veterans exposure concerns: the occupational and environmental medicine history
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Veterans Exposure Concerns: The Occupational and Environmental Medicine History. Debra Milek M.D., Ph.D., M.P.H. Department of Preventive Medicine/Occupational and Environmental Medicine. Occupational/Exposure History. - PowerPoint PPT PresentationTRANSCRIPT
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Veterans Exposure Concerns: The Occupational and Environmental
Medicine History
Debra Milek M.D., Ph.D., M.P.H.Department of Preventive
Medicine/Occupational and Environmental Medicine
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Occupational/Exposure History
• Single most important instrument for obtaining information on the role of occupational and environmental factors in causing disease
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What is an occupational/environmental
medicine evaluation?
• Typical medical history plus an occupational history – Includes an environmental exposure
assessment -----from all possible sources (military, work, home, hobbies, significant other, neighborhood)
– Helpful to have a standardized questionnaire to obtain the factual outline of exposures
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Occupational/Exposure History• Greater emphasis in determining the etiology
of complaint
• Occupational diseases frequently are identical in symptoms and pathology to those of non occupational origin– E.g.Occupational asthma, solvent
encephalopathy, peripheral neuropathy
There may be recognizable and preventable causes or exposures
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Occupational/Exposure History
• Treatment is likely to include exposure reduction, elimination or protection
• In some cases, this may mean inability to return to the same type of work
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Occupational/Exposure History
Identification of a problem or documenting exposure in your patient may benefit others
Increased usefulness with EMR
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Occupational/Exposure History
• Given an exposure history, you can probe for symptoms or signs otherwise not apparent to your patient or you
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Occupational/Exposure History
• Plan for surveillance exams
• Establish the basis for compensation
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Occupational/Exposure History
• To allay fears, address concerns, and support lifestyle modifications that could impact health
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Occupational/Exposure History
Key Concepts
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CONCEPTUALIZING THE OCCUPATIONAL/EXPOSURE HISTORY Review the exposure history with the patient,
amplifying, clarifying
Go into greater detail where there are symptoms or concerns (the patient’s or yours)
Who=Job title and duties
What=The exposure of concern
When =Date(s) when the exposure occurred AND duration
Where=Location and location of individual relative to exposure
How=Route of entry (dermal, inhalation, ingestion; ventilation, personal protective equipment)
Why=Accident, acute or chronic exposure
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Look For A Temporal Relationship
• Between the introduction of a new toxic exposure, accident, injury or stressor
Chemical, physical, biological, psychological
And the onset of illness EXPOSURE MUST PRECEDE THE ILLNESS
– Did symptoms begin shortly after starting a new assignment, task, location or change in the way it’s done or change in the environment or was there an incident?
– Or doing the same job for many years (cumulative exposure)?
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Biological Plausibility of the Exposure and Symptoms
• What is already known? • Easier if previously diagnosed relationship
between exposure and disease• But be observant and record…..• Many chemicals untested for toxicity
– >60,000 new/year industrially– Unfamiliar elements of foreign conflict,
biologicals– May diagnose something previously
unrecognized
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Biological Plausibility of the Exposure and Symptoms
• Important component of biological plausibility is: Dose-Response– Greater likelihood if disease occurs more
commonly in more heavily exposed. Inquire about• Extent of exposure (Amount, Duration)• Proximity• Personal protective equipment• Others affected
• Allows for RISK STRATIFICATION
• Caveat: Differing susceptibilities
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Biological Plausibility of the Exposure and Symptoms
• Basic toxicology still holds:
– Symptoms consistent with route of entry/absorption
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Biological Plausibility of the Exposure and Symptoms
• Effects of removal, relocation, return
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You can get more information later
• Exposure data may be available from air sampling or even personal sampling– USACHPPM as a resource in the future?
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• And now for the details specific to Iraq and Afghanistan….