Occupational and Environmental History

The occupational and environmental history concerns exposure to potential disease-producing substances or environments. Occupational exposures account for an estimated 50,000 to 70,000 deaths annually in the United States. More than 350,000 new cases of occupational disease are recognized each year. These diseases can involve every organ system. Because they often mimic other diseases, occupational diseases may be incorrectly ascribed to some other cause. One of the important barriers to the accurate diagnosis of occupational and environmental diseases is the long latency between exposure and appearance of the illness.

Many occupational diseases have been well described over the years: malignant meso-thelioma in workers exposed to asbestos; cancer of the bladder in workers exposed to aniline dye; malignant neoplasms of the nasal cavities in woodworkers; pneumoconiosis in coal miners; silicosis in sandblasters and quarry workers; leukemia in those exposed to benzene; hepatic angiosarcoma in workers exposed to vinyl chloride; byssinosis in cotton industry workers; skin cancer in those chronically exposed to the sun, such as sailors; ornithosis in bird breeders; toxic hepatitis in solvent users and workers in the plastics industry;and chronic bronchitis in individuals exposed to industrial dusts. It has been shown that there is an association between sterility in men and women and exposure to certain pesticides and an association between dementia and exposure to certain solvents.

The environment is also responsible for significant morbidity and mortality rates. Lead, radon, pesticides, and air pollution cause illness and death. Examples include Chernobyl, with its widespread high levels of radiation;Minamata Bay in Japan, with its mercury poisoning; Hopewell, Virginia, with its poisoning pesticide chlordecone; and Bhopal, India, where a leak at an industrial plant exposed hundreds of thousands of people to toxic methyl isocy-anate gas. In India, thousands died shortly after exposure, and more than 200,000 people have suffered illness from the gas. The long-range effects of these agents have yet to be determined.

A careful occupational and environmental history is the most effective means of properly diagnosing occupational and environmental diseases. It is important to inquire about all occupations and the duration of each. The history should include more than just a listing of jobs. The duration and precise activities must be ascertained. The use of protective devices and cleanup practices, as well as work in adjacent areas, must also be determined. The job title (e.g., electrician, machine operator) is important, but actual exposure to hazardous materials may not be reflected in these descriptions. Industrial work areas are complex, and it is important to ascertain the actual location of work in relation to other areas in which hazardous materials are used. It is well known that just living near areas of industrial toxins is linked to the development of disease many years later. It is therefore relevant to inquire whether the patient resides or ever resided near mines, farms, factories, or shipyards. The following questions regarding occupational and environmental exposure should be asked of all patients:

How long have you been doing this work?'' ''Describe your work.''

Are you exposed to any hazardous materials? Do you ever use protective equipment?'' ''What kind of work did you do before you had your current job?'' ''What was your wartime employment, if any?'' ''Where do you live? For how long?''

''Have you ever lived near any factories, shipyards, or other potentially hazardous facilities?''

''Has anyone in your household ever worked with hazardous materials that could have been brought home?''

''What types of hobbies do you have? What types of exposures are involved?''

Do you now have, or have you previously had, environmental or occupational exposure to asbestos, lead, fumes, chemicals, dusts, loud noise, radiation, or other toxic factors?''

Attention must be paid to any temporal relationship between the onset of illness and toxic exposure in the workplace. Did the symptoms start after the patient began a new job? Did the symptoms abate during a vacation and then recur when the patient resumed work? Were the symptoms related to the implementation of any new chemical or process? Is there anyone else at work or are there any neighbors with a similar illness?

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