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Competency 1 – Good Clinical Care: Elicit a relevant occupational history, identify and manage problems

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.

Resources:

It is important to remember when taking a history from a patient that there might be an occupational cause for their symptoms or ill health. Therefore asking about a person’s occupation is important. If it is suspected that a person may be complaining of an occupational related medical condition, it is not sufficient to only ask “what is your job?” This can be misleading and possibly result in missed diagnosis. In these cases it is important to take a more detailed occupational history to try and understand what hazards the individual might be exposed to and how this might affect them.

A list of questions to ask includes:

  • What is the problem?
  • What work do you do?
  • What do you do in your job?
  • Do you have other jobs, or hobbies?
  • Is anyone else affected?
  • What other jobs have you done?

This is illustrated in the case below.

A normally fit 22 year old man presents with a persistent cough, feeling short of breath and wheezing when he runs up the stairs. Otherwise he is well and has no recent viral infections. He works in the local garage.

Important points to elicit:

  • “What’s bothering you?”
    Chest tightness, wheeze and cough would suggest the respiratory system and asthma as the possible pathology.
  • What do you do in your job at the garage?”
    Determine what his job is and what hazards he might be exposed to. He may not volunteer that part of his job involves spray painting, unless specifically asked.
  • “So how often do you use the paint sprayer?”
    He may not inform you that the spray painting represents 40% of current role unless you enquired about this.
  • “Are there any other tasks you perform in your job? Do you have any other jobs or hobbies?”
    Identify any exposure to other hazards. E.g. he may not recognise the need to inform you that he volunteers at the week end to work on a National Trust property and is exposed to large amount of flower pollens.
  • “So tell me more about your shortness of breath. When did it start? Do you get it all the time? Are there times when it is worse?”
    Here it is important to understand when in relation to the exposure did the symptoms start. Do symptoms improve when away from work/days off/holiday. Are symptoms worse when performing more of a particular task?
  • “Has any one else at work been complaining of similar problems?”
    It is important to establish whether other people at work may have similar symptoms.
  • Remember, other non occupational factors could contribute to the cause or symptoms.

Once you suspect an occupational condition, it is important to manage it appropriately.

Consider the following points.

  • Manage the symptoms and lines of investigation as you would for a non occupational condition. This reflects that the underlying pathology is often the same regardless of the cause.
  • Seek to confirm any suspicions that the condition may be occupational in origin; refer to “sources of information”.
  • Consider referring to other specialists; e.g. Respiratory physician with an interest in occupational lung disease if suspect occupational asthma
  • Elicit from the individual their health beliefs and attitudes, as well as the employer’s attitude.
  • Enquire about any occupational health provision within the place of employment. This could help with further management of the case.

Here are some scenarios. They are followed by some questions to consider, and answers .

Scenario 1

A 35-year-old man presents to surgery 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.

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 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.

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: (See knowledge section for respiratory disease) 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 the day with no health surveillance. This would raise the possibility of Vibration White Finger. See knowledge section HAVS.

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

See knowledge section NIHL

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