Taking an effective occupational history

Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history
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Taking an
occupational
history
Dr. Ahmed-Refat AG Refat
www.SlideShare.net/AhmedRefat

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Required Competency :
Good Clinical Care:
Objective:
to be competent in the assessment and
management of a case which has a significant
occupational health component.
SKILLS:
ELICIT A RELEVANT OCCUPATIONAL HISTORY,
IDENTIFY AND MANAGE PROBLEMS.

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Recognizing Occupational Disease—
Taking an Effective Occupational History
Am Fam Physician. 1998 Sep 15;58(4):935-944.
Raising the Level of
Occupational disease is surprisingly common.
An estimated 860,000 illnesses and 60,300 deaths from
workplace exposures occur annually in the United
States.

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Although many clinicians recognize the importance of taking
a work and exposure history to evaluate certain problems,
most have had little training or practice in doing so.
Extensive knowledge of toxicology is not needed to diagnose
environmental and occupational disease.
The diagnosis of environmental or occupational disease
cannot always be made with certainty. More commonly,
likelihood or unlikelihood is the goal. Sound clinical
judgment must be used, and common etiologies should be
considered.
The multifactorial nature of many conditions, particularly
chronic diseases, must not be overlooked.

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Common Health Conditions Associated with
Occupational Exposure
Condition Selected exposures occupations
Musculoskeletal
Carpal tunnel
syndrome
Repetition Letter sorting
Vibration Assembly work
Awkward postures Computer work
Cold temperature Food processing
De Quervain's
tendinitis
Repetition Meatpacking
High force Manufacturing
Cervical strain Static posture Computer work
Thoracic outlet
syndrome
Static posture, repetition Assembly work

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Respiratory
Interstitial fibrosis Asbestos Mining, construction
trades, building
maintenance
Silica Mining, foundry work,
sandblasting
Coal Mining
Asthma Animal products Laboratory work
Plant products Baking
Wood dust Furniture making
Isocyanates Plastics manufacturing
Metals (e.g., cobalt) Hard metals anufacturing
Cutting oils Machine operation
Irritants (e.g., sulfur dioxide) Various occupations
Bronchitis Acids Plating

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Smoke Fire fighting
Nitrogen oxides Welding
Hypersensitivity
pneumonitis
Moldy hay Farming
Cutting oils Machine operation
Upper airway irritation Indoor air pollution (i.e., sick
building syndrome)
Office work
Teaching
Neurologic
Chronic
encephalopathy
Organic solvents Painting, automobile
body repair
Organophosphate pesticides Pesticide application
Lead Bridge work, painting,
radiator repair, metal
recycling

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Peripheral
polyneuropathy
Organophosphate pesticides Pesticide application
Methyl butyl ketone Fabric coating
Hearing loss Noise Many occupations
Infectious
Bloodborne infections HIV, hepatitis B Health care work, prison
work
Airborne infections Tuberculosis Health care work, prison
work
Infections transmitted
fecally or orally
Hepatitis A Health care work, animal
care
Zoonoses Lyme disease Forestry and other
outdoor work

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Cancer
Lung Asbestos Construction trades
Chromium Welding, plating
Coal tar, pitch Steelworking
Liver Vinyl chloride Plastics manufacturing
Bladder Benzidine Plastics and chemical
manufacturing
Skin
Contact dermatitis Organic solvents Many occupations
Nickel Hairdressing
Latex Health care work

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Reproductive
Spontaneous abortionEthylene oxide Sterilizing
Sperm abnormalities Dibromochloropropane Pesticide manufacturing
Birth defects Ionizing radiation Radiographic technicians
Developmental
abnormalities
Lead Bridge work, metal
recycling
Cardiovascular
Coronary artery
disease
Carbon monoxide Working with combustion
products
Stress Machine-paced work
Gastrointestinal
Hepatitis Polychlorinated biphenyls Electrical equipment
manufacturing and repair

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Index of Suspicion
An occupational etiology should be considered if an
illness fails to respond to standard treatment, does not
fit the typical demographic profile (i.e., lung cancer in
a 40-year-old nonsmoker) or is of unknown origin.
Much is still unknown about the health effects of most
workplace exposures. The introduction of new
chemicals and other materials has far outpaced general
knowledge of their potential toxicity.

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Importance of Occupational History
Most environmental and occupational diseases either manifest as
common medical problems or have nonspecific symptoms.
Etiology distinguishes a disorder as an environmental illness.
Unless an exposure history is pursued by the clinician, the
etiologic diagnosis might be missed, treatment may be
inappropriate, and exposure can continue.
A missed diagnosis that is occupationally related
could impact not only the patient but also their co-
workers, and failure to appreciate an occupational
link can lead to reduced efficacy of medical
treatment.

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Taking a good occupational history can
help primary care physicians prevent
the onset and progression of illness and
potential disability in their patients, as
well as help protect others in the same
workplace.

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There are three ways in which primary
care physicians can improve the
detection of occupational disease
1- Raise the level of suspicion of
occupational disease
2- Build skills for efficiently obtaining
an occupational history
3- Develop routine access to
occupational medicine resources

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Case#1: A 38-year-old man reported several weeks of
generalized headaches. A diagnosis of stress-tension
headache was made, and he was given an analgesic.
Because he continued to have pain, computed tomographic
(CT) scanning was performed. The CT scan was normal.
The patient was referred to a neurologist and then to a
specialty headache clinic. Various treatments were applied
without effect.
An occupational history revealed that he had been a spray
painter for 11 months. While at work, he was routinely
exposed to mixed organic solvents. When he was taken out
of work for four weeks, his headaches cleared.

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Here are some scenarios.
Scenario 1:
A 35-year-old man presents to clinic with a 3 month
history of intermittent wheezing and nocturnal cough.
Further questioning reveals that he is a non-smoker
with no history of atopy (allergy) and informs you that
he works as a junior technician in a local company. You
suspect he may have asthma and the spirometry
confirms the diagnosis of asthma. You then provide him
with a salbutamol inhaler and ask to review him in 4 weeks
time.

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Scenario 2
A 56-year-old gentleman presents to you in a clinic
complaining of tingling in the tips of his fingers. This is
accompanied by colour changes in the cold weather. He
works as a salesman and smokes 20 cigarettes a day.
You suspect he has Reynaud’s disease and commence
him on treatment.
Scenario 3
A 40-year-old lady presents with tinnitus and hearing
loss. She informs you that she works as an assembly
operator in an electronics factory. On clinical
examination the auditory canal is clear and you suspect

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she may have acute labyrinthitis. You start her on
treatment and arrange to review if her symptoms do not
settle.
What links all 3 scenarios?
They have presented with common
enough symptoms. The answer lies in
their occupation as will be made clear
by further questioning.

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Scenario 1: Further questions regarding ‘what do you
do as a junior technician?’ would have revealed his job
included soldering and paint spraying. Both these
activities use agents that are known respiratory
sensitisers: In terms of clues to link an occupational
aetiology, it is important to ask about the relationship of
symptoms to rest days and holidays.
Scenario 2:
Further questioning relating to previous occupations
would have revealed that this person was a miner for 20
years before becoming a salesman. The job of a miner
involved the use of vibratory tools for long periods of

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the day with no health surveillance. This would raise the
possibility of Vibration White Finger.
Scenario 3:
Further questions regarding her work environment
revealed that the noise in the workplace was so loud
that she had difficulty in following a conversation with
her friend who stood 1 metre away from her.
Questions regarding hobbies and lifestyle provided further exposure to
high noise levels as she played the drums in a local band on a weekly
basis. Such information sheds a different light on the diagnosis and
places the possibility of noise induced hearing loss as a likely cause

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Case#5: A 31-year-old laboratory technician is
referred to your clinic by her manager, because of
alleged lateness and poor performance at work.
You are asked to assess whether there is an
underlying medical cause for this.
She tells you that she has not been sleeping well
lately, possibly due to nocturnal coughing. She
says the lab is cold and drafty, and that by the

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end of the working day her right arm is aching.
She says that when she told her manager, he was
unsympathetic; telling her she should leave if she
doesn’t like the job.
1. What are the presenting medical problems?
2. What are the possible work-related causes of her
symptoms?
3. What are the potential hazards in her workplace and
how might you classify them?
4. How will you respond to the manager’s questions?

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Case#1: A 30-year old man presented with episodic
wheeze and cough. He gave as his occupation
‘panel beater’ - a trade involving the repair of the
bodywork of crashed cars. Further questions were
therefore directed at the possibility of exposure to
sprayed paint and he said that this activity did take
place in the garage, but by others and in a specially
constructed booth; he was not exposed to the paint.
By way of explanation, he was told that some two-
part paints contain di-isocyanates and that these
chemicals can cause occupational asthma. He then

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admitted that he had a second job in which he
repaired car bodywork in his own garage at home.
He had been using an isocyanate-based paint spray
without any exhaust ventilation or respiratory
protection! This proved to be the cause of his
asthma and after he had purchased appropriate
respiratory protection and ventilation equipment, he
was able to continue this work without symptoms.

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Processing the historical information
and further questions.
There are a number of similarities between the
processing of information in a clinical occupational
medical history and the decisions regarding criteria
for causal association that one encounters in
epidemiology. Indeed many good occupational
physicians practice both clinical medicine and
epidemiology within the specialty of occupational
medicine.

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Epidemiologic
criteria for
causality:
Clinical questions:
Temporality
When in relation to exposure do/did
the symptoms start?
Reversibility
Do the symptoms improved when no
longer exposed, e.g. on holiday?
Exposure-
response
Are the symptoms especially worse
when undertaking tasks or in areas
with high exposures?

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Strength of
association
Do other workers/patients suffer from
similar symptoms associated with the
same exposures?
Specificity
What other exposures/causal factors
could be responsible for the same
symptoms? (Smoking perhaps?)
Other data or information processing:
Consistency
Are there other reports of the same
symptoms associated with or caused
by the same exposure?

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Analogy
Even if there is no evidence to hand
of identical exposures or
circumstances resulting in the same
symptoms, have similar agents /
chemicals of similar structure been
implicated in the same symptoms of
for example … dermatitis, or asthma?
Biological
plausibility
Do the symptoms ‘add up’ in terms of
what is known about the mechanisms
of disease?

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Occupational History Levels:
1. Basic O.H (a knowledge of the patient's
current occupation and implications of the
present illness for employment),
2. Diagnostic O.H (to investigate an association
with the present illness),
3. Screening O.H (for individual surveillance),
4. Comprehensive O.H (to investigate complex
problems in depth, usually in consultation with
other occupational health professionals)

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Components of Occupational History
Part 1. Exposure Survey
A. Exposures
 Current and past exposure to chemicals, biologic , or physical
hazards,
 Typical workday (job tasks, location, materials, and agents
used)
 Changes in routines or processes
 Other employees or household members similarly affected
B. Health and Safety Practices at Work Site
 Ventilation
 Medical and industrial hygiene surveillance

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 Employment exams
 Personal protective equipment .
 Personal habits (Smoke and/or eat in work area? Wash hands
with solvents?)
Part 2. Work History
 Description of all previous jobs including short-term, seasonal, and
part-time employment and military service
 Description of present jobs
Part 3. Environmental History
 Present and previous home locations
 Home cleaning agents , Pesticide exposure
 Water supply , Recent renovation/remodeling
 Air pollution, indoor and outdoor - Hobbies .

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Current job only
or full occupational history?
Work-related illnesses often present with common signs and
symptoms.
Where you suspect an occupational aetiology, start with the
current job.
In acute cases, only the current job and exposures in last 24
hours are likely to be relevant.

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A job title is not adequate
becausejob titlesare distinguished fromJob duties
titles alone often provide little or misleading
information about occupational exposures.
Furthermore, workers with the same job title, even
within the same company, may have vastly different
exposures based on their job duties

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A Standardized
Set of
Occupational
History Questions

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A- Screening Questions
1. What type of work do you do?
2. Do you think your health problems might be related to
your work?
3. Are your symptoms different at work and at home?
4. Are you currently exposed to chemicals, dusts,
metals, radiation, noise or repetitive work? Have you
been exposed to chemicals, dusts, metals, radiation,
noise or repetitive work in the past?
5. Are any of your co-workers experiencing similar
symptoms?

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If the answers to one or more of these
questions suggest that a patient's
symptoms are job related or that the patient
has been exposed to hazardous material, a
comprehensive occupational history should
be obtained.
B- Comprehensive
Occupational History

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Elements of the Occupational History
1- Job History
 List of jobs
 Lifetime history, with dates of employment and job duties
 Military history
2- Exposure Types

Chemicals (e.g., formaldehyde, organic solvents,
pesticides)
Metals (e.g., lead, arsenic, cadmium)
Dusts (e.g., asbestos, silica, coal)

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Biologic (e.g., HIV, hepatitis B, tuberculosis)
Physical (e.g., noise, repetitive motion, radiation)
Psychologic (e.g., stress)
 Assessment of dose
 Duration of exposure
 Exposure concentration
 Route of exposure
 Presence and efficacy of exposure controls
 Quantitative exposure data from inspections and
monitoring

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3- Disease Symptoms
 Timing of symptoms in relation to work
 Symptoms occur or are exacerbated at work and improve
away from work
 Symptoms coincide with the introduction of new
exposure at work or other change in working conditions
 Presence of similar symptoms among co-workers with
the same type of job and exposures.
4- Evaluation of non-work exposures
 Home environment (e.g., water, air, soil contamination)
 Hobbies or recreational activities..

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Thank You
www.Slideshare.net/ahmedrefat

Taking an effective occupational history

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