Taking an occupational history

1. Taking an occupational history Grant McMillan Hon Senior Clinical Lecturer Institute of Occupational and Environmental Health University of Birmingham Number 4 of a series of lectures and tutorials for medical undergraduates

2. This is a self-help tutorial designed to provide you with an introduction to taking an occupational history Learning Points • What is an occupational history? • Why take an occupational history? • Deciding between a full or only current occupational history. • General procedure – standard form. • Key questions.

3. What is an occupational history? An occupational history is a chronological list of all the patient’s employment, with dates, expanded as necessary to detail any evidence of occupational exposure to potentially hazardous agents and resulting effects on health.

4. Note the key words in the definition An occupational history is a chronological list of all the patient’s employment, with dates, from leaving school – or even earlier. It may be expanded as necessary to detail any evidence of occupational exposure to potentially hazardous agents and resulting effects on health.

5. Why take an occupational history? To determine if there is evidence that: Work is a cause of ill health Work has aggravated existing ill health. Health or ill health has an effect on the capacity for work.

6. An occupational history is the most effective instrument for the proper diagnosis of occupational disease if it provides evidence which generates informed suspicion of risk of harm which is acted upon correctly. Now, look at the three parts of this statement

7. An occupational history is the most effective instrument for the proper diagnosis of occupational disease …

8. if it provides evidence which generates informed suspicion of risk of harm….. which is acted upon correctly.

9. An occupational history may also be an effective instrument for assisting return to work after injury or disease

10. An occupational history may also be an effective instrument for assisting return to work after injury or disease if it helps to identify required standards in health or fitness and how the individual measures up to these.

11. The occupational history or exposure history seeks to define possible exposure to hazards to health and links with actual ill-health outcomes.

12. 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.

13. Moving to a fuller occupational history Move to a fuller history if the short history: • does not provide a solution; • suggests that the problem may have started in a previous job or • if the adverse health outcome is one of a list of specific disorders which merit deeper probing.

14. Specific disorders when you should probe more deeply • anaemia • asthma, acute bronchitis, pneumonitis • chronic lung disease • dermatitis • headaches • hepatitis • injury • nausea and vomiting of unknown origin • new onset of depression/irritability • neuropathy • pneumoconiosis • renal failure • reproductive anomalies

15. Procedures for taking an occupational history • Oral questioning about current job. Patient probably has good recall. Usually a quick process. • Oral questioning about previous jobs. Expect gaps initially and limited or poor recall on dates. This can be a slow process which takes much doctor time • There is advantage in leaving the patient with a pro forma about previous jobs to complete in his/her own time then returning to question. Experience shows that this reduces gaps and inaccuracy which would be present without such an aid. It also reduces the time the doctor must be present.

16. Procedures for taking an occupational history A good pro forma completed in the patient’s in own time + oral questioning probably gives best chance of full and accurate account and is economic with doctor’s time.

17. Key questions - 1 • What work do you do? or Do you have a job? or What is your job? or What do you do for a living? (Record name and address of employer) • Is it full time or part time? • How long have you been doing this job? • In what year and month did you start? • How long is your working day? • Do you do shifts and what is the shift rotation? • What is typical working day for you?

18. Key questions - 2 • What tasks do you do? • What processes do you work with? • How often? • For how long each day? • What materials do you work with? • Do you have or have you had occupational exposure to fumes, chemicals, dust, loud noises, vibration, radiation or other occupational hazards? Take care with maintenance men and their exposures.

19. Key questions - 3 • Have you been told that any of these might make you ill, that is, are hazardous? • Do you have a label, hazard sheet or COSHH assessment? • How might you be exposed to this hazard? • What is the extent of your exposure to these materials?

20. Key questions – 4 • How is exposure controlled? • Is there local extract ventilation? • Do you wear special protective clothing?

21. Key questions - 5 • Do you have any special medical tests because of this work? • Are you better at the weekend or on holidays? • Does anyone at work have the same symptoms or other health problems? • Have you done this job elsewhere in the past?

22. Key questions - 6 • Do you have a second (or third) job? If so, repeat questioning.

23. Key questions - 7 • What are your hobbies and past times? • What DIY or housework do you do? (Examples to look for include adhesives and birds) • Do any of these hobbies or activitiesbring you into contact with chemicals, impure chemicals, breakdown products?

24. Key questions - 8 Are there any sources of environmental pollution in your area? For example, factories, waste sites or contaminated sources of water.

25. Key questions - 9 • Have you done any other kind of work? • What jobs have you had since you left school? ie Move on to a full occupational history.

26. Key questions –10 • Check for gaps – all to be explained. (Prison?) • Have you served in the Armed Forces? • Have you worked overseas? • Has anyone who worked with you in the past had the same symptoms or other health problems?

27. Further reading • Burge PS. How to take an occupational history relevant to lung disease. In Occupational Disorders of the Lung. Eds Hendrick DJ et al. Published by WB Saunders 2002 • Lee WR, Tar-Ching Aw. The occupational history. In Hunter’s Diseases of Occupations 9th edn. Eds Baxter PJ et al Eds. Arnold, London, 2000.