most appropriate next steps in management? Select three (3) from the following list:

Henry Osei, aged 45, presents with chest tightness, shortness of breath, and wheezing that began acutely at work 2 days ago. He works in a pool maintenance company and was exposed to high levels of chlorine gas after a spill occurred while mixing chemicals in an enclosed storage area. He describes immediate coughing, burning in the throat and eyes, and difficulty breathing. He was taken to the emergency department where he received salbutamol and oxygen. He is now stable but continues to experience mild exertional dyspnoea.

Medications: Salbutamol inhaler (post-incident)

Allergies: Nil known

Past history: Nil asthma or respiratory illness

Occupational history: 10 years in pool chemical handling. No formal training provided for chemical mixing. PPE use variable. No fume extraction in the area where the incident occurred.

Examination findings: Vitals stable. Mild expiratory wheeze. SpO2 98% on room air. No clubbing or cyanosis. Chest clear apart from wheeze.

Investigations: Chest X-ray: normal. Spirometry: FEV1 76% predicted, FEV1/FVC ratio 0.68 with 15% improvement post-bronchodilator. Peak flow variable since incident. CRP normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Alice Bourke, aged 33, presents with persistent headaches, dizziness, and intermittent nausea over the past two months. She works in an underground car park as a security attendant, often doing 10-hour shifts in an enclosed booth near vehicle entry points. She reports poor ventilation and frequent exposure to exhaust fumes. Several co-workers have reported similar symptoms. Symptoms improve when she is not at work.

Medications: Nil

Allergies: Nil known

Past history: Migraine in adolescence (resolved)

Occupational history: 2 years in this role. No carbon monoxide monitoring or ventilation assessment has been performed in her area. No access to fresh air during shift.

Examination findings: Mild postural tachycardia. Neurological and cardiorespiratory exams normal. Alert and oriented.

Investigations: Venous carboxyhaemoglobin level post-shift: 11% (normal <2% in non-smokers). CBC, LFTs, and renal function: normal. ECG: normal sinus rhythm. Chest X-ray: clear.

What are the most appropriate next steps in management? Select three (3) from the following list:

Paulina Mendez, aged 36, presents with severe eye irritation, coughing, and facial burning that began while she was cleaning a commercial kitchen oven with an industrial-strength degreaser. She reports immediate symptoms after the spray was applied in an enclosed, unventilated area. She did not wear eye or respiratory protection. Symptoms improved slightly after leaving the area but have persisted for several hours.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: Six years in commercial cleaning. Regularly uses caustic cleaning products. No prior chemical safety training provided. PPE is inconsistently available.

Examination findings: Bilateral conjunctival injection, mild facial erythema, persistent dry cough. Chest clear on auscultation. Vitals stable. Oxygen saturation 99% on room air. No wheeze or stridor.

Investigations: Not performed (symptoms mild and resolving). No visual impairment noted. Peak flow 90% of predicted. No signs of systemic toxicity.

What are the most appropriate next steps in management? Select three (3) from the following list:

Stephen Halabi, aged 49, presents with persistent numbness and tingling in both feet, as well as progressive imbalance over the past year. He is employed as a pest control technician and has frequent dermal and inhalational exposure to organophosphate-based insecticides. He wears gloves, but often applies sprays in enclosed residential spaces without ventilation. He reports occasional headaches, fatigue, and difficulty concentrating.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: 20 years in pest control. Regular use of malathion and chlorpyrifos. No formal PPE fit testing or toxicology screening done previously.

Examination findings: Distal sensory loss to pinprick and vibration in both feet. Mild unsteadiness on tandem walking. Reflexes reduced at ankles. Cranial nerves normal. No muscle weakness or upper motor neuron signs.

Investigations: Nerve conduction studies: distal symmetric axonal sensorimotor polyneuropathy. RBC cholinesterase: markedly reduced. Liver and renal function: normal. HbA1c and B12: normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Daniel Murphy, aged 60, presents with chronic hoarseness, mild dysphagia, and a sensation of throat tightness that has been worsening over the last year. He is a retired firefighter with 30 years of service, during which he was exposed to repeated smoke inhalation and occasionally worked without respiratory protection in the early years of his career. He denies weight loss, haemoptysis, or alcohol use. He is an ex-smoker (quit 10 years ago after 20 pack-years).

Medications: Nil

Allergies: Nil known

Past history: GERD (well controlled), hypertension

Occupational history: 30 years as a firefighter, including structural firefighting and bushfire response. Repeated exposure to combustion by-products and particulate matter.

Examination findings: Hoarse voice, no cervical lymphadenopathy. Flexible nasoendoscopy: chronic laryngeal inflammation, no visible mass. Lungs clear. No focal neurological signs.

Investigations: Laryngoscopy: thickened vocal cords, mild leukoplakia. No evidence of malignancy. Chest X-ray: hyperinflated lungs, no mass or nodules. Spirometry: mild obstructive pattern (FEV1 68% predicted).

What are the most appropriate next steps in management? Select three (3) from the following list:

Emma Sorensen, aged 28, presents with recurrent nosebleeds, nasal crusting, and a metallic taste in her mouth. She has worked for the past 3 years in a small jewellery manufacturing studio, primarily involved in polishing and shaping silver items using buffing wheels and rotary tools. The workshop is poorly ventilated, and she often works without a mask. She reports fine dust accumulation on surfaces and clothing by the end of the day.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: Daily exposure to fine metal dust (primarily silver and copper alloys). No formal respiratory health monitoring or PPE training has been provided.

Examination findings: Mild anterior nasal crusting and erythema bilaterally. Nasal mucosa friable. No septal perforation. Chest clear to auscultation. No clubbing or cyanosis.

Investigations: Blood lead level: 4 µg/dL (normal). Serum silver level: mildly elevated. Spirometry: normal. Nasal swab: negative for infection. No eosinophilia on blood film.

What are the most appropriate next steps in management? Select three (3) from the following list:

Michael Tran, aged 26, presents with worsening itchy eyes, sneezing, and nasal congestion that occur daily during his shifts as an apprentice baker. He reports that symptoms improve significantly on weekends and holidays. He works with flour, yeast, and enzymes in a small bakery where ventilation is limited and masks are not routinely used. He has no previous history of hay fever or asthma.

Medications: Occasional over-the-counter loratadine

Allergies: Nil known

Past history: Nil significant

Occupational history: 1 year as a baker. Frequent direct exposure to flour dust and enzyme additives (e.g. fungal amylase). No previous occupational health review.

Examination findings: Pale, boggy nasal turbinates. Bilateral conjunctival injection. Chest clear to auscultation. No wheeze or respiratory distress.

Investigations: Skin prick testing: positive to wheat flour and fungal amylase. Peak flow variability diary pending. Spirometry: normal baseline values. Serum IgE elevated.

What are the most appropriate next steps in management? Select three (3) from the following list:

James O’Donnell, aged 63, presents with progressive breathlessness and dry cough. He retired 5 years ago after working for over 30 years as a boilermaker in shipyards, where he was regularly exposed to asbestos insulation and lagging. He wore minimal respiratory protection, particularly in the early years. He denies chest pain, haemoptysis, or weight loss. He is a non-smoker.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: Long-term work in shipbuilding and boiler maintenance with frequent asbestos exposure. No occupational health follow-up post-retirement.

Examination findings: Fine bibasal end-inspiratory crackles. No finger clubbing. SpO2 95% on room air. Cardiovascular exam normal.

Investigations: Chest X-ray: bilateral pleural plaques. HRCT chest: subpleural reticulations and early honeycombing at bases, consistent with asbestosis. Spirometry: FVC 68% predicted, DLCO reduced. CRP normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Angela Dixon, aged 51, presents with progressive hand weakness, muscle wasting in the intrinsic hand muscles, and fasciculations over the last 9 months. She has worked for over 20 years as a pesticide sprayer on a fruit farm, frequently handling organophosphates and carbamate insecticides. She notes that gloves were used inconsistently and that she often experienced excessive sweating and light-headedness during long spraying sessions.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: Long-term exposure to neurotoxic pesticides without consistent PPE or workplace monitoring. No biological monitoring conducted.

Examination findings: Marked atrophy of hand muscles, bilateral fasciculations, brisk reflexes, normal sensation, no cranial nerve abnormalities. No upper limb sensory deficits.

Investigations: EMG: widespread denervation and reinnervation in upper and lower limbs. Nerve conduction studies: normal sensory function, reduced motor amplitude. Cholinesterase level: chronically suppressed. MRI brain and spine: no structural abnormalities.

What are the most appropriate next steps in management? Select three (3) from the following list:

Sarah Ibrahim, aged 34, presents with a persistent dry cough, occasional chest tightness, and breathlessness during work hours. She is employed in a newly constructed office building that has been operational for only six months. Several other colleagues have reported similar symptoms. Sarah’s symptoms improve when she spends weekends away from the building and during holidays. She denies fever, sputum production, or systemic symptoms.

Medications: Nil

Allergies: Nil known

Past history: Mild seasonal allergic rhinitis

Occupational history: Administrative assistant in open-plan office with recent fit-out including new carpets, paint, and furnishings. Air conditioning recently serviced but no formal air quality testing performed.

Examination findings: Normal vital signs. Chest clear. No wheeze or crackles. ENT exam normal. No rash or conjunctival irritation.

Investigations: Spirometry: normal. Chest X-ray: clear. CBC and CRP: normal. Peak flow diary: slight decline over workweek, improving on weekends.

What are the most appropriate next steps in management? Select three (3) from the following list:

Amir Patel, aged 40, presents with difficulty breathing and wheezing that began after he started a new job at a polyurethane foam manufacturing plant three months ago. He reports worsening symptoms during the workweek, with improvement on weekends. He is often exposed to isocyanates used in the foam curing process. He wears gloves but not a respirator. He has never had asthma and is a non-smoker.

Medications: Nil

Allergies: Nil known

Past history: Nil respiratory or atopic conditions

Occupational history: Recently employed in isocyanate-based manufacturing. Works indoors with poor ventilation. No baseline lung function testing was conducted prior to starting employment.

Examination findings: Mild expiratory wheeze. Normal oxygen saturation. Chest otherwise clear.

Investigations: Spirometry: FEV1 65% predicted, FEV1/FVC ratio 0.68. Post-bronchodilator FEV1 improvement of 18%. Serial peak flow readings: significant diurnal variation on workdays (>20%). Chest X-ray: normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Linda Jamieson, aged 59, presents with memory problems, mood lability, and tremor that have developed gradually over the past year. She works in an artisanal ceramics studio and has daily exposure to glazes and pigments containing inorganic mercury. She reports that many of the glazes used are mixed in poorly ventilated areas and that she handles them without gloves. She has also noticed increased irritability and sleep disturbance.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Occupational history: 15 years in ceramics. High exposure to mercury-containing compounds. No previous occupational health surveillance performed. No PPE provided other than a cloth apron.

Examination findings: Fine tremor of the hands, mild dysdiadochokinesis. Reflexes normal. No motor weakness. Affect appears labile during consultation.

Investigations: Blood mercury: elevated at 35 µg/L (normal <10 µg/L). Urine mercury also elevated. CBC, renal and liver function: within normal limits. Brain MRI: no acute abnormalities.

What are the most appropriate next steps in management? Select three (3) from the following list:

Thomas Reilly, aged 41, presents with a six-month history of dry cough, intermittent wheezing, and progressive exertional dyspnoea. He works in a furniture-making workshop where he regularly sands wood and applies solvent-based varnishes. He reports the symptoms worsen during the workweek and ease during weekends and holidays. He does not use a respirator and often works in dusty environments without extraction fans.

Medications: Nil

Allergies: Nil known

Past history: Mild childhood asthma (resolved)

Occupational history: 15 years in wood finishing and sanding. Daily exposure to hardwood dust and solvent vapours. No workplace air quality monitoring has been done.

Examination findings: Mild wheeze on forced expiration. Normal oxygen saturation and vital signs. No clubbing or cyanosis.

Investigations: Spirometry: FEV1 70% predicted, FEV1/FVC ratio 0.66. Post-bronchodilator: 16% improvement in FEV1. Peak flow diary: significant variability during workdays. Chest X-ray: no abnormalities.

What are the most appropriate next steps in management? Select three (3) from the following list:

Karen Bishop, aged 46, presents with persistent burning and stinging of her hands, which worsens after exposure to cold water and cleaning products at work. She is employed as a dishwasher in a commercial kitchen. She reports redness, cracking, and skin peeling, particularly during winter. She wears vinyl gloves, but these often fill with water, and she frequently removes them due to discomfort. She uses hand creams irregularly. The symptoms improve slightly on weekends but recur rapidly after returning to work.

Medications: Nil

Allergies: Nil known

Past history: Mild childhood eczema

Occupational history: 8 years in commercial kitchens, significant daily exposure to water, detergents, and harsh cleaning chemicals. No PPE training provided.

Examination findings: Erythematous, dry, fissured skin over dorsal hands and fingers. No pustules, vesicles, or signs of infection. Nails and surrounding skin intact.

Investigations: Not performed. Diagnosis made clinically. Patch testing pending.

What are the most appropriate next steps in management? Select three (3) from the following list: