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The relationship between exposures at work and the development of injury or disease has been well documented throughout history. One of the earliest writings on lung conditions of miners was in the fourth century BC by Hippocrates. With the publishing of De Morbis Artificium Diatriba (Diseases of Workers) by Bernardino Ramazzini in 1700, the description of the health hazards of chemicals, dust, metals, and other agents encountered by workers in 52 occupations established occupational exposure as an important contributor to chronic disease. Ramazzini proposed that physicians should extend the list of questions that Hippocrates recommended they ask their patients by adding, “What is your occupation?”

The importance of the occupational and environmental medical history cannot be overemphasized. Occupational and environmental health and safety is an integral part of population health and is one of the social determinants of health. Working Americans spend greater than ½ of their waking hours at work, and the impact of the many exposures and stress factors encountered on the job can have significant effect on workers’ health, both physical and mental. It can also profoundly influence the health of their families and communities and contribute to the social and economic costs to society as a whole. Moreover, with the advent of industrialization and the introduction of thousands of chemicals and other toxic substances into the environment, it is important for the medical practitioner to consider both occupational and environmental exposures when taking the medical history.

Screening History

The relationship of injury or illness to work is often overlooked or even forgotten in the medical history. An accurate and complete occupational and environmental history is the most important tool in the evaluation and diagnosis of occupational and environmental injuries and illnesses. The patient who presents with wheezing may have asthma related to a long history of seasonal allergies, or the asthma may be related to exposure to isocyanates on the job. Without the occupational and environmental history, the correct diagnosis, treatment plan, and prevention may not be achieved.

Accurate diagnosis of occupational illnesses is important beyond the usual reasons for accuracy in medical diagnosis. There are public and population health, social, and economic implications of occupational disease and injury for the community of workers in the same workplace or in other workplaces with similar exposures. In many states, the diagnosis of an occupational illness triggers additional responsibility on the part of the clinician. These responsibilities are primarily those of timely notification: informing the worker regarding the potential legal and other implications of the diagnosis, informing the workers’ compensation insurer of the diagnosis and the basis for the clinician’s opinion, and reporting to the appropriate public health or labor-related governmental agencies. A differential diagnosis that appropriately includes occupational exposures as potential causes or exacerbating factors of the patient’s presenting symptoms or suspected disease is a crucial first step in recognition (Figure 2–1).


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