Importance of an Occupational History

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Importance of an Occupational History

• Taking An Occupational History Without Taking All
  Day

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Occupational History Collection by Third Year
Medical Students During Internal Medicine and
Surgery Inpatient Clerkships.

• 2,922 initial H and Ps from 137 3rd year
  medical students were examined
• Patients lt40 and women significantly less
  likely than older patients or male patients to
  have notations of occupation and industry.
• Overall reporting frequencies were recorded as
  follows
• industry, 56
• occupation 70
• specific occupational exposures 8.4
• and smoking status 91.4. (Aug 98, MCCurdy et
  al),

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Basic tenets

• Because many occupational and environmental
  disease manifest as common medical problems, or
  have nonspecific symptoms..
• An exposure history is vital for correct diagnosis

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Basic tenets, cont.

• The primary care clinician can play an important
  role in detecting , treating, and preventing
  disease due to toxic exposure by
• taking a thorough exposure history!

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What are the consequences of not recognizing an
exposure?
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What are the consequences of not recognizing an
exposure?

• Diagnosis may be missed
• Treatment may be inappropriate
• Exposures may continue with increase morbidity
  and mortality

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How To Take An Occupational Exposure History
Without Taking All Day
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Learning Objectives

• Understand the importance of a brief exposure
  history
• Understand when to take a more detailed history
• Report suspected cases to the appropriate agency
• Know how to readily research needed resources

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Key Points

• Exposure related disease are prevalent and
  preventable

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Prevalence

• DOL
• 6.2 million nonfatal injuries and illnesses in
  private industry in 1998 (7.4 cases per 100 fte
  workers)
• 171 billion spent in 1996 on occupational
  injury/illness costs
• McCurdy et al article

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Brief OEM History On The Chart of Every Patient

• (1) Job title
• (2) What do you do?
• (3) Known risks?
• (4) What safety measures (ppe) are taken?

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When You Should Probe DeeperSpecific Disorders

• Injury
• Neuropathy
• Asthma, acute bronchitis, pneumonitis.
• Chronic lung disease
• Pneumoconioses
• Hepatitis

• Dermatitis
• Reproductive
• New onset depression, irritability
• Headaches
• Renal failure, anemia, n v of unknown origin

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When You Should Probe DeeperSpecific
High-hazard Jobs

• Jobs
• machinery
• chemicals
• require repetitive motion
• heavy lifting

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When to take a more detailed history

• Illness occurs at an atypical age
• Lack of risk factors, the why me syndrome?
• Lack of response to treatment, atypical course
• Job prompts
• Disease or illness prompts - known or possible
  sentinel pathophysiologic conditions

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Sentinel Health Events(Occupational)

• SHE(O) - is a preventable disease , disability ,
  or untimely death which is occupationally related
  and whose occurrence may provide
• impetus for epidemiologic or industrial hygiene
  studies
• serve as a warning signal that material
  substitution, engineering controls, ppe, or
  medical care may be required.

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SHE(O)

• Two broad categories
• Inherent SHE(O) - diseases or conditions, which,
  by their inherent nature, are necessarily
  occupationally related ex. Pneumoconioses
• Non-inherent SHE(O) - disease such as lung
  cancer, leukemia, peripheral neuropathy, which
  may or may not be occupationally related, but has
  clearly been linked to wp exposures

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SHE(O) Examples

• Malignant neoplasm of nasal cavity
• I/O woodworkers, nickel smelting
• Agent hardwood dust, nickel
• Raynauds phenomenon
• I/O lumberjacks, pvc industry
• Agent segmental vibration, vinyl chloride
• Polyneuropathy
• I/O furniture refinishers, plastic industry
• Agent hexane, acrylamide

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Utility of SHE(O)

• 1) Value as a surveillance tool
• 2) Value for the practicing physician
• 3) Value to help decide safety and research
  priorities
• Rutstein et al article, AJPH, Sept. 1983

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Detailed questions

• What to ask?????
• more detail on agents used, duration
• ppe measures
• spills
• ventilation
• acute symptoms when using agent
• temporal relationship of cc to work or home
  activities
• other coworkers or family members affected

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Detailed History for Assessing Dose

• Concentration
• Duration of exposure
• Frequency of Exposure
• PPE usage
• ventilation
• respirators
• clothing

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Factors that modify risk of occupationally
related illness

• Age
• Sex
• Chronic respiratory disease
• Chronic cardiovascular disease
• Neurologic conditions
• Dermatologic conditions
• Hepatic or renal insufficiency

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Back to basic tenets

• Extensive knowledge of toxicology is not needed
  to diagnose O/E disease.
• Use standard criteria to treat medical
  conditions
• history including temporal relationship
• palliative and provocative factors
• physical exam
• labs

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Inference of causality look for

• temporal relationship
• appropriate latency
• dose-response
• co-morbidity
• biologic plausibility

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Exposure History

• Look at the BIG picture
• occupation
• home
• community
• personal habits/hobbies
• and others with similar symptoms

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Key points of ATSDR exposure history

• Certain toxins have known organ affects -
  table 1
• Common Toxidromes
• metals -- neuropathy, nephropathy
• pesticides -- SLUD
• isocynates -- asthma, pulmonary fibrosis
• solvents -- liver disease

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Key Points, cont.

• Common toxicants in home/environment
• indoor air pollution
• common household products
• pesticides and lawn care products
• lead products
• recreational hazards
• water supply
• soil contamination

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ATSDR key points, cont.

• Identifying Hazardous Agent
• labels
• MSDS
• poison control
• IH, Occ. nurse/doctor
• text books
• databases
• agencies

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ATSDR key points, cont.

• Importance of follow-up and consultations
• And referral resources

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Exposure Case Studies

• Why do physicians miss exposure/causation/mechanis
  m of injury link?
• 1) Lack of training in EOM
• 2) Think they have inadequate time
• 3) Fatigue, bias, bad attitude

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Lack of training, inadequate time Think and
then think again

• 55yo female presents to ED c/o ha. Intermittent
  in past but now daily past 2 weeks. Steady
  pressure in parietal area w radiation to occiput.
  No n,v, visual changes, trauma, weakness or sleep
  disturbances bc of ha, but has awakened with
  tingling ring and fifth fingers of one or both
  hands. Resolves after a few minutes. No fever,
  chills, malaise. Using acetaminophen. PMH -

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Case continuation

• Physical Slightly overwt, NAD, rubs temples
  periodically. HEENT,CN and funduscopic neg. UE
  and LE motor, reflexes, sensory normal.
• Diagnosis Tension ha.
• Rx Ibuprofen 800mg, warm bath. Refer for
  tingling to neurologist.

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Case continuation

• No change in headaches. F/U with family
  phsyician. Seen on three different visits, two
  weeks apart, ave visit time 12 minutes. Given
  different NSAID, 3rd visit MRI ordered.

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Case continuation

• On fourth visit MRI neg. Occ hx was finally
  taken.
• Revealing job description/tasks, poor
  ergonomics.
• Repeat exam careful exam of posterior shoulder
  girdle and neck.
• Based on history and exam dx of myotendinous
  TOS was made.

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Case continuation

• Was initial hx adequate?
• Was initial exam adequate?
• Was initial discharge plans and instructions
  adequate?

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Bias, bad attitude, fatigue

• Whatever it is no excuse!!!!!
• Hx 32 yo CM presents to Occ clinic, works on
  road construction. Sweeping loose asphalt off of
  newly poured road w. industrial broom, stepped
  off 2 foot shoulder and rammed broom up into
  LUQ, left lateral chest.
• CC Left anterior-lateral inferior chest wall
  pain, SOB, pain with breathing

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What would you do?

• Hx
• Physical Exam
• Work up

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What was done?

• Pitiful little
• Hx No further history in physicians notes
• PE mention of rhomboid exam. NO CHEST EXAM,
  EITHER VISUAL INSPECTION, PALPATION OR
  AUSCULTATION, NO LUQ EXAM
• Rx Physical Therapy.

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Outcome and Consequences

• Rib fracture?ruptured intercostal
  vessel?hemothorax?infection?sepsis?
• prolonged surgery?brachial plexus
  injury?brain abscess
• Prolonged hospitalization, surgery, repeat
  surgery
• Disability pulmonary, neurological, loss time,
  not able to return to previous occupation.
• And why??

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Paddle Forward and No Lily Dipping