A 29-year-old auto mechanic with headaches, irritability, and forgetfulness

A 29-year-old man is brought to your office by his wife. He is reluctant to provide a history but does admit that he has been having frequent headaches for the past month. His wife indicates that at times he is somewhat confused and forgetful. She feels these symptoms have developed since they moved to their new home 6 months ago. She tells you that she has also been irritable and that several of their neighbors have been complaining of a variety of nonspecific symptoms, including headaches and forgetfulness. The wife also says that a nearby gas station was recently fined for having a leaking underground storage tank, and she feels that her family and her neighbors are being poisoned by contaminated drinking water.

The patient’s medical history is unremarkable. After completing high school, he entered the Air Force, where he was trained as a mechanic. When he left military service, he and his family moved back to this rural community to be close to his wife’s family. He has taken a job at the hardware store as a temporary position and plans to open an automotive repair shop within the next year. He has had an interest in old automobiles since high school. His new position at the hardware store has allowed him to spend an increasing amount of time working on old cars in his garage in back of the house.

The patient’s physical examination is unremarkable except for mild dermatitis on the hands, which he attributes to grease and the dirty auto parts he handles. Results of laboratory screening tests, including CBC and liver function tests, are within normal limits.

Answers to the Pretest questions are on page 19.