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Zorluk: ZorMedical History Evaluation

A 24-year-old man is brought to the emergency department by his supervisor due to the acute onset of severe nausea, recurrent vomiting, dizziness, and profound weakness. The symptoms began 2 hours ago while he was at work. He is employed as a seasonal agricultural worker and has been manually harvesting tobacco leaves for the past three days. It rained heavily this morning, and the patient reports his clothes have been completely soaked; he was not wearing protective gloves.

Past medical history is unremarkable. Surgical history includes an uncomplicated appendectomy at age 12. Social history reveals he drinks alcohol occasionally but does not smoke or use illicit drugs. He takes no daily medications or supplements.

Physical examination reveals a temperature of 37.1°C (98.8°F), blood pressure of 155/95 mmHg, heart rate of 110/min, and respiratory rate of 18/min. The patient is pale and profusely diaphoretic. Neurologic examination shows a fine resting tremor in the hands but no muscle fasciculations. Pupils are 5 mm in diameter and bilaterally reactive to light. Cardiopulmonary examination reveals clear lungs with no wheezing or rhonchi. Bowel sounds are hyperactive. There is no excessive salivation, lacrimation, or bronchorrhea.

Based on the patient's medical and occupational history, which of the following is the most likely diagnosis?

  1. Nicotine toxicityCevap
  2. B
    Organophosphate poisoning
  3. C
    Carbamate toxicity
  4. D
    Exertional heat exhaustion
  5. E
    Staphylococcal food poisoning

Cevap

Nicotine toxicity
The correct diagnosis is nicotine toxicity, clinically known in this context as Green Tobacco Sickness. Nicotine is a water-soluble alkaloid that is readily absorbed through the skin, a process heavily accelerated when tobacco leaves are wet from rain or morning dew and when the worker is wearing unprotective, soaked clothing. Systemic nicotine absorption initially stimulates both sympathetic and parasympathetic ganglia. This results in prominent gastrointestinal symptoms (severe nausea, vomiting, hyperactive bowel sounds) alongside sympathetic activation (tachycardia, hypertension, diaphoresis, pallor, and tremor). The patient's history perfectly aligns with this classic occupational hazard.

Adım Adım Çözüm

1
Analyze the patient's occupational and environmental exposure history.
The patient is an agricultural worker who was harvesting tobacco leaves in the rain without protective gloves, resulting in soaked clothing.
Identifying the specific environmental exposure is the critical first step in diagnosing occupational toxidromes.
2
Evaluate the clinical presentation and vital signs.
The patient has severe nausea, vomiting, dizziness, diaphoresis, hypertension (155/95 mmHg), tachycardia (110/min), and a fine tremor. He lacks miosis, bradycardia, bronchorrhea, and muscle fasciculations.
Vital signs and physical exam findings help differentiate between competing toxicological syndromes that share overlapping gastrointestinal symptoms.
3
Synthesize the history and physical exam findings to formulate a diagnosis.
The combination of dermal exposure to wet tobacco and a mixed sympathetic/parasympathetic toxidrome without extreme muscarinic signs confirms Green Tobacco Sickness (acute nicotine toxicity).
Nicotine is readily absorbed through the skin, especially in wet conditions, leading to systemic toxicity.

Anahtar Kavram

Green tobacco sickness is a form of acute nicotine toxicity caused by dermal absorption of nicotine, presenting with nausea, vomiting, dizziness, and autonomic instability, and must be differentiated from organophosphate poisoning.
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Medical History Evaluation

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