The New York State Workers Compensation Board has established guidelines for the assessment of History Taking and Physical Examination. These directives are designed to assist physicians and healthcare practitioners in determining appropriate treatment for these procedures.
Healthcare professionals focusing on History Taking and Physical Examination can use the Workers Compensation Board’s guidance to make informed decisions about the most suitable level of care for their patients.
It is crucial to emphasize that these guidelines are not meant to substitute clinical judgment or professional expertise. The ultimate decision regarding care should be a collaborative effort involving the patient and their healthcare provider.
Diagnosis and treatment plans rely on the occupational exposure history, presentation, and the results of diagnostic screening tests.
History of Present Illness
The History of Present Illness (HPI) should record the following:
– Pulmonary exposures, both occupational and non-occupational.
– Current and past occupation details, specifying types of work activities like construction, demolition, mining, manufacturing, and drilling. Refer to the table below for examples.
– Duration of time spent in each job, including positions held years to decades ago.
Exposures should encompass:
– Dusts, covering organic dusts (fungi, bacteria, plant and animal proteins) and inorganic mineral dusts (silica, asbestosis, coal).
– Metals such as Beryllium (found in old light bulbs and aerospace) and tin, cobalt.
– Toxic and inflammatory substances like fumes, gas, vapors, and aerosols.
The history of exposure should not only involve occupational but also non-occupational exposures, detailing the agent, duration, and intensity of exposure. Ideally, intensity should be supported by environmental measurements (industrial hygiene data) or qualitatively described (e.g., daily, weekly, monthly, yearly).
Include inquiries about the individual’s responsibilities and exposure, considering factors like working in an office.
Regarding symptoms:
– Document when symptoms began.
– Specify complaints such as throat tightness, shortness of breath, difficulty with inspiration or expiration, harsh sounds, cough, and sputum production.
– Note the duration, onset, and frequency of symptoms.
– Explore symptom development, including aggravation and alleviation concerning the work environment, changes in the work environment, and variations in symptoms based on days worked and not worked.
– Track the progression of symptoms.
Other essential aspects to cover are pulmonary imaging and testing, previous treatments, the relationship of the illness or injury to work (including a statement on the probability of work-relatedness), and the individual’s ability to perform job duties and activities of daily living.
Past History
• Previous medical records, encompassing, among other things, prior exposure to pulmonary conditions and treatments (covering susceptibility to bronchitis and pneumonia).
• Systematic examination involves, but is not limited to, investigating symptoms related to rheumatologic, neurologic, endocrine, neoplastic, and various systemic diseases.
• Thorough examination of smoking history, including the use of marijuana, vaping, etc.
• Comprehensive overview of medication history, considering the usage of Amiodarone, chemotherapeutic agents, and nitrofurantoin.
• Exploration of both work-related and recreational activities.
• Examination of past imaging studies.
• Assessment of surgical history.
• Collection of allergy-related information.
Physical Examination
An examination focused on occupational pulmonary health should encompass the following components:
• Recording vital signs, including the measured respiratory rate and O2 saturation.
• Evaluation of overall functional abilities, gauging ease of movement, walking, changing positions, dressing, and undressing, while observing signs and symptoms of dyspnea.
• Assessment of respiratory status, taking into account factors like rate, depth, use of accessory muscles, and nasal flaring.
• Visual inspection for signs of pulmonary disease and potential causes, including:
– Abnormalities in mucous membranes
– Presence of nasal polyps, swelling, or discharge
– Clubbing (associated with conditions like asbestosis, idiopathic pulmonary fibrosis, and certain hypersensitivity pneumonitides)
– Anterior-posterior diameter
– Scoliosis
– Kyphosis
• Palpation to identify:
– Chest wall abnormalities
– Presence of adenopathy and neck masses
• Percussion to assess resonance and identify:
– Aeration
– Diaphragm level
– Indications of fluid interface or consolidation
• Auscultation to examine:
– The inspiration to expiration ratio
– Adventitious breath sounds (such as crackles, wheezing – often a secondary manifestation of HP and a primary manifestation of eosinophilic pneumonia, rales, rhonchi)
– Presence of pleural rubs, along with timing, location, and persistence of lung findings
• Cardiac examination with a focus on identifying signs of cor pulmonale and heart failure.
• Dermal examination to spot signs of diseases, like erythema nodosum (associated with sarcoidosis).
Diagnostic Approach
Diagnosing occupational interstitial lung disease (ILD) typically relies on a clinical approach, considering factors like a relevant occupational history with adequate exposure and appropriate latency, supported by objective radiographic evidence (such as chest radiograph and/or HRCT). Additionally, an assessment of pulmonary function is crucial, examining consistent changes in ventilatory capacity, static lung volumes, or gas exchange, while also considering alternative differential diagnoses.
For individuals with a typical clinical profile, including a comprehensive exposure history, appropriate latency, and consistent radiographic presentation, lung biopsy is seldom necessary to confirm the diagnosis of occupational ILD. However, there might be instances where a pathologic examination of lung tissue becomes essential, especially in settings where clinical or radiographic features are inconclusive or atypical.
It is advisable to incorporate periodic medical follow-up into the diagnostic process, involving pulmonary function tests and imaging studies. This ongoing evaluation is instrumental in the medical assessment of pulmonary occupational diseases.
