1. 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

2. Occupational/Exposure History Single most important instrument for obtaining information on the role of occupational and environmental factors in causing disease

3. 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

4. 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

5. 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

6. Occupational/Exposure History Identification of a problem or documenting exposure in your patient may benefit others Increased usefulness with EMR

7. Occupational/Exposure History Given an exposure history, you can probe for symptoms or signs otherwise not apparent to your patient or you

8. Occupational/Exposure History Plan for surveillance exams Establish the basis for compensation

9. Occupational/Exposure History To allay fears, address concerns, and support lifestyle modifications that could impact health

10. Occupational/Exposure History Key Concepts

11. 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

12. 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)?

13. 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

14. 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

15. Biological Plausibility of the Exposure and Symptoms Basic toxicology still holds : –Symptoms consistent with route of entry/absorption

16. Biological Plausibility of the Exposure and Symptoms Effects of removal, relocation, return

17. 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?

18. And now for the details specific to Iraq and Afghanistan….