A DOccMed station on MedMock, start to finish

Good morning. I have read your portfolio case about the 36-year-old commercial baker referred with work-related rhinitis and wheeze. How did you establish from the clinical and occupational history that his respiratory symptoms were likely to be occupational asthma rather than coincidental adult-onset asthma?

I took a chronological occupational and clinical history starting from when he joined the commercial bakery four years ago. He had a latency period of about 18 months working around high-speed dough mixers before developing rhinorrhoea and sneezing at work, followed six months later by cough, wheeze and chest tightness starting two to three hours into shifts when sieving wheat flour and improver enzymes. Crucially, his symptoms improved over weekends and resolved during a two-week holiday, then recurred within days of returning to the mixing bay. That latency period, preceded by work-related rhinitis and clear rest-day improvement, is characteristic of sensitiser-induced occupational asthma caused by high-molecular-weight allergens—specifically wheat flour and fungal alpha-amylase.

How did you confirm the diagnosis objectively, and why was it important to do that while he was still exposed?

Objective confirmation is essential before advising permanent job restriction because removing a worker from their livelihood has major socioeconomic consequences, and diagnostic sensitivity falls once exposure stops. While he remained in his normal baking role, I arranged serial peak expiratory flow measurements recorded every two hours from waking to sleeping for four weeks across both work periods and rest days, analysed using the Oasys system, alongside baseline spirometry and specific IgE to wheat flour and fungal alpha-amylase, and referred him to a specialist occupational lung disease clinic. His serial peak flow chart demonstrated clear work-related falls with an Oasys score confirming occupational asthma, and specific IgE was positive to both wheat flour and alpha-amylase.

Once sensitiser-induced occupational asthma was confirmed, what advice did you give the worker and the employer on workplace controls and fitness for work?

For sensitiser-induced occupational asthma, the clinical priority is complete and early removal from further exposure to the causal respiratory sensitiser, because continued exposure leads to progressive, irreversible airflow obstruction even at very low airborne concentrations. With the baker’s informed consent under the Access to Medical Reports Act 1988 and GMC confidentiality guidance, I advised the employer that he was fit for work provided he was permanently redeployed away from airborne flour dust and bakery enzymes—for example into dispatch office or packaged-goods logistics—as a reasonable adjustment under the Equality Act 2010. For the bakery as a whole, I advised the employer to review their COSHH 2002 risk assessment using the hierarchy of controls: substituting low-dust liquid or pelleted improvers instead of powdered alpha-amylase, enclosing chutes, fitting local exhaust ventilation at mixing and tipping points, avoiding dry sweeping in favour of wet cleaning or HEPA vacuuming, and reviewing health surveillance across the remaining exposed workforce.

What statutory reporting and wider workforce actions did this diagnosis trigger?

Under RIDDOR 2013, a doctor’s written diagnosis of occupational asthma where the worker’s job involves exposure to a known respiratory sensitiser is a reportable occupational disease. With the worker’s consent, I notified the employer in writing of the diagnosis so the responsible person could submit the statutory RIDDOR occupational disease report to the Health and Safety Executive. I also advised the employer to trigger an immediate review of their statutory COSHH Regulation 11 health surveillance programme—questionnaire and spirometry—for all other bakers in the mixing area, as an index case indicates a failure of exposure control that puts co-workers at risk. Finally, I signposted the worker to Industrial Injuries Disablement Benefit for prescribed disease D7.

Thank you. I will now hand over to my co-examiner for the second half of the oral.