Unfortunately, because most physicians have little training in environmental health, these diseases are often misidentified and misattributed to allergic and infectious causes. Many workers do not know all the chemicals being used or the names of the chemicals to which they are exposed, so the occupational and environmental history should seek to uncover possible etiologic associations when patients present with symptoms that suggest a disease of environmental origin. Juarez should be conducted at a level that matches his health literacy. Franzen to identify and prevent potential further toxic exposures in Mr. Juarez.Ī brief environmental and occupational history, which can be obtained through a questionnaire completed in the waiting room would have allowed Dr. In addition, language barriers, lack of health insurance and fear of job loss make a follow-up visit nearly impossible for Mr. First, toxic chemical exposures disproportionately affect workers and communities of low socioeconomic status. However, a number of aspects of this case make a more complete differential diagnosis and investigation of possible work and home exposures critical. Indeed, atopy is common in adults-with a prevalence as high as 20 percent according to one report, and, as the adage goes, hoof beats represent horses more often than they represent zebras. Juarez’s symptoms could be interpreted as signs of a new onset allergy. These data should convince physicians to consider the possibility of toxic chemical exposure, especially when they are assessing the health of farm and factory workers. More than 800,000 illnesses and 60,000 deaths annually are attributable to occupational exposures in the United States, and diseases of environmental origin among American children cost our nation $54.9 billion annually. Because the Toxic Substances Control Act does not require that chemicals be proven safe before they are allowed to be marketed, it is not surprising that diseases of occupational and environmental origin are prevalent in the United States. There are some 90,000 chemicals licensed for use in the United States by the Environmental Protection Agency, and 1,000 to 3,000 new chemicals are approved for use each year. Juarez is unfortunately all too common, as toxic chemical exposures occur with increasing frequency, both in the home and in the workplace. Many of them had not visited a physician, so he thought he would wait longer before going back to Dr. Interestingly, he noticed that there were a number of other farm workers who had symptoms similar to his. Juarez did not improve over the next week, but he could not afford to take another day off to go back to Dr. ![]() He had seen a few patients sporadically with similar symptoms but many never followed up, so he continued to diagnose them with hay fever. Juarez’s circumstances, many of whom never came back to the clinic. Franzen was used to seeing patients in Mr. Franzen gave him a sizable amount of a generic antihistamine and a prescription for more. Juarez would be paying out-of-pocket for his medications, Dr. Juarez with hay fever, thinking it was possible that he was reacting to certain allergens for the first time. Juarez was 27 and had an otherwise unremarkable health history, he diagnosed Mr. Juarez’s symptoms could have been due to any one of many causes. Franzen was experiencing a particularly hectic day at the clinic, and Mr. with his wife and had found work on a farm near where he lived and that he missed the rest of his family back in southern Mexico.ĭr. Juarez’s eyes were red and heard wheezing in his chest. He performed a typical history and physical. Frazen had a working knowledge of Spanish and began to converse with Mr. Franzen realized Spanish would be the preferred language for this encounter. Franzen, entered the room and introduced himself to the patient. Juarez had come to the United States recently to find work and build a family in California. ![]() ![]() He was seeing the physician as a self-pay patient. He was not febrile and reported occasional nausea during the preceding two weeks, although not at the time of the visit. Juarez went to a local community clinic in south central California as a new patient because he was experiencing a slight but persistent cough, shortness of breath, headache, fatigue, muscle weakness and eye irritation.
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