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Taking an Exposure History
What Is the Purpose of Taking an Exposure History?

Course: WB 2579
CE Original Date: June 5, 2015
CE Renewal Date: June 5, 2017
CE Expiration Date: June 5, 2019
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Learning Objective

Upon completion of this section, you will be able to

  • Explain the importance of taking an exposure history.

Purpose

Most environmental and occupational diseases either manifest as common medical problems or have nonspecific symptoms. Unfortunately, hazardous exposures rarely enter into the clinician's differential diagnosis. As a result, clinicians may miss the opportunity to make correct diagnoses that might influence the course of disease. A correct diagnosis may help stop exposure and might prevent disease in others by avoiding exposure [Gehle et al. 2011; Goldman and Peters 1981].

What can a clinician do to improve recognition of disease related to current or past exposures?

  • First, one must be suspicious and think about the possibility of environmental and occupational factors of disease.
  • Next, one needs to incorporate an exposure history questionnaire into clinical practice.

This course illustrates the principles and practices involved in the development of a differential diagnosis that includes possible hazardous exposure related etiologies.

Benefits

Taking an exposure history may enable physicians to

  • Make more accurate diagnoses,
  • Influence the course of disease by stopping current exposure,
  • Prevent disease in others by avoiding future exposure, and
  • Prompt workplace evaluations and the protection of workers.

Goals

The goals of taking an exposure history are

  • Identifying the hazard,
  • Avoiding or stopping the exposure,
  • Preventing disease,
  • Identifying and treating disease early, and
  • Arresting or reversing the progression of the patient's illness.

Exposure Factors and Etiology

The preceding case study describes a patient with angina. He has new, nonspecific symptoms of headache and nausea.

Suppose this patient lived near a hazardous waste site.

  • Would your differential diagnosis change?
  • If the patient refinished furniture as a hobby, would you consider this important?
  • Is there a connection between his headaches and cardiac symptoms?
  • How would you investigate the possible correlation?
  • Could he be exposed to chemicals in his workplace?

Each of these factors could play a role in the etiology of this patient's illness; each exposure could cause disease.

Three Scenarios

The patient described in the case study - a 52-year-old male with angina - is portrayed in three scenarios throughout this document. An exposure history provides clues that prompt the clinician to investigate the possibility of toxic exposure.

  • Scenario 1: This patient is an accountant who has had the same job and the same residence for many years.
  • Scenario 2: This patient owns a commercial cleaning service and uses cleaning products at various industrial and commercial sites.
  • Scenario 3: This patient is a retired advertising copywriter who lives in the vicinity of an abandoned industrial complex.

In each scenario, the clinician's pursuance of the exposure history led to discovery of toxic exposure in each of the three cases.

In each case, the diagnosis and treatment might have been inappropriate without an exposure history.

Etiology Denotes Environmental and Occupational Diseases

Most environmental and occupational diseases either manifest as common medical problems (e.g., rashes, asthma, angina, spontaneous abortion) or have nonspecific symptoms (e.g., headache, difficulty concentrating, behavioral problems, myalgias, difficulty conceiving) [Amdur MO 1991; Marshall et al. 2002; Wigle D 2000].

Establishing the etiology can distinguish a disorder as an environmental illness.

Table 1. Examples of Environmental & Occupational Causes of Medical Problems
[Goldman and Peters 1981; Nelson et al. 2011]

Symptoms and Diseases Agent Mode of Exposure
Immediate or Short-Term Effects
dermatoses (allergic or irritant) metals (chromium, nickel), fibrous glass, solvents, caustic alkali, soaps) electroplating, metal cleaning, plastics, machining, leather tanning, housekeeping
headache carbon monoxide, solvents firefighting, automobile exhaust, wood finishing, dry cleaning
acute psychoses lead, mercury, carbon disulfide removing paint from old houses, fungicide, wood preserving, viscose rayon industry
asthma or dry cough Formaldehyde, toluene diisocyanate, animal dander textiles, plastics, polyurethane kits, polyurethane foam, lacquer, animal handlers
pulmonary edema, pneumonitis nitrogen oxides, phosgene, halogen gases, cadmium welding, farming, chemical operations, smelting
cardiac arrhythmias solvents, fluorocarbons metal cleaning, using solvents, refrigerator maintenance
angina carbon monoxide, methylene chloride car repair, traffic exhaust, foundry, wood finishing
abdominal pain lead battery making, enameling, smelting, painting, welding, ceramics, plumbing
hepatitis (may become chronic) halogenated hydrocarbons (e.g., carbon tetrachloride) using solvents, lacquer use, hospital workers
Latent or Long-Term Effects
chronic dyspnea, pulmonary fibrosis asbestos, silica, beryllium, coal, aluminum mining, insulation, pipefitting, sandblasting, quarrying, metal alloy work, aircraft or electrical parts, foundry work
chronic bronchitis, emphysema cotton dust, cadmium, coal dust, organic solvents, cigarettes textile industry, battery production, soldering, mining, solvent use
lung cancer asbestos, arsenic, nickel, uranium, coke-oven emissions insulation, pipefitting, smelting, coke-ovens, shipyard workers, nickel refining, uranium mining
bladder cancer a-naphthylamine, benzidine dyes dye industry, leather, rubber-workers, chemists
peripheral neuropathy lead, arsenic, hexane, methyl butyl ketone, acrylamide battery production, plumbing, smelting, painting, shoemaking, solvent use, insecticides
behavioral changes lead, carbon disulfide, solvents, mercury, manganese battery makers, smelting, viscose rayon industry, degreasing, manufacture/ repair of scientific instruments, dental amalgam workers
Extrapyrami-dal syndrome carbon disulfide, manganese viscose rayon industry, steel production, battery production, foundry work
aplastic anemia, leukemia benzene, ionizing radiation chemists, furniture refinishing, cleaning, degreasing, radiation workers

Unless an exposure history is pursued by the clinician, the etiologic diagnosis might be missed, treatment may be inappropriate, and exposure can continue.

Key Points

  • Most environmental and occupational diseases either manifest as common medical problems or have nonspecific symptoms. Unless an exposure history is pursued by the clinician, the etiologic diagnosis might be missed, treatment may be inappropriate, and exposure can continue.
  • The goals of taking an exposure history are
    • Identifying the hazard,
    • Avoiding or stopping the exposure,
    • Preventing disease,
    • Early identification and treatment of disease, and
    • Arresting or reversing the progression of the patient's illness.

   

Progress Check

1. Which of the following statements about taking an exposure history is NOT TRUE?

A. Most environmental and occupational diseases have specific symptoms.
B. An exposure history provides clues that prompt the clinician to investigate the possibility of toxic exposure.
C. Etiology distinguishes a disorder as an environmental or occupational illness.
D. Taking an exposure history may enable physicians to influence the course of disease.

Answer:

To review relevant content see this entire section.

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