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Taking an effective occupational history

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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Taking an effective occupational history

  1. 1. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 1 Taking an occupational history Dr. Ahmed-Refat AG Refat www.SlideShare.net/AhmedRefat
  2. 2. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 2 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.
  3. 3. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 3 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.
  4. 4. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 4 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.
  5. 5. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 5 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
  6. 6. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 6 Condition Selected exposures occupations 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
  7. 7. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 7 Condition Selected exposures occupations 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
  8. 8. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 8 Condition Selected exposures occupations 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
  9. 9. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 9 Condition Selected exposures occupations 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
  10. 10. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 10 Condition Selected exposures occupations 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
  11. 11. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 11 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.
  12. 12. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 12 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.
  13. 13. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 13 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.
  14. 14. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 14 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
  15. 15. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 15 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.
  16. 16. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 16 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.
  17. 17. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 17 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
  18. 18. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 18 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.
  19. 19. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 19 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
  20. 20. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 20 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
  21. 21. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 21 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
  22. 22. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 22 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?
  23. 23. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 23 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
  24. 24. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 24 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.
  25. 25. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 25 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.
  26. 26. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 26 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?
  27. 27. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 27 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?
  28. 28. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 28 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?
  29. 29. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 29 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)
  30. 30. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 30 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
  31. 31. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 31  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 .
  32. 32. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 32 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.
  33. 33. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 33 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
  34. 34. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 34 A Standardized Set of Occupational History Questions
  35. 35. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 35 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?
  36. 36. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 36 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
  37. 37. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 37 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)
  38. 38. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 38 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
  39. 39. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 39 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..
  40. 40. Dr.Ahmed-Refat AG Refat Feb. 2013 ……………………………………Taking an occupational and environmental history 40 Thank You www.Slideshare.net/ahmedrefat

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